[Senate Hearing 117-]
[From the U.S. Government Publishing Office]


 
     DEPARTMENT OF THE INTERIOR, ENVIRONMENT AND RELATED AGENCIES 
                  APPROPRIATIONS FOR FISCAL YEAR 2022

                              ----------                              


                       WEDNESDAY, APRIL 28, 2021

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:23 a.m., in room SD-138, Dirksen 
Senate Office Building, Hon. Jeff Merkley (Chairman) presiding.
    Present: Senators Tester, Van Hollen, Heinrich, and 
Murkowski.

                         INDIAN HEALTH SERVICE


               opening statement of senator jeff merkley


    Senator Merkley. This subcommittee will come to order. I 
apologize to participating individuals as we had a technical 
problem with the Internet that seems to be resolved. So that is 
a step forward for the possibility of holding this hearing.
    Ranking Member Murkowski, and Acting Director Fowler, and 
our other colleagues and constituents joining us in person and 
remotely, welcome to our first hearing of the Interior, 
Environment, and Related Agencies Appropriations Subcommittee 
in the 117th Congress.
    Ranking Member Murkowski, this is our first hearing leading 
this subcommittee together, and we are soon diving into all of 
the details of writing appropriation bills. And I look forward 
to your insights, given your very substantial experience as a 
leader on this subcommittee.
    Today, we convened an oversight hearing to examine health 
disparities in Indian Country, review the Indian Health 
Service's COVID response, and explore future funding needs for 
Tribal health.
    I would like to welcome and thank IHS Acting Director, 
Elizabeth Fowler, and IHS Chief Financial Officer, Jillian 
Curtis, for testifying remotely today.
    Both Acting Director Fowler and Ms. Curtis are career 
employees, and we owe them a debt of gratitude for the public 
service, that service has been especially appreciated during 
the COVID-19 pandemic, and during the presidential transition.
    Native communities have been disproportionately affected by 
the COVID-19 pandemic. Native COVID mortality rates are twice 
as high as non-Native populations. And Native Americans and 
Alaska Natives are hospitalized due to COVID-19 complications 
at a rate four times higher than non-Hispanic, White 
individuals.
    This follows a pattern from previous pandemics, like the 
2009 swine flu when Native Americans experienced mortality 
rates four times higher and non-Native populations. These 
numbers are deeply troubling to me, and I think they are 
coupling to everyone participating in the hearing today.
    I am pleased that this subcommittee and Congress have 
recognized the immediate needs and underlining inequities in 
provided much-needed resources to IHS and other agencies in the 
wake of the COVID-19 pandemic.
    More than $9 million was provided to help ensure efficient 
vaccine distribution, improve health IT, and telehealth access, 
provide potable water delivery, and get kids safely back to 
school.
    Today I look forward to hearing from our witness about how 
this funding is being spent to address the pandemic's ongoing 
impacts in Native communities, and most importantly, to hear 
how it has expanded testing and tracing, improve patient 
outcomes and deliver vaccines in Indian Country.
    Yet the work to improve health outcomes for Native 
Americans and Alaska Natives is far from done. We know the 
pandemic has not created health disparities; it has only 
highlighted what we have long known to be unacceptable 
consequences of inequities among minorities, people of color 
and indigenous people.
    There is no clearer statement of values than how our 
government allocates its resources. I am pleased to see the 
Biden administration is proposing significant new investments 
in IHS. The budget blueprint process--or the budget blueprint 
proposes a 2.2 billion, 35 percent increase in annual funding 
for IHS, which would make a historic and unprecedented boost in 
the day-to-day health services for Native Americans.
    Work is also underway to enact a long-awaited 
infrastructure bill, potentially transformational opportunity 
to improve public health infrastructure, including water and 
sanitation systems. The causes of the disparities in Indian 
Country are many, and our response must address that. 
Inadequate water, housing, and health infrastructure all play a 
role.
    In Oregon, for example, I have heard from Tribal leaders 
that multigenerational housing has been especially problematic 
during the pandemic, overcrowded homes with multiple family 
members have made for a terrible environment when you are 
seeking to contain a fast-spreading virus.
    Good health is not just a matter of access to hospitals, 
clinics and doctors, although that is a large part, good health 
also means addressing environmental factors that contribute to 
conditions like asthma, which make individuals more susceptible 
to complications from respiratory diseases like COVID.
    In Oregon, the Confederated Tribes of the Warm Springs have 
57 miles of pipes that are in such a state of disrepair that 
much of the community has repeatedly been left without running 
water. Water is a basic human necessity, it is certainly 
essential for public health.
    In the Southwest many Native American communities are 
adjacent to abandoned uranium mines, exposing Native Americans 
to constant low levels of radiation, causing cancer and other 
serious comorbidities.
    Many of these areas fall under our jurisdictions, such as 
water infrastructure, Superfund cleanups, and enforcement of 
clean air and clean water laws.
    I look forward to discussing how the President's American 
Jobs Plan proposal envisions investing in infrastructure in 
Indian Country. I understand IHS is looking at approximately 
$17 billion in infrastructure backlogs, including healthcare 
and Sanitation Facilities Construction, and essential 
maintenance and repair for other IHS and Tribal facilities.
    I am hoping we can make meaningful progress on addressing 
these needs in an infrastructure package. I look forward to 
discussing our shared commitment to uphold our trust and treaty 
responsibilities to Tribes, and ways we can work together to 
provide the best healthcare available to Native Americans.
    And I now turn over the floor to my colleague and Ranking 
Member, Senator Murkowski.


              opening statement of senator lisa murkowski


    Senator Murkowski. Thank you, Mr. Chairman. And 
congratulations as you take over the helm of what I think is 
one of the best subcommittees on the Appropriations Committee. 
I think the areas of interest that intersect the priorities 
that we have, are clearly for our Native peoples, is 
significant, but then the overlay of clean air, clean water, 
through EPA (Environmental Protection Agency), as well as our 
public lands. It is a significant portfolio within Interior. 
And I offer my congratulations as you take the helm here.
    A lot has happened since our last IHS hearing, it was back 
in May of 2019, the last time we had a hearing on this, so 
obviously we have got a lot of ground to cover.
    I want to thank Ms. Fowler, who is the acting director for 
IHS, for appearing, virtually, before us today. I think we all 
know that the Head of IHS is a--it is tough job, but it is a 
critical job.
    Ms. Fowler, I am glad that you are here today to provide 
testimony and answer questions. But I do want to urge the 
administration to send the Senate a nomination for the IHS 
director soon. I think it is essential that we have leadership 
in place at all the agencies that have a role in navigating and 
helping the public during a pandemic. And that is certainly so 
within IHS.
    Across the multiple COVID relief packages, IHS has received 
a little over $9 billion either directly or indirectly. So to, 
kind of, put this into perspective, the fiscal year 2021 
appropriations for the IHS was approximately $6.2 billion. This 
was an increase of $189 million over the fiscal year 2020 
level.
    This is a significant investment, of course to address a 
very significant problem, but how this funding is or is not 
translating into on-the-ground improvements is the question 
that I think many of us want to look further into.
    At the start of the pandemic, there was a sense of anxiety 
across the entire country. For Tribal communities, especially 
those who recall the toll of the Spanish influenza and 
tuberculosis outbreaks, it added an extra layer of worry.
    For years, we have heard about staff shortages, constrained 
budgets, and general quality control measures throughout the 
entire IHS system. And while there is no doubt that there have 
been challenges and lessons learned over this last year, there 
have also been reports about areas of coordination, 
collaboration, and truly success.
    A pandemic that has disproportionately affected Tribal 
communities has remarkably, at the same time, resulted in some 
of the highest vaccination rates across the country. And I give 
credit to the IHS for giving all Native communities under its 
jurisdiction a choice between receiving vaccines through them 
or from State health departments. That flexibility, certainly 
for us in Alaska, has been key.
    And in Alaska, the decision was made to receive vaccines 
through the State rather than IHS, the Alaska Tribal Health 
Care System, in coordination with the State, now has 44 percent 
of the population over the age of 16 vaccinated with at least 
one dose, and over 40 percent of those vaccinations 
administered through the Tribal Health System.
    In our rural areas the rates are even better, nearly 59 
percent of the Yukon-Kuskokwim Delta's eligible population has 
received the first dose. In the Bering Straits region, 67 
percent of eligible adults have received one dose.
    And Mr. Chairman, I just want to clearly establish on the 
record, the community of Mekoryuk on Nunivak Island has 
achieved 100 percent vaccination. And I was able to visit with 
the gentleman this weekend, who is from Mekoryuk, and that 
community is pretty darned proud of that achievement.
    But it appears that the vaccination rates are not just high 
in Alaska. IHS is posting some of the highest rates across the 
country where IHS or Tribal clinics are the primary source of 
healthcare. We have heard stories that thousands of Tribal 
members have been vaccinated, and some Tribal entities have 
excess doses allowing sites to open up to out-of-town 
travelers.
    So looking forward to finding out more about the user 
population, service delivery, and vaccination rates during the 
questions here.
    With the distribution of vaccines underway, this phase also 
provides us an opportunity to evaluate what has transpired thus 
far. This time last year in States like Alaska and many other 
Tribal communities began to take stock of the necessary 
mitigation measures to slow the virus.
    And what some of us have long known, and others found out, 
is that in many remote villages basic sanitation infrastructure 
is almost nonexistent. And that means including funds for these 
communities to have access to running water was a priority in 
the COVID funding packages.
    And I hope that one of the lessons learned is that the 
development of more water and sanitation infrastructure, it 
must be both an administration as well as a congressional 
priority.
    Funding for these projects under the facilities 
construction account and the Annual Interior Appropriations 
Bill has always been a priority of mine. On April 9 the 
administration released a budget narrative that proposes a $2.2 
billion increase for the IHS. And while we are all eagerly 
awaiting the details on how the administration will propose to 
spend this funding, I will point out that this subcommittee has 
always worked well together in a bipartisan manner to address 
our shared Tribal priorities.
    We have had to work together to navigate the budget 
unpredictability surrounding the 105(l) issue, ensure staffing 
packages were fully funded, and address the overall needs of 
the entire health delivery system, while also taking into 
consideration administration and congressional interests.
    It is never easy, it is never quick, but we have been able 
to do it together. And as we look forward to fiscal year 2022, 
I do hope that we can continue this bipartisan tradition within 
our subcommittee.
    So, Mr. Chairman, I look forward to working with you and 
your team. And look forward to the comments from our witness 
today.
    Senator Merkley. Thank you very much. And congratulations 
to the Native Alaskan group that had 100 percent; which group 
was that again?
    Senator Murkowski. The Native Village of Mekoryuk.
    Senator Merkley. Mekoryuk, the Village of Mekoryuk, 
congratulations to them.
    Senator Murkowski. Nunivak Island.
    Senator Merkley. We are now going to turn to the testimony 
of the director, and that is Elizabeth Fowler, Director of the 
Indian Health Service. Welcome.
STATEMENT OF HON. ELIZABETH FOWLER, ACTING DIRECTOR
    Ms. Fowler. Good morning. Thank you. Good morning, Chairman 
Merkley, Vice Chairman Murkowski, and Members of the 
subcommittee.
    Thank you for the opportunity to testify on the Indian 
Health Service's continued efforts to respond to and mitigate 
the impact of coronavirus in American Indian and Alaska Native 
communities.
    Over the past year, IHS has worked closely with our Tribal 
and urban Indian organization partners, our State and local 
public health officials, and our fellow Federal agencies to 
coordinate a comprehensive public health response to the 
pandemic. Our number one priority has been the safety of our 
IHS patients and staff, as well as Tribal community members.
    I will begin by discussing efforts to distribute and 
administer vaccines. IHS, Tribal, and Urban Indian Health 
programs receiving vaccines for distribution through the IHS 
jurisdiction have administered over 1.2 million doses as of 
yesterday. This achievement is despite the challenges IHS faces 
in terms of the predominantly rural and remote locations we 
serve, and the infrastructure challenges those communities 
face.
    Since December 2020, the IHS has distributed over 1.6 
million vaccine doses of the FDA-authorized COVID-19 vaccines 
to 352 facilities that are coordinating vaccines through the 
IHS. The IHS is grateful to Congress for supporting our efforts 
through the passage of several COVID-19-related laws that 
provided additional resources, authorities and flexibilities 
that have helped the IHS to provide critical services 
throughout the pandemic.
    In particular, the American Rescue Plan Act makes an 
historic investment in Indian Country. The Act provides $6.1 
billion in new funding to support IHS, Tribal and Urban Indian 
Health programs to combat COVID-19, expand services and recover 
critical revenues.
    On April 16 the White House announced the initial 
allocation of $4.3 billion to IHS, Tribal and Urban Indian 
Health programs from this act.
    Over the last year, the IHS has marked considerable 
achievements. We have developed the COVID-19 data surveillance 
system, and the IHS COVID-19 website to share critical health 
information, as well as important COVID-19 vaccine information 
and updates.
    The IHS National Supply Service Center distributed over 84 
million units of personal protective equipment, and other 
coronavirus response-related products to IHS, Tribal and Urban 
Indian Health programs at no cost, including 2.6 million 
testing swabs and transport media. IHS dramatically increased 
our use of telehealth from an average of 1,300 visits per month 
in early 2020 to a peak of over 40,000 visits per month in June 
and July of that year.
    The pandemic also highlighted the challenges and risks 
posed by our current health IT system, which created 
significant barriers to the rapid response needed for COVID-19. 
This experience has reinforced IHS's commitment to the 
modernization of our health IT infrastructure, supporting 
Tribes to ensure they are able to supply water to their 
communities during the COVID-19 outbreak is also an important 
aspect of the IHS COVID-19 response.
    For example, the IHS deployed 19 of Public Health Service 
Commission Corps Officers in support of the Navajo Nation to 
improve access to safe water points.
    The pandemic highlighted the consequences of long-term 
underinvestment in the Indian Health Service. The fiscal year 
2022 President's budget provides an historic increase in annual 
appropriations of $2.2 billion, or 36 percent above fiscal year 
2021, to increase access to high-quality health care in Indian 
Country, and to begin remediating the impacts of chronic 
underfunding of the IHS.
    The budget also proposes advanced appropriations for the 
IHS to insulate health programs from the impact of government 
shutdowns, and the uncertainty of annual appropriations, and 
also commits to a robust, consultative process for Tribes and 
Urban Indian organizations to evaluate options, to provide 
adequate, stable and predictable funding for the IHS in the 
future.
    As we work towards recovery, we are committed to working 
closely with our stakeholders, and understand the importance of 
working with partners during this difficult time.
    Thank you again for the opportunity to speak with you 
today. And I am happy to answer any questions you may have.

    [The statement follows:]
              Prepared Statement of Hon. Elizabeth Fowler
    Good morning Chairman Merkley, Vice Chairman Murkowski, and Members 
of the Committee. Thank you for the opportunity to testify on the 
Indian Health Service's (IHS) continued efforts to respond to and 
mitigate the impact of the Coronavirus pandemic in American Indian and 
Alaska Native communities.
  responding to and mitigating the impact of the coronavirus pandemic
    Over the past year, the IHS has worked closely with our Tribal and 
Urban Indian Organization (UIO) partners, State and local public health 
officials, and our fellow Federal agencies to coordinate a 
comprehensive public health response to the pandemic. Our number one 
priority has been the safety of our IHS patients and staff, as well as 
Tribal community members.
    The IHS continues to play a central role as part of an all-of-
nation approach to prevent, detect, treat, and recover from the COVID-
19 pandemic. We are partnering with other Federal agencies, States, 
Tribes, Tribal organizations, UIOs, universities, and others to achieve 
that mission. We protect our workforce through education, training, and 
distribution of clinical guidance and personal protective equipment 
(PPE). We also protect our Tribal communities through supporting Tribal 
leaders in making their decisions about community mitigation strategies 
that are responsive to local conditions, and to protect the health and 
safety of Tribal citizens as those communities make plans to safely 
open and resume regular operations.
    While the Indian health system is large and complex, we realize 
that preventing, detecting, treating, and recovering from COVID-19 
requires local expertise. We continue to participate in regular 
conference calls with Tribal and UIO leaders from across the country to 
provide updates, answer questions, and hear their concerns. In 
addition, IHS engages in rapid Tribal Consultation and Urban Confer 
sessions in advance of distributing COVID-19 resources to ensure that 
funds meet the needs of Indian Country.
    I am grateful to Congress for supporting our efforts through the 
passage of the Coronavirus Preparedness and Response Supplemental 
Appropriations Act, 2020; the Families First Coronavirus Response Act; 
the Coronavirus Aid, Relief, and Economic Security (CARES) Act; the 
Paycheck Protection Program and Health Care Enhancement Act; the 
Coronavirus Response and Relief Supplemental Appropriations Act; and 
now the American Rescue Plan Act. These laws have provided additional 
resources, authorities, and flexibilities that have helped IHS, Tribal, 
and urban Indian health programs to continue providing critical 
services throughout the pandemic. Together, these Acts have permitted 
the IHS to administer over $9 billion to IHS, Tribal, and urban Indian 
health programs to prepare for and respond to Coronavirus. These 
resources have helped us expand vaccinations, testing, public health 
surveillance, and healthcare services. Moreover, they support the 
distribution of critical medical supplies and PPE in response to the 
pandemic. The American Rescue Plan Act in particular makes a historic 
investment in Indian Country. The Act provides approximately $6.1 
billion in new funding to support IHS, Tribal, and urban Indian health 
programs to combat COVID-19, expand services, and recover critical 
revenues.
    With the passage of each supplemental appropriation, the IHS 
conducted Tribal Consultation tribal consultation and Urban Confer to 
rapidly seek input from Tribal and Urban Indian Organization leaders. 
Their priorities and needs are the foundation for our allocation 
decisions. We have incorporated their requests for maximum flexibility 
to allow Tribal communities and Urban Indian Organizations to respond 
to the unique needs of the patients they serve, rapid funding 
distribution so that urgently needed resources available as soon as 
possible, and the use of existing funding methodologies and mechanisms 
into all of our decisionmaking.
    The IHS communicated all funding decisions through Dear Tribal and 
Urban Indian Organization Leader Letters, which are available on the 
IHS website. A comprehensive overview of all funding allocations to 
date is available at https://www.ihs.gov/sites/coronavirus/themes/
responsive2017/display_objects/documents/FY-2020-2021-COVID19-ARPA-
Funding-Summary.pdf.
    It has been over a year now that IHS and our dedicated workforce 
has been responding to the COVID-19 Pandemic. Over the last year, the 
IHS has marked considerable achievements. The IHS COVID-19 Incident 
Command Structure was created to establish communication protocols to 
ensure comprehensive situational awareness and efficient deployment of 
resources. We instituted reporting mechanisms to create a central 
information repository for the IHS COVID-19 response.
    We developed a COVID-19 data surveillance system and the IHS COVID-
19 website to share critical health information, important COVID-19 
vaccine information and updates, and we disseminate clinical guidance, 
training, and webinars. We provide assistance to the IHS and Tribal 
facilities through Critical Care Response Teams and Tele Infection 
Control Assessment and Response assessments.
    We are detecting COVID-19 through screening and state-of-the-art 
lab testing. We have distributed a total of 830 Abbott ID NOW rapid 
point-of-care analyzers, as well as 1.9 million rapid COVID-19 tests. 
The IHS National Supply Service Center (NSSC) has also distributed over 
84 million units of PPE and other Coronavirus response-related products 
to IHS, Tribal, and UIO (I/T/U) healthcare facilities at no cost, 
including 2.6 million testing swabs and transport media. As of April 
19, 2021, we have performed 2,278,275 tests in our American Indian and 
Alaska Native communities. Of those tests, 193,069 (8.5 percent, 
cumulative data) have been positive.
    The IHS increased coordination with Federal partners to streamline 
access for I/T/U supply requests to the Strategic National Stockpile. A 
PPE request tracking system was developed and IHS staff were placed in 
liaison functions to ensure oversight on I/T/U requests. The IHS burn 
rate calculator for tracking PPE has been implemented to improve the 
data quality. A guide on ordering/requests process for Emergency 
Management Points of Contact has been posted online for ongoing 
strategic purposes. NSSC has supplied testing kits in response to all 
Area requests, a new contract with Abbott ID has started and they are 
shipping directly to I/T/U sites.
    The IHS has a sufficient supply of therapeutic agents currently 
authorized or approved by the Food and Drug Administration (FDA) for 
the treatment of COVID-19, including Remdesivir and the combination 
monoclonal antibody products, and is distributing them to I/T/U 
healthcare facilities upon request. The IHS National Pharmacy and 
Therapeutics Committee provides clinical guidance to Areas and 
facilities regarding new treatments for COVID-19 and, through its 
Pharmacovigilance program, also monitors medication safety in our 
service population.
    During the pandemic, the IHS faced life-threatening medical surges 
that required additional acute care and Intensive Care Unit (ICU) beds. 
The IHS and U.S. Department of Veterans Affairs (VA), Veterans Health 
Administration, signed an Interagency Agreement that set forth terms 
and conditions governing the arrangement for the standardized 
coordination and delivery of healthcare and other services between VA 
and IHS during disasters, public health incidents, and other 
emergencies.
    We are treating each and every patient with culturally competent, 
patient-centered, relationship-based care. As we look to recover from 
COVID-19, the IHS is supporting the emotional well-being and mental 
health of its workforce and the communities we serve, by providing 
training, education, and access to treatment that draws from the faith 
and traditions of American Indians and Alaska Natives, as well as their 
long history of cultural resilience.
    In April 2020, IHS expanded the use of an Agency-wide video 
conferencing platform that allows for telehealth on almost any 
Internet-connected device and in any setting, including patients' 
homes. Around the same time IHS also permitted the emergency use of 
certain commonly available mobile apps to enable the provision of 
services remotely while minimizing exposure risk to both patients and 
staff. These actions, along with the actions taken by the Centers for 
Medicare and Medicaid Services to allow payment for previously non-
billable services, made it possible for IHS to dramatically increase 
our use of telehealth from an average of under 1,300 visits per month 
in early 2020 to a peak of over 40,000 per month in June and July of 
that year. More recent data suggests a plateau of around 30,000 monthly 
telehealth visits. It is important to note that on average, about 80 
percent of telehealth encounters across IHS are conducted using audio 
only, largely related to the limited availability of technologies and 
bandwidth capacity in the communities we serve across the country. IHS 
is currently in the process of procuring an additional cloud-based 
telehealth platform to complement our existing solutions and distribute 
telehealth funds to sites for equipment and devices to improve access 
for more interactive telehealth encounters.
                    ehr and facilities modernization
    As the IHS expands its use of technology to provide telehealth 
services, the pandemic also highlighted the challenges and risks posed 
by the decentralized and distributed health information technology 
architecture currently in use by the Agency. While our facilities use a 
capable, nationally-certified electronic health record (EHR) system, 
the fact that it is internally developed by IHS and is installed 
separately at hundreds of locations nationwide created significant 
barriers to the rapid response needed for COVID-19. We are extremely 
proud of how our informatics and technology staff made changes to the 
system to support COVID-19 testing, diagnosis, and vaccination 
documentation and reporting, and how the field was able to implement 
these changes into clinical workflows. However, we know that those 
activities would have been much more streamlined in an updated 
technology environment.
    This experience has validated and reinforced IHS' commitment to the 
modernization of our EHR system and health information technology 
infrastructure. The funding for EHR modernization provided by Congress 
in the CARES Act, the fiscal year 2021 appropriation, and the American 
Rescue Plan Act will allow us to proceed with the foundational steps in 
this important multi-year effort. In accordance with the language of 
the fiscal year 2021 appropriation, IHS plans to inform the appropriate 
Congressional committees in the near future of the outline for our 
planned approach to EHR modernization.
    The IHS experience with its EHR system underscores issues related 
to infrastructure modernization, more generally. Aging medical 
facilities can impede medical innovation. Modern hospitals have complex 
equipment with high electrical requirements. Contemporary hospitals are 
designed to provide clean, reliable power to ensure that patient care 
is uninterrupted. The difficulty in retrofitting older hospitals with 
modern technology includes the lack of equipment space, inadequate 
power, and lack of cooling capacity, all of which represent a 
significant challenge to technology infrastructure upgrades.
    In addition, the pandemic highlighted challenges that some older 
facilities pose to delivering healthcare services. It is the IHS' 
policy to use the physical environment to help prevent and control the 
spread of infection. This past year has shown that some facilities' 
patient flow often did not allow for social separation and that waiting 
areas are not sized or structured for social distancing. Optimally, 
infected and non-infected patients would be separated, and patients 
would flow in one direction through the facility. This is not possible 
in some IHS facilities, which resulted in limiting appointments, 
renovation of space, or providing temporary space outside of the 
facility to separate patients.
              vaccinations--allocations and administration
    IHS developed a vaccine strategy led by the IHS Incident Command 
Structure and the designated IHS Vaccine Task Force. This effort was 
informed by the Federal Vaccine Response Operation (FVRO) and aligned 
with the Centers for Disease Control and Prevention (CDC), FVRO, and 
Tribal stakeholder input. HHS and IHS participated in Tribal 
Consultation and Urban Indian Confer in development of the plan, and a 
final IHS Vaccine Plan was published on November 18, 2020.
    Working with Tribal communities, I/T/U health programs receiving 
vaccines for distribution through the IHS have administered 1,164,179 
doses as of April 19, 2021. This achievement is despite the challenges 
IHS faces in terms of the predominantly rural and remote locations we 
serve and the infrastructure challenges those communities face. The IHS 
reached its goal to administer 1 million COVID-19 vaccines by the end 
of March (administering 1,007,002 doses as of March 31, 2021) after 
surpassing its goal of administering 400,000 vaccines by the end of 
February 2021. The IHS now aims to have 44 percent of its adult 
patients fully vaccinated by the end of April 2021. As of April 19 
2021, 37.9 percent of IHS adult patient population are fully 
vaccinated.
    In February and March, 260,000 supplemental vaccine doses were sent 
to Indian Country. IHS remains committed to vaccine availability for 
all individuals within our healthcare system. This Federal vaccination 
effort is possible because of strong partnerships with Tribal and Urban 
Indian health facilities, and the resources provided by Congress. At 
IHS, we know that Tribal Nations are in the best position to determine 
the needs of their citizens.
    Information on the number of COVID-19 vaccines administered across 
the IHS can be found at https://covid.cdc.gov/covid-data-tracker/
#vaccinations, displayed in the Federal Entities section under the map. 
The IHS is working diligently with our CDC partners to report and 
validate vaccine administration data as quickly as possible. IHS 
estimates the current number of people vaccinated may be higher than 
reflected in the validated data on the CDC COVID Tracker. Communicating 
accurate and timely information remains a priority for the IHS.
    Since mid-December 2020, the IHS has distributed 1,661,085 vaccine 
doses of the FDA-authorized Pfizer-BioNTech, Moderna, and Johnson & 
Johnson/Janssen COVID-19 vaccines. IHS has shipped vaccines directly to 
295 I/T/U facilities and used a hub and spoke model to ensure all 352 
facilities that are coordinating vaccines through the IHS receive 
vaccines. The table below shows the total number of vaccine doses 
distributed and administered per IHS Area as of April 19, 2021. Based 
on guidance from the FDA and CDC, the IHS paused administration of the 
Johnson & Johnson/Janssen vaccine from April 13-24, 2021. The IHS 
resumed administering the Johnson & Johnson/Janssen vaccine now that 
the FDA and CDC has issued guidance lifting the temporary pause.

                          COVID-19 VACCINE DISTRIBUTION AND ADMINISTRATION BY IHS AREA
----------------------------------------------------------------------------------------------------------------
                                                                                   Total Doses     Total Doses
                                      Area                                        Distributed *  Administered **
----------------------------------------------------------------------------------------------------------------
Albuquerque.....................................................................        114,955         106,747
Bemidji.........................................................................        138,525          99,545
Billings........................................................................         56,355          36,067
California......................................................................        210,695         106,935
Great Plains....................................................................        119,470          69,172
Nashville.......................................................................         78,935          54,002
Navajo..........................................................................        247,165         192,927
Oklahoma City...................................................................        438,790         308,411
Phoenix.........................................................................        162,740         120,010
Portland........................................................................         83,255          62,243
Tucson..........................................................................         10,200           8,120
                                                                                 -------------------------------
    Total.......................................................................      1,661,085       1,164,179
----------------------------------------------------------------------------------------------------------------
* Distributed Data Source: IHS National Supply Service Center, includes total doses ordered and anticipated to
  be delivered by April 19, 2021.
** Administered Data Source: CDC Clearinghouse data from Vaccine Administration Management System (VAMS) and IHS
  Central Aggregator Service (CAS). Data in the CDC Clearinghouse reflects prior day data. Data may be different
  than actual data as there are known CDC data lags and ongoing quality review of data including resolving data
  errors.
Note: Alaska Area--all tribes chose to receive COVID-19 vaccine from the State of Alaska.


    COVID-19 related data are reported from I/T/U facilities, though 
reporting by Tribal and UIOs is voluntary. The table below shows the 
number of cases reported to the IHS through 11:59 p.m. on April 19, 
2021.

                                           COVID-19 CASES BY IHS AREA
----------------------------------------------------------------------------------------------------------------
                                                                                    Cumulative     7-Day Rolling
            IHS Area                  Tested         Positive        Negative         Percent         Average
                                                                                    Positive *     Positivity *
----------------------------------------------------------------------------------------------------------------
Alaska..........................         581,472          11,810         495,810            2.3%            1.2%
Albuquerque.....................          92,911           8,137          63,865           11.3%            4.0%
Bemidji.........................         159,652          11,101         145,164            7.1%            5.8%
Billings........................          97,531           7,373          86,921            7.8%            0.6%
California......................          78,810           7,872          67,782           10.4%            4.1%
Great Plains....................         141,781          14,236         127,018           10.1%            3.2%
Nashville.......................          76,141           6,082          69,190            8.1%            4.5%
Navajo..........................         244,452          31,579         167,889           15.8%            3.2%
Oklahoma City...................         486,290          60,493         420,710           12.6%            2.4%
Phoenix.........................         177,443          23,773         152,820           13.5%            4.3%
Portland........................         115,692           7,848         107,383            6.8%            5.9%
Tucson..........................          26,100           2,765          23,181           10.7%            2.0%
                                 -------------------------------------------------------------------------------
    Total.......................       2,278,275         193,069       1,927,733            9.1%            3.5%
----------------------------------------------------------------------------------------------------------------
* Cumulative percent positive and 7-day rolling average positivity are updated three days per week.

                         access to clean water
    Supporting Tribes to ensure they are able to supply safe water to 
their communities during the COVID-19 outbreak is an important aspect 
of the IHS COVID-19 response. Access to water is critical for hand 
washing and cleaning environmental surfaces to help break the virus' 
chain of infection and reduce the pressure on the IHS healthcare 
delivery system, which is a critical concern.
    To address this concern, the IHS over the past year deployed nine 
teams of 40 U.S. Public Health Service Commissioned Corps Officers in 
support of the Navajo Nation to improve access to safe water points. 
This work included surveying the availability of safe water points 
across 110 Chapters over 27,000 square miles. The survey identified 59 
locations where additional water points were needed. Following the 
survey, the teams completed water points site installation designs, 
construction/beneficial use inspections, and operation and maintenance 
trainings at these locations. The installation of these water points 
resulted in a reduction in round trip travel distance from 52 miles to 
17 miles and was completed within 6 months.
    In addition to increasing the number of water points, the mission 
helped ensure a means to safely transport water for in-home drinking 
and cooking. This was achieved by providing 107 Navajo Chapters over 
37,000 water storage containers to be distributed to each resident 
living in a home with no piped water. Water disinfection tablets, to 
boost water disinfection levels in the water storage containers, were 
also provided to Chapters as needed based on the field team measured 
water point disinfection levels. These innovative actions will help to 
improve the stored water quality and reduce the risk of 
gastrointestinal illness among water point users.
    The teams also worked to increase public awareness of water service 
availability and developed creative public health outreach materials 
describing the importance of the water service use through a multimedia 
campaign (online, print newspaper, and radio) broadcast across the 
Navajo Nation. This included assisting the Navajo Nation in developing 
a website, which includes an interactive map of the water points, to 
communicate the location, hours of operation, and Chapter contact 
information. Officers developed outreach materials highlighting the 
importance of accessing water at regulated water points and promotion 
of safe water storage practices.
                  fiscal year 2022 president's budget
    On March 31, 2021, the White House released the President's Fiscal 
Year 2022 Discretionary Request, which includes $8.5 billion in 
discretionary budget authority for the IHS. This funding level is a 
historic increase of $2.2 billion or 36 percent over fiscal year 2021. 
These funds will increase access to high-quality healthcare in Indian 
Country, and begin to remediate the impacts of chronic underfunding of 
the IHS.
    The Discretionary Request also proposes advance appropriations for 
the IHS to insulate the I/T/U health programs from the impact of 
government shutdowns, and the uncertainty of annual appropriations.
    I look forward to participating in the robust Tribal Consultation 
and Urban Confer to evaluate options, including mandatory funding, to 
provide adequate, stable, and predictable funding for IHS in the 
future. This Tribal consultation process is an important step in 
honoring our government's responsibility to American Indian and Alaska 
Native people.
    These proposals align with feedback from Tribal and UIO leaders. 
The Fiscal Year 2022 Tribal Budget Recommendation included a proposal 
for advance appropriation and a dramatic funding increase for the IHS.
    We look forward to continuing our work with Tribal and Federal 
partners. As we work towards recovery, we are committed to working 
closely with our stakeholders and understand the importance of working 
with partners during this difficult time. We strongly encourage 
everyone to continue to follow CDC guidelines and instructions from 
their local, state, and Tribal governments to prevent the spread of 
COVID-19 and protect the health and safety of our communities. Thank 
you again for the opportunity to speak with you today.

       MOST EFFECTIVE VACCINATION STRATEGIES FOR NATIVE AMERICANS

    Senator Merkley. Thank you very much Director Fowler. And 
you mentioned quite a bit about vaccinations, but I wanted to 
start there.
    I believe the latest report is that 38 percent of the 
Native Americans are fully vaccinated, and 50 percent have at 
least one dose, which is ahead of the general population of the 
United States, 30 percent for the general population, fully 
vaccinated and 41 percent, at least one dose.
    In your written testimony, you noted that you would like--
the goal is to get to 44 percent by the end of April. We are 
almost there. But I wanted to ask you a couple of things. One 
is, in the $2.3 billion that was allocated was it--did the 
formula work in a way that you were rapidly able to get the 
money into the hands of the various Tribal entities?
    Have you faced issues of publicity and solve them, if you 
will, vaccine resistance? What were the strategies that were 
most effective? When you look at the individual Tribal groups 
that have been highly successful, what was the--what magic 
element did they bring to it? Are those lessons being shared 
with other Tribal groups?
    Ms. Fowler. Okay. Let me start by saying a little bit about 
the allocation process, since you mentioned that to begin with. 
I think we were successful in getting the funds out quickly. We 
did conduct consultation--Tribal Consultation and Urban Confer 
on all of the COVID supplemental funding that we received 
regarding the distribution methods to use.
    And the common themes throughout were to use existing 
allocation methods that were not--that did not--that were not 
burdensome to either the Tribe or the Indian Health Service. 
And so, in doing so, being able to use our existing allocation 
methods learnt that, you were able to get the funds out fairly 
quickly, as soon as they were available to us to allocate them. 
And so I think that is something that we have been able to be 
responsive to our Consultation and Confer.
    And I think that you are right, that while the COVID 
pandemic has highlighted challenges for the Indian Health 
Service, it has also highlighted our strengths, which are best 
seen through the vaccination efforts.
    Our goal is to fully vaccinate 44 percent of our active 
adult patient population by the end of April, which is Friday. 
And we are closely watching it, we think that we are going to 
be very close to achieving it, even if we do not, we are at a 
point now where, as you mentioned, I think we are now at 39 
percent of adults fully vaccinated.
    I think some common factors in the locations that have been 
very successful in the vaccination effort are the Tribes being 
able to have the flexibility to make the decisions locally. I 
think that was a primary factor in the success of--in those 
locations.

             NATIVE AMERICANS COVID-RELATED MORTALITY RATE

    And I also think that vaccinations and the focus--the 
public health measure of vaccinations is something that IHS has 
been doing for years. And I think that is really why it has 
been successful for us. I think that we know our patient 
population, the patient population knows us, they know how to 
access care within Indian Health Service, and I think that all 
of that together is what has led to the successes that we have 
seen in the vaccination efforts in Indian Country.
    Senator Merkley. All right. Thank you. When I look at the 
success on vaccinations, we also are looking at the flip side 
of the mortality being twice as high for Native Americans as 
non-Native populations. How much of that is driven by higher 
infection rates? And how much is driven by higher risk factors, 
like diabetes, obesity, cardiovascular disease, and so forth 
that reflected a broader set of health challenges?
    Ms. Fowler. I do not think that I can give you a specific 
breakdown, but definitely the underlying, morbidity and health 
issues experienced, and health disparities experienced within 
the American Indian and Alaskan Native population are our 
primary factors in their vulnerability to the coronavirus 
infection. Certainly, I can take that back and see if we have 
any specifics that we can provide you in follow up.
    Senator Merkley. Thank you very much. And let me turn this 
over to my colleague.
    Senator Murkowski. Thank you, Mr. Chairman.

                        IHS DIRECTOR NOMINATION

    So I mentioned in my opening statement, my request or hope 
that we are going to see an IHS director nominated quickly. Do 
you have any sense on where the administration is right now in 
terms of nomination for the IHS director?
    Ms. Fowler. No. I am sorry. I am not aware that there is a 
nominee as of yet, and I do not have any additional information 
about that at this time.
    Senator Murkowski. Okay. Well, I am sure that they are--
they are paying attention to this morning's hearing too. So 
hopefully they get the message. I think--I think folks 
understand how important it is to have somebody at the head of 
the agency, particularly as we are looking to, significant 
rollout of Federal dollars.
    And I want to turn to that right now. I mentioned IHS has 
received approximately $9 billion over all the various COVID 
funding packages, funds have been provided for testing, 
vaccine, protective equipment, facilities, potable water, 
mobile units, telehealth, and then most recently lost revenue.
    Can you give me some kind of a sense, and in where and what 
activities have received most of the funding? And I do not--I 
do not need you to be really detailed. Basically, you have got 
three buckets, three categories. You know, for instance does 
one-third go to telehealth, one-third to testing. Can you--can 
you give me a sense in terms of the broader parameters of where 
this funding over the past year and several months has ended 
up?

                           IHS COVID FUNDING

    Ms. Fowler. I can certainly, in follow up, provide you 
those details. But just now my overall sense is that most of 
funding, or a significant portion has been for testing with 
some funds available for vaccines more recently. And then I 
think the--I think vaccinations and PPE would be the next 
largest category, and then following that would be 
infrastructure items.
    Senator Murkowski. So given--given that and the amount of 
investment that we have seen, are there still areas, some gaps 
that require additional funding that are not covered in the 
annual appropriations bills. Because we are looking to make 
sure that, that not only we are being responsive to COVID----
    It feels like an earthquake, I am just saying. We had a big 
one in Alaska yesterday, but we do not get a lot of earthquakes 
here. Sorry for that distraction.
    So is there--is there--are there areas where you are 
looking at and saying we need to be doing more, even 
recognizing where the allocations have been in the past year or 
so?
    Ms. Fowler. So I would say that what we have heard from 
Tribes is the need for more funding for Sanitation Facilities 
Construction.
    Senator Murkowski. Right.
    Ms. Fowler. If there--if there is any gap, I think that 
would be the area that we have heard the most about.

          THE PANDEMIC'S IMPACT ON SUICIDES AND DRUG OVERDOSES

    Senator Murkowski. Great. Thank you for that. One of the 
things that I have been trying to better understand is, you 
know, the first--the first impact from COVID was health and 
healthcare, making sure you had ventilators, making sure you 
had PPP, making sure that we had the testing. Then we had the 
economic impact from COVID when businesses were closed down and 
basically, people just went inside.
    But I think we have got a third wave coming at us as a 
follow on from COVID. And I think that is going to be kind of 
the lingering impact, and the stress on individuals' mental 
health and behavioral health issues.
    Can you speak as to what we are seeing within IHS relating 
to suicides, drug overdoses that might be related back to 
isolation, or quarantining, and are we--are we doing right by 
the funding that would be needed and necessary to address some 
of these issues?
    Ms. Fowler. So, again, I do not have specific statistics 
for you right now, but we can provide those on follow up. 
Anecdotally, we have heard a lot about the impact of the 
isolation of--you know, in remote locations, or reservation 
areas in Indian communities that are already remote, the need, 
for those reservations that shut down during the pandemic, it 
was particularly difficult for the--for the youth, and others 
on those reservations.
    We have been very pleased, however, that there was 120 
million that was appropriated and included in the American 
Rescue Plan Act funds. And, yeah, I think that will be helpful 
in starting to address some of these needs. And I think our 
experience is probably going to be similar to the larger 
population in the United States in terms of the impacts in the 
behavioral health, and the need for additional supports.
    We know from even within the staff the more--in the Indian 
Health System, they are resilient, but we know that they are 
tired. But really of how hard they have had to work this past 
year on this wide issue. And so we are acutely aware of the 
need to focus on behavioral health issues, especially those 
that are stemming and becoming worse during this pandemic.
    Senator Murkowski. Thank you for that. And I know we will 
be monitoring this with you. So as you--as you start to see 
data coming in, I think that would be helpful for us here at 
the subcommittee. Thank you, Ms. Fowler.
    Thanks, Mr. Chairman.
    Senator Merkley. Senator Tester.
    Senator Tester. Thank you, Chairman Merkley, and Ranking 
Member Murkowski.
    Interestingly enough, before, you started speaking, Senator 
Murkowski, I had talked to my staff about sending a letter off 
to find out where we were for an IHS director. If you and the 
Chairman, or the Chairman and you would like to send off a 
letter to Becerra, I would be more than happy to sign it, to 
ask them where they are at in the process, because we think it 
is really important we get a confirmed leader heading IHS, I 
really do. So count me in if that is something you guys want to 
do.
    First of all, thank you guys for your testimony. We 
appreciate you--appreciate your being here. I do not think this 
was an issue that is specific to Montana, but I am going to use 
the Fort Peck Indian reservation as an example.
    The Tribal leaders up there that tell me that the number 
one barrier to vaccination and getting more community members 
vaccinated is capacity.
    We all know there is a public health shortage and in IHS, 
we all know that there is public health shortage across the 
country, but we all know that vaccines at IHS facilities are an 
issue that has gone on much longer than this pandemic.
    IHS has said that they would be able to provide special and 
local salary rates to potential providers, and it would be key 
to recruiting and actually retaining providers. By the way, 
that is correct.
    But the GAO reported in 2018 that IHS had only created 
seven national and two local pay tables. And the reason why is 
because only one person at IHS had the experience to develop 
this critical tool for recruitment and retention.
    So my question for either Elizabeth or for Jillian is, has 
IHS created additional special or local pay table since that 
2018 GAO report?

            IHS LOCAL PAY TABLES AND RECRUITMENT INCENTIVES

    Ms. Fowler. Yes, we have. I do not have the specific 
numbers, but we have done so.
    Senator Tester. And do you believe that the pay tables that 
have been enacted since 2018 are adequate? Or do you anticipate 
enacting more special pay tables?
    Ms. Fowler. I believe we have more in the process.
    Senator Tester. What's that now? What did you say?
    Ms. Fowler. Yes. I believe we have more in process.
    Senator Tester. Okay. Okay.
    Ms. Fowler. More than have been--and more that have been 
identified as needed.
    Senator Tester. Okay. Are there any other recruitment 
incentives or benefits that would attract more folks to work at 
IHS that come to mind?
    Ms. Fowler. Well, of course our Loan Repayment Program has 
been successful in addressing--in helping us to address 
recruitment needs. We passed--President's budget requests have 
focused on some additional Title 38 authorities that would be 
helpful to us, including the ability to provide more benefits, 
to provide--the ability to provide scholarship and loan 
repayment recipients so they pay back, yes.
    Senator Tester. But nothing additional. You think you have 
got the tools there to be able to recruit and retain folks 
within IHS. Because this has been a problem, it truly has been 
a problem.

                 ELECTRONIC HEALTH RECORD MODERNIZATION

    Ms. Fowler. Well, we have--we have tools--we have proposed 
additional tools that we have not yet received.
    Senator Tester. Okay. Okay, I would like--if you could get 
me those. You do not have to tell me now, but give me those 
additional tools, I would love to have them. In fact, give them 
to the subcommittee, I think we would all love to have them.
    So I want to talk about electronic health records (EHRs). 
The IHS system is badly outdated. I have got tribal leaders 
from Montana that can't access patient health records from 5 
years ago. Congress appropriated $65 million in the CARES Act, 
and another $140 million in the American Rescue Plan to 
modernize those IHS electronic health record systems. Do you 
know if that--do you know if that modernization is in process, 
as we speak?
    Ms. Fowler. The project has begun, has been initiated, and 
it is both----
    Senator Tester. When was----
    Ms. Fowler [continuing]. Multi-year, multi-million-dollar 
projects.
    Senator Tester. Yes. When was it initiated?
    Ms. Fowler. We have--we have been performing--conducting 
Tribal consultation over the last year. We just began our 
project management office, and the CARES Act training allowed 
us to do that.
    Senator Tester. Have you picked a--have you picked a 
program--a program provider yet?
    Ms. Fowler. No. The project management office that we have 
just set up, that work will be given over the next few months 
to start that acquisition strategy process.
    Senator Tester. So I only have one recommendation, and this 
is an important recommendation. As the Chairman of the 
Veteran's Affairs Committee, we have been working on electronic 
health records for a long time. By the way, we are not where we 
need to be in the VA either. They have Cerner as their provider 
for the electronic health record.
    I would recommend that you make sure that whoever you pick, 
they can communicate with Cerner and others, make sure that is 
the case. There are a lot of veterans that are Native 
Americans, and this information needs to be transferred and 
transferred smoothly. If we have silos of electronic medical--
medical records we have not done justice to anybody in this 
country. So we need to make sure that there can be 
communication between--between those programs.
    With that, thank you, Mr. Chairman.
    Senator Merkley. Thank you very much, Senator Tester.
    And I will just note in follow up that there was a 2018 GAO 
report related to the vacancies in the system that found that 
IHS had 25 percent vacancies overall, and 13 to--it varied from 
13 to 31 percent, depending on the region. And the highest 
regions were the Billings region, of course, Montana being 
affected, and the Navajo region.
    So, Director Fowler, I will not ask you to respond now, but 
if you could give us a follow up to this hearing that gives the 
current numbers, and how the recommendations of the GAO report 
have been implemented, or not implemented, and what was 
successful, that would be helpful. And I want to make sure that 
we get that information to Senator Tester.
    Senator Tester. Thank you, Mr. Chairman.
    Senator Merkley. We are going back and forth between, 
Republicans and Democrats by seniority, but we do not have any 
Republicans waiting right now. So we are going to turn to 
Senator Van Hollen.
    Senator Van Hollen. Thank you, Mr. Chairman, and Ranking 
Member. And I want to thank, Acting Director Fowler and Ms. 
Curtis for your service and your testimony today.
    As we have seen, Native peoples have been particularly hard 
hit by COVID-19, and have faced the highest risks of 
hospitalization and death from this virus. The majority of 
Native peoples, 70 percent live in urban areas, but the Urban 
Indian Health Program comprises only 1 percent of IHS's overall 
budget, and has faced chronic underfunding over the years.

              COVID-19 IMPACT ON URBAN NATIVE POPULATIONS

    I was pleased to see that IHS teamed up with the Native 
American LifeLines of Baltimore and the University of Maryland, 
Baltimore, to set up COVID-19 vaccine appointments devoted to 
Tribal members and families earlier this month. We wish it had 
been sooner, but we are glad that this has happened.
    Ensuring equitable access to care has been an ongoing 
challenge for our country, both during and before the pandemic. 
Can you talk briefly about the unique challenges that IHS has 
faced in supporting Urban Native populations during this 
pandemic?
    Ms. Fowler. Sure. We have 41 Urban Indian Health programs, 
not all of those provide clinical services. There are several 
that only provide outreach and referral. So we have locations 
where we have urban programs, such as Baltimore, for example, 
that because they do not provide clinical services, they were 
not positioned to deliver vaccinations to the population there. 
So we have those situations.
    We also have from a prior report on unmet needs for Urban 
Indian programs. We also know that there are 17 cities 
throughout the--throughout the United States that have a large 
enough Native population to support an Urban Indian program, 
but for which there is no such program there currently. And so 
the pandemic has definitely highlighted the fact that we have a 
fairly large population who reside within these urban areas who 
do not have access to the clinical services that are available 
on reservations and in Indian communities.
    And so our area offices have worked to--in some cases--to 
partner with organizations, to try to deliver services in those 
areas. It has not always been successful. I mean, without--
without a clinical program, without the EHR, without the 
patient registration, and everything, all of the infrastructure 
that supports providing healthcare delivery, it is very 
difficult to set up those types of services.
    But in some locations they have been successful, and we 
would be happy to provide more of an overview and more details 
to you and follow up.
    Senator Van Hollen. I appreciate it. And that would be--
that would be great if you could do that. I mean, based on your 
response, it sounds like you would agree that this is an area 
that has been overlooked, at least in terms of resources, 
right?
    Given the size of the Native populations in urban areas 
over 70 percent, it seems to me that we need to be increasing 
our capacity to serve those communities. Would you agree with 
that assessment?
    Ms. Fowler. I would agree, but with one caveat, that we do 
have several IHS and Tribal health programs that are located in 
urban areas as well. And so there are Natives in urban areas 
able to receive services through these IHS and Tribal programs, 
but they are not entirely reliant on the Urban Indian again.
    Senator Van Hollen. But there are--I think you indicated 
that there are many places in the country, where you have 
Native populations where you have not been able to set up these 
programs. Is that correct?
    Ms. Fowler. Yes. Correct.
    Senator Van Hollen. Well, listen, I do want to work with 
you and your team on these issues to try to beef up our 
capacity to provide services in urban areas. Thank you very 
much.
    Thank you, Mr. Chairman.
    Senator Merkley. Thank you very much.
    And Senator Martin Heinrich is next.
    Senator Heinrich. Thank you, Chairman.
    I want to start by thanking Senator Tester for bringing up 
the vacancy rates. So I will forego my question on that, but I 
think it is a particularly concerning state of affairs at the 
moment, and turn to the digital divide.
    You know, this pandemic has really highlighted for the 
world the immense digital divide among rural tribal 
communities. Access to high-speed Internet has become really 
essential for health and wellbeing.

                        BARRIERS TO TELEMEDICINE

    And unfortunately in too many Tribal communities, in my 
State and across the west, they do not have that connection. 
Over the past year, I want to ask, what barriers have you seen 
in access to telemedicine, in particular for Tribal 
communities? Have you been able to address these barriers? And 
what investments do we need to make in order to make 
telemedicine within the grasp of Tribal communities across the 
country?
    Ms. Fowler. Well, thank you for the question. Because we 
have seen the various types of needs for telehealth during this 
pandemic, definitely broadband, I will have to say is one of 
the barriers to telehealth, but that is not universal. There 
are some very remote locations where that is the major barrier, 
but in other locations the need has been more along the lines 
of equipment, the ability to purchase licenses, and so we have 
received funding through the COVID supplementals for telehealth 
for those types of costs. And it has been very helpful to us in 
expanding telehealth during this pandemic.
    I would say that initially our assumption at the 
headquarters' level was that the need for telehealth would be 
more focused on being able to provide specialty, acute 
consultative services, and acute care consultation services for 
our hospitals for COVID patients. And as it turned out, as we--
as the pandemic--as we went through the pandemic what we 
learned from our Tribes and our Urban Indian organization 
partners was that the focus was more on the infrastructure for 
telehealth, and those needs, rather than the ability to access 
those critical care specialty supports.
    Senator Heinrich. Mr. Chairman, I would point out, you 
know, I have literally seen people on the cable shows 
questioning whether broadband is infrastructure. And when you 
see high school kids gathered around the Tribal community 
center or a library, just to be able to get the bandwidth to be 
able to do their homework, it becomes immediately evident that 
this is the infrastructure of our time.
    And it is something that we need to make accessible to 
first Americans, and really all Americans. As many folks know, 
IHS keeps a list of sanitation deficiencies among Tribal homes 
and communities. And according to the IHS's 2019 report on 
sanitation deficiency levels, over half-a-million homes, over 
half-a-million homes on Tribal lands need sanitation facility 
improvements.
    On the Navajo Nation alone, roughly 30 percent of residents 
live without access to running water or adequate plumbing. And 
New Mexico has over $160 million of deferred maintenance on 
this list.
    The pandemic really highlighted the role that that plays, 
the increased need for Federal investment in basic Tribal 
public health infrastructure. And recent studies around COVID-
19 found that infections among Tribal communities show that 
cases were upwards of 10 times more likely in homes without 
indoor plumbing.
    Can you tell us? What would it take to provide clean 
drinking water to every single family living in Tribal 
communities?

     COST TO PROVIDE ACCESS TO CLEAN DRINKING WATER FOR ALL TRIBAL 
                              COMMUNITIES

    Ms. Fowler. Well, as you referred to our sanitation 
deficiency list, we currently have almost $1 billion worth of 
projects that are considered economically feasible. But when 
you include those that are not economically feasible, that list 
rises to $3 billion worth of projects.
    Senator Heinrich. Mr. Chairman, I would--my time is up. But 
as we have a conversation around infrastructure, we oftentimes 
have the conversation about rebuilding infrastructure. This 
infrastructure was never created in those cases. And, certainly 
if we are going to pass a major infrastructure bill, this 
should be a focus.
    Senator Merkley. Thank you very much. And I certainly agree 
with you that both broadband and water infrastructure are 
absolutely essential and desperately need to be improved, 
expanded, provided in Indian Country.
    I want to turn now to the issue of mental health. This last 
year, the year of COVID has put extraordinary stresses on 
everyone, but often that is magnified with our young folks, and 
in our Native American schools, we have many individuals who 
have suffered from historical trauma who may already struggle 
with mental and behavioral issues, and then comes along the 
COVID year, accentuating all of the related stress.

                  SCHOOL-BASED MENTAL HEALTH SERVICES

    Can you share with us what the Indian Health Service has 
done to help provide enhanced mental health services during 
this year at schools? And, in many cases, where schools have 
been shut down and students have been sent home and are 
operating often on the Internet, or perhaps not operating all, 
how you have provided mental health support to those students 
who have--who have been sent home?
    And I just want to note that I ask this question in the 
context of a Chemawa School in Oregon, which I have visited a 
number of times, and I know how important this type of support 
is for the success of the students.
    Ms. Fowler. Yes. So we have been working with the Bureau of 
Indian Education, collaborating with them, but one of the 
activities, in particular, that we have been engaged in is 
ensuring that students who have been working, I mean, their 
schooling from home have access to the entire behavioral health 
services.
    And, in particular, there at Chemawa, we have worked very 
hard to ensure that students had access to those services. 
While they are on campus, we have our Western Oregon Service 
Unit located right next door, and we have a space within the 
school to provide services, but since they are not on campus, 
we knew that was an important support for the students. And so 
that has been one of our major support activities for them.

                    RELEASE OF THE WEBER CASE REPORT

    Senator Merkley. Have you been able to hire additional 
mental health counselor or additional counselors who have 
proactively reached out to those students off campus to check 
in on them, and see if they have needs that need to be met?
    Ms. Fowler. I do not know about whether we have been able 
to hire additional counselors at this point. I think that the 
funding that we just received through the American Rescue Plan 
Act will definitely be helpful in that regard. We have 
performed outreach. I just--we have done over 250 proactive 
calls and assessments for students, but I think in the follow 
up I can provide you a better list and description of the 
specifics that we have been able to do to support students.
    Senator Merkley. Okay, thanks. Thank you. That is certainly 
an area I want to continue to follow up on. And particularly in 
light of the difficulty IHS has had in filling many positions, 
and the shortage of counselors across the Nation, I want to 
understand just exactly how much challenge is faced in having 
the proper mental health support.
    I want to turn to a case, the Weber case. And this is a 
case in which a pediatrician, hired by IHS, abused children, 
and when it became apparent of what he was doing, he was 
transferred rather than fired, and continued the abuse for more 
than a decade more after. There was a report that has been 
produced on that, and it has not yet been made public. Are you 
preparing to make it public? And when will that happen?
    Ms. Fowler. At this point in time the report has been not 
released, because it falls under medical quality assurance 
protection. We do have some ongoing litigation regarding that 
particular report however, and so I am not able to speak too 
much about it, but that is the reason it has not been released 
as of yet.
    Senator Merkley. Okay. I am going to press this issue, 
because I am not yet satisfied that there are reasons not to 
release the report if sensitive information has to be redacted, 
that can be done. But it is transparency is so important in 
these situations.
    And it is not just about this case. The other follow up I 
want to pursue is to what degree IHS has conducted, recognizing 
that this happened in this case, has conducted an extensive 
review to investigate whether there are other similar cases; 
whether it has been abuse, where individuals who have been 
transferred, who have for repeated abuse, because it is--we 
have such a high responsibility to protect our children.
    And this is certainly--appears to be an egregious example, 
but it may not be the only one. And the only way to address 
this is complete and absolute transparency, and a set of 
recommendations and thorough implementation of those 
recommendations.
    Have you done, has IHS done a thorough investigation of its 
entire agency to determine the extent of the challenge beyond a 
single case and developed a set of recommendations? And has it 
implemented those recommendations?

                    RECOMMENDATIONS FROM WEBER CASE

    Ms. Fowler. So part of the report that you just referenced, 
the review that was conducted that resulted in the report 
included a review, going back decades, to identify whether 
there were similar cases to the Dr. Weber case. So we have done 
that review.
    We continue to--you know, we have made several changes in 
response to what happened in that situation. We have updated 
policies. We have mandated training. We have created a national 
compliance program. We have created a Quality Assurance Risk 
Management Committee at the highest levels at headquarters, to 
ensure that reporting is--that senior leaders are aware of 
those types of incidents so that we can act upon them as 
quickly as possible. We have created a specific website, and a 
specific toll-free number for reporting sexual abuse and other 
types of abuses specifically.
    So it has been--it is a serious issue. We want to make sure 
that anyone that engages in that behavior is held accountable 
for it. And we believe that we have some monitoring processes 
in place now that would not allow it to happen today.
    Senator Merkley. Okay. I am--I am going to press for 
release of the report and its recommendations. I cannot see any 
reason for that. And I will ask for a follow up showing what--
what those recommendations were and how you have implemented 
them. But I think--I know that organizations are resistant to 
release information that may not look good, but the only way to 
make the future better is to face it fully on, disclose it, and 
disclose what has done, and to have a follow up to make sure 
that the new measures are working effectively.
    Let me turn this over to our Co-Chair.
    Senator Murkowski. Thank you. Thank you, Mr. Chairman.
    And let me just follow up on your line of questioning, 
because I was provided just this morning with a copy of an 
article related to the arrest of a local doctor in Juneau, 
Alaska, on multiple sexual assault charges, and charges of 
harassment. You know, you have indicated that following the 
very serious allegations of this pedophile who, effectively, 
has moved from hospital to hospital within the system is a 
shocking, horrible matter.
    You have indicated that with the task force that was formed 
there were--there were recommendations that were provided. It 
sounds like you have implemented some. I do not know whether 
the task force is continuing. I would certainly hope that this 
would not just be a situation where we have taken a look at 
past matters and cases, come up with a few recommendations and 
then we move on.
    As the Chairman has noted, this is something that needs to 
be continually monitored. If we have not put in place 
significant enough measures to address and arrest these, then 
we need to continue to do so.

                       IHS ARP ELIGIBLE EXPENSES

    But, Acting Director Fowler, I am going to ask you to 
provide for me, not here at today's hearing, but more details 
with regards to this indictment of Jeffrey Fultz, with regards 
to whether or not any action has been taken to revoke pension 
or retirement benefits. The victims, when he was placed on non-
duty with paid leave.
    So I would like to get specific responses. But my staff 
will follow up with you about some of the questions that we 
would like to ask.
    Let me turn now to the American Rescue Plan. As has been 
indicated, over $6 billion for the IHS came from that 
legislation, but it required that funds be used for expenses 
incurred prior to the Rescue Plan's enactment, and after the 
public health emergency was declared on January 30 of 2020.
    So what is IHS doing to verify that the amounts provided 
are for eligible expenses during this time period, January 30 
of 2020 and March 11 of 2021? Can you give me some guidance 
there?
    Ms. Fowler. Sure. Well, our regular budget execution and 
monitoring process has in place to help us ensure that the 
funds are being used appropriately and for the timeframe that 
the funds are available.

                     PLAN FOR ARP UNALLOCATED FUNDS

    Senator Murkowski. So you feel like you have got a pretty 
good system there. And in terms of obligating the remaining 
$1.8 billion left from the American Rescue Plan funds, what is 
the current thinking on where you will seek to direct those 
unallocated funds.
    Ms. Fowler. So the unallocated funds are in some specific 
categories, the behavioral health pending, for example, is part 
of the $1.8 billion, and the health facilities' infrastructure 
funds are part of the $1.8 billion.
    We are working on the--I am sorry, and the public health 
workforce is also included. We are working on the allocation 
methods for those with needs now. We anticipate being able to 
allocate those funds within the next couple of weeks. And 
then--any funds that go to our Tribal and urban programs are 
obligated as they are paid out to those organizations.
    The funding that is received by our Federal sites, however, 
those obligations occur a little bit more slowly over time, 
especially if they are used for activities such as salaries, 
you know, as the salaries are incurred and, you know, those 
obligations occur at that point in time.
    So we are able to allocate things quickly and obligate 
funds quickly for tribal and urban programs. And I--I am sorry, 
I am not sure if I went off track there, but----
    Senator Murkowski. No. You have hit, you have hit my high 
points, which is kind of what you anticipate in terms of 
timing, and then the areas where you would seek to devote the 
remaining funds.

                 ARP FUNDING--ESTIMATES OF REVENUE LOSS

    Let me ask one more question about American Rescue Plan 
funding. It included $2 billion for lost revenue. Does IHS have 
estimates on the amount of revenue loss? And do these estimates 
take into account amounts that the IHS system facilities have 
received from the Provider Relief Fund?
    Ms. Fowler. We have estimates of revenue loss for 
federally-managed facilities. Tribal programs and urban 
programs, Tribal programs in particular, are not required to 
report those, either their amount of collections, or in this 
case, the amount of their lost revenue.
    And so we did not use that information to allocate those 
funds. It would have been burdensome on all parties to have to 
structure a data call, and to collect the data, and so we used 
an allocation method that is based on how we allocate our 
normal appropriation, but tied to the budget line items that 
generate revenue.
    Senator Murkowski. So then let me ask one final question on 
this. How exactly will IHS determine how the $2 billion then 
will be allocated across the system here?
    Ms. Fowler. So it is based on the amount of funding that 
the IHS Tribal Urban Program currently receives from the budget 
line items that generate revenue. So it is--it is tied to the 
appropriated dollars that generate revenue. And that is based 
on--that method is based on the Consultation and Confer process 
that we undertook once the American Rescue Plan Act was 
appropriated.
    Senator Murkowski. Thank you.
    Thank you, Mr. Chairman.
    Senator Merkley. Thank you very much. I wanted to turn to 
water infrastructure. Senator Heinrich raised the issue, and we 
have the report, the sanitation's deficiency report that says 
there is a backlog of the $2.57 billion for water 
infrastructure, $1.5 billion for drinking water, and a billion 
for sewer projects.
    And certainly in Oregon, one of our Tribes, the 
Confederated Tribes of the Warm Springs has struggled to 
maintain a water system. And that system just fails 
continuously. The pressure control valves break, the pipes 
break, and the Tribal members are left having to boil their 
water months at a time.
    So I know, because you have filled me in previously, that 
there are some seven projects to repair parts of that water 
system that have been--being funded by Indian Health Services, 
I believe it is through Indian Health Services, just to 
clarify, but seven projects constituting about a $2 million 
investment.
    The Tribe estimates that to bring--to just maintain the 
status quo, that is to keep making repairs so that water will 
get delivered in this highly unreliable system, it is a $5 to 
$7 million project. And to really overhaul the water system is 
a $40 to $50 million project.

                       IMPROVING THE WATER SYSTEM

    As the Tribe looks at that challenge, and we are just 
talking about ancient infrastructure that continuously breaks 
down. Is there a vision for how an improved, high-quality water 
system can be installed? And how would that funding be split 
between Indian Health Services, between Bureau of Indian 
Affairs (BIA), between the State of Oregon? Is there a 
cooperative strategy going on to try to figure out how to bring 
that system up to modern standards?
    Ms. Fowler. So currently, as you referenced, there are 
seven projects underway there at that Warm Springs facility. 
One of the activities underway includes an evaluation to 
determine that the need and the cost associated with the full 
replacement of the system. Part of any project that is impacted 
through the Sanitation Facilities Construction Program includes 
an analysis of whether or not contributions would be required 
for that water system.
    And so, yes, they are--as part of every project there is 
that analysis of whether or not it needs to be conducted or 
carried out in collaboration with other entities.
    Senator Merkley. So it has--is there an active conversation 
going with BIA, and the State of Oregon, and the Tribe on how 
to have a comprehensive overhaul of the system?
    Ms. Fowler. I believe that will take place once the 
evaluation is complete, but I can confirm that, and provide 
that in follow up.

                            IHS VACANCY RATE

    Senator Merkley. Okay. That, you know, that would be great. 
And, you know, some Tribes have significant financial 
resources, and some do not, the Warm Springs does not have any 
significant resources. So any cost share will have to probably 
be undertaken by other--by other entities. And by that I mean, 
probably, the State of--the State of Oregon.
    But I would like to see a dialogue that leads to a 
comprehensive plan, because right now it's: the water system 
goes down, emergency repairs, people are out of water for a 
couple months, it is repaired, then it breaks down immediately 
again. This is just not a sustainable system appropriate for 
human health.
    So that is one of the things I will ask in our follow-up 
questions is, what is the status of such a dialogue, or if it 
does not exist, can it be undertaken? Can a plan be developed 
for a comprehensive overhaul, and what that might look like?
    I want to turn back to the recruitment and retention 
question. And I do not need to spend too much time on this, but 
I just wanted to, again, accentuate the points that Senator 
Tester was making; that across the system, there were 25 
percent vacancies a couple years ago, with the 2018 GAO report. 
What is the overall vacancy rate now in the year 2021?
    Ms. Fowler. Twenty-four percent.

                       IMPROVING IHS RECRUITMENT

    Senator Merkley. So essentially the same. I am somewhat 
surprised it is not higher because we have so many medical 
practitioners retiring. Are there ideas for improving 
recruitment that can be added to the current strategies? 
Because those strategies over the last couple of years have 
left the vacancy rate at about the same level, and in some 
places, as I noted, it is very--it is much lower in the 
Portland region, which while naming a city, it actually refers 
to a region, just for those who are listening in on the 
hearing.
    It is one of the lowest, the Montana region called 
Billings, and the--I think it was--was it the Comanche region 
also that was extremely high? One of the other areas was 
extremely high.
    Are there new tools that you are proposing, for example, 
programs that would improve the write off of medical debt for 
nurses, for medical--physician assistants, for doctors, and so 
forth to improve recruitment?
    Ms. Fowler. So we have submitted proposals for such tools, 
and past President's budget requests have not--they have not 
come to fruition yet, but as I indicated to Senator Tester, we 
would be happy to provide a description of those tools.
    We provided technical assistance on various bills intended 
to assist with recruitment efforts as well. And we would be 
happy to do so again.
    Senator Merkley. Okay. And I would be very curious, which 
ones create the most effective per cost? Is it hiring bonuses? 
Is it debt, student debt write-offs? What does that look like? 
Is it a period of service for 2 years or 4 years? Is it 
dedicated to putting medical practitioners in the areas that 
have the highest need, and so on and so forth; because this 
chronic understaffing is such a big issue for the success of 
the Indian Health Service?
    Ms. Fowler. I would have to say that, one of our most 
effective tools is loan repayment. It does come with a payback 
obligation. Bonuses are helpful, but they are not included as 
they are not counted towards salary, towards--for retirement 
purposes. And so we find that providers or clinicians prefer 
the special salary rate, for that very reason.
    And so I think--I think loan repayment, we have to do a 
little bit more analysis on that, but I definitely think that 
is our most effective tool at this time.
    Senator Merkley. Wait, I am sorry. Which one is the most 
effective tool?
    Ms. Fowler. Loan repayment program, we were able to, 
basically, pay for providers, for example, their medical school 
loan, their nursing school loan, and we do it in chunks. It is 
not--we do not pay their full loan amount off, but we do a 
certain amount per year, and then every year that they receive 
it they incur a pay--a service payback obligation. So they have 
to stay with us for 2 years, 4 years, whatever that particular 
payback obligation is.
    Senator Merkley. Great. I look forward to the--of reading 
over the details of that, and understanding for every million 
dollars we invest in plan A, how much would it affect 
recruitment versus a million dollars in plan B? And what are 
the reasons some are more effective?
    And you mentioned, for example--I think if I heard you 
correctly--that under one of the programs it does not count 
towards retirement, so it is less effective as a recruitment 
tool.
    Ms. Fowler. Right. Those are the incentive programs, they 
are bonus programs. So we are able to pay recruitment bonuses, 
retention bonuses, for example. And they are nice, they are a 
percentage increase to an employee's salary, but as I said, it 
does not count towards salary towards retirement.
    Senator Merkley. Okay. Thank you. I have one more question, 
but I am going to hold it until after my colleague has had 
another round of questions.
    Senator Murkowski. Thank you, Ms. Chairman.
    Ms. Fowler, in my last round of questioning, I was asking 
you about the lost revenue issue. And it prompts another 
question with regards to IHS treatment for non-IHS individuals.
    I think we saw during this public health emergency, that 
IHS facilities were called upon to provide care to non-IHS 
beneficiaries. So we are all in this together as we said.

        REIMBURSEMENT FOR CARE PROVIDED TO NON-IHS BENEFICIARIES

    So I do not know whether IHS tracked information in terms 
of the numbers, how many folks we actually saw. And then, more 
important, whether the treating facility was able to secure 
reimbursement for the services that are provided to non-
beneficiaries.
    Ms. Fowler. So we do track the information. I do not know 
the numbers specifically right now, happy to provide them 
later. And whenever an IHS facility or Tribal facility treats a 
non-beneficiary, we are required to either bill their insurance 
or bill the patient directly. And so we are able to recoup 
those costs that way.
    Senator Murkowski. So then with regards to the lost revenue 
that I raised, does that $2 billion include third-party 
reimbursement losses to care that was provided to non-IHS 
beneficiaries?
    Ms. Fowler. To the extent that we billed and did not get 
paid, it would be included as lost revenue.
    Senator Murkowski. So how challenging is it, or will it be 
to recoup more third-party reimbursements?
    Ms. Fowler. We do have the ability to bill the HRSA, Health 
Resources and Services Administration program.
    Senator Murkowski. Yes.

                   105(L) LEASE AGREEMENT GUIDELINES

    Ms. Fowler. If we are unable to attain the first 
reimbursement from the insurer or the patient directly. So 
there are some avenues that our--that are available to us in 
regards to COVID care. If it is not COVID care, if it is 
treatment of non-COVID care, then we would use our normal debt 
collection procedures, and if we were still unable to collect 
then that becomes a write off as bad debt basically.
    Senator Murkowski. But you are able to make that separation 
within your system, COVID care versus non-COVID?
    Ms. Fowler. Yes. Yes, we are.
    Senator Murkowski. Let me--let me switch to a subject that 
is very familiar to this subcommittee. I raise it every year, 
and this relates to Village Built Clinics (VBCs) and the 105(l) 
leases. And where we are with understanding what the overall 
costs are. In the fiscal year 2021 Omnibus we all agreed to 
separate out the 105(l) costs.
    We created a separate appropriations account, similar to 
what we have done with contract support. We included direction 
to both IHS and Interior to begin a process to establish the 
guidelines regarding the parameters for which a lease agreement 
could be structured.
    So the question to you is whether or not IHS has started 
the process to develop the guidelines as we outlined in the 
fiscal year 2021 Omni?
    Ms. Fowler. We had an initial discussion with the Bureau of 
Indian Affairs, and we plan to have an approach for 
consultation, and a plan in and of itself, and completed by the 
end of next month. But it's kind of the----
    Senator Murkowski. So let me just ask for clarification on 
that. By the end of next month you will have a plan, or you 
will plan to have a plan? I am just--I am trying to understand 
where we are in that timeline.
    Ms. Fowler. Of course. We plan to finalize a timeline and 
an approach for consultation by the end of next month.
    Senator Murkowski. So you said you can, you can understand 
the frustration and the challenge from an appropriations 
perspective, as we are trying to anticipate what this means for 
the budget. In the fiscal year 2021 Omni, again, I mentioned, 
you know, we had this separate funding account, the estimated 
cost at the time of passage for the 105(l) cost $101 million.
    So we are going to have to make estimates again for fiscal 
year 2022. Do you--do you estimate that the budget 
justification is going to be far off from the 2021 estimate? I 
am trying to figure out how we do our planning here. I am sure 
you are as well.
    Ms. Fowler. I think, for this question, I know that at this 
point in time we have received over 300 proposals that total 
roughly $128 million for fiscal year 2021.
    Senator Murkowski. 128 million?
    Ms. Fowler. And that--that is right.
    Senator Murkowski. Okay?
    Ms. Fowler. Yes.

                         VILLAGE BUILT CLINICS

    Senator Murkowski. Okay. So I am just--I do not recall 
where we started, but it seems to me that every year we are 
looking at significant increases from year prior.
    Ms. Fowler. Yes.
    Senator Murkowski. And, again, trying to understand what 
this means going forward is exactly why we need to have this 
process, the guidelines. And so I would just encourage you, as 
you are moving forward with this timeline, that you be as 
diligent, and speed it up as much as we can.
    On Village Built Clinics, so the 105(l)'s have been 
separated from VBCs but both provide funding for lease 
agreements. Should the Village Built Clinics be funded from the 
same account as the 105(l)'s and--well, let me just ask that 
question. Should they be funded from the same account?
    Ms. Fowler. Well, the Village Built Clinics, they are 
funded through a different mechanism than the 105(l) leases. 
And one of the major differences between the two is the Village 
Built Clinics, Lisa, has received a recurring amount of funding 
every year, and it is automatic. And I believe that might be 
one reason why those--several of those leases have not 
converted over to 105(l).
    For the 105(l) leases, a proposal has to be submitted and 
negotiated annually to arrive at the final cost of the lease. 
And so at this point in time there's a predictable amount of 
funding for the Village Built Clinics. But, of course, as you 
have referenced, it is not the same on the 105(l) side.
    So in our view, it is better to keep them separate. And we 
believe that those are some comments that we have heard from 
the Tribe that that is their preference as well.
    Senator Murkowski. So do you know if the Village Built 
Clinics are funded at 100 percent of the--of the cost of the 
lease agreement? Can we determine that?
    Ms. Fowler. So as I said, they get a recurring amount, I 
think, based on anecdotal reports, the Village Built Clinics 
for themselves would say that there are some costs that are not 
covered within those leases.
    Senator Murkowski. Right.
    Ms. Fowler. But we do not have that information and----
    Senator Murkowski. Is that difficult to isolate out?
    Ms. Fowler. It would require us to ask them for those 
costs. So it would not be difficult.
    Senator Murkowski. Mr. Chairman, I have got--I have got one 
more set of questions. But I am getting close to the end here. 
But I will defer to you.
    Senator Merkley. Why don't you go ahead, and then I will 
ask a final question.
    Senator Murkowski. Okay.

         CLEARING THE BACKLOG ON PRIORITY FACILITY CONSTRUCTION

    Then it has been mentioned previously by others about the--
about the backlog on priority facility construction projects, 
with a little over $2 billion backlog, a further estimate of 
$14.5 billion to meet all of IHS construction needs. 
Additionally, IHS works with Indian Tribes and their Tribal 
organizations on joint venture projects, which use the non-IHS 
funds.
    So given--given the backlog of where we are with 
construction projects, how much longer do you estimate it will 
take IHS to clear the backlog were the agency to receive what 
has been requested by the administration?
    Ms. Fowler. I think--I am not--sorry, that is one, my 
colleague, Ms. Curtis, may know the answer to that. I do 
believe that it is still, though, another several years.
    Senator Murkowski. Ms. Curtis, do you have a greater 
certainty on how long we are looking at.
    Ms. Curtis. At current rates of appropriation and budget 
requests, it would likely take another 5 to 10 years to 
complete the project, yes.
    Senator Murkowski. Five to 10 years. So are you working 
with the administration to include any funding for IHS 
construction in the development of the infrastructure project 
that we are looking at?
    Ms. Fowler. We are providing technical assistance on that 
infrastructure bill.
    Senator Murkowski. So then if there are additional funds 
that are provided for facilities construction, do you 
anticipate that we are going to see another joint venture 
solicitation?

            STATE OF ALASKA FACILITY NEEDS ASSESSMENT REPORT

    Ms. Fowler. Yes. I am going to have to go back and find out 
the timing, but we have been trying to do those solicitations 
at least every 3 years, or so. So it would be about time to do 
that.
    Senator Murkowski. Okay. So we had--we had included report 
language in the last several appropriations bills, directing 
the IHS to work with the State of Alaska to conduct an 
assessment of the updated facility needs in the State. And then 
include some recommendations for alternate financing options. 
Do you know the status of this report? Folks are anxious to 
receive it.
    Ms. Fowler. That is one report that I am not familiar with, 
but I believe I have--and Jillian please confirm this--but I 
believe that it is a report that is currently with our 
Facilities Appropriations Advisory Board for review. Is that 
correct, Jillian?
    Ms. Curtis. That is right. We will go back and confirm 
this, but my recollection is that we have received the report 
from the Tribal organization and it is in the review process.
    Senator Murkowski. So if it is in the review process, do we 
have any idea when we might expect to receive it?
    Ms. Fowler. I do not think we have that timeline right now, 
but we can make sure that we provide that for you later. And 
that is as expeditious as possible.

                           IHS CERTIFICATION

    Senator Murkowski. Yes. If you can let us know just, kind 
of, what to anticipate there, that would be appreciated. As I 
mentioned, it has been--it has been an ask in the past several 
appropriations bill.
    And then my last question in the fiscal year 2021 Omni, $3 
million was included for IHS certification. It has been an 
ongoing challenge for us in the State of Alaska to find 
certified operators to perform the certification, which puts in 
jeopardy the entire project.
    So asking if there is a plan for this funding that you can 
provide, again, we have got a lot of folks in Alaska that are 
looking to this, because we can--we can unleash a lot when it 
comes to these projects and the priorities, but we have got to 
get the certification--the certified operators first. So if 
anybody has an update on that, I would appreciate it.
    Ms. Fowler. We can provide more details for you later, but 
we do have a plan for conducting that training.
    Senator Murkowski. Good. I would appreciate that.
    Thank you, Ms. Chairman.
    That is the end of my questions, but I appreciate not only 
Ms. Fowler as acting director, but also Ms. Curtis, in, in 
responding today. And it sounds like they have got some things 
to get back to us, and the other Members of the subcommittee. 
But I thank them for their attention to these matters.
    Senator Merkley. Thank you very much, Senator Murkowski. 
And we will be looking forward to the responses.

                          FRAUD INVESTIGATIONS

    I have one final question. And as we ponder very 
significant increases in the funding for IHS, we want to make 
sure that the funding is well-spent. Does IHS have a fraud and 
investigations unit?
    Ms. Fowler. The Indian Health Service, we have a division 
of audit within our office of finance and accounting. We also 
have--that is focused primarily on the single audits for 
Tribes, and urban programs, and our grantees. But we also have 
our normal budget execution and monitoring processes. We have 
stood out compliance, but withstanding, the process of standing 
up a compliance program within the headquarters' level.
    And, we were also conducting other program reviews that 
would help us ensure that the funds are being used 
appropriately.
    Senator Merkley. Okay. I would like to get details on these 
strategies. I was particularly concerned about the report as an 
example of this, that involved Indian Health Services 
contracting with a company 11 days after the company was 
formed. The company was formed by a former White House deputy 
chief of staff, and it was formed in order to, essentially, be 
the middleman on delivering KN95 masks.

                            IHS CONTRACTING

    And the masks came from a producer that was not certified 
by FDA (Food and Drug Administration). I am thinking about a 
company in my home State that is producing masks, and I visited 
them just before the FDA was visiting to essentially review all 
their processes and make sure the masks met the full standard. 
And it is hard for me to imagine Indian Health Services issuing 
a contract that did not specify that the masks had to come from 
a certified supplier to make sure that they actually met--met 
standards.
    And I cannot understand, for the life of me why, that you 
would have a limited, competitive bidding contract with a 
company that had just been formed.
    This is the type of situation that is best prevented on the 
front end with robust standards. Most contracts should be 
competitive bidding, and those that are not should have 
standards for both the product and for the company's with 
experience.
    And I realize you were not in charge of IHS. You were not 
the director at the time this happened, but has IHS conducted a 
full investigation of this particular case, or other cases that 
suggest the reveal flaws in the contracting process, and 
perhaps the abuse of our citizens' tax revenue.
    Ms. Fowler. There is a full investigation underway by the 
Office of the Inspector General for that particular specific 
case. IHS has put in place some procedures, some processes to 
infer oversight and--oversight to ensure the quality of the PPE 
(Personal Protective Equipment) and other medical supplies that 
were being put forward.
    I would say that supplies that are distributed through our 
National Service and Supply Center, they have a quality 
assurance team that rigorously reviews and tests all of the 
products that are distributed through that NSSC.
    However, within our area offices their acquisition programs 
are now required to conduct similar types of reviews when they 
are procuring those supplies directly. So we have put some 
measures in place to prevent that from happening in the future.
    Senator Merkley. I do not believe we have--we have seen an 
Inspector General's report. Is that forthcoming?
    Ms. Fowler. It is still underway, is my understanding, from 
what was said----
    Senator Merkley. Can we get a date on which that would be 
available? Or do you have some sense of when it would be 
released?
    Ms. Fowler. I do not have a sense right now, but we can 
find out and get it to you.
    Senator Merkley. Okay. Okay. Thank you. And as in other 
cases, there will be--I know the Inspector General provides a 
set of recommendations. I want to make sure that those 
recommendations get fully implemented, when a story comes out 
that--at least on its surface, and that is why I want to see 
the Inspector General's report, it sounds like an insider 
arrangement for a multi-million-dollar contract with someone 
who has no experience in contracting. This should never happen.
    If it happened in the way it was reported, it is an abuse 
of the public trust. And it says that IHS has seriously 
deficient contracting standards that need to be addressed, 
particularly as we are on the verge of considering a 
significant increase in resources to the agency.
    Did you have any follow-up at all? You know, you----
    Senator Murkowski. Mr. Chairman, I just want to add to your 
final question and comment there. So much of today's hearing 
has been focused on really unprecedented dollars that are--are 
coming to IHS. And I am certainly one of those who has 
acknowledged that we have seen unfortunate, chronic 
underfunding over the years between administrations on both 
sides of the aisle, but the reality has been is that, there is 
clearly a need.
    We hear that, and we see that manifested in the--in the 
maintenance facilities backlog, and so many of these other 
areas. But as we--as we work to be responsive to need with 
COVID-related dollars, and also doing right by these accounts, 
particularly in the water and wastewater areas, as you have 
mentioned as priorities, we want to make sure that we are--that 
there is a level of accountability.
    This is a lot of money. And we know that sometimes there 
are capacity issues with monitoring the dollars and making sure 
that it is appropriate. But that is why we have the agencies; 
that is why we have the oversight that we exercise, and so I 
appreciate what you have said, with the level of scrutiny.
    We want to make sure that we have the resources to ensure 
that level of accountability. Whether it is making sure that 
funds are spent within the time period within which Congress 
has required.
    But, again, making sure that these dollars truly go to 
where the need is. And so I know that I will be a good partner 
with you in making sure that as we address these clear needs, 
we do so with an eye towards accountability.
    Senator Merkley. Thank you very much. I know both of us 
have significant Native American communities in our respective 
States, and we are--have a collective sense of wanting to make 
sure that the--our government honors its responsibilities in a 
whole series of fields related to those communities certainly 
in--and certainly in terms of health services.

                     ADDITIONAL COMMITTEE QUESTIONS

    So we really appreciate your work over many, many years, 
Director Fowler. And appreciate your responding to our 
inquiries, and our follow-up inquiries that we will send you, 
as we try to prepare the path for doing more to enhance the 
health across the Nation for Indian Country. Thank you very 
much.

                     ADDITIONAL COMMITTEE QUESTIONS

    And with that I--do I have any formal closing comments I 
need to make? I think those things such as: I would like to 
highlight for my colleagues, and others, that the hearing 
record will be open until two weeks after the arrival of the 
President's fiscal year 2022 budget request, so that everyone 
will get a chance to review it.

    [The following questions were not asked at the hearing, but 
were submitted to the Indian Health Service for response 
subsequent to the hearing:]
              Questions Submitted to Hon. Elizabeth Fowler
            Questions Submitted by Senator Cindy Hyde-Smith
 addressing health disparities in indian country: review of the indian 
            health service's covid response and future needs
    Question 1. An annual eye exam for the detection of diabetes 
related retinopathy (DR) is one of 19 Special Diabetes Program for 
Indians (SDPI) Diabetes Best Practices.\i,ii,iii\ According to the 
National Tribal Budget Formulation Workgroup's Recommendations on the 
Indian Health Service Fiscal Year 2022 Budget, AI/ANs have an age-
adjusted prevalence rate of diabetes 7.3 times that of white 
Americans.\iv\ The 2018 Edition of Indian Health Service Vision Care 
states that 40 to 45 percent of American Indians living with diabetes 
will develop some stage of diabetic retinopathy in their lifetimes.\v\ 
Diabetic retinopathy is the largest cause of preventable blindness in 
adults.\vi\ Despite clinical recommendations, less than half of AI/AN 
patients with diabetes are assessed every year for diabetic 
retinopathy.\vii\

    A. For each year that data has been collected related to the SDPI 
Diabetes Best Practice of eye exams for retinopathy, please provide the 
number and percentage of individuals living with diabetes who have 
received an annual eye exam.

      Answer.

          Data Source: IHS Diabetes Care and Outcomes Audit

            Notes:

              -- Table below provides estimates for each measure for 
        American Indian/Alaska Native (AI/AN) people with diabetes who 
        received care at IHS, Tribal, or Urban Indian health facilities 
        that participated in the IHS Diabetes Audit.
              -- Only percentages of AI/AN patients with diabetes who 
        received care at IHS, Tribal, or Urban Indian health facilities 
        that participated in the IHS Diabetes Audit are available for 
        these measures, not total numbers of people.
              -- Data for each Audit Year represent care and outcomes 
        from previous calendar year (e.g., 2021 reflects Jan 1-Dec 31, 
        2020).

------------------------------------------------------------------------
                                                      Diagnosed with
       Audit Year             Eye Exams (%)        Retinopathy \1\ (%)
------------------------------------------------------------------------
1996                      56
1997                      55
1998                      56
1999                      54
2000                      52
2001                      52
2002                      53
2003                      55
2004                      54
2005                      56
2006                      55
2007                      55
2008                      55
2009                      55
2010                      57
2011                      56
2012                      55
2013                      55
2014                      58
2015                      55
2016                      58
2017                      59
2018                      59
2019                      59                     19
2020                      59                     20
2021                       42 \2\                20
------------------------------------------------------------------------
\1\ Collected beginning with Audit 2019
\2\ Patient care impacted by COVID-19


    B. What data other than the Required Key Measure of the number and 
percent of individuals who receive an exam has been collected from SDPI 
grantees around the Diabetes Best Practice of eye exams for 
retinopathy?

        Answer. The Diabetes Care and Outcomes Audit captures data on:

          -- Number and Percentage of eye exams (dilated exam or 
        retinal imaging) completed.
            -- Please note that the Audit captures data for each 
        Audited patient, including whether they had an eye exam during 
        the Audit Year and whether they ever had documentation of 
        diagnosed retinopathy. Some facilities Audit a random sample of 
        their eligible diabetes patients, instead of all. When the 
        individual data are analyzed to prepare the results provided 
        (percentages), weights are applied to account for the random 
        sampling.
          -- Number and Percentage of patients with diagnosed 
        retinopathy
            -- See data listed above

    Question 2. In 2018 the U.S. FDA granted `breakthrough device' 
status and de novo authorized a technology for the detection of 
diabetic retinopathy at the point of care.\viii\ The technology was 
specifically designed to eliminate bias and was cleared by the FDA 
after rigorous validation and superiority against all preregistered 
endpoints.\ix\ Delivering diagnostics at the point-of-care has the 
potential to address disparities in access, strengthen the ability for 
health centers to provide comprehensive diabetes care and increase the 
efficiency of specialty care to focus on individuals at highest risk 
for vision loss. IHS released Current Procedural Terminology CPT Update 
in March 2021 that includes CPT Code 92229 for retinal imaging with 
automated point-of-care.\x\

    A. Is the IHS aware of any utilization of the new CPT Code 92229 
for fully autonomous artificial intelligence to detect diabetic 
retinopathy?

          Answer. The IHS does not use this CPT Code, since the 
        referenced equipment and specific procedure is not used in IHS.

    B. How might utilization of fully autonomous artificial 
intelligence at I/T/U's complement existing strategies aimed at 
increasing adherence with recommendations that patients with diabetes 
receive an annual diabetic eye exam?

          Answer. The level of adherence is multifactorial and IHS 
        believes a significant component of adherence is related to 
        education and personal interaction that occurs when the imager 
        meets with the patient. The potential benefit of AI is that it 
        would allow us to continue growth of the IHS Teleophthalmology 
        Program (TOP) without hiring additional readers. After initial 
        implementation costs, this would be a financial benefit to the 
        program, but might not impact the level of adherence.
          The TOP is currently working toward developing an AI system 
        using the current equipment used and train it to specifically 
        detect the subtleties of our patient population. This includes 
        the following steps in order to achieve that goal:

            1.  Training models for creating algorithms are being 
        developed for unique patient populations. The TOP is directly 
        involved in this process.
            2.  A protocol to use a previously developed algorithm is 
        being tested to improve grade quality of the images. The 
        purpose is to increase the speed and accuracy of human readers.
            3.  The TOP is working to train and achieve non-biased 
        reading to ultimately create an algorithm specific to American 
        Indian and Alaska Native (AI/AN) patient populations (current 
        AI programs have an inherit bias, as they are not based on this 
        patient population). IHS feels strongly that specific AI/AN 
        algorithm training must be based on AI/AN populations to be 
        successful and accurate.
---------------------------------------------------------------------------
    \i\ https://www.nihb.org/sdpi/docs/01022019/
SDPI%20Best%20Practices.pdf
    \ii\ https://www.ihs.gov/sites/sdpi/themes/responsive2017/
display_objects/documents/bestpractices/SDPI_FY16_BP_Summary.pdf
    \iii\ https://www.ihs.gov/sites/dps/themes/responsive2017/
display_objects/documents/IHS_VisionCare.pdf
    \iv\ https://www.nihb.org/docs/05042020/
FINAL_FY22%20IHS%20Budget%20Book.pdf
    \v\ https://www.ihs.gov/sites/dps/themes/responsive2017/
display_objects/documents/IHS_VisionCare.pdf
    \vi\ American Diabetes Association. Standards of Medical Care in 
Diabetes--2019. Diabetes Care. 2019 Jan 1; 42 (Supplement 1).
    \vii\ https://www.ihs.gov/sites/quality/themes/responsive2017/
display_objects/documents/
FY_2019_GPRA_GPRAMA_NationalandAreaResults.pdf
    \viii\ https://www.fda.gov/news-events/press-announcements/fda-
permits-marketing-artificial-intelligence-based-device-detect-certain-
diabetes-related-eye
    \ix\ https://www.fda.gov/news-events/press-announcements/fda-
permits-marketing-artificial-intelligence-based-device-detect-certain-
diabetes-related-eye
    \x\ https://www.Federalregister.gov/documents/2020/12/28/2020-
26815/medicare-program-cy-2021-payment-policies-under-the-physician-
fee-schedule-and-other-changes-to-part
---------------------------------------------------------------------------

                          SUBCOMMITTEE RECESS

    And with no further comments, this hearing is adjourned.
    [Whereupon, at 12:03 p.m., Wednesday, April 28, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]