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




 
     DEPARTMENT OF THE INTERIOR, ENVIRONMENT, AND RELATED AGENCIES 
                  APPROPRIATIONS FOR FISCAL YEAR 2023

                              ----------                              


                        WEDNESDAY, MAY 11, 2022

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:00 a.m. in room SD-124, Dirksen 
Senate Office Building, Hon. Jeff Merkley (chairman) presiding.
    Present: Senators Merkley, Tester, Van Hollen, Heinrich, 
and Murkowski.

                         INDIAN HEALTH SERVICE

STATEMENT OF HONORABLE ELIZABETH FOWLER, ACTING 
            DIRECTOR
ACCOMPANIED BY JILLIAN CURTIS, CHIEF FINANCIAL OFFICER

               OPENING STATEMENT OF SENATOR JEFF MERKLEY

    Senator Merkley. Today, we convene this hearing at an 
important time when health care remains at the forefront of our 
minds as we attempt to move past the COVID-19 pandemic. We 
faced a number of challenges with wave after wave of new 
variants, and we continue to confront the challenges of new 
variants to come.
    But I'm hopeful that we're finally making progress and 
emerging from this pandemic with a better understanding of the 
virus and with more tools in our toolbox available to fight its 
effects and the fact that we're all here in person today is a 
very good sign of the progress that we have made.
    Welcome, IHS Acting Director Elizabeth Fowler. Good to have 
you as well as Indian Health Service (IHS) Chief Financial 
Officer Jillian Curtis. Good to have both of you here today and 
for your willingness to answer the questions that the Senators 
may have.
    I look forward to hearing from both of you on how a 
combination of fiscal year 2022 funding and previously-
appropriated supplemental funding is being used to address the 
pandemic's ongoing impacts in Native communities, how we are 
working to improve patient outcomes, how bipartisan 
infrastructure funding will make an impact on water 
infrastructure, and most importantly, how we are planning to 
deal with future health care challenges with your agency's 
proposed fiscal year 2023 budget.
    Native communities have been disproportionately affected by 
the COVID-19 pandemic with Native COVID mortality rates twice 
as high as non-Native populations. Native Americans and Alaska 
Natives have been hospitalized due to COVID-complications at a 
rate four times higher than non-Hispanic white individuals.
    Unfortunately, these differences are not uncommon even 
outside the context of COVID-19. These disparities in health 
care have long existed. The pandemic simply highlighted and 
exacerbated them.
    So the work to improve health outcomes for Native American 
communities remains a vital challenge that we must tackle. To 
that end, this committee provided Indian Health Service with 
6.6 billion in the fiscal year 2022 Omnibus, a 394 million 
increase in the agency's funding.
    These increases were provided in the hope that we can move 
the needle towards bettering the lives of Native Americans. 
This is not only a moral obligation, it's a trust and treaty 
responsibility that we must never lose sight of.
    We can never fully atone for the sins of the past in this 
country but we can and must do our best to live up to our 
responsibility for providing the best available health care as 
enshrined in treaties. Because no matter who you are or where 
you live, health care simply is and ought to always be a 
fundamental right in America.
    I am pleased to see the Biden Administration shares this 
commitment and has proposed significant new investments in the 
Indian Health Service. The request includes $9.1 billion in 
funding for fiscal year 2023 or a 2.49 billion or 38 percent 
increase, and for the first time the request includes a 
proposal to move IHS from discretionary funding to mandatory 
funding.
    I am keeping an open mind on this proposal and look forward 
to discussing this in more detail in this hearing during our 
questions, but I'll say right now that I agree with the 
sentiments to want to provide financial stability to the agency 
and to Native communities, and I'm pleased to see ideas being 
proposed to prompt discussion on how we can address chronic 
problems.
    I do have concerns, however, that despite the significant 
important reasons to change the funding trajectory, we need to 
also make sure that there is an important congressional 
oversight role and so how do those two pieces fit together: the 
possibility of mandatory funding and congressional oversight.
    I think I speak for most, if not all, of my colleagues on 
this committee when I say this is something we are not easily 
willing to forego. We feel that annual appropriations is an 
important tool for ensuring close oversight and a close working 
relationship with agencies and the programs we oversee.
    We need to learn a lot more about how this proposal would 
work and I look forward to having that detailed discussion with 
you in the near future.
    I am pleased to see proposed IHS facilities requests of 
$1.6 billion, an increase of 626 million or 67 percent, for 
tribal infrastructure, medical equipment, water infrastructure 
investments to improve access to drinking water and clean water 
systems in Indian Country.
    This investment in water infrastructure is critically 
important for the health and well-being of any community. The 
water infrastructure funding provided for fiscal year 2022 
comes on top of the $3.5 billion that I'm proud we're able to 
provide for tribal water systems in the bipartisan 
infrastructure law.
    There is a direct correlation between improved water and 
sanitation systems and improved public health. The 
infrastructure funding was, frankly, an astounding level of 
investment. It cleared out a backlog that we know will soon be 
replaced by other projects that are desperately needed by other 
Native communities.
    I look forward to hearing how all of this funding is being 
spent and how we can continue to focus on these investments.
    In Oregon, for example, the Confederated Tribes of Warm 
Springs has 57 miles of pipes in such a state of disrepair that 
much of the community is repeatedly left without running water 
and are under almost perpetual instructions to have to boil 
their water to make it safe to drink.
    The system is operated by a computer that was established 
from a landfill that's running on a very old and unsecured 
version of Windows. It's been obsolete for many years, just a 
symbol, if you will, of how out of date this infrastructure is, 
how much it's in need of restoration.
    In 2022, these are stories we shouldn't be hearing about in 
the United States of America. We must do better. So there's a 
lot to discuss and I look forward to that conversation.
    And now I'd like to turn to our Ranking Member Senator 
Murkowski for any opening remarks that she would like to make.

                  STATEMENT OF SENATOR LISA MURKOWSKI

    Senator Murkowski. Thank you, Mr. Chairman, and good 
morning. Good morning, Ms. Fowler. It's good to have you before 
the committee here this morning. We had an opportunity to have 
you before the Indian Affairs Committee last week, so 
appreciate you coming back to the Hill, and an opportunity to 
discuss the fiscal year 2023 budget proposal.
    Mr. Chairman, you have noted the issue about the decision 
that has been made by the Administration proposing to 
reclassify the entire agency's budget and so I just want to 
thank you for having a hearing on this proposal because given 
that we're looking at this proposed reclassification to put the 
entire agency budget for fiscal year 2023 as mandatory, really 
the 2023 IHS budget proposal is technically not in the 
jurisdiction of the Appropriations Committee.
    So I'm glad that we are having the decision to move forward 
with this hearing despite some jurisdictional issues.
    While we're not completely back to pre-pandemic level of 
activity, I am hopeful that we've turned the corner on COVID. 
Over the course of the pandemic, IHS received approximately 
nine billion in supplemental funding to address both pandemic-
related expenses and other long-term infrastructure needs, like 
electronic health records, information technology, and, in 
addition to the investments made by COVID supplemental 
packages, the bipartisan infrastructure law enacted last year 
dedicated 3.5 billion for the IHS to fund all listed wastewater 
and sanitation projects, as the Chairman has mentioned.
    I have consistently raised this funding as a priority in 
our hearings. So it's no secret that securing the money to 
address the IHS backlog was something that I worked really hard 
on to make sure it was included in the final infrastructure 
package.
    We've heard about potential administrative cost concerns 
associated with these funds. So I'll have some follow-up 
questions related to this in our back and forth after 
statements here.
    When you consider the COVID supplemental packages, the 
bipartisan infrastructure law, and the annual appropriations 
bills, the IHS has received approximately 37.5 billion over the 
preceding 4 years. I think that this demonstrates our 
commitment to working together in a bipartisan manner to 
address our shared tribal priorities across the board.
    Whether working together to navigate the budget 
unpredictability and instability surrounding the 105L issue, 
providing money to fully fund staffing packages, or trying to 
address the overall needs of the entire health delivery system 
while also taking into consideration administration and 
congressional interests during a pandemic, I think the work has 
been together and that has been so important.
    When I became Chairman of this subcommittee back in 2016, 
the annual appropriations level for the agency was 4.8 billion. 
An indefinite appropriation for contract support costs was 
created in my first bill as Chairman. Tribal lease payments 
were not a significant portion of the budget, and one of my 
priority issues, sanitation construction, was funded at 99 
million.
    Last year in Fiscal 2022, the agency received 6.6 billion. 
In 7 years, the IHS has received an approximate 37.5 percent 
increase in programmatic funding while the overall allocation 
of the Interior Appropriations bill received an estimated 
increase of 15 percent over this same period.
    So I think it's important to recognize that this could not 
have been accomplished if IHS was only my priority. This had to 
be a shared priority and it clearly, clearly was.
    The increases the IHS has received relative to the overall 
increases for the Interior bill clearly sends the signal that 
this agency is of bipartisan/bicameral importance, and the fact 
that this subcommittee provided significant increased funding 
to the IHS even during times of budget constraints and caps 
should indicate that we are all dedicated and all committed to 
ensuring access and quality care for Indian Country.
    So in light of all of our shared accomplishments, I was 
disappointed to read the 2023 budget proposal. Last year the 
Administration proposed advanced appropriations for the entire 
agency as well as a budget reclassification for the contract 
support costs and the highly unpredictable 105L tribal lease 
payments.
    Advanced appropriations, as you know, Ms. Fowler, is 
something that I have personally been supportive of over the 
years. I also know that when this concept was proposed in the 
budget last year, many of my colleagues and staff had technical 
questions that went unanswered unfortunately and unexplained 
for months.
    This delay likely contributed to the omission of this 
concept in the final Omnibus bill, but I was hopeful that those 
conversations would have carried forward in an effort to 
potentially set us up for success for at least some accounts in 
fiscal year 2023, but this doesn't appear to be the direction 
that the Administration took.
    Not only does this budget proposal fail to take a lessons 
learned approach in an effort to be successful, this budget 
proposal takes a series conversation and I think it makes it 
less serious which is disappointing.
    Another area of concern is the recent actions of the agency 
related to contract support costs. As you know, a large number 
of tribes and tribal organizations are concerned the agency is 
attempting to change the way these costs are calculated as a 
result of the Cook Inlet Tribal Council decision and the Fort 
Defiance letter.
    So I appreciate the answers to my letter on this topic, but 
I hope that we can get some additional information here today, 
and while we're glad you are here today to provide testimony 
and answer questions, I think it's just so important. We need 
permanent leadership. We need permanent leadership at IHS.
    As we all know, the agency was first put on GAO's High Risk 
List back in 2017 and it's still there. It's critical the 
agency have stable executive leadership in place to make 
decisions and address those high-risk concerns.
    So this past March the Administration nominated Ms. Roslyn 
Tso, a citizen of the Navajo Nation and current Director of the 
Navajo Area Indian Health Service, as the new Director. I do 
believe that this is one of the last nominations for agency 
leadership positions to be received in the Senate.
    So while this is welcome news for us, I am concerned about 
the length of time that it has taken to receive the nomination.
    The annual appropriations process is never easy or quick, 
but it is one that we work on together. So as we look to fiscal 
year 2023, I hope that we're able to continue this bipartisan 
tradition.
    With that, Mr. Chairman, back to you, and I look forward to 
the discussion this morning.
    Senator Merkley. Thank you very much, Senator.
    Now we turn to Honorable Elizabeth Fowler. Welcome.

               SUMMARY STATEMENT OF HON. ELIZABETH FOWLER

    Ms. Fowler. Good morning. Chairman Merkley, Vice Chairman 
Murkowski, and Members of the Committee, thank you for the 
opportunity to testify on the President's fiscal year 2023 
Budget Request for the Indian Health Service.
    Before I turn to the fiscal year 2023 Request, I want to 
first acknowledge and thank each of you for your work over the 
years in growing the IHS budget and prioritizing tribal issues 
within your bill.
    With your support, the IHS budget has grown by 57 percent 
in the last decade, and we know that type of growth is 
challenging to accomplish in a constrained discretionary 
funding environment.
    Patients across Indian Country have benefited from your 
efforts. This growth in funding has enabled us to address some 
of the most critical issues facing the Indian Health System, 
from addressing exponential growth and legally-required 
contract support costs and Section 105(l) lease agreements to 
resolving accreditation emergencies to bolstering the core 
administrative functions of the agency.
    We know you also fought hard to tackle urgent disparities 
facing Indian Country, such as the opioid epidemic, HIV, 
maternal health and suicide prevention.
    Over the years this work has always been underscored by our 
shared goal to improve health outcomes for all American Indians 
and Alaska Natives. HHS deeply appreciates this partnership and 
commitment.
    It is with this shared goal in mind that the Administration 
approached the fiscal year 2023 Budget Request for the Indian 
Health Service. We know that despite our shared efforts, IHS is 
still underfunded. Whether you look at per capita spending 
rates compared to other Federal health programs or other 
national health expenditure benchmarks, it is clear that 
current funding is not sufficient to meet the needs of the over 
2.7 million American Indians and Alaska Native patients that 
IHS serves each year.
    This underfunding of the Indian Health System directly 
contributes to stark health disparities in tribal communities. 
American Indian and Alaska Native people born today have a life 
expectancy that is 5.5 years shorter than the U.S. all races 
population with some tribes experiencing life expectancy as 
much as 12 years shorter than the general population.
    Longstanding health disparities were compounded by the 
pandemic with American Indians and Alaska Natives experiencing 
disproportionate rates of COVID-19 infection, hospitalization, 
and death. Addressing these inequities is a moral imperative 
for our nation, and it will require bold action from all of us 
to ensure we are upholding our commitments to Indian Country.

                     IHS MANDATORY FUNDING PROPOSAL

    That is why the President's fiscal year 2023 budget 
proposes the first-ever mandatory budget for the Indian Health 
Service. I acknowledge that this is a substantial change that 
would fundamentally impact how IHS receives funding from 
Congress. The Administration did not propose this change 
lightly.
    We believe that a change of this magnitude is needed to 
deliver on the government's health care responsibility for 
Indian Country.
    This proposal is in line with longstanding recommendations 
from tribal leaders across the nation, including in the Tribal 
Consultation and Urban Confer HHS conducted last year on long-
term funding solutions for the IHS.
    The fiscal year 2023 IHS budget is a starting point for 
ongoing conversations with tribes and Congress to consider and 
refine the proposal through the legislative process.
    Just to summarize, the fiscal year 2023 budget includes a 
total of $9.3 billion in mandatory funding for the Indian 
Health Service which is $2.5 billion above the fiscal year 
2022-enacted level.
    For fiscal year 2024 to 2032, the budget would grow 
automatically to account for the growing costs of providing 
health care as well as population and pay growth.
    This budget would address the three core issues identified 
by GAO: funding stability, predictability, and adequacy. These 
changes will allow IHS, tribal health programs, and urban 
Indian organizations to more effectively plan and implement 
health care services to best meet their community needs.
    As we work towards securing stable and predictable funding 
to meet the needs of Indian Country, we are committed to 
working closely with our stakeholders and understand the 
importance of working with partners, including Congress.
    Thank you again for the opportunity to speak with you 
today, happy to answer any questions that you might have.
    [The statement follows:]
              Prepared Statement of Hon. Elizabeth Fowler
    Good afternoon Chairman Merkley, Ranking Member Murkowski, and 
Members of the Committee. Thank you for your support and for inviting 
me to speak with you about the President's fiscal year 2023 Budget 
Request for the IHS.
    The Indian Health Service (IHS) is an agency within the Department 
of Health and Human Services (HHS) and our mission is to raise the 
physical, mental, social, and spiritual health of American Indians and 
Alaska Natives to the highest level. This mission is carried out in 
partnership with American Indian and Alaska Native Tribal communities 
through a network of over 687 Federal and Tribal health facilities and 
41 Urban Indian Organizations (UIOs) that are located across 37 states 
and provide healthcare services to approximately 2.7 million American 
Indian and Alaska Native people annually.
    On March 28, 2022, the White House released the President's fiscal 
year 2023 Budget, which proposes the first-ever fully mandatory budget 
for the IHS. The bold action taken in the fiscal year 2023 President's 
Budget demonstrates the Administration's continued commitment to 
strengthen the nation-to-nation relationship. This historic proposal 
addresses long-standing challenges that have impacted communities 
across Indian Country for decades.
    The Indian Health system is chronically underfunded compared to 
other healthcare systems in the U.S.\1\\2\ Despite substantial growth 
in the IHS discretionary budget over the last decade, by 57 percent 
from fiscal year 2012 to the current fiscal year 2022 enacted level, 
the growth has not been sufficient to address the well documented 
funding gaps in Indian Country. These funding deficiencies directly 
contribute to stark health disparities faced by tribal communities. 
American Indian and Alaska Native people born today have a life 
expectancy that is 5.5 years shorter than the U.S. all-races 
population, with some tribes experiencing life expectancy as much as 12 
years shorter than the general population. They also experience 
disproportionate rates of mortality from most major health issues, 
including chronic liver disease and cirrhosis, diabetes, unintentional 
injuries, assault and homicide, and suicide. The pandemic compounded 
the impact of these disparities in tribal communities, with American 
Indians and Alaska Natives experiencing disproportionate rates of 
COVID-19 infection, hospitalization, and death.
---------------------------------------------------------------------------
    \1\ Government Accountability Office Report--Indian Health Service: 
Spending Levels and Characteristics of IHS and Three Other Federal 
Health Care Programs https://www.gao.gov/assets/gao-19-74r.pdf
    \2\ U.S. Commission on Civil Rights Report--Broken Promises: 
Continuing Federal Funding Shortfall for Native Americans https://
www.usccr.gov/files/pubs/2018/12-20-Broken-Promises.pdf
---------------------------------------------------------------------------
                      long-term funding solutions
    Our budget plays a critical role in advancing a healthier future 
for American Indian and Alaska Native people. Growth beyond what can be 
accomplished through discretionary spending is necessary to address 
funding gaps and remediate health disparities. Mandatory spending is a 
more appropriate avenue to provide high-quality healthcare that is 
reliable and widely available for American Indians and Alaska Natives.
    To address this historic underinvestment in IHS, the mandatory 
budget provides $9.3 billion in fiscal year 2023, which includes $147 
million in current law authorized funding for the Special Diabetes 
Program for Indians. This is an increase of +$2.5 billion or 37 percent 
above the fiscal year 2022 enacted level. This immediate surge of 
funding is necessary to address long-standing gaps in healthcare and 
tackle chronic health disparities faced across Indian Country.
    Mandatory funding for the IHS provides the opportunity for 
significant funding increases that could not be achieved under 
discretionary funding caps. Further, this mandatory funding proposal 
would authorize and appropriate funding over 10 years, through fiscal 
year 2032, ensuring predictability that would allow IHS, tribal, and 
urban Indian health programs the opportunity for long-term and 
strategic planning. This increased stability and ability to conduct 
longer-term planning will improve quality of healthcare, promote 
recruitment and retention of health professionals, and enhance 
management efficiencies for individual health programs and the Indian 
Health system at large.
    Specifically, the mandatory budget proposal culminates in a total 
funding level of approximately $36.7 billion in fiscal year 2032. When 
compared with the fiscal year 2022 enacted level of $6.8 billion, the 
Fiscal year 2032 proposed funding level represents an increase of 
nearly +$30 billion or +442 percent. In total, the 10-year budget 
includes over $248 billion for the IHS.
    The budget also exempts the IHS from sequestration for proposed 
funding, which is the legislatively mandated process of budget control 
consisting of automatic, across-the-board spending reductions to 
enforce budget targets to limit Federal spending. Exempting the IHS 
budget from sequestration ensures funding for direct healthcare 
services for American Indians and Alaska Natives is not reduced and is 
consistent with the treatment of other critical programs such as 
veterans' benefits and nutrition assistance programs. The budget also 
includes inflation factors to address the growing cost of providing 
direct healthcare services, including pay costs, medical and non- 
medical inflation, and population growth.
    This request responds to the long-standing recommendations of 
tribal leaders shared in consultation with HHS and IHS to make IHS 
funding mandatory, and IHS will continue consulting with tribes to 
inform future policy and budget requests.
                 prioritizing high quality health care
    In fiscal year 2023, the budget prioritizes investments that 
advance high quality healthcare and tackle the stark inequities that 
exist in the Indian Health system. This includes a +$243 million 
increase to the Indian Health Care Improvement Fund to provide 
additional health services and address resource disparities across the 
Indian health system. Likewise, the budget prevents a sharp reduction 
in services by providing an additional +$220 million to partially 
sustain the one-time American Rescue Plan Act investments that were 
appropriated to expand access to mental health and substance abuse 
prevention and treatment services, and to expand the public health 
workforce in Indian Country.
    The Budget also includes a +$215 million general increase to 
Hospitals and Health Clinics to expand access to direct healthcare 
services, which would provide an estimated 41 thousand inpatient 
admissions and almost 16 million outpatient visits at IHS and Tribal 
facilities. The Purchased/Referred Care program, which supports the 
purchase of essential healthcare services not available in IHS and 
Tribal healthcare facilities, is expanded by +$206 million, providing 
an estimated 7,333 additional inpatient admissions; 182,319 additional 
outpatient visits; and 8,006 additional patient travel trips. This 
Purchased/Referred Care increase would also support establishment of an 
Arizona statewide Purchased/Referred Care Designation Area, as directed 
in the Indian Health Care Improvement Act, which will expand access to 
care for over 67,000 IHS patients in Arizona. The Budget also expands 
dental health services by supporting an additional estimated 1 million 
dental visits in fiscal year 2023 through a +$48 million investment. 
Expansion of these programs is essential to ensure that IHS can provide 
high quality medical services and support critical healthcare services 
through contracts with hospitals and other healthcare providers to 
purchase specialized or critical care when IHS and tribally-managed 
facilities are unable to provide the services directly.
    In addition, Current Services, which offset the rising costs of 
providing direct healthcare services, are fully funded at +$207 
million. These resources will help the IHS to maintain services at the 
fiscal year 2022 levels by shoring up base operating budgets of IHS, 
Tribal, and urban Indian health programs in the face of increasing 
costs. Similarly, +$102 million is provided to fully fund staffing and 
operating costs for eight newly-constructed or expanded healthcare 
facilities. These funds support the staffing packages for new or 
expanded facilities, which will expand the availability of direct 
healthcare services in areas where existing healthcare capacity is 
overextended.
    The budget also makes targeted investments to address our Nation's 
most pressing public health challenges, which disproportionately impact 
American Indian and Alaska Native communities. This includes HIV and 
Hepatitis C (+$47 million), improving maternal health (+$4 million), 
and addressing opioid use (+$9 million).
    IHS also recognizes the importance of providing culturally 
competent care to American Indians and Alaska Natives who live off-
reservation or in urban areas. To address this, the Urban Indian Health 
Program is expanded by +$27 million to provide additional culturally 
competent direct healthcare services through a network of 41 Urban 
Indian Organizations located in urban areas across the country. This 
investment will provide an estimated 1.1 additional million healthcare, 
outreach, and referral services to urban Indian users in fiscal year 
2023.
    In fiscal year 2023, the budget also makes numerous investments in 
high priority areas, such as recruitment and retention of high quality 
health professionals, expansion of the successful National Community 
Health Aide Program, expanding emergency medical services, and other 
activities that support high quality healthcare.
    While these fiscal year 2023 investments will make significant 
progress to address the most urgent healthcare needs, further growth is 
needed to address sustained underfunding of the Indian Health system 
that has resulted in documented gaps in funding and service provision. 
Over 5 years, from fiscal year 2024 to fiscal year 2028, the budget 
grows to address the funding gap for direct healthcare services 
documented in the fiscal year 2018 level of need funded analysis.\3\ 
The level of need gap analysis calculated $11.2 billion as the point in 
time estimated funding shortfall identified for a baseline of health 
services in fiscal year 2018. This funding increase would be 
distributed across the IHS funding lines that provide direct healthcare 
services, ensuring a broad benefit of this investment for all tribes, 
while also seeking to address funding disparities within the Indian 
Health system.
---------------------------------------------------------------------------
    \3\ (FY) 2018 Indian Health Care Improvement Fund Workgroup Interim 
Report https://www.ihs.gov/sites/ihcif/themes/responsive2017/
display_objects/documents/2018/2018_IHCIF_WorkgroupInterimReport.pdf
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                  modernizing critical infrastructure
    In addition to funding for direct healthcare services, additional 
investments are needed to address substantial deficiencies in physical 
and information technology infrastructure across the IHS system. 
Outdated infrastructure can pose challenges in safely providing patient 
care, recruiting and retaining staff, and meeting accreditation 
standards. From fiscal year 2023 through fiscal year 2028, the budget 
includes critical funding increases to reduce or eliminate existing 
facilities backlogs and modernize the IHS Electronic Health Record 
(EHR).
    Specifically, the budget provides $285 million in fiscal year 2023 
and +$6 billion from fiscal year 2024 to fiscal year 2028 to stabilize 
the current system and replace IHS's EHR with a modernized system. The 
current IHS EHR is over 50 years old, and the GAO identifies it as one 
of the 10 most critical Federal legacy systems in need of 
modernization. The IHS relies on its EHR for all aspects of patient 
care, including the patient record, prescriptions, care referrals, and 
billing public and private insurance for over $1 billion reimbursable 
healthcare services annually. The EHR holds an extremely high degree of 
mission criticality given the ability to provide much-anticipated 
clinical and administrative capabilities used in modern systems for the 
delivery of timely and impactful healthcare. Expected benefits from 
adopting and implementing a modernized system include, but are not 
limited to, improved patient safety, improved patient outcomes, better 
disease management, enhanced population health, improved clinical 
quality measures, opioid tracking, patient data exchange, third party 
revenue generation, and agency performance reporting. Additionally, the 
new system will be interoperable with the Department of Veterans 
Affairs, Department of Defense, tribal and urban Indian health 
programs, academic affiliates, and community partners, many of whom are 
on different health information technology platforms.
    The IHS system also faces substantial physical infrastructure 
challenges--IHS hospitals are approximately 40 years old on average, 
which is almost four times the age of the average hospital in the 
United States. Infrastructure deficiencies directly contribute to 
poorer health outcomes for American Indians and Alaska Natives. The 
Budget addresses these needs by fully fund the 1993 Health Care 
Facilities Construction Priority list. The remaining projects on the 
list include the Phoenix Indian Medical Center, Phoenix, AZ; Whiteriver 
Hospital, Whiteriver, AZ; Gallup Indian Medical Center, Gallup, NM; 
Albuquerque West Health Center, Albuquerque, NM; Albuquerque Central 
Health Center, Albuquerque, NM; and Sells Health Center, Sells, AZ.
    Furthermore, the budget includes $102 million in fiscal year 2023 
and +$454 million over 5 years, from fiscal year 2024 to fiscal year 
2028, to ensure IHS can replace medical and laboratory equipment at the 
end of its six to eight-year life cycle. Many IHS hospital 
administrators reported that old or inadequate physical environments 
challenged their ability to provide quality care and maintain 
compliance with the Medicare Hospital Conditions of Participation. The 
administrators also reported that aging buildings and equipment is a 
major challenge impacting recruitment and retention of clinicians.
    Maintaining reliable and efficient buildings is also challenge as 
existing healthcare facilities age and the costs to operate and 
properly maintain healthcare facilities increases. Many IHS and Tribal 
healthcare facilities are operating at or beyond capacity, and their 
designs are not efficient in the context of modern healthcare delivery. 
In fiscal year 2023, the Budget tackles this challenge by including a 
+$172 million increase for maintenance and improvement to reduce the 
Backlog of Essential Maintenance, Alteration, and Repair, as well as 
routine maintenance and repair to sustain the condition of Federal and 
Tribal healthcare facilities, and environmental compliance projects to 
meet changing healthcare delivery needs. The Budget proposes to fully 
fund all existing projects by fiscal year 2028.
    Lastly, the IHS is grateful for the additional $3.5 billion in 
Sanitation Facilities Construction funding provided by the 
Infrastructure Investment and Jobs Act (IIJA). These funds will make a 
transformational impact in shoring up essential sanitation facilities 
across Indian Country. In order to maintain existing project completion 
deadlines and support IHS and Tribes in successfully implementing IIJA 
resources, the budget includes +$49 million to support implementation 
of the $3.5 billion provided by the IIJA for Sanitation Facilities 
Construction (SFC). This funding will support additional salary, 
expenses, and administrative costs beyond the 3 percent allowed in the 
IIJA. These funds would also be available to Tribal Health Programs, 
which is not currently permissible under the 3 percent set-aside for 
administrative costs in the IIJA.
    The budget also proposes a new $18 million program to recruit and 
retain new public health engineers by partnering with colleges and 
universities to implement a scholarship program with service 
requirements in support of Sanitation Facilities Construction projects 
across Indian Country. The IHS owns over 10.2 million square feet of 
facilities across 2,119 buildings and 1,758 acres of Federal and trust 
land. The nature of this space varies from sophisticated medical 
centers to residential units and utility plants. Facilities range in 
age from less than 1 year to more than 167 years. A professional and 
fully- functional workforce is essential to ensure effective and 
efficient operations.
                     supporting self-determination
    IHS continues to support the self-determination of tribes to 
operate their own health programs. Tribal leaders and members are best 
positioned to understand the priorities and needs of their local 
communities. The amount of the IHS budget that is administered directly 
by tribes through Indian Self-Determination and Education Assistance 
Act contracts and compacts has grown over time, with over 60 percent of 
IHS funding currently administered directly by tribes. Tribes design 
and manage the delivery of individual and community health services 
through 22 hospitals, 319 health centers, 552 ambulatory clinics, 79 
health stations, 146 Alaska village clinics, and 8 school health 
centers across Indian Country. In recognition of this, the budget 
includes a mandatory indefinite appropriation for Contract Support 
Costs and Section 105(l) lease agreements with estimated funding levels 
of $1.1 billion for Contract Support Costs and $150 million for Section 
105(l) Lease Agreements in fiscal year 2023. The budget maintains 
indefinite mandatory funding for these accounts across the 10-year 
budget window to ensure these payments to tribes are fully funded.
          covid-19 response and future emergency preparedness
    Throughout the COVID-19 pandemic, the IHS has made incredible 
achievements to save lives and improve the health of American Indian 
and Alaska Natives across the nation. The IHS has worked closely with 
our Tribal and Urban Indian Organization 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.
    However, it is clear that COVID-19 has disproportionally impacted 
American Indian and Alaska Natives. Deficiencies in public health 
infrastructure exacerbated the impact of COVID-19 on American Indians 
and Alaska Natives. Based on data from 14 states, age-adjusted COVID-19 
associated mortality among American Indians and Alaska Natives was 1.8 
times that of non- Hispanic Whites. In 23 states with adequate race and 
ethnicity data, the cumulative incidence of laboratory-confirmed COVID-
19 among American Indians and Alaska Natives was 3.5 times that of non-
Hispanic Whites. In the state of Montana, COVID-19 incidence and 
mortality rates among American Indian and Alaska Natives were 2.2 and 
3.8 times those among White persons, respectively. The CDC has also 
reported that 1 in every 168 American Indian and Alaska Native Children 
experienced the death of a parent or primary caregiver due to COVID-19, 
4.5 times more likely than non-Hispanic White children.
    The budget's proposed investments proposed in direct services and 
infrastructure will make substantial progress toward ensuring these 
stark disparities are not repeated in future pandemics. Additionally, 
to ensure that the IHS is prepared for future emergencies, the budget 
requests +$10 million for emergency preparedness activities at IHS 
Headquarters and Area offices to establish a dedicated emergency 
preparedness workforce at IHS and support relevant training and 
capacity building efforts. These additional resources will ensure IHS 
has adequate emergency preparedness capacity to serve American Indian 
and Alaska Native communities during future public health emergencies.
                                closing
    The fiscal year 2023 budget makes bold strides toward the goal of 
ensuring stable and predictable funding to improve the overall health 
status of for American Indian and Alaska Natives. The budget is a 
historic first step and the start of an ongoing conversation with 
tribes to ensure the IHS system is meeting the healthcare needs in 
Indian Country. HHS looks forward to working in consultation with 
tribes, urban Indian organizations, and Congress to refine this 
historic proposal through the legislative process to achieve sustained 
improvements in health status and strengthen the Nation-to-Nation 
relationship.

    Senator Merkley. Thank you very much, and with your 
agreement, we'll put your entire written testimony into the 
record. No objections on the committee, so ordered.
    And let's start with this question of the mandatory 
funding. So it certainly does relate to having stable and 
predictable budget, but as I mentioned in my initial testimony, 
there's always some reservation on Capitol Hill to forego the 
oversight function, and this is set up as a structure for a 10-
year period, and it's quite different from the advanced 
appropriation request that I championed last year at the 
request of IHS and that we supported in our Senate bill.

                         ADVANCE APPROPRIATIONS

    We ultimately did not get agreement on the final 
negotiations between the four corners, the final decision-
makers, but I thought that that had a lot of merit to make sure 
Indian Health Services did not shut down during an government 
shutdown which was a previous significant problem.
    Is it the case that the Administration is dropping its 
request for advanced appropriations in favor of the 
reclassification of mandatory spending?
    Ms. Fowler. So the mandatory proposal for the Indian Health 
Service, if enacted, would eliminate the need for advanced 
appropriations for the agency.

                        CONGRESSIONAL OVERSIGHT

    Senator Merkley. Okay. So the answer is yes, and how would 
you envision that there would be any congressional oversight 
under that structure?
    Ms. Fowler. We understand that if the mandatory proposal 
were to be enacted, that we would fall under the jurisdiction 
of our authorizing committees which we would work with in an 
oversight role, but we also understand the need to continue to 
be responsive to the Appropriations Committees, as well, and we 
would be happy to work with the Appropriations Committees on 
any questions or inquiries or any interests that they have in 
continuing to review our budget and request information from 
us.
    Senator Merkley. So in partnership with our colleagues from 
Indian Affairs, we've been trying to schedule a meeting with 
OMB and IHS to explore the technical details and there's not 
been a responsive communication from the Administration.
    So can we get your assurances that this meeting will happen 
shortly?
    Ms. Fowler. Yes, as I understand, OMB will be leading a 
briefing that we anticipate will occur next week.
    Senator Merkley. Okay. Great. Because if the Administration 
is not responsive, then it's clear it's not a serious proposal 
and so we're ready to dive into the details and explore it, but 
we need the partnership from the Executive Branch in that 
regard.

                            COVID PREVALENCE

    So let's turn to COVID. So the positive test rate remains 
high, and we are seeing across the country stagnating vaccine 
rates.
    Are we seeing the same trends across Indian Country?
    Ms. Fowler. We are. We are seeing higher positivity rates, 
but we believe that is from more patients coming in who are 
symptomatic for testing but a lower volume of testing and so as 
an example, in January there were 12,000 COVID tests performed 
and in April there were 2,000 tests performed. So the positive 
test results combined with the lower denominator is resulting 
in a higher positivity rate.
    Senator Merkley. That makes sense. Thank you for explaining 
that.

                    COVID VACCINES AND THERAPEUTICS

    And the Administration has requested $22.5 billion for 
COVID response and there was no specific request for IHS, but 
it's my understanding that the funding requested by HHS, Health 
and Human Services, that a certain share would be transferred 
to IHS. Is that your understanding, as well?
    Ms. Fowler. Yes, IHS is a jurisdiction that receives 
vaccines and therapeutics from the HHS.
    Senator Merkley. Okay. Do you know how much would be 
transferred under the Administration's vision?
    Ms. Fowler. It's not a funding amount that gets 
transferred. We receive the vaccines directly and we receive 
the therapeutics and some supplies directly.
    Senator Merkley. So let's talk about the therapeutics. 
We've got a couple companies that have produced pills, Merck 
and Pfizer that seem to be significant.
    Are these pills being currently distributed to IHS 
facilities? Do people who need those therapeutics, can they 
readily access them?
    Ms. Fowler. Yes, currently we are able to meet 100 percent 
of the demand from the IHS, Tribal, and Urban Facilities that 
are requesting those therapeutics.
    Senator Merkley. You are requesting therapeutics?
    Ms. Fowler. I said we're able to meet 100 percent of the 
demand from those facilities that are requesting therapeutics.
    Senator Merkley. Okay. Great. We've seen interesting 
reports across the nation from health care clinics that 
essentially have had the therapeutics, but they don't even 
prescribe them when people come in. It's been a strange 
arrangement where we've got a tool that can be very helpful and 
when a person is early in the phase of the infection and not 
necessarily being fully utilized.
    I'm not talking about Indian Health Service specifically, 
more health services more broadly.

                   WARM SPRINGS WATER INFRASTRUCTURE

    Let me turn to Warm Springs water infrastructure, and as 
we've discussed in the past, they've got an ancient system of 
pipes. The pressure gauges are always breaking or pressure 
control valves. The pipes are splitting. It's just the 
contamination results in a lot of the times the water simply is 
unsafe to drink. They've been under the continuous boil 
notices, meaning they have to boil their water to drink it.
    So we are really pleased that the infrastructure bill had 
$3.5 billion to clear the backlog on the sanitation 
deficiencies list at the time of passage and we're looking 
forward to seeing the projects actually get done.
    Do you have a timeline for the Warm Springs project?
    Ms. Fowler. So the last time we talked, there was a 
preliminary engineering assessment that was going to be 
completed, which has been completed. We now know that the 
project will cost roughly $24 million to complete. It is a Tier 
1 project. So we do anticipate that it will be funded with 
fiscal year 2022 funding, whether from the Infrastructure 
Investment and Jobs Act funding or the annual appropriation.
    As I understand it, it will take 30 to 36 months to 
complete once we have the funding available for the project, 
which we anticipate will be very soon.
    Senator Merkley. Great. Is very soon like within the next 
couple weeks?
    Ms. Fowler. I would think so, yes.
    Senator Merkley. Can you personally keep me briefed on 
this? It's so important to the Warm Springs Tribe in my state.
    Ms. Fowler. Yes.
    Senator Merkley. Thank you very much.
    I'll turn to Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman.

                     CHANGE IN IHS BUDGET PROPOSALS

    Ms. Fowler, I'd like to go back to the discussion that the 
Chairman has raised about mandatory versus the discretionary. 
You confirmed to him that in fact the Administration has now 
decided to take an approach on mandatory as opposed to the 
advanced appropriation, and you indicated that, well, if we 
move to mandatory, that means that we don't have to look to 
advanced appropriations.
    But I guess I'm trying to understand why, why the 
Administration chose to move in this direction instead of 
proposing advanced appropriations again.
    Ms. Fowler. Thank you, Senator Murkowski.
    I'm just going to be frank here. The Indian Health System 
needs substantial funding to meet the needs that are out there 
in Indian Country, and we're not able to accomplish that within 
the discretionary spending caps on the mandatory side of the 
budget as has been proposed for fiscal year 2023 and the 10-
year timeframe.
    We're proposing that the budget will grow by almost 300 
percent over that 10-year period, and so we believe that it is 
an approach that is more suitable for funding Indian health 
care.

                 MANDATORY FUNDING LEGISLATIVE PROPOSAL

    Senator Murkowski. Well, as I mentioned in my statement and 
as I have said over the years, I believe that IHS has been 
chronically underfunded and we need to make improvements.
    You and I both noted in our comments that those 
improvements over the years have been dramatic in terms of the 
funding, but with funding also comes the role of oversight and 
that's where the committees come in.
    I am in that enviable position, maybe it's not so enviable, 
maybe it's just more responsibility, but I am not only the 
appropriator for IHS as the Ranking Member on this subcommittee 
but I'm also the authorizer as the Ranking Member on Indian 
Affairs Committee, and so I appreciate what you've shared that 
there's going to be a meeting with OMB coming up.
    This is the first that I have heard of it. I'm asking my 
staff to confirm whether they have been notified of any such 
meeting because so far as I know, there is no legislative 
proposal out there in terms of new authorizing language to 
account for this shift and what we're trying to figure out here 
is whether or not you have identified how you're going to be 
paying for the shift to mandatory appropriations.
    At what point do you expect that you will send to the 
Indian Affairs Committee a legislative proposal to mark up a 
mandatory funding bill for fiscal year 2023?
    Ms. Fowler. I know that there's a supporting document that 
is under development. I will have to get back to you on that 
timeframe of when we'll be able to submit it.
    Senator Murkowski. So I guess I have to admit a little bit 
of confusion here because what we've got is technically there's 
no discretionary appropriations language or money proposed for 
fiscal year 2023. The discretionary funding levels for the IHS 
in fiscal year 2022 was $6.6 billion.
    So in theory, if there's not a discretionary proposal for 
the Interior bill this year, there's $6.6 billion that is 
currently unaccounted for.
    So, Mr. Chairman, we're looking here at $6.6 billion in 
base Indian Health Service funding that can't be used by an 
authorizing committee to pay for mandatory funding on an annual 
basis. It certainly wouldn't cover the scoring for a 10-year 
window that you've just noted, but it's also been 2 months now 
since the budget was released.
    The end of the fiscal year is a little over four and a half 
months away. So the clock is ticking here. So if you're 
planning on sending this plan up, I don't see how you're giving 
us the time as whether we are authorizing or whether we are 
appropriating to consider this in a way that is viewed as a 
serious proposal, and so I share the Chairman's concern here 
that if this is serious coming from the Administration, if we 
recognize that we've got to be doing this together, you've got 
to be working with us a little bit more instead of coming to a 
hearing and saying, well, we're going to sit down and talk with 
you about what the plan is.
    We are in the midst now of these budget and appropriations 
discussions. So I don't know. Is it your proposal that there be 
no IHS title in the fiscal year 2023 Interior appropriations 
bill this year?
    Ms. Fowler. That is the proposal, yes.
    Senator Murkowski. So there would be nothing in the IHS 
title?
    Ms. Fowler. Correct.

                   APPROPRIATIONS COMMITTEE OVERSIGHT

    Senator Murkowski. So oversight again absolutely key to 
everything that we do around here. In fairness, I don't think 
we do enough of it, but I think that this is one of the areas 
within the Appropriations Committee where we are able to do 
active oversight.
    Will you commit to answering questions from this 
Appropriations Subcommittee even though you would propose to 
delete the discretionary account from the Interior bill?
    Ms. Fowler. Yes, we will commit to that.

                      CONTRACT SUPPORT COSTS (CSC)

    Senator Murkowski. Let me ask about contract support costs. 
I've raised the issue of the decision in Cook Inlet Tribal and 
the Fort Defiance letter. There's a lot of questions and 
concerns. Again, we received your response last week, but 
there's still some things that I need some clarification on.
    For the record, in your letter you state that ``the agency 
interprets the Cook Inlet decision and the Fort Defiance letter 
as a restatement of current law and practice.'' You also say 
that ``the IHS will maintain current methods for calculating 
CSC and that there's no plan to change any of the 
calculations.''
    So the question that I would have for you this morning is 
are both of those statements correct and would you support 
codifying current practice in legislative text if you would 
agree that those statements are correct?
    Ms. Fowler. I agree that the statements are correct. We're 
not changing any method of calculating contract support costs 
as a result of the Cook Inlet decision. We believe the Cook 
Inlet decision affirms current statute, and current 
interpretation of the statute, and therefore we believe that 
there's not a reason to codify the current practice of 
calculating contract support costs.
    Senator Murkowski. So there's some buzz out there that this 
may be a situation where Cook Inlet was just one example. In 
the case of the Fort Defiance letter, it stated that the 
``Federal Government errantly overpaid CSC in prior years and 
were seeking to correct it.''
    So the discussion that is out there is whether or not the 
Fort Defiance issue is the only example where the Federal 
Government errantly overpaid. So the question that I would have 
of you is whether you know if this is the only instance in 
which IHS has made overpayments and whether or not you 
conducted any type of an analysis that would lead you to that 
conclusion.
    Ms. Fowler. So there's a process for reconciling contract 
support costs owed to tribes. We're required to fully pay the 
amount of contract support costs required for a tribal 
contract.
    During that process of reconciliation, sometimes there are 
overpayments that are identified. Sometimes there are 
underpayments that are identified. The tribe can bring a 
Contract Disputes Act claim for an underpayment, and IHS can do 
the same for an overpayment, and there are other instances 
where the Indian Health Service has identified overpayments of 
contract support costs and has sought repayment or has sought 
to reconcile the overpayment through the means that are 
available to us.
    Senator Murkowski. So, Mr. Chairman, my time is well over. 
I may come back to this because I'm trying to determine whether 
or not there's been any type of a comprehensive analysis of 
whether or not overpayments are at issue and the extent of 
that.
    I'll defer now to my colleague.
    Senator Merkley. Thank you.

                   SANITATION AND FACILITIES PROJECTS

    Senator Heinrich.
    Senator Heinrich. Thank you, Chairman.
    Ms. Fowler, there are literally hundreds of projects 
representing over $3.3 billion on the IHS fiscal year 2021 
Annual Report of Sanitation Deficiency Levels. Projects in my 
state alone represent nearly $200 million in water and 
sanitation projects.
    As you know, Congress included a total of $3.5 billion for 
the IHS Sanitation and Facilities Account to be spent over the 
next 5 years in the infrastructure law.
    Walk us through what the current status of actually getting 
that funding on the ground and how IHS is preparing agency 
personnel and resources to get those projects on that list 
built.
    Ms. Fowler. Thank you, Senator.
    When the Infrastructure Investment and Jobs Act was passed, 
Indian Health Service quickly planned and implemented a 
consultation process on an allocation method for that funding. 
We held some sessions in December and a session in January. So 
we held several consultation sessions on the funding.
    Once those sessions were completed, we compiled the 
comments. We reviewed the comments and considered every piece 
of input that we had received from the tribes. We then began 
working on a spend plan.
    We also worked on a spend plan for the administrative 
portion of the funding and working to identify what staffing 
resources were going to be needed in order to implement the 
funding and worked to identify how we were going to hire that 
many staff. It's a considerable number that are going to be 
needed. And so we had a couple of different tracks that were 
moving, proceeding.
    We're at the point now where our spend plan for the 
projects is in the last stage of review, and we anticipate that 
we'll be able to announce the decision that we made for which 
projects are going to be funded with the fiscal year 2022 
portion of the $3.5 billion very soon.
    We are also putting----
    Senator Heinrich. How much will that represent in actual 
projects? Do you have a dollar figure yet?
    Ms. Fowler. Let's see. It's $700 million per year and then 
there's three percent--sorry. I'm going to ask my Chief 
Financial Officer. She probably has the numbers at her 
fingertips.
    MS. CURTIS: Certainly. We do expect that the bulk majority 
of the resources will be used specifically for project 
construction. There is the $21 million for admin, of course, 
and then the small portion of funding that goes to the OIG who 
we have already started engaging with on oversight issues, but 
we expect----
    Senator Heinrich. So you're planning to largely just split 
it up equally over the 5 years?
    MS. CURTIS: Since we received the same $700 million each 
year, we will take a similar approach each year.

                   TIMELINE FOR PROJECT CONSTRUCTION

    Senator Heinrich. Okay. How soon do you think we can see 
actual work on the ground within the projects that you've 
selected? Not trying to micromanage which projects make it into 
that first tranche, but when are we going to see the actual 
work begin?
    Ms. Fowler. I would say actual construction is actually 
going to take some time. It's going to take several months 
because even the Tier 1 projects, which are ready to fund, 
still require some additional documentation to be completed and 
so that will take some months to complete.
    So before actual construction and on the groundwork begins, 
I would say it's going to be into next year before that even 
begins on any project.

                         ALBUQUERQUE IHS SYSTEM

    Senator Heinrich. Okay. Let me shift gears to over the 
course of the last year, the Albuquerque area IHS System closed 
two hospital intensive care units, one at Acoma-Canoncito-
Laguna, another at Mescalero. They did that citing lack of 
resources as a contributing factor to the closures, and IHS has 
now decreased service in both locations to only business hour 
urgent care centers.
    As you know, Congress has passed historic funding for the 
IHS through CARES, through the American Rescue Plan, and this 
budget also increases overall funding for the IHS.
    So I'm trying to reconcile the disconnect between the 
historic funding that we've passed in the last 2 years, the 
increase in the current budget, the increase that we heard of 
about over the course of the last 5 years, and the disconnect 
between that and the lack of service at Acoma-Canoncito-Laguna 
and at the Mescalero site.
    Why are we seeing those reductions in services at the same 
time we're increasing overall funding?
    Ms. Fowler. Let me start with the Acoma-Canoncito-Laguna 
facility. The lack of resources there was the result of two of 
the three tribes withdrawing and seeking to manage their own 
health care programs under the Indian Self-Determination and 
Education Assistance Act.
    Senator Heinrich. The 638 Program?
    Ms. Fowler. Yes, the 638. So the resources that were left 
that were the Pueblo Acoma share of that funding of that 
hospital was not enough to sustain an inpatient facility and so 
we did use CARES Act funding. We did use some supplemental 
funding to maintain operation, ER and inpatient services, at 
that facility for a year beyond the intended closure of the 
facility, but at that point there were no other resources that 
were available to us to continue those services.
    The Mescalero facility, the issue there is the inpatient 
census had been decreasing to the point that we could not 
accomplish accreditation as an inpatient facility.
    The Joint Commission would not survey the facility as an 
inpatient facility because there were not enough inpatients 
that it would consider it to be a hospital at that point.
    I don't think that that is unusual in very rural areas of 
the country, and so we started to consider what is the best way 
to continue to ensure access to primary health care for the 
tribal members who reside in that location and taking the 
resources, running an inpatient facility is very expensive 
because you have the 24-hour support that's needed, and so we 
began to consider what is the best approach for some of our 
hospitals that were unable to achieve that accreditation that's 
necessary and also to assure the quality and safety of the care 
that's being provided.
    And so we chose to shift to the urgent care model and the 
primary health care availability during the normal business 
hours of the clinic.
    Senator Heinrich. Thank you, Chairman.
    Senator Merkley. Senator Van Hollen.

                    AMERICAN INDIANS IN URBAN AREAS

    Senator Van Hollen. Thank you, Mr. Chairman.
    Ms. Fowler, it's great to have you here and it's great to 
have a University of Maryland alum.
    Let me turn to the issue of American Indians in urban areas 
because in the state of Maryland, we have 40,000 individuals 
who identify themselves as American Indian or part American 
Indian and nearly half of that population resides in Baltimore, 
and as you know nationally seven out of 10 American Indian or 
Alaska Native people reside in urban areas.
    In my view, this is a population that has not received the 
attention or services that are deserved. That's why earlier 
this year Senator Padilla and I and a few others wrote to the 
President and the Vice President asking the Administration to 
form an Urban Indian Interagency Workgroup. We've not gotten a 
response yet. So my opportunity is to ask you about this.
    Would you support the creation of such a workgroup and work 
with us to focus more closely on the needs of American Indians 
in urban areas?
    Ms. Fowler. The Indian Health Service considers urban 
Indian organizations to be a vital component of the Indian 
Health System, and we would gladly participate and support any 
interagency efforts to address health care for urban Indians.
    Senator Van Hollen. Well, if you could do me a favor, we 
can give you a copy of this letter that was sent by a number of 
Senators, we would like a formal response from the 
Administration as to whether they support our request to 
establish this kind of workgroup which we think would be 
important. Can you do that for us?
    Ms. Fowler. Yes, we will.

                 SUPREME COURT DECISION ON ROE V. WADE

    Senator Van Hollen. All right. As you know, there's lots of 
concern and uncertainty with the real prospect the Supreme 
Court could overturn Roe v. Wade. We don't know what the final 
decision is but that's certainly what the draft decision 
indicates.
    As you know, the Indian Health Services are the sole 
providers in many cases of reproductive health services to 
American Indian populations.
    We also know that the Hyde Amendment has restricted the 
ability of many of these women to obtain reproductive services. 
We also know that in the cases of rape where the Hyde Amendment 
does permit the use of these funds that has to be reported to 
the police within 60 days, and we also know and Senator 
Murkowski and others have highlighted the fact that American 
Indian women have been especially vulnerable and targeted for 
violent crime, including rape.
    So I guess my question to you is if the Supreme Court 
decision does knock out the right to an abortion pursuant to 
Roe v. Wade, what planning do you have in effect to ensure that 
women, including victims of rape, have access to reproductive 
health services?
    Ms. Fowler. Great question. We've actually begun some 
discussions around this topic. I don't have anything specific I 
can share with you today, but we are considering there is some 
regulations specific to the Indian Health Service that we're 
looking at that pertain to this area and our chief medical 
officer will be working with our reproductive health experts on 
reviewing and examining the current Indian Health Service 
policy and considering any updates that will be necessary.
    Senator Van Hollen. Well, I appreciate that. We've been 
looking over the current policy in light of what could come 
from the Supreme Court, and I do think it requires updating to 
ensure that these women have the reproductive health services 
they need.
    I have no further questions. Thank you.
    Senator Merkley. Thank you very much, Senator. It's so rare 
to leave a little bit of time on your clock. Thank you.
    Senator Tester.

                              IHS STAFFING

    Senator Tester. Thank you, Mr. Chairman, and I'll use it. 
So thank you, Senator Van Hollen.
    It's good to have you here. Thank you very much for being 
here in front of the committee.
    What would you say the biggest challenge is for IHS right 
now?
    Ms. Fowler. Staffing.
    Senator Tester. Right answer. Thank you. You didn't have to 
go down this line like I did a few years ago.
    This budget puts significant money, $21 million, 
additional, I believe, is that correct, into staffing? You can 
correct me if I'm wrong. I'm just looking at some notes I've 
made here very quickly.
    Ms. Fowler. Well, when you're referring to staffing, is 
that to hire staff or is that for recruitment and retention?
    Senator Tester. Hopefully that's for both. Is it more than 
that?
    Ms. Fowler. It's more than that.
    Senator Tester. Okay. Good. So the question then that I 
would ask is, is that, I think your priorities are correct in 
this budget. Staffing is a problem. Doctors, nurses. Do you 
have a plan on how to utilize those dollars to get the biggest 
bang for the buck and get the people onboard that you need 
because I think there's a GAO report from a few years back that 
said you were about 25 percent short?
    Ms. Fowler. So the funding that we've requested in the 
President's budget is there are a number of items that are 
included that will be really helpful to us in addressing our 
staff shortages from incentives, additional compensation.
    There's a legislative proposal to exempt our loan repayment 
and scholarship programs from taxes. There is not a provider, 
but we are proposing $18 million to establish a scholarship 
program with payback obligations for engineers.
    Senator Tester. And these are new programs, correct? These 
are programs that you haven't had in the past?
    Ms. Fowler. They're expansion. They're either enhancing our 
current programs. There are some new ones, as well.
    Senator Tester. Okay. So in Montana, for example, it 
doesn't matter if it's Indian Country or if it's in urban 
clinics, we need more people. So how are you going to get out 
to recruit those folks? How are you going to tell them that you 
have these new programs out there available to them and that 
IHS is a good place to work?
    Ms. Fowler. Well, I think that part of the funding that 
we're asking for, if it's enacted, will help us to beef up our 
recruiters so that we can do more work, direct hands-on work 
with students. We're working to increase our residency 
programs.
    We want to get students into the Indian Health Service 
before they graduate, so they'll be interested and come work 
for us. There's actually several strategies that we're already 
employing, we hope to deploy, as well, using the new funding.
    Senator Tester. That's good. My advice is to be as 
aggressive as you possibly can. Otherwise, it's going to be 
hard to make this happen because the doctor shortage is 
everywhere and IHS, because of trust responsibilities we have 
and because it provides health care to people who really need 
health care, we need to make sure we're staffed up.

                             IHS FACILITIES

    Can you talk about the facilities line items in your budget 
a little bit? Are they plussed up because if you don't have 
good facilities, you're not going to be able to recruit doctors 
and nurses? So are the facilities line items plussed up to a 
point where it's adequate and, if so, tell me why?
    Ms. Fowler. Yes, as a matter of fact, the budget proposes 
to complete the Health Care Facilities Construction Priority 
List that was established in 1993 within the first 5 years of 
this 10-year proposal. It will provide an additional $72 
million for our equipment needs so that we can--when we get 
providers who are just coming out of medical school and coming 
to work for us, they're used to some bells and whistles, and 
they don't currently see that within the Indian Health Service.
    So being able to upgrade and keep our equipment updated is 
going to be helpful in that regard.
    Senator Tester. Okay. So you're a hundred percent correct 
and with the increases in budget also comes accountability and 
so I would expect that you guys will be very transparent in how 
you're doing business so that we know that the dollars that are 
appropriated at whatever level gets to the ground because 
there's a lot of need out there, both in staffing and 
facilities, as you already know.

                         ADVANCE APPROPRIATIONS

    Can I ask, IHS did not include advanced appropriations in 
the 2023 budget, is there a reason for that?
    Ms. Fowler. If the mandatory budget proposal is enacted, 
then advanced appropriations will not be necessary because the 
mandatory proposal will automatically appropriate the funding 
each year for the next 10 years.
    Senator Tester. Okay. So are you advocating, just to help 
educate me on this, that this entire budget be mandatory 
funding?
    Ms. Fowler. Yes.
    Senator Tester. What percentage is mandatory funding now?
    Ms. Fowler. Only $147 million for the Special Diabetes 
Program for Indians.
    Senator Tester. How much is the rest of the----
    Ms. Fowler. The total $6 billion budget.
    Senator Tester. And a $147 is mandatory?
    Ms. Fowler. $147.
    Senator Tester. So in the case of a potential government 
shutdown, you guys have to shut down, and if there was 
mandatory funding you would not?
    Ms. Fowler. So let me clarify. Because we provide health 
care, we don't shut down. We're considered excepted. We just 
can't pay our staff if we don't have any other source of 
funding.
    Senator Tester. But that's a problem.
    Ms. Fowler. Yes, it is.
    Senator Tester. Okay. All right. Have you had consultations 
with Indian tribes on the issue of mandatory versus 
discretionary funding?
    Ms. Fowler. Yes, we have.
    Senator Tester. And on advanced appropriations, also?
    Ms. Fowler. We've not consulted on advanced appropriations, 
but we've been hearing for years from tribal leaders that they 
desire advanced appropriations.
    Senator Tester. Okay. All right. Well, I want to thank you 
for being here. Thank you for your knowledge on this budget, 
and I appreciate the opportunity.
    Thank you, Mr. Chairman, Ranking Member Murkowski.
    Senator Merkley. Thank you very much, Senator Tester.

                     BIPARTISAN INFRASTRUCTURE BILL

    I want to turn to the bipartisan infrastructure bill and 
one of the things that is in it is a limit of 3 percent for 
``administrative costs,'' but administrative costs apparently 
includes project critical activities, like the engineering, in 
which case 3 percent doesn't make sense because the engineering 
is often more than that and so like designing a new water 
system is a significant undertaking.
    I don't think of that as administrative costs at all. I 
think of it as a core part of the construction from beginning 
to end to get it designed right.
    So I have pushed for a higher limit of 10 percent on this, 
but from your experience, is this 3 percent limit a problem?
    Ms. Fowler. It is a problem. We do not believe that it will 
fully fund all of the administrative costs that are necessary 
to implement the IIJA funding in a timely way.
    Senator Merkley. Okay. Well, thank you. We want to keep 
working with you to explore that question.
    Maybe the key is that engineering shouldn't be identified 
as an administrative cost. I mean, administrative costs, you 
think of payroll and communications and so forth, but 
engineering is not what I think of in that category.

                       URBAN INDIAN ORGANIZATIONS

    We'll continue that conversation with your team and with 
our colleagues here, and let me turn to the Urban Indian 
Organizations and Senator Van Hollen mentioned the importance 
of that, certainly important in my state of Oregon, and we did 
have the increased funding of--well, it was 17 percent 
increase.
    Did more grants go out to Urban Indian Health Organizations 
as a result?
    Ms. Fowler. We did not fund any more, any additional Urban 
Indian Organizations with that funding, but what it will do is 
allow some of the programs that are currently referral-only 
programs to initiate services, actual clinical services to 
provide the patients.
    Senator Merkley. Okay. I will submit questions for the 
record to better understand how we're spending the additional 
money in that account and understanding how urban Indian 
population is being better served, like what specific changes 
have occurred. Thank you.

                     STUDENT LOAN REPAYMENT PROGRAM

    And Senator Tester raised the issue over staffing, 
significant issue, and one of the things that you testified 
last year was the Student Loan Repayment Program was the most 
effective tool you have in recruiting.
    Have you done specific changes to that program as a result 
of the additional funding for staffing?
    Ms. Fowler. We haven't made changes to the program, but 
what it does is allow us to fund more providers with loan 
repayment. The five million that's provided in fiscal year 2022 
will fund a hundred additional providers.
    Senator Merkley. Okay. So the program remains the same, but 
it remains available at more locations in Indian Country?
    Ms. Fowler. Yes.
    Senator Merkley. Okay. Great. Thank you. Thank you.

                             PROVIDER ABUSE

    I want to turn to the Weber Report and the Weber Report, 
it's a terrible story about how there was a doctor, Dr. Weber, 
who abused children within the Indian Health System and we had 
an independent report that was commissioned by IHS that found 
that officials at the Federal Agency on--I'm quoting now from a 
New York Times article in October ``silenced and punished 
whistleblowers in an effort to protect the doctor who sexually 
abused boys.'' This is like the story we never want to hear.
    Have those individuals who silenced and punished 
whistleblowers been fired?
    Ms. Fowler. So a number of those individuals that were 
involved in the Weber case are no longer with the Indian Health 
Service and any individuals who were found by the Office of 
Inspector General who needed to be disciplined or should be 
disciplined were disciplined.
    Senator Merkley. Can we get details on that?
    Ms. Fowler. To the extent that we're able to provide that 
type of information.
    Senator Merkley. Okay. The report has a number of 
recommendations and other ideas have also been mentioned. So 
I'll just quickly run through them.
    One recommendation of the report was you put in place 
whistleblower protection coordinators at 12 regional offices. 
Have you done this?
    Ms. Fowler. We've not done that yet.
    Senator Merkley. Why not?
    Ms. Fowler. Funding and it's a resource issue.
    Senator Merkley. Hmm. Okay. I am kind of stunned by that 
answer because if we're talking about 12 individuals in a 
system as large as the Indian Health Service to make sure that 
whistleblowers are protected, it seems like it should be a very 
high priority, should it not?
    Ms. Fowler. Well, the approach that we've taken to the 
recommendations, not only to that report but to recommendations 
from the OIG, from the past Administrations, White House Task 
Force on Protecting Children, we've consolidated those 
recommendations.
    There was some overlap, but there are some differences 
amongst those recommendations, as well. We currently have a 
chartered committee that has reviewed each and every one of the 
recommendations, determined that their status of implementation 
within the agency. They're reviewing those recommendations that 
have not been implemented yet, which would include the 
whistleblower coordinators, and they are going to make 
recommendations on the priority for implementing those 
recommendations and whether or not additional resources will be 
required to implement them.
    Senator Merkley. All right. I'll tell you what I think why 
it feels to me like this is such an important question because 
in the medical community, there is a huge reluctance to report 
on the conduct of any other members of the medical community 
and so those who do so, it's very difficult for them to do so, 
and if they are not protected, if they are essentially fired, 
it sends a message that no one else will report and if no one 
else will report, if no one reports, abuse occurs, and so I see 
whistleblower protection as essential.
    Now I will in follow up to this hearing ask about this long 
list of suggestions, and I think one of them you have 
implemented. There is a Hotline in place. There's a number in 
place to call, is there not?
    Ms. Fowler. There is a dedicated Hotline for reporting.
    Senator Merkley. Great. And is that well publicized 
throughout the system now?
    Ms. Fowler. It has been publicized, but we are currently 
planning to increase the visibility of the Hotline and make 
sure that it is well publicized.
    Senator Merkley. Okay. And I'll want to get details on it, 
find out how many--when it went live, how many calls have come 
in, are they being responded to.
    Again, people will be reluctant to call if their careers 
are at risk because they share information, and, you know, we 
have seen this issue that arises in every institution. Yeah. I 
mean, it does so much damage to every single child who is 
abused, for a lifetime, that there has to be a huge priority.
    Another is on training and so I'll want to get details 
about what you've done to implement training for IHS employees 
and contractors. Stronger patient safety protocols that are 
recommended, I'll want to get details on that.
    The preservation of records, which apparently were very 
poorly done in the past, I'll want to get details on that, and 
the Blackfeet Nation in Montana, which was very directly 
affected by Mr. Weber's abuse, is asking for an apology from 
IHS, and I'll want to get details on whether IHS has responded 
to that request or if perhaps you know now, you can tell me.
    Ms. Fowler. I don't know the status of that request.
    Senator Merkley. Okay. Thank you. This should be a huge 
priority. Not one more child should be at risk. I mean, we keep 
seeing these horrific things that occur in organization after 
organization, like, for example, the Olympic Gymnast 
Association, like who would imagine, and so if people who are 
sexual predators know that they will be reported on and that 
those who report will be protected, it dramatically changes the 
situation.

                             IHS MANAGEMENT

    One of the things I was very struck about in this article 
was that it said, ``IHS management ignored or suppressed 
efforts to address this danger.'' Well, when that happens, that 
means more children are abused, like a thousand percent 
unacceptable.
    Ms. Fowler. Senator, I agree with you 100 percent. I 
believe we have taken many steps that are addressing the root 
causes of the failures that occurred in the Weber case. I 
believe we made many improvements and I believe the culture is 
changing within the Indian Health Service, and we're happy to 
provide those additional details.
    Senator Merkley. Thank you.
    Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman, and know that I 
absolutely agree with your concern about this.
    Ms. Fowler, you mentioned that it is a matter of 
resourcing. Yes, it's always about our resourcing, but it's 
also a matter of prioritization, and if this was something that 
had just hit the news and we were responding to it, it's one 
thing, but it's not. It's been out there for awhile and again I 
think this is where I still remain a little bit concerned about 
the approach the Administration is taking with regards to 
moving over to mandatory.
    You have been on the GAO's High Risk List since 2017. I 
mentioned that we are just now at a point where we're going to 
be able to take up the confirmation of the Administrator for 
IHS, and, you know, the fact that maybe it's just a hard 
position to fill. I think it really is. I think it's very, very 
hard, but still it makes me think that the Administration 
doesn't place a high enough priority on it to really try to 
move that, and when you're going to be implementing such a 
really systemic change, when you move an entire, an entire 
Indian Health System to a new approach and you don't have an 
IHS Administrator in place, it makes me question whether or not 
you have the talent that you need, the senior executive team 
that you need to make some really important decisions that will 
need to be implemented and implemented in such a way that it 
gives members who have been around these issues a long time.
    Senator Tester, as you know, was formerly Chairman of the 
Indian Affairs Committee. I've been on the Indian Affairs 
Committee for 20 years now and have served as the Ranking 
Member now several different times.
    These are issues that we all care very deeply about, but 
this is leadership and when leadership is saying a 
whistleblowing protection is not going to be prioritized as it 
needs to be doesn't give me the degree of confidence where I 
can say all right, as the appropriators, we're not going to be 
in there on an annual basis and having the input that the 
appropriators do.
    I appreciate what you said, but you'll come back to the 
committee, but I know for a fact that we oftentimes have to use 
the hammer, if you will, of we're going to bring in front of 
the committee to answer to you about where these funding 
priorities have been.

               FOLLOW-UP IHS MANDATORY PROPOSAL BRIEFING

    I just want to add that I did check with my folks on Indian 
Affairs and have been made aware that OMB is having a tribal 
consultation on the fiscal year 2023 budget with tribes, but 
we're not aware of any other meeting out there and recognize 
that OMB tribal consultation and a meeting to discuss this 
shift to mandatory in my view would be very, very different. So 
again I just raise this to underscore my concern.

                         CONTRACT SUPPORT COSTS

    I was talking about contract support costs before I 
deferred to my colleague here, and I wanted to just ask a 
further question in this vein.
    The issues of contract support costs and the situation with 
Cook Inlet Tribal and Fort Defiance arose during a 
renegotiation. So what guidance have you given tribes or tribal 
organizations who are expected to renegotiate agreements with 
IHS and do you anticipate that those agreements are going to 
have to go through an added level of scrutiny now, now that 
this has all transpired?
    What's the situation with these renegotiations in light of 
Fort Defiance?
    Ms. Fowler. The process for negotiating contract support 
costs is outlined in our Contract Support Cost policy, which 
was developed with a tribal workgroup, tribal Federal 
workgroup, and then we did full consultation on that policy.
    So we do have a policy that has been agreed upon with 
tribes for addressing when a contract is coming to an end, how 
we look at the terms of the contract, including contract 
support costs.
    Senator Murkowski. Including whether or not overpayments 
have been made?
    Ms. Fowler. And it includes a process for reconciling the 
contract support costs because the way the process works, we 
pay contract support costs at the beginning of the period of 
performance, at the beginning of the fiscal year, if that's the 
period of performance, based on the budgeted amounts, and then 
it's reconciled against what the actual contract support costs 
need was once that need is known which is after the end of the 
fiscal year.
    So there's a process in place that where it's routine and 
it's normal to identify whether there's an underpayment or 
overpayment that exists for that contract, for contract support 
costs.
    Senator Murkowski. So you don't see that there would be any 
additional scrutiny or anything that would slow or hinder these 
renegotiations then?
    Ms. Fowler. No additional scrutiny than the current process 
that we currently use.

                          105(L) TRIBAL LEASES

    Senator Murkowski. Okay. Let me ask about 105 tribal lease 
payments. This is something that I raise every year before the 
committee, that and village-built clinics.
    In the fiscal year 2021 Omni, we all agreed to separate out 
the 105(l) costs. We created a separate appropriations account 
similar to what we did with contract support.
    Additionally, there was a general provision that was 
included that directed both IHS and Interior to begin this 
process to establish guidelines regarding the parameters for 
which lease agreements could be structured and paid for.
    But since the 105(l)s have started being paid, we've seen 
estimates really kind of all over the board, I think wildly 
unpredictable, and they have certainly injected some budget 
uncertainty into the process.
    Do you consider that the 105(l) leases are stable and are 
predictable?
    Ms. Fowler. I would say no and that makes it very difficult 
for us to identify the amount that's needed to fund them.
    Senator Murkowski. Which has been a frustration of mine 
because again we've got to figure it out here and we're all 
trying to look into that crystal ball to understand where we're 
going, what is it going to look like, and we've asked for a 
more reliable schedule.
    So then going to the Administration's fiscal year 2023 
mandatory appropriations proposal, you have a $150 million 
proposed there. So is that the current up-to-date estimate for 
the tribal leases because again you and I have both recognized 
we haven't seen a level of stability and it's hard to predict.
    We've seen estimates that are shifting anywhere from $10 
million to $50 million in a matter of months. So what are you 
basing the $150 million on, and do you think that that is a 
figure that you can actually rely on then by the time that IHS 
would submit mandatory funding text?
    Ms. Fowler. So the $150 million was based on the best 
information available at the time. So we don't know what the 
final amount is going to be. We don't know if there are going 
to be any additional tribal leases that are proposed. So it is 
going to be very difficult to provide a firm number for the 
amount that's needed.
    However, we do expect that the amount for both contract 
support costs and the 105(l) lease agreements would remain an 
indefinite appropriation because of the very nature of those 
two funding accounts.
    Senator Murkowski. So, I mean, this has been the challenge, 
is the ability to understand and predict what we can anticipate 
year over year. So if you've got a new account structure, 
105(l) has been separated from the village-built clinics but 
both provide funding for lease agreements.
    So the question for you is whether or not the village-built 
clinics should be funded from the same account as 105(l)s, 
recognizing that they both provide for funding for lease 
agreements, because in last year's Omni we included report 
language for the IHS to include an analysis or a study on the 
funding levels for village-built clinics. We're trying to get a 
handle on that one, as well.
    So your thoughts on whether you separate them out and can 
you tell me where you may be on this report for village-built 
clinics (VBCs)?
    Ms. Fowler. We're currently gathering the information for 
the report, and we do anticipate meeting the deadline that was 
in the bill which I believe was 270 days we were provided.
    Regarding the two programs, village-built clinics, as you 
stated, is separate from the 105(l) lease agreements account. 
It's funded within the services appropriation. It operates in a 
different way. It's under a different authority and so there 
are some village-built clinic leases that are not eligible to 
be funded through a 105(l) lease.
    In addition, there are some tribal programs who prefer to 
continue to have the VBC versus a 105(l) because the VBC leases 
are part of their self-determination agreement on a recurring 
basis, they get paid on a recurring basis, versus the 105(1) 
process which requires a proposal and some negotiation 
regarding what's in the proposal.
    So I think there's going to continue to be a need for both 
the village-built clinics program and the 105(l) lease account.

                       IHS BUDGET PROPOSAL CHANGE

    Senator Murkowski. Well, I don't know. I'm listening to 
this, Mr. Chairman, and the more we have discussions on some of 
these very granular details that are very, very budget-
specific, again it brings me back to what the committee had 
thought was a pretty workable proposal in terms of advanced 
appropriations and so I'm still trying to reconcile with the 
fact that we've seen a pretty dramatic shift in the 
Administration's views on how they want to address the IHS 
budget and moving it completely to mandatory, completely 
eliminating the discretionary aspect of it, and also given that 
there's some very technical things, like we're talking about 
the distinction between the 105Ls and the VBCs, I'm concerned 
about the proposal that we have out there and don't believe 
that it is fleshed out enough.
    Certainly we will look forward to having conversations with 
folks in the Administration.

                    ELECTRONIC HEALTH RECORDS (EHR)

    The last point that I will raise is we've been talking 
about electronic medical records for forever, it seems. Last 
year finally IHS did a data call with tribes and I think that 
that was good, but again we now have to make sure that our 
systems are talking with one another, whether it's IHS through 
VA, which is a big deal for us in Alaska.
    We need to understand who's going to pay for any necessary 
upgrades to the system, whether tribes are responsible for the 
cost or whether IHS is planning to do this. So there's a lot 
more to do with implementation, but again I think that that 
will help with some of the efficiency that we need within IHS.
    Thank you, Mr. Chairman.
    Senator Merkley. Thank you, Senator Murkowski, and I so 
much appreciate your attention to detail on these programs 
because how they get implemented makes a big difference on the 
ground to so many people in Indian Country.

                       PURCHASE AND REFERRED CARE

    I want to note a last issue before we adjourn. I had 
requested information about purchase and referred care, the PRC 
Program, and was supplied with a chart that I'll ask consent to 
put into the record.
    So ordered.
    [The information follows:]
    
    

    Senator Merkley. I looked at it and I just went my 
goodness, this is a nightmare for how a person, a member of a 
tribe in a place like Washington, D.C., accesses medical care, 
and if they have a medical emergency and they have to go to the 
emergency room, they have to give notice within 72 hours after. 
They might still be very, very sick or still be in the hospital 
at that point to have a chance to apply and this chart says, 
you know, the PRC fundings are not sufficient to pay for all 
needed services and so it's basically saying we're not sure 
even if you get a setup, that notice in 72 hours that you're 
going to get helped and this is what's wrong with health care 
in America.
    When accessing medical services requires a complicated 
chart like this going through like, I don't know, what is it, 
about 12 different bubbles of checks and while you're trying to 
recover from an illness or an injury.
    So I will have questions to follow on with about this. One 
of the fellows on my team is a tribal member who has brought to 
my attention this real-life example of here in Washington, 
D.C., that he would have to go to New York or North Carolina to 
receive care or to get a referral to another facility.
    So I will be exploring with you how we can make this system 
work better, and one of the questions I will ask about is 
whether tribal members are given equivalent insurance card to 
be able to submit when they need to get medical services or 
emergency services in a location where there is not an IHS 
facility.

                     ADDITIONAL COMMITTEE QUESTIONS

    So with that, thank you, Senator Murkowski and Members of 
the Committee, and if there are no other statements, the 
hearing record will be open until close of business on May 
18th, 2022.
    Thank you. Thank you, Director Fowler, and thank you, Ms. 
Curtis, for your expertise and hard work to make this system 
work well all across Indian Country.

                          SUBCOMMITTEE RECESS

    [Whereupon, at 11:27 a.m., Wednesday, May 11, the 
subcommittee was recessed to reconvene subject to the call of 
the Chair.]