[Senate Hearing 117-40]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-40

                EXAMINING THE COVID-19 RESPONSE IN NATIVE 
                  COMMUNITIES: NATIVE HEALTH SYSTEMS ONE 
                  YEAR LATER

=======================================================================

                                HEARING

                               BEFORE THE

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 14, 2021

                               __________

         Printed for the use of the Committee on Indian Affairs
         
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


                    U.S. GOVERNMENT PUBLISHING OFFICE                    
45-086 PDF                  WASHINGTON : 2021                     
          
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                      COMMITTEE ON INDIAN AFFAIRS

                     BRIAN SCHATZ, Hawaii, Chairman
                 LISA MURKOWSKI, Alaska, Vice Chairman
MARIA CANTWELL, Washington           JOHN HOEVEN, North Dakota
JON TESTER, Montana                  JAMES LANKFORD, Oklahoma
CATHERINE CORTEZ MASTO, Nevada       STEVE DAINES, Montana
TINA SMITH, Minnesota                MIKE ROUNDS, South Dakota
BEN RAY LUJAN, New Mexico            JERRY MORAN, Kansas
       Jennifer Romero, Majority Staff Director and Chief Counsel
     T. Michael Andrews, Minority Staff Director and Chief Counsel
                           
                           
                           C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on April 14, 2021...................................     1
Statement of Senator Cantwell....................................    44
Statement of Senator Cortez Masto................................    46
Statement of Senator Daines......................................    54
Statement of Senator Hoeven......................................    51
Statement of Senator Lankford....................................    42
Statement of Senator Lujan.......................................    48
Statement of Senator Murkowski...................................     2
Statement of Senator Schatz......................................     1
Statement of Senator Smith.......................................    40

                               Witnesses

Daniels, Sheri-Ann, Ed.D, Executive Director, Papa Ola Lokahi....    28
    Prepared statement...........................................    30
Murillo, Walter, Board President, National Council of Urban 
  Indian Health..................................................    21
    Prepared statement...........................................    23
Onders, Robert, M.D., Administrator, Alaska Native Medical Center    33
    Prepared statement...........................................    34
Smith, Hon. William, Chairperson, National Indian Health Board...     9
    Prepared statement...........................................    11
Toedt, Rear Admiral Michael, M.D., Chief Medical Officer, Indian 
  Health Service.................................................     4
    Prepared statement...........................................     5

                                Appendix

Response to written questions submitted by Hon. Ben Ray Lujan to:
    Hon. William Smith...........................................    65
    Rear Admiral Michael Toedt...................................    63
Response to written questions submitted by Hon. Brian Schatz to 
  Rear Admiral Michael Toedt.....................................    57

 
                  EXAMINING THE COVID-19 RESPONSE IN 
                   NATIVE COMMUNITIES: NATIVE HEALTH 
                         SYSTEMS ONE YEAR LATER

                              ----------                              


                       WEDNESDAY, APRIL 14, 2021


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:43 p.m. in room 
628, Dirksen Senate Office Building, Hon. Brian Schatz, 
Chairman of the Committee, presiding.

            OPENING STATEMENT OF HON. BRIAN SCHATZ, 
                    U.S. SENATOR FROM HAWAII

    The Chairman. Good afternoon.
    Last month, we passed the one-year mark since the World 
Health Organization declared COVID-19 a global pandemic. Two 
dates in March 2020 stand out to me; March 2nd, the first-known 
COVID-19 case documented in a Native community, and March 18th, 
he first known COVID-19 related death of a Native American.
    In just 16 days, everything had changed. The coronavirus 
was no longer an abstract threat; it was real, it was in Native 
communities; and it posed one of the greatest threats to Native 
American health in more than a century.
    Despite decades of underfunding and almost zero access to 
critical pieces of our national health infrastructure, Native 
health systems did their best to rise to the challenge. In 
short order, these systems mobilized and set up one of the most 
complex joint public health emergency responses in our shared 
histories. They rebuilt data and logistics systems. They formed 
new partnerships. They started the rollout of some of the most 
successful vaccine campaigns in the Country, and they continue 
to work every day to keep Native communities safe.
    It really is remarkable how Native health systems have 
overcome long odds, considering how under-resourced they were 
to begin with. It took a global pandemic for us to step up. 
Over the past year, Congress has provided more than $9 billion 
in emergency health supplemental funding for tribes, urban 
Indian organizations, the Indian Health Service and Native 
Hawaiian health systems. Two-thirds of that funding came as a 
direct result of President Biden's American Rescue Plan and 
this Committee's work to enact it. This historic funding is 
proof positive that help is here, that we understand our trust 
responsibilities, that we can do the right thing.
    But this hearing is an opportunity to go one step further, 
to look at the lessons learned one year later, and to improve 
how Federal agencies work with Native communities, so that if 
or when the next pandemic hits, our Native health systems won't 
have quite as steep of a hill to climb.
    Before I turn to the Vice Chair, I want to extend a warm 
welcome and aloha to Dr. Daniels and my thanks to our witnesses 
for joining us today. I look forward to hearing the unique 
perspectives of each of you as we have this conversation.
    Vice Chair Murkowski?

               STATEMENT OF HON. LISA MURKOWSKI, 
                    U.S. SENATOR FROM ALASKA

    Senator Murkowski. Thank you, Mr. Chairman. Naghe nduninyu, 
in the Koyukon Athabaskan language, this means welcome, or even 
better, precious you came. How often do say, it is precious 
that you came? So it is a beautiful way of welcoming.
    I do appreciate the hearing today. As you point out, we are 
a year-plus into this pandemic. We are seeing some positive 
signs, certainly can't let up. Last year at this time, Alaska, 
like so many, was beginning those preliminary steps, the public 
health measures, to work to slow the spread of the virus. But 
for so many of our Native communities, particularly in remote 
villages, that lack basic sanitation infrastructure, where 
there is no running water, no flush toilets, even basic 
safeguards like washing your hands was pretty close to 
impossible.
    This lack of basic resources, what most of us take for 
granted, but this, we certainly believe, helped produce or 
certainly added to the cause of more than 13,000 American 
Indians and Alaska Natives who tested positive for coronavirus 
in Alaska this past year.
    Historically, pandemics have been very hard on our Native 
peoples. Alaska Natives represented 80 percent of Alaska's 
death toll from the 1918 Spanish flu, 80 percent. 
Unfortunately, we continue to see this trend with the 
coronavirus. According to the CDC, American Indians and Alaska 
Natives are among the highest rates of all races to experience 
a death associated with it. In Alaska alone, Alaska Native 
account for 37 percent of the State's total COVID-19 deaths.
    Another complicating factor is the high prevalence for 
serious disease and other health conditions. As you know and 
many of us on this Committee have worked to provide for not 
only the funding but for the reauthorization for the Special 
Diabetes Programs for Indians, we know that we must do more 
when it comes to dealing with health disparities amongst our 
Native peoples.
    The coronavirus pandemic has created major challenges by 
Native health care systems across the Country and revealed 
longstanding deficiencies in infrastructure, resources, and 
staff, which we know we need to work on. It is also important 
to recognize some of the bright spots, and it is important to 
focus on some of the things that have been accomplished in a 
good way.
    Alaska tribes operate their health care system through a 
multi-party compact. They have led the Nation in implementing 
tribal self-governance. The Alaska area also made the decision 
to receive their vaccines through the State rather than IHS. In 
fact, the Alaska Native Medical Center was the first Alaska 
facility to receive the COVID vaccine and two days later, they 
administered its first dose to a long-time physician there.
    With the Alaska Tribal Health Care System, coordinating 
with the State, Alaska has been leading in terms of number of 
vaccinations. Alaska now has 44 percent over the age of 16 that 
are vaccinated with at least one dose, and over 40 percent of 
those vaccinated were administered through the tribal health 
system. In other parts of the State, we have seen some pretty 
incredible numbers. Nearly 59 percent of Yukon Kuskokwim's 
eligible population has received their first dose; half are 
fully vaccinated. In the Bering Straits region, 67 percent of 
eligible adults have received at least one dose.
    So with today's hearing, I think it is going to be helpful 
to know what actions IHS has taken on the pandemic since they 
last testified before this Committee in July, especially with 
the vaccination efforts.
    Then finally, Mr. Chairman, over the last year we have 
heard from Native communities about the ongoing needs 
surrounding maintenance and improvements to existing 
facilities, development of more water and sanitation 
infrastructure, expansion of certain authorities and services, 
including tele-health, to provide better health care. So I look 
forward to hearing more about these needs are going to be 
addressed.
    I would like to briefly introduce two Alaskans that are 
testifying before the Committee today. The first is Dr. Robert 
Onders, who is the Administrator for the Alaska Native Medical 
Center. Dr. Onders is an all-around great guy, let's just put 
it at that. He has provided incredible leadership at ANMC 
during the pandemic.
    We are also fortunate to have the Honorable William Smith, 
who is the National Indian Health Board Chairperson. Mr. Smith 
is an Alaskan, he was born in Cordova. He is Vice President of 
the Valdez Native Tribe. He is a Vietnam veteran, and we 
absolutely thank him for his service and his leadership within 
NIHB as well.
    Mr. Chairman, I have also been made aware that Rear Admiral 
Toedt is retiring after 30 years of service. So we certainly 
want to thank him for his service and congratulations on a 
well-deserved retirement.
    I am looking forward to the comments this afternoon.
    The Chairman. Thank you, Vice Chair Murkowski.
    Are there any members wishing to make an opening statement?
    If not, we will turn to our witnesses. They are Rear 
Admiral Michael Toedt, M.D., Chief Medical Officer of the 
Indian Health Service; the Honorable William Smith, Chairperson 
of the National Indian Health Board; Walter Murillo, Board 
President, National Council of Urban Indian Health; Dr. Sheri-
Ann Daniels, Executive Director, Papa Ola Lokahi, from Hawaii; 
Dr. Robert Onders, Administrator, Alaska Native Medical Center.
    I want to remind our witnesses that your full written 
testimony will be made part of the official hearing record. 
Please keep your statement to no more than five minutes, so 
that members may have time for questions. This is especially 
important because we do have a 3:30 series of votes.
    Rear Admiral Toedt, you may begin.

 STATEMENT OF REAR ADMIRAL MICHAEL TOEDT, M.D., CHIEF MEDICAL 
                 OFFICER, INDIAN HEALTH SERVICE

    Dr. Toedt. Thank you. Good afternoon, Chairman Schatz, Vice 
Chair Murkowski, and members of the Committee. Thank you for 
the opportunity to testify on the Indian Health Service's 
continued efforts to respond to and mitigate the impact of the 
coronavirus in Native communities.
    Over the past year, 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.
    Let me begin by discussing efforts to distribute and 
administer vaccines. IHS, tribal and Urban Indian Organization 
health programs receiving vaccines for distribution through the 
IHS jurisdiction have administered over 1 million doses as of 
April 5th. This achievement is despite the challenges IHS faces 
in terms of the predominantly rural and remote locations we 
serve and the infrastructure challenges those communities face.
    IHS remains committed to vaccine availability for all 
individuals within our health system. I will note that out of 
an abundance of caution, IHS has paused all Johnson and Johnson 
or Janssen vaccine administration. We are doing this to allow 
the FDA and CDC to review data after repots of six female 
recipients in the U.S. developed a rare but severe type of 
blood clot.
    Since mid-December 2020, the IHS has distributed over 1.6 
million vaccine doses of the FDA-authorized COVID-19 vaccines. 
IHS has shipped vaccine directly to 293 IHS, tribal, and urban 
Indian organization health care facilities, and used a hub and 
spoke model to ensure all 352 facilities that are coordinating 
vaccines through the IHS jurisdiction receive those vaccines.
    IHS is grateful to Congress for supporting our efforts 
through the passage of several COVID-19 related laws that 
provided additional resources, authorities and flexibilities 
that have helped the IHS workforce continue to provide critical 
services throughout the pandemic. The American Rescue Plan Act, 
in particular, makes a historic investment in Indian Country. 
The Act provides $6.1 billion in new support funding to IHS, 
tribal, and urban Indian health programs to combat COVID-19, 
expand health services, and recover critical revenues.
    Over the last year, the IHS has marked considerable 
achievements. We developed a COVID-19 data surveillance system 
and an IHS COVID-19 website to share critical health 
information, important COVID-19 vaccine information and 
updates, and we disseminate clinical guidance, training and 
webinars. The IHS National Supply Service Center distributed 
over 84 million units of PPE and other coronavirus-related 
products to IHS, tribal, and urban Indian organization health 
care facilities at no cost, including 2.6 million testing swabs 
and transport media.
    IHS dramatically increased our use of tele-health. IHS is 
currently in the process of procuring an additional cloud-based 
tele-health platform to complement our existing solutions and 
distribute tele-health funds to sites for equipment and devices 
to improve access for more interactive tele-health encounters.
    The pandemic also highlighted the challenges and risks 
posed by our current health IT architecture, which created 
significant barriers to the rapid response needed for COVID-19. 
Our informatics and technology staff made changes to the 
systems for COVID-19 testing, diagnosis, and vaccination 
documentation and reporting. Staff in the field were able to 
implement these changes into clinical workflows. This 
experience has validated and reinforced IHS's commitment to the 
modernization of our health IT infrastructure.
    In addition to supporting tribes to ensure they are able to 
supply water to their communities during the COVID-19 outbreak, 
an important aspect of the IHS COVID-19 response, the IHS 
deployed nine teams of public health service commission corps 
officers in support of the Navajo Nation to improve access to 
safe water points and help ensure a means to safely transport 
water for in-home drinking and cooking.
    As we work toward recovery, we are committed to working 
closely with our stakeholders and understand the importance of 
working with partners during this difficult time.
    Thank you again for the opportunity to speak with you 
today. I am happy to answer questions the Committee may have.
    [The prepared statement of Admiral Toedt follows:]

 Prepared Statement of Rear Admiral Michael Toedt, M.D., Chief Medical 
                     Officer, Indian Health Service
    Good afternoon Chairman Schatz, Vice Chairman Murkowski, and 
Members of the Committee. Thank you for the opportunity to testify on 
the Indian Health Service's (IHS) continued efforts to respond to and 
mitigate the impact of the Coronavirus in Native communities and 
vaccinate Native communities during the Coronavirus pandemic.
Responding to and Mitigating the Impact of the Coronavirus Pandemic
    Over the past year, the IHS has worked closely with our Tribal and 
Urban Indian Organization (UIO) partners, state and local public health 
officials, and our fellow Federal agencies to coordinate a 
comprehensive public health response to the pandemic. Our number one 
priority has been the safety of our IHS patients and staff, as well as 
Tribal community members.
    The IHS continues to play a central role as part of an all-of-
nation approach to prevent, detect, treat, and recover from the COVID-
19 pandemic. We are partnering with other Federal agencies, states, 
Tribes, Tribal organizations, UIOs, universities, and others to deliver 
on that mission. We protect our workforce through education, training, 
and distribution of clinical guidance and personal protective equipment 
(PPE). We also protect our Tribal communities through supporting Tribal 
leaders in making their decisions about community mitigation strategies 
that are responsive to local conditions, and to protect the health and 
safety of Tribal citizens as those communities make plans to safely 
open and return to work.
    While the Indian health system is large and complex, we realize 
that preventing, detecting, treating, and recovering from COVID-19 
requires local expertise. We continue to participate in regular 
conference calls with Tribal and UIO leaders from across the country to 
provide updates, answer questions, and hear their concerns. In 
addition, IHS engages in rapid Tribal Consultation and Urban Confer 
sessions in advance of distributing COVID-19 resources to ensure that 
funds meet the needs of Indian Country.
    I am grateful to Congress for supporting our efforts through the 
passage of the Coronavirus Preparedness and Response Supplemental 
Appropriations Act, 2020; the Families First Coronavirus Response Act; 
the Coronavirus Aid, Relief, and Economic Security (CARES) Act; the 
Paycheck Protection Program and Health Care Enhancement Act, the 
Coronavirus Response and Relief Supplemental Appropriations Act, and 
now the American Rescue Plan Act. These laws have provided additional 
resources, authorities, and flexibilities that have helped the IHS 
workforce continue to provide critical services throughout the pandemic 
and also permitted the IHS to administer over $9 billion to IHS, 
tribal, and urban Indian health programs to prepare for and respond to 
Coronavirus. These resources have helped us expand vaccinations, 
available testing, public health surveillance, and health care 
services. Moreover, they support the distribution of critical medical 
supplies and PPE in response to the pandemic. The American Rescue Plan 
Act in particular makes a historic investment in Indian Country. The 
Act provides $6.1 billion in new funding to support IHS, Tribal, and 
urban Indian health programs to combat COVID-19, expand services, and 
recover critical revenues.
    It has been over a year now that IHS and our dedicated workforce 
has been responding to the COVID-19 Pandemic. Over the last year, the 
IHS has marked considerable achievements. The IHS COVID-19 Incident 
Command Structure was stood up to establish communication protocols to 
ensure comprehensive situational awareness and efficient deployment of 
resources. We instituted reporting mechanisms to become a central 
information repository for the IHS COVID-19 response. We developed a 
COVID-19 data surveillance system and the IHS COVID-19 website to share 
critical health information, important COVID-19 vaccine information and 
updates, and we disseminate clinical guidance, training, and webinars. 
We provide assistance to the IHS and Tribal facilities through Critical 
Care Response Teams and Tele Infection Control Assessment and Response 
assessments.
    We are detecting COVID-19 through screening and state-of-the-art 
lab testing. We have distributed a total of 830 Abbott ID NOW rapid 
point-of-care analyzers, as well as 1.9 million rapid COVID-19 tests. 
The IHS National Supply Service Center (NSSC) has also distributed over 
84 million units of PPE and other Coronavirus response related products 
to IHS, Tribal, and UIO (I/T/U) health care facilities at no cost, 
including 2.6 million testing swabs and transport media. As of April 4, 
2021, we have performed 2,215,027 tests in our American Indian and 
Alaska Native communities. Of those tests, 190,810 (9.3 percent, 
cumulative data) have been positive.
    The IHS increased coordination with Federal partners to streamline 
access for I/T/U supply requests to the Strategic National Stockpile. A 
PPE request tracking system was developed and IHS staff were placed in 
liaison functions to ensure oversight on I/T/U requests. The IHS burn 
rate calculator for tracking PPE has been implemented to improve the 
data quality. A guide on ordering/requests process for Emergency 
Management Points of Contact has been completed and posted for ongoing 
strategic purposes. NSSC has supplied testing kits to all Area 
requests, a new contract with AbbottID has started, and they are 
shipping directly to sites.
    The IHS has a sufficient supply of therapeutic agents currently 
authorized or approved by the FDA for the treatment of COVID-19, 
including remdesivir and the combination monoclonal antibody products, 
and is distributing them to I/T/U health care facilities upon request. 
The IHS National Pharmacy and Therapeutics Committee provides clinical 
guidance to Areas and facilities regarding COVID-19 emerging treatments 
and, through its Pharmacovigilance program, also monitors medication 
safety in our service population.
    During the pandemic, the IHS faced life-threatening medical surges 
that required additional acute care and Intensive Care Unit beds. The 
IHS and U.S. Department of Veterans Affairs (VA), Veterans Health 
Administration, signed an Interagency Agreement that set forth certain 
terms and conditions governing the arrangement for the standardized 
coordination and delivery of health care and other services between VA 
and IHS during disasters, public health incidents, and other 
emergencies.
    We are treating each and every patient with culturally competent, 
patient-centered, relationship-based care. As we look to recovery from 
COVID-19, the IHS is supporting the emotional well- being and mental 
health of its workforce and the communities we serve, providing 
training, education, and access to treatment that draws from the faith 
and traditions of American Indians and Alaska Natives, as well as their 
long history of cultural resilience.
    In April 2020, IHS expanded the use of an Agency-wide 
videoconferencing platform that allows for telehealth on almost any 
Internet-connected device and in any setting, including patients' 
homes. Around the same time IHS also permitted the emergency use of 
certain commonly available mobile apps to enable the provision of 
services remotely while minimizing exposure risk to both patients and 
staff. These authorities, along with the actions taken by the Centers 
for Medicare and Medicaid Services to allow payment for previously non-
billable services, made it possible for IHS to dramatically increase 
our use of telehealth from an average of under 1,300 visits per month 
in early 2020 to a peak of over 40,000 per month in June and July of 
that year. More recent data suggests a plateau of around 30,000 monthly 
telehealth visits. It is important to note that on average, about 80 
percent of telehealth encounters across IHS are conducted using audio 
only, largely related to the limited availability of technologies and 
bandwidth capacity in the communities we serve across the country. IHS 
is currently in the process of procuring an additional cloud-based 
telehealth platform to complement our existing solutions and distribute 
telehealth funds to sites for equipment and devices to improve access 
for more interactive telehealth encounters.
EHR and Facilities Modernization
    As we, the IHS, expanded our use of technology in the telehealth 
area, the pandemic also highlighted the challenges and risks posed by 
the decentralized and distributed health information technology 
architecture currently in use at IHS. While our facilities use a 
capable, nationally certified electronic health record (EHR) system, 
the fact that it is internally developed by IHS and is installed 
separately at hundreds of locations nationwide created significant 
barriers to the rapid response needed for COVID-19. We are extremely 
proud of how our informatics and technology staff made changes to the 
system to support COVID-19 testing, diagnosis, and vaccination 
documentation and reporting, and how the field was able to implement 
these changes into clinical workflows. However, we know that those 
activities would have been much more streamlined in an updated 
technology environment.
    This experience has validated and reinforced IHS' commitment to the 
modernization of our EHR system and health information technology 
infrastructure. IHS is grateful for the funding for EHR modernization 
provided by Congress in the CARES Act, the FY2021 appropriation, and 
the American Rescue Plan Act, which will allow us to proceed with the 
foundational steps in this important multi-year effort. In accordance 
with the language of the FY2021 appropriation, IHS plans to inform the 
appropriate Congressional committees in the near future to outline our 
planned approach to EHR modernization.
    The IHS effort to improve the EHR system underscores the need to 
replace outdated facilities. Aging medical facilities impede medical 
innovation. Modern hospitals are packed with complex equipment with 
high electrical requirements. Contemporary hospitals are designed to 
provide clean, reliable power to ensure that patient care is 
uninterrupted. The difficulty in retrofitting older hospitals with 
modern technology is that the massive concrete structure tends to 
absorb Wi-Fi signals, representing a significant challenge to wireless 
equipment.
    In addition, the pandemic highlighted some of the difficulties that 
older facilities pose to delivering health care services. It is the 
IHS' policy to use the physical environment to help prevent and control 
the spread of infection. This past year has shown that outdated 
facilities' patient flow often did not allow for social separation and 
that waiting areas are not sized or structured for social distancing. 
Optimally, the infected and non-infected would be separated, and 
patients would flow in one direction through the facility. This is not 
possible in some IHS facilities, which resulted in limiting 
appointments, renovation of space, or providing temporary space outside 
of the facility to separate patients.
Vaccinations--Allocations and Administration
    IHS developed a vaccine strategy led by the IHS Incident Command 
Structure and the designated IHS Vaccine Task Force. This effort was 
informed by the Federal Vaccine Response Operation (FVRO) and aligned 
with the Centers for Disease Control and Prevention (CDC), FVRO, and 
Tribal stakeholder input. HHS and IHS participated in Tribal 
consultation and urban Indian confer in development of the plan, and a 
final IHS Vaccine Plan was published on November 18, 2020.
    Working with tribal communities, I/T/U health programs receiving 
vaccines for distribution through the IHS jurisdiction have 
administered 1,029,647 doses as of April 5. This achievement is despite 
the challenges IHS faces in terms of the predominantly rural and remote 
locations we serve and the infrastructure challenges those communities 
face. The IHS reached its goal to administer 1 million COVID-19 
vaccines by the end of March (administering 1,007,002 doses as of March 
31, 2021) after surpassing its goal of administering 400,000 vaccines 
by the end of February. In February and March, 260,000 supplemental 
vaccine doses were sent to Indian Country. IHS remains committed to 
vaccine availability for all individuals within our health system. This 
Federal vaccination effort is possible because of strong partnerships 
with tribal and urban Indian health facilities.At IHS, we know that 
Tribal Nations are in the best position to determine the needs of their 
citizens.
    Information on the number of COVID-19 vaccines administered across 
the IHS can be found at https://covid.cdc.gov/covid-data-tracker/
#vaccinations, and there is a Federal entities section under the map. 
The IHS is working diligently with our CDC partners to report and 
validate vaccine administration data as quickly as possible. IHS 
estimates the current number of people vaccinated may be higher than 
reflected in the validated data on the CDC COVID Tracker. Communicating 
accurate and timely information remains a priority for the IHS.
    Since mid-December 2020, the IHS has distributed 1,562,837 vaccine 
doses of the Food and Drug Administration authorized Pfizer-BioNTech, 
Moderna, and Johnson & Johnson/Janssen COVID-19 vaccines. IHS has 
shipped vaccine directly to 293 I/T/U facilities and used a hub and 
spoke model to ensure all 352 facilities that are coordinating vaccine 
through the IHS jurisdiction receive vaccine. The table below shows the 
total number of vaccine doses distributed and administered per IHS Area 
as of April 5, 2021.

      COVID-19 Vaccine Distribution and Administration by IHS Area
------------------------------------------------------------------------
                               Total Doses             Total Doses
          Area                Distributed*            Administered**
------------------------------------------------------------------------
Albuquerque              112,155                 97,271
Bemidji                  118,105                 85,214
Billings                 51,015                  32,565
California               179,285                 83,254
Great Plains             107,150                 62,750
Nashville                74,867                  45,197
Navajo                   246,065                 183,651
Oklahoma City            432,410                 268,566
Phoenix                  155,500                 109,095
Portland                 77,285                  55,874
Tucson***                9,000                   6,210
------------------------------------------------------------------------
    TOTAL                1,562,837               1,029,647
------------------------------------------------------------------------
*Distributed Data Source: IHS National Supply Service Center, includes
  total doses ordered and anticipated to be delivered by April 2, 2021.
**Administered Data Source: CDC Clearinghouse data from Vaccine
  Administration Management System (VAMS) and IHS Central Aggregator
  Service (CAS). Data in the CDC Clearinghouse reflects prior day data.
  Data may be different than actual data as there are known CDC data
  lags and ongoing quality review of data including resolving data
  errors.
***The Tucson Area vaccine administration data is currently being
  validated.
Note: Alaska Area--all tribes chose to receive COVID-19 vaccine from the
  State of Alaska.

    COVID-19 related data are reported from I/T/U facilities, though 
reporting by Tribal and UIOs is voluntary. The table below shows the 
number of cases reported to the IHS through 11:59 pm on April 4, 2021.

                       COVID-19 Cases by IHS Area
------------------------------------------------------------------------
                                                                7-day
                                               Cumulative      rolling
 IHS Area    Tested    Positive    Negative      percent       average
                                               positive *   positivity *
------------------------------------------------------------------------
Alaska     565,977    11,566      480,985     2.3%          0.8%
Albuquerq  91,714     8,079       62,838      11.4%         5.2%
 ue
Bemidji    152,191    10,576      138,064     7.1%          7.0%
Billings   96,601     7,360       85,879      7.9%          3.3%
Californi  76,191     7,784       65,310      10.6%         2.9%
 a
Great      138,161    14,096      123,535     10.2%         3.8%
 Plains
Nashville  73,823     5,980       66,956      8.2%          4.0%
Navajo     238,530    31,389      163,002     16.1%         3.0%
Oklahoma   473,229    60,186      408,007     12.9%         3.0%
 City
Phoenix    172,323    23,559      147,923     13.7%         2.9%
Portland   110,752    7,491       102,925     6.8%          5.7%
Tucson     25,535     2,744       22,638      10.8%         5.4%
    TOTAL  2,215,027  190,810     1,868,062   9.3%          2.9%
------------------------------------------------------------------------
* Cumulative percent positive and 7-day rolling average positivity are
  updated three days per week.

Access to Clean Water
    Supporting Tribes to ensure they are able to supply water to their 
communities during the COVID-19 outbreak is an important aspect of the 
IHS COVID-19 response. Access to water is critical for hand washing and 
cleaning environmental surfaces to help break the virus' chain of 
infection and reduce the pressure on the IHS health care delivery 
system, which is a critical concern.
    To address this concern, the IHS over the past year deployed nine 
teams of 40 U.S. Public Health Service Commissioned Corps Officers in 
support of the Navajo Nation to improve access to safe water points. 
This work included surveying the availability of safe water points 
across 110 Chapters over 27,000 square miles. The survey identified 59 
locations where additional water points were needed. Following the 
survey, the teams completed water points site installation designs, 
construction/beneficial use inspections, and operation and maintenance 
trainings at these locations. The installation of these water points 
resulted in a reduction in round trip travel distance from 52 miles to 
17 miles and was completed within 6 months.
    In addition to increasing the number of water points, the mission 
helped ensure a means to safely transport water for in-home drinking 
and cooking. This was achieved by providing 107 Chapters over 37,000 
water storage containers to be distributed to each resident living in a 
home with no piped water. Water disinfection tablets, to boost water 
disinfection levels in the water storage containers, were also provided 
to Chapters as needed based on the field team measured water point 
disinfection levels. These innovative actions will help to improve the 
stored water quality and reduce the risk of gastrointestinal illness to 
water point users.
    The teams also worked to increase public awareness of water service 
availability and developed creative public health outreach materials 
describing the importance of the water service use through a multimedia 
campaign (online, print newspaper, and radio) broadcast across the 
Navajo Nation. This included assisting the Navajo Nation in developing 
a website, which includes an interactive map of the water points, to 
communicate the location, hours of operation, and Chapter contact 
information. Officers developed outreach materials highlighting the 
importance of accessing water at regulated water points and promotion 
of safe water storage practices.
    We look forward to continuing our work with Tribal and Federal 
partners. As we work towards recovery, we are committed to working 
closely with our stakeholders and understand the importance of working 
with partners during this difficult time. We strongly encourage 
everyone to continue to follow CDC guidelines and instructions from 
their local, state, and Tribal governments to prevent the spread of 
COVID-19 and protect the health and safety of our communities. Thank 
you again for the opportunity to speak with you today.

    The Chairman. Thank you very much.
    We will now move on to the Honorable William Smith, 
Chairperson of the National Indian Health Board.

 STATEMENT OF HON. WILLIAM SMITH, CHAIRPERSON, NATIONAL INDIAN 
                          HEALTH BOARD

    Mr. Smith. [Greeting in Native tongue], Chairman Schatz, 
and Vice Chair Murkowski, and members of the Committee.
    On behalf of the National Indian Health Board and the 574 
sovereign, federally recognized American Indian and Alaska 
Native tribal nations we serve, thank you for the opportunity 
to be a witness and provide this testimony.
    One year later, our Nation faces a COVID-19 pandemic that 
has continued to ravage our people disproportionately. It has 
been highly publicized how the pandemic has exposed our 
disparities in Indian Country: crowded homes with no options to 
quarantine safely, lack of access to safe water and sanitation 
facilities, aging and inadequate health facilities and 
staffing, non-existent public health or behavioral systems, and 
no access to internet to allow tele-health, remote work, or 
distant learning.
    The CDC has reported that the presence of a chronic health 
condition such as Type II diabetes, obesity, and heart disease 
increases one's risk for severe COVID-19 illness. Each of these 
chronic health conditions painfully impact our people. As of 
April 11th, the Indian Health Service has reported over 191,000 
positive COVID cases. The CDC reported we are 2.4 times more 
likely than non-Hispanics, white people, to die from COVID-19 
infections.
    There are nearly 6,200 American Indian and Alaska Native 
reported deaths related to COVID-19 complications since the 
pandemic was declared, a number which is likely understated. 
Nearly 60 percent of these deaths are from New Mexico, Arizona 
and Oklahoma combined. In my home State of Alaska, 37 percent 
of the State's deaths were reported to be Native.
    A key success story in the dark times has been including 
tribes and IHS as the jurisdictions for vaccine distribution. 
As of April 12th, there have been 1.63 million vaccines 
distributed through IHS, and over 1 million doses have been put 
into arms. For instance, Alaska's success in vaccine is steeped 
in the tribes having the sovereign ability and self-determine 
to exercise flexibility. Some of our tribal communities in 
Alaska have reached a 90 percent vaccination rate among the 
seniors and included Natives and non-Native residents.
    Various tribes in Oklahoma have opened up their vaccine 
efforts to the communities, regardless of IHS eligibility. 
Federal data shows that Native Americans were getting the 
vaccine at a higher rate than all but five States by the end of 
February, 2021.
    H.R. 1319, the American Rescue Plan, provides unprecedented 
investment in Indian Country and Indian health. With over $6 
billion being injected into Indian health, tribal and urban 
systems, we are encouraged to witness the funds' efforts and 
improvements to care, facilities, and lives. National Indian 
Health Board is grateful for this investment and thankful for 
those in Congress who support the funds' inclusion.
    While the American Rescue Plan provides much-needed support 
for Indian Country ongoing requests, there is so much more work 
left to be done. We call on Congress to provide full funding 
and mandatory appropriation for the Indian Health Service. It 
is the most chronically underfunded Federal health care system 
and the only one not exempt from government shutdowns or 
continuing resolutions.
    Congress must further prioritize tribal water and 
sanitation infrastructures. Approximately 6 percent of tribal 
households lack access to running water. When asked to wash 
their hands to keep them safe from COVID-19 some tribal members 
cannot do this for the lack of clean, running water.
    Additionally, there must be continued support for tribal 
mental and behavioral health, access to broadband on tribal 
lands, creation of sustainable tribal health workforce, and 
expanding tribal self-governments across the entire Federal 
Government.
    To close, consider this. During the 1918 Spanish flu 
pandemic and the 2009 H1N1 pandemic, Native people died at four 
times the rate of all other races combined. We are left to fend 
for ourselves and die. We can no longer wait. Our people are 
dying, our women and youth are going missing and being 
murdered, our communities lack resources to fight substance 
abuse and provide much-needed behavioral health service, our 
diabetics would rather stay at home and die than drive all day 
to receive treatment from a dialysis center hours away. Our 
elders, the tribal keepers of our culture, don't have access to 
assisted living or long-term care service. Our public health 
system is addressing pandemic like COVID-19 are non-existent. 
The Federal Government needs to do better at this moment.
    I am grateful for the members of Congress and for your 
actions to support Indian Country. I urge you to prioritize 
tribes and tribal communities further as you continue to 
provide relief from the COVID-19 pandemic and beyond. Please 
remain with us to enhance the ITU system to ensure it never 
happens to Native people again.
    [Phrase in Native tongue.] Thank you for holding today's 
hearing, and for inviting the National Indian Health Board to 
testify. I am looking forward to your questions. Thank you.
    [The prepared statement of Mr. Smith follows:]

Prepared Statement of Hon. William Smith, Chairperson, National Indian 
                              Health Board
    Chairman Schatz, Vice Chairwoman Murkowski, and members of the 
Committee, on behalf of the National Indian Health Board (NIHB) and the 
574 sovereign federally-recognized American Indian and Alaska Native 
(AI/AN) Tribal Nations we serve, thank you for the opportunity to 
submit testimony. The recommendations outlined in this testimony 
encompass critical policy needs to help protect and prepare AI/AN 
communities in response to the current COVID-19 pandemic. These are 
necessary for the Indian health system to be fully functional to 
address the pandemic and other related critical health care priorities. 
NIHB has identified several policy priorities for Indian Country within 
the jurisdiction of the Committee that we urge you to address:

        1.  Provide Full Funding and Mandatory Appropriations for the 
        Indian Health Service

        2.  Prioritize Tribal Water and Sanitation Infrastructure

        3.  Increase Support for Tribal Mental and Behavioral Health

        4.  Provide Greater Health Care Access and Financial Support 
        for I/T/U Facilities

        5.  Create a Sustainable Tribal Health Workforce

        6.  Increase Telehealth Capacity in Indian Country while 
        Expanding Broadband Access

        7.  Establish a 21st Century Health Information Technology 
        (HIT) System at IHS

        8.  Expand and Strengthen the Government-to-Government 
        Relationship with the Federal Government and the Tribes & 
        Expand Self Governance

The Reality of Broken Treaties
    We continue to bear witness and experience the alarming obstacles 
to our everyday lives resulting from this unprecedented crisis. In a 
matter of weeks, COVID-19 reshaped the very fabric of our economy, our 
society, the way we conduct business, relationships and our personal 
livelihoods--in some ways, permanently. The past year has been a 
profoundly uncertain and challenging time; and also times of profound 
opportunity to achieve redress of hundreds of years of injustices, 
which are the children of colonization.
    Today, our nation is confronted by the COVID-19 pandemic that 
continues to disproportionately ravage the most marginalized among us, 
and Indian Country has been right at the center of the pandemic. In 
order to understand how to address and overcome these challenges and 
realize the opportunity for transformation before us, we must first 
insist on an honest reckoning of our history. The challenges we face 
today--most recently evidenced through the impacts of COVID-19 on 
Tribal communicates--are the fruits of colonization. This system of 
exploitation, violence and opportunism is the foundation on which this 
Nation was constructed. Despite the poor social determinants of health 
most frequently found in the Indigenous and other communities of 
color--circumstances that proceed from hundreds of years of 
colonization--we are often blamed for our poor circumstances. What our 
communities are experiencing during this COVID-19 pandemic is simply 
the expected outcome of this historical truth.
    Centuries of genocide, oppression, and simultaneously ignoring our 
appeals while persecuting Our People and our ways of life persist--now 
manifest in the vast health and socioeconomic inequities we face during 
COVID-19. The historical and intergenerational trauma our families 
endure, all rooted in colonization, are the underpinnings of our 
vulnerability to COVID-19. Indeed, we tell our stories of treaties, 
Trust responsibility and sovereignty--over and over--and it often 
appears the listeners are numb to our historic and current truths. But 
the truth does not change: that is the ground we stand on. We hear 
baseless stories about how ``dirty Indians'' are causing the outbreaks, 
or how private hospitals are refusing to accept referrals to treat Our 
People. These same sentiments echoed across all previous disease 
outbreaks that plagued Our People from Smallpox to HIV to H1N1. This 
begs the painful question: what has changed?
    The underpinnings of colonization may finally be loosening as a 
consequence of the exposed neglect, abuse, bad faith and inequities AI/
AN People have experienced during this pandemic. But it did not start 
with COVID-19. This pandemic and the way it is ravaging our Peoples is 
exposing the consequences of hundreds of years of US policy predicated 
on broken promises with the Indigenous Peoples of this land.
Health Inequities Create Additional Risks from COVID-19
    The solemn legacy of colonization is epitomized by the severe 
health inequities facing Tribal Nations and AI/AN Peoples. When you 
compound the impact of destructive federal policies towards AI/ANs over 
time, including through acts of physical and cultural genocide; forced 
relocation from ancestral lands; involuntary assimilation into Western 
culture; and persecution and the outlawing of traditional ways of life, 
religion and language, the inevitable results are the 
disproportionately higher rates of historical and intergenerational 
trauma, adverse childhood experiences, poverty, and lower health 
outcomes faced across Indian Country.
    Chronic and pervasive health staffing shortages -from physicians to 
nurses to behavioral health practitioners--stubbornly persist across 
Indian Country, with 1,550 healthcare professional vacancies documented 
as of 2016. Further, a 2018 GAO report found an average 25 percent 
provider vacancy rates for physicians, nurse practitioners, dentists, 
and pharmacists across two thirds of IHS Areas (GAO 18-580). Lack of 
providers also forces IHS and Tribal facilities to rely on contracted 
providers, which can be more costly, less effective and culturally 
indifferent, at best--inept at worst. Relying on contracted care 
reduces continuity of care because many contracted providers have 
limited tenure, are not invested in community and are unlikely to be 
available for subsequent patient visits. Along with lack of competitive 
salary options, many IHS facilities are in serious states of disrepair, 
which can be a major disincentive to potential new hires. While the 
average age of hospital facilities nationwide is about 10 years, the 
average age of IHS hospitals is nearly four times that--at 37 years. In 
fact, an IHS facility built today could not be replaced for nearly 400 
years under current funding practices. As the IHS eligible user 
population grows, it imposes an even greater strain on availability of 
direct care.
    Tribal Nations are also severely underfunded for public health and 
were largely left behind during the nation's development of its public 
health infrastructure. As a result, large swaths of Tribal lands lack 
basic emergency preparedness and response protocols, limited 
availability of preventive public health services, and underdeveloped 
capacity to engage in disease surveillance, tracking, and response. And 
even though Tribal governments and all twelve Tribal Epidemiology 
Centers (TECs) are designated as public health authorities in statute, 
they continue to encounter severe barriers in exercising these 
authorities due to lack of enforcement and education.
    When you compound the impact of broken treaty promises, chronic 
underfunding, and endless use of continuing resolutions, the inevitable 
result are the chronic and pervasive health disparities that exist 
across Indian Country. These inequities created a vacuum for COVID-19 
to spread like wildfire throughout Indian Country, as it continues to 
do. Indeed, AI/AN health outcomes have either remained stagnant or 
become worse in recent years as Tribal communities continue to 
encounter higher rates of poverty, lower rates of healthcare coverage, 
and less socioeconomic mobility than the general population. On 
average, AI/ANs born today have a life expectancy that is 5.5 years 
less than the national average, with some Tribal communities 
experiencing even lower life expectancy. For example, in South Dakota 
in 2014, median age at death for Whites was 81, compared to 58 for 
American Indians. \1\
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    \1\ South Dakota Department of Health. Mortality Overview. 
Retrieved from https://doh.sd.gov/Statistics/2012Vital/Mortality.pdf
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    According to the Centers for Disease Control and Prevention (CDC), 
in 2017, at 800.3 deaths per 100,000 people, AI/ANs had the second 
highest age-adjusted mortality rate of any population. \2\ In addition, 
AI/ANs have the highest uninsured rates (25.4 percent); higher rates of 
infant mortality (1.6 times the rate for Whites); \3\ higher rates of 
diabetes (7.3 times the rate for Whites); and significantly higher 
rates of suicide deaths (50 percent higher). American Indians and 
Alaska Natives also have the highest Hepatitis C mortality rates 
nationwide, as well as the highest rates of Type 2 Diabetes, chronic 
liver disease and cirrhosis deaths. Further, while overall cancer rates 
for Whites declined from 1990 to 2009, they rose significantly for 
American Indians and Alaska Natives.
---------------------------------------------------------------------------
    \2\ Kochanek KD, Murphy SL, Xu JQ, Arias E. Deaths: Final data for 
2017. National Vital Statistics Reports; vol 68 no 9. Hyattsville, MD: 
National Center for Health Statistics. 2019.
    \3\ Centers for Disease Control and Prevention. Infant, neonatal, 
post-neonatal, fetal, and perinatal mortality rates, by detailed race 
and Hispanic origin of mother: United States, selected years 1983-2014.
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    CDC reported that the presence of underlying health conditions such 
as type II diabetes, obesity, cardiovascular disease, and chronic 
kidney disease significantly increase one's risk for a severe COVID-19 
illness. AI/AN populations are disproportionately impacted by each of 
these chronic health conditions. For instance, type II diabetes 
incidence and death rates are three times and 2.5 times higher, 
respectively, for AI/ANs than for non-Hispanic Whites. Despite 
significant improvements in rates of End Stage Renal Disease (ESRD) as 
the result of the highly successful Special Diabetes Program for 
Indians (SDPI), AI/AN communities continue to experience the highest 
incidence and prevalence of ESRD.
    Increased physical distancing and isolation under the COVID-19 
pandemic have led to recent and alarming spikes in drug overdose 
deaths, suicides, and other mental and behavioral health challenges. 
Population-specific data on increased drug overdose and suicide deaths 
during the pandemic are currently unavailable; yet if trends prior to 
the rise of COVID-19 are any indicator of risk, it is safe to assume 
that AI/AN People are experiencing serious challenges. One of the major 
drivers of increased mortality rates among AI/ANs overall has been 
significantly higher rates of drug overdose and suicide deaths than the 
general population.
    So, into this neglected and stunted health system on which American 
Indians and Alaska Native rely--into this system which is, 
collectively, the living expression of how seriously the federal 
government takes Treaty obligations and the Trust responsibility that 
requires the provision of full and quality health care for American 
Indians and Alaska Natives--into all of this theatre of failure comes 
COVID-19.
Impact of COVID-19 and Vaccine Efforts in Indian Country
    As of April 10, 2021, IHS has reported 191823 positive COVID-19 
cases, with a cumulative percent positive rate of 9.2 percent across 
all twelve IHS Areas. \4\ However, IHS numbers are highly likely to be 
underrepresented because case reporting by Tribally-operated health 
programs, which constitute roughly two-thirds of the Indian health 
system, are voluntary. According to data analysis by APM Research Lab, 
AI/ANs are experiencing the second highest aggregated COVID-19 death 
rate at 51.3 deaths per 100,000. The CDC reported on March 12, 2021, A/
ANs were 3.7 times more likely than non-Hispanic white people to be 
hospitalized and 2.4 times more likely to die from COVID-19 infection. 
Reporting by state health departments has further highlighted 
disparities among AI/ANs.
---------------------------------------------------------------------------
    \4\ Indian Health Service. COVID-19 Cases by IHS Area. https://
www.ihs.gov/coronavirus/

   According to the Centers for Disease Control and Prevention 
        (CDC), AI/AN People are 1.7 times (70 percent) more likely to 
        be diagnosed with COVID-19 when compared to non-Hispanic white 
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        people

   According to the CDC, AI/ANs are 3.7 times (370 percent) 
        more likely to require hospitalization when compared to non-
        Hispanic white people

   According to the CDC, AI/ANs are 2.4 times (240 percent) 
        more likely to die from COVID-19-related infection when 
        compared to non-Hispanic white people.

   There have been 6,206 AI/AN deaths related to COVID-19 
        complications since the pandemic was declared. Nearly 60 
        percent of these deaths are from New Mexico, Arizona, and 
        Oklahoma \5\
---------------------------------------------------------------------------
    \5\ National Indian Health Board. March 17, 2021 CDC Provisional 
Death Count of AI/ANs, 5,981 US, with State Deaths, percent of State 
Deaths and percent of US Deaths. 
https://public.tableau.com/profile/nihb.edward.fox#!/vizhome/CDCMarch
1720215981AIANDeathsfromCOVID19/March172021CDCProvisionalDeathCount
ofAIANs5981USwithStateDeathsofStateDeathsandofUSDeaths

   In Alaska, 37 percent of the total state's deaths are 
        reported to be AI/ANs \6\
---------------------------------------------------------------------------
    \6\ National Indian Health Board. March 17, 2021 CDC Provisional 
Death Count of AI/ANs, 5,981 US, with State Deaths, percent of State 
Deaths and percent of US Deaths. 
https://public.tableau.com/profile/nihb.edward.fox#!/vizhome/
CDCMarch1720215981AIANDeathsfromCOVID19/March172021CDCProvisional
DeathCountofAIANs5981USwithStateDeathsofStateDeathsandofUSDeaths

   The disparity in COVID-19-related death rates is not evenly 
        shared across all AI/AN age groups. Young AI/ANs are 
        experiencing the largest disparities. Among AI/ANs aged 20-29 
        years, 30-39 years, and 40-49 years, the COVID-19-related 
        mortality rates are 10.5, 11.6, and 8.2 times, respectively, 
        higher when compared to their white counterparts \7\
---------------------------------------------------------------------------
    \7\ Arrazola J, Masiello MM, Joshi S, et al. COVID-19 Mortality 
Among American Indian and Alaska Native Persons--14 States, January-
June 2020. MMWR Morb Mortal Wkly Rep 2020;69:1853-1856. DOI: http://
dx.doi.org/10.15585/mmwr.mm6949a3external icon

   Across 23 states, the cumulative incidence rate of 
        laboratory-confirmed COVID-19 infections was 3.5 times (350 
        percent) higher among AI/ANs persons than that of non-Hispanic 
        white persons \8\
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    \8\ Hatcher SM, Agnew-Brune C, Anderson M, et al. COVID-19 Among 
American Indian and Alaska Native Persons--23 States, January 31-July 
3, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1166-1169. DOI: http://
dx.doi.org/10.15585/mmwr.mm6934e1

    Unfortunately, the adverse impacts of COVID-19 in Indian Country 
extend far beyond these sobering public health statistics. Tribal 
economies have been shuttered by social distancing guidelines that have 
also severely strained Tribal healthcare budgets. Because of the 
chronic underfunding of IHS, \9\ Tribal governments have innovatively 
found ways of maximizing third party reimbursements from payers like 
Medicare, Medicaid, and private insurance. For many self-governance 
Tribes, third party collections can constitute up to 60 percent of 
their healthcare operating budgets. However, because of cancellations 
of non-emergent care procedures in response to COVID-19, many Tribes 
have experienced third party reimbursement shortfalls ranging from 
$800,000 to $5 million per Tribe, per month. In a hearing before House 
Interior Appropriations on June 11, 2020, former IHS Director Rear 
Admiral (RADM) Weahkee stated that third party collections have 
plummeted 30-80 percent below last year's collections levels, and that 
it would likely take years to recoup these losses.
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    \9\ Per capita spending at IHS in FY 2018 equaled $3,779 compared 
to $9,409 in national health spending per capita; $9,574 in Veterans 
Health Administration spending per capita; and $13,257 per capita 
spending under Medicare.
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    The COVID-19 pandemic has highlighted the weaknesses and gaps in 
public health infrastructure in Indian Country, and vaccine 
distribution has shown similar results. Tribal governments were forced 
to rely upon the vaccine dissemination channels created by the federal 
government. Tribal governments were forced to choose between receiving 
any one of the available vaccines through either the state in which 
they reside or through IHS, rather than providing the vaccine directly 
to the Tribes themselves. This sidestepping of the government-to-
government relationship can and should be avoided in the future.
    H.R. 1319, The American Rescue Plan, provides $600 million 
specifically for vaccine activities in Indian Country. As of April 5, 
2021, there have been nearly 1.563 million vaccines distributed through 
IHS, and over 1 million doses have been administered. The latest number 
from IHS regarding the number of vaccines administered by the tribes 
who received the vaccine through states is 178,000 doses. NIHB is 
optimistic how this funding will impact this continued effort in 
eradicating the disease.
    For some states in the country, vaccine administration, or ``shots 
in arms,'' have been less than ideal. However, Tribal government 
vaccine rollouts have been far outpacing their state counterparts. 
Regardless of how a Tribe obtained the vaccines, once they had them in 
hand, Tribes were able to get the doses in the arms of their citizens 
faster and more efficient than most of their surrounding communities 
and states. For instance, the state of Alaska had vaccinated 91,000 
people at the end of January 2021 and 10,000 of those shots were 
administered to Tribal patients. Various Tribes in Oklahoma has done so 
well in vaccinating their citizens, they have recently opened their 
vaccine efforts to the community, regardless of if they are IHS 
eligible or not. Anyone in Oklahoma can now receive the vaccine through 
the tribe. For the Rosebud Sioux Tribe, they have been vaccinating 
those in their community nearly double the rate of South Dakota. \10\ 
In an analysis by the AP, federal data showed Native Americans were 
getting vaccinated at a higher rate than all but five states by the end 
of February 2021. \11\
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    \10\ NPR. Why Native Americans Are Getting COVID-19 Vaccines 
Faster. https://www.npr.org/2021/02/19/969046248/why-native-americans-
are-getting
-the-covid-19-vaccines-faster
    \11\ AP. Native Americans embrace vaccine, virus containment 
measures.
 https://apnews.com/article/native-americans-coronavirus-vaccine-
9b3101d306442fbc5198333017b4737d
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Systemic Barriers in COVID-19 Response
    At the core of the federal trust responsibility to Tribal Nations 
is the fact that the federal government is supposed to ensure the 
health and welfare of Native peoples. The COVID-19 pandemic has given 
the federal government an opportunity to uphold their end of the 
bargain in a way that is perhaps unparalleled in modern American 
history. However, Tribes are increasingly running into systemic 
barriers that impede their ability to actually receive help from the 
federal government and this is slowing or even outright denying access 
to aid.
    One reason is because in all but the latest COVID-19 relief 
packages, the federal government decided to use competitive grant 
making as a means of distributing funds to Tribes. To apply for 
competitive grants, you need staff to put together an application. 
Tribes that were lower resourced found themselves having to use a 
skeleton staff to put together applications in order to have access to 
funds that they needed in order to provide care for their people. If 
Tribes could not pull together these resources, they were excluded from 
being able to apply for these pots of money.
    Federal trust obligations to fund healthcare and public health in 
Indian Country cannot, and must not, be achieved through the 
competitive grant mechanism. By their very design, competitive grants 
create an inequitable system of winners and losers. The federal 
obligation to fully fund health services in Indian Country was never 
meant to be contingent upon the quality of a grant application--yet 
that is the construct that the federal government has forced Tribes to 
operate under. That is unacceptable.
    Instead, a more effective way to distribute aid to Tribes would be 
through a fixed funding formula that ensures sufficient, recurring, 
sustainable funding reaches all Tribal Nations. Doing so would allow 
Tribes to know that the funding was coming to them, how much they were 
getting, and be able to plan to utilize that money to help their 
citizens. It would have also alleviated the burden on Tribes to use 
their staff to apply for grant funding and allowed them to use their 
limited resources to treat the issue at hand. We were pleased, for the 
first time, Congress provided a dedicated, standalone section to Indian 
health in the American Rescue Plan. This type of mechanism in the law 
is precisely what Indian Country has been asking for and avoids 
competitive grants altogether.
    Another issue was the insufficient notice of funding opportunities. 
Many Tribes were not told what opportunities were available or how they 
would be able to access the funding. Given the Trust Responsibility, we 
would expect HHS to take special care to ensure that Tribes know of 
these opportunities and are able to submit any required documentation 
within a timely manner. Tribes were also forced to deal with agencies 
with whom they had little experience or knowledge. For example, in the 
initial funding allocations, aid to Tribes was distributed through the 
CDC and not IHS. This, in turn, created a delay in receiving funding as 
the CDC had to create a mechanism to either distribute the funding 
themselves or transfer the money to IHS. However, in the American 
Rescue Plan, funds were directed to flow through IHS, who already has 
an existing relationship with tribes to release these funds more 
efficiently and effectively.
    We have felt deeply troubled by the systemic barriers that 
historically impeded the federal government's response to this crisis. 
As sovereign governments, Tribal Nations have the same inherent 
responsibilities as state and territorial governments to protect and 
promote the public's health. Tribes were largely left behind during the 
nation's development of its public health infrastructure, and Tribal 
health systems continue to be chronically underfunded. As a result, 
many Tribal public health systems remain far behind that of most state, 
territorial, and even city and county health entities in terms of their 
capacity, including for disease surveillance and reporting; emergency 
preparedness and response; public health law and policy development; 
and public health service delivery. However, the American Rescue Plan 
provided unprecedented investments to Indian Country, especially 
regarding Indian health. With over $6 billion being injected into the 
I/T/U systems, we are encouraged to witness the effects of this funding 
and the improvements that will be made to care, facilities, and AI/AN 
Peoples' lives. But we must ask ourselves, what has led us up to this 
point? Additionally, CDC must continue its trajectory of making 
meaningful and sustainable direct investments into Tribal communities 
for public health--thus further closing the gap in the disparities of 
lower health status, and lower life expectancy of AI/AN Peoples 
compared to the general population. We are thankful for the Members of 
this Committee and the continued support they have given Indian Country 
through this pandemic and all the support you have provided to our 
communities to end this pandemic.
Recommendations
    The U.S. must continue to honor its trust and treaty obligations in 
its response to COVID-19. Thus far, the IHS has secured billions in 
emergency aid from Congress and through inter-agency transfers from 
HHS. These investments were necessary, but nowhere near sufficient, to 
stem the tide of the pandemic. NIHB is delighted to see more than $6 
billion secured in the American Rescue Package for Indian health with 
maximum flexibility and no expenditure deadline. This funding nearly 
doubles the annual discretionary budget of IHS and will go so far in 
the continued response to the pandemic, as well as rebuilding our 
communities. NIHB is pleased to see Indian health prioritized in so 
many areas often overlooked, such as lost third party billing, IHS 
facilities improvements, additional Purchased/Referred Care (PRC) 
dollars, dedicated funding to information technology and telehealth 
access, and potable water delivery. In swift fashion, the 
administration has already conducted Tribal consultation and urban 
Indian confer. This came less than a week after the legislation became 
law and they begin to disseminate this supplemental funding. While the 
American Rescue Plan provides much needed to support to Indian 
Country's ongoing requests, the pandemic is far from over and there is 
work still left to be done:
1. Provide Full Funding and Mandatory Appropriations for the Indian 
        Health Service
    The Indian Health Service (IHS) is the only federal healthcare 
system created as the result of treaty obligations. It is also the most 
chronically underfunded federal healthcare system, and the only federal 
healthcare system not exempt from government shutdowns or continuing 
resolutions. Compared to the three other federal health care entities--
Medicare, Medicaid, and the Veterans Health Administration--IHS is by 
far the most lacking in necessary support. In 2018 the Government 
Accountability Office (GAO-19-74R) reported that from 2013 to 2017, IHS 
annual spending increased by roughly 18 percent overall, and roughly 12 
percent per capita. In comparison, annual spending at the Veterans 
Health Administration (VHA), which has a similar charge to IHS, 
increased by 32 percent overall, with a 25 percent per capita increase 
during the same time period. Similarly, spending under Medicare and 
Medicaid increased by 22 percent and 31 percent respectively. In fact, 
even though the VHA service population is only three times that of IHS, 
their annual appropriations are roughly thirteen times higher.
    Tribal treaties are not discretionary. The IHS budget should not be 
discretionary either. Congress must work to provide an appropriately 
scaled and sustainable investment targeted toward primary and 
preventative health, including public health services, for Tribes to 
begin reversing the trend of rising premature death rates and early 
onset of chronic illnesses, including the comorbidities that increase 
the risk of death due to the novel coronavirus.
    Congress will never achieve full funding of IHS through the 
discretionary appropriations process given the restrictive spending 
caps of the Interior, Environment and Related Agencies Appropriations 
account. The Interior account has one of the smallest spending caps at 
only $36 billion in FY 2020, making it extremely difficult to achieve 
meaningful increases to the IHS budget. While the IHS budget increased 
by roughly 50 percent between FY 2010 and FY 2020, those increases 
largely only kept pace with population growth, staffing funding for new 
or existing facilities, and rightful full funding of contractual 
obligations such as Contract Support Costs (CSC) and 105(l) lease 
agreements. The slight year-to-year increases have not even kept full 
pace with annual medical and non-medical inflationary increases, 
translating into stagnant healthcare services, dilapidated healthcare 
facilities, severe deficiencies in water and sanitation infrastructure, 
and significant workforce shortages.
    Tribes call on the 117th Congress to take decisive steps to 
accelerate health gains in AI/AN communities, while preserving the 
investments and health improvements achieved over these past several 
years. To do this, Congress must enact a budget for IHS that is bold, 
effective, and contains important policy reforms to ensure that AI/ANs 
experience the highest standard of care possible. Funding IHS at 
$12.759 billion in FY 2022, as recommended by the TBFWG, will instill 
trust among Tribal leaders that the Administration is truly committed 
to working directly with Tribes to fulfill treaty obligations for 
healthcare and build a more equitable and quality-driven Indian health 
system.

   Phase in full funding of the Indian Health Service and enact 
        a Fiscal Year 2022 IHS Budget in the amount of $12.759 billion, 
        as recommended by the IHS Tribal Budget Formulation Workgroup 
        as the first step toward full funding.

   Fund a Tribally-driven feasibility study in order to 
        determine the best path forward to achieve mandatory 
        appropriations for IHS.

   Enact mandatory appropriations and advanced appropriations 
        for the Indian Health Service annual operating budget.

   Enact indefinite, mandatory appropriations for the 105 (l) 
        lease line item and Contract Support Costs (CSC) outside of the 
        IHS budget.

   Insulate IHS from the effects of budget sequestration, 
        shutdowns, and stopgap measures through advance appropriations.

   Permanently reauthorize the Special Diabetes Program for 
        Indians (SDPI) at a minimum of $250 million with automatic 
        annual funding increases tied to the rate of medical inflation.

2. Prioritize Tribal Water and Sanitation Infrastructure
    Approximately 6 percent of AI/AN households lack access to running 
water, compared to less than half of one percent of White households 
nationwide. In Alaska, the Department of Environmental Conservation 
reports that over 3,300 rural Alaskan homes across 30 predominately 
Alaskan Native Villages lack running water, forcing use of ``honey 
buckets'' that are disposed in environmentally hazardous sewage 
lagoons. Because of the sordid history of mineral mining on Navajo 
lands, groundwater on or near the Navajo reservation has been shown to 
have dangerously high levels of arsenic and uranium. As a result, 
roughly 30 percent of Navajo homes lack access to a municipal water 
supply, making the cost of water for Navajo households roughly 71 times 
higher than the cost of water in urban areas with municipal water 
access. When asked to wash their hands to keep them safe from COVID-19, 
some tribal members are unable to do so from the lack of clean, running 
water.
    Human health depends on safe water, sanitation, and hygienic 
conditions. COVID-19 has highlighted the importance of these basic 
needs and illustrated the devastating consequences of gaps in these 
systems, including the spread of infectious diseases. The lack of 
access to safe drinking water and basic sanitation in Indian Country 
negative impacts the public health of AI/AN communities.

   Increase funding for infrastructure development that can 
        address deficiencies in water and sanitation in Indian Country, 
        including for the IHS's Sanitations Facilities Construction.

   Increase Tribal set-asides for the safe and Clean Drinking 
        Water State Revolving Funds.

3. Increase Support for Tribal Mental and Behavioral Health
    AI/AN communities experienced some of the starkest disparities in 
mental and behavioral health outcomes before the COVID-19 public health 
emergency began, and many of these challenges have gotten worse under 
the pandemic, especially for Native youth. A 2018 study found that AI/
AN youth in 8th, 10th, and 12th grades were significantly more likely 
than non-Native youth to have used alcohol or illicit drugs in the past 
30-days. \12\ According to the CDC, suicide rates for AI/ANs across 18 
states were reported at 21.5 per 100,000--3.5 times higher than 
demographics with the lowest rates. \13\ Destructive federal Indian 
policies and unresponsive or harmful human service systems have left 
AI/AN communities with unresolved historical and generational trauma, 
alongside contemporary trauma.
---------------------------------------------------------------------------
    \12\ Swaim RC, Stanley LR. Substance Use Among American Indian 
Youths on Reservations Compared With a National Sample of US 
Adolescents. JAMA Netw Open. 2018;1(1):e180382. doi:10.1001/
jamanetworkopen.2018.0382
    \13\ 2 Leavitt RA, Ertl A, Sheats K, Petrosky E, Ivey-Stephenson A, 
Fowler KA. Suicides Among American Indian/Alaska Natives--National 
Violent Death Reporting System, 18 States, 2003-2014. MMWR Morb Mortal 
Wkly Rep 2018;67:237-242. DOI: http://dx.doi.org/10.15585/mmwr.mm6708a1

   Enact the Native Behavioral Health Access Act, ensuring 
        funding will reach every Tribe in a Tribally designed and 
        approved formula, rather than competitive grant, and allowing 
        Tribes to receive the funding through self-determination 
---------------------------------------------------------------------------
        contracting or self-governance compacting mechanisms.

   In coordination with Tribes, establish trauma-informed 
        interventions to reduce the burden of substance use disorders 
        including those involving opioids.

   In coordination with Tribes, incorporate behavioral health 
        assessments such as Adverse Childhood Experience (ACE) into IHS 
        and provide funding for Tribal health programs to do the same.

   Authorize reimbursement for additional provider types that 
        render behavioral health services through Medicare and 
        Medicaid, including Professional Counselor, Licensed Marriage 
        and Family Therapist, and similar types of providers that are 
        currently excluded.

   Create set aside, non-competitive funding for Tribes in all 
        general funding streams to support behavioral and mental health 
        initiatives.

4. Provide Greater Health Care Access and Financial Support for I/T/U 
        Facilities
    Medicare and Medicaid play an integral role in ensuring access to 
health services for AI/AN people and provide critically important 
funding support for the Indian health system overall. In fact, in many 
places across Indian Country, these Centers for Medicare and Medicaid 
Services (CMS) programs allow for Indian health system sites to address 
medical needs that previously went unmet as a result of underfunding of 
the Indian health system. The role of these CMS programs in Indian 
Country goes beyond advancing general program goals and meeting the 
needs of individual healthcare consumers. As an operating division of 
the United States Department of Health and Human Services (HHS), CMS 
owes a Trust Responsibility to the Tribes, as that solemn duty runs 
from the entire federal government to all federally-recognized Tribes.
    In addition to the benefits these programs provide to enrollees, 
Medicare and Medicaid also supports the I/T/U system by enabling 
facilities to collect third party revenue. Third party revenue 
significantly contributes to the financial stability of Indian health 
system clinics and hospitals. According to a 2019 report by the 
Government Accountability Office, \14\ between Fiscal Year 2013 and 
Fiscal Year 2018, third party collections at IHS and Tribal facilities 
increased by $360 million, with 65 percent coming from Medicaid, a 
substantial portion by any measure. Moreover, data show that the number 
of AI/ANs with Medicaid increased from 1,458,746 in 2012 to 1,793,339 
in 2018. The 334,593 increase in Medicaid coverage is a 22.94 percent 
increase over 2012. In 2018, 33.55 percent of all AIANs had Medicaid 
compared to 29.55 percent in 2012. During that same period, Medicare 
collections grew 47 percent from $496 million in FY 2013 to $729 
million in FY 2018. To ensure financial health, Indian Country must 
protect and strengthen access to third party revenue within the Indian 
health system.
---------------------------------------------------------------------------
    \14\ See https://www.gao.gov/assets/710/701133.pdf

   Authorize Medicaid reimbursements across all states to allow 
        Indian health system providers to receive Medicaid 
        reimbursement for all mandatory and optional services described 
        as ``medical assistance'' under Medicaid and specified services 
        authorized under the Indian Health Care Improvement Act 
        (IHCIA)-referred to as Qualified Indian Provider Services-when 
---------------------------------------------------------------------------
        delivered to Medicaid-eligible AI/ANs.

   Create an optional eligibility category under federal 
        Medicaid law providing authority for states to extend Medicaid 
        eligibility to all AI/ANs with household income up to 138 
        percent of the federal poverty level (FPL).

   Extend full federal funding through a 100 percent Federal 
        Medical Assistance Percentage (FMAP) rate for Medicaid services 
        furnished by Urban Indian Organizations (UIOs) to AI/ANs.

   Clarify that AI/AN exemptions from mandatory managed care 
        applying to plans enacted through state plan amendments (SPA) 
        also apply to all waiver authorities.

   Amend Section 105(a)(9) of the Social Security Act in order 
        to clarify the definition of ``Clinic Services'' and ensure 
        that services provided through an Indian health care program 
        are eligible for reimbursement at the OMB/IHS all-inclusive 
        rate, no matter where service is provided.

   Exempt AI/ANs from any additional restrictions, such as work 
        requirements, that may be placed on Medicaid access.

   Exempt IHCPs from any measures, such as limiting retroactive 
        eligibility, that are designed as a cost-saving measure for the 
        state

5. Create a Sustainable Tribal Health Workforce
    The Indian Health Service (IHS) and Tribal health providers 
continue to struggle to find qualified medical professionals to work in 
facilities serving Indian Country. Currently, at federal IHS sites, 
estimated vacancy rates are as follows: physician 34 percent; 
pharmacist 16 percent; nurse 24 percent; dentist 26 percent; 
physician's assistant 32 percent, and advanced practice nurse 35 
percent. Current vacancy rates make it nearly impossible to operate a 
quality health care program. With competition for primary care 
physicians and other practitioners at an all-time high, the situation 
is unlikely to improve soon. The IHS cannot meet workforce needs with 
the current strategy. In order to strengthen the healthcare workforce, 
IHS and Tribal programs need investment from the federal government--to 
educate, to recruit, and to expand their pool of qualified medical 
professionals.

   Make the IHS Scholarship and Loan Repayment Program tax-
        exempt.

   Focus on providing aid to students from Tribal communities 
        so they can return to them and expand the program so that it 
        includes additional provider types eligible for the funding.

   Create new and additional set aside funding for Tribal 
        medical residency programs; and require a Tribal set aside 
        within the annual Medicare funding of Graduate Medical 
        Education (GME) for require service to Tribal communities.

   Provide funding for better incentives for medical 
        professionals who want to work at IHS and Tribal sites, 
        including support for spouses and families, and better housing 
        options.

6. Increase Telehealth Capacity in Indian Country while Expanding 
        Broadband Access
    According to a 2019 Federal Communications Commission (FCC) Report, 
only 46.6 percent of homes on rural Tribal lands had access to a fixed 
terrestrial broadband at standard speeds, an astounding 27 points lower 
than non-Tribal lands. This is an unacceptable disparity and 
contributes to the difficulties that Tribes have had in addressing the 
COVID-19 pandemic. The lack of broadband access presents multiple 
barriers for Tribes. It inhibits their ability to fully realize the 
benefits of telehealth. The expansion of telehealth during the COVID19 
pandemic and its lasting effects have increased the importance of 
broadband as a public health issue. In addition to its public health 
implications, the lack of broadband access also presents a barrier to 
economic development, especially in an era where remote work is 
becoming adopted more widely.
    Tribes have been unable to take full advantage of recent federal 
regulatory flexibilities in use of telehealth under Medicare. Because 
the new flexibilities would sunset at the conclusion of the public 
health emergency, it is economically and financially unfeasible for 
many Tribes to make costly investments into telehealth infrastructure 
and equipment for a short-term authority. While mainstream hospital 
systems have largely made a seamless transition to telehealth, Tribes 
once again remain behind due to lack of historical investment.

   Fund a study of Tribal lands to determine where broadband 
        access gaps exist and the best technologies to address them.

   Fund the broadband expansion in Tribal lands in order to 
        help address the disparities between rural Tribal and non-
        Tribal lands.

   Allocate funding directly to Tribes to provide for the 
        expansion of telehealth.

   Permanently extend the existing waiver authority for use of 
        telehealth under Medicare.

   Retire telehealth restrictions to allow for continuation of 
        telehealth beyond the national emergency context.

7. Establish a 21st Century Health Information Technology (HIT) System 
        at IHS
    HHS provides the technology infrastructure for a nationwide 
healthcare system, including a secure wide area network, enterprise e-
mail services, and regional and national Help Desk support for 
approximately 20,000 network users. IHS Health Information Technology 
(HIT) also supports the mission critical healthcare operations of the 
I/T/U with comprehensive health information solutions including an 
Electronic Health Record (EHR) and more than 100 applications.
    A properly resourced IHS HIT program directly supports better ways 
to: (1) care for patients; (2) pay providers; (3) coordinate referral 
services; (4) recover costs; and (5) support clinical decisionmaking 
and reporting, all of which results in better care, efficient spending, 
and healthier communities. The Resource and Patient Management System 
(RPMS)--used by IHS and many Tribal health programs-depends on the VHA 
health IT system, known as the Veterans Information Systems and 
Technology Architecture (VistA). The RPMS manages clinical, financial, 
and administrative information throughout the I/T/U, although, it is 
deployed at various levels across the service delivery types.
    In recent years, many Tribes and several UIOs have elected to 
purchase their own commercial-off-the-shelf (COTS) systems that provide 
a wider suite of services than RPMS, have stronger interoperability 
capabilities, and allow for smoother navigation and use. As a result, 
there exists a growing patchwork of EHR platforms across the Indian 
health system. When the VA announced its decision to replace VistA with 
a COTS system in 2017 (Cerner), Tribes ramped up their efforts to re-
evaluate the IHS HIT system and explore how Veterans Health 
Administration (VHA) and I/T/U EHR interoperability could continue. 
Tribes have significant concerns about Tribal COTS interoperability 
with RPMS, and the overall viability of continuing to use RPMS.

   Provide funding needed to establish a fully functional and 
        comprehensive health IT system for the Indian health system 
        that is fully interoperable with Tribal, urban, private sector, 
        and Department of Veterans Affairs (VA) HIT systems.

   Offset costs for Tribes that have already expended to 
        modernize their system in the absence of federal action.

   Provide additional time for Indian health system providers 
        to comply with CERT 2015.
          --Current legislative language only allows for five years of 
        exemptions. It will take more time for IHS get the RPMS system 
        CERT 2015.

8. Expand and Strengthen the Government-to-Government Relationship with 
        the Federal Government and the Tribes & Expand Self Governance
    The Indian Health Service (IHS) is the only agency within HHS that 
retains authority to establish self-determination contracting or self-
governance compacting (as those terms are defined under the Indian 
Self-Determination and Education Assistance Act) agreements with Tribal 
Nations and Tribal organizations. However, not all IHS programs are 
subject to ISDEAA agreements.
    For example, Tribes are barred from receiving IHS behavioral health 
grants (i.e., Methamphetamine and Suicide Prevention Initiative/
Domestic Violence Prevention Initiative) under ISDEAA agreements. All 
IHS programs and funds should be allocated to Tribes under ISDEAA 
agreements. Tribes also call on the federal government to expand self-
determination and self-governance authority across all of HHS. 
Additionally, authorizing interagency transfer of funds from other HHS 
operating divisions to HIS is the best interim step, given that IHS is 
currently the only agency with ISDEAA authority.
    As background, in 2000, P.L. 106-260, included a provision 
directing HHS to conduct a study to determine the feasibility of a 
demonstration project extending Tribal self-governance to HHS agencies 
other than the IHS. The HHS study, submitted to Congress in 2003, 
determined that a demonstration project was feasible. In the 108th 
Congress, Senator Ben Nighthorse Campbell introduced S. 1696--
Department of Health and Human Services Tribal Self-Governance 
Amendments Act--that would have allowed these demonstration projects. A 
second study was completed in 2011 by the U.S. Department of Health and 
Human Services Self-Governance Tribal Federal Workgroup that noted 
additional legislation would be needed for the expansion. Despite these 
findings supporting expansion of Tribal self-determination and self-
governance, Congress has yet to act legislatively.
    Allowing Tribes to enter into self-governance compacts with HHS and 
its operating divisions would mean that federal dollars are used more 
efficiently because resources in Tribal communities, which are often 
small, could be more easily pooled and would allow Tribes to organize 
wrap-around services to better serve those who have the greatest need. 
Self-governance allows Tribes to extend services to larger populations 
of eligible American Indians and Alaska Natives, leveraging other 
opportunities more efficiently than the federal government. It also 
leads to better outcomes because program administrators are in close 
contact with the people they serve, making programs more responsive and 
effective.
    The most prominent example where the maximum self-governance is 
need is the Special Diabetes Program for Indians (SDPI). Established by 
Congress in 1997, SDPI addresses the disproportionate impact of type II 
diabetes in AI/AN communities. It is the nation's most strategic and 
effective federal initiative to combat diabetes in Indian Country. SDPI 
has effectively reduced incidence and prevalence of diabetes among AI/
ANs and is responsible for a 54 percent reduction in rates of End Stage 
Renal Disease and a 50 percent reduction in diabetic eye disease among 
AI/AN adults. \15\ A 2019 federal report found SDPI to be largely 
responsible for $52 million in savings in Medicare expenditures per 
year. \16\ As a direct result of SDPI, a recent study found that the 
prevalence of diabetes in AI/AN adults decreased from 15.4 percent in 
2013 to 14.6 percent in 2017. \17\
---------------------------------------------------------------------------
    \15\ https://www.ihs.gov/sites/newsroom/themes/responsive2017/
display_objects/documents/SDPI2020Report_to_Congress.pdf
    \16\ https://aspe.hhs.gov/system/files/pdf/261741/SDPI_Paper
_Final.pdf
    \17\ https://www.ihs.gov/newsroom/ihs-blog/april-2020-blogs/new-
study-
shows-decrease-in-diabetes-prevalence-for-american-indianand-alaska-
native-adults/
---------------------------------------------------------------------------
    Congress was able to secure the cost savings to pay for a three-
year extension of SDPI through the end of FY 2023. The SDPI 
reauthorization did not include a critical legislative amendment to 
permit Tribes and Tribal organizations to receive SDPI awards pursuant 
to Title I contracting or Title V compacting agreements under ISDEAA. 
This technical change would prevent any administrative delays in 
implementation of the 638 provision, and further clarify the purpose of 
the new authority. By specifically citing certain sections of P.L. 93-
638, the technical change would ensure that IHS awards SDPI funds to 
those Tribes and Tribal organizations that elect to receive SDPI funds 
through the 638 mechanism. This would guarantee that Tribes and Tribal 
organizations receive all administrative and operational resources 
entitled to them under the 638 mechanism, including access to Contract 
Support Costs (CSC).

   Enact a permanent expansion of Tribal self-determination and 
        self-governance across all agencies within HHS and affirm that 
        all programs at IHS are eligible to be contracted and 
        compacted.

   Expand and codify all Tribal Advisory Committees (TAC) to 
        ensure Tribes have a voice within all operating divisions that 
        provide funding to Tribal governments and communities.

   Authorize Tribes and Tribal organizations to receive SDPI 
        awards through P.L. 93-638 contracts and compacts.

   Wherever permissible, create direct funding to Tribes and 
        avoid grant mechanisms which cause Tribes to compete against 
        other Tribes or against well-resourced states, cities, and 
        counties.

   Streamline reporting requirements to reduce burdens on 
        Tribal nations receiving funding.

Conclusion
    Our treaties stand the test of time. They are the Supreme Law of 
this land. If a nation's honor and exceptionalism is a measure of its 
integrity to its own laws and creed, then one must look no further than 
the United States' continued abrogation of its own treaties to 
recognize that its honor is in short supply. Every square inch of this 
nation is Our People's land. As the sole national organization 
committed to advocating for the fulfilment of the federal government's 
trust and treaty obligations for health, we will always be dedicated to 
bringing into fruition the day where Our People can state with dignity 
that the United States held true to its solemn word. Ideally, 
fulfillment of trust and treaty obligations should be without debate 
and the U.S. should honor its promises. These lands and natural 
resources, most often acquired from us shamefully, are the bedrock of 
U.S. wealth and power today.
    In closing, we thank the Committee for the continued commitment to 
Indian Country and urge you to further prioritize Indian Country as you 
continue to provide relief regarding the COVID-19 pandemic. We 
patiently remind you that federal treaty obligations to the Tribes and 
AI/AN People exist in perpetuity and must not be forgotten during this 
pandemic. We thank you that American Indians and Alaska Natives will 
continue to be prioritized to receive the vaccine, have sufficient 
funds to build and maintain a public health infrastructure, and the 
full faith and confidence of the United States Government will further 
be committed to this nation's first citizens to eradicate this disease. 
As always, we stand ready to work with you in a bipartisan fashion to 
advance health in Indian Country.

    The Chairman. Thank you very much for your very compelling 
testimony.
    Next, we have Mr. Walter Murillo, Board President of the 
National Council of Urban Indian Health.

STATEMENT OF WALTER MURILLO, BOARD PRESIDENT, NATIONAL COUNCIL 
                     OF URBAN INDIAN HEALTH

    Mr. Murillo. Good afternoon. My name is Walter Murillo, I 
am a member of the Choctaw Nation of Oklahoma. I also serve as 
the Board President for the National Council of Urban Indian 
Health, and I am the CEO of Native Health in Phoenix.
    Today, I will share the experiences of the 41 urban Indian 
organizations in the Country during the COVID-19 pandemic. Let 
me start by saying thank you to the Committee and members here 
who have worked tirelessly to help equip the Indian health 
system with essential resources.
    As you know, the trust responsibility does not end at the 
borders of the reservation, and the responsibility for health 
care doesn't, either. Native Health and 40 other UIOs have 
risen tremendously to the challenges of the last year. The UIO 
line item going into the pandemic was only $57.7 million for 41 
UIOs to serve over 70 percent of the American Indian and Alaska 
Natives that reside in urban areas.
    Plus, the Indian health care system and UIOs have never 
been properly fully funded. We started from an extreme deficit 
when the pandemic hit. We faced many challenges beyond the 
pandemic as well. Two UIOs had fires, another endured an 
earthquake, and our Minneapolis UIO is at the center of civil 
unrest. Ten UIOs in California dealt with wildfires and air 
quality issues.
    Despite these challenges, we kept our doors open as best we 
could, with only four UIOs temporarily closing because they did 
not have PPE for their staff. Urban Indians have been an 
afterthought for far too long. UIOs receive only $672 per 
patient per year. This is unacceptable.
    For example, in Baltimore, the UIO also operates a facility 
a Boston. Their total combined budget is less than $1 million. 
That is to run two facilities in two different States. Because 
they are designated as an outreach and referral facility, they 
were not even able to access vaccines for patients until last 
week.
    These past 12 months have reminded us not only how 
resilient our people are, but also highlighted how critical our 
Indian health care system is to the lives of American Indians 
and Alaska Natives, no matter where they live. Tragically, we 
have planned too many funerals and lost far too many family 
members and members of our communities in urban areas who have 
been isolated from their homelands.
    Native deaths continue to be the highest in the world, and 
we are not out of the woods yet. As of now, UIOs have been 
providing testing and vaccines for an outpouring of community 
members. To date, UIOs have tested over 65,000 people and have 
administered over 72,000 doses of vaccine.
    We have stepped up to help other systems as well. One UIO 
in Montana vaccinated 180 teachers, and in the State of 
Washington, they shared vaccines with the NAACP. We have also 
partnered with other local organizations. Native Health in 
Phoenix has been proud to partner with Maricopa County to 
provide services to residential facilities and the local tribal 
communities and tribal enterprises, as well as the association 
of food bank staff.
    UIOs have responded to the pandemic, and responded to the 
increased demands for our regular services, like behavioral 
health, food, and other social services. Many have added tele-
health. Congress has made enormous strides for UIOs, enacting 
medical malpractice coverage for our health care workers 
through expansion of the FTCA, and enabling UIOs to be 
reimbursed for services that we already provide to veterans.
    Yet, parity issues remain a significant barrier for UIOs. 
The Federal Government's trust responsibility is to pay 100 
percent of Medicaid costs for American Indians and Alaska 
Natives, including urban Indians, and was intended to help the 
severely underfunded Indian Health Service system. For the 
first time ever, the government will pay 100 percent FMAP for 
services provided at UIOs, but this last only two years.
    This is something I have been fighting for for over 20 
years. We need this enacted permanently.
    Another issue is the restriction prohibiting UIOs from 
using our COVID-19 funds to make critical repairs or upgrades 
to our HVAC and sanitation systems. We continue to experience 
long bureaucratic discussions that last weeks, even months, 
even to make minor upgrades to our facilities as a result of 
the COVID-19 pandemic.
    We ask for your support of a new bill that will permanently 
fix this provision meant to help UIOs have more resources, not 
fewer. We also need an urban confer policy with the Department 
of Health and Human Services and Indian health serving agencies 
for any issues that affect Indian Country, especially in urban 
areas. This pandemic has taught us that not having a confer 
policy means agencies have no formal mechanism or requirement 
to receive our input on policies that impact us. We would like 
to adhere to the phrase, no policies about us without us.
    Finally, the most important thing you can do is to fully 
fund the Indian Health System by providing $205 million for the 
Urban Indian Health line item in fiscal year 2022. That is what 
is included in the tribal budget recommendations. We need to 
push forward on permanent 100 percent FMAP for Indians and pass 
advance appropriations.
    Thank you for the opportunity to share our experiences. I 
have provided my written testimony, and I am happy to answer 
any questions.
    [The prepared statement of Mr. Murillo follows:]

Prepared Statement of Walter Murillo, Board President, National Council 
                         of Urban Indian Health
    My name is Walter Murillo, and I am a member of the Choctaw Nation 
of Oklahoma. I serve as the Board President of the National Council of 
Urban Indian Health (NCUIH) and I am the CEO of Native Health in 
Phoenix. Today, I will share the experiences of the 41 urban Indian 
organizations (UIOs) in the country in responding to the COVID-19 
pandemic. Let me start by saying thank you to Chairman Schatz, Vice 
Chair Murkowski, Members of the Committee and your staff who have 
worked tirelessly to help equip the Indian health system with essential 
resources.
    NCUIH represents 41 UIOs in 77 facilities across 22 states. UIOs 
provide high-quality, culturally competent care to urban Indian 
populations, constituting more than 70 percent of all American Indians 
and Alaska Natives (AI/ANs). UIOs were recognized by Congress to 
fulfill the federal government's health care- responsibility to Indians 
who live off of reservations. UIOs are a critical part of the Indian 
Health Service (IHS), which oversees a three-prong system for the 
provision of health care: IHS facilities, Tribal Programs, and UIOs. 
This is commonly referred to as the I/T/U system.
COVID-19 Impact on Urban Indian Organizations
    Native Health and the other 40 UIOs have risen tremendously to the 
challenges of the last year. Our annual budget for FY20 was $57.7 
million for 41 UIOs to serve the over 70 percent of American Indians 
and Alaska Natives that reside in cities. Because the Indian health 
care system and UIOs have never been properly funded, we started from 
an extreme deficit going into the pandemic. In fact, we faced 
significant additional obstacles unrelated to COVID-19 as well: two 
UIOs had fires, another endured an earthquake, our Minneapolis UIO was 
at the center of civil unrest, and 10 UIOs in California dealt with 
wildfires and air quality issues. Despite these additional challenges, 
we kept our doors open as best we could, with only four UIOs 
temporarily closing because they did not have PPE for their staff.
    Urban Indians have been an afterthought for far too long. This is 
something we're far too used to in the Indian health care system and 
even more so as an urban Indian health provider. We are asking Congress 
to prioritize the fulfillment of its trust obligation through the full 
funding of the Indian health system and urban Indian organizations.
    In many ways, the past 12 months have reminded us not only how 
resilient our people are, but also highlighted how critical our Indian 
health care system is to the lives of American Indians and Alaska 
Natives. Tragically, we have planned many funerals and lost far too 
many members of our communities. Native deaths continue to be the 
highest in the world and we're not out of the woods yet, which is why 
Congress must continue to prioritize Indian Country for annual and 
future pandemic response packages.
Vaccines Distribution by UIOs
    We always knew that UIOs would serve a vital role in hard-to-reach 
communities and UIOs have gone above and beyond to stretch their 
limited budgets in order to serve their communities during this 
unprecedented pandemic. UIOs have continuously provided services in the 
hardest hit urban areas during the entire pandemic. Over half a million 
AI/AN people live in counties that are both served by UIOs and have the 
greatest number of COVID-19 deaths and new cases.
    UIOs have overcome significant barriers to support their 
communities in responding to COVID-19. For instance, although planning 
for the vaccine distribution began last fall, without an urban confer 
policy at the Department of Health and Human Services, UIOs were 
excluded in all national communications regarding Indian health 
facilities deciding between distribution through the state or through 
IHS, leading to inconsistent messaging and forcing numerous UIOs to 
make a decision of the utmost importance immediately.
    In addition, the only UIO that serves the Baltimore-Washington 
area--an outreach and referral facility (as deemed by IHS) operating on 
an annual budget of less than $1,000,000--only began to receive 
vaccines this week, despite months of coordination that even saw 
several other UIOs offering to fly out staff to administer vaccines to 
the Baltimore-Washington Indian community.
    Our programs have been providing COVID-19 vaccines for an 
outpouring of community members. Urban Indians in our areas have been 
able to come to our facilities rather than traveling long distances to 
reservations by plane to get vaccinated. In fact, we are seeing record 
numbers of patients that we hope to retain following the pandemic, 
which will require adequate levels of funding. Nearly every UIO has 
complimented IHS and their Area Office for their work on vaccine 
distribution.
    UIOs have also filled the gaps that exist in the federal government 
as it relates to care for Native Veterans. In one community, Native 
Veterans stood in lines for hours at the VA and were ultimately turned 
away--refused service and told to ``go to the urban Indian clinic'' 
instead. The VA is funded drastically higher than Indian health and 
UIOs, yet UIOs are the ones stepping up to help them. We have also 
stepped up to help other systems: one UIO in Montana vaccinated 180 
teachers, another shared vaccines with the NAACP and a local LatinX 
organization, and many have partnered with other local organizations to 
reach other vulnerable communities hit by COVID-19.
    Although UIOs have stretched every resource to respond to the 
pandemic, the central problem remains: years of underfunding do not 
allow us to fully meet the needs of our communities. We need to 
capitalize on this opportunity while we have the engagement from our 
community members. And we need our partners in Congress to make that 
happen.
Successes in the Past Year
    We have made enormous strides including enacting medical 
malpractice coverage for our health care workers and enabling UIOs to 
be reimbursed for services that we've been providing to veterans, as 
well as the American Rescue Plan that included two years of 100 percent 
FMAP for services provided at UIOs (a priority I've been working on for 
over 20 years).
    The supplemental funding from COVID-19 relief have enabled UIOs to 
make significant changes, which have included: optimizing the dental 
clinic to meet CDC guidelines, reconfiguring facilities to enable 
social distancing, hiring staff, funding a vaccine location facility, 
creating communication and PSA campaigns to increase vaccine 
acceptance, purchasing of PPE and medical supplies, purchasing a pod 
for testing, creating contact tracing programs, hiring behavioral 
health staff for increased workload of anxiety and depression from 
COVID-19, creating a weather-appropriate outside testing space, 
upgrading electronic health records to accurately and effectively enter 
vaccine and testing data, installing a new HVAC, purchasing a mobile 
unit for testing, new training for staff, and expanded behavioral 
health including victim services. We must continue this pattern of 
success by getting closer to adequate funding of UIOs.
Request: $200.5 million for Urban Indian Health in FY22
    While the American Rescue Plan provided the largest investment ever 
for Indian health and urban Indian health, it is important that we 
continue in this direction to build on our successes of the past year. 
The single most important problem remains the same and that is for the 
federal government to establish a baseline of funding that meets the 
actual need for health care for Natives. The average national health 
care spending is around $12,000 per person; however, Tribal and IHS 
facilities receive only around $4,000 per patient. UIOs receive just 
$672 per IHS patient--that is only 6 percent of the national health 
care spending average. That's what our organizations must work with to 
provide health care for urban Indian patients. The federal trust 
obligation to provide health care to Natives is not optional. The 
Tribal Budget Formulation Workgroup recommendation for the Indian 
Health Service budget for FY22 is just under $13 billion with $200.5 
million for urban Indian health--a step in the right direction towards 
achieving full funding (calculated this year at $48 billion and $749.3 
million, respectively).
    Each year, tribes and urban Indian organizations dedicate countless 
days to preparing a comprehensive document of recommendations related 
to the annual budget for Indian health, but Congress and the 
Administration have failed to provide the funding requested. With the 
ongoing conversations about equity and prioritizing tribal consultation 
and urban confer, it is important that our leaders are actually 
listening to our recommendations.
Request: Extend Full (100 percent) Federal Medical Assistance 
        Percentage for UIOs Permanently
    The federal government has long recognized that the Medicaid 
program supplements the IHS system, and that it's consistent with the 
trust responsibility for the federal government to pay 100 percent of 
Medicaid costs for American Indians and Alaska Natives, including urban 
Indians.
    Because services provided at UIOs have not been reimbursed by the 
federal government at 100 percent, UIOs receive less third-party funds, 
limiting their ability to collect additional reimbursement dollars that 
can be used to provide additional services or serve additional 
patients. In the I/T/U system, only UIOs have been excluded from the 
100 percent FMAP rate. In effect, the federal government only covers 
100 percent of the cost of Medicaid services for AI/ANs receiving those 
services at an IHS or tribal facility and skirts full responsibility if 
an individual happens to receive the service in an urban area. 100 
percent FMAP reimbursement has enabled: (1) IHS and Tribes to receive 
higher rates for services, (2) IHS and Tribes to provide additional 
services, and (3) states to reinvest the money they have saved into the 
Indian health system. UIOs providing services to tribal members 
residing in urban areas are unable to receive these benefits because 
the services they provide are not included in the 100 percent FMAP 
policy.. The American Rescue Plan Act temporarily authorized 100 
percent FMAP for services at UIOs for the next two years, however, the 
need for 100 percent FMAP is continuous and does not end when the 
pandemic ends. We urge the Senate Committee on Indian Affairs to act to 
pass permanent 100 percent FMAP for UIOs this year.
Request: Remove Facilities Restrictions on UIOs
    Unfortunately, a restriction prohibits UIOs from using our IHS 
funds to make critical repairs or upgrade HVAC and sanitation systems--
this even included supplemental COVID-19 funds. With your help, the 
last two bills enacted allowed UIOs to finally use COVID-19 funds to 
make COVID-19 related repairs and upgrades that were badly needed. 
However, we continue to experience long bureaucratic discussions that 
last weeks, and even months, to make even minor upgrades to our 
facilities. We hope that a new bill will help fix this provision meant 
to help UIOs have more resources, not fewer.
    Facility-related use of funds remains the most requested priority 
for UIOs. UIOs do not receive facilities funding, unlike the rest of 
the IHS system. One UIO stated that facility funding would enable them 
to create a space that allows for social distancing during smudging 
healing activities. Another UIO stated that ``our facility remains in 
dire need of support for updates and remediation so we may pursue a 
safe space.'' Not only is this lack of funding detrimental to facility 
sanitation, it also drastically reduces the number of patients UIOs can 
see due to social distancing, furthering compounding health issues of 
Indian Country.
    These restrictions, which are outlined in Section 509 of the Indian 
Health Care Improvement Act (IHCIA) (25 U.S.C.   1659), extend beyond 
COVID-19--they prohibit our health care providers from making any 
renovations using IHS funds solely because they are Urban Indian 
Organizations. This provision limits renovation funding to facilities 
that are seeking to meet or maintain Joint Commission for Accreditation 
of Health Care Organizations (TJC) accreditation (only 1 of 41 even 
have this type of accreditation), leaving most UIOs forced to use their 
limited third-party funds for necessary facility improvements. 
Thankfully, our advocates on this Committee were able to assist with 
loosening restrictions regarding infrastructure upgrades as they 
related to the COVID-19 pandemic. We are working on a permanent 
legislative fix to the facilities restrictions and ask for your support 
of that bill when introduced.
Request: $21 Billion for Indian Health Infrastructure including UIOs
    For the upcoming infrastructure package, we request $21 billion in 
infrastructure funds for the Indian health system. We were disappointed 
to see that the Biden plan did not include any money for Indian health 
infrastructure. The LIFT Act from the House Energy and Commerce 
Committee currently includes $5 billion for Indian health 
infrastructure, however, UIOs are not currently eligible for that 
funding as written. We have informed the Committee and will push for an 
amendment but encourage this Committee to further pursue $21 billion 
for Indian health infrastructure that includes UIOs.
    Many UIO facilities are well beyond their anticipated and projected 
lifespan, the need to adequately fund the upkeep is essential to 
prolonging the usability of such facilities. When patients and 
providers lack access to well-functioning infrastructure, the delivery 
of care and patient health is compromised. A national investment in 
Indian health facilities construction funding continues to be a long-
term discussion of need despite the recent investment of $600 million 
through the American Rescue Act, UIOs continue to be excluded and are 
unable to receive funding from the IHS Health Care Facilities 
Construction Priority program, the Maintenance & Improvement IHS budget 
line item, or participate in the agency's Joint Venture Construction 
Program. Moreover, UIOs are even restricted from using their limited 
IHS appropriation for facilities. As a result, UIOs have had to take 
out loans and collect donations in order to build and maintain health 
facilities for a growing population. UIOs thus must spend millions to 
build, repair, and maintain their facilities--millions that could be 
going to increased services for their patients. Many UIOs are in aging 
buildings--for example, the facility in Denver, CO is in a more than 
50-year old building.
    Without access to facilities funding like that available to IHS and 
tribal facilities, UIOs must use their already limited resources on 
facilities. Equitable construction and facility support funding for 
UIOs can be accomplished by including language authorizing a new budget 
line item to address UIO infrastructure needs. Allowing the continued 
deterioration of critical health facilities goes against the mission of 
the Indian Health Service and Urban Indian Organizations to provide 
quality healthcare to all American Indians and Alaska Natives. When 
patients and providers lack access to well-functioning infrastructure, 
the delivery of care and patient health is always compromised.
Request: Establish a UIO Confer Policy for HHS
    Under Executive Order 13175, Consultation and Coordination with 
Indian Tribal Governments, in 2000, all government agencies were 
mandated to submit procedures to consult with tribes when implementing 
policies that have Tribal implications. Unfortunately, this Executive 
Order as written did not include Urban Indian Organizations. Currently, 
only IHS has a legal obligation to confer with UIOs. It is imperative 
that the many branches and divisions within HHS and all agencies under 
its purview establish a formal confer process to dialogue with UIOs on 
policies that impact them and their AI/AN patients living in urban 
centers. Urban confer policies do not supplant or otherwise impact 
tribal consultation and the government-to-government relationship 
between tribes and federal agencies.
    We commend IHS for the agency's invaluable partnership and tireless 
efforts to disseminate resources to Tribes and UIOs as expeditiously as 
possible. Unfortunately, funds were needlessly tied up for weeks--and 
in more than one instance, months--by other agencies, thereby creating 
unnecessary barriers to pandemic response at UIOs. Compounding on this, 
only IHS has a statutory requirement to confer with UIOs, which has 
enabled other agencies to ignore the needs of urban Indians and neglect 
the federal obligation to provide health care to all AI/ANs--including 
the more than 70 percent that reside in urban areas. In fact, NCUIH has 
only been able to coordinate conversations with the VA, CDC, and other 
agencies by involving IHS due to a lack of urban confer. This is not 
only inconsistent with the government's responsibility but is contrary 
to sound public health policy. Agencies have been operating as if only 
IHS has a trust obligation to AI/ANs, and that causes an undue burden 
to IHS to be in all conversations regarding Indian Country in order to 
talk with agencies. It is imperative that UIOs have avenues for direct 
communication with agencies charged with overseeing the health of their 
AI/AN patients, especially during the present health crisis.
Request: Include UIOs in Advisory Committees with Focus on Indian 
        Health
    When UIOs are not expressly included within a statute enabling them 
to participate in tribal advisory workgroups or committees, they are 
prohibited from participating in a voting role or excluded altogether. 
UIO inclusion in critical advisory committees on Indian health is 
necessary to reflect the reality of much of the AI/AN population, as 
more than 70 percent of AI/ANs living in urban centers today. Without 
explicit inclusion of UIO representation in statute, workgroups using 
the Federal Advisory Committee Act (FACA) intergovernmental exemption 
exclude UIO leaders in their charters by default.
    For UIO leaders to participate in advisory committees that directly 
impact their provision of health care services to AI/AN patients, 
Congressional action is needed.
Request: Include UIOs in the National Community Health Aide Program
    Although UIOs are eligible for the Community Health Aide Program 
(CHAP) under the national expansion policy IHS implemented pursuant to 
authorization in the Indian Health Care Improvement Act (IHCIA), and 
IHS officially initiated Urban Confer on CHAP with UIOs in 2016, IHS 
changed its position in 2018 and further excluded UIOs from the 
consultation and confer process. IHS asserts that UIOs are excluded 
simply because they are not explicitly included in specific statutory 
language. UIOs are eligible for other similarly situated programs under 
IHCIA, including the Community Health Representative program, and 
Behavioral Health and Treatment Services programs. UIOs are explicitly 
named in the statement of purpose in IHCIA, included throughout its 
Subchapter 1 on increasing the number of Indians entering the health 
professions and to assure an adequate supply of health professionals 
involved in the provision of health care to Indian people. Some states, 
such as mine here in Arizona, already have laws on the books reflective 
of UIOs being eligible for CHAP. Furthermore, CHAP is a fully proven 
program and utilizing it as permissible within the entire Indian health 
system will increase the availability of health workers in AI/AN 
communities. It is therefore imperative that Congress fix this 
oversight and clarify that UIOs are indeed eligible for CHAP so they 
may begin to participate in this vital program.
Request: Advance Appropriations
    The Indian health system is the only major federal provider of 
health care that is funded through annual appropriations. For example, 
the Veterans Health Administration (VHA) at the Department of Veterans 
Affairs (VA) receives most of its funding through advance 
appropriations. If IHS were to receive advance appropriations, it would 
not be subject to government shutdowns, automatic sequestration cuts, 
and continuing resolutions (CRs) as its funding for the next year would 
already be in place, and the provision of critical services would not 
be jeopardized by these unrelated budgetary disagreements.
    According to the Congressional Research Service, since FY1997, IHS 
has only once (in FY2006) received full-year appropriations by the 
start of the fiscal year. Last year, during the pandemic ravaging 
Indian Country, Congress enacted two continuing resolutions. When 
funding occurs during a CR, the IHS can only expend funds for the 
duration of a CR, which prohibits longer-term, potentially cost-saving 
purchases. In addition, as most of the Indian health services provided 
by tribes and UIOs under contracts with the federal government, there 
must be a new contract re-issued by IHS for every CR. Instead, IHS was 
forced to allocate resources to contract logistics twice in the height 
of the pandemic when the resources could have better spent equipping 
the Indian health system for pandemic response.
    In addition, lapses in funding can have devastating impacts on 
patient care. During the most recent 35-day government shutdown at the 
start of FY 2019 -the Indian health system was the only federal 
healthcare entity that shut down. UIOs are so chronically underfunded 
that during the 2018-2019 shutdown, several UIOs had to reduce 
services, lose staff or close their doors entirely, forcing them to 
leave their patients without adequate care. In a UIO shutdown survey, 5 
out of 13 UIOs indicated that they could only maintain normal 
operations for 30 days without funding. For instance, Native American 
Lifelines of Baltimore is a small clinic that received five overdose 
patients during the last shutdown, four of which were fatal. Shutdowns 
mean deaths in our communities. We urge this Committee to support the 
President's request for advance appropriations for the Indian Health 
Service including UIOs.
Conclusion
    These requests are essential to ensure that urban Indians are 
properly cared for, both during this crisis and in the critical times 
following. It is the obligation of the United States government to 
provide these resources for AI/AN people residing in urban areas. This 
obligation does not disappear amid a pandemic, instead it should be 
strengthened, as the need in Indian Country is greater than ever. We 
appreciate your support for urban AI/ANs in the Consolidated 
Appropriations Act, American Rescue Plan Act and request your support 
of the policy requests contained herein. We urge you to honor the trust 
obligation and provide UIOs with all the resources necessary to protect 
the lives of the entirety of the AI/AN population, regardless of where 
they live.

    The Chairman. Thank you very much.
    Next, we have Dr. Sheri-Ann Daniels, Executive Director of 
Papa Ola Lokahi. Welcome, and aloha.

STATEMENT OF SHERI-ANN DANIELS, Ed.D, EXECUTIVE DIRECTOR, PAPA 
                           OLA LOKAHI

    Dr. Daniels. Aloha, Chairman Schatz, Vice Chair Murkowski 
and members of the Senate Committee on Indian Affairs.
    Mahalo nui, thank you for the invitation to testify on 
behalf of Papa Ola Lokahi and Native Hawaiian health. I am 
really humbled to present insights on the COVID-19 response in 
our Native Hawaiian community. Also, your work is critical to 
the self-determination of indigenous peoples in the United 
States to perpetuate Native cultures and practices. Thank you 
so much for your successful efforts to ensure that Native 
Hawaiians were finally included in the American Rescue Plan 
Act, as well as your continued support for Federal programs 
that benefit Native Hawaiian families and communities.
    Papa Ola Lokahi and the Native Hawaiian Health Care 
Improvement Act was actually created through Federal statute in 
the original Native Hawaiian Health Care Act of 1988. POL is a 
501(c)(3) non-profit organization responsible for the 
coordination and maintenance of a comprehensive health care 
master plan called E Ola Mau.
    We also train Native Hawaiian health care professionals, 
serve as a clearinghouse for Native Hawaiian health data and 
research, and provide oversight and coordination of policies, 
support the five Native Hawaiian health care systems which 
provide direct and indirect health services on islands within 
the State of Hawaii. We also protect and perpetuate traditional 
Native Hawaiian cultural healing practices and engage with 
partners serving Native Hawaiian health throughout all 49 
States within the U.S. Our functions are very similar to those 
within organizations like the National Indian Health Board and 
the National Council of Urban Indian Health.
    Our Native Hawaiian Health Care Improvement Act stands 
among the trust responsibilities to Native Hawaiians that are 
recognized by the United States. The other two areas include 
housing and education. Numerous Congressional policies 
specifically acknowledge or recognize that Native Hawaiians 
have a special trust relationship as indigenous people who 
never relinquished their right to self-determination.
    This past year, the pandemic's response has truly 
demonstrated that the health needs of Native Hawaiians were and 
are not among the standing emergency priorities, both on the 
Federal, State and county levels. What we have heard today from 
the other witnesses applies across all our Native communities, 
from our tribes, to our urban Indians, to our Native Hawaiians, 
and they show the negative impacts that the lack of resources 
has done over the decades of health services.
    However, we continue to show resiliency. For example, our 
Native Hawaiian health care systems were able to pivot their 
service provisions and reach deeper into their respective 
communities through components such as tele-health services 
expansion, adding.
    But it wasn't only that. It was going back to basics, 
making sure food was distributed, increasing our engagements 
with our kupuna, our elders, which tested our systems' ability 
to leverage their resources and to fund those initiatives. 
Because those initiatives are not covered. They are not 
billable services.
    But as a community, culturally, we recognize that health 
includes more than just physical health, that it encompasses 
and involves having access to food, clean water, resources on 
education and stable housing. That community engagement was 
critical from the start during this pandemic for us, which we 
stated time and time again. Unfortunately, we weren't listened 
to until now. And now it appears that that might be temporary.
    However, we have never stopped maintaining the role that 
our cultural values and beliefs have in working with our 
communities. We have built a community-driven coalition and 
have actively engaged through the Native Hawaiian Pacific 
Islander Hawaii COVID Response Team. We have over 60 
organizations statewide.
    It is not just in Hawaii. We have partnered nationally with 
our membership and our other partners to make sure what is 
happening across other Native communities.
    In retrospect, could we do different? Absolutely. Did we 
learn new things? Did we confirm what we already knew? Yes. Are 
we willing to holomua, to move forward in unity so that we can 
impact change? Yes. And we choose to do this and serve our 
community to the support of culturally appropriate and sound 
practices regardless of what might be lacking. And we do that 
unapologetically. Because it is about the collective of our 
community versus the individual.
    We have reaffirmed and built new relationships with and 
within our communities. It might not be perfect, but it has 
reignited the purpose in sustaining these reciprocal 
relationships that are built on trust. That is important. We 
keep hearing the word trust.
    Moving forward, we are hoping that this Committee really 
looks to explore pathways that identify direct Federal funding 
mechanisms for Native Hawaiians, naming the Native Hawaiian 
Health Care Improvement Act as an eligible entity and relevant 
notice of funding opportunities, create direct consultation 
between Native Hawaiians and other Federal agencies.
    That direct access to agencies such as CDC, OMH, SAMHSA, 
could help provide opportunities that increase capacities for 
Native Hawaiians and can reach into communities. Because we 
recognize even though we are here to serve Native Hawaiians, we 
serve non-Natives as well.
    To update OMB 15 standards that require new revisions on 
the data that is collected, that we are no longer assigned 
together with other ethnicities, that we can stand alone, that 
we are not erased. And furthermore, to create a robust 
enforcement of those standards, especially for ethnic 
minorities which are often easily ignored by States, in not 
collecting data on us or further disaggregating the data on us.
    To have a better understanding of contextual health data 
related to the social determinants of health, housing, 
employment, food, education and more, and its role in 
understanding not only COVID impacts on Native Hawaiians, but 
health impacts in general.
    We also ask the Committee to support permanent 
authorization of all Native Hawaiian acts: health, housing, and 
education. It is prudent to not only learn lessons from 
difficult times, but also commit to change what may prevent or 
mitigate future changes.
    Again, mahalo piha for this time to share and I look 
forward to answering any questions from the Committee.
    [The prepared statement of Dr. Daniels follows:]

Prepared Statement of Sheri-Ann Daniels, Ed.D, Executive Director, Papa 
                               Ola Lokahi
    Mahalo nui (Thank you) for the invitation to testify on behalf of 
Papa Ola Lokahi (POL) and Native Hawaiian health. I am grateful to be 
here to present some highlights on the COVID-19 response in the Native 
Hawaiian community to the Committee. Your work is critical to the self-
determination of Indigenous peoples in the United States to perpetuate 
Native cultures and practices. Thank you also for your successful 
efforts to ensure that Native Hawaiians were included in the American 
Rescue Plan Act, as well as your continued support for federal programs 
that benefit Native Hawaiian families and communities.
Papa Ola Lokahi and the Native Hawaiian Health Care Improvement Act
    Created through federal statute in the original Native Hawaiian 
Health Care Act of 1988 (currently the Native Hawaiian Health Care 
Improvement Act (NHHCIA)), POL is a 501(c)(3) non-profit organization 
that is responsible for the coordination and maintenance of a 
comprehensive health care master plan for Native Hawaiians; training of 
relevant health care professionals; serving as a clearinghouse for 
Native Hawaiian health data and research; and providing oversight, 
coordination, and support to the Native Hawaiian Health Care Systems 
(NHHCSs), which provide direct and indirect health services to the 
islands of Kaua'i, Moloka'i, Lana'i, Maui, O'ahu, and Hawai'i.
    POL and the NHHCIA stand out among the trust responsibilities to 
Native Hawaiians that are recognized by the United States, similar to 
the trust responsibilities to Native Americans and Alaska Natives. 
Congressional policies that uplift Native Hawaiians in areas such as 
education, housing, language, and more have served to fulfill these 
trust responsibilities. Over 150 Acts specifically acknowledge or 
recognize that Native Hawaiians have a special political and trust 
relationship as Indigenous people who never relinquished the right to 
self-determination.
COVID-19 and Native Hawaiian Health
    The pandemic response this past year has demonstrated both old and 
new barriers that demand timely, yet thoughtful, action for public 
health and safety. Simultaneously, the response of the Native Hawaiian 
community during the first year of the pandemic has demonstrated how 
community-driven efforts during unprecedented crisis can lead to 
innovative and effective solutions. We will highlight a sample of the 
discussions, partnerships, strategies and movements this past year in 
which Papa Ola Lokahi has participated to response to the COVID-19 
pandemic.
    Generally, the five NHHCSs were able to pivot their service 
provision through enhanced telehealth. The losses in revenues were 
sudden and major. Thanks to the forethought of Congress over the last 
several years, increases in annual appropriations to the NHHCIA 
somewhat sheltered the NHHCSs. However, the first year of pandemic 
response demonstrated the health needs of Native Hawaiians are not 
among the standing emergency priorities of either the State or 
Counties. Thus, the NHHCSs and other Native Hawaiian health 
organizations, which are relatively small health providers, may be 
better served with direct federal funding mechanisms.
    Specifically naming POL and the NHHCSs as eligible entities in 
relevant Notice of Funding Opportunities would better expand access to 
resources to Native Hawaiian communities, and better enable our staff 
to identify and prepare grant application efforts. Direct access to 
agencies such as the Centers for Disease Control and Prevention (CDC), 
Office of Minority Health (OMH), Substance Abuse and Mental Health 
Services Administration (SAMHSA) would provide opportunities for the 
NHHCSs to increase their capacity.
    The first year of pandemic response also brought to light the need 
for Native Hawaiian consultation with federal health agencies to 
understand health needs during immediate, long-term emergency response, 
and overall. Native Hawaiian communities continue to face stark choices 
due to the complex and inter-related impacts of social determinants of 
health, such as unemployment, food insecurity, and the ``digital 
divide'' that contributes to disparities in work and educational 
opportunities as well as telehealth access. Absent consultation 
relationships with relevant federal agencies, POL has had little 
ability to communicate the disparate needs reported by the NHHCSs. 
Despite record-breaking relief bills from Congress, the precedence of 
funding Asian American (AA) organizations to then act as gatekeepers 
for Native Hawaiians and Pacific Islanders has resulted in delayed, if 
any, funding support reaching Native Hawaiians.
    The NHHCSs were able to respond to community needs to the extent 
possible through relevant outreach and enabling services, as well as 
new innovations in engagement and community response. In the future, 
health equity may be well served through direct consultation between 
Native Hawaiians and federal agencies.
Challenges and Successes During COVID-19 and Beyond
    Salient to the discussion of the first year of COVID-19 response 
are the health issues that frame challenges to COVID-19 response, 
successes celebrated by the Native Hawaiian community, and the 
sustainability of these innovations. It is prudent to not only learn 
lessons from difficult times, but also commit to change what may 
prevent or mitigate future challenges. Below, we discuss three key 
areas--virtually all of which were identified prior to the pandemic--
that we believe will increase how informed, timely, and capable the 
NHHCSs and the health system at large may be in the future, in addition 
to how to leverage successes from pandemic response for Native Hawaiian 
communities.
1. Data Governance and Infrastructure
    The 1997 update to the Office of Management and Budget Directive 
(OMB) 15, ``Race and Ethnic Standards for Federal Statistics and 
Administrative Reporting,'' which disaggregated the ``Asian or Pacific 
Islander'' race category into two major groups, ``Asian'' and ``Native 
Hawaiians and Other Pacific Islanders,'' was a key policy change to 
ensure that Native Hawaiians--as well as Pacific Islanders--were more 
accurately represented and understood in all areas, including health. 
However, the data difficulties after the initial surge of pandemic 
activity in the State of Hawai'i in March 2020 demonstrated that OMB 15 
requires new revision as well as more robust enforcement to improve the 
understanding of ethnic minorities, including Native Hawaiians. In 
addition, the importance of understanding contextual health data on the 
social determinants of health (housing, employment, and food security, 
educational opportunities, and more) also played a large role in 
understanding the specific COVID-19 impacts on Native Hawaiians.
    Without changes to federal data standards, the NHHCSs have limited 
ability to demonstrate a full and nuanced ``picture'' of Native 
Hawaiian health writ large, but especially during emergencies such as 
COVID-19. Many variables reported by the NHHCSs to federal agencies 
capture simple data counts, such as the number of people who received a 
type of service or participated in a program. The statistics that these 
data create do not capture the deeper nuances of Native health, which 
creates a dilemma when Native health systems try to demonstrate 
effective use of funds or identify Native priorities.
    Recommendations for transforming data to better understand and 
serve Native Hawaiians were reported in February 2021 in the report 
Data Justice: About Us, By Us, For Us, \1\ a joint publication of POL 
and the Hawai'i Budget & Policy Center. These recommendations had large 
overlap with COVID-19 health equity recommendations in a March 2021 
report, COVID-19 in Hawai'i: Addressing Health Equity in Diverse 
Populations. \2\ Though focused on data needs and recommendations in a 
state context, the majority of the report recommendations apply to 
federal policies as well, including the need for regular consultation, 
meaningful standardization of data completeness and accuracy across 
agencies and public programs, evaluation, and more.
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    \1\ Kauahikaua, L. and Pieper-Jordan, S. (2021). ``Data Justice: 
About Us, By Us, For Us.'' Hawai'i Budget & Policy Center and Papa Ola 
Lokahi. Available at https://static1.squarespace.com/static/
5ef66d594879125d04f91774/t/60514869451e1d09b75e4317/1615939719621/
Data+Justice+Report_Interactive.pdf
    \2\ Hawai'i State Department of Health (2021). ``COVID-19 in 
Hawai'i: Addressing Health Equity in Diverse Populations.'' Disease 
Outbreak Control Division: Special Report. Available at https://
hawaiicovid19.com/wp-content/uploads/2021/03/COVID-19-Race-Ethnicity-
Equity-Report.pdf
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2. NHHCIA Legislative Changes
    The first year of pandemic response served as a serious example of 
how current NHHCIA language prevents the NHHCSs from fully responding 
to community needs in a timely and meaningful way during crisis. Though 
the NHHCSs were generally able to pivot to telehealth and other 
innovations, which have now expanded to include vaccination efforts, 
the limitations posed by NHHCIA on matching funds during a crisis that 
resulted in lowered revenues for all health providers--both Native and 
non-Native--capped the ability of NHHCS leadership to provide 
proportionate servicing overall as well as the timeliness of response 
activities.
    POL is grateful for the support of the Hawai'i Congressional 
delegation for the work to revise and reauthorize the NHHCIA so that 
Native Hawaiian health resources reach parity with other health 
facilities and providers. As pandemic response shifts into recovery, 
the need for all Native health systems to be able to act is paramount 
for the protection and health of Native communities.
3. Collective Impact and Partnership Successes
    The successes of the NHHCSs and Native Hawaiian organizations were 
achieved through coalition-based efforts, often in solidarity with 
Pacific Islander organizations. POL was able to access and re-
distribute federally-sourced resources like personal protective 
equipment, sanitation items, and more. The NHHCSs identified partners 
to assist in response efforts such as food and diaper distribution and 
more recently, vaccination distribution in Native Hawaiian communities. 
The connections strengthened or created during the first year of 
pandemic response and the results of collective efforts, despite their 
effectiveness and utility to improve Native Hawaiian health--and 
community health, as Native Hawaiians live among larger groups--remains 
underrated. It is our understanding that the CDC has recently 
identified some of the contact tracing efforts for Pacific Islanders as 
a pilot project worth further investigation; we believe that other work 
in the Native Hawaiian and Pacific Islander pandemic response also 
demonstrates successful, sustainable, and culturally appropriate 
practices that can be scaled and potentially applied to other health 
issues affecting Native Hawaiians.
    Mahalo to all the members of this committee for the opportunity to 
share these stories.

    The Chairman. Mahalo, Dr. Daniels.
    Next, and final testifier, we have Dr. Robert Onders, 
Administrator, Alaska Native Medical Center.

STATEMENT OF ROBERT ONDERS, M.D., ADMINISTRATOR, ALASKA NATIVE 
                         MEDICAL CENTER

    Dr. Onders. Thank you, Mr. Chair, and Vice Chair Murkowski. 
It is great to see you as well. Thank you for this opportunity 
to provide testimony to the Committee.
    Alaska Native Tribal Health Consortium is a statewide 
tribal health organization that serves all 229 tribes and all 
Alaska Native and American Indian individuals in Alaska. Alaska 
Native Tribal Health Consortium and South Central Foundation 
co-manage Alaska Native Medical Center, the tertiary care 
hospital for all Alaska Native and American Indian people in 
the State. That is where I serve as administrator.
    My testimony, as provided in the written comments, will 
focus on three areas: to give a brief overview of the response 
to the COVID-19 pandemic in Alaska through the tribal health 
system, lessons learned over the past year, and what we feel is 
needed going forward.
    Our response had some key components that I think showed 
the strength of the tribal health system. I think this is 
common with other people who have provided comments here today. 
Communication and collaboration were key in this response. We 
were dealing with situations of scarce resources, limited 
information and needed coordination. The tribal health system 
is incredibly strong because of the established connections at 
the tribal leadership levels, like Chief Smith, at clinical 
directors and physician levels, at pharmacist levels, at 
community health aide levels. Across the entire system, we have 
those established communication channels.
    And with our partners like Dr. Toedt and the Indian Health 
Service and Ms. Dotomain, the Alaska Area Director, those 
channels were essential in our response.
    The other component that was essential and became obvious 
is, our system is mission-driven and public health minded. The 
people that I work with, the nursing staff here at the 
hospital, the physician staff, the support staff, our partners 
in Indian Health Service, the tribal leaders, everyone went 
beyond and above the call of duty to respond when needed. We 
were constantly standing up new operations and dealing with 
challenges throughout this.
    Our response, I can categorize at least right now, in three 
areas. Early on, testing was key. Alaska was fortunate, being a 
little bit geographically isolated and western on our 
geography, to be able to learn from other areas. We quickly 
identified testing would be key. So we mobilized that across 
communities at many levels. In the local areas, they 
implemented it in an incredible fashion.
    Rural Alaska communities are incredibly creative in finding 
solutions. I felt our need or our responsibility was to give 
them the tools they needed to respond. They did that with 
extensive testing to limit the spread. That limiting of spread 
allowed us to delay the onset in Alaska, allowed better 
therapies to be developed so that we could respond better when 
the surge came.
    For Alaska, I think particularly for Alaska Native Medical 
Center, that surge came in November and December, when we were 
seeing high volumes of COVID patients. It was extremely 
challenging in the hospital setting. One hundred twenty of 
AMC's 170 rooms are double occupancy rooms. The waiting room in 
the emergency room is about a 20 by 20 space, where we do 
50,000 to 60,000 visits per year. The facility is extremely 
space challenged.
    We knew that before COVID, but COVID highlighted that 
challenge. Having two patients in every room is extremely 
challenging with you are dealing with something like COVID, 
where people may not know of symptoms for five to seven days 
after admission. It required us to test everyone in the 
hospital every three days in order to try to prevent spread. 
And this is not the community standard of how a hospital 
facility should be built.
    The key highlight in my mind in the response is the 
vaccination effort. I think a key component of this, as was 
mentioned by other speakers, was that need and recognition of 
Indian health services and tribes as a unique jurisdiction that 
allowed for local flexibility and a response with the 
administration of the vaccine that was extremely successful in 
Alaska.
    As we look for lessons learned as well as future direction, 
I reflect on the H1N1 pandemic in 2008 and 2009. What we 
determined at that time with Alaska Native people and American 
Indian people, with a significant disproportionate burden in 
that time period, was a lot of the challenges were inadequate 
infrastructure. Inadequate water and sewer, inadequate housing, 
inadequate clinical access. What we are seeing with COVID is 
the same challenges.
    So both the lessons learned and I think the takeaways for 
the Committee is, we need resources for adequate water and 
sewer infrastructure in rural Alaska. We need resources for 
adequate housing infrastructure in rural Alaska. We need 
resources for adequate access to health care, both at the tele-
health component with broadband accessibility, but also just 
with infrastructure. I would hate to see another 10 years go by 
and we see the same reflection on why Alaska Native people had 
a disproportional burden of another pandemic because these 
issues are unaddressed.
    So thank you again for the opportunity to provide testimony 
on the experience of the tribal health system in Alaska in 
responding to COVID, and those three critical areas that we 
need further investment in.
    Thank you.
    [The prepared statement of Dr. Onders follows:]

Prepared Statement of Robert Onders, M.D., Administrator, Alaska Native 
                             Medical Center
    My name is Dr. Robert Onders. I serve as the administrator for the 
Alaska Native Medical Center (ANMC) in Anchorage, Alaska. It is my 
privilege to provide testimony on behalf of the Alaska Native Tribal 
Health Consortium (ANTHC).
    ANTHC is a statewide tribal health organization that serves all 229 
tribes and all Alaska Native and American Indian (AN/AIs) individuals 
in Alaska. ANTHC and Southcentral Foundation co-manage the Alaska 
Native Medical Center, the tertiary care hospital for all AN/AI people 
in the state.
    My testimony will focus on three areas: (1) the Alaska Tribal 
Health System response to the COVID-19 pandemic; (2) lessons learned 
over the past year; and (3) what is needed going forward.
Tribal COVID-19 response and needs
    Tribal health organizations across Alaska have long established 
relationships with each other, as well as with State and federal 
officials, so throughout this pandemic our response has been 
coordinated and cooperative with good communication channels. 
Discussions regarding how best to use scarce resources have been held 
as a group to ensure the maximum benefit. We believe that it is the 
inclusion of, and cooperation with, the tribal health system that has 
allowed Alaska to be effective in combatting the pandemic.
    The Alaska tribal health system has mission driven and public 
health minded governance, leadership, and staff. Over and over again, 
our people responded to the quickly changing, and often difficult, 
conditions. Our dedicated staff, along with State and federal support, 
allowed us to quickly stand-up testing sites, open up an Alternate Care 
Site to expand our hospital capacity, dedicate a wing of our hospital 
to COVID-19 patients, and open vaccination clinics.
    Our response to the pandemic can generally be categorized into 
three phases- early identification, response to surges, and 
vaccinations.
    For early identification and eradication, we knew that there would 
be great challenges if COVID-19 entered into rural communities, as the 
conditions in these communities--lack of access to higher level 
healthcare, inadequate sanitation, and overcrowded multigenerational 
housing--have not significantly improved since the 2008-2009 H1N1 
pandemic. Although, thankfully, the effects of H1N1 were comparatively 
small, AN/AI people still experienced 4 times higher cases, 
hospitalizations, and mortality during that pandemic. So, we knew that 
testing and early identification would be key in our response to this 
far more serious pandemic. The support of our congressional delegation 
and the tribal-federal relationship were key in getting recognition of 
the need for an increased investment in testing in rural Alaska and 
gaining access to testing supplies early on. Timely testing was 
essential to address the geographic isolation of many of our 
communities, which are off the road system and only have limited access 
by plane or boat.
    The October-November-December surge of cases in Anchorage 
eventually spilled over into rural Alaska, despite the extensive 
mitigation measures put in place in those communities. The surge also 
highlighted the inadequate capacity of ANMC. ANMC was already 
overcrowded with adult inpatient occupancy rates running over 90 
percent before COVID-19. COVID-19 overwhelmed our inpatient capacity, 
requiring conversion of patient housing to an Alternate Care Site. 
Adding additional inpatient space was complicated because 120 of ANMC's 
170 inpatient rooms are double occupancy rooms.
    Such a high level of inpatient utilization is almost unheard of in 
today's healthcare market and increases the difficulty in preventing 
the spread of infectious disease. In response, we tested every 
inpatient every 3 days. It has also made it very challenging to allow 
family and other caregivers into rooms, as we would now have two 
households in a single room. Other, non-tribal, neonatal intensive care 
units in Anchorage have private rooms where mothers can stay with their 
child. At ANMC, the babies are grouped together and mothers cannot stay 
continuously at the hospital. This situation presents an incredible 
challenge with COVID-19, and is a travesty for a facility that delivers 
more AN/AI babies than any other hospital in the country.
    The recognition of Indian Health Service (IHS) and tribes as a 
separate jurisdiction from states, along with the separate IHS vaccine 
allocation, was critical in ramping up vaccinations in tribal 
communities throughout Alaska. Tribal health has been a model for 
getting the vaccine mobilized quickly. We have a comprehensive system 
that has inpatient, outpatient, and primary care services in a single 
system, which allows for subject matter experts and resources to be 
allocated to the vaccination process in a manner not available to most 
systems. Our Cerner Electronic Health Record already was interfaced 
with the State of Alaska VacTrack system for other immunizations so the 
documentation and ordering processes were already familiar to everyone.
One year later: key takeaways
Inadequate Water and Sewer infrastructure
    The silent crisis in rural Alaska communities is still present. 
Sanitation service in many Alaska Native communities has long been 
lacking, but the pandemic has highlighted how essential adequate 
sanitation is for our communities.
    The importance of adequate sanitation to prevent skin and 
respiratory infections is very clear. CDC studies have documented that 
skin and respiratory infections, in rural Alaska communities without 
sanitation service to homes, are 5 to 11 times higher than the national 
average. Adequate water and sewer services are especially critical now, 
since COVID-19 is a respiratory disease whose spread can be prevented 
by hand washing and avoiding close contact with others. Lack of water 
service in these rural Alaska villages creates extreme challenges in 
practicing two of the most basic prevention techniques.
    Of the 190 Alaska Native communities, 32 are still unserved, 
lacking in-home water and sewer. These communities typically have a 
washeteria building (combination water treatment plant, laundromat, 
toilets and showers) that the entire community uses. Most of these 
communities haul their water from the washeteria to their home in a 5-
gallon bucket, and haul their sewage from their home in a different 5-
gallon bucket.
    The latest IHS Sanitation Deficiency System data show a need of 
nearly $3 billion for sanitation construction projects in Indian 
Country, with $1.8 billion of that need in Alaska. Sanitation 
facilities construction funding needs to be greatly increased this year 
and in future years to address the inadequate sanitation services in 
AN/AI communities.
Inadequate housing infrastructure
    Inadequate housing presents an additional challenge to protecting 
rural and isolated communities during the pandemic, where the 
prevalence of multi-family and multi-generational housing makes social 
distancing very difficult. The latest assessment by Alaska Housing 
Finance Corporation shows that Alaska has twice the national average of 
overcrowded homes, with rates as high as 12 times the national average 
in some rural, predominantly Alaska Native communities. Western regions 
of the state are extremely overcrowded, with the Bering Straits region 
experiencing 37 percent overcrowding and severe overcrowding, compared 
to the national average of just 3 percent overcrowding.
    Overcrowded housing is most prevalent in communities that are 
already under the greatest threat from COVID-19, because they have 
fewer transportation options available to seek higher-level medical 
care and less access to adequate sanitation services.
What is needed to combat pandemics going forward
    On many levels the tribal health response to the pandemic has been 
excellent, but in Alaska, Alaska Natives still experienced a mortality 
rate that is 4 times that of the white population. Many factors 
contribute to reducing the impact of COVID-19, and it can often be 
difficult to discern the most effective measures, but in many Alaska 
Native communities the infrastructure is lacking to provide the 
foundational measures in preventing a pandemic, particularly adequate 
sanitation and housing.
    This pandemic highlighted the need to bring the Alaska Native 
Medical Center up to the industry for standard facility space 
requirements for patient safety. We need to transition away from shared 
patient rooms, high occupancy rates which limit surge capacity, and 
limiting spaces where outpatient and inpatient services are combined 
into single locations. The Alaska Native Medical Center was opened in 
1997 and was in desperate need for expansion prior to the COVID-19 
pandemic. The pandemic further exposed the vulnerabilities created by 
not addressing this need. We need funding to expand inpatient capacity 
for facilities such as ANMC that serve entire states/regions.
    Tribal communities that are unserved, or underserved, with 
sanitation services must be provided with the facilities to provide 
these services. Funding is key toward addressing the $3 billion in 
sanitation facilities need estimated by IHS, but the 32 unserved 
communities in Alaska will not be served unless federal and state 
agencies make a commitment to be more flexible in addressing the unique 
situations of these communities.
    The lack of housing and resultant extreme overcrowding we see in 
rural Alaska, has significant negative impacts on containing COVID-19, 
and other infectious diseases.
    As previously stated, the vaccine allocation through IHS to tribal 
health programs has literally been a life saver. We were rapidly able 
to vaccinate many of our Alaska Native people and communities. Alaska 
now has 43.5 percent of the over age 16 population vaccinated, and over 
40 percent of those vaccinations were administered through the tribal 
health system. It is essential that the IHS vaccine allocation 
continue, and that it be rapidly utilized if the need for booster shots 
that address new variants arises.
    Thank you for the opportunity to provide testimony on the 
experience of the tribal health system in responding to COVID-19 and 
what is needed to better equip us as we continue to battle this 
pandemic.

    The Chairman. Thank you very much to all of our testifiers.
    I will begin with Dr. Toedt. Dr. Toedt, can you explain why 
HHS applies the Federal trust responsibility to Native 
Hawaiians and health care systems differently? Let me provide 
you a couple of glaring example of unequal treatment.
    Congress provided $9 billion to support Native health 
systems, tribal, urban Indian, Native Hawaiian, during COVID. 
All funding dedicated for tribal and urban Indian allocation 
through IHS has gone out without requiring a funding match. But 
HRSA prepares to allocate the first dedicated funding for 
Native Hawaiian health care centers, as it does that, it 
appears that the agency is considering requiring a funding 
match or a formal request for a waiver.
    Second, on the Federal Tort Claims Act coverage, the 
Federal Government extends FTCA coverage to all three branches 
of IHS in recognition of its trust responsibility. Last 
Congress, HHS and HRSA opposed my legislation to provide parity 
for Native Hawaiian health care centers.
    So what is going on here, and how are we going to fix it?
    Dr. Toedt. Thank you, Senator Schatz. You are exactly 
right. Under current law, the Native Hawaiian health system is 
not a part of the Indian Health Service, Indian health system. 
HRSA, Health Resources and Services Administration, administers 
the Federal program for Native Hawaiian health centers pursuant 
to the Native Hawaiian Health Care Act and other agencies 
within DHHS also serve Native Hawaiians. We are committed to 
working with the Senate and would be happy to make sure that we 
can do all we can to improve access to all indigenous persons.
    Senator Schatz. Thank you. I just want to be clear. We are 
all familiar with the statutory architecture here. Some of it 
is a dispositional question. The question is, are you going to 
try to get to equal treatment? And your position, as I 
understand it, under the law, is to be a liaison, an ambassador 
on behalf of Native peoples to other agencies.
    So do we have your commitment to work through these issues 
with Papa Ola Lokahi, with myself, with the Committee?
    Dr. Toedt. Absolutely, yes, sir. You have our commitment.
    The Chairman. Thank you very much.
    Dr. Daniels, reportedly only 15 percent of Native Hawaiian 
and Pacific Islanders have received at least one vaccine dose, 
despite the fact that they account for 40 percent of the 
State's COVID cases. I guess the question that I want to ask is 
about disaggregation of data. Because as we see the case counts 
coming in, there is a fair amount of good disaggregation of 
data among Asian Americans, Pacific Islanders, and Native 
Hawaiians.
    This sort of basket of different communities is sort of not 
informative for how we are going to address whether or not this 
is vaccine hesitancy, whether this is a question of not being 
able to get online, whether this is geographic or 
transportation issues. It is just hard when we can't 
disaggregate the data.
    So could you give us some guidance on how we can move in 
the direction of a kind of common platform for the 
disaggregation of health data, so that we can make use of this? 
These categories are so broad as to be not particularly 
actionable.
    Dr. Daniels. Thank you, Chair.
    I think it goes back to OMB 15, and how they designate how 
data is collected. Currently, Native Hawaiians are combined 
with Pacific Islanders. At minimum, OMB 15 asks the States to 
collect the data. We know in the State of Hawaii, our Governor 
has announced or stated that the date piece is kind of behind 
in what we know has been done in terms of vaccination rollouts.
    But also, when we are combined with another group, there 
has to be that second layer of further disaggregating the data, 
so that we can see where NHs truly stand in comparison to, for 
example, Pacific Islander or in some cases and in some States, 
also with the Asian Americans. Many States didn't even separate 
NHPIs throughout this pandemic. So the fact that Hawaii did and 
then further disaggregated it during the positive cases, they 
haven't been able to do that for the vaccination rollout.
    The other thing to note is we did not have options. Our 
Native Hawaiian health care systems were not identified as 
being able to receive vaccines directly, like community health 
centers were. We are now starting to partner, we are partnering 
with the Department of Health and other partners that get the 
vaccine to be able to push it out into our communities. So 
right there, there is already a system barrier to allowing the 
Native Hawaiian health care systems that access.
    We also know that when States created their own tier 
systems, even though Native Hawaiians were identified as a 
priority population in the National Academy of Medicine's 
vaccination prioritization, that did not roll out in the 
State's plan and tiering. We were not included in that. We were 
at the table, but we were not listened to in adding into the 
tiers.
    When we talk about life expectancy, we know Native 
Hawaiians have a life expectancy of 76 years, 73.9 for men. 
What that means is when they are vaccinating 75 and older, you 
are not capturing our community.
    So it is all those different factors that create the not-
perfect storm for us.
    The Chairman. Thank you very much, Dr. Daniels. I have just 
observed that the problems that she is describing I am sure 
exist in Alaska and across Indian Country. We are, it seems to 
me, moving from a period of vaccine shortages to perhaps a 
challenge with demand and with deployment. Trust is going to be 
one of the key elements in deploying the vaccine. Obviously, 
the people who have gotten vaccinated were the people most 
anxious to get vaccinated, or the most able to get vaccinated, 
either because of their ability to move themselves around their 
community or their ability to sign up in an online forum as 
soon as it became available.
    But the next tranche is going to be harder. We are going to 
need community partners to help us to get to herd immunity.
    Vice Chair Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman.
    Just to follow on your point there, I am reading from an 
article that came out outlining the Native health providers 
vaccination success story. One of the statements that is made 
here is that the cultural value of sharing and taking care of 
one another is one that I think is so shared by our Native 
populations. The journalist goes on to share the real tragedies 
that still remain from 1918, where children who lost their 
parents in the pandemic, boys and girls who grew up not knowing 
what their last name was because everyone in the family had 
died and not being able to have that.
    So making sure that we have learned from that, making sure 
that culturally we are taking care of one another and working 
to address the concerns that you have raised about hesitancy.
    I do think it was helpful to hear from so many who provided 
testimony today of the partnering that has been going on with 
vaccines. In the State of Alaska, I know very early on through 
the IHS system, as Dr. Onders has outlined, we were able to 
establish a sharing, a partnering with the Department of 
Defense to get testing to those within the DOD.
    I want to direct a question to you, Dr. Onders, and I 
really appreciate what you have outlined in terms of the 
lessons learned, the focus on inadequate infrastructure, 
specifically water, sewer, housing, tele-health, broadband, so 
that as we move forward this is not just a lesson in history 
but we have learned from it and built better health care 
infrastructure.
    There was a recent announcement from IHS that there is an 
allocation, the allocation of $95 million for tele-health needs 
from the CARES Act. I guess the question I am going to ask of 
you is how is ANMC best leveraging the dollars to expand tele-
health around the State. There are some services that are not 
currently being provided that you would seek to build out with 
this.
    How do we take advantage of not only these funds that are 
coming from CARES, but the future dollars that will be coming 
from the American Rescue Plan, to help address the 
infrastructure inadequacy that you have pointed out so well?
    Dr. Onders. Thank you for the question. We have not yet 
received a portion of the $95 million for tele-health dedicated 
from IHS, but we are working extensively in this area in 
anticipation of that funding as well as other funding in that 
area.
    As you are well aware, the tribal health system has been a 
leader in providing tele-health services, just because of the 
geography and the remoteness and the need for travel in order 
to see that. But what we saw in COVID, there is great 
opportunity for extending [background noise] --
    Senator Murkowski. You have a day job, too, we appreciate 
that.
    Dr. Onders. I do think there is a great opportunity to 
expand access to tele-health. Particularly what we saw is in-
home services have been extremely receptive to individual 
patients. So what we have done is developed increasing kind of 
standard procedures related to in-home tele-health as well as 
training that is required in order to facilitate those visits 
going smoothly.
    The key piece that I think is missing though is that 
broadband availability. I can speak personally because I spend 
a fair bit of time in Nome as well. To get equivalent service 
in Nome that I have in Anchorage for $80 per month is over $400 
per month. So even though broadband may be ``available'' in 
certain areas, it is not affordable for most people. As well as 
the 40 percent of Alaska villages rely on 2G connectivity.
    So the ability to potentially deliver home services I think 
requires that infrastructure investment in broadband as well.
    Senator Murkowski. We certainly have much more that we need 
to do there.
    Mr. Chairman, I have a question that I would like to direct 
to both Mr. Onders and to Rear Admiral Toedt, and that relates 
to what may be under consideration as we are looking at these 
variants that we are seeing, greater prevalence, not only in my 
State but around the Country. Just very quickly, if you can let 
the Committee know what if anything our Native health care 
system is doing to prepare, either for another potential wave 
of infections or variants that we might not be seeing much 
activity yet.
    Dr. Onders. Thank you, Senator Murkowski, I might start. I 
think vaccination is still key in the response to the variants. 
From what we know, though, the effectiveness of the vaccine in 
doing the major component of preventing hospitalization and 
mortality in many of the variants is still controlled by 
vaccination. As the Chairman mentioned, I think in Alaska we 
are particularly interested in kind of the harder to reach 
individuals that really require a trusting relationship in 
order to receive the vaccine, and/or get to the access to do 
that.
    So within the tribal health system in Alaska for vaccine, 
we are implementing in-hospital vaccination, so ensuring that 
anyone who comes into our hospital who has not received a 
vaccine, we have that discussion and we offer them the vaccine 
while they are here for other reasons. Because they may not 
have the capacity or may not be able to schedule independently 
for that visit. As well as the harder to reach populations that 
may require that trusting relationship, and discussion with the 
provider, in order to take up the vaccine.
    So from my standpoint, the biggest thing we need to do to 
combat the variants is increase vaccination. Although rural 
Alaska has done an incredible job, here in Anchorage, a hub 
community, the vaccination rate still is lower than we would 
like. That creates a risk for rural Alaska.
    Senator Murkowski. Mr. Chair, I am well over my time. But I 
had also asked Rear Admiral Toedt if he had a response on 
variants.
    Dr. Toedt. Yes, just briefly. I want to concur with Dr. 
Onders. But I want to add to that that it is also important 
that we consider vaccination part of the continuum of our 
preventive efforts, and that we continue with mask wearing, 
with social distancing, with hand washing. These things 
continue to be important. And that we don't neglect testing. It 
is so important to continue testing not only to determine what 
types of variants are circulating, but also to make sure that 
we keep control of surveillance and understand where the virus 
is spreading.
    So I will add to that, and agree with Dr. Onders.
    Senator Murkowski. Thank you, Mr. Chairman.
    The Chairman. Thank you very much. Senator Smith.

                 STATEMENT OF HON. TINA SMITH, 
                  U.S. SENATOR FROM MINNESOTA

    Senator Smith. Thank you very much, Mr. Chair, and Vice 
Chair Murkowski. I appreciate this hearing very much.
    I want to just first say that I would like to associate 
myself with the concerns raised by Chair Schatz regarding the 
importance of parity and equity for Native Hawaiians on 
liability coverage. I just want you to know that I look forward 
to working with Senator Schatz and all of you to extend these 
same benefits to Native Hawaiians.
    I would like to start with a question for Mr. Murillo about 
urban indigenous communities. Then if I have time, I want to 
ask a question about data and sharing data to Mr. Smith. Let me 
just then start with you, Mr. Murillo.
    In Minnesota, our tribes are doing an exceptional job, like 
in many places in the Country, to vaccinate their members on 
tribal lands and also reaching out to urban indigenous 
communities. I had the opportunity not so long ago to be with 
Chair Cathy Chavers with the Bois Forte Band to see their new 
mobile vaccine clinic in the Twin Cities. Using resources from 
the CARES Act they were able to purchase an ambulance and 
repurpose this for a mobile vaccination unit. This has been 
great.
    But of course, not everybody has the capacity to reach 
their members in this way. We know that we need to make sure 
that Congress is providing sufficient health care resources 
directly to urban indigenous communities, so that they have 
access to the care that they need.
    So Mr. Murillo, could you tell me whether you think that we 
are doing enough? What in particular do you think we need to do 
more of and better to support the health care needs of urban 
indigenous communities, certainly during COVID but also longer 
term?
    Mr. Murillo. Thank you, Senator Smith, for that question. I 
think that in terms of the COVID response, carving out 
dedicated funds for Urban Indian health programs has been very 
helpful. I think where there have been issues with that is the 
lack of flexibility on the use of those funds. Sometimes that 
is as a result of the appropriation act itself, but sometimes 
it is existing regulation that prevents us from doing certain 
things.
    For example, facilities. Facilities, the requirement in 
legislation, in the law, requires that we seek JCAHO 
accreditation even though many of us are accredited by other 
bodies, CARF, or AAAHC. We are unable to use those funds for 
facilities, even existing funds that we have in our regular 
line item. That is a flaw, I think, in legislation, in the law, 
that could be easily changed.
    I think also extension of FTCA has been very helpful to us 
in terms of reaching outside of our facilities and the ability 
to provide vaccines out into the community. Also, I believe 
FMAP will also help with that. We have seen in many States, 
like in Arizona, where the emergency waiver for providing 100 
percent FMAP for the administration of vaccine has been very 
helpful in terms of reaching out to parts of our communities.
    So in other cases, with the lack of flexibility, it was 
very unclear early on as to whether or not we could use these 
funds for mobile units, funds that had to be directed through 
the CDC, for example. It was unclear whether we could use that 
for mobile units. But in subsequent funds under the ARPA, the 
flexibilities have greatly expanded. We are thankful for that.
    Senator Smith. Thank you. That is great. I think those are 
some great suggestions that I hope we can all think about as we 
look at how to make sure that we have enough flexibility so 
that you can do the work that you need to do.
    I have about a minute left. Let me ask this question 
specifically about data. One of the most important functions 
tribal governments have had over the past year has been your 
role as public health authorities. In order to do this work, of 
course, you need to have access to data.
    We learned last summer through news outlets that several 
Federal and State health care agencies were refusing to give 
tribal governments access to data about COVID-19 cases near 
tribal lands. They were giving this data, CDC was giving this 
data to States, but not always to tribes, even though it seems 
the law is quite clear on this matter.
    So we went to work on this. I am grateful for the chance to 
work with Senator Murkowski and many others on this Committee 
to introduce the Tribal Health Data Improvement Act, which 
would clarify that the CDC has a responsibility to share data 
and encourage that data sharing. We are going to be 
reintroducing that bill soon. It did not pass last year.
    In just a few seconds, Mr. Smith, would you just tell me a 
little bit about how you see this issue, and what you think we 
need to do to strengthen this data sharing?
    Mr. Smith. Thank you for that. We have asked for direct 
access to data through the Indian Health Service and CDC within 
Alaska. Among the tribes where data is in fact 85 percent of 
the programs operated on the sharing data system, this system 
is [indiscernible] misstated by the ANTHC. Regarding the 
vaccines, we do not partner with the State of Alaska, or the 
VaxAct [phonetically] system.
    Senator Smith. Okay. I think we are going to continue to 
work on this. I appreciate that very much. Thank you, Madam 
Chair.
    Senator Murkowski. [Presiding] Thank you, Senator Smith.
    Senator Lankford is next.

               STATEMENT OF HON. JAMES LANKFORD, 
                   U.S. SENATOR FROM OKLAHOMA

    Senator Lankford. Thank you very much for that.
    Let me first say thank you to the Committee staff and your 
leadership and the folks at IHS. We passed last year the Urban 
Indian Health Providers Act, I know that is something several 
members worked together on to be able to get done. We got that 
done, got that passed, and on March 22nd, IHS notified all the 
Urban Indian facilities that they are officially covered with 
the tort claims as well. We appreciate the rapid engagement on 
that and the information that has gone out, and the hard work 
of some of the Committee staff and of IHS to be able to get 
that done. We appreciate that very much.
    I do want to do a follow-up question for Walter on that in 
particular, to be able to find out how that is working and how 
the implementation is going for that tort claims coverage now.
    Mr. Murillo. Thank you, Senator Lankford. I know that FTCA 
coverage is a final lynchpin in helping to achieve parity for 
the two Oklahoma Urban Indian health programs. We are happy 
that they have it.
    We are also happy, this is a good example to show of the 
necessity for IHS to confer with Urban Indian health programs, 
something that doesn't exist with other operatives within HHS, 
and the benefit it has, so that we can have open communications 
and the rapid nature of its deployment with Urban Indian health 
programs has been a plus. So we see that that can work, and it 
does work, especially with FTCA.
    Now, we are awaiting some FAQs and other implementation 
aspects of tort claims coverage. But we are very happy with the 
response, and the rapid nature of it that the Indian Health 
Service has done in informing and having that applied to Urban 
Indian health programs. We would like to see that replicated in 
the other operating divisions within HHS, and HHS's help in 
terms of a confer policy for Urban Indian health programs.
    Senator Lankford. Thanks, Walter. You are welcome to come 
back to Oklahoma any time, the door is always open to be able 
to come back home on that.
    I do want to do a follow-up question. Senator Smith had 
asked you specifically about some of the facilities funding, 
from some of the COVID emergency dollars that came. You said 
there were some issues and some things that needed to be 
clarified in legislation or appropriations language to be able 
to help fix some of that. Do you have a specific recommendation 
on that?
    Mr. Murillo. Sure. I think changing the accreditation, 
which is an admirable goal, and a goal that we all have that 
run clinics, but to specifically align that with JHACO. It 
hurts facilities like Native Health in Phoenix that are 
accredited through the AAAHC. We are an accredited agency, but 
we can't use our funds for facilities.
    I think that is a problem born in the law that can be 
easily changed. I think that will apply not just to the 
pandemic but also other times. It hurts us in that urban 
programs also include the inpatient alcohol and substance abuse 
programs. Their capacity is diminished by as much as 80 or 90 
percent without the ability to make adjustments to their 
facilities. Those programs just could not see those and provide 
those much-needed services in Indian Country.
    Senator Lankford. Thank you. That is helpful to be able to 
get on the record as well.
    Mike, I want to ask you a little bit about the 
administration of the vaccine and the distribution of the 
vaccine as it has gone to tribes all over the Country. In 
Oklahoma, in particular, in the distribution that has happened 
to Native locations across my State, they have been extremely 
efficient in getting the vaccine out, not only just receiving 
the vaccine, but actually getting it into arms.
    We have, just as a point of reference, tribes in Oklahoma 
have vaccinated more people than Washington, D.C. has 
vaccinated people. There have been a lot of folk who have been 
vaccinated through the tribes in Oklahoma and they have done a 
very good job being able to get that vaccine out. Once they 
have received it, it is not sitting in storage. It is getting 
into arms very, very rapidly on that.
    The process for distributing the vaccines to different 
tribes, how is that allocation working right now? Where are you 
seeing strengths and weaknesses? What can we do to continue to 
improve that in the weeks ahead?
    Dr. Toedt. Thank you, Senator Lankford, for the question. I 
want to concur with you that the tribes, through their 
sovereignty, have been doing a fantastic job. I think that one 
of the things that has been most successful in the Indian 
Health Service jurisdiction is the respecting of tribal 
sovereignty and allowing tribes to do what they do best.
    So what we want to do is, we have moved from a push system 
where we are designating how much each area gets, and then each 
area is working with tribes to designate how much they get, to 
actually turn things around and have a pull system, whereby the 
sites that are working under our jurisdiction are pulling that 
vaccine forward. So they are able to order how much they need.
    We certainly give advice to keep an inventory of at least a 
one to two week supply. We have hosted some webinar trainings 
with the vaccine points of contact in the area to demonstrate 
this changeover to a pull system. To date, we have been able to 
fulfill all of the requests from the facilities after switching 
to this system.
    So we think that respecting that tribal sovereignty and 
giving them the ability to make those operational decisions 
about how much vaccine they need is going to improve things 
going forward.
    Senator Lankford. Thank you all.
    Senator Murkowski. Thank you, Senator Lankford.
    Senator Cantwell.

               STATEMENT OF HON. MARIA CANTWELL, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Cantwell. Thank you, Madam Chair. I want to thank 
the witnesses, particularly Mr. Murillo. You might have heard 
me clapping when you said that you wanted to see full 100 
percent FMAP funding. You also just in your answers to previous 
questions talked about this enabled you the one-time fix for 
this, that we were able to get in a previous CARES package, to 
provide more vaccines.
    But I wondered if you or Dr. Daniels, to me this issue is 
just an inequity. It is something that has occurred, but I 
don't understand the logic. If we are giving 100 percent FMAP 
funding to Indian Health Care systems, to a hospital, why 
aren't you giving 100 percent FMAP funding to Urban Indian 
health? It is a formula that if we are doing this based on the 
delivery of health care, it should be the same, whether you are 
urban or rural. It also affects, obviously, Native Alaskans as 
well.
    So I don't know if Dr. Daniels or Mr. Murillo, if you want 
to comment on that. I think we are going to have another shot 
at a discussion here, at least in the President's proposal, to 
increase and support the health care delivery system. I 
certainly would want to get this corrected and made permanent 
once and for all.
    So if either of you could comment on that.
    Mr. Murillo. Thank you, Senator, for that question.
    Yes, the 100 percent FMAP would help equalize the serious 
funding shortage we have in Urban Indian health programs, 
access to enhanced rates, or even initiatives done by certain 
States, whether it is Minnesota, South Dakota, Washington 
State, or even in Arizona. Certain initiatives that the tribes 
and IHS facilities are a part of, because of 100 FMAP through 
the state Medicaid programs, are denied to Indians living in 
urban areas?
    Senator Cantwell. Why, Mr. Murillo? There is no reason why. 
Somebody can give me a technical answer that, oh, because they 
weren't included in the Social Security Act language. But there 
is no reason to distinguish between giving health care to a 
tribal member in an urban hospital or a rural hospital or 
facility.
    Mr. Murillo. Thank you, Senator, I absolutely agree. When 
folks move to the urban areas, they don't leave their disease 
and their health conditions behind. Those need to be treated 
just the same whether they be on a reservation or an IHS 
facility.
    Senator Cantwell. Dr. Daniels, do you have anything to add 
to that?
    Dr. Daniels. Yes, thank you, Senator.
    I think for Native Hawaiians there are a couple of pieces. 
It is not just FMAP, which we are very appreciative of, but it 
is also the tort. We don't have that. So when we look at our 
colleagues, both in tribal and urban, we are like way down the 
rung. When we look at language in our Act currently, we 
actually have to cost-share 20 percent of our dollars.
    So not only do our systems have to deliver services, but 
they also have to find matching dollars to deliver those 
services to our community. That is already an added, another 
added challenge and layer of issue.
    So when we are talking about tort and FMAP, we are also 
looking at 20 percent matching. We are looking at all of those 
things. I wish I had the answer on the technical. But it is not 
there.
    So the fact that we are even at this sharing space today is 
a step forward. This is huge. So however we can provide 
information to the Committee to help move things forward and 
create parity with our partners, with our colleagues, urban and 
tribal, we definitely want to do that.
    Senator Cantwell. I think we have to raise our voices. I 
think we have to tell people that this is what exists. I don't 
think people even understand what it is about. It is complex 
and it sounds--but it is not complex. The United States 
Government has decided that it is going to fully fund the 
health care of Native Americans on a 100 percent match because 
of tribal sovereignty. So that is it, end of story.
    So it doesn't matter whether you are in a rural hospital or 
you are in an urban setting. You deliver the full funding. The 
only thing that might be a glitch is that somebody likes to 
fall back on this Social Security Act and only one was 
mentioned. But that is a technical issue. That is not the 
substance.
    Anyway, I think Urban Indian health is suffering. We do our 
best in Seattle, we do our best all over the United States. But 
it is suffering. They deserve the same equity as a tribal 
member, as Mr. Murillo was saying, they have the same health 
care challenges, they have the same issues. There is no reason 
not to give them parity.
    So we will be working on this, and I appreciate everybody's 
attention to try and help correct this once and for all. Thank 
you.
    Senator Murkowski. Thank you, Senator Cantwell.
    Senator Hoeven. If Senator Hoeven is not ready, is not on 
the line, we will go to Senator Cortez Masto.

           STATEMENT OF HON. CATHERINE CORTEZ MASTO, 
                    U.S. SENATOR FROM NEVADA

    Senator Cortez Masto. Thank you. First of all, let me just 
say I am so grateful to each of you and your organizations for 
the unbelievable time and effort that you have put toward 
helping Native communities fight this pandemic. It has been a 
long year, and I appreciate your tireless commitment to serving 
the needs of Indian Country.
    Rear Admiral Toedt, let me start with you. One of the 
things that I have heard from tribal communities over the 
course of the pandemic was that the amount of information 
coming from the Federal Government was difficult to process and 
act upon. It was hard to keep up with the volume of calls and 
recommendations, and for smaller tribes, much of that work 
falls to just a handful of people.
    So as we begin to distribute the resources and guidance 
that Congress made available under the American Rescue Plan, I 
do want to emphasize that the use of robust, centralized 
technical assistance and feedback loops is essential. I have 
heard from Nevada's tribal communities that something as simple 
as a central calendar for consultation meetings would be 
helpful to avoid agencies scheduling multiple calls for the 
same window, and ensure that this information is easily 
accessible.
    Admiral Toedt, can you speak to some of the lessons learned 
from this pandemic and how to improve communications between 
tribal nations and Federal agencies?
    Dr. Toedt. Yes, thank you so much, Senator Cortez Masto. 
You hit the nail on the head, and actually, if you were to not 
have led me to communications, I would have gone there anyway. 
Communications is so important and is one of the biggest 
lessons learned.
    I will say that as you pointed out, having the opportunity 
for discussion, having robust consultation and urban confer, 
making sure that we do that with every major funding or major 
decisions that are undertaken by the agency. But really across 
government, we have heard from tribes that they value the 
consultation and confer process.
    But then as you pointed out, also having opportunities for 
conversations including when we get down to the technical 
assistance level and having that feedback. We did implement an 
incident command system at headquarters, and we established a 
regular tempo of weekly or biweekly calls, depending on the 
tempo of the activity that was going on. We found that to be 
very helpful. I would consider that a best practice.
    Your points about centralizing communication and avoiding 
confusion such as calendars, including all of this type of 
information, is one that we will include in our lessons 
learned. I appreciate your bringing that up.
    Senator Cortez Masto. Thank you. Do any other panel members 
have any ideas or thoughts on better communications strategies 
or tools? Just curious.
    All right. If not, let me move on to mental health. This is 
an area that I have been concerned about as we emerge from the 
public health emergency. It is one I have mentioned before in 
this Committee. That is the impact that this pandemic has had 
on the mental health and well-being of our Native families. I 
have seen it in my communities. People are struggling with 
everything from loneliness and isolation to substance abuse to 
the anxiety that comes with economic hardship.
    Now, the American Rescue Plan is a critical first step to 
getting families back on their feet. It was important that we 
put funding in there to address the mental health and well-
being.
    Dr. Daniels, let me start with you. Can you describe some 
of the issues brought on by the stress of the pandemic, 
particularly around behavioral health and wellness? What are 
tools and resources that might help our Native communities to 
address these issues?
    Dr. Daniels. Thank you, Senator, for the question. What we 
are seeing in all Native communities are similar, the stress 
around housing, economics, employment, education. It doesn't 
necessarily only focus on health, it is all of these other 
silos that unfortunately, for our communities, all weave 
together. So there is that.
    I believe that for a lot of our communities, we saw this, 
not just now, we saw this six months ago, eight months ago. So 
when we are asking for resources and support, it is on top of 
how do we provide PPE to communities, how do we make sure they 
have food and the basic necessities, how do they have access 
for all these things as well as dealing with a lot of the 
chronic conditions that our communities were already facing 
before COVID.
    So the ARPA monies, I think, can be used to help infuse 
that. But then I think the question becomes, how do we move 
forward. We are still kind of in this space of the COVID. We 
haven't even lifted our heads up to start to plan ahead. I 
think that is going to be the real test, is how do we start 
planting seeds now so that we can start dealing with the mental 
health wave, not just the COVID wave, the mental health wave 
that is moving forward.
    So how do we start messaging to our communities about 
seeking support? I know for a lot of our communities it is 
easier said than done. It is easier to say, okay, go and 
contact somebody you know to talk to, or seek these services. 
But for a lot of our communities, particularly for Native 
Hawaiians, the need to connect, the need to look somebody in 
the eye to help them navigate through this, is going to be very 
critical, which in many cases has been very counter to what we 
have been told.
    So not only do we have to navigate with our communities, 
but we are also navigating the system and what the guidelines 
are in engaging our communities.
    So, yes, tele-health is an amazing opportunity. But how do 
we help our communities understand how to use it? We are 
relying on the younger generation to help the older generation. 
But again, we have to have a point of contact, at least for our 
communities. We need to have that connection. That is part of 
the trust, the trust of provider and community, provider and 
person. I think we have all said that.
    So I think mental health is a growing tsunami waiting to 
happen. I think we all look at each other and other Native 
communities and what is happening there. I know for us, we do 
look at what is happening, or what is being put by the Indian 
Health Board. We are looking at South Central. We are looking 
at what our other colleagues or other Native communities are 
doing, and we try to apply that.
    Senator Cortez Masto. Thank you. I know my time is up, but 
I do want, I cannot stress enough, yes, we need to address 
everything that you have talked about. I do want to make sure 
we are hearing from you on what resources and tools and what we 
can do here in Congress to support your behavioral health needs 
in our Native community. Not even before this pandemic, but 
during the pandemic, which has, really what I have seen, 
magnified some of those issues. We are going to have to deal 
with them as we come out, open our doors again and really kind 
of fight to beat this pandemic.
    Thank you again, thank you all for being here.
    The Chairman. [Presiding] Thank you.
    Is Senator Hoeven available for questions? If not, Senator 
Lujan.

               STATEMENT OF HON. BEN RAY LUJAN, 
                  U.S. SENATOR FROM NEW MEXICO

    Senator Lujan. Thank you, Chair Schatz, and Vice Chair 
Murkowski, for holding this hearing on the Response of Native 
Health Systems to the COVID-19 pandemic. Thank you to each and 
every one of our witnesses for joining today.
    Dr. Toedt, the Indian Health Service has played an 
instrumental role in the Federal response to the COVID-19 
pandemic. Just last month, you announced IHS had reached its 
goal of administering over 1 million vaccines to IHS 
beneficiaries. That was ahead of schedule. I am proud to note 
that the Navajo Area and Albuquerque Area IHS regions have 
distributed over 315,000 vaccines as of last week, and 
administered 280,000 doses, nearly one-third of the total 
administered across all IHS sites.
    This is truly remarkable and a testament to your hard work 
and partnership with tribes, Federal agencies and Congress. As 
an example, I would like to highlight your quick response to an 
issue my office raised regarding the Institute of American 
Indian Arts, a tribal college in my State. IAIA was not 
included in the population estimates the IHS and States 
submitted to CDC in their pre-planning. As a result, it was 
uncertain how the school would procure vaccines for students 
and staff before returning to in-person learning.
    I am glad to report that now IAIA is among those tribal 
colleges and universities that have been able to vaccinate on 
campus, students and staff, thanks to the coordination of IHS 
with our office.
    Dr. Toedt, what is your new goal this month for fully 
vaccinated administration rates?
    Dr. Toedt. Thank you so much, Senator Lujan. We did set a 
new goal for April. Rather than focusing on just number of 
shots, we are focusing now on the percent of the adult 
population that is fully vaccinated. So our new goal is to have 
fully vaccinated 44 percent as a minimum for our active adult 
patients.
    You have heard some communities are already higher than 
that. But we have some communities that are not that high. So 
that is one of our areas of focus there, is to bring everyone 
up, to have all ships rise and make sure that as an agency that 
we have fully vaccinated 44 percent of our adult patients.
    Senator Lujan. I also want to say I applaud and appreciate 
the work you are doing to ensure that there is more acceptance 
and support on college campuses as well. Thank you for that.
    Dr. Toedt, I appreciate that IHS is providing weekly 
updates to the public and Congressional offices on its testing 
and vaccine rates broken down by area office. However, I am 
concerned that IHS does not have the same data available on at 
tribe by tribe basis. You stated in your testimony that COVID-
19 related data reporting from tribes and Urban Indian 
organizations is voluntary.
    Does IHS currently provide vaccination data disaggregated 
by tribe?
    Dr. Toedt. Thank you for that question also. So the vaccine 
data is not available by tribe or tribal affiliation. We do 
have the vaccine distributed to our IHS, tribal or Urban Indian 
facilities. However, the vast majority of those serve more than 
one tribal population. So they serve individuals who come from 
various tribes or nations.
    So we do have the ability to share that information with 
the individual service units and the areas. But we don't have 
the ability to break it down by tribe or tribal affiliation.
    Senator Lujan. I would like, Mr. Chair, for us to work 
together to find out why, and what is needed to do that. The 
reason is, many States, including my own, have had difficulty 
reporting statewide vaccine rates without specific State data 
vaccination data.
    Does IHS report State specific vaccination data to every 
State immunization registry?
    Dr. Toedt. Thank you for that question as well. Per the CDC 
COVID-19 program agreements, IHS reports the administration 
data to the CDC according to that jurisdictional guidance. Our 
jurisdictions can do that through two different pathways. That 
can be through the electronic health record, which is then 
aggregated in IHS and sent to CDC, or alternatively through the 
BAMS system.
    However, there is not a requirement to report it to the 
ITU's respective State immunization registry. Some of our 
facilities, ITUs, included already have automated processes in 
place for routine immunizations to transmit to the State 
immunization registry. So where we can do that, we do that. 
However, in this case, COVID-19 vaccine administration data 
would be reflected in the immunization State registry, but it 
is not universal.
    Senator Lujan. Mr. Chair, this is another area I hope we 
can have some success to identify the challenges that IHS faces 
to provide more granular vaccine data to States. On the 
immunization side, it is my understanding many States have the 
data but are not able to do more finite analysis, because it is 
not disaggregated.
    As my time expires, I hope, Mr. Chair, to be able to 
explore what IHS is doing with the total cost of their IHS data 
base on water projects and how IHS also has the responsibility 
to share with us how many households do not have access to 
running water, and do not have access to electricity. That way 
we can ensure that we are getting 100 percent connectivity when 
it comes to electricity, running water, wastewater, and 
broadband.
    I will submit those into the record, Mr. Chair, so that way 
I don't take more time today. I thank our witnesses and look 
forward to working with all of you to make a positive 
difference here. Thank you for your time today. I yield back.
    The Chairman. Thank you very much.
    I just have one final question for Dr. Toedt. Dr. Toedt, 
this time last year, IHS was not sure how many ventilators or 
hospital beds it had. IHS's strategic medical supply stockpile 
consisted of a few million possibly expired N95 masks. IHS's 
electronic health record systems couldn't actually track real 
time COVID activity within its user population.
    So I would like you to walk us through how IHS has adjusted 
the way it prepares for public health emergencies since the 
COVID-19 pandemic began. For instance, improvements to health 
record systems, interagency coordination, and PPE availability 
and access. I want you to talk us through how you think we will 
be better prepared the next time.
    Dr. Toedt. Thank you, sir. That is a broad question, and I 
appreciate it. Let me see if I can break this down.
    Certainly in terms of our institutional capacity and system 
changes, we recognize that there are some areas where we were 
very successful. But there were things that we had to do during 
the pandemic that certainly for the next round we will take as 
lessons learned to have them well in advance of the next 
pandemic.
    Chief among those are Federal partnerships. During the 
pandemic we had instances where we couldn't provide the 
necessary goods either because we couldn't procure them, 
because they weren't available, or through ordinary sources of 
supply, or there were medical surges where access to care, 
life-threatening emergencies were causing the need for those 
types of PPE and ventilators and so forth that were in short 
supply.
    So planning for these things far in advance, but also I 
would say maintaining the capacity to do that. That takes 
funding and resources. So that is something that we can 
certainly invest in.
    I would say that with respect to Federal partnerships, also 
working with the VA, in September we put an agreement in with 
the VA, with a national reimbursement agreement for the VA for 
direct health care services to include services delivered 
through tele-health. We also in October with the VA signed an 
interagency agreement setting forth the arrangement for 
coordination and delivery of health services. When IHS or 
tribal facilities are experiencing surges, IHS is able to work 
with the VA to secure beds, additional bed status.
    In terms of tele-health, we certainly had successes, 
because we expanded our video conferencing system and we were 
able to see more patients by tele-health. But the vast majority 
of our tele-health visits were by telephone rather than by 
video equipment. That is mainly because of that last mile. The 
person on the other end doesn't necessarily have the bandwidth 
or the capability to do a tele-health visit.
    So a lot of successes, but challenges there. I think 
building that infrastructure in tribal communities so that we 
have broadband access for our patients will help, certainly, 
with the tele-health.
    The EHR modernization, having pandemic-highlighted 
challenges and risks posed by our aging health IT architecture, 
and certainly we are grateful for the funding for EHR 
modernization that was provided by Congress in the CARES Act. 
We will put that to good use to build the foundational steps in 
this important multi-year effort.
    Our aging facilities, just as Dr. Onders stated, facilities 
were built many years ago. The average age of a facility in IHS 
is something around 37 years, and some are much older. In these 
older facilities, the standards for infection control, for 
patient flow, for separation of patients, for even waiting 
areas and so forth, those facility-based standards, we need to 
invest in our facilities in order to make the changes necessary 
to be prepared for future pandemic.
    So that is just a sample of some of the changes, to be 
responsive to your question. If I have not been fully 
responsive, I would be glad to take any follow-up questions.
    The Chairman. Doctor, that is an excellent summary. I will 
offer a couple of thoughts.
    First of all, let's work together on tele-health. Let us 
know what you need. When I was the ranking member of the 
subcommittee that does appropriations for VA, we made a ton of 
progress in this area. I also over the many years have been the 
lead author of the Connect for Health Act, which is the biggest 
and most bipartisan health care bill that has passed over the 
last eight years. Tele-health is popular because it improves 
the quality of care and increases access while reducing costs.
    So let's give you all of the tools and resources that you 
need to expand tele-health.
    Just on the EHR, HER transformation, also from my 
experience with VA, and trying to integrate those systems 
between VA and DOD, this can turn into a monster, logistically, 
in technological terms, bureaucratically and in terms of cost. 
So let's make sure that as you endeavor, even if it is just the 
first steps, that you gather some lessons learned from VA and 
DOD, and make sure that this doesn't turn into costing two or 
three times as much as originally planned and taking two or 
three times as long as originally planned.
    We are already spending billions of dollars on an EHR 
architecture. We may, I don't know, but we may be able to 
piggyback on that architecture since the Federal Government has 
already purchased it.
    So let's work together on those two items as well as the 
other things that you delineated in your response to me.
    And the final Senator is Senator Hoeven.

                STATEMENT OF HON. JOHN HOEVEN, 
                 U.S. SENATOR FROM NORTH DAKOTA

    Senator Hoeven. Thank you, Mr. Chairman. I appreciate it.
    I will start out, for each of the witnesses, what has been 
the biggest challenge in Indian Country with the COVID 
pandemic? Then lessons learned, what have we learned about how 
to be better prepared for the future? Admiral Toedt, if you 
would like to start.
    Dr. Toedt. Yes, Senator Hoeven, thank you.
    I would say that the biggest challenge that we faced is 
really our existing, preexisting conditions, the fact that 
American Indians and Alaska Natives suffer disproportionately 
from diabetes, from challenges of hypertension, from asthma, 
from obesity. These conditions, which predispose American 
Indians and Alaska Natives to poorer outcomes, as well as the 
upstream causes of those diseases. So the social determinants 
of health, the lack of infrastructure, sufficient access to 
healthy foods, access to education and jobs in these 
communities. That was the number one challenge, is addressing a 
pandemic on top of these disparities and social determinants of 
health and the resulting disparities in preexisting health 
conditions.
    And then in terms of the lesson learned and the path 
forward, I would say that we really learned that by having 
strong partnerships with tribes, leveraging their sovereignty 
and their ability to be most responsive to their communities, I 
think has been one of the greatest successes.
    We utilized, of course, our National Service Center and our 
IHS vaccine task force and our centralized ability to 
distribute. But it was really that tribal sovereignty, working 
with sovereign nations and tribal leaders, as well as Urban 
Indian organizations, that made it successful. Thank you.
    Senator Hoeven. Thank you, Admiral.
    Chairman Smith?
    Mr. Smith. Thank you. As I said in my remarks, the key 
success to the vaccine rollout has been including tribes and 
IHS as a jurisdiction for vaccine distribution. By allowing 
tribes to exercise self-government and make decisions for their 
people, tribes have been able to coordinate and distribute the 
vaccine and get them into the arms faster than any other 
surrounding communities. This has been a perfect example of how 
and why self-governance and self-determination works.
    In previous public health emergencies, tribes were left to 
fend for themselves with little or no resources from the 
government. While those previous emergencies were not the same 
level of emergencies as was the widespread COVID-19, this time 
around tribes were prepared. This is because tribes were 
declared a jurisdiction, directly receiving the vaccine, and 
were provided needed flexibility, ensuring that they could 
exercise self-governance and make decisions that were best for 
all the people to receive the vaccines.
    One of the things we need to look at, because when you talk 
about the veterans, it is really kind of sad that the veterans 
and the VA up in Alaska were one of the last go-round to get 
the shots. Even all our people in harm's way should have got 
the vaccines.
    When we talk about mental health, if I am listening 
correctly with what President Biden is saying that he is going 
to be bringing all the troops home from Afghanistan, there is 
going to be a big surge for tele-health needs. Our brothers and 
sisters coming home, they are going to need all the help they 
can get. The Indian Health Service and the VA still needs to be 
working together to help all.
    Thank you very much.
    Senator Hoeven. Thank you.
    Mr. Murillo?
    Mr. Murillo. Thank you. I think some of the challenges that 
we have seen have been things inherent in the law right now 
that don't give Urbans the same authority that it does IHS 
facilities or tribal facilities. Things like facilities, 
infrastructure building and the ability to change our 
facilities.
    Also, the administration of vaccine is something that, in a 
pandemic, the authority to use Indian Health Service funds to 
administer that vaccine to nonbeneficiaries is there for Indian 
Health Service facilities and tribal programs, but not for 
Urbans. So that is very harmful in a pandemic.
    Also, some of the restrictions that are there, this is not 
through the Indian Health Service lack of trying, but simply 
the law, that limited the ability to use some of those funds to 
give us supplies. I am happy that the Indian Health Service 
found a work-around for that, and provided supplied at no cost 
to Urbans.
    I think some of the lessons learned that we can take from 
this is the fast action of the Indian Health Service and their 
ability to confer with Urban Indian health programs. As I said 
earlier in a response to a question, we would like to see that 
repeated across many operatives in HHS that serve Indian 
Country that includes urban areas.
    Tele-health also I think is one of the lessons learned. 
Pivoting to tele-health, especially in behavioral health, has 
been tremendous, a tremendous help. Again, with solving that 
problem of that transportation barrier, and access to care, we 
created a new problem, the infrastructure problem was having 
that telecommunication available to American Indians and Alaska 
Natives. In urban areas, that might mean while the 
infrastructure is there, is it affordable? Do they have minutes 
to even use the phone to call in or to receive a text message 
for an appointment reminder?
    So that is where I would leave on lessons learned.
    Senator Hoeven. Dr. Daniels?
    Dr. Daniels. Thank you for the question. I think for Native 
Hawaiians it really goes back to the lack of understanding 
about trust responsibilities on all levels. So we have the same 
issues around chronic health conditions, we have a lot of the 
same issues as my colleagues here, both in tribal as well as 
urban spaces.
    So the difference here in our thread is the lack of 
understanding about trust responsibility, not only on the 
Federal level, but especially at the State level.
    I think the success, though, not to ponder on the not good, 
but the success is that our communities continue to show 
resiliency. If we don't have that, if we don't have hope, how 
do we continue to move forward as a community to try to uplift?
    Thank you.
    Senator Hoeven. Thank you. Dr. Onders?
    Dr. Onders. Thank you, Senator, for the question. When the 
pandemic started, I went back and looked at 2008 and 2009. 
There was a research article published on the H1N1 pandemic. 
There are some authors here on campus with the CDC Arctic 
Investigations Program as well as ANTHC that authored that 
paper. Because at that time, there were four times higher 
mortality rates seen in Alaska Native and American Indian 
people with the H1N1 pandemic.
    It pointed to the same things that Dr. Toedt and others 
have mentioned: lack of adequate water and sewer, lack of 
adequate housing, preexisting conditions as a result of 
generations of trauma and systemic racism, lack of access to 
adequate health care. I think you could cross out H1N1 and put 
COVID in this now 13, 14 years later, to say the same thing.
    So from a lessons learned standpoint, I think if we are 
going to address those challenges that we saw both in the 
previous pandemic and this pandemic, I think that aspect of 
tribal sovereignty that was mentioned that was extremely 
successful for vaccine could be used in that same mechanism to 
address these infrastructure problems that create the 
preexisting risks.
    Senator Hoeven. Thank you very much to all of you.
    Thank you, Mr. Chairman. I am sorry for going over my time. 
I appreciate it.
    The Chairman. Thank you. Senator Daines?

                STATEMENT OF HON. STEVE DAINES, 
                   U.S. SENATOR FROM MONTANA

    Senator Daines. Chairman Schatz, thank you.
    Last week the Acting Director of IHS was out in Great 
Falls, Montana. Great Falls is home, in fact, to our newest 
federally recognized tribe in the Nation, and that is the 
Little Shell Tribe. It was a long battle. I fought alongside 
the people of the Little Shell Tribe for years to achieve 
Federal recognition and establish this very important 
government-to-government relationship.
    That is why I have to say it was very disheartening to hear 
that during the Acting Director's recent visit to Montana, no 
official notice or information was provided to Little Shell in 
advance of the visit. The most recent, newest federally 
recognized tribe, no advance notice. This government-to-
government relationship demands more than this treatment, when 
a head of a Federal agency that is dedicated to tribal issues 
travels to the city or reservation where a federally recognized 
tribe is headquartered.
    Now, what adds insult to injury here, the Little Shell 
Tribe's headquarters are right there in Great Falls. There 
should be outage, and an official invitation to meet on this 
very important government-to-government basis. It is 
unacceptable, and the Little Shell have fought for recognition 
for far too long to simply be an afterthought for IHS.
    Admiral Toedt, can you and your staff commit to relaying 
these concerns I have articulated here with how the Little 
Shell Tribe was treated during the Acting Director's visit?
    Dr. Toedt. Yes, Senator Daines, I will definitely take the 
message back to leadership for their awareness. When planning 
these visits, we do our best to coordinate with our Federal and 
tribal leaders with as much advance notice as possible. 
Arranging visits during this time is more challenging than 
usual. We appreciate the patience and support of all who helped 
with the visits last week.
    We deeply respect all of our tribal partners, and were 
honored to have an opportunity to meet with the Little Shell.
    Senator Daines. Thank you. While they are the most recently 
federally recognized tribe, it wasn't like it just happened in 
December. It was a year ago, plus, when we got the legislation 
signed by the President.
    I thank you for that response, and I hope that other tribes 
are treated with the respect they deserve, as IHS continues to 
visit tribes throughout Indian Country.
    Admiral Toedt, I was very pleased to see the one millionth 
vaccine distributed in Indian Country last week. It is a very 
important milestone. As you stated in your testimony, IHS has 
faced infrastructure challenges in rural and remote 
communities. We certainly understand that in Montana.
    We know that the outdated or sometimes non-existent 
infrastructure in Indian Country has caused tribes to be hit 
exceptionally hard by COVID. Certainly, the infection rates and 
mortality rates have been much higher than the general 
populations in Montana.
    Admiral Toedt, can you elaborate on effective ways that 
might address the problems with infrastructure in Indian 
Country that we could then in a fiscally responsible manner 
target to areas where we have the greatest need?
    Dr. Toedt. Yes, Senator, thank you for the question.
    I think the theme continues that the most effective way is 
to do this with tribal consultation. We have to make sure to 
continue to consult with tribes and confer with Urban Indian 
organizations.
    The IHS received $9 billion in six supplemental 
appropriation bills since March 2020. This is amazing and 
unprecedented support for Indian Country. So thank you for 
that. These funds are predominantly available to prevent, 
prepare for and response to the COVID-19 pandemic. To date, we 
have directly allocated $2.9 billion in COVID funding from five 
of the six appropriation bills, and we have announced all 
allocations from those funds in a Dear Tribal Leader letter and 
Dear Urban Indian Organization letter. All of those allocations 
were finalized with the input of tribal and Urban Indian 
organization leaders, collected through tribal consultation and 
urban confer.
    Senator Daines. Thanks, Admiral Toedt. I will tell you, it 
is particularly important, as you mentioned, that it is a 
bottoms up driven kind of a prioritization, that our tribal 
leaders know where they need the resources. I appreciate your 
listening to their voice as you prioritize where these 
investments should be made.
    Mr. Chairman, thank you.
    The Chairman. Thank you very much.
    If there are no more questions for our witnesses, members 
may also submit follow-up written questions for the record. The 
hearing record will remain open for two weeks, and I want to 
thank all of our witnesses for their time and their testimony.
    This meeting is adjourned.
    [Whereupon, at 4:28 p.m., the hearing was adjourned.]

                            A P P E N D I X

    Response to Written Questions Submitted by Hon. Brian Schatz to 
                       Rear Admiral Michael Toedt
    Question 1. As mentioned at the hearing, I am deeply concerned that 
IHS entered the COVID-19 pandemic without the necessary resources and 
preparations in place. Prior to the COVID-19 pandemic, did IHS have an 
emergency plan in place to ensure continuity of operations in the event 
of a pandemic involving a highly infectious disease? If so, please 
provide an overview.
    Answer. The Indian Health Service (IHS) had a continuity of 
operations plan (COOP) in place prior to the COVID-19 pandemic. The 
existing plan focused on agency steps necessary for responding to major 
emergency events, including pandemics, which might disrupt agency 
operations. As recently as 2019, the IHS participated in a Department 
of Health and Human Services (HHS) COOP exercise focused on how HHS and 
the federal government would manage a nation-wide pandemic influenza 
response. The exercise examined emergency coordination and 
communication across agencies, local and state pandemic influenza 
response challenges, federal government capabilities and available 
resources to support local and state response efforts, and continuity 
of essential functions by a dispersed workforce in the event major 
administrative offices were inoperable.
    All IHS hospitals and clinics are required to have emergency plans 
in place that include localized flu/pandemic response. Plans cover 
emergency responses necessary to sustain critical health care services 
while protecting the safety of employees and patients. These plans were 
crucial for enabling the IHS to address immediate COVID-19 response. 
However, a pandemic of the magnitude encountered with COVID-19 was not 
foreseen in existing COOP and emergency plans.

    Question 1a. Please describe any analysis IHS has undertaken to 
evaluate its COVID-19 response to date and the results of those 
efforts.
    Answer. During the course of the IHS COVID-19 response, the Agency 
has prioritized continual evaluation of response activities to 
appropriately adjust for evolving needs. The IHS conducted a review of 
activities completed in the first 100 days of formal response that 
outlined key activities tied to the IHS COVID-19 Action Plan. This 
review and resulting report provided detailed accomplishments, 
outcomes, and opportunities for improvement and enhanced engagement.
    In November 2020, the IHS began interviewing IHS Area Office and 
Headquarters leadership, as well as the IHS Incident Command Structure 
staff, to produce a report of lessons learned and considerations that 
will be used for longer-term emergency preparedness planning. The IHS 
now conducts biweekly reviews of activities related to the IHS COVID-19 
Action Plan, and produces quarterly reports detailing response 
activities. Throughout the pandemic response, the IHS has collected 
surveillance data and performed predictive analyses to inform planning 
and response efforts in the IHS Areas.

    Question 1b. What changes--if any--has IHS made to its medical 
supply acquisition protocols and procedures to ensure the Service will 
have strategically necessary stockpiles and supply acquisition plans in 
place for public health emergencies moving forward?
    Answer. The IHS National Supply Service Center (NSSC) expanded its 
operations at the beginning of the response to allow for the mass 
procurement and distribution of critical personal protective equipment 
(PPE) and other COVID-19 related items to all IHS, tribal, and urban 
Indian (ITU) health facilities nationwide. The NSSC is a fee-for-
service comprehensive supply management program that oversees 
pharmaceutical and medical supply chain logistics for the agency. 
Supplemental appropriations allowed the NSSC to procure and distribute 
PPE, supplies, test kits, and related materials at no cost to ITU 
health programs nation-wide.
    The NSSC has its own in-house quality assurance, procurement, 
finance, warehouse, and inventory management teams to ensure high 
quality, safe products are distributed to ITU facilities in an 
efficient, equitable, and accountable manner. The NSSC also works 
closely with other government agencies and operations such as the 
Federal Emergency Management Agency, HHS Office of the Assistant 
Secretary for Preparedness and Response, Defense Logistics Agency, and 
Countermeasure Acceleration Group to procure and coordinate the timely 
delivery of products to ITU health facilities. To date, NSSC has 
distributed 84 million units of COVID-19 related products (PPE, lab, 
therapeutics), including 2.6 million test swabs and transport media.
    The IHS is developing a strategic plan to increase its supply chain 
procurement and logistics capabilities. This will include additional 
staff, inventory management systems, increased space and improvements 
at existing supply centers, and the addition of regional supply centers 
that provide the ability to manage, store, and distribute a six-month 
supply of product and equipment necessary for an emergency response. 
The IHS has also issued Agency-wide guidance on how to avoid price 
gouging and ensure that only safe and high--quality products are 
procured.

    Question 1c. What improvements does the Service believe are 
necessary to better ensure continuity of operations moving forward? 
And, does IHS need additional resources to implement those 
improvements?
    Answer. As a public health agency, emergency response is an 
integral part of IHS operations. The COVID-19 public health emergency 
has highlighted several opportunities for improvement including:

    enhancing preventative activities such as contact tracing 
        and data surveillance and analytics,

    establishing proactive longer-term plans and partnerships 
        that enable more efficient staffing and resource augmentation 
        in times of acute need,

    expanding the public health workforce and creating capacity 
        for dedicated emergency response personnel,

    continuing to increase availability of telehealth services, 
        and

    building out the IHS NSSC's stockpiling capacity and 
        warehouse footprint.

    The COVID-19 public health emergency also amplifies resource 
disparities across the Indian health system. The IHS has received over 
$9 billion in one-time, supplemental appropriations, which have been 
essential for supporting the extreme demands on health care and related 
services to meet shorter-term pandemic response. However, recurring 
annual funding is needed to make longer-term systemic improvements and 
sustain readiness.

    Question 2. At a hearing on COVID-19 response and mitigation last 
year, I spoke with former IHS Director Weahkee about the need to expand 
telehealth access. \1\ He informed me that IHS saw an 11-fold increase 
in use of telehealth services in the initial four-months of the COVID-
19 pandemic. I understand, since that time, IHS has completed a 
telehealth provider survey. Please summarize the findings from this 
recent IHS telehealth survey.
---------------------------------------------------------------------------
    \1\ Evaluating the Response and Mitigation to the COVID-19 Pandemic 
in Native Communities: Hearing on S. 3650 Before the S. Comm. on Indian 
Affairs, 116th Cong. 29 (2020)(response to question from Sen. Brian 
Schatz by Michael Weahkee, Director, Indian Health Service).
---------------------------------------------------------------------------
    Answer. The IHS Telehealth Survey for IHS Providers was open from 
October 20, 2020, through November 11, 2020. There were over 375 
Federal respondents who participated in the survey. The majority of 
responses were from Physicians, Nurse Practitioners, and Counselors/
Social Workers. Almost sixty percent (60 percent) of the respondents 
noted they provided telehealth visits each week (ranging from one visit 
up to 100 visits). Forty-one percent (41 percent) of the respondents' 
noted at least one telehealth visit was performed using telephone 
(audio) only in a typical week. The significant majority agreed or 
strongly agreed telehealth improved access to care, improved the health 
of patients, and that patients seemed satisfied.
    The respondents identified value in offering telehealth services 
such as behavioral health, specialty care, primary care, chronic 
illness care, urgent care and more. Eighty-three percent (83 percent) 
of the respondents shared through qualitative analysis of themes that 
their experience with telehealth had value. Only seventeen percent (17 
percent) of the respondent's qualitative themes noted telehealth as not 
having value. Some examples provided in the survey addressed telehealth 
limitations and that some specialties require in-person patient 
examination and care/treatment. Respondents also indicated that 
improvements were needed for infrastructure, equipment, and telehealth 
platforms. Further, respondents noted that lack of bandwidth and other 
limitations on connectivity, as well as outdated hardware and software 
were challenges that need to be addressed. Despite these issues, 
respondents identified telehealth as an important tool that generally 
made access to health visits possible during the pandemic.

    Question 2a. What additional resources would IHS need to sustain 
and expand telehealth services for the Native communities it serves, 
directly or through a Tribal Health Program or Urban Indian 
Organization?
    Answer. The IHS has relied on telehealth to continue offering 
health care services during the pandemic, when many facilities reduced 
their hours or closed their doors to prevent the spread of COVID-19. In 
April 2020, IHS extended the use of an Agency-wide video conferencing 
platform that allowed telehealth on almost any Internet-connected 
device in any setting, including patients' homes.
    As a result, the IHS dramatically increased its use of telehealth 
from an average of less than 1,300 visits per month in early 2020 to a 
peak of over 40,000 visits per month in June and July of that year. On 
average, about 80 percent of the telehealth encounters across IHS are 
conducted using audio only, primarily due to the limited availability 
of technologies and bandwidth capacity in the communities served.
    The IHS received $95 million for telehealth in the Coronavirus Aid, 
Relief, and Economic Security (CARES) Act, and a portion of $140 
million from the American Rescue Plan Act can also be used for 
telehealth activities.

    Question 2b. What benefits has IHS experienced as a result of the 
temporary loosening of Medicare telehealth restrictions made possible 
by the CARES Act as well as other state actions to expand telehealth 
coverage?
    Answer. During the public health emergency, the IHS has 
significantly increased the use of telehealth to enable the 
continuation of health services while limiting face-to-face visits 
according to COVID-19 safety precautions. Medicare waivers and 
flexibilities implemented as a result of the pandemic have made it 
easier for beneficiaries to access care through telehealth and enabled 
the IHS to bill for these telehealth services, which were previously 
not payable. Before the COVID-19 public health emergency (PHE), only 
15,000 fee-for-service beneficiaries each week received a Medicare 
telemedicine service. Preliminary data show that between mid-March and 
mid-October 2020, over 24.5 million out of 63 million beneficiaries and 
enrollees received a Medicare telemedicine service during the PHE. For 
instance, there are approximately 270 services currently included on 
the list of Medicare telehealth services, including more than 160 that 
were added on a temporary basis during the COVID-19 public health 
emergency. The list of eligible telehealth services is published on the 
CMS website at https://www.cms.gov/Medicare/Medicare-General-
Information/Telehealth/index.html.
    Under Medicaid, States have a great deal of flexibility with 
respect to covering services via telehealth. CMS provided a toolkit at 
https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-chip-
telehealth-toolkit.pdf for States to identify the policy topics that 
should be addressed in order to facilitate widespread adoption of 
telehealth services. In addition to the Medicare waivers and 
flexibilities. IHS has also leveraged state efforts to expand Medicaid 
coverage and access to telehealth such as: allowing new services to be 
delivered via telehealth, expanding the provider types that may deliver 
services via telehealth, expanding the types of technologies used to 
deliver telehealth, and requiring payment parity for services delivered 
via telehealth as compared to face-to-face services. For instance in 
Arizona, effective March 18, 2020 until the end of the COVID-19 public 
health emergency declaration, Arizona Health Care Cost Containment 
System (AHCCCS), Arizona's Medicaid agency, health plans may not 
discount rates for services provided via telehealth and telephonically 
as compared to contracted rates for ``in-person'' services. In 
addition, all services that are clinically able to be furnished via 
telehealth modalities will be covered by AHCCCS throughout the course 
of the COVID-19 emergency.

    Question 2c. Would Native health systems benefit from making some 
of these temporary telehealth changes permanent?
    Answer. These flexibilities have been beneficial to Native health 
systems during the PHE, and we expect they would continue to do so in 
the future. For example, removing the geographic restrictions that 
limited telehealth services to specific rural areas and certain 
locations such as physicians' offices and hospitals has increased 
access to care and continuity of care in Indian country. This is 
especially beneficial in rural areas, those areas with provider 
shortages, and for individuals who might have other barriers, like lack 
of access to public and private transportation.
    Also, the use of audio-only equipment to furnish audio-only 
telephone Evaluation and Management (E/M), counseling, and educational 
services has been vital during the PHE. The IHS serves many of the most 
rural, sparsely populated and technologically underserved locations in 
the country. These areas and the families living in them often lack 
both the connectivity and the technology (smartphones/computers) to 
participate successfully in video-dependent encounters. At the same 
time, these individuals who experience high rates of many chronic 
health conditions, often live many miles from their healthcare 
facilities and may lack reliable transportation. As noted, people 
without any transportation (public or private) are benefiting from 
telehealth with the current flexibilities.
    The IHS will continue to work with the Department to better 
understand the impacts of telehealth flexibilities during the PHE on 
access, quality-including patient experience-of care, and value. We 
look forward to working with members on these important issues to 
deliver the best care possible to Indian Country.

    Question 3. At that same hearing, former IHS Director Weahkee and 
National Indian Health Board Secretary Lisa Elgin testified about the 
impacts that inadequate infrastructure in Native communities had on 
their COVID-19 response. \2\ What is the current backlog of IHS 
maintenance and improvement, sanitation facilities construction, health 
care facilities construction, and equipment needs?
---------------------------------------------------------------------------
    \2\ Id. at 31-32, 49-50, etc. (statements of Michael Weahkee, 
Director, Indian Health Service, & Lisa Elgin, Sec'y, Nat'l Indian 
Health Board).
---------------------------------------------------------------------------
    Answer. With regard to Health Facilities Construction, the priority 
projects have an unfunded balance of $2.0 billion. The total need as 
reported in the 2016 report to congress is $14.5 billion. A new report 
to congress is due in 2021.
    Maintenance and Improvement funding is used to correct a portion of 
the Backlog of Essential Maintenance, Alteration, and Repair (BEMAR) 
deficiencies annually though minor and major projects. The FY 2020 
BEMAR identified at FY 2020 IHS and Tribal healthcare facilities is 
$944.9 million. The IHS and Tribal health programs manage approximately 
90,000 devices consisting of laboratory, medical imaging, patient 
monitoring, pharmacy, and other biomedical, diagnostic, and patient 
equipment valued at approximately $700 million. IHS is using a 
Computerized Maintenance Management System (CMMS) to manage medical 
equipment/devices/systems and to prioritize replacement. The average 
life expectancy is approximately six to eight years and rapid 
technological advancements, medical equipment replacement is a 
continual process making it necessary to replace worn out equipment or 
provide equipment with newer technology to enhance the speed and 
accuracy of diagnosis and treatment. To replace the equipment at the 
end of its six to eight-year life would require approximately $100 
million per year.
Sanitation Facilities Construction
    The IHS Sanitation Deficiency System identifies a Feasible Project 
Cost Estimate of $991 million. Costs for providing piped water and 
sewer facilities to American Indian and Alaska Native homes located in 
remote locations with harsh climates and unusual subsurface conditions 
are extremely high. The Sanitation Facilities Construction Program 
recognizes that piped water and sewer projects for these homes are not 
currently economically feasible, and while these piped water and sewer 
projects are included in the Total Database Estimate, they are not 
included in the IHS Feasible Project Cost Estimate.
    The Total Database Estimate for Sanitation Facilities Construction 
is over $3 billion, for over 230,000 American Indian and Alaska Native 
homes that need some form of sanitation facility improvement. There are 
currently over 1,600 projects identified in the IHS Sanitation 
Deficiency System to serve those homes.
Indian Health Service and Tribal Health Care Facilities' Needs 
        Assessment
    The IHS Health Care Facilities Construction program supports the 
construction of new and replacement health care facilities across 
Indian Country. The last Indian Health Service and Tribal Health Care 
Facilities' Needs Assessment Report to Congress was transmitted to 
Congress in 2016. It identifies a $14.5 billion estimated funding need 
for IHS and Tribal health care facilities. This amount includes the 
$2.1 billion in construction projects remaining on the Health Care 
Facility Construction Priority List, which the IHS is statutorily 
required to complete before spending appropriated funding on additional 
construction projects. The Health Care Facility Construction Priority 
List was established in 1993. An updated facilities needs assessment is 
due to Congress in 2021.
Equipment
    Accurate clinical diagnosis and effective therapeutic procedures 
depend in large part on health care providers using modern and 
effective medical equipment and systems to assure the most accurate 
health diagnosis. The IHS and Tribal health programs manage 
approximately 90,000 devices consisting of laboratory, medical imaging, 
patient monitoring, pharmacy, and other biomedical, diagnostic, and 
patient equipment valued at approximately $700 million.
    Today's medical devices and systems have an average life expectancy 
of approximately six to eight years. The average six-year lifecycle 
combined with rapid technological advancements means that medical 
equipment replacement is a continuous process that requires the 
replacement of aging equipment and equipment that does not meet newer 
technological standards, to enhance the speed and accuracy of diagnosis 
and treatment. To replace equipment at IHS and Tribal health facilities 
at the end of its six-year life would require approximately $100 
million per year, growing at an approximate 2 percent inflation rate 
per year.

    Question 3a. Does the response provided in (a) include the needs of 
Tribal Health Programs and Urban Indian Organizations?
    Answer. The IHS facilities-related reports include the needs of 
Tribal Health Programs, to the extent that these programs have shared 
their needs with the IHS. For example, many Tribal Health Programs that 
directly operate their health programs through Indian Self-
Determination and Education Assistance Act (ISDEAA) compacts and 
contracts provide input for BEMAR and health care facilities 
construction needs, but do not provide direct input for medical 
equipment or Sanitation Facilities Construction needs.
    To date, the IHS facilities-related reports do not include data on 
the needs of Urban Indian Organizations (UIOs). However, the IHS will 
have better data on the facility-related needs of UIOs in the near 
future. As part of the Consolidated Appropriations Act, 2021, the IHS 
received $1 million for a new study of infrastructure needs for 
facilities run by UIOs. The UIO infrastructure study will be the first 
step towards identifying the most critical deficiencies for UIOs and 
formulating a comprehensive action plan.

    Question 3b. Does IHS have an estimate of how much funding would be 
needed to fully complete its electronic health record modernization 
efforts?
    Answer. Investment in modernization of the IHS electronic health 
record (EHR) system, the Resource and Patient Management System (RPMS), 
represents a significant opportunity to improve health care in Indian 
Country and the health status of American Indians and Alaska Natives. 
The current IHS EHR is over 30 years old, and the Government 
Accountability Office identifies it as one of the 10 most critical 
federal legacy systems in need of modernization. A full replacement of 
the RPMS is broadly supported by IHS, tribal, and urban Indian health 
programs.
    The current IHS EHR system is built on the Department of Veterans 
Affairs (VA) Information Systems and Technology Architecture (VistA) 
system, which will soon be replaced by a modernized VA and Department 
of Defense (DOD) EHR. Without the VA's continued support of VistA, the 
IHS lacks the resources and capacity to maintain the RPMS's aging code 
alone. The system cannot be supported over the next decade, nor 
sustained with the current hardware and network.
    The IHS relies on its electronic health record for all aspects of 
patient care, including the patient record, prescriptions, care 
referrals, and billing for over $1 billion public and private insurance 
for reimbursable health care services each year.
    Replacing the IHS EHR will be a multi-year, multi-billion-dollar 
effort. Estimating the total cost of the IHS EHR modernization project 
is difficult at this time due to the early stage of the project. As 
implementation steps progress, estimates will be refined.
    The IHS has recently completed a request for information from 
industry partners to support a final acquisition plan. While the IHS 
will need a significant infusion of funding to select and implement a 
new EHR solution in all sites currently operating RPMS, the level of 
ongoing annual support post-implementation is expected to be a fraction 
of that cost.
    The IHS needs to build an EHR system, to support the unique aspect 
of providing health care services to American Indians and Alaska 
Natives. The IHS has partnered with the VA and DOD to implement lessons 
learned and best practices. In addition, the IHS is in the process of 
piloting a key connection to the VA/DOD health information exchange, 
which would support interoperability between the new IHS system and the 
new VA/DOD system.

    Question 4. According to IHS, the Service's overall vacancy rate of 
21 percent remained stable from February through May of 2020. \3\ Has 
the Service's overall vacancy rate increased since then?
---------------------------------------------------------------------------
    \3\ Id. at 87 (response to written questions submitted by Sen. Tom 
Udall, V. Chairman, S. Comm. on Indian Affairs, to Michael Weakhee, 
Director, Indian Health Service).
---------------------------------------------------------------------------
    Answer. Yes. Prior to the pandemic, the IHS vacancy rate was 21 
percent. As of January of this year, the vacancy rate is 24 percent.
    While we expected that the COVID-19 pandemic would impact IHS 
vacancy rates, human resources flexibilities available during the 
public health emergency likely mitigated this impact. The Office of 
Personnel Management (OPM) authorized the following flexibilities to 
expedite hiring and address short-term staffing needs to respond to the 
pandemic:

    Excepted service temporary appointments,

    Emergency dual compensation salary offset waivers for re-
        employed annuitants, and

    Direct hire authority to 32 additional occupations at IHS.

    In addition, OPM establishes Hazardous Duty Pay and Environmental 
Differential Pay categories that IHS has applied to certain frontline 
staff in IHS hospitals and clinics to compensate them for unusually 
hazardous working conditions.

    Question 4a. Have provider vacancy rates within each IHS service 
area fluctuated during the course of the COVID-19 pandemic?
    Answer. The following chart provides a comparison of vacancy rates 
for IHS Areas. The vacancy rates are captured only for IHS federal 
sites. It was expected that the COVID-19 pandemic would impact vacancy 
rates at IHS, but vacancy rates would likely have been much higher 
without the COVID-19 human resources flexibilities offered during the 
public health emergency, as discussed in the response to the previous 
question.

                        IHS Vacancy Rates by Area
------------------------------------------------------------------------
         IHS Area               February 2020           January 2021
------------------------------------------------------------------------
Alaska                      unavailable            15 percent
Albuquerque                 26 percent             23 percent
Bemidji                     30 percent             28 percent
Billings                    30 percent             35 percent
California                  18 percent             29 percent
Great Plains                22 percent             24 percent
Headquarters                20 percent             14 percent
Nashville                   22 percent             21 percent
Navajo                      17 percent             22 percent
Oklahoma City               16 percent             14 percent
Phoenix                     24 percent             27 percent
Tucson                      19 percent             29 percent
Portland                    24 percent             25 percent
------------------------------------------------------------------------


    Question 4b. Have there been any changes in vacancy rates within 
specific clinical staffing categories (e.g., doctors, physician's 
assistants, nurses, etc.) throughout the course of the pandemic?
    Answer. The following chart provides a comparison of vacancy rates 
for critical healthcare occupations within IHS federal sites. It was 
expected that the COVID-19 pandemic would impact vacancy rates at IHS, 
but vacancy rates would likely have been much higher without the COVID-
19 human resources flexibilities offered during the public health 
emergency, as discussed above.

                   IHS Vacancy Rates by Position Type
------------------------------------------------------------------------
        Discipline              February 2020           January 2021
------------------------------------------------------------------------
Physician                   26 percent             28 percent
Physician Assistant         26 percent             20 percent
Pharmacist                  14 percent             15 percent
Nurse                       28 percent             34 percent
Advance Practice Nurse      24 percent             27 percent
Engineer                    24 percent             24 percent
Behavioral Health           31 percent             35 percent
Dentist                     23 percent             21percent
------------------------------------------------------------------------

    Question 4c. Has the percentage of contract staff working in IHS 
facilities increased over the past year?
    Answer. There is no immediate report available to identify the 
number of contractors, both medical and administrative, at IHS 
facilities. IHS has been working to identify costs for certain contract 
providers on a monthly basis; however, this was not fully implemented 
until November 2020. Therefore, the IHS is unable to compare data over 
the past year.

    Question 4d. What steps--if any--is IHS taking to prevent provider 
and staff ``burn out'' due to the increased demands placed on them by 
the COVID-19 pandemic?
    Answer. The IHS has maintained a focus on the health and safety of 
its workforce throughout the COVID-19 response. In addition to 
promoting the use of existing employee assistance programs, the IHS 
developed additional resources to support staff during the pandemic.
    The IHS TeleBehavioral Health Center of Excellence (TBHCE) tele-
education program provides training to health care providers working in 
the IHS, Tribal, and urban Indian health system. In response to COVID-
19, the TBHCE offered several trainings to prevent provider compassion 
fatigue, burnout, and to support providers dealing with loss. 
Additional information can be found at: https://www.ihs.gov/
teleeducation/. Examples of specific trainings include:

    Compassion Fatigue On-Demand (self-paced) Course,

    Grief and Loss Webinar Series: Supporting Providers Dealing 
        with Loss,

    IHS COVID-19 Response Webinar Series: Compassion Fatigue: 
        Additional Risks while Serving Vulnerable Populations During a 
        Pandemic, and

    IHS COVID-19 Response Webinar Series: Supporting the Mental 
        Health of Healthcare Workers during COVID-19.

    Question 4e. Does IHS need additional resources to attract and 
retain its workforce? If so, please describe the types of resources 
needed?
    Answer. The IHS continues to face challenges in recruiting and 
retaining highly qualified staff. To IHS 2022 budget request includes 
increases in funding for the IHS Scholarship and Loan Repayment 
Programs. The additional funding will allow IHS to offer additional 
scholarships to American Indian and Alaska Native students pursuing 
degrees in health care and in return the students complete a service 
commitment with IHS. Additional funding for the IHS Loan Repayment 
Program will allow IHS to fund more applicants and expand the program 
to fund additional eligible health care occupations. Loan repayment 
recipients also complete a service commitment. Both these programs are 
highly effective in recruiting and retaining IHS' health care 
workforce.

    Question 5. During the hearing, you were asked to explain why HHS 
and HRSA apply the federal trust responsibility to Native Hawaiians and 
their healthcare systems differently than HHS and IHS apply the federal 
trust responsibility to American Indian and Alaska Natives and their 
health care systems. While I am aware that Native Hawaiian health care 
programs and American Indian and Alaska Native health care programs are 
authorized under separate statutes, that architecture does not limit 
the federal trust responsibility of the United States to one agency 
within HHS.
    Please describe the agency's active and planned efforts to follow 
up on your commitment to work within HHS to better educate the 
Department (as well as other agencies) about the trust responsibility 
to Native Hawaiians, and the need for parity in treatment between 
various health care programs administered by HHS that serve Native 
communities? In particular, please include any efforts to educate on 
the unequal treatment I mentioned during the hearing, e.g., matching 
fund requirements, no Federal Torts Claim Act coverage, and a lack of 
direct access to vaccines for the Native Hawaiian Healthcare Systems?
    Answer. The IHS responsibility for providing health care to 
American Indians and Alaska Natives (AI/AN) is grounded in the 
government-to-government relationship and does not, under current 
statutory authorities, include the provision of services to Native 
Hawaiians. Information about other HHS programs that benefit Native 
Hawaiians is available from the other HHS operating divisions that 
administer such programs (i.e., Health Resources and Services 
Administration, the Administration for Children and Families, and the 
Administration for Community Living). The IHS has shared these 
questions with the appropriate HHS operating divisions and leadership 
since Native Hawaiian issues and activities are not under its purview 
or expertise.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Ben Ray Lujan to 
                       Rear Admiral Michael Toedt
    Question 1. What is IHS doing to ensure vaccine acceptance rates 
increase on Tribal College and University campuses and in Bureau of 
Indian Education schools?
    Answer. The IHS is working with the Bureau of Indian Education 
(BIE) and Tribal Colleges and Universities (TCUs) to ensure students 
and staff are provided with the opportunity to be vaccinated. Early in 
the COVID-19 vaccination effort, the BIE provided the IHS with lists of 
estimated teacher and staff numbers for K-12 schools and TCUs. This 
information was included in IHS vaccine planning efforts, and the IHS 
provided BIE with information about the nearest IHS-operated facility 
or tribal health program providing vaccinations for K-12 staff and TCU 
staff and students. The BIE reported a K-12 school staff vaccination 
rate of over 70 percent, and they believe it could be higher based on 
time and attendance records.
    To promote vaccine acceptance, IHS continues to disseminate federal 
resources and materials, such as the HHS We Can Do This and the Office 
of Minority Health #VACCINEREADY campaigns, including toolkits and 
materials specific to American Indian and Alaska Native communities. 
The COVID-19 Vaccine Toolkit for Institutions of Higher Education 
(IHE), Community Colleges, and Technical Schools CDC was released on 
May 24, 2021 and was shared with BIE for further distribution across 
their network. Additionally, IHS continues to provide vaccine 
administration support, outreach, and sharing of best practices across 
the health care system.
    On May 13, 2021 the IHS began vaccinating children ages 12 years 
and older with the Pfizer COVID-19 vaccine, consistent with the 
Advisory Committee on Immunization Practices recommendation and the 
U.S. Food and Drug Administration (FDA) expanded emergency use 
authorization. The IHS is working closely with the BIE to encourage 
collaboration with the nearest IHS-operated facility or tribal health 
program providing COVID-19 vaccinations. Currently BIE is assessing 
school dismissal dates for the summer, as well as back-to-school dates 
in the fall to potentially coordinate vaccination events on site at the 
facilities, if desired by the school. BIE-operated K-12 schools 
primarily remain remote, but approximately \1/3\ resumed classes in a 
hybrid model (partial on site, partial online). Approximately 20 
percent of Tribally Controlled Schools resumed onsite learning, and 
approximately 35 percent are operating in a hybrid model. The remainder 
remain in a remote/distance learning environment. BIE and IHS are 
developing plans for fall back-to-school, including collection of 
COVID-19 and routine vaccination documentation, advance parent/guardian 
consents for all vaccines, and potential on-site vaccination events. 
The IHS does not track school specific vaccination rates or vaccine 
acceptance rates of students and staff but will continue to provide 
outreach and education to tribal communities including schools. The IHS 
and BIE have coordinated COVID-19 response efforts since early January 
2021. Bi-weekly meetings being increased to weekly to ensure the needs 
the BIE COVID-19 needs are addressed.

    Question 2. You state in your testimony that COVID-19 related data 
reporting from Tribes and Urban Indian Organizations is voluntary. What 
challenges and barriers does IHS face to providing Tribe-specific 
vaccination data?
    Answer. The IHS coordinates vaccine distribution for IHS-operated 
facilities and facilities operated by tribal health programs and urban 
Indian organizations that have chosen the IHS jurisdiction for vaccine 
distribution (I/T/Us). Tribal health programs and urban Indian 
organizations entered into Centers for Disease Control and Prevention 
(CDC) COVID-19 Vaccination Program Agreements--Vaccines Coordinated 
through IHS. As part of these agreements, each I/T/U must report 
vaccine administration data, including the required data elements, such 
as race and ethnicity, to the CDC by the pathways determined by the IHS 
jurisdiction. Data may be submitted via the Vaccine Administration 
Management System, a CDC platform, or via the I/T/U's electronic health 
record data transmission file. The required data elements do not 
include reporting administration data by tribe or tribal affiliation 
for the jurisdictions, including IHS. Therefore, the IHS is unable to 
report comprehensive vaccination data by tribe.

    Question 3. I also note that many states, including my own, have 
had difficulty reporting statewide vaccination rates without state-
specific vaccination data. Many states have this data but are not able 
to do more finite analyses because it is not disaggregated by 
geography, ethnicity, or site and there is duplication with states' own 
vaccine registries. What challenges does IHS face to providing more 
granular vaccination data to states?
    Answer. The IHI-operated facilities and facilities operated by 
tribal health programs and urban Indian organizations that have chosen 
the IHS jurisdiction for vaccine distribution, per CDC COVID-19 
Vaccination Program Agreements, must submit data elements for all 
administered vaccines. For example, this includes race, and ethnicity, 
and details about the products, including the lot, product, and other 
facility details. This IHS jurisdiction data is transmitted to the CDC 
and de-identified. The IHS jurisdiction data is sent from the CDC and 
is displayed on the HHS-supported platform, Tiberius, in aggregate. The 
state jurisdictions, as of the week of April 26, 2021, had visibility 
of IHS data for their specific state, which can be viewed at the state 
or zip code level. In general, IHS reviews state-specific data requests 
on a case by case basis to ensure patient data is de-identified and 
protected.

    Question 4. Your testimony discusses the work that IHS has done to 
increase access to clean water on Navajo Nation during the pandemic. 
What would IHS be able to do with $2.6 billion in appropriated funding, 
available until expended, to address the long-term water infrastructure 
challenges and deficiencies on Tribal lands?
    Answer. The IHS Sanitation Facilities Construction (SFC) program 
uses the Sanitation Deficiency System (SDS) to track water and 
sanitation needs in American Indian and Alaska Native communities. 
Currently, the SDS reports a backlog of $991.4 million in economically 
feasible projects. That number grows to nearly $3.09 billion when 
taking into account economically infeasible projects. Economically 
infeasible projects are those that have a ``per home cost'' above a 
State or geographic region-specific threshold.
    An appropriation of $2.6 billion to the IHS SFC program would 
support approximately 1,173 sanitation facilities projects to provide 
water, wastewater, and solid waste facilities serving American Indian 
and Alaska Native homes and communities. Of the 1,173 projects that 
could be supported with a $2.6 billion appropriation, 762 are 
economically feasible, and 411 are economically infeasible. This 
analysis is based on the project cost estimates included in the IHS SDS 
at the end of calendar year 2020, after subtracting the projects 
estimated to be funded with the FY 2021 IHS facilities appropriation.
    It is important to note that if Congress were to appropriate $2.6 
billion to the IHS SFC program, 592 of these projects would require 
non-IHS resources totaling $512 million to complete the full scope of 
identified need. These 592 projects include activities that are not 
legally eligible for IHS SFC program funding. These non-eligible 
activities include the cost to serve non-tribal homes, commercial, 
industrial, agricultural establishments, nursing homes, health clinics, 
schools, and hospital quarters. Tribal communities with non-eligible 
activities can use their own resources, or leverage other federal, 
state, and local funding sources to support the full scope of their 
projects.

    Question 5. What percent of feasible and infeasible projects does 
IHS estimate it would be able to complete with $2.6 billion in 
appropriated funding?
    Answer. There are 1,457 projects in the Sanitation Deficiency 
System, of which 925 are economically feasible and 532 are economically 
infeasible. With $2.6 billion in appropriated funding, the IHS would be 
able to complete 762 feasible projects, or 82 percent of all feasible 
projects and 532 infeasible projects, or 77 percent of infeasible 
projects.

    Question 6. How long does IHS estimate it would take to complete 
the feasible projects identified on its most recent deficiency list?
    Answer. At current funding levels, the average duration of a 
Sanitation Facilities Construction project is four years.

    Question 7. What number and percent of these feasible water and 
wastewater projects are located in New Mexico?
    Answer. There are a total of 96 feasible projects benefiting 
American Indian homes in New Mexico. This represents 10 percent of the 
total feasible projects.

    Question 8. How many households would be served in New Mexico if 
the IHS were able to complete all feasible projects identified on its 
most recent deficiency list?
    Answer. If all 96 feasible projects were completed, 21,098 American 
Indian homes would benefit from the facilities provided.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Ben Ray Lujan to 
                           Hon. William Smith
    Question 1. I was glad to see President Biden's Fiscal Year 2022 
budget include an advance appropriation for IHS in 2023, an issue that 
I know National Indian Health Board has been working on for over a 
decade. Your testimony highlights the importance of budget certainty 
and advance appropriations for IHS to advance health outcomes for 
Native communities. Should the federal government enact legislation to 
permanently provide advance appropriations for IHS and the Bureau of 
Indian Affairs?
    Answer. The Indian health system faces chronic challenges that are 
made worse by endless use of continuing resolutions (CRs) and the 
persistent threat of government shutdowns. Of the four federal health 
care programs, IHS is the only one not protected from government 
shutdowns and CRs. This is because Medicare/Medicaid receive mandatory 
appropriations, and the Veterans Health Administration (VHA) receive 
advance appropriations starting a decade ago. In September 2018, the 
Government Accountability Office (GAO) issued a report (GAO-18-652) 
that noted ``uncertainty resulting from recurring CRs and from 
government shutdowns has led to adverse financial effects on tribes and 
their health care programs.''
    Year after year, the federal government has failed AI/ANs by 
drastically underfunding the IHS far below the figures outlined by the 
IHS National Tribal Budget Formulation Workgroup (TBFWG). For example, 
in 2018, IHS spending for medical care per user was only $3,779, while 
the national health care spending per capita was $9,409--an astonishing 
60 percent difference. This correlates directly with the unacceptable 
higher rates of premature deaths and chronic illnesses suffered 
throughout Tribal communities. While the average life expectancy is 5.5 
years less for all AI/ANs than it is for other Americans, some Tribal 
communities have a life expectancy of up to 20 years less than the 
average American. Tribal treaties are not discretionary, and the IHS 
budget should not be discretionary either.
    The federal budget is a reflection of the extent to which the 
United States honors its promises to American Indian/Alaska Native 
people to provide for basic government and health services. However, 
since 1998 Congress has not enacted federal appropriations bills in a 
timely manner, thus hampering Tribal programs budgeting, recruitment 
and retention of personnel, the provision of services, facility 
maintenance, and construction efforts. Most concerning, the lack of 
timely funding for key federal programs that serve Tribal Nations 
endangers health, life, safety and education of beneficiaries and 
facilities.
    Advanced appropriations would protect these services from future 
lapses in appropriations and ensure they do not count against spending 
caps. IHS funds many critical public services for Tribal Nations, 
including hospitals and clinics. Moving federal Indian programs such as 
IHS to the advance appropriations process will protect Tribal 
governments from cash flow problems that regularly occur due to delays 
in the enactment of annual appropriations legislation.

    Question 2. What impact will advance appropriations have on IHS and 
its ability to improve health outcomes for Native communities and 
Tribal Nations, especially during the pandemic and beyond?
    Answer. Since FY1997, IHS has once (in FY2006) received full-year 
appropriations by the start of the fiscal year. As a consequence, IHS 
activities generally have been funded for a portion of each year under 
a continuing resolution (CR). Receiving its funding under a CR has 
limited the activities that IHS can undertake, in part because IHS can 
only expend funds for the duration of a CR, which prohibits the agency 
from making longer-term, potentially cost-saving purchases.
    Currently, over 60 percent of funding appropriated for the IHS is 
administered by Tribes in carrying out health programs under the Indian 
Self-Determination and Education Assistance Act (ISDEAA). Tribally-
operated health programs are disproportionately affected by disruptions 
in federal appropriations since they rely on IHS funding transferred 
through ISDEAA contracts and compacts, but are not authorized the same 
emergency authorities granted to federal agencies during a lapse. Under 
a CR, these contracts can be issued only for the duration of the CR and 
must be reissued for each subsequent CR (or when full-year 
appropriations are enacted). This can be a time-consuming process for 
both IHS and Tribes, which may divert resources from other needed 
activities.
    Advance appropriations for the IHS could ensure continuity of 
health care provided to American Indian and Alaska Native people, 
especially in the event of a lapse in appropriations. During regular 
order, it could enable timely and predictable funding for IHS-funded 
programs. Advance appropriations could mitigate the effects of budget 
uncertainty on the health care programs operated across the Indian 
health system. The IHS could disburse funds more quickly, which could 
enable IHS, Tribal, and urban Indian health program managers to 
effectively and efficiently manage budgets, coordinate care, and 
improve health quality outcomes for AI/ANs. This planning stability 
could reduce unnecessary contract and administrative costs. Funding 
continuity could also alleviate concerns from potential recruits, 
especially health care providers, about the stability of their 
employment.
    During the most recent government shutdown in 2019, which lasted 35 
days, IHS was the only federal health care program directly harmed. The 
impact was devastating, yet entirely avoidable. Tribal facilities lost 
physicians because they could not keep working without pay. Doctor 
visits could not be scheduled because administrative staff were 
furloughed. Tribes took out private loans to be able to help pay to 
keep the lights on at their clinic. Contracts with private entities for 
sanitation services and facilities upgrades went weeks without payment, 
threatening Tribes' credit and putting patients' health at risk. Tribal 
leaders shared how administrative staff volunteered to go unpaid so 
their Tribe had resources to keep physicians on the payroll. These are 
just a few examples of the everyday sacrifices that widen the chasm 
between the health services afforded to AI/ANs and the nation at large.
    Over the past two decades, only once has Congress passed the 
Interior budget on time--in FY 2006. Every other year, IHS has been 
subject to either short-term or full-year CRs or faced a government 
shutdown. The inevitable results are the chronic and perverse health 
disparities across Indian Country. Advance appropriations for IHS is a 
necessity to ensure patient health is not comprised in the event of 
Congress's failure to enact a budget each year. It is long past due.

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