[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
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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
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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
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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.
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\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.
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\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\
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\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\
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\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\
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\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.
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\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.
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\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
---------------------------------------------------------------------------
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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