[Senate Hearing 117-71]
[From the U.S. Government Publishing Office]
S. Hrg. 117-71
S. 1797, S. 1895 AND H.R. 1688
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HEARING
before the
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
__________
JULY 21, 2021
__________
Printed for the use of the Committee on Indian Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
U.S. GOVERNMENT PUBLISHING OFFICE
45-584 PDF WASHINGTON : 2021
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 July 21, 2021.................................... 1
Statement of Senator Cantwell.................................... 49
Statement of Senator Cortez Masto................................ 44
Statement of Senator Daines...................................... 43
Statement of Senator Hoeven...................................... 40
Statement of Senator Lankford.................................... 4
Statement of Senator Lujan....................................... 42
Statement of Senator Murkowski................................... 2
Statement of Senator Schatz...................................... 1
Statement of Senator Smith....................................... 38
Statement of Senator Tester...................................... 48
Witnesses
Grinnell, Randy, M.P.H., Deputy Director for Management
Operations, Indian Health Service, Department of Health and
Human Services................................................. 5
Prepared statement........................................... 6
Nez, Hon. Jonathan, President, Navajo Nation..................... 13
Prepared statement........................................... 14
Sunday-Allen, Robyn, Vice President, National Congress of Urban
Indian Health.................................................. 34
Prepared statement........................................... 36
Todacheene, Heidi, Senior Advisor, Office of the Assistant
Secretary--Indian Affairs, Department of the Interior.......... 10
Prepared statement........................................... 11
Vigil, Hon. Gil, President, National Indian Child Welfare
Association.................................................... 18
Prepared statement........................................... 20
Appendix
Lucero, Esther, President/CEO, Seattle Indian Health Board,
prepared statement............................................. 55
National Indian Health Board, prepared statement................. 56
Response to written questions Submitted to Hon. Randy Grinnell,
M.P.H. by:
Hon. Ben Ray Lujan........................................... 63
Hon. Lisa Murkowski.......................................... 62
Response to written questions submitted by Hon. Ben Ray Lujan to
Hon. Jonathan Nez.............................................. 61
Response to written questions submitted by Hon. Lisa Murkowski to
Heidi Todacheene............................................... 64
Response to written questions submitted to Hon. Gil Vigil by:
Hon. Ben Ray Lujan........................................... 59
Hon. Lisa Murkowski.......................................... 58
Hon. Brian Schatz............................................ 60
S. 1797, S. 1895 AND H.R. 1688
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WEDNESDAY, JULY 21, 2021
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2:30 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. During today's legislative
hearing, we will consider three bills, S. 1797, the Urban
Indian Health Providers Facilities Improvement Act, S. 1895,
the Indian Health Service Sanitation Facilities Construction
Enhancement Act, and H.R. 1688, the Native American Child
Protection Act.
The Federal Government has a special trust responsibility
to ensure the general welfare of Native communities. That
includes providing adequate health care to Native people,
supplying tribal communities with clean, safe drinking water
and protecting Native children. But for too long, Congress has
underfunded Native-serving programs and ignored Native needs on
the ground.
The bills before this Committee today work toward righting
these past injustices. The bipartisan Urban Indian Health
Providers Facilities Improvement Act, cosponsored by Senators
Lankford, Smith, and Moran, will remove a statutory funding use
limitation and empower Urban Indian organizations to make
needed healthcare facilities enhancements.
UIOs provide care to Native Americans in urban areas. But
according to the National Council of Urban Indian Health, at
least 74 percent of these facilities have critical, unmet
facility infrastructure needs. S. 1797 would stretch Federal
dollars for UIOs to use on facilities renovations, construction
and expansion.
The next bill, Senator Lujan's Indian Health Service
Sanitations Facilities Construction Enhancement Act, will
support tribal sanitation infrastructure development, an urgent
priority across Indian Country. Indeed, the Indian Health
Service has identified 110,000 American Indian and Alaska
Native homes in need of some form of sanitation facility
improvement, including more than 50,000 homes without access to
sanitation facilities.
Finally, the House passed Native American Child Protection
Act will reauthorize and modernize existing programs that help
to ensure the health, safety and well-being of Native children,
incorporate culturally appropriate treatment and services into
these programs, and encourage tribal partnerships with UIOs and
States to address family violence and child abuse.
Before I turn to Vice Chair Murkowski, I would like to
welcome and extend my thanks to our witnesses for joining us
today. Vice Chair Murkowski?
STATEMENT OF HON. LISA MURKOWSKI,
U.S. SENATOR FROM ALASKA
Senator Murkowski. Thank you, Mr. Chairman. I appreciate
the fact that at this first legislative hearing that the
Committee has held this year that it encompasses these very
important topics that we are speaking of today regarding the
health and protection of Native children.
The Chairman has outlined the details of these three
measures before us. S. 1797, again, the Urban Indian Health
Providers Facilities Improvement Act will be significant as we
look to make renovations, construct or expand health facilities
used by UIOs to provide care of urban Indian patients. Many
UIOs have reported their infrastructure needs have increased
greatly due to the coronavirus pandemic. I think it is going to
be important for the Committee to hear how any potential
infrastructure needs could be used to alleviate some of these
needs.
S. 1895, the Indian Health Services Sanitation Facilities
Construction Enhancement Act--that is too long of a title--
introduced by Senator Lujan, with Senator Heinrich, Senator
Sinema, is focused on addressing the water and sanitation
infrastructure needs. The Committee has been very active in
this initiative. Since the start of the pandemic, certainly, we
have held some hearings and roundtables to determine how we can
work to reduce the tribal sanitation facilities construction
backlogs.
I have heard from Alaska Native leaders that their
communities are without access to basic water and sewage
infrastructure. It makes it pretty hard when you are dealing
with a pandemic when you cannot meet the basic health
guidelines of washing your hands.
We have had some very good testimony within the Committee
from tribes and tribal consortia about the need to address the
sanitation facilities backlog. We have made good improvements
in sanitation infrastructure in rural Alaska. But still about
20 percent of rural Native homes still lack in-home piped
water. Thirty-two of 190 Native communities are still unserved,
lacking access to in-home water and sewer. So when we say
unserved, we mean nothing. Nothing.
We know that the need is great. But we do have good news in
this area with regard to how tribal health organizations have
really worked creatively to address some of these needs. Just
recently, the Committee staff sitting here in this room met
with the Alaska Native Tribal Health Consortium. They were
shown various examples of innovative uses of coronavirus relief
funds. ANTHC is installing 100 mini-pass units. They are doing
this in Kivalina, Newtok, there are seven other communities.
But this is effectively a way to help wash hands when you
are in a home that doesn't have any running water. It is a
small unit, it pumps the clean water from this overhead tank
and then down into a faucet for a person to use. The waste
water then runs below the sink, it goes into a bucket. What we
would do without our Home Depot buckets? Then that is later
hauled out and removed.
So obviously this is not a permanent fix. But it shows that
there is a level of innovation. We are trying to address some
of the unique situations and circumstances in the needs of
these underserved and unserved communities.
When you look at the need out there, it is pretty
significant. More than $3 billion needed across the Nation for
sanitation construction projects. So much of that in Alaska. We
have been looking at this issue extensively within the
infrastructure negotiations that I have been part of for these
many weeks. Many of the priorities that we have heard here in
this Committee from tribes across the Country with regard to
water and sanitation infrastructure, broadband tribal energy,
these are many of the pieces that we are trying to advance in
this bipartisan proposal.
The last bill, H.R. 1688, the Native American Child
Protection Act, again, very important to make sure that we are
modernizing our programs to better address abuses against
Native children. We did have a report that was issued by the
Administration for Children and Families in fiscal year 2019,
but when you look at the data, when you look at the statistics
and you realize that American Indian and Alaska Native children
had the highest rates of victimization, 14.8 per 1,000 children
when compared to other races and ethnicity, in Alaska, almost
half of the over 3,000 reported victims were American Indian or
Alaska Native children, unacceptable. Just unacceptable in
every sense.
I spoke on the Floor yesterday. We had a bill before us.
This was the VOCA fix, focused on the Victims Compensation Fund
and how we are able to ensure that that fund is there to meet
needs. I had a VOCA roundtable in Alaska in June. We heard from
many in the victim service provider community. What we heard
about what is happening with far too many of our particularly
Native children when it comes to violence against the children,
severity of the abuse that we have seen recently, advocacy
groups are telling us that they are seeing more cases of child
torture and other egregious, actually heinous forms of abuse
against children.
So at today's hearing, I hope that we can shed more light
on this issue and how H.R. 1688 will help to work to reduce the
levels of abuse and neglect of Native children. I am also going
to be very interested to hear how this bill complements the
work of what we have done with the Alyce Spotted Bear and
Walter Soboleff Commission on Native Children, where part of
that mission is to focus on child abuse, violence, and crimes.
Good bills before the Committee today. We are looking
forward to comments from the witnesses.
Senator Schatz has excused himself to go participate in the
first vote that is underway. So I am going to introduce the
panel. Before I do, I will turn to you, Senator Lankford, or
anybody, any members that might be participating
telephonically, although I don't think we are participating
telephonically.
Senator Lankford, if you would like to make a statement
before we turn to witnesses?
STATEMENT OF HON. JAMES LANKFORD,
U.S. SENATOR FROM OKLAHOMA
Senator Lankford. Thank you. I would actually like to be
able to help introduce one of the witnesses who is here, who I
am a little proud of as well. If I can give just a brief
statement.
Oklahoma UIOs serve the second largest population next to
California and are a critical part of the Indian health system.
Leaders like Robyn Sunday-Allen and Carmelita Skeeter from
Tulsa are why the Oklahoma Indian urban clinics are really the
gold standards for health care and clinic operations.
I was proud to sponsor and help pass into law the Coverage
for Urban Indian Health Providers Act with Senator Smith. As
this Committee knows, I just swiftly acted to implement the law
on March 22nd, which could be record time for them to implement
it, and to bring all the UIOs under the Federal Tort Claims
Act. However, we strongly believe, and I strongly believe that
more must be done to achieve parity for the UIOs within the
Indian Health System umbrella.
According to the National Council of Urban Indian Health,
70 percent of American Indians and Alaska Natives live in urban
and suburban areas. However, UIOs only receive a fraction of
the cost per patient compared to the rest of the Indian Health
system, and have little flexibility for their 501 facility
dollars.
To ensure greater parity and flexibility, I was proud to
introduce the Urban Indian Health Providers Facilities
Improvement Act with Senators Padilla, Moran, Smith, and
Feinstein. The legislation will give UIOs the ability to use
their facility dollars for renovations as needed and remove the
outdated limits on accreditation. That is coming up today. I am
pleased it is on the docket for today.
To speak to the bill, I am proud to introduce a fellow
Oklahoman, Robyn Sunday-Allen, who I mentioned before. Robyn is
a member of the Cherokee Nation, National Council of Urban
Indian Health Vice President, and the Chief Executive Officer
of the Oklahoma City clinic. She knows the clinic from the
ground up, because she started out as a registered nurse,
transitioning to director of nursing and then chief operating
officer, and finally CEO in 2009. I know her testimony today
comes from her years of experience and dedicated service. I am
thankful to have such a strong leader to represent our State
and Indian Country today before the Committee today. I know she
will do an excellent job with her testimony.
With that, I yield back.
Senator Murkowski. [Presiding.] Thank you, Senator
Lankford.
Senator Smith, we have just done opening statements. I
don't know if you would like to make a comment before we turn
to the introduction of witnesses.
Senator Smith. No, I just am ready and looking forward to
hearing from our witnesses. Thank you.
Senator Murkowski. I think we are as well. Thank you, and
thank you, Senator Lankford.
The panel today is with us all virtually. It will be led
off by Mr. Randy Grinnell. He is the Deputy Director for
Management Operations at IHS. Ms. Heidi Todacheene, Senior
Advisor, Office of the Assistant Secretary of Indian Affairs
here in Washington, D.C.
We have the Honorable Jonathan Nez, who is the President of
the Navajo Nation, in Arizona, the Honorable Gil Vigil, who is
the President for the National Indian Child Welfare Association
in Portland, Oregon, and as Senator Lankford has just
introduced, Ms. Robyn Sunday-Allen. We welcome her as well.
If we can begin with testimony from each of our witnesses.
We would ask you to keep your statements to about five minutes
or less. Your full statements will be incorporated as part of
the record.
Mr. Grinnell, if you would like to lead off, please.
STATEMENT OF RANDY GRINNELL, M.P.H., DEPUTY DIRECTOR FOR
MANAGEMENT OPERATIONS, INDIAN HEALTH SERVICE, DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Mr. Grinnell. Good afternoon, Chairman Schatz and Vice
Chair Murkowski and members of the Committee. Thank you for the
opportunity to testify on the bills, S. 1895, S. 1797, and H.R.
1688.
S. 1895 is a bill to require additional funding through the
IHS Sanitation Facilities Construction Program in planning
design, construction, modernization, improvement, and
renovation of water, sewer, and solid waste sanitation
facilities that are funded by IHS. IHS has caried out the
program since 1959 using funds appropriated to provide water
and waste disposal facilities for eligible American Indian and
Alaska Native homes and communities.
About 112,000 eligible homes tracked by IHS need some form
of sanitation facility improvements. Many are very remote and
may have limited access to health care, which increases the
importance of improving environmental conditions.
In fiscal year 2020, for the IHS SFC program, the total
sanitation facility need reported to the Sanitation Deficiency
System was $3.09 billion. In 2020, IHS appropriated $197
million to address deficiencies. They funded projects to
provide services to over 37,000 eligible homes and completed
construction on 260 projects with an average project duration
of 3.9 years.
Also, 373 construction projects were funded with a
construction cost of $220 million using IHS and contributed
funds. These sanitation facilities will benefit over 143,000
American Indian and Alaska Native people, and help avoid over
235,000 inpatient and outpatient visits.
Since fiscal year 2016, the SFC program funding has
increased by nearly 100 percent without any increase in
staffing. Without these staffing increases, the program is
being strained to accomplish the required statutory
obligations.
S. 1797, the Urban Indian Health Providers Facilities
Improvement Act, would amend the Indian Health Care Improvement
Act to extend the funding authority for renovating,
construction, and expanding Urban Indian Organization
facilities. Because of the language in current Federal law, IHS
cannot award funds to a UIO to make minor renovations,
construct, or expand facilities unless the UIO is doing to meet
or maintain accreditation specifically from The Joint
Commission. Only one out of the 41 UIOs maintains Joint
Commission accreditation. Expanding the current authority to be
consistent with the authority of other government contractors
would allow UIOs to make renovations, construct or expand
facilities to improve the safety and quality of care provided
to urban Indian patients.
H.R. 1688, the Native American Child Protection Act, would
amend the Indian Child Protection and Family Violence
Prevention Act and require the Secretary of HHS, acting through
IHS, to establish the Indian Child Abuse Treatment Grant
Program. IHS does not believe Congress has ever appropriated
funding for this program.
The bill would amend current Federal law to expand the
scope of this grant program to treatment programs for Indians
who have been victims of child abuse or neglect. The bill would
also allow UIOs to partner with Indian tribes and inter-tribal
consortia in submitting grant applications. H.R. 1688 would
also amend current Federal law to require IHS to encourage the
use of culturally appropriate treatment services and programs
and providing grants under this program.
IHS has an important role in improving the lives of Native
youth. It is critical to identify and respond to child
maltreatment for the health and well-being of children. A
comprehensive approach is required that integrates health care
and a community response. IHS's efforts include early
intervention, assessment, and education to build resiliency
among children and youth and to promote family engagement. This
proposed legislation would expand access to child advocacy,
center services, often not available in tribal communities.
These include pediatric forensic exam services, mental health
care providers with advanced training in child trauma, and
culturally appropriate services for pediatric patients.
We look forward to continuing our work with Congress on
these bills. We welcome the opportunity to provide technical
assistance as requested.
Thank you again for the opportunity to speak with you
today. I am happy to answer any questions you may have.
Thank you.
[The prepared statement of Mr. Grinnell follows:]
Prepared Statement of Randy Grinnell, M.P.H., Deputy Director for
Management Operations, Indian Health Service, Department of Health and
Human Services
Good afternoon Chairman Schatz, Vice Chairman Murkowski, and
Members of the Committee. Thank you for the opportunity to testify on
the bills S. 1895, a bill to require the Secretary of Health and Human
Services to award additional funding through the Sanitation Facilities
Construction Program of the Indian Health Service, S. 1797, Urban
Indian Health Providers Facilities Improvement Act, and H.R. 1688,
Native American Child Protection Act.
The Indian Health Service (IHS) is an agency within the Department
of Health and Human Services (HHS) and our mission is to raise the
physical, mental, social, and spiritual health of American Indians and
Alaska Natives to the highest level. This mission is carried out in
partnership with American Indian and Alaska Native Tribal communities
through a network of over 687 Federal and Tribal health facilities and
41 Urban Indian Organizations (UIOs) that are located across 37 states
and provide health care services to approximately 2.6 million American
Indian and Alaska Native people annually.
S. 1895
S. 1895, is a bill to require additional funding through the IHS
Sanitation Facilities Construction (SFC) Program for the planning,
design, construction, modernization, improvement, and renovation of
water, sewer, and solid waste sanitation facilities that are funded by
the IHS. According to the bill, funding awards will be prioritized in
accordance with the IHS Sanitation Deficiency System. The bill
authorizes $3 billion in appropriated funds for Fiscal Year (FY) 2022,
which will remain available until expended. Of the appropriated funds,
$350 million shall be used for additional staffing support.
The IHS SFC Program is an integral component of IHS disease
prevention activities. IHS has carried out the program since 1959 using
funds appropriated to provide water and waste disposal facilities for
eligible American Indian and Alaska Native homes and communities. As a
result, infant mortality rates and mortality rates for gastroenteritis
and other environmentally-related diseases have declined. Research
supported by the Centers for Disease Control and Prevention states
populations in regions with a lower proportion of homes with water
service, reflect significantly higher hospitalization rates for
pneumonia, influenza, and respiratory syncytial virus. Researchers
associated the increasing illnesses with the restricted access to clean
water for hand washing and hygiene. \1\ The SFC Program works
collaboratively with Tribes to assure all American Indian and Alaska
Native homes and communities are provided with safe and adequate water
supply and waste disposal facilities as soon as possible.
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\1\ Thomas W. Hennessy, Troy Ritter, Robert C. Holman, Dana L.
Bruden, Krista L. Yorita, Lisa Bulkow, James E. Cheek, Rosalyn J.
Singleton, and Jeff Smith. The Relationship Between In-Home Water
Service and the Risk of Respiratory Tract, Skin, and Gastrointestinal
Tract Infections Among Rural Alaska Natives. American Journal of Public
Health: November 2008, Vol. 98, No. 11, pp. 2072-2078.
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In FY 2020, IHS funded projects to provide service to 37,771
American Indian and Alaska Native homes. IHS also completed
construction on 260 projects with an average project duration of 3.9
years. However, at the end of FY 2020 about 7,140, or 1.8 percent, of
all American Indian and Alaska Native homes tracked by IHS lacked water
supply or wastewater disposal facilities. About 112,082, or
approximately 28 percent, of American Indian and Alaska Native homes
tracked by IHS needed some form of sanitation facilities improvements.
Many of these homes without service are very remote and may have
limited access to health care, which increases the importance of
improving environmental conditions.
The total sanitation facility need reported through Sanitation
Deficiency System (SDS) has increased approximately $0.52 billion, or
20.2 percent, from $2.57 billion to $3.09 billion from FY 2019 to FY
2020. In FY 2020, the IHS was appropriated $197 million to address
sanitation deficiencies and support provision of sanitation facilities
to eligible American Indian and Alaska Native homes and communities.
The magnitude of the sanitation facility needs increase is due to the
IHS implementing a revised prioritization system to indicate the level
of project planning. A ``tier'' system was introduced with the
publication of the 2019 SDS Guidelines document. Projects considered
``ready to fund'' are assigned Tier 1, while projects considered
``engineering assessed'' are assigned Tier 2. Projects considered Tier
3 are those that are only ``preliminarily assessed.'' Previously many
of these projects were not reported to Congress. In FY 2020, there was
a total of $0.67 billion in Tier 3 projects, resulting in an increase
in the total sanitation facility need reported through SDS.
During FY 2020, 373 construction projects to address water supply
and wastewater disposal needs were funded with a construction cost of
$220 million using IHS and contributed funds. Once constructed, these
sanitation facilities will benefit an estimated 143,000 American Indian
and Alaska Native people and help avoid over 235,000 inpatient and
outpatient visits related to respiratory, skin and soft tissue, and
gastro enteric disease over 30 years. The health care cost savings for
these visits alone are estimated to be over $259 million. Every $1
spent on water and sewer infrastructure will save $1.18 in avoided
direct health care cost.
Adequate staffing resources are needed to ensure SFC projects are
designed and constructed within the SFC Program's national average
project duration of 4 years. Since FY 2016, the SFC project funding has
increased by nearly 100 percent without any increase in staffing
resources. Without associated increases in staffing resources, the IHS
SFC Program is being strained to accomplish the required program
statutory obligations of sanitation deficiency needs reporting, project
design, planning, and provision of technical assistance, and as such we
fully expect our project durations to increase beyond 5-6 years. Under
the President's proposed FY 2022 Budget, the IHS SFC project funds will
increase by roughly 60 percent. In addition to the proposed increases
in IHS appropriated funds, an assumption is made that the amount of
project funds to be directed towards the IHS through appropriations and
contributions from other funding sources would double over the FY 2020
levels to $547 million in future fiscal years. The FY 2022 Budget also
proposes an increase of $36 million for the Facilities and
Environmental Health Support program to support additional staff to
implement the proposed funding increases for SFC, Health Care
Facilities Construction, Maintenance & Improvements, and Equipment.
S. 1797
S. 1797, Urban Indian Health Providers Facilities Improvement Act,
would amend the Indian Health Care Improvement Act (IHCIA), at 25
U.S.C. 1659, to expand the funding authority for renovating,
constructing, and expanding urban Indian organization (UIO) facilities.
The bill would delete from existing law the requirement that UIOs may
only use IHS funding for renovation, construction, or expansion of
facilities to meet or maintain specific accreditation standards.
Current federal law at 25 U.S.C. 1659 permits the IHS to make
funds available to UIOs with contracts or grants with IHS under Title V
of the IHCIA to make minor renovations to facilities or construction or
expansion of facilities, including leased facilities, but only to
assist UIOs in meeting or maintaining accreditation standards of The
Joint Commission (TJC). Because of the specificity of the language in
Section 1659, the IHS cannot award funds to an UIO to make minor
renovations, construct or expand facilities, unless the UIO is doing so
to meet or maintain accreditation specifically from TJC.
The IHS enters into limited, competing contracts and grants with 41
501(c)(3) non-profit organizations to provide health care and referral
services for Urban Indians throughout the United States. An UIO is
defined by 25 U.S.C. 1603(29) as a nonprofit corporate body situated
in an urban center, governed by an Urban Indian controlled board of
directors, and providing for the maximum participation of all
interested Indian groups and individuals, which body is capable of
legally cooperating with other public and private entities for the
purpose of performing the activities described in 25 U.S.C. 1653(a).
UIOs provide unique access to culturally appropriate and quality health
care for Urban Indians.
Currently, UIOs seek and maintain accreditation from several health
care accreditation organizations, including TJC, Accreditation
Association for Ambulatory Healthcare (AAAHC), and Commission on
Accreditation of Rehabilitation Facilities (CARF). Some UIOs have also
achieved recognition as Patient Centered Medical Homes (PCMH), with
additional UIOs currently working towards PCMH recognition, as well as
AAAHC accreditation. In addition, some UIOs must meet standards from
the Centers for Medicare & Medicaid Services and/or their respective
state departments of health.
Currently, only 1 out of the 41 UIOs maintain TJC accreditation.
Expanding the current authority to be consistent with the authority for
other government contractors, rather than limiting it under Section
1659 to only TJC accreditation, would allow UIOs to make renovations,
construction, or expansion of facilities necessary to improve the
safety and quality of care provided to Urban Indian patients.
A large proportion of Urban Indians live in or near the poverty
level and thus face multiple barriers to accessing high quality,
culturally relevant health care services in urban centers. They must
overcome additional barriers to receiving appropriate care such as lack
of culturally appropriate care, lack of respect, lack of visibility,
transportation issues, and communication obstacles that often interfere
with the delivery of high-quality health care to Urban Indians.
Providing UIOs with broader authority, similar to other FAR
contractors, to improve their health care facilities will assist in
providing the high quality, safe, and culturally relevant health care
for the Urban Indian population.
H.R. 1688
H.R. 1688, Native American Child Protection Act, would amend the
Indian Child Protection and Family Violence Prevention Act (25 U.S.C.
3201 et. seq.) (the Act), a statute that, among other provisions,
required the Secretary of Health and Human Services, acting through IHS
and in cooperation with the Bureau of Indian Affairs of the Department
of the Interior (Bureau), to establish the Indian Child Abuse Treatment
Grant Program (Program). IHS does not believe Congress has ever
appropriated funding to carry out the Program.
H.R. 1688 would replace references to the ``Secretary of Health and
Human Services'' with references to IHS. The bill would amend section
409 of the Act (25 U.S.C. 3208) to expand the scope of the Program.
Current law requires that Program grants be provided for the
establishment on Indian reservations of treatment programs for Indians
who have been victims of child sexual abuse. The bill would expand the
scope to treatment programs for Indians who have been victims of child
abuse or neglect. The bill would also allow urban Indian organizations
to partner with Indian tribes and intertribal consortia in submitting
grant applications.
Additionally, H.R. 1688 would amend section 409 of the Act (25
U.S.C. 3208) to require IHS to encourage the use of ``culturally
appropriate treatment services and programs'' in providing grants under
the Program. The bill would require IHS to submit a report to Congress,
within two years, on the award of Program grants. The report would
contain a description of treatment and services for which grantees have
used Program funds, and other information that IHS requires. The bill
would authorize $30 million per year for fiscal years 2022 through 2027
to carry out the Program.
Finally, H.R. 1688 would amend section 410 of the Act (25 U.S.C.
3209), which currently requires the Secretary of the Interior to
establish an Indian Child Resource and Family Services Center within
each area office of the Bureau, with staffing for the Centers to be
provided in a Memorandum of Agreement with the Secretary of Health and
Human Services. The bill would remove references to the Secretary of
Health and Human Services, eliminate the requirement for the Memorandum
of Agreement, and require the Secretary of the Interior to establish
one National Indian Child Resource and Family Services Center.
The IHS has an important role in improving the lives of native
youth. Child maltreatment, a term that encompasses all forms of abuse
and neglect, is associated with injuries, delayed physical growth,
neurological damage, and death, and is linked with psychological and
emotional problems such as aggression, depression, anxiety, low self-
esteem, and post-traumatic stress disorder as well as an increased risk
for the development of health problems later in life. It is critical to
identify and respond to child maltreatment for the health and well-
being of children, and it requires a comprehensive approach that
integrates health care within a collaborative community response. IHS'
efforts include early intervention, screening, assessment, education,
and community-based programming to build resiliency among children and
youth and to promote family engagement.
One program that focuses on domestic violence prevention is the IHS
Domestic Violence Prevention Initiative (DVPI). Through this nationally
coordinated grant and Federal award program, mandated through statute,
IHS funds $11.2 million annually to 83 tribes, tribal organizations,
urban Indian organizations, and Federal programs. The DVPI promotes the
development of evidence-based and practice-based models that represent
culturally appropriate prevention and treatment approaches to domestic
and sexual violence from a community-driven context. The DVPI expands
outreach and increases awareness by funding projects that provide
victim advocacy, intervention, case coordination, policy development,
community response teams, sexual assault examiner programs, and
community and school education programs.
From 2010-2015, the DVPI resulted in over 78,500 direct service
encounters including crisis intervention, victim advocacy, case
management, and counseling services. More than 45,000 referrals were
made for domestic violence services, culturally-based services, and
clinical behavioral health services. In addition, a total of 688
forensic evidence collection kits were submitted to federal, state, and
tribal law enforcement.
While the successful administration of the DVPI has assisted our
agency in addressing violence, the program largely assists young adults
experiencing intimate partner violence. Although child abuse and
neglect often overlaps with intimate partner violence, the program does
not specifically focus on treatment and recovery of child abuse and
neglect victims. This proposed legislation would expand access to child
advocacy center services that are often not available within tribal
communities such as pediatric forensic examination services, mental
health care providers with advanced training in child trauma, and
culturally appropriate activities and services geared toward pediatric
patients.
We look forward to continuing our work with Congress on these bills
and welcome the opportunity to provide technical assistance as
requested by the Committee or its Members. We are committed to working
closely with our stakeholders and understand the importance of working
with partners to address the needs of American Indians and Alaska
Natives. Thank you again for the opportunity to speak with you today.
Senator Murkowski. Thank you, Mr. Grinnell.
Ms. Todacheene, welcome.
STATEMENT OF HEIDI TODACHEENE, SENIOR ADVISOR,
OFFICE OF THE ASSISTANT SECRETARY--INDIAN AFFAIRS, DEPARTMENT
OF THE INTERIOR
Ms. Todacheene. Good afternoon, Vice Chair Murkowski and
members of the Committee.
My name is Heidi Todacheene, and I am a member of the
Navajo Nation and Senior Advisor of the Office of the Assistant
Secretary for Indian Affairs at the U.S. Department of the
Interior.
Thank you for the opportunity to provide testimony today on
the Native American Child Protection act. The proposed
legislation would amend the previously enacted Indian Child
Protection and Family Violence Prevention Act, a statute that
required the Bureau of Indian Affairs in collaboration with the
Department of Health and Human Services, to establish an Indian
Child Abuse Treatment Grant Program, National Resource and
Family Services Center, and Child Protection and Family
Violence Prevention Program.
Originally, after the bill's enactment in 1990, Congress
did not fully fund the grant programs included in the bill and
left tribes without resources to implement child preventive
services and abuse programs and neglect services in their
communities. They subsequently expired in 1997.
To date, the two grant programs included under the Native
American Child Protection Act are the only tribally specific
prevention programs for American Indian and Alaska Native
children who are now at risk of being abused or have been
abused.
As you know, there is a continuing need for tribes to build
their capacity for these critical preventive and tribal
treatment service programs. The Department supports this
updated bipartisan legislation to authorize these programs and
to develop tribal capacity for preventive services in Indian
Country. This is necessary to safeguard indigenous children and
strengthen communities, which has been historically overlooked
by the Federal Government.
If the bill is enacted, it will modernize and reauthorize
programs including the Indian Child Abuse Treatment Grant
Program, the National Indian Resource Service Center, and the
Indian Child Protection and Family Violence Prevention Program.
The Department supports all of these programs to empower tribal
communities to provide culturally appropriate tribal welfare
services for their communities and provide the building blocks
for currently non-existent preventive services for American
Indian and Alaska Native children and families.
In furtherance of this work, this bill establishes the
National Indian Child Resource and Family Services Center
through the Bureau to consolidate resources for tribal
capacity, for technical assistance and training, and improving
coordination for effective intergovernmental work to help
identify, prevent, investigate, and treat child abuse, neglect,
and family violence cases.
To carry these activities out, the Department will be
charged with establishing an advisory board consisting of 12
members from Indian tribes, tribal organizations and Urban
Indian organizations with relevant expertise in the subjects
under the provisions of the Indian Self-Determination Act.
Additionally, the Department applauds the scope of funding and
language included under the Indian Child Prevention and Family
Violence Prevention Program. As written the text includes
accountability and tribal consultation requirements, which is a
cornerstone of President Biden's work to promote robust and
meaningful consultation with tribal nations in furtherance of
the well-established responsibility of the Federal Government
to honor its government-to-government relationship with tribes
and uphold its trust and treaty obligations.
The bill does this through the Department's development of
appropriate caseload standards, staffing requirements and the
establishment of a base support funding formula developed in
consultation with tribes. This consultation will help guide the
Bureau to help account for specific factors such as locations
of high rates of reported child abuse and will ensure tribal
communities' needs are appropriately met.
If enacted and funded as originally intended, the $92
million authorization included in this legislation will finally
give tribes preventive social services long overdue,
programmatic funding, and support these efforts. Because all
communities, regardless of where you come from, should have
access to basic safety resources, especially for children.
In sum, the Department supports the Native American Child
Prevention Act, and applauds the bill's inclusion of tribal
consultation requirements and advancement of culturally
appropriate services and self-determination provisions.
Vice Chair Murkowski, and members of the Committee, I thank
you again for this opportunity to provide testimony today. I
look forward to answering any questions that you may have.
Thank you.
[The prepared statement of Ms. Todacheene follows:]
Prepared Statement of Heidi Todacheene, Senior Advisor, Office of the
Assistant Secretary--Indian Affairs, Department of the Interior
Good afternoon Chairman Schatz, Vice Chairman Murkowski, and
Members of the Committee. My name is Heidi Todacheene, and I am a
member of the Navajo Nation in New Mexico and Senior Advisor in Office
of the Assistant Secretary for Indian Affairs at the U.S. Department of
the Interior.
Thank you for the opportunity to provide testimony on behalf of
Indian Affairs on H.R. 1688, the Native American Child Protection Act.
The Department of Interior supports H.R. 1688, the bipartisan
Native American Child Protection Act, which amends the Indian Child
Protection and Family Violence Prevention Act (Act) (25 U.S.C. 3201
et. seq.). The proposed legislation would amend the Act, a statute
that, among other provisions, required the Bureau of Indian Affairs
(the Bureau) of the Department of the Interior, to establish Indian
Child Resource and Family Services Centers within each area office of
the Bureau in collaboration with the Department of Health and Human
Services and to administer the Indian Child Protection and Family
Violence Prevention Program. Congress has not appropriated funding to
the Bureau to carry out the Centers or the Program since the Act's
enactment in 1990.
Today, there continues to be a critical need for violence
prevention and treatment services for tribal communities, and the
Department supports this bill to reauthorize and amend the Act to work
towards the fundamental need for preventative services in Indian
Country to make critical improvements such as to the Indian Child Abuse
Treatment Grant Program, establishment of a new National Indian
Resource Service Center through the Department, and reauthorization of
the Indian Child Protection and Family Violence Prevention Program to
prevent tribal child abuse and neglect.
Significance of the Proposed Legislation
Congress has acknowledged that there is ``no resource that is more
vital to the continued existence and integrity of Indian tribes than
their children.'' \1\ This proposed legislation will empower Tribes to
provide programs and services necessary to safeguard their children and
strengthen their families. The proposed legislation embodies the well-
being of American Indian/Alaska Native (AI/AN) children and families by
preserving family relationships and increasing the capacity of tribes
to provide for their children and families' needs.
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\1\ 25 U.S.C. 1901(3).
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A. Encouraging Use of Culturally Appropriate Treatment and Programs
H.R. 1688 inserts criteria for grant awards under the Act to
encourage use of culturally appropriate treatment services and programs
that respond to the unique cultural values, customs, and traditions of
applicant Indian Tribes. Indian Affairs supports this criterion for
grant awards, and notes alignment with Indian Affairs' efforts to
promote multi-disciplinary work in tribal communities to prevent family
violence and substance abuse.
B. Requires Establishment of a National Indian Child Resource and
Family Services Center
H.R. 1688 amends the Act (section 410, codified at 25 U.S.C.
3209) to require the Secretary of the Interior to establish a National
Indian Child Resource and Family Services Center (the Center) within
one year of enactment. It requires the Bureau to submit a report to
Congress within two years after enactment of the bill. Per H.R. 1688,
the Center's scope of responsibilities would include development of
training and technical assistance materials on the prevention,
identification, investigation, and treatment of incidents of family
violence, child abuse and child neglect for distribution to Indian
tribes, to Tribal organizations and urban Indian organizations.
This legislation requires the Center to develop model
intergovernmental agreements between Tribes and States, and other
materials that provide examples of how Federal, State, and Tribal
governments can develop effective relationships and provide for maximum
cooperation in the furtherance of prevention, investigation, treatment,
and prosecution of incidents of family violence and child abuse and
child neglect involving Indian children and families.
The bill also includes the establishment of a 12-member Advisory
Board appointed by the Secretary of the Interior. These members will
consist of representatives from Indian tribes, Tribal organizations,
and urban Indian organizations with expertise in child abuse and child
neglect.
H.R. 1688 allows the Center to operate subject to the provisions of
the Indian Self-Determination and Education Assistance Act and
authorizes Congress to appropriate $3.0 million per year for fiscal
years 2022 through 2027 for the operation of the Center and associated
activities.
Interior supports the establishment of the National Indian Child
Resource and Family Services Center. The Center will enhance the
activities the Bureau is currently implementing through efforts to
promote multi-disciplinary work in tribal communities to prevent family
violence and substance abuse.
C. Includes Tribal Consultation and Keeps Interior Accountable
The bill requires the Secretary of the Interior to develop caseload
standards and staffing requirements in consultation with Indian tribes
within one year after the bill's enactment. It also requires the Bureau
to submit to Congress a report on the award of grants under Section 411
of the Act within two years of enactment of H.R. 1688. The report shall
include a description of treatment and services for which grantees have
used funds awarded under Section 411 of the Act.
D. Expands the Scope of the Act
H.R. 1688 expands the scope for which funds provided under the
Indian Child Protection and Family Violence Prevention Program (Section
411, codified at 25 U.S.C. 3210), can be used to include three new
provisions: (1) the development of agreements between Tribes, States,
or private agencies on the coordination of child abuse and neglect
prevention, investigation, and treatment services; (2) child protective
services operational costs including transportation, risk and
protective factors, assessments, family engagement and kinship
navigator services, and relative searches, criminal background checks
for prospective placements, and home studies; and (3) the development
of a Tribal child protection or multidisciplinary team to assist in the
prevention and investigation of child abuse and neglect.
Indian Affairs applauds the bill's inclusion of culturally
appropriate actions in Section 411 of the Act. Interior is focused on
multi-disciplinary work in tribal communities to prevent family
violence and substance abuse.
H.R. 1688 authorizes Congress to appropriate $60.0 million per year
for fiscal years 2022 through 2027 for Interior to implement Section
411, the Indian Child Protection and Family Violence Prevention
Program, of the Act.
Conclusion
Chairman Schatz, Vice Chairman Murkowski, Members of the Committee,
thank you for the opportunity to provide testimony today. I look
forward to answering any questions that you may have.
The Chairman. [Presiding] Thank you very much.
Next, we have the Honorable Jonathan Nez, President of the
Navajo Nation, Window Rock, Arizona.
STATEMENT OF HON. JONATHAN NEZ, PRESIDENT, NAVAJO NATION
Mr. Nez. Ya'at'eeh, hello, and greetings from the Navajo
Nation, Chairman Schatz, Vice Chair Lisa Murkowski, and members
of the Committee. Thank you for the opportunity to speak to you
about water infrastructure issues on the Navajo Nation and the
need for funding opportunities through S. 1895, The Indian
Health Service Sanitation Facilities Construction Enhancement
Act.
My name is Jonathan Nez, and I am the President of the
Navajo Nation.
The Navajo Nation has nearly 400,000 enrolled members, the
majority of whom live within our homelands. The Navajo Nation
has over 27,000 square miles of land that extends into the
States of Arizona, New Mexico, and Utah.
Sadly, an alarming number of homes on the Navajo Nation
have insufficient and decrepit water delivery and sewage
disposal systems. Water is a fundamental need. It provides
life, growth, and protection.
Some families were able to wash their hands as recommended
by the CDC during the ongoing pandemic. One major contributing
factor in the spread of COVID-19 on the Navajo Nation was
limited access to water. Therefore, we urge Congress to ensure
the Federal Government upholds its trust and treaty obligations
by protecting and ensuring the deliver of water and sanitation
in Indian Country.
For our Navajo people, the need is tremendous. As of
December, 2020, IHS estimates the need for existing homes at
$535 million. The Navajo Nation estimates the total need for
current domestic and municipal water and sewages projects at
$2.4 billion, more than $4 billion when you consider funding
for critical water infrastructure, such as the Navajo-Gallup
Water Supply Project, the Navajo Indian Irrigation Project, and
the Navajo-Utah Water Rights Settlement Act.
The Navajo Nation has between 9,000 to 16,000 homes without
any running water or sewage disposal. Six thousand of those
homes have no IHS funding because the agency considers those
projects infeasible. The Navajo Nation IHS area has more level
4 and level 5 households than any of the other areas or regions
in the Country.
Roughly 40 percent of Navajo households are multi-
generational, with extended families all living under one roof,
increasing the need for safe, reliable water delivery and
sanitary sewage disposal. Multi-generational households was
another contributing factor during the COVID-19 pandemic, that
impeded safe practices that reduce the risk of transmission.
The IHS office of the Navajo area is chronically
understaffed with 80 positions the Navajo region is currently
struggling to fill.
To put it simply, the Navajo Nation supports S. 1895,
investing in water infrastructure in tribal communities is just
the beginning. IHS also needs to make internal changes to fully
and adequately meet the needs of Indian Country. For example,
the areas with the most need, such as the sparsely populated
western portion of the Navajo Nation may never be addressed
under current rules, because the IHS deems any project that
exceeds a threshold of $107,500 as economically infeasible and
ineligible for funding. In other words, the Navajo area IHS
might only spend $166 million on the feasible project, instead
of $535 million to cover feasible and infeasible projects which
represent our total estimated need.
Additional changes need to occur within the Bureau of
Indian Affairs to expedite rights-of-way so infrastructure
projects are not delayed. The IHS SDS list does factor future
growth of our communities.
We are grateful to the members of this Committee for
considering making meaningful investment in Indian Country.
Although significant administrative hurdles remain, the bill
currently under consideration, S. 1895, would provide the
resources needed to make significant progress toward addressing
the current water and sanitation needs of the Navajo Nation and
across Indian Country. These types of investments are long
overdue, and this legislation is perhaps the most important
legislation, along with other infrastructure measures, that
will leave a permanent and lasting imprint in our communities
and save lives.
Today I represent our Navajo elders, children, and families
who struggle without safe and reliable water. By passing S.
1895, Congress is honoring Indian treaties, including our
Navajo treaty of 1868, and upholding the Federal trust
responsibility.
Thank you for the opportunity to testify, and I am happy to
answer any questions.
[The prepared statement of Mr. Nez follows:]
Prepared Statement of Hon. Jonathan Nez, President, Navajo Nation
Ya'at'eeh (Hello) Chairman Schatz, Vice-Chairman Murkowski, and
Members of the Committee. Thank you for the opportunity to speak to you
about water infrastructure issues on the Navajo Nation and the need for
funding opportunities through the Indian Health Service Sanitation
facilities Construction Enhancement Act, S.1895. My name is Jonathan
Nez and I am the President of the Navajo Nation.
The Navajo Nation, known as Dine, is the largest American Indian
tribe in the United States, with 399,494 enrolled tribal members as of
February 1, 2021. Over half of the Navajo people reside on a land mass
of over 27,000 square miles that extends into the states of Arizona,
New Mexico, and Utah. If the Navajo Nation was a state, it would rank
41st in size, behind South Carolina and just before West Virginia.
The Navajo Nation is committed to improving the standard of living
on the reservation. Access to land, water, and electricity for
families, government programs, public institutions, and businesses are
critical to a better quality of life--equitable to that of most
American communities. Recognizing that water is integral to human
health and economic development, the Navajo Nation has placed water
development as one of its highest priorities.
I. The Navajo Nation's Water System and IHS' SDS Listing
The development of potable water delivery and sewage disposal
systems on the Navajo Nation are among the most pressing issues we need
to address to help our people. This fact is shown in particular by data
collected by the Indian Health Service (IHS) as part of its obligations
under the Indian Health Care Improvement Act:
The Indian Health Care Improvement Act (IHCIA) requires the
Indian Health Service (IHS) to identify the universe of
sanitation facilities needs for existing American Indian and
Alaska Native (AI/AN) homes by documenting deficiencies and
proposing projects to address their needs. These projects
prevent communicable diseases by providing new and existing
homes with services such as water wells, onsite wastewater
disposal systems, or connections to community water supplies
and wastewater disposal systems. These projects can also
include provision of new or upgraded water supply or waste
disposal systems. \1\
\1\ Indian Health Service. (February 2020). Justification of
Estimates for Appropriations Committees. P. CJ-201. Retrieved from:
https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/
display_objects/documents/FY_2021_Final_CJ-IHS.pdf
IHS fulfills this responsibility by maintaining a Sanitation
Deficiency System (SDS) list. As of December 2020, the SDS list
identified water and sanitation projects just on the Navajo Nation that
were deemed necessary (including both feasible and infeasible projects)
at a cost of $535 million, \2\ with a total cost for all of Indian
Country in excess of $2.6 billion for all projects. \3\
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\2\ Roselyn Tso. (Dec. 23, 2020). RE: Navajo Area IHS sanitation
deficiency system (SDS) list--FY 2021. Navajo Nation Department of
Health & Human Services. See Appendix.
\3\ Indian Health Service. (2018). Annual report to the Congress of
the United States on sanitation deficiency levels for Indian homes and
communities. Indian Health Service. P. 9. Retrieved from: https://
www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/
documents/Report_To_Congress_FY1 8_SanitationFacilitiesDeficiencies.pdf
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As the Committee is probably aware, the IHS continually updates the
SDS list to include new deficiencies in water and sewage systems, but
unfortunately this does not mean they are making much progress in
fixing the problems identified on the list. Some projects have been on
the IHS SDS list for more than a decade. Households where projects are
delayed are forced to contend with band-aid solutions such as cisterns
which still require families to haul water, sometimes from unregulated
sources that may be unsafe. The Navajo Nation has at least 9,000 homes
without any running water or sewage disposal, with some estimates as
high as 16,000. Of those homes, 6,000 are included in projects on the
SDS list, but are ineligible for IHS funding as they have been deemed
economically infeasible. \4\
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\4\ From a conversation with Jason John, Director of the Navajo
Nation Department of Water Resources, on July 8, 2021.
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How Projects are Added to and Classified on the SDS Listing
To comprehend how this is possible, it is important to understand
how this list is created. Projects are added to the SDS list if they
are for existing facilities, and a tribe, the Bureau of Indian Affairs,
or the IHS demonstrates that the water, sewage, and solid waste systems
are insufficient based on federal standards of insufficiency. \5\ The
projects are given classifications on a scale of 1 to 5 based on their
level of adequacy in terms of water delivery and solid waste/sewage
disposal. Level 1 is where the water delivery system has reliable
access to clean running water that meets federal standards for water
quality and sanitation--the tribal community has reliable disposal of
sewage and solid waste. It is the stated goal of the IHS Navajo Area
Office that all tribal water and sanitation systems on the Navajo
Nation meet level 1 criteria. \6\ Level 2 projects require capital
improvements to meet the standards of level 1. Level 3 projects include
water supply and sanitation systems that are partially or somehow
inadequate. Level 4 projects have either no reliable access to clean
running water or no safe, healthy sewage disposal system, and level 5
projects have neither. \7\
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\5\ Indian Health Service. (September 2019). SDS: A guide for
reporting sanitation deficiencies for American Indian and Alaska Native
homes and communities. Indian Health Service. P. 5-12. Retrieved from:
https://www.ihs.gov/sites/dsfc/themes/responsive2017/display_objects/
documents/Final_SDS_Guide_v2.pdf
\6\ From a conversation with David McConnell, Chief Project
Engineer for the Navajo Area Indian Health Service, on June 8, 2021.
\7\ Indian Health Service. (September 2019). SDS: A guide for
reporting sanitation deficiencies for American Indian and Alaska Native
homes and communities. Indian Health Service. P. 18. Retrieved from:
https://www.ihs.gov/sites/dsfc/themes/responsive2017/display_objects/
documents/Final_SDS_Guide_v2.pdf
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SDS Project Prioritization
SDS projects are then prioritized based on eight (8) factors. The
first is health impacts, which evaluates the link between disease
outbreaks in tribal communities and the deficiencies in their water
supply, solid waste, and sewage systems. The second is the project
deficiency level, where they are assigned one of the aforementioned
classifications of levels 1-5. The third evaluates whether a house,
facility, or community system has been funded in the past by IHS to
address its deficiencies. If it has not been funded in the past, it
gets a higher score. The fourth is the capital cost, where the most
expensive projects are often given negative scores to move them to a
lower position on the priority list. \8\ The fifth is local tribal
priorities, where the tribe can provide input to adjust the position of
the different projects on the SDS list. The sixth is operation and
maintenance capability, where the results on annual reports on each
project are factored in. The seventh is contributions, an optional
assessment criterion where the availability of outside funding is
assessed, if applicable. The eighth is other factors, another optional
criterion, which include other legal or environmental issues that stand
in the way of a project such as rights of way, or geologic impediments
such as the clay soil in the vicinity of Chinle, Arizona. \9\ The point
values from all of these criteria are combined to produce an assessment
score, which is weighed against the others to find the position of each
project on the SDS list from highest to lowest priority. \10\
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\8\ From a conversation with David McConnell, Chief Project
Engineer for the Navajo Area Indian Health Service, on June 8, 2021.
\9\ Indian Health Service. (September 2019). SDS: A guide for
reporting sanitation deficiencies for American Indian and Alaska Native
homes and communities. Indian Health Service. P. 27-32. Retrieved from:
https://www.ihs.gov/sites/dsfc/themes/responsive2017/display_objects/
documents/Final_SDS_Guide_v2.pdf
\10\ Indian Health Service. (September 2019). SDS: A guide for
reporting sanitation deficiencies for American Indian and Alaska Native
homes and communities. Indian Health Service. P. 32-33. Retrieved from:
https://www.ihs.gov/sites/dsfc/themes/responsive2017/display_objects/
documents/Final_SDS_Guide_v2.pdf
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SDS Listing for the Navajo Area
The Navajo Nation IHS Area has more level 4 and 5 projects than any
of the other IHS Areas throughout the country. \11\ About 40 percent of
households on the Navajo Nation are multigenerational, with extended
families all living under one roof, increasing the need for safe,
reliable water delivery and sanitary sewage disposal. \12\ Finally,
many of the homes that have been addressed in the past have septic
systems that are failing because the households cannot afford to have
them cleaned and maintained, and/or the homeowners were not instructed
how to take care of them. \13\
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\11\ From a conversation with David McConnell, Chief Project
Engineer for the Navajo Area Indian Health Service, on June 8, 2021.
\12\ From a conversation with Jason John, Director of the Navajo
Nation Department of Water Resources, on July 8, 2021.
\13\ From a conservation with Ronnie Ben, Navajo Nation
Environmental Agency Environmental Department Manager, on July 8, 2021.
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II. Concerns and Issues We See
Inadequate Funding and Staffing
For fiscal years 2017-2021, the Sanitation Facilities Construction
Program that administers the SDS list received the following amounts:
FY 2017--$101,772,000
FY 2018--$192,033,000
FY 2019--$193,577,000
FY 2020--$192,931,000
An annual appropriation of nearly $200 million is woefully
insufficient. As noted above, the total estimated cost of all reported
projects is approximately $535 million for the Navajo Region and $2.6
billion for Indian Country for fiscals year 2019 and 2018,
respectively. If we continue this funding trajectory, which only
provides approximately 7 percent of the funding needed, the needs will
never be met, especially as new projects are added to the list every
year. Congress is turning a blind eye to the overwhelming need of
delivering safe water to American Indians.
In addition to funding, we know the IHS offices for the Navajo Area
are chronically understaffed, with 30 positions that the agency is
currently struggling to fill. They need to be able to attract and
maintain engineers and engineering assistants to make these projects go
smoothly and be addressed as soon as possible. \14\
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\14\ From a conservation with Roselyn Tso, Area Director for the
Navajo Area Indian Health Service, on July 8, 2021.
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Prohibitive Internal Policies and Procedures with the SDS Listing
The IHS has internal policies and procedures governing how they
complete assessments which further frustrates IHS' ability to address
our needs, even if Congress fully funds projects listed on the SDS
listing. For example:
The criteria IHS employs to determine whether a project is
``feasible'' is arbitrary and subjective. If a project is too
costly, it is ``not feasible.'' If the project has an issue
that cannot be easily addressed, it is ``not feasible.'' If a
project is deemed to be ``not feasible'' it is ineligible for
IHS funding, even though it remains on the SDS list.
The Sanitation Deficiency list does not take the age of a
reported project into account, meaning some older projects
remain untouched on the list, while newer projects get funded.
Navajo areas with the most need, such as the most remote
parts of the Navajo reservation, are sparsely populated, and
may never be addressed under current rules because the IHS
deems projects that exceed the cost of $107,500 per household
in Arizona and $101,500 in New Mexico and Utah \15\ as
economically infeasible and ineligible for funding. Western
areas, such as the former Bennett Freeze Area, \16\ are among
the communities that have long been neglected and are in dire
need of water.
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\15\ Indian Health Service. (September 2019). SDS: A guide for
reporting sanitation deficiencies for American Indian and Alaska Native
homes and communities. Indian Health Service. P. 47. Retrieved from:
https://www.ihs.gov/sites/dsfc/themes/responsive2017/display_objects/
documents/Final_SDS_Guide_v2.pdf
\16\ The former Bennett Freeze Area consists of nine (9) Navajo
Chapters or Navajo local governments, located in Coconino County,
Arizona on the Navajo Nation, 1) Bodaway/Gap; 2) Coppermine; 3)
Kaibeto; 4) Coalmine Canyon; 5) Leupp; 6) Tolani Lake; 7) Tuba City; 8)
Tonalea; and 9) Cameron. More than 12,000 Navajo people living in the
area were subjected to a 41-year freeze on development until Congress
lifted that freeze in December 2006.
The Navajo Nation is unable to receive its full
proportionate share of funding because too many projects are
deemed not feasible. Currently, the Navajo Nation is only
eligible to receive a third of the IHS funding of what is
actually needed to bring all households up to level 1 (reliable
access to running water, sanitary disposal of sewage,
compliance with federal water quality and sanitation
---------------------------------------------------------------------------
standards).
IHS is permitted to add negative points to any project on
the SDS listing with potential issues. For example, a project
with a right of way issue may be assigned negative points,
pushing the project further down the line from being funded.
Changes need to be made internally at BIA to resolve these
issues to limit unnecessary delays.
Growth is not a Factor in the SDS Listing
The IHS SDS list documents the backlog of water and sanitation
deficiencies, but it does not account for future economic growth, nor
does it consider the fact that the Navajo Nation has a chronic housing
shortage for our current population notwithstanding additional people
and families in the future. As a matter of fact, the IHS is not allowed
to consider future needs for funding. \17\ The Navajo Nation is
planning for water needs 40 years into the future. \18\ This puts our
assessed water development needs at $4 billion total, well over the
$535 million that would fix current deficiencies. Of this, $2.4 billion
would go to the most imperative domestic and municipal projects alone.
\19\
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\17\ Indian Health Service. (September 2019). SDS: A guide for
reporting sanitation deficiencies for American Indian and Alaska Native
homes and communities. Indian Health Service. P. 6 & 15. Retrieved
from: https://www.ihs.gov/sites/dsfc/themes/responsive2017/
display_objects/documents/Final_SDS_Guide_v2.pdf
\18\ From a conversation with Jason John, Director of the Navajo
Nation Department of Water Resources, on July 8, 2021.
\19\ Jason John. (March 24, 2021). Build back better: Water
infrastructure needs for Native communities. Navajo Nation Department
of Water Resources. P. 2. Retrieved from: https://
www.indian.senate.gov/sites/default/files/2021-03-
22%2024March2021_Testimony_draft%20-%20final.pdf
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Proposed Changes
We are concerned that even if S. 1895 is passed with its current
language, IHS' internal rule that bars economically ``infeasible''
projects from being funded would limit the intent of the bill. For the
Navajo Nation, which has the second longest SDS listing in all of
Indian Country, second only to Alaska, \20\ there is nothing more
frustrating than having funds with no ability to spend them. Therefore,
we urge Congress to consider changes to the proposed legislation that
address these concerns or demand that IHS remove administrative
barriers in order to fully realize and address the true magnitude of
the inadequacies of water infrastructure in Indian Country and the
human impact that this widespread problem has.
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\20\ Indian Health Service. (2018). Annual report to the Congress
of the United States on sanitation deficiency levels for Indian homes
and communities. Indian Health Service. P. 1-31. Retrieved from:
https://www.ihs.gov/sites/newsroom/themes/responsive2017/
display_objects/documents/Report_To_Congress_FY1
8_SanitationFacilitiesDeficiencies.pdf
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In addition, IHS should also be permitted to spend a portion of
these funds on educating household members on how to maintain their
water and sewer systems and assist them with upkeep. Maintenance of
critical infrastructure is just as important as constructing it.
III. Conclusion
We applaud Congress and the current Administration for their
commitment to honoring the federal trust obligation by making a
meaningful investment in Indian Country. Although significant
administrative hurdles remain, the bill currently under consideration,
S. 1895, would provide the resources needed to make significant
progress toward addressing the current water and sanitation needs of
the Navajo Nation and Indian Country in general. The funding it will
provide is long overdue, and perhaps most importantly, will literally
save lives by reducing the spread of disease through improved
sanitation in Indian Country.
As we make progress towards fixing many of the problems that
afflict our people, the Navajo Nation is reminded of the valuable
partnership we have with the Indian Health Service and the members of
this Committee. We look forward to working with the 117th Congress to
continue the work on legislation such as S.1895 that can protect the
public health and environment of our tribal communities.
Ahehee' and thank you.
The Chairman. Thank you very much.
Next, we have the Honorable Gil Vigil, President, National
Indian Child Welfare Association, in Portland, Oregon.
STATEMENT OF HON. GIL VIGIL, PRESIDENT, NATIONAL INDIAN CHILD
WELFARE ASSOCIATION
Mr. Vigil. Thank you, Chairman. Good morning, Chairman
Schatz, and Vice Chair Murkowski, and members of the Committee.
It is an honor to be providing testimony on behalf of the
National Indian Child Welfare Association on H.R. 1688, the
Native American Child Protection Act.
My name is Gil Vigil, and I am President of the National
Indian Child Welfare Association and Executive Director for the
Eight Northern Indian Pueblos Council here in New Mexico. I am
a former governor of the Pueblo Tesuque. By virtue of that, I
am a lifetime council member of our council.
Today my testimony is provided on behalf of the National
Indian Child Welfare Association. NICWA is located in Portland,
Oregon, and we are the only national Indian organization solely
dedicated to child welfare issues in the United States. We
accomplish our missions through technical assistance to tribal
communities, training to child welfare professionals, advocacy
to improve services to Native children and families, and
research to fill gaps in data regarding the well-being of
Native families.
My written testimony provides background, statistics and
other context related to child maltreatment in Indian Country.
But I want to use my oral testimony to show why we think the
Native American Child Protection Act is worth your support.
NICWA has been involved in supporting the proper
implementation of the original statute that H.R. 1688 is
reauthorizing, the Indian Child Protection and Family Violence
Prevention Act, which was enacted in 1990. We watched as then
Senator McCain and Senator Inouye worked together to craft this
legislation and move it through the Congress.
Like most legislation, it was not perfect. But Senator
McCain knew how important it was, because of the large gap in
funding of child abuse and neglect prevention and victim
treatment services that existed for tribes. He also saw the
perils of what happens when a community doesn't have the
capacity to effectively respond to child maltreatment. Even
today, over 30 years later, tribal nations are still trying to
secure dedicated funding for these purposes where they don't
have to compete with State or other populations.
As an example, the Federal Government's largest source of
dedicated child abuse prevention funding, the Child Abuse
Prevention and Treatment Act, provides only two tribal grants
each year to tribal nations. We greatly appreciate Senator
Murkowski's effort to address the concerns with CAPTA, but even
if that effort is successful, not all tribal nations can be
funded. The Native American Child Protection Act provides an
opportunity to ensure every tribe will have funding to provide
child abuse and neglect prevention and treatment services.
Why is this legislation so important for Indian Country?
Notwithstanding the risk factors for child maltreatment that
exist in our communities, we also have incredible potential to
develop programs that can address the risk of child abuse and
neglect before it gets to the stage where a child has to be
removed from their home. Sometimes, it is necessary to remove a
child from their home to protect them. But even with good
intentions, children and families experience trauma from these
actions.
When we can intervene early with more prevention oriented,
culturally based services, we can reduce foster care placements
and strengthen families to help them avoid the foster care
system altogether.
Where tribes have resources and have redesigned their child
welfare system to incorporate cultural practices, we can see
evidence of how successful these programs are. For example, the
Confederated Tribes of Umatilla several years ago, like many
tribes in States, were seeing their foster care rates rising
and struggling to find enough foster homes for their children
that were being removed. They came together as a community and
put in motion a redesign of their child welfare program that
emphasized prevention service and trauma informed service to
heal families who themselves had suffered significant trauma in
their lives. The result was that they were able to have 85
children in out-of-home placements to less than 20 in a couple
of years after the redesign was complete.
Their successes continue, and it is happening in other
tribal communities, too. But we can't replicate this on a large
scale without additional funding authority.
Over the last 35 years, NICWA has followed and been
involved in numerous child welfare policy debates. Most of them
were addressing services for children who already had been
placed in foster care. The Native American Child Protection Act
provides an opportunity to address the struggles families have
before they reached a crisis state. We are very grateful for
that.
I hope you will join us in supporting the Native American
Child Protection Act. Thank you for this opportunity, and I am
ready to respond to any questions. Thank you.
[The prepared statement of Mr. Vigil follows:]
Prepared Statement of Hon. Gil Vigil, President, National Indian Child
Welfare Association
I would like to start by thanking the Chairman and Vice-Chairman of
the committee for holding this hearing. I am Gil Vigil, and I am a
member of the Pueblo of Tesuque in New Mexico and Executive Director of
the Eight Northern Indian Pueblos Council also located in New Mexico.
Today I am providing testimony on behalf of the National Indian Child
Welfare Association (NICWA) located in Portland, Oregon where I serve
as the President of the Board of Directors. NICWA is in full support of
H.R. 1688 and has long advocated for the reauthorization of this
important law so tribal nations and urban Indian programs may have the
opportunity to effectively address child maltreatment and domestic
violence in American Indian and Alaska Native (AI/AN) communities.
Our understanding of these issues comes from more than 40 years of
experience working with tribal governments, their child welfare
programs, and the communities themselves. We have developed this
knowledge as nationally recognized providers of training and technical
assistance, leaders in federal and state policy development, and
researchers that examine key issues in Indian child welfare. We do this
work in close partnership with both Indian and non-Indian
organizations, such as the Child Welfare League of America and the
National Congress of American Indians (NCAI). These partnerships allow
us to participate in work that supports increased access to healing
services for affected AI/AN children and families and improve tribal
and urban Indian organization capacity to provide culturally based
prevention and treatment services. From 1998 to2018, we provided
technical assistance to the System of Care Children's Mental Health
tribal grantees who were on the front lines designing and operating
culturally based mental health services for AI/AN children with serious
mental health disorders. We understand the impact of trauma on children
and their families and the toll it takes on communities, especially
when the trauma goes unaddressed or untreated. Our experience has
taught us the importance of supporting tribal self-determination and
the important roles tribal governments play in developing sustainable
and culturally based solutions to child abuse and neglect and domestic
violence.
Our testimony will focus on:
The historical context of, and past government responses to,
child maltreatment in tribal communities
The current research and data available on the risk factors
for, and rates of, AI/AN child maltreatment
The current challenges to tribal program funding and data
collection related to AI/AN child maltreatment
Tribal-state relationships and their impact on efforts to
address AI/AN child maltreatment
Solutions that are working in tribal and urban AI/AN
communities
We also want to note that child maltreatment comes in a variety of
forms, including sexual abuse, physical abuse, and neglect, among
others. Among these different forms of child maltreatment, neglect is
by far the most frequent occurring within AI/AN families- 89 percent of
all AI/AN child maltreatment victims were the result of child neglect
(National Child Abuse and Neglect Data Center Technical Team [NCANDS],
2014). Child neglect is often a form of child maltreatment that
responds best to prevention and treatment efforts, which fits well with
the purposes of the grant programs contained within H.R. 1688.
UNDERSTANDING CHILD MALTREATMENT IN INDIAN COUNTRY
``The diversity of American Indian and Alaska Native tribes
and villages cannot be overemphasized when thinking about child
maltreatment in Indian Country. Tribes, villages, reservations,
and urban Indian communities have vastly different resources,
social and economic conditions, and cultural and traditional
practices. These differing conditions affect child abuse and
neglect and mean that no statements about child maltreatment
can apply to all tribes, villages, and urban communities across
the country'' (Crofoot, 2005, p. 123).
The Historic Context
To understand the context of child maltreatment for AI/AN children,
it is essential to understand that AI/AN communities are at high risk
for child maltreatment in large part because of disparate treatment of
AI/AN families and communities by federal and state governments, such
as funding and service limitations. It is equally important to
understand the lingering effects of historical governmental policies
and practices--including the placement of AI/AN children in boarding
schools, the relocation of AI/AN peoples to major cities, and the large
numbers of AI/AN children removed from their families, often
unnecessarily, by public and private child welfare agencies.
Prior to contact with European immigrants, tribal child-rearing
practices and beliefs allowed a natural system of child protection to
flourish. Traditional Indian spiritual beliefs reinforced that all
things had a spiritual nature that demanded respect, including children
(Cross, Earle, & Simmons, 2000). Not only were children respected, but
they were also taught to respect others. Extraordinary patience and
tolerance marked the methods that were used to teach Indian children
self-discipline (Cross et al., 2000). Behavior management or obedience
was obtained through the fear and respect of something greater than the
punishment of a parent (Cross et al., 2000).
At the heart of this natural system were beliefs, traditions, and
customs involving extended family with clearly delineated roles and
responsibilities. Child-rearing responsibilities were often divided
between extended family and community members (Cross et al., 2000). In
this way, the protection of children in the tribe was the
responsibility of all people in the community. Child abuse and neglect
were rarely a problem in traditional tribal settings because of these
traditional beliefs and natural safety nets (Cross et al., 2000).
As European migration to the United States increased, traditional
tribal practices in child-rearing were often lost as federal programs
sought to systemically assimilate AI/AN people. Efforts to ``civilize''
the Native population were almost always focused on their children. It
began as early as 1609, when the Virginia Company, in a written
document, authorized the kidnapping of AI/AN children for the purpose
of civilizing local AI/AN populations through the use of Christianity
(Cross et al., 2000). The ``Civilization Fund Act'' passed by Congress
in 1819 authorized grants to private agencies, primarily churches, to
establish programs in tribal communities designed to ``civilize the
Indian'' (Cross et al., 2000).
From the 1860s through the 1970s, the federal government and
private agencies established large boarding schools, far from tribal
communities, where AI/AN children were involuntarily placed (Crofoot,
2005; Cross et al., 2000). Indian agents had the authority to withhold
food and clothing from parents who resisted sending their children away
(Crofoot, 2005; Cross et al., 2000). The boarding schools operated
under harsh conditions; children were not able to use their Native
languages or traditional customs, were required to wear uniforms and
cut their hair, and were subjected to military discipline and standards
(Crofoot, 2005). The rate of deaths among AI/AN children that were sent
to boarding schools was extremely high with many dying from infectious
diseases, overworking, harsh discipline, child abuse, and extreme
mental or emotional trauma.
In the 1960s and 1970s, the child welfare system became another
avenue that state and federal governments used to force the
assimilation of AI/AN children. It was during this era that the Child
Welfare League of America and the Children's Bureau, a federal
government agency, sponsored the Indian Adoption Project, which
involuntarily removed hundreds of AI/AN children from their homes and
communities out West and placed them in non-Indian homes on the East
Coast (Cross et al., 2000). At the same time, AI/AN children were
unofficially being removed from their homes and placed in non-Native
homes in large numbers. The Association on American Indian Affairs
conducted a study in the 1970s that found between 25 percent and 35
percent of all Indian children had been separated from their families
(Jones, Tilden, & Gaines-Stoner, 2008). This study also found that 90
percent of the removed Indian children were placed in non-Indian homes
(Jones et al., 2008).
The outcome of these assimilation efforts is heightened risk
factors for child maltreatment in AI/AN communities. These policies
left generations of parents and grandparents subjected to prolonged
institutionalization without positive models of family life and family
discipline (Crofoot, 2005). These individuals, many of them current
parents and grandparents of AI/AN children, may subject their children
or their relatives' children to the harsh discipline and child
maltreatment they endured in boarding school. Further, boarding schools
and relocation efforts to large cities have resulted in the destruction
of kinship networks and traditional understandings of child-rearing and
protection, damaging the natural safety net that was in place
traditionally (Crofoot, 2005). It was not until 1978, with the passage
of the Indian Child Welfare Act (ICWA), that the federal government
acknowledged the inherent sovereign right of tribal governments and the
critical role that they play in protecting their children and
maintaining their families. After two centuries of the United States
usurping tribal nation's rights to care for their families and
significant erosion of the natural helping system in tribal
communities, the federal government enacted ICWA to end the earlier
policies that brought so much trauma to AI/AN children and families.
The effects of these programs are longstanding. Challenges in AI/AN
communities today, including poverty, mental and physical health
problems, poor housing, and violence, are directly related to federal
reservation and relocation policies. Socially and economically isolated
reservations and urban Indian communities are fraught with
disadvantage, including a heightened risk for child maltreatment
(Crofoot, 2005).
The pattern of mistreatment of AI/AN people and communities over
the course of centuries described above, has had an additional effect
on AI/AN families that creates a heightened risk for child
maltreatment: historical trauma. The concept of historical trauma in
AI/AN people and communities originates from studies that examined the
lingering effects that the Holocaust had on the children and
grandchildren of families affected (Brave Heart & DeBruyn, 1998).
Researchers and experts believe that the shared experience by AI/AN
people of historic traumatic events such as displacement, forced
assimilation, suppression of language and culture, and boarding schools
creates a legacy of unresolved grief that, when left untreated, is
passed down through generations (Cross, 2006; Brave Heart & DeBruyn,
1998), and experienced in ways that reflect reactions to trauma, such
as increased mental health disorders, substance abuse, stress, and
social isolation--all risk factors for child maltreatment.
Risk Factors for Child Maltreatment
There is little information on the risk factors for child
maltreatment in AI/AN families specifically (Bigfoot, 2005). This is
problematic because national policy and child welfare practice focus on
the prevention of child maltreatment, and successful prevention
programming requires an understanding of culturally specific risk
factors. (Centers for Disease Control, 2012; Children's Bureau, 2011;
Administration for Children and Families, 2003)
Without an accurate, nuanced understanding of the complex
interaction of risk factors for child maltreatment in AI/AN families,
prevention, identification, and intervention may be ineffective. For
instance, although mainstream research points to ``disorganized''
families as a potential risk factor for abuse and neglect, AI/AN
families often thrive and are most healthy when they take the form of
codependent kinship networks. These codependent networks may be seen by
a mainstream case manager as ``disorganized'' and thus a risk factor--
when it is a protective factor and its disruption could only further
hurt the family in question.
Although not ideal, mainstream child maltreatment risk factors can
be used to provide a general understanding of the likelihood of risk of
child maltreatment in AI/AN communities. The following national
statistics show that AI/AN families appear to be particularly
vulnerable to child maltreatment.
Parental Risk Factors
AI/AN children are more likely to live in households that
are below the poverty line. Thirty-four percent of AI/AN
children live in households with incomes below the poverty line
as compared to 20.7 percent of children nationwide (Maternal
and Child Health Bureau, 2012).
AI/AN parents are more likely to struggle with substance
abuse. Eighteen percent of AI/AN adults needed treatment for an
alcohol or illicit drug use problem in the past year compared
to the national average of 9.6 percent (SAMHSA, 2009).
AI/AN parents are more likely to struggle with mental health
issues and distress related to unresolved trauma. Among U.S.
adults ages 18 and over who reported only one race, AI/ANs had
the highest rate of serious psychological distress within the
last year (25.9 percent), and the highest rate of a major
depressive episode within the last year (12.1 percent) (Urban
Indian Health Institute, 2012).
AI/AN children are more likely to live in families where no
parent has full-time, year-round employment than the national
average. Forty-nine percent of AI/AN children are in homes
where no parent has full-time, year-round employment compared
to 25 percent of White homes (Annie E. Casey, 2012).
AI/AN mothers are likely to be a young age at the birth of
their children. AI/AN women on average have their first child
at age 21.9, younger than all other races and ethnicities; the
average age of first birth for the U.S. population is 25.0
years (Mathews & Hamilton, 2011).
AI/AN parents are less likely to have high educational
attainment. In 2007, 20 percent of AI/AN adults over 25 had not
attained their high school diploma; 36 percent of AI/AN adults
over 25 had completed high school but did not continue to
postsecondary school (DeVoe & Darling-Churchill, 2008). In
2006, 74.7 percent of AI/AN graduation-aged students, compared
to 87.8 percent of the general population, received their high
school diploma (DeVoe & Darling-Churchill, 2008).
AI/AN families are more likely to be single-parent than the
average family. Fifty-two percent of AI/AN children are raised
in single-parent households, while nationally only 34 percent
of children are raised in single-parent households (Annie E.
Casey, 2012).
Family Risk Factors
Many AI/AN families are socially isolated. Reservation
communities are located in remote and sparsely populated areas,
and often the housing within those communities is spread out
over a large area. Because of this, the health care community
has recognized that a major barrier to quality medical care for
AI/AN individuals is social isolation, including the cultural
barriers, geographic isolation, and low income common in
reservation communities (Office of Minority Health, 2012).
AI/AN women are more likely than any other single racial
group to experience intimate partner violence (IPV, also known
as domestic violence); 39 percent of AI/AN women report having
experienced IPV at some point in their lives (Black & Breiding,
2008).
Community and Structural Risk Factors
AI/AN individuals are more likely to live in communities
where they will experience high rates of criminal victimization
and where there is limited law enforcement presence (Wells &
Falcone, 2008; Wakeling, Jorgensen, Michaelson, & Begay, 2001).
AI/AN families are more likely to live in communities where
there is a high level of unemployment. The rate of joblessness
on or near reservation communities is 49 percent (BIA, 2005).
AI/AN families are more likely to live in areas of high
poverty than the average family; 24 percent of AI/AN children
live in areas of highly concentrated poverty compared to the
national average of 11 percent (Annie E. Casey, 2012).
AI/AN individuals are less likely than the average American
to own their homes, one guarantee of housing stability. Only 56
percent of AI/AN households were homeowners, compared with 66
percent of total households (Ogunwole, 2006).
The Prevalence of Child Abuse and Neglect in AI/AN Families
National data on AI/AN children who experience child abuse and
neglect are limited. The National Child Abuse and Neglect Data System
(NCANDS) collects comprehensive data on the rates and characteristics
of child abuse and neglect in all families that enter public child
welfare systems. The data input into this system, however, is only for
families who interface with state and county child welfare systems.
Tribal programs, Bureau of Indian Affairs (BIA) or Indian Health
Services (IHS) programs, or tribal consortia are often the primary
service providers for AI/AN children and families, yet NCANDS does not
include AI/AN children who come to the attention of, and are served by,
tribal child welfare systems.
Research has shown that state and county workers are only involved
in approximately 63 percent of all tribal abuse and neglect cases
(Earle, 2000). These findings would lead to the conclusion that abuse
and neglect of AI/AN children are underreported (Fox, 2003). Other
issues, however, such as the definition of child abuse and neglect, the
process for counting incidents of abuse and neglect in NCANDS, or the
fact that reporting is primarily based on non-Native perceptions and
substantiation of maltreatment would lead to the opposite conclusion--
that numbers of AI/AN abuse and neglect cases in NCANDS are
artificially high (Bigfoot et al., 2005).
It is also important to note that national research studies of the
child welfare system have found a biased treatment of AI/AN families in
state systems. Although these studies tend to focus on out-of-home
placement, one recent study found that, due in part to systematic bias,
where abuse has been reported, AI/AN children are two times more likely
to be investigated, two times more likely to have allegations of abuse
substantiated, and four more times likely to be removed from their home
and placed in substitute care (Hill, 2007).
Nonetheless, the limited data that is available does provide some
basic understanding of the prevalence of child maltreatment in AI/AN
families and communities:
AI/AN children are 1.3 percent of all child maltreatment
victims reported to state and county child welfare agencies
(Children's Bureau, 2017).
AI/AN children experienced a rate of child abuse and neglect
of 14.3 per 1,000 AI/AN children. This rate compares to the
national rates of victimization of 9.1 per 1,000 (Children's
Bureau, 2017).
NICWA requested a special data report from the Department of Health
and Human Services in 2014 regarding select child abuse and neglect
data that is not published or available to the public (NCANDS, 2014).
This special report was not able to provide data for AI/AN on all of
the NCANDS data set but does provide specific data on 18 different
indicators. Some key findings include:
Maltreatment Types by Victim
Of all maltreatment victims, 89.3 percent of AI/AN children
were involved in the child welfare system because of a
disposition of neglect, compared to 78.3 percent of all
children nationwide
Of all maltreatment victims, 15.6 percent of AI/AN children
were involved in the child welfare system because of a
disposition of physical abuse, compared to 18.3 percent of all
children nationwide
Of all maltreatment victims, 5.6 percent of AI/AN children
were involved in the child welfare system because of a
disposition of sexual abuse, compared to 9.3 percent of all
children nationwide
Child Fatalities Subject to Child Maltreatment
2.21 AI/AN children out of 100,000 were reported as
fatalities due to child maltreatment, compared to 2.2 of
100,000 children nationwide
Children and Caregiver Risk Factors
Alcohol Abuse:
--30 percent of AI/AN child victims had a parent with an
alcohol abuse problem, compared to 28.5 percent of child
victims nationwide
--14 percent of AI/AN child non-victims had a parent with an
alcohol abuse problem, compared to 4.9 percent of children
nationwide
Drug Abuse:
--24.5 percent of AI/AN child victims had a parent with a
drug abuse problem, compared to 20 percent of child victims
nationwide
--11.7 percent of AI/AN child non-victims had a parent with a
drug abuse problem, compared to 8.4 percent of children
nationwide
Domestic Violence:
--24.8 percent of AI/AN child victims had a parent involved
in domestic violence, compared to 28.5 percent of child victims
nationwide
--11.4 percent of AI/AN child non-victims had a parent
involved in domestic violence, compared to 8.6 percent of
children nationwide
Although NCANDS is the primary source of data on the abuse and
neglect of children, there are a few other sources of data for AI/AN
children, such as select Bureau of Indian Affairs regional offices,
Indian Health Services, and other agencies concerned with this
information that may collect data on the prevalence of child
maltreatment in the tribal communities with which they work (Bigfoot et
al., 2005; Earle, 2000). This data, however, is not kept consistently
or nationally.
Effects of Child Maltreatment
Facing trauma in the form of child maltreatment has long-term
effects on the well-being of AI/AN children, particularly when it goes
undetected and untreated. Studies have shown that children who have
been abused or neglected have higher rates of mental health and
substance abuse disorders, are more likely to be involved in the
juvenile justice system, have worse educational outcomes (truancy and
grade repetition), and are more likely to have early pregnancies
(Office of Planning, Research and Evaluation, 2012). It is also
important to understand that individuals who experience abuse and
neglect are more likely to be perpetrators of intimate partner violence
and child maltreatment, creating a cycle of violence that is difficult
to break (Child Welfare Information Gateway, 2013). In addition, child
abuse and neglect can have a long-term effect on physical health. One
study has shown that at up to three years following a maltreatment
investigation, 28 percent of children were diagnosed with a chronic
long-term health condition (Office of Planning, Research and
Evaluation, 2007).
Child maltreatment does not just have long-term effects on the
victims; it also comes at a great cost to society and the communities
it touches. According to the Centers for Disease Control, to manage all
of the services associated with the immediate response to all child
maltreatment costs $124 billion a year (Child Welfare Information
Gateway, 2013). Although AI/AN children are only a small fraction of
child maltreatment victims nationally, that would still equate to
billions of dollars a year being spent to respond to child maltreatment
of AI/AN children. For tribes who are already under-resourced in the
area of child welfare and who do not have access to federal child abuse
prevention funding (with the exception of two small, competitive grant
programs), responding to child maltreatment can be a huge drain on
available resources.
Beyond the direct or immediate costs of child maltreatment, there
are also many long-term indirect costs. These include long-term
economic consequences to society such as an increased likelihood of
employment problems, financial instability, and work absenteeism. In
addition, child maltreatment creates long-term economic consequences
related to increased use of the healthcare system, increase cost due to
juvenile and adult criminal activity, and increased use of mental
illness, substance abuse, and domestic violence services (Child Welfare
Information Gateway, 2013).
Chronic social problems like child maltreatment hold back
communities. When they are unaddressed, they ultimately interfere with
efforts to create and encourage economic development by taking from
tribal resources that could be used for economic and infrastructure
development to ``manage'' these chronic and persistent social problems.
Furthermore, as Cornell and Kalt (1998) discuss, ``nation building,''
an approach to successful economic development for Indian tribes,
requires a community where both businesses and humans must flourish
because they are in relationship with one another. Cornell argues that
success in economic development is more than just jobs--it also
includes social impacts and making a community a place where investors
want to do business and where the community is healthy enough to engage
successfully with the economy.
Issues with Funding for Child Abuse Prevention and Child Protection
Funding for child maltreatment prevention, and treatment efforts is
limited in Indian Country. Most funding for child welfare services
comes from federal sources, such as the Bureau of Indian Affairs or the
Department of Health and Human Services. Tribes do have access to some
funds that are flexible (e.g., Bureau of Indian Affairs ICWA Title II
funds, or Department of Health and Human Services Social Security Act
Title IV-B funds) and can be used to prevent and intervene in child
maltreatment cases. However, since tribal funding in child welfare
overall is very limited, available flexible funding sources are often
used to support non-prevention, non-child protection crisis-oriented
services, such as foster care or child welfare case management. States,
while not having access to adequate prevention funding, still receive
proportionately more funding, as well as funding from two major sources
that tribal programs are not eligible for: the Title XX Social Services
Block Grant and the Child Abuse Prevention and Treatment Act (CAPTA)
State Grants.
CAPTA, reauthorized by the CAPTA Reauthorization Act of 2010 (P.L.
111-320), is the only federal law that focuses solely on prevention,
assessment, identification, and treatment of child abuse and neglect.
Tribes are eligible for the two discretionary grant programs under
CAPTA through the Community-Based Grants for Prevention of Child Abuse
and the Discretionary Funds (which support research and demonstration
grants and training programs). This is for one-time, special projects
funding and does not support ongoing prevention and treatment services.
Tribes, however, are not eligible for CAPTA State Grants used to
improve child protection services programs, which provide a small
foundation of funding for child protection services to every state.
Thus, tribal funding to prevent and address child abuse is almost
nonexistent. Under the entire CAPTA statute, tribes typically receive
less than $300,000 a year from the over $100 million a year in
appropriated funds.
Although all tribes recognize the importance of prevention, and
many provide programs that incorporate child abuse prevention
activities, they do so with little or no federal support. Furthermore,
the prevention work they do is in communities with families that are
very high risk for child abuse and neglect. While the funding levels
for states are low under CAPTA, every state still receives some level
of funding to conduct these activities, whereas funding for tribal
governments under this program does not even reach 1 percent of the
tribes nationwide. Furthermore, CAPTA provides support in the form of
matching funds for state Child Abuse Trust Funds, which provide support
for advocacy and child abuse prevention services. Tribes receive little
or no benefit from these state trust funds, and there is no provision
for support to local or a national tribal child abuse prevention trust
fund under CAPTA.
The Title XX Social Services Block Grant is a capped entitlement
that, among other things, supports programs that strive to prevent and
remedy abuse, neglect, or exploitation of those who cannot protect
themselves by promoting community-based care. Recipients (states and
territories) are afforded a great deal of flexibility in terms of how
they use the Title XX funding to meet these goals. These funds are
often used to fill service gaps that exist in other more restrictive
federal child welfare programs-specifically child abuse prevention and
child protection services. The Social Services Block Grant is currently
one of the only major sources of federal funding used for child welfare
services by states to which tribes do not have access.
The Family Violence Prevention and Services Act provides funding
for tribal nations from a set-aside within the law. Currently, the
program provides about $14 million annually that provides small grants
to about 270 tribes to conduct prevention efforts and services to
address family violence. Specific services that can be supported with
the grant funds include increasing public awareness about, and primary
and secondary prevention of, family violence, domestic violence, and
dating violence, and to provide immediate shelter and supportive
services for victims of family violence, domestic violence, or dating
violence, and their dependents. Most of the 270 tribes funded receive
grants under $50,000 a year leaving little room for anything but crisis
services. It is important to note that the presence of domestic
violence in a home is a risk factor for child maltreatment and
effectively addressing domestic violence is critical to prevention of
child abuse or neglect.
To fill gaps in funding due to underfunding and lack of access to
other federal sources, Congress enacted the Indian Child Protection and
Family Violence Prevention Act (P.L. 101-630), which contains three
separate grant programs designed to address child abuse prevention,
investigation, and treatment services. The act authorizes Indian Child
Resource and Family Service Centers staffed by multidisciplinary teams
(MDTs) with experience in ``prevention, identification, investigation
and treatment'' of child abuse and neglect (AI/AN tribes may contract
to run these centers). The act also authorizes funding for grant
programs for the development of Indian child protection and family
violence prevention programs and for the treatment of victims of child
abuse and neglect and family violence. The resource centers grant
program is the only grant program to have received any appropriations
of the three and this only occurred in one year during the mid-1990s.
Tribes are not different from states in their need to respond to child
abuse and neglect in their communities, and they need additional
funding to develop a continuum of services and programming to prevent
and respond to child abuse and neglect.
Issues with Data Collection
Tribal governments need reliable mechanisms for collecting their
own data and the ability to access data for their tribal members who
are under federal or state jurisdiction. Accurate, reliable, well-
coordinated, and accessible data collection is critical to
understanding the scope and trends of child maltreatment in Indian
Country. Data must include AI/AN children under tribal, state, and
federal jurisdiction to paint an accurate picture and highlight unique
issues within each of these systems.
The Indian Child Protection and Family Violence Prevention Act
identifies the federal requirements for reporting and investigating
child abuse in Indian Country. If the alleged abuse, such as child
sexual abuse, is considered to be a criminal violation, the agency
receiving the report is to notify the FBI. In a scenario where child
sexual abuse of an AI/AN child on tribal land is reported and then
investigated, there could be as many as three different governments
and/or law enforcement authorities responding (tribal, federal, or
state) and each collecting different or similar data. While
theoretically each of these entities could share this data, this may be
complicated by conflicting policy mandates or each government's
principles regarding confidentiality and the sharing of information.
Many tribes have established agreements with local child protection
agencies and law enforcement in their area to address issues of
coordination, but this is a complicated and often long process that is
not well resourced and contains several collaboration challenges. One
primary challenge can be misperception by health agencies, whether they
are tribal, federal, or privately operated, that due to the Health
Insurance Portability and Accountability Act (P.L. 104-19, HIPAA), they
cannot share client information with other outside agencies. Agencies
or individuals that operate under this assumption have often not
received accurate information or training on the discretion allowed
under the law, the law's application in child abuse reporting and
investigations, and/or the interaction of federal Indian law with
HIPAA. While the Indian Child Protection and Family Violence Prevention
Act implies that information pertaining to a report or investigation
can and should be shared, it does not provide additional incentives or
resources to assist tribes as they negotiate these complex
relationships and roles.
Tribal and urban AI/AN organizations struggle with data collection
regarding child maltreatment and access to existing data sources. As
mentioned previously, states submit their child maltreatment data to
NCANDS, which was established in amendments to CAPTA in 1988. NCANDS is
a data system that collects child abuse and neglect information both at
the aggregate and case level. The aggregate data is used by the
Department of Health and Human Services to publish an annual report on
the characteristics of child abuse and neglect in the United States
titled Child Maltreatment. Although data on AI/AN children are included
in this report, the data reflected does not include those children in
tribal child welfare systems. In addition, many data elements specific
to AI/AN children that would be helpful to urban and tribal programs
are not reported for this publication. Tribal governments do not
currently submit to NCANDS nor do they have a similar central
repository to which they can submit their data for analysis and annual
report.
A few tribal governments have been able to develop their own
databases and accompanying infrastructure in this area, but the vast
majority of tribes do not have the resources to build and maintain such
a system. The ability to develop these tools and activities has been
primarily tribally funded work with little investment from federal
sources. However, tribes that have been able to develop a child abuse
and neglect database are often looking to develop a system that not
only helps them collect data on individual cases, but also serves as an
electronic case management system, a tool for tracking client and
service trends, and program evaluation. Tribes that develop and operate
these systems are more likely to be able to develop carefully thought-
out responses to children's needs in their community and engage in
larger systems reforms efforts.
It is worth noting that the Bureau of Indian Affairs and Indian
Health Services may collect some limited data based on their roles as
funders or service providers for AI/AN children affected by child
maltreatment, but this data is not readily available to tribes, is not
coordinated with other data sources, and lacks the comprehensiveness
necessary to inform policy and practice.
In addition to accurate systemic data, tribal child protection and
prevention teams also need research specific to child maltreatment in
Indian Country to create and promote effective prevention strategies,
interventions, and policy change. There is little information on the
cultural interventions and assessments that are being used with AI/AN
children. This is largely due to the fact that tribal and urban AI/AN
communities lack the resources necessary to establish evidence-based
practices and create cultural adaptations of evidence-based practices
(BigFoot and Braden, 2007). There is no national focus and very limited
support for funding these types of projects at the federal level. Much
of the federal research on child maltreatment has been funded by
demonstration and discretionary grants authorized under CAPTA.
Typically, these grants are awarded to large public and private
universities, hospitals, or private organizations with extensive
research capacity and infrastructure. These grants support some of the
key research on the effects of child maltreatment; characteristics of
abuse and neglect; and effective prevention, intervention, and
treatment practices. Until the recent reauthorization of CAPTA in 2010,
tribes were not eligible to apply for these demonstration or research
grants, and since that time no tribe has been awarded a grant. Another
consequence of this lack of research is that as federal, state, and
private funders increase their focus on projects that contain evidence-
based practices, tribes and urban AI/AN organizations are increasingly
finding themselves left out since many evidence-based practices have
not established program effectiveness with AI/AN populations, and
tribes may deem some evidence-based programs culturally inappropriate
for the families and children they serve.
TRIBAL-STATE RELATIONS
Because of the direct federal government-to-tribal government
relationship, historically, tribal-state interaction was limited. The
direct tribal relationship with the federal government led to the sense
that there was little role for state governments in tribal affairs.
Although states have no authority to pass laws that interfere with the
federal-tribal relationship, the development of tribal-state
relationships is critical to providing appropriate services to AI/AN
children and families. Additionally, as the federal government has
decreased its involvement in providing direct services to AI/AN
children and families and states have increased their efforts to
implement ICWA, the need for increased intergovernmental coordination
and cooperation among state, county, and tribal governments is greater.
Tribes and states have identified a variety of mechanisms and
models to improve intergovernmental relationships and to provide more
accessible, culturally based, and more effective services to AI/AN
children and families. These mechanisms include (1) coordinating
internal tribal child welfare resources; (2) engaging in discussions
about key child welfare issues such as ICWA implementation or child
abuse/neglect investigations; (3) educating one another on respective
service trends and model practices; (4) negotiating respective
governmental responsibilities; and (5) developing cooperative
strategies for intergovernmental relationships and service delivery
agreements.
It is extremely important for tribes and states to use these
successful mechanisms and models to develop and maintain positive
relationships with one another. Poor tribal-state relationships can
negatively affect the prevention and treatment of child abuse and
neglect on tribal lands. With the federal government serving a
supporting role, tribal-state relationships can be successfully
developed and improved. When tribes and states are unwilling or unable
to develop cooperative relationships, it is children and families who
suffer the most.
In areas where tribal-state relationships in child welfare are the
most successful, there is a policy infrastructure in place--such as
intergovernmental agreements and state ICWA policies--that outlines the
roles and responsibilities of tribes or urban AI/AN organizations and
states in responding to reported child maltreatment of AI/AN children.
While these agreements or policies are not mandatory, they have proven
to be extremely helpful in clarifying expectations and responsibilities
for each of the parties as they carry out their designated roles in
child welfare services. Over 25 states have some form of ICWA related
policy or agreements in place with new policy development happening
each year. The agreements and state policies provide tribes and urban
AI/AN organizations with opportunities to participate in child
protection activities and provide their expertise and resources, even
when they cannot directly provide the services themselves.
SOLUTIONS TRIBES AND URBAN CENTERS ARE EMPLOYING
Elements of Successful Responses to Child Maltreatment in Indian
Country
To effectively address child maltreatment in Indian Country, tribal
governments and urban programs have drawn on the wisdom of their
communities and culture. Programs and services that have been
successful are designed with input from the community and implemented
by those with intimate knowledge and deep understandings of the unique
community needs and the tribal culture. Services are based in cultural
beliefs, teachings, customs, and traditions and aligned with trauma-
informed care that treats both the symptoms of child maltreatment and
also the causes and effects of trauma on all family members.
Another common element of effective child maltreatment prevention
and treatment services is a successful collaboration, whether across
different governments (tribal, federal, state, and local) or within a
particular governmental structure. Collaborative relationships help
leverage funding, clearly define roles and responsibilities,
incorporate cultural resources, eliminate service disparities, and
improve overall communication between agencies serving the same
children and families. Tribal governments, in their efforts to address
child maltreatment, are subject to a variety of jurisdictional
challenges and varying service delivery and funding schemes that can
impact their ability to provide prevention and treatment services. The
ability to form successful collaborative relationships with various
governmental entities outside of tribal lands is critical to addressing
these jurisdictional, funding, and service delivery challenges. Urban
AI/AN programs also experience many of these challenges, especially
those related to funding and service delivery. They will often develop
partnerships with local, state, and sometimes tribal governments.
Successful tribal and urban AI/AN programs work within their respective
governance structures to coordinate between agencies as well.
A third common element of successful child maltreatment programming
for AI/AN children is a strong understanding of the importance of
familial connections as a protective factor for AI/AN children. While
removal may be necessary to protect children in more serious abuse and
neglect circumstances, the removal itself is traumatic for children who
can be separated from their family, community, and culture. A balanced
approach to child protection can keep children safe from harm while
nurturing family and community relationships. By keeping family
relationships intact, children remain connected to their culture, have
a positive sense of belonging, and gain an understanding of their
identity as an individual as well as a member of the collective
community. Tribal and urban AI/AN programs serve an important role in
facilitating these connections through both formal services and access
to informal helping networks.
A fourth element is the location of appropriate community-based
services for AI/AN children and families. Families struggling with
child maltreatment often have multifaceted needs and treatment plans
that require access to different service providers. AI/AN populations
on tribal lands are very often located in rural areas where access to
affordable and timely public transportation can be extremely limited,
if available at all. With high unemployment rates on tribal lands,
other modes of reliable private transportation can also be out of
reach. Services that are located in off-reservation areas and operated
by other public and private entities generally do not incorporate the
values and culture of tribal families and consequently are limited in
their ability to do successful outreach and services for these children
and families. Community-based services ensure that tribal child
protection responses can be accessible, tailored to the needs of
children and families, and incorporate tribal culture.
The following section will describe several tribal and urban AI/AN
programs that have been successful in addressing child maltreatment.
This includes prevention of child maltreatment, community engagement,
healing trauma in adult family members, providing supports to family
members to help keep children safely in their homes, and treating the
trauma in child victims. These examples do not constitute an exhaustive
list, but instead seek to provide some brief examples of how tribal
communities and Indian organizations are using limited resources to
creatively and effectively address child trauma issues, especially
child maltreatment.
Primary and Secondary Child Abuse Prevention
NICWA is a leader in helping tribes build capacity to address the
complex issues surrounding child abuse and neglect in their communities
and develop effective prevention strategies that use cultural resources
and traditions. Grassroots Child Abuse Prevention is a NICWA training
curriculum that helps tribal communities develop community-wide child
abuse and neglect prevention campaigns (NICWA, n.d). Trainees are
provided information about child abuse and neglect, community
organizing techniques, cultural adaptations of mainstream prevention
strategies, and social marketing to develop and support community-based
prevention strategies for AI/AN communities. NICWA also provides on-
site technical assistance to help tribal communities implement their
prevention strategies. School settings can provide an effective
environment for prevention efforts. NICWA provides a training
curriculum that helps Native parents, administrators, and teachers
develop a child sexual abuse prevention program for their Head Start
and pre-school programs. Children's Future: A Child Sexual Abuse
Prevention Curriculum for Native American Head Start Programs covers
program administration, recognizing indicators of abuse, reporting
procedures, and parent and community involvement (NICWA, n.d.). It also
includes a nine-month lesson plan for use in the classroom.
As discussed earlier, the Child Abuse Prevention and Treatment Act
(42 USC 5116) provides funding authority for small grants to tribal
grantees to fund child abuse and neglect prevention activities
(Community-Based Child Abuse Prevention). The amount of funding has
allowed two grantees to be funded every three years. However, these
grantees have developed activities and programs that have been very
successful. In 2008, two tribal grantees used these funds to develop
and operate primary and secondary prevention activities. The grantees
were the Mississippi Band of Choctaw Indians in Mississippi and the
Cahuilla Band of Mission Indians in California. The projects used
cultural adaptations of mainstream models of prevention with additional
cultural activities included.
Each project sought to address both primary and secondary
prevention strategies targeting both offending and non-
offending parents, as well as other families within their
communities that showed interest in the activities. Below are
some additional elements of these projects that used a
combination of education, parent support, and outreach
activities
Included activities for both children and parents separately
and together
Nurtured protective factors in non-offending parents who
remain with the children (Choctaw)
Empowered parents to reduce risk and incidence within their
own families, while also becoming mentors or coaches to other
parents in the community (Choctaw)
Conducted regular sessions for the community at large on
parenting, marriage, and strengthening cultural connections
(Cahuilla)
Provided intensive referral and case management for parents
to help them secure needed family supports and services; as
much as possible, these services will be provided in the home
(Cahuilla)
Culturally adapted mainstream, evidence-based models
(Incredible Years parenting program-Cahuilla)
Integrated family advocate model for case management
(Choctaw)
As this list suggests, the importance of culture and family was a
key part of many interventions as was systems collaboration. A common
thread noted in the assessment of each project was a recognition that
historical trauma and past government efforts to assimilate AI/AN
people have had a negative effect on parenting, and important
traditional values and parent strategies had been replaced with less
effective and sometimes dysfunctional interventions and care.
In-Home Services
In-home services can be an effective method for reducing risk and
still protecting children without creating additional stressors by
placing children in out-of-home care. In-home services are intensive by
definition and require regular contact with parents and children. To
create an in-home service plan, family members contribute to the risk
assessment, help identify formal and informal services to alleviate
stressors that contribute to risk behaviors and engage with a case
manager as well as a network of identified support. These services
allow parents and siblings to maintain their family and cultural
connections, which is critical to the successful rehabilitation of AI/
AN families, while intervening early on any issues that could lead to
child maltreatment.
Denver Indian Family Resource Center
The Denver Indian Family Resource Center (DIFRC) in Denver,
Colorado, has been providing in-home supportive services to AI/AN
families who are involved in the child welfare system since 2000. They
serve a very diverse urban AI/AN population that lives in the Front
Range in and around Denver. To help families meet their basic needs and
provide safe homes for their children, DIFRC provides supportive
services that include job search assistance, life skills education,
housing assistance, and health advocacy (Medicaid/CHP enrollment). For
some families, stabilization begins with learning how to keep a monthly
family budget, maintain a household schedule, and procure
transportation to work or school. Many of these core services are
provided in the home, including coaching for improved communication and
parenting skills, behavior and anger management, consultation with
other social services providers, supervision of home visitation, and
helping families acquire basic needs. DIFRC programs, like the Strong
Fathers and Strong Mothers Parenting Program, are based on American
Indian values and promote the development of positive parenting skills
and the cultivation of cultural resources. As much as 80 percent of the
case management process at DIFRC involves helping families meet basic
needs and balance responsibilities. Based on data compiled by the
Colorado Disparities Resource Center, DIFRC reduced the overall number
of AI/AN children in Colorado being removed from their families and
placed in foster care by 33 percent (NICWA, 2010).
Central Council of the Tlingit and Haida Indian Tribes of Alaska
The Central Council of the Tlingit and Haida Indian Tribes of
Alaska (CCTHITA) has been working closely with the state and their own
Temporary Assistance to Native Families (TANF) department to better
support families at risk of child maltreatment and keep children in
their homes. In Alaska, Alaska Native (AN) children make up over 62
percent of the state foster care system while only representing 15
percent of the state's youth population (Summers, Wood, & Russell,
2012). There, as elsewhere, structural risk factors such as poverty,
joblessness, inadequate housing, substance misuse, and untreated mental
health problems contribute to reports of maltreatment and are often
conflated with neglect. Although neglect, not abuse, is the primary
form of child maltreatment reported, the most common intervention for
AN families is the removal of their children, not in-home services.
Efforts to address these issues by Alaska Native communities have been
ongoing, but state efforts to use tribal in-home services have been
slow in many areas based on a lack of understanding and trust in tribal
services.
The CCTHITA Preserving Native Families Department provides services
to member families and children in both rural southeast Alaska and in
the urban boundaries of Juneau designed to keep children at risk of
maltreatment safely in their homes. CCTHITA also operates a TANF
program. Over half of the families that are served by TANF are also
involved with the Preserving Native Families program or state Office of
Child and Family Services.
The CCTHITA TANF program was often the first program with which
CCTHITA families at risk of abuse or neglect came into contact. At the
same time, referrals from the state OCS to Preserving Native Families
were low, despite significant risk factors within the CCTHITA community
and the availability of robust tribal in-home services. The Preserving
Native Families program uses a cultural adaptation of an evidence-based
assessment tool, Structured Decision Making, to evaluate families at
risk of maltreatment and develop plans to protect children and
rehabilitate families. The Preserving Native Families department saw an
opportunity to increase early identification of at-risk families and
offered training and support to TANF staff on the Structured Decision-
Making tool. The Preserving Native Families program also used the
assessment tool as a platform to educate the state OCS staff on how to
improve referrals of CCTHITA families and help them access in-home
services that can eliminate the need for removal of children into out-
of-home care. These efforts have led to earlier and more frequent
referrals of families at risk and a decrease in the number of children
removed from their homes.
Tribal Home Visiting Program Approaches
Home visiting programs have shown to be effective at helping
children and their families prevent, reduce, and seek timely treatment
for child-related ailments, including child maltreatment. In 2010
tribal communities became eligible for the newly authorized Tribal
Maternal, Infant, and Early Childhood Home Visiting Program. This
program aims to improve outcomes in a range of critical areas of child
well-being such as maternal and prenatal health; infant health; child
health and development; reduction in child maltreatment; improved
parenting practices; school readiness; improved family socioeconomic
status; improved referral and coordination with community resources and
supports; and reduced incidence of injuries, crime, and domestic
violence. To reach these outcomes, the program provides funding to
tribal grantees to culturally adapt conventional evidence-based models
of home visiting programs, or to use national in-home service models
that have included AI/AN clients in their test population in their
communities (Del Grosso et al., 2011). Tribal grantees have elected to
focus on a number of different evidence-based models and integrate
cultural traditions and practices into their newly designed tribal
programs. A number of the tribal programs combined home visiting
services with other services to create more complete in-home service
models. Many of the programs sought to incorporate cultural teachings
and use paraprofessional staff indigenous to the community being
served. Through the use of these culturally adapted models, tribal
participants have reported outcome measures related to the reduction of
child maltreatment, family violence, juvenile delinquency, and crime
(Del Grosso et al., 2011).
Indian Country Child Trauma Center
Over the last 30 years, we have seen increasing efforts by AI/AN
professionals and tribal programs to develop treatment approaches that
are rooted in an intimate knowledge of the characteristics of trauma in
Indian Country, historical trauma, and the criticality of using culture
in developing effective interventions. One of the leaders in this
movement has been the Indian Country Child Trauma Center (ICCTC).
Located at the University of Oklahoma Health Sciences Center, the ICCTC
strives to develop trauma-related treatment protocols, outreach
materials, and service delivery guidelines specifically designed for
AI/AN children and their families. ICCTC has developed an array of
culturally based trainings and resources for treatment professionals
that are working with AI/AN children and families affected by trauma. A
number of their resources are grounded in evidence-based practices,
such as Project Making Medicine, which is a national clinical training
program designed around Honoring the Children, Mending the Circle, a
cultural adaptation of trauma-focused cognitive behavioral therapy
curriculum. In Honoring the Children, Mending the Circle, clinicians
are taught to use cognitive behavioral techniques within a traditional
Native framework that supports the Native belief in spiritual renewal
as a core element of healing from trauma. Similarly, Honoring Children,
Making Relatives is a culturally adapted curriculum based on parent-
child interaction therapy where clinicians are taught to coach parents
with traditional Native ways of teaching that move from observation to
active teaching to promote positive interactions and enhanced parenting
skills. It is resources like these that clinicians across Indian
Country are using to effectively treat trauma and decrease the risk
factors for child maltreatment.
American Indian Life Skills Development Curriculum
AI/AN youth are at high risk for suicide. Childhood maltreatment is
a traumatic experience that increases the likelihood of suicidal
behavior. Developing skills and supports for AI/AN youth that confront
suicide risk factors is essential to reducing risk and addressing
associated trauma. American Indian Life Skills Development Curriculum,
the only evidence-based suicide prevention program in Indian Country,
incorporates features of risk and protective factors specific to tribal
youth to support suicide prevention strategies (SAMHSA, 2007). The
curriculum, designed to be used with middle- and high-school-age youth,
teaches life skills such as communication, problem solving, depression
and stress management, anger regulation, and goal setting. Youth are
taught to seek out cultural knowledge within their communities as they
learn positive strategies for reducing risk for suicide. This
curriculum has been adapted by several tribes across the United States.
Native Aspirations Program
The Native Aspirations Program provides tribal communities with
help to build their capacity to prevent violence, bullying, and youth
suicide (One Sky Center, 2008). The program provides resources and
training to tribal communities on how to use and culturally adapt
evidence-based treatment and practices. Community mobilization and
planning events are central components of Native Aspirations, along
with the identification of tribal cultural interventions that can be
used in the development of prevention programming. As tribal
communities grapple with the violence that can hurt young people, there
is a need to develop new approaches to addressing the risk factors that
can increase threats to safety. In order to do that, tribal communities
need education about the issues impacting their children, a structured
process for identifying and developing culturally based solutions, and
resources to improve their capacity to successfully implement change.
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The Chairman. Thank you very much.
Next, we have Ms. Robyn Sunday-Allen, the Vice President of
the National Council of Urban Indian Health in Washington, D.C.
STATEMENT OF ROBYN SUNDAY-ALLEN, VICE PRESIDENT, NATIONAL
CONGRESS OF URBAN INDIAN HEALTH
Ms. Sunday-Allen. Good afternoon, Chairman Schatz, Vice
Chair Murkowski, Senator Lankford, and members of the Senate
Committee on Indian Affairs. Thank you for the opportunity to
testify today.
I am Robyn Sunday-Allen, a citizen of the Cherokee Nation
and currently Vice President of the National Council of Urban
Indian Health, which represents the 41 Urban Indian
organizations with 77 facilities in 22 States. UIOs provide
high quality, culturally competent care to Urban Indians or
over 70 percent of the American Indians and Alaska Natives
living off reservation.
I am the CEO of the Oklahoma City Indian Clinic, a UIO that
provides comprehensive health care to over 21,000 Native
patients representing over 220 tribes. I would like to thank
the Committee for working tirelessly to help equip the Indian
Health system with essential resources.
I testify today in support of the Urban Indian Health
Providers Facilities Improvement Act, S. 1797, which will
expand the use of existing Indian Health Service resources
under Section 509 of the Indian Health Care Improvement Act.
This legislation would enable IHS Urban Indian health dollars
to be spent where they are needed, including for necessary
facilities maintenance and renovation.
I applaud Senators Lankford and Padilla for introducing
this bill that will fix an unnecessary barrier to care and
allow UIOs to make critical updates to all facilities.
Specifically, this bipartisan bill corrects and oversight in
Section 509 of the Indian Health Care Improvement Act that
effectively prohibits us from using our IHS funding on
infrastructure and facilities improvement projects, unless the
project is undertaken for accreditation by The Joint
Commission.
TJC is no longer the applicable accrediting body among the
vast majority of UIOs. Forty of 41 UIOs do not utilize TJC
accreditation. Since 2004, at the Oklahoma City Indian Clinic,
we have used the Accreditation Association for Ambulatory
Health Care, AAAHC, a nationally accepted accreditation body.
IHS promotes AAAHC as an option for the UIOs and even regularly
holds AAAHC training for UIO staff.
However, AAAHC accreditation effectively bars Oklahoma City
from using IHS funds for any facility improvements because the
statute only mentions TJC. Ultimately, this restriction impacts
the provision of services to our Native patients. For instance,
during the COVID-19 pandemic, UIOs were unable to use IHS funds
to make critical facility renovations to safely serve patients
despite the immediate need for updates, like transitioning to
tele-health, air circulation updates like negative pressure
rooms, and air purification systems and redesigning or adding
space to allow for social distancing. One UIO could not use its
IHS funding to purchase a new HVAC system. In other words, a
health facility could not use its funding from a health agency
to make air purification changes amidst a global pandemic of an
airborne virus that could kill its patients and staff, solely
because of this restriction this bill seeks to fix.
At Oklahoma City Indian Clinic we have been faced with
difficult decisions, at times having no choice but to divert
revenue from patient care to meet the critical infrastructure
needs essential to continue serving our patients. As a nurse
administrator, I am aware of what health care looks like in a
well-maintained medical facility. Inadequate facilities and
safety issues are never something I nor any other UIO want
impacting the care we give our patients. We are in a race
against time, and we need this legislative fix now.
This bill would remove this prohibition immediately
allowing UIOs to use their IHS funding more efficiently and
efficiently. This bipartisan bill has widespread support,
including within Indian Country. For example, NCUIH and 29
Indian organizations included it in an infrastructure
newsletter to Congress. In addition, the National Congress of
American Indians recently passed a resolution in support of
this fix. It also has wide support among policy makers who with
House Interior Appropriations included the UIO facilities fix
in its fiscal year 2022 bill. The President's fiscal year 2022
budget, similarly included it, also noting it has a zero score.
All of this support makes one thing clear: we must act now
to pass this urgent and no-cost legislative fix.
Finally, this issue is not only urgent and ripe for
resolution with the Senate considering the largest
infrastructure framework bill in history. We respectfully
request the inclusion of this bill in this infrastructure
package.
We respectfully urge the members of this Committee to
include S. 1797 in bipartisan infrastructure framework. In
addition, we recommend the Committee hold a markup on this bill
as soon as possible to allow for Floor consideration.
Finally, we ask all members to co-sponsor S. 1797 and thank
you to those who have already taken this important step.
Again, thank you for your time today and for working with
NCUIH as we ensure American Indian and Alaska Native people
receive high quality care regardless of where they live.
[The prepared statement of Ms. Sunday-Allen follows:]
Prepared Statement of Robyn Sunday-Allen, Vice President, National
Congress of Urban Indian Health
Chairman Schatz, Vice Chairman Murkowski, and Members of the Senate
Committee on Indian Affairs, thank you for the opportunity to testify
today on the vital topic of urban Indian health facilities. My name is
Robyn Sunday-Allen, I am a member of the Cherokee Nation, and currently
the Vice President of the National Council of Urban Indian Health
(NCUIH), which represents the 41 Urban Indian Organizations (UIOs)
across the nation who provide high-quality, culturally-competent care
to Urban Indians, who constitute over 70 percent of all American
Indians/Alaska Natives (AI/ANs). I also serve as the Chief Executive
Officer of the Oklahoma City Indian Clinic (OKCIC), a permanent program
within the Indian Health Service (IHS) direct care program and a UIO,
which provides culturally sensitive health and wellness services
including comprehensive medical care, dental, optometry, behavioral
health, fitness, nutrition, and family programs to our nearly 20,000
patients representing over 220 different tribes. I would like to thank
Chairman Schatz, Vice Chairman Murkowski, Members of the Committee and
their staff who have worked tirelessly to help equip the Indian health
system with essential resources. I appreciate you holding this
important hearing on vital facilities and infrastructure issues which
have impacted Indian Country, including UIOs.
I testify today in support of the Urban Indian Health Providers
Facilities Improvement Act, S. 1797, which will expand the use of
existing IHS resources under Section 509 of the Indian Health Care
Improvement Act (IHCIA) (25 U.S.C. 1659). This legislation would
enable IHS urban Indian health dollars to be spent where they are most
needed, including for necessary facilities maintenance and renovation,
ultimately improving patient care without any added cost. As it stands,
UIOs can only use our IHS funding for facilities expenses if the
renovation or maintenance is undertaken in order to meet a specific
accreditation standard, which is inapplicable to the vast majority of
UIOs. In effect, we are left without the ability to use our funding
efficiently and most effectively to best serve our patients. I will
speak to you today about the importance of the technical fix to this
restriction and how it would improve health care outcomes for Oklahoma
City's Urban Indian community, as well as the larger UIO system and,
ultimately, the more than 70 percent of AI/AN people that reside in
urban Indians.
We urge the Members of this Committee to request leadership to
include this simple but urgent fix in the bipartisan infrastructure
framework. In addition, we recommend the Senate Committee on Indian
Affairs hold a markup on this bill as soon as possible to allow for
floor consideration. Finally, to demonstrate a strong showing of
commitment to improving urban Indian health, we ask all Members to
cosponsor S. 1797.
Background
NCUIH represents 41 UIOs operating 77 facilities across 22 states.
As part of the trust obligation, the federal government funds UIOs who
provide high-quality and culturally competent care to urban Indian
populations. UIOs are a critical part of the Indian Health Service
(IHS) system, which includes IHS facilities, Tribal Programs, and UIOs.
This is commonly referred to as the I/T/U system. Unfortunately, UIOs
experience significant parity issues as compared to the other
components of the I/T/U system as well as other federally funded health
care systems, which greatly impact their services and operations. This
includes the inability to use IHS funding for facilities improvements
or maintenance, even if that is where the dollars are most needed.
OKCIC is the UIO serving the Oklahoma City area, with more than 35,000
annual patient visits. Since OKCIC's creation in 1974, the demand for
quality health care has steadily increased, and the clinic has grown in
response. Because of the restriction preventing UIOs from using IHS
funds for facilities, we have multiple times throughout our history
been forced to make difficult decisions to keep up with demand--having
to use limited funding pools and divert revenue from AI/AN patient care
in order to have adequate space to provide critical services.
The inability to use IHS funds for essential facilities renovation
and maintenance expenses impacts patient care, with patients paying the
ultimate price. For example, as our existing medical and behavioral
health facilities age alongside the increased demand for services due
to the COVID-19 pandemic, associated building equipment and components
are deteriorating to a point of failure. This, combined with the
decreasing availability of replacement parts on aged equipment,
significantly disrupts health care service delivery--making it
exceedingly difficult to meet the increased needs for medical and
behavioral health services.
This need is not unique to OKCIC as it impacts all UIOs and their
patients. In fact, NCUIH and 29 other AI/AN-focused organizations
recently sent a joint letter urging Congressional leaders to address
Indian Country's infrastructure priorities, including this legislative
oversight. The National Congress of American Indians also passed a
resolution in support of the UIO facilities fix this past June. This
broad support makes one thing clear--the need is real and the time to
act is now. As a registered nurse, I am aware of what health care looks
like in a quality and well-maintained medical facility; and gambling
with my patients care due to insufficient facilities is not a burden
that I nor any other UIO wants to continue to bear. We are in a race
against time! We need this legislative fix now.
Remove Facilities Restrictions on UIOs
I applaud Senator Alex Padilla (D-CA) and Senator James Lankford
(R-OK) for introducing the Urban Indian Health Providers Facilities
Improvement Act (S. 1797) to allow us to make critical updates and pave
the way for increased investment in renovation and construction of our
facilities by undoing the unnecessary restriction on our funds.
Specifically, this bipartisan bill represents the critical legislative
fix to an oversight in Section 509 (25 U.S.C. 1659) of IHCIA that
prohibits UIOs from using money appropriated through IHS on
infrastructure and facilities improvement projects unless the project
is undertaken to meet accreditation standards from The Joint Commission
(TJC), which is no longer the most used accreditation body among the
vast majority of UIOs. In fact, 40 of 41 UIOs do not utilize TJC
accreditation, with many utilizing other, more applicable accreditation
bodies.
For instance, OKCIC has received full primary care practice
accreditation by the Accreditation Association for Ambulatory Health
Care (AAAHC) for more than 15 years. AAAHC is a nationally accepted
accreditation body, which is even recognized by IHS with an IHS
circular dating back to 1997 encouraging UIOs ``to obtain and maintain
accreditation'' through a ``choice among nationally accepted
accrediting/certifying bodies[,]'' including AAAHC. \1\ IHS even
provides funding for UIOs to attend AAAHC trainings. However, despite
IHS's express encouragement of UIOs choosing to maintain accreditation
through AAAHC, this accreditation nonetheless effectively bars OKCIC
from utilizing IHS funds for any facilities improvements because
Section 509 only expressly mentions TJC, which IHS has interpreted to
exclude UIOs from utilizing IHS funds for facilities improvements.
---------------------------------------------------------------------------
\1\ Indian Health Service Circular No. 97-01, Accreditation/
Certification of Hospitals and Health Centers (effective March 6,
1997).
---------------------------------------------------------------------------
This restriction prevents OKCIC and other UIOs from making
essential facilities improvements and maintenance, which impacts the
provision of services to our patients. This prohibition compounds on
decades of chronic underfunding of UIOs, which has been absent of any
facilities funding. This has real and significant impacts.
For example, as the COVID-19 pandemic was devastating Indian
Country, the whole IHS system had to immediately adjust (i.e.
transition to telehealth, install negative pressurizing rooms, upgrade
air purification systems, and make other facility renovations) to
safely serve patients. However, UIOs were unable to make some of these
necessary improvements because of this restriction, with one UIO even
being denied for installing a new HVAC system that would better purify
and circulate air in the facility. A UIO could not use its funding from
a health agency to make these changes amidst a global pandemic of an
airborne virus that causes severe respiratory illness for health care
staff and patients.
Moreover, this issue predates the pandemic, which only highlighted
an existing problem--the lack of an avenue for using existing resources
for infrastructure improvements at UIOs. In fact, in a NCUIH survey, 86
percent of UIOs surveyed reported a need to make facilities and
infrastructure upgrades, while 74 percent reported unmet needs for new
construction to better serve patients. These needs include, but are not
limited, to the construction of urgent care facilities and infectious
disease areas, capacity expansion projects, ventilation system
improvements, and upgrades to telehealth and electronic health records
systems. All of these upgrades are vital to patient care.
The Urban Indian Health Providers Facilities Improvement Act would
remove this prohibition, immediately allowing UIOs to use their IHS
funding more effectively and efficiently. This bipartisan bill has
widespread support, including within Indian Country as mentioned
earlier and also among policymakers. The House Appropriations
Subcommittee on Interior, Environment, and Related Agencies included
the UIO facilities fix in its FY22 bill; as did the President's FY22
IHS budget, noting it has a zero score. All of this support makes one
thing clear--we must act now to pass this urgent and no-cost
legislative fix.
Finally, this issue is not only urgent and widely supported, but it
is also ripe for resolution, with the Senate this week considering the
largest infrastructure framework bill in history. Because removing this
restriction is vital to the provision of health care to our patients
and the fulfillment of the trust obligation to AI/AN people, we
respectfully request the inclusion of S. 1797 in this infrastructure
package.
Conclusion
S. 1797 is an essential parity issue for UIOs that ensures that AI/
ANs residing in urban areas have access to high quality, culturally
competent health services. For too long, urban Indian health care has
been burdened and limited by an unnecessary restriction on UIO funds
that prohibits us from making critical upgrades. The U.S. has the trust
obligation to provide health care for AI/AN people residing in urban
areas and removing this barrier to the use of existing IHS urban Indian
health funding will bring us closer to meeting that responsibility.
We urge the Committee to enact this legislative fix and continue to
work to enable UIOs to continue providing high quality, culturally
competent care to AI/AN people, regardless of where they live.
The Chairman. Thank you very much to all of the testifiers.
Senator Smith?
STATEMENT OF HON. TINA SMITH,
U.S. SENATOR FROM MINNESOTA
Senator Smith. Thank you, Chair Schatz. I want to thank you
for holding this hearing today and also I want to thank all of
our panelists for being with us.
I would like to touch on the issue of child welfare, and
then also talk a little bit about the Urban Indian Health
Providers bill, which I am proud to cosponsor. First on child
welfare. I want to recognize the tragic discoveries of
children's' remains at the Indian residential school sites in
Canada. These discoveries have forced Native communities to
relive the trauma of boarding school policies and to confront
the conditions and practices in these schools.
Unfortunately, of course, the United States government also
has a long history of separating Native children from their
families, divorcing them from their language and their culture
and their spirituality and disrupting Native communities. This
legacy is shameful. It is long past time that we address it.
Mr. Vigil, I know that in your role in the Native Indian
Child Welfare Association, as well as Executive Director of the
Eight Northern Pueblos in New Mexico, my original home State,
you understand this issue well, even as you focus on providing
and protecting Native children today, both in the child welfare
system and in their own communities.
I am wondering, Mr. Vigil, if you could tell us about how
you see the connection between the Indian boarding school era
and your work today, the work that we have to do today and our
ongoing challenges in addressing child welfare.
Mr. Vigil. Thank you, Senator Smith, for that question.
Certainly, I agree with the comment that you made about what is
happening in Canada. We are seeing similar effects here in the
United States. We applaud Secretary Deb Haaland for her
initiative in addressing this issue in the United States.
Boarding school trauma has affected a lot of our people,
all the way from our young ones to our elders. So today we are
seeing some of that trauma still being connected with some of
the things that are happening with our people. Our efforts are
continuous to provide services, to heal them, from these kinds
of issues. This act certainly will assist us in doing that.
In fact, with COVID, it has become more apparent that we
need more culturally relevant practices to be incorporated with
our programs, so that we can address those issues in a more
meaningful way, with traditional healing practices. This effort
is going to provide services to our people by the funding that
we get appropriated. Thank you.
Senator Smith. Thank you very much. I appreciate your
raising Secretary Haaland's commitment to this issue. I
completely agree with that.
I am really glad to be cosponsoring Senator Warren's
legislation to create a Truth in Healing Commission on Indian
boarding school policies. I look forward to working with this
Committee, Chair Schatz, to understand how this historic trauma
affects so much of the work that we have to do ahead of us
today.
I would like to direct my next question to Ms. Sunday-
Allen. The Indian Health Board, which is an Urban Indian health
organization in Minneapolis, has been in the front lines of the
COVID-19 pandemic for over a year now. Like other UIOs, the
Indian Health Board has struggled to continue providing
services with scarce resources, but of course, they have gotten
creative. They have found ways of using community-driven
solutions to get their patients tested and treated and
vaccinated in the scope of this terrible pandemic.
Despite these added challenges, the Indian Health Board
stands ready to continue trying to figure out how to innovate
and improve their services to benefit the growing indigenous
community in Minneapolis. In fact, the Indian Health Board is
planning on extending and expanding their facilities. I have
heard from Dr. Rock at the IHB that he is unable to spend the
Indian Health Service money on construction, getting exactly at
the issue that we have here. So I am proud to cosponsor this
legislation with Senator Padilla and Senator Lankford.
Ms. Sunday-Allen. could you just talk about how these
restrictions on construction have impacts on UIOs like the
Indian Health Board in Minneapolis?
Ms. Sunday-Allen. First, let me thank you again for
sponsoring this legislation. The story that we are hearing from
your home State is far and wide across Indian Country,
unfortunately, because of the restrictions that this bill has.
A lot of the UIOs, many of the UIOs, I am going to say probably
all of us, have infrastructure needs that we cannot use IHS
funds for. No fault of IHS, it is just that they are following
the letter of the law.
So with this fix, we hope that our facilities will be able
to have those renovations. Some of those renovations will also
help us certainly right now during the pandemic to mitigate
some of the risks we are currently facing each day, just like
those which you mentioned you are seeing in your home State at
your Urban Indian organization that Dr. Rock has.
But again, across Indian Country and in our urban settings,
there is certainly a need for these renovations. A lot of the
facilities are just really cramped for space. A lot of the
infrastructure are old facilities and with that comes old HVAC
systems, old roofs. It is not equipped for the cabling that IT
needs to reach out for our tele-health.
Hopefully, it will fix what I would call the bones of the
operation, the infrastructure, if we can get this fix passed in
S. 1797.
Senator Smith. Thank you so much. You did a great job
painting a picture of why this is so crucial to be able to
provide good, excellent health care.
Thank you, Chair Schatz, for allowing me to go over time.
The Chairman. Thank you, Senator Smith. Senator Hoeven?
STATEMENT OF HON. JOHN HOEVEN,
U.S. SENATOR FROM NORTH DAKOTA
Senator Hoeven. Thank you, Mr. Chairman.
A question for both Deputy Director Grinnell and Senior
Advisor Todacheene. A question for both of you, H.R. 1688 would
update and reauthorize three programs established by the Indian
Child Protection and Family Violence Prevention Act. What
changes does H.R. 1688 make that you believe are important
updates to the program? If I can, Heidi, I would ask you to
start.
Ms. Todacheene. Sure. Thank you, Senator Hoeven, for having
me speak here today. Some of the updates that are critical in
the program from the past bill language, it would expand
services, funding for the services to be expanded to the Urban
Indian organizations, and as you know, those are critical
services to help tribal communities, especially in places where
American Indians and Alaska Natives don't have access to some
of the services on reservations.
Then it also increases the funding from the original text
of the bill, and that is critical, due to inflation rates. And
just providing some of the base funding opportunities for
tribes. Again, as you know, there are issues with tribes
getting funding or professionals to very rural locations on
reservations as well. Some of these services are not
reimbursable under Medicaid.
I see those as two critical provisions that have been
expanded or included in the updated text.
Senator Hoeven. If you would expand a little bit on some of
those services that you think are particularly important.
Ms. Todacheene. The services that are just included in the
bill generally?
Senator Hoeven. Yes, the services that it would provide
funding for that are critically important.
Ms. Todacheene. Yes. This bill is unique because right now
there is no tribal-specific preventive services for child abuse
and neglect in Indian Country. As you know, there is child
welfare service funding available. But this is specific to
preventive services.
So some of those services that it helps bolster to both the
National Resource Family Service Center and then also to the
Protection and Family Violence Prevention Program, help improve
inter-governmental work and coordination. Then funding to help
investigate training that would bolster judicial services in
tribal courts.
Senator Hoeven. Thank you.
Let me ask Deputy Director Grinnell, the National Indian
Child Resource and Family Services Center was authorized by the
Indian Child Protection and Family Violence Prevention Act, but
wasn't established. Why wasn't the center established after it
was authorized? What gaps existed that the center would play a
role in filling?
Mr. Grinnell. Thank you, Senator, for that question.
My understanding is that there was never any funding that
was appropriated for that particular activity. So going
forward, one of the things I did want to mention, you asked
about several of the programs that would be available now under
this particular bill. It actually authorizes treatment programs
for Indians where in the past it did not specify that. It also
is going to allow $30 million per year in grants that would be
made available to tribes as well as the urban programs that
Heidi mentioned earlier.
It also requires IHS to provide culturally appropriate
treatment services and programs.
Senator Hoeven. Okay. So it is just the funding that has
been the issue as far as getting it established?
Mr. Grinnell. Yes, sir.
Senator Hoeven. Okay.
In regard to 1895, the Indian Health Services Sanitation
Facilities Construction Enhancement Act, how does the
additional funding in this bill, how is it going to be used and
allocated?
Mr. Grinnell. Thank you for that question, Senator. As
members of Congress are well aware, the IHS Sanitation
Facilities Construction Program has used the methodology that
is referred to as the Sanitation Deficiency System. That
program starts with communication and coordination at the local
level, with tribes and with IHS staff as well as tribal
contracted staff. As they begin to build the need, that
information is actually put into the system. It is reported
annually to Congress.
As stated earlier in both my testimony as well as others
today, that current unmet need is over $3 billion right now. So
any funding that comes forth with this particular bill will be
directly targeted at those priority projects that have been
established within the priority system.
Senator Hoeven. Thank you, Mr. Grinnell. Thank you, Ms.
Todacheene. I appreciate it. And thank you, Mr. Chairman.
Senator Smith. [Presiding] Thank you.
Next, we have Senator Lujan.
STATEMENT OF HON. BEN RAY LUJAN,
U.S. SENATOR FROM NEW MEXICO
Senator Lujan. Thank you, Chair Smith. It is an honor to be
with you and to Chair Schatz and Vice Chair Murkowski for
holding this hearing to review important legislation, the
Indian Health Services Sanitation Facilities Enhancement Act,
which provides $3 billion to IHS for sanitation projects, and
the Native American Child Protection Act, with Senator Rounds,
Representative Gallego, Representative Young, to ensure Native
communities have the resources they need to help prevent and
treat child abuse are two pieces of legislation that I
introduced that we are reviewing today. I want to thank our
witnesses for being with us.
First, I want to share a story of a constituent I am
honored to represent by the name of Helene Archeletta. Helene,
who sadly does not have running water and wastewater where she
lives in Councilor, New Mexico, is one of the families, one of
too many families that does not have running water in the
Navajo Nation. Many residents must drive 40 or more miles every
day to haul water home for drinking, cooking, and bathing. The
lack of local water infrastructure makes it difficult for
residents to follow CDC guidelines for sanitation and hygiene
in order to stop the spread of COVID-19.
President Nez, I was hoping I could ask you a question, and
I am asking a yes or no question. President Nez, yes or no, did
the lack of basic utilities like running water hurt the Navajo
Nation's ability to respond to and mitigate the COVID-19
pandemic?
Mr. Nez. Absolutely, yes.
Senator Lujan. President Nez, yes or no, would providing
IHS with additional funding for water projects save lives and
strengthen the Navajo Nation's ability to respond to and
recover from the pandemic?
Mr. Nez. Yes.
Senator Lujan. President Nez, I think I read in your
testimony that you included between 9,000 and 16,000 households
who currently do not have access to running water in their home
on the Navajo Nation. Is that accurate?
Mr. Nez. Yes.
Senator Lujan. President Nez, I am hoping I can work with
you to make sure we are able to share where that data came
from, so we can work together in that space. Thank you so much
for that.
President Nez, what would access to water mean for the
Navajo people's quality of life, for those who are not
currently connected to running water?
Mr. Nez. Thank you, Chairman and members of the Committee,
Senator Lujan, for that question. The improvement the quality
of life that many U.S. citizens take for granted turning on
that faucet in the home. Because of the pandemic, it elevated
this problem to number one.
Of course, you always need electricity. Electricity pulls
water into various communities. Right now we are going through
a drought, as you know, Senator, here in the southwest. The
need for water is critical for our animals, our farms, and our
hygiene. If we are going to push back more on COVID-19, we need
to be able to get running water.
So some of our Navajo citizens haul water, and they bring
the water home. You have to put it in our world view as an
indigenous person, the first allocation of water that you bring
home goes to your animals, because they sustain life, and it
goes to the farms. Then whatever is there after that goes to
drinking water. Whatever is left over is for hygiene.
I saw the numbers, I think we hit national media attention
that we got hit hard here on the Navajo Nation. Just imagine if
you had running water how many of these deaths would not have
to be. Some of our people are going through the long-term
health problems from catching COVID-19.
So I appreciate that question. I think we have the ability
to fix this problem within Indian Country.
Senator Lujan. Thank you, Mr. President.
Mr. Grinnell, would any of the projects on the deficiency
list provide water to the Native communities in Councilor, New
Mexico, where Helene lives?
Mr. Grinnell. Thank you, Senator, for that question. The
information that I was provided, yes, there is a project on the
SDS for 60 scattered homes that will provide water to several
communities, including Councilor. They have identified seven
homes in the Councilor community that would be on that project.
Senator Lujan. Mr. Grinnell, what would $3 billion in
appropriated funds for the IHS Sanitation Facilities
Construction account mean for IHS's ability to complete the
backlog of sanitation deficiency projects?
Mr. Grinnell. Yes, Senator, thank you for that question.
The $3 billion would go a long way in providing all the funding
necessary to complete all those projects. One point I would
like to make, that in addition to the $3 billion this bill is
proposing for the projects, it would take an additional $700
million or more of other funding in order to complement the $3
billion that would be made available to IHS to successfully
complete all those projects, both the feasible and those ones
that are more expensive to complete.
So it is an expensive proposition all the way around. But
the $3 billion would go a long way in addressing this unmet
need.
Senator Lujan. Thank you. Chair Smith, thank you so much
for your time today.
Governor Vigil, I apologize, I didn't have time to ask you
questions. It is an honor to see you as well, my brother from
Tesuque Pueblo. Thank you again, Chair Smith, and I will be
submitting the rest of my questions to the record.
Senator Smith. Thank you, Senator Lujan.
Senator Daines?
STATEMENT OF HON. STEVE DAINES,
U.S. SENATOR FROM MONTANA
Senator Daines. Thank you, Senator Smith.
First, I would like to thank our witnesses for being here
today. We have taken a look at the data and found that as of
2018, there are 63, 63 facilities in Montana that were listed
on the Indian Health Services Sanitation Facilities Program's
list of deficiencies. As we have seen throughout the Country, a
lack of proper sanitation and infrastructure has exacerbated
the impact of COVID-19 in Indian Country. I led the effort to
get tribes the access to assistance they needed to combat the
pandemic in one of the most important bipartisan bills we
passed last year.
However, we have seen fundamental shortfalls in tribal
infrastructure that has helped cause Indian Country to be hit
harder by COVID-19 than the rest of the Country.
Mr. Grinnell, under the Indian Health Service's current
regulations, is it correct that IHS sanitation funding cannot
be used to provide access to water and sanitation for non-
residential facilities, even for schools, for grocery stores
that are much-needed, to address education in some of the food
deserts we see in Indian Country?
Mr. Grinnell. Thank you, Senator, for that question. You
are correct in that the funding that IHS has appropriated from
Congress since the program started back in 1959, with Public
Law 86-121, those funds have to be targeted for Indian homes
and communities.
Any time that there is a project that goes beyond those
residential needs and has to locate any commercial or other
type of needs, that funding has to come from another source
other than IHS.
Senator Daines. Thank you. So the IHS program does not
provide services to extremely critical components of a
reservation's community, such as schools or other forms of
economic development. So the question is then, are these needs
even included in the IHS current deficiency list, and if not,
do we really have a true picture of the sanitation deficiency
in Indian Country?
Mr. Grinnell. Thank you for that question. They are not
included on the SDS as it is provided to Congress. As I
mentioned earlier, and made the point about, there is over 800
of these projects that would require over $700 million of other
funding. In many cases, IHS will work with other Federal
agencies and other entities and they will provide their funding
to the IHS project. They will in turn collectively complete
that project and address both the residential, community, and
even commercial needs of a given community.
Senator Daines. I think many in the community want to know
what steps IHS takes that might better address sanitation needs
in Indian Country?
Mr. Grinnell. Thank you, sir. One of the things that, as I
mentioned earlier, is all the projects that are developed are
done so in consultation with the tribes, with those tribal
communities, and with our engineering staff. As they develop
these project lists, then they are ranked and prioritized based
on available funding.
So the ranking of those projects is actually done so in
consultation with those local communities, so that they
establish what the most priority projects need to be going
forward.
Senator Daines. Mr. Grinnell, thank you. Chairman Schatz, I
yield back.
The Chairman. [Presiding] Senator Cortez Masto.
STATEMENT OF HON. CATHERINE CORTEZ MASTO,
U.S. SENATOR FROM NEVADA
Senator Cortez Masto. Thank you, Mr. Chairman, and Ranking
Member Murkowski.
Ms. Sunday-Allen. let me start with you. Thank you to the
panelists and thank you for this discussion today.
One of the issues I am most concerned about as we emerge
from the public health emergency is the impact that this health
pandemic has had on the mental health and wellness of Native
families. In your testimony, you mentioned that the inability
of the Urban Indian organizations to utilize their IHS funding
for facility and infrastructure needs has meant that patients
pay the ultimate price, especially as there is an increase in
demand for medial and behavioral health services due to the
COVID-19 pandemic.
Ms. Sunday-Allen. can you talk more on how this fix to S.
1797 would impact behavioral health and medical services?
Ms. Sunday-Allen. Yes, and thank you for that question.
When we think about mental health and medical, I hope that
we are thinking of it as all one, that is encompassing. I think
a lot of times they are considered separately, and it should
not be so. The brain can be diseased, just like every other
part of the body.
So when I think about this infrastructure bill, I think
about it holistically in that it is not just a fix for
facilities or for the medical side of the house, but it
encompasses the entire framework of all the services that we
provide, including mental health, behavioral health, substance
abuse.
In turn, the bill, this fix, would encompass exactly what
you are talking about and that is addressing those mental
health, behavioral health issues that we have seen certainly
now coming more so out of the pandemic. So I do believe that
this is something that will enable us to continue to focus on
our much-needed behavioral health components with this
legislative fix. So thank you for that question.
Senator Cortez Masto. Thank you. And thank you for your
comments. I agree 100 percent that they shouldn't be put in
buckets or silos separate from one another. They are one and
the same. They should be treated that way, and funded. People
should be able to fund them and access these services in the
same way. There should be parity.
So I completely agree with you, and I hope to work with you
on this issue even more so to make sure we are providing
adequate services along with the medical services, behavioral
services, and wellness services that we need for Indian
Country.
President Vigil, with respect to 1688, the Native American
Child Protection Act, in your testimony you mentioned elements
of success in child maltreatment in Indian Country consisting
of culturally competent programs, successful collaboration
among different governments, strong understanding of familial
connections, and locally based community services.
Can you elaborate for me on how this legislation would aid
in bolstering these elements of success and solutions that
tribes are currently employing? Specifically, how will smaller
tribes across Indian Country be able to obtain the support they
need in implementing these efforts?
Mr. Vigil. Thank you, Senator Cortez Masto. Here at Eight
Northern, we have embarked on a journey. By no means do I want
to criticize anybody, but we are calling it decolonizing
ourselves from western models and concepts of how we do our
work throughout Eight Northern. In our efforts, we have come to
recognize that the way we address these issues is that we have
to go to our communities and we ask the questions in our
communities, from our people. So we came up with a project, we
are calling it Of the Community, For the Community. That is
basically asking the tribes what their concerns and what their
needs are. So we are moving in that direction.
Certainly, this act will allow us to seek funding, and not
just Eight Northern, but all the tribes throughout the Country.
I think we are looking at going to more of a culturally
appropriate healing process. Certainly, the western model is
still working. But our effort is to gap that bridge and bring
it together, so that our services are going to be provided in a
way that many of our people will have a better healing process,
if you will.
With the pandemic, a lot of these things have been brought
to the forefront. Certainly, being from a community of Pueblo,
where we couldn't hold our ceremonies, and this is throughout
Indian Country, the very thing that we did to heal ourselves
was taken away. We couldn't do our cultural ceremonies, our
dances, our songs, as we did in gatherings.
So even that has an impact on our people. Now that we are
coming out of COVID an moving forward, I hope that we can
really bring those back, but more at a level that will address
the need for healing of our community and our people in
general, throughout Indian Country.
Senator Cortez Masto. I do, too.
Thank you so much. Thank you to the panelists.
The Chairman. Senator Lankford.
Senator Lankford. Thank you, Mr. Chairman.
Robyn, it is good to see you. Thanks for being here and
thanks for your testimony today. I want to pummel you with a
few questions to get some things on the record on it.
Robyn, can you talk us through just the decision on
accreditation, the accreditation from AAAHC, how that actually
works, how you receive your accreditation and the process for
making a decision and the cost, if you can give us any details
on that.
Ms. Sunday-Allen. Sure. Thank you, Senator, for the
question. Yes, we chose AAAHC over Joint Commission when we
first became accredited back in 2004. Threefold: one, it was
substantially more cost effective for us. We have to hang onto
every dollar that we get. It was over half the cost it would
have cost us if we had went with the Join Commission. Secondly,
AAAHC was more of a fit as well as for the other UIOs. The
Joint Commission was originally set up to accredit inpatient
hospital settings. AAAHC has always been in the mission of
accrediting outpatient ambulatory sites like the UIOs, and like
Oklahoma City Indian clinic.
So we chose, for those two reasons. Then lastly, AAAHC has
surveyors that are oftentimes from the ITU, the IHS tribal or
urban settings. So our experience has been, we have had two
retired IHS pharmacists as surveyors, one urban CEO, and two
retired IHS physicians. So it has been a great experience for
us because they know the type of patients that we serve and the
infrastructure and the ITU system. So it has been a great fit
for the UIOs, including Oklahoma City.
Senator Lankford. Was IHS supportive of this accreditation
decision, to go with AAAHC?
Ms. Sunday-Allen. Yes, so much so that they offered to
provide ongoing trainings for UIO. I have actually provided
some of those trainings for our Oklahoma City IHS area, for new
CEOs, that they have training there. So we have had a great
deal of support.
Senator Lankford. But you have been limited in the use and
flexibility of your funds based on your accreditation when IHS
has supported it, when AAAHC is a well-recognized entity, meets
the cost objectives. Can you talk us through any limitations
that you have had specific projects or things that you have
been denied or a process that you have had to make your
decisions different based on that accreditation?
Ms. Sunday-Allen. Yes, Senator. We actually have had
several asks, one most recently was to renovate our ambulatory
car lobby to make it more friendly during--when I say friendly,
actually wanting to mitigate the risk of COVID-19 in our lobby.
We were denied that request because it wasn't tied to Joint
Commission accreditation.
Prior to the pandemic, we had asked for a new HVAC system
and upgrades to our aging parking lot, because we were having
some patients and employees fall in our parking lot. Because
those two asks were not tied to Joint Commission accreditation,
we were not able to utilize our funds.
So what we ended up doing was taking revenue from what
could have gone to patient care into infrastructure fixes so
that we could make our place, the facility safe for our
patients.
Senator Lankford. But the bill we are discussing today
would eliminate that disparity, so that you have greater
flexibility, is that correct?
Ms. Sunday-Allen. That is correct.
Senator Lankford. Okay. Thank you, by the way, for that,
Robyn, very much.
Mr. Grinnell, I want to ask you a quick question. I do
appreciate that in the fiscal year 2022 Congressional
justification IHS is including some encouragement, I would say,
toward this. Are there any reasons that you see that
accreditation limitations should still exist based on a
preference for one accreditation or another, as long as they
are a recognized accreditation?
Mr. Grinnell. Thank you, Senator, for that question. No,
sir, I do not see any reason to expand accreditation beyond the
Joint Commission. As Ms. Sunday-Allen has mentioned, AAAHC is
more preferred among the UIOs and would be more appropriate for
that group.
One thing I do also want to mention in addition to the
testimony by Ms. Sunday-Allen is that the UIO program does have
a $1 million infrastructure study that they will begin at the
end of this calendar year and continue through the end of next
calendar year. The idea is to gather information about all the
41 UIOs in terms of their infrastructure needs and make that
information available.
Senator Lankford. So you do not see a gain in all UIOs
having the exact same entity for accreditation? You see a gain
in them having flexibility, or at least not a problem with them
having flexibility for their accreditation?
Mr. Grinnell. Letting them have the flexibility.
Senator Lankford. Okay, thank you for the clarification on
that. I appreciate it very much.
Thanks, Mr. Chairman.
The Chairman. Senator Tester?
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. Thank you, Mr. Chairman.
My first question is for Robyn Sunday-Allen. First of all,
I want to thank all the folks who testified.
Robyn, my question, since you are with the National
Congress of Urban Indian Health, were Urban Indian Health
Centers distributed vaccines to be able to put in Native
American's arms?
Ms. Sunday-Allen. Yes, sir, we were. We had a choice to go
with our State or go to HHS, IHS, to receive our vaccines.
Senator Tester. But they could also go through Urban Indian
Health Centers, correct?
Ms. Sunday-Allen. Yes, correct.
Senator Tester. So tell me why, tell me why we have heard
from some urban tribal members in Montana that have been unable
to secure vaccinations where they live that have had to travel
to Indian Country and to reservations to get to those
facilities? Is it simply because they didn't have an Urban
Indian Health center? Or is there another reason?
Ms. Sunday-Allen. I would think that that is exactly what
it is, was just the access to the vaccine in certain locations.
I have heard that it was rolled out later in a lot of, across
Indian Country. Here in Oklahoma, we were fortunate enough to
be early in the game. But I have heard stories that you are
absolutely right, that there was limited access. So we saw
Indian people having to travel far and wide for vaccines.
Senator Tester. Have you been able to do any surveys or
have any of the panelists been able to do any surveys as far as
uptake in vaccination rates in urban areas versus reservations?
I know the uptake in Montana, the reservations, is quite high.
Maybe the highest in the State overall. Is there any comparison
on the vaccination rate uptake in urban towns, or the urban
Indian population versus on the reservation?
I am not hearing any answers, so I assume we don't have
that. Okay.
Another topic. Mr. Grinnell, are you familiar with 1895,
Senator Lujan's bill?
Mr. Grinnell. Yes, sir, I am.
Senator Tester. Okay. I think it was Senator Daines that
asked about sanitation dollars, if they could go to places like
schools and hospitals, and you said no, it is specifically for
Indian homes and communities. Correct?
Mr. Grinnell. Yes, sir.
Senator Tester. So I assume communities does not include
hospitals, retail stores, schools, those kinds of things?
Mr. Grinnell. No, sir.
Senator Tester. Who made that call?
Mr. Grinnell. That is actually in the initial Public Law
86-121 legislation that established the sanitation facilities
construction program for IHS.
Senator Tester. I appreciate that perspective.
It looks to me like it could have been interpreted
differently, but we will stick with what you have. Does Senator
Lujan's bill, does it allow for investments in sanitation
facilities to be used with schools, hospitals, retail outlets
in Indian Country?
Mr. Grinnell. Thank you for that question, Senator. The
funding that is proposed in that bill is targeted to address
the needs of Indian homes and communities and does not include
funding that will address those other considerations.
Senator Tester. Good. If Senator Lujan is listening, I
would ask him to take a peek at that to see if we can change
that. It makes a lot of sense to deal with homes first. But I
think we also should be dealing with other entities in Indian
Country that are deficient when it comes to sanitation
facilities. I think it is very, very important.
That is about all I have for this. I want to thank the
Chairman for allowing me to get in to ask a few questions.
The Chairman. Thank you, Senator Tester.
Senator Lankford has a 30-second question.
Senator Tester. I just wanted to be able to comment to
Senator Tester as well, just to spike the football a little bit
on this. When you were asking Robyn about vaccination rates, we
had a very, very efficient system for vaccinations in Oklahoma
among our tribal leaders and UIOs. In fact, I was tracking and
watching our tribes in Oklahoma and Washington, D.C. to see who
was actually vaccinating faster. Our tribes were vaccinating in
Oklahoma much faster than what was actually happening in
Washington, D.C. itself.
So it was a very efficient system, and there is a lot that
we can actually learn from how the tribes were handling the
vaccines in Oklahoma, and the distribution system they put in
place.
Senator Tester. I appreciate that. All I would say is that
you are exactly correct. By the way, in Indian Country they got
the vaccinations distributed very, very well, too. It is when I
hear urban areas, and the world has changed now from what it
was in March, when vaccinations were hard to get. But in urban
areas, where they weren't quite as efficient, I think we should
find out why, that is all. I know you don't have any
reservations in Oklahoma, but that is it, yes.
Senator Lankford. Thanks.
The Chairman. Senator Cantwell.
STATEMENT OF HON. MARIA CANTWELL,
U.S. SENATOR FROM WASHINGTON
Senator Cantwell. Thank you, Mr. Chairman. I thank you and
Senator Murkowski for holding this important hearing.
I wanted to ask Ms. Sunday-Allen, how long can we continue
to go on without fully funding the urban FMAP, and what effect
does it have on Urban Indian health, the fact that we don't
have a fix for this?
Ms. Sunday-Allen. Thank you for that question. It is
unfortunate, because it is detrimental to Urban Indians not to
have a 100 percent FMAP. I would just like to say that the $3
billion that is being discussed today, not one dollar of that
will go to UIOs. So having that 100 percent FMAP would
certainly be a game changer for our facilities, because getting
less than 1 percent of the overall IHS budget is very difficult
to run a program and do it efficiently when you are
appropriated less than around $600 per patient compared to some
of the other national programs that are getting upwards of
$4,000 or $5,000 per patient.
So it is critical to get 100 percent FMAP approved.
Senator Cantwell. How can we continue to have this gap in
Urban Indian health? Are we just really treating Urban Indians
differently than others in, say, rural parts of the United
states?
Ms. Sunday-Allen. There is definitely a parity issue. I can
agree to that. It is just longstanding. But we appreciate this
Committee working very hard to get us the parity that we
deserve in the ITU system.
Senator Cantwell. Thank you.
Mr. Grinnell, or Ms. Todacheene, how much long is it going
to take us to fix this?
Mr. Grinnell. Senator, could you repeat that question?
Senator Cantwell. How much longer is it going to take us to
get full FMAP funding for Urban Indian health?
Mr. Grinnell. Yes, thank you, Senator.
Senator Cantwell. I have a lot of people in Seattle who are
waiting, and Portland and probably even Honolulu, although I am
not sure.
Mr. Grinnell. Yes, Senator. And from what I understand,
there is a temporary two-year approval that now allows the
States to enter into negotiations with Urbans to allow them to
do 100 percent FMAP over the next two years. So we hope to
continue to work with CMS and with the UIOs to make that a
permanent fix.
Senator Cantwell. Okay. How long before we can get this
program, I think which we got as part of the last COVID
package, how long will it take for that to take effect?
Mr. Grinnell. I will have to provide that back to you. I am
not sure about the duration on that. But we will get that
information and provide it to you.
Senator Cantwell. I appreciate that.
This is, it really is about parity, and the inequity that
exists in the law. So the challenges facing all of that
inequity during the COVID pandemic really made it a lot
tougher. So we really do want to get parity, and we want to get
that now, and we want to get it permanently fixed.
But we also want to show with these funds that we can get
out the door right now why this is so critical and the
difference it makes in serving and delivering health care in
urban parts of the United States. We have a very big Urban
Indian population that covers tribes from many parts of the
United States that just happen to live in the Seattle area.
Thank you very much. Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Cantwell.
Ms. Todacheene, how does the work of the National Indian
Child and Family Service Resource Center and its advisory board
differ or complement the work currently being done by the Alyce
Spotted Bear and Walter Soboleff Commission on Native Children
that is charged with conducting a comprehensive study on Native
children?
Ms. Todacheene. Thank you, Chairman Schatz. To answer your
question, the Alyce Spotted Bear Commission, that studies
programs and grants to support Native children through
government agencies and tribal communities to help develop
systems to delivery wraparound services for them. The advisory
board under this bill advises the National Resource and Family
Services Resource Center on best practices to provide tribes
for child abuse and treatment prevention programs.
So the commissions differ because one advises on how to
carry out abuse treatment and prevention activities, and the
Alyce Spotted Bear Commission analyzes the grant programs to
support Native children.
The Chairman. Thank you.
President Nez, your testimony highlights the urgent need
for Congress to provide sanitation infrastructure for the
Navajo Nation. Can you explain for the Committee and for the
record how the lack of sanitation facilities affects overall
health, the overall health of communities on the Navajo Nation?
What benefits would providing sanitation infrastructure, in
addition to the obvious health benefits, bring to the Navajo
Nation?
Mr. Nez. Thank you, Chairman Schatz, and members of the
Committee. Thank you, Chairman, for that question.
Just to give you an overview, NTUA, the Navajo Tribal
Utility Authority, states that for water, 16,000 of the Navajo
residents do not have access to running water. Electricity,
over 14,000 of our citizens don't have electricity. We need
both in order to provide drinking water. As you know, because
of the uranium legacy here on Navajo Nation, some of these
wells are contaminated with uranium, too, and of course that's
health.
But in terms of economic development, and Senator Tester
mentioned earlier the need for getting water into communities
is important. That way economic and community development
projects can get developed.
The other thing I wanted to mention on that note is that
there has been much money coming into Indian Country. We thank
the Senators and our Representatives and the President and Vice
President for that infusion of dollars into Indian Country. But
there is also a regulatory change that needs to happen within
Federal trust lands, so that we can be able to get construction
projects done more quickly. We have allotted money and there is
a timeline in the process right now that we have to abide by.
But it is hard, as you were saying, the IHS has some
regulatory processes, the Bureau of Indian Affairs has another
process. I would hate for some of our tribes to be sitting on a
lot of these, maybe ARPA monies, CARES Act monies, where we
could be able to provide water to communities and electricity
for the permanent needs of our Nations.
So those are things that we would like for Congress to
address as well, alongside the need for water and sanitation.
Thank you.
The Chairman. Thank you very much.
My final question, and I will submit a few additional
questions for the record, Mr. Grinnell, the most recent IHS
sanitation deficiency report outlines nearly $2.6 billion in
tribal sanitation infrastructure needs. Here is the interesting
part from my standpoint. It breaks down those unmet needs into
something that you call feasible and infeasible.
What does that even mean? It seems to me that what you are
actually saying is that some things are more expensive than
others. But it is public policy whether or not we fund it. It
is not a matter of it being technically infeasible. Someone is
just drawing a line between types of projects based on cost per
unit connected or whatever it may be.
But infeasible is not the right word to use if what you are
saying is high cost.
Mr. Grinnell. Yes, thank you for that question, Senator.
You are correct; it is the projects that are more expensive to
complete versus those that are determined to be more
economically cost effective to complete. At the end of the day,
the need still does exist across Indian Country to address both
projects. As we have identified in our report to Congress, that
need still is over $3 billion.
The Chairman. I don't want to nitpick here, but it is not a
trivial thing if you report back to Congress that certain
projects are infeasible, because that creates a political and
public policy making context in which, what, we are going to
fund infeasible projects? So I think it is really worth it for
the Department to change its language as it relates to the cost
of projects. We are doing rural broadband. And there is a big
cost per connect if you are in hilly West Virginia or a vast
square State in the middle of the Continental United States, or
trying to connect the northwest Hawaiian islands.
But nobody calls that infeasible. We have decided as public
policy that we are going to try to connect everybody with
broadband infrastructure, even if it is obviously cheaper to
connect people in places where there is density than where
there is not.
I know this may sounds like sort of a linguistic
nitpicking, but it is not that. I think the Department is in no
position to tell us what is feasible and infeasible. All they
can tell us is how much something might cost. I am wondering if
you can please make that change.
Mr. Grinnell. Yes, sir, we will take that back. I did look
up some of the information that drives that particular category
of feasible and infeasible. That was actually developed based
on the IHS health facilities cost index and the Department of
Housing and Urban Development's total development cost index.
Again, those were determined in order to prioritize projects,
based on input from the tribes locally as well as the
engineers, in determining which projects would rank as the
highest priority.
I will take that information back. Thank you, Senator.
The Chairman. Yes. It is just that if you use that
philosophy for government spending and government
infrastructure, Laupahoehoe never gets a public library, right?
And lots of tribal communities never get roads, and clinics,
and electricity infrastructure because the cost per person
served is going to be higher in rural areas, in hard to serve
areas.
So we do think this is important to get right, and we will
follow up with you.
If there are no more questions for our witnesses, members
may also submit follow-up written questions for the record. The
hearing record will be open for two weeks.
I want to thank all the witnesses for taking their time
today and providing their testimony. This hearing is now
adjourned.
[Whereupon, at 4:02 p.m., the hearing was adjourned.]
A P P E N D I X
Prepared Statement of Esther Lucero, President/CEO, Seattle Indian
Health Board
Legislative Request
In alignment with the President Biden's Fiscal Year (FY) 2022
Indian Health Service (IHS) Congressional Justification, we
respectfully request your support of S. 1797 Urban Indian Health
Providers Facilities Improvement Act or consider including this no-cost
legislative fix provision in the upcoming infrastructure package.
Healthcare Informed by Indigenous Knowledge
SIHB is one of 41 IHS-designated Urban Indian Organizations (UIO)
in the Urban Indian Health Program and a HRSA 330 Federally Qualified
Health Center, which serves nearly 5,000 American Indians and Alaska
Natives living in the greater Seattle, Washington area. Nationwide,
UIOs operate 74 health facilities in 22 states and offer services to
over 2.2 million American Indian and Alaska Native people in select
urban areas. As a culturally attuned service provider, we offer direct
medical, dental, traditional health, behavioral health services, and a
variety of social support services on issues of gender-based violence,
youth development, and homelessness. We are part of the Indian
healthcare system and honor our responsibilities to work with our
tribal partners to serve all tribal people by supporting the community
and health needs of the over 71 percent of American Indian and Alaska
Native people living in urban areas.
Our research division, the Urban Indian Health Institute (UIHI), is
a public health authority and IHS-designated tribal epidemiology
center--the only national tribal epidemiology center serving more than
60 UIOs nationwide. UIHI recognizes research, data, and evaluation are
integral to informed decisionmaking by policy and funding partners.
UIHI assists Native communities in making data-driven decisions,
conducting research and evaluation, collecting and analyzing data, and
providing disease surveillance to improve the health of our entire
Native community.
Documented Infrastructure Needs for IHS and Tribal Health Facilities
The chronic underfunding of IHS and tribal health facilities is
well-documented by IHS, \1\ Congressional committees, \2\ the
Government Accountability Office, \3\ and the United States Commission
on Civil Rights. \4\ Currently, the IHS Division of Facilities and
Construction has a backlog of $515 million and it is not uncommon for
IHS or tribal health facilities to be on the waitlist for construction
and renovation projects for over 10 years. \5\ The IHS line item for
facilities and construction is and should continue to be reserved for
the enormous backlog in facility needs of tribal nations and IHS direct
facilities.
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\1\ Indian Health Service. Annual Congressional Justifications.
FY2009-FY2018. Retrieved from: https://www.ihs.gov/budgetformulation/
congressionaljustifications/
\2\ House Committee on Energy & Commerce. (2017). Walden and
Pallone Announce Bi-partisan Taskforce to Examine Indian Health
Service. Retrieved from: https://energycommerce.house.gov/newsroom/
press-releases/walden-pallone-announce-bipartisan-task-force-to-
examine-indian-health
\3\ United States Government Accountability Office. (2018). Indian
Health Service: Spending Levels and Characteristics of IHS and Three
Other Federal Health Care Programs. Retrieved from: https://
www.gao.gov/assets/700/695871.pdf
\4\ United States Commission on Civil Rights. (2018). Broken
Promises: Continuing Federal Funding Shortfall for Native Americans.
Retrieved from: https://www.usccr.gov/pubs/2018/12-20-Broken-
Promises.pdf
\5\ Indian Health Service. (2016). Health Facilities Construction.
Retrieved from: https://www.ihs.gov/newsroom/factsheets/
healthfacilitiesconstruction/
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Significant Infrastructure Gaps for Urban Indian Health Programs
There is no national level data on the infrastructure needs of
Urban Indian Health Programs. The FY 2020 Appropriations set aside $1
million for IHS to conduct an infrastructure study for UIO facilities
through the Urban Indian Health Program. This report will be the first
of its kind for UIO facilities. Yet, we know from experience that UIOs
operate out of severely aged, inefficient, and overcrowded healthcare
facilities which compromise the provision of critical health services
and contribute to health disparities among urban Indian communities.
For example, SIHB serves nearly 5,000 patients out of an aged facility
and has temporary paused services at our 95-bed in-patient behavioral
health facility due to dilapidating infrastructure. Our current
facility is in need of significant renovations to accommodate a growing
patient population and meet the standards of modern medical practices
including integrated care.
Supplemental Investments Support Facilities Improvements
Recent COVID-19 supplements have allowed for some flexible spending
to address the overwhelming and longstanding infrastructure needs of
UIOs. UIOs have been able to use flexible COVID-19 supplemental funding
from IHS, Health Resources and Services Administration (HRSA), and the
Substance Abuse and Mental Health Services Administration (SAMHSA) to
address minimal improvements to facilities and infrastructure including
testing equipment, vaccine freezers, ultra-violet (UV) ventilation
systems, plexi-glass barriers, telehealth services, and minor facility
renovations to accommodate social distancing. This has demonstrated
that with additional flexible funding, UIOs can implement
infrastructure projects for integrated care models that are patient-
centric to meet the needs of our community.
Structural Barriers to Addressing Infrastructure Needs Among UIOs
Currently, the constraints of the Indian Health Care Improvement
Act (IHCIA) 25 U.S.C. 1659 restrict UIOs from using IHS contract
funding for infrastructure projects. These IHS contract funds and
limited programmatic funding are often the sole source of IHS funding
received by UIOs. UIOs do not receive funding from the IHS Health Care
Facilities Construction line item including construction, maintenance,
leasehold improvements, renovation, and equipment.
UIOs receive less than 1 percent of the IHS budget to deliver
services to the 71 percent of American Indians and Alaska Natives who
live in urban areas. UIOs rely on IHS dollars for operating budgets and
investing in infrastructure is not an option without dedicated
infrastructure dollars and flexible use of funds. Current IHCIA law
prohibits UIOs from making even minor renovations to their facilities
using their annual appropriations unless the renovations are connected
to achieving Joint Commission for Accreditation of Health Care
Organizations (JCAHO) standards. The initial intention of this
provision was to help UIOs maintain or attain specific health center
accreditation, but instead has impeded UIOs from using their already
limited funding for any infrastructure needs in an era where many UIOs
seek a variety of health center accreditations outside of JCAHO.
Amending IHCIA will allow for greater resources to reach UIO healthcare
facilities to enhance quality care, accessibility to care, and improve
health outcomes for American Indian and Alaska Native people.
We thank you for your leadership to improve the health and well-
being of urban American Indian and Alaska Native people.
______
Prepared Statement of the National Indian Health Board
Chairman Schatz, Vice Chair Murkowski, and Members of the
Committee, thank you for holding a legislative hearing on July 21, 2021
to receive testimony on S. 1797, S. 1895, and H.R. 1688. On behalf of
the National Indian Health Board and the 574 federally-recognized
sovereign American Indian and Alaska Native (AI/AN) Tribal Nations we
serve, we submit this testimony for the record on S. 1895.
On May 27, 2021, Senator Lujan, along with Senators Heinrich and
Sinema, introduced S.1895, which requires the Secretary of the
Department of Health and Human Services to provide additional funding
for the Indian Health Service (IHS) sanitation facilities construction
program. Such additional funding would assist in addressing a
significant need in Tribal communities.
Sanitation Conditions in Tribal Communities
Human health depends on safe water, sanitation, and hygienic
conditions. The COVID-19 pandemic 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
negatively impacts the public health of AI/AN communities.
However, according to the IHS, ``at the end of FY 2020 about 7,140,
or 1.8 percent, of all AI/AN homes tracked by IHS lacked water supply
or wastewater disposal facilities. About 112,082, or approximately 28
percent, of American Indian and Alaska Native homes tracked by IHS
needed some form of sanitation facilities improvements.'' \1\
---------------------------------------------------------------------------
\1\ Legislative Hearing To Receive Testimony on S. 1797, S. 1895,
and H.R. 1688 Before the S. Comm. On Indian Aff., 117th Cong. 1 (2021)
(statement of Randy Grinnell, Deputy Director for Management
Operations, Indian Health Service, Department of Health and Human
Services) (emphasis added).
---------------------------------------------------------------------------
For example, in Alaska, the Department of Environmental
Conservation reports that over 3,300 rural Alaska homes across 30
predominately Alaska Native Villages lack running water, forcing the
use of ``honey buckets'' that are disposed in environmentally hazardous
sewage lagoons. \2\ Because of the sordid history of mineral mining on
Navajo lands, groundwater on or near the Navajo Nation 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. \3\ The lack of clean, running water and adequate sanitation
facilities makes disease prevention, especially during the COVID-19
pandemic, far more challenging for Tribal communities.
---------------------------------------------------------------------------
\2\ U.S. Water Alliance. 2019. Closing the Water Access Gap in the
United States. Retrieved from http://uswateralliance.org/sites/
uswateralliance.org/files/
Closing%20the%20Water%20Access%20Gap%20in%20the%20United%20States_DIGITA
L.pdf
\3\ Ingram, J. C., Jones, L., Credo, J., & Rock, T. (2020). Uranium
and arsenic unregulated water issues on Navajo lands. Journal of vacuum
science & technology. A, Vacuum, surfaces, and films : an official
journal of the American Vacuum Society, 38(3), 031003. https://doi.org/
10.1116/1.5142283
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The IHS Sanitation Facilities Construction Program
The IHS is one of the primary providers of community water projects
in Tribal communities. The Sanitation Facilities Construction (SFC)
Program provides many AI/AN homes and communities with essential water
supply, sewage disposal, and solid waste disposal facilities. The IHS
environmental engineers plan, design, and manage most SFC projects.
Many of those engineers are assigned to one of the twelve IHS Area
Offices. The SFC program is an integral part of the IHS disease
prevention effort that could potentially impact approximately 413,454
AI/AN homes.
The IHS has identified a Total Database Cost of $2.57 billion in
estimated costs for 1,563 water infrastructure projects to address
existing drinking water and wastewater needs in its 2019 Annual Report
to Congress on Sanitation Deficiency Levels for Indian Homes and
Communities. Specifically, IHS determined that over 110,500 Native
households need some form of sanitation facility improvement, over
51,700 are without access to adequate sanitation facilities, and over
6,600 are without access to a safe water supply system and/or sewage
disposal system. \4\
---------------------------------------------------------------------------
\4\ Department of Health and Human Services, Indian Health Service.
Annual Report to the Congress of the United States On Sanitation
Deficiency Levels for Indian Homes and Communities, Fiscal Year 2019,
at 7.
---------------------------------------------------------------------------
More than 80 percent of the cost of the highest deficiency level
projects per the IHS sanitation deficiency database were in the IHS
Alaska and Navajo areas. The IHS has not released its 2020 report, but
indicated in its testimony that the cost to fund all needed projects
will rise above $3 billion in fiscal year 2020. For the most part, in a
typical year, the IHS is limited to annual appropriations to fund
feasible water projects identified in the Annual Report, approximately
$196.5 million for FY 2021, to address existing water and wastewater
needs. Additional projects and needs waiting to be added to the
sanitation deficiencies list far exceed that amount, with over $1.1
billion in Alaska Native villages alone. Costs for the much-needed
projects will continue to grow without funding to address the needs.
The IHS estimates that every $1 spent on water and sanitation
infrastructure will save $1.18 in avoided direct healthcare cost. \5\
During FY 2020, 373 sanitation projects were funded at $220 million.
Once constructed, these sanitation facilities will benefit an estimated
143,000 American Indian and Alaska Native people and help avoid over
235,000 inpatient and outpatient visits related to respiratory, skin,
and gastroenteric disease over 30 years. \6\ The health care cost
savings for these visits alone is estimated to be over $259 million.
\7\
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\5\ Department of Health and Human Services. Fiscal Year 2022,
Indian Health Service, Justification of Estimates for Appropriations
Committees, at CJ 224.
\6\ Id.
\7\ Id.
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S. 1895--the Indian Health Service Sanitation Facilities Construction
Enhancement Act
Funding. The bill, S. 1895, the Indian Health Service Sanitation
Facilities Construction Enhancement Act authorizes an additional $3
billion for fiscal year 2022 (available until expended) for the
planning, design, construction, modernization, improvement, and
renovation of water, sewer, and solid waste sanitation facilities. Of
that amount, $350 million is set aside for additional staffing support
to carry out this Act. These amounts are in addition to funds provided
for under any other provision of law. These amounts will contribute to
addressing the significant sanitation deficiency levels identified in
Tribal communities.
Project Eligibility. The bill requires that the Secretary shall
prioritize sanitation facilities in accordance with the IHS Sanitation
Deficiency System established pursuant to 302(g) of the Indian Health
Care Improvement Act (25 U.S.C. 1632(g)).
According to the IHS, the Total Database Estimate of $2.57 billion
for FY 2019, and $3.09 billion projected for FY 2020, includes both
economically feasible and infeasible projects. However, those projects
determined to be economically infeasible, according to the IHS, are not
eligible for IHS funding. \8\ The bill does not prohibit the
economically infeasible projects from being funded.
---------------------------------------------------------------------------
\8\ Department of Health and Human Services, Indian Health Service.
Annual Report to the Congress of the United States On Sanitation
Deficiency Levels for Indian Homes and Communities, Fiscal Year 2019,
at 8-9. (``The feasible project cost estimate forms the basis for the
IHS Funding Plan, which is used for developing budget requests and for
allocating appropriated funds to the IHS Areas. Projects with high
capital costs on a per-home basis are considered infeasible and are not
considered when allocating appropriated funds to the Areas by IHS
headquarters.'')
---------------------------------------------------------------------------
The IHS also cites a national average of four years for the design
and construction of the feasible projects. \9\ The 2019 Annual Report
notes that there are 1,088 feasible and 475 infeasible projects. \10\
The average project length and number of projects creates a significant
waiting period for the projects. The amount of funding in the bill made
available immediately until expended should serve to reduce the waiting
period.
---------------------------------------------------------------------------
\9\ Legislative Hearing To Receive Testimony on S. 1797, S. 1895,
and H.R. 1688 Before the S. Comm. On Indian Aff., 117th Cong. 1 (2021)
(statement of Randy Grinnell, Deputy Director for Management
Operations, Indian Health Service, Department of Health and Human
Services)
\10\ Department of Health and Human Services, Indian Health
Service. Annual Report to the Congress of the United States On
Sanitation Deficiency Levels for Indian Homes and Communities, Fiscal
Year 2019, at 9.
---------------------------------------------------------------------------
The IHS has indicated that ``[a]ll projects are re-evaluated
annually to determine whether the costs and priority scoring factors
have changed.'' \11\ However, clarification may be needed regarding how
infeasible projects should be addressed, in light of the additional
funding and current Sanitation Deficiency System priority. \12\
---------------------------------------------------------------------------
\11\ Id.
\12\ Id., at 11. (``The IHS may still support the planning, design,
and construction of projects that are infeasible, typically as a result
of funding contributions from other federal agencies and/or tribal
sources. The SFC Program has provided and will continue to provide
eligible AI/AN homes with other less costly types of sanitation
facilities (e.g., offsite watering points and sewer haul systems). The
SFC Program will also continue to track and estimate project costs to
serve these homes with piped water and sewer systems.)''
---------------------------------------------------------------------------
Conclusion
We thank the Senate Committee on Indian Affairs for holding this
hearing on important legislation. We stand ready to work with Congress
in a bipartisan manner to enact legislation that strengthens the
government-government relationship, improves access to care for all AI/
ANs, and raises health outcomes.
______
Response to Written Questions Submitted by Hon. Lisa Murkowski to
Hon. Gil Vigil
In your written testimony, you describe the current challenges that
Tribal programs are facing with funding instability and data collection
issues, and also on the differing tribal-state relationships over
Native child maltreatment.
Question. What are the biggest challenges that Tribes are facing
when trying to offer prevention and treatment services within their
communities?
Answer. Tribal nations struggle with a patchwork of federal funding
sources to support prevention and treatment services. This patchwork of
funding is almost exclusively discretionary sources that can ebb and
flow from one year to the next and in some cases, requires they compete
against states or other communities to receive the grant funding.
Furthermore, the amount of funding available is often very small,
sometimes with tribes receiving less than $10,000 per year from some
primary sources of child welfare funding such as Title IV-B of the
Social Security Act. Unlike states that have mandatory funding from
programs like Medicaid or the Title XX Social Services Block Grant,
tribes have to contend with small amounts of funding that do not
provide the regular, stable funding needed to address prevention and
treatment needs of their community members who are at risk or have been
victims of child abuse and neglect or family violence. In H.R. 1688 we
see an opportunity to reauthorize grant programs specifically designed
for tribal nations where they would not have to compete with states and
others to receive funding specifically targeted to preventing and
treating child abuse and family violence.
One other major challenge is existing funding at the federal level
is often not designed with tribal communities in mind. The one-size-
fits-all approach to funding prevention and treatment services can make
it much more difficult for tribes to develop effective programs that
are culturally appropriate and can be successful with Native children
and families. When tribes have the opportunity to develop programs of
this nature, as we see in H.R. 1688, it optimizes the community wisdom
and resources already there to address challenging issues like child
abuse and neglect and family violence. One additional benefit is when
tribal nations have stable and effective programs they are also more
likely to be able to be partner with states more effectively too.
Having strong partners on both ends is much more likely to produce
better outcomes for Native children and families.
______
Response to Written Questions Submitted by Hon. Ben Ray Lujan to
Hon. Gil Vigil
Question 1. Mr. Vigil, are there any other Tribal grant programs
targeted at preventing child abuse in Indian Country?
Answer. The only other federal funding for tribes that is dedicated
to child abuse and neglect prevention comes from the Child Abuse
Prevention and Treatment Act, Community-Based Child Abuse Prevention
grant program. This grant program has historically provided prevention
grants to one to two tribes each five-year grant cycle and tribes must
compete with migrant communities to secure a grant. The grants are
relatively small at around $130,000 per year.
Question 2. Mr. Vigil, what other sources of funding are there at
BIA for Tribes to use to support their child welfare programs? Do all
Tribes have access to these funds? Are these funds sufficient hire at
least one caseworker per Tribe?
Answer. The BIA provides sources of funding for child welfare
services, but none that is dedicated to child abuse and neglect
prevention. BIA programs that fund some type of child welfare services
include the Indian Child Welfare Act on-reservation grants, BIA Social
Services grants, and Child Assistance. The Indian Child Welfare Act
grants are primarily used to support tribal involvement in cases where
tribal families are under state jurisdiction. BIA Social Services can
be used for child welfare purposes, but it is also for other social
service purposes and is not available to all tribes. BIA Child
Assistance supports foster care and other out of home placements, but
doesn't support the administrative costs of managing cases, just the
monthly payment for the caregiver, and is not available to all tribes.
All of the BIA child welfare related funds are discretionary. The
Department of Health and Human Services provides discretionary grants
for tribal child welfare purposes, such as the two programs that fall
under Title IV-B of the Social Security Act, but these are not
dedicated to child abuse and neglect prevention and come in very small
amounts so tribes must use this to help fund services to families
already in crisis as opposed to prevention.
The National Indian Child Welfare Association estimates it would
require at least $120,000 to hire one professional child welfare staff
person and support their salary, benefits, and administrative expenses
for a year. Almost three-quarters of tribes that apply for the BIA
Indian Child Welfare Act, On Reservation grant program, are not
eligible to receive this amount of funding. Other BIA programs, such as
BIA Social Services, may provide grants closer to this size, but this
funding source is not available to over 47 percent of tribal nations
and the funding must support more than just child welfare services.
Creating an adequately staffed and effective child welfare program in
Indian Country is extremely challenging given the patchwork of
discretionary grant funds available to them and the amounts provided.
Question 3. Mr. Vigil, why is it important that Tribes have
flexibility in how they can use the funds included in the formula
grants in this bill? Can you give some examples of ways Tribes might
use these funds based on current needs?
Answer. Flexibility allows tribal nations to develop culturally
based services that will be successful in their communities and can be
administered within the resources tribes have access to. Few federal
child welfare programs were developed with tribal communities in mind,
which can lead to roadblocks for the development and operation of
programs and services that tribal communities need and want. Being
successful in child abuse and neglect and family violence prevention
and treatment is highly dependent upon a tribe's capacity to respond to
the unique conditions, culture, and realities of providing services in
their community. Where tribes have this flexibility we can see great
outcomes for Native children and families. In my testimony I shared
what the Confederated Tribes of Umatilla was able to do to reduce
foster care placements by over 70 percent. In Alaska, the Native
Village of Kwigillingok developed a community response protocol based
upon their culture that checks in with families that are known to have
risk for child abuse and neglect. Since implementing their protocol,
they have not had any foster care placements in their community for
over two years. These examples are testaments to what investment in
tribal child welfare can provide with the right approach.
______
Response to Written Questions Submitted by Hon. Brian Schatz to
Hon. Gil Vigil
Question 1. In addition to the proposals contained in H.R. 1688,
what further recommendations would NIWCA propose for improving the
federal government's support of Tribal child welfare programs and
Native child welfare more generally?
Answer. Improving tribal access to the same federal sources of
funding that states have access to is a goal that will go a long way to
ensuring that tribal governments have the resources they need to
provide comprehensive services. Currently, tribal governments are not
eligible for the Title XX Social Services Block Grant, which is a major
funder of state child welfare services, both for child welfare and
family violence services. Providing tribes access to this funding
source could help tribes weather changes in need caused by things like
the opioid crisis and pandemics like COVID-19. Another key
recommendation would be to extend the flexibility that tribes operating
the Title IV-E Foster Care and Adoption Assistance program directly
with the federal government have to tribes that are in agreements with
states to operate this program. Over 130 tribes are in Title IV-E
agreements with states but are required to meet the same requirements
as states to access the prevention services funding. This essentially
prohibits them from using their culturally based services when serving
Native children and families even when states want to support this
flexibility too.
Question 2. Earlier this year, NICWA and a number of other Native
organizations sent a letter to Congress indicating that lack of
investment in Tribal child welfare data systems infrastructure
negatively impacts Tribes. Can you provide some additional details on
the cited data infrastructure needs?
Answer. The letter sent by Native organizations cited
infrastructure needs in a number of tribal governance areas, including
child welfare. The child welfare infrastructure needs for tribes
identified included, (1) support for tribal child welfare data systems
development, (2) support for tribal telemedicine options in working
with children and families, and (3) establishing tribal eligibility to
receive Title XX Social Services Block Grant funds directly through the
federal government. With regard to the data infrastructure needs,
federal funding for tribal child welfare services programs, whether
administered under the Department of Interior or Department of Health
and Human Services, requires data collection related to programs and
services supported by the funds. In addition, tribal governments need
accurate and reliable data collection to track trends in service
delivery and outcomes for tribal children and families they serve, as
well as help them address disaster planning requirements under federal
law. However, little to no funding is available for tribal nations to
develop this critical program infrastructure from existing federal
child welfare programs, while state governments have been the
beneficiary of tens of millions of dollars of data system development
and operational funds from federal sources. As a result, there is
little reliable data available on a regional or national level for
child welfare services operated in tribal communities. This gap in data
leaves tribal, state, and federal policymakers and administrators with
little information on how to respond to trends in services that impact
outcomes for tribal children and families. Congress and tribal leaders
need quality data to understand what is happening on the ground with
at-risk children and families and be able to evaluate options for
improving services and outcomes. Not having good data also threatens
the ability of tribes to respond effectively during natural disasters,
which requires quick identification of high need families and children
and the ability to track the whereabouts of families, children, and
caregivers when people are displaced from their homes. Data systems
also facilitate better collaboration between agencies that are working
with families and children, including funders, as they determine how
best to respond to individual and collective needs.
Question 3. Are there other infrastructure needs you wish to
highlight for the Committee?
Answer. Tribal child welfare capacity and resulting outcomes for
Native children and families are tied together by the ability of tribal
nations to establish quality infrastructure. Good infrastructure can
help create stability in programming and help address dynamic and
challenging environments like those found in child welfare.
Infrastructure is also important to tribal nations attracting and
developing a skilled workforce, reducing the crisis orientation of
child welfare and the costly outlays for crisis-oriented services as
compared to prevention services, and leveraging high value partnerships
that can improve services access and collaboration in the public and
private sector. Often tribal nations don't have the flexible funding
that states do to develop necessary infrastructure or support services
and are left with choices that don't address the root causes of child
maltreatment and continue the crisis orientation which is so costly and
ineffective. Creating access to a base level of funding for tribes that
can help them develop data systems, train and support a quality
workforce, and develop truly community-based and culturally appropriate
services is the infrastructure that tribal nations need. As our written
and oral testimony indicated, where tribal nations have been able to
develop this infrastructure in child welfare they have been able to
reduce costly out of home placements and reduce trauma to children
while strengthening families for the long term.
______
Response to Written Questions Submitted by Hon. Ben Ray Lujan to
Hon. Jonathan Nez
Question 1. You stated in your testimony that between 9,000 and
16,000 homes on the Navajo Nation do not have access to running water.
Where did this data come from?
Answer. On June 8, 2021, David McDonnell, Chief Project Engineer
for the Navajo Area Indian Health Service (NAIHS) advised us that
approximately 9,600 homes on the Navajo Nation do not have running
water. However, Jason John, our Director of the Navajo Nation
Department of Water Resources, estimates that the actual number could
be as high as 16,000. According to Mr. John, the IHS does not have the
resources and capacity necessary to fully assess every home on the
Navajo Nation, which is where the difference in numbers comes from.
Question 2. You stated in your testimony that between 14,000 homes
on the Navajo Nation do not have access to electricity. Where did this
data come from?
Answer. This number is based on the Public Power Association's
Light Up Navajo project. The actual figure is about 15,000, according
to their website. This comprises 32 percent of all homes on the Navajo
Nation and 75 percent of all un-electrified homes in the United States,
according to the same source.
Question 3. You have stated previously that roughly a third of
Navajo Nation homes do not have access to running water. Is this still
the most accurate estimate that Navajo Nation has? Where did this data
come from?
Answer. As noted in an email from David McDonnell of NAIHS in 2020:
``To the best of my knowledge, the 30 percent Navajo homes without
piped water came from the 2000 Census, and more specifically from a
report published by the Navajo Nation Division of Economic Development
called ``Navajo Nation Data from US Census 2000'' that was published
sometime in 2003. See: http://www.navajobusiness.com/pdf/NNCensus/
Census2000.pdf In the beginning of that document there is a table of
data, including ``Housing Units Lacking Complete Plumbing Facilities''
with a percentage of 31.9 percent (15,279/47,827 occupied homes = 0.319
= 31.9 percent).''
Others estimate an even higher number. A Public Broadcasting System
feature called ``How Off-the Grid Navajo Residents Are Getting Running
Water,'' which aired June 20, 2018, estimated as many as 40 percent (or
18,000) of Navajo families still have not been connected to running
water.
While these numbers need to be updated, there continues to be a
struggle to identify what are classified as homes and their occupancy.
The census data is a source of information on housing but the data
behind it needs to be evaluated. There is an ongoing need to have a
coordinated evaluation between the Navajo Nation, NAIHS, and other
programs to understand the data that will reflect the needs for
housing, water, electricity, and other infrastructure.
Question 4. How many Navajo Nation families have been connected to
running water with CARES Act funding? How many of these are in New
Mexico?
Answer. The Navajo Nation provided CARES Act funds to NTUA and
through NTUA, 105 families received a cistern and septic system, and 30
Navajo families received a waterline and septic system connection to
their homes. At this time, we are unable to assess the exact locations
of these homes.
Question 5. How many Navajo Nation families have not been connected
to water yet? How many of these are in New Mexico? How is the Navajo
Nation tracking the need for running water in its communities?
Answer. According to NAIHS in 2020, approximately 9,600 homes still
need to be connected to water, but local knowledge suggests it is much
higher, potentially as high as 16,000 homes. Many of these homes are
situated in the Bennett Freeze area in Arizona, but there exists a
significant shortage of electrical and water infrastructure in the
checkerboard areas of New Mexico as well.
______
Response to Written Questions Submitted by Hon. Lisa Murkowski to
Hon. Randy Grinnell, M.P.H.
Question 1. H.R. 1688 removes references to the HHS Secretary from
the existing law that established the Indian Child Resource and Family
Service Center and allows for the Secretary of the Interior to
establish a more centralized National Indian Child Resource and Family
Services Center. Can you elaborate on whether removing the references
to HHS Secretary in Section 2 of the legislation should be reconsidered
by the Committee? The Indian Health Service provides important services
to Indian people involving child abuse, neglect and maltreatment. Would
it be beneficial for DOI and HHS to work together on these issues?
Answer. The bill H.R. 1688 would amend 25 U.S.C. 3209 to remove
references of the Department of Health and Human Services (HHS)
Secretary, eliminate the requirement for a Memorandum of Agreement
(MOA) between HHS and the Department of the Interior (DOI), and require
the DOI Secretary to establish one National Indian Child Resource and
Family Services Center. The Indian Health Service (IHS) defers to the
bill drafters as to whether this Committee should reconsider the
deletion of the HHS Secretary from the cited statute in the bill.
The IHS efforts to identify and respond to child maltreatment
include early intervention, screening, assessment, education, and
community-based programming to build resiliency among children and
youth and to promote family engagement. Many of the behavioral health
grant programs administered by IHS provide programmatic expertise
highlighting the success, challenges, and lessons learned related to
expanding access to child advocacy centers within tribal communities.
In addition to our grant programs, IHS facilities and organizations
within the Indian health system provide comprehensive and culturally
appropriate health services.
IHS has experience working through a coordinated approach to meet
federal priorities with cross cutting priorities. As an example, the
Tribal Law and Order Act required the establishment of an interagency
MOA for the coordination and collaboration among key federal partners
to understand the scope of substance use disorder among the American
Indian and Alaska Native population.
Question 2. S. 1895 is a bill that will require the IHS to provide
additional funding to the Sanitation Facilities Construction Program
that will be used for the planning, design, construction,
modernization, improvement, and renovation of water, sewer, and solid
waste sanitation facilities funded by the agency. The bill requires the
HHS Secretary to prioritize funding for sanitation facilities in
accordance with the IHS Sanitation Deficiency System. Can you provide
the agency's interpretation of this provision in how the IHS will
prioritize the allocation of this funding?
Answer. If S.1895 bill becomes law, IHS plans to allocate funds and
prioritize project funding following the current methodologies. The
funds will be allocated by IHS Headquarters to IHS Areas using an
allocation formula that includes economically feasible project costs
and counts of tribal homes that have been evaluated as having
sanitation deficiencies at a level of 3, 4, or 5. The allocated funds
will then be used to fund projects that are ready to fund in priority
order from each Area's list. Additional details about the project
scoring methodology can be found in September 2019 guidance document
the Sanitation Deficiency System (SDS) A Guide for Reporting Sanitation
Deficiencies for American Indian and Alaska Native Homes and
Communities, available on the IHS website: https://www.ihs.gov/sites/
dsfc/themes/responsive2017/display_objects/documents/
Final_SDS_Guide_v2.pdf.
Question 3. There are 49 underserved and unserved communities in
Alaska and due to the high cost of construction for water and
sanitation infrastructure are living without basic access to running
water and flush toilets. Due to the lack of infrastructure, it has been
reported that one in three children living in the Yukon-Kuskokwim
villages without running water were hospitalized with respiratory
infections. How will this funding immediately, and in the long-term,
help underserved and unserved Alaska Native communities?
Answer. Funds authorized by the bill S. 1895, similar to all
sanitation facilities project funds appropriated to the IHS, will be
used to address sanitation deficiencies that impact tribal homes and
communities. Estimating which communities will be served by the funding
from the proposed bill at this time is challenging since funds
appropriated through the American Rescue Plan Act have not been applied
to projects and removed from the list. Additionally, IHS is currently
in the process of updating the sanitation deficiency needs list for
calendar year (CY) 2021, which could include new projects. The CY 2021
update will be used to allocate the funds from this bill.
Taking into consideration the limitations described above, the
table below estimates the total number of projects, Alaska Native
Village Communities, tribal homes benefiting, and total eligible
project cost which would be funded in Alaska based on funds authorized
by S. 1895. This analysis assumed a total project funding amount for
projects of $2.65 billion and used the CY 2020 SDS dataset after
removing projects funded with the IHS fiscal year 2021 regular budget
appropriation.
Estimate of Alaska Area IHS Projects funded based on funds authorized by
S. 1895
------------------------------------------------------------------------
Number of Alaska
Total Number of Total Eligible Native Village Number of Tribal
Projects Funded Cost Communities Homes Benefiting
Benefiting
------------------------------------------------------------------------
108 $741,485,094 83 7,379
------------------------------------------------------------------------
______
Response to Written Questions Submitted by Hon. Ben Ray Lujan to
Hon. Randy Grinnell, M.P.H.
Question 1. Mr. Grinnell, how many Tribes total stand to benefit
from the projects on IHS's deficiency list?
Answer. In the CY 2020 IHS sanitation deficiency needs list there
were 1,580 projects that when built would benefit 358 Tribes. An
updated list will be available before the end of CY 2021.
Question 2. Mr. Grinnell, which of the Area Offices have the
greatest number of identified sanitation deficiencies?
Answer. Using the CY 2020 SDS data, the Navajo Area and Alaska
Areas have the greatest number of project to address identified
sanitation deficiency needs. These numbers will change once IHS updates
the SDS data for CY 2021.
------------------------------------------------------------------------
Sum of Eligible Count of SDS Sum of Total
IHS Area Homes Project Number Eligible Cost
------------------------------------------------------------------------
Albuquerque 19,052 96 $73,188,581
Alaska 29,236 373 $1,844,522,330
Bemidji 12,349 84 $59,360,865
Billings 9,005 40 $26,378,799
California 9,523 93 $112,265,365
Great Plains 48,426 182 $ 147,926,384
Navajo 37,406 374 $535,580,490
Nashville 7,262 30 $59,063,240
Oklahoma 11,123 161 $47,775,351
Phoenix 30,606 90 $113,355,089
Portland 9,965 43 $59,592,496
Tucson 1,196 14 $7,764,163
------------------------------------------------------------------------
Grand Total 225,149 1,580 $3,086,773,153
------------------------------------------------------------------------
Question 3. Mr. Grinnell, how many projects and how much money are
identified for the Navajo Nation?
Answer. Estimating which communities will be served by the funding
authorized by S. 1895 at this time is challenging since funds
appropriated through the American Rescue Plan Act have not been applied
to projects and removed from the list. Additionally, IHS is currently
in the process of updating the sanitation deficiency needs list for CY
2021, which could include new projects. The CY 2021 update will be used
to allocate the funds from this bill.
Taking into consideration the limitations described above, it is
estimated that 349 projects included on the CY 2020 sanitation needs
list will be funded on the Navajo Nation if the amount of project
funding ($2.65 billion) authorized in S. 1895 stays the same. The total
eligible cost of these projects are estimated to be $516 million.
______
Response to Written Questions Submitted by Hon. Lisa Murkowski to
Heidi Todacheene
Question. Ms. Todacheene, I have been proud to work on many
legislative efforts to protect the vulnerable, whether that is
supporting Native children, reducing domestic violence against Native
women, or addressing the ongoing epidemic of missing or murdered
Indigenous women. Often what we need to do to address these
vulnerabilities and disparities is strengthen tribal institutions,
improve coordination, and support Indian self-determination.
This is important because we know Native children face overwhelming
obstacles, including experiencing levels of post-traumatic stress,
dramatically increased risks of suicide, and lower high school
graduation rates than any racial or ethnic demographic in the country.
In NICWA's testimony, they point out that in Alaska, Native children
make up over 62 percent of the state foster care system, but they are
only 15 percent of the state's youth population.
H.R. 1688 allows for the National Indian Child Resource and Family
Services Center, with the assistance of its Advisory Board, to develop
intergovernmental agreements between Tribes and states relating to
family violence, child abuse, and neglect. Alaska Tribes have been able
to access BIA funding for their Tribal courts to oversee cases that may
involve child welfare and domestic violence, and this includes the
drafting of codes relating to child and family protection.
How would this bill provide stability for Tribal courts to better
operate and develop stronger relationships with states? Additionally,
how might intergovernmental agreements improve existing tribal-state
relations?
Answer. The bill renames the Indian Child Resource and Family
Services Centers as the National Indian Child Resource and Family
Services Center. It also requires the Center, among other things, to
develop model intergovernmental agreements between tribes and states to
prevent, investigate, treat, and prosecute incidents of family
violence, child abuse, and child neglect involving Indian children and
families. State-tribal agreements to coordinate prevention,
investigation and treatment services, will build stronger
intergovernmental relationships to identify and coordinate child abuse,
investigation, and prosecution services between governments, which
depending on location, may not currently exist or could strengthen
these efforts.