[Senate Hearing 117-71]
[From the U.S. Government Publishing Office]




                                                         S. Hrg. 117-71
 
                     S. 1797, S. 1895 AND H.R. 1688

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

                                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

                              ----------                              
                                                                   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

                              ----------                              


                        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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
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\
---------------------------------------------------------------------------
    \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.