[Senate Hearing 117-547]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-547

             NOMINATION OF ROSELYN TSO TO BE DIRECTOR 
                   OF THE INDIAN HEALTH SERVICE, 
                   DEPARTMENT OF HEALTH AND HUMAN 
                   SERVICES

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

                                 HEARING

                               BEFORE THE

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 25, 2022

                               __________

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

                               __________

                                
                    U.S. GOVERNMENT PUBLISHING OFFICE                    
50-337 PDF                  WASHINGTON : 2023                    
          
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                      COMMITTEE ON INDIAN AFFAIRS

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

                              ----------                              
                                                                   Page
Hearing held on May 25, 2022.....................................     1
Statement of Senator Cantwell....................................    19
Statement of Senator Hoeven......................................     3
Statement of Senator Lujan.......................................    20
Statement of Senator Schatz......................................     1

                               Witnesses

Nez, Hon. Jonathan, President, Navajo Nation.....................     2
Tso, Roselyn, nominated to be director of the Indian Health 
  Service, Department of Health and Human Services...............     4
Biographical information.........................................     7
    Prepared statement...........................................     6

                                Appendix

Letters of support submitted for the record 


Response to written questions submitted to Roselyn Tso by:
    Hon. Maria Cantwell..........................................    32
    Hon. Catherine Cortez Masto..................................    34
    Hon. John Hoeven.............................................    39
    Hon. Ben Ray Lujan...........................................    36
    Hon. Lisa Murkowski..........................................    37
    Hon. Brian Schatz............................................    28
    Hon. Tina Smith..............................................    34
    Hon. Jon Tester..............................................    33

 
                    NOMINATION OF ROSELYN TSO TO BE 
                     DIRECTOR OF THE INDIAN HEALTH 
                   SERVICE, DEPARTMENT OF HEALTH AND 
                             HUMAN SERVICES

                              ----------                              


                        WEDNESDAY, MAY 25, 2022


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:42 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.
    Today, the Committee will consider the nomination of 
Roselyn Tso of Oregon to be the Director of the Indian Health 
Service at the Department of Health and Human Services. 
President Biden nominated Ms. Tso for this position on March 
10th, 2022. Before we begin, I would like to welcome Ms. Tso 
and thank her and her family for joining us today.
    This hearing is an important step in carrying out the 
Senate's constitutional duty to provide advice and consent. It 
is an opportunity to learn about how, if confirmed, Ms. Tso 
plans to carry out and uphold the United States' trust 
responsibilities to provide American Indians and Alaska Natives 
with quality healthcare services, improve operations, and 
address challenges facing the Indian Health Service, advocate 
for all Native communities, including the Native Hawaiian 
community, across the Administration.
    Because the Director of IHS is more than just a manager of 
a multibillion-dollar budget and over 15,000 full-time Federal 
employees, the Director is the most senior Senate-confirmed 
official in Native health charged with developing IHS 
healthcare policy, respecting tribal sovereignty and promoting 
tribal self-determination. All are key to fulfilling the 
agency's mission to raise the health outcomes of Native 
communities.
    Ms. Tso, a citizen of the Navajo Nation, has a nearly 40 
year career at IHS. She has served at all levels of the agency. 
In 1983, she took her first position with IHS as a receptionist 
and, over time, worked her way up to her current position as 
Director of the Navajo Service Area. Ms. Tso's administrative 
and operational experience as a long-time career IHS employee 
has the potential to benefit Indian Country for years to come.
    The Committee has received numerous letters from tribes and 
tribal organizations in support of Ms. Tso's confirmation. I 
have made them all a part of the record.
    I look forward to considering this important nomination and 
to working with the Vice Chair and my colleagues to move this 
nomination expeditiously through our Committee.
    Senator Hoeven, who is serving as Vice Chair today, is en 
route and when he comes, we will recognize him for an opening 
statement. But we will move the Committee along. If Senator 
Cantwell does not have an opening statement, we will move the 
hearing along.
    I will now turn to President Nez of the Navajo Nation to 
introduce our nominee. President Nez?

    STATEMENT OF HON. JONATHAN NEZ, PRESIDENT, NAVAJO NATION

    Mr. Nez. Ya'at'eeh, good afternoon, Chairman Schatz, 
Senator Cantwell, and members of the Senate Committee on Indian 
Affairs. It is a pleasure and an honor to be here today to 
introduce my good friend and colleague, Indian Health Service 
Director-designee, Ms. Roselyn Tso.
    Ms. Tso is an enrolled member of the Navajo Nation. Her 
clans are Deeschii'nii, Start of the Red Streak People, born 
for the Hashk'aa hadzohi, Yucca Fruit Strung Out. Her maternal 
grandfather is Tlogi Dine'e, Zia Pueblo People, and her 
paternal grandfather is Tli zi Lani, Many Goats.
    Ms. Tso grew up in LeChee, Arizona on the Navajo Nation 
with seven brothers and sisters and a large extended kinship 
circle and has had the benefit of family support throughout her 
university and professional life. Ms. Tso holds a Bachelor of 
Arts in Interdisciplinary Studies from Marylhurst University in 
Portland, Oregon and a Masters in Organizational Management 
from the University of Phoenix, Portland Campus.
    In 1984, Ms. Tso began her career with the Indian Health 
Service. Her mission is to address the health disparities 
experienced in Indian Country.
    After many years away from the Navajo Nation, she returned 
to serve as the Director of the Indian Health Service's Navajo 
Area Office. The Navajo Area IHS office provides health 
services to over 244,000 Native Americans stretching over 
27,000 square miles.
    As Director of the Navajo Area Office, Ms. Tso's 
leadership, expertise and compassion have been critical in 
reducing the spread of Coronavirus. When COVID-19 began 
spreading in the Southwest, there were a lot of uncertainties, 
as we know, and fear among everyone. We established a workgroup 
to begin mitigation efforts. Ms. Tso and her team were a part 
of this group. To combat COVID 19, the Navajo Nation 
established a Preparedness Team that was comprised of tribal 
leaders, 638 healthcare facilities, Navajo Department of 
Health, and other organizations such as John Hopkins 
University.
    The Preparedness Team evolved to a Response Team and the 
group of experts continued to provide guidance to continue to 
mitigate the virus. I surround those individuals with me on the 
Navajo Nation. Ms. Tso's quick response and steadfast 
leadership led to a well-coordinated effort with the Navajo 
Department of Health, establishing public health orders even 
before the first COVID cases were confirmed on the Navajo 
Nation.
    Currently, our elder population 65 years and over are 90 
percent fully vaccinated. Most of the general Navajo population 
is vaccinated. At a time when mainstream America had barely 
reached a 50 percent testing rate, the Navajo Nation was at 75 
percent. Through her leadership, the Navajo Nation achieved one 
of the highest vaccination rates in the world.
    Ms. Tso also worked very closely with tribal governments on 
the implementation of the Indian Health Self-Determination and 
Education Act allowing for the swift execution of programs 
under Public Law 93-638 contracts. She has been instrumental in 
securing full funding for IHS-SDS water projects for Navajo 
communities.
    Ms. Tso's commitment to public service stems from her 
family experience which includes many of the challenges many 
families experience in Indian Country. Ms. Tso's work ethic, 
value system and approach to problem solving demonstrates the 
resilience of indigenous peoples and the commitment to combat 
the systematic inequities that have impacted tribal nations 
since the western expansion.
    It is because of her extensive experience working with 
Federal and tribal governments that we are confident that she 
will continue to promote Federal trust responsibilities and 
enhance our nation-to-nation relationship to improve the Indian 
Health Service care delivery throughout Indian Country.
    We are pleased that the Biden-Harris Administration has 
honored the request of tribal leaders and nominated an IHS 
Director who understands the challenges experienced by many of 
our indigenous communities. We fully support President Biden's 
nominee.
    Thank you.
    The Chairman. Thank you, President Nez.
    Before swearing in our nominee, I will now recognize the 
Vice Chair for an opening statement.

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

    Senator Hoeven. Thank you, Mr. Chairman.
    Good afternoon. Thanks for convening today's hearing for 
Roselyn Tso to be Director of the Indian Health Service under 
the Department of Health and Human Services. Welcome.
    Before I begin my opening remarks, I would like to 
acknowledge the absence of Vice Chairman Murkowski who could 
not be here with us today. She is tending to a personal matter 
and extends her apologies to you, Ms. Tso.
    My understanding is that you and the Vice Chairman had a 
good in-person meeting last week and were able to discuss many 
of the issues facing the IHS nationally and in Alaska. I pass 
along her appreciation for that.
    Today, the Committee will hear from Ms. Tso, who has been 
nominated to be the Director of IHS. The IHS Director oversees 
the administration and delivery of healthcare services to 
approximately 2.6 million American Indians and Alaska Natives.
    IHS operates in 37 States throughout a network of 
hospitals, clinics and health stations and employs over 15,000 
doctors, nurses and other healthcare professionals. The IHS 
plays an important role in helping fulfill the Federal trust 
responsibility for the tribes. That is why the agency must 
continue to address its shortcomings and improve upon its 
ability to deliver quality healthcare to American Indians and 
Alaska Natives.
    As tribal communities tend to experience a lower life 
expectancy and a higher prevalence of chronic conditions, IHS 
must play a critical role in providing and meeting the 
healthcare needs in Indian Country through direct IHS 
facilities as well as through tribally-operated and urban 
healthcare clinics.
    I look forward to your testimony and also the hearing and 
our opportunity to ask questions to find out more about your 
outlook and goals for the Indian Health Service.
    Again, thank you, Chairman Schatz. I will turn the 
proceedings back to you.
    The Chairman. Thank you, Senator Hoeven.
    Ms. Tso, we will now swear you in. Please rise and raise 
your right hand.
    Do you solemnly affirm that the testimony you give today 
shall be the truth, the whole truth and nothing but the truth 
under the penalty of perjury?
    Ms. Tso. I do.
    The Chairman. Thank you. Please be seated.
    I want to remind you that your full written testimony will 
be made a part of the official hearing record. Please keep your 
statement to no more than five minutes so that members have 
time for questions.
    Ms. Tso, please proceed with your testimony.

   STATEMENT OF ROSELYN TSO, NOMINATED TO BE DIRECTOR OF THE 
 INDIAN HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Ms. Tso. Thank you, Chairman Schatz and Ranking Member 
Murkowski, who is not here today, and members of the Committee.
    Thank you for considering my nomination to be the Director 
of the Indian Health Service. I am honored by President Biden's 
decision to nominate me for this role, and if confirmed, I look 
forward to serving American Indians and Alaska Natives under 
his leadership and Secretary Becerra's.
    Before I begin my testimony, I would like to properly 
introduce myself to my family and relatives in Navajo.
    [Introduction in Native Language.]
    Ms. Tso. I would also like to recognize and thank my 
family. Seated behind me today is my sister, Delores Tso-
Robinson; her husband, Kenneth Robinson; my niece, Major Ashley 
Najoni-Robinson, United States Marine Corps; my son, Edward 
Lyons, Jr.; and my partner of more than 30 years, Mr. Cory 
Winnie.
    Watching virtually is my mother, Margorie Tso; my brother, 
Lawrence Tso; and my children, Holly, Clayton, and Roberta, as 
well as members of my extended family, relatives, and friends. 
With me in spirit include my father, the late Reverend Alvin 
Tso, my brothers, Ben, Willard, Alvin Jr., Eldon, and my 
sister, Linda. Without their love and support, I would not be 
here today.
    My own father's service as a proud but quiet Korean War 
veteran continues to inspire me to serve at IHS and if 
confirmed, I would be honored to continue this public service.
    I have almost four decades of professional experience 
working at all levels of the Indian Health Service. I also have 
decades of lived experience as a member of the Navajo Nation 
who has had to navigate the services provided by the agency for 
myself, family, and friends.
    Because of both my professional and personal experiences, I 
understand how patients experience the system and where we need 
to focus to improve patient experience and health outcomes. If 
confirmed as the Director of the Indian Health Service, I will 
work to maximize the Agency's resources to improve the 
physical, mental, social, and spiritual health and well-being 
of all American Indians and Alaska Natives served by the 
agency. This is particularly important as we are more than two 
years into a pandemic that has disproportionately affected 
Indian Country.
    Currently, I am the Director of the Navajo Area, the 
largest regional area in IHS, where I am responsible for 
managing more than 4,000 employees and leading a budget of 
nearly $1 billion. When I travel across the region to the 
different IHS facilities, I am reminded of the many health 
disparities facing American Indians and Alaska Natives, health 
disparities that in many cases were made worse by COVID-19. For 
example, sadly, today, too many Navajo families still do not 
have access to running water in their homes. Access to clean, 
safe drinking water is essential to the health and wellbeing of 
our people.
    Throughout my career at Indian Health Service, I have 
worked to improve the agency to better meet the needs of the 
people we serve. This was most evident throughout the pandemic, 
where I saw and was part of a true partnership with the Navajo 
Nation, San Juan Paiute Tribes, the local, State, Federal, and 
private partners to collectively combat COVID-19.
    If confirmed as the Director of the Indian Health Service, 
I will prioritize the following. First, strengthen and 
streamline IHS' business operations to better support the 
delivery of healthcare by creating a more unified healthcare 
system that delivers the highest quality of care. Second, 
developing systems to improve accountability, transparency, and 
patient safety. Third, addressing the workforce needs and 
challenges to provide quality and safe care.
    We cannot achieve any of this without strong partnerships 
and communication with our tribal partners. As a result of my 
personal and professional experiences, I have a deep 
appreciation for tribes and the needs of their communities. 
Each tribe has unique needs and those needs cannot be met if I 
do not understand them.
    The healthcare at the IHS is critical for those we serve. I 
understand this not just because I work there, but because my 
family relies on IHS, my friends rely on IHS, and I rely on 
IHS.
    I look forward to continuing to be a voice for tribal 
communities during these unprecedented times, as well as 
continuing the transformative work that is needed to meet the 
healthcare needs.
    Thank you for the opportunity to testify today. I look 
forward to answering your questions.
    [The prepared statement biographical information of Ms. Tso 
follow:]

  Prepared Statement of Roselyn Tso, Nominated to be Director of the 
     Indian Health Service, Department of Health and Human Services
    Chairman Schatz, Vice Chairman Murkowski, and members of the 
Committee, thank you for considering my nomination to be the Director 
of the Indian Health Service (IHS). I am honored by President Biden's 
decision to nominate me for this role, and, if confirmed, look forward 
to serving American Indians and Alaskan Natives under his leadership 
and Secretary Becerra's.
    Before I begin my testimony, I would like to properly introduce 
myself in Navajo: My name is Roselyn Tso, I am Deeschii'nii--Start of 
the Red Streak People, born for the Hashk'aa hadzohi--Yucca Fruit 
Strung Out, my material grandfather is Tlogi Dine,e--Zia Pueblo, and my 
paternal grandfather is Tli zi Lani--Many Goat. I would also like to 
recognize and thank my family. Seated behind me today is my sister, 
Delores Tso-Robinson, her husband, Kenneth Robinson, my son, Edward 
Lyons, Jr., and my partner of more than 30 years, Mr. Cory Winnie. And 
watching virtually is my mother, Margie Tso, my brother, Lawrence Tso, 
and my children, Holly, Clayton, and Roberta, as well as members of my 
extended family, relatives, and friends. With me in spirit includes my 
father, the late Reverend Alvin Tso and my brothers, Ben, Willard, 
Alvin Jr., Eldon, and my sister, Linda. I would not be here today 
without their love and support.
    My father's own service as a proud but quiet Korean War veteran 
continues to inspire me to serve at IHS and if confirmed, I would be 
honored to continue this public service.
    I have almost four decades of professional experience working at 
all levels of IHS. I also have decades of lived experience as a member 
of the Navajo Nation who has had to navigate the services provided by 
the Agency for myself, family, and friends. Because of both my 
professional and personal experiences, I understand how patients 
experience the system and where we need to focus to improve patient 
experience and health outcomes.
    If confirmed as the Director of the Indian Health Service, I will 
work to maximize the Agency's resources to improve the physical, 
mental, social, and spiritual health and well-being of all American 
Indians and Alaskan Natives served by the Agency. This is particularly 
important as we are more than two years into a pandemic that has 
disproportionately affected Indian Country.
    Currently, I am the Director of the Navajo Area, the largest IHS 
regional area, where I am responsible for managing more than 4,000 
employees and leading a budget of nearly $1 billion. When I travel 
across the region to different IHS facilities, I am reminded of the 
many health disparities facing American Indians and Alaskan Natives--
health disparities that in many cases were made worse by COVID-19. For 
example, sadly, today, too many Navajo families still do not have 
access to running water in their homes. Access to clean, safe drinking 
water is essential to the health and well-being of our people.
    Throughout my career at IHS, I have worked to improve the Agency to 
better meet the needs of the people we serve. This was most evident 
throughout the pandemic, where I saw and was part of a true partnership 
with the Navajo Nation, San Juan Paiute Tribes, and federal, state, 
local, and private partners to collectively combat COVID-19.
    If confirmed as the Director of IHS, I would prioritize the 
following:

  Strengthening and streamlining IHS' business operations to 
        better support the delivery of health care by creating a more 
        unified health care system that delivers the highest quality of 
        care.

        --This requires using the latest technology to develop 
        centralized systems to improve patient outcomes.

  Developing systems to improve accountability, transparency, 
        and patient safety.

        --This requires updating many of the Agency's policies and 
        programs and using its oversight authority to ensure these 
        policies and programs are implemented as intended to best serve 
        Tribal communities.

  Addressing the workforce needs and challenges to provide 
        quality and safe care.

        --Each year, IHS loses too many skilled and experienced 
        employees and struggles to replace them with qualified staff. 
        IHS must improve its recruitment and retention efforts, enhance 
        support and training for its workforce, and institute a robust 
        succession plan to reduce employee turnover and ensure 
        stability.

    We cannot achieve any of this without strong partnerships and 
communication with our Tribal partners. As a result of my professional 
and personal experiences, I have a deep appreciation of Tribes and the 
needs of their communities. Each tribe has unique needs, and those 
needs cannot be met if you do not understand them.
    The health care provided at IHS is critical for those we serve. I 
understand this not just because I work there. My family relies on IHS. 
My friends rely on IHS. I rely on the IHS. If confirmed, I look forward 
to continuing to be a voice for Tribal communities during this 
unprecedented time, as well as continuing the transformative work that 
is needed to meet their health care needs. Thank you for the 
opportunity to testify today. I look forward to answering your 
questions.
                                 ______
                                 
                      a. biographical information
    1. Name: (Include any former names or nicknames used.) Roselyn (no 
middle name) Tso; Roselyn Lyons

    2. Position to which nominated: Director, Indian Health Service

    3. Date of nomination: March 10, 2022

    4. Address: [Information not released to the public.]

    5. Date and place of birth: [Information not released to the 
public.]

    6. Marital status: Single.

    7. Names and ages of children: (Include stepchildren and children 
from previous marriages.) Edward R. Lyons, Jr. (38); Holly R. Phillips 
(35); Roberta L. Lyons (35); and Clayton C. Winnie (28).

    8. Education: (List secondary and higher education institutions, 
dates attended, degree received, and date degree granted.)

        Point Loma University, San Diego, CA--1981-1982 (No degree 
        received)

        Marylhurst University, Portland, OR--1994-1997 Bachelor's 
        Degree 5/1997

        University of Phoenix, Portland, OR--1997-2000 Master's Degree 
        6/2000

    9. Employment record: (List all jobs held since graduating from 
high school, including the title or description of job, name of 
employer, location of work, and dates of employment, including any 
military service (including dates, rank, and type of discharge)).

        8/2019-Current: Indian Health Service (IHS)--Window Rock, AZ--
        Director, Navajo Area IHS

        3/2018-8/2019: IHS-DC Headquarters--Director, Office of Direct 
        Service and Contracting Tribes

        12/2013-3/2018: IHS--DC Headquarters--Administrative Officer--
        Contract Support Costs Lead

        12/2005-12/2013: IHS--Portland, OR--Director, Office of Tribal 
        and Service Unit Operations

        7/1992-1/2005: IHS--Portland, OR--Program Analyst

        4/1989-7/1992: IHS--Portland, OR--Yakima Service Unit 
        Administrative Officer

        8/1984-4/1989: IHS--Portland, OR--Yakima Service Unit Admin 
        Assistant

        3/1984-8/1984: Tribal Employee Rights Program--Yakima, WA--
        Receptionist

        2/1983-9/1983: IHS--Portland, OR--Receptionist

        11/1982-1/1983: Bureau oflndian Affairs--Portland, OR--Support 
        Staff

        6/1981-9/1981: Navajo Nation Presidents Office--Support Staff, 
        Window Rock, AZ

        11/1980-5/1981: Fabulous Inns, Hotel Receptionist--San Diego, 
        CA

    10. Government experience: (List any advisory, consultative, 
honorary, or other part-time service or positions with Federal, State, 
Tribal, or local governments, other than those listed above.)8/2021-
Present: Member of the IHS Contract Support Costs Advisory Committee

    11. Business relationships: (List all positions held as an officer, 
director, trustee, partner, proprietor, agent, representative, or 
consultant of any corporation, company, firm, partnership, or other 
business enterprise, educational, or other institution.) None.

    12. Memberships: (List all memberships and offices held in Tribal, 
professional, fraternal, scholarly, civic, business, charitable and 
other organizations.)

        Mediator, Shared Neutrals, Portland, OR (1997-2000)

        Indian Education/Parent Committee, Portland, OR (1995-2000)

    13. Political affiliations and activities: (a) List all offices 
with a political party which you have held or any public office for 
which you have been a candidate. (b) List all memberships held in or 
political registrations with any political parties during the last 10 
years. (c) List all political offices or election committees during the 
last 10 years. (d) Itemize all political contributions to any 
individual, campaign organization, political party, political action 
committee, or similar entity of $500 or more for the past 10 years. (e) 
Current political party registration, if any.

        Response to (a)-(d): None.

        Response to (e): Independent.

    14. Honors and awards: (List all scholarships, fellowships, 
honorary degrees, honorary society memberships, military medals, and 
any other special recognitions for outstanding service or 
achievements.) 2008 Navajo Nation Tribal Education Scholarship.

    15. Published writings: None.

    16. Speeches: (List the date, location, audience, and topic of any 
formal speeches or videos relevant to the position for which you have 
been nominated that you have delivered during the last 5 years.

    Town Hall Messages regarding COVID-19 (in coordination with the 
Navajo Nation Tribal Leadership)-- Facebook COVID-19 Messaging. (No 
transcript or copies of notes provided.)

    17. Testimony: (Please identify each instance in which you have 
testified before Congress in a non-governmental capacity). None.

    18. Selection: (a) Do you know why you were selected for the 
position to which you have been nominated by the President? (b) what in 
your background or employment experience do you believe affirmatively 
qualities you for this particular appointment?

    I have almost four decades of professional experience working at 
all levels of the Indian Health Service (IHS)--health facilities, area 
offices, and IHS headquarters. My decades of experience at IHS have 
provided me with the background and understanding to take on the 
biggest challenges facing the agency and make the needed changes to 
transform IHS. I have the expertise and professional relationships 
required to see this transformation through. In addition, as a member 
of the Navajo nation who has spent a lifetime helping family and 
friends navigate the services that IHS provides, I understand how 
patients experience the system and where we need to focus in order to 
improve their experience. This ground-level understanding of the nuts 
and bolts of the Agency will serve me well in the role, should I be 
confirmed.

                   b. future employment relationships
    1. Will you sever all connections with your present employers, 
business firms, business associations, or business organizations if you 
are confirmed by the Senate? No (I will continue to work for the Indian 
Health Service).

    2. Do you have any plans, commitments, or agreements to pursue 
outside employment, with or without compensation, during your service 
with the government? If so, please explain. No.

    3. Do you have any plans, commitments, or agreements after 
completing government service to resume employment, affiliation, or 
practice with your previous employer, business firm, association, or 
organization? No.

    4. Has anybody made a commitment to employ your services in any 
capacity after you leave government service? No.

    5. If confirmed, do you expect to serve out your full term, or 
until the next Presidential election, whichever is applicable? Yes.

                   c. potential conflicts of interest
    1. Describe all financial arrangements, deferred compensation 
agreements, and other continuing dealings with business associates, 
clients, or customers.

    Any potential conflict of interest will be resolved in accordance 
with the terms of my ethics agreement, which was developed in 
consultation with ethics officials at the Department of Health and 
Human Services and the Office of Government Ethics. I understand that 
my ethics agreement has been provided to the Committee. I am not aware 
of any potential conflict other than those addressed by my ethics 
agreement.

    2. Indicate any investments, obligations, liabilities, or other 
relationships which could involve potential conflicts of interest in 
the position to which you have been nominated.

    Any potential conflict of interest will be resolved in accordance 
with the terms of my ethics agreement, which was developed in 
consultation with ethics officials at the Department of Health and 
Human Services and the Office of Government Ethics. I understand that 
my ethics agreement has been provided to the Committee. I am not aware 
of any potential conflict other than those addressed by my ethics 
agreement.

    3. Describe any business relationship, dealing, or financial 
transaction which you have had during the last 10 years, whether for 
yourself, spouse or dependents, on behalf of a client, or acting as an 
agent, that could in any way constitute or result in a possible 
conflict of interest in the position to which you have been nominated.

    Any potential conflict of interest will be resolved in accordance 
with the terms of my ethics agreement, which was developed in 
consultation with ethics officials at the Department of Health and 
Human Services and the Office of Government Ethics. I understand that 
my ethics agreement has been provided to the Committee. I am not aware 
of any potential conflict other than those addressed by my ethics 
agreement.

    4. Describe any activity during the past 10 years in which you have 
engaged for the purpose of directly or indirectly influencing the 
passage, defeat, or modification of any legislation or affecting the 
administration and execution of law or public policy, regardless of 
whether you were a registered lobbyist or not. None.

    5. Explain how you will resolve any potential conflict of interest, 
including any that may be disclosed by your responses to the above 
items (please provide a copy of any trust or other agreements).

    Any potential conflict of interest will be resolved in accordance 
with the terms of my ethics agreement, which was developed in 
consultation with ethics officials at the Department of Health and 
Human Services and the Office of Government Ethics. I understand that 
my ethics agreement has been provided to the Committee. I am not aware 
of any potential conflict other than those addressed by my ethics 
agreement.

    6. Do you agree to have written opinions provided to the Committee 
by the designated agency ethics officer of the agency to which you are 
nominated and by the Office of Government Ethics concerning potential 
conflicts of interest, or any legal impediments to your serving in this 
position? Yes.

                            d. legal matters
    1. Have you ever been disciplined or cited for a breach of ethics, 
or been the subject of a complaint to any court, administrative agency, 
professional association, disciplinary committee, or other professional 
group? If so, please explain. No.

    2. Have you ever been a subject of an investigation, or 
investigated, arrested, charged, or held by any Federal, State, Tribal, 
or other law enforcement authority for violation of any Federal, State, 
Tribal, county, or municipal law, regulation, or ordinance, other than 
for a minor traffic offense? If so, please explain. No.

    3. Have you or any entity, partnership, or other association, 
whether incorporated or unincorporated, of which you are or were an 
officer, ever been involved as a party in an administrative agency 
proceeding or civil litigation? If so, please explain. No.

    4. Have you ever been convicted (including pleas of guilty or nolo 
contendere) of any criminal violation other than a minor traffic 
offense? If so, please explain. No.

    5. Are you currently a party to any legal action? If so, please 
provide the nature and status.

    I am currently party to the following litigation in my capacity as 
an IHS official:

   Fort Defiance Hospital--2022, Issue: Contract Support Costs 
        (named as IHS official) Status: In litigation

    Previously, I have been a party to the following litigation in my 
capacity as an IHS official:

   Sage Memorial Hospital--2020, Issue: Contact Support Costs 
        (named as IHS official) Status: Case settled and dismissed

    Previously, I have also been party to legal action in my personal 
capacity:

   Property Tax--2004 Appeal Property Tax Amount, Portland, 
        Oregon Residence (Personal matter) Status: Resolved

    6. Have you ever declared bankruptcy? If so, please describe the 
circumstances. No.

    7. Please advise the Committee of any additional information, 
favorable or unfavorable, which you feel should be disclosed in 
connection with your nomination. None.

                     e. relationship with committee
    1. Will you ensure that your department/agency complies with 
deadlines for information set by congressional committees? Yes.

    2. Will you ensure that your department/agency responds to all 
congressional inquiries and letters from members of Congress in a 
timely matter? Yes.

    3. Will you ensure that your department/agency protect 
congressional witnesses and whistle blowers from reprisal for their 
testimony and disclosures? Yes.

    4. Will you cooperate in providing the committee with requested 
witnesses, including technical experts and career employees, with 
firsthand knowledge of matters of interest to the Committee in a timely 
manner? Yes.

    5. Please explain, if confirmed, how you will review regulations 
issued by your department/agency, and work closely with Congress, to 
ensure that such regulations comply with the spirit of the laws passed 
by Congress.

    The Indian Health Service (IHS) works closely with the Department 
of Health and Human Services and other key partners to develop and 
implement policies that support the overall mission of the IHS and to 
ensure safe and quality health care. Further, the IHS works closely 
with more than 500 American Indian and Alaska Native Tribes and uses a 
robust Tribal consultation policy and process when developing policies 
that impact Tribal Nations. IHS also uses the Urban Confer Policy when 
working with Urban Programs. For example, any changes to internal 
practices or implementation of new processes that relate to the Indian 
Self Determination Act, new funding, development of annual budget 
proposals are subject to tribal consultation or Urban Confer Policy. I 
will commit to work with key partners to ensure any new or amended 
regulations are consistent with the laws passed by Congress. I will 
also ensure a plan of communication with key partners for transparency 
on regulatory actions.

    6. Are you willing to appear and testify before any duly 
constituted committee of the Congress on such occasions as you may be 
reasonably requested to do so? Yes.

    7. Will you commit to submitting timely testimony to the Committee 
consistent with Committee Rule 4(b)? Yes.

                  f. general qualifications and views
    1. How do your previous professional experiences and education 
qualify you for the position for which you have been nominated?

    My experience and expertise qualify me for the role of Director of 
the Indian Health Service. Throughout my almost 40-year career at IHS, 
I have worked at every level of the agency--health facilities, multiple 
area offices, and IHS headquarters. Thanks to my decades of experience, 
understand what is needed to transform the agency and have the 
professional relationships required to see this transformation through. 
In addition, as a member of the Navajo nation who has spent a lifetime 
helping family and friends navigate the services that IHS provides, I 
understand how patients experience the system and where we need to 
focus in order to improve their experience.

    In my various leadership roles at IHS, I have worked to transform 
the agency to better meet the needs of Tribal communities across the 
nation. One of the accomplishments I am most proud of is the work I led 
in partnership with Tribes to update the agency's contract support 
costs policy so Tribes and Tribal Organizations that chose to operate 
their own health care program have the resources to successfully 
deliver health care to their citizens. The changes to the IHS CSC 
Policy incorporated tools to more easily determine appropriate CSC 
amounts. In addition, nine months before the pandemic, I led an effort 
to create a more unified health care system within the Navajo region 
and incorporated agreements within the system to support health care 
providers to more seamlessly provide care at all IHS facilities 
including a streamlined credentialing and privileging process. By 
establishing a more unified health care system, we were able to further 
incorporate our system into a broader unified health care approach 
across the region to collectively address the COVID 19 pandemic with 
tribal, federal and State partners. This has been invaluable over the 
last two years as COVID-19 has disproportionately affected Indian 
Country.

    Transforming IHS requires strong relationships inside and outside 
of the agency. I have a deep understanding and appreciation of Tribal 
government systems and that has allowed me to strengthen relationships 
with Tribes and Tribal leaders. Strengthening these relationships has 
resulted in improved patient care and quality of life for tribal 
communities. Each tribe has unique needs and those needs cannot be met 
if you do not understand them. During this unprecedented time, the IHS 
needs innovation and modernity to address the long-standing needs of 
American Indians and Alaska Natives.

    2. Why do you wish to serve in the position for which you have been 
nominated?

    My family relies on the Indian Health Service (IHS) health care 
system. My friends rely on the IHS health care system. I rely on the 
IHS health care system. I know from personal experience and firsthand 
knowledge how fragmented the IHS health care system can be. Because of 
this, I wish to serve as the Director of the IHS and I believe that I 
can improve the overall health care delivery system of the IHS. During 
this unprecedented time, the IHS needs innovation and operational 
leadership to address the long-standing needs of American Indians and 
Alaska Natives, which is exactly what I am prepared to do ifl am 
confirmed as the Director of the IHS.

    I want to ensure that IHS is a resilient and strong organization 
that improves the lives of American Indians and Alaska Natives. In 
order to ensure that high-quality patient care is provided 
consistently, the IHS requires a healthy and productive workforce. IHS 
currently faces challenges with the recruitment and retention of its 
workforce. In order to address this challenge, I would take a 
comprehensive approach and look to address a number of factors, 
including: lack of housing, remote locations of IHS health care 
systems, and competition with surrounding opportunities. By fostering a 
positive workplace environment for all IHS employees, the IHS will be 
able to best fulfill its mission to raise the physical, mental, social, 
and spiritual health of American Indians and Alaska Natives to the 
highest level.

    Additionally, by aligning all resources, from financial resources 
to human resources, and addressing long-standing issues, I believe all 
employees of the IHS will become more committed, and in turn they will 
better serve patients and demonstrate creative methods by which to 
provide and ensure safe and high-quality health care, while also 
ensuring accountability and providing transparency to patients and key 
stakeholders.

    3. What goals have you established for your first two years in this 
position, if confirmed?

    Should I be confirmed, I would prioritize the following:

        Strengthening and Streamlining Business Operations: The 
        business operations of IHS are just as important as the health 
        care operations because the former supports the delivery of the 
        latter. Therefore, in order to serve Indian Country with safe, 
        high quality care as effectively and efficiently as possible, 
        IHS must strengthen and modernize its business operations to: 
        (1) create one unified health care system that delivers the 
        highest quality of care; and (2) prevent waste, fraud, and 
        abuse and ensure appropriate accountability of resources and 
        workforce at IHS. Ensuring oversight and quality and safe 
        patient care is essential to meet the mission of the IHS and 
        ensure compliance with all applicable requirements.

        Improving Recruitment and Retention: Each year, IHS loses too 
        many skilled and experienced employees and struggles to replace 
        them with qualified staff. In addition, there are a number of 
        longtime leaders across the agency who are due to retire soon. 
        The care the agency provides is only as strong as its 
        workforce. IHS must improve its recruitment and retention 
        efforts, enhance support and training for its workforce and 
        institute a strong succession plan to reduce employee turnover 
        and ensure stability. IHS also needs to expand the pipeline of 
        Native Americans and Alaskan Natives for all positions at the 
        agency--health care positions in particular--so our patients 
        can be served by more people who share lived experiences with 
        them.

        Addressing Health Disparities Across Indian Country: As I drive 
        across Indian Country to different IHS facilities and see the 
        many families who do not have access to running water in their 
        homes, I am reminded of the health disparities facing the 
        American Indian and Alaskan Native populations--health 
        disparities that in many cases were only made worse by COVID-
        19. In order to achieve equitable outcomes in Indian Country, 
        we must dismantle barriers to equitable outcomes, center equity 
        and inclusion, and put supports in places to ensure that native 
        families not only survive but thrive.

    4. What skills do you believe you may be lacking which may be 
necessary to successfully carry out this position? What steps can be 
taken to obtain those skills?

    The health care system is in constant change, especially during the 
COVID-19 pandemic with new information being routinely learned about 
how to best combat COVID-19, including appropriate therapies for 
treatment and mitigation strategies. I do not have a medical 
background, so if confirmed, I will need to be open to learning from 
others who may be more knowledgeable in the health care field on COVID-
19, such as doctors and scientists. It is with their expertise that I 
will help navigate the IHS through this unprecedented pandemic.

    Additionally, this position requires working directly with 
Congress--an experience I have not yet had in my career. If confirmed, 
I look forward to learning from those with more developed skills in 
this area, such as HHS Leadership and Tribal Leaders and would respect 
the oversight authority of Congress and work to build strong, 
collaborative relationships with member of Congress and their staff. My 
focus will be to better understand my role as a Federal official, and 
to learn to balance the roles and responsibilities of the IHS with the 
expectations of Congress and other key partners such as Tribes and 
Tribal organizations.

    6. Please discuss your philosophical views on the role of 
government. Include a discussion of when you believe the government 
should involve itself in the private sector, when society's problems 
should be left to the private sector, and what standards should be used 
to determine when a government program is no longer necessary.

    The Federal Government has long-standing commitments and 
obligations to American Indian and Alaska Native Tribes and Tribal 
Organizations as a result of treaties, Acts of Congress, and Supreme 
Court law. One of the primary obligations includes the provision of 
health care services. Maintaining treaty obligations automatically 
disallows the privatization of the Indian Health Service (IHS). While 
the IHS should never be privatized, there are many reasons why 
individual American Indians and Alaska Natives utilize private sector 
health care services such as a need to access care not available 
through IHS, they reside off of the reservation, and are not located 
near a health care facility overseen or run by the IHS, therefore 
building, fostering, and maintain strong working relationships with 
private sector health care services is important and necessary.

    6. Describe the current mission, major programs, and major 
operational objectives of the department/agency to which you have been 
nominated.

    The overall mission of the Indian Health Service is to raise the 
physical, mental, social and spiritual health of American Indians and 
Alaska Natives to the highest level.

    The IHS Vision: Healthy communities and quality health care systems 
through strong partnerships and culturally responsive practices.

    IHS Strategic Goals: Access, Quality, Management, and Operations.

        1) To ensure that comprehensive, culturally appropriate 
        personal and public health services are available and 
        acceptable to American Indian and Alaska Natives.

        2) To promote excellence and quality care through innovation of 
        the Indian Health care system into an optionally performing 
        organization.

        3) To strengthen IHS program management and operations.

    7. What do you believe to be the top three challenges facing the 
department/agency and why?

    Recruitment and retention of the IHS Agency workforce: The IHS must 
develop a robust approach to recruitment that attracts the brightest 
individuals to the workforce. This includes having an efficient and 
streamlined hiring and onboarding process. IHS also needs to ensure 
that all employees have access to training and professional development 
opportunities and that we utilize all available retention systems and 
use them uniformly throughout the organization.

    Maximizing the use of modem technology that supports efficiency 
throughout the organization: This includes systems that support both 
administrative and health care (i.e., updating the electronic health 
record system and infrastructure that supports telemedicine and 
innovative health care communication with patients).

    Creating a work environment that fosters creative and innovative 
and forward thinking: Over the past two years, the COVID-19 pandemic 
transformed our approach to patient care and brought out the best 
ofIHS. In part, this was accomplished by having a robust communication 
plan that supports transparency with stakeholders, including the IHS 
team. We must apply these lessons learned and continue to keep our 
stakeholders informed of decisions, including the reasoning for those 
decisions.

    8. In reference to question number six, what factors, in your 
opinion, have kept the department/agency from achieving its missions 
over the past several years?

    Workforce needs. This includes a lack of clear defined executive 
leadership development program to support a sufficient succession plan 
to develop future leaders and create a workforce pipeline and support 
change. Leadership development must foster through knowledge of health 
care systems, creative and out of the box thinking and critical 
thinking skills.

    IHS has been historically underfunded, despite significant patient 
and operational/infrastructure needs. The overall lack of resources for 
any health care system impacts the ability to properly address the 
needs of the people served. It has been my experience that choices have 
to be made on a regular basis to address the area of immediate priority 
or need vs using a strategic collectively approach to improve the 
overall health care system. However, the ongoing efforts to improve the 
IHS budget using all available funding strategic are promising for the 
future of IHS.

    An organizational structure that ensures accountability and 
supports overall Agency deliverables and outcomes. IHS has not fully 
strengthened the administrate component of the organization to better 
support the health care component. For example, developing a clear 
communication plan through an updated organizational structure and 
policies will guide the organization to defined outcomes. Adjusting 
these elements of the organization can only support improved quality 
and safe care outcomes.

    The lack of reliable electronic systems to support efficient and 
streamlined business processes and services. Without the use of modem 
technology to support the day-to-day operations is not acceptable for 
IHS. We are reminded throughout the Pandemic that the use of immediate 
and reliable data was necessary to make real time decision, including 
both clinical or administrate. Moreover, having electronic systems to 
create dashboards or monitoring tools to monitor the Agency in real 
time is necessary to ensure an efficient operation of the IHS.

    9. Who are the stakeholders in the work of this department/agency?

   Patients/Customers.

   Tribes/Tribal Organizations and Urban Programs.

   Employees.

   Congress.

   American Taxpayers.

    10. What is the proper relationship between the position to which 
you have been nominated, and the stakeholders identified in question 
number nine?

    The IHS Director should have a relationship with the above 
stakeholders that is built on respect, understanding, partnership, 
accountability, listening, proactivity, and responsiveness.

    11. The Chief Financial Officers Act requires all government 
departments and agencies to develop sound financial management 
practices. (a) What do you believe are your responsibilities, if 
confirmed, to ensure that your department/agency has proper management 
and accounting controls?

    My responsibilities are to: Review policy and processes to ensure 
compliance at all levels of the Organization; evaluate the systems used 
to support efficient business processes and services; and demonstrate 
accountability at all levels of the organization. For example, full 
compliance with the Federal Managers Financial Integrity Act and 0MB 
Circular A123.

    (b) What experience do you have in managing a large organization?

    I have successfully led offices at the Regional, and Headquarters 
level, including my current position as the Director of the Navajo Area 
IHS (the largest IHS regional area) where I am responsible for managing 
over 4,000 employees and a budget of nearly $1 billion. Throughout my 
career, I have served as a change agent to bring about change within 
the IHS that have led to more efficient and streamline systems.

    12. The Government Performance and Results Act requires all 
government departments and agenciesto identify measurable performance 
goals and to report to Congress on their success in achieving these 
goals. (a) What benefits, if any, do you see in identifying performance 
goals and reporting on progress in achieving those goals?

    The Indian Health Service uses the Government Performance and 
Results Act to monitor clinical and non-clinical deliverables and 
outcomes. Several indicators used for IHS are essential to monitor 
health outcomes for the people we serve and thereby adjusting where 
necessary to support and improve the lives we serve. One of the best 
examples for Indian Country is tracking the diabetes indicators, where 
IHS has used the information in support of additional resources. The 
use of the agencies mission and strategic goals are further supported 
by the use of GRPA indicators thereby monitor and meeting broader 
objectives.

    (b) What steps should Congress consider taking when a department/
agency fails to achieve its performance goals? Should these steps 
include the elimination, privatization, downsizing, or consolidation of 
departments and/or programs?

    The performance goals of the department/agency should be reviewed 
by Congress on a regular basis to determine their overall value and 
outcomes. IHS has the responsibility to ensure the highest level of 
care to the people we serve, and compliance is a must. Where 
deliverables are not met, Congress should take necessary steps to hold 
the department/agency accountable.

    (c) What performance goals do you believe should be applicable to 
your personal performance, if confirmed?

    I believe the goals that I laid out in response to questions F.3 
and F.7 above should be the basis for measuring my individual 
performance, should I be confirmed.

    13. Please describe your philosophy of supervisor/employee 
relationships. Generally, what supervisory model do you follow? Have 
any employee complaints been brought against you?

    In general, my approach with employees starts with clearly 
described expectations and goals that are built on trust and 
communication to ensure accountability. I use an open and inclusive 
communication plan, which includes a two-way dialogue to support 
understanding. When necessary, I do not hesitate to take steps to 
address employee issues and ensure accountability. I am not aware of 
any formal complaint against me.

    14. Describe your working relationship, if any, with the Congress. 
Does your professional experience include working with committees of 
Congress? None, other than IHS Agency reports to Congress.

    15. Please explain what you believe to be the proper relationship 
between yourself, if confirmed, and the Inspector General of your 
department/agency.

    I believe the proper relationship between myself and the Inspector 
General is a working, transparent partnership on all matters related to 
the IHS Agency to ensure appropriate accountability and responsiveness. 
This includes, but is not limited to, not impeding the Inspector 
General's work in any way as it relates to the IHS Agency and the 
policies thereof.

    16. In the areas under the department/agency's jurisdiction to 
which you have been nominated, what legislative action(s) should 
Congress consider as priorities? Please state your personal views.

    Congress should consider the views of Tribes and Tribal 
Organizations as they relate to the Indian Self-Determination Act. 
Adjustments should be made to further simplify the process to support 
self-determination of health care systems at the local level for Tribes 
and Tribal Organizations. Additionally, IHS has been historically 
underfunded, despite significant patient and operational needs. 
Consistent, robust resources would help improve patient outcomes and 
address long-standing inequities.

    17. Within your area of control, will you pledge to develop and 
implement a system that allocates discretionary spending in an open 
manner through a set of fair and objective established criteria? If 
yes, please explain what steps you intend to take and a timeframe for 
their implementation. If not, please explain why.

    Yes, I will prioritize transparent accounting of federal resources, 
including the alignment of resources to IHS priorities. This required 
step will allow me to assess what resources are needed to complete 
these priorities with clear, measurable objectives. Any discretionary 
spending will be assessed in this process and each step will be 
communicated through a transparent communication plan with key 
stakeholders.

      g. financial data [information not released to the public.]
                              h. recusals
    If confirmed, do you agree to (1) Abide by the recusal requirements 
imposed by federal conflict of interest laws and the Standards of 
Ethical Conduct for Employees of the Executive Branch; (2) Seek the 
advice of his or her designated agency ethics officer before proceeding 
whenever faced with a situation that may give rise to an actual or 
apparent conflict of interest; and (3) Adhere to the principles of 
ethical conduct and avoid any actions creating the appearance of 
violating the Standards of Ethical Conduct for Employees of the 
Executive Branch. Please answer the above with a yes or no response. 
Yes.

    The Chairman. Thank you very much, Ms. Tso. We appreciate 
your testimony and we thank your family for their collective 
sacrifice so that you can lead this important agency.
    As we discussed in our meeting, the Federal Government has 
a special political and trust relationship with Native 
Hawaiians and that includes providing healthcare through HHS. 
If confirmed, will you commit to educating other HHS agencies 
on that responsibility?
    Ms. Tso. Thank you, Senator, for that question.
    Yes, of course, I will be responsible for that, and I will 
commit to working with you and the Native Hawaiians to improve 
healthcare services.
    The Chairman. Thank you.
    One of the things we found is that it is not enough to make 
a statute and it is not enough to have the agreement of the 
political appointees of the Senate confirm folks. Because where 
the rubber hits the road is in the notice of funding awards, it 
is at the line level where people are trying to configure RFPs 
and all of that.
    What gives me a little more hope is that you have worked 
your way up through this agency, so you know it is not just a 
matter of declaring that Native Hawaiians' trust and treaty, 
that our obligation to Native Hawaiians is both a political and 
a trust responsibility but that people have to do it every day 
in the way they push money out, and in the way they do 
consultation with Native communities.
    I am hoping I have your commitment to not just in front of 
the Committee say all of the right things but to watch your 
folks to make sure they are implementing that policy. Is that 
what I hear from you?
    Ms. Tso. Yes, Senator. Certainly throughout my career, one 
of the strengths that I bring to the organization is my ability 
to work across lines, barriers and so forth to bring about 
improved healthcare to all Native Americans, Alaska Natives and 
in this case, our Native Hawaiians.
    The Chairman. Thank you very much.
    Your questionnaire is in order. I am not complaining about 
it. But there was not any explicit reference to tribal 
sovereignty and self-determination. I am not going to read much 
into that. But for the record, what are your views on the 
government-to-government relationship between the United States 
and Indian tribes?
    Ms. Tso. Thank you, Senator.
    Without a doubt, there is a trust responsibility to the 
Native Americans and Alaska Natives specifically with regard to 
healthcare that has been documented through statute as well as 
Supreme Court decisions.
    The Chairman. If confirmed, how are you going to ensure 
that IHS both respects and uplifts tribal sovereignty, 
particularly through robust consultation?
    Ms. Tso. Thank you, Senator.
    Certainly, the Indian Health Service, as well as HHS, has a 
robust tribal consultation process that we utilize. However, it 
is a little bit more than that. It is not just having a meeting 
and having a conversation with tribes. It is really 
understanding the needs of each tribal community to help them 
best serve the people in their communities.
    The Chairman. Let me ask the question this way. Let's say 
you get confirmed, knock on wood. Nothing is ever guaranteed, 
especially in the Senate. Let's say you get confirmed and you 
wake up the next morning, have your meeting with your senior 
staff, some of whom you know, some of whom have been assigned 
to you and all the rest of it.
    What is the one thing you want to accomplish? I mean in 
terms of the operations of the agency. Because you have now had 
many, many years of experience within the agency, leading a big 
part of it.
    What kind of operational improvements do you see as kind of 
the low-hanging fruit? Is it electronic medical records? Is it 
telehealth? Where do you see the biggest opportunity in the 
short run? Because you know a term of three or four years can 
go by real quick. I want you to prioritize and we want to help 
you to prioritize. Where do you think we can make meaningful 
improvements quickly?
    Ms. Tso. Thank you, Senator.
    Certainly, I have already communicated this to the staff in 
the Navajo Area IHS, and it would be the same for all of the 
Indian Health Service, that we must, we must ensure safe and 
quality care to every eligible patient that we see throughout 
the Indian Health Service and ensure there is accountability 
throughout our processes to hold every employee accountable, 
including myself, so we are able to provide the best care to 
the people we serve.
    The Chairman. Tell me about telehealth. Tell me how much 
potential you see there. I have 30 seconds.
    Ms. Tso. Thank you, Senator.
    That is pretty exciting for me. As we shared when we 
talked, in 2019, we had about 126 visits for telehealth. In 
2020, we had over 13,000 visits. So I know that in spite of 
some of the challenges we have in Indian Country for 
infrastructure, that we can do this and do it very well. I 
would like to continue this outside and beyond COVID-19.
    The Chairman. I will just make this final point about 
telehealth. On a bipartisan basis, this Committee and other 
committees have been deeply committed to telehealth and also 
talking about the broadband that enables higher end telehealth. 
We should make no mistake; a bunch of telehealth does not 
actually require the deployment of high-speed internet 
connectivity. We can't use that as an excuse not to move 
forward with telehealth. There is a lot of stuff we are going 
to have to wait on until we have high speed broadband 
connectivity, but there is a lot of stuff we can change 
immediately, storing forward technology, remote patient 
monitoring, none of that requires that we lay down cable.
    So I want us to do both. We absolutely have to lay down 
broadband. But in the meantime, there are a lot of really 
exciting things we can do to provide better service.
    Senator Hoeven?
    Senator Hoeven. Thank you, Mr. Chairman.
    Earlier this month, the Wall Street Journal published an 
article in regard to how bureaucratic red tape has hindered the 
ability of vital medical equipment to be deployed to IHS 
facilities, particularly in the Great Plains region. The 
article talks about lengthy delays in the deployment of the new 
medical equipment. In some instances, facilities have waited 
over a year for the equipment. Obviously, these delays cause 
hospitals to search for alternatives, sometimes even more 
costly ways to proceed while waiting for the equipment.
    If confirmed, will you commit to examine IHS' procurement 
process and address these delays so that the resources, 
particularly medical equipment, gets to these facilities in a 
timely manner?
    Ms. Tso. Thank you, Senator.
    The priority that I referenced earlier with respect to 
looking at the IHS business component of the organization that 
better supports the healthcare is directly related to our HR 
business processes, our contracting business practices and 
everything in terms of making sure that our policies are up to 
date.
    This can be done. We have systems in place that allow us to 
do that and then making sure that our systems are being 
utilized appropriately and properly which is critical to our 
operation to ensure we have proper medical equipment and 
supplies at all times in each of our healthcare and hospital 
facilities.
    Senator Hoeven. Thank you.
    In 2017, IHS was listed on the Government Accountability 
Office's GAO High Risk List, 2017. That includes programs and 
operations vulnerable to waste, fraud, abuse, or mismanagement, 
and obviously need to be addressed. IHS has taken some steps to 
address GAO's recommendation, but there are still deficiencies 
that need to be addressed.
    How do you make sure those things get addressed?
    Ms. Tso. Thank you, Senator, for that question.
    In the Navajo Area, I arrived there in about August 2019. 
One of the first things I did was to align the governance 
process for the entire Navajo Area as opposed to having five, 
twelve facilities having different governance. We moved to a 
more uniform governance system.
    That is required and is necessary for me to be able to 
determine where we are within the organization instead of 
trying to manage many different activities. We are all required 
to follow the same regulations and so forth. That is the one 
thing I think IHS needs to move to, is a more uniform 
healthcare system.
    What this did for us in the Navajo Area during the pandemic 
was, it then allowed us to move a provider from one facility to 
another facility because we were operating under one 
governance. That means that we did not have to have any delays 
for credentialing, all these other background checks and so 
forth that sometimes come into play.
    Streamlining the Indian Health Service to operate as a 
healthcare system as opposed to individual operations is 
critical. I know that it can be done. This has truly helped the 
way we operate in the Navajo Area to strengthen our system.
    Senator Hoeven. How are you going to recruit the skilled 
people you need in healthcare? Everybody is looking for people 
in almost every type of profession there is. But in healthcare, 
it is just an acute challenge. How do you recruit the quality 
healthcare professionals you need?
    Ms. Tso. Thank you, Senator.
    At the Gallup Indian Medical Center, as an example, when I 
first got to Navajo in 2019, we were dependent on contract 
providers in our emergency department. About 70, 80, almost 90 
percent was contract providers. Today, we are almost 100 
percent IHS filled positions for providers.
    That is not using the typical strategies; well, it is using 
the typical strategies. But what we did was partner with our 
providers that have colleagues out there. They are the best 
recruiters for us. If we can build a system, a culture of care, 
a culture of safety within our organization, that is what is 
going to bring people to us.
    Two weeks ago, when I was visiting with the staff at 
Gallup, we had providers that wanted to come to that facility. 
Again, streamlining the governance part of our organization 
allows us to move around providers to meet the needs of our 
entire healthcare system in Navajo.
    If we can do that, we need to do that and we can do that at 
the national level. I believe we can do this if we continue to 
strive to build a healthcare system versus individual 
healthcare facilities.
    Senator Hoeven. One thing that will help you there is if 
you can reform and improve the credentialing process, 
particularly, for example, dentists. I have talked to dentists 
who want to come do pro bono work on the reservation but they 
cannot get credentialed. I really think that is an area where 
you can have a big impact.
    Ms. Tso. Thank you, Senator.
    We have streamlined that process at Navajo. We do have a 
system in place now including investing in additional staff 
resources to monitor the credentialing process and to make them 
move as quickly as possible into the process.
    Senator Hoeven. That experience will help you I think in 
doing it for IHS. That is good to hear.
    Thank you. Thank you, Mr. Chairman.
    The Chairman. Senator Cantwell.

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

    Senator Cantwell. Thank you, Mr. Chairman.
    It is so good to see you and to have a conversation 
yesterday. Obviously, I want to talk about contract support and 
self-governance, different styles of managing our Indian health 
and healthcare. I wanted to make sure that we talked about how 
important self-governance is and contract support and making 
sure that the actual commitments are made and payments.
    We have had a couple of gaps here. Obviously, you can have 
IHS healthcare not be paid in a timely fashion and then that 
impacts our tribes and their delivery system. What can you do 
to commit to making sure that we remedy these issues?
    Ms. Tso. Thank you, Senator.
    With respect to self-governance, I was fortunate when I 
came into the Indian Health Service to really experience those 
milestones that were put in place by many other tribes, 
especially in the Northwest, where I was able to see many 
tribes move over and become self-governance tribes.
    With that said, certainly we know how important contract 
support cost is for them, for any contractor, to ensure 
compliance with the terms of the contract. Yes, that is one 
area, again, looking at the business component of the Indian 
Health Service, we can strengthen that part to ensure that 
proper payments are made in a timely manner.
    With regard to actual payments of funding, when we do get 
funding at the area level, within the Navajo Area, our goal, 
and my expectation, was to ensure that payments were made 
within 24 hours to every tribe, particularly when the CARES 
money and infrastructure monies were coming down. That was 
critical. We were able to do it and we should be able to do 
that throughout the Indian Health Service.
    Senator Cantwell. On all contract support, you are saying?
    Ms. Tso. On all contract support.
    Senator Cantwell. I am sure that will be music to peoples' 
ears. If that actually transpires, that is very important. 
Because what happens is you cannot deliver care if you do not 
have the resources to do it. Certainly, some of our tribes are 
in very remote parts of the States. so it is not like there are 
accessible, easy options. Having discontinued care or things 
that can't be done in a timely fashion, really do matter.
    I wanted to ask you about 100 percent FMAP funding for our 
Urban Indian Health. Senator Murkowski and I serve a lot of 
constituents who are Alaska Natives and Native Americans in the 
Seattle area and also in Spokane. The issue is that the 
impacted Urban Indian healthcare organizations are not treated 
the same so they do not get the whole 100 percent FMAP funding. 
We were able to fix this I think for one or two years, but to 
me it is a big inequity in the delivery of care.
    Can you commit to securing 100 percent FMAP funding on a 
permanent basis for Indian health clinics in urban areas?
    Ms. Tso. Thank you, Senator.
    I agree that we need to have equity in terms of funding for 
all the programs that serve American Indians and Alaska 
Natives. We also know, I also know, that there are some 
limitations, neither the Indian Health Service nor the 
Department, makes the determination on 100 percent FMAP 
payments.
    However, we can work with States and we can work with our 
partners to make sure there is education and information 
flowing on how important this need is. I will work with you on 
this if I am confirmed.
    Senator Cantwell. Thank you.
    The Chairman. Do we have Senator Lankford online? If not, 
Senator Lujan.

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

    Senator Lujan. Thank you, Mr. Chairman.
    I want to recognize Vice Chair Murkowski and my friend, Mr. 
Hoeven. Thank you all for holding this hearing on the 
nomination of Roselyn Tso to be the Director of the Indian 
Health Service.
    Mr. Nez. it is an honor to be with you, my friend, to see 
you here, and for your excellent introduction as well. It is 
good to see you.
    Ms. Tso, congratulations on your nomination. I especially 
want to recognize your family that is seated behind you and 
those watching online. I want to thank each and every one of 
them for the support that you have lent to Ms. Tso as well, not 
just during this nomination and confirmation process, but 
through the entirety of her life. Thank you for what you have 
done and it means a lot to me to see family here as well.
    Ms. Tso, I look forward to working with you to advance 
tribal sovereignty and important issues, many of which we have 
already worked on together where we both have constituencies of 
responsibility to make things better and troubleshoot tough 
challenges.
    The Bipartisan Infrastructure Law that passed included $3.5 
billion for IHS water projects over the next five years. If 
confirmed, you will oversee $700 million annual investment in 
IHS water projects, over 10 percent of which are located 
between the IHS Navajo and Albuquerque Service Areas across New 
Mexico.
    Just this week, the Navajo Nation Council leaders 
highlighted concerns that IHS is building area water projects 
with construction materials that have caused system failures in 
years past.
    Ms. Tso, if confirmed, what will you do to maximize the 
lifespan of the IHS water projects and ensure that the agency 
is procuring quality materials for community water projects?
    Ms. Tso. Thank you, Senator, for that question.
    I absolutely agree that water infrastructure and improving 
that for all American Indians and Alaska Natives is critical, 
especially right now as we continue to navigate through COVID 
19.
    With respect to the concerns raised by Navajo Nation, I am 
aware of those concerns. I have been working with the local 
tribal leaders to better understand what their issues are. 
However, as I know, we are required to ensure that we buy 
proper products to make sure that we have good water systems.
    In this particular case, though, there is a balance between 
the management operations and ongoing operations. Once IHS 
completes the project, then we work closely with the tribal 
entity that will take over the water system as well as the 
homeowner. That is where there is not just IHS but a broader 
set of people that we need to continue to work with.
    I have worked very closely in Navajo with NTUA, the Navajo 
Tribal Utility Office, as well as other partners to make sure 
we plan the projects together, that we work together on 
projects, and we work together to complete the projects. That 
includes education and training to the homeowner when the 
projects are completed.
    Senator Lujan. I appreciate that. Ms. Tso, because of your 
familiarity with this, I certainly hope you are in a position 
to look at this across the Country.
    My concern that came up when I saw this report that came 
out, as you know, in other water projects in decades past, it 
has been proven that contractors used PVC pipe for electrical 
purposes when they should have been using pipe constructed 
specific to water and wastewater availability, and it 
deteriorated the system. We cannot afford that to happen. I 
look forward to working with you in that space.
    One of the other concerns I have is the rapid closure of so 
many IHS hospitals. Recently, Acoma-Canoncito-Laguna Hospital 
in New Mexico was closed and converted to a Monday to Friday, 
9:00 to 5:00 clinic. I was troubled by the data underpinning 
this closure which took place during the pandemic and how the 
change was communicated to the Pueblos and to the community.
    The question I have, Ms. Tso, is how will you look to 
ensure that IHS stems the tide of hospital closures?
    Ms. Tso. Thank you, Senator. I appreciate the conversation 
that we already had on this topic and will continue to work 
with you to ensure that the Indian Health Service continues to 
maximize access to care for all the patients that we serve.
    To that as well is that we honor the positions and 
decisions of tribal leaders when they determine to assume their 
own healthcare systems under self-governance or self-
determination. That was part of this particular situation.
    I also want to point out that these issues are not limited 
to IHS. These issues are across the Nation right now. You are 
probably aware that one of the hospitals in the little town I 
live in, in Gallup, New Mexico, on a weekly basis, there are 
notices in the paper of the challenges that this facility, this 
hospital, is having which is adjacent to our Gallup Indian 
Medical Center.
    We want this hospital to be successful because if they are 
not, the care reverts to the Indian Health Service, therefore 
more impacting the American Indians and Alaska Natives that we 
have to serve. It is a fine balance here in terms of making 
sure we do maximize the healthcare systems and access to care 
for all our patients.
    Senator, I will commit to continue to work with you on this 
issue and do whatever I can to ensure communication is flowing 
not just with you but with tribal leaders.
    Senator Lujan. I appreciate that.
    Mr. Chairman, I know my time has expired. I do have one 
question on sharing information and datasets with 
epidemiological centers, but I will submit that into the 
record.
    It is always good to see you, Ms. Tso, and your family. 
Again, President Nez, thank you for being with us today.
    I yield back, Mr. Chairman.
    The Chairman. Thank you, Senator Lujan.
    Senator Cortez Masto is on the Floor. Are there any other 
members online wishing to be recognized?
    [No audible response.]
    The Chairman. If there are no more questions for our 
nominee, members will also submit follow-up written questions 
for the record. I would ask members to do that promptly.
    I would also ask our nominee to respond fully and promptly 
to any follow-up questions we may have, and to also meet with 
any remaining Committee members who may wish to do so. The 
hearing record will be open for two weeks.
    Thank you, Ms. Tso, for your time and your testimony today.
    This is Bring Your Daughter to Work Day, so I will now 
recognize my staff director's daughter to adjourn the meeting.
    Ms. Monaco. This hearing is adjourned.
    [Whereupon, at 3:22 p.m., the Committee was adjourned.]

                            A P P E N D I X

Affiliated Tribes of Northwest Indians (ATNI) and Northwest 
                 Portland Area Indian Health Board (NPAIHB)
                                                       May 23, 2022
Dear Chairman Schatz and Vice Chair Murkowski:

    On behalf of the Affiliated Tribes of Northwest Indians (ATNI) and 
Northwest Portland Area Indian Health Board (NPAIHB), we write this 
letter supporting and urging the appointment of a Director of the 
Indian Health Service (IHS).
    ATNI is a regional organization comprised of American Indian/Alaska 
Native tribes in the states of Washington, Idaho, Oregon, Montana, 
Nevada, Northern California, and Alaska. NPAIHB is a tribal 
organization under P.L. 93-638 of the Indian Self-Determination 
Education Assistance Act serving the 43 federally recognized tribes of 
Idaho, Oregon, and Washington.
    In January 2022, ATNI and NPAIHB worked on a resolution calling on 
the President to nominate an IHS Director in order to ensure that IHS 
has a leader who can set forth a vision to address the health 
disparities that American Indians/Alaska Natives face. Resolution No. 
2022-03 was enacted at ATNI's Winter Convention on January 27, 2022.
    On February 24, 2022, the NIHB Board of Directors formally adopted 
Resolution #22-02 supporting and urging the appointment of a Director 
of the IHS. In this Resolution, the NIHB called upon the President to 
nominate an IHS Director to ensure that the IHS has a leader empowered 
to carry the imprimatur of the President and work with the Tribes to 
advance and implement bold, transformational policies necessary to 
honor the federal government's trust responsibility and treaty 
obligations and make measurable improvements in addressing the health 
disparities that American Indian and Alaska Native people face.
    ATNI and NPAIHB fully support a Senate-confirmed IHS Director that 
is American Indian or Alaska Native (AI/AN) with the education and 
requisite knowledge of the Indian health system, proven experience in 
leadership, diplomacy and political acumen, and capabilities required 
to carry out the federal trust responsibilities to provide high quality 
healthcare and public health services to Tribal Nations. The absence of 
a Director impedes the ability of both the Tribes, the Administration 
as well as Congress to carry out the mission of the IHS. IHS's mission 
is `` to raise the physical, mental, social, and spiritual health of 
American Indians and Alaska Natives (AI/AN) to the highest level.''
    First and foremost, the next IHS Director must have an outstanding 
record of supporting Tribal Sovereignty and Addressing Health Equity of 
AI/AN.
    Tribal Sovereignty and Treaty and Trust Obligations. Tribal 
sovereignty and treaty and trust obligations must be the starting point 
of any discussion the next IHS Director has with Tribal Nations. Tribal 
Nations are distinct political bodies with the right to regulate their 
own internal affairs according to their own laws and customs. \1\ This 
right to self-government is grounded in treaties and the U.S. 
Constitution and reaffirmed in U.S. Supreme Court decisions and federal 
legislation. The Supreme Court continues to acknowledge tribes' 
inherent right to self-government, which is not handed from the federal 
government but retained from their existence prior to colonization and 
essentially the formation of the U.S. \2\
---------------------------------------------------------------------------
    \1\ See generally Ex Parte Crow Dog, 109 U.S. 556 (1883);
    \2\ See Worcester v. Georgia, 31 U.S. 515, 581 (1832).
---------------------------------------------------------------------------
    Additionally, the U.S. has a trust responsibility and legal 
obligation to elevate the health status of Tribal Nations and AI/AN 
people. \3\ Several U.S. treaties obligate the federal government to 
provide health care to AI/AN people. \4\
---------------------------------------------------------------------------
    \3\ P.L. 94-437; 25 USC  1602.
    \4\ See Treaty of Point Elliot, 1855, art. 14; Treaty of Medicine 
Creek, 1854, art. 10; and Treaty of Neah Bay, 1855, art. 11; and Treaty 
of Point No Point, 1855, art. 11.
---------------------------------------------------------------------------
    The next IHS Director must have a demonstrated history of 
understanding and honoring the political status of tribes and their 
inherent authority to protect the health and welfare of their citizens 
as to any initiative or funding opportunities proposed or made 
available by IHS. For Northwest Tribes, a commitment to support tribal 
self-determination and support of tribes expanding their ISDEAA compact 
and contracts and honoring treaty and trust obligations is critical.
    Self-Governance and Self-Determination Compacts and Contracts. The 
next IHS Director must support and advocate for tribal self-governance 
by expanding the use of Title I and Title V contracts and compacts 
across IHS and HHS and to move away from grant funding. The Tribes in 
the Northwest have been relentless advocates for Tribal Self-
Determination and Self-Governance resulting in one of the most 
successful programs funded by the Indian Health Service--our Title I 
and Title V contracts and compacts.
    Addressing Health Equity. AI/AN people in the Northwest face high 
health disparities compared to non-Hispanic White (NHW). AI/AN people 
in the Northwest have a life expectancy that is about 7 years lower 
than that of NHW people in the region. Data from the Northwest show 
that AI/AN people experience disparities at all stages of life, and are 
particularly vulnerable to chronic diseases such as heart disease and 
diabetes, injuries, substance misuse and overdoses, and violence. AI/AN 
people in the Northwest are less likely to have health care coverage 
and access compared to their NHW counterparts, which in part explains 
the low rates of preventative health care services accessed by AI/AN 
people.
    These disparities are the consequence of centuries of neglect and 
broken promises by the federal government to adequately fund 
healthcare. IHS is chronically underfunded with the overall budget 
covering only a fraction of the healthcare needs of AI/AN people. \5\ 
Year after year, Northwest Tribes have unmet healthcare needs due to 
the chronic underfunding. The Tribes in our Area continue to face the 
unprecedented COVID-19 public health emergency, as well as the impacts 
of the climate crisis and opioid epidemic. Northwest Tribes lack the 
necessary resources and infrastructure to appropriately respond and 
provide the necessary healthcare to our people. In addition to fully 
funding health programs, in order to address health equity in a 
meaningful way, we need to target social determinants of health and 
invest in programs like the Community Health Aide Program that train 
AI/AN people to provide a primary level of medical, dental, and 
behavioral health care in tribal communities.
---------------------------------------------------------------------------
    \5\ U.S. COMM'N ON CIVIL RIGHTS, BROKEN PROMISES: CONTINUING 
FEDERAL FUNDING SHORTFALL FOR NATIVE AMERICANS AT 19 (2018) available 
at https://www.usccr.gov/pubs/2018/12-20-Broken-Promises.pdf.
---------------------------------------------------------------------------
    An effective IHS Director will advocate on behalf of Tribes for 
adequate program expansion and funding and not just advocate on behalf 
of the administration. The next IHS Director must also be committed to 
the important issues and priorities of Northwest Tribes, including:
    Advance Appropriations and Full Funding for IHS. We need an IHS 
Director committed to supporting advance appropriations in FY 2024 and 
full funding for the IHS at $51 billion. We also need an IHS Director 
willing to work with Tribal Nations to develop an appropriate mandatory 
funding proposal that is in line with the recommendations put forth by 
the National Tribal Budget Formulation Workgroup. Our Area has raised 
concerns year after year of the undue hardships caused by government 
shutdowns--from federal employees not receiving a paycheck to clinics 
reducing hours of operation.
    Supporting Contract Support Costs. We need an IHS Director that 
will continue to support contract support costs (CSC) and to advocate 
to move CSC to mandatory funding to ensure Tribes are fully funded for 
their direct and indirect costs. There are many CSC costs not 
reimbursed by the IHS. We need an advocate that will allow for the 
maximum flexibility when negotiating CSC costs with Tribal Nations.
    Section 105(l) Leases. The next IHS Director must support full 
compensation for tribes or tribal organization for their reasonable 
facility expenses under Section 105(l) of ISDEAA and authorization of 
mandatory funding for Section 105(l) leases. Section 105(l) of ISDEAA 
requires IHS, upon tribal request, to enter into a lease for a facility 
owned or leased by the tribe or tribal organization and used to carry 
out its ISDEAA agreement.
    Purchased and Referred Care (PRC). We need an IHS Director who 
understands and supports areas without hospitals like the Portland 
Area, and the critical need for annual PRC increases. In FY 2022, PRC 
received less than a 1 percent increase. Portland Area does not have an 
IHS hospital so IHS and Tribal facilities (I/T) in our Area must 
purchase all specialty and inpatient care. The PRC program makes up 
over one-third of the Portland Area budget so when there is little 
increase and no consideration of population growth, Portland Area 
Tribes are forced to cut health services. Areas with IHS hospitals can 
absorb these costs more easily because of their infrastructure and 
large staffing packages.
    When there are increases to the PRC budget, the Portland Area 
Tribes receive additional funding to account for the lack of an IHS/
Tribal hospital in the Area, often referred to as the access to care 
factor. However, Congress through the IHS budget has only ever funded 
this access to care factor three times in the past 12 years--in FY 
2010, 2012, and 2014. Without year to year increases to PRC to fund the 
access to care factor, inpatient care for Portland Area Tribes goes 
severely underfunded.
    Community Health Aide Program (CHAP) Expansion. The next IHS 
Director must make CHAP expansion a priority and allocate additional 
funds to areas that have established education programs with 
consideration that new education facilities (i.e., clinical classrooms) 
will be needed to train community health aide providers.
    CHAP is a program that was designed and implemented by the Alaska 
Native Health system over 60 years ago. In nationalizing it to the rest 
of the country, tribes everywhere have an important opportunity through 
the CHAP to tackle social determinants of health while improving access 
to care. CHAP is unique because it not only increases access to care 
but creates access points to health education so that tribal citizens 
can become health care providers and professional wage jobs on 
reservations and in tribal health programs throughout the country. The 
education programs associated with CHAP are the foundation of the 
program.
    In the Portland Area, we have 12 Dental Health Aide Therapists and 
2 Behavioral Health Aides working in tribal communities throughout the 
three state Area. Additionally, we have 29 Behavioral Health Aides in 
training. Our Dental Therapy Education Program in Washington will begin 
accepting students in Autumn 2022 and is a state-of-the-art dental 
education program, our Behavioral Health Aide Education Program first 
cohort is mid-way through their first year, and our Community Health 
Aide Education program is in development with planned campuses in 
Oregon and Washington. These programs are vital to driving equitable 
access to health provider education and the success of the CHAP in our 
Area.
    Regional Specialty Referral Center in Portland Area. The FY 2022 
Congressional Justification has identified $165 million to fund the 
Seattle Area Regional Referral Center with FY 2021 nonrecurring expense 
funds. This has been a longstanding request for Portland Area Tribes 
and we are glad to finally see some movement on this request. This 
facility is crucial for Portland Area because we do not have access to 
any IHS/Tribal hospitals and this model of care can be replicated in 
other areas. The next IHS Director must be committed to making this a 
reality and committed to supporting a staffing package and other 
operational costs for the center.
    Special Diabetes Program for Indians (SDPI). We need an IHS 
Director who will support an increase of the SDPI program to $250 
million and medical inflation rate increases annually. Importantly, 
given that the majority of Portland Area Tribes have ISDEAA compacts or 
contracts, it is imperative that the next IHS Director support a 
legislative fix that would provide tribes the option to receive funds 
through their ISDEAA compacts or contracts. SDPI provides a 
comprehensive source of funding to address diabetes issues in tribal 
communities that successfully provide diabetes community-based 
prevention and treatment services for AI/AN people and results in 
short-term, intermediate, and long-term positive outcomes.
    Public Health Infrastructure. The next IHS Director must be 
committed to expanding funding opportunities to Tribes through their 
ISDEAA contracts and compacts to develop and support public health 
infrastructure. The IHS has neglected supporting basic public health 
infrastructure for Tribes for too long. This is necessary for Tribes to 
have basic public health infrastructure as we have learned in the 
COVID-19 pandemic and as Tribes continue to face other public health 
issues including the impacts of climate change and opioid epidemic.
    Health Care Facilities Construction. The new IHS Director must 
understand the inequities in health care facility construction and be 
committed to consultation with tribes to change the system that not 
only equitably funds Northwest Tribes' health care facilities 
construction priorities but expands funding to support much needed 
behavioral health facilities construction. The 2021 IHS/Tribal Health 
Care Facilities' Needs Assessment Report to Congress found that the 
overall healthcare facility construction need increased by 60 percent 
from 2016. At the current rate of construction appropriations and the 
replacement timeline, a new 2016 facility would not be replaced for 290 
years. Portland Area Tribes have a long wait before they would be 
eligible for funding under the IHS Health Care Facilities Construction 
Priority List. Portland Area Tribes have had to assume substantial debt 
to build or renovate their tribal clinics.
    Joint Venture and Small Ambulatory Programs. Joint venture and 
small ambulatory programs are important funding sources to meet the 
needs of our smaller tribes who cannot compete in the existing new 
facilities construction priority system. The IHS Director must be 
committed to increase funding for these programs especially in areas 
that do not have hospitals, like the Portland Area. In addition, the 
IHS Director must look to expanding the small ambulatory program to 
include staffing packages and not limit access to the program when the 
health care facility priority system opens for all Tribes.
    Division of Behavioral Health--Initiatives and Grant Programs. The 
next IHS Director must support legislative changes that would allow 
tribes the option to receive behavioral health funds through their 
ISDEAA compacts and contracts. IHS Behavioral Health initiatives 
include the Substance Abuse and Suicide Prevention Program, the 
Domestic Violence Prevention Program, and the Zero Suicide Initiative.
    In 2018, IHS conducted consultation on the Consolidated 
Appropriations Act of 2018 which encouraged IHS to transfer behavioral 
health initiative funding through ISDEAA compacts and contracts rather 
than competitive grants. Later, IHS issued a Dear Tribal Leader Letter 
(DTLL) on its decision to continue using a competitive grant mechanism 
to distribute behavioral health funding. Portland Area Tribes were 
disappointed by this decision and ask IHS to reconsider this decision--
as well as all other competitive grant programs--and move them to a 
self-governance.
    The next HIS Director must be able to work across HHS with ACF, 
CDC, NIH and SAMHSA who all have a role in improving access to and 
resources that meet the behavioral health needs of AI/AN communities 
through funding, data, research and access to resources in a multi-
agency approach. We continue to be concerned about the lingering and 
collective impact of the COVID-19 pandemic on behavioral health, which 
includes an increase of substance abuse, suicidal ideation, anxiety and 
depressive disorders, and disruptions in access to behavioral health 
screening, assessment, and treatment services. This also includes the 
role of supporting community members in catching up on needed related 
medical care resources.
    New Community Opioid Prevention Project Grant Program. The next IHS 
Director must create an option for tribes to receive these funds 
through ISDEAA Title I and Title V compacts and contracts for the new 
opioid prevention program and all behavioral health initiatives. 
Congress first appropriated opioid funding for this project in the 
Consolidated Appropriations Act of 2019. In June 2019, IHS opened 
consultation and confer with tribes, tribal organizations, and urban 
Indian organization leaders to understand tribal priorities for this 
opioid funding. In April 2020, IHS announced its decision to create a 
new IHS Opioid Grant Pilot Program and issued a Request for Proposals 
(RFP) on available opioid program funding of $20 million (FY 2019 and 
FY 2020). IHS has awarded $16.2 million to 35 tribes, tribal 
organizations, and urban Indian organizations through the 2021 
Community Opioid Intervention Pilot Project. Three tribes were funded 
in the Portland Area (Klamath, Jamestown and Lummi) and NARA, the urban 
Indian organization. While we know the three tribes in our area are 
grateful for this funding, this is another competitive grant program 
that must be available for all tribes.
    Youth Regional Treatment Centers. The next IHS Director must be 
committed to future generations by supporting facilities for their 
healing and wellness, new Tribal Youth Regional Treatment Centers, and 
expanded prevention and treatment services, inpatient and outpatient 
mental health and substance use recovery services, including 
transitional living support.
    AI/AN adolescents and young adults are a priority for Portland Area 
tribes. Suicide is the second leading cause of death for AI/AN 
adolescents and young adults and suicide mortality in this age group 
(10-29) is 2-3 times greater, and in some communities 10 times greater, 
than that for non-Hispanic whites. Data shows that during the COVID-19 
pandemic, these numbers have increased and amplify the priorities to be 
addressed with the AI/AN adolescent population. While there are two 
Youth Regional Treatment Facilities in the Portland Area, the Healing 
Lodge of the Seven Nations in Spokane and NARA Northwest in Portland, 
more are needed with expanded services to address youth mental health 
needs and/or substance use. The Healing Lodge is underfunded to meet 
the youth behavioral health needs. For example, the Healing Lodge of 
the Seven Nations only receives $275 in 24/7 Per Diem Daily Rate 
compared to the IHS Inpatient Hospital Per Diem Rate of $3,442. 
Consequently, tribal leaders are forced to prioritize what health care 
services are to be provided for their people.
    Maternal Child Behavioral Health. The new IHS Director must ensure 
that pregnant women have access to services and that providers are non-
nonjudgmental in providing services. Maternal mortality rates are 
especially high among AI/AN women--regardless of their income or 
education levels. Fear is the primary factor that inhibits AI/AN 
pregnant women from accessing prenatal care and from seeking treatment 
for substance use disorders. Fear of having their newborn and older 
children taken from the home, fear of legal consequences and 
incarceration, and fear stemming from the stigma associated with 
substance use. This is compounded by COVID-19 which has further 
disrupted services for pregnant women, caused financial hardship, and 
puts these women more at risk.
    Indian Health Professions. The next IHS Director must support 
expansion of the type of Indian Health Professionals that qualify for 
scholarships to meet the healthcare needs in Indian Country, funding 
increases, and loan repayment program prioritization for health 
professionals. In Fiscal Year 2020, there were over 500 unfunded loan 
repayment program applicants. This included over 100 unfunded nurses 
and 63 behavioral health providers. HHS and IHS must fully fund 
scholarships for all qualified applicants to the IHS Scholarship 
Program and support the Loan Repayment Program to fund all physicians, 
nurse practitioners, physician's assistants, nurses and other direct 
care practitioners eligible for the program.
    IHS IT Modernization. The next IHS Director must make IT 
modernization a priority and commit to support Interior Appropriations 
Committee report language that would allow IHS to reimburse tribes for 
the purchase of their commercial off the shelf electronic health record 
(EHR) systems. RPMS is now a legacy system and is inconsistent with 
emerging architectural EHR standards. We recognize that the Veterans 
Administration's (VA) decision to move to a new Health Information 
Technology solution will create a gap for the parts of RPMS that are 
dependent on core coding from the VA. RPMS cannot meet these evolving 
needs without substantial investment in IT infrastructure and software. 
COVID-19 has really highlighted the challenges with RPMS and has 
required double entries of data for reporting purposes. IHS must be 
creative about IT modernization especially as to those facilities still 
using RPMS. These tribes cannot wait 10 years. These systems will be 
interoperable with the new IHS EHR system and supports patient care.
    Elimination of HIV. The next IHS Director must be committed to 
Ending the HIV Epidemic in Indian Country and increase annual 
allocations for this effort so that Indian Country does not get left 
behind. While rates of new HIV diagnoses are not elevated among AI/AN 
people when compared to some other race/ethnicities, there are notable 
concerns: 1) new HIV diagnoses among AI/AN people increased by 70 
percent from 2011 to 2016; 2) AI/AN patients have had the lowest 
survival rates of any race/ethnicity after an AIDS diagnosis; and 3) 
both male and female AI/AN's had the highest percent of estimated 
diagnoses of HIV infection attributed to injection drug use (IDU).
    Elders and Long-Term Care. The next IHS Director must be committed 
to finally funding long-term care services, assisted living services, 
hospice care, and home and community-based services be funded as 
authorized under IHCIA. Our elders are living longer, and need more 
long-term care services. There are only 15 known tribal nursing homes 
in the nation. IHCIA authorized funding for hospice care, assisted 
living services, and home and community-based services; however, 
funding has never been appropriated for these services to IHS.
Conclusion
    Thank you for your consideration of our Northwest priorities and 
recommendations for the role of the IHS Director. Its critically 
important that we have an IHS Director that can realize our long-
standing Northwest priorities.

        Sincerely,
    Nickolaus Lewis, Chair, Northwest Portland Area Indian 
     Health Board; Secretary, Lummi Indian Business Council

Leonard Forsman, President, Affiliated Tribes of Northwest 
                     Indians; Chairman, The Suquamish Tribe
                                 ______
                                 
                             COLT COALITION OF LARGE TRIBES
                                                       May 23, 2022
Dear Honorable Senators of the Committee on Indian Affairs:

    On behalf of the Coalition of Large Tribes. writing to show our 
strong support for the confirmation of Ms. Roselyn Tso, an enrolled 
member of the Navajo Nation, to serve as the Director of the Indian 
Health Service.
    During our quarterly meeting a motion was made and passed by the 
Coalition of Large Tribes to submit this letter of support for Ms. Tso.
    Ms. Tso has attained 38 years of service at Indian Health Service 
as an Administrative Officer, Program Analyst, Director and recently 
NAIHS Area Director. As the current Area Director for the Navajo Area 
Indian Health Service, she has oversight of 12 health care facilities, 
including ongoing collaborations with the Navajo Nation and Tribal 
health organizations. She plays a major role in the COVID pandemic 
providing the necessary health services to the Navajo people. Based on 
her vast experience and knowledge of the federal systems and capacity 
to coordinate with all tribes she will be a valued asset to Indian 
Health Service to uphold its trust responsibility to improving the 
health care systems across Indian Country.

        Respectfully,
Kevin Killer, Chairman Coalition of Large Tribe; President, 
                                         Oglala Sioux Tribe
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Brian Schatz to 
                              Roselyn Tso
    Question 1. At the hearing and in your responses to the Committee's 
nomination questionnaire, you spoke of your commitment to upholding the 
federal government's trust responsibilities to American Indians, Alaska 
Natives, and Native Hawaiians. In my view, this commitment must stand 
equal to the principle of respecting Tribal sovereignty and self-
determination. Please describe your views on the government-to-
government relationship between the United States and Indian Tribes.
    Answer. The principles of Tribal sovereignty and self-determination 
inform all of the Indian Health Service's (IHS's) operations. As the 
federal agency vested with the primary responsibility for providing 
health care to American Indians and Alaska Natives, IHS goes to great 
lengths to ensure that Agency decisions are informed by the priorities 
of the Tribes benefitting from those decisions. To achieve this 
objective, IHS communicates early and often with Tribal leadership so 
that they have the opportunity to express their needs and so that IHS 
can be responsive to those needs as it carries on its mission to raise 
the physical, mental, social, and spiritual health of American Indians 
and Alaska Natives to the highest level. IHS has been a leader in the 
federal government in developing and refining a Tribal consultation and 
urban confer policy, regularly hosts Tribal delegation meetings and 
listening sessions, and regularly relies on federal-Tribal workgroups 
to facilitate the development of policy. Additionally, IHS seeks to 
further Tribal sovereignty and self-determination through the 
negotiation of self-determination contracts and self-governance 
compacts that permit Tribes to directly manage their own health care 
operations.
    Question 1a. If confirmed, how would you ensure IHS both respects 
and uplifts Tribal sovereignty?
    Answer. If confirmed, I commit to working on efforts to advance and 
improve agency Tribal consultation, Urban confer, Self-Determination, 
and Self-governance. IHS acknowledges and respects the inherent 
sovereignty of Indian Tribes and its unique, government-to-government 
relationship with each Indian Tribe. The IHS is committed to providing 
quality, culturally-appropriate personal and public health services to 
American Indian and Alaska Native people, consistent with its statutory 
authorities.

    Question 2. If confirmed, you would serve as vice chair of the 
Department of Health and Human Services' (HHS) interdepartmental 
council on Native American Affairs (ICNAA). What concrete steps would 
you take to ensure other agencies within the Department are living up 
to the federal government's trust and treaty responsibilities?
    Answer. By statute, the Commissioner for the Administration for 
Native Americans within the HHS Administration for Children and 
Families serves as the Chair of the Secretary's Intradepartmental 
Council on Native American Affairs (ICNAA). The Director for the Indian 
Health Service serves as the Vice Chair. If confirmed as IHS Director 
and thus Vice Chair for ICNAA, I commit to working with HHS leadership 
to coordinate policy, budget, and initiatives across the Department for 
Native American populations.

    Question 2a. Will you commit to pushing other HHS agencies to 
engage in more meaningful consultation with Tribes? And, what steps (if 
any) would you recommend for improving consultation practices within 
HHS?
    Answer. If confirmed, I commit to carrying out tribal consultation 
activities consistent with the current Executive Orders, Presidential 
Memoranda, and Department of Health and Human Services and IHS Tribal 
Consultation Policies. Regular and meaningful consultation with Tribes 
is a cornerstone of our government-to-government relationship between 
the United States and Tribes, and is essential for a sound and 
productive relationship with Tribal nations. I will continue to support 
our work with Tribal Leaders and HHS leadership to review and prepare 
recommendations to improve the HHS Tribal consultation policy and 
process. The Director of IHS is uniquely positioned to champion the 
importance of Tribal consultation across the Department, federal 
government, and the health care industry. I would use every opportunity 
to provide technical assistance on tribal consultation across the 
Department. The IHS has decades of experience and vast stores of 
institutional knowledge regarding consultation with Tribes. It is 
incumbent on the IHS to share this knowledge with other agencies to 
improve consultation efforts across HHS.

    Question 2b. Will you commit to pushing other HHS agencies to 
develop confer policies to improve their engagement with urban Indian 
organizations and Native Hawaiian organizations?
    Answer. Federal law establishes the requirement that the IHS 
``confer,'' to the maximum extent practicable, whenever a critical 
event or issue, as defined in the IHS Urban Confer Policy, \1\ arises 
in implementing or carrying out the IHCIA with Urban Indian 
Organizations (UIOs) (section 514 of the Indian Health Care Improvement 
Act (25 U.S.C. 1660d). Extending this requirement outside of the IHS or 
to Native Hawaiian organizations requires legislative change. The 
agency is committed to working with Congress, other components of HHS, 
and UIO leaders across the nation to help protect the health and 
wellbeing of the patients IHS serves in urban areas. If confirmed, I 
commit to educating and providing technical assistance to other 
agencies on the value and benefits of conferring with UIOs.
---------------------------------------------------------------------------
    \1\ Indian Health Manual (Chapter 26--Conferring with Urban Indian 
Organizations) under Part 5--Management Services. https://www.ihs.gov/
ihm/pc/part-5/p5c26/
---------------------------------------------------------------------------
    At this time, other HHS divisions do not have an urban confer 
policy. Other HHS divisions may set up listening sessions with UIOs and 
may seek support from IHS to initiate these discussions. The IHS 
supports other HHS agencies by initiating urban confer, notifying UIOs 
the other agency is seeking input on a critical event or issue, 
conducting the urban confer, and compiling comments.
    Under current law, the Native Hawaiian Health System is not a part 
of the IHS/Indian health system. I commit to working with other HHS 
agencies, such as the Health Resources and Services Administration, 
which administers the federal program for Native Hawaiian Health 
Centers pursuant to the Native Hawaiian Health Care Act.

    Question 3. What is your view of the Indian Health Service's 
(IHS's) role in supporting Urban Indian Organizations and addressing 
the health care barriers for American Indians and Alaska Natives 
residing in urban areas?
    Answer. The role of the IHS is to improve quality, safety, and 
access to health care for American Indian/Alaska Native (AI/AN) people 
living in urban areas. Urban Indian Organizations (UIOs) are an 
integral part of the IHS health care system. The UIOs provide high 
quality, culturally relevant health care services and are often the 
only health care providers readily accessible to Urban AI/AN patients. 
In calendar year 2020, 41 UIOs provided 699,237 health care visits for 
79,502 American Indians and Alaska Natives, who do not have access to 
the resources offered through IHS or tribally operated health care 
facilities because they do not live on or near a reservation. The IHS 
is committed to continuing to work in partnership with UIOs to 
strengthen the provision of health care for urban Indian communities.

    Question 4. In response to question F-7 of the Committee's 
nomination questionnaire, you identified workforce recruitment and 
retention as one of the top three challenges facing the IHS. If 
confirmed, what specific actions would you take to address IHS's health 
provider vacancy issues?
    Answer. If confirmed, I will work with current IHS leadership and 
IHS Office of Human Resources (OHR) to address vacancy issues at IHS. 
There are tremendous needs for healthcare professionals across the 
nation, especially in Indian Country. Staffing a rural and remote 
health care workforce is challenging for all health care organizations, 
and IHS is no different. There may be limited housing, education, basic 
amenities, and spousal employment opportunities. In particular, I would 
work with OHR to include:

   Workforce Development Programs--The IHS is preparing 
        students to enter a health professions program and provide 
        support throughout their educational and post-graduate 
        training. A few examples include the IHS Grant, Extern, and 
        Scholarship Programs.

   Incentives--The IHS uses various incentives to offer pay and 
        benefits that are closer to what a health care provider would 
        receive in the private sector. Some of these incentives 
        include:

          --Title 5 and Title 38 Special Salary Rates, Recruitment, 
        Retention, and Relocation (3Rs) incentives, including 3Rs 
        incentive up to 50 percent of salary (base pay and locality 
        pay) for exceptional nurses and clinical laboratory scientists, 
        and the IHS Loan Repayment Program to assist in repayment of 
        eligible educational loans. The IHS will conduct a Housing 
        Subsidy Pilot Program to allow IHS management the discretion to 
        extend optional housing subsidies to certain eligible medical 
        personnel to enhance recruitment and retention efforts.

   Partnerships--The IHS uses strategic partners to assist in 
        recruiting for IHS health provider vacancies. Some of these 
        partnerships include the Health Research and Services 
        Administration (HRSA) National Health Service Corps scholarship 
        and loan repayment programs along with the HRSA Nurse Corps 
        Programs. In addition, we partner with the Office of the 
        Surgeon General/US Public Health Service Commissioned Corps to 
        recruit candidates to areas of greatest need. IHS has also 
        partnered with the Office of Personnel Management (OPM) to 
        develop an Exit Survey to capture workforce trends in the 
        agency.

   Marketing, Advertising and Outreach--The IHS has designed 
        marketing, advertising and outreach materials and activities to 
        attract and encourage health professionals to seek additional 
        information about the IHS and to apply for Indian health 
        provider positions. Some of the activities include: virtual 
        career fairs and webinars, recruitment videos, social media 
        network platforms, conferences and webinars. Enhanced marketing 
        of the IHS mission and career opportunities is highlighted at 
        these events.

    Question 4a. Based on your experiences working within the IHS so 
far, do you believe IHS is getting enough funding for administrative 
costs and staffing?
    Answer. Funding disparities between IHS and other federal health 
programs are widely documented. These funding gaps impact everything 
from the IHS's ability to provide high quality health care services to 
American Indians and Alaska Natives, to recruit and retain health 
professionals, and to carry out required administrative activities.
    In line with the long-standing recommendations of Tribal Leaders, 
the FY 2023 President's Budget proposes the first-ever mandatory budget 
for the IHS. The FY 2023 President's Budget is a historic step forward 
toward the goal of securing stable and predictable funding to improve 
the overall health status of American Indians and Alaska Natives, and 
to ensure that the disproportionate impacts experienced by tribal 
communities during the COVID-19 pandemic are never repeated.
    The Budget proposes $9.3 billion in FY 2023, and culminates in a 
total funding level of nearly $37 billion in FY 2032, which is an 
increase of nearly $30 billion or almost 300 percent over the ten-year 
window. A mandatory budget for the IHS would provide stable and 
predictable funding to address the negative impacts of budget 
uncertainty. Mandatory funding would also provide funding levels that 
are necessary to meet our commitments to American Indians and Alaska 
Natives, and provide high quality health care services.
    The Budget proposes an additional $20 million to offer additional 
IHS Scholarship and Loan Repayment Program awards, bolstering 
recruitment and retention efforts through these two high demand 
programs, and through other strategies.
    The Budget also proposes an additional $27 million to offset the 
increasing costs of central assessments charged to the IHS by HHS since 
FY 2014. To address the growing cost of shared services at HHS, the IHS 
has delayed hiring and investments in critical systems, working to 
shield direct health care services to the maximum extent possible. 
However, the IHS is at a point where it can no longer sacrifice 
oversight and management of national health programs to absorb these 
rising costs.
    The Budget also includes an additional $18 million to support the 
efficient and effective administration and oversight of national and 
area-level functions like financial management, human resources, grants 
management, acquisitions, Indian Self-Determination and Education 
Assistance Act contracting and compacting administration, contract 
support costs and tribal lease payments administration, performance 
measurement, compliance, and other administrative activities and 
systems.

    Question 4b. Do you believe underfunding of administrative costs 
would impact your ability as IHS Director to strengthen the Service's 
business operations and patient services?
    Answer. Additional resources are necessary to strengthen business 
operations and patient services at the IHS. I strongly support the FY 
2023 President's Budget, which requests funding to dramatically 
increase access to health care services and to strengthen business 
operations at the Agency.

    Question 5. Your response to question F-7 also identified health 
information technology (I.T.) modernization as one of the top three 
challenges facing the IHS. How has your experience working in different 
roles within IHS informed your determination that I.T. modernization 
should be a top priority?
    Answer. One of my priorities is strengthening and streamlining IHS' 
business operations to better support the delivery of health care by 
creating a more unified health care system that delivers the highest 
quality of care. This requires using the latest technology to develop a 
number of centralized systems such as a centralized electronic health 
records (EHR) system so data follows the patient wherever they choose 
to seek care within the IHS system and better data sharing to improve 
patient outcomes. Having modern and efficient system is key to 
improving the organization.
    A modern and capable electronic health record is vital to support 
high-quality care in our communities. Working in different roles at IHS 
has exposed me to the broad EHR needs of our patients, providers, and 
offices that are vital to meeting the IHS Mission. Patients need access 
to their medical records, scheduling, and other tools to engage and 
participate in their healthcare. Our providers need modern tools that 
meet their needs and are easy to use. The various offices in IHS need 
high-quality data to analyze and review to provide data-driven 
decisions.

    Question 5a. If confirmed, how would you make sure the current IHS 
electronic health record modernization initiative spans a few years 
instead of a few decades?
    Answer. If confirmed as IHS Director, I commit to prioritizing the 
budget and work necessary to accelerate the Health IT Modernization 
Program. The work includes implementing hundreds of sites; it will take 
several years to completely transition the existing Resource and 
Patient Management System databases to a new enterprise solution.

    Question 5b. If confirmed, will you prioritize making sure IHS's 
I.T. investments work with other electronic health systems, like those 
used by the VA, Tribes, and urban Indian organizations?
    Answer. If confirmed as IHS Director, I commit to continue the work 
necessary to provide interoperability with the VA, Tribes, and UIOs who 
are using a variety of commercial packages. The Health IT Modernization 
program will use standards-based approaches to ensure the right 
information is available to our patients and providers to support high-
quality care. IHS and the VA have completed an interoperability pilot 
through eHealth Exchange.

    Question 6. In response to question F-15 of the Committee's 
nomination questionnaire, you stated, ``I believe the proper 
relationship between myself and the Inspector General is a working 
transparent partnership on all matters related to the IHS Agency to 
ensure appropriate accountability and responsiveness. This includes, 
but is not limited to, not impeding the Inspector General's work in any 
way as it relates to the IHS Agency and the policies thereof.'' If 
confirmed, how would you ensure IHS maintains a transparent partnership 
with the Office of the Inspector General and other federal oversight 
bodies?
    Answer. I place a high priority on fostering a positive 
relationship with oversight bodies and specifically with the HHS Office 
of Inspector General (OIG) and the Government Accountability Office 
(GAO). Building and sustaining that relationship involves time and 
commitment. The IHS first line of contact with OIG and GAO is often 
through the IHS Liaison(s) to those organizations. This liaison 
official is knowledgeable about IHS programs and information systems 
and facilitates prompt and responsive answers to information requests 
received during the course of OIG or GAO engagements. The liaison role 
creates a pathway of ongoing communication and relationship building, 
promoting accountability and timely, responsive information. 
Additionally, our partnership with oversight bodies is strengthened 
through frequent training of IHS staff, which would include 
collaborative training opportunities together with the oversight bodies 
to ensure IHS staff understand their reporting responsibilities and 
also the roles and authorities of the oversight bodies. A recent 
example of collaborative work with the OIG/Office of Investigations is 
the establishment of the IHS-OIG special hotline for reporting of child 
abuse and sexual abuse. If confirmed, I am committed to working in 
partnership with OIG, ensuring prompt resolution of findings and 
recommendations from each of the OIG components involving 
investigations, audits and evaluations, and also working with GAO 
audits and investigations to obtain the highest level of integrity and 
quality of IHS services and functions.

    Question 6a. As IHS Director, would you commit to striving for 
similar levels of transparency and cooperation in your relationship 
with Congress?
    Answer. If confirmed as IHS Director, I commit to striving for 
similar levels of transparency and cooperation with members of Congress 
and appropriate Congressional authorizing and appropriation Committees, 
consistent with current and applicable laws.

    Question 6b. If confirmed, what steps would you take to increase 
IHS's transparency and communication efforts with Tribal leaders and 
Native communities on how the agency reaches key decisions that affect 
providing health care in Indian Country?
    Answer. If confirmed as IHS Director, I commit to working towards 
improving communication within the organization and with Tribes, UIOs, 
the public, and other external stakeholders. This includes carrying out 
tribal consultation activities consistent with the current Executive 
Order, Presidential Memoranda, and the HHS and IHS Tribal Consultation 
Policies. I will strive to consider all perspectives received during 
Tribal consultation when making decisions that impact tribes. I will 
ensure that all major decisions are communicated to Tribal Leaders as 
expeditiously as possible. The IHS Strategic Plan FY 2019-2023 
identified the need to improve communication and collaboration across 
the system. To help address this need, I will strengthen program 
management and operations with an objective to improve communication 
within the organization with Tribes, Urban Indian Organizations, 
Members of Congress and other stakeholders, and with the general 
public.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Maria Cantwell to 
                              Roselyn Tso
    Question 1. I have heard from multiple Tribes in my state about 
significant administrative lapses that are negatively impacting Tribal 
members' ability to receive essential healthcare services. Unpaid 
bills, lost paperwork, unanswered calls and processing backlogs have 
led to health care providers threatening to cut off services to Tribal 
members. I have also heard these delays, in several cases, resulted in 
Tribal members being turned over to collection agencies and their 
credit being negatively impacted. Can you detail how you would address 
this mismanagement as Director of the Indian Health Service?
    Answer. If confirmed as the IHS Director, I would continue 
oversight reviews conducted by subject matter experts and peers and 
ensure the reviews are conducted on a regular basis with outcomes 
documented as best practices, effective processes, or corrective action 
plan requirements.

    Question 1a. If confirmed to serve as Director of the IHS, will you 
commit to responding with additional information, in writing, on the 
management adjustments needed to address these issues and better ensure 
IHS is paying bills, responding to claims, and communicating to Tribal 
members are healthcare providers?
    Answer. If confirmed, yes, I commit to responding in writing with 
information on the management adjustments needed. The IHS will continue 
to closely monitor the Purchased/Referred Care (PRC) Program and claims 
processing activities in the Portland Area.

    Question 2. The Indian Health Service plays a critical role in 
supporting self-governance, particularly in supporting Tribes and 
Tribal organizations that administer IHS services. Can you talk about 
the importance of Tribal self-governance?
    Answer. The IHS supports self-governance because it strengthens the 
nation-to-nation relationship between the United States and Indian 
Tribes. The IHS respects the choices of Tribes to exercise their 
inherent right to self-determination and self-government in assuming 
the responsibility of providing health care services to their 
communities. The agency is committed to working with Congress and 
tribal leaders across the nation to implement self-governance 
authorities. The benefit of the IHS Tribal Self-Governance Program 
(TSGP) is the flexibility for Tribes to assume health care programs and 
services formerly carried out by IHS and tailor those programs to the 
needs of their communities. The TSGP is and has always been a tribally 
driven initiative, and strong federal-Tribal partnerships have been 
critical to the program's success.

    Question 2a. Other than general, nationwide Tribal consultation, 
what specific steps would you take to incorporate Tribal input as IHS 
addresses contract support costs and self-governance contracts?
    Answer. If confirmed, I commit to carrying out tribal consultation 
activities consistent with the current Executive Order, Presidential 
Memoranda, and the HHS and IHS Tribal Consultation Policies. Regular 
and meaningful consultation with Tribes is a cornerstone of our 
government-to-government relationship between the United States and 
Tribes, and is essential for a sound and productive relationship with 
Tribal nations. I will continue to support our work with Tribal Leaders 
during the IHS budget formulation process, which leads to IHS 
prioritization of funding requests, which includes contract support 
costs and self-governance compacts. The Director of IHS is uniquely 
positioned to champion the importance of Tribal and Urban Indian 
Organizations' input during this budget formulation process and I would 
use every opportunity to work within our budget formulation process 
with IHS's Office of Finance and Accounting and appropriate offices 
within IHS.

    Question 2b. If confirmed, will you commit to securing resources 
for self-governance contracts at IHS?
    Answer. If confirmed, yes, I commit to working within our budget 
formulation process, which prioritizes our funding requests annually, 
to address resources for self-governance compacts at IHS.

    Question 2c. Will you commit to working directly with Tribes to 
improve how IHS communicates with Tribes and Tribal organizations that 
administer IHS programs?
    Answer. Regular and meaningful consultation with Tribes is a 
cornerstone of our government-to-government relationship between the 
United States and Tribes, and is essential for a sound and productive 
relationship with Tribal nations. I am committed to carrying out tribal 
consultation activities consistent with current Executive Orders, 
Presidential Memoranda, and the HHS and IHS Tribal Consultation 
Policies. I fully support the work of the IHS Director's Workgroup on 
Tribal Consultation. Currently, this workgroup, consisting of both 
Tribal Leaders and federal representatives, is reviewing and preparing 
recommendations to improve the IHS Tribal consultation policy and 
process.

    Question 3. The Indian Health Service works closely with Urban 
Indian Organizations to deliver healthcare to American Indians and 
Alaska Natives who live in urban settings. An issue that has impacted 
Urban Indian healthcare organizations is securing 100 percent Federal 
Medical Assistance Percentage, which the Indian Health Service and 
Tribally-operated clinics have had since the 1970s. If confirmed can 
you commit to supporting efforts to secure permanent 100 percent FMAP 
for Urban Indian Organizations?
    Answer. If confirmed, yes, I commit to supporting efforts to secure 
permanent 100 percent FMAP for Urban Indian Organizations.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Jon Tester to 
                              Roselyn Tso
    Question 1. An independent report commissioned by the Indian Health 
Service found that the agency willfully ignored the case of Doctor 
Weber, a doctor who sexually abused boys on both the Blackfeet and Pine 
Ridge Reservations for years. Can you tell me what steps you will take 
to ensure that IHS addresses this systemic failure?
    Answer. There is no more important priority at IHS than the 
protection of our most vulnerable patients, our children; and there is 
no more important job than protecting them from abuse and instilling a 
culture of accountability. Should I be confirmed, IHS will work to 
standardize the practices of our facility's Governing Boards to provide 
oversight at the Area and Headquarters levels. Different approaches to 
provider misconduct and substandard performance from each of the 
different IHS Areas has yielded an inconsistent, confusing, and 
counterintuitive response. Moreover, it has left IHS vulnerable since 
leadership has less oversight authority. This problem was a key finding 
from the Government Accountability Office in their 2020 report, Indian 
Health Service: Actions Needed to Improve Oversight of Provider 
Misconduct and Substandard Performance.
    Further, I would continue the work already underway to standardize 
IHS's governance process, building on the pilot project in the Bemidji 
Area with its implementation in the Billings, Oklahoma, and Nashville 
Areas. In addition, IHS will work on ensuring proper credentialing and 
vetting of IHS providers as well as distributing information to all IHS 
facilities when conduct or competency issues with a provider occurs to 
prevent him or her from moving from facility to facility. This process 
will ensure that only qualified providers are working within the IHS 
system.
    These steps will ensure that IHS leadership can properly oversee 
operations at individual facilities. In addition, if confirmed, I will 
continue to emphasize building a culture of accountability within the 
agency, stressing a duty for every IHS employee to report suspicious 
activity, publicizing the 1-855-SAFE-IHS tool for reporting suspected 
child abuse or sexual abuse, and ensuring that anyone with a report of 
abuse can come forward without fear of retaliation. These steps are 
essential to ensuring that our children are safe while receiving care 
within the IHS system.
    IHS is committed to working with Congress, HHS OIG and local 
enforcement agencies, and tribal and urban Indian organization leaders 
across the nation to ensure we can protect the health and wellbeing of 
the patients we serve. If confirmed, I will do all I can to continue to 
improve and sustain the culture of care throughout the IHS.

Response to Written Questions Submitted by Hon. Catherine Cortez Masto 
                             to Roselyn Tso
    Question 1. The American Rescue Plan Act investments included a 
focus on Urban Indian Organizations (UIOs) that provide critical health 
services to thousands of urban Natives. But concerning reports have 
emerged that IHS has been slow to get these dollars to the frontline 
providers who need them. Based on your experience, do you see 
opportunities for improvement in getting appropriated funds into the 
hands of tribal communities?
    Answer. During my tenure as Area Director for the Navajo Area, and 
my experience with the Navajo Nation, I have worked to ensure timely 
and efficient distribution of funds to the IHS and Navajo facilities 
and health programs within the Navajo Nation. I believe there are ample 
opportunities for improving the distribution of appropriated funds to 
Tribes. Since I am currently the Navajo Area Director, I am not 
currently working at IHS Headquarters and have not been involved in 
issues related to funding distributions to UIOs. However, if confirmed 
as IHS Director, I commit to work with the relevant finance and program 
experts to ensure timely and efficient distribution of funding to IHS, 
Tribal, and Urban Indian health programs.

    Question 2. The red flags that were missed or flatly ignored, from 
displays of classic grooming techniques to outright allegations of 
criminal activity by whistleblowers in the Weber case is appalling. HHS 
as a whole is still managing the response to Mr. Weber's horrific 
crimes, and more needs to be done to ensure accountability and prevent 
future incidents. Should you be confirmed, how will you approach this 
issue as the leader of this agency?
    Answer. There is no more important priority at IHS than the 
protection of our most vulnerable patients, our children; and there is 
no more important job than protecting them from abuse and instilling a 
culture of accountability. Should I be confirmed, IHS will work to 
standardize the practices of our facility's Governing Boards to provide 
oversight at the Area and Headquarters levels. Different approaches to 
provider misconduct and substandard performance from each of the 
different IHS Areas has yielded an inconsistent, confusing, and 
counterintuitive response. Moreover, it has left IHS vulnerable since 
leadership has less oversight authority. This problem was a key finding 
from the Government Accountability Office in their 2020 report, Indian 
Health Service: Actions Needed to Improve Oversight of Provider 
Misconduct and Substandard Performance.
    Further, I would continue the work already underway to standardize 
IHS's governance process, building on the pilot project in the Bemidji 
Area with its implementation in the Billings, Oklahoma, and Nashville 
Areas. In addition, IHS will work on ensuring proper credentialing and 
vetting of IHS providers as well as distributing information to all IHS 
facilities when conduct or competency issues with a provider occurs to 
prevent him or her from moving from facility to facility. This process 
will ensure that only qualified providers are working within the IHS 
system.
    These steps will ensure that IHS leadership can properly oversee 
operations at individual facilities. In addition, if confirmed, I will 
continue to emphasize building a culture of accountability within the 
agency, stressing a duty for every IHS employee to report suspicious 
activity, publicizing the 1-855-SAFE-IHS tool for reporting suspected 
child abuse or sexual abuse, and ensuring that anyone with a report of 
abuse can come forward without fear of retaliation. These steps are 
essential to ensuring that our children are safe while receiving care 
within the IHS system.
    IHS is committed to working with Congress, HHS OIG and local 
enforcement agencies, and tribal and urban Indian organization leaders 
across the nation to ensure we can protect the health and wellbeing of 
the patients we serve. If confirmed, I will do all I can to continue to 
improve and sustain the culture of care throughout the IHS.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tina Smith to 
                              Roselyn Tso
    Question 1. I am very concerned about the continued failure of 
various HHS agencies to properly share public health data with Tribal 
epidemiology centers and Tribal public health authorities as required 
by federal law and regulations. A GAO report released in March found 
systemic failures within HHS agencies to understand the law and have 
proper guidance to comply with the law. The GAO report included two 
recommendations for IHS-that the Director develop guidance for Tribal 
epidemiology centers on how to request data and that the Director 
develop and document agency procedures for reviewing these requests and 
making the data available. Will you commit to implementing these 
recommendations expeditiously and working with other HHS agencies to 
emphasize the importance of data sharing with Tribal epidemiology 
centers?
    Answer. If confirmed, yes, I commit to working to implement 
recommendations consistent with federal laws and regulations in 
partnership with other HHS agencies.
    The Indian Health Service (IHS) maintains data sharing practices 
with Tribal Epidemiology Centers (TEC) using the IHS Epidemiology Data 
Mart. Since 2012, TECs have established data sharing agreements with 
the IHS under this protocol, which permits access to a limited data set 
of public health data from the IHS electronic health record for their 
respective area. While the practices are long established, I agree that 
we need better documentation on how TECs can request data and how IHS 
will review and process these requests.

    Question 2. The IHS must be a steward of the federal government's 
trust responsibility and obligations to Tribal Nations. This is not 
just about informing Tribal Nations of actions or hosting listening 
sessions--it's about engaging in productive, bilateral dialogue to seek 
and implement Tribal guidance. If you're confirmed as the IHS Director, 
it is especially important that you engage with Tribal leaders to 
understand and address the unique healthcare issues in their individual 
communities. Can you explain your understanding of IHS's consultative 
responsibilities and how the process can be improved? Are you committed 
to robust and ongoing consultation with Tribes in all IHS Areas and 
Tribal Nations? How do you plan to achieve a collaborative, consensus-
building relationship with Indian Country?
    Answer. Regular and meaningful consultation with Tribes is 
fundamental to our government-to-government relationship and is 
essential for a sound and productive relationship. I am committed to 
carrying out tribal consultation activities consistent with current 
Executive Orders, Presidential Memoranda, and HHS and IHS Tribal 
Consultation Policies. I fully support the work of the IHS Director's 
Workgroup on Tribal Consultation. Currently, this workgroup, consisting 
of both Tribal Leaders and federal representatives, is reviewing and 
preparing recommendations to improve the IHS Tribal consultation policy 
and process.

    Question 3. Self-governance contracting and compacting are one of 
the most successful and impactful federal Indian policies. Its basis is 
the acknowledgement of inherent rights and authorities of Tribes as 
sovereign nations determining their own destinies. Efforts to expand 
self-governance of HHS programs through the Indian Self-Determination 
and Education Assistance Act have sometimes been met with resistance, 
including for the successful Special Diabetes Program for Indians. The 
Biden administration has shown a commitment to expanding self-
governance, and I hope that this commitment can continue. Do you 
support the expansion of self-governance authorities within HHS?
    Answer. The IHS Tribal Self-Governance Program (TSGP) is beneficial 
because it provides flexibility for Tribes to assume health care 
programs and services formerly carried out by IHS and tailor those 
programs to the needs of their communities. The TSGP is and has always 
been a tribally driven initiative, and strong federal-Tribal 
partnerships have been critical to the program's success. As the 
Department is reviewing the proposal for expansion of self-governance 
throughout the Department, I am committed to sharing the IHS experience 
on self-governance and to educating sister agencies (e.g., the 
Administration of Children and Families and the Substance Abuse and 
Mental Health Services Administration) on Self-Governance and Self-
Governance expansion, as opportunities arise and per request.

    Question 4. IHS only spends about $4,000 per person each year, 
compared to the national average of nearly $10,000. This discrepancy 
exacerbates health disparities for Native and Tribal communities. The 
best way to start addressing this is by fully funding IHS and making 
funding mandatory. As Director, it will be your responsibility to 
propose mandatory or advanced funding proposals and make the case to 
Congress. Can Tribal Nations count on you to support and advance 
proposals for full, mandatory funding of IHS?
    Answer. Yes, if confirmed as IHS Director, Tribal Nations can count 
on my support to advance proposals that secure full funding for IHS. 
With that in mind, I strongly support the FY 2023 President's Budget 
proposal, which proposes the first ever fully mandatory budget for the 
IHS. The Budget proposes $9.3 billion in FY 2023, and culminates in a 
total funding level of nearly $37 billion in FY 2032. This amounts to 
an increase of nearly $30 billion or almost 300 percent over the ten-
year window. A mandatory budget for the IHS would provide stable and 
predictable funding to address the negative impacts of budget 
uncertainty. Mandatory funding would also provide funding levels that 
are necessary to meet our commitments to American Indians and Alaska 
Natives, and provide high quality health care services.

    Question 5. IHS's Tribally-operated facilities are an essential 
component of fulfilling the federal government's trust responsibilities 
to provide quality health care to Tribal communities. Are you committed 
to maintaining Tribally-operated health care services and supporting 
Tribal governments in administering health care services?
    Answer. The Biden-Harris Administration is committed to upholding 
the United States' trust responsibility to Tribal Nations. If 
confirmed, I commit to upholding the Administration's commitment to 
Tribal Nations. Furthermore, I will endeavor to lead the IHS in a 
manner that builds upon the success of the ISDEAA. I firmly believe 
that the success of the IHS is dependent upon the success of Tribal and 
Urban clinics. In short, I am not only committed to maintaining 
tribally operated health services, I am committed to advancing tribally 
operated clinics and supporting the Tribal governments through robust 
Nation-to-Nation consultation.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Ben Ray Lujan to 
                              Roselyn Tso
    Question 1. The Albuquerque Area Southwest Tribal Epidemiology 
Center in New Mexico and Navajo Epidemiology Center are two of the 12 
Tribal Epidemiology Centers (TECs) in the nation. I am committed to 
ensuring that these centers have access to HHS epidemiological data so 
they can better serve New Mexico Tribes and Pueblos.
    The GAO released a report on March 4, 2022, noting that IHS, CDC 
and HHS need to take specific steps to ensure TECs have access to 
agency-generated epidemiological data, as required by federal law.
    GAO's recommendations make it clear that IHS lacks consistent 
procedures to ensure Tribes and TECs can request and receive the data 
they are entitled to. For example, officials from seven of the 12 TECs 
that GAO interacted with said that IHS officials did not recognize that 
HHS is required by federal law to provide health data to TECs. 
Furthermore, IHS told GAO that it has not developed guidance for TECs 
on how to submit data requests or established written agency procedures 
for reviewing and responding to these requests because it believed that 
TECs' requests were infrequent and that IHS had successfully responded 
to all TEC requests. Conversely, TECs reported that they experience 
significant delays, often over a year, or limitations, in accessing IHS 
data. These obstacles make it difficult for TECs to adequately support 
Tribal and community leaders with public health decisionmaking, 
especially during the public health emergency. To date, all five 
recommendations made by the GAO in this report remain open, including 
two for the Director of IHS.
    Ms. Tso, if confirmed, will you develop written guidance for Tribal 
Epidemiology Centers on how to request public health data from the IHS?
    Answer. I appreciate GAO's careful examination of Tribal 
Epidemiology Centers' (TECs') access to public health data. IHS is 
committed to implementing GAO's recommendations and continuing to 
strengthen our data sharing relationships with TECs. If confirmed, I 
will work with the IHS Office of Public Health Support, IHS' primary 
office regarding public health data, to establish written guidance for 
TECs describing the IHS data available to TECs, how to request these 
data, agency contacts for making such requests, criteria for reviewing 
TEC data requests, and timeframes for responding to TEC requests as 
recommended by the GAO.

    Question 2. Ms. Tso, how will you standardize and document agency 
procedures for reviewing Tribal Epidemiology Center requests and create 
a timeline by which these types of requests need to be approved?
    Answer. If confirmed, I will work with the IHS Office of Public 
Health Support to establish documented Agency procedures on data 
sharing with Tribal Epidemiology Centers (TECs). These procedures will 
serve to standardize TEC data sharing practices and will include a 
description of the IHS data available to TECs, agency contacts for 
making such requests, criteria for reviewing TEC data requests, and 
timeframes for responding to TEC requests as recommended by the GAO.

    Question 3. Ms. Tso, how will you communicate obstacles to sharing 
HHS epidemiological data with Tribal Epidemiology Centers and Tribes 
with Congress?
    Answer. If confirmed, I will work with the IHS Office of Public 
Health Support to communicate semi-annual updates through IHS 
Statements of Action to the GAO in response to outstanding GAO 
recommendations on this matter, until closed. These updates will not 
only include highlights of progress made toward satisfying GAO 
recommendations, but also delineate any obstacles encountered or 
anticipated.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Lisa Murkowski to 
                              Roselyn Tso
    Question 1. Please explain how the Indian Health Service ensures 
uniformity in the application of Contract Support Costs (CSCs) policy?
    Answer. The IHS CSC negotiation template is part of the CSC policy, 
IHM Exhibit 6-3-F. All IHS Area negotiators use the template to 
calculate CSC due to each ISDEAA awardee. The negotiation template is 
then shared with each awardee, negotiated with the awardee, and the 
agreed-upon amounts are entered in the agreement.

    Question 2. What CSCs/eligible costs must be covered/reimbursed by 
the Indian Health Service pursuant to the Indian Self-Determination and 
Education Assistance Act and IHS CSC policy?
    Answer. Section 106 of the Indian Self-Determination and Education 
Assistance Act (ISDEAA) requires the agency to add ``an amount'' to the 
primary funding amount under the contract to reimburse the tribe for 
its contract support costs (CSC) (25 U.S.C. 5325(a)(2), (a)(3)(A)). 
Congress authorizes IHS only to pay CSC ``for the reasonable costs for 
activities which must be carried on by a tribal organization as a 
contractor to ensure compliance with the terms of the contract and 
prudent management, but which normally are not carried on by the 
respective Secretary in his direct operation of the program; or are 
provided by the Secretary in support of the contracted program from 
resources other than those under contract'' (25 U.S.C. 5325(a)(2)). 
Therefore, CSC can only be paid for the reasonable and necessary 
expenses that the contracting tribe must incur but which IHS would not 
have funded through the Secretarial amount, either because the federal 
government does not carry out the relevant activity or because the 
federal government would fund the relevant activity using funds other 
than those transferred to the tribe. Congress later clarified that CSC 
can cover both indirect and direct types of expenses (25 U.S.C. 
5325(a)(3)).

    Question 3. Please explain how in your view the Fort Defiance 
Indian Hospital Board could have been ``erroneously overpaid'' for so 
many years?
    Answer. This overpayment should not have happened. If confirmed, I 
would work to ensure that lessons learned from this can be applied to 
prevent it from occurring again.
    As you know, there were a few unique considerations in this 
circumstance. he Fort Defiance Indian Hospital Board (FDIHB) changed 
their method of negotiating indirect CSC; from 2010 to 2016, the FDIHB 
negotiated indirect-type costs with the IHS, which does not necessitate 
the use of an indirect cost rate. However, starting in fiscal year 2017 
they negotiated an indirect cost rate with the HHS Division of Cost 
Allocation (DCA). In 2017 when the FDIHB submitted an indirect cost 
rate proposal to the HHS DCA, the proposal included all types of 
indirect costs, including costs for activities already transferred and 
funded in the Secretarial amount. The HHS DCA is subject to a separate 
set of statutes and regulations, thus properly awarded an indirect cost 
rate to FDIHB, and the HHS DCA did not take into consideration those 
costs already funded by the Secretarial amount. The ISDEAA requires IHS 
to assess which indirect cost activities were already funded and 
transferred under the Secretarial amount, and prohibits IHS from paying 
costs associated with those activities as CSC.

    Question 4. Given your direct involvement with the Fort Defiance 
Indian Hospital Board will you recuse yourself from all matters 
relating to this case, if confirmed?
    Answer. If confirmed, yes, I will recuse myself from this case 
consistent with current and applicable laws.

    Question 5. The Indian Health Service has been the subject of 
numerous investigations on provider misconduct, including sexual abuse 
and physical assault and substandard performance. What steps have you 
taken to protect patients and employees from harm and what steps would 
you take as Director, if confirmed?
    Answer. There is no more important priority at IHS than the 
protection of our most vulnerable patients, our children; and there is 
no more important job than protecting them from abuse and instilling a 
culture of accountability. Should I be confirmed, IHS will work to 
standardize the practices of our facility's Governing Boards to provide 
oversight at the Area and Headquarters levels. Different approaches to 
provider misconduct and substandard performance from each of the 
different IHS Areas has yielded an inconsistent, confusing, and 
counterintuitive response. Moreover, it has left IHS vulnerable since 
leadership has less oversight authority. This problem was a key finding 
from the Government Accountability Office in their 2020 report, Indian 
Health Service: Actions Needed to Improve Oversight of Provider 
Misconduct and Substandard Performance.
    Further, I would continue the work already underway to standardize 
IHS's governance process, building on the pilot project in the Bemidji 
Area with its implementation in the Billings, Oklahoma, and Nashville 
Areas. In addition, IHS will work on ensuring proper credentialing and 
vetting of IHS providers as well as distributing information to all IHS 
facilities when conduct or competency issues with a provider occurs to 
prevent him or her from moving from facility to facility. This process 
will ensure that only qualified providers are working within the IHS 
system.
    These steps will ensure that IHS leadership can properly oversee 
operations at individual facilities. In addition, if confirmed, I will 
continue to emphasize building a culture of accountability within the 
agency, stressing a duty for every IHS employee to report suspicious 
activity, publicizing the 1-855-SAFE-IHS tool for reporting suspected 
child abuse or sexual abuse, and ensuring that anyone with a report of 
abuse can come forward without fear of retaliation. These steps are 
essential to ensuring that our children are safe while receiving care 
within the IHS system.
    IHS is committed to working with Congress, HHS OIG and local 
enforcement agencies, and tribal and urban Indian organization leaders 
across the nation to ensure we can protect the health and wellbeing of 
the patients we serve. If confirmed, I will do all I can to continue to 
improve and sustain the culture of care throughout the IHS.

    Question 6. The IHS has had a difficult time recruiting and 
retaining medical personnel and administrative staff at the agency. In 
your view would any of the following help with recruitment and 
retention: direct hire authority, more competitive pay scales and 
expanded loan repayment programs?
    Answer. Yes, in my view, direct hire authority, competitive pay 
scales and expanded loan repayment programs would help with recruitment 
and retention. Additionally, if confirmed, I will work with current IHS 
leadership and the IHS Office of Human Resources (OHR) to address 
vacancy issues at IHS. There are tremendous needs for healthcare 
professionals across the nation, especially in Indian Country. Staffing 
a rural and remote healthcare workforce is challenging for all 
healthcare organizations, and IHS is no different. There may be limited 
housing, education, basic amenities, and spousal employment 
opportunities. Some actions I would work with OHR would include:

   Workforce Development Programs--The IHS is preparing 
        students to enter a health professions program and provide 
        support throughout their educational and post-graduate 
        training. A few examples include the IHS Grant, Extern, and 
        Scholarship Programs.

   Incentives--The IHS uses various incentives to offer pay and 
        benefits that are closer to what a health care provider would 
        receive in the private sector. Some of these incentives 
        include:

          --Title 5 and Title 38 Special Salary Rates, Recruitment, 
        Retention, and Relocation (3Rs) incentives, including 3Rs 
        incentive up to 50 percent of salary (base pay and locality 
        pay) for exceptional nurses and clinical laboratory scientists, 
        and the IHS Loan Repayment Program to assist in repayment of 
        eligible educational loans. The IHS will conduct a Housing 
        Subsidy Pilot Program to allow IHS management the discretion to 
        extend optional housing subsidies to certain eligible medical 
        personnel to enhance recruitment and retention efforts.

   Partnerships--The IHS uses strategic partners to assist in 
        recruiting for IHS health provider vacancies. Some of these 
        partnerships include the Health Research and Services 
        Administration (HRSA) National Health Service Corps scholarship 
        and loan repayment programs along with the HRSA Nurse Corps 
        Programs. In addition, we partner with the Office of the 
        Surgeon General/US Public Health Service Commissioned Corps to 
        recruit candidates to areas of greatest need. IHS has also 
        partnered with the Office of Personnel Management (OPM) to 
        develop an Exit Survey to capture workforce trends in the 
        agency.

   Marketing, Advertising and Outreach--The IHS has designed 
        marketing, advertising and outreach materials and activities to 
        attract and encourage health professionals to seek additional 
        information about the IHS and to apply for Indian health 
        provider positions. Some of the activities include: virtual 
        career fairs and webinars, recruitment videos, social media 
        network platforms, conferences and webinars. Enhanced marketing 
        of the IHS mission and career opportunities is highlighted at 
        these events.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. John Hoeven to 
                              Roselyn Tso
    Question 1. The Indian Health Service (IHS) has an extensive 
network of facilities and services throughout the United States. Can 
you provide assurances that the Great Plains Tribes will have adequate 
access to you and your staff? If confirmed, will you commit to visit 
North Dakota's tribes in person to hear and observe first-hand, the 
health needs present in tribal communities located in our state?
    Answer. I recognize and understand many of the issues facing the 
Great Plains and neighboring regions. If confirmed, yes, I commit to 
visit with the North Dakota tribes and maintain regular and meaningful 
consultation, which is fundamental to our government-to-government 
relationship and is essential for a sound and productive connection 
with Tribal nations as a whole. The IHS has a long-standing Tribal 
Delegation Meeting policy and process that provides opportunities for a 
Tribe to make a request or meet with IHS leadership to discuss Tribal 
issues or concerns. I am committed to carrying out tribal consultation 
activities per current Executive Order, Presidential Memoranda, and HHS 
Services and IHS Tribal Consultation Policies. Under my leadership, IHS 
will remain committed to working with Congress and tribal and urban 
Indian organization leaders across the nation to ensure we can protect 
the health and wellbeing of the patients we serve.

    Question 2. Do you support the formation of partnerships between 
Tribes, IHS, and private doctors as one way to assist with increasing 
the number of IHS health care providers?
    Answer. The IHS has several mechanisms that support our 
partnerships with tribal organizations and private providers. Tribal 
organizations provide specialty care that can be accessed by the 
patients of the IHS. In regard to private providers, this partnership 
is accomplished through Purchased/Referred Care (PRC) referral and also 
through telehealth access to private providers and specialists. With 
the new telehealth platform, we hope to greatly increase the number of 
providers that can be accessed over the next year. If confirmed, I plan 
to support and bolster these mechanisms and underlying partnerships.

    Question 2a. As we discussed in-person during your hearing, I have 
heard concerns from dentists who would like to provide pro-bono 
services at IHS facilities but who have been dissuaded by burdensome 
credentialing requirements. With medical credentialing taking a 
substantial amount of time, what are your recommendations for 
streamlining the credentialing process for private physicians and other 
health care professionals so that access to health care on Tribal 
reservations can be improved and patients can see providers more 
quickly?
    Answer. Credentialing and privileging is a very important process 
of reviewing the skills, training, and performance record of providers 
to ensure they have no significant findings in their professional or 
personal background. This vetting process is very important for 
maintaining and improving IHS quality. We are very careful to screen 
out any provider that could potentially be injurious to our patients. 
The actual credentialing process is not long, it is usually the 
background clearance that is most challenging. IHS is currently working 
to improve the credentialing process but there are some obstacles that 
must be alleviated.

   Malpractice insurance is imperative for a provider. 
        Currently, FTCA coverage is not offered to most volunteers. 
        Volunteering providers must obtain malpractice insurance.

   There should be consideration of providing FTCA coverage for 
        IHS independent contractors and volunteers similar to that 
        provided to IHS supporting personal service contractors as 
        authorized by the Indian Health Care Improvement Act.

   Complete the standardization of the process through the 
        standardization of the Medical Staff Bylaws that provide 
        oversight of the credentialing and privileging processes.

    If confirmed, I commit to working with the IHS leadership team to 
improve the credentialing system as we expand and enhance our use of 
the electronic credentialing and privileging program across the agency.

    Question 3. The Fort Yates Indian Health Service Hospital was built 
in 1962 and needs significant updates. If confirmed, will you look into 
the timeline for updates and construction to the Fort Yates Indian 
Health Service Hospital, inform the Committee of when updates are 
scheduled to take place, and work with my office to expedite these 
improvements to the greatest extent possible?
    Answer. If confirmed, yes, I will look into the timeline for 
updates and construction to the Fort Yates Indian Health Service 
Hospital and provide a status update to your office and the Committee. 
We will work with your office to expedite improvements, to the extent 
possible.

    Question 4. You began your career with IHS in 1984. What benefits 
do you believe being with the agency for such a significant period of 
time will bring you should you be confirmed as Director? Alternatively, 
how would you respond to critics who may suggest that your long tenure 
with the agency may make you resistant to making necessary changes at 
the agency?
    Answer. I have worked at all three levels of the Agency, and this 
provided me with the unique exposure and understanding of the 
organization, especially my understanding of the ground level 
activities where patient care is provided which is paramount and 
essential to ensuring safe and quality health care. I also have decades 
of lived experience as a member of the Navajo Nation who has had to 
navigate the services provided by the Agency for myself, family, and 
friends. Because of both my professional and personal experiences, I 
understand how patients experience the system and where we need to 
focus to improve patient experience and health outcomes.
    Additionally, throughout my career, I have held various leadership 
roles that provide me with a well-rounded understanding of the 
organization, as is demonstrated by the following examples. Within a 
relatively short period of time, I stood up a uniform governance 
process/oversight throughout the Navajo Area IHS; updated the 
organizational structure to better support a uniform business process 
and elevated essential programs to better meet patient care and tribal 
needs; reviewed and established a more efficient onboarding process of 
hiring essential staff into the agency; and created a quality program 
that can demonstrate and respond to key areas of the organization 
through uniform scorecards and reporting system. The organizational 
changes created under my leadership at the Navajo Area were 
instrumental in addressing the COVID-19 pandemic and has improved our 
overall relationship with the tribe the Navajo Area serves.
    With respect to the critics regarding my length of service, I would 
respond that throughout my career I have served as a catalyst for 
change. My focus has been and continues to be to improve our health 
care system to better serve the population the IHS serves and ensure 
accountability throughout the agency. As an example, I established an 
organizational structure to support the agency priorities, and thereby 
ensuring deliverables are met in a timely and efficient manner. In 
part, I have successfully affected change through clearly developed 
expectations and outcomes that support the overall mission of the IHS.

    Question 5. What are your top priorities for IHS under your 
leadership?
    Answer. If confirmed, my top priorities for IHS under my leadership 
include:

   Strengthening and streamlining IHS' business operations to 
        better support the delivery of health care by creating a more 
        unified health care system that delivers the highest quality of 
        care. This requires using the latest technology to develop a 
        number of centralized systems such as a centralized electronic 
        health records system so data follows the patient wherever they 
        choose to seek care within the IHS system and better data 
        sharing to improve patient outcomes.

   Addressing the workforce needs and challenges to provide 
        quality and safe care. Each year, IHS loses too many skilled 
        and experienced employees and struggles to replace them with 
        qualified staff. In addition, there are a number of longtime 
        leaders across the agency who are due to retire soon. The care 
        the agency provides is only as strong as its workforce. IHS 
        must improve its recruitment and retention efforts, enhance 
        support and training for its workforce, and institute a strong 
        succession plan to reduce employee turnover and ensure 
        stability.

   Developing systems to improve accountability, transparency, 
        and patient safety. This requires updating many of the agency's 
        policies and programs and using its oversight authority to 
        ensure these policies and programs are being implemented as 
        intended to best serve Tribal communities.

    Question 6. What are some examples of innovative plans or ideas 
that you have to help address the systematic challenges at IHS?
    Answer. If confirmed, here are a few examples of innovative plans 
or ideas that I think would help address the systematic challenges at 
IHS:

   Create an executive leadership development program that 
        supports strategic thinking and problem-solving skills, with 
        emphasis on leading people and being results-driven. This type 
        of a program will support the Agency to have a cadre of 
        candidates to assume key leadership positions in a timely and 
        efficient manner.

   Improve communication throughout the organization by widely 
        sharing information (progress and expectations), including 
        agency priorities, and providing clearly described deliverables 
        that the entire organization works towards.

   Create an improved partnership with tribal communities and 
        their leaders and develop communication strategies to better 
        share information throughout Indian Country that supports 
        improved patient care outcomes and public trust.

   Work to reduce the gaps in understanding of the organization 
        by ensure that key leaders understand the foundation of the 
        organization. Establishing this essential element supports the 
        ability to ensure accountability and reduces the disconnections 
        throughout the organization. Reducing the gaps will start 
        within the IHS Headquarters.

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