[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\
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\1\ See generally Ex Parte Crow Dog, 109 U.S. 556 (1883);
\2\ See Worcester v. Georgia, 31 U.S. 515, 581 (1832).
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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\
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\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.
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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.
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\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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