[Senate Hearing 117-672]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-672

               NATIVE AMERICAN VETERANS: ENSURING ACCESS
                     TO VA HEALTH CARE AND BENEFITS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           NOVEMBER 30, 2022

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
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                         U.S. GOVERNMENT PUBLISHING OFFICE
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                 SENATE COMMITTEE ON VETERANS' AFFAIRS

                     Jon Tester, Montana, Chairman
Patty Murray, Washington             Jerry Moran, Kansas, Ranking 
Bernard Sanders, Vermont                 Member
Sherrod Brown, Ohio                  John Boozman, Arkansas
Richard Blumenthal, Connecticut      Bill Cassidy, Louisiana
Mazie K. Hirono, Hawaii              Mike Rounds, South Dakota
Joe Manchin III, West Virginia       Thom Tillis, North Carolina
Kyrsten Sinema, Arizona              Dan Sullivan, Alaska
Margaret Wood Hassan, New Hampshire  Marsha Blackburn, Tennessee
                                     Kevin Cramer, North Dakota
                                     Tommy Tuberville, Alabama
                      Tony McClain, Staff Director
                 Jon Towers, Republican Staff Director
                           
                           C O N T E N T S

                              ----------                              

                           November 30, 2022

                                SENATORS

                                                                   Page
Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
Rounds, Hon. Mike, U.S. Senator from South Dakota................     9
Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas......    10
Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    11
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    15
Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    17
Murray, Hon. Patty, U.S. Senator from Washington.................    29

                               WITNESSES
                                Panel I

The Honorable Roselyn Tso, Director, Indian Health Service, 
  Department of Health & Human Services; accompanied by Benjamin 
  Smith, Deputy Director, Indian Health Service..................     4

Mark Upton, MD, FACP, Deputy to the Deputy Under Secretary for 
  Health, Veterans Health Administration, Department of Veterans 
  Affairs; accompanied by Stephanie Birdwell, Director, Office of 
  Tribal Government Relations, and John Bell, Executive Director, 
  Home Loan Guaranty Program, Veterans Benefits Administration...     2

                                Panel II

Leo Pollock, Administrator, Blackfeet Veterans Alliance..........    21
Larry Wright, Jr., Executive Director, National Congress of 
  American Indians...............................................    23
Nickolaus Lewis, Vice Chairperson, National Indian Health Board..    25
Sonya Tetnowski, President, National Council of Urban Indian 
  Health.........................................................    27

                                APPENDIX
                          Prepared Statements

Opening statement of the Honorable Jerry Moran...................    41
The Honorable Roselyn Tso, Director, Indian Health Service, 
  Department of Health & Human Services..........................    45
Mark Upton, MD, FACP, Deputy to the Deputy Under Secretary for 
  Health, Veterans Health Administration, Department of Veterans 
  Affairs........................................................    50
Leo Pollock, Administrator, Blackfeet Veterans Alliance..........    60
Larry Wright, Jr., Executive Director, National Congress of 
  American Indians...............................................    65
Nickolaus Lewis, Vice Chairperson, National Indian Health Board..    72
Sonya Tetnowski, President, National Council of Urban Indian 
  Health.........................................................    83

                        Questions for the Record

Indian Health Service response to questions submitted by:
  Hon. Kevin Cramer..............................................    95

Blackfeet Veterans Alliance response to questions submitted by:
  Hon. Jerry Moran...............................................    97

National Congress of American Indians response to questions 
  submitted by:
  Hon. Jerry Moran...............................................    98

 
                       NATIVE AMERICAN VETERANS:
                   ENSURING ACCESS TO VA HEALTH CARE
                              AND BENEFITS

                              ----------                              


                      WEDNESDAY, NOVEMBER 30, 2022

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3 p.m., in Room 
SR-418, Russell Senate Office Building, Hon. Jon Tester, 
Chairman of the Committee, presiding.
    Present: Senators Tester, Murray, Brown, Blumenthal, 
Hirono, Sinema, Hassan, Moran, Boozman, Cassidy, Rounds, 
Tillis, and Sullivan.

              OPENING STATEMENT OF CHAIRMAN TESTER

    Chairman Tester. I call this hearing to order. Good 
afternoon. I am sure that Senator Moran will be here shortly, 
but I thought I would get done with my opening statement and 
then we will go to the panel, and hopefully we will have a few 
more folks here. But we need to get this on the road because 
there are a bunch of votes this afternoon.
    I would say good afternoon to all of you. I want to thank 
you for joining us to discuss the delivery of health care and 
benefits to Native American veterans.
    Native Americans have served in every American conflict 
dating back to the Revolutionary War. However, they continue to 
experience unique challenges that greatly affect their quality 
of life and the timeliness and quality of care and services to 
which they are entitled.
    Recently, VA Secretary McDonough announced a new office 
within VA, the Office of Tribal Health, to help improve Native 
American veterans' access to VA health care. I am pleased the 
Biden administration is putting more focus on the health care 
needs of Native veterans, and I will work to ensure that these 
efforts get the appropriate support here in Congress.
    Yesterday, I reintroduced the Tribal HUD-VASH Act to build 
upon a Tribal housing initiative between the VA and HUD, that 
provides rental and housing assistance to veterans in Indian 
Country who are homeless or are at risk of being homeless. The 
bill also ensures that at least 5 percent of the HUD-VASH 
vouchers are set aside for Native veterans.
    Last Congress I worked with members of this Committee on 
several provisions to allow Native veterans to gain easier 
access to VA health care and VA benefits. We required VA to 
establish an Advisory Committee on Tribal and Indian Affairs, 
which has now met three times to provide advance and guidance 
to the Secretary on all matters related to Indian Tribes, 
Tribal organizations, and Native veterans. And we required VA 
to stop collecting copays from Native veterans. However, I am 
disappointed that despite Congress mandating VA to stop 
collecting copays by January 2022, VA has still not implemented 
this law.
    Today I want to hear from the VA about what they plan to do 
to make this right and ensure our Native veterans have equal 
access to both VA and IHS health care facilities.
    On our second panel we have representatives from several 
organizations who serve Native American veterans. I would like 
to hear about their top priorities, what they are hearing from 
their members about access to VA and IHS services and benefits, 
including health care, transportation, and housing.
    Native veterans have answered the call to service 
throughout our country's history, and we all have a 
responsibility to ensure that they have access to the care and 
benefits that they have earned.
    With that I think we are going to go to Panel 1 
introductions and for your opening remarks. First, on our first 
panel, I want to introduce, from the Department of Veterans 
Affairs, Dr. Mark Upton, Deputy to the Deputy Under Secretary 
for Health. He is accompanied by Stephanie Birdwell, Director 
of Office of Tribal Government Relations, and John Bell, 
Executive Director of the Home Loan Guaranty Program.
    From the Indian Health Service we have the Honorable 
Roselyn Tso, Director of Indian Health Service. She is 
accompanied by Benjamin Smith, Deputy Director of the Indian 
Health Service.
    I want to thank you all for being here today. This is a 
very important hearing. We will start with you, Dr. Upton. You 
may begin with your opening statement.

                            PANEL I

                              ----------                              


                    STATEMENT OF MARK UPTON

        ACCOMPANIED BY STEPHANIE BIRDWELL AND JOHN BELL

    Dr. Upton. Thank you, Mr. Chairman and Ranking Member 
Moran, and members of the Committee. We appreciate you inviting 
us here today to discuss our efforts to ensure that American 
Indian and Alaska Native veterans have access to the VA health 
care and benefits they have earned. Today we will discuss what 
VA is doing to improve the provision of benefits and services 
to these veterans as well as our ongoing coordination with our 
partners in the Indian Health Service.
    American Indian and Alaska Native veterans serve in the 
military at one of the highest rates of all racial and ethnic 
groups. They also disproportionately suffer the medical and 
psychological consequences of service. They reside in urban 
areas and some of the most highly rural parts of this country 
and experience health care disparities that are aggravated by 
barriers to access to care, care navigation, and coordination.
    As a VA health care provider myself and a member of the 
Veterans Health Administration senior leadership team, it is 
personally important to me that we strive to achieve the 
absolute best access, experiences, and care outcomes for 
veterans, and that we work to eliminate health care 
disparities. VA is committed to ensure that our Native veterans 
receive the outstanding care and benefits they so rightly 
deserve and that we use the authorities you have provided to 
us, under the PACT Act, to the fullest extent. We owe Native 
veterans our best.
    VA and IHS have worked collaboratively for decades to 
advance the health care and well-being of American Indian and 
Alaska Native veterans. VA and IHS first drafted a memorandum 
of understanding in 2003, and in 2021, VA and IHS made our most 
recent updates to that MOU through a formal process of Tribal 
consultations and urban confers. The revised MOU reflects the 
evolving health care and health information technology 
landscape, and for the first time VHA and IHS have worked 
together to create an operational plan. This plan includes 
strategies, objectives, and measurable outcomes for 
implementing the MOU's goals. This year's operational plan is 
currently in the midst of Tribal consultation, and we greatly 
appreciate the feedback from our Tribal partners.
    As you mentioned, Mr. Chairman, VA appointed the first-ever 
Advisory Committee on Tribal and Indian Affairs on October 4, 
2021. This committee provides advice and guidance to the 
Secretary on all matters related to Indian Tribes, Tribal 
organizations, Native Hawaiian organizations, and American 
Indian and Alaska Native veterans. We are grateful to Congress 
for the legislation that allows veterans' voices to be heard so 
that we can best meet their needs. I personally had a chance to 
meet with the committee a few weeks ago and truly appreciated 
the thoughtful engagement and dialogue that we had.
    In order to provide Native veterans the health care and 
benefits they have earned it takes a whole-of-VA approach. VBA 
offers a variety of benefits to Native veterans, including our 
VBA home loan benefit program that provides eligible veterans 
the opportunity to purchase or construct a home with no down 
payment, no mortgage insurance, competitive interest rates, and 
low closing costs.
    NCA administers VA's Veterans Cemetery Grants Program, 
which has funded grants for the establishment, expansion, or 
improvement of 121 State and Tribal veteran cemeteries in 46 
states and 3 territories. Since 2011, Tribes have received more 
than $37 million for the cemeteries they operate on Tribal 
trust land.
    The Veterans Health Administration is committed to 
providing veterans with excellent patient-centered care, and we 
have many ongoing initiatives currently underway at the local, 
national, and regional levels to improve mental health and 
substance abuse treatment, reduce homelessness, and work to 
ensure culturally competent care is provided to our Native 
veterans.
    The COVID-19 pandemic had a profound impact on this country 
with substantial impact to our Native communities. In 2020, VA 
implemented interagency agreements with IHS that allowed us to 
provide personnel, medications, personal protective equipment, 
and other resources to our IHS facilities. Through this 
pandemic, our dedicated VA employees have stepped up on 
numerous occasions to provide direct health care and support to 
IHS facilities, Tribal health programs, and open the doors of 
our VA medical centers to accept non-veteran patients through 
our fourth mission. In VISN 22 alone, over 430 medical 
personnel have been deployed to IHS and Tribal health 
facilities during the pandemic.
    Lastly, while VHA has worked extensively to support our 
Native veterans, the fact remains there is more work to do. 
Understanding this need, the VHA Office of Tribal Health was 
established earlier this year and provides VHA with leadership, 
strategic direction, and policy guidance in our efforts to 
support Native veterans. In a few short months, they have 
engaged closely with our VHA leaders, the Tribal Advisory 
Committee, VA employees, and most importantly, Tribal leaders 
and Native veterans and their families. We look forward to 
keeping the Committee updated on their continued progress.
    In conclusion, the health and well-being of all of our 
Nation's veterans is of the utmost importance. VA strives to 
consistently provide high-quality services to the veterans, 
caregivers, family members, and survivors who have earned them. 
We are deeply committed to ensuring American Indian and Alaska 
Native veterans have access to the health care and benefits 
they have earned.
    Thank you for your time and your focus on this important 
topic. We appreciate the partnership of this Committee and the 
Indian Health Service, and I am happy to answer your questions.

    [The prepared statement of Dr. Upton appears on page 50 of 
the Appendix.]

    Chairman Tester. There will be questions, but first we are 
going to hear from Director Tso.

             STATEMENT OF THE HONORABLE ROSELYN TSO
                 ACCOMPANIED BY BENJAMIN SMITH

    Ms. Tso. Good afternoon, Chairman Tester, Ranking Member 
Moran, and members of the Committee. Thank you for the 
opportunity to testify on Native veterans' access to Department 
of Veterans Affairs health care and the Indian Health Service.
    I would like to begin with the IHS mission, which is to 
raise the physical, mental, social, and spiritual health of 
American Indians and Alaska Natives. This includes, of course, 
our Native American and Alaska Native veterans.
    IHS provides health care services to approximately 2.7 
million American Indians and Alaska Natives, from 574 federally 
recognized Tribes and 37 states, through a network of more than 
680 health care facilities. As health care needs change, the 
IHS, VA, and our Tribal partners combined our expertise, 
resources, and efforts to help nearly 145,000 Native Americans 
and Alaska Native veterans living in the United States.
    The IHS and the VA veterans health continue to provide 
eligible Native veterans access to care by bringing that care 
closer to their home, promoting a culturally competent and 
quality care, and focus on increasing care coordination, 
collaboration, and resource sharing.
    The MOU that was referenced earlier establishes the 
framework for the Indian Health Service and the VA to leverage 
our resources and investing in support of our mutual goals. We 
believe that the newly signed MOU builds on nearly two decades 
of experience and will continue to support our objectives to 
improve access to health care outcomes for our Native American 
veterans.
    The MOU has four mutual goals: to increase access and 
improve quality of health care and services; focus on patients 
and facilitate enrollment and seamless navigation; facilitate 
and integrate the electronic health record and other health 
information technologies that affect the health care of our 
Native veterans; and improve access through resource sharing, 
including technology, providers, training, human resources, 
services, facilities, communication, and reimbursement.
    More recently, Congress directed the VA to reimburse Urban 
Indian organizations, the IHS, purchased and referred care 
provided to eligible veterans. Since the implementation of the 
reimbursement provision in 2012, the VA has reimbursed over 
$186 million for direct care services provided by IHS and 
Tribal health programs, covering approximately 15,000 Native 
veterans. We are working with the VA on implementing the newly 
enacted legislation, including the exemption from most of the 
VA health care copayments for Native veterans and clarification 
on the related purchase and referred care under the applicable 
laws.
    The IHS and the VA continue to deliberate on adjusting 
Tribal consultation and urban confers to increase national 
awareness of the goals identified in the MOU in order to gather 
meaningful outcomes and deliverables.
    In wrapping up my comments, I want to ensure this Committee 
that IHS remains firmly committed to improving quality and 
access to care for our Native veterans. As the daughter of a 
Korean War veteran, I had the privilege of caring for my father 
toward the end of his life. I understand firsthand the 
challenges of navigating between the IHS and the VA. For my 
father and all Native American veterans, I have made improving 
care coordination for our Native veterans a priority at the 
Indian Health Service.
    We appreciate all of the efforts in helping us provide the 
best possible care to the veterans that we serve. Thank you, 
and I am happy to answer any questions.

    [The prepared statement of Ms. Tso appears on page 45 of 
the Appendix.]

    Chairman Tester. Dr. Upton and Director Tso, thank you very 
much for your testimony. I appreciate it very much.
    I want to start with what I addressed in my opening 
statement about the copay prohibition. I am disappointed the VA 
has not implemented the law that we passed 2 years ago to end 
copays for VA health care for Native veterans. It passed 2 
years ago. This creates a disincentive for Native veterans to 
use the VA health care facilities, which is opposite of what 
should be occurring.
    In September, Secretary McDonough made a commitment that 
the VA copays for Native American veterans would be eliminated 
this year. We are almost at the end of this year. So Dr. Upton, 
is VA on track to implement the copay prohibition by the end of 
next month?
    Dr. Upton. Thank you, Mr. Chairman, and I will just say we 
absolutely understand the urgency and importance of this, for 
the exact reasons you mentioned, to eliminate that 
disincentive. The Secretary has shared publicly that we are 
going to have this done at the end of the year, and I have 
talked to him directly about it as well.
    What I can share with you, Senator, is we are actively 
working the operational and regulation associated pieces to 
meet that goal, and that is ongoing as we speak. Because this 
is still in the regulation process I have to be cautious 
because it is still predecisional, as you can understand.
    But I would like to share one thing, if that is okay, 
because I know how important this is to our community.
    Chairman Tester. Yes.
    Dr. Upton. One of the areas that we are very strongly 
looking into--and again, because it is predecisional I have to 
phrase it that way--we are looking into the ability to make the 
copayment benefit retroactive to the date that Congress 
intended, which is January 2022.
    So as we move forward in this process we commit to keeping 
you and the Committee updated, our veterans updated, and that 
includes in the coming weeks, as you referenced.
    Chairman Tester. So just to follow up with what you just 
said, that means you are going to reimburse the veterans for 
any copays they paid in 2022?
    Dr. Upton. That is the process that we are actively looking 
into, Senator, which would be for veterans--again, this is 
predecisional--for veterans who have paid copayments since 
January 5, 2022, we are looking into the ability to be able to 
reimburse those as part of this process.
    Chairman Tester. And what will determine whether you have 
that ability?
    Dr. Upton. As we go through the regulation process that 
will determine. And so we should know more soon, and I 
apologize that I cannot share more.
    Chairman Tester. That is no problem. When did the 
regulation process start?
    Dr. Upton. It has been in process for a number of months 
now, if not longer, Senator. There are some important 
complexities to this. We did Tribal consultation, sought public 
comment, and the feedback we received about some components of 
this were mixed. And we care very deeply about the feedback 
from our Tribal partners as well as from our new Office of 
Tribal Health, and that is feeding into helping us make sure we 
get this right.
    Chairman Tester. So let me get this right. You got feedback 
from some of the Tribal partners that said they wanted to have 
a copay?
    Dr. Upton. No. The procedural pieces of it, Senator, 
including how Native status is verified, some of the pieces in 
place that go into effectuating the benefit. Certainly not that 
the copayment should be there, to my knowledge, but how we act 
on it in a veteran-centric way that is very sensitive to our 
population.
    Chairman Tester. Right. So this Committee, for all the time 
that I have been on it, has pushed the different Secretaries 
from different parties, pushed. And by the way, I do not think 
that is a bad thing. I think that this Committee has an 
obligation to, when we see something wrong, to try to fix it 
and try to push the VA to address that. It is what happened in 
the PACT Act, okay, to the max.
    I guess the question that I have is that we did pass this 
bill 2 years ago. Government is renowned for working slow, and 
this kind of dots that I, but this does not seem like a big 
issue to me. And I could be wrong. I am not right all the time. 
But it does not seem like a hugely big issue. I am going to get 
to IHS in a second because they do not charge copays.
    So why has this been--I will not say we are wrapped around 
the axle, but maybe we are.
    Dr. Upton. What I can say, Senator, is that I understand 
your frustration and I know that this is so important for our 
Native veterans, and that is what this is all about. So I 
apologize for the delay.
    Chairman Tester. You do not need to apologize. I just think 
that one of the things that I think that our veterans expect 
out of the VA, and I certainly expect out of the VA, and I am 
not a veteran, is that they act in a timely manner. And I think 
Congress did their job, and oftentimes it is hard for Congress 
to do its job. So when we finally do our job it should not take 
2 years to get it done. But thank you.
    Director Tso, just talk a little bit about IHS. It is not 
charging copays. Tell me why eliminating the copays for the VA 
is important, from your perspective. And that is not your 
house, okay. You have got the IHS side of things.
    Ms. Tso. Thank you for that question, Senator. There are a 
number of reasons why we need to make sure that we eliminate 
the copay. Number one, there is already, in many parts of 
Tribal Country, where our veterans have to travel a long 
distance to get their health care services, and on top of that, 
to layer any kind of copay, in any amount, prohibits and really 
creates that barrier for our veterans to get care.
    Not only that, if they need care for multiple services they 
are paying multiple copays, and so that, in itself, creates a 
barrier. So anything we can do to eliminate any barriers for 
our veterans is what we are asking for.
    Chairman Tester. I appreciate that. I would just tell you I 
think the point you made is really important. It is not a point 
that I took into account, and I am from Montana, where we have 
large land-based Tribes. Some of those reservations are as big 
or bigger than some of the States we have in this country. And 
for those folks to drive a long way and then get hit with a 
copay too, it really is a disincentive.
    So I appreciate that you are on it, Dr. Upton, and 
hopefully you will continue to make sure that this gets taken 
care of.
    I want to talk a little bit about mental health, and since 
I am the only one here you can shut the damn clock off because 
I am just going to keep asking questions until I get through 
them all.
    Despite serving in record numbers, the needs of our Native 
veterans has been historically not something I have been 
particularly proud of, quite frankly. I am pleased to see that 
the Fox Suicide Prevention Program created by the Scott Hannon 
Act placed a strong emphasis on providing suicide prevention 
resources to Tribes and organizations serving Native Americans. 
This includes the Great Plans Veteran Service Center located in 
a reservation that is pretty close to where my farm is, the 
Rocky Boy's Indian Reservation.
    I know the VA has also been working to improve its care 
options for Native veterans. Dr. Upton, can you speak to how 
the VA works hand-in-hand with Tribes and Native veterans to 
provide culturally competent mental health care?
    Dr. Upton. Yes, I would be happy to, Mr. Chairman, and 
thank you for mentioning the Staff Sergeant Fox grant as well, 
that fund community suicide prevention. In fact 21 out of 80 
that we awarded go to areas that cover Tribal communities.
    To answer your question, sir, there are a number of ways 
that we work to address culturally component mental health 
care. We think it is critical that both veterans have trust to 
seek our care, that we build those relationships with our 
Tribes at the local level as well as the work we do regionally 
and nationally, so that they trust to seek the care within our 
system. And once they seek that care it needs to ensure that 
they are respected for their cultures, beliefs, and values.
    And so just very briefly our Office of Mental Health and 
Rural Health have placed a focus on this in our Native American 
population. For example, there has been a group working with 
multiple medical centers, with their local Tribes, to 
essentially develop a suicide prevention program focused on 
Native veterans, both partnering with Tribes, because that is 
so critical, partnering with the community, as well as 
culturally specific care associated with that.
    We have a number of other examples, like our Veterans 
Crisis Line workers have an outreach team that after a veteran 
calls our Crisis Line there typically is follow up to make sure 
the veteran is okay to check in. Those secondary responders are 
trained in Native American culture as well as other pieces. And 
then there are a few other examples I could share, sir, 
including culturally appropriate care for telehealth. We have a 
project working on that.
    But there is certainly more work to do, and our Tribal 
Advisory Committee has talked about suicide prevention as a key 
priority, and we are committed to working closely with them on 
that.
    Chairman Tester. Okay. Before I turn to Senator Rounds, I 
do not know if this is a fair question for you, Stephanie but I 
am going to ask it. In your travels have you seen the impacts 
of the VA's mental health from a cultural standpoint?
    Ms. Birdwell. I have seen of VA's mental health services 
from a cultural standpoint. I have seen examples of excellence 
in different pockets of the country. I have seen that occur 
with a project with Camp Chaparral, which is a partnership 
between the VA and the Yakama Nation, that happens every 
summer. There is a veterans camp where you bring together 
American Indian and Alaska Native veterans and VA providers for 
a week-long kind of immersion program. It is something that is 
very powerful and has been ongoing for quite some time.
    And then there is also sweat lodge ceremonies, partnerships 
with traditional healers in different parts of the country. We 
have a strong impact with that in New Mexico with the 
Albuquerque VA Medical Center.
    So like I say, I see pockets of that excellence, but I 
think that there is still work to do in a uniform way, on an 
enterprise-wide basis. But also considering 574 Tribes, 574 
unique ways of doing things traditionally, so there is a lot of 
work to do and a lot to learn as well.
    Chairman Tester. Senator Rounds.

                      SENATOR MIKE ROUNDS

    Senator Rounds. Thank you, Mr. Chairman. Let me just begin, 
I want to thank our guests for taking the time to join us here 
today.
    Before I begin my questions I would like to take a moment 
to talk about the Native American Direct Loan Program. I think 
this is a program which, as you are probably perhaps familiar 
with, that actually is one that would provide a number of our 
Native American veterans with an opportunity for a home loan 
that they may not have today. And so the idea that we have 
Native American veterans that are not able to get a home loan 
because they are, in many cases, living on Tribal trust land, 
seems to me that it is something that we could address.
    It is no secret that this program is not meeting its full 
potential to improve home ownership opportunities for Native 
American veterans, which is why Chairman Tester and I have 
introduced the Native American Direct Loan Improvement Act, S. 
4505. We did that earlier this year. The VA provided testimony 
on this bill during our legislative hearing in July, and I 
appreciate the support and the technical assistance the 
Department has provided since them.
    I spoke with Secretary McDonough yesterday, and he informed 
me that the VA is also taking some steps internally to improve 
its NADL operations while S. 4505 moves through the process. 
This is promising news, and I want to thank the Secretary and 
his team for their continued support for my bill while staying 
active on this important issue.
    While I am encouraged by the VA's recent efforts there is 
still more work to be done, and I remain committed to getting 
S. 4505 across the finish line to make certain that Native 
American veterans are able to use this home loan benefit, which 
they have earned through their service. And Mr. Chairman, I 
really think it is time for us to get this done.
    I do have a question for Mr. Bell. Since the release of the 
GAO report earlier this year your staff has been taking steps 
to improve the NADL program on an administrative level, and I 
appreciate that. I also appreciate the technical assistance 
your staff has provided with crafting an amended version of S. 
4505. I think it is pretty clear that it is going to take some 
legislative action to get this thing fixed for deserving Native 
American veterans in my State and across Indian Country.
    I guess my question would be, do you agree that there is 
still a lot of room for improvement within this program?
    Mr. Bell. Yes, sir, and thank you, Senator, for allowing me 
to address the panel. First of all, 4505, to us, is very 
important. We appreciate the partnership we fully support with 
appropriation, 4505, because it does a few things for our 
program that we just cannot do. One is it removes the MOU 
requirement completely, which will provide VA the flexibility 
in establishing agreements with various Tribal organizations to 
expand the NADL program.
    Second, it expands our NADL loan types, which is huge. 
Because while we have seen a very big increase in the use of 
the guarantee by Native Americans, American Indians, as well as 
Alaska Natives over the past 2 years, it is still important for 
them to be able to purchase, refinance their properties where 
they want to purchase and refinance their properties. This 
allows us to go across the finish line and offer a non-NADL 
loan the chance to refi into a NADL loan, as well as from a 
cash-out standpoint the ability for them to use their equity 
that they have earned as cash-out. Because maybe they want to 
stay there and renovate, and why would they not have the 
opportunity to do that as well?
    And then third, and certainly not least, is the CDFI 
relationships that it allows us to create, just to make it even 
easier for Native Americans to purchase land, to purchase and 
build properties where they want to.
    So while we have seen those huge increases, we still need 
4505 to get us across the finish line, and why we think that it 
is so important.
    But to answer your first question as well about 
administratively, we are very excited, and while we are working 
on 4505 we still believe that there are things that we can do 
from an MOU standpoint to remove some of those impediments and 
really open up the aperture, especially in the State of Alaska, 
where we have been unable to get our NADL loan some success in 
those areas.
    So very exciting and promising in that arena, so thank you.
    Senator Rounds. Thank you, and I appreciate all the help 
and the technical support that you have provided us in moving 
this bill forward.
    Thank you, Mr. Chairman.
    Chairman Tester. Senator Rounds, I would just say that we 
are going to hotline 4505, and if you can clear it on your side 
I will clear it on mine. How is that?
    Senator Rounds. Let us go to work on it.
    Chairman Tester. All right, baby.
    I have got to turn the gavel over to Senator Moran because 
I have got to go vote.

                      SENATOR JERRY MORAN

    Senator Moran [presiding]. Mr. Chairman, thank you. I do 
have an opening statement but I will submit it for the record, 
so I ask unanimous consent that that occur. Without objection, 
so ordered. And my understanding is that Senator Hirono is next 
to ask our witnesses questions.

    [The opening statement of Senator Moran appears on page 41 
of the Appendix.]

                      SENATOR MAZIE HIRONO

    Senator Hirono. Thank you, Mr. Chairman. Dr. Upton and the 
rest of our panel, thank you very much for joining us today to 
discuss issues facing Native veterans.
    As a Senator from Hawaii, I am very disappointed, Dr. 
Upton, that your testimony neglected to mention Native Hawaiian 
veterans. As you know, like other Native communities, Native 
Hawaiians serve in our military at disproportionately higher 
rates. I know the VA understands the importance of ensuring 
Native Hawaiian veterans are treated with the same concern as 
American Indians and Alaska Native veterans, especially 
following the Secretary's recent visit to our State in October 
for a field hearing.
    But it is critical, given the historical lack of parity 
Native Hawaiian have received from the VA that Native Hawaiian 
veterans are always included in our language and our policies. 
Would you be willing to correct the record to include Native 
Hawaiians in your testimony and to show how you are engaging 
with Native Hawaiians as part of the Native American veteran 
community?
    Dr. Upton. Thank you, Senator, and I appreciate the 
acknowledgement of our Native Hawaiians who are so important 
and important in our veteran population. As noted in our 
testimony, they are an important part of our Tribal Advisory 
Committee, and I really appreciate that voice being on the 
group that advises our Secretary.
    In talking with our region of VAs that works very closely 
with the team in Hawaii, I know that they are taking the work 
with our Native veterans very seriously, working on efforts 
with the University of Hawaii as well as other outreach to the 
population there. We certainly welcome the input on how to do 
better and to continue those partnerships.
    Senator Hirono. So my main point is that Native Hawaiians 
should never be deemed an afterthought, and that when we talk 
about focusing on programs that support Native communities or 
Native American veterans that would be three large groups of 
Native peoples, and you know who they are. So I am asking that 
we need to always include Native Hawaiians when we start 
talking about all the things that we are doing.
    I am aware that there are specific programs that support 
Native Hawaiians. So like other Native communities, Native 
Hawaiian veterans have long experienced significantly more 
challenges in accessing resources, an issue that former Senator 
Akaka, Senator Dan Akaka from Hawaii, who had chaired this 
Committee, fought to fix for years, and one that I am committed 
to as well.
    VA's own 2021 National Veteran Health Equity Report chart 
book on Native Hawaiians and other Pacific Islander veterans 
reported that Native Hawaiian veterans often expressed more 
issues with care as compared to white veterans. It is clear 
that the VA needs to increase its understanding of Native 
Hawaiian culture, outreach to Native Hawaiian community, and 
build ties with organizations trusted by the community to 
ensure Native Hawaiian veterans receive the care they deserve. 
And I would greatly appreciate a VA partnership on issues 
important to veterans in Hawaii.
    We have a lot of veterans in Hawaii. A big group of them 
are Native Hawaiians, including, of course, as I mentioned, 
Secretary McDonough's visit to Hawaii earlier this year. But it 
is clear that the VA still has serious work to do to better 
support Native Hawaiian veterans, and I hope that we can 
continue working together to ensure Native Hawaiian veterans 
are getting the care and benefits they earned through their 
service to our country.
    This really requires, in many cases, very different ways of 
outreach to this community. It requires understanding of the 
Native Hawaiian veteran community. So I realize you do a person 
who sits on your advisory group and I will continue talking 
with him as to what more support we can provide.
    I have a question about homelessness in the time I have 
left. Homelessness among veterans is a huge issue for the VA, 
and at one point one of our Secretaries said that eliminating 
homelessness among veterans was his top priority. Clearly that 
is still an issue. So we are talking about the 2022 Point-in-
Time Count showed that Native Hawaiians or other Pacific 
Islander veterans make up the second-largest share of homeless 
veterans on islands, and that veterans overall had twice as 
many health conditions as compared to the broader population 
included in the PIT Count.
    In your testimony you mentioned VA's toolkit to provide, 
and I quote, ``background, planning, resources, and 
programmatic options for organizations interested in finding 
solutions for homelessness among Native veterans,'' and this 
tool does not, again, mention Native Hawaiian veterans at all. 
Does VA have any strategies that specifically address Native 
Hawaiian veterans experiencing homelessness, and if so, do 
these strategies integrate Native Hawaiian cultural practices 
and norms?
    Dr. Upton. Thank you, Senator, and please know I take all 
of that feedback very seriously. I do not know offhand about 
specific programs impacting homelessness for Native Hawaiians 
but I will absolutely take that for the record and we will 
follow up with you.
    Senator Hirono. Thank you. So homelessness as well as so 
many other health issues, including mental health issues and 
suicides of Native Hawaiian veteran group experience much 
higher rates than the larger population. So Mr. Chairman, thank 
you for your indulgence. I am a little bit over time, but 
clearly we have work to do. Thank you.
    Senator Moran. Senator Hirono, thank you very much.
    Before I ask my questions I again want to--it is not again 
because I did not make my opening statement, but I thank our 
witnesses from both IHS and VA for being here this afternoon. 
And before I get to my questions I want the Committee members 
to know that I think this is valuable for us as we presumably 
are bringing this session to a conclusion.
    We have been working on these issues for a long time, and 
progress has been made. There is much further progress we can 
make before we can make certain that American Indians and 
Alaska Native veterans are able to take advantage of all the 
services that they are due and have timely, easy access to 
health care and benefits from both agencies.
    I also want to note that for more than a year now this 
Committee and our House counterparts have been negotiating two 
end-of-the-year legislative packages, the Dole-Cleland Act and 
the STRONG Act. Both of these bills have provisions in them 
that would help veterans and their families across the country, 
including in Indian Country. We are very, very close to 
reaching a final agreement on those bills and being able to get 
them to the President's desk this Congress. In order to do that 
we would need to start the Senate hotline process no later than 
next week, meaning that we would need to reach a final 
agreement between the four corners this week. It would be a 
shame for the topics that we are talking about today, but for a 
variety of other veteran issues, if we are unable to get to 
that point after so much time and effort has been spent.
    Almost every, if not all, members of this Committee have 
something at stake in that legislative package, and I certainly 
am willing to do everything I can to get there, and I would ask 
my colleagues on both sides of the aisle to help us get to that 
point and send another year-end package of important 
legislative items to the White House.
    Let me ask my first question, and that is to Dr. Upton. 
Recognizing the barriers that Tribal communities often have had 
in accessing VA health care and benefits, how is the VA 
targeting outreach and communications regarding the PACT Act to 
toxic-exposed veterans and survivors in Indian Country?
    Dr. Upton. Thank you for that question, Senator, and it is 
so important that we do this outreach, and thank you to you and 
the Committee for passing the PACT Act. It is allowing us to 
help so many veterans.
    As I look at the landscape of the work being done across 
VA, and I have connected with many leaders across our 
organization, including those who work closely with the team in 
Kansas, the importance of the Tribal relationships in the local 
community are so critical. And so there are a number of ways 
that our local VA medical centers as well as the VISNs are 
connecting with Tribes, holding events, meeting with Tribal 
veteran representatives, specifically talking about enrollment 
and now the PACT Act. I have a number of examples that I would 
be happy to share with the Committee, if interested, about some 
really neat ways that our teams have come together, with VBA 
and others in our Tribal community, to share those benefits.
    Ms. Birdwell, you may have some background on this too, 
because she has been doing this for a while, but know it is a 
priority.
    Senator Moran. We would welcome you sharing those examples 
with us, with the Committee, in the future.
    Ms. Birdwell. Sure, so good afternoon, Senator.
    Senator Moran. Good afternoon.
    Ms. Birdwell. Since 2018, our team has worked very closely 
with the Veterans Benefits Administration, VHA, and IHS to hold 
what we call--they are claims events or claims clinics, where 
we go onsite and we provide intensive services to assists 
veterans with filing their claims with the VA, filing for 
health care benefit through VHA. And so that has been an 
outreach that has been ongoing. Again, it is something that has 
become a permanent part of VA business practice for about 4 
years now. So that is something that I would anticipate that 
the PACT Act outreach would roll into that.
    Now I will pause on that to say that it is a very timely 
question. I have calls already being scheduled next week. Our 
team has been contacted directly by VA medical center directors 
and then local IHS area directors, to say we need to start 
having some conversations about coordinating how we are going 
to be doing PACT Act outreach rollout. So the work plan and the 
conversations are happening, and the plan is basically being 
built and growing as we speak.
    I also want to mention that the VA Advisory Committee on 
Tribal and Indian Affairs, I think their voice and their 
recommendations will have a very strong influence on how 
outreach is done.
    Senator Moran. Have they met specifically on implementation 
of the PACT Act?
    Ms. Birdwell. They had their most recent meeting about 2 
weeks ago, and they will have another meeting coming up in 
April. They also have subcommittee meetings in between their 
full public FACA meetings. So I cannot speak for the TAC but I 
think that is something that is very much a priority on their 
radar, that they will be talking about internally.
    Senator Moran. Thank you.
    Ms. Birdwell. And also something else I just want to 
mention to you, that is very much on the table when it comes to 
outreach and getting Tribal input, is broader Tribal 
consultation to get feedback on how effective we are doing and 
to kind of really hold us accountable, moving forward.
    Senator Moran. Are there any questions that you would have 
me ask the second panel that would help elicit that kind of 
input?
    Ms. Birdwell. I think asking them the same question really 
that was presented to us, you know, just really straight up, 
what are the most effective ways of reaching and informing 
veterans in our local, Tribal, and urban communities with 
respect to this information. And then, you know, for better or 
worse, where the TAC has seen areas where VA can improve, apply 
some of those to PACT Act outreach as well. So I would just ask 
them the question directly what they recommend.
    Senator Moran. One of the things that at least initially 
surprised me is the number of times we learn about veterans who 
do not enroll in the VA, who do not know they are eligible for 
health care or for benefits. I do not know off the top of my 
head, although I have a group of experts behind me who could 
probably answer this question, the percentage of veterans that 
fail to take advantage of what they are entitled to at the 
Department of Veterans Affairs. Do you know whether that 
percentage, that number, is different between Native American 
and Alaskan Native veterans than it is the general veteran 
population?
    Ms. Birdwell. I do not know that definitively. It is my 
impression that that is accurate, however, that American Indian 
and Alaska Native veterans enroll in VHA health care at a far 
lower rate than their non-Native counterparts.
    Senator Moran. Thank you. My time has more than expired, 
and while I thought I had a free rein and free run, the Senator 
from North Carolina has arrived and he is recognized.

                      SENATOR THOM TILLIS

    Senator Tillis. Thank you, Senator Moran, and thank you all 
for being here today.
    I want to talk a little bit--and will try not to belabor 
the Committee hearing--but I want to talk a little bit about 
efforts to ensure Native American veterans can access and 
utilize health care and the benefits they have earned and 
deserve. And I know firsthand some of the challenges that 
Native American veterans face receiving VA and non-VA health 
care and benefits, particularly in the rural part of the 
country. It may come as a surprise to some but North Carolina 
has the sixth-largest population of Native Americans in the 
country, and it is home to the largest Tribe east of the 
Mississippi, the Lumbee.
    Native Americans have a long and distinguished history of 
military service, serving in armed forces at a higher rate than 
any other demographic, and I think even more so for the Lumbee, 
not too far away from Fort Bragg.
    Despite their service, Native American veterans have lower 
educational attainment, higher unemployment rates, higher 
suicide rates, and are more likely to have service-connected 
disability than veterans of other races.
    I want to talk a little bit about the progress. I am sorry 
I could not be here; we have had votes and competing meetings. 
I will review some of your statements. But before I get into 
one or two questions I want to ask, give me hope. What 
specifically are we doing for Native American veterans and 
expanding care and addressing some of the disproportionate, 
poor outcomes that we have in that population, and maybe if you 
could speak to some of the root causes.
    Dr. Upton. Very important question, Senator, and I will 
start and turn to Ms. Birdwell, as well as potentially our IHS 
colleagues as well because it is so important.
    I would say, number one, when it comes to VA health care, 
the importance of trust and engagement and listening to our 
Tribal partners is the number one thing I hear all the time. 
And it is so important that when we work with our Tribal 
partners and our Tribal leaders that they are at the table, 
that we make joint decisions together, and we understand the 
needs of the local communities. We know there are 574 federally 
recognized Tribes, and a lot of different customs, values, 
beliefs, and approaches, and history and trust that we need to 
build with them.
    So I will say if there is one common thread I have heard 
across the board is that local engagement, the trust building, 
the dissemination of resources by trusted partners, and then 
when they get in the door, ensuring that they are treated with 
respect and sensitivity to their culture. There is definitely 
work to do, as you mentioned, Senator, and just for the sake of 
time I will turn to you, Stephanie. But it is something that is 
so important.
    Ms. Birdwell. Senator, I would say that there is actually 
quite a bit of good things that are happening. One of them, 
most recently, has been the advent of the VA Advisory Committee 
on Tribal and Indian Affairs. That advisory committee is a 
voice directly to the Secretary, and I have seen firsthand how 
seriously the Secretary takes that relationship and the role 
that they play in advancing the status of our American Indian 
and Alaska Native veterans.
    Another very positive success story has been the 
reimbursement agreements that have happened between the VA and 
IHS. I believe that to date there have been approximately 
15,000 American Indian and Alaska Native veterans who are now 
enrolled in VHA health care over the last decade that 
previously had no visibility or access to VA. And then at the 
same time the Indian Health Service and over 115 Tribal health 
programs have been reimbursed approximately $180 million, which 
is something that is very much needed in the Tribal community.
    And we have got the Office of Academic Affiliations. It has 
been a long, iterative process, but they have authorization to 
VA fund 100 graduate medical education students who will do 
their residency rotations in IHS and Tribal health facilities.
    You know, I could go on, but really it is very exciting. I 
mean, there are still some very serious challenges, of course, 
in serving our Native veteran population, but if you look at 
where we were 10 years ago, there has been a tremendous amount 
of progress that has been made in a relatively short period of 
time.
    Senator Tillis. I will follow because I am more about trend 
lines, programs that are working, and really programs that are 
not working. You know, sometimes when we put programs in place, 
particularly if they are congressionally mandated, and they do 
not work, they still stay there. So the question we have to ask 
ourselves is what is working that we should double down on and 
what is not working that we should quiesce. We will make sure 
that we reach out to your staffs to get more details. I will 
not take you to that level now.
    Ms. Tso, I want to ask you a question. The Lumbee Tribe, I 
think, first sought recognition about 130 years ago. In the mid 
'50s, they were simultaneously recognized and unrecognized. 
More recently, we have seen bipartisan support from the 
Governor, the State legislature. Former President Obama called 
for recognition. Former President Trump called for recognition. 
During the campaign, in President Biden's first term, he also 
said it was time for recognition, and I believe Vice President 
Harris was down in Robeson County and said that to the Lumbee 
Tribe members when she was down there.
    Is it still your understanding that President Biden 
supports recognition of the Lumbee Tribe?
    Ms. Tso. I am going to ask my colleague here to respond to 
that question.
    Senator Tillis. Mr. Smith?
    Mr. Smith. Yes. Thank you very much for the question. This 
is a question that we would first recommend being directed to 
the Department of the Interior, and we can certainly take this 
back and check in with our colleagues at the Interior. But as 
you know there are really two processes for Federal recognition 
for Tribes, one that is administratively managed through the 
Department of the Interior and then the other----
    Senator Tillis. And then congressionally.
    Mr. Smith. Yes.
    Senator Tillis. Yes, and I think in that case I think that 
President Biden, when they made the conscious decision during 
the campaign to say that they thought it was time for 
recognition, understands the two paths, one path that for 130 
years has not worked, and another path that is before us in 
this Congress, and every other Congress for over a century. So 
I was just curious if there had been a change in posture. I 
have had some discussions with Lege Council, and I have gotten 
the impression that they are still behind it, and we are going 
to continue to work on it.
    The last thing I would just offer to you all, to the extent 
that we are talking about the Tribal population in North 
Carolina, of course we have the Eastern Bank of the Cherokee, 
the Lumbee, but we have seven other Tribes, that I feel like 
sometimes if we are going to really increase their access to 
care and benefits you have got to go where they are. If you 
have a program, you hope that they come to it. But I would like 
to talk to you all about potential opportunities we would have 
to go down into the State and make it very clear that we want 
to get them every benefit they deserve. Thank you.
    Chairman Tester [presiding]. Thank you, Senator Tillis. 
Senator Sullivan.

                      SENATOR DAN SULLIVAN

    Senator Sullivan. Thank you, Mr. Chairman, and I appreciate 
the panel being here. Really, really important issue, certainly 
in my State, and I just want to begin by acknowledging what we 
all know, but I just think it bears repeating, about the 
incredible what I refer to as special patriotism of the Native 
American people and Alaska Natives who serve at higher rates in 
the military than any other ethnic group in the country. Think 
about that. It is really remarkable when you think about this 
is a group of Americans who, let us face it, have not always 
been treated well by their own government. And yet generation 
after generation they sign up to sacrifice, protect, and die 
for their country. It is unbelievable.
    I had the great honor, and literally it was the honor of a 
lifetime, to be asked to speak at the Veterans Day ceremony 
this year at the National Museum of the American Indian on the 
Mall, for the dedication of the really powerful memorial to 
American Indian, Alaska Native, Native Hawaiian veterans. It 
was great. The Secretary of the VA came too. It was a fantastic 
ceremony. So I think this is a really appropriate hearing. We 
all need to do better for these wonderful veterans and their 
families.
    So let me first--and I will just throw this out to the 
panel--this is the question I had asked the Secretary in a 
hearing just a couple of weeks ago, and then he and I had a 
discussion yesterday about this. This is the Native American 
Direct Loan Program, which really has not worked for Lower 48 
Indians well, but it really has not worked for Alaska Natives. 
A 40-year-old program and not one Alaska Native veteran has 
ever gotten one loan.
    So the Secretary committed to me again, in a phone call, 
which I really appreciated, that the VA was going to work for 
ways to get an administrative fix to this so we can start doing 
what the bill was intended to do, and the program.
    Can any of you, Mr. Bell, maybe, take this one on?
    Mr. Bell. Thank you, Senator, and good news to report. At 
least we were on the verge of one.
    Senator Sullivan. Oh. One in 40 years. You have got to 
start somewhere.
    Mr. Bell. Yes, sir. I am not looking for a pat on the back, 
just a fact----
    Senator Sullivan. Well, that is helpful.
    Mr. Bell [continuing]. That we are trying to----
    Senator Sullivan. Where are they from? Can you tell me?
    Mr. Bell. It is the Metlakatla Tribe.
    Senator Sullivan. Yes. So that is great, and I love 
Metlakatla. I was out there for the dedication of their VA 
cemetery, which was unbelievable. I mean, so powerful. So many 
veterans on Metlakatla. But let us make sure it is not just 
Metlakatla. As you probably know, Metlakatla is the only Indian 
reservation in Alaska, which is great, but this needs to extend 
beyond Indian Country, because we do not have Indian Country 
other than Metlakatla.
    Mr. Bell. Yes, sir.
    Senator Sullivan. But thank you. Can you do that? Are you 
ready to fix it that way, do you think?
    Mr. Bell. Yes, sir. That was part of the call yesterday, 
that we are----
    Senator Sullivan. Were you on the call yesterday?
    Mr. Bell. No, sir. Here is what we know. S. 4505, the 
legislation, the bill that we are trying to get passed--Senator 
Rounds has been working with our staff certainly since July--
gives us a lot of tools in our toolbox to be able to open up 
and make NADL loans available in those areas where we have the 
12, you know, for-profit centers with shareholders in those 
lands, that we have not just been able to get into.
    The hope is that by expanding the administrative part while 
we wait on 4505--so we are trying to expand the administrative 
look, or understanding, sorry, and the statutory language that 
we have so that we can establish an MOU with that area, with 
those partnerships, so that we can start doing loans in those 
areas.
    Senator Sullivan. Okay.
    Mr. Bell. So that is one thing. The other thing is, the 
reason why 4505 is so important to us is it does away with the 
MOU requirement, period.
    Senator Sullivan. Okay.
    Mr. Bell. So we do not have to worry about that issue.
    The positive thing about our American Indian, Alaska Native 
population is we are seeing that, from a Native American 
housing standpoint--so if you look at the guarantee and you 
look at the direct loan, they qualify for both. It just depends 
on what land that they are wanting to build or purchase or 
refinance. The number of guaranteed loans continue to rise----
    Senator Sullivan. Okay. In Alaska too?
    Mr. Bell. In Alaska too. Yes, sir.
    Senator Sullivan. Okay.
    Mr. Bell. So the guarantee portion of the program is 
growing. It is now how do we get the direct loan program to 
grow along with it. And so hopefully that MOU requirement will 
help us do that, by lifting some of those issues.
    Senator Sullivan. Okay. Mr. Chairman, do I have time for 
one more question?
    So we want to work with you on that. The Secretary is 
committed. I appreciate that. He said it in a hearing. He said 
it to me yesterday on the phone. We all know the end goal here 
should be Native Americans, Alaska Native should be able to 
utilize these programs. That is why they were designed. So we 
want to work with you on that. It is complicated in Alaska, 
given our land status and ANSCA, but that should not be a bar 
to home ownership from the VA, if you have served and 
sacrificed for your country, just because we have a different 
land setup--by the way, which was passed by Congress, right.
    So here is my second question, and again, maybe for 
everybody. And I am sure this is not just an Alaska issue. This 
is probably a Montana issue. But many of our Native veterans 
live in rural communities where housing vouchers are not an 
appropriate solution for vets in need of housing, because there 
is no rental market at all or the vouchers are based too-low 
fair market rents. And these are actually in communities where 
there is not any housing and there is often multigenerational, 
crowded family homes.
    So how can you design a program that is not like, hey, this 
is a VA loan for that nice house in the city or that nice house 
in the suburb, but in a very rural community with very little 
housing stock, when it based on rental vouchers that just do 
not, like, work. And I guarantee you there is a problem in 
Montana and other rural States, not just Alaska. But it is a 
huge problem in Alaska.
    Any takers on this? I am beyond the NADL issue for other 
general VA veteran Native loans. Mr. Upton, do you want to take 
this on?
    Dr. Upton. Sure. I would be happy to take that, Senator, 
and I appreciated your very thoughtful opening about the 
veterans as well. I really appreciate that.
    Senator Sullivan. I care deeply about this issue, for that 
reason.
    Dr. Upton. Absolutely. So with regard to housing, the 
bottom line is it is significantly challenging, as you have 
talked about. We have a very dedicated group within VA, focused 
on tackling homeless. And as I have talked to them and they do 
this work, there are a lot of things they work to do with our 
Tribal communities, but they often say the housing stock is a 
significant limiting factor.
    We have a Tribal HUD-VASH program that works specifically 
on Tribal lands with our Tribal partners, and there are 29 of 
those that are in existence right now, and I am happy to share 
some more background, that help with some of the voucher pieces 
you talked about. But there is a lot of work to do, and we 
would look forward to----
    Senator Sullivan. Well, we would like to work with you and 
the Committee on this. It is just an issue that one size does 
not fit all in the housing market and we should not penalize 
Native Americans, Alaska Natives, Native Hawaiians who have 
this heroic record just because they live in very rural areas. 
We should design a program around that challenge.
    So we want to work with you. I think, Mr. Chairman, this 
would be a good area of bipartisan work on this Committee as 
well.
    Chairman Tester. For sure.
    Senator Sullivan. Thank you.
    Chairman Tester. You bet. I have got one follow-up and it 
goes with Senator Sullivan's questions on the direct loan 
program as it specifically applies to Alaska. The MOU 
situation, if it is fixed, as it in 4505, does that make this 
bill workable in Alaska, the program, the direct loan program 
workable?
    Mr. Bell. Well, it makes it available for us to offer the 
direct loan program in those areas, because the issue was 
around the type of land and the type of trust that that 
property was actually in. So the limitation was the MOU, so 
yes, sir.
    Chairman Tester. Okay. So what we are going to do, because 
Senator Rounds was in a little earlier, we are going to try to 
hotline 4505, so we may need your help to get that done.
    Senator Sullivan. Yes, that would be great. Just to 
clarify, so this does not--so Metlakatla's trust land, Indian 
Country, our own reservation, the rest of Alaska, the 44 
million acres that the Native people got during the Alaska 
Native Claims Settlement Act, is actually fee-simple land.
    Mr. Bell. Yes, sir.
    Senator Sullivan. But that should not--like who cares, 
right? It is still for Native veterans. So it just needs to 
make sure it is not somehow tied to trust land or Indian 
Country or reservation land, because we do not have any in 
Alaska except for Metlakatla. So is that fixed?
    Mr. Bell. Yes, sir. So of course with Metlakatla, they fit 
the parameters of the MOU.
    Senator Sullivan. Yes, that is great. We love that.
    Mr. Bell. Right? So the issue was our authority to 
establish the MOU that we had for national did not fit the 
other 258 Tribal villages in Alaska, which basically made it 
impossible for us to establish that direct loan program in 
those areas. If you remove that piece and you--either, one, you 
remove the piece by 4505, or two, administratively, we take the 
risk to make that right until we can get 4505 done, then that 
also allows us to go into those areas, get a memorandum of 
understanding done, or not, and start asking the next 
question--now that the direct loan program is here, what can we 
utilize across those areas to work with the direct loan program 
if a veteran needs it, such as down payment assistance or other 
available programs so that they have the same capabilities as 
they do across the----
    Senator Sullivan. So, Mr. Chairman, if we can take one more 
final look at that before we move to hotline it, that would be 
great.
    Chairman Tester. Absolutely. So it has been heard in 
Committee. Look, I appreciate what the VA is doing, but it is 
much better if we do it and then you follow our lead. And so if 
we can get 4505 done I think it fixes your problem, 
specifically.
    Senator Sullivan. Okay. Great. Thank you very much.
    Chairman Tester. Yes, thanks.
    I want to thank the panel for being here. I appreciate you 
guys' time, what you do, your attention, and I appreciate you 
being here and answering the questions forthrightly. Thank you, 
and pass my thanks on to everybody you work with too, for the 
job that they do in the different agencies, whether it is the 
VA or IHS. Thank you all.
    We will get the next panel up.
    [Pause.]
    Chairman Tester. So welcome to our panelists on the second 
panel. I am going to introduce our virtual person first. His 
name is Leo Pollock. He is an enrolled member of the Blackfeet 
Nation and Marine Corps veteran, Administrator for the 
Blackfeet Veterans Alliance, who does great work in my home 
State of Montana. As I said, Leo is joining us virtually.
    Next is Larry Wright, Jr. Welcome, Larry. Larry is from the 
Ponca Tribe of Nebraska, Army National Guard veteran, and the 
Executive Director of the National Congress of American 
Indians. I do not know what you do in your free time but it 
does not sound like you have much of it.
    Next we have Nickolaus Lewis, an enrolled member and 
Councilman of the Lummi Nation, that has been talked about 
earlier here today, Vice Chair for the National Indian Health 
Board, a Navy veteran who serves on the VA Advisory Council on 
Tribal and Indian Affairs. Thank you for being here with us, 
Nickolaus.
    And finally joining us also virtually is Sonya Tetnowski, 
President of the National Council of Urban Indian Health and 
CEO of the Indian Health Center of Santa Clara Valley. Sonya is 
an enrolled member of the Makah Tribe, an Army veteran, and 
also a member of the VA Advisory Committee on Tribal and Indian 
Affairs.
    I appreciate all four of you being able to testify in this 
hearing. We will start in the order that I introduced you, and 
will have Mr. Pollock virtually. Please begin.

                            PANEL II

                              ----------                              


                    STATEMENT OF LEO POLLOCK

    Mr. Pollock. Chairman Tester, Ranking Member Moran, the 
rest of the Committee, thank you for having me here today.
    Funny enough, we are actually here with this meeting that 
we are here today. To be here for you to give my testimonial I 
actually left another meeting for access for VA health care for 
our veterans here, not just on the Blackfeet Reservation, for 
all of Montana.
    Our current IHS, the last veteran that was ever served was 
in 2014. We are actually in talks with IHS, the Billings area 
office, as well as the county unit so that we can reestablish 
that. We are also working with our Southern Piegan Health 
Clinic to see if there is any way that they can provide 
services that may be lacking in between the VA and the IHS, 
that they can help fill that gap. And as we head through to do 
those shared services.
    One of the big things that I know we were looking at is 
that our reservation, you know, it is not a small reservation. 
It is over 3,000 miles that we are looking at, square miles 
that we are looking at. We have two counties that are actually 
part of our reservation, the Blackfeet reservation. That is 
Glacier County, which does make up the bulk of that, and our 
other is Pondera County, which is the south, and that actually 
encompasses the small village of Heart Butte.
    The reason why we are fighting so hard to reestablish our 
outpatient clinic for our veterans here on the Blackfeet 
Reservation as well as surrounding communities is that as we 
all are aware, Montana winters, they are not easy to navigate. 
Sometimes some of us are stranded for days on end until we are 
able to get back into civilization.
    We have small communities such as Babb/St. Mary that are to 
the north of us, and oftentimes that should be a 30-minute trip 
with ideal driving conditions. However, given our severe 
weather that we are in right now, we are actually in a winter 
weather advisory until tonight or early tomorrow morning. And 
we did have some VA representatives that came up from Helena. 
They actually drove as far as Great Falls yesterday so that the 
trip was a little safer and easier for them to be here at a 
decent time for us for our meeting earlier today.
    So one of the biggest things we are looking at for our 
veterans here and why we want to make sure that we can 
reestablish our outpatient clinic is, like we said, when you 
have ideal conditions, and what should be a 30-minute drive one 
way, all of a sudden that turns into a hour drive one way. And 
give the ever-changing weather conditions that we have here, 
that can easily turn into 2 hours, which, you know, the numbers 
just keep adding up as we go.
    We currently have, from what I have gathered, we have well 
over 700 veterans here in Glacier County. That is not including 
Pondera County. We just want to make things easier for them. 
But one of the things that we also face with that and why we 
want to reestablish our clinic here in the reservation is that 
a lot of times it is the financial barriers that our veterans 
face here. They may not even have the financial means to get to 
any other VA appointments, more so if those appointments are in 
Fort Harrison and Helena. Many of our veterans cannot afford a 
vehicle or do not have the transportation means to get to those 
appointments.
    Sadly, what happens with a lot of our veterans is that when 
they do not have that they kind of just give up and they just 
move on from there and kind of relegate themselves to this life 
that nobody is going to help them. However, you know, we are 
here to help them and we have been doing that. I have only been 
in this position for, I will be coming up on starting my third 
year in January, and in that time we have slowly begun to 
recreate some other services for our veterans. And we would 
just like to make sure that we can expand on that for our 
veterans and make the accessibility that much easier for them, 
vice having to fight all of these other barriers that we look 
at here in Montana. Blackfeet Reservation, I know it not just 
our reservation, but the other reservations within Montana as 
well.
    So that is what I am here for, is to help be that voice for 
my fellow veterans and that we can do that and give them the 
care that they so deservedly should have.

    [The prepared statement of Mr. Pollock appears on page 60 
of the Appendix.]

    Chairman Tester. Thank you for your testimony, Leo. I 
appreciate you joining us today.
    Next we have got Larry Wright, Jr. You have the floor, 
Larry.

                 STATEMENT OF LARRY WRIGHT, JR.

    Mr. Wright. Good afternoon, Chairman Tester, Ranking Member 
Moran, and members of the Committee. My name is Larry Wright, 
Jr. I am a former Tribal Chairman for the Ponca Tribe of 
Nebraska. I served 11 years in that role. I currently serve as 
Executive Director for the National Congress of American 
Indians, and I thank you for this opportunity to testify on 
behalf of Indian Country and Native American veterans.
    As was shared earlier in your opening remarks, Chairman, 
this Committee is well aware of the valor and service of 
American Indian, Alaska Native, and Native Hawaiian veterans to 
this country. Also we know the high rate that our Native people 
serve in the military, and I also know that despite this 
impressive record of service the Committee knows that the lack 
of health care provided to these veterans upon returning home 
is unacceptable.
    Obtaining health care for Native American veterans often 
means navigating both Veterans Health Administration and the 
Indian Health Service. The primary health care provider in most 
Native communities, for many of our Native veterans, is IHS. 
Thus, one mechanism for improving the health of Native veterans 
is to improve the IHS system, which has long been woefully 
underfunded.
    Additionally, unlike the VA system, IHS continues to be 
subject to the harmful and disruptive effects of government 
shutdowns and short-term stopgap measures because it does not 
yet have advanced appropriations. This is precisely why NCAI 
has long been in support of advanced appropriations for IHS, 
and it is one step that can be taken immediately to help both 
Native veterans and Native communities, more broadly.
    Focusing on Veteran Health Administration more directly, 
there are many barriers Native veterans encounter in accessing 
care. One alarming statistic is that Native veterans use VA 
health care disproportionately less than non-Native veterans, 
despite having the disproportionately higher percentage of 
veterans with a disability. One reason for this is that Native 
veterans seeking to get to a VA facility might have to make a 
200-mile round trip, and in the case of Alaska Native veterans 
it may be much, much higher.
    NCAI recommends that the VA, in coordination with the 
Department of Transportation, work with Tribal governments to 
facilitate transportation from Tribal community hubs to 
Veterans Health Administration hospitals. Additionally, we urge 
the continued exploration of alternative options, such as 
telehealth services, to ensure that all Native veterans are 
being reached.
    When Native veterans are able to get an appointment and 
make it to VA health care facilities, all too often they are 
met with a poor understanding of Native culture, which creates 
another barrier to Natives trying to access services. We are 
hopeful that the recently created Tribal Advisory Committee 
within the VA will assist with some of these issues, and 
applaud the efforts made to create that entity under law and to 
fill its seats.
    That said, more needs to be done to address the cultural 
competency. For example, many forms and questionnaires do not 
address cultural context or risks, additionally, as a result of 
incurring traumatic brain injuries, and some Native veterans 
struggle with second language retention and require services to 
be administered in their Native languages instead of English.
    And finally, there is a dearth in Native professionals and 
individuals with adequate understanding of Tribal communities 
to truly allow individuals with health concerns to be open and 
honest and trusting of the system, something that is essential 
to achieving positive outcomes for those in need. Given the 
importance of cultural competency, NCAI Veterans Committee has 
expressed the need to increase access to Tribal veteran service 
organizations to assist American Indian and Alaska Native 
veterans with benefits claims and accessing other VA services. 
Similarly, more government-to-government consultation between 
the VA and Tribal nations can also generate new methods for 
improving cultural competency across health services.
    Before I close my remarks I also want to briefly highlight 
one other issue impacting Native issues, and will note that I 
have highlighted a few others in my written comments.
    Despite the service that they provide to our country, 
homelessness and housing insecurity remains a major concern for 
our Native veterans. A simple but critically important step to 
combat this issue is to reauthorize and make permanent the 
Native American Housing Assistance and Self-Determination Act. 
NAHASDA reorganized the system of housing assistance provided 
to Native American through the Department of Housing and Urban 
Development by eliminating several separate programs of 
assistance and replacing them with a block grant program. This 
block grant program has successfully been used by Tribal 
nations across the country to focus on specific housing needs 
in their own communities. However, NAHASDA expired 9 years ago, 
and we cannot afford to let this critical legislation go 
unauthorized any longer.
    NCAI urges the members of this Committee to support S. 
2264, the NAHASDA Reauthorization Act of 2021. This legislation 
has been reported out of the Senate Committee on Indian 
Affairs, marking the most progress any NAHASDA reauthorization 
bill has made since 2013.
    Additionally, many of the provisions in S. 2264 are 
included in the Senate Transportation and Housing and Urban 
Development Appropriations Bill, and we strongly urge this 
Committee and other Members of Congress to support these 
efforts. Reauthorizing NAHASDA will also help Native veterans 
struggling with homelessness by improving the HUD Veterans 
Affairs Supportive Housing program. The program has been a 
nationwide success because it combines rental assistance, case 
management, and clinical services for at-risk and homeless 
veterans. Unfortunately, this program is not fully available to 
Native veterans living on Tribal lands, which again is why 
NAHASDA reauthorization is critical.
    Also in the housing space, NCAI urges the passage of S. 
4505, the VA Native American Direct Loan Improvement, and we 
appreciate those comments on it today. This program has only 
provided 190 loans to Native Americans nationwide over the last 
10 years. This legislation would help to increase the number of 
NADL-administered loans by allowing veterans to refinance 
existing non-VA mortgages utilizing the NADL product, and would 
also allow veterans who have built homes with other sources of 
construction financing such as Native CDFI loans, to still use 
this as permanent financing. It also provides grant funding for 
Native CDFIs, Tribal nations, tribally designated housing 
entities, and nonprofits to assist with outreach, homebuyer 
education, and other technical assistance to Native veterans 
seeking home ownership financing.
    Finally, I want to take a moment and acknowledge that when 
the U.S. Government does engage in meaningful dialogue and 
consultation with Tribal nations solutions can be found. We do 
not need to look any further than the Native American Parity in 
Access to Care today, the PACT Act, which was signed into law 
nearly 2 years ago. That piece of legislation has improved 
accessibility to Veterans Health Administration services by 
eliminating copayments for our American Indian and Alaska 
Native veterans, and we are grateful for Senator Tester and his 
leadership on getting this passed. It is a valuable 
demonstration of what we can accomplish for our people, and as 
was said earlier, even though that was passed 2 years ago, we 
still need to get rid of those copays. Thank you.

    [The prepared statement of Mr. Wright appears on page 65 of 
the Appendix.]

    Chairman Tester. Thank you, Larry.
    Next up is Nickolaus Lewis. You have the floor, Nickolaus.

                  STATEMENT OF NICKOLAUS LEWIS

    Mr. Lewis. Good afternoon, Chairman Tester, Ranking Member 
Moran, and honorable members of this Committee. Thank you for 
holding this important hearing and inviting the National Indian 
Health Board here to testify with you all today. The National 
Indian Health Board, or NIHB, serves on behalf of all 574 
federally recognized Tribes.
    My name is Nickolaus Lewis. My traditional name is Juts-
kadim' and I serve as Vice Chairman on the NIHB and as Chairman 
of the Northwest Portland Area Indian Health Board, and as a 
member of the VA TAC. I also have the honor to serve my people 
of the Lummi National as a councilmember for the last several 
years and as a proud Navy veteran of 8 years. I signed up for 
the Navy when I was 17 years old, so please know that serving 
this country and my people with honor has always been a 
priority to me since a young age.
    Chairman Tester and Ranking Member Moran, I know you 
understand and have long been champions for Indian Country, so 
in the interest of time I will be brief and ask that my full 
testimony be submitted for the record.
    More than half of Native veterans are estimated to get 
their health care through IHS or in combination with the VA. 
That is why coordination between the VA and IHS and this 
Committee's oversight for that coordination is vital. It is not 
enough for any agency officials to testify that they are 
committed to this coordination unless and until coordination is 
institutionalized and all staff are trained and held 
responsible, and any improvements made now and through this 
work would erode over time.
    When it comes to veterans' health through IHS, coordination 
is not the only issue, as IHS has not received an annual budget 
on time since 2015. The new normal is stopgap funding through 
continuing resolutions which results in our primary health 
system suffering from disruptions and providing services to our 
people, but most importantly, our veterans. And when the 
Federal Government shuts down, which it has, the problems get 
worse and our lives are put at risk because of this.
    The Northwest Portland Area Indian Health Board has passed 
a resolution at our last quarterly board meeting entitled 
``Condemnation of harm to Indian Health Care System caused by 
disruptions in Federal appropriations and resultant continuing 
resolutions,'' which we would be happy to share with you all as 
well.
    As you know, the VA receives an annual advanced 
appropriation protecting them from shutdowns and stopgap 
funding. In 2018, the Government Accountability Office reported 
how advanced appropriations have helped the VA. Our veterans 
are looking for that same help for IHS. For many of us, getting 
our health care through IHS, as we have heard from others on 
this panel, is not only a choice but it is a necessity which I 
personally can attest to as I only receive my health care 
personally through Indian Health Service. The Indian Health 
Service is vulnerable to shutdowns and stopgap funding, and 
that is not right, and it needs to end, and we need your help 
in fixing this injustice.
    We respectfully ask the Committee to talk with your 
colleagues on the Appropriations Committee and those in 
leadership about including IHS advanced appropriations in the 
final fiscal year 2023 agreement. Please, make them explain why 
they cannot get this done, because the excuses we have been 
hearing so far when we travel back here to the Hill about why 
VA deserves advanced appropriations but IHS does not seem 
unreasonable, unfair, and downright cruel. It violates the 
trust responsibility that our ancestors sacrificed everything 
for when they signed The Treaties with the United States 
Government. And when you help in stabilizing IHS, you are not 
just helping our people. You are also helping our Native 
veterans who we are here all advocating for today.
    Finally, I want to turn to homelessness and housing. Mr. 
Chairman, I know these issues are things that you feel strongly 
about, as do I. Homelessness and housing are public health 
issues. We need to look closer to the social determinants of 
health across the board, and we need the VA to focus on those 
things as well, going forward. Studies show that homelessness 
and substandard housing are risk factors for so many of the 
health problems we have seen across Indian Country today. Our 
veterans are more likely to be homeless, with studies showing 
that 26 percent of our low-income Native veterans are affected 
by homelessness compared to only 13 percent of low-income 
veterans overall.
    Work is still needed to address homelessness for veterans, 
and we call on the Senators to help us in removing these 
funding barriers, to provide direct and reoccurring and 
sustainable funding to Tribes and Tribal organizations, and to 
explore innovative solutions to end the housing crisis in 
Indian Country.
    Today the VA, HHS, and HUD are announcing a Native Veteran 
Homeless Initiative to increase access to care and services. 
The initiative will ensure that Native veterans are aware of 
and have access to available resources. This awareness of 
resources for Native veterans themselves as well as for the 
Tribes supporting their veteran members is an issue that we 
have identified that can be addressed by increased targeted and 
ongoing administration outreach and messaging. For example, the 
Tribal HUD VA Supportive Housing program, or Tribal HUD-VASH, 
has existed since 2015, but awareness of the program and its 
policies are still lacking in our Tribal communities. Mr. 
Chairman, to quote you, sir, ``The VA can outsource work when 
it makes sense, but it cannot outsource the responsibility for 
taking care of their veterans, whether they receive care at the 
VA or care in the community. They are responsible for both.'' 
And we would add that IHS is included in that.
    What you are trying to do with S. 2172, the Building 
Solutions for Veterans Experiencing Homelessness Act of 2021, 
is a good thing and a step in the needed right direction, and 
we will do what we can to help get you across the finish line 
with that bill. In fact, we welcome the opportunity to work 
with you and Ranking Member Moran and any member on this 
Committee on any piece of legislation that supports improving 
the health outcomes for all of our veterans in this country.
    This now concludes my testimony, and I want to thank you 
all for the opportunity to be here with you all and your 
continued efforts in improving the lives of our veterans. Thank 
you.

    [The prepared statement of Mr. Lewis appears on page 72 of 
the Appendix.]

    Chairman Tester. Thanks, Nickolaus.
    You know, we started this panel hearing from snowy Montana. 
Our last testimony, our last panelist, is Sonya Tetnowski, from 
sunny California. So Sonya, you are up, virtually.

                  STATEMENT OF SONYA TETNOWSKI

    Ms. Tetnowski. Thank you. Good afternoon. My name is Sonya 
Tetnowski. I am a citizen of the Makah Tribe, President of the 
National Council of Urban Indian Health, and Chief Executive 
Officer of the Indian Health Center of Santa Clara Valley. I 
also serve as the chair of the health subcommittee within VA's 
first-ever Advisory Committee on Tribal and Indian Affairs. We 
are grateful to you, Chairman Tester, and to Senator Sullivan 
for your partnership on the VA Tribal Advisory Committee Act of 
2020.
    I am sharing my views here today as the President of NCUIH 
and not in my capacity on the advisory committee, to remain in 
compliance with Federal Advisory Committee Act.
    As a U.S. Army veteran and as an Urban Indian organization 
leader it is imperative that our physical, mental, and cultural 
needs are addressed in a culturally competent way. As you know, 
67 percent of Native veterans live in urban areas, and more 
than 50 percent use Indian health care providers. We need the 
ability to go to a facility that understands, respects, and 
recognizes our unique needs.
    Urban Indian organizations provide a wide range of health 
and wellness services. In fact, we currently serve 7 of the 10 
metropolitan areas with largest Native veteran population. 
Therefore, it is critical that VHA work with us to improve the 
health outcomes of Native veterans across the I/T/U system of 
care.
    Since more than 50 percent of Native veterans use the I/T/U 
system for their health care needs, securing advanced 
appropriations for the Indian Health Service is critical. Gaps 
in Federal funding put lives at risk. In fact, five patients 
died during the last shutdown. The risk is too big and the 
price is too high for us to continue without advanced 
appropriations. When the VHA received advanced appropriations 
the President said, ``The care that our veterans receive should 
never be hindered by budget delays.'' Yet we have not protected 
our Native veterans who receive care from our I/T/U system.
    During the last government shutdown, my clinic supported 
another urban program so that they could remain open. This 
should not be happening to our patients, and specifically to 
our veterans. All this due to funding delays caused by the 
shutdown. Therefore, I urge this Committee to help secure 
stable funding for all Native veterans by supporting advanced 
appropriations for IHS.
    It has been about 2 years since we worked with you both, 
Chairman Tester and Ranking Member Moran, on the PACT Act, to 
remove copayments for Native veterans receiving VH health care. 
In September, VA committed to putting this legislation into 
effect and eliminating copays for Native veterans by the end of 
this year. But it needs to go one step further. We ask this 
Committee to encourage the VA to allow self-attestation in 
determining Native identity for VA copayment purposes, because 
many Native veterans may not have the kind of ID that defines 
them as Indian or Urban Indian.
    NCUIH advocated for years, and I testified many times for 
the inclusion of Urban Indian organizations in the VA 
reimbursement program. We are grateful to this Committee for 
fixing this parity issue. However, many urban programs are 
experiencing difficulty in enrolling, and only 1 in 41 
completed the process. We need additional technical assistance 
and the ability to modify these agreements so that they work 
within the scope of services of our respective sites.
    I would like to thank the VA for working with Urban Indian 
health programs, but urban confer policy between VA and our 
clinics would solidify this relationship.
    During the rollout of COVID-19 vaccines some veterans who 
went to the VA received vaccines and were told to go back to 
their Indian clinic. This highlights the need for greater 
coordination among all entities serving our Native veterans.
    In June, the Health Equity and Accountability Act was 
introduced with the first-ever legislative text establishing 
urban confer policy with the VA. We would love to see this 
Committee including language in future packages related to 
Native health care.
    In conclusion, Native people have a long history of 
distinguished service to this country, and we owe it to them to 
address these issues and remove these barriers to ensuring 
greater access to care. Thank you for allowing me to speak on 
these critical issues affecting Native veterans. My full 
testimony was submitted for the record, and I am happy to 
answer any questions. Thank you.

    [The prepared statement of Ms. Tetnowski appears on page 83 
of the Appendix.]

    Chairman Tester. Well, thank you for your testimony, and I 
hope it is sunny in California. I am going to defer to Senator 
Murray for her questions.

                      SENATOR PATTY MURRAY

    Senator Murray. Mr. Chairman, thank you very much for 
holding this hearing. You know, 13 years ago we had a similar 
hearing where a number of issues were raised about access for 
Native Americans to VA health care and benefits, and we made a 
promise to take care of our veterans after their service, and 
it is clear that more work does need to be done to live up to 
that promise to our Native veterans.
    I do want to thank all of our witnesses for being here 
today to speak on these important issues, and I especially want 
to thank Nick Lewis from the Lummi Nation. You heard from him, 
that he served in the Navy, and has been a leader in his 
community and works on these issues on a national stage. So 
welcome and thank you to all of you.
    Mr. Lewis, let me start with you. I have been a very strong 
supporter of the HUD-VASH program to get supportive housing and 
case management services to veterans with high needs. But we 
know that HUD-VASH program has had its challenges, especially 
with the shortage of affordable housing in our State of 
Washington, and challenges VA faces while recruiting staff to 
serve our rural areas. In the Pacific Northwest a number of 
Tribal housing authorities use the Tribal HUD-VASH program for 
veterans who are at risk or are already experiencing 
homelessness in areas that can sometimes be very hard to reach 
in bad weather or that have long drive times to the closest VA 
medical center.
    How would you suggest to all of us that VA improve its 
outreach in the Tribal HUD-VASH program in general, to make 
sure that Native Americans are actually able to access and 
utilize the program?
    Mr. Lewis. I think one of the things that comes to mind, 
and I was talking with our staff in the back, and many of the 
organizations that we sit on as Tribal leaders, and this is 
just something simple, is creating a listserv for Tribal 
veteran directors and Tribal communities, that veteran 
directors can opt into to receive updates. When we get those 
kinds of emails, whether it is through NCAI or NIHB in the work 
that we do, those organizations put a lot of good information 
out, and that would be something that I think our veteran 
director back home in Lummi would appreciate, but we are not 
aware of that when I asked him specifically.
    I think one of the other things that is a challenge, and 
Senator Sullivan kind of alluded to it earlier as well, when he 
talked about his Tribal members in Alaska, is you can have a 
good program like the HUD-VASH program but if there are no 
houses in that community or when there is, the rent is so high 
that it is not able to be used.
    One of the things we have recommended through the VA TAC, 
and it has not gone through its full process yet, and I cannot 
speak on behalf of the full TAC, but we have advocated for 
increased HUD-VASH assistance.
    I think one of the other things that we would recommend is 
working with HUD more, between the VA and HUD, because the VA 
does not build houses. HUD does. And so one of the things that 
we could do is work with HUD a lot more to work on specific HUD 
veteran housing across Indian Country, because a lot of the 
things that we have heard from the testimony is there is no 
housing, especially in Indian Country. So those would be big 
helps.
    Senator Murray. Okay. I very much appreciate that. And on 
the issue of health care access, in your testimony that I read 
you mentioned some of the shortfalls with VA's existing MOU 
with IHS. In Washington State we worked really hard with the VA 
to make sure veterans do have timely access to high-quality 
care, and given some of the geographic challenges and wait 
times, veterans sometimes have to use non-VA providers through 
the Community Care Network to fill access gaps.
    What would it mean for Native veterans' health outcomes to 
have services closer to home and providers that are culturally 
competent?
    Mr. Lewis. I think that means everything when you are 
seeking health care. One of the things, as I mentioned, my 
health care, I only go through IHS and our Tribal clinic. That 
is because I am comfortable with them. They know me. We have a 
history.
    And one of the things--and I am going to speak personally, 
around mental health. And I have heard a lot about mental 
health. There are some things that we have all gone through 
during COVID, where we all struggled. I had to go through 
mental health, and I made appointments to go to that. I 
actually quit going because it did not feel right going to an 
office that I knew somebody that was being paid for to provide 
a listening session for me. But what worked, for me, is one of 
the things that we say in Lummi, our culture, our schelangen, 
is in nature. It is up in the mountains. It is in the water. 
And for many of those that know me, I think especially during a 
time that we have had to use Zoom, I would take meetings in the 
mountains or on the water, because that is where it was filling 
my spirit.
    So when we talk about getting care in our communities, it 
is that. It is in a place that fills your spirit and your soul, 
that you cannot get going to somewhere that is foreign to you.
    Senator Murray. Okay. Excellent. I really appreciate it, 
and again, I appreciate all of our witnesses today. Thank you. 
Thank you, Mr. Chairman.
    Chairman Tester. Thank you, Senator Murray. Now we have 
Senator Moran.
    Senator Moran. Chairman, thank you. This is really a 
question for all the panelists. The PACT Act was signed into 
law, as we know. Its effort is to expand access to VA health 
care and benefits to toxic-exposed veterans and survivors. I 
want to be certain that VA is doing everything it can to spread 
the awareness among veterans and their families about the PACT 
Act so that they can enroll in VA health care systems and file 
claims for benefits they are entitled to.
    This is the question. How can the VA improve outreach about 
the PACT Act to toxic-exposed veterans in Indian Country, and 
will your organizations help spread the word about the PACT Act 
or tell me what you are doing to do so, to those toxic-exposed 
veterans and their families in those communities?
    Mr. Wright. Thank you for the question. I think one of the 
things that we hear time and again from our Native veterans 
especially, in our committee, are the Tribal veteran service 
organizations and the help that they can bring in on the local 
level, regional level, that is Tribal-specific, culturally 
specific, where they have trust from the veterans in those 
specific areas and help them navigate the system as a whole. 
But in this particular case, when you talk about the PACT Act, 
having that understanding of somebody who is willing to do the 
outreach, has the ability to meet them where they are at makes 
a big difference, especially if it is somebody from the 
community that they have that long-time trust in. And I think 
the more we take advantage of that particular program, the more 
opportunities that will present themselves to Native veterans 
who may just be disenfranchised from the system as a whole, or 
because of frustration, whatever that might be, and then when 
you take in the logistical pieces to it as well.
    But I think expanding that program, strengthening that 
program will help go a long way in Indian Country.
    Senator Moran. Mr. Wright, let me take your answer, and 
again, others are welcome to respond. So is the VA doing that? 
Is there evidence they are going to do that? Have there been 
conversations that suggest that that is what is going to take 
place?
    Mr. Wright. I--go ahead.
    Mr. Lewis. I can add a little bit to that. In sitting on 
the VA TAC--and I am glad that Sonja is here as well. I sit on 
the committee with her. She chairs our health subcommittee. And 
one of the things that the previous panel, Stephanie, had 
mentioned, we had meetings a few weeks ago, and our next 
meeting will be in April, and I am thankful to our TAC and to 
the VA staff that we work with that they will be hosting the 
next meeting in our area in Portland. And one of the things 
that we have talked about, and we have talked about this as 
Tribal leaders a lot, you know, hearing from Senators and 
Congresspeople, when we come to these meetings and we travel a 
long way, to sit here and just get talked to, it is not 
meaningful, right. And one of the things that, as a veteran 
myself, and what Larry had mentioned, trust is a big thing. And 
when you look at veterans across the country, whether they are 
Tribal or not, there are a lot of our veterans that have lost 
trust, for one reason or another.
    And what I am going to be working with the VA TAC on and 
proposing, those details have not been worked out so I cannot 
speak that this is going to happen, but what we are pushing 
for, and pushing, I think, more broadly, is that when we host 
those advisory meetings that we also afford our veterans in the 
community that we listen to them, not talk to them. So one of 
the things that we are proposing at our VA TAC is that we work 
with veteran organizations in the Northwest--Washington, 
Oregon, and Idaho--where we meet with veterans where they are. 
We create the space for their voice to be heard. And our job, 
as an advisory committee, is to amplify and bring up their 
concerns to you all, so that we can remove these barriers in 
good faith.
    Senator Moran. Anyone else?
    Mr. Pollock. Yes. Thank you. You know, that is one of the 
toughest things we have, and one of the best things that seemed 
to work for here in Blackfeet Country is to do the VA town 
halls. It gave our veterans the voice. It gave them the floor. 
The last time the VISN 19 team came out, they basically asked, 
they said, ``What is it you want us to do?'' and we cut the mic 
loose and we were able to turn that, and we gathered so much 
more information with that short--I think it was, what, a 2-
hour meeting, and we gathered so much more because our veterans 
had the voice. They had the floor. They were able to tell the 
VA, directly and specifically, what each veteran wanted, 
because not each veteran is or has the same wants and needs, 
depending on what it is.
    So I think for us, given the size of our demographic that 
we have here, the town hall seemed to be one. As long as we 
could get those spread out it helped us spread the word and 
also gather information for all of our veterans here.
    Senator Moran. Useful advice for the Department of Veterans 
Affairs. Useful advice for elected officials in this Committee 
and in Congress.
    My time has expired and I think we have votes that began at 
4:45, so I will ask this for the record and then I will make 
another brief question and then be done.
    I would be happy to hear from any of you what concerns you 
have regarding the VA's partnership with Tribes to help make 
certain that Native veterans have access to culturally 
competent and geographically acceptable burial sites. And 
again, I will save that. What could the Department do to 
improve that circumstance. And if any of you have opinions 
about that please submit them in writing.
    And then, just generally, I would raise the question of 
American Indian and Alaska Native veterans. A lot of the 
circumstances you face are distance. What can we better do to 
utilize community care, telehealth, and other mechanisms that 
close that distance, to make it much less of a burden when 
those veterans are seeking care? And I would indicate that one 
of the things that I am troubled by is any suggestion that the 
Department of Veterans Affairs is going to alter the standards 
by which community care can be attained, as far as distance and 
time. And again, if any of you have those thoughts or have 
thoughts for me in those regards, I would welcome that input.
    Mr. Lewis. I have one brief comment on that. I watched your 
hearing on community care recently, and I was thankful to hear 
a lot of the comments that I heard from the Senators around the 
table as well as some of the responses from Secretary McDonough 
when he was here. But when I think of community care--and 
others may have a difference of opinion--but when we are 
talking about our veterans going through IHS in our 
communities, that is community care. And one of the things our 
veterans have been asking for is they cannot always, as many of 
our panelists have said, they cannot always travel to the VA. 
In the hearing on community care, the VA has shortages just as 
well as anywhere else. The VA does not always have capacity.
    And I am not saying that Indian Health Service is always 
perfect either, but our veterans would rather go through, and 
as the data shows--I sit on the SAMHSA Advisory Committee, and 
they Stated that 52 percent of veterans do not utilize the VA. 
That means that 52 percent, of the SAMHSA data that was 
reported, are going through community care. And our veterans, 
we have over 90 veterans in Lummi. Only 2 are utilizing the VA 
service, is what I was told by our billing department. So it is 
showing that our veterans are going through our health system 
more.
    So what we are asking for is the full faith and credit, and 
then we are going to be working on amending the MOU between our 
Tribe and the VA. But our veterans are saying they want to get 
their health care through our IHS facility instead of being 
able to be forced to travel 2 hours to get to Seattle. I just 
wanted to add those comments.
    Senator Moran. I appreciate that, Mr. Lewis, and I was 
thinking during the testimony that probably in much of Indian 
Country, Indian Health Service is the community care. When I 
think about it, more likely as the local doctor or the local 
hospital in Tribal Country, that very well may be Indian Health 
Services. I will ask my staff here but it causes me to wonder 
whether the use of Indian Health Service care is considered 
community care under the Community Care Act. I do not know that 
but I wonder what criteria are necessary for you to do that. 
And maybe it is just the MOU. I will follow up with my team to 
make sure I understand how this works. Thank you.
    Mr. Wright. If I may.
    Senator Moran. Go ahead.
    Ms. Tetnowski. Can I add something?
    Chairman Tester. Sure. Go ahead, Sonya.
    Ms. Tetnowski. Thank you. I guess I just wanted to ensure 
that there is thought around our Urban Indian health programs 
as well. Because there are no Tribes within many of our 
geographical areas but most of our clinics were placed in 
relocation sites, including mine, in San Jose, most of our 
Native community and Native veterans would rather be seen by us 
as a Native provider.
    So although I absolutely support and completely agree with 
all of what Councilman Lewis just shared, it also applies in 
the urban setting. So I just did not want to disregard that as 
well. Thank you so much for the opportunity to share.
    Chairman Tester. Absolutely. Larry?
    Mr. Wright. No, and I appreciate that because my comments 
were going to be very similar. My Tribe was terminated in the 
'60s and federally reinstated in the '90s, and we were 
reinstated without a reservation. And part of our restoration, 
by Congress, established 15 counties across Nebraska, Iowa, and 
South Dakota, and several of our counties are in the two 
biggest cities in Nebraska.
    And so when we have health clinics in those areas, and VA 
hospitals just down the road, and even when you take out all 
the logistical scheduling, financial barriers for travel and 
geography, even when it is right down the road, taking a bus, 
our veterans want to come to our facility because of the 
cultural competency, because of that care and trust that they 
feel that they have there. And we see many other Native 
veterans taking advantage of that as well, even though the VA 
is just down the street.
    And so I think when you look at the issues, as a whole, it 
is systemic, and we can point to several things. But I do not 
think you can fix one without addressing all of them, and they 
all really do go together.
    Senator Moran. A take-away--Senator Tester and I were just 
talking about this earlier--a take-away is that then means that 
Indian Health Services has to be a consistent, constant 
provider, open for business on an ongoing basis, based upon the 
reliance that Native Americans place in that service. Okay.
    Chairman Tester. Thank you, Senator Moran. A lot of water 
went under the bridge in the last 6, 7 minutes. I will say, 
going back to town hall meetings by the VA, that is very good 
advice by the Ranking Member and it also applies to elected 
officials. Listening is really important. That is why we have 
consultation with Tribes. You guys know that.
    There are challenges in Indian Country that are specific to 
Indian Country, and one of those challenges was brought up by 
Mr. Pollock. With large, land-based Tribes in particular--and I 
really do not care where it is at. I mean, you have either got 
snow, you have got heat, you have got problems when you have 
got distances.
    And I would just like to know from you, Mr. Pollock, you 
talked about geographical and logistic and financial barriers. 
You are working with the Blackfeet Veterans Alliance. How are 
you guys working to overcome those challenges of bad weather 
and no money?
    Mr. Pollock. Chairman Tester, one of the biggest things we 
are working with is we try to build partnerships with other 
veteran services and organizations, not just located here on 
the Blackfeet Reservation. Like I stated, there is one Rocky 
Boy, they recently rebranded there, called the Great Plains 
Veteran Services Center. And one of their departments is 
Transportation Department. Right as I came on we built a 
partnership with them to where they are actually one of our 
primary transportation providers, to provide transportation to 
our veterans to appointments at no cost to the veteran besides 
maybe a meal. However, that is one of the things that between 
my program and their program, we are working on to where we can 
create some kind of funding to even buy a meal for those 
veterans that may not be able to do that.
    So one of the biggest things for us, given this, and we 
continue to do that, start reaching out to the Fort Belknap 
Tribe, most recently with Spirit Lake Reservation in North 
Dakota. I gave a presentation and let them know, hey, we are 
here, that we have got to work together. There are times where 
resources are stretched thin, no matter what it is, if that is 
finance, transportation, all of the above. That is our biggest 
thing, is to create and build those partnerships across all 
Tribes, no matter where they are located. If there is something 
we can do to help or maybe we have somebody that we can get in 
contact with, because we also have veterans who still have ties 
to the reservation. However, you know, they do not live here. 
They live in Great Falls. They live in Havre. They live in 
Missoula. So we try to make sure we create all these 
partnerships throughout the State to get whatever it is we need 
for our veterans, to better serve them, no matter where they 
are located.
    Chairman Tester. Thank you. Thank you, Leo.
    Mr. Wright, Executive Director of NCAI, which is probably 
the premier Native American group out there, representing a lot 
of different Tribes. You talked about the copay issue a little 
bit in your opening statement. Can you give me some information 
about how you are hearing, or you are seeing, the copay issue 
play out with Tribal members, generally speaking?
    Mr. Wright. Yes. I appreciate that. We know that the PACT 
Act was a very crucial piece of legislation for Indian Country, 
knowing that it got passed and it is still not implemented. 
When we talk about the impact of just costs, in general, when 
you compound that issue with trying to just get to the clinic, 
to get to your appointment, and the costs that are associated 
with that, and knowing that going to VA, for Native veterans, 
they have to have this copay on top of it. And sometimes 
scheduling, when you add the scheduling factor in, where they 
may be behind and it gets canceled, and they have already 
incurred that cost, or the Tribal Nation, as the gentleman said 
before, they are taking on the extra cost to help get veterans 
there.
    And so all of those things are just another layer of a 
barrier. And when you add that copay on there, especially for 
Native veterans and Native people, knowing that that is trust 
and treaty responsibility that our ancestors fought very hard 
for, and with the formulation of this country, and have paid 
many times over for land given up, blood, sweat, and tears, to 
have that as a Native veteran on top of everything else is very 
hard.
    And whether that is a personal issue or leads to that, 
again, that disenfranchisement, where we feel that we are not 
good enough. And we know that may just be another factor of 
saying, for a Native veteran, ``I am not going here because I 
am not valued, but I can go to my Tribal clinic, my Indian 
Health Service, where they know those values, and take that 
on.'' But that creates another burden on that system. Or of it 
is an IHS clinic, or if it is a tribally run clinic, which even 
compounds that further. And so we have not said that much, but 
that is still another factor in there.
    Chairman Tester. So one of the things that you brought up 
in that answer, that a lot of the folks that we serve with do 
not understand, is trust responsibility. I know for a fact that 
Senator Moran is not one of those. He understands trust 
responsibility very, very well. But it is specific to Native 
American veterans. And I do not know another group that has 
that kind of an agreement. And so I think it is really 
important we keep that in mind, and for that reason it is an 
issue that I brought up in both panels, and hopefully we can 
get it solved.
    Look, we have had a good hearing today. I want to thank 
everybody for being on each panel. Thank you to the witnesses. 
I look forward to continuing to work with VA and IHS and Tribes 
and tribal organizations to ensure that Native American 
veterans have access to the health care and the benefits that 
they have earned for this service to this country.
    I would also like to say that it has always been something 
that we have tried to achieve here, where the VA and IHS 
becomes seamless, as far as service provided. Now look, I know 
follow the money, because that is typically where it is going 
to go. But the truth is that we have had challenges with hiring 
nurses and doctors and everybody in the VA. We have also had 
challenges in IHS. It is the same thing. And it is about 
resources, truthfully. So we need to continue to work toward 
that, because I think it is the right thing to do for our 
Native American veterans who serve at a higher rate than any 
other minority in this country.
    So with that we will keep this record open for a week, and 
this hearing is adjourned.
    [Whereupon, at 4:54 p.m., the hearing was adjourned.]

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