[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
CHALLENGES AND OPPORTUNITIES FOR
IMPROVING HEALTHCARE DELIVERY IN
TRIBAL COMMUNITIES
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OVERSIGHT HEARING
BEFORE THE
SUBCOMMITTEE ON INDIAN AND INSULAR AFFAIRS
OF THE
COMMITTEE ON NATURAL RESOURCES
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
Wednesday, March 29, 2023
__________
Serial No. 118-14
__________
Printed for the use of the Committee on Natural Resources
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
or
Committee address: http://naturalresources.house.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
51-763 PDF WASHINGTON : 2023
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COMMITTEE ON NATURAL RESOURCES
BRUCE WESTERMAN, AR, Chairman
DOUG LAMBORN, CO, Vice Chairman
RAUL M. GRIJALVA, AZ, Ranking Member
Doug Lamborn, CO Grace F. Napolitano, CA
Robert J. Wittman, VA Gregorio Kilili Camacho Sablan,
Tom McClintock, CA CNMI
Paul Gosar, AZ Jared Huffman, CA
Garret Graves, LA Ruben Gallego, AZ
Aumua Amata C. Radewagen, AS Joe Neguse, CO
Doug LaMalfa, CA Mike Levin, CA
Daniel Webster, FL Katie Porter, CA
Jenniffer Gonzalez-Colon, PR Teresa Leger Fernandez, NM
Russ Fulcher, ID Melanie A. Stansbury, NM
Pete Stauber, MN Mary Sattler Peltola, AK
John R. Curtis, UT Alexandria Ocasio-Cortez, NY
Tom Tiffany, WI Kevin Mullin, CA
Jerry Carl, AL Val T. Hoyle, OR
Matt Rosendale, MT Sydney Kamlager-Dove, CA
Lauren Boebert, CO Seth Magaziner, RI
Cliff Bentz, OR Nydia M. Velazquez, NY
Jen Kiggans, VA Ed Case, HI
Jim Moylan, GU Debbie Dingell, MI
Wesley P. Hunt, TX Susie Lee, NV
Mike Collins, GA
Anna Paulina Luna, FL
John Duarte, CA
Harriet M. Hageman, WY
Vivian Moeglein, Staff Director
Tom Connally, Chief Counsel
Lora Snyder, Democratic Staff Director
http://naturalresources.house.gov
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SUBCOMMITTEE ON INDIAN AND INSULAR AFFAIRS
HARRIET M. HAGEMAN, WY, Chair
JENNIFFER GONZALEZ-COLON, PR, Vice Chair
TERESA LEGER FERNANDEZ, NM, Ranking Member
Aumua Amata C. Radewagen, AS Gregorio Kilili Camacho Sablan,
Doug LaMalfa, CA CNMI
Jenniffer Gonzalez-Colon, PR Ruben Gallego, AZ
Jerry Carl, AL Nydia M. Velazquez, NY
Jim Moylan, GU Ed Case, HI
Bruce Westerman, AR, ex officio Raul M. Grijalva, AZ, ex officio
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CONTENTS
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Page
Hearing held on Wednesday, March 29, 2023........................ 1
Statement of Members:
Hageman, Hon. Harriet M., a Representative in Congress from
the State of Wyoming....................................... 1
Leger Fernandez, Hon. Teresa, a Representative in Congress
from the State of New Mexico............................... 3
Statement of Witnesses:
Alkire, Janet, Great Plains Area Representative, National
Indian Health Board, Washington, DC........................ 5
Prepared statement of.................................... 7
Questions submitted for the record....................... 13
Church, Jerilyn LeBeau, Chief Executive, Great Plains Tribal
Leaders Health Board, Rapid City, South Dakota............. 16
Prepared statement of.................................... 17
Questions submitted for the record....................... 24
Platero, Laura, Executive Director, Northwest Portland Area
Indian Health Board, Portland, Oregon...................... 31
Prepared statement of.................................... 33
Questions submitted for the record....................... 39
Rosette, Maureen, Chief Operations Officer, the NATIVE
Project; Board Member, National Council of Urban Indian
Health, Washington, DC..................................... 44
Prepared statement of.................................... 45
Questions submitted for the record....................... 48
Additional Materials Submitted for the Record:
Submissions for the Record by Representative Westerman
Oglala Sioux Tribe, Statement for the Record............. 63
Salt River Pima-Maricopa Indian Community, Letter to
Chairwoman Hageman dated April 10, 2023................ 75
Submission for the Record by Representative Grijalva
United South and Eastern Tribes (USET) Sovereignty
Protection Fund, Statement for the Record.............. 77
OVERSIGHT HEARING ON ``CHALLENGES AND OPPORTUNITIES FOR IMPROVING
HEALTH-CARE DELIVERY IN TRIBAL COMMUNITIES''
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Wednesday, March 29, 2023
U.S. House of Representatives
Subcommittee on Indian and Insular Affairs
Committee on Natural Resources
Washington, DC
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The Subcommittee met, pursuant to notice, at 10:04 a.m., in
Room 1324, Longworth House Office Building, Hon. Harriet M.
Hageman [Chairwoman of the Subcommittee] presiding.
Present: Representatives Hageman, Radewagen, LaMalfa,
Gonzalez-Colon; Leger Fernandez, and Sablan.
Ms. Hageman. Good morning. The Subcommittee on Indian and
Insular Affairs will come to order.
Without objection, the Chair is authorized to declare a
recess of the Subcommittee at any time. The Subcommittee is
meeting today to hear testimony on ``Challenges and
Opportunities for Improving Healthcare Delivery in Tribal
Communities''.
Under Committee Rule 4(f), any oral opening statements at
hearings are limited to the Chairman and the Ranking Minority
Member. I therefore ask unanimous consent that all other
Member's opening statements be made part of the hearing record
if they are submitted in accordance with Committee Rule 3(o).
Without objection, it is so ordered.
I will now recognize myself for an opening statement.
STATEMENT OF THE HON. HARRIET M. HAGEMAN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF WYOMING
Ms. Hageman. Through treaties and Federal statutes, the
Federal Government has assumed the responsibility of providing
healthcare for American Indians and Alaska Natives. The Indian
Health Service, or IHS, is the primary agency charged with
providing health services to Native people and tribal
communities throughout the United States.
IHS provides an array of medical services to Native people
including in-patient, ambulatory, emergency, dental, public
health nursing, and preventative healthcare.
The agency provides for healthcare in two ways, by direct
service and through self-determination compacts and contracts.
Direct service healthcare is care provided by Federal
employees--doctors, nurses, and healthcare professionals
directly to American Indians and Alaska Natives.
Beginning in the late 1970s, Congress granted authority to
tribes for self-determination compacts and contracts of IHS
services through the Indian Self-Determination and Education
Assistance Acts or ISDEAA, meaning that a tribe could
independently operate their own tribal healthcare facilities.
However, ISDEAA does not remove the responsibility that the
Federal Government has taken upon itself to provide for the
care of American Indians and Alaska Natives.
American Indians and Alaska Natives have much lower health
outcomes than the average American, including lower life
expectancy, and higher levels of disease, including diabetes
and heart disease.
Currently, a Native person's life expectancy is 5\1/2\
years less than the average American. The IHS mission is to
raise the physical, mental, social, and spiritual health of
American Indians and Alaska Natives to the highest level.
To meet this mission, there is a lot of work to do and IHS
must do better. IHS has long been plagued with issues of sub-
standard medical care, various personnel issues, poor staff
performance, aged facilities and equipment, unqualified staff,
backlogs in billing and claims collections, and others.
Many of these issues first came to national attention in
2010, when a Senate report was issued on the utter failings of
the IHS facilities in the Great Plains Area.
For over a decade, the Health and Human Services Inspector
General and the Government Accountability Office have indicated
that inadequate oversight of healthcare continues to hinder the
ability of IHS to provide an adequate quality of care despite
continued increases in the agency's budget.
In 2017, the GAO placed IHS on their high-risk list as one
of the government programs and operations vulnerable to waste,
fraud, and abuse. While IHS has made some progress on key
recommendations, more work remains.
In the GAO's 2021 update, it indicated that IHS still had
seven open recommendations at the end of 2020, one of which was
from 2017, and it had still not yet been completed.
This includes recommendations on developing processes to
ensure effective delivery of care, to prevent provider
misconduct and substandard performances, and to collect
information to inform agency decisions on resource allocation
and staffing.
In 2023, IHS began developing and implementing an agency
workplan to make an immediate impact on the Indian Health
System and align processes with the IHS mission and strategic
plan developed in 2019.
These are good starting steps, but that is just what they
are, starting steps. It would have been helpful to hear from
the Director of IHS today and how they are implementing the
plan and what steps remain, however, despite ample notice of
the hearing date and the importance of the subject matter of
today's hearing, the IHS declined to be with us today.
I am deeply troubled with the Department of Health and
Human Services and the IHS in their lacked capacity to prepare
for this hearing.
I want to thank the witnesses that are here, and I look
forward to their testimony.
The Chair now recognizes the Ranking Minority Member for
her statements.
STATEMENT OF THE HON. TERESA LEGER FERNANDEZ, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW MEXICO
Ms. Leger Fernandez. Thank you so much, Madam Chair. I
think this is a very important and welcome hearing because of
the importance of making sure that we do meet our trust
obligations and that we continue to seek the healthiest of
outcomes for our Native Americans.
The Indian Health Service has been the topic of numerous
hearings before this Committee, including, I think, we looked
at that as a very first hearing in the 117th Congress because
we were dealing with the aftermath and what did we need to do
moving forward in dealing with the pandemic.
But as the Chair noted, IHS provides critically,
culturally, competent health services to American Indians and
Alaska Natives across the United States through its own
facilities and, importantly, through tribally operated
facilities and Indian organizations, which we have with us
today, which is I think some of the brightest points with
regards to the provision of healthcare in this nation for
Native Americans.
But, unfortunately, as tribal leaders, organizations, and
studies like the U.S. Broken Promises Report have noted,
Congress has grossly underfunded IHS compared to its need. The
agency's per capita expenditure per person was only $4,078 in
Fiscal Year 2019, compared to the average U.S. national health
expenditure of $9,726. We are talking about half what is
needed.
American Indians and Alaska Natives face steep health
inequities compared to these other population groups in the
United States, which makes that figure even more alarming. As
noted, a tribal citizens-maintained life expectancy is around
5.5 years less than U.S. citizens. They experience higher death
rates in many categories, including chronic liver disease and
cirrhosis, diabetes, suicide, and chronic lower respiratory
diseases.
Decades of Federal underfunding stymied IHS's ability to
provide healthcare services to Indian Country. I am also
concerned that IHS 1993 healthcare facilities construction
priority list, which originally contained over 40 facilities
identified as high need, remains incomplete.
We know that IHS hospitals have an average of 40 years,
which is almost four times greater than other U.S. hospitals.
In my own district, Navajo Nation citizens have been on the
agency's sanitation facility construction list for years.
They still lack access to crucial water lines in the
interim. This is outrageous and unacceptable, and we should
raise our voices against it regularly and often. Too many
tribal patients simply experience inadequate access to
healthcare.
Let's be clear, we all know this in this panel today, that
the Federal Government has not fully delivered on its trust and
treaty promises to Indian Country, especially in this arena.
Last Congress, we began to address that. We passed the
Bipartisan Infrastructure Law to deliver $3.5 billion for IHS
sanitation facilities. We also approved advanced
appropriations. I know many of you are going to speak to that
and I am adamant that we need to make sure that we keep at
least advanced appropriations going forward.
And it was because of the bipartisan work with leaders like
the late Congressman Don Young. This has always been a
bipartisan effort to make sure that IHS is funded, if not
mandatory, then definitely advanced appropriations.
Because we now know that those advance appropriations are
not permanent and that is something that I look forward to
working with the Republican colleagues to see if we can get
that done, since we got it for 2 years last cycle, and let's
see if we can make it mandatory.
According to the Tribal Budget Formulation Workgroups
Fiscal Year 2024 request, the total need for IHS in the
upcoming year is $50 billion. For too long, tribal health
providers have faced uncertainty in the annual budget process
and it is high time we fixed that.
While we certainly have broader budget discussions on this
Committee in the coming months, I want to note today that the
enacted budget and the budget request for recent years come
nowhere near that estimate of need.
That is why I am concerned about the recent Republican
budget proposal which will revert this year's budget back to
Fiscal Year 2022 enacted levels. For IHS, that would amount to
just $6.6 billion. We know that is not enough.
For example, that would mean IHS would have to reduce
outpatient services by nearly 1.6 million visits, 1.6 million
visits would go away. Dental visits would be reduced by
120,000, mental health visits by nearly 90,000, and the
outpatient services by 4,000.
If we saw a 22 percent reduction in funding levels, the
numbers would be even worse. So, today, I look forward to
learning from our expert panel about what you believe Congress
and this Subcommittee must do to improve healthcare services.
And once again, I am a big fan of subcontracting and
compacting. I worked on several of those efforts, and the
Health Boards delivering services in Jemez Pueblo at Santo
Domingo Pueblo are exemplary and I look forward to hearing from
your testimony today.
Ms. Hageman. Thank you very much.
Now, I will introduce our witnesses. Ms. Janet Alkire,
Board Member for the National Indian Health Board, Washington,
DC; Ms. Jerilyn Church, Executive Director of the Great Plains
Tribal Leaders Health Board, Rapid City, South Dakota; Ms.
Laura Platero, Executive Director of the Northwest Portland
Area Heath Board, Portland, Oregon; and Ms. Maureen Rosette,
Board Member for the National Council of Urban Indian Heath,
Washington, DC.
Welcome. Thank you for coming. I know several of you
traveled quite a long distance and we appreciate your
willingness to come and discuss these incredibly important
issues with us.
Let me remind the witnesses that under Committee Rules,
they must limit their oral statements to 5 minutes, but their
entire statement will appear in the hearing record.
To begin your testimony, please press the talk button on
the microphone. We use timing lights. When you begin, the light
will turn green. When you have 1 minute left, the light will
turn yellow, and at the end of the 5 minutes the light will
turn red, and I will ask you to please complete your statement.
I will also allow all witnesses on the panel to testify
before Member questioning.
The Chair now recognizes Ms. Janet Alkire for 5 minutes.
STATEMENT OF JANET ALKIRE, GREAT PLAINS AREA REPRESENTATIVE,
NATIONAL INDIAN HEALTH BOARD, WASHINGTON, DC
Ms. Alkire. Chairwoman, Ranking Member, and members of the
Subcommittee, thank you for the opportunity to testify on
behalf of the National Indian Health Board.
In our language [Speaking Native language] means I greet
you with a good heart. My name is Janet Alkire. I am the
Chairwoman of the Standing Rock Sioux Tribe. I am also the
Great Plains Representative for the National Indian Health
Board. I am here today with a heavy heart.
I prayed this morning this hearing doesn't bring me to
tears. As I think about my people back home, I think about all
the health problems that go untreated. Even preventable
diseases become life threatening. I think about my people
living in pain and spending way too much time fighting to get
the smallest amount of healthcare and there is no other option.
How many hearings do we have to have here before Congress
does something? Before this Subcommittee does something? The
health of Indian people is getting worse, not better.
We have the lowest life expectancy, and Madam Chair you
just described it also. Since 2019, our life expectancy fell--
65 is 2 years before the Social Security retirement age. We are
dying before we can even get a full Social Security check.
Most Americans are planning for years of retirement,
grandkids, grandchildren. Indian people are surviving day to
day. We live in the richest country in the world, a country
that was built on our lands and resources.
We signed treaties, agreements. We reserved our homelands
and agreed to give up vast lands and resources in exchange for
programs and services from the United States. We exchanged our
lands for healthcare.
I am here to say the United States and Congress is breaking
these treaties. I am talking about all of us sitting here
together in this room, we all need to talk to other Members of
Congress to take action together.
Tribal Nations fought and negotiated to reserve our lands.
We did not take these agreements lightly. It is time for the
United States to live up to its end of the bargain. This is not
a hard problem to solve.
We need a surge in funding, as you mentioned, to bring IHS
to modern healthcare standards, and then Congress must increase
annual IHS funding three times just the same as everyone in the
United States.
We need basic facilities and services. We need hospitals,
clinics and you described many--we need surgical care,
maternity wards, ambulances, dialysis, CT scans. The same
equipment and healthcare that everyone else receives.
The IHS hospital at Standing Rock is more than 60 years
old. It is falling apart and lacks space for life-saving
equipment. We recently purchased a CT scan with our own limited
funds. There was no room and we had to build it in a back entry
to the building, but we do what we have to do, right?
Our babies cannot be born on our reservations. Mothers have
to leave their support network, their families, sometimes the
dads, definitely the grandmothers behind and travel over 75
miles to deliver a baby.
I have a story I wish I could share to you, but I know time
is limited, but if we get time, I would love to share a
cultural story relating to this.
On our reservation, they don't fill cavities, they pull
teeth. Our members line up at 6 a.m. in the freezing winter
hoping they will get one of four dental appointments at 7
o'clock, covered in blankets so they can stand in line. If you
don't get those four, you are out. You don't get it.
We expect to lose our teeth, not get them fixed. We finally
have four dentists, which I learned yesterday, but no dental
assistants.
I know we have made some small progress in recent years. In
2010, as you mentioned, the Indian Health Care Improvement Act,
Special Diabetes Program for Indians, but we need to continue
to work on these things.
Congress must provide mandatory funding for IHS. Our
treaties are the law of the land. The United States' commitment
to Indian healthcare is the same as the commitment to veterans,
which I am proudly a United States Air Force veteran.
Second, Congress must permanently reauthorize the Special
Diabetes Program for Indians before it expires in September of
this year. The program should be funded, at a minimum of $250
million annually.
Third, contract support costs and 105 leasing funds must be
mandatory and paid in full. We cannot run health facilities and
health programs on uncertain budgets. Finally, IHS must recruit
and retain professional healthcare.
These are all important, but what is really needed is right
in front of us. Congress must live up to its treaty
commitments, bring IHS facilities to modern standards, and
increase the funding.
After this hearing, I will return home to our financially
starved Indian Health Service Hospital covered in snow and
running on boiler heat in below freezing temperatures. I will
give all my time and energy to help my people in need, working
my vision for a new medical facility, as you mentioned, that
list is very old.
And I will be waiting. I will be waiting for this
Subcommittee and Congress to finally take action. Congress must
pay its overdue debts and provide American Indians and Alaska
Natives the healthcare that we deserve and the healthcare we
were promised.
[Speaking Native language.] Thank you.
[The prepared statement of Ms. Alkire follows:]
Prepared Statement of Janet Alkire, Great Plains Area Representative,
National Indian Health Board
Chairwoman Hageman, Ranking Member Leger Fernandez, and
distinguished members of the Subcommittee, on behalf of the National
Indian Health Board and the 574 sovereign federally recognized American
Indian and Alaska Native Tribal nations we serve, thank you for this
opportunity to provide testimony on challenges and opportunities for
improving healthcare delivery in Tribal communities. My name is Janet
Alkire. I serve as Tribal Council Chairwoman for the Standing Rock
Sioux Tribe and Great Plains Area Representative for the National
Indian Health Board (NIHB).
The Indian Health Service (IHS) is the principal federal health
care provider and health advocate for Indian people.\1\ Its success is
essential to our success as an organization, and to meeting this
Nation's stated policy goal of ensuring the highest possible health
status for Indians.\2\ The NIHB therefore appreciates this
Subcommittee's focus on Indian healthcare and stands ready to work with
the Subcommittee toward achieving this national goal. We have a long
way to go.
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\1\ https://www.ihs.gov/aboutihs/
\2\ 25 U.S.C. 1602(1)
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The NIHB Board of Directors sets forth an annual Legislative and
Policy Agenda to advance the organization's mission and vision. Our
objectives are to educate policymakers about Tribal priorities,
advocate for and secure resources, build Tribal health and public
health capacity, and support Tribally led efforts to strengthen Tribal
health and public health systems. Today's testimony includes a subset
of recommendations from this Agenda.
Summary Recommendations
1. Reauthorize the Special Diabetes Program for Indians (SDPI)
before September 30, 2023.
2. Authorize full mandatory funding for all IHS programs. Until
then:
a. Authorize mandatory funds for Contract Support Costs and
105(l) Lease Payments.
b. Authorize discretionary advance appropriations.
c. Protect the IHS budget from ``sequestration'' cuts
d. Authorize Medicaid reimbursements for Qualified Indian
Provider Services
e. Authorize federally-operated health facilities and IHS
headquarters offices to reprogram funds at the local level in
consultation with Tribes
3. Oversee federal agency data sharing policies to ensure compliance
with existing law
4. Improve Health Professional Staffing in the Indian Health System
5. Support Tribal self-governance expansion at the Dept. of Health
and Human Services
The Trust Obligation
Tribal nations have a unique legal and political relationship with
the United States. Through its acquisition of land and resources, the
United States formed a fiduciary relationship with Tribal nations
whereby it has recognized a trust relationship to safeguard Tribal
rights, lands, and resources.\3\ In fulfillment of this tribal trust
relationship, the Supreme Court declared in 1832 that the United States
``charged itself with moral obligations of the highest responsibility
and trust'' toward Tribal nations.\4\ In 1976, Congress reaffirmed its
duty to provide for Indian health care when it enacted the Indian
Health Care Improvement Act (IHCIA) (25 U.S.C. Sec. 1602), declaring
that it is the policy of this Nation, in fulfillment of its special
trust responsibilities and legal obligations to Indians--to ensure the
highest possible health status for Indians and to provide all resources
necessary to effect that policy.
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\3\ Worcester v. Georgia, 31 U.S. 515 (1832).
\4\ Seminole Nation v. United States, 316 U.S. 286, 296-97 (1942).
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Current Health Status
Today, 47 years after the enactment of IHCIA, American Indians and
Alaska Natives (AI/ANs) collectively still face the lowest health
status of any group of Americans. The Centers for Disease Control and
Prevention (CDC) reported last year that life expectancy for AI/ANs has
declined by nearly 7 years, and that our average life expectancy has
declined to 65 years--10.9 years less than the national average and
equivalent to the nationwide average in 1944.\5\,\6\ Native
Americans die at higher rates than those of other Americans from
chronic liver disease and cirrhosis, diabetes mellitus, unintentional
injuries, assault/homicide, intentional self-harm/suicide, and chronic
lower respiratory disease.\7\ Native American women are 4.5 times more
likely than non-Hispanic white women to die during pregnancy.\8\ The
CDC also found that, between 2005 and 2014, every racial group
experienced a decline in infant mortality except for Native Americans
who had infant mortality rates 1.6 times higher than non-Hispanic
whites and 1.3 times the national average.\9\ Native Americans are also
more likely than people in other U.S. demographics to experience
trauma, physical abuse, neglect, and post-traumatic stress
disorder.\10\ According to a 2020 study by the Substance Abuse and
Mental Health Services Administration, AI/ANs experience the highest
rates of suicide,\11\ with a recent, February 2023 CDC report finding
that teen girls are experiencing record high levels of violence,
sadness, and suicide risk.\12\
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\5\ U.S. Department of Health and Human Services, Centers for
Disease Prevention and Control, Provisional Life Expectancy Estimates
for 2021 (hereinafter, ``Provisional Life Expectancy Estimates''),
Report No. 23, August 2022, available at: https://www.cdc.gov/nchs/
data/vsrr/vsrr023.pdf, accessed on: March 20, 2023 (total for All races
and origins minus non-Hispanic American Indian or Alaska Native).
\6\ Id.
\7\ See, U.S. Commission on Civil Rights, Broken Promises:
Continuing Federal Funding Shortfall for Native Americans (hereinafter
``Broken Promises''), 65, available at: https://www.usccr.gov/files/
pubs/2018/12-20-Broken-Promises.pdf, accessed on: March 20, 2023.
\8\ Broken Promises at 65.
\9\ Broken Promises at 65.
\10\ Broken Promises at 79-84.
\11\ Substance Abuse and Mental Health Services Administration, Key
Substance Use and Mental Health Indicators in the United States,
Results from the 2020 National Survey on Drug Use and Health, available
at: https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/
NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf, accessed on:
March 22, 2023.
\12\ Centers for Disease Control and Prevention, PRESS RELEASE:
U.S. Teen Girls Experiencing Increased Sadness and Violence, available
at: https://www.cdc.gov/media/releases/2023/p0213-yrbs.html, accessed
on: March 22, 2023.
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Historical--and Ongoing--Trauma
Native Americans experience some of the highest rates of
psychological and behavioral health issues as compared to other racial
and ethnic groups which have been attributed, in part, to the ongoing
impacts of historical trauma.\13\,\14\ AI/ANs have suffered
physical, mental, emotional and spiritual harms resulting from
historical and intergenerational trauma that began with colonization
and the Doctrine of Discovery, whereby Tribal lands were seized and
claimed by governments under the auspices that Tribal lands were
``undiscovered'' prior to colonization. Colonization further includes a
history of genocide against AI/AN people, which spread with westward
expansion and forced removal and relocation of numerous Tribes in the
1830s.
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\13\ Walls, et al., Mental Health and Substance Abuse Services
Preferences among American Indian People of the Northern Midwest,
COMMUNITY MENTAL HEALTH J., Vol. 42, No. 6 (2006) at 522, https://
link.springer.com/content/pdf/10.1007%2Fs10597-006-9054-7.pdf, accessed
on: March 20, 2023.
\14\ Kathleen Brown-Rice, Examining the Theory of Historical Trauma
Among Native Americans, PROF'L COUNS, available at: http://
tpcjournal.nbcc.org/examining-the-theory-of-historical-trauma-among-
native-americans/, accessed on: March 20, 2023.
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Cultural genocide followed. In 1869, the U.S. Government, as a part
of efforts to assimilate AI/ANs into non-Native culture, adopted the
Indian Boarding School Policy to eradicate AI/AN language, culture, and
identity through forced separation and removal of AI/AN children from
their families and Tribal communities. Between 1869 and the 1960s, more
than 100,000 AI/AN children were removed from their family homes and
placed in over 350 schools operated by the Federal Government and
churches. Children were punished for speaking their Native languages,
banned from expressing traditional or cultural practices, stripped of
traditional clothing and hair, and experienced physical, mental,
emotional, and spiritual abuse, including malnourishment, sexual
assault, and medical experimentation. Many AI/AN children died at
boarding schools while separated from their families and Tribal
communities, the true number of which is currently unknown due in part
to suppression and inaccessibility of both government and church
records.
Over 100 years of cultural genocide at Indian Boarding Schools is
not relegated to distant memory but exists in the living memory of many
Tribal members today, and the legacy of unresolved historical and
intergenerational trauma caused by the schools has created health
inequities and disparities, detrimental physical and behavioral health
outcomes, and lack of meaningful connection to Native identity for many
Tribal members. Research links AI/AN historical and intergenerational
trauma to increased rates of depression, suicidal ideation, substance
use disorders, domestic violence and sexual assault, and a lower life
expectancy than any other group in the United States. That is why
addressing the harm of historical and intergenerational trauma and the
efficacy of Tribally led and culturally appropriate healing is an
essential component of improving holistic health outcomes for AI/AN
people.
Chronic Underfunding
In December 2018, the U.S. Commission on Civil Rights' Broken
Promises report found that Tribal nations face an ongoing health crisis
that is a direct result of the United States' chronic underfunding of
Indian health care for decades, which contributes to vast health
disparities between Native Americans and other U.S. population
groups.\15\
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\15\ Broken Promises at 65.
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According to IHS data from April 2022, actual IHS spending per user
remains less than half of Medicaid spending per enrollee, less than
half of Veterans medical spending per patient, and less than one-third
of Medicare spending per beneficiary--even after including 3rd party
revenue received by IHS.\16\ The Federal Disparity Index Benchmark,
which assumes IHS users are provided services similar to those
available to the U.S. population, recommends more than twice the
investment per user than IHS receives \17\--an estimate that excludes
approximately two-thirds of the population that could be served by an
appropriately funded IHS.\18\
---------------------------------------------------------------------------
\16\ Indian Health Service, email correspondence to the National
Tribal Budget Formulation Workgroup, attachment ``2021 IHS Expenditures
Per Capital and other Federal Care Expenditures Per Capita--4-27-
2022,'' dated February 14, 2023.
\17\ Id.
\18\ The Indian Health Service estimates the population served as
of January 2020 at 2.56 million; The U.S. Census Bureau estimates the
AI/AN population as of July 2021 at 7.2 million.
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Chronic and pervasive health staffing shortages--from physicians to
nurses to behavioral health practitioners--stubbornly persist across
Indian Country, with 1,550 healthcare professional vacancies documented
as of 2016. Further, a 2018 GAO report found an average 25% provider
vacancy rates for physicians, nurse practitioners, dentists, and
pharmacists across two thirds of IHS Areas (GAO 18-580). Lack of
providers also forces IHS and Tribal facilities to rely on contracted
providers, which can be more costly, less effective and culturally
indifferent, at best--inept at worst. Relying on contracted care
reduces continuity of care because many contracted providers have
limited tenure, are not invested in community and are unlikely to be
available for subsequent patient visits. Along with lack of competitive
salary options, many IHS facilities are in serious states of disrepair,
which can be a major disincentive to potential new hires. While the
average age of hospital facilities nationwide is about 10 years, the
average age of IHS hospitals is nearly four times that--at 37 years. In
fact, an IHS facility built today could not be replaced for nearly 400
years under current funding practices. As the IHS eligible user
population grows, it imposes an even greater strain on availability of
direct care.
Tribal nations are also severely underfunded for public health and
were largely left behind during the nation's development of its public
health infrastructure. As a result, large swaths of Tribal lands lack
basic emergency preparedness and response protocols, limited
availability of preventive public health services, and underdeveloped
capacity to engage in disease surveillance, tracking, and response.
Recommendations
1. Reauthorize the Special Diabetes Program for Indians (SDPI) before
September 20, 2023.
Congress established the Special Diabetes Program for Indians
(SDPI) in 1997 to address the disproportionate impact of type 2
diabetes in AI/AN communities. This program has grown and become our
nation's most strategic and effective federal initiative to combat
diabetes in Indian Country. SDPI has effectively reduced incidence and
prevalence of diabetes among AI/ANs and is responsible for a 54%
reduction in rates of End Stage Renal Disease and a 50% reduction in
diabetic eye disease among AI/AN adults.\19\ A 2019 federal report
found SDPI to be largely responsible for $52 million in savings in
Medicare expenditures per year.\20\
---------------------------------------------------------------------------
\19\ Indian Health Service, Special Diabetes Program for Indians
2020 Report to Congress, available at https://www.ihs.gov/sdpi/reports-
to-congress/, accessed on: March 20, 2023.
\20\ Department of Health and Human Service, The Special Diabetes
Program for Indians: Estimates of Medicare Savings, ASPE Issue Brief,
May 10, 2019, available at https://aspe.hhs.gov/sites/default/files/
private/pdf/261741/SDPI_Paper_Final.pdf, accessed on: March 20, 2023.
---------------------------------------------------------------------------
Still, diabetes and its complications remain major contributors to
death and disability in nearly every Tribal community. AI/AN adults
have the highest age-adjusted rate of diagnosed diabetes (14.5 percent)
among all racial and ethnic groups in the United States, more than
twice the rate of the non-Hispanic white population (7.4 percent).\21\
In some AI/AN communities, more than half of adults 45 to 74 years of
age have diagnosed diabetes, with prevalence rates reaching as high as
60 percent.\22\
---------------------------------------------------------------------------
\21\ Centers for Disease Control and Prevention. National Diabetes
Statistics Report website. https://www.cdc.gov/diabetes/data/
statistics-report/index.html. Accessed March 20, 2023.
\22\ Lee ET, Howard BV, Savage PJ, et al. Diabetes and impaired
glucose tolerance in three American Indian populations aged 45-74
years: the Strong Heart Study. Diabetes Care. 1995;18:599-610.
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The NIHB strongly supports the permanent reauthorization of the
SDPI at a minimum of $250 million annually, with automatic annual
funding increases matched to the rate of medical inflation. SDPI has
been flat funded since FY 2004. It is also important to note that last
year, the Department of Health and Human Services (HHS) expanded the
pool of potential grantees beyond current grantees to all eligible
grantees. Practically, in 2022, this meant that there were additional,
new grantees in the SDPI program, with the same level of funding.
Additionally, the NIHB supports amending the SDPI's authorizing
statute, the Public Health Service Act, to permit Tribes and Tribal
organizations to receive SDPI funds through self-determination and
self-governance contracts and compacts. This change will establish SDPI
as an essential health service and remove the barriers of competitive
grants--which do not honor the Trust and treaty obligation to tribal
nations. Self-governance also removes unnecessary administrative
burdens which leaves more funding available for services. Self-
governance Supports Tribal sovereignty by transferring control of the
program directly to Tribal governments.
2. Authorize full mandatory funding for all IHS programs.
Through its coerced acquisition of land and resources and genocide
destruction of cultures and peoples the United States formed a
fiduciary relationship with Tribal nations whereby it has created a
trust relationship to safeguard Tribal rights, lands, and resources. As
part of this coerced exchange, Congress has continuously reaffirmed its
duty to provide for Indian health care. Unfortunately, Tribal nations
face an ongoing health crisis directly resulting from the United
States' chronic underfunding of Indian health care for decades. This
contributes to ongoing health and persistent inequities and
disparities. Mandatory appropriations for the IHS are consistent with
the trust responsibility and treaty obligations reaffirmed by the
United States in IHCIA. Even today, 13 years after IHCIA was
permanently enacted, many provisions of IHCIA remain unfunded and
without implementation. Full and mandatory funding must include the
full implementation of all authorized IHCIA provisions.
Until Congress passes full mandatory funding for all IHS programs,
the NIHB urges Congress to pass the following incremental funding
measures:
a. Authorize mandatory funds for Contract Support Costs and 105(l)
Lease Payments.
As the Appropriations Committee has reported for years, certain IHS
account payments, such as Contract Support Costs and Payments for
Tribal Leases, fulfill obligations that are typically addressed through
mandatory spending. Inclusion of accounts that are mandatory in nature
under discretionary spending caps has resulted in a net reduction on
the amount of funding provided for Tribal programs and, by extension,
the ability of the federal government to fulfill its promises to Tribal
nations.
b. Authorize discretionary advance appropriations.
Advance appropriations for the IHS marks a historic paradigm shift
in the nation-to-nation relationship between Tribal nations and the
United States. With advance appropriations, AI/ANs will no longer be
uniquely at risk of death or serious harm caused by delays in the
annual appropriations process. However, the inclusion of advance
appropriations each year is not guaranteed, and the solution in the FY
2023 Omnibus is far from perfect. NIHB urges Congress to pass a bill
authorizing annual advance appropriations for all areas of the IHS
budget and providing for increases from year to year that adjust for
inflation, population growth, and necessary program increases. NIHB
supports advance appropriations until full, mandatory appropriations
are enacted.
c. Protect the IHS budget from ``sequestration'' cuts.
The IHS budget remains so small in comparison to the national
budget that spending cuts or budget control measures would not result
in any meaningful savings in the national debt, but it would devastate
Tribal nations and their citizens. As Congress considers funding
reductions in FY 2024, IHS must be held harmless. As we saw in FY 2013
poor legislative drafting subjected our tiny, life-sustaining, IHS
budget to a significant loss of base resources. Congress must ensure
that any budget cuts--automatic or explicit--hold IHS and our people
harmless.
d. Authorize federally-operated health facilities and IHS
headquarters offices to reprogram funds at the local level in
consultation with Tribes
The Indian Self-Determination and Education Assistance Act (ISDEAA)
authorized Tribal nations to take greater control over their own
affairs and resources by contracting or compacting with the federal
government to administer programs that were previously managed by
federal agencies. This includes the ability to develop and implement
their own policies, procedures, and regulations for the delivery of
these services. Tribal nations may also receive direct services from
the IHS. Unfortunately, some of the flexibility that makes ISDEAA so
cost effective at delivering services is not available at the local
level when direct services are provided by the IHS. Fundamentally, the
ability to direct resources is one of Tribal sovereignty and self-
determination. Just because a Tribe chooses to receive direct services
from IHS does not mean it forfeits these rights. IHS must have greater
budget flexibility, especially at the local service unit level to
reprogram funds to meet health service delivery priorities, as directed
by the Tribes who receive services from that share of the IHS funding.
e. Authorize Medicaid reimbursements for Qualified Indian Provider
Services
In 1976, Congress gave the Indian health system access to the
Medicaid program in order to help address dramatic health and resources
inequities and to implement its trust and treaty responsibilities to
provide health care to AI/ANs and today, Medicaid remains one of the
most critical funding sources for the Indian health system. In order to
ensure that States not bear the increased costs associated with
allowing Indian health care providers access to Medicaid resources,
Congress provided that the United States would pay 100 percent of the
costs for services received through Indian health care providers (100
percent FMAP). While Congress provided equal access to the Medicaid
program to all Indian health care providers, in practice access has not
been equal. Because States have the option of selecting some or none of
the optional Medicaid services, the amount and type of services that
can be billed to Medicaid varies greatly state by state. So, while the
United States's trust and treaty obligations apply equally to all
tribes, it is not fulfilling those obligations equally through the
Medicaid program. To further the federal government's trust
responsibility, and as a step toward achieving greater health equity
and improved health status for AI/AN people, we request that Congress
authorize Indian health care providers across all states to receive
Medicaid reimbursement for a new set of Qualified Indian Provider
Services. These would include all mandatory and optional services
described as ``medical assistance'' under Medicaid and specified
services authorized under the IHCIA when delivered to Medicaid-eligible
AI/ANs. This would allow all Indian health care providers to bill
Medicaid for the same set of services regardless of the state they are
located in. States could continue to claim 100 percent FMAP for those
services so there would be no increased costs for the states for
services received through IHS and tribal providers.
3. Oversee federal agency data sharing policies to ensure compliance
with existing law.
As sovereign nations, AI/AN Tribes maintain inherent public health
authority to promote and protect the health and welfare of their
citizens, using the methods most relevant to their communities.
Respecting and upholding Tribal sovereignty is core to any Tribal data
policy. Tribal governments must always control how their data is
accessed, used, and released.
Section 214 of the IHCIA designated Tribal Epidemiology Centers
(TECs) as public health authorities. The designation of TECs as public
health authorities is derived from the inherent position of Tribal
nations as public health authorities. As sovereign nations, Tribes have
the right of self-determination. They can carry out their public health
functions or delegate that authority to another entity, such as their
area TEC.
We support the ability of TECs to access data in the same way
state, and local health departments do, but none of these entities
should have access to Tribal data without the informed consent of
Tribes. HHS is responsible for developing a data policy that both
ensures Tribal sovereignty is respected and ensures Tribes and TECs
have unfettered access to data to be able to carry out their duties as
public health authorities.
The NIHB urges this Subcommittee to conduct oversight on this issue
to ensure that federal agencies follow the letter and spirit of the law
upholding our right to access public health data.
4. Improve Health Professional Staffing in the Indian Health System
The IHS and Tribal health care providers continue to struggle to
find qualified medical professionals to work in facilities serving
Indian Country. To strengthen the health care workforce, IHS and Tribal
programs need investment from the federal government to educate,
recruit, and expand the pool of qualified medical professionals. IHS
currently provides scholarship opportunities to AI/AN students to enter
the health professions. IHS also provides loan repayment opportunities
for those who work in the Indian health system. However, both of these
programs are severely underfunded. Congress should increase
appropriations for both IHS scholarship and loan repayment programs.
NIHB also supports legislation to move IHS loan repayment program to a
tax-exempt status to increase the dollars available for the program,
which is similar treatment to the National Health Service Corps loan
repayment program. IHS should also provide loan repayment opportunities
to those in health support positions such as Administrators, coders,
and billers. Like other health professionals, these staff are
desperately needed to keep Tribal health systems operating efficiently.
NIHB also encourages Congress to enact legislation that would make
it easier for IHS to recruit and retain medical staff. For example,
Congress should provide the Indian Health Service Discretionary Use of
all Title 38 Personnel Authorities, similar to authorities enjoyed by
the Veterans' Health Administration (VHA). This would make IHS a more
attractive employer for paid time off and scheduling options.
a. Reimburse for traditional healing services.
Integrating traditional health services with medical, dental, and
behavioral health services allows for holistic care to tend to the
mind, body, and spirit of AI/AN individuals. Tribal Nations know that
health care programs are more effective at improving health for AI/AN
people when they incorporate traditional medicine. Tribal nations,
Tribal organizations, and UIOs have developed processes and policies
for credentialing traditional practitioners in parity with western
clinical privileges. They have also developed several traditional
health models that the Centers for Medicare and Medicaid Services (CMS)
can reimburse. Medicare and Medicaid reimbursement for traditional
health services would support access to culturally appropriate
services, which will improve health outcomes for AI/ANs and advance
health equity. Designing the paths to credentialing and billing for
traditional healing services must be Tribally led and approached with
sensitivity and cultural humility, since traditional healing often
includes protected, sacred practices.
b. Support and Expand the Community Health Aide Program (CHAP) and
the Dental Health Aide (DHAT) Program
Since the 1960s, the Community Health Aide Program (CHAP) has
empowered frontline medical, behavioral, and dental providers to serve
Alaska Native communities, successfully expanding access in these
communities to urgently needed health and dental services. CHAP is now
a crucial pathway for AI/AN peoples to become health care providers.
The IHCIA authorized the IHS to expand the CHAP to Tribes outside
Alaska. Based on the IHCIA and the CHAP's success in Alaska, IHS
developed CHAP expansion policies from 2016 to 2020. However, IHS'
implementation of the nationalization of CHAP has been slow, and years
after it was initiated, Tribes outside of Alaska are still waiting for
IHS' to implement this highly successful program. IHS must work to
swiftly operationalize the use of Dental Health Aides, Dental Health
Aide Therapists, and Behavioral Health Aides. As Tribes confront health
care provider shortages and chronically poor health outcomes, they
urgently need the pathways and resources CHAP provides. IHS must finish
the expansion work expeditiously so Tribes outside Alaska can benefit
from the program.
5. Support Tribal self-governance expansion at the Dept. of Health and
Human Services.
Tribal self-determination and self-governance honor and affirm
inherent Tribal sovereignty. A self-governance program model promotes
efficiency, accountability, and best practices in managing Tribal
programs and administering federal funds at the Tribal level. Because
Tribes can tailor programs according to the communities' needs, self-
governance results in more responsive and effective programs. The
Indian Self-Determination and Education Assistance Act (ISDEAA)
provides the mechanisms to achieve this. However, ISDEAA is not applied
to all IHS programs or applicable throughout the HHS. Legislation and
administrative action are needed to expand and strengthen Tribal self-
determination and self-governance in healthcare-related programs
throughout HHS. NIHB supports the introduction of legislation
establishing a demonstration project to implement Title VI of the
Indian Self-Determination and Education Assistance Act across HHS.
Conclusion
For the last 47 years, the United States has had a policy of
ensuring the highest possible health status for Indians and to provide
all resources necessary to effect that policy. Unfortunately, those
responsibilities and legal obligations remain unfulfilled and Indian
Country remains in a health crisis. Clearly, the status quo isn't
working.
Time will tell if today's hearing on the challenges and
opportunities for improving healthcare delivery in Tribal communities
marked the beginning of significant change, or the continuation of the
status quo. The challenges are many, but most are equally matched by
the opportunities and solutions already identified by Tribal leaders,
Congresses, and Administrations past and present.
There is a way forward if Congress can overcome perhaps the
greatest remaining challenge: political will. The NIHB recognizes that
the recommendations offered in this testimony will require coordination
with other committees of jurisdiction, and we stand ready to help with
that effort. But the heavy lifting must be borne by this Subcommittee.
No other subcommittee in the House is as focused on Indian affairs as
this one. For the sake of our People, we hope this Subcommittee in the
118th Congress is up to the challenge.
______
Questions Submitted for the Record to Janet Alkire, Great Plains Area
Representative, National Indian Health Board
Questions Submitted by Representative Westerman
Question 1. Does the current structure of the Indian Health Service
(IHS) of being divided into 12 regions best serve the needs of tribal
communities?
Answer. The IHS area system helps keep local Tribal communities
closer to the administrative functions of IHS. It also means that
Tribal leaders have access to decision makers at the local level when
there are concerns with IHS care. Each area, just like each tribe, is
unique. The needs in the Great Plains are different than those in the
Navajo or Nashville areas. For this reasons, the area system still
serves a purpose.
Unfortunately, the area offices have varying cooperative
relationships with the Tribal Nations in their region. While some work
collaboratively and in partnership, others area offices are reported to
withhold information--both financial and epidemiological--from Tribes.
We are encouraged recent IHS actions to help standardize practices and
management across the 12 areas. We hope that this results in improved
care throughout the system and greater accountability for the IHS area
offices to the Tribal Nations that they serve.
1a) Would you suggest any changes to the IHS operating structure
that you believe would improve healthcare service to tribal
communities?
Answer. Changes in the operating structure of IHS should be done
with full consultation and consent with Tribal Nations. NIHB
acknowledges that there are still challenges with the IHS area system.
Funding and resources across 12 areas could be more equitable. For
example, some service areas have no IHS funded hospital facilities at
all, making them more dependent on scarce Purchased/ referred care
dollars. Areas also vary widely in terms of patient population and
number of Tribal Nations. The Indian Health Care Improvement Act, for
example, has made the provision for a Nevada Area Office, but that
aspect of law has never been implemented.
Question 2. Please further expand on your testimony about the
expansion of tribal self-governance program: Which programs
specifically do you think should have this authority?
Answer. Tribal advocates have identified 23 programs specifically
at HHS to be part of a Self-Governance Demonstration program. These
selected programs are federal programs that Tribal Nations are already
operating under competitive or formula-based grants. We feel that these
programs are all basic lifeline services that would allow Tribal health
programs to effectively and seamlessly provide care to their people.
In addition, incorporating these programs into a Self-Governance
agreement allows Tribes to provide much needed wrap-around services to
their citizens with its programs operating in collaboration rather than
in silos created by federal agencies. HHS has identified most these
programs in previous reports--dating back to 2003--as being feasible
for self-governance. Other programs have been newly created by Congress
since the initial Self-governance report was issued in 2003.
Most importantly, self-governance would allow Tribal Nations to
implement programming in our Tribal Nations that is culturally
appropriate and tailored to local needs. For example, the proposal
includes several programs under the Centers for Disease Control and
Prevention (CDC). As you know, Indian Country was impacted by the
COVID-19 pandemic in greater numbers than other communities. If we had
robust, culturally appropriate public health services, we would have
been able to quickly spring into action to improve information going to
community members and disseminate available resources. Allowing self-
governance programs puts local communities in the driver's seat to
respond to local needs. States and localities are already receiving
this support from CDC. It is time that Tribal Nations receive this
support as well.
Self-governance also allows small tribal communities to more
effectively pool limited resources so that they can get the most impact
for the small dollar amounts. This also includes spending less time on
bureaucracy which includes applying for and reporting on federal
grants. Since 2013, Tribes and Tribal Organizations have continued to
make the expansion of Self Governance at HHS a top priority in their
communications to Congress and with the Department. Expanding Self-
Governance at HHS is the logical next step for the Federal government
to promote Tribal sovereignty and Self-Determination and improve
services to American Indians and Alaska Natives and will help people
get the services they need.
2a) Have you heard from the Department of Health and Human Services
about any concerns they have about including the programs you think
should be included within the tribal self-governance program?
Answer. In recent months, HHS has not been engaged in a substantive
way on this topic with Tribal Nations. While the Secretary and other
political leadership have noted an overall desire to support Tribal
Self-governance expansion, we have seen little effort to engage in a
collaborative process to work through how self-governance would be
implemented. They have noted implementation concerns related to
providing equitable funding, statutory barriers, and the ability to
consolidate eligible programs as concerns. From the perspective of
Tribal Nations, these concerns exemplify some of the great benefits of
Tribal Self-governance. It would allow Tribes to implement programs
efficiently and effectively, without unnecessary government
bureaucracy. It would also shift away from the competitive grants
process which creates unstable or inaccessible funding sources for
Tribal governments. Too often, competitive grants only reward
communities with high levels of institutional resources and capacity,
not necessarily where needs are greatest.
Question 3. In your testimony, you mentioned that allowing IHS
facilities to make reprograming decisions with tribal consultation at a
local level could help meet health service deliver priorities. Could
you further expand on that idea for the Subcommittee, and also provide
any examples of where local reprogramming authority would have been
beneficial?
Answer. Yes, being able to make funding decisions for real time
health issues would be very helpful. For example, if there was an
urgent need to provide behavioral health funding due to a recent surge
in overdose deaths, the local IHS could quickly reevaluate resources
and target them to an area that was needed in the community. Because
direct service tribes have to go through so many burdensome approval
processes, it often takes too much time and we don't have time to waste
when there is a serious, targeted health challenge going on, like
substance abuse.
Health care crises are often quick and in real time. There may be a
need to get resources deployed to increase disease surveillance from
one area to another. Having local funding flexibility will ensure that
health systems can be more nimble, instead of depending solely on a
budget created many months ahead of time. It is critical that any
budgetary changes of this nature be done in consultation with local
tribal communities. The ability to respond in real time to local needs
honors Tribal sovereignty and self-determination. This principle still
applies if the Tribe choose to allow IHS to provide their health
services.
Questions Submitted by Representative Leger Fernandez
Question 1. Could you share more on the anticipated impacts and
loss of services that would occur if the FY24 enacted congressional
budget reflects FY22 enacted levels for the Indian Health Service
(IHS)?
Answer. If the FY 2024 enacted congressional budget reflects FY
2022 enacted levels for the IHS, it is likely that the IHS will face a
reduction in purchasing power greater than or equal to the impacts of
sequestration on the IHS budget in FY 2013, which devastated Indian
health system hospitals and health clinics. We need only look back a
decade to see quite clearly what this would do to Tribal healthcare.
During the FY 2013 funding sequestration, the IHS faced a roughly
five percent cut in funding, which had devastating impacts on Tribes'
and IHS's ability to provide healthcare services. The reductions in
funding, staffing, and services had significant impacts on healthcare
outcomes for Tribal communities.
The reductions in staffing levels meant that there were fewer
healthcare professionals available to provide care to Tribal
communities. This led to longer wait times for appointments and reduced
access to critical healthcare services. The reductions in funding and
staffing levels also led to reductions in preventive healthcare
services, such as immunizations and cancer screenings. Some healthcare
facilities had to reduce operating hours or even close temporarily due
to the funding cuts.
With longer wait times for appointments and reduced access to
primary care, many Tribal members had no choice but to seek care in
emergency rooms. This led to increased utilization of emergency room
services, which can be more expensive and less effective for managing
chronic conditions.
The reductions in funding and staffing levels made it more
difficult for the IHS to recruit and retain healthcare professionals.
This is a challenge that the IHS already faces, and the funding cuts
during the FY 2013 sequestration made it even more difficult to attract
and retain qualified healthcare professionals to serve in Tribal
communities.
The funding cuts during the FY 2013 sequestration also led to
delays or cancellations of critical construction projects, which
resulted in deteriorating healthcare infrastructure and reduced access
to healthcare services. The delays or cancellations of critical
construction projects meant that healthcare facilities in Tribal
communities continued to deteriorate, creating safety concerns for
patients and workers. This had a negative impact on access to
healthcare services and healthcare outcomes for Tribal communities.
The increase from FY 2022 to FY 2023 was roughly 5 percent--the
same amount sequestered in FY 2013. When taking into consideration
fixed costs like pay costs, contract support costs, and payments for
tribal leases, as well as medical and non-medical inflation and the
population growth, it is very easy to predict the harmful impacts of
funding the IHS at FY 2022 levels. Unfortunately, I can guarantee it
will devastate our already starved annual budget.
This is evidenced in the significantly worse health outcomes for
American Indians and Alaska Natives (AI/ANs), as detailed in the
National Indian Health Board's written statement. One impact of lower
budgets has meant a lack of quality medical providers due to lower pay
scales, remote locations and lack of housing for professionals. AI/ANs
experience some of the greatest disparities when it comes to maternal
health and behavioral health, for example. With even fewer resources
available to recruit and retain OB/GYNs or behavioral health teams,
these challenges will get even worse if funding is reduced.
As Congress considers reducing funding levels, it is critical to
understand that these services are not ``nice to have'' programs that
the federal government provides each appropriations cycle. The IHS
budget is the fulfillment of the United States' sacred promise to
Tribal Nations. Failure to fund the IHS decade upon decade has already
resulted in significant loss of life for AI/ANs. Funding reductions to
the IHS budget will not make much of a dent in the fiscal challenges of
the United States, but it will do irreparable harm to those citizens of
this nation that depend on IHS for life or limb services.
______
Ms. Hageman. Thank you.
I thank the witness for your testimony and the Chair now
recognizes Ms. Jerilyn Church for 5 minutes.
STATEMENT OF JERILYN LEBEAU CHURCH, CHIEF EXECUTIVE, GREAT
PLAINS TRIBAL LEADERS HEALTH BOARD, RAPID CITY, SOUTH DAKOTA
Ms. Church. [Speaking Native language.] Chairwoman Hageman,
Ranking Member Fernandez, and distinguished members of the
Subcommittee, on behalf of the Great Plains Tribal Leaders
Health Board, which serves 17 federally recognized tribes in
South Dakota, North Dakota, Nebraska, and Iowa, thank you for
this opportunity.
[Speaking Native language.] My name is Jerilyn Church, and
I am a citizen of the Cheyenne River Sioux Tribe and serve as
the president and CEO of the Great Plains Tribal Leaders Health
Board.
Indian Health Service is the primary source of healthcare
for nearly 150,000 citizens in the Great Plains. Historically,
the Great Plains has been an example of failures that accompany
chronic under resourcing, provider shortages, outdated
facilities, obsolete equipment, and egregious health inequities
are the norm in the Great Plains area.
The first opportunity for changing that reality is for
Congress to authorize mandatory funding for all IHS programs,
ensure discretionary advanced appropriations to protect the
already deficient IHS budget from sequestration.
Second, Indian Health Service must increase its workforce
to actively ensure that competent physician-led healthcare is
provided as called for in the 2021 8th Circuit opinion Rosebud
Sioux Tribe v. United States.
Tribes who exercise their sovereignty through Public Law
93-638 and run their own programs outperform direct service
units on every level. So, IHS needs to ensure its
administrative capacity to adequately support them.
For example, since the Great Plains Tribal Leaders Health
Board assumed management of the Rapid City Service Unit 4 years
ago, the Oyate Health Center has seen a 400 percent increase in
third-party billing.
It has added 10,000 users and has lowered the rate of
uninsured users from 56 percent in October 2019, to 49 percent
in March 2023.
When IHS is funded, they successfully change health
outcomes. For 25 years, the Special Diabetes Program for
Indians has effectively reduced end-stage renal disease and
diabetic eye disease.
Victor is a tribal elder who uses the SDPI Program in Rapid
City. He consistently works with his dietician and lifestyle
coach to meet all his diabetes standards of care. He reduced
his weight by 20 pounds and his A1C dropped from 7.8 to 6.3.
We have seen successes, yet diabetes is still more than
twice the rate of the non-Hispanic White population. For Victor
and thousands of other diabetics, we implore you to reauthorize
SDPI.
A fourth and immediate opportunity to improve healthcare is
for IHS and CDC to respect that tribes and Tribal Epidemiology
Centers are statutorily mandated as public health authorities
and to share public health data for the purposes of addressing
public health threats.
From the start of the pandemic, the Great Plains Tribal Epi
Center requested data on COVID-19 infections in tribal
communities. Instead of sharing that data, as IHS routinely
does with state public health authorities, IHS required the Epi
Center to enter a data sharing agreement then refused to sign
it until 2022, 3 years after it was negotiated.
The tribes never did receive the data that was needed when
it was needed most. A current example, Native babies in the
Great Plains are dying of congenital syphilis, a preventable
disease at epidemic levels.
Tribes and TECS can help stop the spread of syphilis and
protect Native families, but we need public health data.
Fifth, we urge the Committee to work with CMS to ensure the
process of unwinding Medicaid does not result in the loss of
basic services for many thousands of our tribal citizens as
continuous enrollment ends. CMS should urge state Medicaid
programs to work collaboratively with tribes who want to assist
with outreach and recertification of those individuals before
they lose benefits.
Finally, we urge IHS to support integrating culturally
traditional healing practices into clinical services. A recent
tribal survey indicated that American Indian patients who see
both a physician and traditional healer, 61 percent trust the
advice of their traditional healer over their physician. And
they may limit disclosure of their medical history due to
medical distrust and poor coordination of care.
Just as it is widely accepted that prayer improves health
outcomes in clinical settings, that is also true for culturally
traditional practices in our tribal communities.
[Speaking Native language] for allowing me to share these
recommendations on improving healthcare delivery in tribal
communities.
[The prepared statement for Ms. Church follows:]
Prepared Statement of Jerilyn LeBeau Church,
Great Plains Tribal Leaders Health Board
Introduction
Thank you for this opportunity to present testimony on current
challenges and opportunities for improving healthcare delivery, and
ultimately health care outcomes, for Indian people in our communities.
The Indian Health Service (IHS) is the primary source of health
care for nearly 150,000 American Indians/Alaska Natives in the Great
Plains Area. Of the six hospitals in the Great Plains, five are managed
directly by IHS. Of the thirteen ambulatory health clinics in the Great
Plains Area, seven are managed entirely by a tribe or a tribal
organization under a Title I Self-Determination contract, five are
managed directly by IHS, and one is tribally managed through a Title V
Self Governance compact. In addition, the Indian Health Service is
responsible for two substance abuse treatment centers and supports
three urban health care programs.
As requested by the Committee, this testimony will review seven
timely and meaningful challenges and opportunities for improving
healthcare delivery in Tribal communities in the Great Plains Area:
1. Enacting full mandatory funding of the Indian Health Service,
2. Building IHS capacity through workforce development,
3. Expanding self-determination contracting and self-governance
compacting into additional HHS programs,
4. Permanently reauthorizing the Special Diabetes Program for
Indians (SDPI),
5. Enforcing existing law that mandates data sharing with Tribal
public health authorities,
6. Ensuring that state and federal agencies cooperate with Tribes to
continue Medicaid benefits to all eligible AI/AN
beneficiaries, and
7. Integrating and supporting traditional Native American healing
practices throughout the Indian Health system.
Seven Areas of Opportunity
1. Funding: strategies for full and mandatory funding of the Indian
Health Service.
In January 2023, Indian Country celebrated the passage of the
Fiscal Year 2023 omnibus spending package, which for the first time
included advanced appropriations of just over $5 billion for the Indian
Health Service. This historic achievement was clouded by the fact that
$5 billion is only part of IHS's $7 billion budget, and by the fact
that that $7 billion budget is less than half of what patients need.
Therefore, this Committee can use the momentum of this historic
opportunity to:
a. Continue increasing the Indian Health Service's overall budget
to fulfill its Treaty and trust responsibility for Indian healthcare.
In July 2022, a report of the Office of the Assistant Secretary for
Planning and Evaluation, U.S. Department of Health and Human Services,
HP-2022-21, found that IHS's 2022 budget funded less than half of
patient need. A similar 2022 report from the advisory body the Tribal
Budget Formulation Workgroup calculated that IHS would need a $51.4
billion budget to meet the federal obligation to provide adequate
health services in Native American communities (Office of the Assistant
Secretary for Planning and Evaluation, 2022). According to a 2018 GAO
report, GAO-19-74R, per capita spending on IHS patient health care was
less than a third of Medicare per patient spending and less than a half
of Medicaid per patient spending (Government Accountability Office,
2018). The Veteran's Administration, another non-entitlement program,
spent 2.6 times more per patient than the Indian Health Service. Any
equitable increase to the IHS budget would at least double the current
amount, but with the current state of underfunding, any increase is
meaningful.
b. Authorize mandatory funds for the remainder of the IHS budget,
while prioritizing mandatory funding for all nondiscretionary items
such as Contract Support Costs and 105(l) Lease Payments. While
securing advanced appropriations for IHS is an historic success,
extending advanced appropriations to the full IHS budget would be a
better realization of the federal government's trust responsibility
toward Indian County, and would better protect the delivery of
necessary and basic health services from any gaps in the annual funding
cycle. In the alternative, funding at least any remaining
nondiscretionary budget items, in particular contract support costs and
105(l) leases, through advanced appropriations would be a meaningful
step forward.
c. Protect the IHS budget from any further ``sequestration'' cuts.
Any budget control measures implemented on the IHS budget are
catastrophic in their effects on health programs and services to Indian
people. At the same time, the cuts do not have any significant benefit
with regard to actual control of the federal budget. While we are sure
that many small budget programs would like to request exemption from
any future sequestration, budget cuts to Indian Health programs have an
immediate effect on lives and health outcomes in our communities.
Therefore, we urge the Committee to protect the IHS budget from further
sequestration or other budget control measures.
2. Staffing: workforce development will increase the Indian Health
Service's capacity to deliver healthcare services and enable the agency
to fulfill its mission to provide those services to Native communities.
Like most other IHS areas, hospitals and clinics in the Great
Plains service area face enormous challenges with staff recruitment and
retention, sometimes resulting in inability offer services,
particularly specialty services, and always resulting in overdependence
on expensive temporary contractors. As of March 27, 2023, there were
over 250 open positions advertised in the Great Plains Area on the IHS
website. This is very clearly a case where an ounce of prevention is
worth a pound of cure. Front end investment in workforce development,
in recruitment and retention of medical officers and staff will lead
directly to savings by not having to use temporary contractors to fill
those positions, and not having to use limited purchased and referred
care dollars (PRC) to refer patients out for specialty care. Those
savings can be reinvested in the workforce, both to attract and retain
staff and to stabilize and expand services.
Attached to this testimony is support from the Rosebud Sioux Tribe
underscoring the federal government's established legal obligation to
staff its facilities in the Great Plains Area. See Attachment 1,
Comments from Rosebud Sioux Tribe Health Director Skyla Fast Horse,
March 24, 2023. In 2021, the 8th Circuit Court of Appeals reaffirmed
that the Indian Health Service did have a duty to provide ``competent
physician-led health care'' at the Rosebud IHS Hospital. Rosebud Sioux
Tribe v. United States, 8th Cir. 2021 (No. 20-2062). While it is
heartbreaking that the Rosebud Sioux Tribe had to file suit in order to
force IHS to staff its hospital, the court's conclusion lays bare the
need both for additional funding for IHS and for geographically remote
facilities in the Great Plains Area, and specifically for workforce
development.
3. Self-Determination Legislation: the Tribes of the Great Plains Area
support and request legislation establishing a demonstration project to
implement Title VI of the Indian Self Determination and Education
Assistance Act (ISDEAA).
In 2000, Congress enacted Title VI of the Indian Self Determination
and Education Assistance Act (ISDEAA). The purpose of the self-
determination sections of the ISDEAA was to allow Tribes to assume
management of IHS and Bureau of Indian Affairs (BIA) programs created
for the benefit of Indian people, with the assumption that Tribes with
their close knowledge of local culture, people, and resources, would be
better suited to manage those programs. The vehicle for assumption of
those federal programs was a contract under Title I, and later a
compact under Title V. Because of the runaway success of both
contracting and compacting, Congress imagined expanding Self-Governance
under the ISDEAA to include grant programs for Indians administered by
other agencies within HHS. HHS conducted a feasibility study on this
possibility and concluded in 2003 that such expansion was feasible. HHS
identified eleven programs that could be integrated into Self-
Governance under Title VI of the ISDEAA. That was twenty years ago. It
is time, now, to promote Tribal sovereignty by taking this next step to
improve health care delivery in our communities. Through this testimony
and through the attached resolution of its Board of Directors, the
GPTLHB respectfully requests that this Committee introduce legislation
establishing a demonstration project to implement Title VI of the
ISDEAA as described in the 2003 HHS recommendations. See, Attachment 2,
GPTLHB Res. 2022-06, March 10, 2022.
4. Diabetes Prevention: permanent reauthorization of the Special
Diabetes Program for Indians (SDPI) before September 30, 2023.
The Special Diabetes Program for Indians (SDPI) is recognized as
one of the most impactful and successful IHS programs.
In its 2020 report to Congress, Special Diabetes Program for
Indians, IHS found that besides reducing the incidence of Type 2
Diabetes overall, SDPI has reduced End Stage Renal Disease by an
astonishing 54% and diabetic retinopathy by an equally staggering 50%
(Indian Health Service, 2020). In 2019 HHS' report The Special Diabetes
Program for Indians: Estimates of Medicare Savings determined that SDPI
had resulted in an estimated $52 million in Medicare savings annually.
SDPI's impact through patient and community education and prevention
activities ripples through Indian Country and beyond. (Dept. of Health
and Human Services, 2019).
Therefore, the GPTLHB urges the Committee to propose and to
advocate for the permanent reauthorization of the SDPI before September
30, 2023. Further, the GPTLHB joins in the National Indian Health
Board's request that SDPI be reauthorized at a minimum of $250 million
annually, with automatic annual funding increases matched to the rate
of medical inflation, and that the Public Health Service Act be amended
to permit Tribes and Tribal organizations to contract and compact under
the ISDEAA for administration of SDPI funds.
5. Data Sharing: enforce existing law and policy which recognizes
Tribes and Tribal Epidemiology Centers (TECs) as public health
authorities which authorizes HHS agencies, including IHS and CDC,
provide complete and transparent sharing of public health data with
Tribes and TECs at the same level that those agencies share public
health data with states.
The COVID-19 pandemic was particularly devastating to Native
communities. One CDC report found a decline in life expectancy of 6.6
years in AI/AN communities over the course of the pandemic--the largest
decrease of any racial or ethnic group in the United States. A Native
baby born in 2021 had a life expectancy of only 65.2 years (Arias et
al., 2022)--the same of that to a baby born in the 1940s (Bastian et
al., 2020). During the pandemic, tribal governments and TECs were
unable to receive information from IHS about COVID-19 cases and
vaccinations that were provided to state and federal agencies. Tribal
governments and TECs were not regularly provided life-saving
information from IHS, other HHS Agencies, or state health departments,
contributing to the significant loss of life from COVID-19 in Native
communities.
Tribes and TECs are routinely denied access to information from IHS
and non-tribal health departments in all areas of health--not just
COVID-19. Nationally, there is currently a rise in sexually transmitted
infections and we are seeing this increase in the GPA. Native babies
are dying of congenital syphilis, a completely preventable disease.
Tribes and TECs have the ability to address this outbreak and protect
the health of Native people, if only we could access current data
regarding cases in our Area. Yet despite a resolution from every tribal
leader in our Area in support of IHS releasing data on STIs to the TEC,
IHS has not provided the requested information as is required by
federal law. Inaction by IHS is hindering the response to the outbreak
and contributing to the spread of disease.
A 2022 GAO report documented the challenges TECs have in accessing
public health data from HHS Agencies (Government Accountability Office,
2022). Despite the report's acknowledgement that HHS not only can, but
is required to provide health information to TECs, a year later HHS has
not provided any new health information to TECs. The Congress can
improve the health of Native people nationwide by ensuring HHS,
including IHS, comply with current federal law and provide Tribes and
TECs access to protected health information that is shared daily with
local and state public health authorities. No new legislation needs to
be enacted. All HHS agencies should immediately stop defying Congress
and release public health data to Tribes and TECs as has been
repeatedly requested. We urge the Committee to confirm that HHS
provides requested data to Tribes and TECs in compliance with the
Indian Health Care Improvement Act and ask the Committee to work
quickly--before one more baby is lost to a preventable disease.
6. Medicaid unwinding: direct CMS to work with states to share data
with Tribes and Tribal organizations regarding American Indian/Alaska
Native (AI/AN) beneficiaries and if possible to delay termination of
benefits for AI/AN beneficiaries to allow Tribal/state coordination of
redetermination efforts for those individuals.
Another area of concern is the hot-button issue of Medicaid
``unwinding'' and the transition out of the Public Health Emergency.
The end of the continuous enrollment requirement has the potential to
cause confusion and loss of services for AI/AN Medicaid beneficiaries,
as well as direct fiscal impact to Tribal health programs. The Medicaid
program is a federal-state partnership, with wide variation in services
and program rules according to the various state plans. That local
variability has resulted in inconsistent and conflicting implementation
of unwinding guidance from state to state in a manner that protects
eligible Tribal members in some states, while quickly severing access
to benefits in others.
For example, Oklahoma takes an ``eligible until you fail to prove
otherwise'' approach by sending four letters to people at risk of
ineligibility with instructions on reasons for possible ineligibility,
instructions for recertification, and access to a helpline. South
Dakota, by contrast, has the opposite policy. Individuals who are high
risk of ineligibility are sent one letter informing them their Medicaid
has been terminated, and giving them the number for the Health
Insurance Marketplace. The GPTLHB is currently working with South
Dakota Medicaid to get contact information for AI/AN enrollees at risk
of ineligibility, so we can assist and coordinate with recertification
efforts, but to date have only received incomplete data on Tribal
member beneficiaries from the state.
We urge the Committee to exercise its oversight role to work with
States, Tribes, and CMS to make sure that unwinding is accomplished
cooperatively and without terminating services to eligible individuals.
For example, we urge the Committee to (a) work to make sure that states
share data on AI/AN enrollment throughout the unwinding process in
order to help our health programs to assist with outreach efforts by
identifying AI/AN Medicaid enrollees, and (b) work with CMS to provide
financing mechanisms to assist in covering the costs that Tribes incur
when working with the state on the unwinding process.
7. Traditional medicine: integrating Native American healing practices
into IHS services.
Traditional Native American healing practices have never been part
of the Indian Health Service. It is a delicate balance to achieve, to
bridge two very different systems of medicine in a respectful,
effective, and patient-centered way. However, research has indicated
that when recommendations on how to integrate traditional Native
healing systems into the IHS system have been led by traditional
healers in our communities, it is possible for one system to enhance
the other, with great benefit to our patients. These integrative
methods have been shown to be both medically effective and cost
effective at treating chronic physical illness, when used in
conjunction with allopathic medicine (Mehl-Madrona, 1999). We strongly
encourage you to direct IHS to work with Tribes at the Service Unit
level to respectfully incorporate traditional cultural practices and
cultural healing into the Indian Health treatment system.
Conclusion
Thank you again for allowing us to present this testimony on the
most important and immediate opportunities for improving healthcare
delivery in the Great Plains Area. While the last few years were
painful and full of loss, at this moment in the Great Plains Area there
is a great deal of forward motion in Indian Health care. Further, only
the first of these seven opportunities requires significant new
appropriations; the rest require mainly shifts in policy, enforcement,
intergovernmental cooperation, and focus. Sometimes what it takes to
improve healthcare delivery is money, but sometimes it is deep
listening to the people most affected by the problem, and changing how
we do things. I encourage you to listen and take action on all of these
priorities and opportunities, so that we can continue moving forward
together.
References
Arias E., Tejada-Vera, B., Kochanek, K.D., Ahamd, F.B. (2022).
Provisional life expectancy estimates for 2021. Vital Stat Rap Rel, 23,
1-16. DOI: https://dx.doi.org/10.15620/cdc:118999.
Bastian, B., Tejada-Vera, B., Arias, E., et al. Mortality trends in the
United States, 1900-2018. National Center for Health Statistics. 2020.
Dept. of Health and Human Services. (2019). The special diabetes
program for Indians: Estimates of Medicare savings. ASPE Issue Brief.
Retrieved from: https://aspe.hhs.gov/sites/default/files/private/pdf/
261741/SDPI_Paper_Final.pdf
Government Accountability Office. (2018). Indian Health Service:
Spending levels and characteristics of IHS and three other federal
health care programs. (GAO Publication No. 19-74R). Washington, DC.:
U.S. Government Printing Office. Retrieved from: https://www.gao.gov/
assets/gao-19-74r.pdf
Government Accountability Office. (2022). Tribal Epidemiology Centers:
HHS actions needed to enhance data access. (GAO Publication No. 22-
104698). Washington, DC.: U.S. Government Printing Office. Retrieved
from: https://www.gao.gov/assets/gao-22-104698.pdf
Indian Health Service. (2020). Special diabetes program for Indians
2020 report to Congress. U.S. Department of Health and Human Services.
Retrieved from: https://www.ihs.gov/sites/newsroom/themes/
responsive2017/display_objects/documents/SDPI
2020Report_to_Congress.pdf
Mehel-Madrona, L.E. (1999). Native American medicine in the treatment
of chronic illness: developing an integrated program and evaluating its
effectiveness. Altern Ther Health Med, 5(1), 36-44.
Office of the Assistant Secretary for Planning and Evaluation. (2022).
How increased funding can advance the mission of the Indian Health
Service to improve health outcomes for American Indians and Alaska
Natives. (Report No. HP-2022-21). U.S. Department of Health and Human
Services. Retrieved from: https://aspe.hhs.gov/sites/default/files/
documents/1b5d32824c31e113a2df43170c45ac15/aspe-ihs-funding-
disparities-report.pdf
*****
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
PURPOSE: To approve supporting the legislation expanding Tribal
Self-Governance in the Department of Health and Human Services
WHEREAS, the Indian Self-Determination and Education Assistance Act
(ISDEAA) authorizes Tribes and Tribal organizations to be funded by the
federal government to provide services that the Federal government
would otherwise be obligated to provide due to the trust and treaty
obligations of the United States; and
WHEREAS, self-determination and self-governance under the ISDEAA have
led to a significant improvement in the daily lives of American Indians
and Alaska Natives; and
WHEREAS, the success of the ISDEAA prompted Congress in 2000 to
establish permanent Tribal Self-Governance in the Indian Health Service
(IHS) in Title V of the ISDEAA; and
WHEREAS, Title V authorizes participating Tribes to redesign IHS
programs, and redirect funds supporting those programs, in any manner
that the Tribes determine is in the best interest of their communities;
and
WHEREAS, in Title VI of the ISDEAA, enacted in 2000, Congress
envisioned expanding Self-Governance to include grant programs
administered by other agencies within the Department of Health and
Human Services (HHS); and
WHEREAS, in 2003, HHS issued a study concluding such an expansion was
feasible and identifying 11 HHS programs that could be integrated into
Self-Governance; and
WHEREAS, in 2004, the Senate considered legislation to authorize a
demonstration project implementing Title VI, but that legislation was
not enacted; and
WHEREAS, expansion of Self-Governance within HHS is the next logical
step to promote tribal sovereignty improve health care services and has
remained a top legislative priority of Tribes; and
WHEREAS, Tribes have drafted legislation, modeled on the 2004 Senate
bill, that would establish a demonstration project expanding Self-
Governance to specified programs administered by non-IHS agencies
within HHS;
NOW, THEREFORE, BE IT RESOLVED that Great Plains Tribal Leaders Health
Board supports the introduction and enactment of legislation
establishing a demonstration project to implement Title VI of the
ISDEAA.
CERTIFICATION
This is to certify that this resolution was adopted by the Great
Plains Tribal Leaders Health Board, (GPTLHB) Board of Directors through
a duly convened meeting held at the March 10, 2022 Board of Director's
Meeting held over Zoom by a vote of:
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Questions Submitted for the Record to Jerilyn LeBeau Church, Great
Plains Tribal Leaders Health Board
Questions Submitted by Representative Westerman
Question 1. How has telehealth improved access to care? Do you have
any information on how that has been different between tribally run
healthcare facilities and Indian Health Service (IHS) run facilities?
1a) What data can you share with the Committee on how telehealth
may have improved access to care?
Answer.
Telehealth is used heavily in tribal communities across
the country, with telehealth visits making up 60 percent to
70 percent of their healthcare services.\1\
---------------------------------------------------------------------------
\1\ Bailey, 2021. Tribal Communities See Benefits and Challenges in
Using Telehealth.
IHS provides specialty services at 19 facilities in the
Great Plains Area including behavioral health, cardiology,
maternal and child health, nephrology, pain management,
pediatric behavioral health, rheumatology, wound care, ear,
nose and throat care, as well as dermatology.\2\ Many of
these specialty care services are provided through
telehealth.
---------------------------------------------------------------------------
\2\ Indian Health Service, 2016. Great Plains Area Tribal Leaders
Briefing Summary & Follow-up.
One study found that for every dollar spent in telehealth,
$11.50 was saved in travel and child-care expenses and
without any decrease in quality. In order to receive
specialty care (which is often unfunded in Indian Health
Service (IHS) facilities), those living on reservations
must travel great distances, as reservations are typically
geographically isolated. One study examining access to
cancer support groups noted that trips often require
between 2 to 5 hours of travel each way, with travel costs
alone ranging from $50 to $200.\3\
---------------------------------------------------------------------------
\3\ Kruse, Clemens, et al, 2016. Telemedicine Use in Rural Native
American Communities in the Era of the ACA: a Systematic Literature
Review.
A study conducted in Nome, for example, found that, prior
to use of telemedicine for audiology and ear, nose, and
throat (ENT) services, 47% of new patients would wait five
months or longer for an in-person ENT appointment. After
the introduction of telemedicine, this rate dropped to 8%
of all patients in the first three years, and less than 3%
of all patients in the next three years.\4\
---------------------------------------------------------------------------
\4\ Hays, Carroll, et al, 2014. The Success of Telehealth Care in
the Indian Health Service.
Attracting and retaining behavioral health professionals
in rural or remote areas is a significant challenge.
Behavioral health providers are typically in short supply
in any community and have numerous employment opportunities
in urban, higher-paying, and more desirable locations. The
telehealth model allows behavioral health professionals to
live where they like and still provide services equivalent
---------------------------------------------------------------------------
to in-person care to high-need, remote communities.
According to the IHS Tele-Behavioral Health Center of
Excellence (TBHCE) the clinical telebehavioral health
program noted that patients are 2.5 times more likely to
keep their telepsychiatry appointments than in-person
psychiatry sessions.4
The TBHCE also found that in fiscal year 2013 the
telebehavioral health program allowed IHS patients to avoid
more than 500,000 miles of travel, which translated into
over $305,000 in savings for them. Since the telebehavioral
health program was available to patients in 2013, these
patients saved more than 16,450 hours of work or school
that would otherwise have been missed to travel for
appointments.4
Question 2. Could you further expand on the challenges the Great
Plains Area is facing regarding workforce shortages for both IHS and
tribally operated facilities.
Answer. First, it is important to note that finding, hiring,
training, credentialing, and retaining sufficient staff to meet the
needs of clients and provide treatment services are all critical
staffing issues.\5\ Without qualified staff and providers, we are
prevented from fulfilling our statutory and ethical obligations to our
patients.
---------------------------------------------------------------------------
\5\ Great Plains Tribal Leaders Health Board, 2020. Tribal
Treatment Services Needs Assessment Report.
Specific workforce challenges currently facing the Great Plains
---------------------------------------------------------------------------
Area include:
An aging workforce at Indian health facilities throughout
the Great Plains Area.
Out-migration of workforce members (people who leave the
workforce and simply stop working) in large part due to a
shift in attitudes regarding work and life brought on by
the COVID-19 pandemic that has led to a decrease in the
available labor pool
Small local labor pool size. For example, the Oyate Health
Center is located in Rapid City, a city of just over 76,000
people. The small populations in our region do not provide
and adequate staffing pool, so facilities in the Great
Plains Area are often forced to recruit from other markets.
Housing shortages. Lack of availability of housing
throughout the region but especially on Reservations, has
made it difficult to recruit qualified individuals from
other areas to the Great Plains Area.
Cost of housing. Again, using the Oyate Health Center as
an example, rising housing costs in the Rapid City region
make it too expensive for younger potential workforce
members to move to the Rapid City area and purchase homes.
Inflation in the wider economy means workforce members
have fewer resources available to move to the Great Plains
Region for work.
Finally, potential applicants have reported procedural
issues such as difficulty understanding job postings, the
posted salary not reflecting the actual wage, or difficulty
contacting hiring officials to obtain an interview.
2a) What are the greatest challenges to maintain an effective
workforce for tribal health programs?
Answer.
Lack of a competitive salary structure. When Tribal health
programs lag in their review of salary structures, and do
not remain competitive, non-Indian facilities will jump at
the opportunity to pry employees away.
Lack of remote or modular work opportunities, which could
be offered when appropriate.
Lack of technology enhancements to increase services.
Technology like telehealth, virtual reality, wearables, AI,
personalized medicine, and smart clinic management, if done
correctly, could lead to expanded services. The resulting
revenue could then be used to employ the correct size
workforce.
Lack of Congressional appropriations sufficient to meet
federal treaty and trust obligations to tribes. Because of
persistent underfunding, Tribal health programs are left
without the required capital to employ an appropriately
sized workforce and enhance or modernize services. As noted
in Jerilyn LeBeau's testimony, contract support costs and
105(l) lease payments, as well as all IHS funding, should
be made mandatory with a priority for contract support
costs and 105(l) lease payment funding.
The system for recruitment and retention, especially in
IHS facilities, is archaic and does not keep pace with
modern job flexibility, benefits, and salaries that are
offered in private clinics or hospitals, thus making it
extremely hard to compete.
2b) Are there any tribally led efforts on recruitment and retention
that IHS can learn from or institute?
Answer.
IHS could do a lot more with creating formalized and
intentional training opportunities that create labor pool
pipelines between universities, colleges, trade schools,
tribal colleges, job corps, and other organizations whose
mission is to educate and train young and older adults to
enter or re-enter the workforce.
IHS could establish adult vocational education training
programs that occur on an annual, bi-annual or quarterly
basis inviting people interested in healthcare
opportunities to get introduced to health care professions
in a hands-on learning methodology where participants would
gain experience working at Tribally managed facilities.
More IHS funding could be allocated to recruit new
graduates to work in Indian health organizations, while
creating agreements with Tribally managed facilities to
create employment opportunities for new graduates. Then new
providers, especially nurses, could receive training and
grow to be skilled caregivers in a culturally appropriate
environment. We rely too much on hiring experienced nurses;
an understanding that new graduates can be developed in the
first stages of their career at a Tribal organization.
These post-graduate programs would take more investment in
the form of time and training up-front; but investing in
new graduates could result in more individuals deciding to
commit to a career in Tribal communities.
Currently, recent graduates interested in working in Indian
healthcare are too often turned away for lack of an
effective preceptor program in Tribal health organizations.
Question 3. Can you further expand on your testimony about staffing
at Great Plains IHS facilities, and what improvements in recruiting and
retention will not only improve care, but eventually be cost effective.
Answer. As mentioned above, an updated wage structure with
competitive pay is the first fundamental step to attracting qualified
employees. While there are still altruistic individuals who want to
work in Indian Country for less than they can earn in the for-profit
world, reliance on such individuals is not a successful or sustainable
recruitment strategy. Indian healthcare facilities need to offer
competitive and rewarding job opportunities that mirror the for-profit
healthcare world around us. Recruitment efforts should also include
longevity strategies, including pensions, housing, flexible schedules,
and training opportunities for licensing. IHS hiring procedures,
including facility certification processes, need to be streamlined to
get good candidates hired quickly, and creative, clear, and broad
advertisement strategies would reach a larger candidate pool.
IHS recruitment and retention plans should reflect a sincere
recognition that workforce needs and realities have changed, or we will
see greater and greater challenges at filling our open positions.
3a) Would a stand up of the Community Health Aide Program (CHAP),
that currently operates in Alaska and was mentioned in Ms. Platero's
testimony be useful to meeting those staffing challenges?
Answer. Yes, provided it is implemented effectively. The most
successful implementation of the CHAP program has occurred in Alaska;
the program there has existed since the early 1970s. Implementing the
CHAP program outside Alaska will require recognition that the nurse,
mid-level practitioner, and physician approach to health care is not
all encompassing and the CHAP's (paraprofessional level health care
providers) can and should be allowed to practice a certain level of
medicine, especially in smaller Tribal or remote communities.
It would also require establishing a multi-year training program
based on the Alaska model, accompanied by the appropriate funding to
support trainees through their training. Essentially, the plan requires
paying CHAP candidates throughout the training period, with a pay-back
provision once the new CHAPs are working in their home, rural and/or
Tribal. As this is already a proven program in the Alaska Area, we can
list the keys to a successful CHAP program:
Tribal community support
American Medical Association support
Local, regional, and statewide legislative support
Fiscal support
3b) What other creative possibilities exist that tribal
organizations and IHS could implement?
Answer. No response provided.
Question 4. The Subcommittee has heard from many different tribes
that the Purchased/Referred Care (PRC) program has several challenges:
4a) Can you describe some of the issues you have heard about within
the Great Plains region and what challenges are your tribal members
facing when dealing with the PRC program?
Answer.
PRC Eligibility Rules: Residency
The PRC program eligibility rules and procedure are
confusing to most patients. To be eligible for PRC, a
patient needs to reside within the CHSDA (Contract Health
Service Delivery Area) for that Service Unit. Acronyms such
as CHSDA do not help matters, but the basic problem is that
any eligible Indian can receive services at an IHS-funded
facility, but only those who reside in a certain territory
can be referred out for specialty care. Eligibility for
Purchased and Referred Care is dependent on residency.
The residency rule is inconsistent in that the CHSDA in
some IHS Areas only covers certain counties, whereas in
other IHS Areas, the CHSDA is the entire state. Oklahoma
and Nevada are examples of state PRC coverage, whereas in
South Dakota, only residents of Pennington County are
eligible for PRC at the Oyate Health Center in Rapid City,
while residents of neighboring counties can receive care at
the Oyate Health Center, but cannot be referred out to a
cardiologist, for example.
Further, certain PRC programs only cover the enrolled
members of that Tribe, and not other Tribes. For example,
the Cheyenne River IHS Service Unit CHSDA includes the two
reservation counties plus the adjacent Meade County. All
members of federally recognized Tribes who reside on the
two reservation counties are eligible for both services at
the Cheyenne River IHS Hospital and the hospital's PRC
program. But while all members of federally recognized
Tribes who reside in adjacent Meade County may receive
services at the Cheyenne River IHS Hospital, only Cheyenne
River Sioux Tribal members in Meade County are eligible for
the PRC program. An Oglala Sioux Tribal member residing in
Meade County and receiving care at the Cheyenne River IHS
Hospital would have to pay for their own specialty care or
give up that care, unless they could prove a ``close social
and economic tie'' to the Tribe. IHS and tribal PRC
programs have wide discretion to interpret this phrase, and
there is variation.
Then again, some PRC programs choose to set a period of
time the Tribal member has to reside within the CHSDA to
establish eligibility for the PRC program, and those time
periods, usually 30, 60, or 90 days, were inconsistent from
facility to facility.
The rules for residency that establish eligibility for the PRC
program are so complex that often staff at the Indian healthcare
facility get it wrong. Along with the need for patient education on
PRC, this puts an additional burden on ongoing staff training
protocols, keeping employees up to date on an unnecessarily complex and
contradictory set of rules.
Rather than attempting to educate every Tribal member and employee
on this complex and limiting eligibility system, it would be much
simpler, more consistent, and fair to simply expand PRC eligibility to
any eligible Indian patient receiving services through that facility
and to provide sufficient funding for such expanded care.
PRC Eligibility Rules: Notification
72 hour/30 day notification rule \6\
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\6\ 25 U.S.C. Sec. 1646 Authorization for emergency contract health
services, Indian Health Care Improvement Act of 1996 (Pub. L. 94-437,
title IV, Sec. 406, as added Pub. L. 102-573, title IV, Sec. 405, Oct.
29, 1992, 106 Stat. 4566) and 42 CFR Sec. 136.24, Authorization for
contract health services.
If a Tribal member receives emergency health services outside of an
IHS or Tribal facility, they must notify their home facility within 72
hours, or for elderly or disabled patients, within 30 days. There are
---------------------------------------------------------------------------
several problems with implementation of this rule.
First, facilities may not follow the 72-hour rule if that
particular facility did not receive notice through the PRC program.
While some IHS facilities consider notification to anyone in the IHS
facility as notification of an Emergency Room (ER) visit, other
facilities require that the patient notify ``PRC and PRC only.'' This
is inconsistent and places an improper requirement on the language of
25 U.S.C. Sec. 1646 and 42 CFR Sec. 136.24.
There are also inconsistent implementation issues within single IHS
facilities. For example, if a patient notifies the IHS facility of an
unscheduled non-IHS ER visit, some nursing staff will log a `telephone
encounter,' while others will not. If this becomes the key issue on
whether IHS allows or refuse to authorize PRC Program funds for that
patient, the PRC system becomes unacceptably capricious.
PRC Procedure
The effectiveness of the PRC Program can be hampered by a
lack of specialty providers locally. For example, there is
only one private health care facility in Rapid City
offering Gastroenterology (GI) services. Limited
availability for services like GI and Neurology leads to
long wait times--measured in months--for scheduling
appointments. Better availability of telehealth in
specialty areas could help with this issue.
Lack of notification to the patient and/or Tribal facility
when PRC bills are paid. IHS has contracted with Blue Cross
Blue Shield (BCBS) of New Mexico to pay PRC bills, but they
often do not notify patients when their PRC bills are paid.
Tribal PRC programs also experience difficulties with
communications with this IHS vendor.
Communication and appeals of PRC denials. The denial
letter generated in the IHS Resource and Patient Management
System (RPMS)/Contract Health Services Management System
(CHS-MS) software package is not patient friendly. Patients
cannot review and understand the denial letter, which
creates a challenge for them to understand their rights to
appeal the denial in a timely manner.
PRC health service request deferrals. As you know,
budgetary limitations on PRC dollars have led to IHS
implementing a ranking system where PRC service requests
are categorized into levels of descending priority 1-5, a
system which many Tribal health facilities inherited and
still implement. While PRC committees try to approve as
many levels as possible, and while most Level 1 requests
will be approved, PRC requests at levels 2-5 of urgency are
often deferred, sometimes temporarily, and sometimes
indefinitely. It is easy to forget that every request for
PRC services is made by a provider, reviewed by a care team
or doctor, and is medically necessary. If the PRC budget
had adequate funding to cover all PRC service requests, the
level system of deferrals and denials would not be
necessary. Many if not all of the problems with the PRC
program could be resolved by adequate program funding.
4b) And what suggestions or recommendations would you provide to
the Committee to make that process better?
Answer.
Staff and patient training on the PRC program should be
done at each level of the IHS/Tribal/Urban facility. This
includes the patient registration area, clinic rooms,
urgent care, primary care, emergency room staff as well as
all support staff. PRC eligibility and rules should be
discussed and reviewed at staff meetings. Medical providers
and nursing staff should have a thorough enough
understanding of the PRC program to answer patient
questions and guide them through the process with a solid
understanding of the eligibility requirements.
Staff and patients should be trained on residency
eligibility specific to the CHSDA for that facility and any
facility-specific rules regarding which patients are
eligible for PRC and which are not.
There should be national guidance regarding what
constitutes adequate notification to the facility under the
PRC 72-hour/30-day notification rule. This would reduce
inconsistency both nationally and within individual IHS
facilities.
To address the availability of specialty providers for PRC
services, Indian health facilities could contract with
providers to conduct clinics onsite at the facility,
reducing the need for PRC funding to be used for specialty
care. This onsite direct care could include telehealth
services.
IHS PRC programs should be required to send written notice
to patients when their PRC bill has been paid. Oyate Health
Center (OHC) does this, but to the best of our knowledge,
the federal sites do not.
PRC programs should be required meet with each PRC service
vendor in their service area and report on these meetings
to their Tribe or Tribes. Vendors need to understand the
PRC process, know the contact for that vendor in the PRC
program staff, and know that they will receive payment in a
timely manner.
The IHS RPMS/CHS-MS automatically generated denial letter
needs to be scrapped and rewritten in a way that each
patient understands what the facility needs from them to
approve their PRC referral, for example proof of residency,
whether their referral was deferred or denied and for what
reason, and their appeal rights. The status of their
request, who to contact with any questions, and how to
contact them should be crystal clear.
Question 5. Your testimony and the hearing discussed how the
Department of Health and Human Services (HHS) is not sharing public
health data with Tribal Epidemiology Centers.
5a) Is there any further information you believe the Subcommittee
should have regarding this issue?
Answer. HHS is in violation of federal law regarding data sharing
with Tribal Epidemiology Centers (TECs). We are not expecting that IHS
will respond to the Government Accountability Office (GAO) report with
expanded access to IHS data. Congress needs to hold HHS and HHS
agencies accountable for the lack of data provided to TECs. In some
sense, this is an easy fix. No law needs to be changed and no new law
needs to be passed. HHS simply needs to follow existing federal law
which clearly states that TECs are to be given access to any and all
data that is held by the HHS Secretary. We refer the subcommittee to
the work of the National Committee on Vital and Health Statistics which
recently made five additional recommendations to the Secretary of
Health and Human Services regarding sharing of data, primarily from the
CDC and IHS, with Tribes and TECs.\7\ These recommendations are in
addition to the recommendations made in the March 2022 GAO Report
regarding data sharing with TECs,\8\ and the similarly-themed July 2022
Report by the HHS Office of the Inspector General.\91\
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\7\ https://ncvhs.hhs.gov/wp-content/uploads/2022/12/NCVHS-Tribal-
Data-Recommendations-12-12-final-w-review-508.pdf
\8\ https://www.gao.gov/products/gao-22-104698
\9\ https://oig.hhs.gov/oei/reports/OEI-05-20-00540.asp
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5b) Are you aware of any changes that have happened or are in the
works at IHS or HHS on their data sharing policies?
Answer. HHS, IHS, and Centers for Disease Control and Prevention
(CDC) are developing their responses to the March 2022 GAO report
regarding data sharing with TECs. CDC created a ``Tribal Data'' page,
and their response has been marked as ``Closed--Implemented'' by the
GAO. HHS and CDC have not yet fulfilled the recommendations of the GAO
and they remain open. These responses are currently being developed and
will be released at some point. Outside of the responses to the GAO
report, we are unaware of any other changes that have been made or are
in progress related to data sharing policies at HHS.
Question 6. Can you provide the Committee with information about
facility construction in the Great Plains area, specifically how the
lack of new IHS facilities has impacted delivery of healthcare for
tribes in your area?
6a) Given the significant amount of federal funds that have been
allocated to IHS's priority list in the past two years, what
recommendations do you have to Congress and IHS to approach facility
construction needs in the future to ensure federal funds are pushed out
expeditiously?
Answer. While we are appreciative of increased funding for facility
construction, and the very real opportunities to improve both care and
outcomes as a new facility opens, the following issues continue to
stymy federal construction efforts for Indian healthcare facilities.
Funding-related construction delays.
Some Indian health facilities were built with funds allocated under
the American Recovery and Reinvestment Act (ARRA). These buildings were
``fully funded,'' meaning the total construction dollars were released
in one distribution, allowing the facility to be completed on a regular
commercial timeline. Normally, IHS construction projects are not fully
funded, they are ``phase funded.'' This means the project is divided
into phases and funding is distributed one phase at a time. This often
results in construction delays and complications, especially when the
federal government's annual budget is delayed and funded by a series of
continuing resolutions. Fully funding IHS construction projects instead
of phase funding them would help push those funds out in an expeditious
manner.
Tribal control over the initial process and building design.
Another change which would both expedite construction and result in
more patient centered and culturally appropriate buildings would be to
ensure IHS gives Tribes the opportunity, consistent self-determination
regulations, to assume the authority for the pre-planning, planning and
design of construction projects, including through the use of their own
architecture and engineering (A/E) firm. Construction projects which
are fully funded and where the Tribe controls the design, such as the
IHS Hospital in Eagle Butte which was completed in 2012, produce a
better result than the traditional IHS construction process. IHS needs
to ensure that it complies with its own regulations and provides tribes
such opportunities with respect to all construction funding. A
requirement that IHS document that it has provided an adequate
opportunity for each Tribe impacted by the new construction funding to
assuming the preplanning, planning, design and construction and that it
has obtain an affirmative statement from the tribal governing body that
it has declined the opportunity. This should involve an informational
presentation at each stage of the project's development to the proper
tribal officials of the pros and cons of assuming the project
responsibilities.
Other considerations in the construction process.
Even if Congress completely funded the existing IHS facilities need
tomorrow, IHS's construction and engineering programs do not have the
capacity to construct that many facilities in a timely fashion.
Enhancing capacity in those departments, or creating a scalable project
management model in IHS's construction management program, would help
IHS respond to increased Congressional funding for these badly needed
projects.
In summary, the following points could help Congressional funds
allocated for new IHS facility construction be put to use more quickly
and effectively:
Full funding each IHS construction project, instead of
phase funding
Including sufficient money for staffing and operations, in
particular adequate Maintenance and Improvement (M&I)
funding for each new facility, in the staffing package for
that building.
Formalizing Tribal authority in the design and initial
document process, including use of the Tribe's A/E firm.
Questions Submitted by Representative Leger Fernandez
Question 1. Could you share more on the anticipated impacts and
loss of services that wouldoccur if the FY24 enacted congressional
budget reflects FY22 enacted levels for theIndian Health Service (IHS)?
Answer. No response provided.
______
Ms. Hageman. I thank the witness for their testimony.
The Chair now recognizes Ms. Laura Platero for 5 minutes.
STATEMENT OF LAURA PLATERO, EXECUTIVE DIRECTOR, NORTHWEST
PORTLAND AREA INDIAN HEALTH BOARD, PORTLAND, OREGON
Ms. Platero. Good morning, Chair Hageman, Ranking Member
Leger Fernandez, and members of the Subcommittee. I appreciate
this opportunity to testify today.
My name is Laura Platero, and I am a citizen of the Navajo
Nation and serve as Executive Director of the Northwest
Portland Area Indian Health Board.
The Northwest Portland Area Indian Health Board is a tribal
organization under the Indian Self-Determination Education
Assistance Act, also known as ISDEAA, serving the 43 federally
recognized tribes of Idaho, Oregon, and Washington.
We also operate the Northwest Tribal Epidemiology Center,
one of 12 across Indian Country, which are public health
authorities under the Indian Healthcare Improvement Act.
Epi Centers collect and protect tribal data, evaluate
health outcomes of programs, and assist with public health
response, among many other core functions.
In the Northwest, American Indians and Alaska Native people
face significant health disparities compared to other
populations. Like all under resourced communities, they are
vulnerable to chronic diseases, such as heart disease,
diabetes, substance misuse and overdose, and experience higher
numbers of unintentional injuries and violence.
Fentanyl overdoses are currently a serious concern in many
Northwest tribal communities. This is why we are organizing a
national tribal opioid summit later this year. These
significant health disparities in large part are due to
historical and ongoing funding shortfalls.
In this regard, this Committee inherits the legacy of the
Federal Government not fulfilling trust and treaty obligations
to Tribal Nations. Tribal Nations were promised healthcare for
their people. It must be high quality and comprehensive care to
ensure that our future generations are healthy and thriving.
More improvements today will also result in reduced
disparities and costs down the road. Honoring the promises to
Tribal Nations must be at the forefront of this Subcommittee.
Despite gaps in healthcare and limited funding, tribal
communities have been innovative in addressing their community
health needs. This would not be possible without ISDEAA
contracts and compacts.
These contracts and compacts have upheld tribal sovereignty
and given tribes the resources to control and develop
innovative health programs that meet the needs of their
community in a culturally responsive way.
These programs also maximize dollars by reducing IHS
administrative costs to run the program at the local and area
level, more dollars are allocated to tribal health programs.
This allows programs to increase services and providers and
increase access to care.
While American Indian and Alaskan Native people were
disproportionately impacted by COVID-19, due to underlying
health disparities and the lack of infrastructure in many
communities, tribal innovation in response to COVID prevailed.
When tribes are given the resources and control of those
resources, they know how to respond to meet the needs of their
community. Many tribes received funds in their ISDEAA contracts
and compacts and were able to quickly roll out COVID-19
vaccinations to not only their own community members, but their
surrounding non-Native communities.
They also had the flexibility to rapidly stand up community
testing sites, vaccination sites, conduct case investigations,
and provide treatments for COVID-19.
COVID-19 clearly shows us that self-determination and self-
governance works. We request that this Subcommittee support
expansion of ISDEAA compacts and contracts across HHS and its
agencies.
For ISDEAA, tribal health programs, contract support costs,
and 105(l) leases are critical to support operation of these
programs. Our Northwest tribes request that contract support
costs and 105(l) lease funds be provided through mandatory
appropriations.
We also ask this Subcommittee to swiftly enact H.R. 409,
the IHS Contract Cost Support Cost Amendment Act to protect
contract support cost payments.
Another important ask of Northwest tribes is related to
workforce. Given the remote location of many tribal
communities, IHS and tribal health programs find it hard to
recruit and retain providers.
Fortunately, Tribal Health Programs, through their ISDEAA
contracts and compacts, have found ways to address staffing
needs, for example, to address behavioral health provider
needs, programs have been able to contract with psychiatrists
to provide tele-psychiatry services. Tele-health flexibilities
have allowed tribal health providers to expand their services
and reduce no-show rates.
We need tele-health to remain permanent. Another innovative
way tribes are addressing staffing needs is through the
Community Health Aid Program. This program is creating mid-
level providers across tribal health programs for dental,
behavioral health, and medical services.
Northwest tribes have been very resourceful in standing up
three education programs and a CHAP certification board with
minimal IHS funds. We now need additional funding to maintain
and grow this program in the Northwest.
We have also included a number of Medicaid and Medicare
legislative initiatives that this Subcommittee should consider
in our written testimony to expand health services and staffing
in the Northwest.
I thank the Committee for this opportunity to testify. We
invite you to attend our opioid summit in August, August 22 and
24 in Tulalip, Washington.
[The prepared statement of Ms. Platero follows:]
Prepared Statement of Laura Platero, The Northwest Portland Area Indian
Health Board
Chair Hageman and Ranking Member Fernandez, and Members of the
Subcommittee, I appreciate the opportunity to present this testimony on
``Challenges and Opportunities for Improving Healthcare Delivery in
Tribal Communities.''
My name is Laura Platero, and I serve as the Executive Director of
the Northwest Portland Area Indian Health Board (NPAIHB or Board).
NPAIHB was established in 1972 and is a tribal organization under the
Indian Self-Determination and Education Assistance Act (ISDEAA), P.L.
93-638. The Board advocates on specific health care issues in support
of the 43 federally-recognized Indian tribes in Idaho, Oregon, and
Washington (Northwest or Portland Area). The Board's mission is to
eliminate health disparities and improve the quality of life for
American Indians and Alaska Natives (AI/AN) by supporting Northwest
Tribes in the delivery of culturally-appropriate, high-quality health
care. ``Wellness for the seventh generation'' is the Board's vision. We
thank the Subcommittee for their continued support in improving the
delivery of healthcare services in Indian Country.
I provide the following testimony to address opportunities and
challenges for improving healthcare delivery in the Northwest:
Northwest Tribes have been strong advocates in requesting that the
federal government uphold trust and treaty obligations to Tribal
Nations, including full funding for the Indian Health Service (IHS).
They are also known for their long history in IDSEAA Self-Determination
contracting and Self-Governance compacting. There are 13 ISDEAA Title I
Contract Tribes, 25 ISDEAA Title V Compact Tribes, five federally
operated IHS facilities and three urban Indian facilities. In the
Portland Area, there are 200,000 AI/AN users \1\ of the Indian health
system. There are no IHS or tribally-operated hospitals in the Portland
Area. The lack of an IHS or tribally-operated hospital limits AI/AN
people's access to the breadth of inpatient care and specialty services
provided by hospitals. To fill this gap in services, tribal health
programs purchase all in-patient and specialty care not provided in
their outpatient clinics with IHS Purchased and Referred Care (PRC)
dollars. In 2025, IHS, with the Portland Area Tribes Facilities
Advisory Committee (PAFAC), will stand up the first Regional Specialty
Referral Center (``Center'') in the Indian health system, a specialty
outpatient care facility in Puyallup, Washington. Two more Centers in
other parts of the Portland Area will ensure outpatient access to care
across the region. No funding has been allocated for the two additional
Centers yet.
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\1\ In the Portland Area Indian Health Service system, there are
approximately 218,000 users registered, with 114,000 active users.
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Health Disparities, COVID-19, and Tribal Innovation in the Northwest
Like AI/AN people across Indian Country, AI/ANs in the Northwest
experience significant health disparities when compared to other
populations. They have a life expectancy that is about 7 years lower
than that of non-Hispanic Whites (NHW). They also experience
disparities at all stages of life and are particularly vulnerable to
chronic diseases such as heart disease and diabetes, injuries,
violence, substance misuse and overdoses. In the past year, there has
been an alarming increase in Fentanyl overdoses in Northwest Tribal
communities. AI/AN people in the Northwest are also less likely to have
health care coverage and access compared to their NHW counterparts
which, in part, explains the low rates of preventative health care
services accessed by AI/AN people. Chronic health disparities \2\ and
lack of access to care, resulted in COVID-19 disproportionately
impacting AI/AN people. AI/AN people had significantly higher rates of
COVID-19 cases (3.5x),\3\ hospitalizations (5.3x), and deaths (1.8x)
\4\ than non-Hispanic Whites.
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\2\ Chronic health disparities among AI/AN people is the result of
significant underfunding of the Indian Health Service. U.S. Comm'n On
Civil Rights, Broken Promises: Continuing Federal Funding Shortfall For
Native Americans At 19 (2018) available at https://www.usccr.gov/pubs/
2018/12-20-Broken-Promises.pdf.
\3\ Hatcher SM, Agnew-Brune C, Anderson M, et al. COVID-19 among
American Indian and Alaska Native persons--23 states, January 31-July
3, 2020. MMWR Morb Mortal Wkly Rep 2020; 69:1166-9.
\4\ Arrazola J, Masiello MM, Joshi S, et al. COVID-19 Mortality
Among American Indian and Alaska Native Persons--14 States, January-
June 2020. MMWR Morb Mortal Wkly Rep 2020; 69:1853-1856. DOI: http://
dx.doi.org/10.15585/mmwr.mm6949a3
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While COVID-19 was devastating to many Tribal communities, it also
highlighted the resilience and innovation of Tribal communities to
respond to the pandemic. When Tribes have adequate resources and
control of those resources, Tribes know how to respond to public health
emergencies and to address the healthcare needs of their community
members. For example, Tribes were successful in quickly rolling out
COVID-19 vaccinations in their communities. AI/AN people were the most
vaccinated ethnic and racial group in the U.S. early in the pandemic.
Many Northwest Tribes also provided vaccines to non-Natives in and
around their communities.
Based on this experience, NPAIHB recommends that the Subcommittee:
Expand the use of ISDEAA Self-Determination contracts and Self-
Governance compacts.
Northwest Tribes have had long-standing requests to the IHS and HHS
to move away from grant funding and allow tribes the option to receive
funds through their contracts and compacts. Self-determination and
Self-governance contracts and compacts honor tribal sovereignty and the
government-to-government relationship. IHS continues to provide funding
through grant programs, such as the Special Diabetes Program for
Indians and several IHS Behavioral Health grant initiatives. Grant
programs result in IHS administrative costs to operate the grant
program and reduce funds to tribes. This Subcommittee must support an
option for tribally-operated facilities to receive grant funds through
their ISDEAA contracts and compacts.
In addition, during the pandemic, HHS agencies allocated funding to
IHS that was distributed to tribes through existing formulas and ISDEAA
contracts and compacts (e.g., Centers for Disease Control and
Prevention). This process successfully allowed tribes to receive funds
quickly from CDC and to use those funds to best meet the needs in their
communities. All HHS funding should be allocated to Tribes through this
mechanism. This Subcommittee must support legislation expanding ISDEAA
contracting and compacting to HHS and its agencies.
Maintain advance appropriations.
IHS was provided advanced appropriations for the first time in
Fiscal Year 2024. This is essential to ensure that the IHS has stable
funding year after year to shield our tribal health programs from
potential government shutdowns and continuing resolutions. Tribal
health programs cannot budget for future years and plan for expansion
of services without stable funding year after year. We thank members
for supporting advance appropriations that was included in the
Consolidated Appropriations Act, 2023.
Support mandatory funding for Contract Support Costs and ISDEAA 105(l)
Leases.
Mandatory appropriations is needed for contract support costs (CSC)
and the ISDEAA 105(l) leasing program to ensure that discretionary
appropriations for other IHS subaccounts are not impacted by the
growing costs of these programs. If CSC and 105(l) programs do not
receive mandatory appropriations, IHS program increases, medical
inflation and population growth will continue to be underfunded and
result in increased health disparities and increased chronic healthcare
needs.
Create workforce opportunities through the Community Health Aide
Program.
The Community Health Aide Program (CHAP) is a program that was
designed and implemented by the Alaska Native Health system over 60
years ago. In nationalizing it to the rest of the country, tribes
everywhere have an important opportunity to tackle social determinants
of health while improving healthcare workforce and retention. CHAP is
unique because it not only increases access to care but creates access
points to health education so that tribal citizens can become health
care providers with professional wage jobs on reservations and in
tribal health programs throughout the country; thus, addressing poverty
and supporting economic viability in Tribal communities. The education
programs associated with CHAP are the foundation of the program.
In the Northwest, we have established a Dental Therapy Education
Program, two Behavioral Health Aide Education Program, and are in the
process of developing the Community Health Aide Education programs. We
have also worked with the Portland Area IHS Office to standup a CHAP
Certification Board to certify our Portland Area CHAP providers.
Approval of the certification process is in process. Portland Area
Tribes and NPAIHB have been innovative and creative in securing funding
for CHAP expansion despite only receiving one IHS grant of $1 million
(of the $20 million appropriated to IHS for the expansion of CHAP in
the lower 48). This Subcommittee must consider this crucial opportunity
to address workforce shortages in Tribal communities.
Consider innovative approaches to address facility construction needs.
At the current rate of appropriations for construction and the
facility replacement timeline, a new 2021 facility would not be
replaced for 290 years. Many tribes and tribal organizations in the
Northwest have assumed substantial debt to build or renovate clinics
for AI/AN people to receive IHS-funded health care. This Subcommittee
should consider opportunities to utilize the demonstration authority
under the Indian Health Care Improvement Act to provide flexible funds
to Tribes to address unmet construction needs for health facilities.
Reauthorize and increase funding for Special Diabetes Program for
Indians (SDPI).
Diabetes impacts AI/AN people at significantly higher rates.
Nationally, 8.2% of the population has diabetes (all populations, over
18 years old) \5\ compared to 14.7% of AI/AN people across the country
with diabetes. This is significantly higher than any other national
demographic, with Hispanic people the next highest at 12.5%. COVID-19
continues to be a threat to our diabetic patient populations. Recent
data shows that there are higher rates of long COVID in people with
diabetes and an increased risk of diabetes with individuals with long
COVID.\6\
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\5\ National Diabetes Statistics Report 2020, Estimates of Diabetes
and its Burden in the United States. Centers for Disease Control and
Prevention.
\6\ See Raveendran AV, Misra A. Post COVID-19 Syndrome (``Long
COVID'') and Diabetes: Challenges in Diagnosis and Management. Diabetes
Metab Syndr. 2021 September-October; 15(5): 102235. https://doi.org/
10.1016/j.dsx.2021.102235
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Congress reauthorized the SDPI program at $150 million per fiscal
year until Fiscal Year 2023.\7\ SDPI funding has remained stagnant at
$150 million and has not increased in pace with inflation and
population growth. This program has been successful in creating
positive health outcomes that reduce costly care for more chronic
conditions and hospitalizations. We request that this Subcommittee
reauthorize SDPI at $250 million for FY 2024, exempting the program
from mandatory sequestration, and increase the funding to $260 million
in FY 2025 and $270 million in FY 2026 in order to expand our diabetes
programs. Lastly, this Subcommittee should consider creating an option
for tribes to receive SDPI funds through their ISDEAA contracts and
compacts.
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\7\ See Consolidated Approps. Act 2021, Pub. L. No. 116-260, 134
stat. 2923 (2020).
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Provide Health IT Modernization funds to reimburse tribes.
The Resource and Patient Management System (RPMS) is now a legacy
system and is inconsistent with emerging architectural electronic
health record (EHR) standards. NPAIHB recognizes that the Veterans
Administration's (VA) decision to move to a new Health Information
Technology solution will create a gap for the parts of RPMS that are
dependent on core coding from the VA. RPMS cannot meet these evolving
needs without substantial investment in IT infrastructure and software.
COVID-19 has really highlighted the challenges with RPMS and has
required double entries of data for reporting purposes. Many Tribes
have had to use their own revenues and incur substantial debt to
purchase electronic health record systems to interface with local
hospital systems to improve patient care. However, since IHS has been
appropriated hundreds of millions of dollars in recurring and one-time
funding for EHR, Tribes have not received any funding to support Tribal
health IT investments. This Subcommittee must support IT modernization
efforts with priority for Tribes that have purchased commercial off the
shelf systems.
Support Access to Care Factor in Purchased and Referred Care
Allocations.
The PRC program makes up over one-third of the Portland Area budget
because we have no IHS or tribally-operated hospital. Year after year,
PRC receives nominal increases often less than 1% despite this being
the second rated priority of the National Tribal Budget Formulation
Workgroup every year. Areas with IHS hospitals can absorb these costs
more easily because of their infrastructure and large staffing
packages.
When there are increases to the PRC budget, the Portland Area
Tribes receive additional funding to account for the lack of an IHS/
Tribal hospital in the Area, often referred to as the access to care
factor. However, Congress through the IHS budget has only ever funded
this access to care factor three times in the past 12 years--in FY
2010, 2012, and 2014. Without year-to-year increases to PRC to fund the
access to care factor, inpatient care for Portland Area Tribes goes
severely underfunded. We request this Subcommittee support annual
funding for the access to care factor.
H.R. 409--IHS Contract Support Cost (CSC) Amendment Act
The federal appeals court decision in Cook Inlet v. Dotomain that
decided tribal overhead costs are disqualified from being reimbursed if
the IHS would ``normally'' incur that same cost in running the
contracted programs undermines the long-standing understanding of the
ISDEAA. The Northwest Tribes have been relentless advocates for Tribal
Self-Determination and Self-Governance Title I and Title V contracts
and compacts. However, the Cook Inlet decision can destabilize our
tribal health program operations and threaten our Tribal Self-
Determination and Self-Governance to provide health care to our people
by significantly reducing our contract support cost recovery.
In Fort Defiance Indian Health Board v. Becerra, 604 F.Supp.3d 118
(D. NM 2022), IHS cut a tribal contractor's Contract Support Cost (CSC)
FY 2022 payments by 95% or nearly $17 million arguing that historic
overpayment has occurred relying on the Cook Inlet decision. Although
Fort Defiance has been settled, there still remains an urgency to
swiftly enact H.R. 409 to reverse the Cook Inlet decision. The
Northwest Tribes are concerned that IHS will not fully reimburse tribes
for their CSC payments and assert claims for past payments just as the
agency has done in the Fort Defiance case. We urge the Subcommittee to
swiftly enact H.R. 409 to reverse Cook Inlet and restore the long-
standing interpretation of the Indian Self-Determination Act related to
CSC payments.
Opioid Epidemic
The Northwest Tribes are facing an alarming opioid and Fentanyl
epidemic that is disproportionately affecting Indian Country. The rate
of illicit drug use for AI/AN's use is nearly twice as high compared to
the rate for non-Hispanic Whites in the U.S. Recently, from 2020 to
2021, AI/ANs experienced a 33.8% increase in all drug overdose deaths
compared to a 14.5% increase among the total U.S. population for the
same period.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
.epsThe Northwest Tribes need increased funding to address the
opioid epidemic through self-governance and self-determination compacts
and contracts. The IHS Special Behavioral Health grants and SAMHSA
Tribal Opioid Response grants are difficult to access with the many
administrative requirements of applying for and receiving grant
funding. Grants do not provide administrative flexibility to allow the
Tribes to establish programs that meet the needs of their own
communities. Many tribes do not have grant specialists and the grant
programs make tribes compete with each other for limited resources.
This Subcommittee should consider ways to provide funding for
behavioral health and opioid response through their contracts and
compacts to address this growing opioid crisis in Indian Country.
The Northwest Portland Area Indian Health Board will be hosting a
National Tribal Opioid Summit at the Tulalip Tribes, Washington on
August 22-24, 2023. We invite the Subcommittee Members to come together
in partnership with tribes to have meaningful discussions across
Federal, regional, and state decision-makers to address this epidemic.
Medicare and Medicaid
Medicaid and Medicare third party reimbursements are vital sources
of revenue for the sustainability of tribal health programs. Tribal
health programs continue to face barriers in recovering these third-
party reimbursements to their full capacity despite federal law
authorizing reimbursement. Some of these challenges include managed
care plans inappropriately reimbursing tribal health programs, states
that have not expanded Medicaid under the Affordable Care Act, lack of
partnership between state and tribal health programs on eligibility.
These challenges have resulted in high rates of uninsured AI/AN people.
According to recent data, AI/AN adults had the highest rate of
uninsured than any other race -25% of AI/AN nonelderly adults are
uninsured.\8\
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\8\ Samantha Artiga, Kendal Orgera, & Anthony Damico, Changes in
Health Coverage by Race and Ethnicity since the ACA, 2010-2018, Henry
J. Kaiser Family Found. (Mar. 5, 2020), https://www.kff.org/racial-
equity-and-health-policy/issue-brief/changes-in-health-coverage-by-
race-and-ethnicity-since-the-aca-2010-2018/
NPAIHB makes the following legislative requests related to Medicaid
and Medicare:
Make permanent Medicare reimbursement for telehealth for tribal health
programs.
The NPAIHB, Affiliated Tribes of Northwest Indians, and National
Congress of American Indians have called upon the states and the
Centers for Medicare and Medicaid Services (CMS) to make Medicaid and
Medicare reimbursement permanent for telehealth, including the use of
audio-only calls beyond the COVID-19 Public Health Emergency (PHE).\9\
The use of telehealth has expanded access to vital healthcare services
to our AI/AN people. In order to maintain these services in tribal
health programs, Northwest Tribes need to be able to continue to
receive Medicaid and Medicare reimbursements at the OMB encounter rate.
The Consolidated Appropriations Act of 2023 extended certain Medicare
telehealth flexibilities through December 31, 2024. However, we ask
this Subcommittee to enact legislation that permanently expands those
Medicare telehealth flexibilities, including access to telehealth in
patients' homes and through audio-only, and to remove any in-person
requirements for mental health or substance use disorder treatment or
any other services.
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\9\ See Nw. Portland Area Indian Health Bd. Res. 2022-03-03, Call
on Ctrs. for Medicare and Medicaid Servs. and States to Permanently
Expand Telehealth (2022); Affiliated Tribes of Nw. Indians Res. 2022-
20, Call on Ctrs. for Medicare and Medicaid Servs. and States to
Permanently Expand Telehealth (2022); Nat'l Cong. of Am. Indians Res.
ANC-22-024, Call on Ctrs. for Medicare and Medicaid Servs. and States
to Permanently Expand Telehealth (2022).
---------------------------------------------------------------------------
Expand Part B coverage to include pharmacists and community health
providers.
Congress recently expanded Part B coverage for marriage and family
therapists and mental health counselors in the Consolidated
Appropriations Act of 2023. Although this was an important first step
to expand behavioral health services for Medicare, we request that Part
B is expanded to include Tribal pharmacists, certified community health
aides and practitioners, behavioral health aides and practitioners, and
dental health aide therapists.
Authorize Medicaid reimbursements for Qualified Indian Provider
Services.
The Northwest Tribes request that the Subcommittee enact
legislation that authorizes all Indian Health Care Providers to bill
Medicaid for all Medicaid optional services as well as specified
services authorized under the Indian Health Care Improvement Act
regardless of whether the State authorizes those services in their
Medicaid program for other providers. It's important that Congress
honors their federal trust and treaty responsibility to provide
healthcare to AI/AN people and that that responsibility and obligation
should not be passed through states to provide healthcare.
Provide Medicaid reimbursements for services furnished by Indian Health
Care Providers outside of an IHS or tribal facility (Four Walls
Issue).
In 2016, CMS informed states that they have updated their payment
policy for services received by AI/AN people through Indian Heath Care
Providers (IHS or tribal health programs). Through further guidance in
2017, CMS clarified that IHS or tribal clinics could not receive
reimbursement for services furnished to AI/AN people outside the ``four
walls'' of their clinic. CMS has provided a grace period (which ends
nine months after the end of the COVID-19 public health emergency) to
allow states and tribes to come into compliance with this updated
policy and to implement revisions to state Medicaid programs to create
a Tribal Federally Qualified Health Center (FQHC) workaround. Many
Tribal health programs provide health care services to their people in
their community, such as community schools, community events, or in
their homes. Providing healthcare services in community and not just in
the brick and mortar clinic has become an essential part of healthcare
delivery in tribal communities.
In order to fix this ``four walls'' issue, we request this
Subcommittee enact legislation that amends the ``clinic services''
definition to ensure that reimbursements for services furnished by IHS
and tribal clinic services providers will be available wherever the
service is delivered.
Conclusion
Thank you for this opportunity to provide testimony on our
challenges and opportunities to improve the delivery of healthcare in
honor of trust and treaty obligations to Tribal Nations. As evidenced
by our testimony, when tribes are given control of health care funding
and grant funding, tribes are creative, innovative and can reduce
health disparities in their communities.
I invite you to visit the Northwest to learn more about our health
care needs in our Area. I look forward to working with the Subcommittee
on our requests and we are happy to share proposed legislative language
for our requests.
______
Questions Submitted for the Record to Laura Platero, Executive
Director, Northwest Portland Area Indian Health Board
Questions Submitted by Representative Westerman
Question 1. How has telehealth improved access to care? Do you have
any information on how that has been different between tribally run
healthcare facilities and IHS run facilities?
Answer. Many tribes in the Northwest were already providing some
form of telehealth prior to the COVID-19 public health emergency (PHE).
With the declaration of the PHE, tribal health programs were provided
numerous flexibilities to expand telehealth, including audio only calls
without compromising any Medicaid and Medicare reimbursement.
Additionally, these flexibilities ensured they were not violating any
federal privacy laws. Tribal health programs quickly rolled out
telehealth services in their programs to reduce face to face encounters
in the height of the pandemic.
Through the expansion of telehealth, tribal health programs found
that expansion of telehealth reduced no-shows, maintained continuity of
care, and expanded the breadth of services in an ambulatory care
clinic. American Indian and Alaska Native (AI/AN) patients were more
likely to show up for their telehealth visit than a face to face
encounter which continued care for many patients that would have
otherwise gone unseen. Because many tribal health programs are in
remote locations and cannot compete with larger healthcare systems,
tribes face challenges recruiting and retaining specialty providers.
For example, a number of Tribes have reported on successfully
contracting with psychiatrists to provide services through telehealth.
The upcoming end of the public health emergency and roll back of many
flexibilities to provide telehealth, especially through audio-only
threaten the ability of tribes to maintain telehealth services in their
health programs.
Indian Health Service (IHS) and Tribal health programs are operated
and managed very differently. Tribal health programs through their
self-governance contracts and compacts are able to rapidly alter their
services and operations to meet the needs of their communities compared
to IHS-operated facilities. Some tribes noted that tribal health
programs were more successful in implementing telehealth in their
services and programs because of the limitations IHS-ran facilities
have in making local decisions. One tribe explained that broadband is a
significant limitation to one IHS operated facility to expand
telehealth. Through the course of the public health emergency, this
facility has not been able to procure and maintain a functioning and
reliable Internet services throughout the facility. The direct service
tribes often point to the inability for IHS-operated facilities to make
decisions at their service units and having to seek permission through
the Area office to make changes in their services, procure and purchase
equipment, or even provide any specific staff training.
1a) What data you can share with the Committee on how telehealth
may have improved access to care?
Answer. One tribe shared that with implementation of telehealth in
their behavioral health program they were able to significantly reduce
no-shows. The no show rate for this year was at 272 no-shows compared
to 2,216 no shows in 2019 when telehealth was not offered.
Question 2. Could you further expand on the challenges the Portland
area is facing regarding workforce shortages for both IHS and tribally
operated facilities.
Answer. The Portland Area face chronic workforce shortages that has
been heightened by the COVID-19 pandemic. These shortages are due to
programs not able to compete with salaries and benefits of working
within larger health care systems and tribes being in rural areas in
the Northwest. Now, tribal health programs are grappling with retention
of their workforce.
2a) What are the greatest challenges to maintain an effective
workforce for tribal health programs?
Answer. Some of the greatest challenges is providers working for
tribal health programs that are not from the tribal communities. This
results in a revolving door of providers which makes it difficult to
maintain steady workforce that the community grows to trust and build
relationships. Additionally, housing and the remote locations of some
tribal health programs make it difficult to recruit specialty
providers.
2b) Are there any tribally led efforts on recruitment and retention
that IHS can learn from or institute?
Answer. Through the course of the COVID-19 public health emergency,
there were many flexibilities that made it easier for programs to
implement telehealth. Many tribal health programs were quick to
implement telehealth to expand services and minimize face to face
exposure. As part of the expansion of telehealth across the U.S.,
tribal health programs used this as an opportunity to contract with
providers to provide services through telehealth. For example, a number
of tribes reported implementing telepsychiatry programs because
psychiatrists are very difficult to recruit to tribal health programs.
Requiring face to face visits to continue telepsychiatry services
threaten tribal health programs from providing these critical services.
Another tribally-led effort to address recruitment and retention of
providers in the Northwest is through the expansion of the Community
Health Aide Program (CHAP). CHAP addresses chronic workforce shortages
by training community members to become midlevel providers to return to
and serve their communities. CHAP providers can be trained to provide
dental services, behavioral health services, and medical services. The
NPAIHB and the Northwest Tribes have developed education programs to
train dental therapists and behavioral health aides, and are in the
process of building out a community health aide education program. This
Subcommittee should continue to support additional funding to further
build out the CHAP workforce and education programs in the Northwest.
Question 3. Your statement mentioned the Community Health Aide
Program and your work to develop a program for the Pacific Northwest.
3a) Can you further expand on how you are working to establish that
program?
Answer. NPAIHB, through the Tribal Community Health Provider
Program (TCHPP) has been working on CHAP implementation since 2015. In
order to expand CHAP in the Northwest, we have worked in three areas:
regulatory, education programs, and tribal/clinical integration.
Regulatory
For our regulatory work, NPAIHB has been working on the development
of the Portland Area CHAP Certification Board, national infrastructure,
and state infrastructure. The TCHPP staff work closely with tribal
partners and Portland Area IHS Staff on the design and implementation
of the Portland Area CHAP Certification Board (federal certification
board necessary for certification of providers and education programs),
Academic Review Committees, Area specific standards and procedures, and
other infrastructure necessary to provide regulatory oversight to CHAP
providers and education programs. This work is similar to national
accreditation agencies and state licensing boards. Last week, the IHS
Director has formally recognized the Portland Area CHAP Certification
Board which will allow our Portland Area CHAP providers to become
certified.
TCHPP staff work closely with Portland Area IHS and IHS
Headquarters through the national CHAP Tribal Advisory Group to support
the design, creation, and implementation of federal infrastructure
necessary for CHAP implementation. TCHPP also provides technical
support to other Areas interested in CHAP implementation and provides
regular learning opportunities through a CHAP learning collaborative
Echo, giving presentation at conferences and meetings, and 1:1 with
other Area partners.
TCHPP staff work closely with the Tribes and state Medicaid
agencies on state infrastructure including state plan amendments, state
legislation (when necessary), administrative rules, and other state
specific activities to ensure CHAP providers are integrated into IHS
and tribal health systems and reimbursed by third party payors.
CHAP Education Programs
In Alaska, there are education programs for all CHAP provider types
available. TCHPP staff for the Portland Area work closely with
curriculum experts, tribal partners, and education institutions to
design, implement, and support CHAP education programs for all
disciplines of CHAP specifically to meet the needs of the 43 Tribes in
Washington, Oregon, and Idaho. In the Portland Area, there are
education programs for Dental Health Aide Therapists (DHAT) at Skagit
Valley College in partnership with the Swinomish Indian Tribal
Community and Behavioral Health Aides (BHA) at the Northwest Indian
College in partnership with the Lummi Nation and Heritage College in
partnership with the Yakama Nation. We are in the process of developing
a Community Health Aide (CHA) education program to further expand
primary and emergency care clinicians in tribal communities. These
education programs have not received funding from the IHS for year to
year operations. All of our education programs would benefit from
federal funding to support their operations.
TCHPP staff are working closely with curriculum experts to design
curricula for the remaining levels of Dental Health Aides (DHA) and
BHAs and Practitioners and all levels of Community Health Aides. TCHPP
staff are also working closely with tribal partners and education
institutions to design and implement education programs around these
curricula.
The TCHPP team and the Northwest tribes recruit students into the
programs and support the students once they have entered the programs
through funding (stipends and scholarships), mentorship programs such
as with Elders, knowledge holders, and culture keepers ECHO, and other
direct support of students.
Because of the limited financial resources available for CHAP,
TCHPP staff are constantly fundraising to support implementation,
tribal partners, education partners, and students. We encourage the
Subcommittee to come to the Northwest to visit our CHAP education
programs to learn more on CHAP implementation in the lower 48. This is
an opportunity to expand access to care across IHS and Tribal health
systems.
Tribal/Clinical Integration
Lastly, TCHPP staff work closely with tribal health programs to
provide clinical supervision for CHAP providers, train supervising
providers, and work with all levels of staff to integrate CHAP
providers into existing processes and structures. We host the CHAP ECHO
Learning Collaborative every month to bridge the gap between
traditional practices and modern standards of care through bringing
together DHATs, BHAs, and CHAs.
3b) Would that program that works only with tribally run healthcare
programs, or do you think it could work within IHS also? Would any
structural changes need to happen at IHS to make the CHAP program work
within IHS's system?
Answer. The CHAP program is designed to work both with tribally run
health care programs and with IHS programs. IHS will need to do some
work on their internal infrastructure in order to incorporate CHAP into
their workforce, so IHS facility implementation might take a few years
longer than implementation in tribally run health care programs. That
infrastructure work has already begun at the IHS Headquarters level.
CHAP--done correctly CHAP is structural change--CHAP was designed
to sit outside of state regulatory environments and provide tribes and
tribal organizations the ability to regulate a health system where they
could provide the necessary tools to break down current barriers to
health provider education and care. Current implementation outside of
Alaska is struggling to grasp the supportive (and not regulatory) role
that the federal government is meant to take in successful CHAP
implementation. The Alaska CHAP Program has been successful for over 60
years and has been tribally run and operated with support from the
Alaska Area IHS office. This has allowed CHAP to develop organically in
Alaska Native communities over that time and provides the backbone of
primary care in Alaska Native communities.
In order for CHAP to be successful outside of Alaska to the same
degree--tribes and tribal health organizations need the flexibility to
build a CHAP that is responsive to their needs and does not necessarily
look exactly like the existing IHS system which has been failing tribes
for centuries. Tribes are in the best position to understand the unique
structural barriers that affect their citizens' ability to enter health
provider education programs and access primary care.
CHAP education programs are tailored to meet the unique needs of
tribal communities and are also successful for non-tribal citizens
interested in health provider careers. Doing things like embedding
prerequisites into pre-sessions (prerequisites are often barriers to
entry), providing extra academic support during the education program,
``indigenizing'' curriculum to make it more relevant to the communities
served, and building competency-based education programs are some of
the ways that CHAP education programs are tailored to meet the needs of
tribal communities.
3c) What other creative possibilities exist that tribal
organizations and IHS could implement?
Answer. Structural change is slow and hard won because the existing
structures have so much support to keep them in place--if we could
focus on CHAP implementation with an eye toward structural change, this
could open up so many possibilities for tribal health programs, IHS,
and tribes to experiment with creative ways to meet the health care
needs of their communities
Question 4. The Subcommittee has heard from many different tribes
that the Purchased/Referred Care program has several challenges:
4a) Can you describe some of the issues you have heard about within
the Portland Area, and what challenges are your tribal members facing
when dealing with the PRC program?
Answer. The Purchased/Referred Care (PRC) program is a critical
program for the Portland Area because there is no IHS or Tribal
hospital. The PRC program makes up over one-third of the Portland Area
budget. IHS and Tribal health programs have to purchase all inpatient
and specialty care which results in very limited services available for
these programs to cover. Tribally-operated PRC programs need additional
funding to cover higher level of services. Without year-to-year
increases to PRC to fund the access to care factor, inpatient care for
Portland Area Tribes goes severely underfunded.
One tribe has reported challenges in demonstrating eligibility for
and obtaining specialty care from their IHS-ran PRC program. Some of
these challenges include onerous documentation requirements not
required by the IHS handbook or any other IHS authority; length of time
IHS takes to process authorizations for PRC referrals; private health
providers considering refusing to accept PRC referrals because of the
administrative barriers to receive timely payment. These challenges
have resulted in AI/AN people not receiving the necessary care they
need, being referred to collection agencies for unpaid bills, and even
deaths. We are happy to provide your office with the name of the tribe
for any additional follow-up on these PRC issues stemming from IHS-
operated facilities.
4b) And what suggestions or recommendations would you provide to
the Committee to make that process better?
Answer. We recommend that the Committee supports increased funding
for PRC. PRC has not received a significant increase since 2014 which
has resulted in less funding available to expand covered referred
services. For any changes to IHS-ran PRC programs, the IHS facility and
Area Office should consult with the tribes on the chronic challenges in
obtaining eligibility for and accessing PRC services in an IHS-operated
facility.
Question 5. In your testimony, you mentioned difficulties in
accessing certain grants at IHS and SAMHSA. Could you further expand on
those difficulties?
Answer. The Northwest Tribes have been advocates for the expansion
of Indian Self-Determination Education Assistance Act (ISDEAA)
contracts and compacts across the Department of Health and Human
Services (HHS). Tribal self-governance and self-determination compacts
and contracts provide tribes the administrative flexibility to develop
programs and services that meets the needs of the tribal communities.
Over the past years, more and more funding has been made available in
agencies such as SAMHSA and CDC, but they have required tribes to
submit competitive grants. Many tribes do not have the administrative
capacity to track open grant opportunities, apply for those grants, and
maintain in compliance with exhaustive granting requirements.
COVID-19 showed how successful the self-governance and self-
determination programs. Many tribes faced challenges maintaining their
grants when they had to alter their programs and services to limit face
to face exposure. Many tribes were unable to spend down their grants
during COVID-19, such as Special Diabetes Program for Indians (SDPI)
and behavioral health grants. With contracts and compacts, Tribes are
able to easily move around funds to address the most pressing health-
related issues. This resulted in quick response to address the public
health emergency that ultimately resulted in American Indians and
Alaska Natives being of the most vaccinated racial and ethnic groups in
the U.S.
5a) What are the specific challenges for tribes and tribal
organizations?
Answer. The federal government has treaty and trust obligations to
provide healthcare services to American Indian and Alaska Native
people. Grants do not fulfill these treaty and trust obligations
because they do not provide funding to all tribes and tribal
organizations. Tribes do not always have the administrative staff or
grants specialists to keep track of opened grant opportunities, apply
for those grants, and maintain in compliance with specific reporting
requirements.
One specific challenge with SAMHSA grants is the burdensome
Government Performance and Results Act (GPRA) Data Reporting
requirements. We have found that GPRA reporting requirements took more
time to complete and submit than the actual delivery of services
provided by the funds. These reporting requirements use more
administrative resources than the SAMHSA funding provided to Tribes and
tribal organizations. Currently, SAMHSA grants are set with a 20%
administrative funding cap, but grantees frequently find additional
resources must be expended to complete the reporting requirements. In
other cases, many Tribes and Tribal organizations lack the time, staff,
and resources necessary to meet the GPRA grant reporting and because of
this, they are unable to apply for those grants or may decide not to
reapply.
5b) What do you think should be changed about the grant process to
make them more accessible to tribes and tribal organizations?
Answer. First and foremost, we recommend that IHS and HHS moves
away from grant funding and allow tribes the option to receive funds
through their contracts and compacts. This Subcommittee must support
legislation expanding ISDEAA contracting and compacting to HHS and its
agencies. Until there is legislation in place, HHS agencies should
allocate funds to IHS to distribute to Tribes through ISDEAA contracts
and compacts using existing formulas. Moving forward, Tribes should be
exempt from GPRA reporting requirements, so more resources can go
directly to services instead of being redirected to data collection,
data entry, and data reporting.
Questions Submitted by Representative Leger Fernandez
Question 1. Could you share more on the anticipated impacts and
loss of services that would occur if the FY24 enacted congressional
budget reflects FY22 enacted levels for the Indian Health Service
(IHS)?
Answer. In the Consolidated Appropriations Act of 2023, Congress
appropriated $7 billion for IHS which includes a $327 million increase
over FY 2022 enacted level.\1\ Of this increase for the overall IHS
budget, Hospitals and Health Clinics received $100 million increase,
Tribal Epidemiology Centers received additional $10 million, dental
services received $12 million increase, Purchased/Referred Care
received $12 million increase, and Alcohol and Substance Abuse received
$8 million increase. These are all crucial line items to Portland Area
IHS and Tribal health programs which has allowed providers to keep pace
with population growth and medical inflation. Medical costs are
significantly increased in the Northwest and our tribal health programs
cannot compete with large healthcare systems in the urban areas.
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\1\ See Consolidated Approps Act 2023, Pub. L. No. 117-328.
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Additionally, Purchased/Referred Care (PRC) received only a 1%
increase over FY 2022 enacted levels. This does not even cover medical
inflation and population growth. PRC has not received a significant
increase since 2014. When there are increases to the PRC budget, the
Portland Area Tribes receive additional funding to account for the lack
of an IHS/Tribal hospital in the Area, often referred to as the access
to care factor. Cutting PRC back to FY 2022 levels would put us even
further behind to even address population growth and medical inflation
let alone to fund the access to care factor. We request this
Subcommittee ensures that PRC is prioritized for increased funding and
that it is not further cut.
Lastly, the Northwest Portland Area Indian Health Board operates
the Northwest Tribal Epidemiology Center (NWTEC) that provides health-
related research, surveillance, training and technical assistance to
improve the quality of life of AI/AN people in the Northwest. With the
increased funding for TECs, we have been able to expand the NWTEC and
employ eight (8) epidemiologists and biostatisticians to increase
services to the Northwest Tribes. The NWTEC conducts critical data
linkage work to improve data validity and accuracy as AI/AN are
chronically misclassified in state and federal data sets. Without
accurate data, this impacts our Tribes from understanding healthcare
needs and funding priorities. Any proposed cuts to TECs would require
us to scale back our epi-related work including reducing the number of
epidemiologists and biostatisticians we have on staff.
Conclusion
Thank you for this opportunity to submit follow-up responses to the
Indian and Insular Affairs Subcommittee. I invite the Subcommittee to
come visit the Northwest Portland Area Indian Health Board and our
Northwest tribes to learn more about our challenges and programs and
services.
______
Ms. Hageman. I thank the witness for her testimony and the
Chair now recognizes Ms. Maureen Rosette for 5 minutes.
STATEMENT OF MAUREEN ROSETTE, CHIEF OPERATIONS OFFICER, THE
NATIVE PROJECT; BOARD MEMBER, NATIONAL COUNCIL OF URBAN INDIAN
HEALTH, WASHINGTON, DC
Ms. Rosette. Good morning. My name is Maureen Rosette, and
I am a citizen of the Chippewa Cree Tribe and also a Board
Member of the National Council of Urban Indian Health, NCUIH.
NCUIH is the national advocate to ensure urban Indian
organizations have the resources and policy support to help
serve the over 70 percent of American Indians and Alaska
Natives living off reservation.
I am also the Chief Operating Officer at the NATIVE
Project, an UIO in Spokane, Washington, which has a service
population of over 20,000 American Indians and Alaska Native
people.
In our facility alone, we have served Natives from over 300
different tribes. Let me start by thanking Chairwoman Hageman,
Ranking Member Leger Fernandez, and members of the Subcommittee
for inviting NCUIH to testify.
I wanted to remind the Committee of the importance of urban
Indian organizations to the Indian Health System. Growing up, I
lived and grew up on my reservation and I was a consumer of my
own tribally-operated health program.
At the age of 28, I moved to Spokane to go to law school,
had no health insurance. I had two little kids, a 3-year-old
and a 5-year-old. We had no health insurance.
At the time, if the NATIVE Project had had medical
services, we would have had some healthcare, at least access to
healthcare, but we didn't at the time. I just hoped and prayed
that none of us got sick.
Now, I have insurance and I can go anywhere I want, but our
family has chosen to be consumers of the NATIVE Project because
of the excellent healthcare we get there and it is culturally
appropriate. That is what we want.
Today, there are 41 UIOs, which are a fundamental and
necessary component of the Indian Health System, and we work
hand-in-hand with IHS to help provide the resources necessary
to provide healthcare to Native people.
As the Committee knows, IHS has been on the GAOs high-risk
report since 2017. Although IHS has been making progress on the
GAO recommendations, full and stable funding has continuously
been a barrier to addressing these recommendations.
We are grateful that Congress finally passed advanced
appropriations for IHS in last year's omnibus. For over 50
years, without advanced appropriations or mandatory funding,
our providers have been operating without budget certainty.
Indian health providers had to operate knowing they will
not be able to pay their doctors on time because of late
payments due to politics in Congress. This instability created
barriers for our providers, and we could not be the hubs for
innovative solutions for our communities.
Advanced appropriations will now allow IHS to make long-
term cost saving purchases and minimize the administrative
burdens for the agency and UIOs. Advanced appropriations will
also improve accountability and increase staff recruitment and
retention at IHS.
When IHS distributes its funding on time, our UIOs can pair
doctors and providers. This means that Native people can have
access to the care and services they need to be thriving
communities.
As such, we request the Committee work with the
appropriators to ensure advanced appropriation is maintained in
future years. Despite these historical challenges, urban Indian
organizations have been great stewards of the funds we can
access.
Increases in funding have been met with improvements in the
care we provide to our community. For example, my organization,
the NATIVE Project, has used our funding to build and create a
new Children and Youth Services Center.
We broke ground on the center in May 2022 and are looking
forward to the increased care we will be able to provide our
community. This new building will provide substance use and
mental health resources, such as therapy and wellness practices
and provide space for traditional Indigenous practices.
We will now have a space for healing our children as they
grow to become the future of our communities. The declaration
of the National Indian Health Policy states, ``It is the policy
of this nation, in fulfillment of its special trust
responsibilities and legal obligations to Indians to ensure the
highest possible health status for Indians and urban Indians to
provide all resources necessary to affect that policy.''
The Indian Health Service System is essential to fulfilling
this policy. As IHS works to address the key issues and
recommendations provided by the GAO, they must not be hindered
by lack of funding, funding stability, and budgetary cuts.
Full funding will ensure IHS operates to provide the best
healthcare possible for our people. We urge Congress to take
this obligation seriously and work with IHS to ensure they have
the resources necessary to protect Native lives. Thank you.
[The prepared statement of Ms. Rosette follows:]
Prepared Statement of Maureen Rosette, National Council of Urban Indian
Health (NCUIH)
My name is Maureen Rosette, I am a citizen of the Chippewa Cree
Nation and the Chief Operations Officer of the NATIVE Project, an urban
Indian organization (UIO) in Spokane, Washington. I am also a Board
member of the National Council of Urban Indian Health (NCUIH), the
national advocate for health care for the over 70% of American Indians
and Alaska Natives (AI/ANs) living off-reservation, and the 41 UIOs
that help serve these populations. I would like to thank Chair Hageman,
Ranking member Fernandez, and members of the Subcommittee for inviting
NCUIH to testify at this hearing.
The Beginnings of Urban Indian Organizations
The Declaration on National Indian Health Policy in the Indian
Health Care Improvement Act states that ``Congress declares that it is
the policy of this Nation, in fulfillment of its special trust
responsibilities and legal obligations to Indians to ensure the highest
possible health status for Indians and urban Indians and to provide all
resources necessary to effect that policy''. In fulfillment of the
National Indian Health Policy, the Indian Health Service funds three
health programs to provide health care to AI/ANs: IHS sites, tribally
operated health programs, and Urban Indian Organizations (referred to
as the I/T/U system).
As a preliminary issue, ``urban Indian'' refers to any American
Indian or Alaska Native (AI/AN) person who is not living on a
reservation, either permanently or temporarily. UIOs were created in
the 1950s by American Indians and Alaska Natives living in urban areas,
with the support of Tribal leaders, to address severe problems with
health, education, employment, and housing caused by the federal
government's forced relocation policies.\1\ Congress formally
incorporated UIOs into the Indian Health System in 1976 with the
passage of the Indian Health Care Improvement Act (IHCIA). Today, UIOs
continue to play a critical role in fulfilling the federal government's
responsibility to provide health care for AI/ANs and are an integral
part of the Indian health system. UIOs serve as critical health care
access points for and work to help provide high-quality, culturally
competent care to the over 70% of AI/ANs living in urban settings.
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\1\ Relocation, National Council for Urban Indian Health, 2018.
2018_0519_Relocation.pdf (Shared)-Adobe cloud storage
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Consistent and Full Funding Leads to Accountability and Solutions
In 2017, IHS was first added to the Government Accountability
Office's (GAO) High-Risk Series report, where several key
recommendations were identified for IHS to undertake in order to remove
the High-Risk designation. Since then, IHS has continuously worked to
address the recommendations, closing out almost all of GAO's initial
recommendations.\2\
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\2\ High-Risk Series: Substantial Efforts Needed to Achieve Greater
Progress on High-Risk Areas, US Government Accountability Office, 2019.
https://www.gao.gov/products/gao-19-157sp
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The GAO has cited a lack of consistent and full funding as a
barrier for IHS. Up until the passage of the Consolidated
Appropriations Act, 2023, IHS was the only federally funded health care
provider that did not receive advance appropriations. This uncertainty
and disruption drastically impacted the ability of IHS to make
important, long-term and cost saving purchases, as stated by the
Congressional Research Service.\3\ This new funding stability will also
allow for IHS, and UIOs, to continue to serve their communities and
patients regardless of the status of a funding package, which will
decrease administrative burdens on both the agency and UIOs. For
example, with each continuing resolution (CR), UIOs must negotiate and
execute brand new contracts with IHS, specific to the timing of the
package, sometimes delaying the distribution of funding until the end
of the resolution. For a population that not only has significantly
poorer health disparities and has seen a significant decrease in life
expectancy,\4\ and delays in funding can be the difference between life
and death.
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\3\ Advance Appropriations for the Indian Health Service: Issues
and Options for Congress, Congressional Research Services, 2022.
\4\ Provisional Life Expectancy Estimates for 2021, Elizabeth
Arias, Betzaida Tejada-Vera, Kenneth Kochanek, and Farida Ahmad, 2022.
https://www.cdc.gov/nchs/data/vsrr/vsrr023.pdf
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Full, stable and reliable funding is the most critical piece to
allow IHS to truly begin to address its outstanding issues and improve
the care it provides to Indian Country. When IHS can issue payments to
UIOs on time, UIOs are able to create long-term plans and better
improve the care and resources they provide to their communities. It is
for this reason that we request that the Committee work with
appropriators to maintain advance appropriations for IHS and protect
IHS from sequestration. including
UIOs Use of Critical Funds Positively Impacts Communities and Tribal
Partners
It is important to note that UIOs are excellent stewards of the
funding they receive and fill a critical role in fulfilling the trust
responsibility. While UIOs are funded through a single line item in the
IHS budget, they have been able to do as much as possible, and then
some, for their patients and communities. Most UIOs have a service area
with a Native population of tens of thousands, and that does not
include patients who may drive hours to come to a UIO specifically for
the culturally competent care it offers.
Since the last Congressional session, with the passage of the
Infrastructure Investment and Jobs Act, UIOs are now allowed to use
existing IHS contracts and funding to upgrade their facilities. Since
then, six UIOs have opened new facilities in the past year and an
additional 16 UIOs have plans to open new facilities over the next two
years.
In fact, the NATIVE Project was able to break ground in May 2022 on
a new wellness center focused on child and youth wellness.\5\ This new
building will provide not only behavioral and mental health resources,
such as therapy and wellness practices, but will also provide space for
traditional Indigenous practices. During a ceremony held the day we
broke ground, a Kalispel elder spoke about the significance of keeping
children at the center of work like this and praised the NATIVE Project
for our work. ``It's important for me to note that my life and the life
of many of us are well, we are well in heart because of concepts (such
as) the NATIVE Project'' said Francis Cullooya, whose Indian name
`Tsisulex' translates to `standing on the ground'. The NATIVE Project
is also honoring elder Cullooya by dedicating a room in the new
building to him.
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\5\ `Watch and learn from our children': The Native Project breaks
ground on new youth wellness center inspired by the kids it will serve,
Amber D. Dodd, The Spokesman-Review, 2022. https://www.spokesman.com/
stories/2022/may/20/watch-and-learn-from-our-children-the-native-proje/
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The work UIOs do is critical not only to their communities and
their patients, but also to our Tribal neighbors. Many UIOs work in
partnership with neighboring Tribes to provide overflow patient care
when Tribal facilities are at capacity. Andrew Joseph Jr., a member of
the Colville Tribe, the Health and Human Services Chair for the
Colville Business Council and Co-Chair of the IHS Tribal Budget
Formulation Workgroup, has repeatedly praised the NATIVE Project for
taking care of his Tribal citizens. ``The Colville Tribe has, I would
say, over 2,000 tribal members that utilize the NATIVE Project, over
160 families that utilize the NATIVE Project, and the way IHS is
funded, if the NATIVE Project wasn't there, our people would come home
to a depleted . . . low funded IHS facility, so the NATIVE Project
actually does a lot of work in saving our people's lives'' said Chair
Joseph in a video of support. Therefore, it is essential that IHS
continues to receive the support it needs, through funding and prompt
appointment of leadership. Without it, UIOs cannot continue to increase
the care and resources we provide to our communities.
These funds are critical to UIOs, and yet, due to lack of full
funding for IHS, it has taken over a year to receive funds due to the
administrative burden it takes for IHS to receive these funds, create
guidance, and distribute funds with the lack of resources, personnel,
and funding to issue these funds in a timely manner.
Administrative and Leadership Turnover Impacts Communication and
Transparency with UIOs
Another regular recommendation that GAO provides to IHS is the need
for stable leadership and senior staff. Since 2015, IHS has routinely
gone for extended periods of time without a permanent Director due to
nomination delays.\6\ This can lead to concerns and questions over the
legitimacy of the policy decisions that these acting directors make.
Recently, IHS was functioning under the direction of an Acting
Director, Elizabeth Fowler, for nearly two years, prior to President
Biden's nomination of Director Roselyn Tso. And again, it took the
Senate over 6 months to confirm Director Tso to the position.\7\
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\6\ Crisis at Indian Health Service, Indianz.com, 2019. https://
www.indianz.com/News/2019/02/06/ihs-leadership-crisis.asp
\7\ Senate Confirms Roselyn Tso as Director of the Indian Health
Service, National Council of Urban Indian Health, 2022. https://
ncuih.org/2022/09/21/senate-confirms-roselyn-tso-as-director-of-the-
indian-health-service/
#:?:text=Today%2C%20September%2021%2C%202022%2C,without%
20a%20permanent%20IHS%20Director
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The lack of an IHS Director has routinely prevented Tribes, Tribal
organizations, and UIOs from addressing the health care needs of their
Native American populations. For urban Indian organizations, we were
unable to share our priorities for our communities with the IHS
Director until mid-December 2022, nearly three years into this
administration's tenure. Additionally, the lack of consistent
leadership and the constant turnover of acting leadership has led to
lapses in communication, particularly with urban Indian organizations.
On several occasions, UIOs have not received updates on a number of key
policy changes, updates and collaborations. For example, UIOs
experienced the lack of communication regarding the implementation of
the VA-IHS Memorandum of Understanding (MOU). IHS did not facilitate
conversations between VA and UIOs prior to the publication of the VA's
rule on identification for Native veterans. With the expansion of the
VA Reimbursement Agreement Program (RAP) to include UIOs, through the
MOU, there are currently less than one-tenth of UIOs enrolled to
receive reimbursement from the VA for care to Native veterans. UIOs
have requested additional guidance be provided from both VA and IHS to
assist with increasing UIO enrollment in the Reimbursement Agreement
Program to improve health outcomes for our Native veterans.
While awaiting confirmation of a director, IHS has been working to
fill a number of key senior agency positions. Specifically, Dr. Rose
Weahkee became Director of the Office of Urban Indian Health Programs
in 2020 and it has been under her leadership that UIOs, and NCUIH, have
experienced increased interaction with the agency. For example, because
of the leadership that Dr. Weahkee provides, the Office of Urban Indian
Health Programs has been involved in a collaborative process with UIOs
for over a year now in the development of the OUIHP Strategic Plan.
Throughout this process, the Office of Urban Indian Health Programs has
held several Urban Confers with UIOs and NCUIH, as well as continuously
incorporated the feedback and edits to the Strategic Plan, from UIOs
and NCUIH, that have resulted from these confers.
Since her confirmation, Director Tso has greatly stepped up to fill
the void from the continued lack of a permanent Director. In the first
5 months of her tenure, Director Tso has visited at least three
different urban Indian organizations--one in California, one in Arizona
and one in Nebraska. Director Tso has also made an effort to ensure
that UIOs are being heard throughout the agency and that IHS is as
transparent as possible with our organizations and NCUIH. As mentioned
previously, the Director was able to attend the NCUIH Board of
Directors quarterly meeting. During this meeting, we were able to
highlight several of our concerns, including communication challenges.
Despite challenges highlighted within the GAO report and the impact of
the political process, IHS has consistently made efforts and worked to
address the outstanding issues, making great strides in improving the
agency's relationship, collaboration, and partnership with the UIOs.
Conclusion
Among the most important legal obligations within the federal trust
responsibility is the duty to provide for Indian health care, and the
I/T/U system is essential to executing this trust and treaty
responsibility. As IHS works to address the key issues and
recommendations provided by the GAO, they must not be hindered by a
lack of full funding, funding stability, budgetary cuts, and
administrative and leadership turnover. Full, stable funding and
exemptions from budget cuts and shutdowns are the only way to truly
invest in the oversight of IHS and support the optimal care that our
people deserve. We urge Congress to take this obligation seriously and
work with IHS to ensure they have the resources necessary to protect
Native lives.
______
Questions Submitted for the Record to Maureen Rosette, National Council
of Urban Indian Health
Questions Submitted by Representative Leger Fernandez
Question 1. Could you share more on the anticipated impacts and
loss of services that would occur if the FY24 enacted congressional
budget reflects FY22 enacted levels for the Indian Health Service
(IHS)?
Answer. IHS is chronically underfunded, and reducing its budget to
the FY22 enacted levels would have a significant impact in its ability
to provide care to Native patients. For example, the $220 million
reduction in IHS' budget authority for FY 2013 resulted in an estimated
reduction of 3,000 inpatient admissions and 804,000 outpatient visits
for AI/ANs.\1\ If Congress were to decrease the budget to FY22 enacted
levels, the resulting reduction of $360 million in IHS' budget
authority would have an even greater impact on Native healthcare
compared to the effects seen in 2013.
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\1\ Contract Support Costs and Sequestration: Fiscal Crisis in
Indian Country: Hearings before the Senate Committee on Indian
Affairs.(2013) (Testimony of The Honorable Yvette Roubideaux)
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Returning to FY22 enacted levels would have a significant impact on
urban Indian organizations (UIOs) as it would reflect a 19% decrease in
the Urban Indian Health line item. UIOs are already underfunded, for
example, in FY 2018 U.S. healthcare spending was $11,172 per person,
but UIOs received only $672 per AI/AN patient from the IHS budget.\3\
This underfunding is due, in part, to the fact that UIOs receive direct
funding only from the Urban Health line item and do not receive direct
funds from other distinct IHS line items. As a result, UIOs rely on
every penny in the Urban Health line item to provide culturally
competent care to their patients.
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\2\ Recent Trends in Third-Party Billing at Urban Indian
Organizations. National Council of Urban Indian Health. 2018. Recent-
Trends-in-Third-Party-Billing-at-Urban-Indian-Organizations-1.pdf
(ncuih.org)
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As funding for UIOs has increased over the past few years, it has
been met with expansions in services for our communities. For example,
my clinic, the NATIVE Project, was able to break ground on a new
wellness center focused on child and youth wellness. This new building
will provide not only behavioral and mental health resources, such as
therapy and wellness practices, but will also provide space for
traditional Indigenous practices. Across the country, we are seeing
UIOs expand services such as maternal and neonatal health, youth
support services, and traditional healing services. Any reduction in
the IHS budget will halt the progress made to address the needs in our
communities and further constrain our ability to expand services or
address facilities-related costs.
In addition to regular budgetary concerns, reducing the budget will
have a direct impact on UIOs' ability to recruit and retain staff and
providers. Many of our clinics have expressed difficulty in providing
competitive pay, particularly compared to private or larger healthcare
provider organizations in their service areas. Without more funding,
UIOs cannot compete with inflation, high cost of living, or pay higher
raises and hazard pay like other facilities. In a survey of UIO
leaders, one leader highlighted the impact of underfunding by saying,
``due to inflation and market changes, salaries have grown
exponentially. It is becoming exceedingly difficult to staff the
organization with high-quality employees, especially medical providers,
while IHS funding stays the same year after year.'' \3\ In the IHS
Portland Area, where my UIO is located, underfunding has caused
significant recruitment challenges, with 100% of Dentist positions
being vacant in 2021.\4\ Without sufficient staffing levels, Native
patients will go unserved and may compromise the critical care needed
for their well-being and ability to thrive.
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\3\ The National Council of Urban Indian Health. 2022 Annual Policy
Assessment. 2023. Policy-Assessment-22_NCUIH_D284_V6.pdf
\4\ Assistant Secretary for Planning and Evaluation, Indian Health
Service. How Increased Funding Can Advance the Mission of the Indian
Health Service to Improve Health Outcomes for American Indians and
Alaska Natives. 2021. https://aspe.hhs.gov/sites/default/files/
documents/1b5d32824c31e113a2df43170c45ac15/aspe-ihs-funding-
disparities-report.pdf
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It is critical that our Native communities are appropriately cared
for, in the present and in future generations. We urge Congress to take
this obligation seriously and provide UIOs with all the resources
necessary to protect the lives of the entirety of the Native
population, regardless of where they live. The federal government must
continue to work toward its trust and treaty obligation to maintain and
improve the health of American Indians and Alaska Natives and ensure
our budget is protected as budget-cutting measures are being
considered.
______
Ms. Hageman. I thank the witness for her testimony.
The Chair will now recognize Members for 5 minutes for
questions, and I will begin.
Ms. Alkire, in your testimony, you stated that Congress
should conduct oversight to ensure that tribes and tribal
organizations, specifically Tribal Epidemiology Centers have
access to public health information at the same level as state
and local health departments.
Could you further expand on that and give examples of the
barriers that exist for data sharing right now?
Ms. Alkire. Yes. Thank you. Prior to becoming the
chairwoman, I actually worked where Ms. Church works right now,
at the Great Plains Tribal Chairman's Health Board. I was the
administrator for the Northern Plains Epidemiology Center at
that time, and one of the things, way back in 2010, we were
asking for data sharing then from the state. And here we are in
2023, we just went through a pandemic, we don't know if we are
going to go through another one, and we are still asking that
question. Why are we not sharing data?
And as a tribal chairwoman now, I can say this, it is not
the only agency that we struggle with that. At the Bureau of
Indian Affairs, it is the same thing. And I don't mean to throw
that in there, but I mean, this is something that we need to
get past.
We cannot adequately address all our needs at the tribe,
even as decision makers and these ladies here at the Health
Boards, in addressing our healthcare needs without collecting
the data and sharing the information so we can tell our story
to you, and you can tell the story adequately also.
So, the epidemiology, the data is so important. We just
need to get past that.
Ms. Hageman. Ms. Church, you seem to have some experience
with this same problem?
Ms. Church. Recently, I shared what happened during COVID-
19 and not having that information made it so that we couldn't
prioritize which of our 17 reservations that we were going to
support for emergency operations.
We operated a Regional Emergency Operation Center and I
believe, because of that, people died unnecessarily. We could
have done more if we were at the right place at the right time,
and we didn't know where to be at the right place at the right
time.
Right now, with the syphilis outbreak, we reached out to
CDC, we reached out to IHS for information. We reached out to
CDC for Epi-Aid. They are in the process now of responding to
that request for Epi-Aid, but I still don't know where to tell
them to go first.
And IHS has, I think, 10 days to respond with an answer.
The acting area director in Aberdeen responded, when I followed
up on Day 10 for information on the outbreak. His response was,
we are still looking into the legality of sharing that
information.
Ms. Hageman. OK. All right. I would like to direct my next
question to Laura Platero. Since Portland area has both
tribally run and IHS run health facilities, can you discuss
some of the differences you have seen between management
styles, and do you think facilities are learning from each
other about what are best practices and how to ensure
culturally competent healthcare for your tribal members?
Ms. Platero. Thank you, Chair Hageman. In terms of
management styles, I would say that tribally operated
facilities have more decision-making authority, and this
results in more timely decisions. For example, they are able to
purchase equipment and supplies that they need without having
to get approval at the area level.
Similarly, staff training. They can make those decisions
locally, rather than have to go to the area to get approval for
those. For hiring, it also can take months for a Federal
facility to get someone hired. By the time the person gets
through the process, they may not be available.
In terms of the tribal facilities, of course they have that
flexibility to expedite hiring when there is a need. There are
also funding flexibilities for tribally operated facilities, in
terms of moving funding across sub-accounts.
So, if someone would like to direct some healthcare funds
to their behavioral health program or their mental health
program, they can move those funds. Federal facilities are
unable to do this.
There is just a lack of flexibility overall. And we have
heard from some of our communities, even with presence in the
community, many individuals who work at the federally operated
facilities may not necessarily be integrated into the community
or be part of social events, and it does, I think, it does
matter to have a presence, like, at events locally in the
community. And I am sure that is not the case for all places,
but I heard that from one tribe.
Also, PRC eligibility for federally operated facilities. We
have heard there are a lot of delays. There are penalties to
members who get billed for services. This has been extremely
burdensome.
We heard of one incidence where it resulted in someone not
getting care and they ended up passing. And that tribe did, I
would rather not give their name, but I am happy to share that
later with the Committee and connect you with the tribe. They
did want to talk with you.
Ms. Hageman. OK. Well, thank you for that.
I am now going to recognize the Ranking Member, Ms. Leger
Fernandez, for your questioning.
Ms. Leger Fernandez. Thank you so much, Chair. And I want
to really thank the witnesses because what is really key is, I
think one of you said it is, that making sure that the voices
that you represent are heard by us so we can raise our voices
in support of what you are doing.
And I really want to thank you, from the heartbreaking
thought of babies dying because we don't get them the care they
need, with regards to this congenital syphilis, to the idea
that somebody, if you are a Native American, you might not make
it to see the Social Security.
These are really impactful stories that paint the picture.
And I want to touch a bit on the advanced appropriations,
mandatory appropriations. And I know that you have each
testified you would like to see both, but I really am pleased
that we at least got to the advanced appropriations for IHS
last year on a bipartisan basis.
So, once again, let me just hear, Ms. Rosette, would you
support advanced appropriations for IHS on a permanent basis?
Ms. Rosette. Yes.
Ms. Leger Fernandez. Ms. Church?
Ms. Church. Yes.
Ms. Leger Fernandez. Ms. Platero?
Ms. Platero. Yes.
Ms. Leger Fernandez. Ms. Alkire?
Ms. Alkire. Yes.
Ms. Leger Fernandez. And Ms. Alkire, I really hope we might
have time for a second round of questions, because I do want to
hear the story about cultural competency and I think the
important piece that I have witnessed over the years is that
the tribally run organizations, either compacted or contracted,
are able to blend in cultural competency much better.
But you have also pointed out that some of the IHS
facilities also have that, and the study about getting better
when you have trust in your doctor.
Do you see that using traditional healing practices also
helps in terms of following the Western prescriptions as well?
Maybe Ms. Church, if you want to answer that?
Ms. Church. Sure. Absolutely. When our relatives feel
comfortable in a healthcare facility that speaks to who they
are and their culture, they trust even the Western physicians
even more because they see those physicians respecting their
culture. They see them respecting their spirituality.
And the quality of the care provided by the physicians also
changes because they are exposed to culture, and they are aware
that this is an important piece of that relative's healing
journey.
Ms. Leger Fernandez. Thank you. And I think that the other
thing I have seen is that 638 compacted-contracting facilities
also do a great job of recruiting Native American providers
into them.
I wanted to follow up real quickly on the issue of, if each
of you could give me one example of how having advanced
appropriations has helped? Ms. Rosette?
Ms. Rosette. Well, before we were having problems, we
couldn't plan ahead, is how it has helped. Like, with our new
building. Before we couldn't plan for things like that because
we were not sure if we were going to have the funding.
Now, we know, at least for a while, that we will have the
funding there for us so we don't have to use what money we have
saved for operations.
Ms. Leger Fernandez. Right. When there is uncertainty,
everything costs more.
Ms. Platero, quickly?
Ms. Platero. Same thing. Certainty in funding. Being able
to plan, security with providers knowing they will have
continued employment.
Ms. Leger Fernandez. Ms. Church?
Ms. Church. Being able to use those resources more
effectively and with confidence.
Ms. Leger Fernandez. Yes. And Ms. Alkire? I am sorry if I
said it wrong.
Ms. Alkire. Alkire.
Ms. Leger Fernandez. I am from New Mexico, so my apologies
for the mispronunciation.
Ms. Alkire. That is OK, thank you. I think the ladies all
stated very well. It does come down to planning. It does come
down to not feeling the uncertainty of what is going to happen
next.
I mean, our people we have a lot of issues in regards to
trusting systems in the first place, and when we have these
issues with IHS, whether they can pay for something or not pay
for it or the funding ends, as we used to say early, the first
2nd quarter, they just can't help you.
That is devastating, actually.
Ms. Leger Fernandez. Right.
Ms. Alkire. It is just devastating for us.
Ms. Leger Fernandez. Thank you. And on two things, because
I am coming near the end of my time. What I like to say is,
here in Congress we are your WD-40, so when you run into those
problems, with regards to data sharing, which is legally
required, reach out to us.
We will push, to the extent we can. We can't guarantee
anything, but we can get our big can of WD-40, I have a
lifetime supply that comes in every week, because there are so
many things we have to push, so remember to do that.
And I do intend to address the diabetes, because it is a
big issue, so we will be addressing the reauthorization. I will
take that up, and I just wanted to make sure you knew that.
Thank you so much, Madam Chair.
Ms. Hageman. Thank you. The Chair now recognizes Member
Radewagen for 5 minutes of questioning.
Mrs. Radewagen. [Speaking Native language]. Thank you,
Chairwoman Hageman and Ranking Member Leger Fernandez for
holding this hearing today and thank you to the panel for your
testimony.
Indian Health Service direct service facilities have faced
significant medical staffing challenges and currently there is
a scarcity of people entering the medical profession leading to
staffing shortages throughout the healthcare system.
So, in each of your opinions, what are the current
workforce challenges unique to the IHS system and has IHS
provided any recent initiatives to support the tribal
healthcare systems' unique staffing needs?
Ms. Alkire?
Ms. Alkire. I love that question, actually, because I can
answer it in two ways. Definitely, we need more healthcare
professionals. I come from a community; it is rural. I think
where we talk about additional funding for Indian Health
Service, they have a hard time recruiting, I think because a
lot of times we are asking these professionals to come to my
community or our communities that are very rural.
We have one store, one gas station, and you want someone
that probably is going to make a couple hundred thousand
dollars out here to come to where we live. The housing that was
built in our community, I told you our hospital is 60 years
old, the housing is probably about that too.
So, you are asking them to come there. I think that is a
big deterrent, in regards to funding. The other part is, I have
a niece that went to school to be an occupational therapist.
She took advantage of the IHS scholarship.
Unfortunately, when she graduated school and she wanted to
come work for her people and work for us, the IHS told her she
could either go to Alaska or Arizona, to pay it back. And she
was willing to pay it back.
The problem, and this is probably comes down to that
flexibility thing, she did go to Arizona, but eventually,
because we are who we are and these ladies know, we go back
home. So, she came back to North Dakota and now she is paying
back her scholarship.
And, unfortunately, she is not an occupational therapist
anymore because it is discouraging. And she has to get another
job to pay that back. It is just a long story.
I think if IHS could work on that, that would help with
recruitment, but I think it all comes down to additional funds
and resources for the organization to help with that recruiting
effort. To bring those people in, because I think it is going
to be a tough ask to bring them into our communities.
Mrs. Radewagen. Thank you. My time is almost out.
Ms. Alkire. I am sorry.
Mrs. Radewagen. The thing is, I had hoped to hear briefly
from Ms. Church, Ms. Platero, and Ms. Rosette, but Ms. Church?
Ms. Church. Yes. The systems that IHS has in place for
recruitment and onboarding are very slow. So, we have a young
physician that works for us right now and I asked her about her
experience and what she said was, she couldn't even get people
to answer the phone and follow up to her application.
So, she ended up going to the IHS facility, walking in, and
asking for the status of her application. I don't know if it is
because they are understaffed, but they need to improve their
systems so that people don't have to knock on their doors to
work for them.
Again, antiquated facilities, low pay, rural environments
are not attractive to a lot of our providers.
Mrs. Radewagen. Ms. Platero? I think Ms. Rosette's going to
have to submit it for the record.
Ms. Platero. Thank you. Another issue, besides what Ms.
Church stated, is also housing. There is a lack of housing. And
also, many providers don't want to move to rural areas.
In addition, I think if a provider finds out that they may
have a caseload of 900 patients. We have one facility that
currently with their shortage in staffing, they have a caseload
of 900 patients per provider.
And also, there is no, which is really important, there is
no same-day care at many of the facilities, just because they
don't have the capacity, given the limited number of providers
that are available.
Mrs. Radewagen. Thank you. Ms. Rosette?
Ms. Rosette. We don't really have the same problem in our
facility at Spokane because we are in the city. So, as far as
recruiting providers and employees, it has not been that big of
an issue because we do, but on the other side of it, it seems
like they are understaffed. So, it takes us longer to get our
contracts and everything like that. So, that has been our side
of it. It is not necessarily on our own physicians but on
getting contracts from IHS.
Mrs. Radewagen. Thank you very much. It is very important
information, and I often visit Indian reservations when I am
moving around in the states.
Thank you, Madam Chairwoman.
Ms. Hageman. Thank you. Very important testimony. That is
one of the reasons why I really wish that the Representative
from IHS would have been here today. I think that that would
have been important information for them to hear.
I come from a rural area in Wyoming, grew up outside of a
town of about 300 people. Our closest city was about 4,000
people and it was 25 miles away. So, when there was an injury
or something, I can relate to the fact of getting to healthcare
and accessing healthcare.
And I appreciate your comments, and hopefully we can get
the IHS to address some of these. With that, I will recognize
Representative Sablan for his 5 minutes of questioning.
Mr. Sablan. Thank you very much, Madam Chair.
Good morning to our witnesses. In about 3 years, IHS will
be celebrating 50 years of its existence, I will say, and we
still have some of the things you are bringing up today,
problems maybe.
No, problems certainly, but each one of you seem to hint at
the need for additional resources or funding or things for your
communities for Native Americans.
Do you agree funding would help? Because while we do
oversight here, the [inaudible] in another room somewhere,
those are the people who need to hear this.
And, look, with all the best of intentions, no one can
provide everything, but this thing didn't start 47 years ago,
this inequity, it started at first contact with non-Native
Americans a long time ago.
But we need to work and continue to get it better as much
as we can, and I want to thank all of you for your testimony.
At this time, I yield my time to Ms. Leger Fernandez.
Ms. Leger Fernandez. Thank you so much, Mr. Sablan.
I do want to take a little moment of personal privilege and
note that all of our witnesses, the Chair, and the Ranking
Member are all women.
Not to mention anything, I know you are brilliant, Mr.
Sablan and Mr. LaMalfa, but you know, that doesn't happen, it
didn't used to happen, and now it happens with great frequency.
Mr. Sablan. [Inaudible].
Ms. Leger Fernandez. We will fix everything. We can fix
everything, right? We can get that done. So, one of the things
that I wanted to touch on briefly is, thank you Mr. Sablan, it
made me think about the budget issues, right? Because we are
going to go into a budget.
I mentioned on a macro basis what would happen if we would
cut back funding to 2022 levels for IHS. And as we look at the
budget, like, where are those needs the greatest and where
should we not cut back?
Can you tell me what would happen if there would be, let's
a modest 15, you know, not a modest, that would be huge, but a
10 percent cut, a 10 to 20 percent cut on what your budgets
would be? What would that look like at the local level?
I gave you the macro. And it would hit everybody, right?
From urban to Lakota. So, can you share with us quickly, I have
about a minute left on that. Let's start with----
Ms. Church. [Inaudible] which in turn would then help PRC
because we would have those services in house instead of
sending them out. It would also impact our ability to provide
some of the preventative work that we do.
We really take our public health seriously because that is
the first step in making sure that chronic disease doesn't
happen in the first place.
Ms. Leger Fernandez. Ms. Rosette?
Ms. Rosette. Yes. At our facility, the problem with a lot
of the UIOs, we would probably end up having to reduce our
staffing and that is, like was mentioned earlier, we spend half
as much on our individuals as the national average, so taking
10 percent more would take us even down further and we need our
providers.
In Spokane alone, we gained about 10,000 additional
American Indian and Alaska Natives between 2010 and 2020. So,
reducing that would just put a greater burden on the problem.
Ms. Leger Fernandez. Ms. Platero?
Ms. Platero. For our area, we don't have an IHS or tribally
operated hospital. So, for us it would result in reduced
purchasing referred care, which would mean less specialty care
and the ability or the lack thereof to be able to provide for
higher levels of priority.
As it is, we are already feeling medical inflation and less
funding and to have a cut of 10 percent would be drastic to the
Northwest.
Ms. Leger Fernandez. OK. Ms. Alkire, I am sorry that I have
run out of time, but I would welcome if you would like to
submit, if anybody would like to submit, written testimony in
response to what that would mean at your level? Because you
painted some of the big broad strokes, what does that mean, in
terms of the baby who won't get prenatal care, the mother who
won't get preventative care so that she has a healthy baby, if
you could just kind of describe what that would look like, I
think that would be very powerful as we look at it. Thank you
very much.
Ms. Hageman. The Chair now recognizes Mr. LaMalfa for his 5
minutes of questioning.
Mr. LaMalfa. Thank you, Madam Chair. I also share your
disappointment with the IHS not sending representation today as
the interactions are extremely important here, but maybe
another round.
So, thank you panelists for your time and for your travel
to get here all the way to DC. A couple of questions. I wanted
to follow up on facilities and I think Ms. Platero, you
represent Northwest Portland, is that considered, for IHS
purposes, urban?
Ms. Platero. No. We represent the 43 tribes of Washington,
Oregon, and Idaho.
Mr. LaMalfa. Yes.
Ms. Platero. Our office is based in Portland.
Mr. LaMalfa. But none of your work is in urban area then?
Ms. Platero. No, it is not.
Mr. LaMalfa. All right. Thank for you clarifying that. My
understanding is that there are difficulties sometimes within
the way IHS administers the dollars for facilities to get the
funding allocated.
I understand it is an urban problem, but for rural
facilities as well, for facility maintenance, equipment, et
cetera, they are not able to use that general IHS budget for
that. Is that something that, I see you nodding your head too,
but Ms. Platero and then we will come to Ms. Rosette too.
Ms. Platero. That is correct for the Portland area. For
healthcare facilities construction, we haven't received, or our
tribal facilities haven't received, funding in over 15 years
for----
Mr. LaMalfa. And it is ineligible? Is it somehow ineligible
according to IHS?
Ms. Platero. There is a great need for facility
construction, so the wait list is very long. There is a
priority system that currently exists so that our tribes
basically have to pay for their own facilities with their own
funds.
Mr. LaMalfa. But I guess more zeroing in on it, are some of
those funds you are just flat ineligible because of the way IHS
categorizes them or is more of just the back end?
Ms. Platero. There are just not enough funds.
Mr. LaMalfa. There is not enough? OK.
Ms. Platero. It is significantly underfunded for
construction.
Mr. LaMalfa. OK. Thank you. Ms. Rosette, you are nodding
too?
Ms. Rosette. Yes. Urban Indian organizations are only
included within IHS's budget through an Urban Indian Line Item.
We do not receive direct funds from most of the other distinct
IHS line items, such as hospitals and clinics, Indian health
professionals, or facilities.
So, yes, we only are eligible under the Urban Indian Health
line item and do not have access and are not eligible for any
kind of facilities funding.
Mr. LaMalfa. OK. Ms. Church, I was referring back to some
information, going back to the Dorgan Report of 2010, and some
of the issues they had brought up with IHS in that report are
pretty shocking.
Some of the things listed are missing or stolen narcotics,
as well as not strong pharmaceutical audits, backlogs in
billings and claims, and discouraging the employees there from
communicating with us as overseers in Congress, and personnel
issues, et cetera, et cetera.
So, since 2010, when that report came out reviewing things
pre-2010, what do you see has improved in that area with IHS's
performance within?
Ms. Church. Yes. Sure. In the beginning, Indian Health
Service responded the best they could. They came in and they
started to work with the facilities in the Great Plains and
many of the direct service units are now accredited, but they
have not been able to sustain that level of activity and
quality assurance in order to keep it there.
So, without additional funding, I imagine that it won't be
long until they are back to the same place they were before.
Mr. LaMalfa. So, a tick of improvement, but then quickly
falling off, you think?
Ms. Church. Yes. Because it takes a great deal of resources
and it takes human capital to----
Mr. LaMalfa. And retention must be very difficult, as we
are talking about rural, whether it is Indian healthcare or in
general, rural healthcare, which I face in a very rural
district with many tribes, and in small-town healthcare, it is
very tough to get and retain people there.
So, the time has already eclipsed. Madam Chair, I will
yield back and hope for a second round perhaps.
Ms. Hageman. Why don't we go for a second round of
questions. I have a couple of questions that I wanted to ask,
specifically to Ms. Church. You mentioned in your statement,
the lack of staffing at Great Plains IHS facilities and that
you think improvements in recruiting and retention will not
only improve care, but eventually be cost effective.
Could you further expand on that and what recruitment and
retention initiatives you have found to be useful and
effective?
Ms. Church. What we believe at Oyate Health Center, I can
speak from the tribal perspective, is that we have to grow our
own. We run a health facility, but we also run, what I call a
learning facility.
We create opportunities within every area of Oyate Heath
Center to foster additional training for our current employees
and we want to become a learning center for programs, whether
it is phlebotomy, or our next goal is residency.
If you are fostering your own community and your own staff,
they are more likely to stay and the commitment is there, not
because they have an IHS payback, but because they believe in
the mission.
Ms. Hageman. OK. And I just wanted to ask Ms. Platero--
actually, Ms. Rosette--do all of the urban areas in the United
States have Indian Healthcare Services that they provide?
Ms. Rosette. There are some of them. I mean, there are some
that provide alcohol treatment and some of them provide
referrals for medical care. There is outreach and referral.
There is limited ambulatory and then there is full ambulatory.
So, there are three different types of services they can
provide, so in some form, yes.
Ms. Hageman. OK. Thank you. I will then go ahead and turn
to the Ranking Member Ms. Leger Fernandez for her supplemental
questions.
Ms. Leger Fernandez. Thank you. And I love the fact that
many of my supplemental questions were asked by my colleagues
on this panel, so we are clearly all on the same wavelength as
wanting to make sure that things get better in Indian Country.
And that is why I love this Committee, because it is so
bipartisan, recognizing that we have problems and recognizing
that we will find solutions for them.
I wanted to quickly ask the panelists a bit about the data
sharing. Give us a little context, and Ms. Church, I think you
spoke the most about it, about the agency practices that need
to be changed to be able to facilitate better communications,
and Ms. Rosette, if you see that something isn't answered with
regard to UIOs that would be great.
Ms. Church?
Ms. Platero. Sure. IHS needs to partner with us and see the
Heath Boards and the Epi Centers as a resource for them. If we
are partnering together, we are in the communities.
If the state goes to one of our reservations to address
syphilis, the people there are not going to talk to them. They
are not going to trust them. We will work with our own tribal
leaders and our own tribal health directors to identify those
folks that need to be brought to treatment.
By working together, IHS is going to be more successful as
well. I don't understand the issue with not wanting to share
data when it is so clearly stated in statute. I never
understood and it has been a long, long battle.
Ms. Leger Fernandez. Thank you very much. And did you want
to add anything to that, Ms. Rosette, regarding the Urban
Indian Health organizations?
Ms. Rosette. Yes, just that a lot of us, several of us are
not on the IHS's RPMS system. So, we have other off-the shelf
EHR systems and our data, it is hard to get our data to them
with the antiquated system that they have. And when we do send
data to IHS, it is often recorded wrong or there is always a
problem with our numbers.
I think if we had some formal system, EHR system, where we
could talk to each other and share our data easily, that would
be very helpful.
Ms. Leger Fernandez. Thank you. And I know former Chair and
now Ranking Member Grijalva had a bill that dealt with part of
encouraging more collaboration between the Urban Health Units
and this is another piece of that that definitely--what the
frustration is, it is already in statute, right?
But the need that came up last cycle that we discussed was
the need to be seen as partners in this. Your statement is so
accurate.
And Ms. Alkire, share with us the culturally relevant story
you wanted.
Ms. Alkire. Thank you. I would love to. I talk about this
story because it talks about identity. It talks about
definitely about our culture. You talked about the facilities.
I am trying to get us a new medical facility.
I know IHS is not going to pay for it. I know, as a tribal
chairwoman, I am having to try to think innovatively to look at
ways to get this hospital built for our people, but I am hoping
and, as you said, the IHS is going to staff this for us.
So, I am very hopeful, no matter what, but the story I
wanted to share with you all is the Grandma story and this is
about, we call it [Speaking Native language]--I can't even say
it now.
[Speaking Native language] and basically, what is it is to
touch the Earth. My passion is to have our babies born on
Standing Rock. In the Great Plains, there is only one unit, one
hospital that delivers babies yet and that is the Pine Ridge
Indian Reservation, the rest of them don't.
We all became clinics. Now our babies, like I said, are
born in these places far away. What [Speaking Native language]
basically means is that when our babies are born and when the
mother, when her water breaks how our ancestors did it, that
was the ground, that was the place that that baby would be tied
to.
I feel, and I don't know where this come from, but I feel
in my heart that this is also a big break in who we are as a
people, that our people are born in these communities that they
are not related to culturally and these ceremonies can't be
done because now, I feel like, our babies would be lost again.
They start right at the beginning and the way we did it was
we take the baby, and we touch them to the Earth of the ground
where the water was broken so they are tied to the Earth.
And I say this, I have to use this example. We see now the
geese flying North. That is because they are going back to
where their babies are born. Turtles travel thousands of miles
to go back to where they belong.
Us, as a people, I feel I want our babies born on Standing
Rock, it is going to be hard already, I want them to feel like
this is where they belong. They will never be lost.
Ms. Leger Fernandez. Thank you. That is a beautiful story,
and my time has expired. I yield back.
Ms. Hageman. Thank you. The Chair now recognizes Ms.
Radewagen for additional questioning.
Mrs. Radewagen. Thank you, Chairwoman Hageman.
Several testimonies mentioned traditional healing practices
and that further integration of those practices would be useful
for healthcare delivery to Native peoples.
So, I wanted to give each of you the opportunity to expand
on that, particularly, how those practices have been beneficial
to tribal members and how IHS could encourage use of them in
both direct service and tribally run health programs.
Ms. Church?
Ms. Church. Sure. How we are approaching integrating
traditional healers, teachers at Oyate Health Center is we are
developing a cultural advisory board. I have identified
knowledge keepers across the region, and they guide us on how
to do that appropriately.
It is very sensitive because in our tradition, our
traditional healers don't ask for money. They don't say, this
is my fee, right? So, we have to look at innovative ways to
support them and to find ways to have those ceremonies
appropriately, but still integrate them with the work that is
being done in the clinical setting.
So, they tell us what is appropriate and what is not
appropriate. Some of the ceremonies, they say, it is not
appropriate to do it at the health center, but send them to
this healer or to that healer.
A lot of our physicians and even some of our own tribal
members may not have grown up with those traditions, so there
is a longing for knowledge. And when we are advocating for
people to take care of themselves, if we are incorporating
those teachings that they may not have heard before or maybe
their parents or grandparents, they come, they show up for
their appointments, they show up for health education, and they
show up for ceremony. And families are strengthened, and their
spirits are strengthened.
Mrs. Radewagen. Ms. Platero?
Ms. Platero. Thank you. Traditional healing practices are
definitely part of the holistic approach to care. You can't
have healing without addressing the spiritual aspect of a
person.
Similar to what Ms. Church said, our people will show up to
appointments, events that are focused on a cultural practice
event, whether it is a healer or an activity. For our tribal
clinics and tribes, they have been asking for traditional
healing practices to be reimbursed under Medicaid and Medicare.
This is one way that would allow for continuity of these
services, so that when there is some kind of cost involved,
they are paying a healer, there is the ability to pay that
person and keep the service going, thus improving holistic
healthcare for people in our communities.
Mrs. Radewagen. Ms. Alkire?
Ms. Alkire. I agree with the ladies, basically, I don't
want to take up too much time. I feel like I ramble on, but I
wanted to talk traditional. During COVID, we had a lot of our
people who did not take the immunization, because they don't
believe in it.
So, we have to rely on our traditional healers, and they
do. I think it all comes down to communication. IHS needs to
hear that and definitely allow these things to happen. I think
we can all get there, though. Thank you.
Mrs. Radewagen. Ms. Rosette?
Ms. Rosette. Yes, thank you. We are also supposed to
[inaudible] healing within their own facilities. We have not
yet implemented that into our UIO because we don't have the
space for it right now. We don't have a job description for a
traditional healer, so to hire somebody, it has to be somebody
that is willing to do that work for you.
So, in our facility, that is what we want to find somebody
that is known as a healer, but it is hard to find that type of
person that wants to do that in a facility like ours.
Mrs. Radewagen. Thank you, Madam Chairwoman. I yield back.
Ms. Hageman. Thank you. And now for the last set of
questions, the Chair recognizes Mr. LaMalfa.
Mr. LaMalfa. Thank you, Madam Chair.
Keeping it compact, I appreciate it. Let's see, I want to
ask our panel here about mobile health clinics and, obviously,
most tribes face the rural issues, the rural challenges.
So, mobile clinics could be a very, and probably are, and
that is why I want to hear from you. How important are they to
the far-flung rural tribes that have a chance to utilize those
and what are the issues with them or with having more of them?
And are there any regulations that you see that are standing in
the way of their further expansion?
And I will stop there and maybe ask a second question on
that.
Are they something that tribes wish to use more? Is there
something stopping them from doing so? Ms. Alkire, I will start
with you.
Ms. Alkire. I will be honest; I haven't seen very many of
them lately. I used to see mobile units come for women's
clinics and I don't know if IHS resources have gotten scarce,
so I don't see them.
Mr. LaMalfa. You wish for more of them?
Ms. Alkire. Yes.
Mr. LaMalfa. OK. You are not seeing them----
Ms. Alkire. And that would be helpful because the
reservation I come from is 2.3 million acres. It straddles both
North and South Dakota and a lot of our communities are far
apart from one another.
And our one medical facility is on the North Dakota side,
and so it takes a long time for them to get to those
appointments.
Mr. LaMalfa. OK. I want to get to the other panelists, but
you don't see it enough? Are there any barriers by IHS stopping
them from happening?
Ms. Alkire. I think the barriers are just lack of
resources. They just don't have the money to have them.
Mr. LaMalfa. OK. Thank you. Let's keep moving. Ms. Church?
Ms. Church. Yes. If you have a limited budget and you need
to prioritize inpatient or ambulatory care and choose between a
new program with mobile units, you are going to focus on your
internal services.
Mr. LaMalfa. Your brick and mortar? Yes. So, you are not
aware of IHS barriers or any regulation against having them? It
is more funding, probably, again?
Ms. Church. Exactly.
Mr. LaMalfa. OK. Ms. Platero, what do you think?
Ms. Platero. I am not aware of any barriers. I would say
that a way to increase providers in rural areas is the
community health aid program expansion. That is a way to grow
your own and have more providers in rural areas.
Mr. LaMalfa. OK. Ms. Rosette, what do you think?
Ms. Rosette. I am in an urban area, so the mobile vans are
not really an issue there, but transportation is. So, even
though we have a bus system at IHS, there is no barrier though
from IHS for us to have a mobile van.
Mr. LaMalfa. OK. So, funding probably? All right.
Ms. Rosette. Yes.
Mr. LaMalfa. Let me ask all the panelists, you have 2
minutes. How do you feel about the delivery of healthcare via
an in-house IHS system versus a tribal operated, you know, the
tribe runs itself instead of under IHS's umbrella?
How well is IHS delivering the product versus when the
tribe has more self-control over it? Ms. Alkire?
Ms. Alkire. Do you want to take this?
Ms. Church. Sure. Rapid City Service Unit was one of those
facilities at CMS where they lost their accreditation or
certification, and they were not able to provide the level of
care that the community needed.
Since Oyate Health Center was established, we have so much
more flexibility on every level. We hire people faster. Most
importantly, we get to hold people accountable if they are
not----
Mr. LaMalfa. And IHS isn't doing that when they are
operating it, is that----
Ms. Church. It is very hard for them to hold people
accountable because of the Federal H.R. laws.
Mr. LaMalfa. Yes. Yes.
Ms. Church. So, that is the biggest thing, we can foster
people to grow professionally, and we can hold people
accountable who are not doing their jobs.
Mr. LaMalfa. OK. Thank you. Ms. Platero?
Ms. Platero. Self-governance tribes or tribes that run
their own health programs are able to make decisions as to
funding, like moving funding through sub-accounts from clinical
or healthcare to behavioral health. I mean, they can make those
on-site decisions to improve healthcare.
Mr. LaMalfa. OK. Ms. Rosette?
Ms. Rosette. It is not applicable in the urban setting.
Mr. LaMalfa. OK. All right. Well, bottom line in here is
you would like the funding challenges and more flexibility to
come from within the tribe than from 2,000 miles away?
OK. Thank you. Well, my own experience is that one day I
was in district, and all of a sudden had a tooth problem and
was able to pop into a tribal clinic where I knew the folks and
such and been working with them, and they fixed me up in no
time. And it was really great, at least getting me to where I
can get to my dentist to do the longer-term work. So, I like
that experience.
Madam Chair, thank you. I yield back.
Ms. Hageman. Thank you. I want to thank the witnesses for
the valuable testimony that you have provided today, and again
for your willingness to travel to Washington, DC so that we
could hear directly from you.
I also want to thank the Members for your questions and
your willingness to engage on this incredibly important
subject.
The members of the Committee may have some additional
questions for the witnesses, and we will ask you to respond to
those in writing. Under Committee Rule 3, members of the
Committee must submit questions to the Committee Clerk by 5
p.m. on Monday, April 3, 2023.
The hearing record will be held open for 10 business days
for these responses. And if there is no further business,
without objection, the Committee stands adjourned.
[Whereupon, at 11:30 a.m., the Subcommittee was adjourned.]
[ADDITIONAL MATERIALS SUBMITTED FOR THE RECORD]
Submissions for the Record by Rep. Westerman
Statement for the Record
Frank Star Comes Out
President of the Oglala Sioux Tribe
The Oglala Sioux Tribe appreciates the opportunity to submit
testimony for the record for this important Subcommittee hearing.
Improving the healthcare delivery to tribal communities, especially to
our people on our Pine Ridge Indian Reservation, is one of our Tribe's
highest priorities. It is past time for the Federal Government to take
the bold actions required to finally ensure our people have the high
quality of healthcare they deserve. Our Treaty requires it. For too
long our people have suffered from inadequate healthcare delivery. We
hope this testimony will help Congress finally fix this.
Introduction
The Oglala Sioux Tribe has approximately 54,000 members. It is a
member of the Oceti Sakowin (Seven Council Fires, known as the Great
Sioux Nation). The Tribe was a party to an 1825 Treaty (7 Stat. 252),
which in Article 2, brought the Oglala Sioux Tribe under the protection
of the United States and the Oglala Sioux Tribe has been a protectorate
Nation of the United States ever since. This treaty established the
legal relationship between the Oglala Sioux Tribe and the United
States. The Oglala Sioux Tribe is also a signatory to the Fort Laramie
Treaty of 1851 (11 Stat. 749) and the 1868 Sioux Nation Treaty (15
Stat. 635). The Fort Laramie Treaties of 1851 and 1868 cemented the
United States' obligations to the Oglala Sioux Tribe. In Articles IV
and XIII of the Fort Laramie Treaty of 1868 the United States
specifically committed to providing healthcare to the Sioux people. In
Rosebud Sioux Tribe v. United States, the Eighth Circuit affirmed that
the U.S. Government has a judicially enforceable duty to provide
competent physician-led healthcare to us as a signatory of the Fort
Laramie Treaty of 1868, and because of the numerous promises and
commitments the Federal Government has made to provide healthcare for
Tribes.\1\ Despite this, the chronic underfunding of the Indian Health
Service (IHS) and Indian Country programs in general has taken an
enormous toll on our Tribe and our citizens.
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\1\ See Rosebud Sioux Tribe v. United States, 9 F.4th 1018 (8th
Cir. 2021); and see Blue Legs v. U.S. Bureau of Indian Affairs, 867
F.2d 1094 (8th Cir. 1989) (Snyder Act imposes affirmative obligations
on Federal Government to provide healthcare to Tribes).
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We look to you to fulfill the Federal Government's obligations, and
we look forward to working with this Subcommittee to ensure the legal
and policy authorities are in place along with fully-dedicated funding
for the IHS programs that serve Tribal Nations and Native people so
that our people get the high-quality healthcare they deserve. We
emphasize that our Tribe is a direct service tribe: our healthcare is
delivered directly from the IHS as a treaty obligation, with certain
programs that we have contracted to carry out ourselves. Thus, we need
Congress to dedicate full funding to the IHS to carry out its treaty
obligation to deliver high-quality healthcare to our people and full
funding to the specific programs we carry out via 638 contracts with
the IHS.
Full funding of Indian Country healthcare programs is demanded of
the Federal Government because of the Treaty and trust obligations owed
to our people. Any cuts to such programs would be devastating given the
historic and severe underfunding of such programs and the impact that
has had on our people. All of the Indian healthcare programs need
attention. Below, however, we focus on certain specific high priorities
for our healthcare. We also lay out the overarching needs of our
Reservation and the Great Plains Area overall, which warrant
congressional action to address.
First, to focus the vast and desperate need to correct the
healthcare delivery inadequacies on our Reservation and in the Great
Plains Area, we remind you of former Chairman Byron Dorgan's 2010
Senate Committee on Indian Affairs Report, In Critical Condition: The
Urgent Need to Reform the Indian Health Service's Aberdeen Area
(commonly known as the ``Dorgan Report.'') The Dorgan report identified
``deficiencies in management, employee accountability, financial
integrity, and oversight of IHS' Aberdeen Area facilities'' and
reported that ``these weaknesses have contributed to reduced access and
quality of health care services available to patients.'' \2\ The Pine
Ridge Service Unit, which provides healthcare for the Oglala Sioux
Tribe, had the second highest incidence of employee grievances in the
Aberdeen Area.\3\ The Report chronicled ``substantial'' diversion of
health care services due to a range of issues ``including a shortage of
providers, inadequate reimbursement from public and private insurers,
and lack of bed availability.\4\ The Dorgan report also identified a
linkage between the understaffing of pharmacist positions in IHS
facilities with a substantial issue in the area of loss and theft of
narcotics and controlled substances from these pharmacies.\5\ In
addition, ``[o]ther reasons for service diversions included: no
available inpatient beds, nonworking equipment, water outages, and high
humidity.'' \6\ We regret to report that, unfortunately, such severe
problems have persisted almost thirteen years later.
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\2\ U.S. Senate Committee on Indian Affairs, In Critical Condition:
The Urgent [Need] to Reform the Indian Health Service's Aberdeen Area,
4 (Dec. 28, 2010) (``Dorgan Report'').
\3\ Dorgan Report, 14.
\4\ Id. at 19.
\5\ Id. at 15.
\6\ Id. at 20.
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More recently, the Government Accountability Office (GAO) testimony
addressed the quality of healthcare provided by the IHS and concluded
that the IHS provided limited and inconsistent oversight over the
timeliness and quality of care provided in its facilities, and that
those ``inconsistencies in quality oversight were exacerbated by
significant turnover in area leadership.'' \7\ In addition, the GAO
testimony reported that incomplete funding of the Purchased/Referred
Care program has resulted in gaps in services that delay diagnoses and
treatments, which can exacerbate patient issues and necessitate more
intensive treatment.\8\ We also point you to the 2018 Broken Promises
Report, which conveys that the problems with the Federal Government's
delivery of healthcare to Native people persist, stating ``[O]ver the
years, Native American health care has been chronically underfunded''
and cites statistics showing that in 2017, IHS health care expenditures
per person were $3,332, compared to $9,207 for federal health care
spending nationwide.'' \9\ These reports provide a mere sketch of what
healthcare looks like for our people.
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\7\ Government Accountability Office, High Risk: Status of Prior
Recommendations of Federal Management of Programs Serving Indian
Tribes, 2, GAO 17-790T (Sep. 13, 2017).
\8\ Id. at 19.
\9\ United States Commission on Civil Rights, Broken Promises:
Continuing Federal Funding Shortfalls for Native Americans (December
2018) at 66-67; see all of Chapter 2 for discussion of Health Care; see
also Government Accountability Office, Indian Health Service: Spending
Levels and Characteristics of IHS and Three Other Federal Health Care
Programs, GAO-19-74R (Dec. 10, 2018).
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We support the testimony provided to the Subcommittee by Jerilyn
Church on behalf of the Great Plains Tribal Leaders Health Board.
However, we note that there were no witnesses presenting at the hearing
representing direct service tribes. As a direct service tribe, we
implore you to take action to address the following issues.
I. Protect & Strengthen the Indian Health System
Modernize the Funding Model: the President's FY 2024 Request
A. Move the Entire Indian Health Service Account to Mandatory Spending
and Fully Fund the Indian Health Service
At present, Indian Country healthcare is frustratingly vulnerable
to federal shutdowns and Indian Country healthcare is the only major
federal healthcare system subject to this treatment. The healthcare
provided by the Veterans Health Administration--the Federal
Government's other non-entitlement health program--is not subject to
federal shutdowns, and the same should be true for the Indian Health
Service. We, therefore, urge Congress to move the entire Indian Health
Service (IHS) account over to mandatory spending. Our Treaties call for
this. These changes would ensure that our services are not interrupted
by political machinations far outside of our control. Continuous
funding will also ensure that Native people are no longer treated as
second class citizens--entitled only to a lesser type of federal
healthcare.
Barring the mandatory and full funding of all IHS accounts,
Congress must do everything in its power to minimize service
interruptions for the Indian Health Service. The Consolidated
Appropriations Act of 2023 took the monumental first step toward
sustainable funding of the IHS by providing advance appropriations for
FY 2024. But Congress must maintain this momentum and provide advance
appropriations once again. We urge you to provide advance
appropriations for FY 2025 and beyond so that health care programs can
actually undertake long-term planning and our patients can rest assured
that their treatments will continue even in uncertain political times.
Relatedly, we support the proposal to immunize IHS from the federal
budget sequestration process.\10\ Healthcare cannot be something that
is blindly cut as the collateral damage of a political impasse in
Washington, D.C.
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\10\ Department of Health and Human Services, Fiscal Year 2024
Indian Health Service Justification of Estimates for Appropriations
Committees, (hereafter IHS Budget) CJ-248.
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In addition to making the entire Indian Health Service Account
mandatory spending, Congress must FULLY fund the IHS. The President's
2024 IHS budget includes a 10-year plan to close funding gaps, a move
that we support because it would not only provide greater stability for
the IHS but it would provide more money for healthcare programs. While
we do support this request, the bottom-line is that Congress must fully
support the IHS so it and the tribes that contract or compact its
programs, services, functions and activities can do so at the level of
need and without being extremely under-resourced, as they are now--
especially in the Great Plains Region.
B. Permanently reauthorize the Special Diabetes Program for Indians
Congress must reauthorize the Special Diabetes Program for Indians
and should do so before the program expires later this year. The
Program has been a tremendous success story for public health and for
Indian Country. From 2013 to 2017, diabetes in American Indian and
Alaska Native adults decreased from 15.4% to 14.65%; and end-stage
renal disease due to diabetes fell by 54% between 1999 and 2013.\11\
What these numbers hide, however, is that the incidence of these health
outcomes not only did not rise, but fell despite an increasingly
unhealthy dietary and lifestyle environment of fast-food, processed and
pre-packaged meals, and reduced mobility. In addition, the Office of
the Assistant Secretary for Planning and Evaluation reported in 2019
that the 54% decrease in end-stage renal disease in American Indian and
Alaska Native populations saved Medicare an estimated $436 million to
$520 million over a 10-year period.\12\ The Program is doing what
Congress intended it to do, and it has returned measurable success.
Permanent reauthorization and continued funding of this program will
ensure that the hard work and resources that made the last twenty years
of the program a success will not be lost and that we will keep making
strides for the next generation. Accordingly, we support the
President's budget request of $250 million for the program for FY 2024,
$260 million for the Program for FY 2025, and $270 million for the
program for FY 2026,\13\ and we implore Congress to permanently
reauthorize the Program.
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\11\ National Indian Health Board, SDPI Overview https://
www.nihb.org/sdpi/sdpi_overview.php (accessed Mar. 30, 2023).
\12\ Office of the Assistant Secretary for Planning and Evaluation,
The Special Diabetes Program for Indians: Estimates of Medicare Savings
(May 9, 2019) https://aspe.hhs.gov/reports/special-diabetes-program-
indians-estimates-medicare-savings.
\13\ IHS Budget, CJ-242.
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C. Implement the North And South Dakota State-Wide Purchased/Referred
Care Delivery Area
We support the President's proposal to appropriate $12 million to
actually implement the North and South Dakota State-wide Purchased/
Referred Care Delivery Area (PRCDA).\14\ However, the budget must also
include additional funding to pay for the additional Purchase Referred
Care (PRC) services that will be needed as a result of expanding the
PRCDA. As the President's request notes, a 2010 amendment to the Indian
Healthcare Improvement Act directed the IHS to establish this
Purchased/Referred Care Delivery Area, but the IHS has not done so.
Establishing this Delivery Area will ensure that tribal members located
anywhere within those states are able to access needed Purchased/
Referred Care services. This is critically important as many of our
members live in the State but outside the current PRCDA and therefore
are not eligible for PRC services even though they desperately need
them. IHS estimates that implementing this provision will provide
services to 24,000 tribal members in the Dakotas.\15\ This provision of
the Act must finally be implemented and adequate additional funding
must accompany this authorization.
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\14\ IHS Budget, CJ-136.
\15\ Id. at CJ-137
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D. TRANSAM Program
The President's FY 2024 budget requests $500,000 for the TRANSAM
program so that IHS can purchase medical equipment and ambulances from
the Department of Defense. While we wholeheartedly support the
acquisition of needed equipment and vehicles for IHS and tribal
facilities, we object to this manner of acquisition. First, the
Department of Defense and the Indian Health Service are both arms of
the Federal Government. Under this model, the Indian Health Service--
one of the most historically and egregiously underfunded federal
agencies--is required to draw funds from its budget to pay the
Department of Defense--one of the wealthiest and most excessively
funded federal agencies--to gain access to basic healthcare delivery
necessities. Taxpayer dollars helped fund the Department of Defense's
purchases of this equipment. There should not be another toll,
especially one that will severely impact Native peoples via a reduction
in IHS dollars. Congress must fix this facially inequitable policy and
authorize the Defense Department to donate the equipment to the IHS.
Modernize the Funding Model: Other Proposals
Congress must fully fund and implement all provisions of the Indian
Healthcare Improvement Act.\16\ Those heretofore unfunded authorities
in that Act are expected to help with workforce development, behavioral
healthcare, and substance use management, and are expected to improve
access to healthcare generally, but for long-term and home-based care
in particular.\17\ Fully funding these provisions will provide long-
overdue resources for IHS and tribal facility construction and
maintenance projects to ensure that our community has access to modern,
state-of-the-art healthcare facilities.
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\16\ National Indian Health Board, 2022 Legislative and Policy
Agenda for Indian Health, 14-15 https://www.nihb.org/covid-19/wp-
content/uploads/2022/04/2022-NIHB-Legislative-and-Policy-Agenda-.pdf.
\17\ Id.
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We support the 2022 policy recommendations of the National Indian
Health Board regarding Medicare reforms to improve access to and obtain
financial support for Indian healthcare.\18\
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\18\ National Indian Health Board, 2022 Legislative and Policy
Agenda for Indian Health, 47-49 https://www.nihb.org/covid-19/wp-
content/uploads/2022/04/2022-NIHB-Legislative-and-Policy-Agenda-.pdf.
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The Federal Government should facilitate tribal governments'
decisions to assume healthcare delivery, but it also must acknowledge
and act on the fact that even when those assumptions occur the Federal
Government cannot evade its Treaty and trust obligations. That said, we
support the expansion of contracting and compacting under Titles I, V,
and VI of the Indian Self-Determination Education and Assistance Act
and the opportunity for to decide for themselves how best to ensure
their citizens have the best healthcare services possible. The Federal
Government must support tribally run programs, but also continue to
uphold its Treaty and trust obligations whether a Tribe is direct
service, operates entirely under a 638 contract, or some combination.
We emphasize that our Tribe is a direct service tribe: our healthcare
is delivered directly from the IHS as a treaty obligation, with certain
programs that we have contracted to carry out ourselves.
Provide Adequate Supportive Infrastructure
We have significant infrastructure problems in the Great Plains
region. In particular roads, bridges, and culverts are in terrible
shape, despite our repeated pleas for federal assistance. These
conditions delay emergency response times and at times our roads are
impassable. If we are going to seriously address the challenges of
healthcare delivery in the Great Plains Region, we need Congress to
also take bold measures to build and maintain our roads so that they do
not pose a hindrance to routine and emergency medical care. Congress
must adequately fund the Bureau of Indian Affairs roads accounts and
create a new roads maintenance account, not subject to the formula,
that targets backlogged road and bridge projects by taking mile
inventory, remoteness, and weather conditions into consideration.
Conduct an Audit of the IHS
Tribes have a right to know exactly where federal appropriations to
the IHS go, especially direct service tribes like ours. We ask Congress
to require the IHS to conduct a comprehensive audit at the Central,
Regional and Service Unit levels, and make that audit available for
Tribes to review and comment on in government-to-government
consultation.
II. Build the Healthcare Workforce
We need Congress to employ a multi-faceted approach to improve the
healthcare workforce. Most urgently, we need Congress to appropriate
funds and legislate additional enticements for the recruitment and
retention of healthcare workers for Indian Country and specifically on
our Pine Ridge Reservation. These funds and enticements must cover not
only physicians, dentists, and other specialists, but must support the
employment of administrative professionals and other staff. At a
minimum, these resources must support full staffing of our current
facilities. Salaries must be competitive with other healthcare
positions so that we are not losing professionals to wealthier areas of
this country. Moreover, given the unique hardships on the Pine Ridge
Reservation, we support the idea that healthcare workers in our area be
entitled to higher and/or hazard pay to incentivize them to come and
serve our community.
Because of the urgent need to fill positions in our area, we
support the President's proposals regarding discretionary Title 38
hiring authorities for IHS, authority for IHS to conduct 60-day mission
critical emergency hiring, application of Title 38 on-call pay to IHS,
and authority for IHS to hire and pay experts and consultants to
address particularized needs.\19\
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\19\ IHS Budget, CJ-287-88, CJ-295-96, CJ-298-99, CJ-296-97.
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It is important to not only recruit healthcare workers to our
Reservation, but also to retain them. This is the only way our people
can even begin to receive any continuity of care: through healthcare
providers who get to know them, which, importantly, will lead to our
people coming to trust them. As it stands now, our people have very
little trust in the IHS's Pine Ridge Service Unit. This is a core
problem that needs to be addressed. Retainment of healthcare
professionals on our Reservation would be a good first step toward
addressing this core problem.
We also need Congress to provide funding for our community to build
the housing units necessary to support our healthcare workforce. As we
have testified before to many different committees, we have a housing
deficit of 4,000 homes on our Reservation. We cannot attract (or
retain) healthcare professionals to our area if we have no place for
them to live. Our reservation is approximately the size of the entire
country of Cyprus; it is simply too vast for healthcare providers to
commute long-distance. We need housing directly in the vicinity of our
facilities.
We need Congress to get to work on growing the healthcare
professional pipeline for Indian Country. We need additional funding
and authorities that would better facilitate an educational and
training pipeline for more Native people to join the ranks of
healthcare professionals. Congress should also expand the availability
of scholarships and loans for medical education in service of Indian
Country and should expand loan forgiveness for similar service. The
cost of graduate medical education has surpassed the value of the
incentives Congress is currently providing. These programs must also
provide flexibility for graduating students to choose to go home to
serve their communities. As a small step toward addressing these
issues, we support the President's proposals to provide federal income
tax exemptions for scholarship and loan repayment funds and to permit
scholarship and loan repayment on a half-time but double duration
basis.\20\
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\20\ IHS Budget CJ-291-92, CJ-289-290.
Our native community has brilliant, hard-working, and service-
minded students who want to work for the benefit of our people. The
Community Health Aide, Dental Health Aide, and Behavioral Health Aide
Programs that debuted as pilot programs in Alaska work to train Native
students to provide culturally informed community-based care. This is
consistent with how we have healed our sick since time immemorial.
Congress should fund these programs at scale across Indian Country as
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soon as possible.
Relatedly, we need resources to provide traditional healing to
ensure that our healers can take care of themselves while they take
care of others. It is often the case in our tradition that our healers
do not ask for money or compensation in exchange for their services, as
such a transactional concept is not native in origin. Nevertheless, we
recognize that our healers need to be able to provide for themselves in
a modern capitalist economy. Accordingly, we need for IHS and tribal
facilities to have the flexibility to support our healers in various
ways. First, reimbursement of traditional healing services through
Medicare and Medicaid would help our facilities support our healers and
our patients who request their services. Second, we need healthcare
coverage for tribal healers to provide services outside of the physical
clinic environment because some ceremonies are not appropriately
conducted nor possible inside a health clinic. We need for our healers
to be able to provide covered care in the manner they see fit,
unrestrained by federal statute or regulation. We also need the Federal
Government to respect us and our healers when we decline to provide
details about sensitive traditional knowledge and ceremonial practices.
Finally, Congress should devote attention and funding to
cultivating a pool of talented professionals able to competently teach
our youth by focusing on culturally relevant professional development
(in collaboration with Tribal colleges and universities). Science,
technology, engineering, the arts, and mathematics (STEAM) training and
education is especially important to building holistically trained
healthcare professionals to serve our Tribe. With that in mind, our
Tribe is working toward creating a Tribal Research and Training Center,
which would encourage our citizens to pursue careers in STEAM fields.
The Center would also serve as a data and research hub where we can
research, collect, and analyze our own data for use in support of
initiatives to benefit our citizens in a broad spectrum of areas from
health to economic development. Facilities that house valuable
professional development in the community improve health outcomes and
are the backbone of a healthy economy. We ask for financial support as
we pursue this project.
III. Learn from the Pandemic
The pandemic taught us many lessons, the importance of an emergency
response plan chief among them. We struggled to navigate federal
bureaucracy during the pandemic to access life-saving personal
protective gear and other resources from our federal partners. Tribes
sought access to the Strategic National Stockpile and other federal
repositories but were met with long wait times and insufficient
communication. Knowing what we know now, we need Congress to cut
through red tape to ensure that tribes have a direct through line to
the federal government (not through states) to access federal emergency
resources.
We also need the Federal Government to improve data sharing with
our tribal health providers so that we can implement agile responses to
quickly evolving crises and for everyday use. This should not require
the implementation of data sharing agreements since Tribes (and tribal
epidemiology centers) are federally recognized public health
authorities.\21\ Since there has been some confusion on this matter, we
need Congress to legislate to clarify that data sharing agreements are
not required for sharing public health data with Tribes. We also need
the Federal Government to provide a national catalog of available
resources.
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\21\ See 45 C.F.R. Sec. 164.501 (defining ``public health
authority'' to include a Tribe).
We ask Congress to glean the best practices from the COVID-19
pandemic, which were developed in real-time during the pandemic and
perfect them in consultation with Tribes for use in future public
healthcare emergencies.
IV. Resources for Our Other Pandemics: Crises in Mental Health, Drug
Addiction, and Crimes Against Our People
Mental Health
Between 2001 and 2020, suicide was the leading cause of death of
American Indian and Alaska Native children in South Dakota aged 10 to
14 and the second leading cause of death for those aged 15 to 24 and 25
to 34.\22\ On our Reservation alone, the suicide rate is twice the
national average for all ages and four times the national average for
teenagers.\23\ Our children and youth are in distress. Worse, this is a
well-known problem which we have all failed to correct.\24\
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\22\ Centers for Disease Control and Prevention, WISQARS Leading
Causes of Death Visualization Tool, https://www.cdc.gov/injury/wisqars/
fatal.html. Nationwide, suicide is the second leading cause of death
for AI/AN across the same time frame for all three groups. However, in
2020 suicide became the leading cause of death in the 10-14 age range
nationwide.
\23\ Patrick Strickland, Life on the Pine Ridge Native American
reservation, Al Jazeera (Nov. 2, 2016) https://www.aljazeera.com/
features/2016/11/2/life-on-the-pine-ridge-native-american-reservation.
\24\ National Indian Council on Aging, Inc., American Indian
Suicide Rate Increases (Sep. 9, 2019) https://www.nicoa.org/national-
american-indian-and-alaska-native-hope-for-life-day/ (suicide rate up
139% for AI/AN women and 71% for AI/AN men between 1999 and 2019);
Deborah Stone, Eva Trinh, et. al. Suicides Among American Indian or
Alaska Native Persons--National Violent Death Reporting System, United
States, 2015-2020, CDC Morbidity and Mortality Weekly Report (Sep. 16,
2022) https://www.cdc.gov/mmwr/volumes/71/wr/mm7137a1.htm (suicide
rates among non-Hispanic AI/AN persons increased nearly 20% from 2015
to 2020).
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The United States has, for years, watched as the mental distress of
American Indian and Alaska Native people has increased to the point
where the despair of our people eclipses all others. Congress must act
on this. These statistics prove that the United States has failed to
honor its Treaty and Trust responsibilities to our people. Interpreting
the same laws that affect our Tribe, the Eighth Circuit in Rosebud
Sioux Tribe v. United States affirmed that the U.S. Government has a
judicially enforceable duty to provide competent physician-led
healthcare to the Rosebud Sioux Tribe. In coming to that conclusion,
the court considered the promises the United States Government made to
provide medical care in the Fort Laramie Treaty of 1868 (to which we
are subject), to authorize appropriations for the ``relief of distress
and conservation of health'' in the Snyder Act, and to raise the health
status of Indians to the ``highest possible level'' in the Indian
Healthcare Improvement Act.\25\
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\25\ Rosebud Sioux Tribe v. United States, 9 F.4th 1018 (8th Cir.
2021).
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Congress needs to address the epic mental health challenges we face
through funding and bold legislative actions. We need resources for
behavioral and mental health prevention and intervention for all of our
people. We need services for those who are depressed, have suicidal
ideation, and have attempted suicide in the past. We need services for
the family members, friends, and colleagues who lost someone to
suicide. We need to be flexible and innovative in the delivery of these
services and to reduce barriers to access and stigma associated with
these services. We need to provide our youth and families with life and
socio-emotional learning skills so that they are able to navigate the
everchanging world in which we live in now. We need resources to
recruit, retain, and house mental health professionals on our
Reservation, including trauma resource counselors for our schools. All
of these professionals must be paid competitive salaries so they will
come and stay and help us turn the tide of mental health on our
Reservation.
One of our top funding priorities is the completion of a Youth
Rehabilitation Center to address the youth opioid, suicide, and alcohol
abuse epidemic on our Reservation. The 29,987 square foot facility
would provide targeted residential treatment services for female and
male patients coping with opioid addiction, alcoholism, and sexual
trauma. Through this facility, Lakota youth will be able to receive
comprehensive mental and behavioral health services in their home
community. We envision that counselors, caseworkers, therapists,
medical professionals, and family members will be involved in creating
and sustaining a safe environment for our youth to heal and make
progress toward their goals. We need funding for facilities,
administration, security, support services, and to hire a Project
Manager. Financing this position would allow project development to
move forward for the betterment of the mental, physical, and spiritual
welfare of our Lakota youth.
Drug Addiction
Our Tribe is also fighting a tidal wave of substance use disorders.
The problem escalated to the point that our Tribe declared a State of
Emergency due to the increasing rates of homicide and methamphetamine
use on our lands.\26\ Such activities are antithetical to the Lakota
way of life and the balance of our society. Despite the documented and
increasing rates of these issues, we lack the facilities and trained
personnel to mount a comprehensive response.
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\26\ In 2016, we saw the number of homicides on the Pine Ridge
Reservation nearly double in what was widely reported to be crime
fueled by an increase in methamphetamine use. In early 2017, the FBI
reported that the drugs were coming to the Reservation from outside
areas, such as Denver. Tiffany Tan, FBI: Murders down 80% on Pine Ridge
following meth-fueled spike in 2016, Rapid City Journal, (Mar. 4, 2018)
https://tinyurl.com/498cz7dk; see also Associated Press, Homicides on
Pine Ridge reservation nearly doubled in 2016, (Feb. 12, 2017) https://
apnews.com/article/6d7b7f5f215b47a299e65eca09466a16. Last year, this
theory was confirmed after six individuals were convicted in a meth
conspiracy after trafficking meth into South Dakota from Colorado,
primarily to the Pine Ridge Reservation. Hunter Dunteman, Six convicted
in Pine Ridge meth conspiracy after `pounds' of drug entered South
Dakota, Mitchell Republic, (Mar. 17, 2022) https://tinyurl.com/
bdctbk9v.
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One of our most pressing needs is for on-reservation drug treatment
facilities. We need detox facilities, and our existing residential and
outpatient treatment facilities are in desperate need of renovations to
accommodate additional patients. We would also like to offer skills-
based transitional living facilities to assist patients with their
long-term recovery goals, but we lack the necessary resources for their
development and operation. We need funds for harm reduction services,
medication-assisted treatment, diversion programs, and for peer
recovery support systems.
We also desperately need funding to specifically address the law
enforcement, public health, and mental health impacts of the opioid and
methamphetamine epidemics on our Reservation. We need funding to
purchase Naloxone and similar overdose kits for our public spaces, and
to support training of law enforcement officers and other public
officials on the use of such medicines. We need funding for education
initiatives targeted at preventing drug use. We need funding to support
families who have lost someone to this epidemic and for those who are
dealing with the ongoing traumas of having a loved one struggling with
this addiction. We need the Federal Government to focus on this crisis
and develop and fund these initiatives and others to combat it. We also
need support for us to provide culturally appropriate healing practices
the way we see fit.
It should go without saying that our Native veterans deserve a
proportional investment in mental health and substance use resources.
American Indian and Alaska Natives serve in the United States Armed
Forces at a rate five times the national average.\27\ Like all
veterans, our Native veterans face monumental struggles with
depression, alcoholism, post-traumatic stress disorder, challenges
adapting to civilian life and, devastatingly, suicide. We need
resources and initiatives for them too.
---------------------------------------------------------------------------
\27\ Danielle DeSimone, A History of Military Service: Native
Americans in the U.S. Military Yesterday and Today, (Nov. 8, 2021)
https://www.uso.org/stories/2914-a-history-of-military-service-native-
americans-in-the-u-s-military-yesterday-and-
today#:?:text=Native%20Americans%
20serve%20in%20the,the%20Armed%20Forces%20for%20centuries.
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Certain Crimes Against Our People
Concurrently with our mental health and substance abuse pandemics,
Indian Country is facing a substantial domestic violence and human
trafficking crisis that is finally starting to get the long overdue
attention it needs.\28\ More than four in five American Indian and
Alaska Native men and women have experienced violence in their
lifetime, including 56.1% of women who have experienced sexual
violence.\29\ American Indian and Alaska Native women die from homicide
at a rate more than twice that of non-Hispanic white women.\30\ Between
the violence, the high rates of depression, suicide, and drug
addiction, we have deeply traumatized communities. As noted above, we
need resources for mental healthcare to address these issues head on.
But, we also need health resources for support services for the
families of our missing and murdered community members. They need
access to counseling and they need financial support for their
households, especially when their major income-earner goes missing. We
also need the United States Government to step up and provide the
resources to make our Reservation safe again. Our citizens will not be
healthy if they are not safe.
---------------------------------------------------------------------------
\28\ President Joe Biden, A Proclamation on Missing or Murdered
Indigenous Persons Awareness Day, 2022 (May 4, 2022) https://
www.whitehouse.gov/briefing-room/presidential-actions/2022/05/04/a-
proclamation-on-missing-or-murdered-indigenous-persons-awareness-day-
2022/.
\29\ Bureau of Indian Affairs, Missing and Murdered Indigenous
People Crisis https://www.bia.gov/service/mmu/missing-and-murdered-
indigenous-people-crisis (accessed Mar. 29, 2023)
\30\ National Indian Health Board, 2022 Legislative and Policy
Agenda for Indian Health, 26 https://www.nihb.org/covid-19/wp-content/
uploads/2022/04/2022-NIHB-Legislative-and-Policy-Agenda-.pdf
---------------------------------------------------------------------------
On a related note, we support the President's proposed legislative
initiative to withhold annuity and retiree pay for federal employees
convicted of crimes against children.\31\ The individual, Stanley
Patrick Weber, whose case prompted the proposal, committed his crimes
at our Pine Ridge IHS facility. This hideous issue demands protection
of our children and retribution from their abusers.
---------------------------------------------------------------------------
\31\ IHS Budget, CJ-294.
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V. Rural Cancer Care
We strongly support the President's request for funding to improve
rural cancer care. The Pine Ridge Reservation is one of the largest
reservations in the United States and also one of the most rural
communities. There are no cancer treatment services available at the
Pine Ridge Hospital. Instead, patients must travel 110 miles to Rapid
City for access to chemotherapy, radiation therapy, surgery, and
palliative care. Too many of our people live below the poverty line.
They should not be faced with the decision of choosing to spend their
scarce dollars on gas money to get to cancer treatments or putting food
on the table for their families. We need cancer treatment services on
our Reservation--for our patients, their families and our quality of
life.
In addition to the challenges of cancer care that all rural
communities face, our people also have unique health disparities that
make circumstances even more dire for us. As of late 2016, the cervical
cancer rate on our Reservation is five times higher than the nationwide
average.\32\ Tribes of the Great Plains also have had significantly
higher than average mortality rates for colorectal cancer (58%), lung
cancer (62%), cervical cancer (79%) and prostate cancer (49%).\33\
---------------------------------------------------------------------------
\32\ Patrick Strickland, Life on the Pine Ridge Native American
reservation, Al Jazeera, (Nov. 2, 2016) https://komengreatplains.org/
wp-content/uploads/2013/03/Komen-South-Dakota-2015-Community-Profile-
Report-updated-10.28.16.pdf.
\33\ Deborah Rogers & Daniel G. Petereit, Cancer Disparities
Research Partnership in Lakota Country: Clinical Trials, Patient
Services, and Community Education for the Oglala, Rosebud, and Cheyenne
River Sioux Tribes, Am. J. Public Health 95(12): 212902132 (Dec. 2005)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449496/.
---------------------------------------------------------------------------
The Susan G. Komen for the Cure Foundation identified the three
counties, Oglala Lakota, Jackson, and Bennett Counties, where the Pine
Ridge Reservation is located as high risk for breast cancer disparities
due to socioeconomic factors like high unemployment, low education,
high uninsurance, and high poverty.\34\ Other reported obstacles to our
members' care include communication difficulties, lack of information
about side effects, cost of treatment, difficulty obtaining and
maintaining insurance, fear, language barriers, lack of education,
perceived racial, economic, and gender bias, lack of cultural
competence in healthcare professionals, and transportation
challenges.\35\ These problems are compounded because our people are
diagnosed at later stages because they ``never enter the continuum [of
care] due to lack of accessible screening sites and lack of Native-
specific education.'' \36\ Likewise, even though our people have a high
rate of tobacco use, we also have a high rate of late-stage lung cancer
diagnoses.\37\
---------------------------------------------------------------------------
\34\ Susan G. Komen South Dakota, Community Profile Report 2015, at
6 https://komengreatplains.org/wp-content/uploads/2013/03/Komen-South-
Dakota-2015-Community-Profile-Report-updated-10.28.16.pdf.
\35\ Deborah Rogers & Daniel G. Petereit, Cancer Disparities
Research Partnership in Lakota Country: Clinical Trials, Patient
Services, and Community Education for the Oglala, Rosebud, and Cheyenne
River Sioux Tribes, Am. J. Public Health 95(12): 212902132 (Dec. 2005)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449496/.
\36\ Susan G. Komen South Dakota, Community Profile Report 2015, at
7 https://komengreatplains.org/wp-content/uploads/2013/03/Komen-South-
Dakota-2015-Community-Profile-Report-updated-10.28.16.pdf.
\37\ Monica M. Bertagnolli, Cancer Care in the Rural United States:
A Visitor's Perspective from Appalachian Ohio; Pine Ridge, South
Dakota; and Sidney, Montana, JCO Oncology Practice 16, no. 7 (July 1,
2020) https://ascopubs.org/doi/full/10.1200/OP.20.00244.
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Many of these disparities also relate to the health of our
environment, though we are waiting for science to catch up and paint a
clearer picture on that. Only three years ago we had to cap a community
drinking water well after uranium in excess of the safe Drinking Water
Standards was detected by our Department of Water Maintenance and
Conservation.\38\ Our springs have also returned elevated levels of
arsenic, lead, and uranium, though some uranium may be naturally
occurring.\39\ As of late 2010, as many as 35% of private wells on the
Reservation contained arsenic in excess of the EPA's maximum
contaminant limit and as many as 6% contained uranium in excess of the
maximum contaminant limit.\40\ According to the Keepers of the Waters,
there are 272 abandoned uranium mines in South Dakota which are also
contaminating our land and water.\41\ These contaminants place us at a
higher risk for cancer and other illnesses,\42\ so our Tribe needs
resources for environmental remediation to prevent further disease and
for cancer care to address the existing legacy of contamination. We
also need the Federal Government to ensure our Mni Wiconi Project
(clean drinking water project) is finally completed (see details
below).
---------------------------------------------------------------------------
\38\ Talli Nauman, Native Sun News Today: Oglala tribal staff caps
water well with uranium in it, Indianz.com (Feb. 19, 2020) https://
www.indianz.com/News/2020/02/19/native-sun-news-today-oglala-tribal-
staf.asp.
\39\ Allen J. Heakin, Water Quality of Selected Springs and Public-
Supply Wells, Pine Ridge Indian Reservation, South Dakota, 1992-97,
U.S. Geological Survey Water-Resources Investigations Report 99-4063
(2000) https://pubs.usgs.gov/wri/wri994063/.
\40\ Charles J. Werth, et al., Final Report: Use of Bone Char for
the Removal of Arsenic and Uranium from Groundwater at the Pine Ridge
Reservation, EPA Grantee Research Project Results https://
cfpub.epa.gov/ncer_abstracts/index.cfm/fuseaction/
display.abstractDetail/abstract_id/9210/report/F.
\41\ Keepers of the Waters, Living Waters of the Cheyenne River,
https://www.keepersofthewaters.org/projects/cheyenne-
river#:?:text=There%20are%20currently%20about
%2015%2C000,and%20people%20surrounding%20these%20waterways.
\42\ See Maryalice Yakutchik, Killer in the Water: Tracing
arsenic's threats to health in the Badlands, Johns Hopkins School of
Public Health (2022) https://magazine.jhsph.edu/2022/killer-water
(noting that arsenic in drinking water is ``considered one of the
prominent environmental causes of cancer death in the world'' and that
arsenic exposure is linked to cancer, diabetes, cognitive deficits, and
cardiovascular disease); National Cancer Institute, Arsenic, https://
www.cancer.gov/about-cancer/causes-prevention/risk/substances/
arsenic#:?:text=Which%20
cancers%20are%20associated%20with,skin%20cancer%20in%20epidemiological%2
0studies (reporting that arsenic in drinking water is linked to bladder
cancer and skin cancer, and general exposure to arsenic has been linked
to ``cancers of the lung, digestive tract, liver, kidney, and lymphatic
and hematopoietic systems.'')
---------------------------------------------------------------------------
VI. Environmental Health
Essential to our Lakota conception of health is understanding that
we are at our healthiest when we are in harmony and balance with the
world around us. Unfortunately, as our cancer statistics partially
demonstrate, our environment is in a state of disarray. The legacy of
hard rock mining has poisoned our water tables and our open lagoons
pose an obvious public health risk to our community. Further, the
Federal Government continues to invest in the fossil fuels we know are
warming our climate and ultimately making our world less livable.
We need Congress to invest in clean water infrastructure for our
people. Water is life, but unclean water leads to disease and death. We
want to work with you to finally complete the Mni Wiconi Project,
which, as you probably know, is a Bureau of Reclamation-funded rural
water project. It is a monumental clean drinking water project that
serves Missouri River water to our Reservation as well as to the
Rosebud Reservation, Lower Brule Reservation, and neighboring non-
Indian water districts. The Project's Service Area is 12,500 square
miles, its pipelines run 4,200 miles, and will serve approximately
52,000 people. The Mni Wiconi Project Act specifically states the
United States' trust responsibility to ensure adequate and safe water
supplies are available to meet the economic, environmental, water
supply, and public health needs of the Reservations.
While the Project is a life-changing project for our Reservation,
it is still not complete decades after its inception. We still need
approximately $25 million to upgrade 19 existing community water
systems on Pine Ridge and transfer them into the Project as intended by
the Act. Once transferred, these systems will be operated and
maintained pursuant to authorized funding under the Mni Wiconi Project
Act. The Project will not be complete until this work is done.
We also need increases in Operations, Maintenance, and Replacement
(OM&R) funding for the Project so this significant federal investment
and important project for our people's health and welfare does not fall
into disrepair due to inadequate funding. Further, we need increased
Funding for Tribal Water Maintenance Departments. We need to do water
systems upgrades, pipe construction and repairs, well maintenance, and
address water tank needs and associated equipment maintenance. We also
need support for Low Income Water Assistance Programs (which includes
water hook ups, pump repairs, and minor home repair for sanitation and
safety).
Similarly, we need resources to address our aging and overstressed
lagoon system because our lagoons are at and beyond their limits. We
also need resources to investigate the health of our local water
sources because preliminary data we have collected indicates that we
have dangerous chemicals in our rivers and streams. We need to be able
to test our water sources, track the source of this pollution, and
treat our water so that our people, animals, and crops have access to
clean, unpolluted water. We need Congress to continue to provide
resources for tribes through the Clean Water Act funds. We also need
Congress to ensure that the IHS Sanitation Facilities Construction
account is funded at a level sufficient to support all of the clean
water infrastructure projects across Indian Country. The Infrastructure
Investment & Jobs Act made a crucial investment in these issues, but
the amounts to be appropriated under that law still will not meet our
needs. In addition, we echo the recommendations made by the National
Congress of American Indians that Congress should appropriate $100
million for the EPA Tribal General Assistance Program and $30 million
for the Tribal Air Quality Management Program.\43\
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\43\ National Congress of American Indians, Written Testimony of
President Fawn Sharp to U.S. Senate Committee on Indian Affairs, 3
(Mar. 8, 2023) https://www.indian.senate.gov/sites/default/files/
Testimony%20NCAI%20-%20SCIA%20-%20Tribal%20 Priorities%20-%202023-03-
08.pdf
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Crucial to all environmental health is the very basic premise that
poisons should not be spilled on our lands and in our waterways. We
have opposed numerous federally approved mining, drilling, and pipeline
projects over the years. Some have called us radicals, but the recent
Keystone pipeline spill--the ``largest U.S. crude oil spill in a
decade''--underscores the importance of our fight and that it is
reality-based.\44\ That spill left a community in Kansas reeling from a
spill of 14,000 barrels of oil onto livestock pasture and into a nearby
creek. The spill is the third spill of several thousand barrels of oil
since the Keystone pipeline opened in 2010. Yet local residents seem to
acknowledge that pipeline breaks and oil spills are just a part of life
and business.\45\ This has been one of our major concerns all along--
there is no such thing as a safe pipeline just as there is no such
thing as a clean mining operation. These activities endanger the health
of our environment and they are conducted on our Treaty lands and on
our sacred sites (Dakota Access Pipeline and Jenny Gulch gold mining
exploration in He Sapa). The Federal Government must stop these
activities. They are done without our consent, they are bad for our
local environment, and the oil and gas activities are bad for our
global climate. Instead, the Federal Government should be proactively
investing in sustainable energy projects and forest restoration
initiatives (with tribal consent!)--investments which actually improve
our health.
---------------------------------------------------------------------------
\44\ Erwin Seba and Nia Williams, Kansas residents hold their noses
as crews mop up massive U.S. oil spill, Reuters (Dec. 11, 2022) https:/
/www.reuters.com/world/us/residents-hold-their-nose-crews-mop-up-huge-
us-oil-spill-2022-12-10/
\45\ ``Stuff breaks. Pipelines break, oil trains derail.''
Washington, Kansas resident Dana Cecrle, 56. ``Hell, that's life.''
``We got to have the oil.'' Carol Hollingsworth of Hollenberg, Kansas,
70. Erwin Seba and Nia Williams, Kansas residents hold their noses as
crews mop up massive U.S. oil spill, Reuters (Dec. 11, 2022) https://
www.reuters.com/world/us/residents-hold-their-nose-crews-mop-up-huge-
us-oil-spill-2022-12-10/
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Like water, quality food is the key to good health. The
Supplemental Nutrition Assistance Program (SNAP), the Food Distribution
Program on Indian Reservations (FDPIR), and the Supplemental Nutrition
Program for Women, Infants, and Children (WIC) provide desperately
needed meals and school lunches for our most vulnerable. Congress must
protect and fully fund these programs in the upcoming Farm Bill. We
also need for these programs to be expanded to incorporate more locally
grown and raised foods. Locally sourced foods produce multi-pronged
benefits for our people. First, inclusion of local crops and animal
protein directly stimulates our tribal economies when these programs
purchase from our tribal ranchers and farmers. Second, the inclusion of
our local foodstuffs actualizes a return to traditional practices and
provides a spiritual benefit to our people. Third, increasing variation
of the foods provided by these programs maximizes health outcomes as we
become empowered to turn away from the ultra-processed wheat flour and
sugar-based meals that have defined the Indian Country culinary
experience from the Federal Government. Finally, sourcing these foods
locally reduces the greenhouse gas emissions needed to transport foods
for these programs across the country. This helps the environment which
in turn helps us, our crops, and our animals.
Similarly, we request that Congress invest more resources in
developing meat processing facilities on tribal lands. We would like to
be able to process animals, like the sacred buffalo, on our
Reservation, in our traditional ways. Currently, a lack of funding is
an obstacle, as are some U.S. Department of Agriculture laws,
regulations, and policies requiring oversight by certain types of
inspectors (ex. under the Federal Meat Inspection Act). We urge
Congress to provide us funding to build and run these facilities and
enact flexibility so that we are not hamstrung in our efforts by an
overly fretful federal nanny state.
With respect to the food programs discussed above, Congress should
expand 638 contracting and compacting abilities so that tribes cannot
only administer these programs but can design them from the ground up.
VII. Conclusion
Thank you for your tireless work in service of Indian Country and
for your consideration of these comments. As you can see from these
comments: Mitakuye Oyasin, which means everything is connected. This is
our philosophy and way of moving through the world. It is a fact and
particularly evident when talking about healthcare. The health of our
people relies not on only on having healthy bodies and dedicated
professionals to treat us when we are sick or injured in body, but also
having, among other things: (1) adequate behavioral and mental health
prevention and intervention for healthy minds and spirit; (2) safe,
clean, and modern healthcare facilities and safe and clean environs;
and (3) fueling our bodies with clean and nutritious water and food.
Our Tribe stands ready to work with this Subcommittee and Congress
overall to make sure the Federal Government is living up to its Treaty
and trust obligations and our people are getting the high-quality
healthcare they deserve.
______
SALT RIVER PIMA-MARICOPA INDIAN COMMUNITY
Scottsdale, Arizona
April 10, 2023
Hon. Harriet Hageman, Chairwoman
House Natural Resources Committee
Subcommittee on Indian and Insular Affairs
1324 Longworth House Office Building
Washington, DC 20515
Re: Oversight hearing on Improving Healthcare Delivery in Tribal
Communities
Dear Chairwoman Hageman:
On behalf of the Salt River Pima-Maricopa Indian Community
(``SRPMIC'') I am pleased to submit this letter to be made part of the
hearing record of the Subcommittee on Indian and Insular Affairs (``the
Committee'') for the oversight hearing conducted on March 29, 2023 on
the topic of Improving Healthcare Delivery in Tribal Communities. As a
Tribal nation located in the State of Arizona in the Phoenix
metropolitan area we are making tremendous progress to improve the
healthcare system and delivery for not only the membership of our
Community but also for area urban Native Americans. The Community's
River People Health Center (``RPHC'') is central to this mission and is
tribally operated by Self-Governance Compact with the Indian Health
Service (``IHS'') under Title V of the Indian Self-Determination and
Education Assistance Act (``ISDEAA''). Based in our newly constructed
200,000 square foot state of the art health center, RPHC is creating a
Community of Care offering a robust health and services delivery model
that addresses the 5 Determinants of Health: Social, Behavioral Health,
Clinical, Environmental and Genetics. As such, I want to share with the
Committee the SRPMIC views on how IHS funding decisions impact
healthcare delivery in our Community paired with recommendations for
how Congress can help IHS improve its service to Tribal Organization.
Continue Advance Appropriations for the Indian Health
Service (``IHS''). In the FY 2023 Consolidated
Appropriations Act, Congress in a historic move, finally
provided advance appropriations for the IHS for FY 2024.
Going forward, we urge that all necessary steps be taken to
continue advance appropriations for the IHS for FY 2025 and
beyond, which would bring IHS in alignment with the U.S.
Department of Veterans Affairs' eligibility for advance
appropriations.
Fully fund critical IT infrastructure investments. In FY
2023 Electronic Health Record modernization was funded at
$217 million, which was an increase of $72.5 million (50%)
over FY 2022. We need the same kind of increase in this
critical line item for FY 2024 to ensure that full
implementation of interoperable Electronic Health Records
(EHR) and tele-health occurs. For Tribes and Tribal health
organizations who have committed their own resources to
move away from RPMS and making their systems functional,
IHS should take this into consideration with any new
resources and ensure these programs are not only
interoperable, but compensated accordingly.
Mandatory Funding for Contract Support Costs and 105(l)
lease payments. We appreciate the continuing commitment to
ensure that Contract Support Costs (CSC) and 105(l) lease
costs are fully funded by including an indefinite
discretionary appropriation in recent years for both of
these accounts. We strongly support the transition of these
accounts to mandatory funding. This change would bring the
appropriations process into line with the clear legal
requirements of the authorizing statute. CSC and 105(l)
lease funds are already an entitlement under substantive
law that enables the ISDEAA to function as intended by
Congress. It is legally contradictory and operationally
problematic to appropriate funding for CSC on a
discretionary basis. A simple amendment to a permanent
appropriations statute could solve this challenge.
In some IHS Regions, CSC funding decisions take an
adversarial position rather than advocate for Tribal Self-
Determination and Self-Governance. We remain concerned with
recent actions of the IHS that effectively impede the
efforts of the SRPMIC and other Tribes to expand and
improve healthcare services. The IHS often bars access to
the very CSC resources that this Committee seeks to provide
Tribes. There have been no substantive amendments to the
ISDEAA in recent years, yet the new IHS administration has
shifted its CSC award determinations and negotiation
positions so dramatically they no longer align with
longstanding IHS policy and practice over the last 20
years. These recent CSC determinations and positions also
fail to align with the mission of IHS, or even its newly
established commitments identified in the IHS 2023 Agency
Work Plan. The SRPMIC would welcome the opportunity to talk
with the Committee in further detail regarding our
experiences assuming operation of the RPHC in the
Scottsdale/Phoenix, AZ area.
Amend Indian Self-Determination and Education Assistance
Act to Clarify CSC provisions. We also request assistance
to amend the ISDEAA to clarify that when agency funding
paid to a tribe for program operations is insufficient for
contract and compact administration, CSC will remain
available to cover the difference. In the recent court
decision Cook Inlet Tribal Council, Inc. v. Dotomain, a
federal appeals court held that costs for activities
normally carried out by IHS are ineligible for payment as
CSC--even if IHS transfers insufficient, or even no,
funding for these activities in the Secretarial amount.
Under this new ruling, if facility costs are higher for a
Tribe than for IHS, the Tribe is forced to cover the
difference by diverting scarce program dollars. Recently,
this serious misinterpretation of the ISDEAA was applied to
one Tribal organization resulting in the threat of a 90%
reduction of CSC reimbursement. A legislative fix is
urgently needed to clarify the intent of Congress for this
matter and ensure consistency with precedent.
Extend Self-Governance Funding Options to the Special
Diabetes Program for Indians (SDPI) and increase funding to
$250 million/year. We appreciate that Congress included a
three-year reauthorization of SDPI in the Consolidated
Appropriations Act, 2021 (P.L. 116-260). SDPI's success
rests in the flexibility of its program structure that
allows for the incorporation of culture and local needs
into its services. SDPI needs to be reauthorized in a
manner that ensures participants have the option of
receiving their federal funds through either a grant (as
currently used) or self-governance funding mechanisms under
ISDEAA. Additionally, SDPI has not had an increase in
funding since FY 2004. SDPI should be permanently
reauthorized at a minimum of $250 million per year with
annual adjustments for inflationary increases.
In closing, I want to thank you for conducting the oversight
hearing on Improving Healthcare Delivery in Tribal Communities. Your
consideration of the SRPMIC recommendations is greatly appreciated. If
you have any questions please contact Mr. Gary Bohnee, Office of
Congressional and Legislative Affairs.
Sincerely,
Martin Harvier,
President
______
Submission for the Record by Rep. Grijalva
Statement for the Record
United South and Eastern Tribes
Sovereignty Protection Fund
On behalf of the United South and Eastern Tribes Sovereignty
Protection Fund (USET SPF), we write to provide the House Committee on
Natural Resources Subcommittee on Indian and Insular Affairs with the
following testimony for the record for its March 29, 2023 hearing
entitled Challenges and Opportunities for Improving Healthcare Delivery
in Tribal Communities. We share this testimony in pursuit of solutions
to the systemic challenges facing the Indian Health Service (IHS) and
Tribally-operated facilities. While USET SPF appreciates efforts to
address problems within the Indian Health System and acknowledges that
certain preventable issues persist within IHS, we maintain that the
majority of these challenges are due to chronic federal underfunding.
Until Congress fully funds the IHS, the Indian Health System will never
be able to fully overcome its challenges and fulfill its trust
obligations. Congress must meet its trust responsibility to Tribal
Nations by providing full, stable funding to the IHS. Further, while we
support reforms that will improve the quality of services delivered by
the IHS, we assert that any attempts to reform the IHS, though
Congressional action or otherwise, must be accomplished through
extensive Tribal consultation that results in the incorporation of
Tribal guidance.
USET SPF is a non-profit, inter-tribal organization advocating on
behalf of thirty-three (33) federally recognized Tribal Nations from
the Northeastern Woodlands to the Everglades and across the Gulf of
Mexico.\1\ USET SPF is dedicated to promoting, protecting, and
advancing the inherent sovereign rights and authorities of Tribal
Nations and in assisting its membership in dealing effectively with
public policy issues. Our member Tribal Nations operate in the
Nashville Area of the Indian Health Service, and our citizens receive
health care services both directly at IHS facilities, as well as in
Tribally-operated facilities under contracts with IHS pursuant to the
Indian Self-Determination and Education Assistance Act (ISDEAA), P.L.
93-638.
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\1\ USET SPF member Tribal Nations include: Alabama-Coushatta Tribe
of Texas (TX), Catawba Indian Nation (SC), Cayuga Nation (NY),
Chickahominy Indian Tribe (VA), Chickahominy Indian Tribe-Eastern
Division (VA), Chitimacha Tribe of Louisiana (LA), Coushatta Tribe of
Louisiana (LA), Eastern Band of Cherokee Indians (NC), Houlton Band of
Maliseet Indians (ME), Jena Band of Choctaw Indians (LA), Mashantucket
Pequot Indian Tribe (CT), Mashpee Wampanoag Tribe (MA), Miccosukee
Tribe of Indians of Florida (FL), Mi'kmaq Nation (ME), Mississippi Band
of Choctaw Indians (MS), Mohegan Tribe of Indians of Connecticut (CT),
Monacan Indian Nation (VA), Nansemond Indian Nation (VA), Narragansett
Indian Tribe (RI), Oneida Indian Nation (NY), Pamunkey Indian Tribe
(VA), Passamaquoddy Tribe at Indian Township (ME), Passamaquoddy Tribe
at Pleasant Point (ME), Penobscot Indian Nation (ME), Poarch Band of
Creek Indians (AL), Rappahannock Tribe (VA), Saint Regis Mohawk Tribe
(NY), Seminole Tribe of Florida (FL), Seneca Nation of Indians (NY),
Shinnecock Indian Nation (NY), Tunica-Biloxi Tribe of Louisiana (LA),
Upper Mattaponi Indian Tribe (VA) and the Wampanoag Tribe of Gay Head
(Aquinnah) (MA).
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IHS Reform Efforts
In prior Congresses, there have been various attempts to improve
the IHS through legislative reforms. While USET SPF has always welcomed
efforts to improve healthcare delivery in Indian Country, we have also
maintained that one-size-fits all policy approaches are inappropriate
for the Indian Health System.
Tribal Nations are not a monolith, and some IHS areas do not
experience the same challenges and failures as others. Any attempts to
reform the IHS should be done in close, meaningful consultation with
Tribal Nations, as broad solutions risk harming relationships and best
practices at the Area level. Despite the present challenges, there are
many successes within the Indian Health Care System that stand to be
harmed by overly broad IHS reform efforts. Legislative proposals aimed
at priorities like increasing Tribal sovereignty and fulfillment of
solemn trust and treaty obligations should be the focus of Congress
(and the federal government as a whole) and will garner broad support
from Tribal Nations compared to proposals to over-legislate the IHS.
Fulfill Trust and Treaty Obligations Through Full and Mandatory IHS
Funding
The United States has trust and treaty obligations to Tribal
Nations that have been reaffirmed time and again through treaties,
statutes, regulations, judicial decisions, and Executive Orders.
Congress itself reaffirmed the trust responsibility in 2010 when it
permanently reauthorized the Indian Health Care Improvement Act,
declaring that ``it is the policy of this nation, in fulfillment of its
special trust responsibilities and legal obligations to Indians to
ensure the highest possible health status for Indian and urban Indians
and to provide all resources necessary to effect that policy.'' This
necessitates a budget for the IHS that reflects both the resources
necessary to operate a comprehensive health system and the priorities
of Tribal Nations. For far too long, the chronic underfunding of the
IHS has had disastrous effects on the health and wellbeing of Native
peoples--effects that could have been largely preventable in a full and
mandatory funding atmosphere. Until the IHS is fully funded through
mandatory appropriations, the United States will continue to fall short
of its obligation to provide for the health and wellness of Tribal
Nations.
Through the Fiscal Year (FY) 2025 Budget Formulation Process,
Tribal Nations and the IHS have built a budget request based on an
estimated funding figure--$54 billion--that approaches full funding.
This figure is not fully representative of full funding, as it does not
include activities such as necessary investments in public health. Full
funding for the IHS would also need to be determined in close
consultation with Tribal Nations. USET SPF is pleased that the IHS has
convened the ``FY 2025 Sub-Workgroup on Mandatory Appropriations for
the IHS,'' a collaborative effort with Tribal Nations to determine a
full funding figure of the agency. We have long advocated for a joint
Tribal-federal workgroup to ascertain a funding figure that accounts
for the full scope of the IHS's charge and circumstances in Indian
Country, in addition to determining how to fund the agency on a
mandatory basis. In September 2021, USET SPF sent comments to the
Department of Health and Human Services (HHS) Secretary Xavier Becerra
offering input on approaches for funding the IHS on a mandatory basis.
While USET SPF does not dispute that the IHS has challenges to
overcome, we assert that they are largely due to the chronic
underfunding of the agency and could be solved in a full funding
atmosphere. For example, the memorandum issued for the hearing cited
challenges in the Purchased/Referred Care (PRC) program, including
problems with the formula and cost overruns. The PRC program, which
provides for specialty health care services not available within the
IHS, exists mainly because of the IHS's lack of resources for specialty
and intensive care. Many of the challenges associated with the PRC
program currently could be avoided with proper investments in hospital
and clinical services within Indian Country--investments that would be
made in a full, mandatory funding atmosphere.
The Biden-Harris Administration's FY 2024 Request continues to
propose a shift in funding for IHS from the discretionary to the
mandatory side of the federal budget, including a 10-year plan to close
funding gaps and an exemption from sequestration, a move that would
provide even greater stability for the agency and is more
representative of perpetual trust and treaty obligations. This 10-year
plan would shift the IHS to mandatory funding beginning in FY 2025 with
funding increases each year to account for inflation, cost increases,
staffing needs and current deficiencies within the system. By FY 2033,
the total annual funding level for the IHS would reach $44 billion, a
figure that approaches the resources necessary to fund the agency more
comprehensively. The plan includes a proposal to establish a new
dedicated funding stream for innovative public health infrastructure
investment in Indian Country and, importantly, the President's proposed
plan also includes a mandatory indefinite appropriation for Contract
Support Costs (CSC) and Section 105(l) Lease agreements beginning
immediately. USET SPF strongly supports immediately shifting CSC and
105(l) lease agreements to mandatory funding. Year after year, USET SPF
has urged multiple Administrations and Congresses to request and enact
budgets that honor the unique, Nation-to-Nation relationship between
Tribal Nations and the U.S., including providing full and mandatory
funding that accounts for all agency authorities, including currently
unfunded Indian Health Care Improvement Act (IHCIA) authorities. While
we firmly believe all Indian Country funding should be fully funded
today, including the IHS, we continue to strongly support this
proposal, recognizing that additional detail and planning is necessary
to provide a fully developed plan to fund IHS on a full and mandatory
basis. USET SPF strongly urges Congress to take up this proposal, and
we look forward to working with the Committee on potential legislative
language.
Expand Self-Governance Compacting and Contracting
The U.S. Government bears a responsibility to uphold the trust
obligation, and that obligation includes upholding Tribal sovereignty,
self-determination, and self-governance. The Indian Self-Determination
and Education Assistance Act (ISDEAA) authorizes the federal government
to enter into compacts and contracts with Tribal Nations to provide
services that the federal government would otherwise be obligated to
provide under the trust and treaty obligations. Although self-
government by Tribal Nations existed far before the passage of ISDEAA,
Tribal Nations have demonstrated through ISDEAA authorities since the
bill's enactment that we are best positioned to deliver essential
government services to our citizens, including through the assumption
of federal program and services. Tribal Nations are directly
accountable to and aware of the priorities and problems of our own
communities, allowing us to respond immediately and effectively to
challenges and changing circumstances.
The success of self-governance under the ISDEAA is reflected in the
significant growth of Tribal self-governance programs since its
passage. In the USET region, the majority of our Tribal Nations engage
in self-governance compacting or contracting to provide essential
health care services. Across Indian Country, nearly two-thirds of
federally recognized Tribal Nations engage in self-governance, either
directly through the IHS or through Tribal organizations and
intertribal consortia. In Fiscal Year (FY) 2020, approximately 50% of
the IHS budget was distributed to self-governance Tribal Nations.
However, despite the success of Tribal Nations in exercising these
authorities under ISDEAA, the goals and potential of self-governance
have not yet been fully realized. Many opportunities still remain to
improve and expand self-governance, particularly within HHS. USET SPF,
along with Tribal Nations and other regional and national
organizations, has consistently advocated for all federal programs and
dollars to be eligible for inclusion in self-governance compacts and
contracts.
Attempts to expand self-governance compacting and contracting
administratively have encountered barriers due to the limiting language
under current law, as well as the misperceptions of federal officials.
In 2013, the Self-Governance Tribal Workgroup (SGTFW), established
within the HHS, completed a study exploring the feasibility of
expanding Tribal self-governance into HHS programs beyond those of IHS
and concluded that the expansion of self-governance to non-IHS programs
was feasible, but would require Congressional action. USET SPF
maintains that if true expansion of self-governance is only possible
through legislative action, Congress must prioritize this action. We
strongly support legislative proposals that would create a
demonstration project at HHS aimed at expanding ISDEAA authority to
more programs within the Department. In addition, a major priority for
Tribal Nations during the upcoming reauthorization of the Special
Diabetes Program for Indians (SDPI), along with increased funding and
permanency for the program, is ISDEAA authority. USET SPF looks forward
to supporting legislation aimed at fulfilling these priorities during
this Congress.
Improve Public Health Funding and Data Sharing
Many of the challenges and shortfalls plaguing the Indian Health
Care System are the result of sustained, chronic underinvestment in
prevention and public health measures paired with generations of
historical trauma and structural discrimination. As the United States's
public health infrastructure took shape and grew throughout the
twentieth century, Tribal Nations were routinely left out of resource
distribution. While Tribal Nations have always and continue to invest
in the health and wellbeing of our citizens, our efforts continue to be
hampered by lack of funding and inconsistently applied data sharing
authorities. In order to more effectively respond to the challenges in
our communities, including those posed by current and future public
health crises, Tribal Nations need increased resources as well as the
ability to efficiently and easily obtain necessary public health data.
In an already strained funding environment, there are often little
resources left for public health prevention and surveillance activities
in Tribal Nations. Although the IHS supports limited public health
activities at federally operated facilities, the primary responsibility
for the development and delivery of public health infrastructure and
services often lies with Tribal Nations, particularly in regions with
high concentrations of self-governance Tribal Nations. While many
Tribal Nations and IHS regions have worked to incorporate some public
health components in their governments, these entities often do not
operate at the same capacity as state programs, and certainly lack much
of the authority afforded to state entities. The Indian Health Care
Improvement Act (IHCIA) authorized the formation of Tribal Epidemiology
Centers (TECs), and since 1996, the TECs have been working to improve
the capacity of Tribal health departments to deal with public health
issues and priorities. TECs are charged with seven main functions,
including data collection, evaluation of systems, and the provision of
technical assistance to Tribal Nations. The USET TEC, which serves
Tribal Nations in the Nashville IHS Area, provides both aggregate and
Tribal Nation-specific public health and mortality data in addition to
its other functions. However, despite the critical nature of this
invaluable work and Congressional directives to share data, TECs
struggle with accessing public health data not only on the federal and
state levels, but the Tribal levels as well. Access to timely, accurate
data is vital to the delivery of healthcare services in Indian Country,
as it is difficult to direct resources appropriately without fully
understanding the challenges facing our people.
Congress has the obligation to correct these challenges within
Indian Country. In addition to providing full funding to the IHS,
Congress must meaningfully invest in public health capacity building in
Indian Country. Funding for expanding the Community Health Aide Program
(CHAP) to the lower 48 is one example of necessary investments in
public health and preventative care in Tribal Nations. To mitigate
challenges in data access, the federal government should compel
agencies like the Centers for Disease Control and Prevention (CDC) and
the Centers for Medicare and Medicaid Services (CMS) to issue specific
guidance to states and other public health entities directing them to
comply with legislative directives to share usable data with Tribal
Nations. USET SPF is appreciative of efforts within the Subcommittee to
conduct oversight in these matters.
Conclusion
While the challenges in delivering healthcare in Indian Country are
numerous, the opportunities for correcting them are simple and widely
supported. The United States has a trust responsibility to provide for
the ``highest possible health status'' of Tribal communities, and that
necessitates funding the entities and organizations that provide that
healthcare fully. It also requires an expanded recognition of Tribal
sovereignty and self-determination in our health care. Tribal Nations
are unequivocally best positioned to provide for the health and
wellness of our communities, but we require the proper resources to
which we are legally and morally entitled. USET SPF appreciates the
work of the Subcommittee in calling additional attention to the
challenges within the Indian Health System, and we look forward to
working with the Subcommittee and its members to advance solutions to
these challenges this Congress.
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