[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]


                   CHALLENGES AND OPPORTUNITIES FOR
                   IMPROVING HEALTHCARE DELIVERY IN 
                          TRIBAL COMMUNITIES

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

                           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
       
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        Available via the World Wide Web: http://www.govinfo.gov
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          Committee address: http://naturalresources.house.gov
          
                              __________

                                
                    U.S. GOVERNMENT PUBLISHING OFFICE                    
51-763 PDF                  WASHINGTON : 2023                    
          
-----------------------------------------------------------------------------------     
 
                     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
                                 ------                                

               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

                              ----------                                
                                                                
                               CONTENTS

                              ----------                              
                                                                   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''

                              ----------                              


                       Wednesday, March 29, 2023

                     U.S. House of Representatives

               Subcommittee on Indian and Insular Affairs

                     Committee on Natural Resources

                             Washington, DC

                              ----------                              

    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.
---------------------------------------------------------------------------
    \1\ https://www.ihs.gov/aboutihs/
    \2\ 25 U.S.C. 1602(1)
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \3\ Worcester v. Georgia, 31 U.S. 515 (1832).
    \4\ Seminole Nation v. United States, 316 U.S. 286, 296-97 (1942).
---------------------------------------------------------------------------
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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \15\ Broken Promises at 65.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \1\ In the Portland Area Indian Health Service system, there are 
approximately 218,000 users registered, with 114,000 active users.
---------------------------------------------------------------------------

  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.
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \7\ See Consolidated Approps. Act 2021, Pub. L. No. 116-260, 134 
stat. 2923 (2020).
---------------------------------------------------------------------------
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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \1\ See Consolidated Approps Act 2023, Pub. L. No. 117-328.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \1\ Relocation, National Council for Urban Indian Health, 2018. 
2018_0519_Relocation.pdf (Shared)-Adobe cloud storage
---------------------------------------------------------------------------
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\
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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/
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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)
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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)
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \19\ IHS Budget, CJ-287-88, CJ-295-96, CJ-298-99, CJ-296-97.
---------------------------------------------------------------------------
    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 
---------------------------------------------------------------------------
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\
---------------------------------------------------------------------------
    \25\ Rosebud Sioux Tribe v. United States, 9 F.4th 1018 (8th Cir. 
2021).
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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/
---------------------------------------------------------------------------
    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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