[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
H.R. 6489, H.R. 8942, H.R. 8955, AND H.R. 8956
=======================================================================
LEGISLATIVE HEARING
before the
SUBCOMMITTEE ON INDIAN AND INSULAR AFFAIRS
of the
COMMITTEE ON NATURAL RESOURCES
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
SECOND SESSION
__________
Wednesday, July 24, 2024
__________
Serial No. 118-140
__________
Printed for the use of the Committee on Natural Resources
Available via the World Wide Web: http://www.govinfo.gov
or
Committee address: http://naturalresources.house.gov
COMMITTEE ON NATURAL RESOURCES
BRUCE WESTERMAN, AR, Chairman
DOUG LAMBORN, CO, Vice Chairman
RAUL M. GRIJALVA, AZ, Ranking Member
Doug Lamborn, CO Grace F. Napolitano, CA
Robert J. Wittman, VA Gregorio Kilili Camacho Sablan,
Tom McClintock, CA CNMI
Paul Gosar, AZ Jared Huffman, CA
Garret Graves, LA Ruben Gallego, AZ
Aumua Amata C. Radewagen, AS Joe Neguse, CO
Doug LaMalfa, CA Mike Levin, CA
Daniel Webster, FL Katie Porter, CA
Jenniffer Gonzalez-Colon, PR Teresa Leger Fernandez, NM
Russ Fulcher, ID Melanie A. Stansbury, NM
Pete Stauber, MN Mary Sattler Peltola, AK
John R. Curtis, UT Alexandria Ocasio-Cortez, NY
Tom Tiffany, WI Kevin Mullin, CA
Jerry Carl, AL Val T. Hoyle, OR
Matt Rosendale, MT Sydney Kamlager-Dove, CA
Lauren Boebert, CO Seth Magaziner, RI
Cliff Bentz, OR Nydia M. Velazquez, NY
Jen Kiggans, VA Ed Case, HI
Jim Moylan, GU Debbie Dingell, MI
Wesley P. Hunt, TX Susie Lee, NV
Mike Collins, GA
Anna Paulina Luna, FL
John Duarte, CA
Harriet M. Hageman, WY
Vivian Moeglein, Staff Director
Tom Connally, Chief Counsel
Lora Snyder, Democratic Staff Director
http://naturalresources.house.gov
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SUBCOMMITTEE ON INDIAN AND INSULAR AFFAIRS
HARRIET M. HAGEMAN, WY, Chair
JENNIFFER GONZALEZ-COLON, PR, Vice Chair
TERESA LEGER FERNANDEZ, NM, Ranking Member
Aumua Amata C. Radewagen, AS Gregorio Kilili Camacho Sablan,
Doug LaMalfa, CA CNMI
Jenniffer Gonzalez-Colon, PR Ruben Gallego, AZ
Jerry Carl, AL Nydia M. Velazquez, NY
Jim Moylan, GU Ed Case, HI
Bruce Westerman, AR, ex officio Raul M. Grijalva, AZ, ex officio
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CONTENTS
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Page
Hearing Memo..................................................... v
Hearing held on Wednesday, July 24, 2024......................... 1
Statement of Members:
Hageman, Hon. Harriet M., a Representative in Congress from
the State of Wyoming....................................... 2
Leger Fernandez, Hon. Teresa, a Representative in Congress
from the State of New Mexico............................... 4
Panel I:
Johnson, Hon. Dusty, a Representative in Congress from the
State of South Dakota...................................... 5
Newhouse, Hon. Dan, a Representative in Congress from the
State of Washington........................................ 7
Peltola, Hon. Mary Sattler, a Representative in Congress from
the State of Alaska........................................ 8
.............................................................
Statement of Witnesses:
Panel II:
Smith, Benjamin, Deputy Director, Indian Health Services,
U.S. Department of Health and Human Services, Rockville,
Maryland................................................... 9
Prepared statement of.................................... 11
Questions submitted for the record....................... 17
Erickson, Hon. Jarred-Micheal, Chairman, Confederated Tribes
of the Colville Reservation, Nespelem, Washington.......... 18
Prepared statement of.................................... 19
Questions submitted for the record....................... 22
Torres, Amber, Chief Operating Officer, National Indian
Health Board (NIHB), Washington, DC........................ 22
Prepared statement of.................................... 24
Questions submitted for the record....................... 26
Mallott, Ben, Vice President for External Affairs, Alaska
Federation of Natives (AFN), Anchorage, Alaska............. 26
Prepared statement of.................................... 28
Church, Jerilyn, Executive Director, Great Plains Tribal
Leader's Health Board (GPTLHB), Rapid City, South Dakota... 29
Prepared statement of.................................... 31
Questions submitted for the record....................... 34
GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT
To: House Committee on Natural Resources Republican Members
From: Indian and Insular Affairs Subcommittee staff, Ken
Degenfelder ([email protected]), Jocelyn Broman
(Jocelyn.Broman@ mail.house.gov), and Kirstin Liddell
([email protected]) x6-9725
Date: Wednesday, July 24, 2024
Subject: Legislative Hearing on 4 Bills
________________________________________________________________________
_______
The Subcommittee on Indian and Insular Affairs will hold a
legislative hearing on four bills: H.R. 8942 (Rep. Hageman),
``Improving Tribal Cultural Training for Providers Act of 2024''; H.R.
8955 (Rep. Johnson of SD), ``IHS Provider Integrity Act''; H.R. 8956
(Rep. Newhouse), ``Uniform Credentials for IHS Providers Act of 2024'';
and H.R. 6489 (Rep. Peltola), ``Alaska Native Village Municipal Lands
Restoration Act of 2023'' on Wednesday, July 24, 2024, at 10:15 a.m. in
1334 Longworth House Office Building.
Member offices are requested to notify Haig Kadian
(Haig.Kadian@mail. house.gov) by 4:30 p.m. on Tuesday, July 23, 2024,
if their member intends to participate in the hearing.
I. KEY MESSAGES
H.R. 8942 would amend the Indian Health Care Improvement
Act \1\ (IHCIA) to require mandatory annual training for
specified Indian Health Service (IHS) employees on the
history and culture of tribes that they are serving.
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\1\ 25 USC 1601 et seq.
H.R. 8955 would require the IHS to solicit the history of
any applicant from the medical board of each state in which
the applicant is licensed. Additionally, the IHS would be
required to notify and provide the necessary documentation
to state medical boards once an investigation of a licensee
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has started.
H.R. 8956 would establish a uniformed and centralized
Service-wide credentialing system at the IHS for health
care providers.
H.R. 6489 would amend Sec. 14(c)(3) of the Alaska Native
Claims Settlement Act \2\ (ANCSA) to return lands currently
held in trust by the State of Alaska for future
municipalities back to Alaska Native village corporations.
Only eight villages out of 101 that conveyed lands under
this section have created a municipality since ANCSA was
passed in 1971. The bill would also eliminate the
requirement for an Alaska Native village corporation to
convey land to the state Alaska under Sec. 14(c)(3) if that
has not already occurred.
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\2\ 43 USC 1601 et seq.
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II. WITNESSES
Mr. Benjamin Smith, Deputy Director, Indian Health
Service, U.S. Department of Health and Human Services,
Rockville, MD [H.R. 8955, H.R. 8942, and H.R. 8956]
The Hon. Jarred-Michael Erickson, Chairman, Confederated
Tribes of the Colville Reservation, Nespelem, WA [H.R.
8955, H.R. 8942, and H.R. 8956]
Ms. Amber Torres, Chief Operating Officer, National Indian
Health Board (NIHB), Washington, DC. [H.R. 8955, H.R. 8942,
and H.R. 8956]
Ms. Jerilyn Church, Executive Director, Great Plains
Tribal Leader's Health Board (GPTLHB), Rapid City, SD [H.R.
8955, H.R. 8942, and H.R. 8956]
Mr. Ben Mallott, Vice President for External Affairs,
Alaska Federation of Natives (AFN), Anchorage, AK [H.R.
6489] [Minority Witness]
III. BACKGROUND
H.R. 8942 (Rep. Hageman), ``Improving Tribal Cultural Training for
Providers Act of 2024''
H.R. 8942 would amend the IHCIA to require mandatory annual
training for specified IHS employees on the history and culture of the
tribes that they are serving. Currently, IHS employees are required to
participate in a program on the tribal history and culture of the
tribes they serve, but it is not an annual requirement.
Because IHS's mission is to work with American Indian and Alaska
Native (AI/AN) people to promote their physical, mental, social, and
spiritual health, IHS medical providers need cultural competence to
work toward the best AI/AN health outcome.\3\ Culture competence is
defined by the Center for Disease Control and Prevention (CDC) as ``the
integration and transformation of knowledge about individuals and
groups of people into specific standards, policies, practices, and
attitudes used in appropriate cultural settings to increase the quality
of services; thereby producing better outcomes.'' \4\ If a health care
practitioner provides care that is culturally sensitive and well-
versed, the patient often gains a sense of security and satisfaction
which can lead to a more transparent relationship and improved health
outcomes.\5\
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\3\ Quality at IHS. https://www.ihs.gov/quality/
#::text=The%20mission%20of%20the%
20Indian,AN)%20to%20the%20highest%20level.
\4\ CDC. Cultural Competence in Health and Human Services. https://
npin.cdc.gov/pages/cultural-competence-health-and-human-services#what
\5\ McKesey et al. (2017, December) Cultural Competence for the
21st Century Dermatologist Practicing in the United States. Journal of
the American Academy of Dermatology. https://assets.ctfassets.net/
1ny4yoiyrqia/5czczxfoQvg0P0JoDcuIsh/da49853b61635975925a99813dd790f2/
Cultural_competency_21st_century_.pdf
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While American Indian life expectancy has increased by
approximately 10 years since 1973, AI/ANs still generally have a lower
life expectancy than the United States's general population.\6\ That
life expectancy is even lower for AI/ANs that have chronic liver
disease, diabetes mellitus, and experience assault or homicide or
commit self-harm or suicide.\7\ Health care practitioners practicing
culturally competent care can remove disconnect between patient and
practitioner, ensuring patients are heard, seen, and understood. When
the relationship between patient and practitioner is strained, the
level of care is decreased, which can be attributed to the higher rate
of death among American Indians.\8\ Studies have shown a correlation
between perceived discrimination and the rates of hypertension,
cardiovascular disease, and diabetes throughout racial minorities.\9\
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\6\ IHS. Quick Look Fact Sheet. https://www.ihs.gov/newsroom/
factsheets/quicklook/
\7\ Id.
\8\ Melissa L. Walls, et. al. Unconscious Biases: Racial
Microaggressions in American Indian Health Care. The Journal of the
American Board of Family Medicine. March 2015. https://www.jabfm.org/
content/28/2/231.long. Accessed July 10, 2024.
\9\ Id.
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For example, an American Indian child who avoids eye contact or
takes longer than average to respond to a question could be diagnosed
with autism. However, this behavior may actually be culturally
appropriate with their tribal community.\10\ AI/AN patients who discuss
their mental health struggles in spiritual terms could be misdiagnosed
with drug-related psychosis, when that is the way the individual
processes what is occurring.\11\ If a practitioner is trained in the
history and culture of the demographic they are treating, they can
better understand the nuances associated with providing care for the
whole person.
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\10\ American Psychological Association. The Healing Power of
Native American Culture is Inspiring Psychologists to Embrace Cultural
Humility. October 2023. https://www.apa.org/monitor/2023/10/healing-
tribal-communities-native-americans.
\11\ Id.
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Currently the IHCIA requires IHS to have a program educating
``appropriate employees'' with an ``educational instruction in the
history and culture'' of tribes.\12\ However, this program is not
mandatory nor required annually by statute. H.R. 8942 would amend the
current culture and history program provision under IHCIA to a
mandatory annual program for IHS employees. The legislation also
specifies which employees should be required to have the annual
training, including IHS employees, locum tenens medical providers,
health care volunteers, and other contracted employees working at IHS
facilities that have direct patient access.
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\12\ P.L. 94-437.
Staff contact: Jocelyn Broman ([email protected]) and
Kirstin Liddell ([email protected]), (x6-9725)
H.R. 8955 (Rep. Johnson of SD), ``IHS Provider Integrity Act''
H.R. 8955 would require the IHS to notify state medical boards when
an investigation is undertaken into an IHS health care provider
licensed by a state medical board, and also requires IHS to provide
information on any health care provider's medical license violations to
any state medical boards the provider is licensed under. Additionally,
the bill requires that during the hiring process of a health care
provider, IHS must receive information on any violation of a provider's
medical license dating 20 years, as well as information on any
settlement agreements that the provider entered into for a disciplinary
charge related to their medical practice.
The IHS has long been plagued with issues, particularly when it
comes to direct service providers and facilities.\13\ In 2010, a major
congressional review of the IHS Great Plains Area Region (GPA) by the
Senate Committee on Indian Affairs (SCIA) detailed serious deficiencies
at IHS facilities.\14\ A hearing and its subsequent investigative
findings were released by SCIA in the Dorgan Report in December 2010.
The report detailed major deficiencies ranging from medical care to
administrative procedures.\15\ It was found that IHS lacked a proper
system to detect practitioners using revoked, suspended, or otherwise
inadequate licenses.\16\ The investigation requested the IHS to provide
all information pertaining to healthcare providers with disciplinary
actions on their licenses. The IHS submitted information relating to
two providers, but the investigation revealed that there were more
practitioners than previously disclosed or known.\17\ There continues
to be instances of lack of care ranging from quality and safety of
patients,\18\ extreme vacancies,\19\ and misconduct in the IHS.\20\
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\13\ Direct Service means health care provided by IHS federal
employees at IHS facilities to American Indians and Alaska Natives.
See, ``Direct Service Tribes'' Indian Health Service, https://
www.ihs.gov/odsct/dst/.
\14\ U.S. Senate. Committee on Indian Affairs. In Critical
Condition: The Urgent Need to Reform the Indian Health Service's
Aberdeen Area, 2010. https://www.govinfo.gov/content/pkg/CHRG-
111shrg63826/pdf/CHRG-111shrg63826.pdf. http://www.indian.senate.gov/
sites/default/files/upload/files/63826.PDF.
\15\ Dorgan Report, p. 5-6.
\16\ Dorgan Report, p. 6.
\17\ Dorgan Report, p. 29 and 67.
\18\ Ferguson, Dana. ``IHS hospital in `immediate jeopardy,' feds
say. The Argus Leader, May 24, 2016. http://www.argusleader.com/story/
news/2016/05/23/reservation-hospital-immediate-jeopardy-feds-say/
84812598/.
\19\ Gemma DiCarlo, ``New Indian Health Service funding provides
stability, but long-standing issues remain,'' Oregon Public
Broadcasting. Jan. 20, 2023. https://www.opb.org/article/2023/01/20/
new-indian-health-service-funding-provides-stability-but-long-standing-
issues-remain/.
\20\ Government Accountability Office, ``Indian Health Service:
Actions Needed to Improve Oversight of Provider Misconduct and
Substandard Performance.'' Dec. 2020. GAO-21-97. https://www.gao.gov/
assets/gao-21-97.pdf.
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The IHS has historically had a history of hiring individuals with a
history of medical malpractice. In some instances, this negligence
occurred because the individual had flags under one state license, but
not the other. Such was the case with Dr. Marrocco who was hired at an
IHS hospital in New Mexico in 2012. Dr. Marrocco had disciplinary flags
on her licenses in New York and Florida, but her Pennsylvania license
was clean, so the IHS went ahead and hired her. Dr. Marrocco went on to
play a role in the development of a stroke in an eighteen-year-old
patient.\21\
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\21\ Christopher Weaver, et. al. ``The U.S. Gave Troubled Doctors a
Second Chance. Patients Paid the Price,'' Frontline. PBS. Nov. 22,
2019. https://www.pbs.org/wgbh/frontline/article/u-s-indian-health-
service-gave-troubled-doctors-second-chance-patients-paid-price/.
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Other instances have shown that the IHS has failed to fully
investigate their applicants before hiring. In 2019, the Wall Street
Journal studied 171 doctors who had allegedly provided negligent care
at the IHS. Of the 171 sample, 44 doctors should have raised red flags
by the IHS's own standards of care, yet they were hired at the
detriment of patients.\22\
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\22\ Id.
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The guidelines self-imposed by the IHS emphasize the need to
investigate applicants for past malpractice, sanctions, and criminal
convictions.\23\ However, an official who approved Henry Stachura's
appointment was unaware of his problematic employment history.
Stachura, who had a career littered with malpractice settlements, was
employed by IHS after being suspended from Memorial Medical Center in
New Mexico.\24\ Prior to his service at the IHS, Dr. Stachura performed
surgery resulting in a bile duct injury. Once at the IHS, he operated
on Ms. Jeanise Livingston which resulted in a cut bile duct and a
subsequent coma for Ms. Livingston. Dr. Stachura retired in 2019 with
three deaths and $1.8 million in settlement payments paid by the U.S.
government to round out his time at the IHS.\25\
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\23\ IHS. Indian Health Manual. Parts and Chapters. Part 3-1.4
https://www.ihs.gov/IHM/pc/part-3/p3c1/
\24\ Weaver, ``The U.S. Gave Troubled Doctors a Second Chance.
Patients Paid the Price,'' Frontline. PBS. Nov. 22, 2019. https://
www.pbs.org/wgbh/frontline/article/u-s-indian-health-service-gave-
troubled-doctors-second-chance-patients-paid-price/.
\25\ Id.
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While IHS does have challenges filling medical provider positions,
as the entire health care industry faces),\26\ ensuring the providers
hired by IHS meet standards is essential to ending substandard care at
IHS facilities. H.R. 8955 would require the IHS to solicit the history
of any applicant from the medical board of each state in which the
applicant is licensed. Additionally, the IHS would be required to
notify and provide the necessary documentation to state medical boards
once an investigation of a licensee has started. To ensure compliance,
the IHS would also be required to submit a report to Congress
showcasing implementation no later than 180 days after enactment.
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\26\ Caitlin Owens, ``The health care workforce crisis is already
here'' AXIOS. Jun. 7, 2024. https://www.axios.com/2024/06/07/health-
care-worker-shortages-us-crisis.
Staff contact: Jocelyn Broman ([email protected]) and
Kirstin Liddell ([email protected]), (x6-9725)
H.R. 8956 (Rep. Newhouse), ``Uniform Credentials for IHS Providers Act
of 2024''
H.R. 8956 would require the IHS, in consultation with tribes and
stakeholders, to establish a uniformed and centralized IHS-wide
credentialing system, while authorizing the enhancement and expansion
of its existing system to ensure all requirements are met.
Additionally, the IHS would be required to undergo a formal review of
the system to ensure compliance every five years at minimum.
Credentialing is the process of assessing the qualifications of
specific types of health care providers to show they have the proper
education, training, and licenses to care for patients.\27\ The Centers
for Medicare and Medicaid Services (CMS) requires a credentialing
process before a provider can be eligible for Medicare or Medicaid
reimbursement within the health care industry.\28\ Because IHS provides
health care directly to AI/ANs at IHS facilities, they have their own
process of credentialing health care providers which requires that
medical staff must meet the credentialing and privileging standards of
a national accrediting body like the Joint Commission or CMS.\29\
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\27\ ``Why Provider Credentialing is a Necessary Hassle and a Vital
Safeguard,'' CAQH. April 7, 2021. Accessed July 16, 2024. https://
www.caqh.org/blog/why-provider-credentialing-necessary-hassle-and-
vital-safeguard.
\28\ CMS certification process. https://www.cms.gov/Medicare/
provider-enrollment-and-certification/certificationandcomplianc/
downloads/certandcomplianceprocess.pdf.
\29\ IHS. Indian Health Manual Part 3-1.3 A. https://www.ihs.gov/
ihm/pc/part-3/p3c1/
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However, IHS has a history of concerning and inadequate
credentialing with IHS leadership touting improvement. The 2010 Dorgan
report revealed that the IHS had failed to ensure that all healthcare
practitioners in the Aberdeen Area had an active license, in one case
the nurse had her license indefinitely suspended in 2005 but was
employed by the IHS.\30\ Ensuring health care providers have the
necessary licenses is a part of the credentialing process, and health
care facilities that do not meet these licensing requirements can have
their accreditation revoked and find themselves unable to bill Medicare
and Medicaid for services unlicensed providers perform.\31\
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\30\ Dorgan Report, p. 45 and 68.
\31\ Id. at 27.
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During a Senate Committee on Indian Affairs (SCIA) hearing in June
of 2017, then Acting Director of the IHS Chris Buchanan testified that
the IHS recently awarded a contract for credentialing software with the
goal of standardizing the credentialing system.\32\ The Presidential
Task Force on Protecting Native American Children in the Indian Health
Service System report, published in July 2020, noted inconsistencies
between facilities in their credentialing, privileging, and hiring
processes.\33\ Some hiring committees prioritized filling a vacant spot
``over a thorough background and credentialing check.'' \34\ A lack of
shared information increased the practice of hiring individuals with
otherwise questionable history and qualifications from one facility to
another.\35\
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\32\ Chris Buchanan Testimony. June 2017. https://
www.indian.senate.gov/sites/default/files/upload/
6.13.17%20Chris%20Buchanan%20Testimony.pdf.
\33\ Department of Justice. Presidential Task Force on Protecting
American Children in the Indian Health Service System Report. July 23,
2020. at 16, https://www.justice.gov/usao-ndok/press-release/file/
1297716/dl?inline
\34\ Id.
\35\ Id.
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An April 2024 Government Accountability Office (GAO) report \36\
found that IHS was not adhering to its current credentialing
requirements. GAO pulled 91 clinician files who were employed at an IHS
facility as of 2022 for review. Of the sample, 12 percent of the files
did not meet IHS's requirement to verify all licenses held by the
clinician, and in three of those files the IHS had not verified any
licenses.\37\ In eight of the files, it was found that IHS verified one
license held by the clinician but did not verify the licenses for other
states.\38\
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\36\ Government Accountability Office, ``Indian Health Service:
Opportunities Exist to Improve Clinical Screening Adherence and
Oversight.'' April 2024. GAO-24-106230. https://www.gao.gov/assets/
d24106230.pdf.
\37\ Id.
\38\ Id.
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The IHS concurred with GAO's recommendation to develop a single,
authoritative source for credentialing and privileging requirements,
and defining the steps necessary to meet national credentialing
requirements. Elaborating further, IHS noted that the Indian Health
Service Manual has been updated with a new credentialing policy which
would continue through the approval process ending in a standard
operating procedure in September 2024.\39\
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\39\ Id.
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The IHS has consistently acknowledged the need for a centralized
medical system and has shown strides toward that goal. The Draft Indian
Health Service Strategic Plan for Fiscal Years 2024-2028 has a
performance goal of standardizing credentialing software and
applications across the agency.\40\ The IHS requested public comment on
the new credentialing policy in May 2023.\41\ In the FY 2025 Budget
Justification, IHS noted that they had implemented a nationwide
electronic provider credentialing system within federally operated
hospitals and clinics.\42\
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\40\ Indian Health Service. Draft Indian Health Service Strategic
Plan for Fiscal Years 2024-2028. https://www.ihs.gov/sites/newsroom/
themes/responsive2017/display_objects/documents/2024 _Letters/
Enclosure_DTLL_DUIOLL_050224.pdf
\41\ Request for Public Comment: 60-Day Information Collection:
Indian Health Service Medical Staff Credentials Application, 88 Fed.
Reg. 30317 (May 11, 2023). available at: https://
www.federalregister.gov/documents/2023/05/11/2023-09998/request-for-
public-comment-60-day-information-collection-indian-health-service-
medical-staff.
\42\ IHS Budget Justification, FY25, at CJ-8. https://www.ihs.gov/
sites/budgetformulation/themes/responsive2017/display_objects/
documents/FY-2025-IHS-CJ030824.pdf.
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However, IHS has not been fully transparent while it is creating
this new system. H.R. 8956 would place the requirement for IHS to
establish a uniformed and centralized IHS-wide credentialing system in
statute, providing Congress the opportunity to ensure the standardized
credentialing system is put in place.
Staff contact: Jocelyn Broman ([email protected]) and
Kirstin Liddell ([email protected]), (x6-9725)
H.R. 6489 (Rep. Peltola), ``Alaska Native Village Municipal Lands
Restoration Act of 2023''
In 1971, ANCSA \43\ was enacted to settle the aboriginal land
claims of Alaska Natives. Through ANCSA, Alaska Native Corporations
(ANCs) were established to receive land under the settlement and
disperse the payments to Alaska Natives. Alaska Natives received a
$962.5 million settlement payment and roughly 44 million acres of land,
which were divided between almost 200 village corporations and 12
regional corporations established by the legislation.\44\
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\43\ 43 U.S.C. 1601, et seq.
\44\ Id.
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Section 14(c)(3) of ANCSA requires that an Alaska Native Village
Corporation receiving land under ANCSA conveys some lands to an
existing municipality for use by the municipality. If no municipality
exists, then these lands are conveyed to the State to be held in trust
for a future municipality.\45\ However, most Alaska Native villages
have not established municipalities, and these lands remain
undeveloped.
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\45\ 43 U.S.C. 1613.
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Since 1971, a total of 101 Alaska Native Village Corporations have
seen their lands held in trust by the State for the purpose of a future
municipality, but only eight have seen a municipality created, with the
last being created in 1995. Ten Alaska Native Village Corporations have
reached agreements with the State to have these lands returned without
forming a municipality, but 83 Alaska Native Village Corporations still
have approximately 11,500 acres held in trust and unable to be
developed with no end in sight, since ANCSA did not have a sunset date
for this provision.\46\
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\46\ Senate Energy and Natural Resources Committee. S. Rept. 118-
177-Alaska Native Village Municipal Lands Restoration Act. May 16,
2024. https://www.congress.gov/congressional-report/118th-congress/
senate-report/177/1
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The estimated 11,500 acres held in trust by the State remain nearly
impossible to develop since the lands must be reserved for future
municipalities. If the municipality requirement was lifted, Alaska
Native villages would be able to consider developing the lands for
housing, community, expansion, and other economic development plans.
Some Alaska Native Village Corporations did not reconvey land under
14(c) due to concerns with the 14(c)(3) provision and land being held
in trust for perpetuity, resulting in murky land titles.\47\
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\47\ Id.
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H.R. 6489 would amend ANCSA to return the land conveyed back to the
village corporation that conveyed to the State, while eliminating the
requirement for an Alaska Native village corporation to convey land
under the ANCSA 14(c)(3) provision.
There is wide support for the reconveyance within the state of
Alaska. The Alaska State Senate unanimously passed Senate Joint
Resolution No. 13 on May 9, 2024, which encourages the United States
Legislative and Executive branches to pass and sign legislation to
return certain land in trust back to affected Alaska Native village
corporations.\48\ Alaska Governor Mike Dunleavy is also supportive of
the legislative fix that H.R. 6489 would provide.\49\
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\48\ The Alaska State Legislature. Bill History for ``Amend Alaska
Native Claims Settlement Act.'' SJR 13. 33rd Legislature. https://
www.akleg.gov/Basis/Bill/Detail/33?Root=SJR%2013
\49\ IIA Subcommittee has Letter of Support on file.
Staff contact: Jocelyn Broman ([email protected]) and
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Kirstin Liddell ([email protected]), (x6-9725)
IV. MAJOR PROVISIONS & SECTION-BY-SECTION
H.R. 8942 (Rep. Hageman), ``Improving Tribal Cultural Training for
Providers Act of 2024''
Section 2. Tribal Culture and History
Requires an annual mandatory training program related to tribal
culture and history for specified IHS employees.
H.R. 8955 (Rep. Johnson of SD), ``IHS Provider Integrity Act''
Section 2. Notification of Investigation Regarding Professional
Conduct; Submission of Records.
Requires the IHS to notify and provide relevant records to State
Medical Boards no later than 14 calendar days after starting an
investigation into the professional conduct of a licensee practicing at
an IHS facility.
Section 3. Fitness of Health Care Providers.
Requires the IHS during the agency's hiring process to solicit an
applicant's history of license violations or settlements over the
previous 20 years from any state's medical board in which the applicant
is medically licensed. Requires the IHS to provide to the medical board
of each state in which a provider is licensed, detailed information
regarding any violations by the provider in their IHS capacity.
Requires the IHS to submit to Congress a report detailing its
compliance with these policies no later than 180 days post enactment of
this act.
H.R. 8956 (Rep. Newhouse), ``Uniform Credentials for IHS Providers Act
of 2024''
Section 2. Medical Credentialing System
Requires IHS, no later than one-year post-enactment, to establish,
in consultation with tribes and stakeholders, a uniformed and
centralized Service-wide credentialing system for individuals providing
services at IHS facilities. Authorizes the IHS to enhance and expand
its existing credentialing system to meet the requirements listed.
Requires the IHS to undergo a formal review of its credentialing
service to ensure all guidelines are met at least every five years.
Current credentialed employees would be grandfathered into the new
system and would not be re-credentialed until expiration date of
current credentials.
H.R. 6489 (Rep. Peltola), ``Alaska Native Village Municipal Lands
Restoration Act of 2023''
Section 2. Reversion of Certain Land Conveyed in Trust to the State
of Alaska
Amends ANCSA to remove the requirement that an Alaska Native
village corporation must convey land into trust to the State of Alaska
for future municipal governments. Additionally, provides village
corporations the opportunity to regain title to the lands held in trust
by dissolving the trust through a formal resolution by the village
corporation and the residents of the Native village.
V. CBO COST ESTIMATE
None of the bills received a formal cost estimate from the
Congressional Budget Office.
VI. ADMINISTRATION POSITION
During a Senate Energy and Natural Resources Committee hearing on
S. 2615, the Alaska Native Village Municipal Lands Restoration Act, an
identical bill to H.R. 6489, Principal Deputy Director Nada Wolff
Culver of the Bureau of Land Management testified in support of the
overall goal of the bill. Citing mild concerns with a lack of a
timeline for village corporations to initiate and complete the entire
14 (c) process, which is beyond the scope of this bill.\50\
---------------------------------------------------------------------------
\50\ Senate Energy and Natural Resources Committee. S. Rept. 118-
177-Alaska Native Village Municipal Lands Restoration Act. May 16,
2024. https://www.congress.gov/congressional-report/118th-congress/
senate-report/177/1.
The administration position on the remaining legislation is unknown
---------------------------------------------------------------------------
at this time.
VII. EFFECT ON CURRENT LAW (RAMSEYER)
H.R. 8942 (Rep. Hageman), ``Improving Tribal Cultural Training for
Providers Act of 2024''
https://naturalresources.house.gov/uploadedfiles/bill-to-
law_hagema_265_xml.pdf
H.R. 8955 (Rep. Johnson of SD), ``IHS Provider Integrity Act''
https://naturalresources.house.gov/uploadedfiles/bill-to-
law_johnsd_079_xml.pdf
H.R. 8956 (Rep. Newhouse), ``Uniform Credentials for IHS Providers Act
of 2024''
https://naturalresources.house.gov/uploadedfiles/bill-to-
law_newhou_083_xml.pdf
H.R. 6489 (Rep. Peltola), ``Alaska Native Village Municipal Lands
Restoration Act of 2023''
https://naturalresources.house.gov/uploadedfiles/h.r._6489_-
_ramseyer.pdf
LEGISLATIVE HEARING ON H.R. 6489, TO AMEND THE ALASKA NATIVE
CLAIMS SETTLEMENT ACT TO PROVIDE THAT VILLAGE CORPORATIONS
SHALL NOT BE REQUIRED TO CONVEY LAND IN TRUST TO THE STATE OF
ALASKA FOR THE ESTABLISHMENT OF MUNICIPAL CORPORATIONS, AND FOR
OTHER PURPOSES, ``ALASKA NATIVE VILLAGE MUNICIPAL LANDS
RESTORATION ACT OF 2023''; H.R. 8942, TO AMEND THE INDIAN
HEALTH CARE IMPROVEMENT ACT TO ENSURE THAT CERTAIN EMPLOYEES,
PROVIDERS, AND VOLUNTEERS ASSOCIATED WITH THE INDIAN HEALTH
SERVICE RECEIVE EDUCATIONAL TRAINING IN THE HISTORY AND CULTURE
OF THE TRIBES SERVED BY SUCH PERSONS, AND FOR OTHER PURPOSES,
``IMPROVING TRIBAL CULTURAL TRAINING FOR PROVIDERS ACT OF
2024''; H.R. 8955, TO AMEND THE INDIAN HEALTH CARE IMPROVEMENT
ACT TO ENSURE THAT, WHENEVER THE INDIAN HEALTH SERVICE
UNDERTAKES AN INVESTIGATION INTO THE PROFESSIONAL CONDUCT OF A
LICENSEE OF A STATE, THE SERVICE NOTIFIES THE RELEVANT STATE
MEDICAL BOARD, AND FOR OTHER PURPOSES, ``IHS PROVIDER INTEGRITY
ACT''; AND H.R. 8956, TO AMEND THE INDIAN HEALTH CARE
IMPROVEMENT ACT FOR THE DEVELOPMENT AND IMPLEMENTATION OF A
CENTRALIZED SYSTEM TO CREDENTIAL LICENSED HEALTH PROFESSIONALS
WHO SEEK TO PROVIDE HEALTH CARE SERVICES AT ANY INDIAN HEALTH
SERVICE UNIT, ``UNIFORM CREDITIALS FOR IHS PROVIDERS ACT OF
2024''
----------
Wednesday, July 24, 2024
U.S. House of Representatives
Subcommittee on Indian and Insular Affairs
Committee on Natural Resources
Washington, DC
----------
The Subcommittee met, pursuant to notice, at 10:17 a.m., in
Room 1334, Longworth House Office Building, Hon. Harriet M.
Hageman [Chairwoman of the Subcommittee] presiding.
Present: Representatives Hageman, Radewagen, LaMalfa,
Westerman, Newhouse, Johnson; Leger Fernandez, Sablan, and
Peltola.
Ms. Hageman. The Subcommittee on Indian and Insular Affairs
will come to order.
Without objection, the Chair is authorized to declare
recess of the Subcommittee at any time. The Subcommittee is
meeting today to hear testimony on four bills, H.R. 8942, H.R.
8955, H.R. 8956, and H.R. 6489.
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, so ordered. I ask unanimous consent that
the gentleman from South Dakota, Mr. Johnson; the gentleman
from Washington, Mr. Newhouse; and the gentlewoman from Alaska,
Ms. Peltola, be allowed to sit and participate in today's
hearing.
Without objection, 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. Today, the Subcommittee is meeting to consider
four bills. Three of the bills will improve the Indian Health
Service or the IHS, and the fourth would return lands to Alaska
Native village corporations that have been held by the state of
Alaska for unfulfilled purposes.
First, I want to especially thank Congressman Dusty Johnson
for working with this subcommittee on improving IHS and being a
champion for improving the tribal health system for all tribes.
Last July, the Subcommittee held a hearing on Congressman
Johnson's restoring accountability in the Indian Health Service
Act in draft form. After much discussion, this Subcommittee and
Congressman Johnson decided to take three key elements from the
larger bill and introduce them as individual bills that we
think get at specific issues that we can improve right now.
The first bill is H.R. 8942, the Improving Tribal Cultural
Training for Providers Act of 2024, of which I am very proud to
sponsor. H.R. 8942 would require a mandatory annual training
program for specific employees of the IHS on the history and
culture of the tribes that they are serving.
Because IHS's mission is to work with American Indian and
Alaska Native people to promote their physical, mental, social,
and spiritual health, IHS healthcare providers need cultural
competence to best serve their patients.
Several studies have indicated that culturally appropriate
healthcare can improve doctor-patient relationships and improve
health outcomes for patients.
Currently, IHS employees are required to have training on
the history and culture of the tribes they serve, but it is not
an annual requirement.
My bill would also explicitly state which IHS employees
should have annual training requirements. Each of our 574
federally recognized tribes has a unique history and culture.
It is vital that healthcare providers receive the education
they need to connect with the patients that they serve, and
that this training requirement has the flexibility needed to
avoid a one-size-fits-all approach.
Many tribally run healthcare programs already provide this
education for their healthcare providers, and we can learn from
them to make this requirement work.
The second bill is H.R. 8955, the IHS Provider Integrity
Act, introduced by Congressman Dusty Johnson. H.R. 8955 would
require the IHS to solicit the history of an applicant from
every state medical board where the applicant is licensed.
The IHS would also be required to notify each state medical
board where a provider is licensed if IHS begins an
investigation into the provider.
The IHS has consistency issues surrounding healthcare
provider licensing, including providers being hired without
full review of all of their licenses and IHS providers with
lapsed licenses continuing to work at IHS facilities.
This long-standing issue first came to national attention
in 2010 when the Senate Committee on Indian Affairs
investigated the many issues surrounding IHS facilities
operating in the Great Plains area.
That investigation found that the IHS lacked a proper
system to detect practitioners using revoked, suspended, or
otherwise inadequate licenses. Later investigations continued
to show that doctors were hired without full license checks at
IHS facilities in violation of IHS policies, thereby imperiling
patients.
It is important that the IHS holds providers to a high
level of care. H.R. 8955 would work to ensure all parties have
the information necessary to keep their patients safe and make
the best hiring decisions possible.
The third bill, H.R. 8956, the Uniform Credentials for IHS
Providers Act of 2024, introduced by Congressman Newhouse,
would require the IHS to establish a uniform and centralized
service-wide credentialing system. This system would be
formally reviewed at least every 5 years.
Credentialing is the process by which healthcare providers
are evaluated to show that they have the proper education,
training, and licenses to fulfill a position at a healthcare
facility.
IHS has its own process of credentialing providers that
requires medical staff to meet the credentialing and
privileging standards of a national accrediting body like the
Centers for Medicare and Medicaid Services.
However, the credentialing process has not been in practice
the same across all IHS facilities and has specifically not
caught issues of lapsed licenses, as previously mentioned.
While the IHS has initiated the process to create a
centralized credentialing system in recent years, Congress has
a responsibility to conduct oversight on the process and ensure
that it meets the highest standard and is implemented
consistently.
The final bill up for discussion today is H.R. 6489, the
Alaska Native Village Municipal Lands Restoration Act of 2023
introduced by Congresswoman Peltola, this bill would amend
Section 14(c)(3) of the Alaska Native Claims Settlement Act, or
ANCSA, to return lands back to the Alaska Native Village
corporations that are currently held in trust by the state of
Alaska for future municipalities.
ANCSA was enacted to settle the aboriginal land claims of
Alaska Natives, and Alaska Native corporations were created to
receive land and disburse payments to Alaska Natives.
The settlement also included a provision requiring Alaska
Native village corporations to convey some land to an existing
municipality. However, if no municipality existed, the land was
conveyed to the state of Alaska to be held in trust for a
future municipality.
As of today, 83 village corporations still have land held
in trust for the purposes of a municipality which has not yet
been created and likely never will be. There was no sunset date
for this provision, so this land remains in limbo, unable to be
developed.
Village corporations would anticipate developing this land
if returned for housing, community buildings, and other
economic development projects. H.R. 6489 would also amend ANCSA
to return this land and eliminate the requirement in statute.
I want to take the time to thank our witnesses for being
here today, and I look forward to today's discussion.
The Chair now recognizes the Ranking Minority Member for
her statement.
STATEMENT OF THE HON. TERESA LEGER FERNANDEZ, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW MEXICO
Ms. Leger Fernandez. Good morning to our witnesses and
thank you for joining us. Thank you, Representative Johnson,
for the good work that you did on the bill from which we are
pooling many of the legislative proposals today, including
Chair Hageman's H.R. 8942, which would provide Indian Health
Service employees with educational and cultural training to
better serve their tribal communities.
I also appreciate the written testimony that we have
received, that points out that each tribe is going to have
unique cultural traditions, and it is important that IHS
develop that training in consultation with the tribes that they
serve.
We would love to see that added to this legislation.
Representative Johnson's H.R. 8955, which would make sure that
the Indian Health Service is transparent with state medical
boards, which are the professional conduct of a licensed health
provider.
The sad history of the issues where they have not been
transparent are suffered by the patients. We will also consider
H.R. 8956 from Representative Newhouse, which would establish a
service-wide, centralized credentialing system at the Indian
Health Service.
These three bills sound familiar, as noted, because they
are all sections of Representative Johnson's Restoring
Accountability in Indian Health Service Act, which this
Subcommittee had a hearing on last July and was reintroduced
earlier this month.
I will repeat what I said in that hearing, we cannot
continue to ignore the lack of funding that tribes and the
Indian Health Service have to deal with on a daily basis.
None of these bills have the funding necessary to support
these important efforts. As we noted in the earlier hearing,
the average spending for Americans on healthcare is $9,726.
The average spending for a patient at IHS is $4,078. And
sadly, only 672 of you are in urban areas. It is important that
we begin to address this as well as include funding resources
when we take on important reform bills.
In that hearing, the witnesses also shared their concerns
about the lack of resources when creating new mandates. They
suggested that this could ultimately hurt tribes' ability to
provide the care.
There are also many other positive sections of
Representative Johnson's larger bill that we should discuss
today but aren't included in these bills, particularly the
efforts to better recruit and retain IHS staff and streamline
their hearing process.
I hope that we can address the issues that tribes have
raised in the last hearing and make a real change at the Indian
Health Service to support providing culturally competent care
to American Indians and Alaska Natives across the United
States.
The final bill today on the agenda is Representative
Peltola's H.R. 6489, the Alaska Native Village Municipal Lands
Restoration Act. This bill would amend the Alaska Native Claims
Settlement Act to retire the requirement for village
corporations of unincorporated communities to reconvey lands to
the state entrust for a future city for municipal purposes.
I look forward to hearing from our witnesses about this
bill and their impacts it will have in Alaska. Before I end, I
also want to note that this is our last legislative hearing
before the August recess.
And when we get back, we have a lot of legislation from
Democratic Members that haven't had any hearings yet, and we
have bipartisan legislation that hasn't seen a markup. So, I
look forward to having a very productive session in September
so that we can address some of those wonderful bipartisan
bills.
With that, I want to once again and always thank the
witnesses, because especially on a day like today, it is not
easy to get here. It is not easy to get in here. So, thank you
for your patience, and I yield back, Madam Chair.
Ms. Hageman. Thank you.
I will now recognize Mr. Johnson from South Dakota for 5
minutes to speak on his legislation.
STATEMENT OF THE HON. DUSTY JOHNSON, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF SOUTH DAKOTA
Mr. Johnson. Thanks, Madam Chair, Madam Ranking Member, I
just want to start by thanking you. This is actually how
Washington is supposed to work.
We worked with your teams for a long time together on the
discussion draft that you both referenced, the Restoring
Accountability to IHS Bill. And then we kept working on it. We
realized that politics is the art of the possible.
You all had coached us about the value of breaking this
into smaller pieces so we could get some movement, gain some
traction. So, it is really the fruits of those labors that
bring us here today.
And I just want to thank you for this hearing, as well as
the diligence of this Committee in trying to make sure that we
are moving the ball in the right direction and trying to
improve the quality of care in IHS. It is just an incredibly
important obligation we have that we are not always doing a
very good job of meeting.
In South Dakota, the average age of death is 78 years old.
For Native American enrolled members, it is 58 years, just a
remarkable 20-year gap. And there are a lot of reasons for
that, and we should address all of them. But one of the reasons
for that is the poor quality of healthcare in Indian Country,
and that is something that we have trust and treaty obligations
to address.
And we also know that part of the problem with the
healthcare is we also have a provider problem. Now, to be
clear, there are tremendous human beings who choose to serve in
Indian Country because they have huge hearts, and they want to
make a difference.
But we also know that there have been times that IHS has
been a refuge for providers who are not good, who should not be
practicing medicine. And study after study has shown us that. I
would refer to the 2021 report, which we have to give some
credit to IHS for independently commissioning that report.
So often in government, you see people try to cover up
their errors. But IHS, in this 2021 report, was able to uncover
that IHS had willfully ignored and actively suppressed efforts
to go out and identify this particular provider who had been
later convicted of a series of sexual misconduct.
The kind of person who should not be practicing medicine.
And, obviously, we have a lot of work to do on that front.
There are also instances where you have a provider who gets
rejected to practice medicine off reservation because of
malpractice, and then they apply for a job on IHS, and they get
hired.
And clearly, if they are not a provider that should see
non-enrolled members, they are not a provider who should see
enrolled members either.
So, the bills before you today are really an attempt,
particularly the bill that I am talking about, is an attempt to
get at both of those issues with two things:
(1) strengthening the information sharing practices between
the state medical boards and IHS so we can figure out who the
bad actors are and make sure we don't hire them.
And then (2) requiring IHS to gather information on medical
license violations so they can consider that before hiring
somebody to work at an IHS facility.
And I know that there are some conversations ongoing about,
OK, how do we do these things while still providing due process
to providers? And, obviously, let's make sure that we are
striking the right balance here. Those conversations are
ongoing.
I am not under any illusions that the bills before us today
are perfect. Let's continue to work on them so we do strike
that right balance.
I want to thank the witnesses for being here, a number of
whom we have heard from before. But, of course, I have to call
out my friend from South Dakota, Jerilyn Church. She is
incredibly respected as the head of the Great Plains Tribal
Chairman's Health Board. She has done as much as anybody to
educate the South Dakota politicians about why this matters and
what we can do together to make it happen.
So, of course, I am going to be interested to hear her
remarks as well. And I will close where I began, by thanking
you all for the incredibly collaborative efforts that we are
engaged in.
We so often talk about what doesn't work in Washington, DC,
but today is a pretty good day because we are moving closer to
making progress. It is a little progress, and we need a lot of
progress, but let's celebrate the little progress when we get
it. With that, I yield.
Ms. Hageman. Thank you, Congressman.
And the Chair will now recognize Mr. Newhouse from
Washington for 5 minutes to speak on his legislation.
STATEMENT OF THE HON. DAN NEWHOUSE, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF WASHINGTON
Mr. Newhouse. Thank you very much, Chair Hageman, Ranking
Member Leger Fernandez, and members of the Committee for
allowing me the opportunity to speak on and be part of
something that is, like my colleague from South Dakota
described, making some real progress on a very, very important
issue.
I am just proud to be a part of this and look forward to
not only accomplishing these important steps, but much, much
more.
So, thank you for everybody's efforts today. Before I talk
about my legislation at all, though, I am very proud to be able
to see on the witness stand Chairman Erickson from the Colville
Reservation, Chairman of the Confederated Tribes there.
Jarred is a good friend and has been working very hard on
these issues for several years, many years. And I just want to
point out that while this is important stuff, literally home
fires are burning.
There are two major fires going on right now on the
reservation. So, I very much appreciate Chairman Erickson's
presence here to talk about these issues, while I am sure his
thoughts are back home with his people.
To get to my part of this legislation, which I think covers
a very important aspect of it, it is the Uniform Credentials
for IHS Providers Act, which is part of the larger package, and
I am very happy to have reintroduced this legislation with my
colleague Dusty Johnson.
IHS is responsible, as we all know, for providing direct
medical and public health services to members of the federally
recognized Native American tribes and the Alaska Natives.
This duty includes reviewing and verifying professional
quality qualifications of clinicians through a process that is
known as credentialing and privileging.
Currently, this process involves meeting credentialing
requirements that are spread across multiple and sometimes
conflicting documents, making it quite challenging for
officials to effectively and efficiently credential incoming
medical providers.
This lack of a standardized credentialing system has led to
issues for the IHS and for those who utilize its services.
In my district, my constituents have reported instances in
which the current IHS credentialing system has truly negatively
impacted health provider recruitment and our onboarding
efforts, including one instance in which providers who were
interested in working for the local service unit only to pursue
an opportunity elsewhere because of the slow pace of the
credentialing process.
So, given that the health disparities that exist in Tribal
Nations around the United States, recruitment of quality health
personnel should be of utmost priority.
On top of that, there have been reports of inconsistencies
between facilities and their credentialing, privileging, and
hiring process in which hiring committees have prioritized
filling vacant positions over thorough background and
credentialing checks.
And on top of that, it has been reported that a lack of
shared information increases the practice of hiring individuals
with otherwise, shall we say, questionable history in
qualifications from one facility to another.
A recent GAO report described the effect of the lack of a
centralized system. In one instance, the report found that at
an IHS facility that was reviewed, 12 percent of clinician
files that were analyzed did not meet IHS's requirement to
verify all licenses held by the clinician, and in three of
those files, the IHS had not verified any licenses.
My bill seeks to address such issues by requiring the
Indian Health Service, in consultation with tribes and
stakeholders, to establish a uniformed, centralized, service-
wide credentialing system for individuals providing services at
IHS facilities.
The development of such a system, I think, would ensure
that IHS providers are equipped with the tools that they need
to efficiently and effectively hire qualified personnel in
their facilities and ensure that all of them are thoroughly
vetted.
I think this is of utmost importance, that all patients
receive the highest quality of care, no matter where they are.
And I believe that this legislation, my legislation, is a step
in the direction that we should be taking and certainly urge
the Committee to support this important measure.
Again, thank you very much for allowing me to be part of
the Committee hearing today.
Ms. Hageman. Thank you, Congressman.
I do have to report, and I apologize about the fact that we
are going to be disrupted because we are going to have to go
vote.
I did note that it is going to be a bit shorter than what
we initially thought the voting process would take, but I am
going to go ahead and have Representative Peltola do her
opening statement to describe her bill.
As soon as she is finished with that, we will go ahead and
go over and vote. We anticipate we will be coming off the Floor
at 11:10. We should be back in our seats about 11:15, and then
we will reconvene and continue to discuss these bills.
Representative Peltola, you have 5 minutes to discuss your
bill.
STATEMENT OF THE HON. MARY SATTLER PELTOLA, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF ALASKA
Ms. Peltola. Good morning. And thank you, Madam Chair and
Ranking Member Leger Fernandez. I appreciate you hearing my
bill today. H.R. 6489, the Alaska Native Village Municipal
Lands Restoration Act.
I greatly appreciate the support and advocacy of our
witness, Ben Mallott from the Alaska Federation of Natives, as
well as the Chenega Corporation. We have Greg Renkes with us,
our former Alaska Attorney General, many folks at the state of
Alaska, and our state legislature, among a lot of other folks,
for their expertise and eagerness to rightfully restore Alaskan
lands to the entities they were derived from, Alaska Native
village corporations.
Though Section 14(c)(3) of the Alaska Native Claims
Settlement Act intended to support the future development of
Alaskan municipalities, the lands given to the state to be held
in trust have instead become largely unavailable for
development.
In response, communities across Alaska have been
arbitrarily hamstrung from practicing the self-determination
promised to them by ANCSA. Everyone agrees that the land now
held by the state ought to be free from this obligation to be
made available for the economic and social well-being of
Alaskans.
And I again want to thank you for the opportunity to move
this bill forward, and I look forward to working with all of
you to move this across the finish line.
And Madam Chair, I would like to cede the rest of my time.
Ms. Hageman. Thank you. And we will be back in about 30 to
40 minutes. The hearing is recessed.
[Recess.]
Ms. Hageman. We are going to go ahead and get started, and
I am now going to introduce our witnesses for our panel.
Mr. Benjamin Smith is the Deputy Director, Indian Health
Service, U.S. Department of Health and Human Services,
Rockville, Maryland; the Honorable Jarred Michael Erickson,
Chairman, Confederated Tribes of the Colville Reservation,
Nespelem, Washington; Ms. Amber Torres, Chief Operating
Officer, National Indian Health Board, Washington, DC; Mr. Ben
Mallott, Vice President for External Affairs, Alaska Federation
of Natives, Anchorage, Alaska; and Ms. Jerilyn Church,
Executive Director, Great Plains Tribal Leaders Health Board,
Rapid City, South Dakota.
Thank you all for being here. I am sorry about the
disruption. I don't think that we will have another one and we
should be able to finish our hearing today.
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. At the end of 5 minutes, the light will turn
red, and I will ask you to please wrap up your statement.
I will also allow all witnesses on the panel to testify
before Member questioning.
The Chairman now recognizes Mr. Benjamin Smith for 5
minutes.
STATEMENT OF BENJAMIN SMITH, DEPUTY DIRECTOR, INDIAN HEALTH
SERVICES, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES,
ROCKVILLE, MARYLAND
Mr. Smith. Good morning Chair Hageman, Ranking Member Leger
Fernandez, and members of the Subcommittee. Thank you for the
opportunity to provide testimony on three legislative proposals
before the Subcommittee and for your continued support for the
efforts of the Indian Health Service and the Department of
Health and Human Services to improve the health and well-being
of American Indians and Alaska Natives.
Your consideration today of H.R. 8942, Improving Tribal
Cultural Training for Providers Act of 2024; H.R. 8955, the
Indian Health Service Provider Integrity Act; and H.R. 8956,
the Uniform Credentials for Indian Health Service Providers Act
of 2024, underscores that commitment to improving the quality
of healthcare provided by the Indian Health Service.
Again, my name is Benjamin Smith and I serve as the Deputy
Director at the Indian Health Service. The Indian Health
Service has worked hard over the past several years to train
our providers that work in our Indian Health Service and tribal
facilities.
This includes American Indian and Alaska Native culturally
appropriate training to all our IHS employees, including all
healthcare providers, whether Federal employees, contractors,
or volunteers.
This helps to meet our goal to ensure our licensed
providers meet professional standards required for their
discipline before authorizing them to provide healthcare in our
Indian Health Service facilities.
In addition, we continue to ensure our credentialing system
filters out providers that are not licensed or who are
professionally unfit to provide healthcare in our facilities.
We thank Representative Leger Fernandez for raising
workforce issues. In fact, the impacts of the workforce
challenges experienced at the Indian Health Service rank among
the top concerns that we hear from both tribes at the Indian
Health Service and the Department of Health and Human Services.
And I want to point out that our written testimony points
and discusses some of these workforce challenges and
recommendations in greater detail.
At the Indian Health Service, we continue to support new
strategies to develop the workforce and leverage advanced
practice providers and paraprofessionals to improve the access
to quality care in American Indian and Alaska Native
communities.
As the Subcommittee is aware, the Indian Health Service
executes its mission in partnership with our tribal communities
through a network of over 600 Federal and tribal health
facilities and to 41 urban Indian organizations that are
located across 37 states and provide healthcare on an annual
basis to approximately 2.87 million American Indian and Alaska
Native peoples.
The Indian Health Service operates under the authority of
the Indian Healthcare Improvement Act. The three legislative
proposals before the Subcommittee would amend that Act by: (1)
to ensure that certain employees, providers, and volunteers
associated with the Indian Health Service receive educational
training in the history and culture of the tribes served by the
Indian healthcare system; (2) to ensure that whenever the
Indian Health Service undertakes an investigation into the
professional conduct of a licensee in a state, that the Indian
Health Service notifies the relevant state medical board; and
finally (3) to develop and implement a centralized system for
credentialing licensed healthcare professionals seeking to
provide healthcare services at any of our IHS facilities.
I want to immediately jump into sharing with this
Subcommittee some of the comments and concerns that we have
with the three bills, but point this Subcommittee to our
written testimony for details and examples.
For H.R. 8942, the Training for Providers Act, the Indian
Health Service recommends the drafters consider whether
conditions of employment is feasible when applicable to
contractors and volunteers.
The Indian Health Service is concerned with creating a
condition of employment that depends on the Indian Health
Service setting up the program, which might be different, or a
separate training module for each tribe.
Thus, an employee, contractor, or volunteer could be
violating the terms of their agreement through no fault of
their own.
Moving to H.R. 8955, the Provider Integrity Act, the Indian
Health Service has concerns about the proposed timeline
requirement for notice and providing relevant documentation to
state medical boards.
We would like to further explore this requirement to ensure
that it contemplates the amount of time needed to complete a
required appropriate investigation before reporting an adverse
event, as well as to ensure providers have a right to due
process and an appropriate investigation and that medical
quality assurance records are properly safeguarded, consistent
with Section 805 of the Indian Health Care Improvement Act.
The drafters of H.R. 8955 should consider clarifying what
constitutes an investigation into the professional conduct. It
is unclear whether this is limited to peer review for
activities related to medical care or could it include any sort
of human resources review for the person's conduct as an
employee.
We also refer this Subcommittee to see our recommendations
and our written testimony on this bill regarding the Freedom of
Information Act and the 14-day timeline.
For H.R. 8956, the Credentials Act, the drafters may want
to note that the non-duplication of efforts language states,
the Secretary is not required to establish a new medical
credentialing system under the proposed legislation if the
service has begun implementing or has completed implementation
of a system that otherwise meets the requirements of this
section.
Taking this text into consideration, the Indian Health
Service already has the authority to create such a
credentialing system and has established and is fully
implementing the new system.
To conclude, again, I want to refer you back to our written
testimony. At the Indian Health Service, we are committed to
providing quality healthcare consistent with its statutory
authorities and its government-to-government relationship with
each Indian tribe.
Thank you for the opportunity to provide technical
assistance, and I am happy to answer your questions. Thank you.
[The prepared statement of Mr. Smith follows:]
Prepared Statement of Benjamin Smith, Deputy Director, Indian Health
Service, Department of Health and Human Services
on H.R. 8955, H.R. 8942, and H.R. 8956
Good morning Chair Hageman, Ranking Member Leger Fernandez, and
Members of the Subcommittee. Thank you for the opportunity to provide
testimony on three legislative proposals before the Subcommittee, and
for your continued support for the efforts of the Indian Health Service
(IHS) and the Department of Health and Human Services (HHS or
Department) to improve the health and well-being of American Indians
and Alaska Natives (AI/AN). Your consideration today of H.R. 8942,
Improving Tribal Cultural Training for Providers Act of 2024; H.R.
8955, IHS Provider Integrity Act; and H.R. 8956, Uniform Credentials
for IHS Providers Act of 2024, underscores that commitment to improving
the quality of health care provided by the IHS.
I am Benjamin Smith, the Deputy Director at IHS. The Biden-Harris
Administration, the Department and IHS have worked hard over the past
several years to not only provide needed training for our providers
that work in our IHS and Tribal facilities, but to also provide
American Indian and Alaska Native culturally appropriate training to
all our IHS employees, including all health care providers, whether
federal employees, contractors, or volunteers. We have also worked hard
to ensure that our licensed providers meet professional standards
required for their discipline before authorizing them to provide health
care in our IHS facilities, and we have worked to ensure our
credentialing system filters out providers that are not licensed or who
are professionally unfit to provide health care in our facilities.
It should be noted that the President's Fiscal Year (FY) 2025
budget request includes a proposal to allow for withholding or revoking
of annuity and retiree pay for retired civil service employees
convicted of moral turpitude--including sexual abuse--during the
commission of their federal duties. This proposed amendment is in line
with the Department's mission of protecting vulnerable, underserved
populations, and the Presidential Task Force on Protecting Native
American Children in the Indian Health Service System.
Workforce challenges--and the impacts on care that come with them--
are one of the top concerns raised to the Department by tribes. The IHS
continues to support new strategies to develop the workforce and
leverage advanced practice providers and paraprofessionals to improve
the access to quality care in AI/AN communities. Ultimately, the Indian
Health Service needs additional authorities and resources to build out
their workforce pipeline. That is why the President's budget also
included a number of proposals, some dating back to FY 2019, that have
sought to make the IHS more competitive with other federal agencies in
their hiring process and reduce systemic barriers to recruitment and
retention. HHS looks forward to working with Congress on policy
solutions to this effect. For example, the IHS seeks a tax exemption
for Indian Health Service Health Professions Scholarship and Loan
Repayment Programs to increase the number of health care providers
entering and remaining within the IHS to provide primary health care
and specialty services. The agency is also seeking the discretionary
use of all Title 38 Personnel authorities that are currently available
to the Veterans Health Administration. The IHS also seeks permanent
authority to hire and pay experts and consultants. Hiring experts and
consultants is another tool IHS can use to strengthen its workforce and
better serve the AI/AN population, and IHS seeks legislative authority
to conduct mission critical emergency hiring needs beyond 30-day
appointments.
As the Subcommittee is aware, the IHS executes its mission in
partnership with AI/AN tribal communities through a network of over 600
federal and tribal health facilities and 41 Urban Indian Organizations
that are located across 37 states and provide health care services to
approximately2.87 million AI/AN people annually.
As you know, the IHS operates under the authority of the Indian
Health Care Improvement Act (IHCIA). The IHS receives annual
appropriations to carry out its authorities, including those under the
Snyder Act and IHCIA. The three legislative proposals before the
Subcommittee would amend the IHCIA to 1) ensure that certain employees,
providers and volunteers associated with the IHS receive educational
training in the history and culture of the Tribes served by the Indian
health care system; 2) ensure that, whenever the IHS undertakes an
investigation into the professional conduct of a licensee in a State,
the IHS notifies the relevant State medical board; and 3) develop and
implement a centralized system for credentialing licensed health
professionals seeking to provide health care services at any of our IHS
facilities.
IHS Credentialing Process, Professional Conduct Investigations, Tribal
Cultural Training for Providers
IHS Credentialing Process
Over many decades, all IHS federal facilities and programs have
utilized various tracking and management systems to manage large
volumes of provider credentialing and privileging data. There was no
formal process or standardization. However, IHS began the evolutionary
process of transforming into a paperless medical staff credentialing
environment that would support standardization and centralized document
and verification efficiencies to strengthen patient safety by
implementing an enterprise-wide credentialing software system and
hiring a certified credentialing specialist at IHS Headquarters.
Currently, all IHS direct service health care facilities have fully
implemented the credentialing software, which includes centrally
sharing licensed practitioners' files where federal law, accrediting
bodies, and organizational terms of use allow. Use of a centralized
system has significantly reduced the time to credential licensed
practitioners. As of June 2024 year, 181 initial and reappointment
applications were processed in IHS, with an average application
processing time of 28 days.
The IHS currently maintains credentialing and privileging of 3,308
licensed practitioners at 10 IHS Areas, 23 hospitals, 49 health
centers, 26 health stations, 8 treatment centers, and 1 dental clinic;
this includes telemedicine providers. Of the 3,308 licensed
practitioners in the IHS, 603 are credentialed and privileged at more
than one facility. There are 98 Medical Doctor-Staff end users,
including Medical Staff Professionals (Credentials), Clinical
Directors, Chief Medical Officers, and Quality Managers. The IHS
processed 1,778 licensed practitioners initial and reappointment
applications over the past 12 months (July 2023-June 2024).
In addition, the use and standardization of the credentialing
software have increased inter-departmental collaboration with pharmacy,
nursing, human resources, and information technology modernization
efforts to identify practitioners' compliance with training
requirements, staffing trends, and emerging needs and standardize
quality credentialing metrics across the IHS.
Additionally, the IHS is in the final stages of updating and
publishing the Indian Health Manual, Chapter 3 Clinical Credentials and
Privileges policy for the agency. We anticipate publishing the revised
policy by the end of August 2024. Following the policy issuance will be
the update of the IHS Credentialing and Privileging Standard Operating
Procedures. These documents provide additional guidance and support to
the medical staff professionals in assuring credentialing processes are
clearly defined and implemented.
The IHS will next begin to create, develop, and provide
credentialing staff development and strengthening quality improvement
activities at all levels of the organization. Per the 2025 Budget, IHS
plans to hire an additional credentialing specialist who is dually
certified in credentialing, to enhance effective training and develop
and integrate additional quality standards and metrics into governance,
management, and operations.
Tribal and urban Indian health programs operating under the Indian
Self-Determination and Education Assistance Act and IHCIA,
respectively, are encouraged to adopt IHS policy as appropriate but are
not required to do so, especially to the extent they are governed by
other legal or policy requirements that do not apply to federal
agencies.
IHS Professional Conduct Investigations
The IHS is committed to ensuring safe and high-quality patient care
through appropriate hiring, credentialing, peer review, and
professional review processes for licensed providers/practitioners as
part of a comprehensive clinical risk management system. Licensed
providers/practitioners are held to the highest standards for conduct
and performance. When provider misconduct or poor clinical performance
is identified through appropriate review, the IHS notifies relevant
authorities (e.g., state licensing boards, the National Practitioner
Data bank, specialty boards). For example, the IHS activities in this
area are:
Hiring, credentialing, conducting focused and ongoing
professional practice evaluation, and professional peer
review processes are all part of a comprehensive IHS
vetting system and continuous oversight of provider
competence, clinical performance, and professional conduct.
The IHS encourages reporting suspected misconduct or
substandard performance of licensed providers.
Reports of alleged provider misconduct and/or substandard
clinical performance are promptly investigated by service
unit leadership with referral to the area leadership
through governance. If there is merit it will be forwarded
to the Headquarters (HQ) Quality and Risk Management (QARM)
committee for review by the QARM committee.
Certain egregious incidents of provider misconduct (e.g.,
sexual abuse, physical assault) or poor performance (e.g.,
impairment threatening patient safety) are grounds for
immediate reporting to appropriate authorities, including
the state licensure board.
The Medical Staff Bylaws detail processes for suspending
and terminating provider privileges for misconduct, poor
clinical performance, and impairment of licensed providers/
practitioners.
For the sake of quality/safe patient care, it is essential
to set a low threshold for reporting alleged misconduct,
poor performance, and/or impairment.
Upon investigation, when allegations of misconduct or poor
performance are found to be without merit, they should not
result in any adverse action.
Reporting to State Licensure Boards and other authorities
(e.g., National Practitioner Data bank, specialty boards
should be based on confirmed evidence of misconduct, poor
performance, and/or impairment.
As part of a comprehensive system of clinical risk
management, the IHS has established criteria \1\ for
reporting by its healthcare entities to authorities such as
state licensure boards, to include:
---------------------------------------------------------------------------
\1\ Risk Management and Medical Liability, A Manual for Indian
Health Service and Tribal Health Care Professionals, Third Edition,
Paul R. Fowler, DO, JD, FCLM, FAOCOPM, FAAFP, Risk Management Program,
Office of Clinical and Preventive Services, Indian Health Service
Headquarters, August 2018.
+ Any professional review action that adversely affects
---------------------------------------------------------------------------
the clinical privileges for more than 30 days.
+ Acceptance of the surrender of clinical privileges or
any restriction of such privileges,
- While the (provider/practitioner) is under
investigation by the healthcare entity relating to
possible incompetence or improper professional conduct
or
- In return for not conducting such an investigation
or proceeding
+ In the case of a healthcare entity that is a
professional society, when it takes a professional review
action.
While safety and clinical quality are always the priority,
determinations regarding adverse actions must afford the
provider due process rights.
Processes for investigating and reporting alleged provider
misconduct, poor performance, and/or impairment should
remain consistent with standards for other healthcare
organizations to ensure fairness and support for a robust
clinical workforce in the IHS, as well as requirements that
apply to federal employees.
As with the Credentialing policy, the Tribal and urban Indian
health programs operating under the Indian Self-Determination and
Education Assistance Act and IHCIA are encouraged to adopt IHS policy
as appropriate. However, they are not required to abide by it,
especially to the extent they are governed by other legal or policy
requirements that do not apply to federal agencies.
Tribal Cultural Training for Providers
The IHS acknowledges the role that trauma resulting from violence,
victimization, colonization, and systemic racism plays in the lives of
AI/AN populations, specifically AI/AN youth who are two and a half
times more likely to experience trauma compared to their non-Native
peers. Delivering trauma-informed services requires an understanding of
the profound neurological, biological, psychological, spiritual, and
social effects trauma and violence can have on individuals, families,
and communities. The IHS workforce must be aware of the high prevalence
of trauma in AI/AN populations and be prepared to respond effectively
to this trauma, which affects many individuals who seek services in IHS
facilities. It is also important to recognize and build on the
resiliency of AI/AN people, which comes, at least in part, from their
cultures and spirituality.
Creating policies and services that support a trauma-informed
perspective that appreciates the frequency of trauma, understands the
impact at the individual and community level, and supports appropriate
response is critical for improving the many health conditions
experienced by the AI/AN population. IHS can enhance its capacity for
promoting relational well-being and improving patient outcomes by
increasing understanding of the direct and transgenerational impacts
traumatic experiences have on a patient's health and how the patient
engages in healthcare, by using trauma-informed policies, practices,
and interventions.
Delivered with cultural humility and sensitivity, a trauma-informed
care organization emphasizes physical, psychological, and emotional
safety for patients and providers. Trauma-informed care helps survivors
rebuild a sense of control and empowerment. IHS has been expanding its
work as a trauma-informed care organization with a variety of efforts:
\2\
---------------------------------------------------------------------------
\2\ Indian Health Service, Indian Health Manual, Part 3, Chapter
37.
In FY 2020, the IHS released the Indian Health Manual
Chapter 37, Trauma-Informed Care policy and implemented
trauma-informed care principles to ensure the agency
understands the prevalence and impact of trauma,
facilitates healing, avoids re-traumatization, and focuses
---------------------------------------------------------------------------
on strength and resilience.
In FY 2021, the IHS updated the policy to align with
current trauma informed care best practices.
The Trauma-Informed Care policy reflects training
requirements and guidance to support IHS's efforts of
providing patient-focused, driven, recovery-oriented care,
integrating cultural humility and appropriateness, and
providing trauma-informed care services.
Trauma-informed care training is mandated for all IHS
employees, including contractors and volunteers, and is to
be completed annually. Compliance is enforced.
+ The training content includes information on impact of
trauma, including historical trauma and the importance of
trauma informed care approach. A knowledge check is a
requirement to pass the training.
The IHS is updating the training to ensure all trauma
informed care information is up-to-date and aligned with
best practices. The IHS anticipates this training will be
available to all employees by the end of 2024.
In FY 2022, the IHS formed a multidisciplinary workgroup
comprised of subject matter experts representing all IHS
Areas, aiming to understand the agency's readiness and
identify resources to support a trauma-informed care
agency.
The IHS is developing a readiness assessment to assist
facilities in meeting the agency policy ``to ensure
policies, practices, and protocols are Trauma Informed''
and will identify existing/developing evidence-based
activities, including cultural factors.
It is also highly recommended that each service unit develop a
unique orientation for all staff regarding tribal cultural training
appropriate to each tribe served by the healthcare facility.
H.R. 8942, ``Improving Tribal Cultural Training for Providers Act of
2024''
The Improving Tribal Cultural Training for Providers Act of 2024
would amend 25 U.S.C. Sec. 1616(f), titled ``Tribal culture and
history,'' in the IHCIA to direct the Secretary of HHS to establish an
annual mandatory training program where all employees of IHS, locus
tenens medical providers, health care volunteers, and other contracted
employees who work at IHS hospitals or service units whose employment
requires regular direct patient access, and require such annual
participation and completion of this annual mandatory training program.
As noted prior, the IHS is highly recommending that each IHS
service unit develop a unique orientation for all staff regarding
cultural training appropriate to each tribe served by the IHS
healthcare facility. H.R. 8942 would complement the existing IHS
activities regarding Tribal cultural training of providers in the IHS
system. However, IHS recommends the drafters consider whether
``condition of employment'' is feasible when applicable to contractors
and volunteers. IHS is concerned with creating a ``condition of
employment'' that depends on IHS setting up the program, which might be
different, or a separate training module for each Tribe. Thus, an
employee/contractor/volunteer could be violating the terms of
employment/contracting/volunteering, through no fault of their own.
H.R. 8955, ``IHS Provider Integrity Act''
The IHS Provider Integrity Act would amend IHCIA by adding a new
section to Title VIII of the Indian Health Care Improvement Act.
Specifically, H.R. 8955 would require IHS to notify, not later than 14
days, the State medical board of an investigation, and thereafter
require the IHS to provide relevant records to State medical boards
within 14 days upon generation of such relevant records into the
professional conduct of a licensee practicing at an IHS facility.
H.R. 8955 also would add to Title VIII of the IHCIA, a requirement,
as part of the hiring process, that the Director of the IHS solicit
from the medical board of each state in which a provider has a medical
license information on such provider's history of license violations or
settlements over the previous 20 years. Additionally, H.R. 8955 would
require IHS to provide to the medical board of each state in which a
provider is licensed detailed information regarding any violations by
the provider in their IHS capacity, and would direct the IHS to submit
a report to Congress regarding its compliance with H.R. 8955.
The IHS appreciates the intent of H.R. 8955, but notes, as stated
prior, the IHS is committed to ensuring safe and quality patient care
through appropriate hiring, credentialing, ongoing monitoring, and
professional peer review and the IHS already notifies relevant
authorities when provider misconduct or poor clinical performance is
confirmed through appropriate review. The IHS has concerns about the
proposed timeline requirement for notice and providing relevant
documentation to State medical boards. We would like to further explore
this requirement to ensure that it contemplates the amount of time
needed to complete a required appropriate investigation before
reporting an adverse event, as well as to ensure that providers have a
right to due process and an appropriate investigation and that medical
quality assurance records are properly safeguarded, consistent with
section 805 of the Indian Health Care Improvement Act (25 U.S.C.
Sec. 1675). The drafters of H.R. 8955 should consider clarifying what
constitutes ``an investigation into the professional conduct.'' It is
unclear whether this is limited to peer review for activities related
to medical care or could it include any sort of Human Resources review
for the person's conduct as an employee.
We would also urge Congress to consider standards that exist in
other agencies or health care systems. Additionally, Congress should
also consider adding language to make it clear that any records or
documents provided pursuant to this statute shall be exempt from
disclosure under the Freedom of Information Act (FOIA), section 552 of
title 5. This would ensure that H.R. 8955 would be construed a statute
described in subsection (b)(3)(B) of section 552 (records exempt from
mandatory disclosure in response to a FOIA request. Additionally,
Congress should consider adding language that protects the
confidentially of the employee and their personnel documents.
The IHS would not be able to report within 14 days because it is
not feasible to complete a full review and investigation within this
time frame. An appropriate investigation is required before reporting
an adverse event. All providers have a right to due process and an
appropriate investigation. If the investigation concludes that the
provider is acting in an inappropriate or unsafe manner, then the
findings will be immediately reported to the licensing boards where the
provider holds a license. The IHS recommends the drafters propose a
longer timeline that is triggered not by the initiation of an
investigation but by the conclusion of an adequate investigation. In
addition, the IHS recommends that the drafters limit the documentation
to be shared with the state boards, consistent with section 805 of the
Indian Health Care Improvement Act (25 U.S.C. Sec. 1675). It would be
impossible to provide due process to the provider and complete an
adequate investigation in the proposed 14-day time frame. The proposed
time frame would require IHS to meet a standard that does not exist in
other agencies or healthcare systems.
Further, the IHS advocates timely reporting requirements consistent
with the reasonable standards of other healthcare organizations, which
prioritize evidence over allegations. Also, the proposed requirements
in H.R. 8955 are actually not new requirements because IHS always
primary source reviews all licenses of each provider that is
credentialed in the IHS healthcare system.
H.R. 8956, ``Uniform Credentials for IHS Providers Act of 2024''
The Uniform Credentials for IHS Providers Act of 2024 would amend
the IHCIA. Specifically, H.R. 8956 would direct IHS to establish, in
consultation with Indian tribes and stakeholders, a uniform,
centralized, Service-wide credentialing system for health professionals
providing services at IHS Service units. Health professionals
credentialed in accordance with existing IHS policy are not required to
be recredentialed under the new system until they are otherwise
required to be recredentialed. Providers are prohibited from practicing
within a Service unit if they are not credentialed in accordance with
H.R. 8956. Finally, IHS is authorized to expand or enhance an existing
credentialing system to meet the requirements set forth in this
section.
H.R. 8956 also specifies that nothing in its provisions negatively
impacts the right of an Indian tribe to enter into a compact or
contract under the Indian Self-Determination and Education Assistance
Act or applies to such a compact or contract unless expressly agreed to
by the Indian tribe.
The drafters of H.R. 8956 may want to note that the nonduplication
of efforts language states the Secretary is not required to establish a
new medical credentialing system under the proposed legislation, if the
Service has begun implementing or has completed implementation of a
system that otherwise meets the requirements of this section. Taking
this text into consideration, IHS already has the authority to create
such a credentialing system, and has established, and is fully
implementing the new system. Additionally, the requirements imposed by
the new proposed legislation, particularly the requirement for tribal
consultation, would result in duplication of effort and create
additional, resource-intensive hurdles to implementation without
improving on the IHS's current process, and the consultation
requirement could open inherent federal functions to tribal
consultation and make it challenging to meet the deadline for
implementation in H.R. 8956.
The drafters of H.R. 8956, should also be aware that the
requirements imposed by this proposed legislation would create conflict
with current and existing CMS and accreditation standards. IHS has
established the policy and procedures for medical staff credentialing
and clinical privileging of health care providers working in IHS health
facilities. The governing body is the only authority that can grant
full medical staff membership and/or clinical privileges. In the case
of IHS, under current federal law (section 601 of the Indian Health
Care Improvement Act (25 USC 1661)), the person(s) legally responsible
for the conduct of the hospital is the Secretary, acting through the
IHS Director. This operational authority is extensive, including
approval and implementation of procedures for employee hiring,
recruitment and dismissal.
The drafters of H.R. 8956 should be aware, the quoted text in H.R.
8956, ``the Secretary may authorize licensed health professionals to
provide health care services at any service unit,'' is inconsistent
with existing CMS standards regarding credentialing and privileging of
medical providers. Only the Governing Board has the authority to
authorize Licensed Independent Practitioner (LIPs) to provide health
care services at their Service Unit per accrediting bodies and CMS
CoPs. IHS recommends the drafters consider deleting this text to avoid
duplication of effort with the Governing Board.
We look forward to continuing our work with Congress on these
bills, and as always, welcome the opportunity to provide technical
assistance as requested by the Subcommittee or its members. Thank you
again for the opportunity to testify today, and I am happy to answer
any questions you may have.
______
Questions Submitted for the Record to Mr. Benjamin Smith, Indian Health
Service, U.S. Department of Health and Human Services
Mr. Smith did not submit responses to the Committee by the appropriate
deadline for inclusion in the printed record.
Questions Submitted by Representative Westerman
Question 1. During the hearing you noted the importance of any
culturally competent care training being tailored to each individual
tribal population an IHS facility is serving. In what way could this be
accomplished, and how should H.R. 8942 be amended to reflect this
initiative?
Question 2. In your written testimony you note that the
requirements of H.R. 8955 are not new requirements because the IHS
always reviews all licenses of a provider that are credentialed in the
IHS healthcare system. Yet, there have been various reports of this
procedure not being followed. Please expand on your testimony and
provide more information about how IHS is improving this system and
ensuring that the hiring personnel are meeting IHS's stated
requirements?
Question 3. Under its current authority, would IHS review their
centralized credentialing system at least every five years?
3a) How often does the IHS currently review its credentialling
systems?
Question 4. Your written testimony noted that IHS will focus on
publishing guidance and manuals containing the Service's standard
operating procedures related to the centralized credentialing, and then
move on to staff education. What is the timeline for both final
publication of guidance and manuals as well as implementing the new
training program?
4a) How long does IHS estimate it will take to educate all
appropriate IHS personnel?
______
Ms. Hageman. We appreciate your testimony and being willing
to identify some potential tweaks that we could make to the
legislation. I know it is in your written testimony. There may
be additional questions as well.
Obviously, we want to work to make these bills the best
that they can be. So, thank you for that information.
The Chair now recognizes the Honorable Jarred-Michael
Erickson for 5 minutes.
STATEMENT OF THE HON. JARRED-MICHEAL ERICKSON, CHAIRMAN,
CONFEDERATED TRIBES OF THE COLVILLE RESERVATION, NESPELEM,
WASHINGTON
Mr. Erickson. Thank you. Good afternoon, Chairwoman
Hageman, Ranking Member Leger Fernandez, and members of the
Committee.
My name is Jarred-Michael Erickson. I am the Chairman for
the Colville Business Council, the governing body of the
Colville Tribes. Thank you for inviting me to testify on the
three Indian Health Service-related bills that are the subject
of today's hearing.
I want to extend my thanks to one of the Colville Tribes'
Congressional Representatives, Dan Newhouse, for introducing
the Uniform Credentials for IHS Providers Act of 2024.
I would also like to thank Chairwoman Hageman and
Congressman Dusty Johnson for introducing two other bills and
for their continued interest in Indian health issues.
Congressional oversight of IHS is especially important to
direct service tribes like Colville. Unlike tribes that have
contracted or compacted IHS functions, direct service tribes
are not able to directly control IHS operations on our
reservations. I will briefly discuss each of the three bills.
The first bill, the Uniform Credentials for IHS Providers
Act, requires IHS to develop and implement an IHS wide,
centralized credentialing system in consultation with Indian
tribes.
Credentialing refers to the process that IHS engages in to
review and verify the professional qualifications of health
providers, such as verifying medical licenses. The Colville
Tribe supports the credentialing bill because it requires IHS
to establish a uniform credentialing that would apply
nationwide.
The Colville Tribes has expressed instances where the lack
of uniformity in IHS processes have negatively impacted Indian
beneficiaries. I previously informed this Subcommittee about
some of these examples, specifically with the Purchase,
Referred, and Care Program. When the IHS Portland area office
took the PRC program away from the local Colville Service Unit
and began administering it remotely in Portland from 2017 to
2022, the Portland area imposed an eligibility requirement that
was not required by the IHS Indian Health Manual to PRC users
at the Colville Service Unit.
We have traced these in additional unwarranted eligibility
requirements to patient deaths. Having a credentialing system
that applies uniformly to all IHS areas would help prevent the
situation from being repeated in the credentialing context.
The second bill, the IHS Provider Integrity Act, will
require IHS to notify the state medical boards within 14 days
after the date that IHS undertakes an investigation of
professional conduct of a licensed health provider.
The bill would also require IHS to obtain information on
license violations or settlement agreements that health
providers may have been involved in before hiring those health
providers in the IHS system.
As the Colville Tribes and other tribes and organizations
have previously informed the Subcommittee, IHS's onboarding
process for health providers takes an unreasonably long time.
We have had health providers that our tribal employees have
recruited in their own districts on their own express interest
in working at the Colville Service Unit only to accept other
employment elsewhere when IHS's background process extended 6
months or longer.
The Colville Tribe supports this bill and suggests that the
Committee consider requiring deadlines for IHS to initiate
requests for information from state medical boards at the
beginning of the background check process.
This would ensure that the new background requirement does
not contribute to existing delays in the IHS onboarding health
providers.
The third bill, the Improving Tribal Cultural Training for
Providers Act, will require IHS to implement a mandatory annual
tribal culture and history training program for the IHS
employees and volunteers whose duties involve direct patient
access.
The Colville Tribe supports this bill because the training
program, if implemented correctly, would improve IHS customer
service to Indian beneficiaries. We recognize the tribal
culture and history topics in any training program will vary
across the Lower 48 states and Alaska.
What may be an appropriate training program for IHS
employees working in the Southwest may not be applicable to the
IHS Service Unit employees in the Pacific Northwest or the
Great Plains areas.
We suggest the bill include language that directs IHS to
consult with Indian tribes in each IHS area in developing the
training program that will be required in those IHS areas.
We further recommend the bill include language that
requires IHS area offices to revisit and update their training
programs every 5 years. This concludes my testimony. I would be
happy to answer any questions that the Committee may have.
Thank you.
[The prepared statement of Mr. Erickson follows:]
Prepared Statement of the Honorable Jarred-Michael Erickson, Chairman,
Confederated Tribes of the Colville Reservation
on H.R. 8955, H.R. 8942, and H.R. 8956
The Confederated Tribes of the Colville Reservation (``Colville
Tribes'' or the ``CCT'') appreciates the Subcommittee holding today's
hearing on three bills related to the Indian Health Service (``IHS'').
All three bills were derived from provisions of the ``Restoring
Accountability in the Indian Health Service Act of 2023.'' The CCT
worked extensively with the committees of jurisdiction when the
original version of the bill was first being developed in 2016 and
appreciates the Subcommittee's attention to issues relating to IHS and
the health of Indian people.
The CCT supports all three bills and is pleased to provide some
suggestions for the sponsors and the Subcommittee to consider that we
believe will improve them.
The CCT is a direct service tribe, which means that health care and
associated billing and administrative support is provided by IHS
employees. The CCT is in the beginning stages of contracting all IHS
functions, but this process will take time. In the meantime, we must
rely on IHS to provide quality health care to our tribal citizens.
These bills focus on IHS issues that are most relevant to direct
service tribes and we appreciate the Subcommittee's attention to and
consideration of them.
The Colville Tribes is a confederation of 12 aboriginal tribes from
across eastern Washington state, northeastern Oregon, Idaho, and
British Columbia. The 12 constituent tribes historically occupied a
geographic area ranging from the Wallowa Valley in northeast Oregon,
west to the crest of the Cascade Mountains in central Washington state,
and north to the headwaters of the Okanogan and Columbia Rivers in
south-central and southeast British Columbia. Before contact, the
traditional territories of the constituent tribes covered approximately
39 million acres.
The present-day Colville Reservation is in north-central Washington
state and was established by Executive Order in 1872. The Colville
Reservation covers more than 1.4 million acres, and its boundaries
include portions of both Okanogan and Ferry counties, two of the lowest
median income counties in the state. Geographically, the Colville
Reservation is larger than the state of Delaware and is the largest
Indian reservation in the Pacific Northwest. The Colville Tribes has
just under 9,300 enrolled members, about half of whom live on the
Colville Reservation.
A. H.R. 8956, the ``Uniform Credentials for IHS Providers Act of 2024''
This bill would require IHS, in consultation with Indian tribes, to
develop and implement an IHS-wide centralized credentialing system to
credential licensed health care professionals that seek to provide
health care services at IHS Service Units. The bill would require
formal review of the credentialing system at least every five years in
consultation with Indian tribes.
Credentialing refers to the process that IHS engages in to review
and verify the professional qualifications of health providers, such as
verifying medical licenses. The intent of the credentialing process is
to ensure qualified and skilled providers in the IHS system. There are
many health provider vacancies at the Colville Service Unit and
throughout the IHS system. This makes credentialing a critical process
to ensure that those providers who are currently working at IHS
facilities are qualified to provide quality health care.
The Colville Tribes supports H.R. 8956 because it would address
several long-standing problems with IHS's credentialing process. In
April 2024, the Government Accountability Office (``GAO'') released a
report on IHS's credentialing process that stated, among other things,
the following:
[GAO] identified two primary causes for why IHS failed to
consistently meet all of the credentialing and privileging
requirements we reviewed. First, IHS does not have a single
comprehensive document that clearly specifies all the agency's
credentialing and privileging requirements in one place.
Second, IHS headquarters' oversight of credentialing and
privileging processes conducted by facilities and area offices
is not sufficient to identify nonadherence to requirements.\1\
---------------------------------------------------------------------------
\1\ U.S. Gov't Accountability Off, GAO-24-106230, Opportunities
Exist to Improve Clinician Screening Adherence and Oversight (April
2024), available at https://www.gao.gov/assets/gao-24-106230.pdf
The CCT has experienced instances where the lack of uniformity in
IHS's processes has negatively impacted Indian beneficiaries. We have
previously informed this Subcommittee about some of these examples,
specifically with the Purchased and Referred Care (``PRC'') program.
When IHS's Portland Area Office took the PRC program away from our
local Colville Service Unit and began administering it remotely in
Portland from 2017 through 2022, the Portland Area imposed eligibility
requirements that were not required by IHS's Indian Health Manual to
PRC users at the Colville Service Unit. The CCT has traced these
additional and unwarranted eligibility requirements to patient deaths.
Having a credentialing system that applies uniformly to all IHS Areas
would prevent such a situation from being repeated in the credentialing
context.
We understand that IHS is continuing to work to develop an IHS-wide
credentialing system. IHS apparently has been undertaking this effort
since at least 2017, when IHS officials testified before Congress on a
prior version of the Restoring Accountability in the IHS Act that the
agency had ``awarded a contract for credentialing software that will
provide enhanced capabilities and standardize the credentialing process
across IHS.'' \2\
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\2\ S.Hrg. 115-89, at 14 (June 13, 2017) (prepared statement of
Rear Admiral Chris Buchanan, Acting Director of IHS).
---------------------------------------------------------------------------
Depending on how IHS's efforts have progressed, the CCT recommends
that the bill include language that clarifies that, in addition to the
bill's other requirements, IHS must have all credentialing and
privileging requirements in a single document in a single location.
Because IHS's current credentialing process is lengthy and consumes
significant staff time, the CCT recommends that the Subcommittee work
with IHS to identify reasonable timelines for completion of the
credentialing process for health providers.
B. H.R. 8955, the ``IHS Provider Integrity Act''
H.R. 8955 would require IHS to notify state medical boards within
14 days after the date that IHS undertakes an investigation of
professional conduct of a licensed health provider. The bill would also
require IHS to obtain information on license violations or settlement
agreements that health providers may have committed or entered into
before hiring those health providers in the IHS system.
The CCT supports the intent of this bill, which is intended to
address instances where a provider engages in professional misconduct
and can move to other locations in the IHS system without their
respective state medical boards knowing. For example, an October 5,
2021, New York Times article reported that an independent report
commissioned by IHS found that IHS officials ``silenced and punished
whistle-blowers in an effort to protect a doctor who sexually abused
boys on several Native American reservations for decades.'' There are
other similar, unfortunate examples of health providers in the IHS
system. To the extent that IHS initiates misconduct investigations,
this bill would provide an additional level of accountability with
state medical boards.
As the CCT and other tribes and organizations have previously
informed this Subcommittee, IHS's onboarding process for health
providers takes an unreasonably long time. The CCT has had health
providers that tribal employees have recruited on their own express
interest in working at the Colville Service Unit only to accept
employment elsewhere when IHS's background process exceeded six months.
The CCT recommends the bill include deadlines for IHS to initiate
requests for information from state medical boards at the beginning of
the background check process to ensure that this requirement does not
further contribute to delays in hiring health providers.
C. H.R. 8942, the ``Improving Tribal Cultural Training for Providers
Act of 2024''
This bill would require IHS to implement a mandatory, annual tribal
culture and history training program for IHS employees and volunteers
whose duties involve direct patient access. The CCT supports this bill
because the training program, if implemented correctly, would improve
IHS customer service to Indian beneficiaries. At the Colville Service
Unit, we are aware of a tribal member who experienced a health care
provider tell them, ``You're fat,'' during a medical appointment. This
type of comment should never happen in any professional health setting.
The CCT hopes that annual, mandatory training for IHS employees would
help ensure that these types of patient interactions are not repeated.
The Colville Tribes notes that the substantive tribal culture and
history topics in any training program will vary across the lower 48
states and Alaska. What may be an appropriate training program for IHS
employees working in the southwest may not be as applicable to IHS
Service Unit employees in the Pacific Northwest or Great Plains Areas.
The CCT suggests that the bill include language that directs the IHS to
consult with Indian tribes in each IHS area in developing the training
program that will be required in those IHS areas. We further recommend
that the bill include language that requires IHS Area Offices to
revisit and update the training programs every five years.
______
Questions Submitted for the Record to the Hon. Jarred-Michael Erickson,
Chairman, Confederated Tribes of the Colville Reservation
The Honorable Jarred-Michael Erickson did not submit responses to the
Committee by the appropriate deadline for inclusion in the printed
record.
Questions Submitted by Representative Westerman
Question 1. H.R. 8955 would ensure that state medical boards would
be notified of medical provider investigations and requires IHS to
obtain information of license violations and settlements of providers
during the hiring process. How would implementation of H.R. 8955 impact
the overall attitude toward IHS units around the Colville Reservation?
Question 2. Would H.R. 8942 impact the hiring or onboarding process
for IHS providers, and if yes, what language could be added to the bill
to mitigate that concern?
______
Ms. Hageman. Thank you.
The Chair now recognizes Ms. Amber Torres for 5 minutes.
STATEMENT OF AMBER TORRES, CHIEF OPERATING OFFICER, NATIONAL
INDIAN HEALTH BOARD (NIHB), WASHINGTON, DC
Ms. Torres. [Speaking Native language]. Good morning
everyone, my name is Amber Torres. I am a tribal citizen of the
Walker River Paiute Tribe in Schurz, Nevada, a previous NIHB
board member, and I now serve as the interim chief operating
officer for the National Indian Health Board.
Chairman 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 Tribal Nations we serve, thank you for this
opportunity to provide testimony on three pieces of legislation
aimed at improving the healthcare workforce at the IHS.
The healthcare workforce is a critical component of the
Indian Health System that directly meets the trust and treaty
obligation to provide for the healthcare of our people.
The legislation before the Committee today seeks to address
several important components of the workforce issues IHS faces,
which includes the staffing, hiring, and onboarding process.
Overall, we are thankful to the Committee for taking the
time to consider these bills. We support the purpose and intent
of the legislation. The pieces of legislation being considered
address several concerns that the tribes have raised.
We feel the language of the proposed bill would benefit
from a deeper dialogue with tribes and IHS to ensure they fully
meet the intent of Congress to improve the hiring and
onboarding processes for providers, the healthcare experience,
and the outcome for tribal citizens.
It is also important that the legislation does not infringe
on the sovereignty of tribes operating their programs through
self-governance agreements.
As the Committee considers these bills, it is important to
acknowledge the current provider vacancy rates and the timeline
for hiring providers to fill vacancies. Additional requirements
to the hiring and onboarding process creates the possibility of
slowing the current onboarding of critical providers.
As of February 2024, IHS had a vacancy rate of 36 percent
for physicians, 44 percent for behavioral health, 37 percent
for dentists, and 35 percent for nurse practitioners.
In some areas, vacancy rates are as high as 78 percent.
Lower levels of staffing in IHS and tribal facilities can
impact access to care, reduce overall quality, and contribute
to increased burnout for providers.
Reducing staff can make it difficult to get referrals for
specialty care to treat acute or chronic conditions. Reliance
on low levels of staffing can undoubtedly impact the quality of
care.
IHS has been working to improve its HR recruitment, hiring,
and onboarding experience through a centralized process known
as One HR. Additional statutory requirements for system changes
to improve hiring and onboarding also need to come with the
appropriate resources to ensure the successful implementation
of those changes.
The House Appropriations Committee has moved to increase
funding to IHS in support of new facility staff, recruitment
tools, and construction of staff quarters.
However, we must work to ensure that the increase to the
IHS budget goes to support that work. Contract support costs
and 105(l) lease payments have been determined by the Supreme
Court to be required costs regardless of the appropriation
levels.
Therefore, Congress must first pay these costs before other
areas of the IHS and Bureau of Indian Affairs Budgets can be
considered. The increases to CSC and 105(l) leases have limited
growth in direct services, facilities, and other administrative
support to the IHS budget that could have otherwise gone to
support maintaining current staffing and service levels.
Following the recent ruling in the Becerra v. San Carlos
Apache Tribe, are costs that are likely to increase, further
straining the IHS in the Interior Appropriations Bill.
We continue to request that CSC and 105(l) leases be
appropriately classified as mandatory spending by Congress.
This will allow any increases to the IHS budget to go toward
important agency needs, such as improving staff and to continue
meeting the Federal trust and treaty responsibilities to Tribal
Nations.
In conclusion, we thank the Committee for the consideration
of these bills. We look forward to working with the Committee
staff and the bill sponsors to ensure that the language does
not negatively impact the efficiency of the IHS hiring process
and that tribal sovereignty is upheld.
[Speaking Native language] for the time.
[The prepared statement of Ms. Torres follows:]
Prepared Statement of Amber Torres, Interim Chief Operating Officer,
National Indian Health Board
on H.R. 8955, H.R. 8942, and H.R. 8956
Chairwoman Hageman, Ranking Member Leger Fernandez, and
distinguished members of the Subcommittee, on behalf of the National
Indian Health Board (NIHB) and the 574 sovereign federally recognized
American Indian and Alaska Native Tribal nations we serve, thank you
for this opportunity to provide testimony on three pieces of
legislation, H.R. 8956, the Uniform Credentials for IHS Providers Act
of 2024, H.R. 8942, the Improving Tribal Cultural Training for
Providers Act of 2024, and H.R. 8955, the IHS Provider Integrity Act.
My name is Amber Torres. I am a member of the Walker River Paiute Tribe
of Nevada and I serve as the Interim Chief Operations Officer for the
National Indian Health Board (NIHB).
Healthcare workforce is the critical component of the Indian health
system that directly meets the trust and treaty obligation to provide
for the healthcare of our People. The legislation before the committee
today seeks to address several important components of the staffing and
provider hiring and onboarding process. The Uniform Credentials for IHS
Providers Act of 2024 proposes to streamline the hiring process and the
ability for providers to move around the Indian Health Service's
network of hospitals and clinics. Uniform credentialing promises to
improve the ability of IHS to quickly address staffing shortages across
its system by more quickly deploying providers to areas which may have
high vacancy rates. NIHB has shared feedback with the committee to
ensure that the legislation includes definitions that would be
appropriate to only IHS-operated facilities.
The Improving Tribal Cultural Training for Providers Act of 2024
would require IHS staff to receive cultural training. This bill would
ensure that those working in our communities have a better
understanding of our cultures and our ways to improve the experience
that our Tribal citizens receive their care. This is critical to
improving the patient experience and improving outcomes. When patients
feel that they are understood and their concerns are received in a
culturally informed manner, they are more likely to return for their
follow up care and feel that their healthcare provider has their best
interests at heart and the best interests of the community's overall
health. Many tribal health providers already conduct this type of
training, and we would encourage IHS to utilize these models as best
practices as they implement the requirements of this bill.
Finally, H.R. 8955 would require in statute that providers under
investigation be reported to their licensing boards. Further, the bill
requires that as part of the hiring processes, IHS contact licensing
boards to verify the good standing of provider's licensure,
particularly seeking disciplinary actions or findings made by the
licensing board. This legislation would address quality of providers to
ensure that they can appropriately meet the needs of the IHS. NIHB has
shared feedback with the Committee and the bill's sponsors that would
streamline the legislation so as not to make this onerous on the hiring
process of the IHS. Often, state licensing boards can be under-staffed
and it is possible this could create delays in the hiring process. It
is also important to consider how long IHS and other providers keep
personnel records. The 20 years outlined in the legislation may not be
a feasible timeline to access records. Additionally, we would encourage
the legislation to share only investigations that have reasonable
findings, as investigations can often be started and there is found to
be no wrongdoing by the provider.
As the Committee considers these bills, it is important to consider
the current provider vacancy rates and the timeline for bringing on
providers to fill vacancies. Additional requirements in the hiring and
onboarding process creates the possibility to slow the current
onboarding of critical providers. As of February 2024, IHS had a
vacancy rate for physicians of 36 percent; for behavioral health
providers, that rate is 44 percent. The dentist vacancy rate is 37
percent, and nurse practitioner vacancy is 35 percent. When we look at
specific Areas, individual rates go as high as 58 percent vacancy rate
for physician assistants in Billings Area, 63 percent vacancy rate for
physicians in Great Plains and 78 percent for behavioral health
providers in the Albuquerque Area. These incredibly high vacancy rates
correspond to low staffing levels on the ground.
Lower levels of staffing in IHS and Tribal facilities can impact
access to care, reduce overall quality, and contribute to increased
burnout for providers. Reduced staffing can make it difficult to get
referrals for specialty care to treat chronic or comorbid conditions,
which can have both individual and larger, enterprise-level impacts.
Reliance on low levels of staffing also can impact quality of care.
Providers working through burnout can miss important symptoms, but
further, it creates reliance on particular providers that can leave
huge gaps in service delivery if and when a provider moves on. IHS and
Tribal providers also work in an environment that requires cultural
competence, sensitivity and awareness. Tribes have long requested that
providers, employees, and Commissioned Officers go through cultural
training to better serve and understand the communities in which they
live and work. Cultural competence training for positions that work in
Indian country is vital for the IHS, but there are positions across
many federal departments and agencies which need this type of training
to properly understand Tribal communities and the Indian health system.
The IHS has been working to improve its human resources,
recruitment, hiring, and on-boarding experience through a centralized
process known as One HR. Additional statutory requirements for systems
changes to improve hiring and onboarding also need to come with
appropriate resourcing to ensure the successful implementation of those
changes. The House Appropriations Committee has moved to increase
staffing funding to IHS in support of new facilities staff, recruitment
tools, and staffing quarters to improve the current staffing crisis the
Agency has been facing.
The pieces of legislation being considered address several concerns
Tribes have raised. The language of the proposed bills would benefit
from deeper dialog with Tribes and IHS to ensure they fully meet the
intent of Congress to improve the hiring and onboarding process for
providers and the healthcare experience and outcomes for Tribal
citizens. It is also important that the legislation is clear in its
intent to improve the operations of the IHS, and that it does not
infringe on the sovereignty of Tribes which operate their programs
through agreements under the Indian Self-Determination and Education
Assistance Act (25 U.S.C. ch. 14, subch. II Sec. 5301 et seq).
There are also other legislative initiatives which are currently
pending before Congress which would improve the tools already available
to the IHS and Tribes to improve the recruitment and retention of a
culturally competent and trained workforce. Although the Indian Health
Program received a substantial increase in the House's Interior,
Environment, and Related Agencies bill, the scholarship and loan
repayment programs are not treated equally to other equivalent programs
offered within HHS which enjoy tax-exemption, which allows all of the
available funding to support recruitment. Additional funding for this
program will be an important part of any multipart strategy to improve
the workforce difficulties facing the Agency. NIHB supports language
included in H.R. 8318, the Tribal Tax and Investment Reform Act of
2024, that would make IHS scholarship and loan repayment programs tax
exempt. We encourage the House Natural Resources Committee members to
voice their support for this legislation.
Expansion of midlevel provider types and grow-your-own education
programs are another critical piece to the workforce development reform
that is necessary to support the whole Indian health system. IHS has
been working to expand the successful Community Health Aide Program,
better known as CHAP, to help smaller communities have providers in
their community even when it is difficult to hire a physician level
provider. Tribal programs to encourage and educate youth and young
professionals in healthcare careers need to be supported and resourced
to ensure we are developing a larger pool of providers to meet current
and future staffing needs.
Finally, we must work to ensure that the increases to the IHS
budget go to support this work. Contract support costs and 105(l) lease
payments have been determined by the U.S. Supreme Court to be required
costs, regardless of the appropriation levels. Therefore, Congress must
essentially pay these costs first before other areas of the IHS and
Bureau of Indian Affairs budgets can be considered. In recent years,
increases to CSC and 105(l) leases limited growth in direct services,
facilities and other administrative support to the IHS budget that
would have otherwise gone to support maintaining current staffing and
service levels. Following the recent ruling in the Becerra v. San
Carlos Apache Tribe, the costs are likely to increase, further
straining the IHS and the Interior appropriations bill. As part of
long-term support for addressing IHS workforce needs, it is critical
that these costs, which are essentially already a mandatory cost
provided as an ``indefinite discretionary'', be is addressed through
common sense reform by appropriately classing them as mandatory
appropriations. This will allow increases to the IHS budget to meet the
important staffing needs to continue meeting the federal treaty and
trust responsibility to Tribes. These funds are already required to be
paid, and the Appropriations Committee does not have input in how much
to allocate to these accounts. Without this change, the administrative
funds that IHS would use to implement the changes outlined in these
bills, will not be possible.
Conclusion:
In conclusion, we thank the Committee for their consideration of
these bills that address important challenges to IHS staffing and
cultural competency at IHS-operated facilities. As the process moves
forward, we look forward to working with Committee staff and the bill's
sponsors to ensure that the language would not inadvertently impact
Tribally operated health systems, and would not have a deleterious
impact on the efficiency of the IHS hiring process (a process that is
already exceedingly slow and overburdened by bureaucracy). We also
encourage the House Natural Resources Committee to support changes that
would categorize CSC and 105(l) leases as mandatory funding. This will
make it possible for they agency to allocate additional funds for
activities to support staffing at IHS-operated facilities.
______
Questions Submitted for the Record to Ms. Amber Torres, Chief Operating
Officer, National Indian Health Board (NIHB)
Ms. Torres did not submit responses to the Committee by the appropriate
deadline for inclusion in the printed record.
Questions Submitted by Representative Westerman
Question 1. Would H.R. 8942 impact the hiring or onboarding process
for IHS providers, and if yes, what language could be added to the bill
to mitigate that concern?
Question 2. Please expand from your testimony as to why H.R. 8942,
H.R. 8955, and H.R. 8956 should only apply to IHS direct service
facilities.
______
Ms. Hageman. Thank you for your testimony.
The Chair now recognizes Mr. Ben Mallott for 5 minutes.
STATEMENT OF BEN MALLOTT, VICE PRESIDENT FOR EXTERNAL AFFAIRS,
ALASKA FEDERATION OF NATIVES (AFN), ANCHORAGE, ALASKA
Mr. Mallott. Good morning and thank you Chair Hageman,
Ranking Member Leger Fernandez, and members of the Subcommittee
on Indian Affairs.
My name is Ben Malott. I have had the honor of serving as
Vice President of General Affairs for AFN and also the
president elect of AFN. I would like to thank you for the
opportunity to provide testimony in support of H.R. 6489, the
Alaska Native Village Municipality Lands Restoration Act.
Also, I would like to thank Congresswoman Mary Peltola for
her work on this bill.
For background, AFN is a large statewide Native
organization in Alaska. Our membership includes 177 tribes, 154
village corporations, 9 of our 12 village corporations, and 9
of our regional tribal consortiums.
As Chairman Hageman outlined earlier, ANCSA as passed in
1971, included a provision called 14(c)(3). At the time, many
of our communities at passage in 1971 were unincorporated
lands.
Section 14(c)(3) was included in the bill in case there was
an opportunity or that community wanted to establish a city,
government, or municipality. It required every Alaska Native
business corporation to give about 1,200 acres of land and
sometimes the most viable land within the community at the
center of the community for this purpose, and that was about 50
years ago. Currently, there are 83 communities of the 101
communities within the program and since then only 8 of those
communities have established the city government, the last one
being 1995.
The State of Alaska Municipal Land Trust, or the MLT, has
approximately 11,500 acres of valuable lands in each of our
communities. This is land that is in central communities.
It is land that could be used for housing, could be used
for student services and other purposes that are right now
currently managed by the state and can be an underfunded and
overtasked office.
Lands to transfer out program, under the current system, is
very burdensome and troublesome. It hinders our village
corporations from using this land for community development and
work with our tribes to figure out what is best for communities
to grow.
Additionally, as our tribes and ANCs figure out what to do
with these lands, if the corporation wants to transfer lands
out, the state still has to transfer over lands because the
state as a trust has an obligation under current law to manage
those lands in the tribes' best interests or in the state's
best interest for a future city government.
As such, the MOT takes this job seriously and continues to
hinder our communities to expansion. Many of our state MOT
communities have expressed a strong interest in removing this
provision of 14(c)(3), a resolution was passed at AFN for many
years, and to expand this program and to sunset the provision.
H.R. 6489, as I mentioned, sunsets the supporting 14(c)(3)
provision. It also empowers corporations and communities that
make the best decisions for the communities.
These two components are significant because, as I
mentioned, according to Save Alaska, of the original 101
villages conveyed in the program, only 8 have been
incorporated.
As mentioned, for many communities where cities have not
been formed, these lands sit vacant, empty, and not being used
for community purposes. And, additionally, moving the Section
14(c)(3) provision eliminates the need for future conveyances.
So, as a community wants to or ANC wants to convey lands, I
want to recognize my village corporation's manuka's testimony,
which is also on the record for a community of Rampart or
Chenega, or other community villages, if the city wants to
move, or the village wants to move those lands for purposes of
economics, the state still has a title over those lands for
14(c)(3) provisions.
So, it still holds the lands even for purposes under pretty
much overworked and under tasked office. I am sorry, I am tired
and am starting to stutter. I apologize.
So, H.R. 6489 still has that burdensome hurdle. Overall,
14(c)(3) is a 50-year-old relic of its day. As mentioned, the
last municipality was set up in 1995. H.R. 6489 sunsets the
provision encourages our communities to make the best decision
for the community. As such, AFN fully urges Congress to pass
this bill. [Speaking Native language.]
[The prepared statement of Mr. Mallott follows:]
Prepared Statement of Benjamin Mallott, Alaska Federation of Natives
on H.R. 6489
Chair Representative Harriet Hageman, Ranking Representative Teresa
Leger Fernandez, Ranking Member Lee, and members of the House Natural
Resources Subcommittee on Indian and Insular Affairs, thank you for the
opportunity to provide written testimony for the hearing record in
support of H.R. 6489, the ``Alaska Native Village Municipal Lands
Restoration Act of 2023.''
My name is Benjamin Mallott, and I am honored to serve as the
President-Elect of the Alaska Federation of Natives (AFN). AFN was
formed to achieve a fair and just settlement of Alaska Native
aboriginal land claims. Today, AFN is the oldest and largest statewide
Native membership organization in Alaska. Our membership includes 177
Alaska Native tribes, 154 for-profit village Native corporations, 9
for-profit regional Native corporations established pursuant to the
Alaska Native Claims Settlement Act (ANCSA), and 9 regional nonprofit
tribal consortia that contract and compact to administer federal
programs under the Indian Self-Determination and Education Assistance
Act. The mission of AFN is to advance and enhance the political voice
of Alaska Natives on issues of mutual concern.
Today, I want to submit written testimony supporting H.R. 6489, the
``Alaska Native Village Municipal Lands Restoration Act of 2023.''
Resolutions passed by AFN that support H.R. 6489 are attached to this
testimony.
For background, ANCSA was signed into law on December 18, 1971.
Alaska Natives were compensated with fee simple title to 44 million
acres of land and $962.5 million. ANCSA created 13 regional for-profit
corporations and more than 200 village corporations. Alaska Native
Corporations received land and monetary entitlements. In addition,
Congress charged ANC with providing for their people's economic,
social, and cultural well-being in perpetuity.
ANCSA was a complicated act and laid out multiple types of land
conveyances. Most of our communities at the time were in unincorporated
portions of the state. Section 14(c) of ANCSA was included if a
community wanted to establish a municipality. Section 14(c)(3) required
every Alaska Native Village Corporation to turn a portion of their
lands over to the State of Alaska to be held in trust for a possible
future municipal government. These lands conveyed to the State include
``the surface estate of the improved land on which the Native village
is located and as much additional land as is necessary for community
expansion, and appropriate rights-of-way for public use, and other
foreseeable community needs,'' with the amount of lands to be
transferred to ``be no less than 1,280 acres unless the Village
Corporation and the Municipal Corporation or the State in trust can
agree in writing on an amount which is less than 1,280 acres.'' Less
than half of our village corporations came to an agreement with the
State on lands to be turned over to the trust, and in only a few
instances has a municipality been established.
For nearly 50 years, the State Municipal Land Trust (MLT) has
managed 14(c)(3) lands in Alaska, an underfunded and overtasked office.
Despite decades of administration, only eight ANCSA villages have
formed new municipalities, the last one established in 1995. It is
evident that, for many remote Native Villages in Alaska, forming a
municipality is not foreseeable.
Currently, 83 communities across Alaska have their lands tied up
under the MLT program, which is approximately 11,550 acres. The land
transferred under 14(c)(3) requires an overly burdensome and almost
impossible process to transfer lands into private hands or back to the
Alaska Native Village Corporation. Some village corporations defied the
law and never transferred land into the MLT. Other than the original
initiative by the BLM, there was no enforcement mechanism at the state
level to require participation. However, for these village corporations
that chose not to participate, the title remains on their lands, and
they are subject to ANCSA 14(c)(3). Any land use authorized by the
Village Corporation requires the State's written disclaimer of interest
and has resulted in the current law having a broader negative impact
beyond the 83 communities currently tied up with lands held in the MLT.
The State's view of its trust responsibilities is that conveyance
in fee simple is not possible under current law. Because the MLT is a
trust, it has a legal and fiduciary obligation to manage the lands in
the best interests of the municipality or, in the absence of one, the
future municipality. The MLT takes this trust responsibility seriously,
and this obligation severely limits the available uses of what are
often the most important parcels of land in these remote rural
villages, many of which desperately need facilities and economic
development. Many MLT communities have indicated a strong interest in
having the lands they transferred to the State returned to expand
economic development in their communities.
H.R. 6489, the ``Alaska Native Village Municipal Lands Restoration
Act of 2023,'' sunsets the Alaska Native Claims Settlement Act (ANCSA)
14(c)(3) provision. AFN supports H.R. 6489 because removing the
14(c)(3) provision will empower Alaska Native corporations and
communities to make informed decisions about best utilizing their lands
and resources, leading to greater economic prosperity and self-
sufficiency.
Essential components of this legislation are removing the 14(c)(3)
provision and restoring lands conveyed to the MLT to the appropriate
Alaska Native Village Corporation. These two components are significant
because, according to the State of Alaska, of the original 101 villages
covered by the MLT program, eight villages have been incorporated into
a municipality. For the many communities where a municipality has not
been formed, and the village corporation conveyed all or partially
required land to the MLT, the property conveyed to the MLT will revert
to the village corporation under H.R. 6489. Additionally, the sunset of
the 14(c)(3) provision eliminates the need for future conveyances,
thereby reducing the barriers for Alaska Native communities to decide
what they want to do with their lands without having to go through a
bureaucratic hurdle.
H.R. 6489 is the right step forward for continued support for the
economic empowerment and self-sufficiency of Alaska Native communities.
It is important to note that ANCSA came into existence during the era
of Indian self-determination. ANCSA reflects this policy approach by
providing Alaska Native people the resources necessary for economic,
cultural, and political self-determination. As such, I urge full
consideration of H.R. 6489 before Congress and its passage into law.
Over 50-year-old legislative loose ends need to be addressed to fulfill
the promise of self-determination embodied in the 1971 ANCSA
settlement.
Thank you for your consideration.
Quyana, Gunalcheesh, Haw'aa, Baasee, Taikuu, Thank you.
______
Ms. Hageman. Thank you, Mr. Mallott, for your testimony.
The Chair now recognizes Ms. Jerilyn Church for 5 minutes.
STATEMENT OF JERILYN CHURCH, EXECUTIVE DIRECTOR, GREAT PLAINS
TRIBAL LEADER'S HEALTH BOARD (GPTLHB), RAPID CITY, SOUTH DAKOTA
Ms. Church. [Speaking Native language.] Thank you, Ranking
Member Leger Fernandez, Chairwoman Hageman, Representative
Johnson, and Representative Newhouse for allowing me the
opportunity to provide testimony this afternoon on behalf of
the Great Plains Tribal Leaders Health Board.
The Health Board serves as a liaison between the Great
Plains tribes and various agencies of the HHS, including the
IHS. We work to reduce public health disparities, improve the
health and wellness of our American Indian people and tribal
communities, and we also administer nearly all IHS funded
health services in Rapid City through the Oyate Health Center.
We recognize that IHS faces difficulties and challenges in
improving healthcare delivery and outcomes for our tribal
communities. I have testified several times before to the
Subcommittee on proposed legislation and appreciate the members
of the Subcommittee and their work emphasizing the improvement
of Indian Health Service and its operations.
As the Subcommittee is considering these bills, we
emphasize the need to make sure that they and other legislation
do not confer additional unfunded mandates on the already
seriously under resourced Indian Health Service.
Concerning the Uniform Credentialing for IHS Providers, the
bill should be amended to clarify that tribally operated
facilities and programs are not subject to the mandated IHS
centralized credentialing system unless the tribal health
program has expressly opted into that system.
It would also be helpful to clarify when IHS and tribally
operated service units can accept credentials of licensed
health professionals who were credentialed by the tribal health
programs.
We have provided some amended language in our written
testimony to address those issues. We are concerned with the
use of the term licensed health professionals in the bill, that
it may be broader than it is intended.
Centralizing the credentialing for various types of
providers that are included in that term, as defined by a YDE,
the Indian Healthcare Improvement Act, with all the various
requirements, might be particularly challenging.
Finally, we strongly urge that Subsection (c)(1) be amended
to add tribal organizations and inter-tribal consortia after
Indian tribes as entities with which IHS must consult.
Regarding Tribal Cultural Training for Providers, we are
concerned that the bill might be interpreted to apply to
employees of tribal health programs, including Federal
employees assigned to work for tribal health programs under an
interpersonal agreement or memorandum agreement.
That requirement would be disruptive, expensive, and
duplicative for tribal programs, so we want them to not have to
be required in addition to what we already implement as a
tribal health program. We have included proposed language in
our written testimony to address this issue as well.
Regarding the IHS Provider Integrity Act, the Great Plains
Tribal Leaders Health Board appreciates the Subcommittee's
emphasis on making sure IHS hires the best and most qualified
individuals to care for our relatives.
However, we are concerned with the proposed 20-year look
back requirement because providers are often licensed in
several states over the course of long careers.
We suggest that the Subcommittee work collaboratively with
the Indian Health Service to determine whether the mandated
exchange of information can be accomplished without creating
additional delays or barriers for filling critical provider
positions.
As you all know, there is a great need to fill many, many
positions, and we just don't want to see an overreach, and we
want to find that balance between ensuring that there is due
diligence but also filling positions as quickly as possible.
And finally, these proposed amendments to the Indian
Healthcare Improvement Act provide another opportunity for us
to urge members of the Subcommittee to work with your
colleagues to direct IHS to reinstate the National Steering
Committee on the reauthorization of the Indian Healthcare
Improvement Act.
Thank you very much for the opportunity to provide
testimony today on these vital issues and appreciate your
efforts to improve health care delivery to all of our people.
[Speaking Native language.]
[The prepared statement of Ms. Church follows:]
Prepared Statement of Jerilyn Church, MSW President/CEO, Great Plains
Tribal Leaders Health Board
on H.R. 8955, H.R. 8942, and H.R. 8956
Thank you for the opportunity to testify at today's legislative
hearing on behalf of the Great Plains Tribal Leaders Health Board
(GPTLHB). GPTLHB serves as a liaison between the Great Plains Tribes
and the various Health and Human Services divisions, including the
Great Plains Area Indian Health Service (IHS), and works to reduce
public health disparities and improve the health and wellness of
American Indian people and Tribal communities across the Great Plains.
The GPTLHB also administers nearly all IHS-funded health services in
Rapid City, SD through the Oyate Health Center.
In our region, the Indian Health Service (IHS) is the primary
source of hospital care for 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, with one operated by a tribal health
program under a Title V Self-Governance compact. Ambulatory care is
increasingly carried out by tribal health programs, except in the five
locations where IHS still operates hospitals. Tribal health programs
deliver ambulatory health services, with seven programs managed
entirely by a tribe or a tribal organization under a Title I Self-
Determination contract and two more tribally managed through a Title V
Self-Governance compact. The Indian Health Service is responsible for
two substance abuse treatment centers and supports three urban health
care programs.
At GPTLHB, we are acutely aware of the difficulties and challenges
that the IHS faces in improving healthcare delivery and healthcare
outcomes for American Indian people in our communities. Over the last
few years, I have testified several times before this Subcommittee on
these current challenges and opportunities and legislation targeted at
improving healthcare delivery through the IHS system. We appreciate the
members of this Subcommittee emphasizing improving the IHS and its
operations.
As the Subcommittee is considering these bills, we emphasize the
need to make sure that they--and any other related legislation--do not
confer additional unfunded mandates on the already seriously under-
resourced IHS and that additional administrative requirements
(including agency reporting requirements) will not be so burdensome as
to take time and resources away from patient care. Regarding
improvements to IHS operations, the most crucial factor is ensuring the
agency has sufficient resources to do its job.
With these general concerns in mind, we turn to the specific
legislation before the Committee.
The Uniform Credentials for IHS Providers Act of 2024 (H.R. 8956)
Application to tribal health programs. GPTLHB believes it is
essential to clarify that Tribally-operated facilities and programs are
not subject to the mandates of the IHS's centralized credentialing
system this bill requires unless the tribal health program has
expressly opted to participate in the IHS's credentialing system fully
or in part. Section 125(f)(1) appears to intend that result to achieve
this by providing that nothing in the section [125] ``negatively
impacts the right of an Indian tribe to enter into a compact or
contract under the [ISDEAA].'' If read narrowly, IHS may interpret this
exemption as not applying to tribal organizations or inter-tribal
consortia. The risk of this is elevated by the language in subsection
(f)(2), which limits the application of Section 125 to ``a compact or
contract unless expressly agreed to by the Indian tribe.'' There is a
significant risk that IHS might require that the tribal resolutions
that authorized a tribal organization or inter-tribal consortia carry
out programs of the Service expressly address the credentialing system.
It would also be helpful to expressly describe some of the
circumstances under which a centralized credentialing system could be
useful to tribal health programs without imposing the entire process on
the tribal health program, as well as when the Service and tribally-
operated Service units can accept the credentials of licensed health
professionals who were credentialed by a tribal health program.
The exemption currently in the bill can be clarified and the
additional objectives achieved by amending the proposed subsection (f)
to read, as follows:
``(f) Effect.--Nothing in this section----
``(1) negatively impacts the right of an Indian tribe, tribal
organization, or inter-tribal consortium (as those terms are
defined at 25 U.S.C. Sec. Sec. 5304(e) and (l) and 5381(a)(5)
and (b)) to enter into a compact or contract under the Indian
Self-Determination and Education Assistance Act (25 U.S.C. 5301
et seq.);
``(2) applies to the programs, services, functions, and
activities (or portions thereof) carried out by an Indian
tribe, tribal organization, or inter-tribal consortium under
such a compact or contract unless expressly agreed to by the
contracting or compacting Indian tribe, tribal organization, or
inter-tribal consortium;
``(3) prevents an Indian tribe, tribal organization, or inter-
tribal consortium from partially participating in the
credentialling system by accepting the credentials of a Service
licensed health professional without independently verifying
them; and
``(4) prevents the Service from allowing a licensed health
professional who has been credentialed by a health program
carried out by an Indian tribe, tribal organization, or inter-
tribal consortium under a contract or contract as described in
subsection (1) to provide health care services at any hospital
or ambulatory directly operated by the Service or at any
tribally operated Service unit if approved by that Service
unit.
Scope of ``licensed health professionals.'' It is not clear how
broadly the sponsors of this bill intend it to reach. The term
``licensed health professional'' may apply more broadly than intended.
The term ``health profession'' is defined very broadly in the IHCIA to
mean ``allopathic medicine, family medicine, internal medicine,
pediatrics, geriatric medicine, obstetrics and gynecology, podiatric
medicine, nursing, public health nursing, dentistry, psychiatry,
osteopathy, optometry, pharmacy, psychology, public health, social
work, marriage and family therapy, chiropractic medicine, environmental
health and engineering, an allied health profession, or any other
health profession.'' The fact that centralized credentialing would
apply only to licensed health professionals is still quite expansive.
Nurses, social workers, optometrists, optical dispensers, social
workers, marriage and family therapists, chiropractors, other
behavioral health providers (e.g., three states license mental health
technicians), pharmacists (and possibly pharmacy assistants) are
subject to state regulation with most requiring a license. The
licensing requirements vary by state, so the people subject to these
credentialing requirements may differ from state to state. This will be
a particularly challenging process.
Consultation. Finally, we are very concerned that subsection (c)
neglects to include tribal organizations and inter-tribal consortia
among entities with which the Secretary must consult. We urge that
subsection (c)(1) be amended to add ``tribal organizations and inter-
tribal consortia'' after ``Indian tribes.''
Tribal organizations and inter-tribal consortia have been
authorized by Indian tribes to carry out health programs on their
behalf. While carrying out that work, the tribal organizations and
inter-tribal consortia acquire significant expertise in technical
health care administration matters, including credentialing. That
should not be ignored or given less weight than other entities listed.
Improving Tribal Cultural Training for Providers Act of 2024 (H.R.
8942)
GPTLHB appreciates the emphasis on expanding the reach of IHS'
Tribal culture and history training.
We are concerned, however, that the bill may be interpreted to
apply to employees of tribal health programs, including Federal
employees assigned to work for a tribal health program under an IPA
(Intergovernmental Personnel Agreement) or MOA (Memorandum of
Agreement). The list of types of employees in subsection (a) extends
not only to those working in ``Service hospitals'' but also in ``other
Service units.'' ``Service unit'' is a defined term in the IHCIA (25
U.S.C. Sec. 1603(20)). The term ``means an administrative entity of the
[Indian Health] Service or a tribal health program through which
services are provided, directly or by contract, to eligible Indians
within a defined geographic area.''
The requirement for all these employees to participate in annual
training under Subsection Sec. Sec. (c) if applied to tribal health
programs, including federal employees assigned to a tribal health
program under the Indian Self-Determination Act, is likely to be very
disruptive to tribal health programs and potentially expensive since
that training will likely be duplicative and more general than training
the tribal health program already delivers to its employees. We also
believe that regardless of whether tribal health programs are subject
to the mandatory provisions of this section, deference should be given
to tribal culture and history programs developed by Indian tribes and
tribal health programs and that the access to such training should be
as flexible as possible. These concerns can be readily addressed, if it
is amended to read:
Sec. 2. Tribal Culture and History. (Sec. 113 of the IHCIA; 25
U.S.C. Sec. 1614f)
(a) Program established. The Secretary, acting through the
Service, shall establish an annual mandatory training program
under which employees of the Service, locum tenens medical
providers, health care volunteers, and other contracted
employees who work at hospitals or other Service units operated
directly by the Service and whose employment requires regular
patient access who serve particular Indian tribes shall receive
educational instruction in the history and culture of such
tribes and in the history of the Service.
(b) Tribally controlled community colleges. To the extent
feasible, and in the absence of training programs available to
the Service that were developed by Indian tribes, tribal
organizations, or inter-tribal consortia, the program
established under subsection (a) shall----
(1) be carried through tribally controlled colleges or
universities (within the meaning of section 2(a)(4) of the
Tribally Controlled Colleges and Universities Act of 1978 [25
USCS Sec. 1801(a)(4)]) and tribally controlled postsecondary
vocational institutions (as defined in section 390(2) of the
Tribally Controlled Vocational Institutions Support Act of 1990
(20 U.S.C. 2397h (2)),
(2) be developed in consultation with the affected tribal
governments, and Indian tribes, tribal organizations, and
inter-tribal consortia delivering health services in the
geographic area in which the employees described in subsection
(a) are located; and
(3) include instruction in Native American studies.
(c) Requirement to Complete Training Program.--Notwithstanding
any other provision of law, beginning on the date of enactment
of the Improving Tribal Cultural Training for Providers Act of
2024, each employee or provider described in subsection (a) who
enters into a contract with the Service, shall, as a condition
of employment, annually participate in and complete the program
established under subsection (a).
(d) Exemption.--Nothing in this section shall prevent a health
program operated by an Indian tribe, tribal organization, or
inter-tribal consortium from obtaining the training developed
under this section for its employees, including those assigned
to it under provisions of the Indian Self-Determination and
Education Assistance Act.
IHS Provider Integrity Act (H.R. 8955)
GPTLHB appreciates the Subcommittee's emphasis on making sure that
IHS hires the best and most qualified individuals to take care of our
family members. It is important that IHS knows that the providers it
hires do not have serious disciplinary records. We do, however, have
some concerns regarding the proposed 20-year lookback requirement. Many
providers have, over the course of long careers, been licensed in
multiple states. We also have concerns about the notification of any
open investigation into the professional conduct of a licensee. We
think it is essential to consider trigger points for reporting
depending on the severity of professional conduct requiring
investigation.
We recommend that the Subcommittee work collaboratively with the
IHS to determine whether it is feasible to interface with several State
medical boards (including receiving information in a timely manner)
during the hiring process without creating additional delays and
barriers to filling critical provider positions.
These bills and the underlying issues raise the larger question of
the process of including Tribal voices in potential legislative
improvements through amendments to the Indian Health Care Improvement
Act. In the past, these legislative efforts would be driven by input
from the knowledge, wisdom, and difficult decision-making of the Tribal
leaders who made up the National Steering Committee (NSC) on the
Reauthorization of the IHCIA. Now that the IHCIA has been made
permanent, that mechanism for critical Tribal input no longer exists.
We urge the Members of the Subcommittee to work with your colleagues to
direct IHS to reinstate the NSC and provide sufficient appropriations
to support its critical work.
Thank you for the opportunity to provide testimony today on these
crucial issues and for your efforts to improve healthcare delivery to
all our People and communities.
______
Questions Submitted for the Record to Jerilyn Church, Executive
Director, Great Plains Tribal Leaders Health Board
Ms. Church did not submit responses to the Committee by the appropriate
deadline for inclusion in the printed record.
Questions Submitted by Representative Westerman
Question 1. Reports have shown a lack of accountability when it
comes to IHS employees and misconduct. Anecdotally, can you provide any
examples of instances in which a practitioner used the IHS's negligence
to work elsewhere despite past malpractice?
Question 2. During the hearing you brought up the importance of
relying on tribal elders when it comes to culture and history. Could
you provide the Committee with what you think best practices would be
for ensuring tribal elders and healers are included in the
implementation of a tribal culture and history training for all
relevant IHS staff?
Question 3. Would H.R. 8942 impact the hiring or onboarding process
for IHS providers, and if yes, what language could be added to the bill
to mitigate that concern?
______
Ms. Hageman. Thank you for your testimony and for your
suggestions as well.
The Chair will now recognize the Members for 5 minutes for
questioning, beginning with me.
On H.R. 8942, I am going to direct my first couple of
questions to Mr. Benjamin Smith. H.R. 8942 would require
mandatory annual training on the history and culture of the
tribes involved for specific employees.
Mr. Smith, what is the current format for tribal history
and culture training for IHS employees?
Mr. Smith. Thank you, Chair, for the question. As we know,
the Indian Health Service is one of the primary healthcare
providers to American Indians and Alaska Natives.
But we are not the only Federal agency that works with
American Indian Alaska Native governments. So, our approach in
looking at training and as you can see in our testimony, we do
recommend that each IHS Service Unit develop a unique
orientation for all staff regarding cultural training
appropriate to each tribe served by an Indian healthcare
facility.
Understanding that some facilities serve multiple tribes
and there could be distinct differences----
Ms. Hageman. Let me just ask it in a little bit different
way. Is there any standard within IHS specific to the format
for tribal history and culture training?
Mr. Smith. Absolutely. And the lens that we have taken and
have implemented over the past 3 years is a trauma informed
care approach.
As we know, trauma resulting from violence, victimization,
colonization, and systematic racism have played a part in
American Indian and Alaska Native lives.
On an annual basis, all of our employees are required to
take a mandatory training to become trauma informed.
Ms. Hageman. Specific to this issue. But that is specific
to trauma?
Mr. Smith. Correct. Which covers the historical trauma and
history of American Indians and Alaska Natives in this country,
as well as some of the intergenerational trauma for those who
may have not personally experienced what previous generations
have done.
But that approach really sets a common framework across our
system to have a basic understanding of the history and
experience of American Indians and Alaska Natives in this
country.
Ms. Hageman. I am going to direct my next couple of
questions to Ms. Torres. H.R. 8942 includes in the list of
employees mandated to take the annual mandatory training, locum
tenens, providers, or medical providers or practitioners that
temporarily fill a need at the facility.
Can you expand on whether this type of medical employee
needs to receive cultural training, and if so, should they be
added to the annual requirement?
Ms. Torres. I appreciate the question.
H.R. 8942 includes the list of employees mandated to take
the annual mandatory training. It also includes locum tenens
providers or medical practitioners that temporary fill in at a
facility.
I believe that all providers that are placed in those
communities need cultural training to learn the best approach
possible for competent care.
Also gaining the trust of the patient so that you can
continue to have that good experience going forward and
continue to combat the healthcare comorbidities in conjunction
with the patient so that the overall care is achieved.
[Speaking Native language.]
Ms. Hageman. OK, and I am going to direct my next questions
to Chairman Erickson, Ms. Torres, and Ms. Church.
Several written statements that were provided highlighted
that each federally recognized tribe has its own history and
culture, and any mandated tribal and cultural training should
be flexible enough to accommodate the area the IHS facility and
employees are serving. By that, I mean geographical area.
Can each of you expand on what you think are the best
practices that IHS should follow as they offer their current
training, and if there are specific ideas we should add to H.R.
8942 to improve it?
Chairman Erickson, you first, please.
Mr. Erickson. Thank you for that question. And you are
right, here at Colville, there are 12 different tribes into one
tribe now. So, there are four different languages. We are very
unique in that.
There are a lot of culturally involved things that are
different for each respective tribe that we represent. I think
there are multiple ways you can go about this. You can do
online modules, in-person classes, but I think the best
approach would be community-immersive training because it is
very specific to each tribe, and the tribes are similar to us
that are confederation, that it is not a one-size-fits-all,
even within our tribe.
So, again, that is, I think getting those involved in the
community and our elders will help with that a lot in creating
that training for those individuals.
Ms. Hageman. Ms. Church, if you can briefly give your
thoughts on this.
Ms. Church. Certainly. There are shared values across many
of the tribes. There is diversity, but there are also shared
values. So, emphasizing those shared values, I think is very
important.
Additionally, I think looking to our elders as we do to
provide that guidance. At the Great Plains Tribal Leaders
Health Board, we have a [speaking Native language] committee of
respected elders across the Great Plains who guide us as we not
only do our orientation, but also incorporate traditional
cultural values and traditional healing into our work.
So, looking to those wisdom keepers is an important part of
the process.
Ms. Hageman. Ms. Torres, very briefly, if you have any
ideas?
Ms. Torres. Yes, thank you so much. I would just want to
make sure that they are consulting with tribes early and often
on what that process will be, and again, making sure to include
our youth and elders, as those are our most precious
commodities, and we want to get that feedback and that buy in
from our communities.
[Speaking Native language.]
Ms. Hageman. OK, thank you.
I do appreciate all of you giving us ideas, and I would
hope that you would continue to stay engaged on this very
important issue.
I am going to recognize Representative Johnson for 5
minutes of questioning. Thank you.
Mr. Johnson. Thanks very much, Madam Chair. Mr. Smith, I
want to come to you because I think we are all trying to make
the legislation better.
You talked about concerns with the timeline on the 14 days.
Kind of coach me, where is a better spot for us to land?
Mr. Smith. Yes, thank you very much for the question,
Representative Johnson.
What we wanted to share and underscore first is that at the
Indian Health Service, today, all IHS direct healthcare
facilities have fully implemented the uniform credentialing
software.
Mr. Johnson. Can you move that mic a little closer?
Mr. Smith. Again, we have fully implemented a uniform
credentialing software, but it is also important to note that
the Indian Health Service is committing to ensure safe and
high-quality patient care through appropriate hiring,
credentialing, peer review, and professional review processes
for licensed providers, practitioners, and that we hold them to
the highest standards for----
Mr. Johnson. So, Deputy Director, do we have a sense of
what timeline might be more appropriate?
Mr. Smith. Yes. This is what we would like to investigate
further and discuss with this Subcommittee. We are aware of
other Federal agencies that have longer timelines, such as the
Veterans' Health Administration, and we just want to make sure
that we are setting tenable dates to afford somebody who is
being investigated due process, but also to be similar to other
standards across the healthcare industry.
Mr. Johnson. I am unaware, what does the Veteran Health
Service utilize?
Mr. Smith. To my knowledge, and I will have to verify this,
we would be happy to follow up with you, but we understand it
is around 30 days.
Mr. Johnson. Around 30 days?
Mr. Smith. Yes.
Mr. Johnson. OK. So, as you all have talked internally,
just, again, trying to make sure it is workable, if 14 is
clearly not workable, or it would be workable some of the time?
I mean, here is why I am asking. I wonder if there is a
scenario under which you could have a standard amount of time
in the statute and then kind of an extra bonus time in
extraordinary circumstances where you all determined that you
needed extra time.
I know that deadlines drive achievement, and, of course,
when we push timelines out further, just as a matter of course,
we don't get the urgency we generally want. We see that all the
time here in Washington.
We only really act when we have to. Any thoughts? I mean.
And would 14 days be workable any of the time?
Mr. Smith. Well, we would urge the Subcommittee to also
contemplate the fact that the Indian Health Service works in
multiple states.
We understand that 50 different states with 50 different
internal timelines and knowing that their boards meet at
different frequencies does pose a challenge of really trying to
simmer down to a concrete timeline.
Mr. Johnson. And I know I won't put you on the spot
anymore, I mean, I understand the discomfort with 14 days, and
I am totally willing to work with you all.
It is hard for us to make legislation fit if we don't get
some specificity, right? I know why 14 doesn't work. What I
don't know is, does 18 work? Does 21 work? Does 25 work?
So, as you said, we will continue to dive in and work
together. You did note that you inform folks when you identify
problems with providers. Does that include state licensing
boards?
Mr. Smith. Absolutely. If an appropriate investigation
occurs and is deemed valid, then, yes, we follow the protocols
as outlined in our policies.
Mr. Johnson. And then, Ms. Church, I thought you made some
great points about not wanting to interrupt the hiring process,
because I think the percentage of vacant positions is in excess
of 25 percent.
And, again, to your point, there is a lot of regional
variability in those numbers. So, what can we do to make sure
that we don't interrupt the hiring process?
Ms. Church. I think we have to take a look at the global
picture of what is required to onboard a provider and ensure
that we are not adding additional burden onto that process that
would create more delays.
The thing that stood out to me was going back 20 years. I
don't know how many institutions even keep records for 20
years.
Mr. Johnson. Is there a better spot to land?
Ms. Church. I would defer to Ben on that one. I would use
common sense. Look at when did they start? When did they
graduate? When did they start in the workforce? And I would say
at least 5 years, but 20 years seems a little bit.
Mr. Johnson. Very good. Thanks.
I yield back.
Mr. Westerman [presiding]. The gentleman yields back.
The Chair now recognizes the gentlelady from New Mexico,
Ms. Leger Fernandez.
Ms. Leger Fernandez. Thank you so much, Mr. Chairman. And
once again, thank you very much for your presence here today.
And sorry that there are so many things happening here at the
Capitol.
Ms. Torres, in your testimony, you highlighted the Supreme
Court decision in Becerra v. Northern Arapaho Tribe that made
it a requirement for contract support costs to be paid
regardless of appropriations level.
This will have a significant impact on the delivery of
health services in Indian Country. Can you talk a bit more
about that and how we need to think about that funding
requirement now as we look at funding the Indian Health
Service?
Ms. Torres. Yes, thank you.
Again, I think the Supreme Court decision is so crucial to
making sure that CSC and 105(l) are taken into perspective and
that they do not cut into the IHS budget as a whole.
Again, we know that those are federally mandated costs that
need to be taken care of. We shouldn't have to stretch all the
dollars to make it work. I think making sure that it is part of
the mandatory funding is going to be crucial moving forward so
that we can continue to build on what we need to take care of
first and then continue to advocate for more funding going
forward.
So, again, making sure that CSE and 105(l) are in the
mandatory funding.
Ms. Leger Fernandez. I completely agree with you with
regards to that, because we cannot be letting this requirement,
which is a requirement the Supreme Court has already told us
that, we cannot let that requirement then sap resources from
the rest of IHS.
And I see all the nodding heads over there, let the record
reflect that the witnesses are nodding their heads because they
recognize the importance of adequate funding for IHS.
And we, as I mentioned in my opening statement, we were
following way too low on that with about half, right. And worse
for rural areas.
Ms. Church, we love having you here because you bring such
a great perspective of what it is like on the ground. And I
really appreciate as well the recent studies we have done, some
in New Mexico that point out that the health boards make such a
difference, right? Because they are able to gather the
expertise.
You mentioned the fact that there were 150,000 American
Indian and Alaska Natives in the Great Plains area. Can you
speak a bit more to what it would mean for your area if we did
not make these changes we are talking about and why it is so
important that we address the concerns you mentioned in your
written testimony?
Ms. Church. We want to make sure that we are getting not
only the most qualified providers in our Indian Health System
providing services to our relatives, but also to ensure that
our relatives can connect to them, that they have a
relationship with them, that they are able to fully disclose
when they are having challenges, not only with their health,
but in their communities.
Our relatives come in with a wide range of issues that they
are dealing with. And sometimes those other issues,
socioeconomic issues, stand in the way of them getting the
basic health care that they need.
So, having culturally sensitive, culturally informed, as
well as highly qualified, because of the enormous health
disparities that are within our population, we are the worst of
the worst, oftentimes. So, we need that expertise as well.
Ms. Leger Fernandez. And I like the way you talk about our
relatives. This is what we are talking about, families. You
know everybody and you care for everybody.
And that is the beauty of the tribal communities, right? Is
that there is a sense that we are one. We are all related, and
thank you for being related to the rest of us as well.
But addressing the entire health aspect, it does not stop
at any one part of the body. It includes the mind and includes
your surroundings, which lead to some of those health
disparities. I really appreciate that.
Mr. Mallott, you spoke to the impact Section 14(c)(3) of
ANCSA has on tribal communities and the need to remove this
provision. I appreciate that.
Can you provide the Committee with examples of specific
projects that community is seeking, but are precluded from as a
result of the lands being held in trust?
Mr. Mallott. Thank you for that question. I am going to
cite a couple of our member testimonies. My village
corporation, my mom's home village of Rampart, has dealt with
14(c)(3) for a while, most recently with the city dump.
We actually had leased a land to the tribe, which couldn't
go through a 14(c)(3) process. That is just a community growth
project that communities did grow. Our current dump is by the
airport. It is actually hazardous because seagulls fly through
the planes.
So, we had to have leased the land to the tribe, I believe,
instead of going to ports and (c)(3) process, because it was
taking too long.
Another example in my mom's home, Rampart, the ANC actually
leased land to the tribe for a satellite telecom site.
We wanted to go through the 14(c)(3) process, but then we
also want to make sure that the tribe has economic benefits as
well. So, if we lease to the state, the state will actually get
the money for the lease site for a satellite, not the tribe.
So, actually a lease to the tribes. This tribe actually
gets a little bit of money from the satellite dish. In Chenega,
for example, the 14(c)(3) land is where the cemetery is at. So,
the community doesn't even own their own cemetery, and they had
to go through that process with the state MOT.
As mentioned, most of these lands are in the most valuable
part of our communities. So, if a town or a city that is not
incorporated wants to create a new subdivision for homes, they
have to go through the process.
And right now, it is a very, very slow and burdensome
process that really slows down our community development.
Ms. Leger Fernandez. Thank you. I come from New Mexico, so
the imagination of seagulls going around is, like, OK, I have
to get my head around that. And with that Mr. Chair, I yield
back.
Mr. Westerman. The gentlelady yields back.
I now recognize myself for 5 minutes of questioning and
also want to thank the witnesses for being here today.
As I listened to your testimony, my mind started thinking
about a lot of things from past experiences, and I know Ms.
Torres mentioned the difficulty of getting positions filled in
IHS.
I come from a very rural district. I don't have any IHS
facilities in my district, but I know it is a challenge in
rural areas. Many IHS facilities are in rural areas, and it is
critical to get those positions filled.
From traveling around the country and visiting different
IHS facilities, I have seen some really good examples of how
IHS works, and I have seen some examples that are not so good
in IHS facilities.
But the one thing that is common when an IHS facility is
working well is that they have good staff. And that is true, I
think, about any kind of healthcare facility.
I have seen some big failures in publicly funded healthcare
facilities. When I was a State Legislator in Arkansas, we had
an issue with a Medicaid provider that was a child abuser who
kept practicing as a pediatrician and billing Medicaid for the
services.
Since being in Congress, I saw a VA pathologist back home
in Arkansas who was impaired on the job, misdiagnosed many
people, and people died because of that. But he remained
employed in the VA.
So, there are lots of challenges. There is a desire to be
able to fill positions. We also have to make sure that we have
quality people in those positions.
And Chairman Erickson, I had the great pleasure to visit
the Colville Tribe and spend some time with you. But you
mentioned a lot of times about timelines, and you mentioned
that in all three of the bills in your testimony.
Can you expand more on why deadlines and timelines are
important to include in these bills, and if there are any
specific timelines, you think that will be beneficial for us to
consider adding to the bills on top of what is already there?
Mr. Erickson. Thank you for that question. The shortest
answer is accountability, right? If we don't hold our Federal
agencies accountable with timelines, nothing will get done.
I see dragging of the feet, and I am not trying to be rude
or anything, but that is what we run into with BIA, any
department, we just have a lot of issues. If we don't put
timelines on things, accountability is not had, and then things
just drag on.
So, I think with the hiring process, as far as the medical
boards go, I think the biggest or the easiest thing to
implement there is really starting that process right at the
beginning of the hiring process, the background check process.
That way, it is not making that process any longer for them
to go through. They are already doing that with the background
check. I don't think those should take as long as they do.
At Colville, we are supposed to have five doctors, and we
have one right now. We finally have a dentist, and that took
years to fill, and he has only been there 6 months. And we hope
he stays. We hope we don't lose our last doctor.
Anytime these processes take long, we have had lots of
employees that were potential good employees left because the
hiring process took too long. And a lot of that was background
checks and other things.
So, I think implementing that right at the beginning of the
background check process will reduce having any added time to
the hiring process.
Mr. Westerman. And we all understand what it is like to
work under deadlines, and we know that a lot of times people
just wait until the last minute when they have a deadline.
Have you or your tribal members seen any issues when it
comes to cross state licenses and the hiring process for IHS
applicants at the Colville Service Unit?
Mr. Erickson. That is a good question. I will get back to
you on that. I don't have an answer for that right now. I
apologize.
Mr. Westerman. Ms. Torres, H.R. 8955 would require the IHS
to solicit any applicant's history from all medical boards in
which they are licensed, going back at least 20 years.
Can you expand on your written statement about why 20 years
cannot be a feasible timeline and maybe also suggest what other
length of time we should consider?
Ms. Torres. Thank you for the question. I appreciate that.
H.R. 8955 would require the IHS to solicit any applicant's
history from all medical boards in which they are licensed
going back at least 20 years. It was presented here that some
areas may not have 20 years' worth of history on that.
But I think, again, it is important to try to go back as
far as possible. The suggestion was made of 5 years, but I
think at NIHB, we could come up with some further suggestion
and follow up to make sure that you get a copy of that, because
we are not just looking at now. We are looking at the future as
well for those that are still yet to come. And we want to make
sure that we implement good, solid changes, but we also don't
affect tribes that are self-governance and self-determined.
Mr. Westerman. All right, I see that I am out of time. We
may have more questions that will get submitted for the record.
Again, I want to thank the witnesses for your valuable
testimony and the Members for the questions today.
The members of the Subcommittee may have some additional
questions for the witnesses, and we will ask you to respond to
these in writing.
Under Committee Rule 3, Members of the Subcommittee must
submit questions to the Subcommittee Clerk by 5 p.m. on Monday,
July 29, 2024. The hearing record will be held open for 10
business days for these responses.
If there is no further business without objection, the
Subcommittee stands adjourned.
[Whereupon, at 12:14 p.m., the Subcommittee was adjourned.]