[Senate Report 116-180]
[From the U.S. Government Publishing Office]

                                                       Calendar No. 388
116th Congress  }                                              {   Report
 1st Session    }                                              {  116-180




               December 18, 2019.--Ordered to be printed


           Mr. Hoeven, from the Committee on Indian Affairs, 
                        submitted the following

                              R E P O R T

                         [To accompany S. 2365]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Indian Affairs, to which referred the 
bill, S. 2365, to amend the Indian Health Care Improvement Act 
to authorize urban Indian organizations to enter into 
arrangements for the sharing of medical services and 
facilities, and for other purposes, having considered the same, 
reports favorably thereon without amendment and recommends that 
the bill do pass.


    The bill is intended to authorize the U.S. Departments of 
Veterans Affairs (VA) and Defense (DOD) to enter into 
reimbursement agreements with urban Indian organizations (UIOs) 
for direct health care services provided to eligible 
beneficiaries of either Department.


    The Indian Health Service (IHS) provides primary health 
care and public health services to an estimated 2.6 million 
American Indians and Alaska Natives through a network of 605 
facilities located in 37 states. Operation of these facilities 
fall into one of three categories of health care facilities: 
federally-operated, Tribally-operated, and UIO-operated.\1\ 
UIOs operate 40 facilities and serve more than 75,000 IHS 
patients each year.\2\ However, the three branches of IHS do 
not have equal access to federal Indian health resources--
including reimbursements from the VA for direct health care 
provided by IHS facilities to eligible beneficiaries.
    \1\Under the Indian Relocation Act of 1956, Native communities saw 
federal policy push massive numbers of Tribal members off the 
reservation to urban centers for the first time. By the 1970s, 45% of 
AIANs lived in urban areas--up from a mere 8% in the 1940s. This forced 
diaspora led tribal leaders to call for the establishment and inclusion 
of UIOs within the IHS system in 1976.
    \2\U.S. Dep't of Health and Human Services, Fiscal Year 2020 Indian 
Health Service Justification of Estimates for Appropriations Committees 
CJ-140 (2019) (https://www.ihs.gov/sites/budgetformulation/themes/
    Section 405 of the Indian Health Care Improvement Act 
(IHCIA) authorizes the VA to reimburse federally-operated and 
Tribally-operated IHS facilities for any services they provide 
to Native VA-eligible beneficiaries. VA has entered into one 
national reimbursement agreement that covers 74 federally-
operated IHS facilities and 114 individual reimbursement 
agreements with tribally-operated IHS sites using this 
authority since 2012.\3\ Between August 2012 and September 
2019, the Department reimbursed these IHS facilities over $104 
million for services provided to 10,645 Native veterans.
    \3\Oversight/Legislative Hearing on ``Recognizing the Sacrifice: 
Honoring a Nation's Promise to Native Veterans'' and to receive 
testimony on S.1001 and S.2365 Before the S. Comm. on Indian Affairs, 
116th Cong. (2019) (statement of Robert L. Wilkie, Sec'y, U.S. Dep't of 
Veterans Affairs).
    However, because IHCIA Section 405 does not explicitly 
reference UIO reimbursements, these facilities are legally 
excluded from receiving them.\4\
    \4\Oversight/Legislative Hearing on ``Recognizing the Sacrifice: 
Honoring a Nation's Promise to Native Veterans'' and to receive 
testimony on S. 1001 and S. 2365 Before the S. Comm. on Indian Affairs, 
116th Cong. (2019) (statements of Robert L. Wilkie, Sec'y, U.S. Dep't 
of Veterans Affairs, & RADM Chris Buchanan, Dep. Director, Indian 
Health Service, U.S. Dep't of Health and Human Services).

                          SUMMARY OF THE BILL

    The bill, S. 2365, amends IHCIA Section 405 to explicitly 
reference UIOs. This amendment will make UIOs eligible to enter 
into reimbursement agreements with the VA and DOD for health 
care services provided by UIOs to eligible VA and DOD 
beneficiaries. It will also authorize the VA and DOD to 
reimburse UIOs through these reimbursement agreements.

                          LEGISLATIVE HISTORY

    On July 31, 2019, Senators Udall, Tester, Moran, Rounds, 
and Smith introduced S. 2365, the Health Care Access for Urban 
Native Veterans Act. Senators Duckworth, Sinema, McSally joined 
the bill as additional co-sponsors on October 30, November 20, 
and December 10, 2019, respectively.
    On November 20, 2019, the Committee on Indian Affairs held 
a legislative hearing on S. 2365. At this legislative hearing, 
the honorable Robert Wilkie, VA Secretary, testified in support 
of the bill. Additionally, IHS Deputy Director RADM Chris 
Buchanan testified to the need for the legislation.
    On December 11, 2019, the Committee on Indian Affairs of 
the Senate met at a duly called business meeting to consider 
two bills, including S. 2365. No Committee Members filed 
amendments to S. 2365. The Committee passed both bills, 
including S. 2365, by voice vote and ordered the bills reported 
    On August 2, 2019, Representatives Khanna, Gosar, Haaland, 
Gianforte, Lujan, Young, Moore, Bacon, Tonko, and Estes 
introduced a companion bill, H.R. 4135, the Health Care Access 
for Urban Native Veterans Act, which the House of 
Representatives referred to the Committees on Natural Resources 
and Energy and Commerce. Representatives Gallego, Blumenauer, 
Kilmer, Hastings, O'halleran, Cook, Roybal-Allard, Fitzpatrick, 
Kirkpatrick, McMorris Rodgers, Cole, DeGette, Aguilar, Mullin, 
Joyce, and Sewell have since joined the H.R. 4135 as additional 
    On August 21, 2019, the Committee on Natural Resources 
referred the identical companion bill, H.R. 4153, to the 
Subcommittee for Indigenous Peoples of the United States. The 
Subcommittee held a hearing on the bill on September 19, 2019, 
but has taken no further action since that time.

                      SECTION-BY-SECTION ANALYSIS

Section 1. Short title

    Section 1 states S. 2365 may be cited as the ``Health Care 
Access for Urban Native Veterans Act of 2019.''

Section. 2. Sharing agreements with Federal agencies

    Section 2 amends IHCIA section 405 to insert ``urban Indian 
organizations,'' ``an urban Indian organization,'' before ``and 
tribal organizations''' in subsections (a)(1) and (c).


    The following cost estimate, was provided by the 
Congressional Budget Office via email dated December 17th, 
    To expedite the filing of the Committee report, CBO 
Directors Robert Stewart and Ann Futrell, provided the 
following statement. CBO estimates that the bill would have no 
effect on direct spending or revenues.


    Paragraph 11(b) of rule XXVI of the Standing Rules of the 
Senate requires each report accompanying a bill to evaluate the 
regulatory and paperwork impact that would be incurred in 
carrying out the bill. The Committee believes that S. 2365 will 
have minimal impact on regulatory or paperwork requirements.

                        EXECUTIVE COMMUNICATIONS

    The Committee has received no communications from the 
Executive Branch regarding S. 2365.

                        CHANGES IN EXISTING LAW

    On February 6, 2019, the Committee unanimously approved a 
motion to waive subsection 12 of rule XXVI of the Standing 
Rules of the Senate. In the opinion of the Committee, it is 
necessary to dispense with subsection 12 of rule XXVI of the 
Standing Rules of the Senate to expedite the business of the