[Senate Report 119-21]
[From the U.S. Government Publishing Office]
Calendar No. 74
119th Congress } { Report
SENATE
1st Session } { 119-21
======================================================================
TO AMEND THE INDIAN HEALTH CARE IMPROVEMENT ACT TO ALLOW INDIAN HEALTH
SERVICE SCHOLARSHIP AND LOAN RECIPIENTS TO FULFILL SERVICE OBLIGATIONS
THROUGH HALF-TIME CLINICAL PRACTICE, AND FOR OTHER PURPOSES
_______
May 12, 2025.--Ordered to be printed
_______
Ms. Murkowski, from the Committee on Indian Affairs,
submitted the following
R E P O R T
[To accompany S. 632]
The Committee on Indian Affairs, to which was referred the
bill (S. 632), to amend the Indian Health Care Improvement Act
to allow Indian Health Service scholarship and loan recipients
to fulfill service obligations through half-time clinical
practice, and for other purposes, having considered the same,
reports favorably thereon, without amendment and recommends
that the bill do pass.
PURPOSE
S. 632 would amend the Indian Health Care Improvement Act
to permit recipients of the Indian Health Service's Health
Professions Scholarship and Loan Repayment programs to fulfill
service obligations through half-time practice in order to
increase the recruitment and retention of clinicians in areas
experiencing high vacancy rates.
BACKGROUND AND NEED
The Indian Health Care Improvement Act authorizes the
Indian Health Service (IHS) to offer scholarships and loan
repayments to eligible health care professionals in exchange
for a full-time, two-year service commitment within an Indian
health program, including those contracted or compacted under
the Indian Self Determination and Education Assistance Act.\1\
The IHS Indian Health Professions Scholarship Program (IHS
Scholarship Program) provides qualified American Indian and
Alaska Native health professions students with financial
support of a monthly stipend, full tuition assistance, or other
educational expenses, in exchange for a minimum two-year
service commitment of a chosen health professional discipline
within an IHS Indian health program.\2\ The IHS Loan Repayment
Program (LRP) provides funding to health professionals to
repay, up to $50,000, of their eligible health professions
education loans, in exchange for an initial two-year service
commitment, with opportunity to extend annually, to practice in
health facilities serving American Indian and Alaska Native
communities.\3\ Similar programs, such as the National Health
Service Corps (NHSC) Loan Repayment program, do not condition
eligibility on committing to practice on a full-time basis.\4\
---------------------------------------------------------------------------
\1\Pub. L. 93-638; 25 U.S.C. Sec. Sec. 1613a, 1616a.
\2\IHS Scholarship Program, Indian Health Service, https://
www.ihs.gov/scholarship (last visited March 26, 2025).
\3\Loan Repayment Program, Indian Health Service, https://
www.ihs.gov/loanrepayment/ (last visited on March 26, 2025).
\4\Patient Protection and Affordable Care Act, 42 U.S.C.
Sec. 293b(5); Loan Repayment Program, Indian Health Service, https://
www.ihs.gov/loanrepayment (last visited Oct. 21, 2024).
---------------------------------------------------------------------------
S. 632 is modeled on the NHSC Loan Repayment Program and
Scholarship Programs. These NHSC programs provide loan
repayment and scholarship recipients with the ability to
satisfy their service obligations through half-time clinical
work for double the amount of service time or to accept half
the amount of loan repayment award in exchange for a two-year
service obligation. S. 632 would provide similar flexibilities
to the IHS Scholarship Program and the LRP by extending the
current two-year obligation under both programs for full-time
health professionals to a four-year obligation for half-time
health professionals or reduce the amount of the award in both
programs for eligible half-time health professionals who select
a two-year obligation.
As a largely rural health care provider, the IHS has well-
documented difficulty recruiting and retaining health care
professionals.\5\ Further exacerbating the workforce challenges
within the IHS, the agency experiences high vacancy rates in
several key occupations including physicians, advanced practice
nurses, and behavioral health clinicians.\6\ The IHS's current
full-time work requirement for eligible individuals to access
its scholarship and loan repayment programs is a barrier to
recruitment and retention of health professionals in Tribal
communities.\7\ Providing flexibility to allow half-time health
professionals to qualify for the IHS scholarship and loan
repayments programs could increase the number of providers
interested in serving at an Indian health program, thereby
strengthening recruitment and retention outcomes.\8\
---------------------------------------------------------------------------
\5\IHS Workforce Parity Act and Tribal Access to Clean Water Act of
2023: Hearing on S. 4022 and S. 2385 Before the S. Comm. on Indian
Affs., 118th Cong. 1 (2024) (statement of Melanie Anne Egorin,
Assistant Sec'y for Legis., U.S. Dep't of Health & Human Res.)
(testifying that there are currently over 1,856 vacancies for health
care professionals at IHS) (hereinafter ``SCIA Hearing''); see also
U.S. Gov't Accountability Off., GAO-18-580, Indian Health Service:
Agency Faces Ongoing Challenges Filling Provider Vacancies 9-10 (Aug.
2018) (reporting that the IHS had an overall health care provider
vacancy rate of 25 percent across service areas as of 2017).
\6\Fiscal Year 2025 Justifications of Estimates for Appropriations
Committees, Indian Health Service, U.S. Dep't of Health and Human
Services (2024).
\7\SCIA Hearing, supra note 9, at 2 (statement of Melanie Anne
Egorin, Assistant Sec'y for Legis., U.S. Dep't of Health & Human Res.).
\8\Id.
---------------------------------------------------------------------------
SUMMARY OF S. 632
S. 632 would amend the Indian Health Care Improvement Act
to allow IHS scholarship and loan repayment recipients to
fulfill service obligations through half-time clinical
practice. This change to existing law creates parity between
IHS scholarship and loan repayment programs and the NHSC
programs and enables IHS to make better use of these tools to
recruit and retain key professionals in a highly competitive
employment environment.
LEGISLATIVE HISTORY
S. 632 was introduced by Senators Cortez Masto and Mullin
on February 19, 2025.
In the 118th Congress, a similar bill, S. 3022, was
introduced by Senators Cortez Masto and Mullin. The Committee
held a hearing on S. 3022 on February 8, 2024.\9\ The
Committee, in an open business meeting on May 1, 2024, by a
majority voice vote of a quorum present, ordered S. 3022, as
amended, favorably reported by voice vote (S. Rept. 118-
240).\10\ The Senate passed S. 3022, as amended, by voice vote
on December 17, 2024.\11\
---------------------------------------------------------------------------
\9\S. Hrg. 118-416: Hearing on S. 2385, S. 2796, S. 2868, S. 3022,
and S. 3230 Before the S. Comm. on Indian Affairs, 118th Cong. (2024).
\10\S. Rept. No. 118-240 (2024).
\11\170 Cong. Rec. S7097 (daily ed. Dec. 17, 2024).
---------------------------------------------------------------------------
COMMITTEE RECOMMENDATION
The Senate Committee on Indian Affairs, in an open business
meeting on March 5, 2025, by a majority voice vote of a quorum
present, recommends that the Senate pass S. 632.
SECTION-BY-SECTION ANALYSIS
Section 1--Short title
This section provides the short title for the bill, the
``IHS Workforce Parity Act of 2025.''
Section 2--Indian Health Service Scholarship and loan recipients
Section 2(a) amends the Indian Health Care Improvement Act
to:
permit recipients of an Indian Health
Professions Scholarship to meet their service
obligations through half-time practice if they agree in
writing to serve for double the period of obligated
service set for full-time practice; and
clarify that when an Indian Health
Professions Scholarship recipient fails to begin or
complete their service obligation, the recipient is
subject to breach of contract provisions in the Indian
Health Care and Improvement Act and the periods of
service completed in half-time practice shall be
converted to their full-time equivalents for purposes
of determining breach of contract damages.
Section 2(b) amends the Indian Health Care Improvement Act
to:
expand participation in the IHS Loan
Repayment program to individuals who have contracted to
serve in clinical practice with an Indian health
program for at least four years if at half-time service
and subject to certain conditions, or for two years at
half-time service if the individual's loan payment is
equal to 50 percent of the amount of an individual who
contracted to work full-time for two years; and
clarify that when an IHS Loan Repayment
recipient fails to begin or complete their period of
obligated service through half-time practice, those
periods of service completed in half-time practice
shall be converted to their full-time equivalents for
purposes of determining breach of contract damages.
COST AND BUDGETARY CONSIDERATIONS
The Committee has requested, but has not yet received, the
Congressional Budget Office's estimate of the cost of S. 632 as
ordered reported. When the Congressional Budget Office
completes its cost estimate, it will be posted on the Internet
at www.cbo.gov., and printed in the Congressional Record.
EXECUTIVE COMMUNICATIONS
The testimony provided by the U.S. Department of Health and
Human Services from the February 8, 2024 hearing on S. 3022
follows:
Good afternoon, Chairman Schatz, Vice Chair Murkowski, and
Members of the Committee. Thank you for the opportunity to
provide testimony on two important legislative proposals before
your Committee, and for your continued support for Department
of Health and Human Services (HHS or Department) efforts to
improve the health and well-being of American Indians and
Alaska Natives (AI/AN). Your consideration today of Senator
Cortez Masto's IHS Workforce Parity Act of 2023, and Senator
Bennet's Tribal Access to Clean Water Act of 2023 underscores
that commitment to improving the quality of life in Indian
Country.
I am Melanie Anne Egorin, the Assistant Secretary for
Legislation (ASL) at HHS. My office serves as the primary link
between the Department and Congress. The Office of the ASL
provides technical assistance on legislation to Members of
Congress and their staff, facilitates informational briefings
relating to Department programs to support policy development
by Congress, and supports implementation of legislation passed
by Congress.
The Department has been pleased to collaborate with
Congress and this Committee to investigate the many challenges
facing Indian Country. We have been engaged specifically in
recent months as the Committee has examined issues with water
access in Native communities, and operational challenges such
as workforce recruitment and retention, and the direct and
secondary impacts that the Indian Health Service has faced in
combatting the growing fentanyl crisis. As both IHS Director
Roselyn Tso and Deputy Director Benjamin Smith have
respectively testified to this committee, we remain committed
to working with Congress to improve health for AI/AN
communities including finding solutions to challenges related
to clean water access and workforce shortages. We are deeply
appreciative of the work of Senators Cortez Masto and Bennet to
draft legislation that aims to tackle some of these urgent
problems in Indian Country.
The IHS, as a rural health care provider, experiences
difficulty recruiting and retaining health care professionals.
In particular, recruiting physicians and other primary care
clinicians has been especially challenging. There are currently
over 1,856 IHS vacancies for health care professionals
including: physicians, dentists, nurses, pharmacists, physician
assistants, and nurse practitioners. Staffing shortages are
particularly prevalent in the behavioral and mental health
fields, which has only exacerbated the concurrent substance use
crisis and suicide crisis that tribes across the country are
facing in their communities. AI/ANs overdose mortality rates
and suicide rates remain the highest compared to other racial
and ethnic groups.
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 has
included a number of proposals dating back to Fiscal Year 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,
several of which are outlined below.
I want to also reiterate that the Biden-Harris
Administration agrees that water is a sacred resource that must
be protected. The Administration and HHS have worked hard to
make good on decades of chronic underinvestment in
infrastructure for AI/AN communities. The bipartisan efforts of
Congress--including many champions in this room--helped to
ensure that critical funds for clean drinking water and modern
wastewater and sanitation systems were included in the
Infrastructure Investment and Jobs Act (IIJA). The Department
of Health and Human Services and the IHS are grateful for this
partnership with Congress, and our shared commitment to ensure
that this historic funding is implemented successfully and that
these dollars reach Indian Country as quickly as possible. That
being said, too many tribal families still do not have access
to clean water and reliable wastewater infrastructure.
S. 3022, IHS Workforce Parity Act of 2023
The IHS Workforce Parity Act, would amend the Indian Health
Care Improvement Act to allow recipients of the IHS scholarship
and loan programs to fulfill their service obligations through
half-time clinical practice.
Under current law, the Indian Health Care Improvement Act
requires recipients of IHS Health Professions Scholarships or
loan repayments to provide clinical services on a full-time
basis. The Public Health Service Act (PHSA) was amended by the
Patient Protection and Affordable Care Act (ACA) to permit
certain National Health Service Corps (NHSC) loan repayment and
scholarship recipients to satisfy their service obligations
through half-time clinical practice for double the amount of
service time or, for NHSC loan repayment recipients, to accept
half the loan repayment award amount in exchange for a two-year
service obligation fulfilled on a half-time basis. The PHSA
defines ``full-time'' clinical practice as a minimum of 40
hours per week, for a minimum of 45 weeks per year. It also
defines ``half-time'' as a minimum of 20 hours per week, for a
minimum of 45 weeks per year.
The Indian Health Care Improvement Act would permit both
IHS Health Professions Scholarship and loan repayment
recipients to fulfill service obligations through half-time
clinical practice, under authority similar to that now
available to the NHSC Loan Repayment Program (LRP) and
Scholarship Program. Thus, if similar authority provided in
section 331(i) of the PHSA were extended to IHS, IHS loan
repayment and scholarship recipients would have more options
and flexibility to satisfy their service obligations through
half-time clinical work for double the amount of service time
or to accept half the amount of loan repayment award in
exchange for a two-year service obligation. This legislative
change would create parity between IHS and the NHSC programs
and enable IHS to make better use of these tools to recruit and
retain key professionals in a highly competitive environment.
S. 3022 as drafted attempts to model the language used in
the NHSC demonstration language. It should be noted, however,
that the NHSC language combines the two programs--Scholarship
and LRP--in their language whereas S. 3022 separates
Scholarship and LRP. Additionally, IHS is still examining how
the text in S. 3022 might apply to the IHS Health Professions
Scholarship, a tool that plays a significant role in the
recruitment and retention of the health care professionals
needed to fill workforce vacancies. Lastly, the NHSC language
goes further in that the recipient has to agree to the
conversion to full-time equivalents in determining damages if a
breach occurs. IHS would like to work with the drafters of S.
3022 to ensure the language fits within the IHS Scholarship and
Loan Repayment Program.
The IHS Workforce Parity Act is certainly aligned with the
goals of the IHS in many respects. The Fiscal Year (FY) 2024
President's Budget includes a similar proposal to permit both
IHS scholarship and loan repayment recipients to fulfill
service obligations through half-time clinical practice. The
ability to provide scholarship and loan repayment awards for
half-time clinical service would make these recruitment and
retention tools more flexible and cost-effective, providing
incentives for an additional pool of clinicians and other
medical providers that otherwise may not consider a commitment
to the IHS federal, tribal, and urban Indian sites. Having
similar authority as the NHSC would increase the ability of the
IHS to recruit and retain health care clinicians to provide
primary health care and specialty services and otherwise
support the IHS and HHS priorities.
Additional half-time direct care employees could also
reduce the number and cost of Purchased/Referred Care program
referrals, especially at sites that do not need full-time
specialty care services. There are also a number of smaller
rural IHS sites where clinicians will be able to provide a
minimum of half-time clinical services with the remainder of
their time devoted to much needed administrative/management
responsibilities. This proposal will provide flexibility for
providers who might not otherwise consider service in the IHS
by allowing part-time practice in IHS to coincide with a part-
time private practice, as well as part-time practice in the IHS
combined with part-time administrative duties within the IHS.
Human Resources Proposals
As the IHS continues to prioritize recruitment and
retention of providers in our system, we would encourage
members of this Committee to review other proposals in the FY
2024 President's Budget that would better enable the IHS to
attract top talent. Many of these proposals are budget
neutral--small fixes that would have a major impact on the
efficacy and quality of the IHS. For example, the IHS seeks a
tax exemption for Indian Health Service Health Professions
Scholarship and Loan Repayment Programs. Exempting the IHS Loan
Repayment Program would allow the IHS to award an additional
190 loan repayment contracts in a given year. Thus, the IHS
would be better able 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 to pay higher salaries and
offer more flexible time off to their providers. Typically, the
private sector can offer candidates better scheduling options
and paid time off--particularly important benefits to providers
who serve in remote and rural locations. The VHA has
demonstrated the impact of these authorities on public sector's
ability to hire for these critical roles, particularly in rural
areas. As such, the IHS faces specific public sector
competition in the area of annual leave accrual. Supervisors
report anecdotally that the IHS has lost many candidates to the
private sector and VHA due to this difference in accrual rates.
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. These highly specialized
individuals can bring added skills, knowledge, and expertise to
meet mission-critical tasks. To combat future pandemics,
emergencies, and unique health-care challenges, it would be
beneficial to hire experts and consultants to provide
additional high-level resources to the IHS unavailable within
the current workforce.
Additionally, the IHS seeks legislative authority to
conduct mission critical emergency hiring needs beyond 30-day
appointments. Critical hiring occurs when an agency needs to
fill positions to meet agency requirements brought on by
natural disasters, emergencies, or threats. The IHS has
previously used this hiring authority to fill positions in
nursing, facility management, radiology, and many other
critical areas to ensure the operation of IHS facilities and
quality patient care.
Lengthening emergency hire appointments from 30 to 60 days
would better enable the IHS to effectively provide services and
staff health care facilities from both an operational and
budgetary perspective. The effort to hire, onboard, and vet
candidates through the pre-clearance and background
investigation process is significant, reducing the benefit of
this hiring tool.
REGULATORY AND PAPERWORK IMPACT STATEMENT
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. 632, as
reported, will have minimal impact on regulatory or paperwork
requirements.
CHANGES IN EXISTING LAW
In the opinion of the Committee, it is necessary to
dispense with the requirements of subsection 12 of rule XXVI of
the Standing Rules of the Senate to expedite business of the
Senate.
[all]