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


                   EXAMINING THE PRESIDENT'S FISCAL
                   YEAR 2024 BUDGET REQUEST FOR THE 
                        INDIAN HEALTH SERVICE

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

                           OVERSIGHT HEARING

                               BEFORE THE

               SUBCOMMITTEE ON INDIAN AND INSULAR AFFAIRS

                                 OF THE

                     COMMITTEE ON NATURAL RESOURCES
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                         Thursday, May 11, 2023

                               __________

                           Serial No. 118-25

                               __________

       Printed for the use of the Committee on Natural Resources
       
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        Available via the World Wide Web: http://www.govinfo.gov
                                   or
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                             __________

                                
                    U.S. GOVERNMENT PUBLISHING OFFICE                    
52-324 PDF                 WASHINGTON : 2023                    
          
-----------------------------------------------------------------------------------     
                     COMMITTEE ON NATURAL RESOURCES

                     BRUCE WESTERMAN, AR, Chairman
                    DOUG LAMBORN, CO, Vice Chairman
                  RAUL M. GRIJALVA, AZ, Ranking Member

Doug Lamborn, CO		Grace F. Napolitano, CA		
Robert J. Wittman, VA		Gregorio Kilili Camacho Sablan, 
Tom McClintock, CA		  CNMI
Paul Gosar, AZ			Jared Huffman, CA
Garret Graves, LA		Ruben Gallego, AZ
Aumua Amata C. Radewagen, AS	Joe Neguse, CO
Doug LaMalfa, CA		Mike Levin, CA
Daniel Webster, FL		Katie Porter, CA
Jenniffer Gonzalez-Colon, PR    Teresa Leger Fernandez, NM
Russ Fulcher, ID		Melanie A. Stansbury, NM
Pete Stauber, MN		Mary Sattler Peltola, AK
John R. Curtis, UT		Alexandria Ocasio-Cortez, NY
Tom Tiffany, WI			Kevin Mullin, CA
Jerry Carl, AL			Val T. Hoyle, OR
Matt Rosendale, MT		Sydney Kamlager-Dove, CA
Lauren Boebert, CO		Seth Magaziner, RI
Cliff Bentz, OR			Nydia M. Velazquez, NY
Jen Kiggans, VA			Ed Case, HI
Jim Moylan, GU			Debbie Dingell, MI
Wesley P. Hunt, TX		Susie Lee, NV
Mike Collins, GA
Anna Paulina Luna, FL
John Duarte, CA
Harriet M. Hageman, WY                                

                    Vivian Moeglein, Staff Director
                      Tom Connally, Chief Counsel
                 Lora Snyder, Democratic Staff Director
                   http://naturalresources.house.gov
                   

               SUBCOMMITTEE ON INDIAN AND INSULAR AFFAIRS

                     HARRIET M. HAGEMAN, WY, Chair

                JENNIFFER GONZALEZ-COLON, PR, Vice Chair

               TERESA LEGER FERNANDEZ, NM, Ranking Member

Aumua Amata C. Radewagen, AS         Gregorio Kilili Camacho Sablan, 
Doug LaMalfa, CA                         CNMI
Jenniffer Gonzalez-Colon, PR         Ruben Gallego, AZ
Jerry Carl, AL                       Nydia M. Velazquez, NY
Jim Moylan, GU                       Ed Case, HI
Bruce Westerman, AR, ex officio      Raul M. Grijalva, AZ, ex officio

                              ----------                                
                              
                               CONTENTS

                              ----------                              
                                                                   Page

Hearing held on Thursday, May 11, 2023...........................     1

Statement of Members:

    Hageman, Hon. Harriet M., a Representative in Congress from 
      the State of Wyoming.......................................     1

    Leger Fernandez, Hon. Teresa, a Representative in Congress 
      from the State of New Mexico...............................     3

Statement of Witnesses:

    Tso, Hon. Roselyn, Director, Indian Health Service, U.S. 
      Department of Health and Human Services, Rockville, 
      Maryland, accompanied by Jillian Curtis, Director of 
      Budget, Indian Health Service..............................     5
        Prepared statement of....................................     6
        Questions submitted for the record.......................    12



 
OVERSIGHT HEARING ON EXAMINING THE PRESIDENT'S FISCAL YEAR 2024 BUDGET 
                 REQUEST FOR THE INDIAN HEALTH SERVICE

                              ----------                              


                         Thursday, May 11, 2023

                     U.S. House of Representatives

               Subcommittee on Indian and Insular Affairs

                     Committee on Natural Resources

                             Washington, DC

                              ----------                              

    The Subcommittee met, pursuant to notice, at 2:07 p.m., in 
Room 1324 Longworth House Office Building, Hon. Harriet M. 
Hageman [Chairwoman of the Subcommittee] presiding.

    Present: Representatives Hageman, Radewagen, LaMalfa, 
Gonzalez-Colon, Carl; and Leger Fernandez.

    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 related 
to examining the President's Fiscal Year 2024 budget request 
for the Indian Health Service. 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 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. Under the Constitution, Congress has the power 
to tax and to spend, and within those powers are Congress' 
responsibility to tax and spend wisely and make decisions on 
how best to prioritize finite Federal resources among all the 
programs and policies implemented across the United States and 
the world. It is also Congress' responsibility to conduct 
oversight of how Federal funds are spent and to hold agencies 
accountable for their spending and their prioritization of 
programs and policies.
    This hearing will focus on the President's Fiscal Year 2024 
budget request for the Indian Health Service and how best to 
allocate funds to the IHS and consider what changes need to be 
made. IHS, like every other agency, is accountable to the 
American people, and particularly to the tribal communities and 
Native people that they serve. Through treaties and Federal 
statutes, the Federal Government has assumed the responsibility 
of providing healthcare for American Indians and Alaska 
Natives, and IHS is the primary agency charged with that 
responsibility.
    IHS provides an array of medical services to Native people, 
including primary care, emergency services, public health 
nursing, and substance abuse care, just to name a few. As 
previous hearings have shown, IHS has not always delivered the 
best possible care and improvements must be made. Over the past 
several years, Indian Country has seen substantial Federal 
funding increases across agencies and programs that serve 
Native communities, including for tribal healthcare and health 
facilities.
    The Federal Government has also increased its spending 
generally over the past decade and that means a higher deficit 
and intense concern for many Americans about the fiscal future 
facing our nation. In fact, I just did a poll this week as to 
some of the issues that are the most important to my 
constituents in the state of Wyoming, and the budget, and 
government, and Federal spending is at the top of the list.
    The President's budget proposes a $2.45 billion increase 
for IHS in the next fiscal year. The budget also proposes to 
shift contract support costs in Section 105(l) Lease Funding to 
mandatory spending in Fiscal Year 2024 and then further shift 
all IHS funding to mandatory spending beginning in Fiscal Year 
2025.
    While I understand the need for consistent funding, I also 
believe that continued oversight and accountability of IHS is 
needed at this time. We need to see significant progress before 
how IHS is funded can significantly change.
    The discretionary appropriations process helps to encourage 
and facilitate oversight as well as further discussion about 
what innovative approaches IHS should incorporate to ensure the 
healthcare provided to Native communities is not only of high 
caliber, but fiscally responsible. It is also important to note 
that IHS remains on the Government Accountability Office's 
high-risk list as one of the government programs in operations 
vulnerable to waste, fraud, and abuse. And while the Agency has 
made some progress on key recommendations, much more work 
remains.
    Specifically, this Subcommittee has heard many concerns 
about the Purchased/Referred Care Program, including how claims 
are either accepted or denied, as well as how slowly these 
claims have been paid by IHS, which is then affecting the 
personal credit scores when the claims are sent to collections.
    Ensuring effective care when IHS facilities cannot provide 
such services to tribal members is critically important and has 
life-changing implications. In short, equitable access to PRC 
funds must be a priority. There are also problems with the 
speed of completing the 1993 Priority List for Indian Health 
Facilities. It is now 30 years later, and the list has not yet 
been completed. That is unacceptable, and our tribal members 
have suffered as a result.
    There are questions on how to best care for individuals 
suffering from substance abuse and mental health disorders, how 
to ensure full hiring and retention of IHS medical and support 
personnel, how to expand access to labor and delivery services 
for women in their home communities, and how to provide dental 
services. IHS medical staff and tribal health professionals are 
the boots on the ground ensuring healthcare to Native peoples, 
and it is the best that it can be. Their work is needed now 
more than ever.
    Continuing oversight of IHS to ensure they are fulfilling 
their mission to efficiently and effectively operate for the 
benefit of Native communities is a main priority of this 
Subcommittee, and it will help to make sure resources get to 
where they need to go. Today, that means having a good 
discussion about the Agency's budget and where resources should 
be allocated.
    I want to thank the Director for being here to testify 
today, and I look forward to your testimony.
    The Chair now recognizes the Ranking Minority Member for 
any statement.

STATEMENT OF THE HON. TERESA LEGER FERNANDEZ, A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW MEXICO

    Ms. Leger Fernandez. Thank you so much, Madam Chairwoman, 
for holding this hearing, for raising the issues that you do. I 
will try to talk about some of them, but I think that I really 
appreciate the fact that we already had a hearing in our 
oversight regarding healthcare, and what came across loud and 
clear was that IHS provides critical, culturally-competent 
healthcare services to American Indians and Alaska Natives 
across the United States either directly or through compacted 
and contracted tribal facilities.
    Unfortunately, Congress and past administrations have 
failed to fund IHS at the level that IHS patients deserve. 
Reports from the GAO and the U.S. Commission on Civil Rights 
confirmed that reality: IHS is grossly undersized and 
underfunded compared to its current need.
    At our last hearing, tribal health organizations made one 
thing very clear, we need to fully fund the IHS. Indeed, 
Chairwoman Alkire, from that table, told us that the National 
Indian Health Board estimates that IHS spending per patient is 
less than half of Medicaid's spending, less than half of 
Veterans' medical spending per patient, and less than one-third 
of Medicare spending per beneficiary, even after we include 
third-party revenue received by IHS. We know that each of these 
healthcare providers are already underfunded, but IHS receives 
even less so.
    So, President Biden's Fiscal Year 2024 budget, which I 
think we should address and talk about, I agree with you, we 
need to talk about how it impacts deficit. But that 2024 budget 
would decrease the Federal deficit by $3 trillion over a 10-
year period. And over the last 2 years, with Congress and 
Biden, we have reduced the deficit already by $1.7 trillion. 
So, there are ways to reduce the deficit while also investing 
in what is important.
    This year's budget requests a 35.8 percent increase in 
funding. It still falls far short of parity with the other 
Federal healthcare programs, but it is a step in the right 
direction. The IHS request is $9.65 billion with an additional 
proposal to make funding for the Agency mandatory beginning in 
Fiscal Year 2025.
    The budget request also would fully fund the remaining 
projects on the 1993 Healthcare Facilities Priority List. Let 
me say that again--1993 Priorities List. It is a disgrace that 
these priority projects, 30 years out, have not been built yet. 
We also have $691 million to modernize the IHS electronic 
health records system which has also been in the planning 
stages for too long.
    We would increase by $742 million the direct healthcare 
services and an additional $24.7 million for urban Indian 
health. And we know that more tribal members receive their 
healthcare in urban areas than not, so that is really 
important.
    But in order to really provide these services, you need to 
address staff recruitment and retention concerns, which is why 
I am really pleased to see the IHS scholarship and loan 
repayment awards, the graduate medical education programs, 
nurse preceptorships, and the national Community Health Aide 
Program. Because everywhere I go in Indian Country, I hear over 
and over again, we do not have enough doctors, nurses, and 
health technicians. It is best if we can invest in the 
communities themselves so that we can create that pipeline of 
healers from our tribal communities.
    At our last hearing as well, our tribal witnesses 
highlighted three additional areas: the facilities, contract 
support costs, and the Special Diabetes Program for Indians. 
So, this budget request actually responds to those issues that 
we heard in this hearing room. It includes a legislative 
proposal to reauthorize the Special Diabetes Program for 
Indians for 3 years, something I support and am co-sponsoring. 
These allocations would be historic for the Agency in its 
tribal service populations.
    But I still want to highlight the gaps in funding that 
would still exist even with these increases. The cumulative 
budget request from the Tribal Budget Formulation Work Group 
says in order to cover salaries, inflation, population growth, 
we would need services and facilities program of $49.65 
billion.
    And I also want to touch on the Republican's proposed 
budget cuts. Their proposal would require at least a 22 percent 
budget reduction for IHS. The New York Times highlighted that 
that might be as high as 51 percent. Imagine, that would be 
10,000 fewer inpatient admissions, nearly 4 million fewer 
outpatient visits. Also slashing dental health, mental health, 
alcohol, and substance abuse.
    I want everybody to think of what it would be like for a 
tribal family of four. At least one member of that family would 
not get the healthcare, mental care, diabetes care that she 
needs. Who would we sacrifice? If we don't make needed 
investments now, it is going to actually cost us more later 
because we need to invest in healthy communities rather than 
just dealing with the health problems later.
    I am so glad that last year we did pass on a bipartisan 
basis advanced appropriations for the Agency, and I look 
forward to doing that once again.
    Thank you so much, Madam Chair, and I yield back.

    Ms. Hageman. Thank you. And just to make one correction, 
while the New York Times may argue that there would be a 22 
percent reduction in the Republican's proposal, the reality is 
that the debt reduction package that the Republicans have put 
forward would be based upon spending in 2022 levels. Seeking an 
increase of $2.45 billion in this particular budget to a total 
of $9.65 billion, I don't see how any math possible would show 
that that was a 22 percent reduction. Just wanted to make that 
correction.
    I will now introduce the witness, Ms. Roselyn Tso, Director 
of the Indian Health Service out of Rockville, Maryland. And 
sitting with her today on the dais is Director, Office of 
Budget, Ms. Jillian Curtis. Let me remind the witness 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, and when you begin the 
light will turn green. When you have 1 minute left, the light 
will turn yellow. And at the end of 5 minutes, the light will 
turn red, and I will ask you to please complete your statement. 
I will also allow all witnesses on the panel to testify before 
Member questioning.
    The Chair now recognizes Director Tso for 5 minutes. Thank 
you.

  STATEMENT OF THE HON. ROSELYN TSO, DIRECTOR, INDIAN HEALTH 
    SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, 
   ROCKVILLE, MD, ACCOMPANIED BY JILLIAN CURTIS, DIRECTOR OF 
                 BUDGET, INDIAN HEALTH SERVICE

    Ms. Tso. Good afternoon. Thank you, Madam Chair Hageman and 
Ranking Member Leger Fernandez, and members of the 
Subcommittee. Thank you for the opportunity to testify on the 
President's Fiscal Year 2024 Request for the Indian Health 
Service.
    Before I turn to the 2024 budget, I also want to restate 
and state again that we always welcome the opportunity to 
appear before the Subcommittee as part of our commitment to 
oversight and transparency. I know earlier we made every 
attempt to try to make the March meeting work, and we were 
unfortunately not able to do so. I look forward to our 
continued partnership in ensuring that IHS fulfills its mission 
to providing quality and safe care to our tribal communities.
    Next, I want to acknowledge and thank you for the work that 
you have done over the years to grow the Indian Health Service 
budget and prioritize health throughout Indian Country. We are 
also especially grateful for your work in providing IHS 
advanced appropriations in the Fiscal Year 2023 bill that truly 
is an historic achievement and that will greatly improve lives 
of American Indians and Alaska Natives throughout Indian 
Country. I also appreciate the opportunity to share with you 
the steps that I have taken as the Indian Health Service 
Director to improve transparency, accountability, and oversight 
of the Indian Health Service.
    As we seek additional funding and new funding authorities, 
it is critical that the Indian Health Service improve its 
internal operations to ensure safe, high-quality healthcare 
services and protect and support the relationships that we have 
with our tribes and our urban Indian organizations. To that 
end, I have posted for the first time an agency work plan to 
manage the high-priority topics including building an 
enterprise-wide risk system on January 15.
    The agency work plan addresses a wide-range of topics 
including patient safety, human capital, finance, operations, 
compliance, and strategies. This work builds on our effort to 
meet the GAO criteria for removal from its high-risk list. The 
IHS has already achieved two major accomplishments in the work 
plan. The first one was to designate and commission a team to 
look at the Agency's quality program in December 2022 with a 
primary focus of improving oversight and quality safe care for 
all of our patients.
    Also in December 2022, we achieved a milestone as part of 
our plan to standardize governance structure throughout the 
IHS-operated healthcare facilities by adopting standardize 
governance bylaws at all 12 areas. Standardizing governance 
practices at direct health facilities further supports uniform 
oversight and accountability while increasing efficiencies.
    With your support, the IHS budget has grown 68 percent in 
the last decade. We know that this type of growth is 
challenging to accomplish in a constrained discretionary 
funding environment. Over the years, the work with our tribal 
and urban partners underscore our shared goals to improve 
health outcomes for all American Indians and Alaska Natives.
    With the shared goals in mind that the Administration has 
approached the Fiscal Year 2024 budget's request for Indian 
Health Service, we know that despite our shared efforts, IHS is 
still underfunded. This underfunding of the Indian Health 
Service system directly contributes to the stark health 
disparities in tribal communities.
    American Indians and Alaska Natives born today have an 
average life expectancy that is 10.9 years fewer than all race 
population. Long-standing health disparities were compounded by 
the pandemic with American Indians and Alaska Natives 
experiencing disproportionate rates of COVID-19 infections, 
hospitalizations, and deaths. Addressing these inequities is a 
moral imperative for our nation, and it will require bold 
actions from all of us to ensure we are upholding the 
commitment to Indian Country.
    This is why the budget proposes to build on the enactment 
of advanced appropriations by funding the Indian Health Service 
and facilities accounts as discretionary in Fiscal Year 2024. 
It also proposes to reclassify contract support costs in 
Section 105(l) to mandatory in 2024. We believe that this is 
the most appropriate funding source for these legally required 
payments to the tribes. Beginning in Fiscal Year 2025, we will 
be working to make the budget mandatory for Indian Health 
Service.
    As we work together to secure stable, predictable, and 
adequate funding to meet the needs of Indian Country, we are 
committed to working closely with our stakeholders. Thank you 
for the opportunity to speak with you today, and I am happy to 
answer any questions.

    [The prepared statement of Ms. Tso follows:]
  Prepared Statement of Roselyn Tso, Director, Indian Health Service, 
                Department of Health and Human Services

    Good afternoon Chair Hageman, Ranking Member Leger Fernandez, and 
Members of the Subcommittee. Thank you for your support and for 
inviting me to speak with you about the President's Fiscal Year (FY) 
2024 Budget Request for the IHS.
    IHS is an agency within the Department of Health and Human Services 
(HHS) and our mission is to raise the physical, mental, social, and 
spiritual health of American Indians and Alaska Natives (AI/AN) to the 
highest level. This mission is carried out in partnership with AI/AN 
Tribal communities through a network of over 600 Federal and Tribal 
health facilities and 41 Urban Indian Organizations (UIOs) that are 
located across 37 states and provide health care services to 
approximately 2.8 million AI/AN people annually.
    On March 9, 2023, the White House released the President's FY 2024 
Budget, which takes a two pronged approach to build on the historic 
enactment of advance appropriations for the IHS in the FY 2023 Omnibus. 
In FY 2024, the Budget proposes to fund IHS Services and Facilities 
accounts as discretionary, building on the enacted 2024 advance 
appropriations. It also proposes to reclassify Contract Support Costs 
and Section 105(l) Leases to mandatory funding in FY 2024, which is the 
most appropriate funding source for these legally required payments to 
tribal health programs. Beginning in FY 2025, the Budget would make all 
funding for IHS mandatory. The bold action proposed in the FY 2024 
President's Budget demonstrates the Administration's continued 
commitment to strengthening the nation-to-nation relationship. This 
historic proposal addresses long-standing challenges that have impacted 
communities across Indian Country for decades.
Leadership Priorities

    I have been traveling across Indian Country to visit the places 
where we are serving our people since my appointment last fall. These 
visits have provided me a better perspective on national and regional 
issues affecting the tribal members we serve and have informed my 
priorities for the agency. I have two key priorities as IHS Director: 
providing safe, high quality patient care; and improving our 
relationships with Tribes, Tribal Organizations, and Urban Indian 
Organizations.
    To those ends, I have taken significant steps to increase 
transparency, accountability, and oversight at the IHS. The IHS 
published its first ever Agency Work Plan \1\ to manage high priority, 
enterprise-wide risks on January 15. I hold quarterly strategic 
planning sessions with leadership from across the Agency to ensure 
progress on the Work Plan, and I have assigned a lead to each action on 
the Work Plan. These actions address a wide range of Agency-wide issues 
including patient safety, human capital, operations, finances, 
compliance, and strategy. This work builds on the IHS' efforts to meet 
the Government Accountability Office's (GAO) criteria for removal from 
its high risk list.
---------------------------------------------------------------------------
    \1\ Indian Health Service--2023 Agency Work Plan: https://
www.ihs.gov/quality/work-plan-summary/
---------------------------------------------------------------------------
    The IHS has achieved two major accomplishments on the Work Plan 
thus far. I initiated an evaluation of the Agency's quality program in 
December 2022, with a primary focus on improving oversight of quality 
and safe care for patients. In general, this evaluation included a 
continued focus on oversight and accountability through developing 
policies, standardizing the IHS governance structure and strengthening 
IHS' enterprise risk management program. Standardizing governing board 
practices at direct service facilities improves oversight and 
accountability while increasing efficiency and effectiveness of 
governing board meetings. These actions allow the Agency to be 
proactive on governance issues by being able to review information in 
an efficient manner. These efforts were led by a team of subject matter 
experts from across the Agency, with oversight and technical direction 
by the IHS Chief Medical Officer.
    Funding issues directly contribute to challenges in providing safe, 
high-quality care for patients, and supporting productive relationships 
between the IHS and Tribes and Urban Indian Organizations. The Indian 
Health system is chronically underfunded compared to other healthcare 
systems in the U.S.\2\,\3\ Despite substantial growth in the 
IHS discretionary budget over the last decade, 68 percent from FY 2013 
to the current FY 2023 enacted level, the growth has not been 
sufficient to address the well-documented funding gaps in Indian 
Country. These funding deficiencies directly contribute to stark health 
disparities faced by tribal communities. AI/ANs born today have an 
average life expectancy that is 10.9 years fewer than the U.S. all-
races population. AI/AN life expectancy dropped from an estimated 71.8 
years in 2019 to 65.2 years in 2021--the same life expectancy as the 
general United States population in 1944.\4\ They also experience 
disproportionate rates of mortality from most major health issues, 
including chronic liver disease and cirrhosis, diabetes, unintentional 
injuries, assault and homicide, and suicide. AI/AN people also have 
higher rates of colorectal, kidney, liver, lung, and stomach cancers 
than non-Hispanic White people.\5\ The pandemic compounded the impact 
of these disparities in tribal communities, with AI/ANs experiencing 
disproportionate rates of COVID-19 infection, hospitalization, and 
death.
---------------------------------------------------------------------------
    \2\ Government Accountability Office Report--Indian Health Service: 
Spending Levels and Characteristics of IHS and Three Other Federal 
Health Care Programs https://www.gao.gov/assets/gao-19-74r.pdf
    \3\ U.S. Commission on Civil Rights Report--Broken Promises: 
Continuing Federal Funding Shortfall for Native Americans https://
www.usccr.gov/files/pubs/2018/12-20-Broken-Promises.pdf
    \4\ Centers for Disease Control and Prevention (CDC) Report--Life 
Expectancy in the U.S. Dropped for the Second Year in a Row in 2021 
https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/
20220831.htm#:?:text=AIAN%20people%20had%20a%20life,total%20 
U.S.%20population%20in%201944
    \5\ Centers for Disease Control and Prevention (CDC)--Cancer Within 
American Indian and Alaska Native (AI/AN) Populations https://
www.cdc.gov/healthytribes/native-american-cancer.html
---------------------------------------------------------------------------
Building on the Historic Achievement of Advance Appropriations

    The FY 2024 President's Budget builds on the historic enactment of 
advance appropriations for IHS in the FY 2023 Omnibus. For the first 
year of the proposal, the Budget includes $9.7 billion in total funding 
for the IHS, which includes $8.1 billion in discretionary funding, and 
$1.6 billion in proposed mandatory funding for Contract Support Costs, 
Section 105(l) Leases, and the Special Diabetes Program for Indians. 
This is an increase of $2.5 billion above the FY 2023 Enacted level. 
Advance appropriations represent an important step toward securing 
stable and predictable funding to improve the overall health status of 
AI/ANs, and ensuring that the disproportionate impacts experienced by 
tribal communities during government shutdowns and continuing 
resolutions are never repeated.
    While the progress achieved through the enactment of advance 
appropriations will have a lasting impact on Indian Country, funding 
growth beyond what can be accomplished through discretionary spending 
is needed to fulfill the federal government's commitments to AI/AN 
communities. Funding for IHS has grown substantially in the last 
decade, but this growth is not sufficient to address the historic under 
investment and persistent health disparities in AI/AN communities.
    The Administration continues to support mandatory funding for IHS 
as the most appropriate long-term funding solution for the agency and 
will continue to work collaboratively with tribes and Congress to move 
toward sustainable, mandatory funding. Until this solution is enacted, 
it is critical that Congress continue to provide advance appropriations 
for IHS through the discretionary appropriations process for FY 2025 
and beyond.
Long-Term Funding Solutions

    The Budget proposes to fully shift the IHS budget to mandatory 
funding in FY 2025. This mandatory formula culminates in a total 
funding level of approximately $44.0 billion in FY 2033. In total, the 
mandatory budget would provide nearly $288 billion for the IHS over ten 
years. When accounting for the discretionary baseline, the net-total 
for the proposal is $192 billion over ten years.
    Under the proposed mandatory structure, IHS funding would grow 
automatically to address inflation factors to address the growing cost 
of providing direct health care services, including pay costs, medical 
and non-medical inflation, and population growth, as well as key 
operational needs, and existing backlogs in both healthcare services 
and facilities infrastructure.
    Mandatory funding for the IHS provides the opportunity for 
significant funding increases that could not be achieved within 
discretionary spending levels. Further, this mandatory funding proposal 
ensuring predictability that would allow IHS, tribal, and urban Indian 
health programs the opportunity for long-term and strategic planning. 
This increased stability and ability to conduct longer-term planning 
will improve the quality of healthcare, promote recruitment and 
retention of health professionals, and enhance management efficiencies 
for individual health programs and the Indian Health system at large.
    The Budget also exempts all IHS funding from sequestration, which 
is the legislatively mandated process of budget control consisting of 
automatic, across-the-board spending reductions to enforce budget 
targets to limit federal spending. Exempting the IHS budget from 
sequestration ensures funding for direct health care services for AI/
ANs is not reduced and is consistent with the treatment of other 
critical programs such as veterans' health care and nutrition 
assistance programs.
    Lastly, the Budget proposes to reauthorize the Special Diabetes 
Program for Indians and provide $250 million in FY 2024, $260 million 
in FY 2025, and $270 million in FY 2026 in new mandatory funding. This 
program has proven to be effective at reducing the prevalence of 
diabetes among AI/AN adults,\6\ and is associated with an estimated 
net-savings to Medicare of up to $520 million over 10 years due to 
averted cases of end-stage renal disease.\7\ The budget's proposed 
increases will enable the program to expand to additional grantees, and 
allow the grantees to plan for larger and longer-term community-driven 
interventions more effectively. Without the reauthorization of this 
program in FY 2024 services would end for this successful program.
---------------------------------------------------------------------------
    \6\ 4 British Medical Journal--Prevalence of diagnosed diabetes in 
American Indian and Alaska Native adults, 2006-2017 https://
drc.bmj.com/content/8/1/e001218
    \7\ HHS Assistant Secretary for Planning and Evaluation Issue 
Brief--The Special Diabetes Program for Indians Estimates of Medicare 
Savings https://aspe.hhs.gov/sites/default/files/private/pdf/261741/
SDPI_Paper_Final.pdf
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    This request responds to the long-standing recommendations of 
tribal leaders shared in consultation with HHS and IHS to make IHS 
funding mandatory. The IHS recognizes that we must continue to work in 
consultation with Tribes and confer with urban Indian organizations, 
and with our partners in Congress. To this end, a joint OMB and HHS 
tribal consultation and urban confer will be conducted in June to 
review this proposal and receive feedback to inform further refinements 
to the mandatory formula structure.
Prioritizing High Quality Health Care

    The Budget prioritizes investments that advance high quality health 
care and tackle the stark health care inequities AI/ANs face every day.
    In FY 2024 the Budget provides +$742 million increase to expand 
access to direct health care services by increasing funding across IHS' 
direct health care service program lines. These resources will support 
efforts to reduce health disparities and improve the overall health 
status for AI/ANs by increasing the availability of health care 
services in Indian Country. Specifically, this funding level will 
support an estimated additional 45,670 inpatient admissions and 
16,976,299 outpatient visits at IHS and Tribal facilities in FY 2024. 
This funding also expands access to the Purchased/Referred Care program 
for contract health care services that are not available in IHS or 
Tribal health facilities by providing an estimated 3,138 additional 
inpatient admissions, 92,248 additional outpatient visits, and 3,262 
additional patient travel trips. The Budget also expands Dental health 
services, supporting an estimated 167,119 additional dental visits and 
529,462 additional dental services in FY 2024. Within this total, the 
Budget includes an additional $21 million for the Urban Indian Health 
Program to expand access to culturally competent direct health care 
services through a network of 41 Urban Indian Organizations located in 
urban areas across the country. Expansion of these programs is 
essential to ensure that IHS can provide high quality medical services 
and support critical health care services that meet the unique needs of 
AI/AN communities.
    In addition, Current Services, which offset the rising costs of 
providing direct health care services, are fully funded at +$346 
million in FY 2024. These resources will help the IHS to maintain 
services at the FY 2023 levels by shoring up base operating budgets of 
IHS, Tribal, and urban Indian health programs in the face of increasing 
costs. Similarly, in FY 2024, the Budget includes +$82 million to fully 
fund staffing and operating costs for eight newly-constructed or 
expanded health care facilities. These funds support the staffing 
packages for new or expanded facilities, which will expand the 
availability of direct health care services in areas where existing 
health care capacity is overextended. The mandatory funding formula 
fully funds Current Services and staffing and operating costs for newly 
opening facilities in the out-years.
    The Budget also makes targeted investments to address our Nation's 
most pressing public health challenges, which disproportionately impact 
AI/AN communities. For the first time ever, the Budget proposes 
dedicated funding to address disparities in cancer rates and mortality 
among AI/AN, providing $108 million for the Cancer Moonshot Initiative. 
Through this initiative, the IHS would develop a coordinated public 
health and clinical cancer prevention initiative to implement best 
practices and prevention strategies to address incidence of cancer and 
mortality among AI/AN. Similarly, the Budget requests funding to 
address HIV, Hepatitis C, and Sexually Transmitted Infections (+$47 
million), improve maternal health (+$3 million), and address opioid use 
(+$9 million) in Indian Country.
    The Budget also makes numerous investments in high priority areas, 
such as recruitment and retention of high quality health professionals, 
expansion of the successful Community Health Aide Program, and other 
activities that support high quality health care.
    Likewise, from FY 2025 to FY 2029, the Budget requests an 
additional +$11.2 billion in mandatory funding for the Indian Health 
Care Improvement Fund to address the funding gap for direct healthcare 
services documented in the FY 2018 level of need funded analysis.\8\ 
The Budget would continue growth for direct services once the 2018 gap 
is addressed. This funding would be distributed using the Indian Health 
Care Improvement Fund formula. The formula is used to target the Indian 
Health Care Improvement Fund appropriations to the sites with the 
greatest need, as compared to the benchmark of National Health 
Expenditure Data, which is maintained by the Centers for Medicare and 
Medicaid Services. The formula is the product of long-standing 
consultation with Tribes.
---------------------------------------------------------------------------
    \8\ Indian Health Service--FY 2018 Indian Health Care Improvement 
Fund Workgroup Interim Report https://www.ihs.gov/sites/ihcif/themes/
responsive2017/display_objects/documents/2018/
2018_IHCIF_WorkgroupInterimReport.pdf
---------------------------------------------------------------------------
    The outyear mandatory formula also prevents a sharp reduction in 
services by providing an additional +$220 million in FY 2025 to 
partially sustain the one-time American Rescue Plan Act investments 
that were appropriated to expand access to mental health and substance 
abuse prevention and treatment services, and to expand the public 
health workforce in Indian Country.
Modernizing Critical Infrastructure

    In addition to funding for direct health care services, additional 
investments are needed to address substantial deficiencies in physical 
and information technology infrastructure across the IHS system. 
Outdated infrastructure poses challenges in safely providing patient 
care, recruiting and retaining staff, and meeting accreditation 
standards. From FY 2024 through FY 2029, the Budget includes critical 
funding increases to reduce or eliminate existing facilities backlogs 
and modernize the IHS Electronic Health Record (EHR) system.
    Specifically, in FY 2024, the Budget provides $913 million in 
discretionary funding for EHR modernization. The Budget then builds 
funding for EHR by +$1.1 billion each year from FY 2025 through FY 2029 
under the proposed mandatory formula. Once the EHR modernization effort 
is fully funded, the Budget provides sufficient resources for ongoing 
operations and maintenance of the new system. The current IHS EHR is 
over 50 years old, and the GAO identifies it as one of the 10 most 
critical federal legacy systems in need of modernization. The IHS 
relies on its EHR for all aspects of patient care, including the 
patient record, prescriptions, care referrals, and billing public and 
private insurance for over $1 billion reimbursable health care services 
annually. Expected benefits from adopting and implementing a modernized 
system include, but are not limited to, improved patient safety, 
improved patient outcomes, better disease management, enhanced 
population health, improved clinical quality measures, opioid tracking, 
patient data exchange, third party revenue generation, and agency 
performance reporting. Additionally, the new system will be 
interoperable with the Department of Veterans Affairs, Department of 
Defense, tribal and urban Indian health programs, academic affiliates, 
and community partners, many of whom are on different health 
information technology platforms.
    The IHS system also faces substantial physical infrastructure 
challenges--IHS hospitals are approximately 42 years old on average, 
which is almost four times the age of the average hospital in the 
United States. Infrastructure deficiencies directly contribute to 
poorer health outcomes for AI/ANs. The Budget addresses these needs by 
fully funding the 1993 Health Care Facilities Construction Priority 
list over 5 years. The remaining projects on the list include the 
Phoenix Indian Medical Center, Phoenix, AZ; Whiteriver Hospital, 
Whiteriver, AZ; Gallup Indian Medical Center, Gallup, NM; Albuquerque 
West Health Center, Albuquerque, NM; Albuquerque Central Health Center, 
Albuquerque, NM; Sells Health Center, Sells, AZ; Alamo Heath Center, 
Alamo, NM; Bodaway Gap Health Center, The Gap AZ; and Pueblo Pintado 
Health Center, Pueblo Pintado, NM. After the 1993 Health Care 
Facilities Construction Priority List is completed, funding will 
continue to increase to begin addressing the full scope of Facilities 
needs as identified in the most recent IHS Facilities Needs Assessment 
Report to Congress.
    Furthermore, the Budget includes +$10 million in discretionary 
funding in FY 2024 and +$454 million in mandatory funding over two 
years, from FY 2025 to FY 2026, to fully fund the medical equipment 
backlog. Many IHS hospital administrators reported that old or 
inadequate physical environments challenged their ability to provide 
quality care and maintain compliance with the Medicare Hospital 
Conditions of Participation. The administrators also reported that 
aging buildings and equipment is a major challenge impacting 
recruitment and retention of clinicians.
    Maintaining reliable and efficient buildings is also a challenge as 
existing health care facilities age and the costs to operate and 
properly maintain health care facilities increases. Many IHS and Tribal 
health care facilities are operating at or beyond capacity, and their 
designs are not efficient in the context of modern health care 
delivery. The Budget tackles this challenge by providing a +$10 million 
discretionary increase for maintenance and improvement in FY 2024 and 
fully funding the 2022 Backlog of Essential Maintenance, Alteration, 
and Repair for IHS and Tribal facilities of $1.02 billion over two 
years, from FY 2025 to FY 2026 under the mandatory formula.
    The Budget ensures that these facilities investments can be rapidly 
addressed by providing sufficient administrative support increases. 
Specifically, the mandatory formula increases the Facilities and 
Environmental Health Support funding line at 13 percent of the rate of 
growth in Sanitation Facilities Construction (SFC) and 5 percent of the 
rate of growth in Health Care Facilities Construction, consistent with 
historical funding needs and IHS' current estimation methodology. This 
funding supports staff to oversee and implement facilities projects, as 
well as a comprehensive environmental health program within IHS. Within 
this increase, the Budget dedicates $10 million in FY 2025 to support a 
nation-wide analysis to understand the cost implications of 
implementing section 302 of the Indian Health Care Improvement Act (25 
US.C. 1632), which authorizes funding for operations and maintenance 
costs for tribes who choose to directly compete their own SFC projects. 
The results of this analysis will be used and implemented as part of 
the updated mandatory formula structure. These funds would be used by 
IHS and tribes to ensure that existing SFC projects are reaching their 
maximum life-cycle and operations of these projects are sustainable for 
as long as possible. In FY 2027, the Budget provides an additional $250 
million in mandatory funding to address operation and maintenance costs 
for complete sanitation facilities projects, addressing long-standing 
recommendations from Tribes.
    Lastly, the IHS is grateful for the additional $3.5 billion in 
Sanitation Facilities Construction funding provided by the 
Infrastructure Investment and Jobs Act (IIJA). These funds will make a 
transformational impact on essential sanitation needs across Indian 
Country. To maintain existing project completion deadlines and support 
IHS and Tribes in successfully implementing IIJA resources, the Budget 
includes +$49 million in FY 2024 to support implementation of the $3.5 
billion provided by the IIJA for Sanitation Facilities Construction 
(SFC). This funding is within the Facility and Environmental Health 
Support funding line and will support additional salary, expenses, and 
administrative costs beyond the 3 percent allowed in the IIJA. These 
funds would also be available to Tribal Health Programs, which is not 
currently permissible under the 3 percent set-aside for administrative 
costs in the IIJA.
Supporting Self-Determination

    IHS continues to support the self-determination of tribes to 
operate their own health programs. Tribal leaders and members are best 
positioned to understand the priorities and needs of their local 
communities. The amount of the IHS budget that is administered directly 
by tribes through Indian Self-Determination and Education Assistance 
Act contracts and compacts has grown over time, with over 60 percent of 
IHS funding currently administered directly by tribes. Tribes design 
and manage the delivery of individual and community health services 
through 22 hospitals, 330 health centers, 559 ambulatory clinics, 76 
health stations, 146 Alaska village clinics, and 7 school health 
centers across Indian Country. In recognition of this, the Budget 
proposes to reclassify these costs to a mandatory indefinite 
appropriation with estimated funding levels of $1.2 billion for 
Contract Support Costs and $153 million for Section 105(l) Lease 
Agreements in FY 2024. The Budget maintains indefinite mandatory 
funding for these accounts across the 10-year budget window to ensure 
these payments to ISDEAA contractors and compactors are fully funded.
COVID-19 Response and Future Emergency Preparedness

    Throughout the COVID-19 pandemic, the IHS has made incredible 
achievements to save lives and improve the health of AI/ANs across the 
nation. The IHS has worked closely with our Tribal and Urban Indian 
Organization partners, state and local public health officials, and our 
fellow Federal agencies to coordinate a comprehensive public health 
response to the pandemic. Our No. 1 priority has been the safety of our 
IHS patients and staff, as well as Tribal community members.
    COVID-19 has disproportionally impacted AI/ANs. Deficiencies in 
public health infrastructure exacerbated the impact of COVID-19 on AI/
ANs. To address the long-term impacts of COVID-19, in FY 2025 the 
Budget provides a +$130 million mandatory funding increase to support 
IHS patients in recovery from the long-lasting effects of the COVID-19 
pandemic, including treatment for long haul COVID-19. Based on data 
from 14 states, age-adjusted COVID-19 associated mortality among AI/AN 
was 1.8 times that of non-Hispanic Whites. In 23 states with adequate 
race and ethnicity data, the cumulative incidence of laboratory-
confirmed COVID-19 among AI/AN was 3.5 times that of non-Hispanic 
Whites. COVID-19 hospitalizations and mortality rates among AI/AN were 
2.7 and 1.4 times those among White persons, respectively.
    The Budget also establishes a new dedicated funding stream within 
the mandatory formula to address public health capacity and 
infrastructure needs in Indian Country. This funding will support an 
innovative hub-and-spoke model to address local public health needs in 
partnership with tribes and urban Indian organizations. Establishing a 
new program to build public health capacity is a key lesson learned 
from the COVID-19 pandemic, and a top recommendation shared by tribal 
leaders in consultation with HHS. This includes $150 million in FY 
2025, and would grow in the out-years under the formula, for a total of 
$500 million over the ten-year window. Additional resources are 
necessary to develop appropriate public health and emergency 
preparedness capacity in AI/AN communities to prevent these 
disproportionate impacts in the future. As of 2021, only four tribal 
public health agencies are accredited through the Public Health 
Accreditation Board. Comparatively, 40 State and 305 local public 
health agencies were accredited as of 2021.\9\
---------------------------------------------------------------------------
    \9\ Office of Disease Prevention and Health Promotion--Increase the 
number of tribal public health agencies that are accredited https://
health.gov/healthypeople/objectives-and-data/browse-objectives/public-
health-infrastructure/increase-number-tribal-public-health-agencies-
are-accredited-phi-03/data
---------------------------------------------------------------------------
Closing

    The FY 2024 Budget makes bold strides toward the goal of ensuring 
stable and predictable funding to improve the overall health status of 
AI/AN communities. The Budget is a historic step and the start of an 
ongoing conversation with tribes to ensure the IHS system is meeting 
the healthcare needs in Indian Country. HHS looks forward to working in 
consultation with tribes, urban Indian organizations, and Congress to 
refine this proposal through the legislative process to strengthen the 
Nation-to-Nation relationship.

                                 ______
                                 

   Questions Submitted for the Record to the Honorable Roselyn Tso, 
                    Director, Indian Health Service

The Honorable Roselyn Tso did not submit responses to the Committee by 
the appropriate deadline for inclusion in the printed record.

            Questions Submitted by Representative Westerman
    Question 1. Please further detail other ways IHS is addressing the 
GAO recommendations that are still open for the agency.

    Question 2. The IHS Budget Justification included information about 
using a portion of the requested increased funding for FY 2024 to 
expand access to the Purchased/Referred Care program so that more 
patient visits and admissions would be covered. However, there was no 
mention of how those funds are distributed across IHS Areas, or whether 
the current distribution process needs to be revisited.

    2a) How are Purchased/Referred Care program funds distributed among 
IHS Areas? And is this distribution is equitable?

    2b) Does IHS plan to revisit those allocations in consultation with 
tribes in the near future? If so, when?

    Question 3. Can you further elaborate on how IHS works with credit 
reporting agencies to make sure that negative credit consequences don't 
affect individual IHS patients with the following information:

    3a) How is IHS informed of unpaid bills sent to collections for 
patients receiving Purchased/Referred Care?

    3b) How long does it take IHS to send documentation to the credit 
reporting agency when this occurs?

    3c) Does IHS have agreements with all credit reporting agencies to 
work with them when these situations do happen, so patient's credit 
score can be repaired?
    Question 4. What are IHS's plans for developing new facility 
construction priorities once the 1993 List is completed?

    4a) Will IHS consult with Indian Country on this important issue 
before making any decisions on how to decide IHS and tribal health care 
facilities priorities?

    Question 5. Agencies can budget the best when there is timely 
budget execution and when there is detailed budget formulation. Having 
the latest operational data from budget execution is crucial to make 
sure there is no confusion over how agencies operate.

    5a) How is IHS tracking the appropriated dollars you receive to 
ensure they are all accounted for? And do improvements need to be made 
to that system?

    5b) What is IHS doing to improve its estimates for Contract Support 
Costs and Payments for 105(L) leases? Have those improved over the past 
few fiscal years?

    Question 6. Recruitment and retention continue to be challenges for 
the Indian Health Service, particularly in rural areas.

    6a) Can you further expand on your written testimony about where 
IHS is making investments in recruitment and retention for medical 
personnel?

    6b) What has IHS heard from medical personnel about what the 
barriers are to staying and working for IHS?

    6c) How does IHS ensure there is a pipeline of new medical 
professionals that want to work at IHS?

    6d) Are the recruitment incentives that IHS offers in line with the 
rest of the labor market for medical professionals?

    Question 7. What is IHS's policy on telework? What percentage of 
the IHS workforce is back in the office full time?

    Question 8. The FY 2024 IHS budget justification states that $220 
million in ARPA funds were used to expand access to mental health and 
substance abuse prevention and treatment services.

    8a) Could you provide a breakdown of how that funding was 
administered and the outcomes to Indian Country?

    8b) How does IHS work specifically in conjunction with SAMSA and 
HRSA to provide the best care to AI/AN patients?

    Question 9. As part of the IHS Strategic Plan, IHS states the 
agency is working to integrate behavioral health into the healthcare 
system and increase access to mental health and substance use disorder 
treatment and recovery services for individuals and families. 
Currently, IHS provides mental health services, but it appears that 
most inpatient services are purchased from non-IHS hospitals.

    9a) Can you further detail how the IHS plan to expand access to 
mental health services within IHS facilities?

    9b) What specific plans for recruitment and retention of mental 
health professionals and substance abuse professionals does IHS have in 
place?

             Questions Submitted by Representative Grijalva

    Question 1. Director Tso, I have introduced H.R. 630, the Urban 
Indian Health Confer Act, to create a Department-wide confer policy 
with urban Indian organizations. This bill would enable UIOs to provide 
input on Department policy decisions that impact urban American Indians 
and Alaska Natives. Are you able to state the agency's support for UIO 
input in relevant Department health policy decisions?

             Questions Submitted by Representative Gallego

    Question 1. The President's FY 2024 budget includes a $24.7 million 
increase in urban Indian programs. However, these would be jeopardized 
by the proposed Republican budget cuts in the debt ceiling bill. Can 
you elaborate further on what the reductions of services would look 
like for urban Indian communities?
    Question 2. During this Subcommittee's last hearing on tribal 
health, tribal organizations highlighted the need for the reimbursement 
of traditional healing services. Are you able to detail the current 
resources that IHS offers in this space? Does the budget request for 
this year address this need?

    Question 3. Can you speak to the current challenges that IHS faces 
regarding the recruitment and retention of personnel, and how this 
year's budget will address those challenges?

                                 ______
                                 

    Ms. Hageman. Thank you very much. The Chair will now 
recognize Members for 5 minutes of questioning, and I will 
recognize myself first.
    We held a hearing in March on issues speaking with tribal 
members from around the country as to ways to improve IHS 
services, and I am sorry to say that the Director did not come 
to that hearing. I thought that the testimony was extremely 
enlightening and helpful, and I wish that you had been here to 
listen to the women who traveled across the country to provide 
us with that information.
    This Committee has heard from tribes and tribal 
organizations about the importance of Purchased/Referred Care 
funds for specialty care, and these PRC funds are specially 
critical in areas without large IHS hospitals where costs can 
be internalized. We have learned from tribes in federally 
managed service units that there are multiple obstacles to 
their tribal members receiving referrals for specialty care, 
and this is one of the reasons identified by the GAO for IHS 
being on its high-risk list.
    What steps has IHS taken to address the deficiencies 
identified in the GAO report?
    Ms. Tso. Thank you for that question. And I also want to 
note that I support the comments that you make in terms of 
holding Indian Health Service accountable. To that, there are a 
number of steps that I have taken already. One, is the report 
that I have already noted that we have posted on the Indian 
Health Service website that describes the priorities that we 
are focusing on, including how we improve purchased and 
referred care for all of the patients that we serve.
    There are other ways that we have done that. We have 
acknowledged fully not just the GAO report but the OIG, the 
White House report, and also internal reports that we have set 
out. And all of those recommendations that we received from 
those reports are similar in nature and those are also 
published on the IHS website. One, to first acknowledge what 
those recommendations are; and two, to ensure that they are 
incorporated into the work that we are doing today.
    Ms. Hageman. Thank you. Our Committee has also heard from 
tribes and tribal leaders that they have been referred to 
collection agencies because IHS does not timely pay the bills 
from the PRC providers. Is this supposed to happen in the first 
place, No. 1; and No. 2, what are you doing to address that?
    Ms. Tso. Thank you. No, this should not happen at any place 
for the services that we provide. Unfortunately, at this point, 
we are looking at our system to streamline our PRC process to 
ensure that patients do not fall into this particular 
situation. There are a number of steps, and it is a complicated 
process, but there are still too many steps in our process, and 
we are working to reduce those, so we do not have people that 
fall into this particular situation.
    Ms. Hageman. And when this happens, because we know that it 
does, and you have acknowledged that, what other procedures or 
mechanisms does IHS have in place to make sure that these 
issues are clarified with the credit reporting agencies so that 
IHS's failure to pay doesn't result in negative credit 
consequences for individual Native patients?
    Ms. Tso. Thank you, Madam Chair. One of the first things 
that I did at the Indian Health Service, because I was also the 
director at the Navajo area and saw this gap between the 
regional and the IHS headquarters, upon my appointment as the 
Director, I immediately reduced that gap by bringing in area 
directors. We have 12 regions and 12 regional directors. 
Bringing them to the table and ensuring there are coordinated 
efforts to try to improve not just PRC but all of Indian Health 
Service and having my leadership team at one meeting to make 
sure that we all understand our responsibilities.
    I now meet with my team on a quarterly basis. We are using 
the work plan to make sure that we are meeting the deliverables 
of that plan.
    Ms. Hageman. Recruitment and retention continue to be 
challenges for the Indian Health Service, particularly in rural 
areas. We have learned that one of the obstacles in recruitment 
is the IHS's personnel system. On average, how long does it 
take from job announcement to onboarding for IHS to hire health 
providers?
    Ms. Tso. Too long.
    Ms. Hageman. What can be done to fix that?
    Ms. Tso. So, at this point, we are looking at an overall 28 
percent vacancy rate, and even in the mental health space, 
which is a very important topic for me, we are at 40 percent 
vacancy rate at the Indian Health Service. What we have done, 
and a couple examples of what we have done to rectify the 
situation is, of course, as part of the $3.5 billion water 
infrastructure bill, that we now have an agency-wide approach 
to this, meaning that we don't have 12 different areas trying 
to recruit, we are using one way to bring in people into the 
Indian Health Service and therefore, again, being more 
efficient.
    The other thing that we are doing is we are standardizing 
and building out professional systems throughout our agency to 
really leverage the best practices that we have, again, to 
streamline and act as efficiently as possible. We have done 
that on the onboarding side, and we are now doing that on the 
hiring side.
    Ms. Hageman. Very quickly, because I am out of time. Have 
your changes or the efforts that you have made, are they having 
results?
    Ms. Tso. Yes, ma'am.
    Ms. Hageman. OK. And I am now going to recognize Ms. Leger 
Fernandez for 5 minutes for questioning.
    Ms. Leger Fernandez. Thank you so much, Madam Chair.
    Director Tso, your testimony notes the need to reauthorize 
the Special Diabetes Program because it is effective. I know 
too many of my good friends and colleagues who I have lost to 
diabetes, who have lost their limbs and their lives. But you 
also point out that there would be an estimated net savings to 
Medicare of up to $520 million over 10 years.
    Tell us real quickly, how does like an investment of that 
now save us money later?
    Ms. Tso. Thank you. Specifically, the SEPI, the model that 
we have in place, really focuses on prevention. So, if we can 
get patients at the beginning or even before they are diagnosed 
as diabetics, then we can prevent that and use those strategies 
to help build a healthier patient outcome at the end of that. 
If we don't, that is where the cost incurs, that is where a 
higher level of care is needed.
    Ms. Leger Fernandez. Thank you so very much. And I want to 
touch briefly on the debt ceiling proposals that would slash 
funding for IHS. The concern that we have is that if the 
Republicans say that the budget cuts are not going to impact 
defense spending and a few other agencies, that means that it 
needs to be spread out over other agencies and that is how we 
get to a 22 percent hit on the discretionary funding.
    I kind of want to touch on two things. That kind of hit on 
funding, rather than an increase, a decrease, how would that 
affect IHS? And we had before, I need to be honest with you, I 
am a big fan of compacting and contracting so that tribes and 
tribal health boards run their own health facilities. I have 
seen the difference that it makes. Even as I know that the 
Navajo Nation is very pleased with how you helped them get 
through the pandemic. You were well-regarded in the Navajo 
Nation. The IHS was well-regarded in how it responded to the 
pandemic.
    But do these kinds of cuts impact both the independent 
health boards and the IHS?
    Ms. Tso. Yes, they do. I will give you one example. I just 
spent about 7 days in Alaska traveling through some of the 
smaller villages, and the only way that you can get to these 
villages is by air, permitted the weather and all of that. The 
cost in these locations for air transport for patient care has 
just about doubled. That is, again, if we can even get the 
flights in and out for these particular emergencies or 
situations that we have. So, that is not even taking into 
consideration when we are talking about any reduction in 
resources to the Indian Health Service.
    So, in those particular examples, one of the things that we 
have seen is the increased cost of travel transportation for 
our patients. There is also going to be a direct impact to 
direct services that are provided, regardless if it is being 
provided by the Federal Government, or our tribal programs, or 
our urban programs.
    Ms. Leger Fernandez. Thank you. And the issue about 
staffing I think is really important, and to have that high of 
a need for hiring, can you describe how in the past not having 
advanced appropriations impacted the ability to get people into 
the system and working for the IHS, and whether budget cuts 
would also have an impact on the ability to bring on the 
staffing we need to serve the patients?
    Ms. Tso. Yes, ma'am. During the pandemic, again, we relied 
on that very fresh information where we relied on contractors 
to come into the Indian Health Service to help us do the work. 
If we don't have money on October 1 to be able to fully fund 
those contractors, we cannot allow them to continue to provide 
services. So, there is an immediate, immediate decrease in 
services, a risk to the Agency in terms of not being fully 
staffed in many of our facilities, and therefore, having to, 
again, refer patients out to a higher level of care because we 
are not able to care for people in our healthcare facilities.
    So, the contracting side, any kind of term positions that 
we might have where we rely on those resources to be in our 
bank on October 1, if we don't have those, we cannot allow 
those individuals to work for us.
    Ms. Leger Fernandez. Well, I look forward to the fact that 
we are going to hit September and you are going to know you 
have the money on October 1. And, hopefully, we will be able to 
keep that, we have it for 2 years, and I know there is very 
strong bipartisan support for that advanced appropriations. I 
am going to look forward to asking you that same question next 
year and you telling us whether it made a difference.
    Thank you very much, and I yield back.
    Ms. Hageman. The Chair will now recognize other Members for 
5 minutes.
    Ms. Radewagen.

    Mrs. Radewagen. Thank you, Chairwoman Hageman and Ranking 
Member Leger Fernandez, for holding this hearing today. Thank 
you to the witness for your testimony.
    Your written testimony mentioned the $3.5 billion for 
sanitation facilities construction that is still being 
implemented in tribal communities. How much of those funds have 
been spent so far, and what is the timeline for releasing all 
the funds to projects in Native communities?
    Ms. Tso. Thank you for that question. Earlier in April, I 
posted for the very first time an interactive website on the 
IHS website that describes every project, where they are at in 
the process, and when we anticipate those projects to be 
completed. I am going to ask Jillian to talk specifically about 
the obligations that have been made to date.
    Ms. Curtis. Thank you very much for the question. The 
Fiscal Year 2022 funds provided by the bill are approximately 
80 percent obligated at the IHS and we expect releasing the 
spend plan for the Fiscal Year 2023 funds in the coming weeks.
    Mrs. Radewagen. The GAO's most recent update of their high-
risk series mentioned that there are concerns that IHS's 2022 
action plan does not address root causes of substandard 
healthcare management weaknesses within your agency. Now, how 
is IHS working with GAO to make sure root causes of issues are 
addressed within the agencies, and what changes to the 2022 
action plan is IHS looking to make based on this feedback from 
GAO?
    Ms. Tso. Thank you. Great question. Let's use Patient 
Referred Care, PRC, as an example. We identified that as an 
area that needs to be reviewed by the Indian Health Service and 
improved. What we are doing now is we are using our leadership 
team to take a more deeper dive into what are those root 
causes, what do we need to change, how are we going to change 
them, and not only that, to set milestones to make sure that we 
are evaluating ourselves to ensure accountability at the Indian 
Health Service.
    Mrs. Radewagen. Thank you. Madam Chairwoman, I yield back 
the balance of my time.
    Ms. Hageman. Thank you. The Chair now recognizes Mr. Carl 
for 5 minutes of questioning.
    Mr. Carl. Thank you, Madam Chair.
    Director Tso, thank you for joining us again. Good to see 
you. I appreciate your work; I appreciate you taking time to 
come talk to us. Don't take the lack of presence here for 
granted. We have multiple meetings going on in multiple places. 
I know you know that, but I want to tell you that.
    Very early in 2020, I started screaming the Fentanyl issue. 
The Fentanyl issue--trying to get people to understand how big 
that was going to be. We are living it today. We have close to 
300 people that are dying daily, and I know the Indian 
reservations have a higher percentage of that 300 people and a 
higher percentage of addiction.
    So, let me just run through my questions here. It should be 
pretty easy for you. We are all aware of the Fentanyl crisis 
and major issues across the country. Fentanyl continues to pour 
into our southern borders, as you well know. And with today, 
the expiration of Title 42, it is only going to make it worse. 
That does not help any tribes, it doesn't help any of those 300 
that are going to die today and tomorrow.
    The CDC continues to report that overdose deaths among 
American Indians and Alaskan Natives continue to be above the 
national average. And I think you know that. The Fentanyl 
crisis is deeply concerning to me, and it is so 
disproportionately impacting the Native community. It is very 
troubling to me.
    Can you please tell me specifically about how you are using 
money to target these illegal drugs?
    Ms. Tso. Thank you for that question. Two things I would 
like to point to is, one, of course, we know that throughout 
the country, but even more so in our tribal communities, are 
the social determinants of health. That contributes to why 
maybe some of this is occurring on our tribal lands. That being 
said, we are doing everything that we can to make sure that we 
are addressing it.
    In August already, we have a summit that will be held in 
the Northwest, and we are partnering with the tribes out in the 
Northwest to set up a summit. We need to have a more 
coordinated conversation about what do we do together, how does 
Indian Health Service and also reaching across HHS to my 
partners at SAMHSA and HRSA to make sure that they are at the 
table to help us develop results. Because, again, as these are 
occurring on tribal lands, the IHS does not just go in and 
decide how we are going to find solutions. We really have to 
work lock and step with tribes to make sure that we are a 
partner in finding solutions on this.
    But there are a number of also treatment activities, risk 
reduction activities that we are working on. Really also 
sharing the 988 options and other options that we have 
throughout the government that could help our patients and our 
people.
    Mr. Carl. Thank you. Another quick one here. What are you 
hearing on the ground from the tribes across the country about 
substance abuse funds, how are they being used?
    Ms. Tso. A majority of the alcohol substance abuse and the 
behavioral health funds have been contracted and compacted by 
tribes, meaning that they operate their own programs.
    What we are doing at the Indian Health Service, because the 
majority of those resources are with the tribes, is really 
looking at how do we build toolkits, how do we help them do it. 
A majority of my time since I have been in this role has been 
on the ground, and every community, every tribal leader that I 
have met with raises this concern and how it is taking their 
people away from them.
    So, we have to find solutions of treatment programs, 
treatment options, culturally-appropriate care that we can 
build and integrate into our healthcare system. Again, working 
partnership with our tribes to make sure that we are addressing 
the whole person's need out in Indian Country.
    Mr. Carl. So, I really try to make myself open to the 
different Indian tribes. I just find them fascinating, the 
history. I mean, being from Alabama, if you got roots in 
Alabama, you've got Creek or Cherokee in you, and I am very 
proud of that. Not enough to qualify to be that, but you know 
how that is.
    But you will never fix that issue, the Fentanyl issue and 
the drug issue. Now, alcohol is a different story, but you will 
never fix it when you have some of these tribes that are 
covering thousands and thousands of acres, and they have seven 
police officers to enforce things. And I think it is going to 
take a combination of both, and I would love to work with you. 
I realize you are focused on the healthcare side, but between 
the dirt roads, between the law enforcement, it is going to be 
an endless fight. I mean, there is no way to stop the drug 
trafficking.
    With that, thank you again for your time and coming and 
joining us.
    Madam Chair, I return my time. Thank you.

    Ms. Hageman. Thank you. The Chair now recognizes 
Representative Gonzalez-Colon.

    Mrs. Gonzalez-Colon. Thank you, Madam Chair, and thank you 
to our witnesses for being here today. I would like to echo Mr. 
Carl. There are many hearings and many things happening today, 
but we are happy that you are here.
    I am going to question in terms of the Federal bureaucracy 
across the nation in many areas that make it harder and harder 
to operate in certain areas than it should be, and that is 
happening also not just with territories but with the Indian 
communities as well. And in that sense, I mean, having those 
healthcare situations back home, the lack of professionals, the 
lack of physicians that are available, the skills that 
healthcare programs are paying those providers is still a mess.
    In telehealth, it has been one of the areas that is being 
used to try to compensate or give some access to those 
communities, so in that sense, the telehealth in Native 
communities is becoming more and more prevalent which makes 
sense given the geography in many parts of the Indian Country. 
So, my question to you will be, can you go further into what 
investments in healthcare infrastructure like telehealth may 
help maintain services while IHS improves staffing and services 
for physical facilities?
    Ms. Tso. Thank you for that question. I will say that 
certainly for telehealth, we have to have that, we have to 
maintain that within our tribal lands. Part of that is, of 
course, building out infrastructure and making sure that we can 
support those kinds of systems throughout.
    As an example, though, when I first arrived in Navajo as 
the Area Director in 2019, we were recovering maybe about 
$19,000 worth of reimbursement for telehealth. When I left 
there, we were at more than $30 million. So, in a place where, 
again, challenging because of distances, and resources, and 
infrastructure, we thought, well, people are not going to use 
telehealth. No, that was just the opposite.
    Mrs. Gonzalez-Colon. Are you still investing in telehealth? 
Is the office still investing in telehealth?
    Ms. Tso. Yes.
    Mrs. Gonzalez-Colon. In infrastructure. And that budget 
includes money for that?
    Ms. Tso. Yes, we did include resources for that.
    Mrs. Gonzalez-Colon. What barriers are there to using 
telehealth now that you understand Congress can jump in to try 
to fix something?
    Ms. Tso. I'm sorry?
    Mrs. Gonzalez-Colon. Do you believe that there are some 
barriers to improve telehealth to a good use, that Congress 
should jump in to fix it, or do you have all the resources 
necessary to manage telehealth in those communities?
    Ms. Tso. No, we don't have all of the resources.
    And, Jillian, if you can----
    Ms. Curtis. Absolutely. I think you have raised a really 
good question here. There are sort of two elements that create 
barriers for us beyond resources. The first is the availability 
of broadband in rural and remote locations. And secondly, we 
understand that after November we will likely not be able to 
bill for telephone only telehealth visits, which was allowable 
under the public health emergency. And the overwhelming 
majority of our telehealth visits are phone only because of 
those broadband issues. So, those are two key areas where we 
could use some additional help.
    Mrs. Gonzalez-Colon. How is the percentage of all the cases 
that you work in a telephone mode?
    Ms. Curtis. I think it is close to 90 percent, but we can 
get back and provide you that exact percentage.
    Mrs. Gonzalez-Colon. OK. So, 90 percent of your telehealth 
because of the broadband issues are going by phone. In mostly 
which areas, or is it all over the place?
    Ms. Curtis. It is really all over the place. It depends 
community to community.
    Mrs. Gonzalez-Colon. And when we are talking about mental 
health, which is a big issue, how does telehealth play a role 
in the mental health programs?
    Ms. Tso. Certainly, mental health is a huge need throughout 
the whole country, but also especially in our Native American 
communities. One of the ways that we are addressing mental 
health is really looking at what we are calling the CHAP 
program, the Community Health Aides that we can build out. 
There is a great example out in Alaska where it has been 
operational for many, many years, and bringing that down to the 
Lower 48.
    What that is, is that we are actually identifying 
individuals from the community that can serve and that can be 
trained, and serve and be certified to do these services on the 
ground, and that means that----
    Mrs. Gonzalez-Colon. Yes, but I am talking about telehealth 
to address mental health, not physical counseling.
    Ms. Tso. As I said earlier, with regards to support, we are 
about 40 percent efficient in hiring at the Indian Health 
Service for mental health providers. So, that is already a 
challenge. And also, a reason why we rely heavily on building 
out our telehealth program.
    Mrs. Gonzalez-Colon. OK. Thank you. Madam Chair, I yield 
back.
    Ms. Hageman. In light of the fact that I think we have some 
extra time here, and I think that there were perhaps some 
follow-up questions that folks wanted to ask, we are going to 
have another round of questioning. I don't think it will last 
very long. I just have a few questions I would like to ask.
    I would like to follow up on what Mr. Carl was talking 
about with regard to Fentanyl. That is one of the issues. And 
Wyoming has been hit hard with that as well, and we have two 
tribes in Wyoming, we have the Northern Arapaho and the Eastern 
Shoshone.
    We have had over 14,000 pounds of Fentanyl cross the border 
over the last 2 years, and it is obviously something that has 
affected our ability to provide healthcare to our tribes. We 
have the addiction problems. So, I am going to ask you, until 
we start stopping the flow of Fentanyl, it is going to continue 
to be the scourge of our communities, whether it is on 
reservations, or it is in Portland, or Denver, or wherever it 
may be.
    What has your agency done in terms of asking President 
Biden or Mr. Mayorkas to please help to control the border in 
order to stop the flow of illegal drugs coming across?
    Ms. Tso. We have worked very closely with the Department of 
the Interior on tribal lands that they are the responsible 
party for, law enforcement, working with them to coordinate a 
number of efforts to make sure that we are addressing and 
bringing safe care to our Native reservations.
    That being said, we are working very closely with Secretary 
Haaland on her Road to Healing, which is, of course, is a 
boarding school initiative, and then now the MMIP, which is the 
Missing and Murdered Indigenous People, and moving from that, 
really helping support and being that health arm of even as 
late as yesterday talking about how do we build out facilities 
in our Native communities where individuals that need to be 
incarcerated, and then how do we provide that healthcare if 
there is healthcare needed in that.
    So, we are starting that conversation. We will continue 
that as we try to build out more resources for Native American 
lands.
    Ms. Hageman. So, Ms. Tso, would you agree with me that 
stopping the flow of illegal drugs across the border is 
probably one of the most important things we can do to address 
the drug crisis and Fentanyl crisis we have in this country?
    Ms. Tso. Yes.
    Ms. Hageman. OK. I would also like to continue talking 
about some of the hiring issues associated with your agency. 
And the question I have is, is it possible for tribes with 
federally managed service units to contract or otherwise assume 
control of the hiring function to carry out those activities 
more efficiently for the IHS related to your job and employment 
situation?
    Ms. Tso. Yes. At the Indian Health Service, any tribe that 
assumes their own healthcare program also does their own hiring 
of what was once operated as IHS programs, so about 60 percent 
of the Indian Health Service has been contracted. Tribe and 
tribal governments have responsibility for all the hiring in 
those areas.
    We do some recruiting for them because we believe that we 
have a little wider span to be able to get job information out 
there.
    Ms. Hageman. In terms of the funding for those positions, 
is that part of the $9.65 billion that you are requesting, or 
do those tribes pay for those services or those employees 
themselves?
    Ms. Tso. Our entire budget includes tribes and urban 
programs.
    Ms. Hageman. Even when they do their own hiring?
    Ms. Tso. Yes, ma'am.
    Ms. Hageman. OK. For federally managed service units with 
very high vacancy rates, does IHS have the ability to deploy 
Commissioned Corps or other HHS health providers to those areas 
to address immediate needs?
    Ms. Tso. Certainly, during COVID-19, and particularly when 
I was in Navajo, we had a number of resources that came to us, 
including the Commissioned Corps. Unfortunately, over the past 
few years, there has been a decline in Commission officers 
being brought on, and so we don't have always the luxury of 
having those. We have about 1,400 officers at the Indian Health 
Service right now that either work for IHS or are assigned to 
tribal or urban programs.
    Ms. Hageman. And, finally, at our previous hearing about 
IHS, one of the stories we heard was about a tribal member who 
studied to enter the medical profession with the intent of 
coming back to her community to work at the IHS facility there. 
But that was not an option for her when she was finally offered 
a job at IHS. Is there a specific policy in place to promote 
tribal members being able to serve in their own community as 
medical professionals?
    Ms. Tso. We follow the Indian Preference Law which, of 
course, are members of federally recognized tribes that have 
tribal enrollments, that certainly they have preference at the 
Indian Health Service. Now, we can't specifically say or 
guarantee someone a job, that you can work at this particular 
location, but if there is a job open, that is certainly the 
place that they can apply to and be considered.
    Ms. Hageman. Thank you. I now recognize Ms. Leger Fernandez 
for her second round of questioning.
    Ms. Leger Fernandez. Thank you so very much, Madam 
Chairwoman.
    And I really do appreciate learning the issue around the 
telephone telehealth. I didn't realize that that was a problem, 
and that is indeed an issue. The Bipartisan Infrastructure 
Bill, we are very hopeful that in 2, 3 years we will have the 
buildout, but we do not have it now, and there is the need to 
get that telehealth funding now. So, thank you for raising 
that, and I am hopeful that we will see if we can find a 
solution to that.
    I wanted to touch a little bit about the 1993 Healthcare 
Facilities Construction Priority List. I represented several 
tribes who were on that list, and in the end, ended up deciding 
to do a joint venture agreement, build their own facilities. 
But not everybody is in a position to be able to do a joint 
venture agreement to be able to put up those funds. We have the 
Navajo-Gallup, which I think is going to be built. Is that 
correct?
    Ms. Tso. Yes, it is on the list.
    Ms. Leger Fernandez. But where is it in terms of the----
    Ms. Tso. We have about $66 million of what was needed, but 
the entire project will be close to probably $1 billion.
    Ms. Leger Fernandez. So, how would the budget request that 
you have put in now address, as an example, Navajo-Gallup?
    Ms. Curtis. Certainly. The President's budget requests a 
total of $10.3 billion for facilities construction over 10 
years, so those dollars would allow us to fully fund the nine 
remaining projects on the priority list including the Gallup 
facility, and then, finally, start to get funding out to those 
facilities that are not on the list but are still critically 
needed.
    Ms. Leger Fernandez. Right. And as I understand, am I 
correct that the Navajo-Gallup facility is the largest facility 
serving a Native American population?
    Ms. Tso. We have two facilities that are, it is the Gallup 
Indian Medical Center and the Phoenix Indian Medical Center as 
well, and both of those projects are being considered.
    Ms. Leger Fernandez. Yes. And I think that that is really a 
priority to think that a community has been waiting that long. 
Imagine, in order to get on that list, your building needs to 
be close to condemnable, right, and it doesn't fit, and it 
doesn't work. And to be on that list for 30 years, which this 
pushes you further, and further, and further along.
    I wanted to ask, an issue that comes up a lot when I am out 
in Gallup and speaking with the community there is what role 
the Indian Health Service can play. I know it can play a really 
good role with regards to assisting members, people who are not 
members but married into a community, and you can do that, I 
have helped tribes subcontract in contracts, so they end up 
serving communities around them.
    The limitations that IHS has on that, do you see a role for 
IHS, especially with third-party building, being able to expand 
in those places where there is not rural healthcare? I mean, we 
have a problem that we do not have enough rural healthcare 
facilities and sometimes the IHS is the only healthcare 
facility, but it has its limitations. Do you have a sense of 
how IHS might serve a role in addressing that rural healthcare?
    And also, in terms of training the health professions, 
which is what you are concerned about as well, Madam Chair, 
because what we understand is that you go back and work in the 
community you come from or where you were last trained. That is 
a really good way of getting people to serve in a community. Do 
you have any thoughts on a role IHS could play in that? Just 
kind of brainstorming a little bit.
    Ms. Tso. Yes, absolutely. As I travel throughout Indian 
Country, I was also just in Oregon, and there are rural health 
facilities that are closing down, and the only healthcare 
system that is available is a tribally-operated program, and 
they have already opened up to serving all of the people that 
they can in their communities. Of course, it can't be 
everybody, but there is already that model that is in place for 
tribally-operated programs.
    At the Gallup Indian Medical Center, and maybe similar 
facilities as well, as you know, our Rehoboth facility has 
struggled from time to time, and when they go on, we are the 
only other option there in that particular area. So, we already 
do that in rare circumstances. But making that fine balance 
there I think is really critical.
    And I would like to take a look at more how much of these 
rural health facilities that are closing are now coming over 
and we are picking them up on the Indian Healthcare side, which 
is either tribally-operated programs or urban programs. So, I 
think there is a lot that can be done.
    Ms. Leger Fernandez. Thank you. And thank you, Madam Chair, 
for allowing additional conversation around this urgent topic.
    Ms. Hageman. You bet. Thank you.
    I will now recognize Mr. LaMalfa.
    Mr. LaMalfa. Thank you, Madam Chair. I'm sorry I couldn't 
be in two committees at once, but I appreciate the opportunity 
to be here and be part of the hearing.
    The issue with IHS's current base funding method, it is not 
appropriately allocating the funds across the Agency, which 
leads to large cost overruns that ultimately prevent our 
clients with the tribes from obtaining basic care except in 
more extreme situations. So, what has IHS been able to do to 
help develop a new method to get the program funds more 
appropriately allocated since there was a directive, my 
understanding is, back in 2012 to move in that direction?
    Ms. Curtis. Certainly, sir, thank you very much for this 
question. I think you may specifically be referring to funding 
for our Purchase and Referred Care Program, and this is a 
concern that we have heard from tribal leaders in many areas, 
including in the California area and other locations where 
there are not IHS-constructed healthcare facilities. We do have 
a Purchase/Referred Care tribal advisory committee. There is a 
work group to improve Purchase/Referred Care that we are 
convening on a regular basis, and this is a continuing topic of 
conversation for that group.
    Mr. LaMalfa. How far along do you think that process is 
improved, what would the grading scale say is, from customer 
angles, how would they say that it is looking?
    Ms. Curtis. So, there are representatives from all 12 IHS 
areas on that work group, and there are some tribal leaders 
that feel strongly that the formula for distribution needs to 
be changed, and there are some that feel strongly that it 
should not be changed, and that is much of the discussion of 
that group.
    Mr. LaMalfa. So, you have to figure out how to be in the 
middle of that. All right, that is tough. As you mentioned, 
thank you for paying attention to California. Representing the 
far north part of the state, we have had a lot more in recent 
years due to the risk of wildfire in our forested areas, there 
has been a lot of de-energizing protocols for turning off the 
power because the wind comes up and it might blow a tree or a 
branch into a powerline. That is how we are dealing with things 
these days. They are almost Third World in that sense. We have 
to shut off the power because we are not doing enough in the 
forested areas to clear around powerlines.
    So, they do help in limiting risk of wildfire, but 
obviously, they are a real interruption for those folks that 
are using electricity. I drive through whole counties of mine 
that are dark at night sometimes as I am traveling the 
district.
    So, especially as this affects tribal health. And we know 
the facilities that many tribes are dealing with might be 60 
years old or more and they may not have the backup generation 
or maybe they can't get it approved because we have air quality 
issues on who is running a diesel generator or not. So, 
obviously, the health clinics are going to have trouble. 
Hopefully, there is enough backup for a hospital with somebody 
being treated with a serious issue perhaps.
    We know all tribal health programs provide vaccines and 
many others keep specialty drugs on hand, so there is just a 
whole litany of things that is important about having a good 
electricity supply that is steady, you know, proper temperature 
for storage of vaccines and other medical needs, blood, et 
cetera. It does threaten the stability of the medication, 
possibly making them unsafe. So, these power outrages of more 
than 4 hours can really mess them up.
    These rural programs are not equipped with essentials, like 
backup generators, is what I am understanding. Do we believe 
now that funding needs to be ensured for the basic necessities 
such as generators that meet code and are completely reliable 
in a power outage situation, whether it is a purposely public 
safety power shutoff as they call it, or due to accident with 
an actual wildfire. Are we in a position to improve that 
availability?
    Ms. Tso. Yes. Thank you for that. Of course, in the 
President's budget, we included $3 million specifically for 
generators. And more recently, in one of the tribes in the 
California area that experienced flooding, we also made sure 
that generators were available to them if they needed that for 
the reasons that they didn't have power.
    Mr. LaMalfa. Did you say the figure was $3 million?
    Ms. Tso. Yes, $3 million.
    Mr. LaMalfa. OK. I hope that goes far enough with what we 
need. Has IHS been successful in executing its actual budget 
over the last few years, have you been able to stay close to 
that?
    Ms. Curtis. I apologize, sorry. Are you referring to the 
emergency generators funding?
    Mr. LaMalfa. No, in general.
    Ms. Curtis. In general?
    Mr. LaMalfa. Has its overall budget been able to come close 
to meeting goals at least?
    Ms. Curtis. I think that the most recent analysis that was 
performed by our Indian Healthcare Improvement Fund work group 
identified that the IHS is approximately 50 percent funded 
compared to the total funding level needed.
    Mr. LaMalfa. OK. All right, a lot of work to do. Thank you.
    I am a little over time. I yield back, Madam Chairman.
    Ms. Hageman. Thank you. The Chair now recognizes 
Representative Radewagen.
    Mrs. Radewagen. Thank you, Madam Chair.
    Your written testimony mentioned that IHS had achieved two 
major accomplishments of the Agency's work plan. Can you 
further expand on the work and what next steps are according to 
IHS's strategic plan and the Agency's work plan, please?
    Ms. Tso. Yes. Thank you again for that. As I shared 
earlier, the first accomplishment was really commissioning a 
team within IHS to help us look at and improve our quality 
program. We had some changes when I first came on with 
staffing, so we were able to take a deeper dive into the office 
of quality, which is really the heartbeat of any healthcare 
system, and making sure that we can evaluate the work that we 
are doing and ensuring quality and safe care.
    So, we re-looked at that, and we looked at our structure, 
we looked at the work that we are putting out of that, again, 
to ensure accountability and to be able to monitor the work 
that we are doing and be able to communicate that back to our 
patients. So, that is now in process and we are taking a look 
at that and really trying to stabilize from the accountability 
standpoint, and compliance standpoint, and risk management 
standpoint.
    The second thing that we did, which is critically 
important, is that we have 12 regions within the Indian Health 
Service. When I was the Director at the Indian Health Service, 
I sort of just worried about Navajo area, I didn't sort of 
worry about what was going on in my colleague's other regions 
and things like that. What we have done by standardizing 
governance within the IHS, is that we all now operate under one 
set of governance in our healthcare hospitals and our 
outpatient facilities.
    What is important about that is I, as the Director, can 
scan the Agency now and look where we have best practices, look 
where we have improvements that need to be made so we can share 
those more easily across the Indian Health Service. Moreover, I 
want to be able to make sure that we are as efficient as 
possible when we are looking at clinical care and when we are 
looking at administrative operations.
    So, building a more system approach to healthcare, it is 
going to maximize resources for us. It has already paid off for 
us to be able to do and to make some of the changes that we are 
doing. So, I don't have to worry about which area is doing 
what, I know now what we are all working toward, and that is 
what that work plan was intended to do, to help us come 
together. Because we don't have all of these resources, we can 
now evaluate safe and quality care.
    When we are talking about credentialing of providers, 
before I would have to credential a provider at Navajo, and 
then if they went to Phoenix, they have to be re-credentialed 
over there. Now, that information can move with the provider 
instead of having to have the provider go through all those 
steps again for credentialing and privileging at another 
facility. So, it is more efficient now and operating as a 
system as we get smaller and smaller, whether it is recruiting, 
whether it is purchasing, whether it is providing the 
healthcare, it is now moving toward a system. And it is not 
moving as fast as I want it to go, but we are getting there, 
and we are looking at that in every aspect of the IHS, so we 
can then again evaluate across Indian Health Service to ensure 
that quality and safe care.
    I will also say that by the end of January, we were able to 
review every physician's record that is at the Indian Health 
Service to ensure that the credentialing packet that was 
provided for that provider is still sound and that we can then 
ensure that providers at the Indian Health Service are 
providing the best in quality care and have the credentials to 
do what it is that we are asking them to do. We are now looking 
at the nursing because it is just as critical.
    So, all of these steps that we are taking are really 
intended to strengthen the Indian Health Service so we can move 
forward in a more positive way.
    Mrs. Radewagen. OK. So, looking forward, is IHS also 
considering what their next 5-year strategic plan looks like? 
How will discussions of fiscal responsibility be a part of that 
planning?
    Ms. Tso. Yes, moving forward, our strategic plan is through 
2024, so we are already working on that to make sure that we 
set that in place. That will be accompanied by an additional 
work plan for 2024. Every day we are talking about fiscal 
responsibility. Every day we are making choices and decisions, 
and hard choices and decisions, about what we can do and what 
we can't do, and where we can, again, continue to streamline 
our processes to maximize the resources that we have.
    Mrs. Radewagen. Thank you, Madam Chair, I yield back.

    Ms. Hageman. Thank you. I want to thank the witnesses for 
your valuable testimony and the Members for your questioning 
today. I think that this has been very enlightening and very 
helpful for many of us sitting up here and looking at the 
budgeting issues that we are facing in this country right now.
    The members of the Committee may have some additional 
questions for the witnesses, and we will ask you to respond to 
these in writing if we receive them. Under Committee Rule 3, 
members of the Committee must submit such questions to the 
Committee Clerk by 5 p.m. on Tuesday, May 16, 2023, and the 
hearing record will be held open for 10 business days for your 
responses.
    If there is no further business, without objection, the 
Committee stands adjourned. Thank you.

    [Whereupon, at 3:12 p.m., the Subcommittee was adjourned.]

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