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







      H.R. ____, ``RESTORING ACCOUNTABILITY IN THE INDIAN HEALTH  
                         SERVICE ACT OF 2023''

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

                          LEGISLATIVE HEARING

                               before the

               SUBCOMMITTEE ON INDIAN AND INSULAR AFFAIRS

                                 of the

                     COMMITTEE ON NATURAL RESOURCES
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        Thursday, July 27, 2023

                               __________

                           Serial No. 118-53

                               __________

       Printed for the use of the Committee on Natural Resources





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        Available via the World Wide Web: http://www.govinfo.gov
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          Committee address: http://naturalresources.house.gov 
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                 U.S. GOVERNMENT PUBLISHING OFFICE
                 
53-077 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
Robert J. Wittman, VA
Tom McClintock, CA
Paul Gosar, AZ
Garret Graves, LA
Aumua Amata C. Radewagen, AS
Doug LaMalfa, CA
Daniel Webster, FL
Jenniffer Gonzalez-Colon, PR
Russ Fulcher, ID
Pete Stauber, MN
John R. Curtis, UT
Tom Tiffany, WI
Jerry Carl, AL
Matt Rosendale, MT
Lauren Boebert, CO
Cliff Bentz, OR
Jen Kiggans, VA
Jim Moylan, GU
Wesley P. Hunt, TX
Mike Collins, GA
Anna Paulina Luna, FL
John Duarte, CA
Harriet M. Hageman, WY

                                     Grace F. Napolitano, CA
                                     Gregorio Kilili Camacho Sablan, 
                                         CNMI
                                     Jared Huffman, CA
                                     Ruben Gallego, AZ
                                     Joe Neguse, CO
                                     Mike Levin, CA
                                     Katie Porter, CA
                                     Teresa Leger Fernandez, NM
                                     Melanie A. Stansbury, NM
                                     Mary Sattler Peltola, AK
                                     Alexandria Ocasio-Cortez, NY
                                     Kevin Mullin, CA
                                     Val T. Hoyle, OR
                                     Sydney Kamlager-Dove, CA
                                     Seth Magaziner, RI
                                     Nydia M. Velazquez, NY
                                     Ed Case, HI
                                     Debbie Dingell, MI
                                     Susie Lee, NV

                    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, July 27, 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
    Johnson, Hon. Dusty, a Representative in Congress from the 
      State of South Dakota......................................     4

Statement of Witnesses:

    Marchand, Cynthia, Secretary, Tribal Council, Confederated 
      Tribes of the Colville Reservation, Nespelem, Washington...     6
        Prepared statement of....................................     7
        Questions submitted for the record.......................    10
    Spoonhunter, Lee, Billings Area Representative, National 
      Indian Health Board, Washington, DC........................    12
        Prepared statement of....................................    13
        Questions submitted for the record.......................    21
    Church, Jerilyn, Executive Director, Great Plains Tribal 
      Leaders Health Board, Rapid City, South Dakota.............    22
        Prepared statement of....................................    24
        Questions submitted for the record.......................    25

Additional Materials Submitted for the Record:

    Submissions for the Record by Representative Grijalva

        United South and Eastern Tribes, Statement for the Record    32
                                     


 
   LEGISLATIVE HEARING ON H.R. ____, TO AMEND THE INDIAN HEALTH CARE 
 IMPROVEMENT ACT TO IMPROVE THE RECRUITMENT AND RETENTION OF EMPLOYEES 
  IN THE INDIAN HEALTH SERVICE, RESTORE ACCOUNTABILITY IN THE INDIAN 
   HEALTH SERVICE, IMPROVE HEALTH SERVICES, AND FOR OTHER PURPOSES, 
 ``RESTORING ACCOUNTABILITY IN THE INDIAN HEALTH SERVICE ACT OF 2023''

                              ----------                              


                        Thursday, July 27, 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 2:22 p.m., in 
Room 1334, Longworth House Office Building, Hon. Harriet 
Hageman [Chairwoman of the Subcommittee] presiding.
    Present: Representatives Hageman, Carl; and Leger 
Fernandez.
    Also present: Representative Johnson.
    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. In fact, 
that may be necessary as we have one more vote series today, 
but we might be able to get through all the testimony, we will 
just see how the schedule goes.
    The Subcommittee is meeting today to hear testimony on a 
Discussion Draft of the ``Restoring Accountability in the 
Indian Health Service Act of 2023.'' Under Committee Rule 4(f), 
any oral opening statements at hearings are limited to the 
Chairman and the Ranking Minority Member. I therefore ask 
unanimous consent that all other Member's opening statements be 
made part of the hearing record if they are submitted in 
accordance with Committee Rule 3(o).
    Without objection, so ordered.
    I ask unanimous consent that the gentleman from South 
Dakota, Mr. Johnson, be allowed to sit and participate in 
today's hearing.
    Without objection, so ordered.
    I will now recognize myself for an opening statement.

 STATEMENT OF THE HON. HARRIET M. HAGEMAN, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF WYOMING

    Ms. Hageman. Today, the Subcommittee is meeting to consider 
a discussion draft of the ``Restoring Accountability in the 
Indian Health Service Act of 2023.'' This legislation aims to 
provide tools so the agency can recruit and retain the very 
best people. The bill would do this by aligning IHS's pay 
system with the Veterans Administration's, providing better and 
slightly expanded benefits for healthcare workers, direct 
higher authority, improving data collection on patient care, 
among other reforms.
    The legislation would streamline processes to get rid of 
unqualified and even predatory staff in an efficient way that 
protects patients and improves care. The bill would also 
confirm whistleblower protections that protect those who bring 
issues to the attention of the IHS, the Department of Health 
and Human Services, and Congress. The bill also includes 
several required reports on the reforms that would be 
instituted to make sure they work as Congress intended.
    It is a goal of this hearing to discuss what provisions of 
this draft bill are still needed and what changes and other 
improvements to IHS can be included. The IHS has long been 
plagued with issues of substandard medical care, high staff 
vacancy rates, aging facilities and equipment, and unqualified 
or predatory healthcare staff. Many of these issues first came 
to national attention in 2010 when the Senate Committee on 
Indian Affairs held a hearing and completed subsequent 
investigation on the issues surrounding IHS of the Great Plains 
area, showing in detail the extreme deficiencies across IHS 
Direct Service Health Units.
    The agency has self-identified that its inability to 
attract and retain quality employees has a domino effect on the 
quality of care they provide. It is disheartening and 
frustrating to think about how long these issues have 
continued. In 2015, further issues came to light in the Great 
Plains area resulting in the termination of CMS contracts, the 
closure of an emergency department, and the deaths of nine 
patients. And in Fiscal Year 2021, the Portland area reported 
100 percent of their dentist positions were vacant.
    Vacancies are not the only issue. Issues of hiring sub-par 
candidates, lengthy hiring timelines, and lower-tier benefits 
have also factored into the issues of staffing IHS facilities. 
One doctor was hired at an IHS facility in the Southwest 
without consideration of all medical licenses, ignoring 
disciplinary marks she had received in other states. Another 
doctor who was unable to find work in other Southwest area 
hospitals was hired at IHS after five malpractice settlements 
in 5 years.
    These are just two grievous examples that highlight the 
policy changes that need to be made. While IHS does have 
authority to improve some of these issues on its own, statutory 
efforts is the most certain way to provide stronger guidelines 
and require oversight. This draft legislation works toward this 
goal and has the two-pronged approach of also including more 
incentives for medical professionals to come work at IHS for 
the betterment of the served communities. We must do better for 
our American Indians and Alaska Natives. This conversation and 
this discussion draft is a start.
    We have now had several hearings dealing with the IHS and 
our ability or inability to provide adequate medical and dental 
services to our Native people in the United States. We have had 
several women who have come to testify and provided extensive 
information and detail about what they have encountered for 
their tribal members, and it is just simply unacceptable. We 
need to fix this, and I am hoping that this is an excellent 
step in that direction. There are many aspects of the IHS and 
Native healthcare that can be improved, and I hope this hearing 
pushes those conversations forward.
    I want to thank all of our witnesses for appearing before 
the Subcommittee today, and I look forward to a robust 
discussion on this important issue.

    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, Madam Chairwoman, and thank 
you, witnesses, for coming and sharing with us your expertise, 
for sharing with us your written testimony.
    The Indian Health Service and the work they do on behalf of 
American Indians and Alaska Natives is critical. What they do, 
and sometimes what they fail to do, is a matter of life and 
death, and we need to remember that the life expectancy for 
American Indians and Alaska Natives is just 65 years old. That 
is 10 years lower than the national average. That is 
unacceptable. Congress and IHS simply have to do better.
    So, the draft discussion, which is great because we can 
have a discussion about it, the ``Restoring Accountability in 
the Indian Health Service Act'' is a good starting point. I do 
appreciate the sponsors and this Committee's focus on the IHS 
and the bill's intent to address many of the issues that the 
IHS faces.
    As an example, recruiting and retaining medical providers 
remains a serious challenge for the IHS, given the rural 
communities they serve. With that in mind, the draft bill would 
provide tenant-based rental assistance to an employee of the 
service who agrees to serve for not less than 1 year. It also 
expands the IHS loan repayment eligibility to attract more 
professionals. Things I hear about all the time, both of those, 
housing and let's get some professionals from here and get them 
back and recruit them.
    The draft bill would also require HHS to update its 2006 
Tribal Consultation Policy every 5 years and establish a 
demonstration project where IHS may provide service units with 
additional resources. They are meaningful provisions. They have 
the potential to translate into better service and care 
outcomes.
    However, we know our witnesses here are going to tell us, I 
have read it in your written testimony, that Congress has 
grossly underfunded the Indian Health Service compared to its 
current need. Historic underfunding contributes directly to 
shortages and adequate healthcare for tribal patients, 
resulting in gaps in treatment or referrals to outside 
facilities, which could be impossible for some tribal members 
who are living in rural communities.
    In fact, the 2018 U.S. Broken Promises Report noted the 
annual budget request for IHS meets just over half of the 
needs. As one example of this underfunding, IHS hospitals are 
overcrowded and falling apart. They have an average age of 
around 40 years compared to about 10 in the private sector. I 
have seen these hospitals; I have seen the leaky roofs. The 
Gallup Indian Medical Center has been on the priority list for 
way too long. It is clear that the Federal Government has not 
delivered on its trust and treaty promises to Indian Country.
    Despite the additional IHS programs and requirements in 
this draft bill, it doesn't authorize any additional 
appropriations to accomplish the goals it sets out. And I 
appreciate the funding inquiries for IHS and the current House 
Interior Environment Appropriations bill. But that is still 
$2.2 billion less than what the Administration requested.
    Our witness from the National Indian Health Board also 
highlights in his testimony that funding for IHS this year 
should be roughly $50 billion. In other words, the current 
proposed funding is seven times less than what is needed. If 
Congress continues to underfund the Service, we won't make the 
progress we need to.
    So, I thank you, Madam Chair, for hearing this bill. I hope 
you will also be willing to work together so we can support 
additional funding for IHS to address the concerns of this bill 
and to meet the expectations. This draft, however, does help 
IHS in offering critical, culturally-competent, culturally-
competent, that is so key, healthcare services through its 
provisions to improve hiring and retention, to require cultural 
training for certain employees, and encourage greater 
transparency and dialogue between the tribes and the IHS. 
Improving IHS care with appropriate funding, creative 
authorities, and accountability is important work that our 
Committee should and is addressing today.
    I am committed to working with the tribes, the IHS, and the 
Majority to do just that. As part of this work, it is key that 
we hear directly from tribes across the country and with direct 
service providers and 638 contracts and compacts. Indian 
Country deserves better care. Let's get it to them.
    With that, I yield back.

    Ms. Hageman. Thank you. The Chair now recognizes Mr. 
Johnson for 5 minutes to speak on his legislation.

   STATEMENT OF THE HON. DUSTY JOHNSON, A REPRESENTATIVE IN 
            CONGRESS FROM THE STATE OF SOUTH DAKOTA

    Mr. Johnson. Thank you, Madam Chair and Madam Ranking 
Member.
    When I am traveling in Indian Country in South Dakota, of 
course you hear a lot of concerns, lots of tribal members will 
note areas for improvement. We will talk about transportation, 
we will talk about law enforcement, we will talk about economic 
development. But no topic comes up more often than IHS. And 
these can, as our witnesses know, be very emotional 
conversations because we are dealing with some of the most 
important issues that people deal with in their lives, the 
health of themselves and their family members.
    And this is a progress that Members of Congress have cared 
about this a long time. These concepts were originally 
introduced by Senators Barrasso and Thune and then 
Congresswoman Noem way back in the 115th Congress. But we 
continue to talk to experts because we realize that the 
healthcare that is being provided is not meeting our needs, the 
needs of tribal members.
    There are a lot of reasons for that, but I think we know 
that we are involved in a staffing crisis in the IHS system. 
Many of the providers are excellent providers. You can see and 
feel their compassion. But we also know that there are some 
providers that are not competent and that there are not enough 
providers in general.
    Now you don't need to take my word for it, Madam Chair. A 
staffing analysis from a few years ago, I think 2018, said that 
there was a 25 percent vacancy rate for providers within IHS. 
And anecdotally, those people who work for IHS are telling me 
that it has gotten considerably worse since 2018.
    Now those deficiencies in staffing, they do manifest 
themselves in poorer outcomes. The Ranking Member mentioned the 
alarming life expectancy numbers in Indian Country, and we see 
that in South Dakota. The life expectancy of a Native American 
in South Dakota is almost 20 years lower than for a white 
person in South Dakota. There are a lot of reasons for that, 
but IHS staffing concerns are clearly an important part of 
that.
    And they also manifest themselves sometimes in really 
terrible headlines. The Chairman mentioned some of them. In 
2015, when the Pine Ridge Emergency Room closed, and it wasn't 
because of a lack of activity, this was an emergency room that 
was and is needed there in Indian Country. It took until 2019 
before there was a final report about what caused that closure. 
It was staffing problems, it was inconsistent leadership, and 
it was a lack of vision from IHS. Again, not my words, those 
are the findings of the report. And then we have also had truly 
unfortunate headlines where bad people are allowed to be 
providers in the system, and in some instances, have 
systematically abused people that they are to be caring for.
    So, this is just a discussion draft. We know that this is 
not a perfect format. That is why I am so grateful for our 
witnesses because they are going to help us make this better.
    But I think what we have here is a great start, an 
opportunity to address things like credentialing, like hiring 
practices, like accountability, like how do we coordinate and 
get better information from the state medical boards so that we 
know that these providers have not gotten in trouble somewhere 
else.
    Madam Chair, thanks for this opportunity. I am just so 
grateful for us to work together to improve healthcare in 
Indian Country.

    Ms. Hageman. Thank you. The gentleman yields back. I will 
now introduce our witnesses for our panel. Ms. Cindy Marchand, 
Secretary, Tribal Counsel, Confederated Tribes of the Colville 
Reservation; Mr. Lee Spoonhunter, the Rocky Mountain Area 
Representative of the National Indian Health Board, and I am 
very pleased to say a member of the Northern Arapaho Tribe in 
the State of Wyoming; Ms. Jerilyn Church, Executive Director, 
Great Plains Tribal Leaders Health Board. Welcome. We are 
excited to have you, and we appreciate your willingness to work 
with us on this incredibly important legislation.
    Let me remind the witnesses that under Committee Rules, 
they must limit their oral statements to 5 minutes, but their 
entire statement will appear in the record. To begin your 
testimony, please press the talk button on the microphone. We 
use timing lights. When you begin, the light will turn green. 
When you have 1 minute left, the light will turn yellow. At the 
end of the 5 minutes, the light will turn red and I will ask 
you to please complete your statement. I will also allow all 
witnesses on the panel to testify before we begin our Member 
questioning.
    The Chair now recognizes Ms. Cindy Marchand for 5 minutes.

   STATEMENT OF CYNTHIA MARCHAND, SECRETARY, TRIBAL COUNCIL, 
  CONFEDERATED TRIBES OF THE COLVILLE RESERVATION, NESPELEM, 
                           WASHINGTON

    Ms. Marchand. Thank you, Madam Chairwoman. Good afternoon, 
Chairwoman Hageman, Ranking Member Leger Fernandez, and members 
of the Committee. My name is Cindy Marchand, and I am the 
Secretary of the Colville Business Council, the governing body 
of the Colville Tribes. Thank you for inviting me to testify on 
the ``Restoring Accountability in the Indian Health Service 
Act.''
    The Colville Tribes is a direct service tribe which means 
that healthcare and associated billing and administrative 
support is provided by Federal IHS employees. We are in the 
beginning stages of contracting all IHS functions under the 
Indian Self Determination Act, but this process will take time. 
In the meantime, we have to rely on IHS.
    My tribe has endured multiple problems with the IHS's 
delivery of healthcare to our citizens during the past few 
years. We support the Restoring Accountability in the IHS Act 
and believe that its reforms are long overdue. Like other rural 
communities recruiting and retaining health providers on the 
Colville Reservation is challenging. There is a 55 percent 
vacancy rate at the Colville Service Unit, which is nearly 
twice the IHS-wide vacancy rate of 28 percent. We currently 
have 46 vacancies out of a total of staff of 84, and many of 
the vacant positions have been unfilled for years.
    IHS's hiring and credentialing processes are extremely 
slow. When a doctor or other healthcare provider applies for a 
vacant position at the Colville Service Unit, they will often 
accept a position elsewhere because they simply cannot wait for 
IHS to complete its background and credential review processes, 
which usually take months.
    The recruitment and retention provisions in Title I of the 
Act would help address some of these issues. Section 101 would 
provide parity in the pay schedules for health providers at IHS 
with those at the Veterans Health Administration and would also 
expedite credentialing. The Colville Tribe supports these 
reforms.
    As the Committee is aware, Purchased/Referred Care, or PRC, 
is a program where IHS beneficiaries receive care from private 
non-IHS health providers when IHS is unable to provide the care 
in its own facilities. For the 3-year period the IHS Portland 
area office administered the PRC program at the Colville 
Service Unit, during this time the PRC program was administered 
so poorly that we can trace it to deaths in our community.
    IHS required on an annual basis our members to produce 
utility bills, certificates of Indian blood, and other proof of 
tribal enrollment, and other information not required by the 
IHS regulations or the IHS handbook to get PRC referrals. Those 
who were unable to produce this information either went without 
care or obtained care on their own and subsequently faced 
third-party collection agencies when IHS refused to pay for the 
services. To our knowledge, none of the IHS staff at the 
Portland area office who imposed these obstacles to eligibility 
have ever been held accountable.
    Two years ago, one of our tribal elders tried repeatedly to 
obtain a referral for ongoing heart issues and was unable to 
get calls from IHS returned or otherwise secure a purchase 
order for the referral by the IHS staff responsible for 
processing them. The tribal elder died of a heart attack before 
securing that referral.
    There have been many stories like this in our tribal 
communities, and me and my colleagues on the Colville Business 
Council field these calls from our constituents regularly. If a 
referral for PRC is secured, there is no way to predict if IHS 
will pay the provider in a timely manner, if at all. When IHS 
does not pay PRC providers, the providers send medical bills to 
IHS beneficiaries directly.
    Section 222 of the Indian Health Care Improvement Act 
explicitly states that an IHS beneficiary should under no 
circumstances be liable for payment for authorized PRC 
services. IHS has never effectively implemented this provision, 
and providers send the bills IHS does not pay to IHS 
beneficiaries anyway. We have provided the Committee with 
language to strengthen Section 222 and address these issues 
that we would like to see included in Title I of the Act.
    In conclusion, the Colville Tribe supports the bill and 
would like to work with the Committee to ensure that the final 
bill includes provisions to improve the PRC program for the 
Colville Tribes and other direct service tribes. I would be 
happy to answer any questions that the Committee may have. 
Thank you.

    [The prepared statement of Ms. Marchand follows:]
    Prepared Statement of the Honorable Cindy Marchand, Secretary, 
            Confederated Tribes of the Colville Reservation
    As a rural, land-based Indian tribe, the Confederated Tribes of the 
Colville Reservation (``Colville Tribes'' or the ``CCT'') has unique 
challenges to providing health care for our tribal community. The CCT 
is a direct service tribe, which means that health care and associated 
billing and administrative support is provided by Indian Health Service 
(``IHS'') employees. The CCT is in the beginning stages of contracting 
all IHS functions, but this process will take time. In the meantime, we 
have to rely on IHS to provide quality health care to our tribal 
citizens.
    The Confederated Tribes of the Colville Reservation is a 
confederation of twelve aboriginal tribes from across eastern 
Washington state, northeastern Oregon, Idaho, and British Columbia. The 
twelve constituent tribes historically occupied a geographic area 
ranging from the Wallowa Valley in northeast Oregon, west to the crest 
of the Cascade Mountains in central Washington State, and north to the 
headwaters of the Okanogan and Columbia Rivers in south-central and 
southeast British Columbia. Before contact, the traditional territories 
of the constituent tribes covered approximately 39 million acres.
    The present-day Colville Reservation is in north-central Washington 
state and was established by Executive Order in 1872. The Colville 
Reservation covers more than 1.4 million acres, and its boundaries 
include portions of both Okanogan and Ferry counties, two of the lowest 
median income counties in the state. Geographically, the Colville 
Reservation is larger than the state of Delaware and is the largest 
Indian reservation in the pacific Northwest. The Colville Tribes has 
just under 9,300 enrolled members, about half of whom live on the 
Colville Reservation.
    The CCT appreciates the Committee holding today's hearing on the 
``Restoring Accountability in the Indian Health Service Act of 2023'' 
(the ``Act''). The CCT worked extensively with the committees of 
jurisdiction when the bill was first being developed in 2015. Much of 
the bill focuses on IHS issues that are most relevant to direct service 
tribes. As a direct service tribe that has endured multiple problems 
with the IHS's delivery of health care to our citizens during the past 
few years, the Colville Tribes supports the Act and believes that its 
reforms are long overdue.
A. Recruitment and Retention

    Like other rural communities, recruiting and retaining health 
providers on the Colville Reservation is challenging. There is a 55 
percent vacancy rate at the Colville IHS Service Unit, which is nearly 
twice the IHS-wide vacancy rate of 28 percent that IHS Director Roslyn 
Tso reported during her May 11, 2023, testimony before this Committee. 
Currently, there is a single, part-time dentist at the Colville Service 
Unit and many of the vacant positions have been unfilled for years.
    Health providers in our area have expressed interest in providing 
health care services on the Colville Reservation but have indicated 
they would only do so if they contracted directly with the Colville 
Tribes and bypass having to work through IHS. Providers have indicated 
to us that the protracted administrative processes and problems locally 
with IHS's administration of the Purchased/Referred Care (``PRC'') 
program are the primary reasons for their interest working with the CCT 
directly. When a doctor or other health provider applies for a vacant 
position at the Colville Service Unit, they will often accept a 
position elsewhere because they simply cannot wait for IHS to complete 
its background and credential review processes, which often takes 
months.
    Every health provider vacancy at an IHS service unit creates a 
domino effect that negatively impacts tribes and tribal citizens. 
First, a provider vacancy means longer waits by IHS beneficiaries for 
health care. Other providers must also absorb the patient load, which 
often leads to providers burning out and looking for employment 
elsewhere.
    Worse, without enough providers, the user population for a given 
IHS Service Unit has decreased, which ultimately reduces the Service 
Unit's allocation of PRC funds under the PRC distribution formula. 
IHS's Portland Area (which includes tribes in Washington, Oregon, and 
Idaho) does not have and has never had an IHS or tribally operated 
hospital. Without hospitals that can internalize costs, tribes in the 
Portland Area are particularly reliant on PRC funds to refer patients 
to private providers for specialty care that their facilities cannot 
accommodate. For a direct service tribe, a single health provider 
vacancy leads to multiple negative outcomes. The Colville Service Unit 
currently has 46 vacancies out of a total staff of 84.
    The recruitment and retention provisions in Title I of the Act 
would help address some of these issues. Section 101 would provide 
parity in the pay schedules for health providers at IHS with those at 
the Veteran's Health Administration and would also authorize housing 
assistance. The CCT supports these provisions and recommends that 
Section 101 also add a provision that allows for incentives for service 
unit CEOs or other senior management positions at the service unit 
level. IHS recently advertised the CEO position at the Colville Service 
Unit and, in the Tribes' view, the pay grade was initially too low to 
attract the type of applicant to a rural area with the experience and 
qualifications necessary to implement reforms in our Service Unit.
B. Staffing Demonstration Program

    The CCT is particularly supportive of Section 108 of the Act, the 
``Staffing Demonstration Program.'' The CCT developed this provision in 
response to its challenges to update its staffing ratios, which have 
not changed for nearly one hundred years.
    The Colville Tribes has previously testified before this Committee 
regarding the unique challenges that direct service tribes face in 
updating their staffing levels. For the CCT and similarly situated 
direct service tribes, these staffing ratios are determined when their 
initial IHS health facility opens for operation. There are two ways for 
direct service tribes to update their staffing levels. One is to 
construct a new facility with IHS funds under the Facility Construction 
Priority List (``Priority List''), and the other is to build a facility 
using tribal funds under the Joint Venture program. The Priority List 
has been closed since 1992 and remaining projects will cost an 
estimated $6 billion to complete. Applications for Joint Venture 
projects are rarely offered, highly competitive, and at the expense of 
the tribes.
    Tribes that have not been able to update their staffing ratios by 
constructing a new facility under the Priority List or the Joint 
Venture facility construction programs are frozen in time for staffing 
ratio purposes. For the CCT, these historic staffing ratios date back 
to 1927 when the U.S. Public Health Service converted a Department of 
War building in Nespelem, Washington, for use as the CCT's initial 
health clinic.
    The Colville Tribes was fortunate to have been awarded a Joint 
Venture facility construction project in 2020 and hopes to update its 
staffing levels soon. Many other direct service tribes, however, 
continue to face challenges associated with historically low staffing 
levels. The Staffing Demonstration Program would allow the IHS to 
provide federally managed service units with staffing resources on a 
temporary basis with the expectation that third party revenue generated 
by the staff would allow them to be permanent. There is currently no 
other IHS program that allows this.
C. The Act Should Address IHS's Administration of the PRC Program

    As noted above, the PRC program is critical for the Colville Tribes 
and other Indian tribes in the Portland Area because of the lack of 
inpatient hospital facilities. Based on the Colville Tribes' 
experiences in recent years, more congressional oversight of IHS's 
administration of the PRC program is not only warranted, but necessary, 
as the PRC program for direct service tribes is literally a matter of 
life and death.
    For an approximately three-year period that ended in October 2022, 
the Portland Area IHS Office administered the PRC program for the 
Colville Service Unit in Portland using Portland Area Office staff, not 
local IHS employees located on-reservation. This led to catastrophic 
results, including deaths. The severity of these issues prompted the 
House Committee on Appropriations to direct IHS to brief the Committee 
on its efforts to improve care at the Colville Service Unit in its 
report accompanying the FY 2024 Interior spending bill, which the 
Committee approved last week.
    Once the Portland Area Office began administering the PRC program, 
IHS began imposing onerous documentation requirements not required by 
the IHS handbook or any other IHS authority on Colville tribal members 
to prove they were eligible for PRC funds. This meant that tribal 
elders and other IHS beneficiaries, on an annual basis, had to produce 
utility bills, certificates of Indian blood and other proof of tribal 
enrollment, and other information not required by the IHS regulations 
or the IHS handbook in order to get referrals for specialty care. Those 
who were unable to produce this information either went without care or 
obtained care on their own and subsequently faced third party 
collection agencies when IHS refused to pay for the services.
    The Portland IHS Area Director informed the CCT in late 2022 that 
the additional eligibility requirements should never have been 
implemented. The damage had already been done, however, and there has 
never been accountability for those Portland Area IHS personnel that 
ordered the eligibility requirements implemented at the Colville 
Service Unit.
    In addition to eligibility roadblocks, the communication and 
beneficiary customer service that IHS provides at the Colville Service 
Unit has been woeful. Two years ago, a Colville tribal elder tried 
repeatedly to obtain a referral for ongoing heart issues, complaining 
to CCT elected officials that he was unable to get calls from IHS 
returned or otherwise secure a purchase order for the referral by IHS 
staff responsible for processing them. The tribal elder died of a heart 
attack before securing the referral. Tragically, there have been many 
stories like this in the Colville Tribes' tribal community.
    For those CCT members who can get referrals and receive specialty 
care through the PRC program, there is no way to predict if IHS will 
pay the provider. When IHS does not pay PRC providers in a timely 
manner, the providers will begin sending the medical bills to IHS 
beneficiaries directly.
    Section 222 of the Indian Health Care Improvement Act (IHCIA) 
explicitly states that an IHS beneficiary should under no circumstances 
be liable for payment for authorized PRC services. IHS has never 
effectively implemented this provision, however, and providers send the 
bills that IHS does not pay to IHS beneficiaries anyway, which are 
often later referred to third party collection agencies. This has 
happened to scores of Colville tribal members in recent years, 
including CCT elected officials. The CCT is aware of instances where 
PRC providers have refused to make appointments with IHS 
beneficiaries--even those with chronic conditions--where the 
beneficiary has an outstanding balance to the provider that IHS has not 
paid and the provider has billed to the beneficiary directly.
    When faced with notices from collection agencies, the few fortunate 
IHS beneficiaries who can afford to, will pay the bills out-of-pocket 
to avoid damage to their credit scores--again, notwithstanding Section 
222 of the IHCIA. The IHS has no beneficiary-accessible mechanism for 
reimbursing IHS beneficiaries in these situations. For the vast 
majority of IHS beneficiaries that cannot afford to pay the bills that 
IHS does not pay themselves, they must live with impaired credit 
scores, higher interest rates, or the inability to obtain credit 
altogether.
    As the Committee and some in Indian Country are aware, in recent 
years IHS has amassed hundreds of millions in unobligated PRC carryover 
funds and billions more in carryover funds from other IHS accounts. 
Despite this carryover, IHS administers the PRC program like rationed 
healthcare. The fact that IHS has significant PRC carryover funds and 
Colville tribal members and others in Indian Country struggle to obtain 
referrals for PRC care is unconscionable. Even worse, when PRC 
providers do not get paid by IHS in a timely manner, the CCT has seen 
providers to refuse to participate in the PRC program. The Colville 
Reservation is in a rural, low-income area where there are only a small 
number of providers to begin with, so the loss of a provider 
participating in the PRC program because of non-payment by IHS is 
devastating.
    The Colville Tribes has provided the Committee with language that 
would amend section 222 of the IHCIA to clarify IHS's duties to inform 
providers that the IHS beneficiaries are not liable for PRC bills and 
require IHS to implement a reimbursement process for those IHS 
beneficiaries who pay PRC bills that IHS does not pay. We urge the 
Committee to consider including this language in Title I of the Act.

                                 ______
                                 

    Questions Submitted for the Record to the Hon. Cindy Marchand, 
    Secretary, Tribal Council, Confederated Tribes of the Colville 
                              Reservation

Ms. Marchand did not submit responses to the Committee by the 
appropriate deadline for inclusion in the printed record.

            Questions Submitted by Representative Westerman
    Question 1. Previous versions of the Restoring Accountability in 
the Indian Health Service Act included a section on medical chaperones.

    Do you believe there still a need for medical chaperones for 
patients at IHS facilities? If so, please elaborate on what language 
should be added to this discussion draft to address the issue.

    Question 2. Recruitment and retention of health care personnel are 
two issues this committee has heard about time and time again, 
especially in rural areas. The entire health care system faces 
challenges of hiring and retaining medical professionals.

    2a) Anecdotally, what barriers do you know medical professionals 
face to work at either IHS or tribally run health care programs?

    2b) What have you seen in tribally run health care programs 
regarding improvements to hiring and recruitment that could help IHS 
fill their staff vacancies and improve employee retention?

    2c) What sections of this discussion draft could help with 
recruitment and retention of personnel the most?

    Question 3. There have been reports regarding the lack of 
accountability when it comes to IHS employees and misconduct.

    3a) Anecdotally, can you provide any examples of complaints toward 
IHS medical staff not being taken seriously by IHS officials?

    3b) Are you aware of any incidents that have not been previously 
reported where an IHS employee retained their position despite 
complaints being raised against them?

    3c) Are the protections provided in this discussion draft enough 
for IHS employees to raise objections and be certain they are safe to 
do so?

    Question 4. The NIHB raised the question of reimplementing a tribal 
advisory committee like the National Steering Committee to Reauthorize 
of the Indian Health Care Improvement Act (IHCIA) that had previously 
advised the federal government about changes to the IHCIA, prior to its 
permanent reauthorization.

    4a) Would your tribe be supportive of that sort of committee being 
established? What if the tribal leaders who serve on the committee 
would serve without pay?

    4b) What other advisory committees or councils that are currently 
established in HHS or IHS that could be used to provide the expertise 
the National Steering Committee previously provided?

    4c) What further ways aside from a national steering committee may 
be beneficial to institute so IHS will have more input from tribes on 
how to improve IHS policies and procedures?

    Question 5. Concerns were raised in NIHB written testimony about 
the discussion draft affecting tribally run health programs that have 
been compacted or contracted out from IHS.

    5a) What sections of this discussion draft could most affect 
tribally operated health programs and how?

    5b) What language do you think should be included to reduce that 
effect?

    5c) Are there aspects of this discussion draft that would improve 
tribal autonomy and control over tribally run health programs?

    Question 6. From your perspective, what regulations and official 
guidance from IHS cause the largest challenges for tribal members 
seeking care? What about for tribes compacting or contracting out 
health care services from IHS?

    Question 7. In your testimony you explained that Confederated 
Tribes of the Colville Reservation were in the process of contracting 
out all IHS related functions. Could you provide more background as to 
why that decision was made?

    Question 8. In your testimony, you stated that provisions should be 
included to Section 101 to allow for incentives to be given to Service 
Unit CEOs as well as other upper management positions.

    Could you elaborate on that idea and detail what kind of incentives 
you think should be made available?

    Question 9. Your testimony discussed the ``purchase/referred care'' 
(PRC) program and how tribes use the program. its use for tribal 
entities, such as Colville. One of the core functions of the PRC 
programs is its availability to provide care when staffing at 
facilities fail to meet the needs of the patient base.

    9a) Could you elaborate further on the various obstacles a tribe 
faces when utilizing the program?

    9b) Are there specific implementation issues related to IHS 
staffing that could be addressed by the proposed changes in this 
legislation?

    Question 10. In your testimony you outlined IHS has had significant 
carryover funds in the PRC program.

    What would you recommend that IHS do with the PRC carryover that is 
has for the Colville Service Unit or the Portland Area?

    Question 11. In your written testimony you stated frustrations with 
the staffing ratios at IHS, noting the limited ways that IHS will 
change the ratios--either through constructing a new facility under 
IHS' ``priority list,'' or building a facility using Joint Venture 
funds.

    11a) In your opinion, would the proposed ``staffing demonstration 
program'' found in Section 108 of the discussion draft address this 
issue?

    11b) How else could the ratio be addressed by Congress to improve 
review of the ratios for all IHS areas?

         Questions Submitted by Representative Leger Fernandez

    Question 1. A common theme throughout the hearing was the need for 
Congress to hear directly from tribes and tribal organizations across 
the country on any policies designed to improve direct or indirect IHS 
care for American Indians and Alaska Natives.

    1a) How do you believe Congress should consult with Tribes on their 
unique experiences and perspectives to inform potential legislation to 
improve the Indian Healthcare Improvement Act (IHCIA)?

    1b) One recommendation put forward was for Congress to support a 
National Steering Committee (NSC) process to examine necessary reforms 
to IHS and IHCIA. How do you believe Congress can best support Tribes 
in such processes to ensure policy outcomes are led by tribal leaders?

                                 ______
                                 
    Ms. Hageman. I thank the witness for her testimony.
    The Chair now recognizes Mr. Lee Spoonhunter for 5 minutes.

  STATEMENT OF LEE SPOONHUNTER, BILLINGS AREA REPRESENTATIVE, 
          NATIONAL INDIAN HEALTH BOARD, WASHINGTON, DC

    Mr. Spoonhunter. Chairwoman Hageman, Ranking Member Leger 
Fernandez, and distinguished members of the Subcommittee, thank 
you for this opportunity to provide testimony on the 
``Restoring Accountability in the Indian Health Service Act.'' 
My name is Lee Spoonhunter. I serve as a tribal council member 
for the Northern Arapaho Tribe and the Rocky Mountain Area 
representative for the National Indian Health Board.
    This bill arises from our conflicted past with the United 
States and the staffing and accountability issues caused by 
chronic underfunding of the Indian Health Service, and how 
staffing shortages persist throughout Indian Country from top 
to bottom. Earlier this year, I had just testified that it has 
a 28 percent provider vacancy rate and a 40 percent mental 
health professional vacancy rate. The lack of providers forces 
IHS and tribal facilities to rely on contracted services, which 
can be more costly, less effective, and culturally inept.
    We are supportive of the intent of this bill to address 
policy concerns at the IHS. However, we believe there is more 
work needed before there are any amendments to the Indian 
Healthcare Improvement Act. To that end, the bill should not 
supersede any consensus recommendations of the IHCIA National 
Steering Committee and should seek to empower collaborative 
policy development around IHS accountability on a government-
to-government basis.
    The draft bill has many well-intended provisions that seek 
to address past misconduct and a lack of accountability at the 
IHS, such as modifications to the IHS loan repayment plan, 
streamlined hiring practices, and culturally-appropriate, 
historically-accurate training for staff. The bill would also 
address best practices for IHS area offices and service unit 
governing boards as well as establish clear rules for 
misconduct and disciplinary action. Unfortunately, we are 
worried that the good intentions could negatively impact our 
sovereignty. It could set us on a path backward in U.S. tribal 
relations.
    A number of issues addressed in this bill came up in the 
regional and national meetings on the reauthorization of the 
Indian Healthcare Improvement Act. For years, when it came to 
renewing or modifying IHCIA, there was a national steering 
committee charged with identifying the needed objectives and 
policy changes for the law. The national steering committee 
worked diligently to reach consensus on many issues, some of 
which were contentious and controversial.
    We call upon Congress to support a national focused 
steering committee process again. We hear from tribal leaders 
that there is a lack of transparency around activities and 
decision-making at IHS, such as when a tribe receives its 
services directly through the IHS operator service unit. We are 
concerned that one of the issues with IHS accountability is 
that there is not a clear and common understanding of what 
gives them to rise in the first place.

    When policy is enacted, the impact is often pushed on 
direct service tribes with no explanation. We are concerned 
that this bill has been developed so far without national 
tribal consensus and could harm tribes and their past work. 
However, we will not study this problem away. There is no 
amount of red tape that can patch an underfunded system. 
Imagine having one day's worth of food for a week for 
generations.

    The funding at IHS on one-seventh of the estimate of the 
tribal budget formulation work groups sets us up for failure. 
For example, at the Northern Arapaho, our tribal citizens are 
at a disadvantage for referred care. Those dollars are so 
limited that patients are not given the needed referrals until 
they are often too sick to receive curative treatment. We 
recently hired a nephrologist with our third-party revenue 
dollars, someone that would not likely have been hired if we 
had IHS direct care, who informed us that we could have greatly 
improved patient care and saved lives if the care was provided 
sooner. But the PRC dollars are so scarce it is often too late 
by the time they get the referral.

    Thank you again for this hearing and the draft legislation 
addressing IHS staffing and accountability issues. I know that 
if we work together as sovereigns we can do so much more. I 
look forward to any questions you have. Thank you.

    [The prepared statement of Mr. Spoonhunter follows:]

 Prepared Statement of Councilman Lee Spoonhunter, Rocky Mountain Area 
              Representative, National Indian Health Board

    Chairwoman Hageman, Ranking Member Leger Fernandez, and 
distinguished members of the Subcommittee, on behalf of the National 
Indian Health Board and the 574 sovereign federally recognized American 
Indian and Alaska Native Tribal nations we serve, thank you for this 
opportunity to provide testimony on the Restoring Accountability in the 
Indian Health Service Act of 2023. My name is Lee Spoonhunter. I serve 
as Tribal Councilmember for the Northern Arapaho Tribe and Rocky 
Mountain Area Representative for the National Indian Health Board 
(NIHB).

    Formed in 1972, NIHB is recognized nationally and internationally 
for its expertise in Indian health policy. NIHB's membership consists 
of the eleven Area Indian Health Boards (AIHBs) and the Tribes of the 
Tucson Area directly. NIHB supports Tribal policy through collaborative 
partnerships with Tribal, Congressional, federal, state, and 
International governmental and non-governmental organizations, as well 
as through original research and development, public education, and 
outreach.

    The Indian Health Service (IHS) is the principal federal health 
care provider and health advocate for Indian people. Its success is 
essential to our success as an organization, and to meeting this 
Nation's stated policy goal of ensuring the highest possible health 
status for Indians. The NIHB, therefore, appreciates this 
Subcommittee's focus on Indian healthcare and stands ready to work with 
the Subcommittee toward achieving this national goal. We have a long 
way to go.

    The NIHB Board of Directors sets forth an annual Legislative and 
Policy Agenda to advance the organization's mission and vision. Our 
objectives are to educate policymakers about Tribal priorities, 
advocate for and secure resources, build Tribal health and public 
health capacity, and support Tribally led efforts to strengthen Tribal 
health and public health systems. Today's testimony includes a subset 
of recommendations from this Agenda.
IHS Accountability

        ``For decades and generations, IHS has had a notorious 
        reputation in Indian Country but it is all we have to count on. 
        We do not go there because they have superior health care; we 
        go there because it is our treaty right, and we go there 
        because many of us lack the resources to go elsewhere.''

        2016 Statement of Victoria Kitcheyan, Treasurer, Winnebago 
        Tribal Council, to the Senate Committee on Indian Affairs.

    The Restoring Accountability in the Indian Health Service Act of 
2023 arises from our conflicted past relations with the United States 
and from the chronic underfunding of the United States treaty and trust 
obligations to provide for the health of Tribal nations and their 
citizens.\1\ The NIHB is supportive of the intent of this draft 
legislation to address policy concerns at the IHS. However, we believe 
there is more work to be done to improve this legislation before there 
are any amendments to the Indian Health Care Improvement Act (IHCIA). 
To that end, the bill should not supersede any consensus 
recommendations of the IHCIA National Steering Committee (NSC) and 
should seek to empower collaborative policy development on a 
government-to-government basis.
---------------------------------------------------------------------------
    \1\ See, U.S. Commission on Civil Rights, Broken Promises: 
Continuing Federal Funding Shortfall for Native Americans (hereinafter 
``Broken Promises''), available at: https://www.usccr.gov/files/pubs/
2018/12-20-Broken-Promises.pdf, accessed on: November 20, 2022.
---------------------------------------------------------------------------
    Chronic and pervasive health staffing shortages--from physicians to 
nurses to behavioral health practitioners--stubbornly persist across 
Indian Country, with 1,550 healthcare professional vacancies documented 
as of 2016. Further, a 2018 Government Accountability Office (GAO) 
report found an average of 25% provider vacancy rates for physicians, 
nurse practitioners, dentists, and pharmacists across two thirds of IHS 
Areas (GAO 18-580). In May of this year, IHS Director Roselyn Tso 
testified before this Subcommittee that the agency currently has a 28% 
provider vacancy rate and a 40% mental health professional vacancy 
rate. This challenge is not getting better. Lack of providers also 
force IHS and Tribal facilities to rely on contracted providers, which 
can be more costly, less effective, and culturally indifferent, at 
best--inept at worst. Relying on contracted care reduces continuity of 
care because many contracted providers have limited tenure, are not 
invested in community and are unlikely to be available for subsequent 
patient visits. Along with a lack of competitive salary options, many 
IHS facilities are in a serious state of disrepair, which can be a 
major disincentive to potential new hires. While the average age of 
hospital facilities nationwide is about 10 years, the average age of 
IHS hospitals is nearly four times that--at 37 years. In fact, an IHS 
facility built today could not be replaced for nearly 400 years under 
current funding practices. As the IHS eligible user population grows, 
these aging facilities impose an even greater strain on availability of 
direct care.
    NIHB is glad to see that the draft legislation would focus on 
improving staffing at the IHS. We must continue to think creatively 
about how to recruit and retain the best medical professionals to the 
Indian health system. We hope that we can continue this conversation 
about how to attract the best providers to the agency. We are also glad 
to see language to help improve and standardize the IHS. However, the 
policies identified in this bill must be done with the necessary 
appropriations to back them up. NIHB also supports ensuring that the 
legislation would not impact Tribal health programs negatively, and 
that the true needs of IHS are adequately reflected.
IHCIA and the National Steering Committee

    A number of the issues addressed in the Restoring Accountability in 
the Indian Health Service Act of 2023 came up in the regional and 
national meetings on the reauthorization of the IHCIA. For years, when 
it came to renewing and modifying IHCIA, there was a National Steering 
Committee (NSC) that consisted of Tribal representatives from across 
the country. During this process there were multiple regional 
consultation meetings and a national consultation in Washington, DC. 
This process identified the needed objectives and policy changes for 
IHCIA. This allowed any amendments to IHCIA to be supported by Tribes 
and for Indian Country to speak with a unified voice. The NSC worked 
diligently to reach national consensus on many issues, some of which 
were contentious or controversial.
    As we work with the Subcommittee to support and examine necessary 
reforms to IHS, we call upon Congress to support a nationally-focused 
NSC process again. This process would balance the perspectives and 
needs of the entire Tribal health system resulting in a consensus among 
Indian Country and stakeholders. The NIHB stands with its partners and 
allies that any federal policymaking should be respectful of the Tribal 
leaders' decisions and policy outcomes that came through such process.
    For example, NIHB consistently hears that there is that the lack of 
transparency around activities and decision making at IHS, particularly 
when a Tribe receives its services directly through an IHS operated 
service unit. NIHB partners are concerned that one of the issues with 
IHS accountability is that there is not a clear and common 
understanding of the rules and procedures that give rise to these 
issues. When policy is enacted regarding IHS, the impact of that policy 
is often thrust upon Tribes receiving direct services from IHS to bear 
regardless of whether the driving force of the underlying policy or 
decision is explained. The IHS Restoring Accountability Act, to our 
knowledge, was not a product of an NSC process. A considerable amount 
of the policy in this bill has been developed and proposed without 
national Tribal consensus and is at risk of inadvertently harming 
Tribal nations and Tribal health systems.
Treaties, Trust, and the Duty Owed

    Tribal nations have a unique legal and political relationship with 
the United States as defined by the U.S. Constitution, treaties, 
statutes, court decisions, and administrative law. Through its 
acquisition of land and resources, the United States formed a fiduciary 
relationship with Tribal nations whereby it has recognized a trust 
relationship to safeguard Tribal rights, lands, and resources.\2\ In 
fulfillment of this Tribal trust relationship, the United States 
``charged itself with moral obligations of the highest responsibility 
and trust'' toward Tribal nations.\3\ This bargained for exchange means 
that Tribal nations paid, in full, for the duties owed by the United 
States and that the United States has to duty to uphold its end of the 
exchange, which it continues to generously benefit directly from.
---------------------------------------------------------------------------
    \2\ Worcester v. Georgia, 31 U.S. 515 (1832).
    \3\ Seminole Nation v. United States, 316 U.S. 286, 296-97 (1942).
---------------------------------------------------------------------------
    The United States' long-standing and repetitive use of language 
regarding trust relationships and legal obligations is not by accident. 
In a trust relationship, a trustee owes certain fundamental duties to 
the beneficiaries, including a duty of loyalty to all beneficiaries, a 
duty to provide requisite resources, and a duty to act in good faith. 
The duty to provide requisite resources is not only one of quantity, 
but one of continuity and stability. Otherwise, the purpose of the 
trust relationship recognized by the United States for centuries is 
effectively meaningless.
    Most recently, Congress reaffirmed its duty to provide for Indian 
health care when it enacted the Indian Health Care Improvement Act 
(IHCIA) (25 U.S.C. Sec. 1602), declaring that it is the policy of this 
Nation, in fulfillment of its special trust responsibilities and legal 
obligations to Indians--to ensure the highest possible health status 
for Indians and urban Indians and to provide all resources necessary to 
effect that policy.'' Unfortunately, those responsibilities and legal 
obligations remain unfulfilled and Indian Country remains in a health 
crisis.
    Today, most Tribal lands are held in trust by the United States or 
have been completely taken from our Nations through the long history of 
U.S. war, removal, assimilation, reorganization, and termination. As a 
result, Tribes do not have the same asset base or tax base as other 
governments. Tribal nations rely on federal government funding and on 
economic development, but infringement on Tribal tax jurisdiction and 
drastically reduced land bases leave most Tribal nations in a position 
of unique reliance on annual appropriations for their healthcare 
infrastructure and delivery.
The Health Status of Indian Country

    The Centers for Disease Control and Prevention (CDC) now reports 
that life expectancy for AI/ANs has declined by nearly 7 years, and 
that our average life expectancy is now only 65 years--equivalent to 
the nationwide average in 1944.\4\ With a life expectancy 10.9 years 
less than the national average,\5\ Native Americans die at higher rates 
that those of other Americans from chronic liver disease and cirrhosis, 
diabetes mellitus, unintentional injuries, assault/homicide, 
intentional self-harm/suicide, and chronic lower respiratory 
disease.\6\ Native American women are 4.5 times more likely than non-
Hispanic white women to die during pregnancy.\7\ Between 2005 and 2014, 
every racial group experienced a decline in infant mortality except for 
Native Americans \8\ who had infant mortality rates 1.6 times higher 
than non-Hispanic whites and 1.3 times the national average.\9\ Native 
Americans are also more likely to experience trauma, physical abuse, 
neglect, and post-traumatic stress disorder.\10\ AI/ANs experience the 
highest rates of suicide according to a 2020 SAMHSA study,\11\ with a 
recent, February 2023 CDC report finding that teen girls are 
experiencing record high levels of violence, sadness, and suicide 
risk.\12\ Additionally, Native Americans experience some of the highest 
rates of psychological and behavioral health issues as compared to 
other racial and ethnic groups \13\ which have been attributed, in 
significant part, to the ongoing impacts of historical trauma.\14\
---------------------------------------------------------------------------
    \4\ U.S. Department of Health and Human Services, Centers for 
Disease Prevention and Control, Provisional Life Expectancy Estimates 
for 2021 (hereinafter, ``Provisional Life Expectancy Estimates''), 
Report No. 23, August 2022, available at: https://www.cdc.gov/nchs/
data/vsrr/vsrr023.pdf, accessed on: October 13, 2022 (total for All 
races and origins minus non-Hispanic American Indian or Alaska Native).
    \5\ Id.
    \6\ Broken Promises at 65.
    \7\ Broken Promises at 65.
    \8\ Broken Promises at 65.
    \9\ Broken Promises at 65.
    \10\ Broken Promises at 79-84.
    \11\ Substance use And Mental Health Services Administration, Key 
Substance Use and Mental Health Indicators in the United States, 
Results from the 2020 National Survey on Drug Use and Health, available 
at: https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/
NSDUHFF RPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf, accessed on: 
March 22, 2023.
    \12\ Centers for Disease Control and Prevention, Press Release: 
U.S. Teen Girls Experiencing Increased Sadness and Violence, available 
at: https://www.cdc.gov/media/releases/2023/p0213-yrbs.html, accessed 
on: March 22, 2023.
    \13\ Walls, et al., Mental Health and Substance Abuse Services 
Preferences among American Indian People of the Northern Midwest, 
Community Mental Health J., Vol. 42, No. 6 (2006) at 522, https://
link.springer.com/content/pdf/10.1007%2Fs10597-006-9054-7.pdf, accessed 
on: November 20, 2022.
    \14\ Kathleen Brown-Rice, Examining the Theory of Historical Trauma 
Among Native Americans, Prof'l Couns, available at: http://
tpcjournal.nbcc.org/examining-the-theory-of-historical-trauma-among-
native-americans/, accessed on: November 22, 2022.
---------------------------------------------------------------------------
The Resources Provided to the Indian Health Service

    Although annual appropriations for IHS have consistently increased 
since 2009, after adjusting for inflation and population growth, the 
IHS budget has remained static in recent decades. In December 2018, the 
U.S. Commission on Civil Rights' Broken Promises report found that 
Tribal nations face an ongoing funding crisis that is a direct result 
of the United States' chronic underfunding of Indian health care for 
decades, which contributes to vast health disparities between Native 
Americans and other U.S. population groups. We saw this crisis manifest 
in the worst way possible during the COVID-19 pandemic, and now we see 
it in the latest data and reporting.
    Supplemental appropriations enacted during the pandemic were 
historic investments for Indian Country. It cannot be lost to history 
that the United States' swift action saved lives, but it must also be 
clear that the IHS is so disproportionately underfunded by Congress 
that a historic investment in response to a global virus still provided 
less resources than the estimate of annual obligations for IHS services 
in a single year--an amount collaboratively developed by the IHS 
National Tribal Budget Formulation Workgroup (NTBFW). For comparison, 
the latest enacted regular appropriations for IHS totals about $7 
billion, or roughly 7 times less than the need-based estimate from the 
Workgroup for FY 2023.
    Imagine having only one day's worth of food for a week: for 
generations. Imagine if the federal government asked you why you are so 
hungry all the time when they `already gave you food;' why you can't 
manage your groceries like someone with a full pantry when they took 
nearly all of your resources. This staggering comparison underscores 
the purposeful inequity that continues to result in American Indians 
and Alaska Natives (AI/ANs) having some of the worst health outcomes of 
any U.S. population. Surely, this cannot be the highest possible health 
status promised by the United States in the IHCIA.
    We understand and appreciate the need for Congress to embrace 
fiscal restraint and balancing the national debt. However, our 
ancestors have already prepaid for health care. This is not a new or 
``nice to have'' program. IHS is an essential program that is the 
fulfillment of sacred promises made to Tribal nations. It is time that 
the U.S. Congress finally live up to these obligations and provide his 
with adequate funding. We cannot expect the Indian health system to 
improve when it does not have the resources it needs.
Just Like our Life Expectancy--U.S. Spending Policy is Stuck in the 
        Termination Era

    Regardless of the Fund source or authorizing provision, the United 
States is making an annual budget policy decision much like the dark 
Termination Era policies that we pretend are behind us. Tribes and 
their citizens originally had a system of health care delivery imposed 
on them that was intentionally insufficient. Meanwhile, States and 
local governments violated Tribes' tax jurisdiction, effectively 
rendering Tribal nations without a way to fund basic infrastructure and 
governance in often isolated and drastically reduced or wholly taken 
lands.
    As part of this imposed system, the resources provided to IHS have 
been chronically underfunded and measurably unequal compared to 
investments in other U.S. populations. We see this systematic 
isolation, sovereign infringement, forced dependence, assimilation, and 
termination in the annual appropriations process each year. We feel it 
in our communities, and the outcomes and data have been placed before 
us. We cannot expect Tribal communities' health to improve when they 
are consistently starved for resources. Too often, Tribal nations are 
trapped in a federal funding structure operating on the assumption that 
only state governments are worthy of base funding, essentially, 
assuming that we do not exist as jurisdictional sovereigns.
IHS Restoring Accountability Act--Step in the Right Direction

    The IHS Restoring Accountability Act is well intentioned, and we 
sincerely appreciate the work that the subcommittee has undertaken to 
elevate the quality of care challenges at IHS. The legislation does 
move the needle forward in some respects by expanding eligibility on 
student loan repayment and the types of providers required to complete 
Tribal culture and history training. Below, we offer some comments on 
specific areas of the draft legislation.

     SEC. 104: Clarification regarding eligibility for Indian 
            Health Service loan repayment program. Loan repayment 
            programs are smaller in scale, when considering their 
            availability to individuals, than loan forgiveness 
            programs. Expanding the eligibility requirements of the 
            Indian Health Service Loan Repayment Program (IHSLRP) to 
            include individuals willing to serve in half-time practice 
            and individuals with master's degrees in health care 
            programs who are also certified in business administration 
            and health-related fields could result in an increase of 
            applicants for employment. Additionally, this program 
            addresses the broad employment need and ongoing shortage of 
            employees by providing employment in exchange for 
            assistance with student loans rather than outright 
            forgiveness. To further address employment vacancies, 
            payments made through the IHS loan repayment program should 
            be tax exempt. Making this assistance tax exempt, as it is 
            for other federally-operated health care loan repayment 
            programs, would help address the workforce shortages at IHS 
            and throughout Indian Country.

     SEC. 105: Improvements in Hiring Practices. We are glad to 
            see language in the bill that would improve on IHS' ability 
            to quickly hire medical professionals. Too often, we hear 
            stories of critical staff being lost to IHS because the 
            federal hiring process is too burdensome and bureaucratic. 
            We also agree with the language in the bill to provide 
            notice to Tribal nations on key personnel changes. NIHB 
            looks forward to working with Tribal nations and the 
            committee to think of creative ways to recruit and retain 
            medical professionals in a timely and efficient manner.

     SEC. 107. Tribal Culture and History. The legislation 
            accurately addresses the need to strengthen and expand the 
            current training requirements for culture and history 
            provided in IHCIA. While issues regarding the creation of 
            training curriculum and consultation of Tribes on the 
            curriculum is not discussed, requiring the training be 
            mandatory and completed annually is a step in the right 
            direction. Expanding the list of individuals required to 
            complete the training to include employees, volunteers, and 
            contractors allows for more culturally aware and educated 
            employees providing care to every individual.

     SEC 108. Staffing Demonstration Program. In this section 
            the bill would direct IHS to carry out a demonstration 
            project in which IHS may provide federally managed Service 
            units with staffing resources. Staffing is a key challenge 
            for health care providers everywhere. The creative 
            demonstration project at these facilities could impact 
            long-term staffing. However, we urge the Subcommittee to 
            work with Tribal nations to examine how this provision 
            could be more broadly expanded throughout the IHS and 
            Tribal health system. We also would urge that critical 
            resources are appropriated as part of this project.

     SEC. 111. Enhancing Quality of Care in the Indian Health 
            Service. Section 111 requires HHS to consult with Indian 
            tribes, governing boards, Area offices, Service units, and 
            other stakeholders and establish best practices for 
            governing boards and Area offices. The language contained 
            in this section is thorough and will go a long way in 
            standardizing care for IHS patients and improving the 
            overall safety of the IHS. However, Congress must ensure 
            that it is fully funded for it to have a significant 
            impact.

Overarching Impacts:

    Self-Governance Impact. Certain provisions in the bill would 
require the IHS to adopt policies or practices that would impact 
compacting and contracting pursuant to the Indian Self-Determination 
and Education Assistance Act (ISDEAA). For example, Section 111 of the 
draft bill requires the Secretary of HHS to establish best practices 
provisions for governing boards and for Area offices and ultimately 
``adopt'' those best practices, but there is no apparent shield from 
the effects of that adoption for Tribes that enter into ISDEAA 
agreements. On its face, the language appears to intend to address best 
practices at IHS-operated Service units, but the definitions used for 
the purpose of this section would include tribal health programs 
operated by a Tribe or Tribal organization through an ISDEAA agreement. 
Policies such as draft Section 111 put forward without an exemption for 
Tribes or Tribal organizations that enter into ISDEAA agreements could 
result in policies that infringe on the notions of Tribal sovereignty 
and self-determination that were and are the fundamental policy 
underpinnings of ISDEAA. Further, it undermines the government 
efficiency aspects of ISDEAA compacts and contracts because it could 
add another compliance layer to operations that are a return to the 
United States telling Tribes how their treaty and trust rights should 
be structured.

    With respect to the impacts of this draft bill on contracting and 
compacting under ISDEAA, it is important to note that draft section 111 
is a single example of how well-intended policies may impact tribal 
sovereignty and self-determination in ways that were not intended or 
expected. NIHB is not an ISDEAA compact or contract negotiator for 
Tribal nations, and the potential for impacts on self-determination or 
`638' contacting and self-governance compacting expand beyond that of 
draft Section 111 in the bill. One solution may be to include a section 
in the bill that clarifies that none of the bill's provisions are 
intended to have an impact on tribally-operated programs, unless a 
tribe specifically agrees otherwise. NIHB continues to collaborate with 
its partners to identify these provisions and propose solutions, but 
the activity, again, underscores why outreach to Tribal nations from 
this Committee is absolutely necessary to identify these concerns and 
develop policy solutions on a government-to-government collaborative 
basis.

    Unfunded mandates. This draft bill has twenty-four sections, seven 
of the sections specifically add additional reporting requirements for 
IHS and five others establish additional programs to be created and 
implemented by either HHS or IHS. Many sections, like section 111: 
Enhancing Quality of Care in the Indian Health Service, add more than 
one additional reporting requirement for multiple different agencies 
including but not limited to The Department of Health and Human 
Services, IHS, the Centers for Medicare and Medicaid Services, and GAO. 
While many of the reporting requirements and programs outlined in the 
draft bill are well intentioned, and likely needed, Congress must 
provide appropriated funds for these actions to occur. Additional 
transparency from IHS is essential in improving care and ensuring that 
the scarce dollars appropriated to IHS are well spent. But time and 
time again, Congress enacts legislation that places yet another barrier 
on Indian Country receiving access to quality healthcare. Mandatory 
appropriations for the IHS are consistent with the trust responsibility 
and treaty obligations reaffirmed by the United States in IHCIA. It's 
time for Congress to provide essential appropriated funding, otherwise 
this legislation will be another set of unfunded challenges at IHS.
Additional Key Policy Recommendations:

    In addition to the comments below, we would like to reiterate some 
policy recommendations to improve and enhance the Indian Health 
Service.

     Expansion of Tribal Self Governance for the Special 
            Diabetes Program for Indians (SDPI): Tribes and Tribal 
            organizations have repeatedly called for a change to the 
            Special Diabetes Program for Indians (SDPI) program 
            structure to allow recipients the option to receive funding 
            through 638 contracts and compacts which would allow for 
            self-determination and self-governance. This would 
            establish SDPI as an essential health service, remove the 
            culturally inappropriate competitive grant structure, 
            prevent the unnecessary federal administrative burden, and 
            support Tribal sovereignty by transferring control of the 
            program directly to Tribal governments.

         Data sharing with IHS operated sites and TECs: CDC data from 
2021 show that rates of syphilis are increasing exponentially for 
American Indians and Alaska Natives nationwide, far outpacing the 
national average. Despite these high rates, Tribal Epidemiology Centers 
have not been told the number of infant deaths from syphilis by any 
state or federal agency. Up to 40% of infants born to mothers with 
untreated syphilis can be stillborn or die. Great Plains Tribal 
Leaders' Health Board and its Tribal Epi Center along with Great Plains 
Area Tribes have asked, repeatedly, for more information around the 
syphilis outbreak to help better monitor and address the devastating 
syphilis rates in the region. But it has not be provided by IHS. 
Without this data, TECs and Tribes cannot target prevention and 
education activities; provide testing and treatment to those who need 
it most; or ensure that not one more Native baby is born with 
congenital syphilis.

         This is just one example of a serious issue. This happens time 
and again where our Tribes and TECs are not given access to data that 
they are entitled to receive by law. It is critical that leadership at 
the highest level take immediate action.

     Authorize full mandatory funding for all IHS programs. 
            Through its coerced acquisition of land and resources and 
            genocide destruction of cultures and peoples the United 
            States formed a fiduciary relationship with Tribal nations 
            whereby it has created a trust relationship to safeguard 
            Tribal rights, lands, and resources. As part of this 
            coerced exchange, Congress has continuously reaffirmed its 
            duty to provide for Indian health care. Unfortunately, 
            Tribal nations face an ongoing health crisis directly 
            resulting from the United States' chronic underfunding of 
            Indian health care for decades. This contributes to ongoing 
            health and persistent inequities and disparities. Mandatory 
            appropriations for the IHS are consistent with the trust 
            responsibility and treaty obligations reaffirmed by the 
            United States in IHCIA. Even today, 13 years after IHCIA 
            was permanently enacted, many provisions of IHCIA remain 
            unfunded and without implementation. Full and mandatory 
            funding must include the full implementation of all 
            authorized IHCIA provisions.

    Until Congress passes full mandatory funding for all IHS programs, 
the NIHB urges Congress to pass the following incremental funding 
measures:

  a.  Authorize mandatory funds for Contract Support Costs and 105(l) 
            Lease Payments.

         As the Appropriations Committee has reported for years, 
certain IHS account payments, such as Contract Support Costs and 
Payments for Tribal Leases, fulfill obligations that are typically 
addressed through mandatory spending. Inclusion of accounts that are 
mandatory in nature under discretionary spending caps has resulted in a 
net reduction on the amount of funding provided for Tribal programs 
and, by extension, the ability of the federal government to fulfill its 
promises to Tribal nations.

  b.  Permanently Authorize discretionary advance appropriations.

         Advance appropriations for the IHS marks a historic paradigm 
shift in the nation-to-nation relationship between Tribal nations and 
the United States. With advance appropriations, AI/ANs will no longer 
be uniquely at risk of death or serious harm caused by delays in the 
annual appropriations process. NIHB urges Congress to pass a bill 
authorizing annual advance appropriations for all areas of the IHS 
budget and providing for increases from year to year that adjust for 
inflation, population growth, and necessary program increases. NIHB 
supports advance appropriations until full, mandatory appropriations 
are enacted.

  c.  Protect the IHS budget from ``sequestration'' cuts.

         The IHS budget remains so small in comparison to the national 
budget that spending cuts or budget control measures would not result 
in any meaningful savings in the national debt, but it would devastate 
Tribal nations and their citizens. As Congress considers funding 
reductions in FY 2024, IHS must be held harmless. As we saw in FY 2013 
poor legislative drafting subjected our tiny, life-sustaining, IHS 
budget to a significant loss of base resources. Congress must ensure 
that any budget cuts--automatic or explicit--hold IHS and our people 
harmless.

  d.  Authorize federally-operated health facilities and IHS 
            headquarters offices to reprogram funds at the local level 
            in consultation with Tribes.

         The Indian Self-Determination and Education Assistance Act 
(ISDEAA) authorized Tribal nations to take greater control over their 
own affairs and resources by contracting or compacting with the federal 
government to administer programs that were previously managed by 
federal agencies. This includes the ability to develop and implement 
their own policies, procedures, and regulations for the delivery of 
these services. Tribal nations may also receive direct services from 
the IHS. Unfortunately, some of the flexibility that makes ISDEAA so 
cost effective at delivering services is not available at the local 
level when direct services are provided by the IHS. Fundamentally, the 
ability to direct resources is one of Tribal sovereignty and self-
determination. Just because a Tribe chooses to receive direct services 
from IHS does not mean it forfeits these rights. IHS must have greater 
budget flexibility, especially at the local service unit level to 
reprogram funds to meet health service delivery priorities, as directed 
by the Tribes who receive services from that share of the IHS funding.

  e.  Authorize Medicaid reimbursements for Qualified Indian Provider 
            Services.

         In 1976, Congress gave the Indian health system access to the 
Medicaid program in order to help address dramatic health and resources 
inequities and to implement its trust and treaty responsibilities to 
provide health care to AI/ANs and today, Medicaid remains one of the 
most critical funding sources for the Indian health system. In order to 
ensure that States not bear the increased costs associated with 
allowing Indian health care providers access to Medicaid resources, 
Congress provided that the United States would pay 100 percent of the 
costs for services received through Indian health care providers (100 
percent FMAP). While Congress provided equal access to the Medicaid 
program to all Indian health care providers, in practice access has not 
been equal. Because States have the option of selecting some or none of 
the optional Medicaid services, the amount and type of services that 
can be billed to Medicaid varies greatly state by state. So, while the 
United States's trust and treaty obligations apply equally to all 
tribes, it is not fulfilling those obligations equally through the 
Medicaid program. To further the federal government's trust 
responsibility, and as a step toward achieving greater health equity 
and improved health status for AI/AN people, we request that Congress 
authorize Indian health care providers across all states to receive 
Medicaid reimbursement for a new set of Qualified Indian Provider 
Services. These would include all mandatory and optional services 
described as ``medical assistance'' under Medicaid and specified 
services authorized under the IHCIA when delivered to Medicaid-eligible 
AI/ANs. This would allow all Indian health care providers to bill 
Medicaid for the same set of services regardless of the state they are 
located in. States could continue to claim 100 percent FMAP for those 
services so there would be no increased costs for the states for 
services received through IHS and tribal providers.
Conclusion
    For the last 47 years, the United States has had a policy of 
ensuring the highest possible health status for Indians and to provide 
all resources necessary to affect that policy. Unfortunately, those 
responsibilities and legal obligations remain unfulfilled and Indian 
Country remains in a health crisis. Clearly, the status quo isn't 
working.
    Time will tell if today's hearing on the challenges and 
opportunities for improving healthcare delivery in Tribal communities 
marked the beginning of significant change, or the continuation of the 
status quo. The challenges are many, but most are equally matched by 
the opportunities and solutions already identified by Tribal leaders, 
Congresses, and Administrations past and present.
    There is a way forward if Congress can overcome perhaps the 
greatest remaining challenge: political will. NIHB recognizes that the 
recommendations offered in this testimony will require coordination 
with other committees of jurisdiction, and we stand ready to help with 
that effort. But the heavy lifting must be borne by this Subcommittee. 
No other subcommittee in the House is as focused on Indian affairs as 
this one. At the same time, as noted earlier, we encourage Congress to 
support an NSC process that would allow for Tribes to advocate for 
needed changes to IHCIA with one united voice. This process is critical 
to ensure that the changes only improve, and do not cause unintentional 
harm for the Indian health system. For the sake of our People, we hope 
this Subcommittee in the 118th Congress is up to the challenge.
    Thank you again for the opportunity to offer testimony on this 
legislation today. We are happy to answer any questions you might have.

                                 ______
                                 

  Questions Submitted for the Record to Mr. Lee Spoonhunter, Billings 
           Area Representative, National Indian Health Board

Mr. Spoonhunter did not submit responses to the Committee by the 
appropriate deadline for inclusion in the printed record.

            Questions Submitted by Representative Westerman
    Question 1. Previous versions of the Restoring Accountability in 
the Indian Health Service Act included a section on medical chaperones.

    Is there still a need for medical chaperones for patients at IHS 
facilities? And if so, please elaborate on what language should be 
added to this discussion draft to address the issue.

    Question 2. Recruitment and retention of health care personnel are 
two issues this committee has heard about time and time again, 
especially in rural areas. The entire health care system faces 
challenges of hiring and retaining medical professionals.

    2a) Anecdotally, what barriers do you know medical professionals 
face to work at either IHS or tribally run health care programs?

    2b) What have you seen in tribally run health care programs 
regarding improvements to hiring and recruitment that could help IHS 
fill their staff vacancies and improve employee retention?

    2c) What sections of this discussion draft could help with 
recruitment and retention of personnel the most?

    Question 3. There have been reports regarding the lack of 
accountability when it comes to IHS employees and misconduct.

    3a) Anecdotally, can you provide any examples of complaints toward 
IHS medical staff not being taken seriously by IHS officials?

    3b) Are you aware of any incidents that have not been previously 
reported where an IHS employee retained their position despite 
complaints being raised against them?

    3c) Are the protections provided in this discussion draft enough 
for IHS employees to raise objections and be certain they are safe to 
do so?

    Question 4. NIHB raised the question of reimplementing a tribal 
advisory committee like the National Steering Committee to Reauthorize 
of the Indian Health Care Improvement Act (IHCIA) that had previously 
advised the federal government about changes to the IHCIA, prior to its 
permanent reauthorization.

    4a) Would your organization be supportive of that sort of committee 
being established? What if the tribal leaders who serve on the 
committee would serve without pay?

    4b) What other advisory committees or councils that are currently 
established in HHS or IHS that could be used to provide the expertise 
the National Steering Committee previously provided?

    4c) What further ways aside from a national steering committee may 
be beneficial to institute so IHS will have more input from tribes on 
how to improve IHS policies and procedures?

    Question 5. Concerns were raised in NIHB written testimony about 
the discussion draft affecting tribally run health programs that have 
been compacted or contracted out from IHS.

    5a) What sections of this discussion draft could most affect 
tribally operated health programs and how?

    5b) What language do you think should be included to reduce that 
effect?

    5c) Are there aspects of this discussion draft that would improve 
tribal autonomy and control over tribally run health programs?

    Question 6. From your perspective, what regulations and official 
guidance from IHS cause the largest challenges for tribal members 
seeking care? What about for tribes compacting or contracting out 
health care services from IHS?

    Question 7. In your testimony, NIHB raised concerns regarding 
unfunded mandates and programs included in this discussion draft.

    7a) Does NIHB have concerns with these programs specifically, or 
are the concerns only about funding?

    7b) If IHS has already begun to institute some of these policies 
and programs with their current funding, does that change NIHB's 
position?

         Questions Submitted by Representative Leger Fernandez

    Question 1. A common theme throughout the hearing was the need for 
Congress to hear directly from tribes and tribal organizations across 
the country on any policies designed to improve direct or indirect IHS 
care for American Indians and Alaska Natives.

    1a) How do you believe Congress should consult with Tribes on their 
unique experiences and perspectives to inform potential legislation to 
improve the Indian Healthcare Improvement Act (IHCIA)?

    1b) One recommendation put forward was for Congress to support a 
National Steering Committee (NSC) process to examine necessary reforms 
to IHS and IHCIA. How do you believe Congress can best support Tribes 
in such processes to ensure policy outcomes are led by tribal leaders?

                                 ______
                                 

    Ms. Hageman. Thank you, Mr. Spoonhunter, for your 
testimony.
    The Chair now recognizes Ms. Jerilyn Church for 5 minutes.

 STATEMENT OF JERILYN CHURCH, EXECUTIVE DIRECTOR, GREAT PLAINS 
     TRIBAL LEADERS HEALTH BOARD, RAPID CITY, SOUTH DAKOTA

    Ms. Church. Good afternoon, Chairwoman Hageman, Ranking 
Member Fernandez, distinguished members of the Subcommittee, 
and Representative Johnson, thank you so much for the 
opportunity to be here this afternoon and to share my thoughts 
and testimony on the discussion draft for ``Restoring 
Accountability in the Indian Health Service.''
    On behalf of the Great Plains Tribal Leaders Health Board, 
my name is Jerilyn Church. I am a member of the Cheyenne River 
Sioux Tribe. I serve as the President and CEO of the Great 
Plains Tribal Leaders Health Board and the Oyate Health Center 
in Rapid City, South Dakota.
    We serve as a liaison between the tribes in the Great 
Plains, North Dakota, South Dakota, Nebraska, and we have one 
member tribe in Iowa, and we represent the tribes on various 
Health and Human Services divisions, including the Indian 
Health Service.
    In our region, the Indian Health Service is the primary 
source of healthcare for nearly 150,000 American Indians and 
Alaska Natives in the Great Plains area. So, we are acutely 
aware of the difficulties and challenges within the Indian 
Health Service and of the need to improve healthcare delivery 
and health outcomes for Indian people in our communities. In 
fact, this past spring, I had the opportunity to testify before 
this Subcommittee on some of these challenges and appreciate 
the members of this Subcommittee placing an emphasis on 
improving IHS and its operations.
    This draft legislation brings up important improvements, 
improving IHS management, the whistleblower protections, 
provision for housing, strengthening training requirements, the 
establishment of a compliance assistance program and, of 
course, providing for transparency in CMS surveys. However, we 
believe that there are additional opportunities to improve the 
language.
    One of the concerns that we have is that in order to make 
changes and improvements, IHS is already under-resourced 
significantly, so any changes and improvements that are put 
forward need to be funded adequately to make meaningful change. 
We don't want it to become an issue where there are additional 
red tape or additional reporting requirements that take away 
from healthcare delivery, but strengthen already existing 
provisions that the Indian Health Service is required to 
provide that they may not be. We don't want it to be so 
burdensome that we end up just adding additional barriers to 
improve healthcare.
    We want to make sure that there is parity between tribally-
operated systems and direct service units that are managed 
directly by IHS. That is a really important distinction. If the 
language is not written in such a way that doesn't make those 
distinctions, then there becomes an issue of tribes that are 
already running their systems perhaps not being able to have 
the same flexibilities that they had before and to be 
innovative, which is one of the main reasons why tribes pursue 
self-determination and self-governance so that they can work 
outside of some of the parameters and red tape that Indian 
Health Service sometimes has that gets in the way.
    The Health Board is happy to work with the members of the 
Subcommittee on suggestions. As my colleague here stated, one 
of the most effective mechanisms for tribal leaders to lend a 
voice and share their knowledge and wisdom was through the 
national steering committee on the reauthorization of the 
Indian Healthcare Improvement Act. So, we would strongly urge 
the members of the Subcommittee to work with your colleagues to 
direct Indian Health Service to reinstate that committee.
    We thank you again for this opportunity to provide 
testimony today. This is a critical issue in the Great Plains. 
And, again, appreciate the opportunity to work with you to 
improve healthcare delivery for our people. [Speaking Native 
language.]

    [The prepared statement of Ms. Church follows:]
   Prepared Statement of Jerilyn LeBeau Church, Great Plains Tribal 
                          Leaders Health Board
    Thank you for this opportunity to present testimony on the 
discussion draft of the ``Restoring Accountability in the Indian Health 
Service Act of 2023'' on behalf of the Great Plains Tribal Leaders 
Health Board (GPTLHB). GPTLHB serves as a liaison between the Great 
Plains Tribes and the various Health and Human Services divisions, 
including the Great Plains Area Indian Health Service (IHS), and works 
to reduce public health disparities and improve the health and wellness 
of American Indian people and Tribal communities across the Great 
Plains. In our region, the Indian Health Service (IHS) is the primary 
source of health care for nearly 150,000 American Indians/Alaska 
Natives in the Great Plains Area. Of the six hospitals in the Great 
Plains, five are managed directly by IHS. Of the 13 ambulatory health 
clinics in the Great Plains Area, seven are managed entirely by a tribe 
or a tribal organization under a Title I Self-Determination contract, 
and five are managed directly by IHS. One is tribally managed through a 
Title V Self Governance compact. In addition, the Indian Health Service 
is responsible for two substance abuse treatment centers and supports 
three urban health care programs.

    Therefore, at GPTLHB, we are acutely aware of the difficulties and 
challenges the IHS faces in improving healthcare delivery and 
healthcare outcomes for Indian people in our communities. In fact, just 
this spring, I testified before this Subcommittee on these current 
challenges and opportunities. We appreciate the members of this 
Subcommittee' placing an emphasis on improving the IHS and its 
operations. This draft legislation raises several important issues and 
proposes important improvements to the system, including;

     improvements to IHS management;

     employee whistleblower protections;

     the provision for housing vouchers for recruitment and 
            retention;

     strengthening the training requirements for tribal culture 
            and history;

     the establishment of a compliance assistance program; and

     providing for transparency in CMS surveys.

    We do, however, have concerns about the legislation as drafted. 
These include the need to make sure that the legislation does not 
confer additional unfunded mandates on the already seriously under-
resourced IHS and that additional administrative requirements 
(including agency reporting requirements) will not be so burdensome as 
to take time and resources away from patient care. Concerning 
improvements to IHS operations, ensuring the agency has sufficient 
resources to do its job is the most crucial factor. It is also 
essential to make sure that the legislation does not duplicate 
authorities that IHS already has and that it maintains parity between 
Tribally operated healthcare facilities and programs where appropriate. 
It is also essential that Tribal facilities and programs are allowed to 
opt into or not participate in certain IHS-specific requirements 
imposed by the bill, such as the proposed uniform medical credentialing 
system. As legislation is passed to ensure that it is implemented in 
ways most appropriate to balancing IHS and tribal concerns, we 
recommend that the legislation require negotiated rulemaking where 
representatives of IHS and tribes around the country can meet together 
to determine the most effective implementation.
    GPTLHB is happy to work with the Members of the Subcommittee on 
suggestions for improvements to the legislation as drafted, but the 
discussion draft--and the issues underlying it--raise the larger 
question of the process of including Tribal voices in potential 
legislative improvements through amendments to the Indian Healthcare 
Improvement Act (IHCIA). In the past, these legislative efforts would 
primarily be driven by input from the knowledge, wisdom, and difficult 
decision-making of the Tribal leaders who made up the National Steering 
Committee (NSC) on the Reauthorization of the IHCIA. Now that the IHCIA 
has been made permanent, that mechanism for critical Tribal input no 
longer exists. We strongly urge the Members of the Subcommittee to work 
with your colleagues to direct IHS to reinstate the NSC and to provide 
sufficient appropriations to support its critical work.
    Thank you for the opportunity to provide testimony today on this 
critical issue and for your efforts to improve healthcare delivery to 
all our People and communities.

                                 ______
                                 
  Questions Submitted for the Record to Ms. Jerilyn Church, Executive 
           Director, Great Plains Tribal Leaders Health Board

Ms. Church did not submit responses to the Committee by the appropriate 
deadline for inclusion in the printed record.

            Questions Submitted by Representative Westerman

    Question 1. Previous versions of the Restoring Accountability in 
the Indian Health Service Act included a section on medical chaperones.

    Is there still a need for medical chaperones? And if so, please 
elaborate on what language should be added to this discussion draft to 
address the issue.

    Question 2. Recruitment and retention of health care personnel are 
two issues this committee has heard about time and time again, 
especially in rural areas. The entire health care system faces 
challenges of hiring and retaining medical professionals.

    2a) Anecdotally, what barriers do you know medical professionals 
face to work at either IHS or tribally run health care programs?

    2b) What have you seen in tribally run health care programs 
regarding improvements to hiring and recruitment that could help IHS 
fill their staff vacancies and improve employee retention?

    2c) What sections of this discussion draft could help with 
recruitment and retention of personnel the most?

    Question 3. There have been reports regarding the lack of 
accountability when it comes to IHS employees and misconduct.

    3a) Anecdotally, can you provide any examples of complaints toward 
IHS medical staff not being taken seriously by IHS officials?

    3b) Are you aware of any incidents that have not been previously 
reported where an IHS employee retained their position despite 
complaints being raised against them?

    3c) Are protections provided in this bill are enough for I-H-S 
employees to raise objections and be certain they are safe to do so?

    Question 4. NIHB raised the question ofreimplementing a tribal 
advisory committee like the National Steering Committee to Reauthorize 
of the Indian Health Care Improvement Act (IHCIA) that had previously 
advised the federal government about changes to the IHCIA, prior to its 
permanent reauthorization.

    4a) Would your organization be supportive of that sort of committee 
being established, even if it would require tribal leaders who serve on 
the committee to serve without pay?

    4b) What other advisory committees or councils that are currently 
established in HHS or IHS that could be used to provide the expertise 
the National Steering Committee previously provided?

    4c) What further ways aside from a national steering committee may 
be beneficial to institute so IHS will have more input from tribes on 
how to improve IHS policies and procedures?

    Question 5. In your testimony you mentioned the need to ensure that 
this discussion draft does not duplicate authorities IHS already has.

    5a) Could you elaborate further on that point and provide examples 
of sections of the bill that may duplicate current IHS authorities?

    5b) Are you aware of programs or policies within this discussion 
draft that IHS is already working to implement or improve and, if so, 
what are they?

    Question 6. From your perspective, what regulations and official 
guidance from IHS cause the largest challenges for tribal members 
seeking care? What about for tribes compacting or contracting out 
health care services from IHS?

    Question 7. During the hearing, you brought up concerns with the 
medical credentialing aspect of the legislation as well as tribal 
health program autonomy.

    7a) What specific medical credentials could IHS institute that 
could be detrimental to tribally run medical facilities?

    7b) Could you elaborate on how the discussion draft should balance 
tribal autonomy and ensuring parity of care and credentialing occurs 
across both IHS and tribally run health programs?

    7c) Is there anything else Congress should need to know to make the 
best policy decisions on this topic?

         Questions Submitted by Representative Leger Fernandez

    Question 1. A common theme throughout the hearing was the need for 
Congress to hear directly from tribes and tribal organizations across 
the country on any policies designed to improve direct or indirect IHS 
care for American Indians and Alaska Natives.

    1a) How do you believe Congress should consult with Tribes on their 
unique experiences and perspectives to inform potential legislation to 
improve the Indian Healthcare Improvement Act (IHCIA)?

    1b) One recommendation put forward was for Congress to support a 
National Steering Committee (NSC) process to examine necessary reforms 
to IHS and IHCIA. How do you believe Congress can best support Tribes 
in such processes to ensure policy outcomes are led by tribal leaders?

                                 ______
                                 

    Ms. Hageman. Thank you, Ms. Church. And we all agree that 
this is a very important issue, so, again, we appreciate you 
being here.
    I believe they have called votes, but we are going to go 
ahead and have Mr. Carl do his 5 minutes of questioning just to 
make sure that we can get those in. So, Mr. Carl, if you would 
please proceed with 5 minutes of questioning.
    Mr. Carl. Thank you, Madam Chairman, and thank you to the 
panel for coming and speaking and taking your time. Mr. 
Spoonhunter, it is always great to see you. We have developed a 
friendship over time. My question is targeted at you, but let 
me run through a list here real quick.
    As you are aware, the Indian Health Services play a 
critical role in providing healthcare to the Native American 
community. It is evident that the Indian Health Services has 
been struggling with issues like substandard medical care, high 
staff vacancy rate, and I think we were around 50 percent a 
while ago when I heard some numbers talked about, and 
inadequacy of the facilities, making it hard for them to 
deliver quality healthcare to those who need it the most.
    The Restoring of Accountability in the Indian Health 
Services Act aims to address various problems. One is the 
inability to retain quality healthcare professionals. I know 
that the Federal Government always feels like they have all the 
answers. I am one of those that don't believe that. I grew up 
digging ditches and working with my hands, and most of the 
answers, you have to go to the field to actually figure that 
out and talk to the people and learn what the problems truly 
are.
    So, my question to you, in your experience, what measures 
do you believe this Act should include to effectively improve 
overall state of healthcare delivery in the Indian Health 
Services?
    Mr. Spoonhunter. Thank you, Representative Carl, it is 
always good to see you here on the Hill. At Wind River, we have 
a very unique situation. We have two tribes there: the Eastern 
Shoshone and the Northern Arapaho. The Eastern Shoshone, the 
majority of their tribal members go to a direct IHS funded 
facility which was built in the 1800s, that is still open today 
and still needs to be replaced. That is the standard that 
hopefully this bill will cover.
    And then you have the Northern Arapaho who have taken the 
Arapaho Clinic there and they have 638 self-determination, took 
the resources from IHS and developed quality healthcare for our 
people there without the bureaucratic red tape that IHS has in 
place that sometimes prevents our tribal members from receiving 
the adequate quality care that they need. Through self-
governance, we are able to have competitive wages for the 
medical team, doctors, nurses, all of the staff, with the 
surrounding Fremont County that we live in.
    And we are also able to provide insurance and a 401(k) 
package that is a lot better than what IHS can provide. So, we 
retain a lot of our doctors, and a lot of our doctors have come 
and stayed with us. But it is through self-governance that we 
are so successful.
    We have been able to take one clinic in of our communities 
and open up two clinics, one in Ethete, Wyoming and the one in 
Riverton, Wyoming which is on the neighboring town of the 
reservation. The Riverton Clinic is more visited than the 
reservation clinics because a lot of our tribal members have a 
lack of housing, so they have to stay in a neighboring town.
    But the answer to your question is, it is through self-
governance and through 638 that we are able to use our tribal 
sovereignty to provide better care to our tribal members, and 
we encourage our Eastern Shoshone tribal counterparts to do the 
same, and I know they are in that process now. But it is 
through, again, I say the bureaucratic red tape of IHS and what 
they have to endure that sometimes the quality of care for 
tribal members and Native American people gets lost in all of 
the government rules and regulations that IHS has to go 
through, and that is unfortunate.
    It is unfortunate because we should be talking about 
quality healthcare for our people and a lot less rules and 
regulations. But with this bill, we look forward to continued 
dialogue so that we can get it right. We want to work with 
Congress and let's get it right once and for all.
    Mr. Carl. Thank you, Mr. Spoonhunter. Might I make a 
suggestion? I would love to do a CODEL and go out and look at 
some of these places that these tribal members actually pick 
for us to look at, not for IHS to choose for us. I would like 
to go out there and look at it. My background is healthcare, I 
spent 35 years in it, in managing, so I would love to go out 
and look and see what they are actually dealing with. And if we 
could do that as a group, that would be great.
    Ms. Hageman. I think that is an excellent idea and we will 
work with staff to see if that is something that we can put 
together.
    Mr. Carl. I yield back my time. Thank you.
    Ms. Hageman. Thank you very much. The Chair now recognizes 
Ms. Leger Fernandez for her 5 minutes of questioning.
    Ms. Leger Fernandez. Thank you so much for pointing out 
really the task before us, which is just how do we go about, 
(1), coming up with the ideas for the bill. And the issue of 
what I am hearing from you, Mr. Spoonhunter, is that going back 
to the system of using the CSA, and I heard, Ms. Church, you 
say that as well. Do you agree with that, too? OK.
    So, the process that you would like to see is to make sure 
that we are able to gather input from the wide range of tribes 
and tribal communities receiving healthcare.
    Mr. Spoonhunter, the idea is that it is very distinct. Like 
in one reservation, you have a 638 compacted facility and then 
a direct, and what you see is very different. And I have helped 
build and set up health boards, and oh my god, it is amazing 
when you can end up having a joint venture facility, being able 
to staff it like it should be instead of, as you pointed out, 
frozen in time, was it 1927 or something? And that is key in 
being able to make those distinctions. So, I think that that is 
something that we really need to do.
    So, this idea of a consultation process, can you just 
explain a little bit more how you would like that to look?
    Ms. Church. Yes, I will throw my two cents in there. The 
national steering committee that was established when the 
Indian Healthcare Improvement Act was reauthorized, and that no 
longer exists, but that body that consisted of tribal 
representation, tribal leaders from across all of Indian 
Country was the driving force. Their voice was the driving 
force to make the recommendations for what needed to happen to 
improve and update the Indian Healthcare Improvement Act.
    At that time, that body, they were the primary authors. 
There are still some things that could be finessed with that, 
but it was tribal leadership, not Indian Health Service, that 
was driving those changes and that is what made the Indian 
Healthcare Improvement Act so much more effective and brought 
the opportunities that we have today.
    Ms. Leger Fernandez. And in essence it was tribal 
leadership and also not Congress, right? We were listening to 
what was coming out of this process.
    Ms. Church. Exactly.
    Ms. Leger Fernandez. Which was lengthy. If we don't act 
quickly, I mean, every day that we wait to get better services, 
it is heartbreaking, somebody dies, right, somebody is ill.
    Mr. Spoonhunter, did you want to add something?
    Mr. Spoonhunter. Yes, thank you, Representative Fernandez. 
As a 638 and as a self-governance, it is the tribal leaders who 
oversee the clinic. We are responsible for the day-to-day 
activities of that clinic, as where in an IHS direct service we 
are not. And Ms. Church hit on a key point. Come to the tribal 
leaders, come to us, and when you are doing the consultation of 
this bill, and in working through what we need to fix, because 
it is not IHS that needs to fix it. As tribal leaders, the 
sovereign nations, we know what we need to do for our people to 
provide better healthcare. Just give us the opportunity. Thank 
you.
    Ms. Leger Fernandez. Thank you. And, Ms. Church, you are in 
a very interesting position because you are in the process 
right now of building the joint venture facility, which meant 
you had to come up with the money, right? I have helped finance 
those. And not every tribe is going to be in that position. So, 
what is your recommendation to us for those tribes who are not 
in a position to finance a facility and/or compete for those 
joint venture slots?
    Ms. Marchand. I am not sure what my recommendation would 
be. Obviously, more money. That is always a key. But, again, I 
think as those to the left of me have said, by going to those 
tribes and listening to what their needs are, possibly you may 
not find out it is as expensive as what they need.
    So, I would say just going with the consultation and just 
finding out like what other programs or things that maybe we 
could do for them that may not be a joint venture or that 
magnitude but things that could improve their Indian Health 
Services through appropriations.
    Ms. Leger Fernandez. OK, thank you so much, and we will 
submit any additional questions in writing because I think 
there is a lot of material that you have given us that we need 
to flesh out, so I truly appreciate it.
    Ms. Hageman. Thank you. The Chair now recognizes Mr. 
Johnson for 5 minutes of questioning.
    Mr. Johnson. You are so very gracious, ma'am, thanks. I 
won't take the 5 minutes because you may want to get in before 
votes as well.
    But first off, Ms. Church, I would just validate everything 
you were saying about being under-resourced. That is clearly a 
big part of the issue. I did like the distinction you drew, I 
think an important one between tribally-administered facilities 
and those that are directly administered.
    Give us a little more meat on that bone. How specifically 
could we help strengthen this legislation by calling out those 
important distinctions?
    Ms. Church. Thank you. Yes, so I can give examples probably 
better than getting into the details. For instance, I think one 
of the recommendations in the bill was around credentialing and 
having a uniform credentialing process. I think that would work 
for Federal facilities that are managed directly by IHS. Some 
of our programs that are run by tribes, they may partner with 
another health system that may not be part of the Indian Health 
Service. So, there is flexibility that tribes and tribal 
organizations such as ours have to get creative with how to 
make our system work better.
    Another example is our tribal sponsorship. One of the ways 
that Oyate Health Center helps to make our dollars go further 
is we have a tribal sponsorship program. We take a portion of 
our PRC dollars, and we buy insurance for a group of our 
beneficiaries who may not be eligible, meet the criteria for 
Medicaid, but don't have insurance. So, that is something that 
the Federal Government cannot do that we can do. We can 
purchase tribally-sponsored insurance that brings revenue back 
into our system and it helps those PRC dollars go a lot 
further. Those are a couple of examples.
    Mr. Johnson. Oh, it is wonderful, and South Dakota is so 
grateful for your leadership, ma'am, thanks.
    And, Madam Chair, I yield back.
    Ms. Hageman. Thank you for that. The Chair now recognizes 
myself for 5 minutes of questioning.
    First of all, Mr. Spoonhunter, you were speaking my 
language in your testimony when you talked about the challenges 
associated with the over-regulation that comes from the IHS. 
What I would like to do, because I would think that it might 
take us 6 or 7 hours if I were to ask you all of the 
regulations that create problems for you, I would like to have 
an opportunity to engage with you, since I represent the state 
of Wyoming, where you can perhaps identify for us, and we will 
send some written questions to this effect, that maybe you can 
identify some of those regulations that cause the largest 
challenges, maybe for one or two of your facilities, maybe for 
all of your facilities.
    But I am a strong advocate, No. 1, in making sure that you 
have the autonomy to do what you need to do to take care of 
your tribal members, because I think you are going to be better 
at it than anybody out of Washington, DC. I am not trying to 
disparage anyone, I am just saying you care about the people 
there more than anyone here ever will, and it is just the 
reality. The closer you are to the situation, the more 
effective you are going to be.
    So, I would like to identify some of those rules and 
regulations coming out of IHS, or HHS, or wherever it may be 
coming from that are causing the challenges that you have, and 
let's see if we can fix some of those as well.
    In your testimony, Mr. Spoonhunter, you stated that the 
NIHB looks forward to working with Tribal Nations and the 
Committee to think of creative ways to recruit and retain 
medical professionals in a timely and efficient manner. I would 
also throw in there perhaps dental professionals because that 
is one of the other issues that has been brought to us 
repeatedly is the challenges of finding dental care for our 
tribal members.
    So, the question I have for you is, could you please expand 
on what those creative ways could be and how they could align 
with the goals of the IHS staff recruitment and retention 
related to this particular draft legislation?
    Mr. Spoonhunter. Thank you, Chairwoman. On the staffing 
levels that the IHS has had a problem with filling, again, yes, 
underfunding positions is a problem within IHS. We all know 
that. But that would just be a Band-Aid fix. We really need to 
sit down, with self-governance, at Wind River, we were able to 
get a person that would recruit our physicians, providers, 
nurses, and vet them through a very rigorous process, and we 
were able to also offer housing through the self-governance and 
through third-party billing.
    As you know, in my area, the Billings area that I 
represent, Fort Peck cannot keep a doctor because there is no 
housing there. And I know this bill covers a housing voucher in 
a similar way, but we were able to also bring on the signing 
bonus for providers through the third-party billing. But, 
again, it is a lot of bureaucracy that IHS has to go through to 
hire. It takes a whole process.
    I mean, we were talking today about an administrator 
position in one of the IHS service units that they had to raise 
the wage in order to hire someone to meet the qualifications of 
that job, and now that job has to wait 90 days because of IHS 
rules. That is an example of the bureaucracy that we have to 
wade through in order to hire someone of that administrative 
magnitude that will help direct these facilities.
    So, again, it is a matter of allowing the tribes to come in 
and be part of that process and asking IHS these necessary 
questions that Congress I am sure that you have asked IHS, why 
does it take you so long to hire someone, why are you not able 
to recruit and keep someone in that position. Those things are 
very critical.
    And you talk about the dentist program. We are all 
scrambling to try to find dentists and retain dentists 
throughout Indian Country, and I know IHS is doing the same 
thing. But what can we do on a creative side that some of the 
self-governance 638 programs have done to recruit dentists? 
Let's look at their plans and what they did, because as tribes 
we are resourceful.
    We are resourceful because we take what we have, and we 
make it work. And I think that the plans, like my colleague 
here Ms. Church said, have IHS sit down at the table with the 
tribal leaders and learn from us. We have taken self-governance 
638 and we have done it better than what IHS could ever do.
    Ms. Hageman. OK. I appreciate that, and we want to learn 
from you. Ms. Marchand and Ms. Church, I would request the same 
thing, if you have ideas of how we can streamline this and 
address it.
    One of the things in Wyoming, because we are the least 
populated state in the nation, and we only have one university, 
and we don't provide either dental training or medical 
training, so we have arrangements with other universities. We 
send our physicians to the University of Washington, UW, 
another UW, for example, and then we do the same thing with 
dental care, and then they come back to Wyoming and must spend, 
I believe it is, a minimum of 5 years practicing in the state 
of Wyoming, but they can get in-state tuition when they are 
going out of state to be able to receive that training.
    I don't know if those are the kinds of programs that we 
could do with our tribal members as well, but I am absolutely 
willing to look at innovative ways to address this issue. I 
know Mr. Johnson is. I am extremely proud to have him with us 
on the Committee today for the hearing to talk about these 
things.
    We do have to leave and go vote, so what I am going to say 
is that I really want to thank all of you for being here. I 
wish we could have spent a bit more time together. It is kind 
of a strange time for all of us. You have provided extremely 
valuable testimony. We are going to follow up with you because 
we do have additional questions.
    The members of the Committee may have some additional 
questions for the witnesses, and we will ask you to respond to 
these in writing. Under Committee Rule 3, members of the 
Committee must submit questions to the Committee Clerk by 5 
p.m. on Tuesday, August 1, 2023. The hearing record will be 
held open for 10 business days for these responses.

    And if there is no further business, without objection, the 
Committee stands adjourned.

    [Whereupon, at 3:14 p.m., the Subcommittee was adjourned.]

            [ADDITIONAL MATERIALS SUBMITTED FOR THE RECORD]

Submission for the Record by Rep. Grijalva

                        Statement for the Record
                    United South and Eastern Tribes
                      Sovereignty Protection Fund
         on H.R.____, ``Restoring Accountability in the Indian
                      Health Service Act of 2023''

    The United South and Eastern Tribes Sovereignty Protection Fund is 
pleased to provide testimony for the record of the House Natural 
Resources Subcommittee on Indian and Insular Affairs legislative 
hearing on the discussion draft of H.R. ____, The Restoring 
Accountability in the Indian Health Service Act of 2023. As we have 
indicated in the past, we can appreciate the intent of legislation to 
address shameful failures in the execution of the Indian Health 
Service's (IHS) trust and treaty obligations to deliver quality health 
care to Tribal Nations and our citizens. However, it is disingenuous to 
ignore the decades of chronic underfunding of the agency and how IHS' 
lack of resources contributes in large part to these failures. In 
addition, although we recognize that this bill remains a discussion 
draft, we underscore the need for thorough Tribal consultation to occur 
prior to further consideration. As written, we join our partners in 
expressing several concerns about the bill's provisions. Although USET 
SPF supports reforms that will improve the quality of service delivered 
by the IHS, we continue to underscore the obligation of Congress to 
meet its trust and treaty obligations by providing full and mandatory 
funding to IHS and support additional innovative legislative solutions 
to improve the Indian Health System.

    USET SPF is a non-profit, inter-tribal organization advocating on 
behalf of thirty-three (33) federally recognized Tribal Nations from 
the Northeastern Woodlands to the Everglades and across the Gulf of 
Mexico.\1\ USET SPF is dedicated to promoting, protecting, and 
advancing the inherent sovereign rights and authorities of Tribal 
Nations and in assisting its membership in dealing effectively with 
public policy issues.
---------------------------------------------------------------------------
    \1\ USET SPF member Tribal Nations include: Alabama-Coushatta Tribe 
of Texas (TX), Catawba Indian Nation (SC), Cayuga Nation (NY), 
Chickahominy Indian Tribe (VA), Chickahominy Indian Tribe--Eastern 
Division (VA), Chitimacha Tribe of Louisiana (LA), Coushatta Tribe of 
Louisiana (LA), Eastern Band of Cherokee Indians (NC), Houlton Band of 
Maliseet Indians (ME), Jena Band of Choctaw Indians (LA), Mashantucket 
Pequot Indian Tribe (CT), Mashpee Wampanoag Tribe (MA), Miccosukee 
Tribe of Indians of Florida (FL), Mi'kmaq Nation (ME), Mississippi Band 
of Choctaw Indians (MS), Mohegan Tribe of Indians of Connecticut (CT), 
Monacan Indian Nation (VA), Nansemond Indian Nation (VA), Narragansett 
Indian Tribe (RI), Oneida Indian Nation (NY), Pamunkey Indian Tribe 
(VA), Passamaquoddy Tribe at Indian Township (ME), Passamaquoddy Tribe 
at Pleasant Point (ME), Penobscot Indian Nation (ME), Poarch Band of 
Creek Indians (AL), Rappahannock Tribe (VA), Saint Regis Mohawk Tribe 
(NY), Seminole Tribe of Florida (FL), Seneca Nation of Indians (NY), 
Shinnecock Indian Nation (NY), Tunica-Biloxi Tribe of Louisiana (LA), 
Upper Mattaponi Indian Tribe (VA) and the Wampanoag Tribe of Gay Head 
(Aquinnah) (MA).

---------------------------------------------------------------------------
Chronic Underfunding Leads to IHS Failures

    As the Subcommittee is well aware, Native peoples have endured many 
injustices as a result of federal policy, including federal actions 
that sought to terminate Tribal Nations, assimilate Native people, and 
to erode Tribal territories, learning, and cultures. This story 
involves the cession of vast land holdings and natural resources, 
oftentimes by force, to the United States out of which grew an 
obligation to provide benefits and services--promises made to Tribal 
Nations that exist in perpetuity. These resources are the very 
foundation of this nation and have allowed the United States to become 
the wealthiest and strongest world power in history. Federal 
appropriations and services to Tribal Nations and Native people are 
simply a repayment on this perpetual debt.

    At no point, however, has the United States honored these sacred 
promises; including its historic and ongoing failure to prioritize 
funding for Indian Country. The chronic underfunding of federal Indian 
programs continues to have disastrous impacts upon Tribal governments 
and Native peoples. As the United States continues to break its 
promises to us, despite its own prosperity, Native peoples experience 
some of the greatest disparities among all populations in this country 
and have for generations. It is no surprise, then, that the failures of 
the federal government to fund the IHS have come into horrifyingly 
sharper focus over the years and especially during the global pandemic. 
Decades of broken promises, neglect, underfunding, and inaction on 
behalf of the federal government left Indian Country severely under-
resourced and at extreme risk during this COVID-19 crisis.

    These long-term challenges are multi-faceted and cannot be solved 
overnight by one-size-fits-all reforms. Any efforts to reform IHS, 
through Congressional action or otherwise, must be accomplished through 
extensive Tribal consultation to reflect the complex challenges faced 
by different Tribal communities, including Tribally-operated healthcare 
facilities. Although USET SPF supports innovative legislative solutions 
to improve the Indian Health System and recognizes that policy 
improvements could be made, we continue to underscore the obligation of 
Congress to meet its trust responsibility by providing full funding to 
IHS. The federal trust responsibility obligates the federal government 
to provide quality healthcare to Tribal Nations which can only be 
accomplished when the Indian Health System is fully funded.

Full and Mandatory Funding for Federal Trust and Treaty Obligations

    USET SPF celebrates and expresses its gratitude to this body for 
its role in the historic achievement of advance appropriations for the 
Indian Health Service (IHS). For the very first time, the agency's 
clinical services will have budgetary certainty in the face of 
continuing resolutions and government shutdowns. It is our expectation 
that appropriators will continue to include language providing advance 
appropriations for IHS beyond Fiscal Year (FY) 2024. We urge the 
inclusion of all of IHS' budget line items in this mechanism, as well 
as advance appropriations for all federal Indian agencies and programs 
as next steps for this Congress. Despite its importance in the 
stabilization of funding, however, we continue to view advance 
appropriations as a temporary funding mechanism in our overall advocacy 
for the full delivery of trust and treaty obligations.

    Above all, the COVID-19 crisis has highlighted the urgent need to 
provide full and guaranteed federal funding to Tribal Nations in 
fulfillment of federal obligations. Because of our history and unique 
relationship with the United States, the federal government's trust and 
treaty obligations to Tribal Nations, as reflected in the federal 
budget, is fundamentally different from ordinary discretionary spending 
and should be considered mandatory in nature. Payments on debt to 
Indian Country should not be vulnerable to year to year 
``discretionary'' decisions by appropriators. Honoring the first 
promises made by this country, in pursuing the establishment of its 
great principled democratic experiment, should not be a discretionary 
decision.

    The Biden Administration's FY 2024 Request continues to propose a 
shift in funding for IHS from the discretionary to the mandatory side 
of the federal budget, including a 10-year plan to close funding gaps 
and an exemption from sequestration, a move that would provide even 
greater stability for the agency and is more representative of 
perpetual trust and treaty obligations. Year after year, USET SPF has 
urged multiple Administrations and Congresses to request and enact 
budgets that honor the unique, Nation-to-Nation relationship between 
Tribal Nations and the U.S., including providing full and mandatory 
funding. We continue to ask that Congress join us in genuine 
partnership, along with the Administration, to craft an enact this 
necessary change. We firmly believe that full and mandatory funding for 
the IHS is the only way to make meaningful inroads in the Agency's 
challenges. To suggest otherwise ignores the primary source of these 
challenges.

    The FY 2024 Request also, once again, proposes mandatory funding 
for Contract Support Costs and 105(l) leases--binding obligations--at 
IHS, as well as the Bureau of Indian Affairs and the Bureau of Indian 
Education. While we contend that all federal Indian agencies and 
programs should be subject to mandatory funding, in recognition of 
perpetual trust and treaty obligations, we continue to support the 
immediate transfer of these lines to the mandatory side of the federal 
budget. This will ensure that funding increases are able to be 
allocated to service delivery, as opposed to the federal government's 
legal obligations. The Senate Interior Appropriations Subcommittee 
ultimately supported these important first steps in achieving mandatory 
funding for Indian Country in its mark for FY 2023. We now call 
Congress to work with Tribal Nations and the Administration fulfill its 
responsibilities and work to ensure that this proposal is included in 
any final FY 2024 appropriations legislation.

Expand Self-Governance Compacting and Contracting

    The United States government bears a responsibility to uphold the 
trust obligation, and that obligation includes upholding Tribal 
sovereignty, self-determination, and self-governance. The Indian Self-
Determination and Education Assistance Act (ISDEAA) authorizes the 
federal government to enter into compacts and contracts with Tribal 
Nations to provide services that the federal government would otherwise 
be obligated to provide under the trust and treaty obligations. 
Although self-government by Tribal Nations existed far before the 
passage of ISDEAA, Tribal Nations have demonstrated through ISDEAA 
authorities since the bill's enactment that we are best positioned to 
deliver essential government services to our citizens, including 
through the assumption of federal program and services. Tribal Nations 
are directly accountable to and aware of the priorities and problems of 
our own communities, allowing us to respond immediately and effectively 
to challenges and changing circumstances.

    The success of self-governance under the ISDEAA is reflected in the 
significant growth of Tribal self-governance programs since its 
passage. In the USET region, the majority of our Tribal Nations engage 
in self-governance compacting or contracting to provide essential 
health care services. Across Indian Country, nearly two-thirds of 
federally recognized Tribal Nations engage in self-governance, either 
directly through the IHS or through Tribal organizations and 
intertribal consortia. In Fiscal Year (FY) 2020, approximately 50% of 
the IHS budget was distributed to self-governance Tribal Nations. 
However, despite the success of Tribal Nations in exercising these 
authorities under ISDEAA, the goals and potential of self-governance 
have not yet been fully realized. Many opportunities still remain to 
improve and expand self-governance, particularly within HHS. USET SPF, 
along with Tribal Nations and other regional and national 
organizations, has consistently advocated for all federal programs and 
dollars to be eligible for inclusion in self-governance compacts and 
contracts.

    Attempts to expand self-governance compacting and contracting 
administratively have encountered barriers due to the limiting language 
under current law, as well as the misperceptions of federal officials. 
In 2013, the Self-Governance Tribal Federal Workgroup (SGTFW), 
established within the HHS, completed a study exploring the feasibility 
of expanding Tribal self-governance into HHS programs beyond those of 
IHS and concluded that the expansion of self-governance to non-IHS 
programs was feasible, but would require Congressional action. USET SPF 
maintains that if true expansion of self-governance is only possible 
through legislative action, Congress must prioritize this action. We 
strongly support legislative proposals that would create a 
demonstration project at HHS aimed at expanding ISDEAA authority to 
more programs within the Department. In addition, a major priority for 
Tribal Nations during the upcoming reauthorization of the Special 
Diabetes Program for Indians (SDPI), along with increased funding and 
permanency for the program, is ISDEAA authority. USET SPF looks forward 
to supporting legislation aimed at fulfilling these priorities during 
this Congress.

Improve Public Health Funding and Data Sharing

    Many of the challenges and shortfalls plaguing the Indian Health 
Care System are the result of sustained, chronic underinvestment in 
prevention and public health measures paired with generations of 
historical trauma and structural discrimination. As the United States's 
public health infrastructure took shape and grew throughout the 
twentieth century, Tribal Nations were routinely left out of resource 
distribution. While Tribal Nations have always and continue to invest 
in the health and wellbeing of our citizens, our efforts continue to be 
hampered by lack of funding and inconsistently applied data sharing 
authorities. In order to more effectively respond to the challenges in 
our communities, including those posed by current and future public 
health crises, Tribal Nations need increased resources as well as the 
ability to efficiently and easily obtain necessary public health data.

    In an already strained funding environment, there are often little 
resources left for public health prevention and surveillance activities 
in Tribal Nations. Although the IHS supports limited public health 
activities at federally operated facilities, the primary responsibility 
for the development and delivery of public health infrastructure and 
services often lies with Tribal Nations, particularly in regions with 
high concentrations of self-governance Tribal Nations. While many 
Tribal Nations and IHS regions have worked to incorporate some public 
health components in their governments, these entities often do not 
operate at the same capacity as state programs, and certainly lack much 
of the authority afforded to state entities. The Indian Health Care 
Improvement Act (IHCIA) authorized the formation of Tribal Epidemiology 
Centers (TECs), and since 1996, the TECs have been working to improve 
the capacity of Tribal health departments to deal with public health 
issues and priorities. TECs are charged with seven main functions, 
including data collection, evaluation of systems, and the provision of 
technical assistance to Tribal Nations. The USET TEC, which serves 
Tribal Nations in the Nashville IHS Area, provides both aggregate and 
Tribal Nation-specific public health and mortality data in addition to 
its other functions. However, despite the critical nature of this 
invaluable work and Congressional directives to share data, TECs 
struggle with accessing public health data not only on the federal and 
state levels, but the Tribal levels as well. Access to timely, accurate 
data is vital to the delivery of healthcare services in Indian Country, 
as it is difficult to direct resources appropriately without fully 
understanding the challenges facing our people.

    Congress has the obligation to correct these challenges within 
Indian Country. In addition to providing full funding to the IHS, 
Congress must meaningfully invest in public health capacity building in 
Indian Country. Funding for expanding the Community Health Aide Program 
(CHAP) to the lower 48 is one example of necessary investments in 
public health and preventative care in Tribal Nations. To mitigate 
challenges in data access, the federal government should compel 
agencies like the Centers for Disease Control and Prevention (CDC) and 
the Centers for Medicare and Medicaid Services (CMS) to issue specific 
guidance to states and other public health entities directing them to 
comply with legislative directives to share usable data with Tribal 
Nations. USET SPF is appreciative of efforts within the Subcommittee to 
conduct oversight in these matters.

                    Discussion Draft Recommendations

Clarification for Tribal Health Programs

    While it appears that this bill is intended to apply to IHS-
operated health care facilities only, we are concerned that potential 
unintended impacts to Tribal Nations operating facilities pursuant to 
the Indian Self-Determination and Education Assistance Act (ISDEAA), 
P.L. 93-638 have not been adequately examined. ISDEAA is among the most 
successful federal Indian policies, as it recognizes our inherent 
Tribal sovereignty and self-determination by ensuring we--and not the 
federal government--are in the drivers-seat in addressing the needs of 
our communities. USET SPF member Tribal Nations operate in the 
Nashville Area of the Indian Health Service, which contains 36 IHS, 
Tribal, and urban health care facilities, of which 26 are Tribally-
operated through contracts and compacts. Through exercising this self-
governance authority under ISDEAA, USET SPF Tribal Nations have greater 
flexibility and control over federally funded programs to more 
efficiently and effectively utilize funding to meet the unique 
conditions within our Tribal communities. It is absolutely critical 
that the effects of this legislation on Tribally-operated programs are 
analyzed and consulted upon before it receives any further 
consideration.

Unfunded Mandates

    Several provisions place additional administrative requirements on 
the IHS without providing additional resources for the agency to carry 
these out. USET SPF is concerned that in addition to creating 
compliance difficulties for the agency, these provisions will overtax 
the agency's existing administrative resources to the point of 
impacting other agency functions. It is unrealistic to expect that 
these new requirements can be successfully implemented in the absence 
of increased funding. As written, these new requirements will only 
exacerbate existing difficulties faced by the agency.

Section-by-Section Comments

    Below, USET SPF offers section-by-section comments and concerns. 
Again, this bill should not move forward without additional, thorough 
Tribal Consultation on a national basis.

Section 101. Incentives for Recruitment and Retention.

    In order to address the ongoing challenges with the recruitment and 
retention of IHS staff, the legislation would allow HHS to provide 
housing vouchers or reimburse the costs for those relocating to an area 
experiencing a high level of need for employment. Though this provision 
provides the Secretary discretion to determine whether a location is 
experiencing a high level of need, USET SPF suggests including language 
for positions that are ``difficult to fill in the absence of an 
incentive.'' This addition would allow IHS more flexibility when 
determining when to offer relocation compensation.

    USET SPF agrees that there is a need for recruitment and retention 
programs. However, the establishment of these programs should not come 
at the cost of health care services. USET SPF recommends that 
additional appropriations be authorized for the proposed recruitment 
and retention programs.

    Additionally, it is unclear why the bill includes a sunset date on 
the housing voucher program. It is unlikely that IHS staff housing 
needs will be fully addressed in only a 3-year period. USET SPF 
suggests that the sunset date be stricken.

Section 102. Medical Credentialing System.

    This section would create a uniform, standardized, and central 
credentialling system for the IHS to use in its hiring procedures. USET 
SPF has deep concerns about the centralization of any Area Office 
functions, including credentialing. Nashville Area Tribal Nations have 
consistently advocated for Area Office presence and for services to be 
administered at the Area level. Collectively, we have worked hard to 
establish the strong relationship we have with our Area Office today. 
Taking away functions from Area offices causes significant backlogs in 
services, and disrupts an established and trusted relationship between 
the Area Office and Tribal Nations. We believe credentialing should be 
kept at the Area level, utilizing established best practices. In 
addition, this provision serves as an example of the aforementioned 
unfunded mandates included in this bill.

Section 104. Clarification Regarding Eligibility for Indian Health 
        Service Loan Repayment Program.

    USET SPF encourages efforts that would expand the Indian Health 
Service Loan Repayment Program to include degrees in business 
administration, health administration, hospital administration, or 
public health professions as eligible for awards. We recommend 
including language that would expand these degrees as eligible under 
the IHS Scholarship Program as well. Allowing for comprehensive 
eligibility under these programs would increase the number of AI/AN 
individuals seeking business and health administration degrees, as well 
as increase the pool of qualified health professionals within Indian 
Country. In addition, we have long supported legislation that would 
confirm the nontaxable status of IHS student loan repayments in parity 
with other federal loan repayment programs.

Section 105. Improvements in Hiring Practices.

    This section makes several changes to the IHS's hiring authority 
that aim to give the Agency more ability to quickly address staffing 
shortages. First, it gives the IHS Direct-Hire Authority, which allows 
the Agency to bypass certain federal hiring procedures in order to 
appoint candidates directly to positions when there is a severe 
shortage of candidates or a critical hiring need.

    On Waivers of Indian Preference, USET SPF firmly believes that the 
providers best suited to care for our communities are ones that come 
from the communities themselves. At the same time, there is room for 
improvements in hiring practices to ensure that positions are being 
filled in a timely manner with qualified candidates. We appreciate the 
inclusion of language to require Tribal requests to waive Indian 
Preference in order for the Agency to do so. However, we note that IHS 
included this policy change in its FY 2024 Budget Request in the 
absence of Tribal consultation or a provision requiring Tribal Nation 
approval. With this in mind, it is absolutely essential that this 
provision receive thorough Tribal consultation. Tribal Nations must 
guide its development and implementation to ensure that it accomplishes 
its aims without negatively impacting the development of a culturally 
competent workforce.

Section 106. Improved Authorities of Secretary to Improve 
        Accountability of Senior Executives and Employees of the Indian 
        Health Service.

    While USET SPF understands the purposes of including language that 
would expand the Secretary's authority to remove or demote IHS 
employees based on performance or misconduct, we believe Tribal 
governments must also be notified when IHS employees within their 
Service Area become subject to a personnel action such as removal, 
transfer or demotion. In addition, we ask that the Report to Congress 
describing the 1-year period following the enactment of this provision 
also be shared with Tribal Nations.

Section 107. Tribal Culture and History.

    USET SPF has consistently supported additional training for all 
federal employees on the nature and history of U.S.-Tribal Nation 
relations, trust and treaty obligations, and respectful diplomacy with 
Tribal Nations. With this in mind, we support the inclusion of Section 
107. However, because each Tribal Nation is a unique sovereign entity, 
language should be included that would require each IHS Area to design 
these trainings through consultation with the Tribal Nations they serve 
on a regional basis. This will allow the training to encompass regional 
cultural commonalities, as opposed to attempting to ascribe cultural 
similarities to Tribal Nations across the country.

Section 108. Staffing Demonstration Program.

    This section would establish a demonstration project to provide 
staffing resources to individual clinics or service units. While we 
support efforts to increase staffing throughout the Indian Health 
System, our concerns with this provision are similar to those with 
Section 101. Financial resources are essential to the proper 
implementation to this provision. In addition, it remains unclear how 
the Agency would take just four years to make the program self-
sustaining--especially without increased appropriations. Finally, the 
Agency appears to have outsize discretion in choosing sites for the 
demonstration.

Section 111. Enhancing Quality of Care in the Indian Health Service.

    This section contains many provisions aiming to enhance the quality 
of care at IHS. While we appreciate Tribal consultation requirements 
and assurances that parts of this provision are optional for Tribally-
operated facilities, we want to underscore the need to ensure that the 
diversity of Tribal Nations and Indian Country is reflected in the 
development of this provision. What may work for one Area and the 
Tribal Nations it serves may not work for another. In addition, any 
necessary resources should be extended to IHS in order to comply.

Section 112. Notification of Investigation Regarding Professional 
        Conduct; Submission of Records.

    This section requires the IHS to notify relevant Medical Boards no 
later than fourteen calendar days after starting an investigation into 
the professional conduct of a licensee at an IHS facility. This 
notification should also be extended to Tribal Nations served by that 
particular facility.

Section 113. Fitness of Health Care Providers.

    Similarly, the reporting to Medical Boards under this provision 
must also be extended to Tribal Nations served.

Section 114. Standards to Improve Timeliness of Care.

    This section requires IHS to establish standards that measure the 
timeliness of health care services provided in in IHS facilities. It is 
imperative that any timeliness of care standards are developed in 
consultation with Tribal Nations and that this section confirms 
unequivocally that the standards do not apply to Tribally-operated 
facilities. In addition, we request that any data collected under the 
provision be provided to Tribal Nations as well as the Secretary.

Section 203. Fiscal Accountability.

    USET SPF has concerns with this section and its effect on base 
funding. This section requires further technical evaluation and 
explanation, including from IHS, in order to assess its true impact.

Sections 302-304. Reports by the Secretary of HHS, Comptroller General, 
        Inspector General.

    USET SPF recommends including language that would require greater 
collaboration and consultation with Tribal Nations. We feel the reports 
laid out in this section should be conducted in collaboration with 
Tribal Nations and provided to those Tribal Nations for consultation 
prior to their release to Congress or the public.

Section 305. Transparency in CMS Surveys.

    As above, USET SPF recommends adding language that would require 
collaboration and consultation with Tribal Nations during the 
formulation of these compliance surveys. We also believe the results of 
these surveys should be provided to Tribal Nations prior to their 
public release.

Conclusion

    USET SPF acknowledges the efforts of the Committee and others 
within Congress in seeking to address the long-standing challenges 
within IHS. However, we believe that the discussion draft continues to 
fail to recognize the deep disparities in funding faced by IHS and how 
these disparities contribute to failures at the Area level. We maintain 
that until Congress fully funds the IHS, the Indian Health System will 
never be able to fully overcome its challenges and fulfill its trust 
obligations. Finally, a number of provisions within the bill seem to be 
responding to Area-specific concerns. While we stand with our brothers 
and sisters who are experiencing these failures, we ask that the 
Committee strongly consider the national (rather than regional) 
implications of the bill, and work with Tribal Nations to ensure its 
impact is positive in all IHS Areas. We thank the Committee for the 
opportunity to provide comments on this bill and look forward to 
further consultation The IHS Accountability Act, as well as an ongoing 
dialogue to address the complex challenges of health care delivery in 
Indian Country.

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