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






                                 



 
            H.R. 6489, H.R. 8942, H.R. 8955, AND H.R. 8956

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

                          LEGISLATIVE HEARING

                               before the

               SUBCOMMITTEE ON INDIAN AND INSULAR AFFAIRS

                                 of the

                     COMMITTEE ON NATURAL RESOURCES
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             SECOND SESSION

                               __________

                        Wednesday, July 24, 2024

                               __________

                           Serial No. 118-140

                               __________

       Printed for the use of the Committee on Natural Resources


        Available via the World Wide Web: http://www.govinfo.gov
                                   or
          Committee address: http://naturalresources.house.gov


                     COMMITTEE ON NATURAL RESOURCES

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

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

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

               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 Memo.....................................................     v
Hearing held on Wednesday, July 24, 2024.........................     1

Statement of Members:

    Hageman, Hon. Harriet M., a Representative in Congress from 
      the State of Wyoming.......................................     2
    Leger Fernandez, Hon. Teresa, a Representative in Congress 
      from the State of New Mexico...............................     4

    Panel I:

    Johnson, Hon. Dusty, a Representative in Congress from the 
      State of South Dakota......................................     5
    Newhouse, Hon. Dan, a Representative in Congress from the 
      State of Washington........................................     7
    Peltola, Hon. Mary Sattler, a Representative in Congress from 
      the State of Alaska........................................     8
    .............................................................

Statement of Witnesses:

    Panel II:

    Smith, Benjamin, Deputy Director, Indian Health Services, 
      U.S. Department of Health and Human Services, Rockville, 
      Maryland...................................................     9
        Prepared statement of....................................    11
        Questions submitted for the record.......................    17
    Erickson, Hon. Jarred-Micheal, Chairman, Confederated Tribes 
      of the Colville Reservation, Nespelem, Washington..........    18
        Prepared statement of....................................    19
        Questions submitted for the record.......................    22
    Torres, Amber, Chief Operating Officer, National Indian 
      Health Board (NIHB), Washington, DC........................    22
        Prepared statement of....................................    24
        Questions submitted for the record.......................    26
    Mallott, Ben, Vice President for External Affairs, Alaska 
      Federation of Natives (AFN), Anchorage, Alaska.............    26
        Prepared statement of....................................    28
    Church, Jerilyn, Executive Director, Great Plains Tribal 
      Leader's Health Board (GPTLHB), Rapid City, South Dakota...    29
        Prepared statement of....................................    31
        Questions submitted for the record.......................    34
 GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT



To:        House Committee on Natural Resources Republican Members

From:     Indian and Insular Affairs Subcommittee staff, Ken 
        Degenfelder (Ken.Degenfelder@mail.house.gov), Jocelyn Broman 
        (Jocelyn.Broman@ mail.house.gov), and Kirstin Liddell 
        (Kirstin.Liddell@mail.house.gov) x6-9725

Date:     Wednesday, July 24, 2024

Subject:   Legislative Hearing on 4 Bills
________________________________________________________________________
        _______

    The Subcommittee on Indian and Insular Affairs will hold a 
legislative hearing on four bills: H.R. 8942 (Rep. Hageman), 
``Improving Tribal Cultural Training for Providers Act of 2024''; H.R. 
8955 (Rep. Johnson of SD), ``IHS Provider Integrity Act''; H.R. 8956 
(Rep. Newhouse), ``Uniform Credentials for IHS Providers Act of 2024''; 
and H.R. 6489 (Rep. Peltola), ``Alaska Native Village Municipal Lands 
Restoration Act of 2023'' on Wednesday, July 24, 2024, at 10:15 a.m. in 
1334 Longworth House Office Building.

    Member offices are requested to notify Haig Kadian 
(Haig.Kadian@mail. house.gov) by 4:30 p.m. on Tuesday, July 23, 2024, 
if their member intends to participate in the hearing.

I. KEY MESSAGES

     H.R. 8942 would amend the Indian Health Care Improvement 
            Act \1\ (IHCIA) to require mandatory annual training for 
            specified Indian Health Service (IHS) employees on the 
            history and culture of tribes that they are serving.
---------------------------------------------------------------------------
    \1\ 25 USC 1601 et seq.

     H.R. 8955 would require the IHS to solicit the history of 
            any applicant from the medical board of each state in which 
            the applicant is licensed. Additionally, the IHS would be 
            required to notify and provide the necessary documentation 
            to state medical boards once an investigation of a licensee 
---------------------------------------------------------------------------
            has started.

     H.R. 8956 would establish a uniformed and centralized 
            Service-wide credentialing system at the IHS for health 
            care providers.

     H.R. 6489 would amend Sec. 14(c)(3) of the Alaska Native 
            Claims Settlement Act \2\ (ANCSA) to return lands currently 
            held in trust by the State of Alaska for future 
            municipalities back to Alaska Native village corporations. 
            Only eight villages out of 101 that conveyed lands under 
            this section have created a municipality since ANCSA was 
            passed in 1971. The bill would also eliminate the 
            requirement for an Alaska Native village corporation to 
            convey land to the state Alaska under Sec. 14(c)(3) if that 
            has not already occurred.
---------------------------------------------------------------------------
    \2\ 43 USC 1601 et seq.

---------------------------------------------------------------------------
II. WITNESSES

     Mr. Benjamin Smith, Deputy Director, Indian Health 
            Service, U.S. Department of Health and Human Services, 
            Rockville, MD [H.R. 8955, H.R. 8942, and H.R. 8956]

     The Hon. Jarred-Michael Erickson, Chairman, Confederated 
            Tribes of the Colville Reservation, Nespelem, WA [H.R. 
            8955, H.R. 8942, and H.R. 8956]

     Ms. Amber Torres, Chief Operating Officer, National Indian 
            Health Board (NIHB), Washington, DC. [H.R. 8955, H.R. 8942, 
            and H.R. 8956]

     Ms. Jerilyn Church, Executive Director, Great Plains 
            Tribal Leader's Health Board (GPTLHB), Rapid City, SD [H.R. 
            8955, H.R. 8942, and H.R. 8956]

     Mr. Ben Mallott, Vice President for External Affairs, 
            Alaska Federation of Natives (AFN), Anchorage, AK [H.R. 
            6489] [Minority Witness]

III. BACKGROUND
H.R. 8942 (Rep. Hageman), ``Improving Tribal Cultural Training for 
        Providers Act of 2024''

    H.R. 8942 would amend the IHCIA to require mandatory annual 
training for specified IHS employees on the history and culture of the 
tribes that they are serving. Currently, IHS employees are required to 
participate in a program on the tribal history and culture of the 
tribes they serve, but it is not an annual requirement.
    Because IHS's mission is to work with American Indian and Alaska 
Native (AI/AN) people to promote their physical, mental, social, and 
spiritual health, IHS medical providers need cultural competence to 
work toward the best AI/AN health outcome.\3\ Culture competence is 
defined by the Center for Disease Control and Prevention (CDC) as ``the 
integration and transformation of knowledge about individuals and 
groups of people into specific standards, policies, practices, and 
attitudes used in appropriate cultural settings to increase the quality 
of services; thereby producing better outcomes.'' \4\ If a health care 
practitioner provides care that is culturally sensitive and well-
versed, the patient often gains a sense of security and satisfaction 
which can lead to a more transparent relationship and improved health 
outcomes.\5\
---------------------------------------------------------------------------
    \3\ Quality at IHS. https://www.ihs.gov/quality/
#::text=The%20mission%20of%20the% 
20Indian,AN)%20to%20the%20highest%20level.
    \4\ CDC. Cultural Competence in Health and Human Services. https://
npin.cdc.gov/pages/cultural-competence-health-and-human-services#what
    \5\ McKesey et al. (2017, December) Cultural Competence for the 
21st Century Dermatologist Practicing in the United States. Journal of 
the American Academy of Dermatology. https://assets.ctfassets.net/
1ny4yoiyrqia/5czczxfoQvg0P0JoDcuIsh/da49853b61635975925a99813dd790f2/
Cultural_competency_21st_century_.pdf
---------------------------------------------------------------------------
    While American Indian life expectancy has increased by 
approximately 10 years since 1973, AI/ANs still generally have a lower 
life expectancy than the United States's general population.\6\ That 
life expectancy is even lower for AI/ANs that have chronic liver 
disease, diabetes mellitus, and experience assault or homicide or 
commit self-harm or suicide.\7\ Health care practitioners practicing 
culturally competent care can remove disconnect between patient and 
practitioner, ensuring patients are heard, seen, and understood. When 
the relationship between patient and practitioner is strained, the 
level of care is decreased, which can be attributed to the higher rate 
of death among American Indians.\8\ Studies have shown a correlation 
between perceived discrimination and the rates of hypertension, 
cardiovascular disease, and diabetes throughout racial minorities.\9\
---------------------------------------------------------------------------
    \6\ IHS. Quick Look Fact Sheet. https://www.ihs.gov/newsroom/
factsheets/quicklook/
    \7\ Id.
    \8\ Melissa L. Walls, et. al. Unconscious Biases: Racial 
Microaggressions in American Indian Health Care. The Journal of the 
American Board of Family Medicine. March 2015. https://www.jabfm.org/
content/28/2/231.long. Accessed July 10, 2024.
    \9\ Id.
---------------------------------------------------------------------------
    For example, an American Indian child who avoids eye contact or 
takes longer than average to respond to a question could be diagnosed 
with autism. However, this behavior may actually be culturally 
appropriate with their tribal community.\10\ AI/AN patients who discuss 
their mental health struggles in spiritual terms could be misdiagnosed 
with drug-related psychosis, when that is the way the individual 
processes what is occurring.\11\ If a practitioner is trained in the 
history and culture of the demographic they are treating, they can 
better understand the nuances associated with providing care for the 
whole person.
---------------------------------------------------------------------------
    \10\ American Psychological Association. The Healing Power of 
Native American Culture is Inspiring Psychologists to Embrace Cultural 
Humility. October 2023. https://www.apa.org/monitor/2023/10/healing-
tribal-communities-native-americans.
    \11\ Id.
---------------------------------------------------------------------------
    Currently the IHCIA requires IHS to have a program educating 
``appropriate employees'' with an ``educational instruction in the 
history and culture'' of tribes.\12\ However, this program is not 
mandatory nor required annually by statute. H.R. 8942 would amend the 
current culture and history program provision under IHCIA to a 
mandatory annual program for IHS employees. The legislation also 
specifies which employees should be required to have the annual 
training, including IHS employees, locum tenens medical providers, 
health care volunteers, and other contracted employees working at IHS 
facilities that have direct patient access.
---------------------------------------------------------------------------
    \12\ P.L. 94-437.

    Staff contact: Jocelyn Broman (Jocelyn.Broman@mail.house.gov) and 
Kirstin Liddell (Kirstin.Liddell@mail.house.gov), (x6-9725)
H.R. 8955 (Rep. Johnson of SD), ``IHS Provider Integrity Act''

    H.R. 8955 would require the IHS to notify state medical boards when 
an investigation is undertaken into an IHS health care provider 
licensed by a state medical board, and also requires IHS to provide 
information on any health care provider's medical license violations to 
any state medical boards the provider is licensed under. Additionally, 
the bill requires that during the hiring process of a health care 
provider, IHS must receive information on any violation of a provider's 
medical license dating 20 years, as well as information on any 
settlement agreements that the provider entered into for a disciplinary 
charge related to their medical practice.
    The IHS has long been plagued with issues, particularly when it 
comes to direct service providers and facilities.\13\ In 2010, a major 
congressional review of the IHS Great Plains Area Region (GPA) by the 
Senate Committee on Indian Affairs (SCIA) detailed serious deficiencies 
at IHS facilities.\14\ A hearing and its subsequent investigative 
findings were released by SCIA in the Dorgan Report in December 2010. 
The report detailed major deficiencies ranging from medical care to 
administrative procedures.\15\ It was found that IHS lacked a proper 
system to detect practitioners using revoked, suspended, or otherwise 
inadequate licenses.\16\ The investigation requested the IHS to provide 
all information pertaining to healthcare providers with disciplinary 
actions on their licenses. The IHS submitted information relating to 
two providers, but the investigation revealed that there were more 
practitioners than previously disclosed or known.\17\ There continues 
to be instances of lack of care ranging from quality and safety of 
patients,\18\ extreme vacancies,\19\ and misconduct in the IHS.\20\
---------------------------------------------------------------------------
    \13\ Direct Service means health care provided by IHS federal 
employees at IHS facilities to American Indians and Alaska Natives. 
See, ``Direct Service Tribes'' Indian Health Service, https://
www.ihs.gov/odsct/dst/.
    \14\ U.S. Senate. Committee on Indian Affairs. In Critical 
Condition: The Urgent Need to Reform the Indian Health Service's 
Aberdeen Area, 2010. https://www.govinfo.gov/content/pkg/CHRG-
111shrg63826/pdf/CHRG-111shrg63826.pdf. http://www.indian.senate.gov/
sites/default/files/upload/files/63826.PDF.
    \15\ Dorgan Report, p. 5-6.
    \16\ Dorgan Report, p. 6.
    \17\ Dorgan Report, p. 29 and 67.
    \18\ Ferguson, Dana. ``IHS hospital in `immediate jeopardy,' feds 
say. The Argus Leader, May 24, 2016. http://www.argusleader.com/story/
news/2016/05/23/reservation-hospital-immediate-jeopardy-feds-say/
84812598/.
    \19\ Gemma DiCarlo, ``New Indian Health Service funding provides 
stability, but long-standing issues remain,'' Oregon Public 
Broadcasting. Jan. 20, 2023. https://www.opb.org/article/2023/01/20/
new-indian-health-service-funding-provides-stability-but-long-standing-
issues-remain/.
    \20\ Government Accountability Office, ``Indian Health Service: 
Actions Needed to Improve Oversight of Provider Misconduct and 
Substandard Performance.'' Dec. 2020. GAO-21-97. https://www.gao.gov/
assets/gao-21-97.pdf.
---------------------------------------------------------------------------
    The IHS has historically had a history of hiring individuals with a 
history of medical malpractice. In some instances, this negligence 
occurred because the individual had flags under one state license, but 
not the other. Such was the case with Dr. Marrocco who was hired at an 
IHS hospital in New Mexico in 2012. Dr. Marrocco had disciplinary flags 
on her licenses in New York and Florida, but her Pennsylvania license 
was clean, so the IHS went ahead and hired her. Dr. Marrocco went on to 
play a role in the development of a stroke in an eighteen-year-old 
patient.\21\
---------------------------------------------------------------------------
    \21\ Christopher Weaver, et. al. ``The U.S. Gave Troubled Doctors a 
Second Chance. Patients Paid the Price,'' Frontline. PBS. Nov. 22, 
2019. https://www.pbs.org/wgbh/frontline/article/u-s-indian-health-
service-gave-troubled-doctors-second-chance-patients-paid-price/.
---------------------------------------------------------------------------
    Other instances have shown that the IHS has failed to fully 
investigate their applicants before hiring. In 2019, the Wall Street 
Journal studied 171 doctors who had allegedly provided negligent care 
at the IHS. Of the 171 sample, 44 doctors should have raised red flags 
by the IHS's own standards of care, yet they were hired at the 
detriment of patients.\22\
---------------------------------------------------------------------------
    \22\ Id.
---------------------------------------------------------------------------
    The guidelines self-imposed by the IHS emphasize the need to 
investigate applicants for past malpractice, sanctions, and criminal 
convictions.\23\ However, an official who approved Henry Stachura's 
appointment was unaware of his problematic employment history. 
Stachura, who had a career littered with malpractice settlements, was 
employed by IHS after being suspended from Memorial Medical Center in 
New Mexico.\24\ Prior to his service at the IHS, Dr. Stachura performed 
surgery resulting in a bile duct injury. Once at the IHS, he operated 
on Ms. Jeanise Livingston which resulted in a cut bile duct and a 
subsequent coma for Ms. Livingston. Dr. Stachura retired in 2019 with 
three deaths and $1.8 million in settlement payments paid by the U.S. 
government to round out his time at the IHS.\25\
---------------------------------------------------------------------------
    \23\ IHS. Indian Health Manual. Parts and Chapters. Part 3-1.4 
https://www.ihs.gov/IHM/pc/part-3/p3c1/
    \24\ Weaver, ``The U.S. Gave Troubled Doctors a Second Chance. 
Patients Paid the Price,'' Frontline. PBS. Nov. 22, 2019. https://
www.pbs.org/wgbh/frontline/article/u-s-indian-health-service-gave-
troubled-doctors-second-chance-patients-paid-price/.
    \25\ Id.
---------------------------------------------------------------------------
    While IHS does have challenges filling medical provider positions, 
as the entire health care industry faces),\26\ ensuring the providers 
hired by IHS meet standards is essential to ending substandard care at 
IHS facilities. H.R. 8955 would require the IHS to solicit the history 
of any applicant from the medical board of each state in which the 
applicant is licensed. Additionally, the IHS would be required to 
notify and provide the necessary documentation to state medical boards 
once an investigation of a licensee has started. To ensure compliance, 
the IHS would also be required to submit a report to Congress 
showcasing implementation no later than 180 days after enactment.
---------------------------------------------------------------------------
    \26\ Caitlin Owens, ``The health care workforce crisis is already 
here'' AXIOS. Jun. 7, 2024. https://www.axios.com/2024/06/07/health-
care-worker-shortages-us-crisis.

    Staff contact: Jocelyn Broman (Jocelyn.Broman@mail.house.gov) and 
Kirstin Liddell (Kirstin.Liddell@mail.house.gov), (x6-9725)
H.R. 8956 (Rep. Newhouse), ``Uniform Credentials for IHS Providers Act 
        of 2024''

    H.R. 8956 would require the IHS, in consultation with tribes and 
stakeholders, to establish a uniformed and centralized IHS-wide 
credentialing system, while authorizing the enhancement and expansion 
of its existing system to ensure all requirements are met. 
Additionally, the IHS would be required to undergo a formal review of 
the system to ensure compliance every five years at minimum.
    Credentialing is the process of assessing the qualifications of 
specific types of health care providers to show they have the proper 
education, training, and licenses to care for patients.\27\ The Centers 
for Medicare and Medicaid Services (CMS) requires a credentialing 
process before a provider can be eligible for Medicare or Medicaid 
reimbursement within the health care industry.\28\ Because IHS provides 
health care directly to AI/ANs at IHS facilities, they have their own 
process of credentialing health care providers which requires that 
medical staff must meet the credentialing and privileging standards of 
a national accrediting body like the Joint Commission or CMS.\29\
---------------------------------------------------------------------------
    \27\ ``Why Provider Credentialing is a Necessary Hassle and a Vital 
Safeguard,'' CAQH. April 7, 2021. Accessed July 16, 2024. https://
www.caqh.org/blog/why-provider-credentialing-necessary-hassle-and-
vital-safeguard.
    \28\ CMS certification process. https://www.cms.gov/Medicare/
provider-enrollment-and-certification/certificationandcomplianc/
downloads/certandcomplianceprocess.pdf.
    \29\ IHS. Indian Health Manual Part 3-1.3 A. https://www.ihs.gov/
ihm/pc/part-3/p3c1/
---------------------------------------------------------------------------
    However, IHS has a history of concerning and inadequate 
credentialing with IHS leadership touting improvement. The 2010 Dorgan 
report revealed that the IHS had failed to ensure that all healthcare 
practitioners in the Aberdeen Area had an active license, in one case 
the nurse had her license indefinitely suspended in 2005 but was 
employed by the IHS.\30\ Ensuring health care providers have the 
necessary licenses is a part of the credentialing process, and health 
care facilities that do not meet these licensing requirements can have 
their accreditation revoked and find themselves unable to bill Medicare 
and Medicaid for services unlicensed providers perform.\31\
---------------------------------------------------------------------------
    \30\ Dorgan Report, p. 45 and 68.
    \31\ Id. at 27.
---------------------------------------------------------------------------
    During a Senate Committee on Indian Affairs (SCIA) hearing in June 
of 2017, then Acting Director of the IHS Chris Buchanan testified that 
the IHS recently awarded a contract for credentialing software with the 
goal of standardizing the credentialing system.\32\ The Presidential 
Task Force on Protecting Native American Children in the Indian Health 
Service System report, published in July 2020, noted inconsistencies 
between facilities in their credentialing, privileging, and hiring 
processes.\33\ Some hiring committees prioritized filling a vacant spot 
``over a thorough background and credentialing check.'' \34\ A lack of 
shared information increased the practice of hiring individuals with 
otherwise questionable history and qualifications from one facility to 
another.\35\
---------------------------------------------------------------------------
    \32\ Chris Buchanan Testimony. June 2017. https://
www.indian.senate.gov/sites/default/files/upload/
6.13.17%20Chris%20Buchanan%20Testimony.pdf.
    \33\ Department of Justice. Presidential Task Force on Protecting 
American Children in the Indian Health Service System Report. July 23, 
2020. at 16, https://www.justice.gov/usao-ndok/press-release/file/
1297716/dl?inline
    \34\ Id.
    \35\ Id.
---------------------------------------------------------------------------
    An April 2024 Government Accountability Office (GAO) report \36\ 
found that IHS was not adhering to its current credentialing 
requirements. GAO pulled 91 clinician files who were employed at an IHS 
facility as of 2022 for review. Of the sample, 12 percent of the files 
did not meet IHS's requirement to verify all licenses held by the 
clinician, and in three of those files the IHS had not verified any 
licenses.\37\ In eight of the files, it was found that IHS verified one 
license held by the clinician but did not verify the licenses for other 
states.\38\
---------------------------------------------------------------------------
    \36\ Government Accountability Office, ``Indian Health Service: 
Opportunities Exist to Improve Clinical Screening Adherence and 
Oversight.'' April 2024. GAO-24-106230. https://www.gao.gov/assets/
d24106230.pdf.
    \37\ Id.
    \38\ Id.
---------------------------------------------------------------------------
    The IHS concurred with GAO's recommendation to develop a single, 
authoritative source for credentialing and privileging requirements, 
and defining the steps necessary to meet national credentialing 
requirements. Elaborating further, IHS noted that the Indian Health 
Service Manual has been updated with a new credentialing policy which 
would continue through the approval process ending in a standard 
operating procedure in September 2024.\39\
---------------------------------------------------------------------------
    \39\ Id.
---------------------------------------------------------------------------
    The IHS has consistently acknowledged the need for a centralized 
medical system and has shown strides toward that goal. The Draft Indian 
Health Service Strategic Plan for Fiscal Years 2024-2028 has a 
performance goal of standardizing credentialing software and 
applications across the agency.\40\ The IHS requested public comment on 
the new credentialing policy in May 2023.\41\ In the FY 2025 Budget 
Justification, IHS noted that they had implemented a nationwide 
electronic provider credentialing system within federally operated 
hospitals and clinics.\42\
---------------------------------------------------------------------------
    \40\ Indian Health Service. Draft Indian Health Service Strategic 
Plan for Fiscal Years 2024-2028. https://www.ihs.gov/sites/newsroom/
themes/responsive2017/display_objects/documents/2024 _Letters/
Enclosure_DTLL_DUIOLL_050224.pdf
    \41\ Request for Public Comment: 60-Day Information Collection: 
Indian Health Service Medical Staff Credentials Application, 88 Fed. 
Reg. 30317 (May 11, 2023). available at: https://
www.federalregister.gov/documents/2023/05/11/2023-09998/request-for-
public-comment-60-day-information-collection-indian-health-service-
medical-staff.
    \42\ IHS Budget Justification, FY25, at CJ-8. https://www.ihs.gov/
sites/budgetformulation/themes/responsive2017/display_objects/
documents/FY-2025-IHS-CJ030824.pdf.
---------------------------------------------------------------------------
    However, IHS has not been fully transparent while it is creating 
this new system. H.R. 8956 would place the requirement for IHS to 
establish a uniformed and centralized IHS-wide credentialing system in 
statute, providing Congress the opportunity to ensure the standardized 
credentialing system is put in place.

    Staff contact: Jocelyn Broman (Jocelyn.Broman@mail.house.gov) and 
Kirstin Liddell (Kirstin.Liddell@mail.house.gov), (x6-9725)
H.R. 6489 (Rep. Peltola), ``Alaska Native Village Municipal Lands 
        Restoration Act of 2023''

    In 1971, ANCSA \43\ was enacted to settle the aboriginal land 
claims of Alaska Natives. Through ANCSA, Alaska Native Corporations 
(ANCs) were established to receive land under the settlement and 
disperse the payments to Alaska Natives. Alaska Natives received a 
$962.5 million settlement payment and roughly 44 million acres of land, 
which were divided between almost 200 village corporations and 12 
regional corporations established by the legislation.\44\
---------------------------------------------------------------------------
    \43\ 43 U.S.C. 1601, et seq.
    \44\ Id.
---------------------------------------------------------------------------
    Section 14(c)(3) of ANCSA requires that an Alaska Native Village 
Corporation receiving land under ANCSA conveys some lands to an 
existing municipality for use by the municipality. If no municipality 
exists, then these lands are conveyed to the State to be held in trust 
for a future municipality.\45\ However, most Alaska Native villages 
have not established municipalities, and these lands remain 
undeveloped.
---------------------------------------------------------------------------
    \45\ 43 U.S.C. 1613.
---------------------------------------------------------------------------
    Since 1971, a total of 101 Alaska Native Village Corporations have 
seen their lands held in trust by the State for the purpose of a future 
municipality, but only eight have seen a municipality created, with the 
last being created in 1995. Ten Alaska Native Village Corporations have 
reached agreements with the State to have these lands returned without 
forming a municipality, but 83 Alaska Native Village Corporations still 
have approximately 11,500 acres held in trust and unable to be 
developed with no end in sight, since ANCSA did not have a sunset date 
for this provision.\46\
---------------------------------------------------------------------------
    \46\ Senate Energy and Natural Resources Committee. S. Rept. 118-
177-Alaska Native Village Municipal Lands Restoration Act. May 16, 
2024. https://www.congress.gov/congressional-report/118th-congress/
senate-report/177/1
---------------------------------------------------------------------------
    The estimated 11,500 acres held in trust by the State remain nearly 
impossible to develop since the lands must be reserved for future 
municipalities. If the municipality requirement was lifted, Alaska 
Native villages would be able to consider developing the lands for 
housing, community, expansion, and other economic development plans. 
Some Alaska Native Village Corporations did not reconvey land under 
14(c) due to concerns with the 14(c)(3) provision and land being held 
in trust for perpetuity, resulting in murky land titles.\47\
---------------------------------------------------------------------------
    \47\ Id.
---------------------------------------------------------------------------
    H.R. 6489 would amend ANCSA to return the land conveyed back to the 
village corporation that conveyed to the State, while eliminating the 
requirement for an Alaska Native village corporation to convey land 
under the ANCSA 14(c)(3) provision.
    There is wide support for the reconveyance within the state of 
Alaska. The Alaska State Senate unanimously passed Senate Joint 
Resolution No. 13 on May 9, 2024, which encourages the United States 
Legislative and Executive branches to pass and sign legislation to 
return certain land in trust back to affected Alaska Native village 
corporations.\48\ Alaska Governor Mike Dunleavy is also supportive of 
the legislative fix that H.R. 6489 would provide.\49\
---------------------------------------------------------------------------
    \48\ The Alaska State Legislature. Bill History for ``Amend Alaska 
Native Claims Settlement Act.'' SJR 13. 33rd Legislature. https://
www.akleg.gov/Basis/Bill/Detail/33?Root=SJR%2013
    \49\ IIA Subcommittee has Letter of Support on file.

    Staff contact: Jocelyn Broman (Jocelyn.Broman@mail.house.gov) and 
---------------------------------------------------------------------------
Kirstin Liddell (Kirstin.Liddell@mail.house.gov), (x6-9725)

IV. MAJOR PROVISIONS & SECTION-BY-SECTION

H.R. 8942 (Rep. Hageman), ``Improving Tribal Cultural Training for 
        Providers Act of 2024''

    Section 2. Tribal Culture and History

    Requires an annual mandatory training program related to tribal 
culture and history for specified IHS employees.

H.R. 8955 (Rep. Johnson of SD), ``IHS Provider Integrity Act''

    Section 2. Notification of Investigation Regarding Professional 
Conduct; Submission of Records.

    Requires the IHS to notify and provide relevant records to State 
Medical Boards no later than 14 calendar days after starting an 
investigation into the professional conduct of a licensee practicing at 
an IHS facility.

    Section 3. Fitness of Health Care Providers.

    Requires the IHS during the agency's hiring process to solicit an 
applicant's history of license violations or settlements over the 
previous 20 years from any state's medical board in which the applicant 
is medically licensed. Requires the IHS to provide to the medical board 
of each state in which a provider is licensed, detailed information 
regarding any violations by the provider in their IHS capacity. 
Requires the IHS to submit to Congress a report detailing its 
compliance with these policies no later than 180 days post enactment of 
this act.

H.R. 8956 (Rep. Newhouse), ``Uniform Credentials for IHS Providers Act 
        of 2024''

    Section 2. Medical Credentialing System

    Requires IHS, no later than one-year post-enactment, to establish, 
in consultation with tribes and stakeholders, a uniformed and 
centralized Service-wide credentialing system for individuals providing 
services at IHS facilities. Authorizes the IHS to enhance and expand 
its existing credentialing system to meet the requirements listed. 
Requires the IHS to undergo a formal review of its credentialing 
service to ensure all guidelines are met at least every five years. 
Current credentialed employees would be grandfathered into the new 
system and would not be re-credentialed until expiration date of 
current credentials.

H.R. 6489 (Rep. Peltola), ``Alaska Native Village Municipal Lands 
        Restoration Act of 2023''

    Section 2. Reversion of Certain Land Conveyed in Trust to the State 
of Alaska

    Amends ANCSA to remove the requirement that an Alaska Native 
village corporation must convey land into trust to the State of Alaska 
for future municipal governments. Additionally, provides village 
corporations the opportunity to regain title to the lands held in trust 
by dissolving the trust through a formal resolution by the village 
corporation and the residents of the Native village.

V. CBO COST ESTIMATE

    None of the bills received a formal cost estimate from the 
Congressional Budget Office.

VI. ADMINISTRATION POSITION

    During a Senate Energy and Natural Resources Committee hearing on 
S. 2615, the Alaska Native Village Municipal Lands Restoration Act, an 
identical bill to H.R. 6489, Principal Deputy Director Nada Wolff 
Culver of the Bureau of Land Management testified in support of the 
overall goal of the bill. Citing mild concerns with a lack of a 
timeline for village corporations to initiate and complete the entire 
14 (c) process, which is beyond the scope of this bill.\50\
---------------------------------------------------------------------------
    \50\ Senate Energy and Natural Resources Committee. S. Rept. 118-
177-Alaska Native Village Municipal Lands Restoration Act. May 16, 
2024. https://www.congress.gov/congressional-report/118th-congress/
senate-report/177/1.

    The administration position on the remaining legislation is unknown 
---------------------------------------------------------------------------
at this time.

VII. EFFECT ON CURRENT LAW (RAMSEYER)

H.R. 8942 (Rep. Hageman), ``Improving Tribal Cultural Training for 
        Providers Act of 2024''

https://naturalresources.house.gov/uploadedfiles/bill-to-
law_hagema_265_xml.pdf
H.R. 8955 (Rep. Johnson of SD), ``IHS Provider Integrity Act''

https://naturalresources.house.gov/uploadedfiles/bill-to-
law_johnsd_079_xml.pdf
H.R. 8956 (Rep. Newhouse), ``Uniform Credentials for IHS Providers Act 
        of 2024''

https://naturalresources.house.gov/uploadedfiles/bill-to-
law_newhou_083_xml.pdf
H.R. 6489 (Rep. Peltola), ``Alaska Native Village Municipal Lands 
        Restoration Act of 2023''

https://naturalresources.house.gov/uploadedfiles/h.r._6489_-
_ramseyer.pdf
                                     

 LEGISLATIVE HEARING ON H.R. 6489, TO AMEND THE ALASKA NATIVE 
  CLAIMS SETTLEMENT ACT TO PROVIDE THAT VILLAGE CORPORATIONS 
 SHALL NOT BE REQUIRED TO CONVEY LAND IN TRUST TO THE STATE OF 
ALASKA FOR THE ESTABLISHMENT OF MUNICIPAL CORPORATIONS, AND FOR 
    OTHER PURPOSES, ``ALASKA NATIVE VILLAGE MUNICIPAL LANDS 
   RESTORATION ACT OF 2023''; H.R. 8942, TO AMEND THE INDIAN 
 HEALTH CARE IMPROVEMENT ACT TO ENSURE THAT CERTAIN EMPLOYEES, 
  PROVIDERS, AND VOLUNTEERS ASSOCIATED WITH THE INDIAN HEALTH 
SERVICE RECEIVE EDUCATIONAL TRAINING IN THE HISTORY AND CULTURE 
 OF THE TRIBES SERVED BY SUCH PERSONS, AND FOR OTHER PURPOSES, 
   ``IMPROVING TRIBAL CULTURAL TRAINING FOR PROVIDERS ACT OF 
2024''; H.R. 8955, TO AMEND THE INDIAN HEALTH CARE IMPROVEMENT 
    ACT TO ENSURE THAT, WHENEVER THE INDIAN HEALTH SERVICE 
UNDERTAKES AN INVESTIGATION INTO THE PROFESSIONAL CONDUCT OF A 
 LICENSEE OF A STATE, THE SERVICE NOTIFIES THE RELEVANT STATE 
MEDICAL BOARD, AND FOR OTHER PURPOSES, ``IHS PROVIDER INTEGRITY 
     ACT''; AND H.R. 8956, TO AMEND THE INDIAN HEALTH CARE 
  IMPROVEMENT ACT FOR THE DEVELOPMENT AND IMPLEMENTATION OF A 
CENTRALIZED SYSTEM TO CREDENTIAL LICENSED HEALTH PROFESSIONALS 
 WHO SEEK TO PROVIDE HEALTH CARE SERVICES AT ANY INDIAN HEALTH 
  SERVICE UNIT, ``UNIFORM CREDITIALS FOR IHS PROVIDERS ACT OF 
                             2024''

                              ----------                              


                        Wednesday, July 24, 2024

                     U.S. House of Representatives

               Subcommittee on Indian and Insular Affairs

                     Committee on Natural Resources

                             Washington, DC

                              ----------                              

    The Subcommittee met, pursuant to notice, at 10:17 a.m., in 
Room 1334, Longworth House Office Building, Hon. Harriet M. 
Hageman [Chairwoman of the Subcommittee] presiding.
    Present: Representatives Hageman, Radewagen, LaMalfa, 
Westerman, Newhouse, Johnson; Leger Fernandez, Sablan, and 
Peltola.

    Ms. Hageman. The Subcommittee on Indian and Insular Affairs 
will come to order.
    Without objection, the Chair is authorized to declare 
recess of the Subcommittee at any time. The Subcommittee is 
meeting today to hear testimony on four bills, H.R. 8942, H.R. 
8955, H.R. 8956, and H.R. 6489.
    Under Committee Rule 4(f), any oral opening statements at 
hearings are limited to the Chairman and the Ranking Minority 
Member. I therefore ask unanimous consent that all other 
Member's opening statements be made part of the hearing record 
if they are submitted in accordance with Committee Rule 3(o).
    Without objection, so ordered. I ask unanimous consent that 
the gentleman from South Dakota, Mr. Johnson; the gentleman 
from Washington, Mr. Newhouse; and the gentlewoman from Alaska, 
Ms. Peltola, be allowed to sit and participate in today's 
hearing.
    Without objection, so ordered.
    I will now recognize myself for an opening statement.

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

    Ms. Hageman. Today, the Subcommittee is meeting to consider 
four bills. Three of the bills will improve the Indian Health 
Service or the IHS, and the fourth would return lands to Alaska 
Native village corporations that have been held by the state of 
Alaska for unfulfilled purposes.
    First, I want to especially thank Congressman Dusty Johnson 
for working with this subcommittee on improving IHS and being a 
champion for improving the tribal health system for all tribes.
    Last July, the Subcommittee held a hearing on Congressman 
Johnson's restoring accountability in the Indian Health Service 
Act in draft form. After much discussion, this Subcommittee and 
Congressman Johnson decided to take three key elements from the 
larger bill and introduce them as individual bills that we 
think get at specific issues that we can improve right now.
    The first bill is H.R. 8942, the Improving Tribal Cultural 
Training for Providers Act of 2024, of which I am very proud to 
sponsor. H.R. 8942 would require a mandatory annual training 
program for specific employees of the IHS on the history and 
culture of the tribes that they are serving.
    Because IHS's mission is to work with American Indian and 
Alaska Native people to promote their physical, mental, social, 
and spiritual health, IHS healthcare providers need cultural 
competence to best serve their patients.
    Several studies have indicated that culturally appropriate 
healthcare can improve doctor-patient relationships and improve 
health outcomes for patients.
    Currently, IHS employees are required to have training on 
the history and culture of the tribes they serve, but it is not 
an annual requirement.
    My bill would also explicitly state which IHS employees 
should have annual training requirements. Each of our 574 
federally recognized tribes has a unique history and culture.
    It is vital that healthcare providers receive the education 
they need to connect with the patients that they serve, and 
that this training requirement has the flexibility needed to 
avoid a one-size-fits-all approach.
    Many tribally run healthcare programs already provide this 
education for their healthcare providers, and we can learn from 
them to make this requirement work.
    The second bill is H.R. 8955, the IHS Provider Integrity 
Act, introduced by Congressman Dusty Johnson. H.R. 8955 would 
require the IHS to solicit the history of an applicant from 
every state medical board where the applicant is licensed.
    The IHS would also be required to notify each state medical 
board where a provider is licensed if IHS begins an 
investigation into the provider.
    The IHS has consistency issues surrounding healthcare 
provider licensing, including providers being hired without 
full review of all of their licenses and IHS providers with 
lapsed licenses continuing to work at IHS facilities.
    This long-standing issue first came to national attention 
in 2010 when the Senate Committee on Indian Affairs 
investigated the many issues surrounding IHS facilities 
operating in the Great Plains area.
    That investigation found that the IHS lacked a proper 
system to detect practitioners using revoked, suspended, or 
otherwise inadequate licenses. Later investigations continued 
to show that doctors were hired without full license checks at 
IHS facilities in violation of IHS policies, thereby imperiling 
patients.
    It is important that the IHS holds providers to a high 
level of care. H.R. 8955 would work to ensure all parties have 
the information necessary to keep their patients safe and make 
the best hiring decisions possible.
    The third bill, H.R. 8956, the Uniform Credentials for IHS 
Providers Act of 2024, introduced by Congressman Newhouse, 
would require the IHS to establish a uniform and centralized 
service-wide credentialing system. This system would be 
formally reviewed at least every 5 years.
    Credentialing is the process by which healthcare providers 
are evaluated to show that they have the proper education, 
training, and licenses to fulfill a position at a healthcare 
facility.
    IHS has its own process of credentialing providers that 
requires medical staff to meet the credentialing and 
privileging standards of a national accrediting body like the 
Centers for Medicare and Medicaid Services.
    However, the credentialing process has not been in practice 
the same across all IHS facilities and has specifically not 
caught issues of lapsed licenses, as previously mentioned.
    While the IHS has initiated the process to create a 
centralized credentialing system in recent years, Congress has 
a responsibility to conduct oversight on the process and ensure 
that it meets the highest standard and is implemented 
consistently.
    The final bill up for discussion today is H.R. 6489, the 
Alaska Native Village Municipal Lands Restoration Act of 2023 
introduced by Congresswoman Peltola, this bill would amend 
Section 14(c)(3) of the Alaska Native Claims Settlement Act, or 
ANCSA, to return lands back to the Alaska Native Village 
corporations that are currently held in trust by the state of 
Alaska for future municipalities.
    ANCSA was enacted to settle the aboriginal land claims of 
Alaska Natives, and Alaska Native corporations were created to 
receive land and disburse payments to Alaska Natives.
    The settlement also included a provision requiring Alaska 
Native village corporations to convey some land to an existing 
municipality. However, if no municipality existed, the land was 
conveyed to the state of Alaska to be held in trust for a 
future municipality.
    As of today, 83 village corporations still have land held 
in trust for the purposes of a municipality which has not yet 
been created and likely never will be. There was no sunset date 
for this provision, so this land remains in limbo, unable to be 
developed.
    Village corporations would anticipate developing this land 
if returned for housing, community buildings, and other 
economic development projects. H.R. 6489 would also amend ANCSA 
to return this land and eliminate the requirement in statute.
    I want to take the time to thank our witnesses for being 
here today, and I look forward to today's discussion.
    The Chair now recognizes the Ranking Minority Member for 
her statement.

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

    Ms. Leger Fernandez. Good morning to our witnesses and 
thank you for joining us. Thank you, Representative Johnson, 
for the good work that you did on the bill from which we are 
pooling many of the legislative proposals today, including 
Chair Hageman's H.R. 8942, which would provide Indian Health 
Service employees with educational and cultural training to 
better serve their tribal communities.
    I also appreciate the written testimony that we have 
received, that points out that each tribe is going to have 
unique cultural traditions, and it is important that IHS 
develop that training in consultation with the tribes that they 
serve.
    We would love to see that added to this legislation. 
Representative Johnson's H.R. 8955, which would make sure that 
the Indian Health Service is transparent with state medical 
boards, which are the professional conduct of a licensed health 
provider.
    The sad history of the issues where they have not been 
transparent are suffered by the patients. We will also consider 
H.R. 8956 from Representative Newhouse, which would establish a 
service-wide, centralized credentialing system at the Indian 
Health Service.
    These three bills sound familiar, as noted, because they 
are all sections of Representative Johnson's Restoring 
Accountability in Indian Health Service Act, which this 
Subcommittee had a hearing on last July and was reintroduced 
earlier this month.
    I will repeat what I said in that hearing, we cannot 
continue to ignore the lack of funding that tribes and the 
Indian Health Service have to deal with on a daily basis.
    None of these bills have the funding necessary to support 
these important efforts. As we noted in the earlier hearing, 
the average spending for Americans on healthcare is $9,726.
    The average spending for a patient at IHS is $4,078. And 
sadly, only 672 of you are in urban areas. It is important that 
we begin to address this as well as include funding resources 
when we take on important reform bills.
    In that hearing, the witnesses also shared their concerns 
about the lack of resources when creating new mandates. They 
suggested that this could ultimately hurt tribes' ability to 
provide the care.
    There are also many other positive sections of 
Representative Johnson's larger bill that we should discuss 
today but aren't included in these bills, particularly the 
efforts to better recruit and retain IHS staff and streamline 
their hearing process.
    I hope that we can address the issues that tribes have 
raised in the last hearing and make a real change at the Indian 
Health Service to support providing culturally competent care 
to American Indians and Alaska Natives across the United 
States.
    The final bill today on the agenda is Representative 
Peltola's H.R. 6489, the Alaska Native Village Municipal Lands 
Restoration Act. This bill would amend the Alaska Native Claims 
Settlement Act to retire the requirement for village 
corporations of unincorporated communities to reconvey lands to 
the state entrust for a future city for municipal purposes.
    I look forward to hearing from our witnesses about this 
bill and their impacts it will have in Alaska. Before I end, I 
also want to note that this is our last legislative hearing 
before the August recess.
    And when we get back, we have a lot of legislation from 
Democratic Members that haven't had any hearings yet, and we 
have bipartisan legislation that hasn't seen a markup. So, I 
look forward to having a very productive session in September 
so that we can address some of those wonderful bipartisan 
bills.
    With that, I want to once again and always thank the 
witnesses, because especially on a day like today, it is not 
easy to get here. It is not easy to get in here. So, thank you 
for your patience, and I yield back, Madam Chair.

    Ms. Hageman. Thank you.
    I will now recognize Mr. Johnson from South Dakota for 5 
minutes to speak on his legislation.

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

    Mr. Johnson. Thanks, Madam Chair, Madam Ranking Member, I 
just want to start by thanking you. This is actually how 
Washington is supposed to work.
    We worked with your teams for a long time together on the 
discussion draft that you both referenced, the Restoring 
Accountability to IHS Bill. And then we kept working on it. We 
realized that politics is the art of the possible.
    You all had coached us about the value of breaking this 
into smaller pieces so we could get some movement, gain some 
traction. So, it is really the fruits of those labors that 
bring us here today.
    And I just want to thank you for this hearing, as well as 
the diligence of this Committee in trying to make sure that we 
are moving the ball in the right direction and trying to 
improve the quality of care in IHS. It is just an incredibly 
important obligation we have that we are not always doing a 
very good job of meeting.
    In South Dakota, the average age of death is 78 years old. 
For Native American enrolled members, it is 58 years, just a 
remarkable 20-year gap. And there are a lot of reasons for 
that, and we should address all of them. But one of the reasons 
for that is the poor quality of healthcare in Indian Country, 
and that is something that we have trust and treaty obligations 
to address.
    And we also know that part of the problem with the 
healthcare is we also have a provider problem. Now, to be 
clear, there are tremendous human beings who choose to serve in 
Indian Country because they have huge hearts, and they want to 
make a difference.
    But we also know that there have been times that IHS has 
been a refuge for providers who are not good, who should not be 
practicing medicine. And study after study has shown us that. I 
would refer to the 2021 report, which we have to give some 
credit to IHS for independently commissioning that report.
    So often in government, you see people try to cover up 
their errors. But IHS, in this 2021 report, was able to uncover 
that IHS had willfully ignored and actively suppressed efforts 
to go out and identify this particular provider who had been 
later convicted of a series of sexual misconduct.
    The kind of person who should not be practicing medicine. 
And, obviously, we have a lot of work to do on that front.
    There are also instances where you have a provider who gets 
rejected to practice medicine off reservation because of 
malpractice, and then they apply for a job on IHS, and they get 
hired.
    And clearly, if they are not a provider that should see 
non-enrolled members, they are not a provider who should see 
enrolled members either.
    So, the bills before you today are really an attempt, 
particularly the bill that I am talking about, is an attempt to 
get at both of those issues with two things:
    (1) strengthening the information sharing practices between 
the state medical boards and IHS so we can figure out who the 
bad actors are and make sure we don't hire them.
    And then (2) requiring IHS to gather information on medical 
license violations so they can consider that before hiring 
somebody to work at an IHS facility.
    And I know that there are some conversations ongoing about, 
OK, how do we do these things while still providing due process 
to providers? And, obviously, let's make sure that we are 
striking the right balance here. Those conversations are 
ongoing.
    I am not under any illusions that the bills before us today 
are perfect. Let's continue to work on them so we do strike 
that right balance.
    I want to thank the witnesses for being here, a number of 
whom we have heard from before. But, of course, I have to call 
out my friend from South Dakota, Jerilyn Church. She is 
incredibly respected as the head of the Great Plains Tribal 
Chairman's Health Board. She has done as much as anybody to 
educate the South Dakota politicians about why this matters and 
what we can do together to make it happen.
    So, of course, I am going to be interested to hear her 
remarks as well. And I will close where I began, by thanking 
you all for the incredibly collaborative efforts that we are 
engaged in.
    We so often talk about what doesn't work in Washington, DC, 
but today is a pretty good day because we are moving closer to 
making progress. It is a little progress, and we need a lot of 
progress, but let's celebrate the little progress when we get 
it. With that, I yield.

    Ms. Hageman. Thank you, Congressman.
    And the Chair will now recognize Mr. Newhouse from 
Washington for 5 minutes to speak on his legislation.

    STATEMENT OF THE HON. DAN NEWHOUSE, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF WASHINGTON

    Mr. Newhouse. Thank you very much, Chair Hageman, Ranking 
Member Leger Fernandez, and members of the Committee for 
allowing me the opportunity to speak on and be part of 
something that is, like my colleague from South Dakota 
described, making some real progress on a very, very important 
issue.
    I am just proud to be a part of this and look forward to 
not only accomplishing these important steps, but much, much 
more.
    So, thank you for everybody's efforts today. Before I talk 
about my legislation at all, though, I am very proud to be able 
to see on the witness stand Chairman Erickson from the Colville 
Reservation, Chairman of the Confederated Tribes there.
    Jarred is a good friend and has been working very hard on 
these issues for several years, many years. And I just want to 
point out that while this is important stuff, literally home 
fires are burning.
    There are two major fires going on right now on the 
reservation. So, I very much appreciate Chairman Erickson's 
presence here to talk about these issues, while I am sure his 
thoughts are back home with his people.
    To get to my part of this legislation, which I think covers 
a very important aspect of it, it is the Uniform Credentials 
for IHS Providers Act, which is part of the larger package, and 
I am very happy to have reintroduced this legislation with my 
colleague Dusty Johnson.
    IHS is responsible, as we all know, for providing direct 
medical and public health services to members of the federally 
recognized Native American tribes and the Alaska Natives.
    This duty includes reviewing and verifying professional 
quality qualifications of clinicians through a process that is 
known as credentialing and privileging.
    Currently, this process involves meeting credentialing 
requirements that are spread across multiple and sometimes 
conflicting documents, making it quite challenging for 
officials to effectively and efficiently credential incoming 
medical providers.
    This lack of a standardized credentialing system has led to 
issues for the IHS and for those who utilize its services.
    In my district, my constituents have reported instances in 
which the current IHS credentialing system has truly negatively 
impacted health provider recruitment and our onboarding 
efforts, including one instance in which providers who were 
interested in working for the local service unit only to pursue 
an opportunity elsewhere because of the slow pace of the 
credentialing process.
    So, given that the health disparities that exist in Tribal 
Nations around the United States, recruitment of quality health 
personnel should be of utmost priority.
    On top of that, there have been reports of inconsistencies 
between facilities and their credentialing, privileging, and 
hiring process in which hiring committees have prioritized 
filling vacant positions over thorough background and 
credentialing checks.
    And on top of that, it has been reported that a lack of 
shared information increases the practice of hiring individuals 
with otherwise, shall we say, questionable history in 
qualifications from one facility to another.
    A recent GAO report described the effect of the lack of a 
centralized system. In one instance, the report found that at 
an IHS facility that was reviewed, 12 percent of clinician 
files that were analyzed did not meet IHS's requirement to 
verify all licenses held by the clinician, and in three of 
those files, the IHS had not verified any licenses.
    My bill seeks to address such issues by requiring the 
Indian Health Service, in consultation with tribes and 
stakeholders, to establish a uniformed, centralized, service-
wide credentialing system for individuals providing services at 
IHS facilities.
    The development of such a system, I think, would ensure 
that IHS providers are equipped with the tools that they need 
to efficiently and effectively hire qualified personnel in 
their facilities and ensure that all of them are thoroughly 
vetted.
    I think this is of utmost importance, that all patients 
receive the highest quality of care, no matter where they are. 
And I believe that this legislation, my legislation, is a step 
in the direction that we should be taking and certainly urge 
the Committee to support this important measure.
    Again, thank you very much for allowing me to be part of 
the Committee hearing today.

    Ms. Hageman. Thank you, Congressman.
    I do have to report, and I apologize about the fact that we 
are going to be disrupted because we are going to have to go 
vote.
    I did note that it is going to be a bit shorter than what 
we initially thought the voting process would take, but I am 
going to go ahead and have Representative Peltola do her 
opening statement to describe her bill.
    As soon as she is finished with that, we will go ahead and 
go over and vote. We anticipate we will be coming off the Floor 
at 11:10. We should be back in our seats about 11:15, and then 
we will reconvene and continue to discuss these bills.
    Representative Peltola, you have 5 minutes to discuss your 
bill.

STATEMENT OF THE HON. MARY SATTLER PELTOLA, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF ALASKA

    Ms. Peltola. Good morning. And thank you, Madam Chair and 
Ranking Member Leger Fernandez. I appreciate you hearing my 
bill today. H.R. 6489, the Alaska Native Village Municipal 
Lands Restoration Act.
    I greatly appreciate the support and advocacy of our 
witness, Ben Mallott from the Alaska Federation of Natives, as 
well as the Chenega Corporation. We have Greg Renkes with us, 
our former Alaska Attorney General, many folks at the state of 
Alaska, and our state legislature, among a lot of other folks, 
for their expertise and eagerness to rightfully restore Alaskan 
lands to the entities they were derived from, Alaska Native 
village corporations.
    Though Section 14(c)(3) of the Alaska Native Claims 
Settlement Act intended to support the future development of 
Alaskan municipalities, the lands given to the state to be held 
in trust have instead become largely unavailable for 
development.
    In response, communities across Alaska have been 
arbitrarily hamstrung from practicing the self-determination 
promised to them by ANCSA. Everyone agrees that the land now 
held by the state ought to be free from this obligation to be 
made available for the economic and social well-being of 
Alaskans.
    And I again want to thank you for the opportunity to move 
this bill forward, and I look forward to working with all of 
you to move this across the finish line.
    And Madam Chair, I would like to cede the rest of my time.

    Ms. Hageman. Thank you. And we will be back in about 30 to 
40 minutes. The hearing is recessed.
    [Recess.]

    Ms. Hageman. We are going to go ahead and get started, and 
I am now going to introduce our witnesses for our panel.
    Mr. Benjamin Smith is the Deputy Director, Indian Health 
Service, U.S. Department of Health and Human Services, 
Rockville, Maryland; the Honorable Jarred Michael Erickson, 
Chairman, Confederated Tribes of the Colville Reservation, 
Nespelem, Washington; Ms. Amber Torres, Chief Operating 
Officer, National Indian Health Board, Washington, DC; Mr. Ben 
Mallott, Vice President for External Affairs, Alaska Federation 
of Natives, Anchorage, Alaska; and Ms. Jerilyn Church, 
Executive Director, Great Plains Tribal Leaders Health Board, 
Rapid City, South Dakota.
    Thank you all for being here. I am sorry about the 
disruption. I don't think that we will have another one and we 
should be able to finish our hearing today.
    Let me remind the witnesses that under Committee Rules, 
they must limit their oral statements to 5 minutes, but their 
entire statement will appear in the hearing record.
    To begin your testimony, please press the ``talk'' button 
on the microphone. We use timing lights. When you begin, the 
light will turn green. When you have 1 minute left, the light 
will turn yellow. At the end of 5 minutes, the light will turn 
red, and I will ask you to please wrap up your statement.
    I will also allow all witnesses on the panel to testify 
before Member questioning.
    The Chairman now recognizes Mr. Benjamin Smith for 5 
minutes.

  STATEMENT OF BENJAMIN SMITH, DEPUTY DIRECTOR, INDIAN HEALTH 
    SERVICES, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, 
                      ROCKVILLE, MARYLAND

    Mr. Smith. Good morning Chair Hageman, Ranking Member Leger 
Fernandez, and members of the Subcommittee. Thank you for the 
opportunity to provide testimony on three legislative proposals 
before the Subcommittee and for your continued support for the 
efforts of the Indian Health Service and the Department of 
Health and Human Services to improve the health and well-being 
of American Indians and Alaska Natives.
    Your consideration today of H.R. 8942, Improving Tribal 
Cultural Training for Providers Act of 2024; H.R. 8955, the 
Indian Health Service Provider Integrity Act; and H.R. 8956, 
the Uniform Credentials for Indian Health Service Providers Act 
of 2024, underscores that commitment to improving the quality 
of healthcare provided by the Indian Health Service.
    Again, my name is Benjamin Smith and I serve as the Deputy 
Director at the Indian Health Service. The Indian Health 
Service has worked hard over the past several years to train 
our providers that work in our Indian Health Service and tribal 
facilities.
    This includes American Indian and Alaska Native culturally 
appropriate training to all our IHS employees, including all 
healthcare providers, whether Federal employees, contractors, 
or volunteers.
    This helps to meet our goal to ensure our licensed 
providers meet professional standards required for their 
discipline before authorizing them to provide healthcare in our 
Indian Health Service facilities.
    In addition, we continue to ensure our credentialing system 
filters out providers that are not licensed or who are 
professionally unfit to provide healthcare in our facilities.
    We thank Representative Leger Fernandez for raising 
workforce issues. In fact, the impacts of the workforce 
challenges experienced at the Indian Health Service rank among 
the top concerns that we hear from both tribes at the Indian 
Health Service and the Department of Health and Human Services.
    And I want to point out that our written testimony points 
and discusses some of these workforce challenges and 
recommendations in greater detail.
    At the Indian Health Service, we continue to support new 
strategies to develop the workforce and leverage advanced 
practice providers and paraprofessionals to improve the access 
to quality care in American Indian and Alaska Native 
communities.
    As the Subcommittee is aware, the Indian Health Service 
executes its mission in partnership with our tribal communities 
through a network of over 600 Federal and tribal health 
facilities and to 41 urban Indian organizations that are 
located across 37 states and provide healthcare on an annual 
basis to approximately 2.87 million American Indian and Alaska 
Native peoples.
    The Indian Health Service operates under the authority of 
the Indian Healthcare Improvement Act. The three legislative 
proposals before the Subcommittee would amend that Act by: (1) 
to ensure that certain employees, providers, and volunteers 
associated with the Indian Health Service receive educational 
training in the history and culture of the tribes served by the 
Indian healthcare system; (2) to ensure that whenever the 
Indian Health Service undertakes an investigation into the 
professional conduct of a licensee in a state, that the Indian 
Health Service notifies the relevant state medical board; and 
finally (3) to develop and implement a centralized system for 
credentialing licensed healthcare professionals seeking to 
provide healthcare services at any of our IHS facilities.
    I want to immediately jump into sharing with this 
Subcommittee some of the comments and concerns that we have 
with the three bills, but point this Subcommittee to our 
written testimony for details and examples.
    For H.R. 8942, the Training for Providers Act, the Indian 
Health Service recommends the drafters consider whether 
conditions of employment is feasible when applicable to 
contractors and volunteers.
    The Indian Health Service is concerned with creating a 
condition of employment that depends on the Indian Health 
Service setting up the program, which might be different, or a 
separate training module for each tribe.
    Thus, an employee, contractor, or volunteer could be 
violating the terms of their agreement through no fault of 
their own.
    Moving to H.R. 8955, the Provider Integrity Act, the Indian 
Health Service has concerns about the proposed timeline 
requirement for notice and providing relevant documentation to 
state medical boards.
    We would like to further explore this requirement to ensure 
that it contemplates the amount of time needed to complete a 
required appropriate investigation before reporting an adverse 
event, as well as to ensure providers have a right to due 
process and an appropriate investigation and that medical 
quality assurance records are properly safeguarded, consistent 
with Section 805 of the Indian Health Care Improvement Act.
    The drafters of H.R. 8955 should consider clarifying what 
constitutes an investigation into the professional conduct. It 
is unclear whether this is limited to peer review for 
activities related to medical care or could it include any sort 
of human resources review for the person's conduct as an 
employee.
    We also refer this Subcommittee to see our recommendations 
and our written testimony on this bill regarding the Freedom of 
Information Act and the 14-day timeline.
    For H.R. 8956, the Credentials Act, the drafters may want 
to note that the non-duplication of efforts language states, 
the Secretary is not required to establish a new medical 
credentialing system under the proposed legislation if the 
service has begun implementing or has completed implementation 
of a system that otherwise meets the requirements of this 
section.
    Taking this text into consideration, the Indian Health 
Service already has the authority to create such a 
credentialing system and has established and is fully 
implementing the new system.
    To conclude, again, I want to refer you back to our written 
testimony. At the Indian Health Service, we are committed to 
providing quality healthcare consistent with its statutory 
authorities and its government-to-government relationship with 
each Indian tribe.
    Thank you for the opportunity to provide technical 
assistance, and I am happy to answer your questions. Thank you.

    [The prepared statement of Mr. Smith follows:]
 Prepared Statement of Benjamin Smith, Deputy Director, Indian Health 
            Service, Department of Health and Human Services
                 on H.R. 8955, H.R. 8942, and H.R. 8956

    Good morning Chair Hageman, Ranking Member Leger Fernandez, and 
Members of the Subcommittee. Thank you for the opportunity to provide 
testimony on three legislative proposals before the Subcommittee, and 
for your continued support for the efforts of the Indian Health Service 
(IHS) and the Department of Health and Human Services (HHS or 
Department) to improve the health and well-being of American Indians 
and Alaska Natives (AI/AN). Your consideration today of H.R. 8942, 
Improving Tribal Cultural Training for Providers Act of 2024; H.R. 
8955, IHS Provider Integrity Act; and H.R. 8956, Uniform Credentials 
for IHS Providers Act of 2024, underscores that commitment to improving 
the quality of health care provided by the IHS.
    I am Benjamin Smith, the Deputy Director at IHS. The Biden-Harris 
Administration, the Department and IHS have worked hard over the past 
several years to not only provide needed training for our providers 
that work in our IHS and Tribal facilities, but to also provide 
American Indian and Alaska Native culturally appropriate training to 
all our IHS employees, including all health care providers, whether 
federal employees, contractors, or volunteers. We have also worked hard 
to ensure that our licensed providers meet professional standards 
required for their discipline before authorizing them to provide health 
care in our IHS facilities, and we have worked to ensure our 
credentialing system filters out providers that are not licensed or who 
are professionally unfit to provide health care in our facilities.
    It should be noted that the President's Fiscal Year (FY) 2025 
budget request includes a proposal to allow for withholding or revoking 
of annuity and retiree pay for retired civil service employees 
convicted of moral turpitude--including sexual abuse--during the 
commission of their federal duties. This proposed amendment is in line 
with the Department's mission of protecting vulnerable, underserved 
populations, and the Presidential Task Force on Protecting Native 
American Children in the Indian Health Service System.
    Workforce challenges--and the impacts on care that come with them--
are one of the top concerns raised to the Department by tribes. The IHS 
continues to support new strategies to develop the workforce and 
leverage advanced practice providers and paraprofessionals to improve 
the access to quality care in AI/AN communities. Ultimately, the Indian 
Health Service needs additional authorities and resources to build out 
their workforce pipeline. That is why the President's budget also 
included a number of proposals, some dating back to FY 2019, that have 
sought to make the IHS more competitive with other federal agencies in 
their hiring process and reduce systemic barriers to recruitment and 
retention. HHS looks forward to working with Congress on policy 
solutions to this effect. For example, the IHS seeks a tax exemption 
for Indian Health Service Health Professions Scholarship and Loan 
Repayment Programs to increase the number of health care providers 
entering and remaining within the IHS to provide primary health care 
and specialty services. The agency is also seeking the discretionary 
use of all Title 38 Personnel authorities that are currently available 
to the Veterans Health Administration. The IHS also seeks permanent 
authority to hire and pay experts and consultants. Hiring experts and 
consultants is another tool IHS can use to strengthen its workforce and 
better serve the AI/AN population, and IHS seeks legislative authority 
to conduct mission critical emergency hiring needs beyond 30-day 
appointments.
    As the Subcommittee is aware, the IHS executes its mission in 
partnership with AI/AN tribal communities through a network of over 600 
federal and tribal health facilities and 41 Urban Indian Organizations 
that are located across 37 states and provide health care services to 
approximately2.87 million AI/AN people annually.
    As you know, the IHS operates under the authority of the Indian 
Health Care Improvement Act (IHCIA). The IHS receives annual 
appropriations to carry out its authorities, including those under the 
Snyder Act and IHCIA. The three legislative proposals before the 
Subcommittee would amend the IHCIA to 1) ensure that certain employees, 
providers and volunteers associated with the IHS receive educational 
training in the history and culture of the Tribes served by the Indian 
health care system; 2) ensure that, whenever the IHS undertakes an 
investigation into the professional conduct of a licensee in a State, 
the IHS notifies the relevant State medical board; and 3) develop and 
implement a centralized system for credentialing licensed health 
professionals seeking to provide health care services at any of our IHS 
facilities.
IHS Credentialing Process, Professional Conduct Investigations, Tribal 
        Cultural Training for Providers
IHS Credentialing Process

    Over many decades, all IHS federal facilities and programs have 
utilized various tracking and management systems to manage large 
volumes of provider credentialing and privileging data. There was no 
formal process or standardization. However, IHS began the evolutionary 
process of transforming into a paperless medical staff credentialing 
environment that would support standardization and centralized document 
and verification efficiencies to strengthen patient safety by 
implementing an enterprise-wide credentialing software system and 
hiring a certified credentialing specialist at IHS Headquarters.
    Currently, all IHS direct service health care facilities have fully 
implemented the credentialing software, which includes centrally 
sharing licensed practitioners' files where federal law, accrediting 
bodies, and organizational terms of use allow. Use of a centralized 
system has significantly reduced the time to credential licensed 
practitioners. As of June 2024 year, 181 initial and reappointment 
applications were processed in IHS, with an average application 
processing time of 28 days.
    The IHS currently maintains credentialing and privileging of 3,308 
licensed practitioners at 10 IHS Areas, 23 hospitals, 49 health 
centers, 26 health stations, 8 treatment centers, and 1 dental clinic; 
this includes telemedicine providers. Of the 3,308 licensed 
practitioners in the IHS, 603 are credentialed and privileged at more 
than one facility. There are 98 Medical Doctor-Staff end users, 
including Medical Staff Professionals (Credentials), Clinical 
Directors, Chief Medical Officers, and Quality Managers. The IHS 
processed 1,778 licensed practitioners initial and reappointment 
applications over the past 12 months (July 2023-June 2024).
    In addition, the use and standardization of the credentialing 
software have increased inter-departmental collaboration with pharmacy, 
nursing, human resources, and information technology modernization 
efforts to identify practitioners' compliance with training 
requirements, staffing trends, and emerging needs and standardize 
quality credentialing metrics across the IHS.
    Additionally, the IHS is in the final stages of updating and 
publishing the Indian Health Manual, Chapter 3 Clinical Credentials and 
Privileges policy for the agency. We anticipate publishing the revised 
policy by the end of August 2024. Following the policy issuance will be 
the update of the IHS Credentialing and Privileging Standard Operating 
Procedures. These documents provide additional guidance and support to 
the medical staff professionals in assuring credentialing processes are 
clearly defined and implemented.
    The IHS will next begin to create, develop, and provide 
credentialing staff development and strengthening quality improvement 
activities at all levels of the organization. Per the 2025 Budget, IHS 
plans to hire an additional credentialing specialist who is dually 
certified in credentialing, to enhance effective training and develop 
and integrate additional quality standards and metrics into governance, 
management, and operations.
    Tribal and urban Indian health programs operating under the Indian 
Self-Determination and Education Assistance Act and IHCIA, 
respectively, are encouraged to adopt IHS policy as appropriate but are 
not required to do so, especially to the extent they are governed by 
other legal or policy requirements that do not apply to federal 
agencies.
IHS Professional Conduct Investigations

    The IHS is committed to ensuring safe and high-quality patient care 
through appropriate hiring, credentialing, peer review, and 
professional review processes for licensed providers/practitioners as 
part of a comprehensive clinical risk management system. Licensed 
providers/practitioners are held to the highest standards for conduct 
and performance. When provider misconduct or poor clinical performance 
is identified through appropriate review, the IHS notifies relevant 
authorities (e.g., state licensing boards, the National Practitioner 
Data bank, specialty boards). For example, the IHS activities in this 
area are:

     Hiring, credentialing, conducting focused and ongoing 
            professional practice evaluation, and professional peer 
            review processes are all part of a comprehensive IHS 
            vetting system and continuous oversight of provider 
            competence, clinical performance, and professional conduct.

     The IHS encourages reporting suspected misconduct or 
            substandard performance of licensed providers.

     Reports of alleged provider misconduct and/or substandard 
            clinical performance are promptly investigated by service 
            unit leadership with referral to the area leadership 
            through governance. If there is merit it will be forwarded 
            to the Headquarters (HQ) Quality and Risk Management (QARM) 
            committee for review by the QARM committee.

     Certain egregious incidents of provider misconduct (e.g., 
            sexual abuse, physical assault) or poor performance (e.g., 
            impairment threatening patient safety) are grounds for 
            immediate reporting to appropriate authorities, including 
            the state licensure board.

     The Medical Staff Bylaws detail processes for suspending 
            and terminating provider privileges for misconduct, poor 
            clinical performance, and impairment of licensed providers/
            practitioners.

     For the sake of quality/safe patient care, it is essential 
            to set a low threshold for reporting alleged misconduct, 
            poor performance, and/or impairment.

     Upon investigation, when allegations of misconduct or poor 
            performance are found to be without merit, they should not 
            result in any adverse action.

     Reporting to State Licensure Boards and other authorities 
            (e.g., National Practitioner Data bank, specialty boards 
            should be based on confirmed evidence of misconduct, poor 
            performance, and/or impairment.

     As part of a comprehensive system of clinical risk 
            management, the IHS has established criteria \1\ for 
            reporting by its healthcare entities to authorities such as 
            state licensure boards, to include:
---------------------------------------------------------------------------
    \1\ Risk Management and Medical Liability, A Manual for Indian 
Health Service and Tribal Health Care Professionals, Third Edition, 
Paul R. Fowler, DO, JD, FCLM, FAOCOPM, FAAFP, Risk Management Program, 
Office of Clinical and Preventive Services, Indian Health Service 
Headquarters, August 2018.

            +  Any professional review action that adversely affects 
---------------------------------------------------------------------------
        the clinical privileges for more than 30 days.

            +  Acceptance of the surrender of clinical privileges or 
        any restriction of such privileges,

                  -  While the (provider/practitioner) is under 
                investigation by the healthcare entity relating to 
                possible incompetence or improper professional conduct 
                or

                  -  In return for not conducting such an investigation 
                or proceeding

            +  In the case of a healthcare entity that is a 
        professional society, when it takes a professional review 
        action.

     While safety and clinical quality are always the priority, 
            determinations regarding adverse actions must afford the 
            provider due process rights.

     Processes for investigating and reporting alleged provider 
            misconduct, poor performance, and/or impairment should 
            remain consistent with standards for other healthcare 
            organizations to ensure fairness and support for a robust 
            clinical workforce in the IHS, as well as requirements that 
            apply to federal employees.

    As with the Credentialing policy, the Tribal and urban Indian 
health programs operating under the Indian Self-Determination and 
Education Assistance Act and IHCIA are encouraged to adopt IHS policy 
as appropriate. However, they are not required to abide by it, 
especially to the extent they are governed by other legal or policy 
requirements that do not apply to federal agencies.
Tribal Cultural Training for Providers

    The IHS acknowledges the role that trauma resulting from violence, 
victimization, colonization, and systemic racism plays in the lives of 
AI/AN populations, specifically AI/AN youth who are two and a half 
times more likely to experience trauma compared to their non-Native 
peers. Delivering trauma-informed services requires an understanding of 
the profound neurological, biological, psychological, spiritual, and 
social effects trauma and violence can have on individuals, families, 
and communities. The IHS workforce must be aware of the high prevalence 
of trauma in AI/AN populations and be prepared to respond effectively 
to this trauma, which affects many individuals who seek services in IHS 
facilities. It is also important to recognize and build on the 
resiliency of AI/AN people, which comes, at least in part, from their 
cultures and spirituality.
    Creating policies and services that support a trauma-informed 
perspective that appreciates the frequency of trauma, understands the 
impact at the individual and community level, and supports appropriate 
response is critical for improving the many health conditions 
experienced by the AI/AN population. IHS can enhance its capacity for 
promoting relational well-being and improving patient outcomes by 
increasing understanding of the direct and transgenerational impacts 
traumatic experiences have on a patient's health and how the patient 
engages in healthcare, by using trauma-informed policies, practices, 
and interventions.
    Delivered with cultural humility and sensitivity, a trauma-informed 
care organization emphasizes physical, psychological, and emotional 
safety for patients and providers. Trauma-informed care helps survivors 
rebuild a sense of control and empowerment. IHS has been expanding its 
work as a trauma-informed care organization with a variety of efforts: 
\2\
---------------------------------------------------------------------------
    \2\ Indian Health Service, Indian Health Manual, Part 3, Chapter 
37.

     In FY 2020, the IHS released the Indian Health Manual 
            Chapter 37, Trauma-Informed Care policy and implemented 
            trauma-informed care principles to ensure the agency 
            understands the prevalence and impact of trauma, 
            facilitates healing, avoids re-traumatization, and focuses 
---------------------------------------------------------------------------
            on strength and resilience.

     In FY 2021, the IHS updated the policy to align with 
            current trauma informed care best practices.

     The Trauma-Informed Care policy reflects training 
            requirements and guidance to support IHS's efforts of 
            providing patient-focused, driven, recovery-oriented care, 
            integrating cultural humility and appropriateness, and 
            providing trauma-informed care services.

     Trauma-informed care training is mandated for all IHS 
            employees, including contractors and volunteers, and is to 
            be completed annually. Compliance is enforced.

            +  The training content includes information on impact of 
        trauma, including historical trauma and the importance of 
        trauma informed care approach. A knowledge check is a 
        requirement to pass the training.

     The IHS is updating the training to ensure all trauma 
            informed care information is up-to-date and aligned with 
            best practices. The IHS anticipates this training will be 
            available to all employees by the end of 2024.

     In FY 2022, the IHS formed a multidisciplinary workgroup 
            comprised of subject matter experts representing all IHS 
            Areas, aiming to understand the agency's readiness and 
            identify resources to support a trauma-informed care 
            agency.

     The IHS is developing a readiness assessment to assist 
            facilities in meeting the agency policy ``to ensure 
            policies, practices, and protocols are Trauma Informed'' 
            and will identify existing/developing evidence-based 
            activities, including cultural factors.

    It is also highly recommended that each service unit develop a 
unique orientation for all staff regarding tribal cultural training 
appropriate to each tribe served by the healthcare facility.
H.R. 8942, ``Improving Tribal Cultural Training for Providers Act of 
        2024''

    The Improving Tribal Cultural Training for Providers Act of 2024 
would amend 25 U.S.C. Sec. 1616(f), titled ``Tribal culture and 
history,'' in the IHCIA to direct the Secretary of HHS to establish an 
annual mandatory training program where all employees of IHS, locus 
tenens medical providers, health care volunteers, and other contracted 
employees who work at IHS hospitals or service units whose employment 
requires regular direct patient access, and require such annual 
participation and completion of this annual mandatory training program.
    As noted prior, the IHS is highly recommending that each IHS 
service unit develop a unique orientation for all staff regarding 
cultural training appropriate to each tribe served by the IHS 
healthcare facility. H.R. 8942 would complement the existing IHS 
activities regarding Tribal cultural training of providers in the IHS 
system. However, IHS recommends the drafters consider whether 
``condition of employment'' is feasible when applicable to contractors 
and volunteers. IHS is concerned with creating a ``condition of 
employment'' that depends on IHS setting up the program, which might be 
different, or a separate training module for each Tribe. Thus, an 
employee/contractor/volunteer could be violating the terms of 
employment/contracting/volunteering, through no fault of their own.
H.R. 8955, ``IHS Provider Integrity Act''

    The IHS Provider Integrity Act would amend IHCIA by adding a new 
section to Title VIII of the Indian Health Care Improvement Act. 
Specifically, H.R. 8955 would require IHS to notify, not later than 14 
days, the State medical board of an investigation, and thereafter 
require the IHS to provide relevant records to State medical boards 
within 14 days upon generation of such relevant records into the 
professional conduct of a licensee practicing at an IHS facility.
    H.R. 8955 also would add to Title VIII of the IHCIA, a requirement, 
as part of the hiring process, that the Director of the IHS solicit 
from the medical board of each state in which a provider has a medical 
license information on such provider's history of license violations or 
settlements over the previous 20 years. Additionally, H.R. 8955 would 
require IHS to provide to the medical board of each state in which a 
provider is licensed detailed information regarding any violations by 
the provider in their IHS capacity, and would direct the IHS to submit 
a report to Congress regarding its compliance with H.R. 8955.
    The IHS appreciates the intent of H.R. 8955, but notes, as stated 
prior, the IHS is committed to ensuring safe and quality patient care 
through appropriate hiring, credentialing, ongoing monitoring, and 
professional peer review and the IHS already notifies relevant 
authorities when provider misconduct or poor clinical performance is 
confirmed through appropriate review. The IHS has concerns about the 
proposed timeline requirement for notice and providing relevant 
documentation to State medical boards. We would like to further explore 
this requirement to ensure that it contemplates the amount of time 
needed to complete a required appropriate investigation before 
reporting an adverse event, as well as to ensure that providers have a 
right to due process and an appropriate investigation and that medical 
quality assurance records are properly safeguarded, consistent with 
section 805 of the Indian Health Care Improvement Act (25 U.S.C. 
Sec. 1675). The drafters of H.R. 8955 should consider clarifying what 
constitutes ``an investigation into the professional conduct.'' It is 
unclear whether this is limited to peer review for activities related 
to medical care or could it include any sort of Human Resources review 
for the person's conduct as an employee.
    We would also urge Congress to consider standards that exist in 
other agencies or health care systems. Additionally, Congress should 
also consider adding language to make it clear that any records or 
documents provided pursuant to this statute shall be exempt from 
disclosure under the Freedom of Information Act (FOIA), section 552 of 
title 5. This would ensure that H.R. 8955 would be construed a statute 
described in subsection (b)(3)(B) of section 552 (records exempt from 
mandatory disclosure in response to a FOIA request. Additionally, 
Congress should consider adding language that protects the 
confidentially of the employee and their personnel documents.
    The IHS would not be able to report within 14 days because it is 
not feasible to complete a full review and investigation within this 
time frame. An appropriate investigation is required before reporting 
an adverse event. All providers have a right to due process and an 
appropriate investigation. If the investigation concludes that the 
provider is acting in an inappropriate or unsafe manner, then the 
findings will be immediately reported to the licensing boards where the 
provider holds a license. The IHS recommends the drafters propose a 
longer timeline that is triggered not by the initiation of an 
investigation but by the conclusion of an adequate investigation. In 
addition, the IHS recommends that the drafters limit the documentation 
to be shared with the state boards, consistent with section 805 of the 
Indian Health Care Improvement Act (25 U.S.C. Sec. 1675). It would be 
impossible to provide due process to the provider and complete an 
adequate investigation in the proposed 14-day time frame. The proposed 
time frame would require IHS to meet a standard that does not exist in 
other agencies or healthcare systems.
    Further, the IHS advocates timely reporting requirements consistent 
with the reasonable standards of other healthcare organizations, which 
prioritize evidence over allegations. Also, the proposed requirements 
in H.R. 8955 are actually not new requirements because IHS always 
primary source reviews all licenses of each provider that is 
credentialed in the IHS healthcare system.
H.R. 8956, ``Uniform Credentials for IHS Providers Act of 2024''

    The Uniform Credentials for IHS Providers Act of 2024 would amend 
the IHCIA. Specifically, H.R. 8956 would direct IHS to establish, in 
consultation with Indian tribes and stakeholders, a uniform, 
centralized, Service-wide credentialing system for health professionals 
providing services at IHS Service units. Health professionals 
credentialed in accordance with existing IHS policy are not required to 
be recredentialed under the new system until they are otherwise 
required to be recredentialed. Providers are prohibited from practicing 
within a Service unit if they are not credentialed in accordance with 
H.R. 8956. Finally, IHS is authorized to expand or enhance an existing 
credentialing system to meet the requirements set forth in this 
section.
    H.R. 8956 also specifies that nothing in its provisions negatively 
impacts the right of an Indian tribe to enter into a compact or 
contract under the Indian Self-Determination and Education Assistance 
Act or applies to such a compact or contract unless expressly agreed to 
by the Indian tribe.
    The drafters of H.R. 8956 may want to note that the nonduplication 
of efforts language states the Secretary is not required to establish a 
new medical credentialing system under the proposed legislation, if the 
Service has begun implementing or has completed implementation of a 
system that otherwise meets the requirements of this section. Taking 
this text into consideration, IHS already has the authority to create 
such a credentialing system, and has established, and is fully 
implementing the new system. Additionally, the requirements imposed by 
the new proposed legislation, particularly the requirement for tribal 
consultation, would result in duplication of effort and create 
additional, resource-intensive hurdles to implementation without 
improving on the IHS's current process, and the consultation 
requirement could open inherent federal functions to tribal 
consultation and make it challenging to meet the deadline for 
implementation in H.R. 8956.
    The drafters of H.R. 8956, should also be aware that the 
requirements imposed by this proposed legislation would create conflict 
with current and existing CMS and accreditation standards. IHS has 
established the policy and procedures for medical staff credentialing 
and clinical privileging of health care providers working in IHS health 
facilities. The governing body is the only authority that can grant 
full medical staff membership and/or clinical privileges. In the case 
of IHS, under current federal law (section 601 of the Indian Health 
Care Improvement Act (25 USC 1661)), the person(s) legally responsible 
for the conduct of the hospital is the Secretary, acting through the 
IHS Director. This operational authority is extensive, including 
approval and implementation of procedures for employee hiring, 
recruitment and dismissal.
    The drafters of H.R. 8956 should be aware, the quoted text in H.R. 
8956, ``the Secretary may authorize licensed health professionals to 
provide health care services at any service unit,'' is inconsistent 
with existing CMS standards regarding credentialing and privileging of 
medical providers. Only the Governing Board has the authority to 
authorize Licensed Independent Practitioner (LIPs) to provide health 
care services at their Service Unit per accrediting bodies and CMS 
CoPs. IHS recommends the drafters consider deleting this text to avoid 
duplication of effort with the Governing Board.
    We look forward to continuing our work with Congress on these 
bills, and as always, welcome the opportunity to provide technical 
assistance as requested by the Subcommittee or its members. Thank you 
again for the opportunity to testify today, and I am happy to answer 
any questions you may have.

                                 ______
                                 

Questions Submitted for the Record to Mr. Benjamin Smith, Indian Health 
         Service, U.S. Department of Health and Human Services

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

            Questions Submitted by Representative Westerman

    Question 1. During the hearing you noted the importance of any 
culturally competent care training being tailored to each individual 
tribal population an IHS facility is serving. In what way could this be 
accomplished, and how should H.R. 8942 be amended to reflect this 
initiative?

    Question 2. In your written testimony you note that the 
requirements of H.R. 8955 are not new requirements because the IHS 
always reviews all licenses of a provider that are credentialed in the 
IHS healthcare system. Yet, there have been various reports of this 
procedure not being followed. Please expand on your testimony and 
provide more information about how IHS is improving this system and 
ensuring that the hiring personnel are meeting IHS's stated 
requirements?

    Question 3. Under its current authority, would IHS review their 
centralized credentialing system at least every five years?

    3a) How often does the IHS currently review its credentialling 
systems?

    Question 4. Your written testimony noted that IHS will focus on 
publishing guidance and manuals containing the Service's standard 
operating procedures related to the centralized credentialing, and then 
move on to staff education. What is the timeline for both final 
publication of guidance and manuals as well as implementing the new 
training program?

    4a) How long does IHS estimate it will take to educate all 
appropriate IHS personnel?

                                 ______
                                 
    Ms. Hageman. We appreciate your testimony and being willing 
to identify some potential tweaks that we could make to the 
legislation. I know it is in your written testimony. There may 
be additional questions as well.
    Obviously, we want to work to make these bills the best 
that they can be. So, thank you for that information.
    The Chair now recognizes the Honorable Jarred-Michael 
Erickson for 5 minutes.

   STATEMENT OF THE HON. JARRED-MICHEAL ERICKSON, CHAIRMAN, 
  CONFEDERATED TRIBES OF THE COLVILLE RESERVATION, NESPELEM, 
                           WASHINGTON

    Mr. Erickson. Thank you. Good afternoon, Chairwoman 
Hageman, Ranking Member Leger Fernandez, and members of the 
Committee.
    My name is Jarred-Michael Erickson. I am the Chairman for 
the Colville Business Council, the governing body of the 
Colville Tribes. Thank you for inviting me to testify on the 
three Indian Health Service-related bills that are the subject 
of today's hearing.
    I want to extend my thanks to one of the Colville Tribes' 
Congressional Representatives, Dan Newhouse, for introducing 
the Uniform Credentials for IHS Providers Act of 2024.
    I would also like to thank Chairwoman Hageman and 
Congressman Dusty Johnson for introducing two other bills and 
for their continued interest in Indian health issues.
    Congressional oversight of IHS is especially important to 
direct service tribes like Colville. Unlike tribes that have 
contracted or compacted IHS functions, direct service tribes 
are not able to directly control IHS operations on our 
reservations. I will briefly discuss each of the three bills.
    The first bill, the Uniform Credentials for IHS Providers 
Act, requires IHS to develop and implement an IHS wide, 
centralized credentialing system in consultation with Indian 
tribes.
    Credentialing refers to the process that IHS engages in to 
review and verify the professional qualifications of health 
providers, such as verifying medical licenses. The Colville 
Tribe supports the credentialing bill because it requires IHS 
to establish a uniform credentialing that would apply 
nationwide.
    The Colville Tribes has expressed instances where the lack 
of uniformity in IHS processes have negatively impacted Indian 
beneficiaries. I previously informed this Subcommittee about 
some of these examples, specifically with the Purchase, 
Referred, and Care Program. When the IHS Portland area office 
took the PRC program away from the local Colville Service Unit 
and began administering it remotely in Portland from 2017 to 
2022, the Portland area imposed an eligibility requirement that 
was not required by the IHS Indian Health Manual to PRC users 
at the Colville Service Unit.
    We have traced these in additional unwarranted eligibility 
requirements to patient deaths. Having a credentialing system 
that applies uniformly to all IHS areas would help prevent the 
situation from being repeated in the credentialing context.
    The second bill, the IHS Provider Integrity Act, will 
require IHS to notify the state medical boards within 14 days 
after the date that IHS undertakes an investigation of 
professional conduct of a licensed health provider.
    The bill would also require IHS to obtain information on 
license violations or settlement agreements that health 
providers may have been involved in before hiring those health 
providers in the IHS system.
    As the Colville Tribes and other tribes and organizations 
have previously informed the Subcommittee, IHS's onboarding 
process for health providers takes an unreasonably long time.
    We have had health providers that our tribal employees have 
recruited in their own districts on their own express interest 
in working at the Colville Service Unit only to accept other 
employment elsewhere when IHS's background process extended 6 
months or longer.
    The Colville Tribe supports this bill and suggests that the 
Committee consider requiring deadlines for IHS to initiate 
requests for information from state medical boards at the 
beginning of the background check process.
    This would ensure that the new background requirement does 
not contribute to existing delays in the IHS onboarding health 
providers.
    The third bill, the Improving Tribal Cultural Training for 
Providers Act, will require IHS to implement a mandatory annual 
tribal culture and history training program for the IHS 
employees and volunteers whose duties involve direct patient 
access.
    The Colville Tribe supports this bill because the training 
program, if implemented correctly, would improve IHS customer 
service to Indian beneficiaries. We recognize the tribal 
culture and history topics in any training program will vary 
across the Lower 48 states and Alaska.
    What may be an appropriate training program for IHS 
employees working in the Southwest may not be applicable to the 
IHS Service Unit employees in the Pacific Northwest or the 
Great Plains areas.
    We suggest the bill include language that directs IHS to 
consult with Indian tribes in each IHS area in developing the 
training program that will be required in those IHS areas.
    We further recommend the bill include language that 
requires IHS area offices to revisit and update their training 
programs every 5 years. This concludes my testimony. I would be 
happy to answer any questions that the Committee may have. 
Thank you.

    [The prepared statement of Mr. Erickson follows:]
Prepared Statement of the Honorable Jarred-Michael Erickson, Chairman, 
            Confederated Tribes of the Colville Reservation
                 on H.R. 8955, H.R. 8942, and H.R. 8956

    The Confederated Tribes of the Colville Reservation (``Colville 
Tribes'' or the ``CCT'') appreciates the Subcommittee holding today's 
hearing on three bills related to the Indian Health Service (``IHS''). 
All three bills were derived from provisions of the ``Restoring 
Accountability in the Indian Health Service Act of 2023.'' The CCT 
worked extensively with the committees of jurisdiction when the 
original version of the bill was first being developed in 2016 and 
appreciates the Subcommittee's attention to issues relating to IHS and 
the health of Indian people.
    The CCT supports all three bills and is pleased to provide some 
suggestions for the sponsors and the Subcommittee to consider that we 
believe will improve them.
    The CCT is a direct service tribe, which means that health care and 
associated billing and administrative support is provided by IHS 
employees. The CCT is in the beginning stages of contracting all IHS 
functions, but this process will take time. In the meantime, we must 
rely on IHS to provide quality health care to our tribal citizens. 
These bills focus on IHS issues that are most relevant to direct 
service tribes and we appreciate the Subcommittee's attention to and 
consideration of them.
    The Colville Tribes is a confederation of 12 aboriginal tribes from 
across eastern Washington state, northeastern Oregon, Idaho, and 
British Columbia. The 12 constituent tribes historically occupied a 
geographic area ranging from the Wallowa Valley in northeast Oregon, 
west to the crest of the Cascade Mountains in central Washington state, 
and north to the headwaters of the Okanogan and Columbia Rivers in 
south-central and southeast British Columbia. Before contact, the 
traditional territories of the constituent tribes covered approximately 
39 million acres.
    The present-day Colville Reservation is in north-central Washington 
state and was established by Executive Order in 1872. The Colville 
Reservation covers more than 1.4 million acres, and its boundaries 
include portions of both Okanogan and Ferry counties, two of the lowest 
median income counties in the state. Geographically, the Colville 
Reservation is larger than the state of Delaware and is the largest 
Indian reservation in the Pacific Northwest. The Colville Tribes has 
just under 9,300 enrolled members, about half of whom live on the 
Colville Reservation.
A. H.R. 8956, the ``Uniform Credentials for IHS Providers Act of 2024''

    This bill would require IHS, in consultation with Indian tribes, to 
develop and implement an IHS-wide centralized credentialing system to 
credential licensed health care professionals that seek to provide 
health care services at IHS Service Units. The bill would require 
formal review of the credentialing system at least every five years in 
consultation with Indian tribes.
    Credentialing refers to the process that IHS engages in to review 
and verify the professional qualifications of health providers, such as 
verifying medical licenses. The intent of the credentialing process is 
to ensure qualified and skilled providers in the IHS system. There are 
many health provider vacancies at the Colville Service Unit and 
throughout the IHS system. This makes credentialing a critical process 
to ensure that those providers who are currently working at IHS 
facilities are qualified to provide quality health care.

    The Colville Tribes supports H.R. 8956 because it would address 
several long-standing problems with IHS's credentialing process. In 
April 2024, the Government Accountability Office (``GAO'') released a 
report on IHS's credentialing process that stated, among other things, 
the following:

        [GAO] identified two primary causes for why IHS failed to 
        consistently meet all of the credentialing and privileging 
        requirements we reviewed. First, IHS does not have a single 
        comprehensive document that clearly specifies all the agency's 
        credentialing and privileging requirements in one place. 
        Second, IHS headquarters' oversight of credentialing and 
        privileging processes conducted by facilities and area offices 
        is not sufficient to identify nonadherence to requirements.\1\
---------------------------------------------------------------------------
    \1\ U.S. Gov't Accountability Off, GAO-24-106230, Opportunities 
Exist to Improve Clinician Screening Adherence and Oversight (April 
2024), available at https://www.gao.gov/assets/gao-24-106230.pdf

    The CCT has experienced instances where the lack of uniformity in 
IHS's processes has negatively impacted Indian beneficiaries. We have 
previously informed this Subcommittee about some of these examples, 
specifically with the Purchased and Referred Care (``PRC'') program. 
When IHS's Portland Area Office took the PRC program away from our 
local Colville Service Unit and began administering it remotely in 
Portland from 2017 through 2022, the Portland Area imposed eligibility 
requirements that were not required by IHS's Indian Health Manual to 
PRC users at the Colville Service Unit. The CCT has traced these 
additional and unwarranted eligibility requirements to patient deaths. 
Having a credentialing system that applies uniformly to all IHS Areas 
would prevent such a situation from being repeated in the credentialing 
context.
    We understand that IHS is continuing to work to develop an IHS-wide 
credentialing system. IHS apparently has been undertaking this effort 
since at least 2017, when IHS officials testified before Congress on a 
prior version of the Restoring Accountability in the IHS Act that the 
agency had ``awarded a contract for credentialing software that will 
provide enhanced capabilities and standardize the credentialing process 
across IHS.'' \2\
---------------------------------------------------------------------------
    \2\ S.Hrg. 115-89, at 14 (June 13, 2017) (prepared statement of 
Rear Admiral Chris Buchanan, Acting Director of IHS).
---------------------------------------------------------------------------
    Depending on how IHS's efforts have progressed, the CCT recommends 
that the bill include language that clarifies that, in addition to the 
bill's other requirements, IHS must have all credentialing and 
privileging requirements in a single document in a single location. 
Because IHS's current credentialing process is lengthy and consumes 
significant staff time, the CCT recommends that the Subcommittee work 
with IHS to identify reasonable timelines for completion of the 
credentialing process for health providers.
B. H.R. 8955, the ``IHS Provider Integrity Act''

    H.R. 8955 would require IHS to notify state medical boards within 
14 days after the date that IHS undertakes an investigation of 
professional conduct of a licensed health provider. The bill would also 
require IHS to obtain information on license violations or settlement 
agreements that health providers may have committed or entered into 
before hiring those health providers in the IHS system.
    The CCT supports the intent of this bill, which is intended to 
address instances where a provider engages in professional misconduct 
and can move to other locations in the IHS system without their 
respective state medical boards knowing. For example, an October 5, 
2021, New York Times article reported that an independent report 
commissioned by IHS found that IHS officials ``silenced and punished 
whistle-blowers in an effort to protect a doctor who sexually abused 
boys on several Native American reservations for decades.'' There are 
other similar, unfortunate examples of health providers in the IHS 
system. To the extent that IHS initiates misconduct investigations, 
this bill would provide an additional level of accountability with 
state medical boards.
    As the CCT and other tribes and organizations have previously 
informed this Subcommittee, IHS's onboarding process for health 
providers takes an unreasonably long time. The CCT has had health 
providers that tribal employees have recruited on their own express 
interest in working at the Colville Service Unit only to accept 
employment elsewhere when IHS's background process exceeded six months.
    The CCT recommends the bill include deadlines for IHS to initiate 
requests for information from state medical boards at the beginning of 
the background check process to ensure that this requirement does not 
further contribute to delays in hiring health providers.
C. H.R. 8942, the ``Improving Tribal Cultural Training for Providers 
        Act of 2024''

    This bill would require IHS to implement a mandatory, annual tribal 
culture and history training program for IHS employees and volunteers 
whose duties involve direct patient access. The CCT supports this bill 
because the training program, if implemented correctly, would improve 
IHS customer service to Indian beneficiaries. At the Colville Service 
Unit, we are aware of a tribal member who experienced a health care 
provider tell them, ``You're fat,'' during a medical appointment. This 
type of comment should never happen in any professional health setting. 
The CCT hopes that annual, mandatory training for IHS employees would 
help ensure that these types of patient interactions are not repeated.
    The Colville Tribes notes that the substantive tribal culture and 
history topics in any training program will vary across the lower 48 
states and Alaska. What may be an appropriate training program for IHS 
employees working in the southwest may not be as applicable to IHS 
Service Unit employees in the Pacific Northwest or Great Plains Areas. 
The CCT suggests that the bill include language that directs the IHS to 
consult with Indian tribes in each IHS area in developing the training 
program that will be required in those IHS areas. We further recommend 
that the bill include language that requires IHS Area Offices to 
revisit and update the training programs every five years.

                                 ______
                                 
Questions Submitted for the Record to the Hon. Jarred-Michael Erickson, 
       Chairman, Confederated Tribes of the Colville Reservation

The Honorable Jarred-Michael Erickson did not submit responses to the 
Committee by the appropriate deadline for inclusion in the printed 
record.

            Questions Submitted by Representative Westerman

    Question 1. H.R. 8955 would ensure that state medical boards would 
be notified of medical provider investigations and requires IHS to 
obtain information of license violations and settlements of providers 
during the hiring process. How would implementation of H.R. 8955 impact 
the overall attitude toward IHS units around the Colville Reservation?

    Question 2. Would H.R. 8942 impact the hiring or onboarding process 
for IHS providers, and if yes, what language could be added to the bill 
to mitigate that concern?

                                 ______
                                 

    Ms. Hageman. Thank you.
    The Chair now recognizes Ms. Amber Torres for 5 minutes.

 STATEMENT OF AMBER TORRES, CHIEF OPERATING OFFICER, NATIONAL 
           INDIAN HEALTH BOARD (NIHB), WASHINGTON, DC

    Ms. Torres. [Speaking Native language]. Good morning 
everyone, my name is Amber Torres. I am a tribal citizen of the 
Walker River Paiute Tribe in Schurz, Nevada, a previous NIHB 
board member, and I now serve as the interim chief operating 
officer for the National Indian Health Board.
    Chairman Hageman, Ranking Member Leger Fernandez, and 
distinguished members of the Subcommittee, on behalf of the 
National Indian Health Board and the 574 sovereign federally 
recognized Tribal Nations we serve, thank you for this 
opportunity to provide testimony on three pieces of legislation 
aimed at improving the healthcare workforce at the IHS.
    The healthcare workforce is a critical component of the 
Indian Health System that directly meets the trust and treaty 
obligation to provide for the healthcare of our people.
    The legislation before the Committee today seeks to address 
several important components of the workforce issues IHS faces, 
which includes the staffing, hiring, and onboarding process.
    Overall, we are thankful to the Committee for taking the 
time to consider these bills. We support the purpose and intent 
of the legislation. The pieces of legislation being considered 
address several concerns that the tribes have raised.
    We feel the language of the proposed bill would benefit 
from a deeper dialogue with tribes and IHS to ensure they fully 
meet the intent of Congress to improve the hiring and 
onboarding processes for providers, the healthcare experience, 
and the outcome for tribal citizens.
    It is also important that the legislation does not infringe 
on the sovereignty of tribes operating their programs through 
self-governance agreements.
    As the Committee considers these bills, it is important to 
acknowledge the current provider vacancy rates and the timeline 
for hiring providers to fill vacancies. Additional requirements 
to the hiring and onboarding process creates the possibility of 
slowing the current onboarding of critical providers.
    As of February 2024, IHS had a vacancy rate of 36 percent 
for physicians, 44 percent for behavioral health, 37 percent 
for dentists, and 35 percent for nurse practitioners.
    In some areas, vacancy rates are as high as 78 percent. 
Lower levels of staffing in IHS and tribal facilities can 
impact access to care, reduce overall quality, and contribute 
to increased burnout for providers.
    Reducing staff can make it difficult to get referrals for 
specialty care to treat acute or chronic conditions. Reliance 
on low levels of staffing can undoubtedly impact the quality of 
care.
    IHS has been working to improve its HR recruitment, hiring, 
and onboarding experience through a centralized process known 
as One HR. Additional statutory requirements for system changes 
to improve hiring and onboarding also need to come with the 
appropriate resources to ensure the successful implementation 
of those changes.
    The House Appropriations Committee has moved to increase 
funding to IHS in support of new facility staff, recruitment 
tools, and construction of staff quarters.
    However, we must work to ensure that the increase to the 
IHS budget goes to support that work. Contract support costs 
and 105(l) lease payments have been determined by the Supreme 
Court to be required costs regardless of the appropriation 
levels.
    Therefore, Congress must first pay these costs before other 
areas of the IHS and Bureau of Indian Affairs Budgets can be 
considered. The increases to CSC and 105(l) leases have limited 
growth in direct services, facilities, and other administrative 
support to the IHS budget that could have otherwise gone to 
support maintaining current staffing and service levels.
    Following the recent ruling in the Becerra v. San Carlos 
Apache Tribe, are costs that are likely to increase, further 
straining the IHS in the Interior Appropriations Bill.
    We continue to request that CSC and 105(l) leases be 
appropriately classified as mandatory spending by Congress. 
This will allow any increases to the IHS budget to go toward 
important agency needs, such as improving staff and to continue 
meeting the Federal trust and treaty responsibilities to Tribal 
Nations.
    In conclusion, we thank the Committee for the consideration 
of these bills. We look forward to working with the Committee 
staff and the bill sponsors to ensure that the language does 
not negatively impact the efficiency of the IHS hiring process 
and that tribal sovereignty is upheld.
    [Speaking Native language] for the time.

    [The prepared statement of Ms. Torres follows:]
 Prepared Statement of Amber Torres, Interim Chief Operating Officer, 
                      National Indian Health Board
                 on H.R. 8955, H.R. 8942, and H.R. 8956

    Chairwoman Hageman, Ranking Member Leger Fernandez, and 
distinguished members of the Subcommittee, on behalf of the National 
Indian Health Board (NIHB) and the 574 sovereign federally recognized 
American Indian and Alaska Native Tribal nations we serve, thank you 
for this opportunity to provide testimony on three pieces of 
legislation, H.R. 8956, the Uniform Credentials for IHS Providers Act 
of 2024, H.R. 8942, the Improving Tribal Cultural Training for 
Providers Act of 2024, and H.R. 8955, the IHS Provider Integrity Act. 
My name is Amber Torres. I am a member of the Walker River Paiute Tribe 
of Nevada and I serve as the Interim Chief Operations Officer for the 
National Indian Health Board (NIHB).
    Healthcare workforce is the critical component of the Indian health 
system that directly meets the trust and treaty obligation to provide 
for the healthcare of our People. The legislation before the committee 
today seeks to address several important components of the staffing and 
provider hiring and onboarding process. The Uniform Credentials for IHS 
Providers Act of 2024 proposes to streamline the hiring process and the 
ability for providers to move around the Indian Health Service's 
network of hospitals and clinics. Uniform credentialing promises to 
improve the ability of IHS to quickly address staffing shortages across 
its system by more quickly deploying providers to areas which may have 
high vacancy rates. NIHB has shared feedback with the committee to 
ensure that the legislation includes definitions that would be 
appropriate to only IHS-operated facilities.
    The Improving Tribal Cultural Training for Providers Act of 2024 
would require IHS staff to receive cultural training. This bill would 
ensure that those working in our communities have a better 
understanding of our cultures and our ways to improve the experience 
that our Tribal citizens receive their care. This is critical to 
improving the patient experience and improving outcomes. When patients 
feel that they are understood and their concerns are received in a 
culturally informed manner, they are more likely to return for their 
follow up care and feel that their healthcare provider has their best 
interests at heart and the best interests of the community's overall 
health. Many tribal health providers already conduct this type of 
training, and we would encourage IHS to utilize these models as best 
practices as they implement the requirements of this bill.
    Finally, H.R. 8955 would require in statute that providers under 
investigation be reported to their licensing boards. Further, the bill 
requires that as part of the hiring processes, IHS contact licensing 
boards to verify the good standing of provider's licensure, 
particularly seeking disciplinary actions or findings made by the 
licensing board. This legislation would address quality of providers to 
ensure that they can appropriately meet the needs of the IHS. NIHB has 
shared feedback with the Committee and the bill's sponsors that would 
streamline the legislation so as not to make this onerous on the hiring 
process of the IHS. Often, state licensing boards can be under-staffed 
and it is possible this could create delays in the hiring process. It 
is also important to consider how long IHS and other providers keep 
personnel records. The 20 years outlined in the legislation may not be 
a feasible timeline to access records. Additionally, we would encourage 
the legislation to share only investigations that have reasonable 
findings, as investigations can often be started and there is found to 
be no wrongdoing by the provider.
    As the Committee considers these bills, it is important to consider 
the current provider vacancy rates and the timeline for bringing on 
providers to fill vacancies. Additional requirements in the hiring and 
onboarding process creates the possibility to slow the current 
onboarding of critical providers. As of February 2024, IHS had a 
vacancy rate for physicians of 36 percent; for behavioral health 
providers, that rate is 44 percent. The dentist vacancy rate is 37 
percent, and nurse practitioner vacancy is 35 percent. When we look at 
specific Areas, individual rates go as high as 58 percent vacancy rate 
for physician assistants in Billings Area, 63 percent vacancy rate for 
physicians in Great Plains and 78 percent for behavioral health 
providers in the Albuquerque Area. These incredibly high vacancy rates 
correspond to low staffing levels on the ground.
    Lower levels of staffing in IHS and Tribal facilities can impact 
access to care, reduce overall quality, and contribute to increased 
burnout for providers. Reduced staffing can make it difficult to get 
referrals for specialty care to treat chronic or comorbid conditions, 
which can have both individual and larger, enterprise-level impacts. 
Reliance on low levels of staffing also can impact quality of care. 
Providers working through burnout can miss important symptoms, but 
further, it creates reliance on particular providers that can leave 
huge gaps in service delivery if and when a provider moves on. IHS and 
Tribal providers also work in an environment that requires cultural 
competence, sensitivity and awareness. Tribes have long requested that 
providers, employees, and Commissioned Officers go through cultural 
training to better serve and understand the communities in which they 
live and work. Cultural competence training for positions that work in 
Indian country is vital for the IHS, but there are positions across 
many federal departments and agencies which need this type of training 
to properly understand Tribal communities and the Indian health system.
    The IHS has been working to improve its human resources, 
recruitment, hiring, and on-boarding experience through a centralized 
process known as One HR. Additional statutory requirements for systems 
changes to improve hiring and onboarding also need to come with 
appropriate resourcing to ensure the successful implementation of those 
changes. The House Appropriations Committee has moved to increase 
staffing funding to IHS in support of new facilities staff, recruitment 
tools, and staffing quarters to improve the current staffing crisis the 
Agency has been facing.
    The pieces of legislation being considered address several concerns 
Tribes have raised. The language of the proposed bills would benefit 
from deeper dialog with Tribes and IHS to ensure they fully meet the 
intent of Congress to improve the hiring and onboarding process for 
providers and the healthcare experience and outcomes for Tribal 
citizens. It is also important that the legislation is clear in its 
intent to improve the operations of the IHS, and that it does not 
infringe on the sovereignty of Tribes which operate their programs 
through agreements under the Indian Self-Determination and Education 
Assistance Act (25 U.S.C. ch. 14, subch. II Sec. 5301 et seq).
    There are also other legislative initiatives which are currently 
pending before Congress which would improve the tools already available 
to the IHS and Tribes to improve the recruitment and retention of a 
culturally competent and trained workforce. Although the Indian Health 
Program received a substantial increase in the House's Interior, 
Environment, and Related Agencies bill, the scholarship and loan 
repayment programs are not treated equally to other equivalent programs 
offered within HHS which enjoy tax-exemption, which allows all of the 
available funding to support recruitment. Additional funding for this 
program will be an important part of any multipart strategy to improve 
the workforce difficulties facing the Agency. NIHB supports language 
included in H.R. 8318, the Tribal Tax and Investment Reform Act of 
2024, that would make IHS scholarship and loan repayment programs tax 
exempt. We encourage the House Natural Resources Committee members to 
voice their support for this legislation.
    Expansion of midlevel provider types and grow-your-own education 
programs are another critical piece to the workforce development reform 
that is necessary to support the whole Indian health system. IHS has 
been working to expand the successful Community Health Aide Program, 
better known as CHAP, to help smaller communities have providers in 
their community even when it is difficult to hire a physician level 
provider. Tribal programs to encourage and educate youth and young 
professionals in healthcare careers need to be supported and resourced 
to ensure we are developing a larger pool of providers to meet current 
and future staffing needs.
    Finally, we must work to ensure that the increases to the IHS 
budget go to support this work. Contract support costs and 105(l) lease 
payments have been determined by the U.S. Supreme Court to be required 
costs, regardless of the appropriation levels. Therefore, Congress must 
essentially pay these costs first before other areas of the IHS and 
Bureau of Indian Affairs budgets can be considered. In recent years, 
increases to CSC and 105(l) leases limited growth in direct services, 
facilities and other administrative support to the IHS budget that 
would have otherwise gone to support maintaining current staffing and 
service levels. Following the recent ruling in the Becerra v. San 
Carlos Apache Tribe, the costs are likely to increase, further 
straining the IHS and the Interior appropriations bill. As part of 
long-term support for addressing IHS workforce needs, it is critical 
that these costs, which are essentially already a mandatory cost 
provided as an ``indefinite discretionary'', be is addressed through 
common sense reform by appropriately classing them as mandatory 
appropriations. This will allow increases to the IHS budget to meet the 
important staffing needs to continue meeting the federal treaty and 
trust responsibility to Tribes. These funds are already required to be 
paid, and the Appropriations Committee does not have input in how much 
to allocate to these accounts. Without this change, the administrative 
funds that IHS would use to implement the changes outlined in these 
bills, will not be possible.
Conclusion:

    In conclusion, we thank the Committee for their consideration of 
these bills that address important challenges to IHS staffing and 
cultural competency at IHS-operated facilities. As the process moves 
forward, we look forward to working with Committee staff and the bill's 
sponsors to ensure that the language would not inadvertently impact 
Tribally operated health systems, and would not have a deleterious 
impact on the efficiency of the IHS hiring process (a process that is 
already exceedingly slow and overburdened by bureaucracy). We also 
encourage the House Natural Resources Committee to support changes that 
would categorize CSC and 105(l) leases as mandatory funding. This will 
make it possible for they agency to allocate additional funds for 
activities to support staffing at IHS-operated facilities.

                                 ______
                                 

Questions Submitted for the Record to Ms. Amber Torres, Chief Operating 
              Officer, National Indian Health Board (NIHB)

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


            Questions Submitted by Representative Westerman

    Question 1. Would H.R. 8942 impact the hiring or onboarding process 
for IHS providers, and if yes, what language could be added to the bill 
to mitigate that concern?

    Question 2. Please expand from your testimony as to why H.R. 8942, 
H.R. 8955, and H.R. 8956 should only apply to IHS direct service 
facilities.

                                 ______
                                 

    Ms. Hageman. Thank you for your testimony.
    The Chair now recognizes Mr. Ben Mallott for 5 minutes.

STATEMENT OF BEN MALLOTT, VICE PRESIDENT FOR EXTERNAL AFFAIRS, 
     ALASKA FEDERATION OF NATIVES (AFN), ANCHORAGE, ALASKA

    Mr. Mallott. Good morning and thank you Chair Hageman, 
Ranking Member Leger Fernandez, and members of the Subcommittee 
on Indian Affairs.
    My name is Ben Malott. I have had the honor of serving as 
Vice President of General Affairs for AFN and also the 
president elect of AFN. I would like to thank you for the 
opportunity to provide testimony in support of H.R. 6489, the 
Alaska Native Village Municipality Lands Restoration Act.
    Also, I would like to thank Congresswoman Mary Peltola for 
her work on this bill.
    For background, AFN is a large statewide Native 
organization in Alaska. Our membership includes 177 tribes, 154 
village corporations, 9 of our 12 village corporations, and 9 
of our regional tribal consortiums.
    As Chairman Hageman outlined earlier, ANCSA as passed in 
1971, included a provision called 14(c)(3). At the time, many 
of our communities at passage in 1971 were unincorporated 
lands.
    Section 14(c)(3) was included in the bill in case there was 
an opportunity or that community wanted to establish a city, 
government, or municipality. It required every Alaska Native 
business corporation to give about 1,200 acres of land and 
sometimes the most viable land within the community at the 
center of the community for this purpose, and that was about 50 
years ago. Currently, there are 83 communities of the 101 
communities within the program and since then only 8 of those 
communities have established the city government, the last one 
being 1995.
    The State of Alaska Municipal Land Trust, or the MLT, has 
approximately 11,500 acres of valuable lands in each of our 
communities. This is land that is in central communities.
    It is land that could be used for housing, could be used 
for student services and other purposes that are right now 
currently managed by the state and can be an underfunded and 
overtasked office.
    Lands to transfer out program, under the current system, is 
very burdensome and troublesome. It hinders our village 
corporations from using this land for community development and 
work with our tribes to figure out what is best for communities 
to grow.
    Additionally, as our tribes and ANCs figure out what to do 
with these lands, if the corporation wants to transfer lands 
out, the state still has to transfer over lands because the 
state as a trust has an obligation under current law to manage 
those lands in the tribes' best interests or in the state's 
best interest for a future city government.
    As such, the MOT takes this job seriously and continues to 
hinder our communities to expansion. Many of our state MOT 
communities have expressed a strong interest in removing this 
provision of 14(c)(3), a resolution was passed at AFN for many 
years, and to expand this program and to sunset the provision.
    H.R. 6489, as I mentioned, sunsets the supporting 14(c)(3) 
provision. It also empowers corporations and communities that 
make the best decisions for the communities.
    These two components are significant because, as I 
mentioned, according to Save Alaska, of the original 101 
villages conveyed in the program, only 8 have been 
incorporated.
    As mentioned, for many communities where cities have not 
been formed, these lands sit vacant, empty, and not being used 
for community purposes. And, additionally, moving the Section 
14(c)(3) provision eliminates the need for future conveyances.
    So, as a community wants to or ANC wants to convey lands, I 
want to recognize my village corporation's manuka's testimony, 
which is also on the record for a community of Rampart or 
Chenega, or other community villages, if the city wants to 
move, or the village wants to move those lands for purposes of 
economics, the state still has a title over those lands for 
14(c)(3) provisions.
    So, it still holds the lands even for purposes under pretty 
much overworked and under tasked office. I am sorry, I am tired 
and am starting to stutter. I apologize.
    So, H.R. 6489 still has that burdensome hurdle. Overall, 
14(c)(3) is a 50-year-old relic of its day. As mentioned, the 
last municipality was set up in 1995. H.R. 6489 sunsets the 
provision encourages our communities to make the best decision 
for the community. As such, AFN fully urges Congress to pass 
this bill. [Speaking Native language.]

    [The prepared statement of Mr. Mallott follows:]
  Prepared Statement of Benjamin Mallott, Alaska Federation of Natives
                              on H.R. 6489

    Chair Representative Harriet Hageman, Ranking Representative Teresa 
Leger Fernandez, Ranking Member Lee, and members of the House Natural 
Resources Subcommittee on Indian and Insular Affairs, thank you for the 
opportunity to provide written testimony for the hearing record in 
support of H.R. 6489, the ``Alaska Native Village Municipal Lands 
Restoration Act of 2023.''
    My name is Benjamin Mallott, and I am honored to serve as the 
President-Elect of the Alaska Federation of Natives (AFN). AFN was 
formed to achieve a fair and just settlement of Alaska Native 
aboriginal land claims. Today, AFN is the oldest and largest statewide 
Native membership organization in Alaska. Our membership includes 177 
Alaska Native tribes, 154 for-profit village Native corporations, 9 
for-profit regional Native corporations established pursuant to the 
Alaska Native Claims Settlement Act (ANCSA), and 9 regional nonprofit 
tribal consortia that contract and compact to administer federal 
programs under the Indian Self-Determination and Education Assistance 
Act. The mission of AFN is to advance and enhance the political voice 
of Alaska Natives on issues of mutual concern.
    Today, I want to submit written testimony supporting H.R. 6489, the 
``Alaska Native Village Municipal Lands Restoration Act of 2023.'' 
Resolutions passed by AFN that support H.R. 6489 are attached to this 
testimony.
    For background, ANCSA was signed into law on December 18, 1971. 
Alaska Natives were compensated with fee simple title to 44 million 
acres of land and $962.5 million. ANCSA created 13 regional for-profit 
corporations and more than 200 village corporations. Alaska Native 
Corporations received land and monetary entitlements. In addition, 
Congress charged ANC with providing for their people's economic, 
social, and cultural well-being in perpetuity.
    ANCSA was a complicated act and laid out multiple types of land 
conveyances. Most of our communities at the time were in unincorporated 
portions of the state. Section 14(c) of ANCSA was included if a 
community wanted to establish a municipality. Section 14(c)(3) required 
every Alaska Native Village Corporation to turn a portion of their 
lands over to the State of Alaska to be held in trust for a possible 
future municipal government. These lands conveyed to the State include 
``the surface estate of the improved land on which the Native village 
is located and as much additional land as is necessary for community 
expansion, and appropriate rights-of-way for public use, and other 
foreseeable community needs,'' with the amount of lands to be 
transferred to ``be no less than 1,280 acres unless the Village 
Corporation and the Municipal Corporation or the State in trust can 
agree in writing on an amount which is less than 1,280 acres.'' Less 
than half of our village corporations came to an agreement with the 
State on lands to be turned over to the trust, and in only a few 
instances has a municipality been established.
    For nearly 50 years, the State Municipal Land Trust (MLT) has 
managed 14(c)(3) lands in Alaska, an underfunded and overtasked office. 
Despite decades of administration, only eight ANCSA villages have 
formed new municipalities, the last one established in 1995. It is 
evident that, for many remote Native Villages in Alaska, forming a 
municipality is not foreseeable.
    Currently, 83 communities across Alaska have their lands tied up 
under the MLT program, which is approximately 11,550 acres. The land 
transferred under 14(c)(3) requires an overly burdensome and almost 
impossible process to transfer lands into private hands or back to the 
Alaska Native Village Corporation. Some village corporations defied the 
law and never transferred land into the MLT. Other than the original 
initiative by the BLM, there was no enforcement mechanism at the state 
level to require participation. However, for these village corporations 
that chose not to participate, the title remains on their lands, and 
they are subject to ANCSA 14(c)(3). Any land use authorized by the 
Village Corporation requires the State's written disclaimer of interest 
and has resulted in the current law having a broader negative impact 
beyond the 83 communities currently tied up with lands held in the MLT.
    The State's view of its trust responsibilities is that conveyance 
in fee simple is not possible under current law. Because the MLT is a 
trust, it has a legal and fiduciary obligation to manage the lands in 
the best interests of the municipality or, in the absence of one, the 
future municipality. The MLT takes this trust responsibility seriously, 
and this obligation severely limits the available uses of what are 
often the most important parcels of land in these remote rural 
villages, many of which desperately need facilities and economic 
development. Many MLT communities have indicated a strong interest in 
having the lands they transferred to the State returned to expand 
economic development in their communities.
    H.R. 6489, the ``Alaska Native Village Municipal Lands Restoration 
Act of 2023,'' sunsets the Alaska Native Claims Settlement Act (ANCSA) 
14(c)(3) provision. AFN supports H.R. 6489 because removing the 
14(c)(3) provision will empower Alaska Native corporations and 
communities to make informed decisions about best utilizing their lands 
and resources, leading to greater economic prosperity and self-
sufficiency.
    Essential components of this legislation are removing the 14(c)(3) 
provision and restoring lands conveyed to the MLT to the appropriate 
Alaska Native Village Corporation. These two components are significant 
because, according to the State of Alaska, of the original 101 villages 
covered by the MLT program, eight villages have been incorporated into 
a municipality. For the many communities where a municipality has not 
been formed, and the village corporation conveyed all or partially 
required land to the MLT, the property conveyed to the MLT will revert 
to the village corporation under H.R. 6489. Additionally, the sunset of 
the 14(c)(3) provision eliminates the need for future conveyances, 
thereby reducing the barriers for Alaska Native communities to decide 
what they want to do with their lands without having to go through a 
bureaucratic hurdle.
    H.R. 6489 is the right step forward for continued support for the 
economic empowerment and self-sufficiency of Alaska Native communities. 
It is important to note that ANCSA came into existence during the era 
of Indian self-determination. ANCSA reflects this policy approach by 
providing Alaska Native people the resources necessary for economic, 
cultural, and political self-determination. As such, I urge full 
consideration of H.R. 6489 before Congress and its passage into law. 
Over 50-year-old legislative loose ends need to be addressed to fulfill 
the promise of self-determination embodied in the 1971 ANCSA 
settlement.
    Thank you for your consideration.
    Quyana, Gunalcheesh, Haw'aa, Baasee, Taikuu, Thank you.

                                 ______
                                 

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

 STATEMENT OF JERILYN CHURCH, EXECUTIVE DIRECTOR, GREAT PLAINS 
TRIBAL LEADER'S HEALTH BOARD (GPTLHB), RAPID CITY, SOUTH DAKOTA

    Ms. Church. [Speaking Native language.] Thank you, Ranking 
Member Leger Fernandez, Chairwoman Hageman, Representative 
Johnson, and Representative Newhouse for allowing me the 
opportunity to provide testimony this afternoon on behalf of 
the Great Plains Tribal Leaders Health Board.
    The Health Board serves as a liaison between the Great 
Plains tribes and various agencies of the HHS, including the 
IHS. We work to reduce public health disparities, improve the 
health and wellness of our American Indian people and tribal 
communities, and we also administer nearly all IHS funded 
health services in Rapid City through the Oyate Health Center.
    We recognize that IHS faces difficulties and challenges in 
improving healthcare delivery and outcomes for our tribal 
communities. I have testified several times before to the 
Subcommittee on proposed legislation and appreciate the members 
of the Subcommittee and their work emphasizing the improvement 
of Indian Health Service and its operations.
    As the Subcommittee is considering these bills, we 
emphasize the need to make sure that they and other legislation 
do not confer additional unfunded mandates on the already 
seriously under resourced Indian Health Service.
    Concerning the Uniform Credentialing for IHS Providers, the 
bill should be amended to clarify that tribally operated 
facilities and programs are not subject to the mandated IHS 
centralized credentialing system unless the tribal health 
program has expressly opted into that system.
    It would also be helpful to clarify when IHS and tribally 
operated service units can accept credentials of licensed 
health professionals who were credentialed by the tribal health 
programs.
    We have provided some amended language in our written 
testimony to address those issues. We are concerned with the 
use of the term licensed health professionals in the bill, that 
it may be broader than it is intended.
    Centralizing the credentialing for various types of 
providers that are included in that term, as defined by a YDE, 
the Indian Healthcare Improvement Act, with all the various 
requirements, might be particularly challenging.
    Finally, we strongly urge that Subsection (c)(1) be amended 
to add tribal organizations and inter-tribal consortia after 
Indian tribes as entities with which IHS must consult.
    Regarding Tribal Cultural Training for Providers, we are 
concerned that the bill might be interpreted to apply to 
employees of tribal health programs, including Federal 
employees assigned to work for tribal health programs under an 
interpersonal agreement or memorandum agreement.
    That requirement would be disruptive, expensive, and 
duplicative for tribal programs, so we want them to not have to 
be required in addition to what we already implement as a 
tribal health program. We have included proposed language in 
our written testimony to address this issue as well.
    Regarding the IHS Provider Integrity Act, the Great Plains 
Tribal Leaders Health Board appreciates the Subcommittee's 
emphasis on making sure IHS hires the best and most qualified 
individuals to care for our relatives.
    However, we are concerned with the proposed 20-year look 
back requirement because providers are often licensed in 
several states over the course of long careers.
    We suggest that the Subcommittee work collaboratively with 
the Indian Health Service to determine whether the mandated 
exchange of information can be accomplished without creating 
additional delays or barriers for filling critical provider 
positions.
    As you all know, there is a great need to fill many, many 
positions, and we just don't want to see an overreach, and we 
want to find that balance between ensuring that there is due 
diligence but also filling positions as quickly as possible.
    And finally, these proposed amendments to the Indian 
Healthcare Improvement Act provide another opportunity for us 
to urge members of the Subcommittee to work with your 
colleagues to direct IHS to reinstate the National Steering 
Committee on the reauthorization of the Indian Healthcare 
Improvement Act.
    Thank you very much for the opportunity to provide 
testimony today on these vital issues and appreciate your 
efforts to improve health care delivery to all of our people. 
[Speaking Native language.]

    [The prepared statement of Ms. Church follows:]
 Prepared Statement of Jerilyn Church, MSW President/CEO, Great Plains 
                      Tribal Leaders Health Board
                 on H.R. 8955, H.R. 8942, and H.R. 8956

    Thank you for the opportunity to testify at today's legislative 
hearing on behalf of the Great Plains Tribal Leaders Health Board 
(GPTLHB). GPTLHB serves as a liaison between the Great Plains Tribes 
and the various Health and Human Services divisions, including the 
Great Plains Area Indian Health Service (IHS), and works to reduce 
public health disparities and improve the health and wellness of 
American Indian people and Tribal communities across the Great Plains. 
The GPTLHB also administers nearly all IHS-funded health services in 
Rapid City, SD through the Oyate Health Center.
    In our region, the Indian Health Service (IHS) is the primary 
source of hospital care for 150,000 American Indians/Alaska Natives in 
the Great Plains Area. Of the six hospitals in the Great Plains, five 
are managed directly by IHS, with one operated by a tribal health 
program under a Title V Self-Governance compact. Ambulatory care is 
increasingly carried out by tribal health programs, except in the five 
locations where IHS still operates hospitals. Tribal health programs 
deliver ambulatory health services, with seven programs managed 
entirely by a tribe or a tribal organization under a Title I Self-
Determination contract and two more tribally managed through a Title V 
Self-Governance compact. The Indian Health Service is responsible for 
two substance abuse treatment centers and supports three urban health 
care programs.
    At GPTLHB, we are acutely aware of the difficulties and challenges 
that the IHS faces in improving healthcare delivery and healthcare 
outcomes for American Indian people in our communities. Over the last 
few years, I have testified several times before this Subcommittee on 
these current challenges and opportunities and legislation targeted at 
improving healthcare delivery through the IHS system. We appreciate the 
members of this Subcommittee emphasizing improving the IHS and its 
operations.
    As the Subcommittee is considering these bills, we emphasize the 
need to make sure that they--and any other related legislation--do not 
confer additional unfunded mandates on the already seriously under-
resourced IHS and that additional administrative requirements 
(including agency reporting requirements) will not be so burdensome as 
to take time and resources away from patient care. Regarding 
improvements to IHS operations, the most crucial factor is ensuring the 
agency has sufficient resources to do its job.
    With these general concerns in mind, we turn to the specific 
legislation before the Committee.
The Uniform Credentials for IHS Providers Act of 2024 (H.R. 8956)

    Application to tribal health programs. GPTLHB believes it is 
essential to clarify that Tribally-operated facilities and programs are 
not subject to the mandates of the IHS's centralized credentialing 
system this bill requires unless the tribal health program has 
expressly opted to participate in the IHS's credentialing system fully 
or in part. Section 125(f)(1) appears to intend that result to achieve 
this by providing that nothing in the section [125] ``negatively 
impacts the right of an Indian tribe to enter into a compact or 
contract under the [ISDEAA].'' If read narrowly, IHS may interpret this 
exemption as not applying to tribal organizations or inter-tribal 
consortia. The risk of this is elevated by the language in subsection 
(f)(2), which limits the application of Section 125 to ``a compact or 
contract unless expressly agreed to by the Indian tribe.'' There is a 
significant risk that IHS might require that the tribal resolutions 
that authorized a tribal organization or inter-tribal consortia carry 
out programs of the Service expressly address the credentialing system.
    It would also be helpful to expressly describe some of the 
circumstances under which a centralized credentialing system could be 
useful to tribal health programs without imposing the entire process on 
the tribal health program, as well as when the Service and tribally-
operated Service units can accept the credentials of licensed health 
professionals who were credentialed by a tribal health program.

    The exemption currently in the bill can be clarified and the 
additional objectives achieved by amending the proposed subsection (f) 
to read, as follows:

        ``(f) Effect.--Nothing in this section----

        ``(1) negatively impacts the right of an Indian tribe, tribal 
        organization, or inter-tribal consortium (as those terms are 
        defined at 25 U.S.C. Sec. Sec. 5304(e) and (l) and 5381(a)(5) 
        and (b)) to enter into a compact or contract under the Indian 
        Self-Determination and Education Assistance Act (25 U.S.C. 5301 
        et seq.);

        ``(2) applies to the programs, services, functions, and 
        activities (or portions thereof) carried out by an Indian 
        tribe, tribal organization, or inter-tribal consortium under 
        such a compact or contract unless expressly agreed to by the 
        contracting or compacting Indian tribe, tribal organization, or 
        inter-tribal consortium;

        ``(3) prevents an Indian tribe, tribal organization, or inter-
        tribal consortium from partially participating in the 
        credentialling system by accepting the credentials of a Service 
        licensed health professional without independently verifying 
        them; and

        ``(4) prevents the Service from allowing a licensed health 
        professional who has been credentialed by a health program 
        carried out by an Indian tribe, tribal organization, or inter-
        tribal consortium under a contract or contract as described in 
        subsection (1) to provide health care services at any hospital 
        or ambulatory directly operated by the Service or at any 
        tribally operated Service unit if approved by that Service 
        unit.

    Scope of ``licensed health professionals.'' It is not clear how 
broadly the sponsors of this bill intend it to reach. The term 
``licensed health professional'' may apply more broadly than intended. 
The term ``health profession'' is defined very broadly in the IHCIA to 
mean ``allopathic medicine, family medicine, internal medicine, 
pediatrics, geriatric medicine, obstetrics and gynecology, podiatric 
medicine, nursing, public health nursing, dentistry, psychiatry, 
osteopathy, optometry, pharmacy, psychology, public health, social 
work, marriage and family therapy, chiropractic medicine, environmental 
health and engineering, an allied health profession, or any other 
health profession.'' The fact that centralized credentialing would 
apply only to licensed health professionals is still quite expansive. 
Nurses, social workers, optometrists, optical dispensers, social 
workers, marriage and family therapists, chiropractors, other 
behavioral health providers (e.g., three states license mental health 
technicians), pharmacists (and possibly pharmacy assistants) are 
subject to state regulation with most requiring a license. The 
licensing requirements vary by state, so the people subject to these 
credentialing requirements may differ from state to state. This will be 
a particularly challenging process.

    Consultation. Finally, we are very concerned that subsection (c) 
neglects to include tribal organizations and inter-tribal consortia 
among entities with which the Secretary must consult. We urge that 
subsection (c)(1) be amended to add ``tribal organizations and inter-
tribal consortia'' after ``Indian tribes.''
    Tribal organizations and inter-tribal consortia have been 
authorized by Indian tribes to carry out health programs on their 
behalf. While carrying out that work, the tribal organizations and 
inter-tribal consortia acquire significant expertise in technical 
health care administration matters, including credentialing. That 
should not be ignored or given less weight than other entities listed.
Improving Tribal Cultural Training for Providers Act of 2024 (H.R. 
        8942)

    GPTLHB appreciates the emphasis on expanding the reach of IHS' 
Tribal culture and history training.
    We are concerned, however, that the bill may be interpreted to 
apply to employees of tribal health programs, including Federal 
employees assigned to work for a tribal health program under an IPA 
(Intergovernmental Personnel Agreement) or MOA (Memorandum of 
Agreement). The list of types of employees in subsection (a) extends 
not only to those working in ``Service hospitals'' but also in ``other 
Service units.'' ``Service unit'' is a defined term in the IHCIA (25 
U.S.C. Sec. 1603(20)). The term ``means an administrative entity of the 
[Indian Health] Service or a tribal health program through which 
services are provided, directly or by contract, to eligible Indians 
within a defined geographic area.''
    The requirement for all these employees to participate in annual 
training under Subsection Sec. Sec. (c) if applied to tribal health 
programs, including federal employees assigned to a tribal health 
program under the Indian Self-Determination Act, is likely to be very 
disruptive to tribal health programs and potentially expensive since 
that training will likely be duplicative and more general than training 
the tribal health program already delivers to its employees. We also 
believe that regardless of whether tribal health programs are subject 
to the mandatory provisions of this section, deference should be given 
to tribal culture and history programs developed by Indian tribes and 
tribal health programs and that the access to such training should be 
as flexible as possible. These concerns can be readily addressed, if it 
is amended to read:

        Sec. 2. Tribal Culture and History. (Sec. 113 of the IHCIA; 25 
        U.S.C. Sec. 1614f)

        (a) Program established. The Secretary, acting through the 
        Service, shall establish an annual mandatory training program 
        under which employees of the Service, locum tenens medical 
        providers, health care volunteers, and other contracted 
        employees who work at hospitals or other Service units operated 
        directly by the Service and whose employment requires regular 
        patient access who serve particular Indian tribes shall receive 
        educational instruction in the history and culture of such 
        tribes and in the history of the Service.

        (b) Tribally controlled community colleges. To the extent 
        feasible, and in the absence of training programs available to 
        the Service that were developed by Indian tribes, tribal 
        organizations, or inter-tribal consortia, the program 
        established under subsection (a) shall----

        (1) be carried through tribally controlled colleges or 
        universities (within the meaning of section 2(a)(4) of the 
        Tribally Controlled Colleges and Universities Act of 1978 [25 
        USCS Sec. 1801(a)(4)]) and tribally controlled postsecondary 
        vocational institutions (as defined in section 390(2) of the 
        Tribally Controlled Vocational Institutions Support Act of 1990 
        (20 U.S.C. 2397h (2)),

        (2) be developed in consultation with the affected tribal 
        governments, and Indian tribes, tribal organizations, and 
        inter-tribal consortia delivering health services in the 
        geographic area in which the employees described in subsection 
        (a) are located; and

        (3) include instruction in Native American studies.

        (c) Requirement to Complete Training Program.--Notwithstanding 
        any other provision of law, beginning on the date of enactment 
        of the Improving Tribal Cultural Training for Providers Act of 
        2024, each employee or provider described in subsection (a) who 
        enters into a contract with the Service, shall, as a condition 
        of employment, annually participate in and complete the program 
        established under subsection (a).

        (d) Exemption.--Nothing in this section shall prevent a health 
        program operated by an Indian tribe, tribal organization, or 
        inter-tribal consortium from obtaining the training developed 
        under this section for its employees, including those assigned 
        to it under provisions of the Indian Self-Determination and 
        Education Assistance Act.
IHS Provider Integrity Act (H.R. 8955)

    GPTLHB appreciates the Subcommittee's emphasis on making sure that 
IHS hires the best and most qualified individuals to take care of our 
family members. It is important that IHS knows that the providers it 
hires do not have serious disciplinary records. We do, however, have 
some concerns regarding the proposed 20-year lookback requirement. Many 
providers have, over the course of long careers, been licensed in 
multiple states. We also have concerns about the notification of any 
open investigation into the professional conduct of a licensee. We 
think it is essential to consider trigger points for reporting 
depending on the severity of professional conduct requiring 
investigation.
    We recommend that the Subcommittee work collaboratively with the 
IHS to determine whether it is feasible to interface with several State 
medical boards (including receiving information in a timely manner) 
during the hiring process without creating additional delays and 
barriers to filling critical provider positions.

    These bills and the underlying issues raise the larger question of 
the process of including Tribal voices in potential legislative 
improvements through amendments to the Indian Health Care Improvement 
Act. In the past, these legislative efforts would be driven by input 
from the knowledge, wisdom, and difficult decision-making of the Tribal 
leaders who made up the National Steering Committee (NSC) on the 
Reauthorization of the IHCIA. Now that the IHCIA has been made 
permanent, that mechanism for critical Tribal input no longer exists. 
We urge the Members of the Subcommittee to work with your colleagues to 
direct IHS to reinstate the NSC and provide sufficient appropriations 
to support its critical work.
    Thank you for the opportunity to provide testimony today on these 
crucial issues and for your efforts to improve healthcare delivery to 
all our People and communities.

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

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


            Questions Submitted by Representative Westerman

    Question 1. Reports have shown a lack of accountability when it 
comes to IHS employees and misconduct. Anecdotally, can you provide any 
examples of instances in which a practitioner used the IHS's negligence 
to work elsewhere despite past malpractice?

    Question 2. During the hearing you brought up the importance of 
relying on tribal elders when it comes to culture and history. Could 
you provide the Committee with what you think best practices would be 
for ensuring tribal elders and healers are included in the 
implementation of a tribal culture and history training for all 
relevant IHS staff?

    Question 3. Would H.R. 8942 impact the hiring or onboarding process 
for IHS providers, and if yes, what language could be added to the bill 
to mitigate that concern?

                                 ______
                                 

    Ms. Hageman. Thank you for your testimony and for your 
suggestions as well.
    The Chair will now recognize the Members for 5 minutes for 
questioning, beginning with me.
    On H.R. 8942, I am going to direct my first couple of 
questions to Mr. Benjamin Smith. H.R. 8942 would require 
mandatory annual training on the history and culture of the 
tribes involved for specific employees.
    Mr. Smith, what is the current format for tribal history 
and culture training for IHS employees?
    Mr. Smith. Thank you, Chair, for the question. As we know, 
the Indian Health Service is one of the primary healthcare 
providers to American Indians and Alaska Natives.
    But we are not the only Federal agency that works with 
American Indian Alaska Native governments. So, our approach in 
looking at training and as you can see in our testimony, we do 
recommend that each IHS Service Unit develop a unique 
orientation for all staff regarding cultural training 
appropriate to each tribe served by an Indian healthcare 
facility.
    Understanding that some facilities serve multiple tribes 
and there could be distinct differences----
    Ms. Hageman. Let me just ask it in a little bit different 
way. Is there any standard within IHS specific to the format 
for tribal history and culture training?
    Mr. Smith. Absolutely. And the lens that we have taken and 
have implemented over the past 3 years is a trauma informed 
care approach.
    As we know, trauma resulting from violence, victimization, 
colonization, and systematic racism have played a part in 
American Indian and Alaska Native lives.
    On an annual basis, all of our employees are required to 
take a mandatory training to become trauma informed.
    Ms. Hageman. Specific to this issue. But that is specific 
to trauma?
    Mr. Smith. Correct. Which covers the historical trauma and 
history of American Indians and Alaska Natives in this country, 
as well as some of the intergenerational trauma for those who 
may have not personally experienced what previous generations 
have done.
    But that approach really sets a common framework across our 
system to have a basic understanding of the history and 
experience of American Indians and Alaska Natives in this 
country.
    Ms. Hageman. I am going to direct my next couple of 
questions to Ms. Torres. H.R. 8942 includes in the list of 
employees mandated to take the annual mandatory training, locum 
tenens, providers, or medical providers or practitioners that 
temporarily fill a need at the facility.
    Can you expand on whether this type of medical employee 
needs to receive cultural training, and if so, should they be 
added to the annual requirement?
    Ms. Torres. I appreciate the question.
    H.R. 8942 includes the list of employees mandated to take 
the annual mandatory training. It also includes locum tenens 
providers or medical practitioners that temporary fill in at a 
facility.
    I believe that all providers that are placed in those 
communities need cultural training to learn the best approach 
possible for competent care.
    Also gaining the trust of the patient so that you can 
continue to have that good experience going forward and 
continue to combat the healthcare comorbidities in conjunction 
with the patient so that the overall care is achieved.
    [Speaking Native language.]
    Ms. Hageman. OK, and I am going to direct my next questions 
to Chairman Erickson, Ms. Torres, and Ms. Church.
    Several written statements that were provided highlighted 
that each federally recognized tribe has its own history and 
culture, and any mandated tribal and cultural training should 
be flexible enough to accommodate the area the IHS facility and 
employees are serving. By that, I mean geographical area.
    Can each of you expand on what you think are the best 
practices that IHS should follow as they offer their current 
training, and if there are specific ideas we should add to H.R. 
8942 to improve it?
    Chairman Erickson, you first, please.
    Mr. Erickson. Thank you for that question. And you are 
right, here at Colville, there are 12 different tribes into one 
tribe now. So, there are four different languages. We are very 
unique in that.
    There are a lot of culturally involved things that are 
different for each respective tribe that we represent. I think 
there are multiple ways you can go about this. You can do 
online modules, in-person classes, but I think the best 
approach would be community-immersive training because it is 
very specific to each tribe, and the tribes are similar to us 
that are confederation, that it is not a one-size-fits-all, 
even within our tribe.
    So, again, that is, I think getting those involved in the 
community and our elders will help with that a lot in creating 
that training for those individuals.
    Ms. Hageman. Ms. Church, if you can briefly give your 
thoughts on this.
    Ms. Church. Certainly. There are shared values across many 
of the tribes. There is diversity, but there are also shared 
values. So, emphasizing those shared values, I think is very 
important.
    Additionally, I think looking to our elders as we do to 
provide that guidance. At the Great Plains Tribal Leaders 
Health Board, we have a [speaking Native language] committee of 
respected elders across the Great Plains who guide us as we not 
only do our orientation, but also incorporate traditional 
cultural values and traditional healing into our work.
    So, looking to those wisdom keepers is an important part of 
the process.
    Ms. Hageman. Ms. Torres, very briefly, if you have any 
ideas?
    Ms. Torres. Yes, thank you so much. I would just want to 
make sure that they are consulting with tribes early and often 
on what that process will be, and again, making sure to include 
our youth and elders, as those are our most precious 
commodities, and we want to get that feedback and that buy in 
from our communities.
    [Speaking Native language.]
    Ms. Hageman. OK, thank you.
    I do appreciate all of you giving us ideas, and I would 
hope that you would continue to stay engaged on this very 
important issue.
    I am going to recognize Representative Johnson for 5 
minutes of questioning. Thank you.
    Mr. Johnson. Thanks very much, Madam Chair. Mr. Smith, I 
want to come to you because I think we are all trying to make 
the legislation better.
    You talked about concerns with the timeline on the 14 days. 
Kind of coach me, where is a better spot for us to land?
    Mr. Smith. Yes, thank you very much for the question, 
Representative Johnson.
    What we wanted to share and underscore first is that at the 
Indian Health Service, today, all IHS direct healthcare 
facilities have fully implemented the uniform credentialing 
software.
    Mr. Johnson. Can you move that mic a little closer?
    Mr. Smith. Again, we have fully implemented a uniform 
credentialing software, but it is also important to note that 
the Indian Health Service is committing to ensure safe and 
high-quality patient care through appropriate hiring, 
credentialing, peer review, and professional review processes 
for licensed providers, practitioners, and that we hold them to 
the highest standards for----
    Mr. Johnson. So, Deputy Director, do we have a sense of 
what timeline might be more appropriate?
    Mr. Smith. Yes. This is what we would like to investigate 
further and discuss with this Subcommittee. We are aware of 
other Federal agencies that have longer timelines, such as the 
Veterans' Health Administration, and we just want to make sure 
that we are setting tenable dates to afford somebody who is 
being investigated due process, but also to be similar to other 
standards across the healthcare industry.
    Mr. Johnson. I am unaware, what does the Veteran Health 
Service utilize?
    Mr. Smith. To my knowledge, and I will have to verify this, 
we would be happy to follow up with you, but we understand it 
is around 30 days.
    Mr. Johnson. Around 30 days?
    Mr. Smith. Yes.
    Mr. Johnson. OK. So, as you all have talked internally, 
just, again, trying to make sure it is workable, if 14 is 
clearly not workable, or it would be workable some of the time?
    I mean, here is why I am asking. I wonder if there is a 
scenario under which you could have a standard amount of time 
in the statute and then kind of an extra bonus time in 
extraordinary circumstances where you all determined that you 
needed extra time.
    I know that deadlines drive achievement, and, of course, 
when we push timelines out further, just as a matter of course, 
we don't get the urgency we generally want. We see that all the 
time here in Washington.
    We only really act when we have to. Any thoughts? I mean. 
And would 14 days be workable any of the time?
    Mr. Smith. Well, we would urge the Subcommittee to also 
contemplate the fact that the Indian Health Service works in 
multiple states.
    We understand that 50 different states with 50 different 
internal timelines and knowing that their boards meet at 
different frequencies does pose a challenge of really trying to 
simmer down to a concrete timeline.
    Mr. Johnson. And I know I won't put you on the spot 
anymore, I mean, I understand the discomfort with 14 days, and 
I am totally willing to work with you all.
    It is hard for us to make legislation fit if we don't get 
some specificity, right? I know why 14 doesn't work. What I 
don't know is, does 18 work? Does 21 work? Does 25 work?
    So, as you said, we will continue to dive in and work 
together. You did note that you inform folks when you identify 
problems with providers. Does that include state licensing 
boards?
    Mr. Smith. Absolutely. If an appropriate investigation 
occurs and is deemed valid, then, yes, we follow the protocols 
as outlined in our policies.
    Mr. Johnson. And then, Ms. Church, I thought you made some 
great points about not wanting to interrupt the hiring process, 
because I think the percentage of vacant positions is in excess 
of 25 percent.
    And, again, to your point, there is a lot of regional 
variability in those numbers. So, what can we do to make sure 
that we don't interrupt the hiring process?
    Ms. Church. I think we have to take a look at the global 
picture of what is required to onboard a provider and ensure 
that we are not adding additional burden onto that process that 
would create more delays.
    The thing that stood out to me was going back 20 years. I 
don't know how many institutions even keep records for 20 
years.
    Mr. Johnson. Is there a better spot to land?
    Ms. Church. I would defer to Ben on that one. I would use 
common sense. Look at when did they start? When did they 
graduate? When did they start in the workforce? And I would say 
at least 5 years, but 20 years seems a little bit.
    Mr. Johnson. Very good. Thanks.
    I yield back.
    Mr. Westerman [presiding]. The gentleman yields back.
    The Chair now recognizes the gentlelady from New Mexico, 
Ms. Leger Fernandez.
    Ms. Leger Fernandez. Thank you so much, Mr. Chairman. And 
once again, thank you very much for your presence here today. 
And sorry that there are so many things happening here at the 
Capitol.
    Ms. Torres, in your testimony, you highlighted the Supreme 
Court decision in Becerra v. Northern Arapaho Tribe that made 
it a requirement for contract support costs to be paid 
regardless of appropriations level.
    This will have a significant impact on the delivery of 
health services in Indian Country. Can you talk a bit more 
about that and how we need to think about that funding 
requirement now as we look at funding the Indian Health 
Service?
    Ms. Torres. Yes, thank you.
    Again, I think the Supreme Court decision is so crucial to 
making sure that CSC and 105(l) are taken into perspective and 
that they do not cut into the IHS budget as a whole.
    Again, we know that those are federally mandated costs that 
need to be taken care of. We shouldn't have to stretch all the 
dollars to make it work. I think making sure that it is part of 
the mandatory funding is going to be crucial moving forward so 
that we can continue to build on what we need to take care of 
first and then continue to advocate for more funding going 
forward.
    So, again, making sure that CSE and 105(l) are in the 
mandatory funding.
    Ms. Leger Fernandez. I completely agree with you with 
regards to that, because we cannot be letting this requirement, 
which is a requirement the Supreme Court has already told us 
that, we cannot let that requirement then sap resources from 
the rest of IHS.
    And I see all the nodding heads over there, let the record 
reflect that the witnesses are nodding their heads because they 
recognize the importance of adequate funding for IHS.
    And we, as I mentioned in my opening statement, we were 
following way too low on that with about half, right. And worse 
for rural areas.
    Ms. Church, we love having you here because you bring such 
a great perspective of what it is like on the ground. And I 
really appreciate as well the recent studies we have done, some 
in New Mexico that point out that the health boards make such a 
difference, right? Because they are able to gather the 
expertise.
    You mentioned the fact that there were 150,000 American 
Indian and Alaska Natives in the Great Plains area. Can you 
speak a bit more to what it would mean for your area if we did 
not make these changes we are talking about and why it is so 
important that we address the concerns you mentioned in your 
written testimony?
    Ms. Church. We want to make sure that we are getting not 
only the most qualified providers in our Indian Health System 
providing services to our relatives, but also to ensure that 
our relatives can connect to them, that they have a 
relationship with them, that they are able to fully disclose 
when they are having challenges, not only with their health, 
but in their communities.
    Our relatives come in with a wide range of issues that they 
are dealing with. And sometimes those other issues, 
socioeconomic issues, stand in the way of them getting the 
basic health care that they need.
    So, having culturally sensitive, culturally informed, as 
well as highly qualified, because of the enormous health 
disparities that are within our population, we are the worst of 
the worst, oftentimes. So, we need that expertise as well.
    Ms. Leger Fernandez. And I like the way you talk about our 
relatives. This is what we are talking about, families. You 
know everybody and you care for everybody.
    And that is the beauty of the tribal communities, right? Is 
that there is a sense that we are one. We are all related, and 
thank you for being related to the rest of us as well.
    But addressing the entire health aspect, it does not stop 
at any one part of the body. It includes the mind and includes 
your surroundings, which lead to some of those health 
disparities. I really appreciate that.
    Mr. Mallott, you spoke to the impact Section 14(c)(3) of 
ANCSA has on tribal communities and the need to remove this 
provision. I appreciate that.
    Can you provide the Committee with examples of specific 
projects that community is seeking, but are precluded from as a 
result of the lands being held in trust?
    Mr. Mallott. Thank you for that question. I am going to 
cite a couple of our member testimonies. My village 
corporation, my mom's home village of Rampart, has dealt with 
14(c)(3) for a while, most recently with the city dump.
    We actually had leased a land to the tribe, which couldn't 
go through a 14(c)(3) process. That is just a community growth 
project that communities did grow. Our current dump is by the 
airport. It is actually hazardous because seagulls fly through 
the planes.
    So, we had to have leased the land to the tribe, I believe, 
instead of going to ports and (c)(3) process, because it was 
taking too long.
    Another example in my mom's home, Rampart, the ANC actually 
leased land to the tribe for a satellite telecom site.
    We wanted to go through the 14(c)(3) process, but then we 
also want to make sure that the tribe has economic benefits as 
well. So, if we lease to the state, the state will actually get 
the money for the lease site for a satellite, not the tribe.
    So, actually a lease to the tribes. This tribe actually 
gets a little bit of money from the satellite dish. In Chenega, 
for example, the 14(c)(3) land is where the cemetery is at. So, 
the community doesn't even own their own cemetery, and they had 
to go through that process with the state MOT.
    As mentioned, most of these lands are in the most valuable 
part of our communities. So, if a town or a city that is not 
incorporated wants to create a new subdivision for homes, they 
have to go through the process.
    And right now, it is a very, very slow and burdensome 
process that really slows down our community development.
    Ms. Leger Fernandez. Thank you. I come from New Mexico, so 
the imagination of seagulls going around is, like, OK, I have 
to get my head around that. And with that Mr. Chair, I yield 
back.
    Mr. Westerman. The gentlelady yields back.
    I now recognize myself for 5 minutes of questioning and 
also want to thank the witnesses for being here today.
    As I listened to your testimony, my mind started thinking 
about a lot of things from past experiences, and I know Ms. 
Torres mentioned the difficulty of getting positions filled in 
IHS.
    I come from a very rural district. I don't have any IHS 
facilities in my district, but I know it is a challenge in 
rural areas. Many IHS facilities are in rural areas, and it is 
critical to get those positions filled.
    From traveling around the country and visiting different 
IHS facilities, I have seen some really good examples of how 
IHS works, and I have seen some examples that are not so good 
in IHS facilities.
    But the one thing that is common when an IHS facility is 
working well is that they have good staff. And that is true, I 
think, about any kind of healthcare facility.
    I have seen some big failures in publicly funded healthcare 
facilities. When I was a State Legislator in Arkansas, we had 
an issue with a Medicaid provider that was a child abuser who 
kept practicing as a pediatrician and billing Medicaid for the 
services.
    Since being in Congress, I saw a VA pathologist back home 
in Arkansas who was impaired on the job, misdiagnosed many 
people, and people died because of that. But he remained 
employed in the VA.
    So, there are lots of challenges. There is a desire to be 
able to fill positions. We also have to make sure that we have 
quality people in those positions.
    And Chairman Erickson, I had the great pleasure to visit 
the Colville Tribe and spend some time with you. But you 
mentioned a lot of times about timelines, and you mentioned 
that in all three of the bills in your testimony.
    Can you expand more on why deadlines and timelines are 
important to include in these bills, and if there are any 
specific timelines, you think that will be beneficial for us to 
consider adding to the bills on top of what is already there?
    Mr. Erickson. Thank you for that question. The shortest 
answer is accountability, right? If we don't hold our Federal 
agencies accountable with timelines, nothing will get done.
    I see dragging of the feet, and I am not trying to be rude 
or anything, but that is what we run into with BIA, any 
department, we just have a lot of issues. If we don't put 
timelines on things, accountability is not had, and then things 
just drag on.
    So, I think with the hiring process, as far as the medical 
boards go, I think the biggest or the easiest thing to 
implement there is really starting that process right at the 
beginning of the hiring process, the background check process.
    That way, it is not making that process any longer for them 
to go through. They are already doing that with the background 
check. I don't think those should take as long as they do.
    At Colville, we are supposed to have five doctors, and we 
have one right now. We finally have a dentist, and that took 
years to fill, and he has only been there 6 months. And we hope 
he stays. We hope we don't lose our last doctor.
    Anytime these processes take long, we have had lots of 
employees that were potential good employees left because the 
hiring process took too long. And a lot of that was background 
checks and other things.
    So, I think implementing that right at the beginning of the 
background check process will reduce having any added time to 
the hiring process.
    Mr. Westerman. And we all understand what it is like to 
work under deadlines, and we know that a lot of times people 
just wait until the last minute when they have a deadline.
    Have you or your tribal members seen any issues when it 
comes to cross state licenses and the hiring process for IHS 
applicants at the Colville Service Unit?
    Mr. Erickson. That is a good question. I will get back to 
you on that. I don't have an answer for that right now. I 
apologize.
    Mr. Westerman. Ms. Torres, H.R. 8955 would require the IHS 
to solicit any applicant's history from all medical boards in 
which they are licensed, going back at least 20 years.
    Can you expand on your written statement about why 20 years 
cannot be a feasible timeline and maybe also suggest what other 
length of time we should consider?
    Ms. Torres. Thank you for the question. I appreciate that.
    H.R. 8955 would require the IHS to solicit any applicant's 
history from all medical boards in which they are licensed 
going back at least 20 years. It was presented here that some 
areas may not have 20 years' worth of history on that.
    But I think, again, it is important to try to go back as 
far as possible. The suggestion was made of 5 years, but I 
think at NIHB, we could come up with some further suggestion 
and follow up to make sure that you get a copy of that, because 
we are not just looking at now. We are looking at the future as 
well for those that are still yet to come. And we want to make 
sure that we implement good, solid changes, but we also don't 
affect tribes that are self-governance and self-determined.
    Mr. Westerman. All right, I see that I am out of time. We 
may have more questions that will get submitted for the record.
    Again, I want to thank the witnesses for your valuable 
testimony and the Members for the questions today.
    The members of the Subcommittee may have some additional 
questions for the witnesses, and we will ask you to respond to 
these in writing.
    Under Committee Rule 3, Members of the Subcommittee must 
submit questions to the Subcommittee Clerk by 5 p.m. on Monday, 
July 29, 2024. The hearing record will be held open for 10 
business days for these responses.
    If there is no further business without objection, the 
Subcommittee stands adjourned.

    [Whereupon, at 12:14 p.m., the Subcommittee was adjourned.]