[Senate Hearing 114-441]
[From the U.S. Government Publishing Office]
DEPARTMENT OF THE INTERIOR, ENVIRONMENT, AND RELATED AGENCIES
APPROPRIATIONS FOR FISCAL YEAR 2017
----------
WEDNESDAY, MARCH 9, 2016
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 10:03 a.m., in Room SD-124, Dirksen
Senate Office Building, Hon. Lisa Murkowski (chairman)
presiding.
Present: Senators Murkowski, Cochran, Daines, Udall,
Tester, and Merkley.
INDIAN HEALTH SERVICE
STATEMENT OF MARY SMITH, PRINCIPAL DEPUTY DIRECTOR
ACCOMPANIED BY:
ELIZABETH FOWLER, DEPUTY DIRECTOR FOR MANAGEMENT OPERATIONS
GARY HARTZ, DIRECTOR OF THE OFFICE OF ENVIRONMENTAL HEALTH AND
ENGINEERING
OPENING STATEMENT OF SENATOR LISA MURKOWSKI
Senator Murkowski. Good morning. We will call to order the
Senate Appropriations Subcommittee on Interior, Environment,
and Related Agencies.
Today's hearing is on the fiscal year 2017 budget request
for Indian Health Service (IHS).
Before I begin my comments and welcoming, we do have the
chairman of the full Committee on Appropriations. So at this
time, Chairman Cochran, I would defer to you if you would like
to make any opening comments.
STATEMENT OF SENATOR THAD COCHRAN
Senator Cochran. Thank you, Madam Chair. I appreciate the
recognition and to join you in welcoming our witnesses this
morning, reviewing the budget request for the Indian Health
Service. Specifically in our State of Mississippi, we're
pleased to host the Mississippi Band of Choctaw Indians' state-
of-the-art medical center. It is a new health center, and I
know that people are still getting adjusted to the fact that
there's such a fine facility that is available for healthcare
services for the Mississippi Band of Choctaw Indians in
particular. I hope we can continue to stay in touch with the
management of the hospital, and we hope we will learn from this
hearing how it's being received and whether the needs are being
met for appropriated dollars that are necessary.
Thank you.
Senator Murkowski. Thank you, Mr. Chairman.
At this time, I again would like to welcome all.
Today we will examine the budget request for Indian Health
Service. I want to thank Mary Smith, the Principal Deputy
Director for IHS, for appearing before us today.
Ms. Smith was named to the top position at the agency just
last week, so we wish you well. The head of the IHS, I think we
recognize, is a tough job. It's a critical job for us in
Alaska, where all of the healthcare for Native Alaskans is
delivered through compacts between tribal organizations and the
IHS.
Ms. Smith is accompanied by Elizabeth Fowler, who is the
Deputy Director for Management Operations, as well as Gary
Hartz, Director of the Office of Environmental Health and
Engineering. We welcome all of you.
Last year we started what I hope will be a tradition. We
held the first IHS budget hearing in over 5 years. These issues
are too important in terms of your work to have such a lapse,
so I'm pleased that we are having this hearing.
With a budget of over $5 billion, a seemingly limitless
number of needs for healthcare delivery for Native Americans,
it's critical that this subcommittee exercise a strong
oversight role to make sure scarce resources are spent as
efficiently as possible. The IHS budget request for fiscal year
2017 is $5.185 billion for programs within this subcommittee's
jurisdiction. This is an increase of $377 million, or 8
percent, above last year's enacted.
There are worthy increases in this budget, including $82
million for contract support costs. I'm pleased that this
budget fully funds these costs and adopts the approach that I
put forward in the Senate bill for fiscal year 2016, which
establishes a separate indefinite appropriation for contract
support costs to ensure these legal obligations are met and
other programs will not be affected.
Other important increases include $132 million to address
the more than $2 billion backlog on the current healthcare
facilities construction list, as well as $15 million for the
substance abuse and suicide prevention program, with a
particular focus on youth. I'm particularly interested in the
initiatives in your budget to address substance abuse, suicide,
and domestic violence. These are enormous problems within
Indian Country and are particularly acute in Alaska.
I think we look at the statistics and are just truly
overwhelmed by them. One out of every three American Indian or
Alaska Native women will be sexually assaulted in her lifetime.
The alcohol-related death rate for Native Americans is six
times greater than the rest of the population, and the suicide
rate for 15 to 24-year-olds is 2.5 times the rate for other
ethnicities.
We've had a very courageous group of young people from
Tanana, Alaska who have spoken out about these issues in their
community over the past few years. They stood before several
thousand Alaska Natives at our largest gathering at the Alaska
Federation of Natives conference. They've written what is known
as the Tanana Pledge to encourage Native Alaskans around the
State to stand together against suicide, against substance
abuse.
It was just a few weeks ago there was an article in our
newspaper and on the radio about dozens of young people from
the village of Kwethluk who took a stand against alcohol and
drugs in their community. They marched through the streets of
the village with homemade signs basically saying enough is
enough. So when your children stand in front of you, stand in
front of the adults and say stop it, enough is enough, it is
well past time to act.
In an effort to push for more effective ways to address
issues like suicide among Indian youth, I sent a letter last
December to Secretary Burwell with 11 other senators, including
our ranking member here, concerning the issue of complex
trauma. In that letter we asked Department of Health and Human
Services to develop a coordinated interagency approach that
incorporates the growing evidence that complex childhood trauma
is often the underlying cause of substance abuse and youth
suicide.
I see that your budget discusses trauma-informed care and
indicates that the agency's mental health and social service
program provides training and workforce development to IHS and
tribal healthcare providers to incorporate culturally relevant
and trauma-informed approaches.
When we get to the time for questions, I'd like to learn
more about what IHS and the Department of Health and Human
Services as a whole are doing in this area. I think it's
critical that we continue to make progress on these issues.
And then finally, I'm very concerned with the situation
that we have at the IHS Rosebud Hospital on the Rosebud Indian
Reservation in South Dakota. Conditions at the hospital are so
bad that IHS sent out a notice on March 1, indicating that the
Center for Medicare and Medicaid Services will terminate its
provider agreement with the hospital effective March 16. This
means that IHS can no longer bill for Medicare and Medicaid
services and that in many instances tribal members will have to
travel long distances to get care.
There have been cases reported in the press where employees
at Rosebud were washing surgical instruments by hand because
the hospital sterilization machine was broken for 6 months.
Also, a case where staff members left a pregnant woman
unattended and she delivered her premature baby on the floor of
a hospital bathroom--absolutely, absolutely unacceptable.
So we need to hear from you today what the Indian Health
Service and Health and Human Services is doing to rectify this
situation and when the hospital can restore its provider
agreement with the Center for Medicare and Medicaid Services
(CMS).
So again, thank you for being here.
I would now like to turn to my ranking member, Senator
Udall, for his comments this morning.
STATEMENT OF SENATOR TOM UDALL
Senator Udall. Thank you, Madam Chair.
Let me also welcome Mary Smith, the new Principal Deputy
Director of the Indian Health Service, to this hearing before
the subcommittee. Deputy Director Smith, congratulations on
your new leadership role within the agency. We're glad you're
able to join us to share your perspective on the President's
2017 budget request for the Indian Health Service and to hear
from members of the subcommittee about our particular
priorities for the Service and about its budget.
I also want to welcome Elizabeth Fowler, Deputy Director
for Management Operations, and Mr. Gary Hartz, Director of the
Office of Environmental Health and Engineering. We appreciate
you being here today and look forward to hearing from you.
Before we turn to the 2017 budget, I want to thank Chairman
Murkowski for working with me to produce a very solid budget
for the Service this year. Overall, we were able to support a
3.5 percent increase for the Service, including important
investments in facilities and substance abuse treatment. I also
want to applaud the Chairman for coming up with a more
sustainable way to fund contract support costs so that these
costs aren't funded at the expense of other programs.
Madam Chairman, you've been a great champion for programs
that are so critical to Native communities in both our States
and throughout Indian Country, and I'm proud of this entire
subcommittee and the effort it has made to fund tribal health
programs and make them a priority.
But more is clearly needed. Indian Country needs better
access to clinical services. This is especially true for
preventive care, and also for mental health and substance abuse
programs. These are critical services. We want to see IHS build
more hospitals and health clinics, and we need to make sure the
agency has the right tools to staff its facilities with
qualified doctors and nurses.
All of these issues affect tribes in New Mexico. We see it
in the lack of funding for substance abuse treatment in Gallup.
We see it there in Gallup. We see it in the staffing shortages
in Crownpoint, which forced the closure of emergency medical
services last year. The challenges are very clear.
So I look forward to hearing more about possible solutions.
I also want to hear how the agency plans to address serious
problems we're seeing in other areas, including in the Great
Plains, as the Chairman has mentioned, where some IHS
facilities are at risk of losing accreditation and have been
forced to cut back vital medical services. This budget request
takes on some of those challenges by requesting an 8 percent
overall increase for the agency.
It's going to be an uphill battle for this subcommittee to
fully fund your proposal given the flat budget caps in 2017,
but we will do everything we can to support you, Deputy
Director Smith, and to support Indian Country. Your appearance
today to share some of the details of the budget is critical to
helping the subcommittee do its work.
Again, congratulations on your new position, and thank you
for providing testimony to us today.
Senator Murkowski. Thank you, Senator Udall.
With that, let us go to you, Ms. Smith. Welcome again, and
I will repeat the ranking member's comments about
congratulations for the appointment to this position.
So if you would like to begin your comments, I understand
that it will just be you testifying and that Ms. Fowler and Mr.
Hartz are there to answer questions.
Ms. Smith. Yes, that's correct.
Senator Murkowski. Very good. If you can begin, please.
SUMMARY STATEMENT OF MARY SMITH
Ms. Smith. Good morning. Thank you, Chair Murkowski and
Ranking Member Udall, and all the members of the subcommittee,
for allowing us to be here today to talk about the fiscal year
2017 IHS budget request. As was mentioned, accompanying me
today are Elizabeth Fowler, Deputy Director for Management
Operations, and Gary Hartz, Director of the Office of
Environmental Health and Engineering.
I've only been in my job as Principal Deputy Director for a
little over 1 week, and although I've been at the agency for a
little bit longer, about 5 months in the role of Deputy
Director, it has become quite clear to me that while the IHS is
firmly committed to the mission of providing quality healthcare
for American Indians and Alaska Natives, we face steep
operational and quality of care challenges. This situation is
unacceptable.
I appear before you today to underscore my commitment to
fixing these challenges, including those in the Great Plains,
and the more systemic issues that we face at the agency such as
staffing and housing. We are committed to fixing these issues
not simply in the short term but so that these changes are
sustainable over time. I and the rest of the team at IHS are
committed to creating a culture of quality, leadership, and
accountability. It is far from business as usual at IHS.
With that preamble, I am pleased to present testimony on
the President's proposed fiscal year 2017 budget for IHS, which
will allow us to continue to make a difference in addressing
our agency mission. I'm committed to working with our partners,
including those on this subcommittee, to provide access to
quality healthcare to Native Americans.
The fiscal year 2017 President's budget proposes to
increase the total IHS program budget to $6.6 billion, which
will add $402 million to the fiscal year 2016 enacted funding
level. If appropriated, this funding level would represent a 53
percent increase in funding for the IHS since fiscal year 2008.
The overall funding increases proposed in the President's
budget are consistent with tribal priorities and would continue
to address longstanding health disparities among American
Indians and Alaska Natives compared to other Americans.
Specific investments include expanding behavioral and
mental health services, improving healthcare quality, capacity
and workforce, and supporting self-determination by fully
funding contract support costs.
The President's budget proposal includes funding for pay
costs, inflation, and population growth increases totaling $159
million, which are critical to maintaining the budgets of IHS
and tribal hospitals, clinics, and other programs at current-
year levels.
The budget also includes program increases of $49 million,
of which $46 million will be focused on critical behavioral
health services, including generating indigenous substance
abuse and suicide prevention projects to increase the number of
child and adolescent behavioral professionals; continued
integration between medical care, behavioral health, and tribal
community organizations, and domestic violence prevention
programming, to name a few.
The budget also includes an HHS-wide, 2-year mandatory
proposal to address mental and behavioral health. For the IHS,
the proposal includes a new $15 million Tribal Crisis Response
Fund which would allow IHS to expeditiously assist tribes
experiencing behavioral health crises, and an additional $10
million to increase the number of behavioral health
professionals through the American Indians Into Psychology
Program and IHS scholarships and loan repayment programs.
The budget proposes an additional investment for healthcare
information technology to fund improvement, enhanced
modernization and security of health IT systems; and also $2
million for IHS Quality Consortium, which will coordinate
quality improvement activities among the 28 IHS hospitals,
critical access hospitals, and the over 200 outpatient
ambulatory clinics.
The budget includes funds for infrastructure that is
critical to healthcare delivery, including to fund additional
staff for five newly-constructed facilities, for tribal clinic
leases and maintenance costs, specifically in Alaska, and to
address the backlog of $473 million at Federal and tribal
facilities.
In addition, the budget proposes funding of $12 million for
the replacement and addition of new housing quarters in
isolated and remote locations to enhance IHS recruitment and
retention of healthcare professionals.
As was mentioned, the budget supports self-determination by
continuing the separate indefinite appropriation account for
contract support costs through fiscal year 2017. Additionally,
the budget proposes to reclassify contract support costs as a
mandatory 3-year appropriation.
Finally, I do want to acknowledge that we are working
aggressively to address quality of care issues at our three
facilities in the Great Plains. The challenges there are
longstanding, especially around recruitment and retention of
providers, but the deficiencies cited by CMS are unacceptable.
We have an intense effort underway. We have brought in
Commissioned Corps officers to help. We have the full support
of the Department of Health and Human Services. We have
established a Council on Quality, staffed by people throughout
the Department of Health and Human Services, and we have
established a new Deputy Director of Quality, who is Dorothy
Dupree. We are working diligently to address those issues.
We look forward to working in partnership with you to enact
the President's budget, and I want to say that we take these
challenges seriously, and you have my commitment that we will
work tirelessly to make meaningful, measureable progress. Thank
you so much.
[The statement follows:]
Prepared Statement of Mary Smith
Chairman and members of the subcommittee:
Good morning. I am Mary Smith, Principal Deputy Director of the
Indian Health Service (IHS). Accompanying me today are Elizabeth
Fowler, Deputy Director for Management Operations, and Gary Hartz,
Director of the Office of Environmental Health and Engineering. I am
pleased to provide testimony on the proposed fiscal year 2017
President's budget for the IHS, which will allow us to continue to make
a difference in addressing our agency mission to raise the physical,
mental, social, and spiritual health of American Indians and Alaska
Natives (AI/ANs) to the highest level.
The IHS is an agency within the Department of Health and Human
Services (HHS) that provides a comprehensive health service delivery
system for approximately 2.2 million AI/ANs from 567 federally
recognized tribes in 36 States. The IHS system consists of 12 Area
Offices, which are further divided into 170 Service Units that provide
care at the local level. Health services are provided through
facilities managed directly by the IHS, by tribes under authorities of
the Indian Self-Determination and Education Assistance Act, through
services purchased from private providers, and through Urban Indian
Health Programs.
As an agency we are committed to ensuring a healthier future for
all AI/AN people, and the IHS budget is critical to our progress in
accomplishing this. From fiscal year 2008 through fiscal year 2016, IHS
appropriations have increased by 43 percent thanks in part to your
subcommittee, and these investments are making a substantial impact in
the quantity and quality of healthcare we are able to provide to AI/
ANs. The fiscal year 2017 President's budget proposes to increase the
total IHS program level to $6.6 billion, which will add $402 million to
the fiscal year 2016 enacted funding level, and if appropriated, this
funding level would represent a 53 percent increase in funding for the
IHS since fiscal year 2008.
The overall funding increases proposed in the President's budget
are consistent with tribal priorities and would continue to address
long-standing health disparities among AI/AN, compared to other
Americans. Specific investments include expanding behavioral and mental
health services, improving healthcare quality, capacity, and workforce,
supporting self-determination by fully funding Contract Support Costs
(CSC) of tribes who manage their own programs, and ensuring increased
healthcare access through addressing critical healthcare facilities
infrastructure needs.
prioritizing health care services
More specifically, the President's budget proposal includes funding
for pay costs, inflation and population growth increases totaling $159
million, which are critical to maintaining the budgets of our IHS and
tribal hospitals, clinics and other programs at current year levels,
and ensure continued support of services that are vital to improving
health outcomes.
The budget also includes program increases of $49 million to grow
healthcare services by targeting funding increases to help close the
gap in health disparities experienced by AI/AN and improve their
overall health and well-being. Of the $49 million, $46 million will be
focused on critical behavioral health services, including $15 million
for Generation Indigenous substance abuse and suicide prevention
projects to increase the number of child and adolescent behavioral
professionals; $21 million to fund continued integration between
medical care, behavioral health, and tribal community organizations to
provide the entire spectrum of prevention to impact health outcomes; $4
million to fund implementation of pilot projects for the Zero Suicide
Initiative in IHS, Tribal, Urban (I/T/U) organizations; $2 million to
fund a youth pilot project to provide a continuum of care for AI/AN
youth after they are discharged and return home from Youth Regional
Treatment Centers; and $4 million for domestic violence prevention to
fund approximately 30 additional I/T/U organizations. And $3 million to
expand services provided through the Catastrophic Health Emergency Fund
and Urban Indian Health Programs.
improving the quality of health care delivery
The budget includes funding increases intended to strengthen the
provision of high-quality care. The budget proposes an additional $20
million for health information technology (IT) to fund improvement,
enhancement, modernization, and security of health IT systems used for
patient care data. And an additional $2 million for the IHS Quality
Consortium, which will coordinate quality improvement activities among
the 27 IHS Hospitals, Critical Access Hospitals and over 200 Outpatient
Ambulatory Clinics to reduce hospital acquired conditions, avoidable
readmissions, support the IHS Quality Consortium Work Plan with
associated buildup of professional Quality staff and development of a
National Quality Manager Council. Additionally, this funding would help
to address recent standard of care issues at three of our Great Plains
Area hospitals.
increasing access to quality health care services through improved
infrastructure
The budget includes funds for infrastructure that is critical to
healthcare delivery. Funding increases totaling $43 million are
proposed as follows: $33 million to fund additional staff for five
newly constructed facilities opening between 2016 and 2017, including
three Joint Venture facilities where tribes funded the construction and
equipment costs; $9 million for tribal clinic leases and maintenance
costs, specifically where tribal space is ineligible for IHS
Maintenance and Improvement funds, such as Village Built Clinics in
Alaska; $.5 million to provide additional funds in reducing the
maintenance backlog of $473 million at Federal and tribal facilities.
In addition, a total budget of $133 million is proposed, (1) to
complete construction of the Phoenix Indian Medical Center Northeast
Ambulatory Care Center ($53 million), (2) to begin design of the White
River Hospital ($15 million), (3) to continue construction of the Rapid
City Health Center ($28 million), (4) to continue construction of the
Dilkon Alternative Rural Health Center ($15 million), (5) to fund the
Small Ambulatory Grants Program ($10 million), and (6) to fund the
replacement and addition of new staffing quarters in isolated and
remote locations to enhance IHS recruitment and retention of healthcare
professionals ($12 million).
Public and private collections represent a significant portion of
IHS and tribal healthcare delivery budgets and are critical to support
the IHS priority to improve the quality of and access to care. Third
party collections from Medicare, Medicaid, the Veterans Health
Administration, and private insurance allows IHS and contracting tribes
to provide additional healthcare services, purchase new equipment, hire
necessary medical staff, and make essential building improvements. IHS
estimates that in fiscal year 2017 it will collect approximately $1.2
billion in funds from Medicare, Medicaid, private insurance companies,
and the Department of Veterans Affairs.
supporting indian self-determination
The budget supports self-determination by continuing the separate
indefinite appropriation account for CSC through fiscal year 2017.
Additionally, the budget proposes to reclassify CSC as a mandatory, 3-
year appropriation in fiscal year 2018, with sufficient increases year
over year to fully fund the estimated need for both the IHS and the
Bureau of Indian Affairs. This funding approach continues the policy to
fully fund CSC and helps to support self-determination.
mandatory funding proposal for mental health initiatives
The budget includes a HHS-wide 2-year mandatory proposal to address
mental and behavioral health. For the IHS, the proposal includes a new
$15 million Tribal Crisis Response Fund, which would allow the IHS to
expeditiously assist tribes experiencing behavioral health crises, and
an additional $10 million to increase the number of AI/AN behavioral
health professionals through the American Indians into Psychology
program and IHS scholarships and loan repayment programs.
legislative proposals
I would also like to highlight two of our legislative proposals.
First, IHS is seeking a consistent definition of ``Indian'' in the
Affordable Care Act (ACA). Currently, the ACA includes different
definitions of ``Indian'' when outlining eligibility requirements for
certain coverage provisions. These definitions are not consistent with
eligibility requirements used for delivery of other federally supported
health services to AI/AN under Medicaid, the Children's Health
Insurance Program, and the IHS. The budget proposes to standardize ACA
definitions to ensure all AI/ANs will be treated equally with respect
to the Act's coverage provisions, including access to qualified health
plans with no cost sharing.
IHS is also seeking permanent reauthorization of the Special
Diabetes Program for Indians (SDPI). The SDPI grant program provides
funding for diabetes treatment and prevention to approximately 301 I/T/
U health programs. Most recently, the SDPI has been reauthorized
through September 2017. Reauthorization of the SDPI beyond fiscal year
2017 will be required to continue progress in the prevention and
treatment of diabetes in AI/AN communities. Permanent reauthorization
allows the programs more continuity and the ability to plan more long
term interventions and activities.
great plains hospitals
Finally, I want to acknowledge that we are working aggressively
with the full support of the HHS to address quality of care issues at
three of our facilities in the Great Plains Area--Winnebago, Rosebud,
and Pine Ridge. The challenges there are long-standing, especially
around recruitment and retention of providers, but the deficiencies
cited in the reports by the Centers for Medicare and Medicaid Services
(CMS) are unacceptable. We have an intense effort underway right now
through our corrective action plans to address the problems cited by
CMS at these three hospitals. We brought in independent third-party
reviewers to advise us on addressing the specific deficiencies found by
CMS. The equipment identified in the CMS findings has already been
replaced or procurement actions are underway. To further assist with
addressing and implementing corrective actions, additional U.S. Public
Health Service officers are supplementing IHS personnel in the Great
Plains Area. I am also pleased to report that as part of our continuing
workforce improvement efforts we recently received approval for an
emergency department physicians' pay package. At the same time, we are
working to improve communications with the tribes impacted. More
broadly, we are redoubling their efforts to ensure that sustained,
quality care is delivered consistently across IHS facilities. The HHS
Secretary established the Executive Council on Quality Care, in which
IHS is an active participant, and we are partnering with CMS to
establish an agreement that will address systemic issues. As part of
these longer-term efforts to make sustained change, we transformed our
Hospital Consortium into a Quality Consortium and I have a new Deputy
Director, Dorothy Dupree, who will work across the IHS to solely focus
on quality improvement. We are also developing a strategic framework
and sustainability plan for the Great Plains Area, in consultation with
the tribes, that is agile and will be used to evaluate and ensure
quality across the entire system.
I close by emphasizing that even with all the challenges we face, I
know that, working together throughout HHS, with our partners across
Indian Country and in Congress, we can improve our Agency to better
serve tribal communities. I appreciate all your efforts in helping us
provide the best possible healthcare services to the people we serve,
and in helping to ensure a healthier future for American Indians and
Alaska Natives.
Thank you and I am happy to answer any questions you may have.
Senator Murkowski. Thank you, Ms. Smith. I appreciate your
comments, and we will now move to questions from those of us
here on the dais. It looks like the clock is 6 minutes.
CONTRACT SUPPORT COSTS
Contract support costs, as you have mentioned and as I have
mentioned that this has long been a priority of mine to make
sure that full contract support costs are without question, and
the separate appropriations account that we developed I think
is going to be important to make sure that, again, we're honest
with this, we're not taking from one account to help meet this
obligation.
You mentioned the mandatory 3-year approach here that you
are laying out. Frequently we've seen the administration make
some general statements about providing mandatory funding for
certain programs, but then it never sends up the legislative
proposal. Last week we talked about mandatory proposals by the
administration for accounts like the Land and Water
Conservation Fund (LWCF) and the National Parks, but there were
no offsets for those.
So a question for you this morning is whether or not you do
plan to send the Congress the proposal for mandatory funding
for contract support costs, and if so when, and then whether or
not there will be any offset identified.
Ms. Smith. Thank you, Senator Murkowski. Yes, we are
committed to fully funding contract support costs. As you
mentioned, in our fiscal year 2017 budget proposal we are
proposing to make contract support costs mandatory for 3 years
starting in fiscal year 2018, and we are committed to sending
up language. We look forward to working with this subcommittee
and others to provide language throughout the process.
I will defer to Liz Fowler. I am not sure about the offset
question.
Senator Murkowski. Ms. Fowler.
Ms. Fowler. Good morning. The overall President's budget
takes care of the offset for all of the mandatory proposals
that are in the President's budget request. There's not a one-
to-one offset within the IHS budget, so it's addressed by the
President's budget overall.
Senator Murkowski. Well, that may continue to be an issue.
As you know, there have been many concerns raised by those of
us that are looking at the President's budget and how they are
proposing to address specific offsets. I have had a lot of
constituents coming to me over the years expressing some
frustration about contract support costs and, again, making
sure that there is that full funding.
So now we got to full funding, and the push has been can we
make this mandatory? And I think it will be met with good news
that the proposal is that we do see it on the mandatory side.
But as we all know, this is the last year of a two-term
President, and I think there are many that have said there has
been time that was wasted here, and it's unfortunate that we're
just seeing it on the way out.
Now, I am told that the agency has still failed to settle
about 30 percent of all the contract support cost claims filed
against it by tribes, and this dates back many years. Where are
you on prioritizing the conclusion of all the outstanding
claims that are currently on file? If you can just give me an
update on that.
Ms. Smith. Yes. Thank you, Senator, for asking about the
settling of the contract support cost claims. You are about
right. My understanding is we have settled about 75 percent of
those, and my understanding is that a majority of the remaining
ones are ones for more recent years. So I understand that we
have worked through the longer-standing disputes, and we are
working on more recent cases as a general matter. So we are
committed to continuing to resolve those and paying full
contract support costs.
Senator Murkowski. Who is in charge of executing that plan
just in terms of making sure you move through as many of them
as quickly as possible?
Ms. Smith. I think that, obviously, as head of the agency,
ultimate responsibility is with me. But I know that Ms. Fowler,
in her role in Management and Operations, oversees and works
very closely with our Office of General Counsel to ensure that
these are a priority, and we continue to make progress on the
settlements.
Senator Murkowski. I know that that continues to be a very,
very high priority.
VILLAGE BUILT CLINICS
In my last minute here, I want to raise the issue of
village-built clinics. As you know, this is an issue that I
have raised for years with your predecessor and, quite
honestly, gotten nowhere, gotten nowhere, which was very, very
frustrating. Last year we were able to include $2 million to
help address the issue of village-built clinics. We've got
about 150 in my State, many of them being the only local
options for any healthcare. Many have serious maintenance
needs, and again the frustration was your predecessor said
basically that the tribes are responsible for paying these
costs out of other funds that they get from the Service. That
just was not right.
So again, we've got $2 million to help address it, but this
issue I hear more from local folks than just about anything
else when I'm out in the villages. So can you tell me how the
agency plans to allocate these funds and when they will be
distributed?
Ms. Smith. Thanks, Senator, for that question. I'm glad you
asked about it because one of the first things that I was
looking into when I started last fall was I did see that you
had spent over a year asking about this issue.
Senator Murkowski. It was like every hearing on an annual
basis.
Ms. Smith. Yes, yes, and I read all your correspondence,
and I started talking to people at the agency, including Ms.
Fowler, and it seemed to me that there was a gap there of
something that we needed to address.
So we worked out a way--there's $2 million in the fiscal
year 2016 budget, but I'm pleased to say also we have now
created a line item in the fiscal year 2017 budget for $9
million to fund clinics of this type. As you pointed out, a
majority of them, I believe, are in Alaska, but I do believe
there might be some in the other 48 States, and we wanted to
make sure that everyone who was in this gap category would be
covered.
So with respect to the $2 million in the fiscal year 2016
budget, we are going to start a tribal consultation to ensure
that these funds are distributed where they're needed, and
equitably. As you mentioned, there are quite a number of
clinics in Alaska, and I have also personally read--I know the
Alaska Health Board wrote a fantastic report just on the
maintenance that's needed on these village-built clinics.
So I know that our area director in Alaska will be doing a
consultation to----
Senator Murkowski. Will that be pretty soon, then?
Ms. Smith. Yes, it will be soon.
Senator Murkowski. All right. Well, we will look forward to
that. I appreciate working with you on it. As you are aware,
the need is great, and we appreciate the increase that we will
see in this account.
Let me turn to my ranking member.
Okay, Senator Tester.
Senator Tester. Thank you, Madam Chair, and I want to thank
the ranking member for his courtesy.
IHS BUDGET
There is an expectation that Indian Health Service provides
the healthcare that we expect. It's a direct responsibility.
We've heard issues of life and limb in the past where IHS has
run out of money, and then there have been the issues with
contract care that the Chairman brought up.
This budget is increased by $377 million, which is a lot of
money. But is it enough when you consider that IHS is currently
at 50 percent of what we spend on veterans and probably the
least amount of money we spend for healthcare of any group that
the Federal Government supports? So tell me about this budget.
Tell me where it's at. Tell me if it's adequate.
Ms. Smith. Senator Tester, thanks so much for your
question. As you mentioned, this budget has a total of $402
million increase, and as I mentioned in my opening statement,
if enacted, that would represent a 53 percent increase since
fiscal year 2008.
We believe that this budget is a strong budget put forth by
the President that focuses on critical needs such as staffing,
behavioral health issues, and critical needs in housing and
facilities. So we do believe that it makes important progress.
STAFFING
Senator Tester. Let's talk about staffing for a second,
because that's a problem. What is the plan? What is the plan to
get folks on and retain those folks?
Ms. Smith. Thanks, Senator. Yes, what I want to say at the
outset, and I want to be very honest with this committee, we, I
think along with any agency that provides services in rural
remote locations, we have problems with staffing, including
recruiting and retaining staff, particularly medical staff.
Senator Tester. That's correct. So what are we going to do
about it?
Ms. Smith. We have to have, I think, a multi-prong
approach. So what we are doing, for instance in the Great
Plains now, in the very short term we are working with
deployments of Commissioned Corps. We are also looking into
contracting for staffing, and then we are also working very
vigorously on permanent staffing. Just last week, I'm pleased
to report, we were able to get an approval and a pay package
for emergency rooms so that we are able to pay more now.
Senator Tester. So can I ask you, is what you pay your
staff for equivalent capabilities competitive with the VA?
Ms. Smith. Not in all instances, Senator, no.
Senator Tester. And why is that?
TITLE 38
Ms. Smith. We use Title 38, which is also the pay scale
that VA uses. We have some of the authorities in the pay scale.
We can pay certain special salaries. We can pay some market
pay. But we don't have the full Title 38 authorities.
Senator Tester. Have you guys made a recommendation to give
yourselves some more flexibility in that area?
Ms. Smith. We are discussing it and we have, like I said,
done some proposals, and I know we are working on a number of
items.
STAFFING
Senator Tester. Look, healthcare in Indian Country is a
great experience because you get to deal with a myriad of
problems, but it's very difficult to get people to come if they
know they've got to take a pay cut to come. So if you need
flexibility, I wish the Department would make that
recommendation to the Chair and ranking member so we could
analyze that and maybe pursue it, and the same thing with the
Indian Affairs Committee, Senator Barrasso and myself.
MEDICAID EXPANSION
Let me talk about Medicaid expansion very quickly. Some
States have done it, some States haven't. Montana just did it.
I think it's a good thing. I think it's a good thing for Native
Americans. This budget is for the whole country. Some States
don't have Medicaid expansion. I understand that States that do
have Medicaid expansion, these IHS dollars have been able to go
further. Is that correct? Yes?
Ms. Smith. Yes, that's correct, Senator.
Senator Tester. So what about the States that don't have
Medicaid expansion? What do we do about that from an Indian
health standpoint? Because it appears to me we could have two
classes of Native Americans out there.
Ms. Smith. No, Senator, thanks so much for your question,
and you are correct. I do think that in States where Medicaid
has been expanded, we are able to leverage our dollars further,
particularly with respect to our purchase referred care
program, and your point is well taken. We do not want to create
different classes of Native Americans because everyone who is
eligible for IHS should receive the same standard of quality
care.
So I know we are working very intensely on that and making
sure that the provider agreements we have create equity among
the people that we serve.
THIRD-PARTY BILLING
Senator Tester. Okay. How much success are you having with
tribes and third-party billing? If they don't bill third party,
then the dollars can't be extended out further. Are tribes on
board with this or are they balking at it?
Ms. Smith. You mean when they run their own program?
Senator Tester. Yes, that's correct.
Ms. Smith. I do believe that they are doing that, but we
don't actually have a lot of information on which tribes run
their programs.
Senator Tester. All right. How about IHS themselves?
Ms. Smith. Yes. Every year I think we have steadily
increased our third-party billing, and we have adopted a number
of practices at our business office that we are disseminating
across the field to further leverage----
Senator Tester. Do you have the figures on how much that
third-party billing has brought into the program?
Ms. Smith. Yes. I think for fiscal year 2017, I think we're
estimated to be at about $1.2 billion of third-party billing.
Senator Tester. And how much of that is your total budget,
then?
Ms. Smith. Our total budget is $6.5 billion, including the
mandatory----
Senator Tester. It's significant.
Ms. Smith. Yes.
Senator Tester. Okay. Thank you, Mary.
Thank you, Madam Chairman.
Thank you, ranking member.
Senator Murkowski. Senator Daines.
Senator Daines. Thank you, Madam Chair.
It's very good to have you here today.
HEALTHCARE OUTCOMES
Recently we had Jace Killsback from Indian Affairs
Committee. He's Executive Health Manager for Northern Cheyenne
Tribal Board of Health. In IHS testimony last month he said,
and I quote, ``It has become normal and okay to be misdiagnosed
and to wait until you're going to lose a leg or your life to
receive the right healthcare that you need.''
I know as I travel around Indian Country in Montana, there
aren't a lot of folks back home that are real happy with the
outcomes. We've heard a lot today about spending on various
programs, not much on concrete outcomes for tribal communities.
Just a question. What would you say are two or three of the
most important metrics you look at in terms of outcomes in
terms of improving Indian health that you evaluate here in
terms of whether it's working or not?
Ms. Smith. I think we have very important outcomes in
several areas. One is I think we have made tremendous strides
with addressing diabetes in Indian Country. The childhood
obesity rate is going down, and also I think the incidence of
Type II diabetes has stabilized over the past few years. That's
one example.
Senator Daines. If you were to try to take it up to the--I
mean, you quote a couple where we have made some progress, but
if you just kind of step back and try to evaluate the success
or failures of a program, what are the top three outcomes you
say really are good measures in terms of whether or not we're
improving health in Indian Country?
Ms. Smith. I think, Senator, one top-line measure would
certainly be the overall life expectancy in Indian Country,
where I think we've shown progress over the years, over a long
term. That would be one high-level measure.
Senator Daines. What else?
Ms. Smith. I think looking at health disparities across
other populations would be a good measure. I know that there
has been some progress made, but more progress needs to be made
on those health disparities.
Senator Daines. My concern in looking at the testimony here
is we've invested another $2 billion in IHS. It looks like
round numbers here. You mentioned the 53 percent increase if
funded at the President's request versus 2008. So if we put
approximately $2 billion more, plus or minus the programs, and
that's relative to about a $4 billion base, roughly, add
another $2 billion, the question is what's improved because of
that? I hear, again, a lot of concerns about outcomes in Indian
Country. I don't hear a lot of feedback to say we're very
pleased with IHS. To the contrary, I think virtually everywhere
I go I hear about the challenges and the failures of the
program.
Ms. Smith. Yes, Senator, I share your concerns. I know that
there are a lot of issues. I know that I have heard personally
myself from a number of patients and people in tribal
communities, but I do think there are a lot of dedicated people
who work at IHS as well, and I know that there's also a lot of
good work. But that's not to diminish the challenges that you
are talking about.
Senator Daines. My request would be when we look at
budgets, of course you've got to look at where the spending is
going to be, but also to bring the outcomes, bring the metrics.
Let's go back to 2008, or let's say a 5-year timeline, are we
getting better or not. What are the top three to five measures
that really help us understand better is Indian health getting
better or is it getting worse as we look at the investment
choices and prioritizing on it.
ADMINISTRATIVE COSTS
And along that line, when Dr. Roubideaux was here, she
cited the IHS admin costs at around 10 to 11 percent of the
total. It looks like now--well, let me ask you, what are the
admin costs as a percentage of the overall budget for this
year?
Ms. Smith. I think the IHS-wide administrative costs are at
12 percent, and then some of the areas are lower than that.
Senator Daines. Overall. I'm just looking at what Dr.
Roubideaux told us, the 12 percent. It looks like the
percentage of administrative costs are actually going up versus
going down. And typically when budgets are increasing
oftentimes, because you have a bigger denominator, the admin
costs will start going down. Having spent many, many years
doing budgets in the private sector, why are admin costs going
up?
Ms. Smith. Senator, I'd have to look back at the number
that Dr. Roubideaux gave you. I'm not aware that they're going
up between 11 and 12, but we can certainly look at that, and I
will say that we are committed to--I think your points are well
taken. We are committed to ensuring that we are efficient in
how we spend the funds and that we have deliverable outcomes
and metrics and timelines for achieving results.
Senator Daines. Yes, and part of the overall challenge
here, I'd like to see some clear goals set, that we want to
take admin costs as a percentage--if they're at 12 percent
today, how do we get to 11 percent, 10 percent, and 9 percent
over the course of the next 3 or 4 years? Because every dollar
that's spent in admin arguably is a dollar getting taken out of
the help that people here who need it the most in Indian
Country.
Ms. Smith. Yes, Senator, thank you so much, and we
definitely can take a look at that. I share your thoughts on
that.
Senator Daines. And again, this is just my concern. This
disproportionate spending on admin costs doesn't translate into
better care in Indian Country. A recent study showed in Montana
that white men live 19 years longer than American Indian men,
and white women live 20 years longer than American Indian
women. I know there are other factors involved, but I do
believe it's unacceptable that we've reached disparities like
these under the watch of IHS, and I urge you to address the
real health challenges facing Indian Country and really turn
the focus back to results versus just activities.
Ms. Smith. Thank you, Senator, and I totally agree, and
that is a point well taken.
Senator Daines. All right. Thank you.
Senator Murkowski. The ranking member has asked that we
defer to Senator Merkley from Oregon.
Senator Merkley. Thank you very much to the ranking member,
I appreciate that.
HEALTHCARE COSTS
I appreciate this conversation about the Indian Health
Service. It certainly serves a vital role in many parts of my
home State of Oregon. One thing I was looking at was a number I
found very interesting, and that is the number that, per
patient, the Indian Health Service spends about $3,100 compared
to, say, Medicare, at almost $12,000, or the national average
for those who are not in either Medicaid, Medicare, Veterans,
et cetera, of about $8,100. So $3,100 sounds like a very low
number.
Is that so low in part because there are lots of folks who
qualify who don't actually utilize the Indian Health Service,
they live in urban areas and have other health service
providers, or is that just a reflection of how desperately
underfunded IHS is?
Ms. Smith. Thank you, Senator. I think the number that you
are referencing is the per capita funding for certain Federal
programs that provide healthcare. The per capita funding for
IHS is, as you correctly stated, about $3,100 per capita. I
think the number is derived from our total population served,
about 2.2 million, and then dividing out our budget. So I think
that's how the number is derived.
Senator Merkley. So of those 2.2 million who are eligible,
how many in a given year utilize the IHS as their primary
health provider?
Ms. Smith. Senator, I would have to get back with you on
that, but we're happy to provide an answer.
[The information follows:]
1. $12,179--2014 AVERAGE MEDICARE BENEFIT PER ENROLLEE: Source--2015
ANNUAL REPORT OF THE BOARDS OF TRUSTEES OF THE FEDERAL HOSPITAL
INSURANCE AND FEDERAL SUPPLEMENTARY MEDICAL INSURANCE TRUST FUNDS;
available at https://www.cms.gov/Research-Statistics-Data-and-Systems/
Statistics-Trends-and-Reports/ReportsTrustPFunds/Downloads/TR2015.pdf
in Table II.B1 Medicare Data for 2014, page 11.
2. $8,517--PROJECTED 2015 NATIONAL HEALTH CARE EXPENDITURES PER CAPITA:
Source--Table 5 Personal Health Care Expenditures; Aggregate and per
Capital Amounts, Percent Distribution and Annual Percent Change by
Source of Funds: Calendar Years 2014-2024; available at https://
www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/NationalHealthExpendData/Downloads/Proj2014tables.zip.
3. $8,760--2015 CURRENT ESTIMATE OBLIGATIONS PER UNIQUE PATIENT: Source--
Volume II--Medical Programs and Information Technology Programs--
Congressional Submission, available http://www.va.gov/budget/docs/
summary/FY2016-Volumell-MedicalProgramsAndInformationTechnology.pdf
(page VHA-23).
4. $5,790--2011 MEDICAID SPENDING PER ENROLLEE. Spending per enrollee
calculations includes both state and federal payments to Medicaid.
These figures represent the average (mean) level of payments across all
Medicaid enrollees, including those receiving full or partial Medicaid
benefits, during federal fiscal year 2011, based on date of payment.
Available at http://kff.org/medicaid/state-indicator/medicaid-spending-
per-enrollee/.
5. $5,460--FDI BENCHMARK PER IHS USER (Interim Inflated to 2015): The
ACA expands health care resources potentially available to AIANs. IHS'
long standing methodology projecting per-capita resource needs has not
yet incorporated these factors due to unavailable data. In the interim,
the last benchmark was inflated to 2015 pending future methodological
adjustments for ACA effects.
6. $3,136--2014 IHS MEDICAL CARE EXPENDITURES PER USER*: Source--IHS
appropriations for 2015. Appropriations spent for personal health care
services plus IHS collections from third parties are totaled and
divided by 2015 user counts (1,613,450). IHS spends an additional $524
per person for *OTHER public health, community programs, sanitation and
environmental projects, education, and other purposes unrelated to
personal medical care. An unknown additional amount of spending occurs
outside the IHS system when patients obtain a portion of their medical
services elsewhere, e.g. payments by private insurance, Medicare and
Medicaid to non-IHS providers for services to Indians who also use the
IHS.
------------------------------------------------------------------------
* Payments by other sources for medical services provided to AIANs
outside IHS is unknown.
Senator Merkley. That would be helpful to try to understand
really how this compares to other healthcare settings.
TELEMEDICINE
I wanted to turn to telemedicine. I believe that in Alaska,
and the Chair will correct me if I'm wrong about this, that
they have piloted the Dental Health Aide Therapist Program to
provide telemedicine in dental care. This trains tribal members
to become mid-level dental professionals, 2 years of training.
It provides care such as oral exams, cleaning, fluoride
treatments, sealants, x-rays, crowns, extractions, while doing
it through a video conference with a dentist. Has this worked
well in Alaska?
Senator Murkowski. Well, I will let Ms. Smith speak to it.
I think everything that you have said is correct, although the
dental health therapists don't do the extractions necessarily,
but it has proven to be phenomenally successful to get mid-
level providers out in areas where we would never find the full
provider.
Senator Merkley. Well, the reason I wanted to raise this is
I'd heard rave reviews about Alaska, and Oregon is the first
State outside of Alaska to provide this. I believe that we had
to pass a State law to authorize it. Given the success and the
cost-effectiveness of this, is this something that the Indian
Health Service is hoping to expand substantially?
Ms. Smith. Thank you, Senator, for your question. I agree
with the premise of your question. I think they're doing some
amazing, innovative things in Alaska and serving the community
well, and this is one example. I think your question, you
mentioned it in the dental context, but I think the premise of
your question I think expands more broadly on how can we
leverage resources and how can we leverage the use of
telemedicine. I can tell you that we are very committed to
doing that because, as was mentioned earlier, we have
significant staffing challenges, and we have to think
creatively, and everything has to be on the table. I think
telemedicine is one of the ways, along with a lot of other
things, that we can leverage those resources.
I know that we are using telemedicine for behavioral
health. We have the Telehealth Center of Excellence that's in
partnership with the University of New Mexico, and we are doing
several sites in the Great Plains, for instance. We actually
just--we're going to do a telemedicine area-wide contract in
the Great Plains that is in process now, and one of the things
last week we actually had our budget formulation workgroups,
and I think one of the things we would like to see on a going-
forward basis is a more concerted effort nationally to focus on
telemedicine.
Senator Merkley. Well, thank you. I think that's an area
where we can help address some of the concerns that Senator
Daines was mentioning in terms of how do we get more outcomes
for the dollars invested.
CONTRACT SUPPORT COSTS
I did want to ask about contract support costs. My
understanding is that this budget line pays for tribes for
things such as financial management accounting, training,
program startup, but that pretty much it has had a substantial
shortfall, and you're recommending an $82 million increase. Is
that based on a certain percent of assistance to tribes for
administrative overhead? How is that calculated, and how much
of a difference will that make?
Ms. Smith. Thanks, Senator. I will answer at a high level,
and if you need more detail we're happy to get that to you. I
understand that there was an estimate made in consultation with
tribes, and after the Supreme Court's decision in Ramah we are
obviously fully supportive of the full contract support costs,
and I personally actually have spent a lot of time. We are
actually going to be putting forth a new contract support cost
policy this year with IHS. But I've spent a lot of time with
the Contract Support Cost Working Group and I understand, even
from our tribal partners, that the number that we have put
forward is on the generous end of the estimate, and I do
believe that it will fully fund contract support costs.
Senator Merkley. Thank you very much, and thank you for
your very--you said you hadn't been there that long, but you're
presenting very thorough responses to all of our questions, and
it gives me great confidence in IHS going forward. Thank you.
Senator Murkowski. Thank you, Senator Merkley.
Senator Udall.
SUBSTANCE ABUSE
Senator Udall. Thank you, Madam Chair and Deputy Director
Smith. I'm very pleased to see that you've included a 14
percent increase for alcohol and substance abuse programs as
part of your 2017 budget request. I've already had the chance
to visit with you about a particular issue in New Mexico that
has to do with the Gallup detox center. It's also called NCI
(Na'nizhoozhi Center Inc.). I wanted to raise this issue again
this morning and ask for your help.
As I've mentioned, the center has been providing
detoxification services to the Gallup community for more than
20 years. In a community struggling to reduce exposure deaths
related to alcohol and substance abuse, the services it
provides literally mean the difference between life or death.
Twenty-five people have died from alcohol-related exposure
incidents between this winter and last winter, with the recent
report of another death just 2 weeks ago. There were five
deaths this January alone. According to the center's director,
they have admitted more than 2,500 individuals since October
2015, which is approximately 10 percent of the population of
Gallup.
The need is clearly there, and the community is desperate
to maintain these life-saving services. Over the past few years
NCI has lost some of the funding that it received from Indian
Health Service and other sources, and the center has been on
the brink of closure ever since.
I'm grateful that the Indian Health Service just stepped up
to the plate to provide some emergency funding to help keep the
center open through June 30, funding that was particularly
critical to keep it open through the coldest winter months,
when the risk of weather-related deaths is the highest. But
that's just a temporary fix, and we must do more.
I want to work with all the partners involved with NCI,
IHS, the tribe, the State and the city to come up with a plan
to provide sustainable funding. Senator Heinrich and
Congressman Ben Lujan have been great partners on this issue,
and we have all been working together to find a way forward and
to encourage communication between the local stakeholders.
Can I have your commitment that you will work with me and
with members of the delegation to develop a long-term plan to
keep the center open so it can continue to provide essential
services?
Ms. Smith. Senator, first I want to thank you for your
leadership and all that you've done to help that situation, and
you do have my commitment. As we've talked about at this
hearing, there are great issues of alcohol and substance abuse
in Indian Country, and since we talked I've been thinking about
this issue a lot, and to me it's similar to the village-built
clinic. This is like a gap that we're not addressing, and I am
committed to working with you to find a sustainable solution.
Senator Udall. Thank you so much for that. We've talked
specifically about the needs in Gallup, but obviously, as
you've just said, substance abuse treatment is a critical need
in many of our Native communities, and I continue to hear from
tribal leaders in New Mexico, including the Mescalero Apache
Tribe and others who are concerned for the well-being of their
people. That's why I'm pleased to see we were able to provide a
$10 million increase for alcohol and substance abuse treatment
as part of the 2016 omnibus.
Could you tell us more about how these increased funds will
be used, what improvements in counseling and treatment services
will these additional resources provide, and how soon will
these improvements be available to tribes?
BEHAVIORAL HEALTH
Ms. Smith. Thank you, Senator, so much for highlighting the
great need we have for behavioral health issues in Indian
Country, and we appreciate all your help and leadership on that
issue.
Our fiscal year 2017 budget, we actually have $46 million
to focus on critical behavioral health needs. $15 million of
that is for the generation of indigenous substance abuse and
suicide prevention projects to increase the number of child and
adolescent behavioral health professionals. We have $21 million
to fund continuing integration of behavioral health services
throughout our IHS system. We have $4 million to fund pilot
projects for Zero Suicide Initiative. We have $2 million to
fund another gap that I think we realized is for after-care,
after people leave regional youth treatment centers. So we have
a $2 million pilot project for that, and then we have $4
million for domestic violence prevention to fund 30 additional
organizations.
Senator Udall. Are you able, when you ramp up like this,
able to get the funds and the resources down to the ground
quickly?
Ms. Smith. I think we are able to do that. I know that even
since the time that I've been at IHS, we have had a number of
tribes who have had what I'll call behavioral health crises,
and one of the things I know a number of us have been working
on at IHS as well is that sometimes grant programs are timed a
certain way and you cannot time when a behavioral health crisis
happens. So one of the things that I am particularly excited
about in our budget is we have $15 million for a new Tribal
Crisis Response Fund so that those funds will be immediately
available upon the request of a tribe when they're having a
behavioral health crisis in their community.
Senator Udall. Thank you very much.
Thanks, Madam Chair.
SUICIDE AND SUBSTANCE ABUSE
Senator Murkowski. Thank you, Senator Udall. I appreciate
your focus on these issues of suicide, substance abuse. Know
that this is something that I really want us to try to focus on
within this IHS budget. I think there are so many other areas
that we can look to. We're going to have a hearing this
afternoon in Indian Affairs on the budget as it relates to
Indian Affairs. I think about the job creation programs and the
other things that we will do, education. But if, in fact, our
Native peoples are not healthy, it makes it difficult to really
be there to provide much else. So making sure that they have
hope, that they do not view suicide as an answer or that they
turn to substance abuse that not only takes them down but their
families down and their whole communities is just so key.
I mentioned complex trauma in my opening remarks. Your
budget request talks briefly about it, but know that, again,
that's something where we'd like to have better understanding.
You mentioned this integrated approach to addressing
primary healthcare, mental health and substance abuse
disorders. I know that you have made some commitment to some of
our tribes to perhaps come up to Alaska sometime this summer,
but I do hope that you will take full advantage of visiting
with the folks at South Central Foundation to really come to
understand what they have done with the Nuka model, which is
truly this integrated, whole-person approach to providing
healthcare services. It's a model that is not only being built
on within the State of Alaska but really around the country and
as an international model. It's not too often that in Alaska we
are leading the way in healthcare reform, but I view what
Katherine Gottlieb and those at South Central have done over
the years with the Nuka model as not only innovative and
pioneering, it's the way of the future. I would certainly
commend that to you as you're talking about this integrated
approach.
I mean, if you'd care to make any comments about that, I'm
happy to hear them.
Ms. Smith. Senator, I completely agree. Healthcare needs to
be integrated in all facets of life, and it's family, tribe,
and community. I look forward to a trip to Alaska. I'm
committed, and I certainly look forward to learning more about
that because I have heard of all the innovative things that are
happening in Alaska and I hope to learn a lot and see if
there's any way we can replicate some of those best practices
elsewhere in the country. So, thank you so much.
DEFINITION OF INDIAN
Senator Murkowski. We certainly believe we can, and we're
ready to show you.
Let me ask about a technical thing. This is the definition
of ``Indian'' under the Affordable Care Act. We continue to
hear the complaints about the inconsistent definition that is
contained in that Act that has caused confusion and
inconsistent treatment, unfortunately. A person who is an
Indian for purposes of Indian Health Service programs and for
Medicaid is not treated as an Indian for purposes of the ACA--
incredible. And yet we knew that this was an issue coming
forward. The National Congress of American Indians (NCAI)
weighed in, the National Indian Health Board, and yet the
administration chose to interpret the legislation in a way that
really created a problem.
We believe that there is authority within the
administration to grant regulatory waivers, but it hasn't taken
action to ensure that the benefits of open enrollment and
protection from cost-sharing would be available to all Indians.
We asked the administration to fix this administratively, but
they haven't. We included report language in the fiscal year
2015 omnibus containing a directive to work together to
establish a consistent definition of ``Indian'' for purposes of
providing health benefits.
What's the administration going to do this year to fix the
problem? Because it really needs to be addressed.
Ms. Smith. No. Thank you so much, Senator, for your
leadership. I know you have also been advocating for this for a
long time, and I have also looked into this since I've been
there. The definition definitely should be consistent, and as
part of our fiscal year 2017 budget proposal we have a
legislative proposal to make the fix. I think there's been a
determination that this needs to be done legislatively.
Senator Murkowski. Well, I understand that. But I also
understand that the ACA passed at the beginning of this
administration. It is now the end of this administration. And I
understand that it didn't come into play until a couple of
years ago. But in the interim, again, you have American
Indians, Alaska Natives that are just kind of caught in this
back and forth. It was just so, so unnecessary.
So I appreciate the administration coming forward and
saying, well, now we think we need legislation. Before they
were looking at administrative fixes. So I know that I'm just
taking on the messenger here, but I think it needs to be made
very clear that this became a problem when it didn't need to be
a problem, and it could have been remedied. If the
administration determined it needed legislation, we've been
prepared to address it, and it's just been a failure, so know
that it's been a priority.
PRIORITY LIST AND CONSTRUCTION
Let me ask a question about two very small communities in
Alaska, Gambell and Sevoonga. They are located on St. Lawrence
Island out in the middle of the Bering Sea. You want to talk
about remote, it does not get any more remote than Gambell and
Sevoonga. They are communities that have roughly 700 people
each. The only way you can get there is by airplane, and more
often than not the weather is not very forgiving. The existing
facilities are old, old, old and really rundown. I have seen
the facility there at Sevoonga, but they are simply
unacceptable in terms of their condition.
The Norton Sound Health Corporation, along with some very
dedicated folks from Gambell and Sevoonga, have tried to get
Federal financing to construct new clinics. They were in to
visit with me about a month ago. We sent a letter to the
Department and were told that the current IHS healthcare
facilities priority list has a $2 billion backlog of projects
and that you can't add any new projects to the list, which for
the people of Gambell and Sevoonga is incredible. You've got to
be kidding me. There's no way to possibly provide some upgrades
to a situation that is in desperate need.
So, first of all, I want to know whether or not that is
still your position, that they cannot be added to the list. And
second, I want to ask about the small ambulatory clinic
program. For the first time since 2008, the agency has
requested funds for this program. There's $10 million in it.
Would Gambell and Sevoonga be eligible for funding for this
program if funds were to be provided? As you can probably
understand, the people in these two communities are really most
desperate and are seeking some answers. So if you could provide
me something here today, that would be helpful.
Ms. Smith. Thanks, Senator. I certainly can appreciate your
frustration. I get frustrated, too. As you correctly mentioned,
we have a list of priority projects that actually gets approved
by Congress, and there is a $2 billion backlog. I wish that we
had more flexibility with the list. Unfortunately, that's the
way the system is set up. So I think adding to the list, we
don't actually have flexibility at IHS. Congress dictates how
we have to move through the list. So I appreciate your
frustration.
In terms of other options or trying to think creatively how
to address this issue, and I know you've raised the small
ambulatory clinic, if I may defer to Mr. Hartz to see IHS
thoughts on that.
Senator Murkowski. Mr. Hartz.
SMALL AMBULATORY PROGRAM
Mr. Hartz. Thank you, Senator. The small ambulatory program
is one of the programs to be considered for Sevoonga and
Gambell. There are criteria, and we'd be happy to send in
advance of even the solicitation, we would go ahead and send to
Manilick what the criteria were when we last implemented the
program so that they can get some idea of the specifics of
that.
Furthermore, we understand that those two locations are
considering applying under the tribally built program for
equipment, and they certainly would be strongly considered for
equipment dollar support should they move forward as a tribally
built facility.
JOINT VENTURE
So there are some options available, and the most popular
program is the JV, the joint venture program that's been
utilized throughout Indian Country, and that would be another
option should they consider the next solicitation.
Senator Murkowski. Thank you, Mr. Hartz and Ms. Smith. Know
that we will continue to try to work with you on this.
Ms. Smith, I know it is a long way out of the path of
Anchorage or Fairbanks where you will likely be, but I do think
that when you visit it would be most important to get out to
some of our smaller villages and see the needs and how
isolation really makes imperative the need to have some
facilities out there.
Let me turn to my colleague here, Senator Udall.
STAFFING
Senator Udall. Thank you, Madam Chair.
Deputy Director Smith, New Mexico emergency medical
services were halted last year at an IHS medical center in
Crownpoint, New Mexico. This was due in part to staffing
issues, though some emergency services were ultimately
restored. I'm told the hospital is still unable to provide
certain medical services like labor and delivery. My concerns
about this situation are amplified by the problems that the
service is having in other areas like the Great Plains, where
multiple facilities are on the brink of losing their
accreditation, and other tribes there have faced the loss of
emergency services as well as substandard care.
It goes without saying that patients deserve competent and
timely care. It's absolutely intolerable for any IHS emergency
facility to close for any amount of time, and cutbacks to
essential services like obstetrics are also unacceptable.
Can you talk about what the IHS is specifically doing to
address staffing shortages at Crownpoint and other facilities
in New Mexico?
Ms. Smith. Thank you, Senator. Yes, we certainly agree with
you on access to quality care and certain services being
provided. I know that across the agency, including at
Crownpoint, we are looking at staffing issues, like I said kind
of in three simultaneous ways, in the short term, in the
intermediate term and the longer-term sustainable solutions. So
we are definitely working on that and it is certainly a
priority for us.
Senator Udall. And are you able to tell me today anything
specific about Crownpoint, or would you rather do that----
Ms. Smith. Yes, I have one specific. I know that the
quarters are being upgraded out at Crownpoint, so I'm able to
tell you that today.
Senator Udall. Okay, thank you. Maybe you can update me on
additional things in the record for specifically what we're
doing out at Crownpoint.
Ms. Smith. I certainly will.
Senator Udall. On a related note, I'd like to raise the
concerns I'm hearing about service reductions at the Santa Fe
Indian Hospital. This is an issue that was brought to my
attention recently by the Pueblo of Tesuque. Deputy Director
Smith, I'd like to ask for your help in reviewing the situation
with the hospital, and I'm going to ask you to provide some
data for the record regarding services and staffing levels so
that we can get to the bottom of these concerns. Would you work
with me on this issue?
Ms. Smith. Senator, we will certainly work with you and
your staff on this issue and get you whatever answers and work
together to find a solution. Thank you.
Senator Udall. Great, thank you.
LOAN REPAYMENT AND STAFF QUARTERS
On the issue of loan repayment and staff quarters and
things like that, as you know the Indian Health Service
currently spends an estimated 30 percent of its health
professions account to pay taxes to the Federal Government,
taking needed funding away from investments in skilled medical
professionals. I've introduced a bill with the Chairman,
Senator Murkowski, that will make the IHS Health Professions
Awards Program exempt from a Federal income tax requirement,
and I'm pleased to see that your budget includes a similar
proposal.
Can you talk about the importance of this specific issue
for recruitment purposes? And if this proposal would be
enacted, how many additional scholarships and loans could IHS
provide with the existing resources?
Ms. Smith. Thank you so much, Senator, and thank you so
much for your leadership on this issue. All 100 percent of the
dollars for both the scholarships and loans can go for the
purposes for which they're intended rather than taxes. As you
mentioned, we do support that proposal. I understand that if
the proposal went forward, that would free up $11 million, $8
million of it for loan repayment and $3 million for
scholarships, and I think that would allow us to do 200 more
loan recipients. So, thank you so much.
Senator Udall. Well, we haven't gotten it done yet, but we
look forward to working on this and actually accomplishing
this. It helps a lot that the Chairman is also the chairman of
the authorizing committee.
FACILITIES CONSTRUCTION
I'm pleased that this subcommittee was able to provide $63
million in new funds for construction and maintenance needs as
part of the 2016 omnibus, and I'm pleased to see that you build
on that request in your 2017 budget by asking for another 9
percent increase. We really need these kinds of things to
happen in Indian Country. The issue is particularly important
to me because there are a number of tribal health facilities in
New Mexico that have been waiting their turn on the IHS
priority list for years. These include outpatient facilities in
Alamo, Pueblo Pintado, and Albuquerque. And, of course, we also
have the replacement of the Gallup hospital on the list.
How long will it take at current funding levels to complete
work on the current priority list? Is it fair to say that
should additional resources become available, that you would be
in a position to accelerate this timetable?
Ms. Smith. Senator, thanks so much for your question. Yes,
I do understand, I think. This is a ballpark estimate. I think
it's in the nature of 18 to 20 years to fully fund all the
needs that there would be, and certainly if there were more
funding we would be able to do more projects.
Senator Udall. And I understand that the Alamo facility is
next up for funding on the priority list, but it's not part of
your fiscal year 2017 request. What's the earliest we can
expect to see funding for that project?
Ms. Smith. I will defer to Mr. Hartz on this question.
Mr. Hartz. Thank you, Senator. You are correct, it is the
next project on the outpatient list. Based on the current level
of funding, it would probably be reached within the next 2
years.
Senator Udall. Thank you.
Maybe I'll come back with this one. Thank you, Madam Chair.
Senator Murkowski. Thank you.
FACILITIES CONSTRUCTION
I want to ask one more Alaska-specific question, and then I
want to turn my attention to what I raised in my opening, which
is the situation at Rosebud.
But first, I want to ask specifically about Southeast
Alaska. The Mount Edgecombe service unit is an area, it's about
35,000 square miles but entirely tribally operated, mostly by
the Southeast Alaska Regional Health Consortium, SEARHC. It is
anchored by about a 70-year-old hospital there in Sitka that
was built just after World War II by the War Department. It's
in pretty tough shape. I will just tell you that. It's ill-
suited to the 21st century model of healthcare that's dominated
by primary and ambulatory care facilities. What we have seen in
Southeast in particular has been more facilities focused on
localized care provided through 13 clinics serving 18 Alaska
communities.
What is Indian Health Service doing to collaborate with
SEARHC in the development of a plan moving forward for how we
provide for healthcare across Southeast Alaska, and then
dealing with the situation with Mt. Edgecombe Hospital there
and the deteriorating conditions? Is this on anybody's radar?
Ms. Smith. Yes, Senator. Let me again defer to Mr. Hartz to
speak to that issue.
Senator Murkowski. Okay.
Mr. Hartz. Thank you, Senator. You're taking me back a
number of years because I worked in that service unit.
Senator Murkowski. Ah, then you know well, you know well.
Mr. Hartz. I know well that facility. I was stationed at
the time in Ketchikan, so I got in there to work with Art
Wallman, bless his heart, for many, many, many years.
You are absolutely correct regarding the age and the
condition of that facility. I know SEARHC has been a major
force in all of Southeast Alaska in providing coordination for
healthcare in the outlying areas and probably left that Federal
facility pretty much intact.
As was discussed earlier about the existing priority list,
we have to work our way down through that. We have prepared,
are prepared to implement a new priority system or a modified
priority system to address the needs across Indian Country, and
we will soon be providing a report to Congress talking about
all of the needs in Indian Country. That's required of us every
5 years. That facility, along with a number of others, even
though not specifically identified, are part of that
significant need in Indian Country.
Upon working our way down further on that existing priority
list, we would essentially then create a new list that would
not last so many years. We would prioritize those that are of
the highest rank and address them maybe over a 3-year period so
we wouldn't have this ongoing list and reassess what's the
greatest need in Indian Country as we move forward in
healthcare facility construction.
ROSEBUD HOSPITAL
Senator Murkowski. Well, thank you for that. It kind of
dovetails with my questions here about the Rosebud Hospital. I
indicated that the Center for Medicare and Medicaid Services
(CMS) is intending to terminate the hospital provider agreement
effective March 16, and I mentioned some of the issues,
allegations concerning sanitary conditions, instances of drug
theft, lack of infection control measures, clearly a
fundamental lack of oversight within the hospital.
So the question to you this morning is--I mean, I suppose
we could talk about how we got here, but that's not our
problem. What we really need to know is that there is a plan
going forward. How does the agency intend to address this
situation, and what management reforms or changes are being put
in place as we go forward? Because I think we would all agree
that this is simply not tolerable, it's not acceptable. If CMS
does terminate, you've got individuals that are going to have
to travel long distances to get urgent care that they would
have received.
This is not a tolerable situation. What are you doing?
Ms. Smith. Thank you, Senator. I certainly agree, and I
know that the team at IHS does as well. This is simply not
tolerable, it's unacceptable. I do want to give you an update
and then segue into what we are doing to address it.
We did receive that notice from CMS with the potential
termination date of March 16. At IHS we requested an extension
on that date, which CMS has now granted. We requested an
extension to be able to work with CMS collaboratively on what's
called a Systems Improvement Agreement, and this type of
agreement is different than the normal corrective action plans
that are developed when you get these types of notices from CMS
because they address systemic root-based causes for how the
issues developed. They are very specific types of agreements
that have, as I know was mentioned earlier in this hearing,
measureable outcomes and timelines for when they will be
addressed.
So this agreement will address issues such as staffing,
housing, and quality and compliance, and creating a culture of
accountability and compliance and leadership, even leadership
skills and issues with the governing board. So as we speak we
are working very closely with CMS on developing such an
agreement. It will involve a major commitment of time and
resources and a new sense of leadership I think out at Rosebud
Hospital. But that is our plan to address it.
Senator Murkowski. So you sound relatively certain that the
hospital provider agreement will not be terminated, that
services will still continue as you are working through these
issues; is that correct?
Ms. Smith. Yes. So, just to be very clear, CMS has
responded in writing that we're happy to give to any members of
the subcommittee that we have an extension until May 16, a
provisional period to work on the systems improvement
agreement, and in the letter from CMS the agreement actually
has to be entered into by April 29, because if we have not
entered into the agreement by that point there's a 10-day
notification period. So that is the extension we have been
granted.
Of course, I do want to make clear it's not only in the
purview of IHS. CMS has to approve the agreement, and that
would be part of the regulatory duties. But we are heartened
that they are at least talking to us and working closely with
us on this agreement.
PINE RIDGE HOSPITAL
Senator Murkowski. Well, then let me ask about another,
because I understand that CMS has raised similar questions with
regards to Pine Ridge Hospital, also in South Dakota, and
they've also received a termination letter. Is this the same
situation where you're able to work something out with CMS?
That's one question, but it really does beg the question as to
whether or not we've got some systemic failures within IHS to
have Rosebud and also Pine Ridge in this situation. Are there
others that are also in a similarly precarious situation?
Ms. Smith. Thank you, Senator. I guess what I'll say just
as a general matter, we are committed to doing whatever it
takes. This is not an option. We need to ensure that these
hospitals are delivering quality care, and that is I think the
top priority for all of us at the agency right now. But as you
mentioned, I think there are systemic problems, not just at
those hospitals but throughout our system, things that we've
talked about in terms of staffing and housing. One of the
things we are working on also is establishing a system of
quality across the agency.
With respect to Pine Ridge specifically, we did actually
receive two notices from CMS. One was on the hospital, and one
was on the emergency services. We did receive notice from CMS
that with respect to the hospital we had met the requirements.
We are still waiting on the emergency department, but we are
committed to doing whatever it takes to ensure that these
hospitals are providing quality care.
Senator Murkowski. Very discouraging because, again, you
don't get these notices unless there has been a long buildup,
and what that long buildup means is that these people have been
left behind, their health has potentially been compromised or
put at risk. And again, it is just not acceptable.
Senator Udall.
Senator Udall. Great. Thank you, Madam Chair.
SANITATION FACILITIES CONSTRUCTION
I just have one additional question on sanitation
improvements. As you know, the subcommittee provided a 25
percent increase there, and nearly half of all homes in Indian
Country are in need of sanitation improvements. I frequently
hear from the tribes in my State such as the Navajo Nation
about the importance of these funds. The Nation is unique
because the tribe is making its own aggressive investments to
upgrade water infrastructure on the reservation, and they are
particularly interested in leveraging IHS sanitation funds to
provide service to their members.
Can you talk about the progress you expect to make with the
increased funds provided in the omnibus? How specifically are
you working with tribes specifically like the Navajo Nation to
ensure that the additional funds are being used strategically
to take care of the most critical needs?
Ms. Smith. Thank you, Senator, and thanks for the funding
to address the urgent sanitation needs. We certainly agree with
you, and I know we have another commitment in our fiscal fear
2017 budget. With respect to the specific measures, I again
will refer to my colleague, Mr. Hartz.
Mr. Hartz. Thank you, Senator. First of all, I thank the
subcommittee for the additional $20 million in fiscal year
2016. Nationwide, that's going to provide over 3,000 additional
homes with improved water and sewer facilities, or new water
and sewer facilities, because there are many places where
potable water is not available in the home as we know it.
As far as the collaboration with the Navajo Nation, I guess
I would say it's not unique because we do it with all tribes
and all corporations across the country in providing water and
sewer facilities, but it is unique from the standpoint of the
Navajo Nation coming forward with such a substantial plan to
support funding for projects on the sanitation facilities
priority list. They have actually worked directly with our
staff scattered around the Navajo reservation and the area
office to look at the sanitation deficiency system, and they
actually use that list, Senator, to start identifying how they
would provide resources to projects.
So I guess they're leveraging. It's kind of a mutual
leveraging to see these projects be addressed and work down the
list. My understanding is they're planning to address their
contributions over the next 5 years, and even address the large
infrastructure projects, large transmission mains where they
really are very remote in parts of the Navajo reservation. It's
always been a good relationship, and you touched my heart, just
like Senator Murkowski did, because I started on the Navajo
reservation.
Senator Udall. That's great. A lot of challenges out there.
Mr. Hartz. Absolutely.
Senator Udall. But interesting things going on. Thank you
very much.
Thank you, Madam Chair.
SANITATION FACILITIES CONSTRUCTION
Senator Murkowski. Thank you, Senator Udall.
I will conclude my comments in thanking you all. You raised
the issue, Senator Udall, about the water and sanitation, and I
had an opportunity a few weeks ago to bring the Secretary of
Energy and five of our colleagues to Bethel, Alaska in mid-
February, and then we went to the little community of
Oscarville. Oscarville is about 80 people, and it's just down
river, down the Kuskokwim River from Bethel. Out in that area,
there are no roads. So in order for us to get there, we were
going to take snow machines, but there wasn't enough snow
cover, so we took trucks on the ice, which kind of freaked some
of my colleagues out, but the ice was nice and thick.
But we got to Oscarville, and Oscarville is a community
that has no running water, it has no sanitation facility. Human
waste disposal is through the honey bucket. Usually it's the
younger kids in the family that are given the job of dumping
the honey bucket outside and digging a pit and hoping it
freezes over quick.
Talking to the elementary school teacher there--there are
only two teachers in the school. One is elementary and the
other is everybody else. But she has five kids, and I asked
her, how do you do the laundry for your family, and she very
matter-of-factly described that during the summertime you just
go down--usually it's the kids that haul the water up from the
river. During the winter, when the ice is thick enough that you
can drive your trucks on it, you chop ice and you put it on a
sled and haul it up to the house and you heat it on the stove.
Basically, it's no different than way back when. This is a
community of Alaskans, of Americans who are figuring out how to
deal with the challenges of the day-to-day world, trying to get
Internet and broadband, but at the same time literally dumping
their human waste in a pit, in a hole, and hauling their water
from a river.
So the issues of disease and the concerns that are
associated when you cannot keep clean, when you do not have
safe drinking water, when you just have a level of exposure,
these are issues that are very close to my heart because there
are far too many communities in my State and, unfortunately,
still around the country where we have these issues.
So know that I want to work with you on so many of them.
And to those of you that work every day on these issues, know
that we appreciate your work. We've got a lot to do in this
area. But when I look at that segment of the Interior budget
that you all represent through IHS, these are very serious
commitments that we make to our Native peoples, that the
healthcare that they receive will be good and adequate and
equal. I think some of the questions that you heard raised here
today suggest that that care is not yet adequate nor equal. So
we've got a ways to go, but know that we're committed to doing
that. We appreciate you being here.
SUBCOMMITTEE RECESS
With that, we stand adjourned.
[Whereupon, at 11:30 a.m., Wednesday, March 9, the
subcommittee was recessed, to reconvene subject to the call of
the Chair.]