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S. HRG. 115–89 

S. 1250, S. 1275, AND S. 1333 

HEARING 

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

JUNE 13, 2017 

Printed for the use of the Committee on Indian Affairs 

( 

(II) 

COMMITTEE ON INDIAN AFFAIRS 

JOHN HOEVEN, North Dakota, Chairman 

TOM UDALL, New Mexico, Vice Chairman 

JOHN BARRASSO, Wyoming 

JOHN MCCAIN, Arizona 

LISA MURKOWSKI, Alaska 

JAMES LANKFORD, Oklahoma 

STEVE DAINES, Montana 

MIKE CRAPO, Idaho 

JERRY MORAN, Kansas 

MARIA CANTWELL, Washington 

JON TESTER, Montana, 

AL FRANKEN, Minnesota 

BRIAN SCHATZ, Hawaii 

HEIDI HEITKAMP, North Dakota 

CATHERINE CORTEZ MASTO, Nevada 

T. MICHAEL ANDREWS, Majority Staff Director and Chief Counsel 

JENNIFER ROMERO, Minority Staff Director and Chief Counsel 

(III) 

C O N T E N T S 

Page 

Hearing held on June 13, 2017 ............................................................................... 1 

Statement of Senator Barrasso ............................................................................... 11 

Statement of Senator Cortez Masto ....................................................................... 10 

Statement of Senator Daines .................................................................................. 44 

Statement of Senator Franken ............................................................................... 7 

Statement of Senator Heitkamp ............................................................................. 9 

Statement of Senator Hirono .................................................................................. 7 

Statement of Senator Hoeven ................................................................................. 1 

Statement of Senator Murkowski ........................................................................... 5 

Statement of Senator Schatz .................................................................................. 4 

Statement of Senator Tester ................................................................................... 49 

Statement of Senator Thune ................................................................................... 51 

Statement of Senator Udall .................................................................................... 3 

WITNESSES

Buchanan, Rear Admiral Chris, Acting Director, Indian Health Service, U.S. 

Department of Health and Human Services ...................................................... 12 

Prepared statement .......................................................................................... 14 

Charlie, Mark, President/CEO, Association of Village Council Presidents 

(AVCP) Regional Housing ................................................................................... 67 

Prepared statement .......................................................................................... 69 

Crowley, Dr. Joseph P., President-Elect, American Dental Association ............. 22 

Prepared statement .......................................................................................... 23 

Difuntorum, Sami Jo, Chairwoman, National American Indian Housing Council ........................................................................................................................... 75 

Prepared statement .......................................................................................... 78 

Frechette, Heidi, Deputy Assistant Secretary, Office of Native American Programs, U.S. Department of Housing and Urban Development ........................ 54 

Prepared statement .......................................................................................... 56 

Harris, Dr. Keith, Director of Clinical Operations, Homeless Programs Office, 

U.S. Department of Veterans Affairs ................................................................. 59 

Prepared statement .......................................................................................... 61 

Kitcheyan, Hon. Victoria, Treasurer, Winnebago Tribe of Nebraska Tribal 

Council .................................................................................................................. 16 

Prepared statement .......................................................................................... 18 

Onnen, Hon. Liana, Vice President, Southern Plains Region, National Congress of American Indians (NCAI) ...................................................................... 63 

Prepared statement .......................................................................................... 65 

Stier, Max, President/CEO, Partnership for Public Service ................................. 27 

Prepared statement .......................................................................................... 30 

APPENDIX

Allen, Hon. W. Ron, Chairman, Self-Governance Communication & Education 

Tribal Consortium; Tribal Chairman/CEO, Jamestown S’Klallam Tribe, prepared statement ................................................................................................... 96 

American Academy of PAs, prepared statement ................................................... 89 

Begaye, Hon. Russell, President, Navajo Nation and Jonathan Hale, Chairman, Health, Education & Human Services, Navajo Nation Council, joint 

prepared statement .............................................................................................. 102 

Cladoosby, Hon. Brian, Chairman, Swinomish Indian Tribal Community, prepared statement ................................................................................................... 123 

Danner, Robin Puanani, Chairman, Sovereign Councils of the Hawaiian 

Homeland Assembly (SCHHA), prepared statement ........................................ 116 

Page

IV 

Department of Hawaiian Home Lands, prepared statement ............................... 107 

Gundersen Health System, prepared statement ................................................... 124 

Hawaii Congressional Delegation, prepared statement ....................................... 89 

Hodson, Mike, Chairman, Board of Commissioners, Homestead Housing Authority, prepared statement ................................................................................ 111 

Navajo Housing Authority Board of Commissioners, prepared statement ......... 99 

Office of Hawaiian Affairs (OHA), prepared statement ....................................... 112 

Response to written questions submitted by Hon. Jon Tester to: 

Heidi Frechette ................................................................................................. 130 

Dr. Keith Harris ............................................................................................... 125 

United South and Eastern Tribes Sovereignty Protection Fund, prepared 

statement .............................................................................................................. 104 

United States Merit Systems Protection Board (MSPB), prepared statement ... 93 

Weston, Hon. Troy ‘‘Scott’’, President, Oglala Sioux Tribe, prepared statement ...................................................................................................................... 120 

Yazzie,Aneva J., CEO, Navajo Housing Authority, prepared statement ............ 90 

(1) 

S. 1250, S. 1275, AND S. 1333 

TUESDAY, JUNE 13, 2017 

U.S. SENATE, COMMITTEE ON INDIAN AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 2:55 p.m. in room 

628, Dirksen Senate Office Building, Hon. John Hoeven, 

Chairman of the Committee, presiding. 

OPENING STATEMENT OF HON. JOHN HOEVEN, 

U.S. SENATOR FROM NORTH DAKOTA 

The CHAIRMAN. I call the meeting to order. 

Today, the Committee will examine three bills in two panels: S. 

1250, the restoring accountability to the Indian Health Service Act 

of 2017; S. 1275, the bringing useful initiatives to Indian land development or the BUILD Act; and S. 1333, the Tribal HUD/VASH 

Act of 2017. 

Regarding Panel 1, on May 25, 2017, Senators Barrasso, Thune 

and I introduced S. 1250, the restoring accountability to the Indian 

Health Service Act of 2017. This bill is intended to increase transparency and accountability, improve patient safety and care, and 

boost recruitment and retention of employees to the IHS. 

We introduced this bill again this Congress to begin reversing 

years of poor health care delivery in some IHS facilities. A significant amount of work by the Committee with the agency, the Government Accountability Office and stakeholders, has been put into 

this bill and the predecessor bill introduced by then-Chairman 

Barrasso and Senators Thune, Rounds and McCain. 

Nearly one year ago in the last Congress on June 17, 2016, the 

Committee held a hearing on the predecessor bill, S. 2953. The Acting Deputy Secretary of the Department of Health and Human 

Services, Mary Wakefield, testified in support of some provision of 

the bill and gave suggestions on other provisions. 

The Committee favorably reported a substitute amendment to 

address the department’s issues. Those changes are also reflected 

in this bill, along with a few additional provisions. 

I look forward to hearing from our witnesses today on this bill 

as well as improvements. I join everyone on the dais, that we can 

do better in providing health care to Native communities. 

As far as Panel 2, on May 25, 2017, I introduced S. 1275, the 

BUILD Act, to reauthorize the Native American Housing and Self 

Determination Act to eliminate duplicative bureaucracy, when multiple agencies are involved in a tribal housing project, and encourVerDate Mar 15 2010 13:50 Nov 30, 2017 Jkt 027650 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 S:\DOCS\27650.TXT JACK
2 

age new forms of investment by extending leaseholds on trust or 

restricted lands from 50 years to a maximum of 99 years. 

The bill is intended to improve housing conditions within tribal 

communities by providing greater tribal control over housing development on their lands. We all know what a pressing issue housing 

is on the reservation. 

This Committee has worked for several years to reauthorize the 

Native American Housing and Self Determination Act, NAHASDA, 

and improve housing conditions for Indian people. Prior bills have 

been held up in past Congresses with substantial effort into finding 

a path forward. 

This bill has been held up in the last Congress and the Congress 

prior to that. We would like to pass it. 

As I mentioned to the National American Indian Housing Council’s Legislative Conference in February, the BUILD Act is the 

Chevy model of reauthorization. The engine of the BUILD Act is 

the reauthorization of the Indian Housing Block Grant which was 

the centerpiece of NAHASDA when it was first introduced and 

passed this body back in 1996. 

In previous versions of the NAHASDA reauthorization, there 

were over 20 different pieces of legislation included. Some of them 

are more controversial than others obviously, but some of the 

pieces included were lease requirements, program income, rental 

income caps, total development, maximum project costs, demonstration programs, limitation on use for the Cherokee Nation, 

the Native Hawaiian Block Grant and other aspects. 

Instead of just reintroducing all the past bills, I wanted to take 

a fresh look at getting a bill across the finish line. I know some of 

the members on the Committee have expressed their desire to include some of these previous positions in this bill, a different vehicle or a combination of both. 

With that, I am willing to work with any member here on finding 

a path forward. This is one of the reasons why I wanted to have 

a legislative hearing early on, as we are doing today, so we can roll 

up our sleeves and work towards finally getting these bills to the 

President’s desk, only after giving everyone opportunity for meaningful input, not only in the housing bill but the other features I 

just covered. 

On June 12, 2017, Senators Tester, Isakson, Udall and myself introduced S. 1333, the Tribal HUD/VASH Act of 2017. This bill is 

intended to improve the Housing and Urban Development and Veterans Affairs support of housing programs. 

This program combines housing and choice of voucher rental assistance for homeless tribal veterans with case management and 

clinical services provided by the Veterans Administration through 

the Veterans Administration Medical Centers. 

The bill would authorize the Department of Housing and Urban 

Development and the VA to modify program administration to facilitate the recruitment of VA case managers and create a set aside 

for rental assistance. The bill would also require the program to be 

administered in accordance with the Native American Housing Assistance and Self Determination Act, NAHASDA. It would also 

mandate IHS work cooperatively to provide assistance as requested 

by HUD or the VA in carrying out the program. 

3 

Finally, it would require review and a report by the agencies to 

be submitted to the congressional committees of jurisdiction. 

All three of these are important bills to help Indian people obtain 

critical services for health care and for housing. I look forward to 

hearing how we can best advance these measures and get them 

signed into law. 

The Native American people I think have the highest rate of 

service in our military of any group. We are talking about housing, 

health care and veterans. 

Before we turn to the witnesses, I would like to turn to the Vice 

Chairman for any comments that you may have, Senator Udall. 

STATEMENT OF HON. TOM UDALL, 

U.S. SENATOR FROM NEW MEXICO 

Senator UDALL. Thank you, Chairman Hoeven, for calling this 

legislative hearing today on S. 1250, S. 1275 and S. 1333. 

The issues presented in these bills are important to Indian Country and reflect our shared priorities on this Committee. In fact, 

each of the bills is important enough to merit its own hearing. 

S. 1250 would impose sweeping reforms on the Indian Health 

Service, S. 1275 would reauthorize certain housing programs created by the Native American Housing and Self Determination Act, 

while imposing changes to that law, training and technical assistance programs and environmental review processes; S. 1333 would 

authorize the Tribal HUD/Veterans Affairs Supported Housing Program and ensure that our Native veterans receive the housing benefits they assuredly deserve. 

These bills would have real and long-lasting impacts on Indian 

Country and deserve a thorough vetting to ensure that the final 

product reflects the meaningful consideration of Indian Country’s 

concerns. 

I encourage all stakeholders present at this hearing, as well as 

those listening online, to submit statements for the record. Your 

input matters. 

Touching briefly on S. 1250, I share the goals of achieving accountability, strengthening the workforce and improving quality of 

care at IHS. The health care crisis facing many IHS facilities in the 

Great Plains and throughout Indian Country is a concern this 

Committee takes very seriously. 

We must do more beyond tinkering with Federal employment law 

to address the need for transparency and quality assurance. We 

must also take care not to jettison well established, constitutional 

protections in the process of holding IHS leadership and staff accountable at every level. 

Let us not overlook the fact that for decades, tribal health care 

programs have been severely underfunded, which I believe has contributed greatly to the health care crisis we are in today. I look forward to working with Senator Barrasso and the Chairman to make 

sure this bill addresses IHS issues identified by all tribes and patients in an effective way. 

With regard to S. 1275, Mr. Chairman, you and I know that 

NAHASDA is critically important. The overwhelming need for adequate, safe and sanitary housing in all Native communities is well 

documented. 

4 

That is just as true for Native Hawaiian homesteads as it is for 

reservations, pueblos and Alaska Native villages. Given that understanding, I was concerned to see that S. 1275 does not include a 

reauthorization of Title 8. I will defer to my colleague, Senator 

Schatz, to explain why carving out Native Hawaiian programs from 

this bill sets a dangerous precedent for his constituents and Indian 

Country as a whole. We must do all we can to make sure 

NAHASDA is fully reauthorized for all Native American communities that rely on its housing programs. 

Turning to Senator Tester’s Tribal Veterans Housing bill, I am 

proud to join him, VA Committee Chair, Senator Isakson and 

Chairman Hoeven to sponsor this bill. It is a powerful message to 

bring together bipartisan leadership from two Senate committees 

in support of one goal, better serving Native veterans. 

S. 1333 represents all the good that can happen when members 

from both sides of the aisle listen to Indian Country and work together to advance tribal priorities. This body has a rich history of 

acknowledging that Native issues can rise above beltway party politics. Indeed, I am reminded this Committee accomplishes so much 

more when it works from the viewpoint that Indian issues are 

largely bipartisan. 

I look forward to continuing this tradition and honoring the special political and trust relationship the United States has with all 

its indigenous peoples. It is clear to me that any potential changes 

to the national policy regarding Medicaid and health insurance programs like those contained in the AHCA, will directly impact tribal 

communities and Native lives. 

For the record, I would like to urge the majority on all committees to follow regular order and to hold hearings and seek tribal 

consultation on any proposal that would cut access to life saving 

health care programs. 

With that, Mr. Chairman, I will yield back. 

The CHAIRMAN. Thank you, Senator Udall. 

I would invite any other comments at this point. 

Senator SCHATZ. Mr. Chairman? 

The CHAIRMAN. Senator Schatz. 

STATEMENT OF HON. BRIAN SCHATZ, 

U.S. SENATOR FROM HAWAII 

Senator SCHATZ. Thank you, Mr. Chairman. 

Thank you for the opportunity to talk about the impact of the 

BUILD Act. I have a few statements for the record from Native Hawaiian organizations and Native Hawaiian-serving organizations I 

would like to submit for the record. 

The CHAIRMAN. Without objection. 

Senator SCHATZ. Thank you. 

I would like to welcome leaders from the Hawaiian community 

including several members of the Office of Hawaiian Affairs in the 

audience today. They are here to represent the people who would 

suffer if the BUILD Act were to proceed. Several of them are direct 

beneficiaries. 

With us, we have Robin Danner, the Chairman of the Sovereign 

Councils of the Hawaiian Homelands Assembly; Coty-Lynne Haia, 

D.C. Bureau Chief for the Office of Hawaiian Affairs; Sheri-Ann 

5 

Daniels, Executive Director, Papa Ola Lokahi; Kawika Riley, Chief 

Advocate for the Office of Hawaiian Affairs; and Timmy Wailehua, 

Operations Manager, Office of Hawaiian Affairs, Native Hawaiian 

Revolving Loan Fund. Thank you all for being here. 

The BUILD Act is a serious departure from the way this Committee does business and breaks our longstanding tradition of bipartisanship and standing together. Just last Congress, this Committee reported out a bipartisan NAHASDA reauthorization that 

included Native Hawaiians. Even the House passed a bipartisan 

NAHASDA reauthorization that included Native Hawaiians. 

The BUILD Act is a dramatic departure from the norm. By leaving out Native Hawaiians, this bill is an attack on my State and 

my people. It dishonors the legacies of Daniel K. Inouye and Daniel 

Akaka and threatens the future work of the Committee. 

The Committee has always been a bastion of bipartisanship. For 

decades, American Indians, Alaska Natives and Native Hawaiians 

have stood together on behalf of all Native people. We have had our 

challenges on the Floor and I am sure we will continue to face 

more but we have never faced this kind of attack in Committee. 

There is a reason for that. That is because most everything that 

comes out of the Committee depends on unanimous consent on the 

Floor. That is just how we work and how we get things done. That 

solidarity is being strained and it is unfortunate in the extreme. I 

worry it is the beginning of the end of the Committee’s productivity. 

Serving Native Hawaiians is foundational to my service in the 

Senate. It is why I made Native Hawaiians the subject of my maiden speech on the Senate floor. It will be difficult to maintain the 

unanimity of this Committee’s work, the work we rely on, when my 

people are being left out. 

I strongly urge this Committee to preserve the spirit of bipartisanship by changing course and including Native Hawaiians going 

forward. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Are there other opening statements? Senator 

Murkowski. 

STATEMENT OF HON. LISA MURKOWSKI, 

U.S. SENATOR FROM ALASKA 

Senator MURKOWSKI. Thank you, Mr. Chairman. 

I must first start by thanking the Committee for moving out S. 

825, the Southeast Alaska Regional Health Consortium Land 

Transfer Act of 2017. I was not here but you did a fine job in moving that. I appreciate that. I know the people of SEARHC appreciate that as well. 

I want to thank you both for having this hearing today and focusing on some very foundational issues. As you mentioned, health 

care and housing our veterans really is so important. 

I would like to welcome Mark Charlie to the Committee today. 

Mark is Yupik. He is a member of the Native Village of Tununak. 

He serves as the present CEO of the Association of Village Council 

Presidents Regional Housing Authority in Bethel. 

As you will hear from Mark, AVCP Housing is the tribally-designated housing entity of southwest Alaska responsible for 51 

6 

tribes. His team has a pretty tough job in providing housing in a 

very remote and very, very costly area where weather can be a deciding factor if you can even build or not in any given year. 

Today, Mark is going to be providing testimony on both the 

BUILD Act and on the Tribal HUD/VASH Act. This is a long way 

to come and I appreciate his willingness to be here. I do agree very 

strongly with Mark that we must find a way to reauthorize 

NAHASDA and continue to support this very important program. 

I want to tell my colleague from Hawaii that I remain dedicated 

and willing to work with him, with other members of the Committee and members of the Senate to try to find the best route to 

do this. 

As you noted, Senator Schatz, Alaska Natives and Native Hawaiians have been allies and friends in many different areas. Sometimes it can be difficult to work through the issues but I think continued effort, conversation, dialogue and a willingness to get there 

is important. Know that I remain dedicated to do just that. I think 

this is important to Alaska Natives, to those across Indian Country 

and certainly to Native Hawaiians. 

I also want to thank you, Senator Hoeven and Senator Udall, as 

well as Senators Isakson and Tester, for the work on the Tribal 

HUD/VASH Act. It is really an important program and one I would 

hope we can all get behind. 

We have run into some challenges in Alaska in implementation, 

so I hope we will hear from President Charlie, HUD and the VA 

on how we get there as well. 

Thank you again for the hearing and I thank all the witnesses 

for coming a long way and doing a good job. 

The CHAIRMAN. Thank you, Senator Murkowski, for your comments. 

I will turn to other opening statements in a moment but I want 

to respond to both Senator Schatz, and it seems appropriate following Senator Murkowski, as you are the Chair of the Subcommittee on Interior and EPA. 

We have included in the BUILD Act the things that we felt there 

was no objection to so that we would be able to move the bill. Left 

out are things where we have had objections. I am not opposed to 

adding things if we can get enough support to move the bill. 

As I said to Senator Schatz directly, I am certainly open to working with him and finding a way to advance the bill. Not only that, 

in fact, I have offered to you, Senator Schatz, in addition to moving 

the BUILD Act, that I would work with Senator Murkowski to get 

funding for Native Hawaiians through the appropriations bill. You 

and I are both members of the Appropriations Committee. 

I understand that is not exactly what you want but I just want 

to make sure the record is clear that I am trying to be of assistance 

and trying to get this legislation passed. If there is some way to 

do it, even in a multistep process, I am trying to work on that, including approaching Senator Murkowski about getting it funded 

through the appropriations process. 

Again, I am trying to solve the challenge we face in getting legislation advanced. As Senator Murkowski said, we will keep working 

on it but the NAHASDA bill, the BUILD Act, is $650 million for 

housing in Indian Country. It includes the Native Alaskans beVerDate Mar 15 2010 13:50 Nov 30, 2017 Jkt 027650 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 S:\DOCS\27650.TXT JACK
7 

cause of the status Native Alaskans have. We have a challenge and 

that has not been done yet for Native Hawaiians. 

I understand that you may perceive it differently. All I want to 

be clear on is that I am trying to find a way to advance the housing 

legislation and that I am open to ideas that enable us to do that. 

I know Senator Hirono is here to probably have the same discussion. 

I wanted to make that a part of the record. It seems timely because Senator Murkowski has been very helpful in saying if there 

is another way to solve this challenge, she is more than willing to 

help. 

Senator MURKOWSKI. I might just note, Mr. Chairman, that your 

Ranking Member is also my Ranking Member on the Interior Appropriations Committee. 

The CHAIRMAN. I have always found him to be extremely helpful, 

so I am pretty sure he would roll up his sleeves and help as well. 

Senator Franken. 

STATEMENT OF HON. AL FRANKEN, 

U.S. SENATOR FROM MINNESOTA 

Senator FRANKEN. I would just like to associate myself with Senators Schatz and Murkowski. This covered Native Hawaiians before and I think it should do it again. I appreciate your willingness 

to work toward that end with both Senator Murkowski and Senator 

Udall. I trust that will get done. 

Thank you. 

The CHAIRMAN. Other opening statements? 

Senator HIRONO. Mr. Chairman? 

The CHAIRMAN. Senator Hirono. 

STATEMENT OF HON. MAZIE K. HIRONO, 

U.S. SENATOR FROM HAWAII 

Senator HIRONO. Thank you very much. 

I am not a member of this Committee. Thank you so much for 

allowing me the opportunity. 

This Committee holds important jurisdiction over matters involving indigenous people. I am here to speak against S. 1275 in its 

current form. Our indigenous peoples are the American Indians, 

Alaska Natives and Native Hawaiians. These are our original peoples. 

As members of this Committee, you are aware of the experiences 

and challenges of Native peoples, including the history of decimation and prolonged subjugation by the Federal Government. This 

history is one of the reasons the Federal Government has enacted 

laws intended to help our indigenous peoples and recognize our 

government’s trust responsibilities to them. 

While I am not a member of this Committee, I am here because 

the matters you are discussing today are very important for the 

Native Hawaiian community. I am here to share my serious concerns over the decision to exclude Native Hawaiian housing programs in S. 1275, the Bringing Useful Initiatives for Indian Land 

Development Act, also known as the BUILD Act. 

As this legislative vehicle to reauthorize the Native American 

Housing Assistance and Self Determination Act, also known as 

8 

NAHASDA, the BUILD Act is an opportunity to support all Native 

communities. 

The BUILD Act, however, strips out Title 8, which includes the 

Native Hawaiian Housing Block Grant and 184(a), Native Hawaiian Home Loan Guarantee Programs. By omitting Native Hawaiian 

housing programs, the BUILD Act strikes a blow not only to the 

37,000 Native Hawaiians who could directly benefit from their inclusion, but also strikes a blow to the over 500,000 Native Hawaiians in our Country. 

This is about much more than just stripping out Native Hawaiian housing programs from a bill. At a time when we see us 

against them perspectives rising in our Country, we cannot allow 

divide and conquer tactics to undermine collaborative efforts to 

bring people together. 

Sadly, intended or not, the BUILD Act is an example of dividing 

Native peoples. This bill threatens strong alliances and partnerships Native communities have forged over decades. I understand 

suggestions have been made to Native tribes that supporting Native Hawaiian programs may jeopardize funding for their own programs. 

I strongly oppose those suggestions and I believe that dividing 

Native communities is, frankly, unconscionable. The history of our 

government’s treatment of Native peoples is not a proud one. For 

Native Hawaiians, this includes illegal overthrow of the Hawaiian 

monarchy in 1893. 

Today, Native Hawaiians, like other Native peoples across the 

Country, continue to face high levels of poverty, lower educational 

attainment, and lack of affordable housing. For those who do not 

recognize Native Hawaiians as an indigenous people or oppose Native Hawaiian programs, I would ask that you learn more about 

their history and experiences. 

Today’s hearing would have been an excellent opportunity for 

members of this Committee to learn more about Native Hawaiians, 

their history, and how Federal housing programs have made a real 

difference in their lives. Unfortunately, no Native Hawaiians or 

Native Hawaiian organizations were invited to testify on the 

BUILD Act, but they are here. They are sitting in the audience; 

they are watching; and they are listening. 

Many of you on the Committee are long-time advocates for indigenous peoples. You are aware of their history and why Congress 

enacted programs that promote better health, quality education, 

and access to housing for their communities, programs that provide 

opportunities for growth and sustained strength. 

Without these programs, the progress made in their communities 

would have been harder and taken longer to achieve. That is why 

reauthorization of NAHASDA, including Native Hawaiian housing 

programs, is so important. 

All of our Native people, American Indians, Alaska Natives and 

Native Hawaiians, should be treated with equal respect. That certainly extends to supporting programs that benefit all our Native 

peoples and communities. 

For these reasons, I ask this Committee to restore reauthorization for Native Hawaiian housing programs in NAHASDA. I ask 

9 

you to do the right thing and welcome the opportunity to work with 

you to find a path forward. 

I would also like to submit a longer statement for the record on 

behalf of the Hawaiian Congressional Delegation signed by Senators Schatz and myself and Representatives Hanabusa and 

Gabbard in opposition to the BUILD Act in its current form. 

Mr. Chairman, I do thank you for your openness in going forward so that our Native peoples can be treated with the respect 

they deserve. 

The CHAIRMAN. Thank you, Senator Hirono. 

Again, I want to make clear that I am not holding it up. If we 

pass the bill out with it in, my expectation is, unless we can figure 

out something, we will end up with the same result we have had 

the last two Congresses, that we will move the bill out of Committee and that will be it. 

We were not able to move it across the floor in the last Congress 

or the Congress before, so I am trying to find a solution. We have 

not precluded not including it in the bill, we just have to find a way 

to move it forward or we are just going to move it out of Committee. 

I am very sensitive to Senator Schatz’s talking about the bipartisanship of this Committee. I think that is very important. I want 

to do everything I can to preserve it, but we are confronted with 

the situation of having either a bill we can move out of Committee 

with the provision in but we cannot move across the floor or putting the provision in the bill in Committee but then we have to 

somehow figure out how we can advance it. 

That is why I offered the appropriations process but I am open 

to other ideas. Obviously, this is a work in progress. We are looking 

for solutions. Whoever has a great solution, as Ross Perot used to 

say, I am all ears. 

Senator Heitkamp. 

STATEMENT OF HON. HEIDI HEITKAMP, 

U.S. SENATOR FROM NORTH DAKOTA 

Senator HEITKAMP. Mr. Chairman, thank you. 

I know the motivation here is to get a bill and to get a housing 

program and move it forward. 

Ben Franklin once famously said, ‘‘If we don’t all hang together, 

surely we will hang separately.’’ I think NAHASDA and the Native 

Hawaiian provision has been a long history of weaving together a 

compromise. When we start pulling it apart, I can assure my good 

friends, Senator Hirono and Senator Schatz, will provide equal resistance to what we have seen in the last two Congresses if we exclude Native Hawaiians. We are between a rock and a hard place. 

I surely will do everything that I can. I think one of the most 

critical challenges we face in Indian Country, especially in our neck 

of the woods, is housing and the lack of affordable, quality, good 

housing. We should all be working together to prevent these problems in the future. 

Thank you, Mr. Chairman. 

The CHAIRMAN. That is it exactly, because we are talking about 

reauthorizing $650 million for housing in Indian Country. It is 

10 

something we want to move. Figuring out how to do it is very important. 

Senator CORTEZ MASTO. Mr. Chairman, if I may? 

The CHAIRMAN. Senator Cortez Masto. 

STATEMENT OF HON. CATHERINE CORTEZ MASTO, 

U.S. SENATOR FROM NEVADA 

Senator CORTEZ MASTO. Thank you. 

I appreciate the conversation and bipartisanship here. As a new 

member, you may not realize that although I represent Nevada, a 

desert State, believe it or not, Nevada is home to the largest number of Hawaiians in the Country outside of Hawaii. This is an important issue for my constituents and something I will be advocating for as well. 

I appreciate the opportunity to work with you to address the 

housing needs of my constituents in Nevada. 

The CHAIRMAN. Senator, are you saying that Hawaiians are coming to Nevada rather than Nevadans going to Hawaii? Is that what 

I heard you say? 

Senator CORTEZ MASTO. Absolutely correct. There are a good 

number of them coming into southern Nevada, so much so that 

when Senator Schatz comes to Las Vegas, they recognize him more 

so than I think in his State. Yes, this is an important issue, I believe, for so many reasons. I look forward to the opportunity to 

work with you. 

Thank you. 

The CHAIRMAN. Senator Schatz. 

Senator SCHATZ. Thank you, Mr. Chairman. I will be really brief. 

I appreciate the conversation and the goodwill here. 

What Senator Heitkamp said is really exactly right which is that 

what we are doing here is trying to accommodate the fact that we 

cannot get cloture or we are not going to be able to get unanimous 

consent, because there will be members who will oppose NAHASDA 

on the basis of it including Native Hawaiians. 

I think it is really clear that you are not going to get unanimous 

consent for this bill on the basis of it not including Native Hawaiians. The solution, on the floor, is to get cloture. The way to get 

cloture is for us to work together on a bipartisan basis and get to 

60. 

I will just add that because of the unique time we are in, normally the primary commodity in the Senate is Floor time, but the 

cupboard is bare. There is not a lot of legislation flying off the 

shelf. We are cooking up votes to come up with for Mondays and 

Wednesdays, a lot of assistant secretaries and a lot of judgeships 

that are going 93 to 5 and such. 

We actually, I think, have a pathway to get floor time for this. 

I know it will be an effort to get to 60, but with your support and 

Senator Murkowski, and I hope for Senator Sullivan and others 

support, we might be able to get to 60. 

The solution is not to accommodate one person’s filibuster and 

force the other side to filibuster. I think we are between a rock and 

a hard place. The only solution is cloture. I think we can do it. 

The CHAIRMAN. I appreciate that. Again, we have not in the last 

two Congresses, but I am not ruling out any options at this point. 

11 

We will keep working. Again, that is part of the reason we are having the early hearing so that we have more time to work on it. 

Senator Barrasso. 

STATEMENT OF HON. JOHN BARRASSO, 

U.S. SENATOR FROM WYOMING 

Senator BARRASSO. Thank you very much, Mr. Chairman. 

I appreciate your holding this hearing today to consider legislation on a number of topics, none more important than tribal health 

care. 

For decades, the Indian Health Service has failed to deliver even 

basic standards of care. In 2010, former Chairman Dorgan began 

an investigation that resulted in the infamous and often cited Dorgan Report. 

The issue of the Indian Health Service revealed widespread staffing issues, expired medical credentials, and we heard about exceptionally poor delivery of the services. These issues, reported more 

than seven years ago, still exist within the Indian Health Service. 

During my time as chairman of this Committee, we all spent a 

great deal of time working on issues related to the quality of care 

at the Indian Health Service. As both a doctor and a Senator, I find 

the level of dysfunction completely unacceptable. 

Not only does the United States Government have a trust responsibility that they much fulfill, but failures of the Indian Health 

Service should never result in the loss of life. Yet, stories of unnecessary patient deaths have dominated Indian Health Service oversight hearings for years. 

Ms. Kitcheyan, I appreciated hearing your story when you testified before this Committee last year. I appreciate you traveling 

here to be with us again today. Your story and those like it make 

it obvious why I joined with Senators Hoeven and Thune in introducing the bill before us today. Restoring accountability in the Indian Health Service is not just the name of the legislation, but also 

the goal of this Committee, in a bipartisan way, in any action we 

take related to health care. 

The bill addresses recruitment and retention of high quality 

staff. It addresses shortcomings in the process to remove problem 

staff, requires improvement of metrics that will measure Health 

Service delivery, and makes significant changes to credentialing to 

allow for better, faster patient treatment. 

Chairman Hoeven, I appreciate the leadership you and Senator 

Thune have shown on this issue over the years. The bill and the 

care it seeks to improve have real implications for daily life in Indian Country. 

Though there is no silver bullet, the need is clear. Across the 

Country, across the Country, interest in improving the Indian 

Health Service has led to countless comments on the bill so far, in 

addition to those we are here to receive today. 

I see suggestions for additional ways to address the many shortcomings at the agency and they continue to arrive. I look forward 

to working with you, the witnesses, and the Administration to advance meaningful change. 

Again, thank you, Senator Hoeven. Thank you to the witnesses 

for traveling to be with us today. 

12 

The CHAIRMAN. Thank you, Senator Barrasso. 

Thank you for your work both as the former chairman of this 

Committee and also as a physician on this important issue and 

your commitment, which I think is such a huge priority, to 

strengthen IHS and provide better health care services throughout 

Indian Country. 

We have our first panel and will now ask for their testimony. 

Ranking Member, did you have anything else before we go to testimony? 

Senator UDALL. No.‘ 

The CHAIRMAN. We will go to testimony. 

I want to welcome all of you. We have with us Rear Admiral 

Chris Buchanan, Acting Director, Indian Health Service, U.S. Department of Health and Human Services; the Honorable Victoria 

Kitcheyan, Tribal Council Treasurer, Winnebago Tribe of Nebraska; Dr. Joseph P. Crowley, President-Elect, American Dental 

Association; and Max Stier, President, Partnership for Public Service. 

Thanks to all of you for being here. Admiral, why don’t you start? 

STATEMENT OF REAR ADMIRAL CHRIS BUCHANAN, ACTING 

DIRECTOR, INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF 

HEALTH AND HUMAN SERVICES 

Mr. BUCHANAN. Good afternoon, Chairman Hoeven, Vice Chairman Udall, and members of the Committee. 

I am Chris Buchanan, an enrolled member of the Seminole Nation of Oklahoma. I am the Acting Director of the Indian Health 

Service. I am pleased to be here and have the opportunity to testify 

before the Senate Committee on Indian Affairs on S. 1250, the Restoring Accountability in the Indian Health Service Act of 2017. 

The mission of IHS, in partnership with American Indians and 

Alaska Natives, is to raise the physical, mental, social and spiritual 

health of American Indians and Alaska Natives to the highest 

level. Providing quality health care is our highest priority. We 

share the urgency of addressing longstanding, systemic problems 

that hamper our ability to fully carryout the IHS mission. 

In November 2016, we launched our Quality Framework and Implementation Plan to strengthen the quality of care that IHS delivers to patients we serve. Since November 2016, IHS has made substantial progress in implementing the Quality Framework and addressing many of the challenges you have identified in your proposed legislation. 

The Quality Framework guides how we develop, implement and 

sustain an effective quality program that improves patient experiences and outcomes. We are doing this by strengthening the organizational capacity and ensuring the delivery of reliable, high quality health care at IHS direct service facilities. 

The new IHS credentialing system will streamline credentialing 

and facilitate the hiring of qualified practitioners, as well as privileging and performance evaluation of IHS practitioners. It will 

allow the local and area offices to perform these functions in alignment with the Centers for Medicare and Medicaid Services’ conditions of participation and accreditation standards for governance of 

hospitals and ambulatory care facilities. 

13 

We will pilot in four IHS areas in July 2017 and implement it 

across the remaining IHS areas by the end of 2017. 

Ensuring timely access to care requires that we develop standards for wait times for appointments, as well as for time spent in 

the provider’s offices and that we benchmark against clear standards. 

Agency-wide standards for wait times are also in development to 

ensure accountability at the highest level. To improve transparency 

and access to quality of care, IHS is implementing a performance 

accountability dashboard. This includes reporting on patient wait 

times, pilot testing of dashboards and associated data collection is 

targeted for this summer. 

Strengthening governance and leadership at all levels of IHS is 

essential to ensure quality health care. IHS now requires a standardized governance process and use of a standard governing board 

agenda across all IHS areas with federally-operated facilities. 

The first leadership training class to prepare selected individuals 

to serve in leadership positions at the service unit area and headquarters levels was launched on June 6 with 34 participants. 

IHS faces significant recruitment challenges due to remote, rural 

locations of our health care facilities and area offices. IHS is implementing various strategies to increase recruitment and retention. 

Global recruitment is one strategy we have implemented for a 

streamlined approach to filling critical provider vacancies at multiple locations. 

Applicants only need to apply at a single vacancy announcement 

and can be considered for multiple positions throughout the Country. Recruiting for critical positions by using a single announcement to recruit for multiple positions is showing promise. Now, 

IHS has priority access to new commissioned Corps applicants. 

This allows IHS to make first contact with these applicants in an 

effort to recruit and fill health professional vacancies throughout 

IHS. 

Also, IHS facilities can use the National Health Services Corps’ 

scholarship and loan repayment incentive to recruit and retain primary care providers. As of April 2017, 472 NHSC recipients are 

currently part of our workforce serving in IHS, tribal and urban facilities. 

These actions demonstrate that IHS is taking its challenges seriously and is continuing to take assertive and proactive steps to address them. IHS is prepared to provide technical assistance on specific authorities proposed in S. 1250. 

Despite all of the challenges, I am firmly committed to improving 

quality, safety and access to health care for American Indians and 

Alaska Natives in collaboration with HHS, our partners across Indian Country and Congress. We look forward to working with the 

Committee on this legislation as it moves through the legislative 

process. 

I am happy to answer any questions the Committee may have. 

Thank you. 

[The prepared statement of Mr. Buchanan follows:] 

14 

PREPARED STATEMENT OF REAR ADMIRAL CHRIS BUCHANAN, ACTING DIRECTOR, 

INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Mr. Chairman and Members of the Committee: 

Good afternoon, Chairman Hoeven, Vice-Chairman Udall, and Members of the 

Committee. I am Chris Buchanan, an enrolled member of the Seminole Nation of 

Oklahoma and Acting Director of the Indian Health Service (IHS). I am pleased to 

have the opportunity to testify before the Senate Committee on Indian Affairs on 

S. 1250, the Restoring Accountability in the Indian Health Service Act of 2017. I 

would like to thank you, Chairman Hoeven, Vice-Chairman Udall, and Members of 

the Committee for elevating the importance of delivering quality care through the 

IHS. 

IHS plays a unique role in the Department of Health and Human Services (HHS) 

because it was established to carry out the responsibilities, authorities, and functions of the United States to provide healthcare services to American Indians and 

Alaska Natives. The mission of IHS, in partnership with American Indian and Alaska Native people, is to raise the physical, mental, social, and spiritual health of 

American Indians and Alaska Natives to the highest level. IHS provides comprehensive healthcare delivery to approximately 2.2 million American Indians and Alaska 

Natives through 26 hospitals, 59 health centers, 32 health stations, and nine school 

health centers. Tribes also provide healthcare access through an additional 19 hospitals, 284 health centers, 163 Alaska Village Clinics, 79 health stations, and eight 

school health centers. 

Providing quality healthcare is our highest priority. We share the urgency of addressing longstanding systemic problems that hamper our ability to fully carry out 

the IHS mission. In November 2016, we launched our 2016–2017 Quality Framework and Implementation Plan to strengthen the quality of care that IHS delivers 

to the patients we serve. Implementation of the Quality Framework is intended to 

strengthen organizational capacity to improve quality of care, improve our ability 

to meet and maintain accreditation for IHS direct service facilities, align service delivery processes to improve the patient experience, ensure patient safety, and improve processes and strengthen communications for early identification of risks. The 

Quality Framework will be reviewed and updated at least annually in partnership 

with Tribes. 

The HHS Executive Council on Quality Care (the Council), which was stood up 

in November 2016, provides support to IHS by identifying and facilitating collaborative, action-oriented approaches from across the Department to address issues 

that affect the quality of healthcare provided to American Indians and Alaska Natives we serve. The Council includes leadership from 12 HHS Staff and Operating 

Divisions. The Council’s mission is to support IHS’ efforts to develop, enact, and sustain an effective quality program—to improve quality and patient safety in the hospitals and clinics that IHS administers. This may include providing technical assistance to bolster quality and safety, identifying solutions to address workforce recruitment and retention challenges, seeking creative solutions to infrastructure needs, 

and enhancing stakeholder engagement. The Council partners with HHS leadership 

and staff in policy implementation. 

Since November, 2016, IHS has made substantial progress in implementing the 

Quality Framework and in addressing many of the challenges you have identified 

in your proposed legislation. 

Strengthening Organizational Capacity 

The Quality Framework guides how we develop, implement, and sustain an effective quality program that improves patient experience and outcomes. We are doing 

this by strengthening our organizational capacity, and ensuring the delivery of reliable, high quality healthcare at IHS direct service facilities. 

We recently awarded a contract for credentialing software that will provide enhanced capabilities and standardize the credentialing process across IHS. The new 

system will streamline credentialing and facilitate the hiring of qualified practitioners as well as, privileging and performance evaluations of IHS practitioners. 

This will help ensure the quality and safety of care delivered in IHS Federal Government hospitals and health centers. We are on course with the implementation 

of this medical credentialing system. We expect to test it in four IHS Areas in July 

2017, and plan to implement it across the remaining IHS Areas by the end of 2017. 

Our agency credentialing policy is in the process of being updated. 

Ensuring timely access to care requires that we develop standards for waiting 

times for appointments, as well as for the time spent in the provider’s office, and 

that we benchmark against clear standards. IHS Service Units currently collect patient wait time data to track the patient care experience as part of the Improving 

15 

Patient Care program. Agency-wide standards for wait times are also in development. To ensure accountability at the highest level, and to improve transparency 

about access to and quality of care, IHS is implementing a performance accountability dashboard. This includes reporting on patient wait times. Pilot testing of the 

dashboard and associated data collection is targeted for this summer. 

Strengthening governance and leadership at all levels of the IHS system is essential to assuring quality healthcare. IHS now requires a standardized governance 

process and use of a standard governing board agenda across all IHS Areas with 

federally-operated facilities. The first leadership training class to prepare selected 

individuals to serve in leadership positions at the Service unit, Area, and Headquarters levels was launched June 6th with 34 participants. In addition, IHS has 

begun implementing a leadership coaching and mentoring program in the Great 

Plains Area as new leaders are recruited. 

Workforce Strategies 

IHS faces significant recruitment challenges due to the remote, rural location of 

our healthcare facilities and Area offices. To make a career in IHS more attractive 

to modern healthcare practitioners, IHS is implementing various strategies to increase recruitment and retention. Global recruitment is one strategy we have implemented that allows for a streamlined approach to filling critical provider vacancies 

at multiple locations. Applicants only need to apply to a single vacancy announcement and can be considered for multiple positions throughout the country. Recruiting for critical positions by using a single announcement to recruit for multiple positions is showing promise. 

IHS continues the successful partnership with the Office of the Surgeon General 

to increase the recruitment and retention of Commissioned Corps officers, and most 

recently the IHS has been given priority access to new Commissioned Corps applicants. This allows IHS to make the first contact with these applicants in an effort 

to recruit them to fill health professional vacancies throughout IHS. This new effort 

began in May, and we can provide periodic updates on this effort. IHS also continues to partner with the National Health Service Corps (NHSC). Use of NHSC allows IHS facilities to recruit and retain primary care providers by using NHSC 

scholarship and loan repayment incentives. As of April 2017, 472 NHSC recipients 

are currently part of our workforce serving in IHS, tribal and urban facilities. 

These actions demonstrate that IHS is taking its challenges seriously, and is continuing to take assertive and proactive steps to address them. 

S. 1250 

S. 1250 proposes specific authorities to aid us in elevating the health of American 

Indians and Alaska Natives to the highest level. IHS is prepared to provide the 

Committee technical assistance on the legislation and I would like to provide additional technical comments on various sections of the bill. 

Section 101 would address the need for IHS to offer more flexible and competitive 

benefits to recruit employees by establishing a comparable pay system as allowed 

under Chapter 74 of Title 38. IHS appreciates the authority we already have to use 

the pay flexibilities under Chapter 74 of Title 38. We are working with OPM, OMB, 

and other affected agencies to explore ways to enhance utilization of our current pay 

authorities to enhance our ability to recruit and retain high quality staff. 

Section 102 requires a Service-wide centralized credentialing system to credential 

licensed health professionals who seek to provide healthcare services at any Service 

facility. IHS supports the use of a standard system for credentialing. We are implementing a national system for credentialing as well as privileging and evaluating 

performance of IHS practitioners. Our new system will allow the local and/or Area 

offices to perform these functions in alignment with the Centers for Medicare & 

Medicaid Services (CMS) Conditions of Participation and external accreditation 

standards for governance of hospitals and ambulatory care facilities. 

Section 104 would make certain healthcare management or healthcare executive 

positions eligible professions for loan repayment awards, in exchange for non-clinical 

service obligations. Management expertise is very important in a health system as 

large as IHS. 

Section 106 addresses IHS authority to remove or demote employees. IHS has existing authorities to implement adverse employment actions. 

Section 107 requires IHS to develop and implement standards to measure the 

timeliness of care at direct-service IHS facilities. As described above, IHS is in the 

process of establishing agency-wide standards for wait times to each federally-operated service unit. A process for uniform data collection and reporting is also being 

established. 

16 

Section 108 adds specific requirements for implementation of annual mandatory 

cultural competency training programs for IHS employees, and other contracted employees engaged in direct patient care. Cultural competency in the IHS workforce 

is essential to the provision of quality care and is a requirement under the accreditation standards for hospitals. I have recently issued direction for all IHS employees 

to complete training, which will become an annual requirement. 

Section 110 requires IHS to establish a tribal consultation policy. The specific provision is unnecessary as IHS already has a tribal consultation policy in place. The 

requirements for consultation are contained in statutes and various Presidential Executive orders including: the Indian Self-Determination and Education Assistance 

Act, Indian Health Care Improvement Act, Presidential Memoranda in 1994 and 

2004, and Executive Orders in 1998 and 2000. It is the policy of HHS and IHS that 

consultation with American Indian and Alaska Native Tribes will occur to the extent practicable and permitted by law before any action is taken that will significantly affect Indian Tribes. IHS is committed to regular and meaningful tribal consultation and collaboration as an essential element for a sound and productive relationship with Tribes. 

Despite all of the challenges, I am firmly committed to improving quality, safety, 

and access to healthcare for American Indians and Alaska Natives, in collaboration 

with HHS, our partners across Indian Country, and Congress. I appreciate all your 

efforts in helping us provide the best possible healthcare services to the people we 

serve to ensure a healthier future for all American Indians and Alaska Natives. 

We look forward to working with the Committee on this legislation as it moves 

through the legislative process. Thank you for your commitment to improving quality, safety, and access to healthcare for American Indians and Alaska Natives. I am 

happy to answer any questions the Committee may have. 

The CHAIRMAN. Thank you, Admiral. 

Ms. Kitcheyan. 

STATEMENT OF HON. VICTORIA KITCHEYAN, TREASURER, 

WINNEBAGO TRIBE OF NEBRASKA TRIBAL COUNCIL 

Ms. KITCHEYAN. Good afternoon, Chairman Hoeven and Vice 

Chairman Udall. 

Thank you for the opportunity to testify today on S. 1250, the 

Restoring Accountability in the Indian Health Service Act. 

My name is Victoria Kitcheyan. I am a member of the Winnebago Tribe of Nebraska where I serve as Tribal Council Treasurer. 

I am also the Great Plains Area Rep to the National Indian Health 

Board. I will be making some national level comments on NIHB as 

well. 

The Winnebago Tribe and national Tribal advocates support the 

efforts of Congress to address the ongoing challenges for health delivery at the IHS-operated facilities. Legislative efforts to address 

these issues should be conducted in conjunction with the tribes. Increased oversight and scrutiny are essential to improving the service unit care. 

Essentially, we need to get this right. We are at a point where 

our people need help. Some of the quality care issues in the Great 

Plains and my tribe cannot be overlooked any further. It is important that we garner the voice of Indian Country and that we all 

have input on this legislation. The best outcome can only be derived from the tribes. 

We look forward to working with Indian Country in the coming 

months and weeks on how we can further have legislative consultation on this bill because it is going to affect all of us. We want to 

make sure that is a part of this process. 

I have shared in previous testimony with this Committee that 

the IHS hospital on my reservation has demonstrated deficiencies 

17 

back to 2007. These deficiencies were so numerous, egregious and 

life threatening that in 2015, we lost our CMS certification. Two 

years later, we are still without that certification. 

Month after month this decertification is delayed due to lack of 

resources, key staff vacancies, and the lack of CMS-generated third 

party revenue is an additional strain on the service unit. In addition to the staffing challenges, this has kept the facility in dire constraint. 

It is important that the leadership roles be filled with qualified, 

permanent providers so that we can continue to offer the services 

the tribes need. It is this dedicated staff that we need to be committed to making these improvements that have been identified. 

It is this rolling of administrators and recycled employees from 

other Great Plains service units that are, in our opinion, dumped 

on one of the most dire service units. It is the unacceptable level 

of administration and this revolving door that has left area hospitals in the Great Plains continuing to suffer. The resources and 

continuity of leadership has been a problem. 

Given this critical state, we are much appreciative of this Committee taking the action to introduce S. 1250. However, there are 

a few items in this legislation that I want to address and make 

sure it works for everyone in Indian Country. 

As I mentioned before, the legislation should not be enacted 

without the proper consultation of all of Indian Country. This legislation is going to affect everyone, so we want everyone’s voice to 

be a part of this. This is particularly important as a National Indian Health Board representative. We do not want to take down 

any other tribe in our path of turmoil. That is important to me as 

a rep and as a member of NIHB. 

Also, there are provisions in the bill that address new programs 

and functions in IHS. Although these would be beneficial, we need 

adequate oversight and funding to make these beneficial. We want 

to make sure that this is not just a program that becomes an unfunded mandate. 

This is very much true in the Indian Health Care Improvement 

Act which was implemented seven years ago and has yet to be fully 

funded. We do not want to make this another broken promise to 

Indian Country. We want this to be funded and be a real commitment to improving the health care. 

The Winnebago Tribe and NIHB also support the intent to make 

a streamlined system for licensed health care professionals, 

credentialing procedures, including volunteers. However, I want to 

note this is not the substitute or final step in increasing available, 

permanent, full-time providers in IHS and throughout Indian 

Country. 

Tribes in some areas have already come up with some very creative and innovative solutions to address this problem. We would 

like to replicate that model throughout Indian Country. We hope 

to discuss that more in the future and develop some creative solutions together. 

When it comes to hiring authorities outlined in the legislation, 

NIHB and the Winnebago are happy to see there is some streamlining of Federal hiring authority, but we believe this section needs 

18 

more tribal input, especially when it comes to waiving Indian preference. 

Tribes need to have important input on that so that it becomes 

a tool and not so much the norm to Indian preference. More details 

are outlined in the testimony. 

Section 10 establishes rules regarding a tribal consultation policy. We are in complete agreement that a consultation policy should 

exist and that Tribes should have input into ways that will provide 

community input. 

If this had been done earlier, I think some of our issues at the 

local level may not have reached the levels they have. 

We strongly agree with increasing fiscal accountability measures 

in the bill. We hope we can modify the language, especially around 

third party revenue so that we can include the community input 

on where those monies should go. We should have access to that 

in the programs we know we need the most. 

Finally, we are glad to see the reporting requirements but we 

would also like to see those done in the purchased and referred 

care so that we can assure the quality through that process as well. 

Overall, this legislation is important and necessary. We thank 

this Committee for their genuine interest in being a partner to the 

tribes so that we can address the transparency, accountability, recruitment and management. All these continue to be a problem. 

I would like to plead with you that we cannot continue to starve 

the system and expect a different result. 

I thank you for this time. I am happy to answer any questions. 

[The prepared statement of Ms. Kitcheyan follows:] 

PREPARED STATEMENT OF HON. VICTORIA KITCHEYAN, TREASURER, WINNEBAGO

TRIBE OF NEBRASKA TRIBAL COUNCIL

Good afternoon Mr. Chairman and Members of the Committee: 

Thank you for holding this hearing on this very important piece of legislation. My 

name is Victoria Kitcheyan. I am a member of the Winnebago Tribe of Nebraska 

and I currently serve as Treasurer of the Winnebago Tribal Council. I also serve 

as the Great Plains Area Representative of the National Indian Health Board and 

will offer national-level comments on behalf of NIHB as well. The National Indian 

Health Board serves all 567 federally-recognized Tribal nations when it comes to 

health. This means we serve both tribes who receive care directly from the Indian 

Health Service and those who operate their health systems through self-governance 

compacts and contracts. 

The Federal Government has a duty, agreed to long ago and reaffirmed many 

times by all three branches of government, to provide healthcare to Tribes and their 

members throughout the country. Yet, the federal government has never lived up 

to that trust responsibility to provide adequate health services to our nation’s indigenous peoples. Historical trauma, poverty, lack of access to healthy foods, loss of culture and many other social, economic and environmental determinants of health as 

well as lack of a developed public health infrastructure in Indian Country all contribute to the poor state of American Indian and Alaska Native (AI/AN) health. AI/ 

ANs suffer some of the worst health disparities of all Americans. We live 4.5 years 

less than other Americans. In some states, life expectancy is 20 years less, and in 

some counties, the disparity is even more severe. With these statistics, it is unconscionable that some IHS-operated facilities continue to deliver a poor quality of care 

to our people. 

The Winnebago Tribe and national Tribal advocates support the efforts of Congress to address the ongoing challenges for health delivery at the IHS-operated facilities. We appreciate the commitment of the Senate Committee on Indian Affairs 

to find real change. Legislative efforts to address these issues should be conducted 

in tandem with increased oversight and scrutiny over the administration of the delivery of care at service units operated by the Indian Health Service. The legal curVerDate Mar 15 2010 13:50 Nov 30, 2017 Jkt 027650 PO 00000 Frm 00022 Fmt 6633 Sfmt 6621 S:\DOCS\27650.TXT JACK
19 

rent framework for IHS provides much of the necessary guidelines for the operation 

of the agency. 

While we appreciate the speed at which the Senate is considering the legislation 

given the critical situation going on in the Great Plains region, we need to make 

sure we get this right. It is true, our people need help. Some of the quality of care 

issues found at my Tribe and elsewhere in the Great Plains region cannot go on any 

longer. However, it is also important that these changes are accompanied by input 

from tribes across the country to ensure the best possible outcome and product. We 

think legislation is needed and would have appreciated an opportunity for the Winnebago Tribe and other tribes across the county to review any draft legislative language before S. 1250 was introduced. NIHB is ready and willing to lead a legislative 

consultation on this bill and we intend to do so in throughout the coming weeks and 

months. This step must happen first before anything can be enacted. 

Winnebago IHS Hospital 

For those of you that may not know, the Winnebago Tribe is located in rural 

northeast Nebraska. The Tribe is served by a thirteen (13) bed Indian Health Service operated hospital, clinic and emergency room located on our Reservation. This 

hospital provides services to members of the Winnebago, Omaha, Ponca and Santee 

Sioux Tribes. It also provides services to a number of people from other tribes who 

reside in the area. Collectively, the hospital has a service population of approximately 10,000 people. 

As I have shared in previous testimony before this Committee, since at least 2007 

the Winnebago IHS Hospital has been operating with demonstrated deficiencies 

which should not exist at any hospital in the United States. The Centers for Medicare and Medicaid Services (CMS) deficiencies were so numerous and so life-threatening that in July 2015 the IHS Hospital in Winnebago became what still is, to the 

best of our knowledge, the only federally operated hospital ever to lose its CMS certification. Other IHS facilities in the Great Plains Region have been experiencing 

similar quality of care issues throughout this time and are also under threat of decertification by CMS. 

Nearly two years have passed since the Winnebago Hospital lost its certification 

and IHS has yet to submit the application to CMS for recertification. Initially, the 

target date to apply for recertification was scheduled for October 2015. Since then, 

the date for submitting the application has been repeatedly delayed. It is an extremely frustrating situation and it is unacceptable that such a bad situation should 

take so long to correct. While the staff at the facility have been working hard to 

prepare for recertification and corrective action plans have been implemented, including multiple mock surveys, staff training and necessary policy changes, the fact 

remains that the facility continues to lack critical resources necessary to move forward. 

Senior officials at IHS have said that recertification at Winnebago is a top priority, but for some reason the practical resources to achieve this have not reached 

the ground level. The inability to generate necessary revenue from all third party 

sources has caused serious budget issues. The financial constraints in addition to 

staffing challenges have kept the facility in a dire situation. The Hospital Governing 

Body finally decided last month that the Hospital was ready for recertification. 

However, the application has not been submitted due to key staff vacancies including the CEO, Director of Nursing and Lab Supervisor. The fact that these vital positions are vacant is a huge indicator that the hospital is not adequately staffed to 

be ready for CMS review. 

Many of the situations that led to the Hospital losing its certification in the first 

place have also played a role in the delay to submit the application for recertification. For example, the Great Plains Region has operated under an Acting Regional 

Director for nearly one and a half years. At Winnebago, the hospital also operated 

with a series of Acting CEO’s until a permanent hire was made approximately 6 

months ago. Both the Omaha and Winnebago Tribes have been very pleased with 

the progress he has made at the facility. Unfortunately, due to personal reasons, 

he is now resigning as the CEO and the position will be vacant once again later 

this month. 

These important leadership roles need to be filled by permanent, qualified and 

dedicated employees who have a vested interest making improvements. There have 

been instances where the IHS has continued to hire key personnel without any 

input from the Tribe and/or ‘‘recycled’’ employees who were found to be unacceptable 

at other IHS hospitals in the Great Plains Region. A multi-million dollar staffing 

contract was awarded to a company previously used by IHS that had placed unsatisfactory employees in many of the Great Plains IHS hospitals. Finally, the federal 

hiring freeze implemented earlier this year caused great delays in filling critical poVerDate Mar 15 2010 13:50 Nov 30, 2017 Jkt 027650 PO 00000 Frm 00023 Fmt 6633 Sfmt 6621 S:\DOCS\27650.TXT JACK
20 

sitions. While waivers were eventually obtained for many positions, it is our understanding that some positions necessary for CMS certification remain under a freeze 

status. The hiring freeze is detrimental to the needs of our tribal members and others who rely on IHS for their healthcare. 

Many missteps could have been avoided by getting input from the Tribes and actually acting on that input. The Governing Body for the Winnebago Hospital was 

basically non-functional around the time of the loss of the CMS Certification. Although the Governing Body appears to be meeting more often, the tribal representatives have since lost their seats on the Governing Body since IHS deemed that the 

non-IHS members (Tribal Council representatives from the Winnebago Tribe and 

the Omaha Tribe) have no oversight over IHS and therefore should not be on the 

Board. This is ridiculous and counter-intuitive. Perhaps Tribal Council members 

have no ‘‘authority’’ over IHS, but they know their own communities and are more 

likely to have an interest in holding management accountable if their actions are 

not conducive to patient care or a well operated medical facility. We have already 

learned that IHS officials in the Great Plains region were not using their authority 

to police each other, which was another reason that led to the decertification in the 

first place. 

Although some IHS regions around the country seem to function better than others, the Great Plains Region has been problematic for years, despite several reports 

conducted by Congress and U.S. Government agencies. Many provisions contained 

within this proposed legislation are designed to correct some of the issues that 

plague the Winnebago Hospital and other IHS Hospitals within the region. I will 

now provide more specific comments on S. 1250 and how certain provisions will help 

the situation in Winnebago or how it might be amended to meet our specific needs. 

Comments on S. 1250 

First, we have some general areas of concern regarding the proposed legislation 

that we would like to stress. There are provisions in the bill that address new programs and functions for the IHS, which will be beneficial if they are actually funded. We want to make sure the legislation does not put forward programs that become in essence unfunded mandates. We urge this Committee to work with Appropriations to ensure that these provisions are funded so they do not end up just being 

lip service to tribal communities. The Indian Health Care Improvement Act was permanently enacted in 2010 and contained many provisions designed to modernize the 

provision of care, such as the development of new health care delivery demonstration projects and expansion the types of health professionals available within the 

Indian health system. Yet those provisions remained unimplemented due to lack of 

adequate funding. We do not want to see the same type of thing happen with this 

legislation. Congress cannot continue to starve the Indian health system and expect 

major change. 

The Winnebago Tribe is working its way toward self-governance, a status many 

other tribes throughout the country already have. In fact, about 60 percent of the 

IHS budget is delivered directly to the tribes through contracts and compacts. The 

proposed legislation does not do an adequate job of stating which provisions of the 

legislation pertain to self-governance tribes and which do not. The legislation provides a ‘‘Savings Clause’’ that appears to ensure that the legislation does not interfere with tribal contracting or compacting. Yet the provision at 607(e) of the proposed legislation is not clear on what provision or provisions that Savings Clause 

language pertains. Since we hope to be a self-governance tribe in the reasonably 

near future we would certainly appreciate some clarity regarding the application of 

this provision. The Winnebago Tribe and NIHB are happy to work with you on the 

drafting of that provision. 

The Winnebago Tribe and NIHB support the intent to make a streamlined system 

for licensed health care professional credentialing procedures, including volunteers, 

as outlined in Section 102. However, we note that these provisions should not be 

considered a substitute or final step for increasing available providers to the IHS 

and tribes throughout the country. For example, NIHB and the tribes fully support 

the expansion of the dental therapy model, which was first brought to the United 

States by tribes in Alaska in 2004. It is a highly effective way to provide reliable, 

safe, and quality dental care providers to underserved areas. We urge the Committee to consider models such as these to address the chronic staffing shortages 

in the Indian health system. 

Section 105 addresses Improvement in Hiring Practices. While we certainly agree 

that hiring practices need drastic improvement we are not completely comfortable 

with the language in the proposed legislation. First, this provision indicates that the 

Secretary has direct hire authority, which in and of itself is not a bad idea. However, the Winnebago Tribe and NIHB want to make sure that Tribal Preference is 

21 

not ignored in the direct hire authority. This provision of the proposed legislation 

goes on to note that the Secretary shall notify each tribe in the service area prior 

to the direct hire taking place. While notice is appreciated, it would be useful if 

tribes could file objections to any hire, especially if the new hire is somebody who 

has been recycled through the system previously and has not performed well with 

other tribes in the Region, which has been a common practice at IHS. Lastly, this 

provision provides that the Secretary may seek waivers to Indian preference from 

each Indian tribe concerned if certain criteria are met. We understand that when 

there are no qualified ‘‘Indian’’ candidates or the Indian candidates have not performed well in the past, it may be appropriate to hire a non-Indian candidate. However, Tribes are concerned about diminishing Indian preference in the hiring process. This path should only be used in the most extreme circumstances and should 

be initiated by the Tribe(s) served by the facility in question. 

We are pleased to see a provision addressing the Timeliness of Care in Section 

107. We believe that timeliness of care has been an issue at the Winnebago Hospital 

and that additional standards to improve the reporting and tracking of timeliness 

are necessary. It should be noted that underfunding also contributes to the inadequate and timely care. There is currently a system in place that, if implemented, 

correctly tracks these important care initiatives. However, if a region does nothing 

to implement the current system or inadequate staffing impedes the ability to track 

these initiatives, then it becomes a major problem. We feel that additional Congressional oversight over this particular area may be necessary. Section 107 also states 

that regulations and standards to measure the timeliness of the provisions of health 

care services must be done within 180 days of the enactment of this legislation. We 

are concerned that 180 days may not be enough time to develop the regulations and 

standards if proper consultation with the tribes is used to develop said regulations 

and standards. Lastly, we request that any data gathered regarding the timeliness 

of care be provided to the tribes as well as the Secretary. 

The Winnebago Tribe finds Section 108 regarding training programs in tribal culture and history to be of utmost importance. Meaningful cultural training can do 

nothing but help IHS employees as they learn the history and culture of the people 

they are serving on a daily basis. We think this training should be mandatory and 

it should include all IHS employees from headquarters to all staff at the service unit 

facilities, who have daily interaction with Native American people. It would be even 

more useful if the training involved and was tailored specifically for the tribes in 

the service area. 

Section 110 establishes rules regarding a tribal consultation policy. We are in 

complete agreement that a consultation policy should exist and that Tribes should 

have input into the way services are provided to tribal communities. However, it is 

imperative that the consultation policy developed under this section mandate to IHS 

staff that consultation shall be more than simple lip service or a listening session 

with the tribes. It should be viewed as a true partnership and collaborative effort. 

Tribal input is key to IHS in providing high quality services and must be taken seriously. The issues with the Winnebago Hospital would have never have risen to the 

level that existed if there was true consultation and collaboration at every step in 

this process and they never would have received the attention it has if it were not 

for Tribal action. 

Fiscal accountability is never a bad thing as laid out in Section 202, but the provision in subsection (b) that addresses the prioritization of patient care is somewhat 

troubling in its specificity. This section explains that IHS should only use certain 

dollars for patient care directly and limits their use to essential medical equipment; 

purchased/referred care; and staffing. While we certainly appreciate the need for 

more scrutiny, we worry that the criteria may end up being too constraining on the 

programs. IHS should consult with the Tribes in their service area before they make 

decisions on what can be done with the funds pertaining to this section. With consultation, the money can go to the most needed programs in a particular service 

areas. 

Most of Title III of the proposed legislation deals with a variety of reports. The 

one report that drew our attention was the Inspector General reports on patient 

care in Section 304. We definitely agree that reports on the quality of care and patient harm at IHS are necessary. However, we want to draw attention to the fact 

that many tribal members end up receiving their care outside of the IHS system 

through the purchased and referred care program. For example, in South Dakota, 

approximately 70 percent of care referred outside of IHS facilities. It would be useful to also have information on quality of care once a patient has left the IHS facility and is care for in an outside facility. We suggest that another subsection be 

added to Section 304 in order to address this issue. 

22 

Overall, we think this proposed legislation is necessary and once again thank the 

Committee for its genuine interest in trying to alleviate problems within IHS. It is 

clear that management, recruitment, accountability and transparency are all still 

issues that need to be addressed, most of which are covered in the proposed legislation. Nearly two years has passed since the CMS certification was terminated at the 

Winnebago Hospital and our CEO, Director of Nursing and Lab Director positions 

are once again vacant. As we have stated at prior hearings, real change and the 

rebuilding of the hospital cannot happen without permanent qualified personnel and 

the funding necessary to carry out the mission. 

Mr. Chairman, the Winnebago Tribe supports the passage of this legislation once 

the issues listed above are addressed and after thorough comment and review by 

Indian Country. As I stated last year at a hearing and this bears repeating, while 

everything in this bill is needed, legislation alone will not solve our problem. Proper 

training of hospital staff costs money, new equipment costs money, and recruitment 

under these circumstances is also going to cost money. We would consider the passage of this legislation an initial solid first step and implore you not to abandon us 

after this bill is passed. Correcting this situation is going to require a continuous 

team effort, additional resources, and consistent Congressional oversight of IHS activity. 

Thank you again for allowing me to testify, I will be happy to answer any questions you may have. 

The CHAIRMAN. Thank you. 

Dr. CROWLEY. 

STATEMENT OF DR. JOSEPH P. CROWLEY, PRESIDENT–ELECT, 

AMERICAN DENTAL ASSOCIATION 

Dr. CROWLEY. Thank you, Mr. Chairman. 

As stated, my name is Joe Crowley. I am President-elect of the 

American Dental Association and a practicing general dentist in 

Cincinnati, Ohio. 

The ADA supports the ‘‘medical credentialing system’’ provision 

(section 102) of the S. 1250, ‘‘Restoring Accountability in the Indian 

Health Service Act of 2017.’’ 

The provision calls for the IHS to implement a centralized 

credentialing system to licensed health care professionals who seek 

to provide health care services at any IHS facility. A central 

credentialing system would benefit both the practitioners and the 

IHS. 

According to former and current IHS area dental chiefs, the 

credentialing process easily takes eight to twelve hours of staff 

time at local service unit levels at a cost of about $1,000 per application. The current credentialing process makes it difficult for the 

Service to timely fill dental vacancies. It serves as a disincentive 

to those who want to contract IHS or volunteer their services. 

As an example, a private sector dentist in Mayville, North Dakota, who currently contracts with the Spirit Lake Reservation in 

Fort Totten, said that his IHS paperwork was much more difficult 

and much more extensive than the paperwork for his hospital 

privileging credentials. 

In 2012, despite the best efforts of the South Dakota Dental Association and Delta Dental of South Dakota to place volunteers in 

IHS dental clinics, the time-consuming credentialing process 

proved too large a barrier to overcome for all but two pediatric dentists. There were 70 volunteers who started that application. 

The Dental Association ultimately abandoned this project and established a partnership with the Jesuit Mission on the Rosebud 

Reservation just eight miles down the road from the IHS facility 

23 

where the two pediatric dentists worked. This speaks to the issue 

raised by the current credentialing services and it can be corrected 

with the language in this bill today. 

As my testimony details, many of the Federal services currently 

operate centralized credentialing services. The IHS dental officers 

that the ADA spoke with suggested that the IHS would benefit 

from a centralized credentialing unit with the proper technology 

that enabled applicants to upload documents similar to the other 

Federal services. 

The good news is that it appears IHS is making progress in centralizing the credentialing process according to the November 2016 

press release from the agency. The ADA recommends that the IHS 

agency be encouraged to support continuing down this path with 

adequate funding in its project. In addition, the ADA encourages 

this Committee to ask the Indian Health Service to provide an update on the status of this new credentialing process. 

Mr. Chairman, I would also like to point out that the ADA is currently supporting implementation of a ten-year health and wellness 

plan which includes oral health and is designed to reduce oral disease by 50 percent among the Navajo tribal communities. This will 

be done by developing a foundation of prevention, early detection 

and treatment of dental disease and utilizing the interprofessional 

models of care, while providing timely and accessible oral health 

care. 

This model is being considered by other Indian Nations in Arizona and Washington State tribes. Centralizing the credentialing 

process will facilitate these efforts by getting more dentists into 

IHS and tribal clinics. Having more dentists available to provide 

care will also greatly enhance access to oral health care services as 

shown in the Navajo Health Plan. It builds capacity utilizing existing resources, including their Community Health Representatives 

and the ADA community Delta health coordinators. 

Mr. Chairman, thank you for this opportunity to share with you 

and the members of the Committee why the ADA supports the 

medical credentialing system provisions of S. 1250. 

I would be pleased to answer any questions. 

[The prepared statement of Dr. Crowley follows:] 

PREPARED STATEMENT OF DR. JOSEPH P. CROWLEY, PRESIDENT-ELECT, AMERICAN

DENTAL ASSOCIATION

My name is Dr. Joseph P. Crowley, president-elect of the American Dental Association (ADA) and a practicing general dentist from Cincinnati, Ohio. The ADA represents over 161,000 dentists nationwide, including many dentists working in the 

federal dental services, such as the Indian Health Service (IHS), as both U.S. Public 

Health Service commissioned officers and civil servants. 

The ADA supports the ‘‘medical credentialing system’’ provision (section 102) of 

the ‘‘Restoring Accountability in the Indian Health Service Act of 2017’’ (S. 1250) 

that calls for the IHS to implement a Service-wide centralized credentialing system 

to credential licensed health care professionals who seek to provide health care services at any IHS facility. 

Need for Centralized Credentialing 

Based on discussions with current and former IHS officials and a number of private sector dentists and state dental associations who have had experience with the 

credentialing process at various IHS facilities, the ADA believes a centralized 

credentialing system would benefit both practitioners and the IHS. 

According to former and current IHS area dental chiefs, credentialing is handled 

at the service unit level and generally assigned to a clerical employee. The 

24 

credentialing process easily takes 8–12 hours of staff time for a full-time dentist, 

a part-time dentist, or a volunteer. Because of the challenges associated with this 

process and the cost (estimated to be about $1,000 per applicant), IHS dental chiefs 

do not put a high priority on recruiting volunteers, especially if they only have a 

limited block of time to devote to the assignment. 

A private-sector dentist from Mayville, N.D., Dr. Rob Lauf, currently contracts 

with the Spirit Lake Reservation in Fort Totten, N.D. He describes the credentialing 

process as ‘‘arduous,’’ noting that the IHS paperwork far exceeded the amount of 

paperwork required for his hospital privileging credentials. Despite this administrative burden, Dr. Lauf sees that the dental need is very apparent and he intends to 

continue to provide services. The most recent credentialing guide published by IHS 

is 74 pages long with one short paragraph on volunteer credentialing, which focuses 

solely on residencies through medical schools. 

In 2012, the South Dakota Dental Association (SDDA), working with Delta Dental 

of South Dakota, made a serious attempt at placing volunteers in IHS dental clinics. 

The SDDA surveyed its membership of 400 practicing dentists and approximately 

70 indicated a willingness to volunteer or contract with IHS. All of these dentists 

were sent the IHS credentialing packet and the instructions needed to complete 

them. Due in part to the fact that the packet is quite large and intimidating for 

the uninitiated, out of the 70 dentists who indicated interest in volunteering ultimately only two members, both pediatric dentists, became credentialed to work in 

an IHS facility. SDDA ultimately abandoned this project and established a partnership with the Jesuit Mission on the Rosebud Reservation, just eight miles down the 

road from the facility where the two pediatric dentists volunteered. In order to volunteer at the Mission, dentists must only have a current license to practice dentistry in South Dakota or, if they are from outside of the state, obtain a volunteer 

license issued by the South Dakota State Board of Dentistry. Of course, private 

charities are not subject to the same quality control constraints as those placed on 

federal facilities. This example is cited merely as a means of showing that many 

dentists are more than willing to help address the oral health care needs of the 

American Indian/Alaska Native population and that streamlining the credentialing 

process will facilitate those efforts. 

In fact, the IHS dental officers that the ADA spoke with suggested that the IHS 

would benefit from a centralized credentialing unit with the proper technology that 

enabled applicants to upload documents. This would allow for the appropriate primary source verification of dental education, license verification, and National Practitioner Databank checks to be conducted in a timely manner, saving significant 

work at the service unit level. 

Federal Agencies with Centralized Credentialing 

The ADA inquired about centralized credentialing and privileging among the federal services. All three of the military services and the U.S. Coast Guard use the 

Centralized Credentials & Quality Assurance System (CCQAS). 

According to information provided by the Coast Guard and verified by the Army, 

Navy and Air Force: 

The Centralized Credentials & Quality Assurance System is a standard Department of Defense (DOD) system jointly undertaken, operated, and controlled by 

the Army, Navy, and Air Force medical departments within the overall corporate sponsorship and policies of the Office of the Assistant Secretary of Defense for Health Affairs. The Defense Health Services System is responsible for 

the development, deployment, and maintenance of credentialing and quality 

policies. CCQAS is a Web-based worldwide credentialing, privileging, risk management, and adverse actions application that supports medical personnel readiness. 

This centralized system enables the military medical community to electronically manage provider credentialing and privileging, malpractice and disability 

claims, and adverse action investigations of diverse, multi-disciplinary health 

care professionals and their support personnel at all levels of the Department 

of Defense. 

The system provides the following features: 

• Maintains and tracks the credentials and privileging history of all military 

and civilian health care providers, including Active Duty, Reserves, and National Guard. 

• Contains comprehensive provider demographic, specialty, licensing, training, 

education, privileges, assignment history, and provider photographs for identification purposes. 

25 

• Enables providers to complete and submit an application for clinical privileges online. 

• Automates the online review and approval of a provider’s application for initial and renewal of privileges. 

• Expedites the transfer of provider credentialing and privileging information 

for temporary change of assignment or Permanent Change of Station. 

As noted in the last bullet, each facility is still charged with the responsibility for 

actually granting privileges to a provider when assigned to that facility either temporarily or permanently. 

According to Dr. Patricia Arola, Assistant Under Secretary for Health for Dentistry, within the U.S. Department of Veterans Affairs (VA), ‘‘Centralization of the 

privileging process has been on the wish list for years; but unfortunately, the process remains local. There is, however, a repository for credentialing information 

called VetPro, which allows for online entry of information by providers and 

credentialing staff.’’ It appears that this particular VA process is similar to but distinct from the DOD centralized credentialing and privileging system. 

IHS Making Progress toward Centralized Credentialing 

The good news is that it appears that the IHS is making progress on the centralized credentialing issue and should be encouraged and supported to continue down 

this path with adequate funding for its project. The Office of Human Resources at 

the IHS is spearheading this initiative, based a November 16, 2016, press release, 

titled ‘‘Indian Health Service (IHS) Quality Framework, 2016–2017’’ at: https:// 

www.ihs.gov/newsroom/includes/themes/newihstheme/displaylobjects/documents/IHSl2016–2017lQualityFramework.PDF. 

As you can see, the first order of business in this plan was to assign a key leader 

(https://www.ihs.gov/aboutihs/keyleaders/) as the Deputy Director for Quality 

Health Care. Mr. Jonathan Merrell, RN, BSN MBA has been assigned these duties 

in an acting role. 

In the press release cited above, the IHS addresses the centralized credentialing 

issue in Objective 1B: Standardize Governance: Standardizing and strengthening 

governance processes and structures promotes reliability, consistency, and management excellence while emphasizing quality improvement as an Agency priority. 

• A standard governing body structure will be developed to improve planning 

and oversight processes while ensuring that all Direct Service facilities are 

meeting external accreditation and certification Governance requirements. 

• IHS will support a central repository of key IHS policies and procedures accessible to each Area Office and Service Unit to ensure consistency across the 

Agency and enable easy access to, and version control of, current policies and 

procedures. This effort will include a review of policies and procedures to reduce 

variation across the Agency. 

• IHS will standardize the credentialing business process and implement a single 

credentialing software system for Direct Service facilities. IHS will automate 

business processes where possible and review, update, and simplify 

credentialing and privileging policies and procedures. Training and technical assistance will be provided to staff. The Quality Office will provide operational 

support and oversight to ensure system-wide high quality credentialing processes and procedures. 

The ADA encourages the Committee to ask the Indian Health Service to provide 

an update on its implementation of the Quality Framework, including implementing 

the credentialing business process. It is important to ensure there are adequate 

funds available to complete this initiative. As the committee knows, the IHS has 

approximately 100 funded dental vacancies at the time of this testimony. Other disciplines, such as nursing and medical, have similar recruitment challenges. Streamlining the credentialing process could help fill those vacancies with quality health 

care professionals in a timely, efficient manner. 

Improving Oral Health in Tribal Communities 

Working closely with Navajo tribal leaders, the ADA is currently supporting implementation of a 10 Year Health and Wellness Plan, which includes oral health 

and is designed to reduce oral disease by 50 percent among the Navajo tribal communities. This will be done by developing a foundation of prevention, early detection 

and treatment of dental disease, and utilizing interprofessional models of care, while 

providing timely and accessible oral health services. This model is being considered 

by other Arizona and Washington State tribes. Centralizing the credentialing process will facilitate these efforts by getting more dentists into IHS and tribal clinics. 

26 

Having more dentists available to provide care will also greatly enhance access 

to oral health services as the Navajo Health Plan builds capacity utilizing existing 

resources, namely Community Health Representatives (CHRs). Utilizing both the 

Smiles for Life oral health curriculum and educating a number of Navajo CHRs and 

dental assistants with Community Dental Health Coordinator (CDHC) certification 

will enable greater community outreach, community education, and preventive services. The role of a CDHC is threefold: educating the community about the importance of oral health to overall health across the lifespan; providing limited preventive services, such as fluoride varnish and dental sealants; and connecting the community to oral health teams that can provide needed dental treatment. CDHCs 

work in inner cities, remote rural areas and Native American lands. Most grew up 

in these communities, allowing them, through cultural competence, to better understand the problems that limit access to dental care. 

A September 2013 evaluation of 88 case studies of the CDHC program conducted 

by the ADA verified the real world value of the CDHC in making the dental team 

more efficient and effective. Screenings, dental education and certain preventive 

services were delivered by the CDHC and an increasing number of individuals needing dental care did not ‘‘fall through the cracks’’ of a complicated delivery system. 

Before the end of this summer, the CDHC program will have over 100 graduates 

working in 21 states. This includes 16 CDHCs working in tribal facilities, including 

clinics serving the Chickasaw Nation Division of Health, Wewaka Indian Health, 

and the Muskogee Creek Nation in the Oklahoma City area. And more are being 

trained. For example, four additional Navajo CHRs are being trained at the Central 

Community College in New Mexico. These four will soon join two Navajo CDHCs 

serving in Fort Defiance on the Navajo Reservation. Following the lead of the Navajo Nation, the Chickasaw Nation is working on a grant to begin a CDHC program 

with Pontotoc Technical College. 

Mr. Chairman, thank you for this opportunity to share with you and the members 

of the committee why the ADA supports the medical credentialing system provision 

of S. 1250, which calls for the IHS to implement a Service-wide centralized 

credentialing system. 

Attachments 

ARIZONA TRIBAL COMMUNITIES ORAL HEALTH PLAN OFFERING—2016 

Making Oral Health a Priority 

Goal: Reduce incidence of oral disease by 50 percent among the Arizona 

Tribal Communities by developing a foundation of prevention, early detection and treatment of dental disease, and utilizing Interprofessional models 

of care, while providing timely and accessible referral services. 

Practical Goals Across the Lifespan 

• Every individual will have access to the benefits of water fluoridation 

• Every pregnant woman will have a healthy mouth 

• Every child will start kindergarten cavity free 

• Every individual with a chronic disease such as diabetes or hypertension will 

have oral health as an integral part of their disease management 

• Every elder will have access to dentures or other tooth replacement options 

Objectives to Achieve Practical Goals 

• Establish collaboration between dental and medical services 

• Build grassroots support for oral health throughout tribal leadership 

• Build a collaborative relationship with organized dentistry 

• Establish/enhance strong, sustainable community oral health prevention programs 

• Establish/enhance electronic health record for tribal individuals that incorporates medical, dental and behavioral health data 

• Build relationships with dental industry and research entities 

• Promote health literacy for sustainable results of health improvement actions 

• Incorporate Community Dental Health Coordinators (CDHCs) into tribal health 

clinics and communities 

• Develop awareness and encouragement to pursue oral health careers for teens 

and young adults 

27 

Action Steps 

Building Capacity 

• Work with Tribal Community Health Representatives to become CDHCs 

• Recruit students for dental school careers 

• Actively work with local dental offices to expand access for tribal oral health 

care 

• Create ‘‘on the job’’ training for high school students to learn dental assisting 

skills 

• Promote interdisciplinary approach to improve Native American health care: 

• Establish a dental home by age 1 

• Provide mouthguards for athletes 

• Establish oral health protocols for pregnant women, young children and individuals living with chronic diseases 

Building Infrastructure 

• Establish reliable data and surveillance to support health improvement efforts 

• Coordinate research efforts building upon relevant historical data and medical 

surveys 

• Educate physicians to enter oral health findings into shared health record and 

educate patients on the value of oral health to overall health 

• Educate oral health professionals to promote overall prevention efforts, such 

as hypertension and cancer screenings, immunizations and good nutrition 

Building Community 

• Incorporate CDHCs into existing CHR programs 

• Build upon existing efforts to integrate oral health education into WIC, Early 

Health Start, Head Start and elementary education programs 

• Expand community prevention programs for tobacco cessation, school-based 

sealant programs, and oral cancer screening events 

• Raise awareness of oral health value through events for tribal populations 

Building Partnerships 

• Contract with local dentists in order to expand oral health access without expense of additional ‘‘brick and mortar’’ expansion 

• Participate in Local and State Oral Health Coalition meetings 

• Enhance the voice of Native Americans to advocate to the Indian Health Service for oral health improvement initiatives 

• Encourage the dental industry to contribute materials to support/sustain oral 

health activities to improve tribal oral health 

The CHAIRMAN. Thank you, Doctor. 

Mr. Stier. 

STATEMENT OF MAX STIER, PRESIDENT/CEO, PARTNERSHIP 

FOR PUBLIC SERVICE 

Mr. STIER. Thank you very much, Mr. Chairman, Mr. Vice Chairman, and Senator Heitkamp. 

It is a great pleasure to be here. You are focusing on a very important issue. I would like to put this in context, however. The 

problems you are seeing at IHS are not unique to IHS. They actually exist across the Federal Government. 

My proposition to you would be, learn from what else is going on 

in the Federal Government. Don’t see this as an insulated, isolated 

example. There is a lot of learning to be done. Senator Heitkamp 

has done some very important work on some broader changes. 

Senator Udall, you said let us not tinker around the edges. Tinkering is not going to get you what you want. If you want to have 

28 

better quality service, you are going to have to do a lot more. You 

are going to have to fix the system that was designed for a different era and a different age. 

Let us look at the data. It is devastating. IHS hospital rates, 

physician vacancy rates are at 33 percent; 1,550 health care professional vacancies exist across the system. Only 38.3 percent of the 

IHS employees believe that their work unit can recruit people with 

the right skills. 

Only 7.3 percent of the employees there are actually under the 

age of 30. Nearly three-quarters of the employees do not believe 

that steps are taken to deal with poor performers. This is a real 

problem. You are focusing on something important but I would propose to you that there are better ways for you to fix these issues. 

You have jurisdiction for IHS. I think there are some key things 

you can do around the areas of hiring and accountability that 

would be much more powerful. Let us start with accountability. 

You are on a path now that the Veterans Affairs Committee has 

been down for more time than you have. I would propose to you 

that you look to see what kind of changes they have made. The provisions you have on accountability are Version 1.0 from the Veteran Affairs Committee. They are beyond that. I would take a look 

at the things they are doing already. Let me point out four particular opportunities to promote accountability that I think will do 

more. 

First and foremost, you have to understand what the problem is. 

One of the real problems is that employees who are excellent technical experts are promoted to management because that is the only 

way for them to be promoted. 

One solution is, have dual tracks where you can have expertise 

that are technical experts that get promoted through the system 

that they don’t have to go into management in order to move up 

in the system. 

Second, we have a probation period in the Federal Government, 

typically a year long. A lot of folks point at it to say it doesn’t work, 

they want to extend it. The problem is it doesn’t work. Why doesn’t 

it work? Because managers don’t use it appropriately. They don’t 

actually decide whether an employee deserves non-probationary 

status. 

My proposition to you would be to flip the presumption. Today, 

if you are a Federal employee, you have been there for a year, you 

automatically become non-probationary. I would say it should be 

the opposite. You are not actually non-probationary unless the 

manager who is supervising you determines that you are right for 

the job. Put the burden on the manager. 

The same goes for the manager. If you are put into management, 

you have a probation period of a year. You should not stay in management unless your supervisory affirmatively decides that you are 

doing that job well and then you become non-probationary for that 

position. That is the second point. 

Third, we need to do more training for managers. Right now, 

people are made managers but not helped in any way to actually 

do the difficult and different things they have to do as managers. 

Fourth, I think you have to hold leadership accountable. There 

is a performance plan requirement for the head of the Indian 

29 

Health Service. My view is I don’t know where that performance 

plan is. It ought to include the management functions of running 

the organization. 

Let me move to hiring. One, we need to focus more on the entry 

level side on student level talent. The Federal Government does not 

do the most basic thing that every other private sector organization 

does which his to see student interns as a primary way of bringing 

talent in at the entry level. It doesn’t happen. A lot more could be 

done on that. 

Secondly, we have a pay system that was designed in 1949. That 

is not a pay system that is designed for today’s world. We need 

more market sensitive pay. Again, look at the VA. It is not just 

enough to duplicate Title 38. 

You need to think about what kind of pay you need to get the 

right talent into the jobs. It is not just the doctors; it is actually 

the leaders of the hospitals and the medical directors for the system, the same problems you see at the VA. 

Then you are going to have to evaluate the impact of the authorities and flexibilities that already exist that oftentimes are not used. 

The bottom line is you have a lot of talented people. The system 

is failing them. 

Finally, you do need more data. I propose that you really need 

a dashboard that has four critical elements around quality of care 

to health outcomes, number one; number two, what is customer 

service perspective; number three is the employee voice which you 

have which is very powerful. I think you can look at that more. 

Fourth obviously is fiscal prudence because there are only so many 

resources to get this done. 

I work at the Partnership for Public Service. I should say at the 

front end, it is a non-partisan, non-profit organization. We would 

be pleased to help in any way we can. There is a lot you can do. 

I am glad you are focusing on it. 

Thank you very much. 

[The prepared statement of Mr. Stier follows:] 

30 

PREPARED STATEMENT OF MAX STIER, PRESIDENT/CEO, PARTNERSHIP FOR PUBLIC

SERVICE


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31 


613a2.eps

reported four or more CEOs within that same period! 1be Department of Health and Human SeiVkes 

Office of the [nspector General5imilarly found that 24 of28 hospitals they i~JVC~~tigated had someone 

acting in a leadership rolc.4 Eleven of the 28 hospitals had an acting CEO, while 10 had an acting clinicnl 

director and nine reported an acting director ofnll!S!ng.' One hospital repDrted an astounding three 

different acting CEOs in e six W<:ekperiod.1 

II goes without saying t1mtsuclt situations e&US\l significant ltarm to an organization, and m: c~using hann 

otthe IHS. The Partnership has found that high-level vacancies in federal agencies have the elfcct of 

''slowing decislon-maldag and ultimately diluting agencies' ability to best mvethe public interes~' and 

put agencies in a neutral gear in which they delay important decisions and plans.' Findings from GAO 

canlinned that this was indead happening at tOO IHS, whlll"e turnover and vacancies in key leader:; hip 

positions proved "detrimental to the oversight of facility operations and the supervision of per:;onnd," 

with acting leaders who were aafi:aid to commit to decisions" and who needed "additional supervisor 

!mining."' The HHS OIG reinforced this finding by reporting that in some c~ses individuals in nonsupervisory roles were being BSSigned to acting leadcrshi? pooitions and that leadership vacancies and 

hli"Tiover led to inconsi<t<mtor ab<ent over<ight of the qui!ity of~ore at the fa~ttlty leveL" To Its credit. the 

agency is taking ru:tiom to address its leadership vacanci.s by, for exampl~, establishing a senior 

executive search committee process that is recruiting highly qualified e:-:ecutives to the organization and 

beginning a soocesslon plnnning process ocross its fuc:ilitiea. 1

' However, the upshot ofthc findings ofH1e 

HHS-OIG, GAO, and others is that alack of sustained leadership and acting leaders without the training 

or tools to lead effectively are hurting the quality of care at service units across the COWIITy. 

A dearth ofleader.;hip development opportunities is another real challenge facing the Indian Health 

Service. Titc tendency to fill agency leadership roles with individuals who have risen lhroush the nmks 

strengthens the strong commitment of the IRS to the communitiea it sciVcs but alsa rcinforcca an insulll.l" 

and inward-looking orgnnlza.t!onal culture. This Insularity Is true of many other government organlzntlons 

as well. Research by the Partnership and McKinsey has demonstrated that the vast majority ohenior 

executives and other senior leaders come from within their agency and that eKternDI recruitment is largely 

ad hoe. u The commirtee should explore ways to encourage greater inveshnent in leadership development 

and efforts by the agency to seek external candidates for critical executive and senior management 

positions. One solutioo that I strongly believe would be h~lpful is the creation of a public-private talent 

eK<:hange that would provide ricl!. development opportunities nnd ollow eurrentand nspiring IHS leaders 

Care." GAO Publication No. 17-1&1, ],.,uory 2()1 7, p. 21, httpldlwww.g•c.gevla."'e~69016K t9.5 !.pdf. 

'!bid., 21. 

• Department ofHeoiH11Wd Hum on Services Officeofltlspeclor General. "Indian Health Service Hnspilals: 

Longotaruliog Chall..,ges W:ammt Focuaed Attenlicn to Support Qwllity Care." OEr-06-14-0001 I, October 

2016, p.13, Mta;-//olg.~hs.gov{oe!lrepotts/Ml-!)6-14-000JI.pdf. 

'Ibid., 13. 

6lbid., !3. 

7 "Government DiosOJ"Vice: Overoomiug Wasltingtcn Dysfuncti:m 10 Improve Congressional Stewanlship of Ute 

Executive Branch." Partnership far Public S•rvice, Seplfmber 20 15, p. 29, 

https:ffoumuhlfcsorvicft.nrg/puhlioatlonslvieWM!ltentd•tn11<.nhp?ldmSK9. 3GovemmentAcoouotnbility Office, No. 11·18l,p. 15. 9 Department of Health ond HumM ScrYi- Office oftnspO<:tOr General, OEf-06-!4-00011, p. !3. 10 High Rbk, No l/f!ward- G.-!O's High Risk List far lndla!t Pro.,-mns: Hcarl~~g before the Commiflce on Indian 

AjJair11, Seuote, IIS!h Cong. I (:2017}. 

' 1 "l'reporing the People Pipeline: A Fedend Succession Planning Primer.~ Partmmhipj& Pub(£, Service wilh Baaz 

Aile" Jlamillon, June 2011, http;/Jwv.w.govm,:&g.oom/edfs!OGQGl nl! ,pdf. 
32 


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to build managerial skills and infuse new thinking inlD tbeiragenc:y. Congress has recently created such 

~xchan!l"" at the Deportment!: of Defense aml Vet~llllS Affuirs. Another option W<>uld be to exploN the 

VA model of portncring with medicll1111:hool3 around the Clluntry. These partnel'!hips would allllw the 

IHS to get a head start on recroiHngnew dllctors by giving them hands-on opportunities to work in IHS 

facilities. 

Beyond the impact that leadership vacancies and lack ofleadership development have on the mission of 

the lndiauHealth Servic~, these ddicicn~ics hurt employee morale as well. Da.l.a from the lndinn Health 

Service bear this out. The !'mtnernhip's lJe.rl Plrwe5/e> Work In the Federal Government Rankings®bave 

found thnt leadership is lhe single biggest factor in dctcmining how employees view their orgnnizatinn." 

In fact, leadecl!ip effectivmess has boon a key driver every year since the i'artnershlp began publilhing 

its rankings in :2003. 13 ]t has also been one ofthc lov;est-rntcd workplaC<J catecories overall, esrecia!ly 

when compared to the private sector. 14 Regarding overall worale,.IHS employees rank their agency 249 

out ofJOS subcomponents included in the Partnership's rnnkings with a 5oore ofS5.0 out of 100. Th~ 

agency perfom~s even worse in emplayees' views ofleadership, mnkingjust291 of303 ranked agencies 

in the workpli!Ce category of"Effective Leadership." The JHS perfom1s similarly poorly In the tour 

leadership subcategories mnkcd by the ?armership: uEm)O'I'.'\mllent~ (261 of303), "Fairness" (281 of 

303}, ~Senior Leaders" {272 of303) and "Supervisors" (297 of303).11 There ranldngs are borne about by 

employeeresporuc3 to questions from the Federal Employee Viewpobrl Survey {FEVS). For ..:.:ample, just 

36.4 percent of employees are satisfied with the policies and practices of the agency's senior leaders, 

while just over half (50.5 peroenl) believe prohibited per;onncl practi~cs are taferoled in their 

organiution. Though over half of employees (57 percent) believe their supervisor is doing a good job, 

that nmnber is well below the govcrnmcnt-11idc score (6S.2 percmtl) and the privatesector(82 percent).16 

There are, however, a few bright spots fur the agency: th:s pil.Styear the IHS increil.5ed its score in every 

cllte.~:orybut satisfaction with pay and its overn.H employoo satisfaction ooom, or ind~J<ooore, by 0.5 

points. Further, the agency saw its large~ Increase, of2.4 points, in the workp!nce category ofuEffective 

Leadership- Fairness." It is also worth noting that low morale was not always rtte norm. From 2003 to 

2007 the IHS scored above th~ govcrruncnt-widc average in overall employee satisfaction, and survey 

data show that Indian Health Servi~e employees areeJ<ceptionally committed to lhelr jobs. In the category 

of"Employee..Ski!ls Mission Motcb," which measures ti-c extent to which employees get satisfaction 

from their work, theiHS scored 80.tl out oflOO (53 of304).-These findings, combined with the fact that 

"The B .. t Ploces to Wolk rankin~ offer the mo!t oomprchcn•ive asse;,ment of how feder11l public servanm view 

!heir jolrs and workplaces, providing employee perspeolive• ooleade:.hip, pay, inoovation, W<>rk-life bal1111ceand 

glher issu...,, The Vll5lmajority of the dllla used to develop tha "'"fM IUld r11nkings WIIS ootlooted by the Office of 

Personnel Management's l'edernl Employee VieWpoint Survey (I'EVS) from April througll Jwte 2016. 

11 Partnership forPubllc Service. "Government-Wide Analysis: C..tegooyl'inding•." Bestl'!tJCt<s to Work, 2017, 

http· flbesJOI&eslRWO di ooo'BPIWiaoal vsislc•tesorie•.php. 

"' Porlnei:Ship for Public Service. "Government-Wide Analysis: Overnll Findings and Privat~ Seot>:>r Comparison.n 

&s/1'/aces to Work, 2017, http:f{bestplncestowork.oWBPTWfanalvsisf. 1' 1he "Empowennent" suboategory measl!reS the extent to which employees believe lcrulorship at all level• ofthe 

organization generales moti'l'l'ltion and eommihnon4 encourages integrity and m~n~gos people fhlrly; lhe "l'almess" 

subci!legmy measures the e:ctent to v;fdoh employees believe d:spntes are resolved foirly, wlH!IliOlr employees believe 

arbitrary action and personal fiworitism are tolerated :md If em~loyeu feel comfortable reporting illegol llClivity; the 

"Senior Leaders" sul.>category meosun:~ til~ level ofre1pect employees haVI: for scnior r .. dern and pe,.eptiDIIS about 

senior leaders' hon~, integrity ond ability to motivate employees; tho "SuporviMrS" eotegl>f'/ moasures employee 

opiniDllll aboul lhdr immediate SUJ>Cr.'iO!lr'•job porfumtonce. 10 Tlu:so data IIJC hasod on the Partne!!hip's analysis ofOPM'< I'I>VS dota. 
33 


613a4.eps

IHS has seen its inde:< score increasefl.ll'two consecutive years, should give the agency's leadership as 

v;ell as tlte committee 11 foundntion to build on going forward. 

A la.ckofgood dllblobout its pcrfonuance also hampers the Indian Health Service.!! is a wellacknowledged mn:im of management that an organization cannot mrumge what it does not measure. For 

the IHS, th~ lack of meaningful data has a very real impact on its ability to achieve its mission. For 

el<ll!llple, GAO found that while the IHS did review some clinical quality data oonsistenlly, oth~r 

performance data, such as on customer satisfaction, was not "oonsistently obtained or reviewed b~ ull area 

offices because JHS has not required that tl1ey be reviewed or reported.H17 To truly and measurably 

improve, IHS mnsl bec;in consistently collecting quality data that leaders con immediately sec and react 

to. Especially valuable would be infonnation on customer satisfaction, health outcomes, employee 

perfonmmce data, hiring process infonnationnnd disciplinW)' outcomes thatencomp8Sl< the key aspects 

of the IHS mission. 

Faxterfirinl:";,;, not~ p:~th to sust:lined accoual'llbility 

The Partnership supports the committ~c's goal of an Indian Health Servioe that holds employees 

accountable for their performance and ptevents bad actors from tElffiishing the reputation of the thousands 

of romm!tted employees who have dedicated their professional careers tQ serving Native communities. 

MiSCQnduct such as that described in the committee's 2010 report, ulu Critical Condition: The Urgent 

Need to Refonn the lndioo Health Service's Aberdeen Area" clearly has no place In governmeut.ln fac~ 

UTS employees themselves believe there is an accouut.ability problem in their organization- according to 

the :20!5FEVS, three-quarters oflllS employees believe that their work unit does no/ tak~stcps to deal 

IYith poorperfonners and that pay raises do 1101 depend on how well employees perform their jobs. But as 

the committee strives towards tlte goal ofa more accountable Indian Health Service, I strongly urge you 

tel conslderwhetller the changes to due process 1-lld out in Section 106 ofS.\:250 represent the right 

approach.1s In thePartnernhip's view, simply making it easier to remove ClOployees wilhoutaddressin~;> 

larger rnnnagemcntchallunges will fail to create sustained improvement or accountability and will furtl1er 

hiuder the agency's recruitment of needed talent. 

The authority created in Section 106 is mC811t to be in addition to statutory authorities already available 

under Chapter.s 43 and 75 of Title 5, but! believe that oucl1 additional authority is urmecessary. As I noted 

in my ~tement for the record of June 17,2016, the Indian Health Service already !las the statutory and 

other authorities it needs to take corrective nction to remove, suspend, demote or trnrufer an employee. 1

' 

Data from the Merit Systems Protection Board beMthls out: though data for Ute IHS alone is not 

ava.ilall1e, its parent agency, the Department of Health md Human Services, had just 2.1 percent of its 

decisions reversed atMSPB.20 The MSPB appeals process is just not asisnificant barrier to holding 

cmploycl!!! accounlablc, and reducing the time that an emplo~ee facing an adverse action ha.s to up pen! to 

MSPB will not brlngrelll uccountllbility. &:ction 106 also presents a potential constitutional issue. Last 

May, tile Department of Justice declined to enforce a nearly identicnl provi:;"1on in the Veterans Access, 

17 GovommontAoeoulltability Office, No. 17-181, p. 10. 11 In Crilical Condit{ on- The Urgent N•ed lo Rifmm Indian HMitlrServ/ce "s Ahenken Anm; Hearing before the 

C!Jmmittu onlndlanAjfo~. SonErtc, tilth Cong. I (2010). 10 Unitod Stat.,.. Cong. Senate. Committee an Indilln Affairs. lmproPing Account~blli!Y and Quo:lfo"/y of Con. <11 tile 

Indtnn HeolthServiae 11JraughS.295J.1nne 17,2016. !14th Cong. 2nd sess. WB!lhington: GPO, 2016 

('latcmont ofMIIX Siler, Preoidcnt ll!ld CEO, Partru:,..hip ior Public Service). 

'"U.S. Merit S%1ems Protection Boord. "Annu•l Rl:port for PY 2016." Jonuary 20 17, p. 24, 

httvs-Uwww.rn•nb.govlm!!Jlh.<oan:hlviowd~"·"'P"?Oocnumb"'~ 1 :l742G9&v•rsjon-l:i7964J&Qilll!iq~onACR0BAT. 
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Choice, and Accountability Act cf2014 (P.L. 113-146), c:tins concems that the I~w violat~d the 

Constitution's Appointments Clause." Passing a law U1at immcdilllcly fiu:es constitutional challenges will 

only set back the cawe ofaccountabl\ity at tho ~·rn:y furth~>r. Instead, the IHS and this committee should 

L!ik.e •teps to empower IHS managers to deal W!Ui poor performers and burl i!CID!"81!S well as to motivate 

the best and brightest. 

There is much the committee can do to Improve the qualit1 of supervision and performance Rt the IHS, 

particularly by focusing on the beginning of an employee's or supervisor's tenure when the opporlunity to 

affect employ<:<: habits and attitudes is greatest. For instance, the committee should req1rire additiolll!l 

training to supervisors lllldmWJagers on t\lWarding high perlbrmers and dealing with poor p~rformcrs, and 

work to ensure that funding Is available to make the requirement rcal.ln many COlies, agencies select for 

superv!sozy roles technical experts who may lack the people skills or training In be successful." Without 

these skills, supervisors are being set up for failure fiom the very beginning. Mditionally, the committee 

should provide further support In the agency by Instituting adual-trocl: promotional system by which both 

aspiring managers and technical experts can adv!!Ilce their careers by focusing on their ~trcngths, and !he 

agency can allow those individuals >vho want to become leaders to self-select into those roles. Finally, the 

committee shouldstr~ngthen the probationary period at the lHS for both new employ= ami rtewly 

promoted supervisors and managers. The probation!ll)' period represents an important continuation of the 

asseSlimcnt process -an opportunity for the agency to see how the ~mployee performs on the job. More 

often than not the probatioll31Yperiad is treated as a formality. MSPB has found that m311llgers h:nd to 

treat probationers the same as tenured employees and thEII: more !han half of supervisors would be likely 

to k<;!ep a probationer on regardless of performance."' The committee should address this by holding IHS 

3upervisors i!Dd manager~ accountable for using the probatiOn!ll)' period as Congress originally Intended 

by making an affirmative decision to relnin an employee once their probation cnds.Tiw comminee ~hould 

also encourngethe IHS to deal with employee oonductand porfbrmance issues through Chapter75 of 

Title 5 to the cxt<.mt possible. as it is less administrmively burdrnsome !ban procedures under Chapter 43. 

Given that many employee perf01mance issues have cond\.d elements as well, this ~h!ft should cover the 

vast majority of adverse actions In th~ Service. 

Jliragreforms area strong start, but more can be done 

The talentoballenges of the IndiWJ Health Service have bern widely pub!icired. Remote !ocatio115, 

uncompctitivc pay, ond a lengthy and inefficient hiring process all contribute to the agency's problems 

recruiting, hiring and retaining mission-critical lalent. The IHS contends with a vacancy rate o£33 percent 

for physicians in i1s hoopitals, wilileacross the system overall vacancy rnles are 23 peroontfor physici!IIIS 

and 17 percent of nursing positions."~ The agency's 1.550 medical professional voonncies represetlt the 

lmgestobstacle to improving the qtuality of care, according to GAO." The complex and rigid hiring 

process does little to help. Witnesses before this committee have noted that IHS officials feel they "'e 

Wake·Up can.~ January ZOO!, 
35 


613a6.eps

held back by the currentsystenl, noting that the agency has lost many candidates who are foroed to wait 

six or more months before the agency can hire them.z• Findings afth~ lnspcctar General of the 

Department ofHeulth and Humrm Services reinforce there concems, noting t!w.t while time-to-hire at the 

IHS was just under OPM's SO-day benchmark, it oouldstill take up to six months to hire new staff.2

' 

Employees themselves are aware of these challenges-just 38.3 percent believed that their work unit was 

able to re.::ruit people with the right •kills.21 The result is that IHS filcilities like the Blackfeet Community 

Hospital in Browning, Montana CllllllO! provide the level of care that patients deserve. <9 

With lhe:sc interoonnected challenges in mind, I Ml pleased to sec the aggressiveness with which the 

committee is working to OOdrcss JHS staffing challenges. The authorities made available by S.l2SO 

should help the agency bring in lllld keep top talent. In particular, direct hire RUthority represents a 

valuable tool, and th>::! JHS has already tbund it to be useful in streamlining the hiring process for medical 

professionals.'" I urge the commiHeeto ensure, however, thatthls ~uthorlty ls, on the one hand, us()(! 

I'IISponsibly by hiring managers ltlld, on the other, mad!: flexible enough to meet the agency's needs. At 

the very least, this authority should be Implemented immediately fur mission-critical positions of 

demonstrated need that have bc<:t~ vacant at least six mor.ths. 

The committee is also right to include in Section !01 ofS.I2SO Ianguace allowing the IHS to ecstablish a 

pay system for its medical professionals that establishes pay parity with individuals campens$ted under 

Title 38 of the U,S. Code. Butwhil~this authority will help the IHS close the eup, it is worth noting VA 

Itself struggles to recruit and retain medical professional! even underTitleJ!J!' Tile committee should 

also make clear that this pay authority works not just for medical profe.ssionals but to hospital COOs and 

other senior healthcare administrators in the agency whose pooitions remain hard to fill. The committee 

must go further in reforming the UlS oompensation system, recognizing the added difficulti"" that the 

agency facea in recruiting providen.to facilities located in rural and remote locations. In the Partnership's 

view, !!Us means a market-sensitive compensation system forlHS medicalmd hcalthcaro adminis'lration 

prof.,sionals. Individuals in private sector medical leadership positions typically see compensation 

multiple times greater thfill that of federal e:<eeutives with similar responsibilities. Though the IHS 

!llready has limited ability to prov!despecinl poy l'l1tcs to medical profe.ssionals who fill critical need~;, 

granting broad market-sensitive pay would eliminate the need for lengthy application processes." 

Jmplemellling a new pay system will nlro require that IHS conduct a comprehensive compensation survey 

which allows the agency to understand the positions fur which it underpays, those for which itoverp•ys, 

and how it can adjust its compensation to ensure that it can beccmpetitive in recruiting the talent it needs. 

While the federal govenunent will likely never be able tc match private sector compensntion levels, 

Congress must be willing to invest in it.s leaders if it is to expect results. 

lndi.., H""lth Sorvice 

p.J. 

I, 
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There are other actions the committee can take to grant the !liS short-term flexibilitie.s to recruit ond 

retain top talent. The committee could allow the IHS to noncompctiliNly rehire fonncrfcderal 

govemnumtmedical prof~ssionals to any grade for which they qualifY, providing an addltlonal incentive 

to former IHS medical professionals t<J return to tlw agrmcy aft« having gained experience outside of 

government. Sen. Heitkamp, a member of this committee, introduced legislation, the CBP JriR~ Act, to 

improve r~crultmentand retention of CUstoms and Border Pnlrol officers in rural and remote locatioru. 

'The biU allows the agency tu "liSe eldsting hiring and retenticn authcrities with more flexibility" and is a 

narrowerVcrEi<>n <>f!cgislati<>n the Senator introduced last year that would have provided the same 

flexibility to all agencies." The Partnership supports this legislation nud believes it represents a potential 

model fllr addressing th& unique hiring challenges of the IHS. Finally, I hope the committee might take 

another look at recommendations ftom the Partnership's prav!ollS statement, Including implementing an 

IHS exit survey, co11ccting data <>n hiring process outcomes, providing training to hiring managers on 

flcxibilitie.! available to their agency and better utilizing student interns as a pipeline foreniT}~level talent. 

Rei'ommendations 

Provide Tmfntngto JHS SltPel1'/.1ors Mfi Manager& on Rewarding High Performers and Mllllaging Poor 

Performers 

As I lmve noted. elsewhere In this statement, mnny supcrvisors and manogers ore p<~orly prepnredand ill 

equipped fllrsupervisory and management roles. Pnrticulnrly difficult fur new supervisors maybe the 

challenge of dealing withemployoes who c!liiiiot or will not perform. In many cas<.:s, going through the 

disciplinary procll58 may be a period of"discovery learning" for these supervisors. The IHS and this 

committee should help support newsupen>iOOrs by mandating immediate as well as =urrlng;training for 

new supervisors on leading pellple, managing performance, understanding whistleblov.w protootions, and 

engaging their teams. By better equipping new supervisors to lead ti'oro the very beginning of their tenure, 

the IHS can actively address performance issues when they occur. 

Establish a Dual-TrackCtu'eer Palh That A flaws Aspiring Leaders Ia Self-8~lect!nto Supervisory Ra/e.s 

The rigid structure of the General Schedule syst<:m tends lo force employees to take on superviliory roles 

beeause It is the only way advance their careers, regardless of whether the employee has the skills or 

Inclination to be an effective manager. For employees with valuableteclutical expertise but who are not 

suited fllr or interested in supervisory duties. this is especially problem ali c. A dual-track career flllth that 

allows employees to become managers or advance /IS technical experts would give employees more 

options and provide ageocies with a cadre of man<~ gars who have chosen to lead people. Th~ result is 

more effective managers thr<Jughout the organization and mere satisfied employees overall. 

Stnmgthen 1h~ Probalirmary Period for New Hires and Sr~penoisQ/'s 

As noted nbove, agencies typically select supervisors for lhcirtcchnical expertise rather than their 

leadership abilities. The selecli<>n process, and the fact that government does not treat lcadCIShip as a 

discipline !caves managers without the tools or incentives to manage eff""tively. The committee should 

include as part ofS.l250 language requiring managers to make an affimtative detenninatlon ro continue a new employee or supervisor past their probntionruy period-the period during which the individual is 

suppw;ed to dt.:monstrate sucCGSsful pcrforman~e in tlteir position- only if the individual has 

demonstrated their fitness for the role. Managers should be held accountable in theirperfonnance plans 

fur making this detennination and providing fe6dback to probationers throughout this time. Raising the 

" Office ofS..,alor Heidi Heitkamp. (2017). CB!' Heed& Heitkamp:.- rt!pi!!Zied Cr:lls (O Proactively Address Fe<km/ 

Hir/tog, Rer:railimmt & Rc~<mt!Oll!ssuc& [Press release]. Retrie1-ed from 

htms:tt;, ww .be itkamp. <e<l3le.!!<>v!DU b t io'indcx.clm/20 17/l/cbp·heed "'h e itkarn e::s·repealed.catls-kl· 

pro•otivoty-•ddress.fodernl·hirlng.uonottmont-r=tton-tss"""· 
37 


613a8.eps

profile of the probationary period is one of1he quickest and most effective ways by which the wmmlttee 

can ensure th~t poor perfumtcrs do not find a pci11LlLI1Cnl place in the IHS. 

HQ/d Political Appohltecs Accr;!Witable 

The Indian Hcallh Service deserves credit fur requiring ils Director to have a pelformance plan connected 

to the organizal.ion's slmtcgic goals and which cascades down Into the plans of other employees, though 

the plWJ itself does notappenrto be publically availablc.31 The committee should request that plan and 

hold the Dirootoraccoll!L!ablc for the goal~ contained thecein. In reooiewing the plan, the committee should 

alw ensure that it includes goals rellltingto building a pipeline of future leaders within the organiZil.Lion, 

crcatins; a culture of accountability, filling mission-critical positions with high-qnnlity to.len~ and ensuring 

that employees are engaged in their work and committed to the goals of the organization. Additionally, 

the performance plan of the Director should be widely available and :accessible to both employees within 

the agency and the public. Having these goals as part Dftltl: Director's performance plan, and by 

oonnection, the plans of other senior Jeadecship will help drive grcaM focus on employee ongagement 

and leadership development. 

IlequinlHS to Us~ th~ "Hfghly-Qualfjied" S/011dm-d When Hiringlndtvidr!Ols Through the Direct Hire 

Authority Gr-antiUJ By 8.1250 

Direct hire ilUthority provides agencies much greater flexibility to fill mission-critical and hard-to-fill 

jobs. The committee shoulcl ensure that the direct hire authorized by Section lOS truly meeiS the agency's 

need by including a requirement thi!l candidates be "highly-qnnlified" to be appointed directly to a career 

pDSition in the IHS. Current law allows the use Dfdirect !tire authority requires Dnly that aclllldidll.Le is 

minimally qualified fur the position. By making clear that the candidate must be ltighly qualified, IHS can 

ensure that it is appointing top talent into these criticaljDbs. The Partnership believes the government 

should seck Dnly the most highly-qualified candidates, as opposed to individuals whD meet only the 

minimlll qulllifi<mtiaru forthcjob. Further, thia chans;e would bette:rfocus the agency's use of direct hire 

autlwrity on the quality of its hires, rather thWl simply the time it ll!kcs tD iill a pcsitio11. 

Aulfwrfze the IHStoNommnpelitiVely Rehire Former Employees to Any PositiDnfor Which They QualifY 

Acwrding tD current law, federal employees whD have htld a career or Cllfeer-conditional position can be 

reinstated non-comp<:titivcly within the federal government only to a job that is at or below the grade 

level they l351:held in the federal government regardless ufthe experience they may haw gained durins 

their time outside ofgDvernmenl The result is that government unn=arily disinccntivizcs talented 

furmerfederal employees from returning to public scrvic~. This proposal would encoumgemore 

movement between the HIS and the private sector, particularly private sector hospitals, and cncollfllgc 

tslented individuals to relum tD gDVernmentservlce. 

Better Align Pay for !HS Medical Proftu!onals and Healthcare AdminislratDrs wit/1 the Private Sector 

Executives and medical professiOllals at Indian Health s~rvice facilities take on exceptionally difficult 

jobs in unique, sometimes challenging environments. lftbe IHS is to attract and rclllin individuals with 

the skills needed tD meet il8 mission, it must be able to compensate them at a level that is at least roughly 

comparable to the private sector. Unfortun:rtely,lhe Geneml Schedule dDcs not allow for the kind cf 

flexibility that the ll·TS needs. While the legislation under dil;cussiDn today v:ould ~realtl pay parity with 

medical professionals under Title 38 of the United States Code, which provides for limited mw-keL· 

3cnsitivity. the problem Df private .sector ccmparability w:ll remain. Ideally, Congress wDuld revamp the 

filderal pay <y<tem tn enable all federol ~yoncles ID net ana level ptnyingfield to attract the best end 

"GovemmcntAoO<Jnnlllbil!ty Offiee, No. 17-llll, p. 7. 
38 


613a9.eps

brightesl As a first step. h<lwcvcr, the committoo !hould :ook for ways to niore aggressively close the gap 

between IHS medlool and henlthcare Bdministration profossiom!ls and th" private sector. 

Require IHS Th Conduct Regu/w SIICCessfon Planning .E::crcf&cs 

One of the key findings from GAO's January 2017 repor1 on the quality of care a\ the lHS is the prossing 

need for stronger succession planning activities ~cross the organization. IHS report~dly had not defined 

mcCI!ssion or contingency plans for key personnel across the organization." Such plmmlng Is especiaUy 

critical because 45.3 percent oflHS medical professioruili are over the age of 50 while jl1!;t 30 percent nre 

nndcr40.16 The •gency deserves credit for taking up GAO's recommendatiOIJand beginning the 

succes:;ion pllllllling prOC\lSS by distributing succession plmning instructions and descriptions of 

competencies for leadership positions to office and area directors. However, this should be an ongoing 

process. The P111'1n=bip and Booz Allen Hamilton found, in Preparing the People Pipeline: A Federal 

S"""ession Planning Primer, that such plannill{: is an eff<ctive tool for dealing with both d~partures and 

retention by helping niwlagers wulcr.itand the critical skills within theirorganizatioiJ.'l and retain needed 

talent. '

1 The eommlttee should require that the IHS regularly regular succession planning exercises and 

ask GAO to repor1 oo the quality ofth<lse plans. 

Collect and rJu High·Qualo'ty Peifmmance Data B•twhmarked to the Prh·ate Sec/ar 

To effe;:tively achieVe Its mission, the Indian Health Service must collect, report and, m01;t importantly, 

use higb"''uality data that allows it to understand the needs of the individuals and communities It serves. 

While the Service collects some clinical quality daia used by area offices in perfunnance evaluation and 

de<.:ision·making, it could and should do more. Data should include the cl!StOmer experience, employee 

engasemenr, healthcare quality, and human resources metrics like time-to-hire, quality of hire, and 

disciplinary process outcomes. Furlhcr, the Service should mllke this information publically available and 

assure stakeholders through Its actions that it is a<11ing on it to improve perfonnance. The committee 

sl10uld mandale that this information is collected and reported and make it a subject of ongoing owrsighl 

The native IXlmmunities served by the IHS deoorvc no lesl, 

Promote Greatu Mobility between Ihe lHS and the Privar .. Sector 

Breaking down the Wlllls between the !Mioo Health Service and the uutsidc world is a proven way to 

improve the agency's performance. Creating exchange programs that temporary assign high-performing 

employees to private soctororgani7.ntions, oroth~r agencies with similar missions like theDep!!rlment uf 

Veterans Affairs, ""mild llllow the IHS to offer tmiqne development opportunities for I!Spiring leaders, 

strategi<:ally fill critical vacancies, !llld bring innovative keas lnlo the organ! uti on. A well-designed 

exchnnge progrmn would alw IHS employees that the ngmcy values their development. Assignments 

could last from slxmonths to oneye!ll'with optioJJS to c:<tond and would 00 in addition to the talent 

exchange authcrity already avallabl~ under the lntergovemmentnl Personnel Act. 11Ie committee should 

also encournge and, when: necessary, authorize the Service to develop academic partnerships with local 

medicnl schools, ns the VA does today. 

Reform of the Indian Hl!llltb Sbould Serve as a Cablyst for Government-Wide Changes 
39 

The CHAIRMAN. Thank you for being here and for your testimony. 

We really appreciate it. 

I will turn to the Ranking Member and see if you would like to 

begin the questions. 

Senator UDALL. As we all heard at the last hearing, Medicaid 

billing accounts for a substantial part of IHS funding. That means 

the loss of CMS certification is both a safety concern and a funding 

issue. 

The Committee frequently receives status updates on the IHS– 

CMS system improvement agreements for the three South Dakota 

facilities placed on probation last Congress. The Committee has 

heard very little about the efforts to regain accreditation at the 

Omaha Winnebago. Omaha Winnebago tribal leaders, like Ms. 

Kitcheyan, report that they have similarly received few updates. 

What is the current CMS accreditation status of the Omaha Winnebago IHS facility, Admiral Buchanan? 

Mr. BUCHANAN. Currently, it remains unchanged. As mentioned 

earlier, it has been about two years since the certification was lost. 

One of the challenges we have had has been locating a senior 

leader for that position, a CEO position. We were able to locate a 

senior leader to operate the Omaha Winnebago Hospital and with 

input from the Winnebago Tribe and the Omaha Tribe, that person 

was selected, brought onboard and started implementing changes. 

As I understand, he has been holding regular meetings with the 

tribes, both Omaha and Winnebago, to provide those regular updates. 

Some of the challenges continue to be the leadership positions. 

Some of our key positions there still remain vacant. I recently 

heard that the CEO we hired will be resigning at the end of the 

month. That could pose a continual challenge going forward. 

Senator UDALL. Do you have a timeline for getting them back up 

and getting accreditation? 

Mr. BUCHANAN. We have been working continuously to try to get 

that timeline. It continues to move. Specifically, as new leaders 

come in, we want to apply for that certification when it is safe to 

do so. The next step in the process is to bring in a contractor such 

as Joint Commission Resources to evaluate and see where we are. 

That has been the next step. That is where we are. 


613a10.eps
40 

Senator UDALL. Admiral, you are very aware that Medicaid and 

Medicare, if these facilities are in a status where they don’t get 

those, that hurts the ability to their offering health care to a significant degree. It is very important to try to make sure we get 

them off that list and up and running, as you are well aware. 

Identifying and removing bad IHS employees is certainly an 

issue this Committee has heard about for some time but I really 

want to use this hearing today to drill down and make sure we are 

addressing the root cause. 

This question is to Mr. Stier. Mr. Stier, has your organization 

done any sort of analysis of how many IHS employees are reinstated through the MSPB appeal? When you mentioned leadership, 

you have heard we don’t have leadership at one of these facilities 

or more. We don’t have leadership today of the overall IHS in 

terms of a permanent person. We have the very well qualified gentleman here but he is in an acting capacity. Do you believe it is 

important to get full-time leadership rather than an acting person? 

Mr. STIER. Senator, there is no question that it is critical to get 

full-time leadership at IHS. I have no doubt that Acting Director 

Buchanan is terrific but the reality is, when you are in an acting 

status, it is impossible to really do the job in the same way. 

My analogy is the substitute teacher. You can be an excellent educator but the reality is that you are not perceived as having that 

long-term authority and it is very difficult to do the job as well as 

you might. 

It is also true, we just heard from testimony now that they are 

missing a CEO in a critical place. That kind of leadership vacancy 

is incredibly debilitating and fundamental to all of these issues. 

Figuring out how to deal with that, I would propose that a more 

market sensitive pay system would be one way of getting at that 

in a bigger way, again very much analogous to what the VA is experiencing as well. 

On the issue you raised directly about the Merit Systems Protection Board, the reality is the agency wins in the vast number of 

times. Only 2.1 percent of the cases actually get reversed in favor 

of the employee. That is not where the real issue is. 

Federal employees themselves, three-quarters of them at IHS, 

will tell you that poor performers are not dealt with. The problem 

is not creating rules to fire them faster, in fact, that will actually 

have unintended negative consequences, but the problem is trying 

to improve the management, the leadership. That is where you will 

get real improvement. 

That has not been done in the way that it needs to be. Your 

Committee could do it. 

Senator UDALL. Thank you. 

I yield back, Mr. Chairman. 

The CHAIRMAN. Senator Heitkamp. 

Senator HEITKAMP. Thank you, Mr. Chairman, for letting us go 

ahead of you. 

First, Mr. Stier, thank you so much for the plug for the work we 

are doing over in Homeland Security and Government Affairs. Senator Lankford, who is also a member of this Committee, and I have 

really made this a major initiative. We appreciate your support but 

41 

I think there are other lessons we are learning that can be applied 

here equally. 

I really appreciate your reference to our bill. I think it can, in 

fact, provide that support on hiring but we also have a supervisory 

training bill that I think can also be extraordinarily helpful. Could 

you comment on that? 

Mr. STIER. Yes, absolutely, I think you are entirely correct. 

These problems are the same across the board. You have general 

jurisdiction. Obviously, it is great that this Committee is focusing 

on the particular agencies over which it has oversight. 

The training piece is fundamental. Right now, we put great people in place without the tools they actually need to do their jobs 

well. The first thing that gets cut in these agencies is the training 

and development budgets. There really isn’t the kind of investment 

or requirements around managers that I think is necessary to actually see improvements in productivity and outcomes for the people 

being served. 

I think you are very much on the right track in the work you are 

doing. I think there ought to be, again, sort of alignment across the 

board with the efforts being done. 

Senator HEITKAMP. Admiral Buchanan, before she left her post, 

Mary Wakefield, who was the Deputy Secretary for HHS, performed a lot of hours of review of the problems we have at HHS 

or at the Indian Health Service. Where is that work? We don’t really need legislation for you guys to fix this. It is important to send 

a message that you guys can fix this on your own. I am appalled 

that the Winnebago Tribe still does not have a facility that is CMScertified. That is not acceptable. 

Where are those initiatives? Have you benchmarked them? Why 

haven’t those initiatives been carried out to the point where we 

could see the Winnebago of Nebraska actually having a full service 

medical facility? 

Mr. BUCHANAN. I heard the comments down the line related to 

acting. This is actually personal to me. 

I am a member of the Seminole Nation of Oklahoma, having 

been born in an IHS hospital, with family members that work at 

IHS. I hear Ms. Kitcheyan, a friend of mine, experiencing the 

issues at Omaha Winnebago Hospital and having worked there for 

three weeks to get an idea of what the conditions were and the 

challenges at Omaha Winnebago, this is truly personal. 

I respect the acting questions but I have family members that 

rely on the IHS system. I have family members who work in the 

system, so I hear your concerns and the issues you are raising. 

We are working hard to make those changes. One of the things 

that Ms. Wakefield developed, and the former Administration, was 

something we implemented in November 2016. It is the Quality 

Framework and Implementation Plan. That is the culmination of 

all the activities and recommendations of experts where the goal is 

to provide top quality health care and get back the trust of the 

tribes related to those issues. 

We have specifically identified five priority areas going forward: 

organizational capacity, accreditation, getting back the accreditation for the Omaha Winnebago Hospital, doing that specifically 

42 

with contracting to get one contractor to accredit all of our IHS 

hospitals across the Country. That is one avenue. 

Senator HEITKAMP. I just think this Committee would benefit. 

Maybe there are some changes we should make to those plans, but 

it would benefit from an analysis of where we were at the end of 

that survey, where we are headed going forward, and what additional tools does Indian Health believe they need to meet quality 

standards. 

I think it is not just about discipline. No discipline in the world 

is going to prevent a CEO from resigning literally weeks after the 

CEO took the job. 

Finally, I want to speak to Ms. Kitcheyan. How has this really 

affected the availability of health care for your tribe? 

Ms. KITCHEYAN. It has impacted the services at the service unit. 

Without that third-party revenue, which makes it enough, the services are weakened, the reputation is poor and the PRC, the preferred care dollars, are minimal. 

We were at Level 1 for a while. I think now they are down to 

Level 2. Many of the services aren’t available at the service unit 

so they are referred out. If you are only referred out, life or limb, 

there are many people who are sick and have chronic conditions 

that are not life or limb and continue to suffer. It is an essential 

piece of the operating revenue, this third-party revenue. 

I also want to mention that we are also without our Director of 

Nursing and our lab supervisor, two essential pieces along with 

this CEO. I guess I have to acknowledge our Acting Area Director, 

again another acting role, in getting the job posted. 

We have to celebrate our success where we can celebrate it, but 

that is such a small thing that we are happy it was posted in a 

timely manner. We are trying and they are trying as well but it 

is just not successful. It is very frustrating to lose these administrators in whom we put our confidence. We understand people have 

their lives and have to leave these positions, but we are not making 

any progress in these two years. I wish I could tell you differently. 

Senator HEITKAMP. I think this Committee shares that frustration that we aren’t making progress. We need benchmarks and 

then levels of accountability. Without it, I don’t see this getting better. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Heitkamp. 

Senator Cortez Masto. 

Senator CORTEZ MASTO. Thank you, Mr. Chairman. Thank you 

to the panel members. I appreciate you being here. 

Ms. Kitcheyan, let me just follow up because I also was concerned with what I was hearing regarding on what is going on with 

your community. You addressed some concerns with S. 1250, one 

being that Indian Country should be consulted because they are 

going to be impacted within its entirety. 

The need for adequate funding and oversight for new programs 

and no under-funded mandates, I agree with you. I don’t like unfunded mandates or unintended consequences. 

Then, you talked about tribal best practices for retaining providers. Are there models out there? Are there things we should be 

43 

looking at as we look to retain our providers in our tribal communities that you can cite? 

Ms. KITCHEYAN. I wasn’t so much talking about the retention of 

employees, but innovative programs such as the dental health therapy program in the Alaska area that has been successful with recruiting permanent, local providers who are more like a long-term 

solution than short-term volunteers who are not going to be sustained or circle back. 

Senator CORTEZ MASTO. Models that we should be looking to for 

recruitment? 

Ms. KITCHEYAN. We should be looking, at the local level, at programs such as the Alaska Native Dental Health Therapy Program 

which has been successful for that area and models like that which 

can mimicked throughout Indian Country. 

Senator CORTEZ MASTO. Thank you. I appreciate that. 

Ms. KITCHEYAN. We are looking for sustainable change for our 

communities. 

Senator CORTEZ MASTO. Mr. Stier, thank you for being here as 

well. 

In your testimony, you acknowledged the Committee’s focus on 

the workforce challenges facing IHS. You said in your statement, 

‘‘The myriad of challenges that confront the IHS are the result of 

both a broader Federal civil service system that is poorly suited to 

the needs of the modern health care delivery system.’’ 

I agree that we need some fundamental reforms in our delivery 

system. What do you think is the biggest exterior challenge to our 

leadership that is causing such a high turnover rate? 

Mr. STIER. I think there are so many different pieces to this but 

I think it would be best to think about how must the Federal Government stop being an island, an insulated and isolated institution 

and adopt practices that are now the norms in the private sector. 

When I say that, I mean very fundamentally the pay system. It 

was a pay system that was designed literally in 1949 and intended 

for a government that was almost, in large majority, a clerical 

workforce. Now it is a professional workforce. 

When you think about the challenges of hiring what is already 

a short supply set of professionals in areas that are very difficult 

to recruit for in rural and remote areas, I think it is really important to make sure IHS has the same tools that the best in class 

in the private sector has. 

That means finding market sensitive pay, in particular, not just 

for the physicians. Again, I think of the comparison to the Veterans 

Affairs problems, and they are very much the same thing. They 

have the same kinds of issues, especially in remote and rural areas. 

I think one issue they face is it is very hard to recruit CEOs, hospital directors, people who are phenomenal administrators that are 

fundamental to the success of those institutions. 

If you ask me what the largest factor is right now, it is a system 

that doesn’t offer the same kinds of tools to the government that 

the best in class in the private sector has. If you have those, then 

IHS will beat anyone out there. 

What is amazing when you look at the data, what the employees 

have to say is, you have a workforce that is fundamentally charged 

up about its mission; they care about what they are doing. You 

44 

hear that from Director Buchanan. He cares about what he wants. 

That is something private sector employees would die for, that kind 

of intensity of mission commitment. 

What they don’t have is the right tools. That is one thing you can 

give. 

Senator CORTEZ MASTO. Thank you. I appreciate that. 

I have one final question. Because I am new to the Committee, 

I am going to focus this on Admiral Buchanan. I am curious how 

you would handle this. 

I was the Attorney General in Nevada for eight years. As part 

of that work, I represented the State agencies. Anytime there was 

legislation passed, we helped them to interpret it and address unfunded mandates, unintended consequences, and also, constitutionality provisions. 

I understand, after reading through everything, there is a concern with Section 106 in S. 1250. That particular section has been 

held unconstitutional by the U.S. Court of Appeals for the Federal 

Circuit in Helman v. Department of Veterans Affairs. 

If that provision is still in the bill as we pass it, how would you 

address the constitutionality provision in Section 106 that has been 

held unconstitutional by the court? 

Mr. BUCHANAN. That is a great question. 

At the Indian Health Service, we defer to the Department of Justice for court issues and litigation. We would typically defer to 

them. 

Senator CORTEZ MASTO. To legal counsel, similar to what I addressed. Thank you for that. 

Mr. Chairman, as a new member, I don’t know how this would 

normally be handled, but I would love an opportunity to address 

that provision if it has truly been held unconstitutional by the 

courts, how that normally would be handled in the Committee, and 

that process. 

Thank you to the panel members. I appreciate the comments 

made today. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Senator Daines. 

STATEMENT OF HON. STEVE DAINES, 

U.S. SENATOR FROM MONTANA 

Senator DAINES. Thank you, Mr. Chairman and Ranking Member Udall. 

I think it is pretty clear from what we have heard today, as well 

as what I hear as I jump in my Ford pickup and drive all across 

Montana and Indian Country, that the Indian Health Service isn’t 

working. 

However, across the Country, we see large, complex health systems that are deploying the principles of improvement science to 

improve the quality of care and health outcomes. One mechanism 

to do so is through the Collaborative Improvement and Innovation 

Networks, also known as CoIIN, whereby these multidisciplinary 

teams of Federal, State and local leaders work together to tackle 

a common problem. 

IHS has certainly been a common problem for Montana’s Native 

American communities. I cannot tell you how many hours, if you 

45 

are a member of the United States Senate and you come from Indian Country, you spend time engaging and sitting down with 

tribes and you get an earful. As soon as your left ear is full, your 

right ear gets full in terms of the challenges we face right now in 

IHS. 

Admiral Buchanan, I believe you are familiar with the CoIIN 

model. I understand IHS has been participating in the HHS Health 

Resources and Services Administration’s CoIIN design to prevent 

infant mortality, an important place to start. How has the participation of IHS in that CoIIN improved infant mortality rates in Indian Country? 

Mr. BUCHANAN. IHS has been using elements of the CoIIN model 

through NOAs and IPAs for a very long time. The Indian Health 

Service has partnered with HRSA in partnerships related to the infant mortality CoIIN with the goal of preventing and reducing 

American Indian and Alaska Native infant mortalities. 

We have implemented the recommended strategies that are culturally appropriate with the pre-natal and post-natal education activities. I can provide additional details for the record if you like. 

Senator DAINES. Admiral, can you think of any other specific 

trends you are seeing in Indian health where a CoIIN might be 

able to address it? 

Mr. BUCHANAN. There are some other activities we have been 

doing. One that comes to mind right off the bat is the Special Diabetes Program for Indians where we provided funding to NCAI, I 

believe, of $1 million or so where they work with a TRAIL program 

to implement something similar to the CoIIN model you are referencing. 

Senator DAINES. Thank you, Admiral. 

Ms. Kitcheyan, among the reforms in the system included in the 

Restoring Accountability in the Indian Health Service Act, I know 

you found the expansion of training for IHS personnel in tribal cultural and history to be ‘‘of utmost importance’’ just as it is to the 

Montana tribal leaders with whom I consulted on this legislation. 

Could you share with this Committee why you believe that is important? 

Ms. KITCHEYAN. It is important that the IHS personnel, whether 

it be the providers or the administrators, have the proper cultural 

sensitivity training when they engage with the tribal community. 

One of the things I want to impress upon this Committee is that 

it is not going to be a one size fits all model. We need to design 

these cultural sensitivity programs that are distinct to the Nation 

that this provider or administrator will be working in. 

That is one of the challenges with solutions for Indian Country. 

It is like this pan-Indian idea that they want to roll out to every 

tribe. We find it does not fit for every tribe. We have to have respect for that distinct Nation and their cultural norms, especially 

with the elders and some of the lady relatives and things that are 

appropriate and inappropriate in our communities. I will just leave 

you with that. 

Senator DAINES. Would you say then it would also be beneficial 

to train new medical personnel on the unique history? I am using 

the words unique history and culture of each tribal community in 

which they serve prior to beginning the work at an IHS facility? 

46 

Ms. KITCHEYAN. Yes. Thank you. I think that is an amazing suggestion. It is only fair to the provider as well, in order them to feel 

like they are fully prepared to engage with the tribal community 

and patient. 

Senator DAINES. It seems like a tool in an on-boarding process. 

You get off to a much better start if you have some those issues 

trained ahead of time. 

Ms. KITCHEYAN. Right, and that might help with the retention so 

that the provider feels they know where they are going and they 

would, I feel, be further embraced by the community if they had 

that respect and effort into learning about the people. 

Senator DAINES. I am out of time but it is good to hear. I would 

be interested in exploring that concept in working with the tribal 

leaders back in Montana, as well as with my colleagues here in the 

Committee, as well as with IHS. 

Thank you. 

Ms. KITCHEYAN. Thank you. 

The CHAIRMAN. Dr. Crowley, in S. 1250, we are trying to come 

up with a simplified, uniform credentialing process so that dentists 

who are willing to volunteer can go out and provide services on the 

reservation. What recommendations do you have for us? 

The Dental Association and dentists have approached me and 

they are willing to do this. I think it is a remarkable opportunity 

and there is an incredible need out there. How do we make sure 

that we set up a system that gets them credentialed and gets them 

out there helping in Indian Country? 

Dr. CROWLEY. Thank you, Senator. I thought you were going to 

let me off the hook. 

The CHAIRMAN. No, sir. 

[Laughter.] 

Dr. CROWLEY. I think the model is there. The other Federal services have a credentialing service that is national that goes to simplification, using online means and they can get all the data they 

need with licensing, the national databank, issues and any other 

education issues they need. It can be done in a simple and fast way 

through online credentialing. 

The CHAIRMAN. Who administers that? 

Dr. CROWLEY. Maybe the Admiral would know but it is the Federal service, the Army, Navy, Coast Guard, I think the Veterans 

Service. I think they use that service now as they credential. It is 

a much more condensed, abbreviated, quicker pathway to get the 

information they need to accredit someone they want to bring onto 

their service. 

The CHAIRMAN. IHS could plug into that system? 

Dr. CROWLEY. The Admiral may be able to answer whether there 

is a plug-in to that but I certainly think there is a model there. 

The CHAIRMAN. You would be willing to work with us and IHS 

to try to plug-in to that type of model? 

Dr. CROWLEY. Most certainly. If I can speak to a higher level of 

what you have said, the millennials in dentistry are almost half of 

our dentists now. Our dentist millennials are just like the other 

millennials. They take social responsibility seriously. They want to 

reach out; they want to do good. 

47 

To have the availability to be able to quickly go someplace, coupled with the fact that the dental students today graduate with 

more debt than any professional in the Country, and the fact they 

have loan payment systems, it certainly is an eye opener for these 

young people to combine their social consciousness with the ability 

to get a job that they can go help people. 

We also know the Indian Nations have the highest amount of 

dental disease as any of our population. The care needs to be there. 

We have to get the model there to help them prevent this disease. 

You cannot treat your way out of it. 

I think our system where we are working with our CDHCs, we 

are going in with the Navajos and bringing young people to the 

table to help educate so they can go back to their populations and 

be a culturally competent person from the get-go on how we are 

treating prevention of oral disease and access to work with others 

and collaborate with our other health care professionals to bring 

oral care to the level it needs to be with the Indian population. 

Getting the dentists there is critical. This credentialing would 

simplify that tremendously. I think you would see very good results 

because of that. 

The CHAIRMAN. I really appreciative of the Dental Association 

and individual dentists. Their willingness to do this is just an incredible opportunity. It is something we need to put in place as 

soon as we can. 

I would ask Admiral for your commitment to work with the Dental Association to effectuate that type of credentialing process so 

that we can get these dentists out there doing the good work they 

are willing to do. 

Mr. BUCHANAN. That is a great question and I am happy to work 

with the Committee, with Mr. Crowley and Mr. Stier on the issues 

they have raised. 

I wanted to provide a quick update on the credentialing process. 

We recently awarded a contract for a national credentialing system. We are excited about that. We are rolling that out to four pilot 

sites across IHS through July. All of our facilities will be on that 

credentialing system and all of our areas will have that by the end 

of the year. 

We are excited that it will streamline and standardize the process. As a former CEO and former area director, I know what it 

takes to go through the credentialing process for a provider. It is 

a huge binder and lots of checks, making sure the provider has the 

training, credentials, and checking databases. That is just for one 

provider. That goes on for a long time. 

Those documents get rolled up to the area office. My chief medical officer and I will review those. We will signoff. It is a cumbersome process. Putting it in an electronic format, as discussed, 

is a goal that we are implementing now. We definitely will be 

happy to work with the Committee. 

The CHAIRMAN. How long will it take to get that in place and 

working? 

Mr. BUCHANAN. We have awarded it and have pilots going out 

right now. We have updated our policies. Of course, with government agencies, you have to create policy and guidance on how to 

48 

operate the credentialing system. That is in place and it is going 

through clearance right now. 

Dr. CROWLEY. Senator, if I may. I promise that the American 

Dental Association will work with the Admiral and IHS to move 

this forward. We will get out the message to the dentists of America that this opportunity exists for them to help in this process. 

The CHAIRMAN. I very much appreciate that, Doctor. Do you have 

a time frame to have it activated? 

Mr. BUCHANAN. We do. By the end of July, we will have it going. 

It is actually in process right now. 

The CHAIRMAN. The end of July? 

Mr. BUCHANAN. Yes. 

The CHAIRMAN. Good. I thank you both. 

Ms. Kitcheyan. 

Ms. KITCHEYAN. I am sorry, I have to make a comment. 

Although I appreciate the partnership that is being garnered 

right now, Indian Country does not need more short-term providers. That is not a long-term solution. With all due respect to the 

panel, I just have to voice that. 

The CHAIRMAN. It is not mutually exclusive of long-term solutions. It would be in addition to that. 

Ms. KITCHEYAN. There are some creative solutions happening 

within Indian Country that I would like the Committee to consider. 

It is just that we don’t need more short-term, revolving doors in Indian Country in terms of chronic oral health. We already have that 

problem on the other side of the aisle. I just want to make that 

comment so it is clear that Indian Country wants sustainable solutions, not short-term volunteers. 

The CHAIRMAN. Absolutely. Thank you. 

At this point, I am going to turn over the gavel to Senator Murkowski to preside. Senator Udall also had some more questions. I 

am turning it over to you. 

Senator MURKOWSKI. [Presiding]. Thank you. 

I have what is not really a question. I apologize that I was not 

able to hear the full testimony. 

Ms. Kitcheyan, you mentioned some of the innovative solutions 

that are out there. In Alaska, we led on the middle level provider, 

the dental health therapist, and the DHATS Program that I think 

for many years was viewed as far too experimental, that we would 

see poor health outcomes, and that it was less than acceptable 

care. 

The reality was that getting dentists full-time out to our villages 

was just not going to happen. We did have a great many dentists 

who were very generous with their time who would literally volunteer to come out for a month or six weeks in the summer. 

However, that meant for a family in a village to wait a full year 

when your child needed dental care and when you needed dental 

care. Then when the dentist did come, they literally worked around 

the clock to provide for the needs. 

What we have been able to do with the DHATS Program, I think 

has been viewed as a model, as remarkable and as a response that 

was generated by the extraordinary need. What has been very 

heartwarming to me is to see how over the years, the Dental AssoVerDate Mar 15 2010 13:50 Nov 30, 2017 Jkt 027650 PO 00000 Frm 00052 Fmt 6633 Sfmt 6601 S:\DOCS\27650.TXT JACK
49 

ciation has come to accept, I think is a fair word, that the level of 

service that has been provided has been important. 

We now have preventative care being given in our villages when 

we had nothing before. It is being done by local people who, when 

you are in the grocery store and you see an eight-year old, say, how 

is that flossing coming? That is kind of a reminder instead of waiting and hoping you will have a dentist who actually comes to your 

village that year. 

Being innovative is important. Longer term solutions are important. I think in Alaska we have clearly seen the proven success of 

mid-level providers. 

The Chairman did not give me a list but I am told that Senator 

Tester has a question. 

STATEMENT OF HON. JON TESTER, 

U.S. SENATOR FROM MONTANA 

Senator TESTER. Boy, do I ever. Thank you, Madam Chair. 

Admiral Buchanan, what is the biggest challenge IHS has? You 

have been onboard since when, January. What is the biggest challenge it has, in your opinion? 

Mr. BUCHANAN. Recruiting and retention of qualified providers in 

rural and remote areas. 

Senator TESTER. The budget is not a problem? 

Mr. BUCHANAN. We are very effective with the resources that we 

have. 

Senator TESTER. You understand that we pay more money for 

health care for prisoners and our prison system than we do for 

folks in Indian Country? 

Mr. BUCHANAN. I have seen those reports. 

Senator TESTER. So you are saying we are spending too much 

money on prisoners? 

Mr. BUCHANAN. I did not say that. 

Senator TESTER. I will tell you that I think IHS has a huge problem. That problem is you are dealing with rural areas of this Country where, quite frankly, it is hard to get people because it is tough 

work, number one, and very challenging work, number two. 

I think it is very difficult to keep people when the budget, before 

ACA, what was the term they used, ‘‘If you weren’t going to die, 

you ran out of time.’’ I think that is a huge problem. 

The question becomes, you are low on staff, right, just like the 

private sector, just like the VA, and cannot get enough doctors or 

nurses. What are you doing about that? How long does it take you 

to hire somebody in the VA? 

Mr. BUCHANAN. It depends. 

Senator TESTER. Not the VA, IHS. 

Mr. BUCHANAN. I understand. I want to comment a little bit to 

Senator Murkowski’s comments related to the Alaska issues related to DHATS and some other providers. 

Last week, I had the opportunity to visit Alaska. I was invited 

by some of the chiefs to see some of the innovative activities going 

on. I would be remiss if I did not mention Allakaket Village, Rampart, Marshall, and Bethel, Alaska where they are implementing 

the DHAT Program and providing the training with some truly inVerDate Mar 15 2010 13:50 Nov 30, 2017 Jkt 027650 PO 00000 Frm 00053 Fmt 6633 Sfmt 6601 S:\DOCS\27650.TXT JACK
50 

novative ways in Alaska in truly challenging conditions. Hats off 

to them. 

We are looking at those as opportunities to move those types of 

activities forward specifically with developing work groups related 

to those mid-level activities. That is something we are actually 

doing and will be implementing very soon in the near future. 

Of course, recruitment and retention is a huge challenge. The 

time that it takes to get a physician onboard can depend. We have 

implemented the Global Recruitment Initiative where you can announce in one location for a physician and that announcement can 

go across IHS to a field where that physician wants to go. 

To answer your question, we have been able to get a physician 

on as quickly as 60 days. 

Senator TESTER. Sixty days if they were within the VA. What if 

they are not within the VA? 

Mr. BUCHANAN. That is within IHS. 

Senator TESTER. I mean within IHS. What if they are not within 

IHS? 

Mr. BUCHANAN. That is actually them coming in off the street 

into the Indian Health Service. 

Senator TESTER. You can get them hired in 60 days? That is not 

bad. 

Have you guys implemented any best practices since you have 

been head of the IHS? 

Mr. BUCHANAN. Specifically related to recruitment and retention? 

Senator TESTER. Specifically recruited to patient care, because I 

think that also impacts recruitment and retention. 

Mr. BUCHANAN. Quality is at the focus of everything we do. The 

quality framework is something we have been implementing. I 

mentioned one of the items, the credentialing software program 

that we have rolled out. Patient wait times is another activity 

where we have identified a standard that is going through our 

process to formalize. We will have those by July. 

We have been implementing telemedicine that recently rolled out 

in the Great Plains starting with Pine Ridge and Rosebud. Eagle 

Butte is also on the list and scheduled to roll out today. We have 

done several things. 

Senator TESTER. That is great. What is your wait time standard? 

Mr. BUCHANAN. Wait time standard, I have yet to see the document. It is working its way through the process. 

Senator TESTER. We would love to have that as soon as you get 

it. 

Lastly, this is for Dr. Crowley and Mr. Stier, very quickly because I am out of time. 

Could you give me your top recommendations on how we can recruit better folks to the IHS, whether dentists, MDs or whatever? 

Dr. CROWLEY. From my perspective, for dentistry, it is to make 

it easy for the dentists to get there and actually hire them and 

bring them on board to do the work. 

Senator TESTER. In a timely manner, you are talking about? 

Dr. CROWLEY. Yes. 

Mr. STIER. My recommendation would be to focus at the top. 

Make sure that you actually give IHS the tools to recruit the CEOs 

and the hospital directors they need. They can then do the recruitVerDate Mar 15 2010 13:50 Nov 30, 2017 Jkt 027650 PO 00000 Frm 00054 Fmt 6633 Sfmt 6601 S:\DOCS\27650.TXT JACK
51 

ing for the physicians and other staff that they need. If you do not 

have the people at the top, nothing else underneath is going to 

work the way you want it to. 

Senator TESTER. Very good. 

I want to thank you all for your work. I can tell you that IHS 

has been a failure, quite frankly. We have had a couple different 

Administrations; this is the third one, since I have been in the Senate. 

One of the best things that transpired for Native Americans is 

Medicaid expansion because it freed up some money for IHS and 

helped move the ball forward for people who were not making 

enough money to be able to afford health insurance. 

As we approach taking up a health care bill a week from Mon- day, as I see a budget that is about $300 million short, I might be 

off on that, I think we have some tough decisions to make here. I 

do not know if we can make them and actually accomplish the 

trust responsibilities we have for our Native Americans across this 

Country. 

Rear Admiral, I think everyone on this Committee is more than 

happy to work with you, but you cannot get blood out of a turnip. 

Thank you. 

Senator MURKOWSKI. Thank you, Senator Tester. 

I think Senator Udall and I are both looking at one another as 

the appropriators on the Interior Appropriations that has the oversight of IHS. I think we want to continue to try to do right by these 

budgets. You mentioned it is tough but we have an obligation here. 

Senator Thune. 

STATEMENT OF HON. JOHN THUNE, 

U.S. SENATOR FROM SOUTH DAKOTA 

Senator THUNE. Thank you, Madam Chair. 

I thank you and Senator Udall for your indulgence and letting 

me briefly join the Committee. This is an issue in which, as you 

know, I have a great interest. It has a profound impact on our 

State of South Dakota. Thank you for giving me a chance to ask 

a couple of questions. 

I just want to echo what Senator Tester said and say it as plainly as possible. That is that the Indian Health Service just continues 

to underperform. The consequences continue to negatively impact 

the quality of care, with sometimes devastating consequences. 

What we see is taxpayer dollars get wasted and patients are put 

at risk. We have significant problems at the facilities in South Dakota. Even after two IHS facilities had entered systems improvement agreements with CMS, they continue to find serious deficiencies at both facilities. 

These systemic problems are what prompted Senators Barrasso, 

Hoeven and I to introduce the Restoring Accountability in the IHS 

Act, one of the issues we are here to discuss today. 

It is long past time to address the problems with IHS. They have 

been identified time and time and time again. This bill is aimed 

at giving the Indian Health Service and the tribes the tools they 

need to provide quality care for patients. 

Our tribes deserve better than the status quo. This hearing, I 

think, is an important first step in getting these reforms passed 

52 

through Congress and hopefully to the President’s desk for his signature. 

I want to ask, if I might, Director Buchanan, a question that has 

to do deal with what is going on in South Dakota as I referenced 

earlier. I appreciate the IHS’s efforts to address these systemic 

issues but it seems to me that what my colleagues and I are told 

by IHS often does not match what is happening on the ground. 

You mentioned in your testimony that ‘‘In November 2016, IHS 

launched the Quality Framework and Implementation Plan to 

strengthen the quality of care and organizational capacity.’’ Yet in 

April, 12 months after the Rosebud and Pine Ridge IHS facilities 

entered into their systemic improvement agreement with CMS, unannounced CMS site visits found both facilities out of compliance 

for failures within the governing body and the quality assessment 

and performance improvement programs. Even more concerning is 

feedback from my staff and what I hear from Pine Ridge and Rosebud tribal members that the quality of care has not improved and, 

in some cases, has gotten worse. 

My question is, how can we trust IHS in addressing these issues 

when CMS site visits and tribal members consistently say otherwise? 

Mr. BUCHANAN. That is a great point. I acknowledge the concerns 

that you bring up. We are implementing the quality framework 

going forward specifically related to organizational capacity which 

is one of our priorities. 

The other priority is transparency and accountability, communications with the tribe, which I believe we have increased even 

more so, and accreditation, trying to maintain that going forward. 

We have been doing several things to make those changes to be 

more long term going forward. 

Implementing the quality framework, putting area quality assurance officers at the area level, at the service unit levels, is another 

activity we have done. We have doubled our efforts by bringing 

folks from other areas to assist. 

As to Ms. Kitcheyan’s point, we do not want short-term fixes. We 

want them to be sustained over a long period of time. 

Senator THUNE. One of the things you state in your testimony is 

‘‘IHS is committed to regular, meaningful tribal consultation and 

collaboration for a sound and productive relationship with the 

tribes.’’ That is your quote. 

We continually hear that there is a lack of consultation. It is a 

complaint I deal with all the time, as does my staff. What steps are 

you taking, in the midst of this mess that we have in South Dakota, to consult with and hear from the tribes when it comes to 

some of the issues we have raised about quality? 

Mr. BUCHANAN. We have created a template. One of the things 

that comes to mind is the request for budgets, financial documents, 

and those sorts of things. As the area director when I was in the 

Great Plains, I provided those documents, what I thought, at least 

twice to all the tribal leaders in the Great Plains. There was obviously a breakdown in communication. 

Specifically related to the budget issue, we have created a template that we were utilizing for not only the Great Plains but 

53 

throughout IHS. It is a template of those financial documents so 

that we can standardize those and be streamlined. 

Some of the other things we are doing is we have had all tribes 

calls where if an issue is brought up and there are questions, 

whether related to the budget, we provide budget 101 to increase 

those communications and transparencies. 

When an issue was raised regarding the budget, the $300 million 

decrease in the budget, we reached out to all the tribes and had 

a call to explain the $300 million reduction and also where that information can be found on websites across the agency. 

Senator THUNE. Madam Chair, I want to be respectful with the 

Committee’s time so I have other questions I would like to submit 

for the record. 

I just want to say that I hope this Committee can move quickly 

on this legislation being discussed today. I think there are some 

steps in here that will help enormously with some of the issues I 

identified, certainly with respect to the Great Plains tribal issues 

but hopefully all across the Country. 

Thank you for the time. 

Senator MURKOWSKI. Thank you, Senator Thune. 

Senator Udall. 

Senator UDALL. Thank you. I have just a couple of quick questions. 

Ms. Kitcheyan, last year when you testified before this Committee you told us, ‘‘Employees need to be held accountable for 

their actions. No longer can IHS continue to protect, cover up, shuffle, transfer or perpetuate incompetency.’’ That is your quote. 

Is it your opinion that the employee accountability problem at 

IHS stems from fired employees gaming the appeals process and 

being reinstated or in the alternative, do you believe it comes from 

a failure of IHS to formally identify and take action against bad 

employees? 

Ms. KITCHEYAN. I believe it is the failure to take action against 

bad employees. For so long, there was this system, I know we have 

used the term ‘‘cronyism’’ where they protected one another. Bad 

nurses protected other bad nurses. 

It had become so egregious that there was just a culture of that 

amongst my service unit. It is that cronyism that led to some of 

the deficiencies in patient care because things had become so acceptable because you could just cover it up. 

I would say it is directly tied to the relationships they had 

amongst each other that it never reached area or headquarters. 

Senator UDALL. Thank you for that answer. 

At our last hearing, I mentioned the Democratic members of this 

Committee sent a letter to President Trump urging him to exempt 

Indian programs from a February hiring freeze. Mr. Buchanan, I 

then asked you if IHS was being impacted by the subsequent ‘‘reduction in force’’ planning ordered by the President. You stated it 

was not. 

However, in her testimony today, Ms. Kitcheyan states, ‘‘While 

hiring freeze waivers were eventually obtained for many IHS positions, it is our understanding that some positions necessary for 

CMS certification remain under freeze status.’’ 

54 

Mr. Buchanan, what is the current hiring status of the IHS? This 

is really a yes or no answer. Are all critical medical vacancies being 

actively and expeditiously filled? 

Mr. BUCHANAN. Yes, sir. 

Senator UDALL. Thank you very much. 

Thank you, Madam Chair. 

Senator MURKOWSKI. Thank you. 

We do have a second panel we would like to go to. If there are 

no further questions, we thank each of you for your testimony here 

this afternoon and invite the second panel to come before the Committee. We appreciate the patience of each of you in spending time 

with us. 

This afternoon we will hear from Heidi Frechette, Deputy Assistant Secretary, Office of Native American Programs, U.S. Department of Housing and Urban Development here in Washington; Dr. 

Keith Harris, Director of Clinical Operations, Homeless Programs 

Office, U.S. Department of Veterans Affairs here in Washington; 

The Honorable Liana Onnen, Area Vice President, Southern Plains 

Region, National Congress of American Indians also here in Washington; and our long traveler, my friend, Mr. Mark Charlie, President/CEO, AVCP Regional Housing Authority located in Bethel, 

Alaska. I think you get the prize for traveling the farthest. We appreciate your making the trip to be here. The panel is rounded out 

by Sami Jo Difuntorum, Chairwoman, National American Indian 

Housing Council here in Washington, D.C. 

Ms. Frechette, would you begin your testimony. We would ask 

that you please limit your testimony to no more than five minutes. 

Your full statement will be incorporated as part of the record. 

STATEMENT OF HEIDI FRECHETTE, DEPUTY ASSISTANT 

SECRETARY, OFFICE OF NATIVE AMERICAN PROGRAMS, U.S. 

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 

Ms. FRECHETTE. [Greeting in native tongue.] Hello and thank 

you. 

My name is Heidi Frechette. I am the Deputy Assistant Secretary for Native American Programs at the Department of Housing and Urban Development. 

Thank you, Chairman Hoeven and Senator Murkowski as well as 

Vice Chairman Udall, and members of the Committee, for this opportunity to discuss Senate Bill 1275, the BUIILD Act, and Senate 

Bill 1333, The Tribal HUD–VASH Act of 2017. 

I also wish to say thank you to the Committee staff for coordinating the hearing and their ongoing engagement with HUD on 

many Native American issues. 

I am honored and humbled to testify with this esteemed panel 

of tribal leaders, tribal advocates and the Department of Veterans 

Affairs. As a career SES at HUD, I administer the largest national 

Indian housing programs and work closely with tribal leaders, tribally-designated housing authorizes known as TDHEs and tribal 

housing departments who are doing amazing and innovative work 

in their communities. 

Since I began my tenure in June 2016, I have visited Native communities in most of your States to discuss the issues and chalVerDate Mar 15 2010 13:50 Nov 30, 2017 Jkt 027650 PO 00000 Frm 00058 Fmt 6633 Sfmt 6601 S:\DOCS\27650.TXT JACK
55 

lenges tribes face and to hear directly from the tribal leaders on 

what HUD can do to strengthen Indian housing programs. 

Today, one out of every four Native Americans lives in poverty, 

including more than one-third of all Native American children. 

Given these grave statistics, HUD looks forward to working with 

Congress on the reauthorization of the Native American Housing 

Assistance and Self-Determination Act known as NAHASDA, 

which authorizes the single largest source of Federal funding for 

housing in Indian Country. 

Tribes have made great strides under NAHASDA and a recently 

published Indian Housing Needs Study concluded NAHASDA 

works. Under NAHASDA, tribes have produced more housing units 

per year and have produced better housing, housing tailored for 

local conditions, customs and climates. 

NAHASDA supports the government-to-government relationship 

between the Federal Government and tribal governments. It recognizes tribal sovereignty by providing flexibility and local control so 

that each tribe can decide how to best address the unique housing 

and community needs. 

NAHASDA funds are often used as seed money to leverage funding for new construction and rehabilitation. Last week, I had the 

honor of visiting the San Felipe Pueblo in New Mexico. The TDHE 

used their $500,000 annual IHB block grant, HUD’s Title VI Loan 

Guarantee Program and HUD’s Section 184 Program to attract an 

additional $5 million in funding to construct a new housing subdivision. 

There are examples like this from tribes across the Country. 

Tribes are leveraging NAHASDA dollars and utilizing other programs such as low income housing tax credits to address their 

housing needs. 

The BUILD Act, in addition to reauthorizing NAHASDA, also 

seeks to streamline the environmental review process, authorize 

technical assistance funding for a broader range of TA providers 

and reauthorize the HUD Section 184 Program, which is a home 

loan program and is the largest mortgage program for Native 

American families. HUD looks forward to working with the Committee on this bill. 

Senate Bill 1333, the Tribal HUD–VASH Act of 2017, permanently authorizes the current pilot program that HUD is conducting in conjunction with the VA which has made great strides 

in housing Native veterans in Indian Country. The Tribal HUD– 

VASH pilot was authorized to reach eligible veterans who were unable to access the general HUD–VASH Program because they were 

Native and lived on Indian lands. 

As of June 1, the Tribal HUD–VASH Demonstration Program 

has housed 103 veterans in tribal areas. Tribal HUD–VASH has 

real tangible impacts on veterans’ lives. One veteran in the program struggled with substance abuse for many years. Through 

Tribal HUD–VASH, she accessed safe and affordable housing along 

with support services to help her combat her addiction. 

This alone is amazing. However, equally amazing is to see how 

her neighboring veterans check in on her and help protect her sobriety by preventing contact from people who come around and try 

56 

to trigger a relapse. She is now employed and is maintaining her 

sobriety. 

At Standing Rock, North Dakota, veterans are being housed in 

Title VI-financed units and the Black Feet Tribe of Montana is finishing construction of 50 new units, 20 of which will be new units, 

new project-based Tribal HUD–VASH units. 

We can see the difference Tribal HUD–VASH is making in the 

lives of individual veterans. HUD is committed to serving this population. We look forward to working with Congress, VA and IHS 

to ensure that they are well served. 

In closing, HUD’s Indian housing programs do more than just 

build homes. They bring hope to communities. Last week, I visited 

a tribe and was invited into a new home of a mother and her four 

children. 

Often on my visits to tribal communities, I am shown vacant 

units so that we do not disturb families in their homes. I was surprised this mother was so insistent that we visit her house. When 

we arrived, we were welcomed by the grandmother because the 

mother was at work. The grandmother was accompanied by her 

eight-year old granddaughter who was out of school for the summer. 

It was so moving to see how happy and excited this young girl 

was as she moved out of overcrowded conditions. She insisted on 

giving me a tour of her new home. She was particularly proud to 

show me her new bedroom which she pointed out she did not have 

to share with her three little brothers. That was very important to 

her. 

Senator MURKOWSKI. Ms. Frechette, if you can wrap up, you are 

well over your time. I am sorry because it is a very compelling 

story. 

Ms. FRECHETTE. I will hurry. 

As I left, I thanked the grandmother for hosting us and she gave 

me a hug and thanked me for the hope and opportunities the HUD 

programs provide. That is the gist of why we do what we do. I was 

encouraged by the difference the tribe made, the TDHE made and 

is making in the lives of people utilizing HUD programs. 

Thank you. It was an honor to appear before you. I am happy 

to answer any questions you may have. 

[The prepared statement of Ms. Frechette follows:] 

PREPARED STATEMENT OF HEIDI FRECHETTE, DEPUTY ASSISTANT SECRETARY, OFFICE

OF NATIVE AMERICAN PROGRAMS, U.S. DEPARTMENT OF HOUSING AND URBAN

DEVELOPMENT

Thank you Chairman Hoeven, Vice Chairman Udall, and Members of the Committee, for this opportunity to discuss Senate bill 1275, ‘‘Bringing Useful Initiatives 

for Indian Land Development Act’’ (BUIILD Act), and Senate bill 1333, ‘‘Tribal 

HUD–VASH Act of 2017’’, providing rental assistance to Indian veterans who are 

experiencing or at-risk of homelessness through the tribal Department of Housing 

and Urban Development—Department of Veterans Affairs Supportive Housing Program (Tribal HUD–VASH). I also wish to acknowledge and thank the Committee’s 

staff, not only for coordinating this hearing, but also for their ongoing engagement 

with HUD staff on the many issues that impact the Native American communities 

across our nation. 

As the Deputy Assistant Secretary for Native American Programs, I have had the 

opportunity to visit Native communities to learn first-hand about the issues and 

challenges the tribes face, and to hear directly from tribal leaders what we need to 

do to strengthen and improve HUD’s policies and programs for Native Americans. 

57 

Far too many Native American communities struggle with severely overcrowded 

housing, affordable housing shortages, substandard living conditions, and significant 

barriers to economic opportunity. 

Today, one out of every four Native Americans lives in poverty—including more 

than one-third of all Native American children. Far too many families live in unacceptable circumstances and face a future that lacks educational and economic opportunity. In the last 14 years (2003–2016), the number of low-income families in the 

Indian Housing Block Grant (IHBG) formula areas grew by 44 percent and now exceeds 322,000 families. The number of overcrowded households, or households without adequate kitchens or plumbing, grew by 23 percent to over 111,000 families. Finally, the number of families with severe housing costs grew by 58 percent to over 

66,000 families. 

To put these numbers in greater perspective, American Indian and Alaska Native 

people living in tribal areas in 2006–2010 had a poverty rate and an unemployment 

rate that were approximately twice as high as those rates for non-Indians nationally. American Indian and Alaska Native people in large tribal areas were more 

than 8 times as likely to live in housing that was overcrowded, and more than 6 

times as likely to live in housing that did not have adequate plumbing facilities 

than the national average. 

HUD looks forward to working with Congress on reauthorization of the Native 

American Housing Assistance and Self-Determination Act (NAHASDA), which authorizes the single largest source of Federal funding for housing in Indian Country. 

Tribes have made great strides under this legislation. The recently published Housing Needs of American Indians and Alaska Natives in Tribal Areas, the product of 

a congressionally mandated, multi-year study of housing needs and conditions in Indian Country concluded, ‘‘. . .tribes have demonstrated the capacity to construct 

and rehabilitate housing for low-income families at substantial levels under the 

NAHASDA framework.’’ Since 1998, under NAHASDA, tribes have not only produced more housing units per year, but they have produced better housing-housing 

that is tailored for local conditions, customs, and climates. Tribes also use the flexible block grant in many different and innovative ways to address unique local 

needs, such as assisting college students with housing, counseling prospective homeowners, providing self-sufficiency training to residents, and maintaining critical 

community infrastructure. 

NAHASDA supports the government-to-government relationship between the Federal Government and tribal governments, established by long-standing treaties, 

court decisions, statutes, Executive Orders and the United States Constitution. 

NAHASDA recognizes the importance of tribal sovereignty and is designed to provide flexibility and local control, so that each tribe can decide how best to address 

its unique housing needs and economic priorities. 

Since 2014, HUD has led a workgroup of several Federal agencies to develop a 

coordinated environmental review process for housing and housing-related infrastructure in Indian Country, as directed by the report of the Senate Appropriations 

Committee. HUD issued a Final Report on the workgroup’s activities in December 

2015. The Final Report and its recommendations would not have been possible without the invaluable input of numerous tribal leaders and Indian communities. The 

workgroup interviewed tribes and tribally designated housing entities (TDHEs) 

about their existing environmental review processes. Tribes and TDHEs participated in a series of briefings and listening sessions around the country to explain 

this effort and discuss their concerns and suggestions. Additionally, two formal tribal consultations were held to discuss findings, seek feedback, and garner additional 

information regarding processes and barriers. HUD is very grateful to those who 

generously gave, and continue to give, their time and attention to this effort. 

The Final Report made several recommendations, including measures that could 

be taken to coordinate agencies’ environmental review processes within existing 

frameworks and processes. The workgroup continues to meet to implement the recommendations of the Final Report. The workgroup is finalizing a Memorandum of 

Understanding to encourage the use of National Environmental Policy Act efficiency 

tools, and is drafting an implementation plan that puts forth action items derived 

from the recommendations of the final report and tribal consultation. The goal of 

the workgroup is to facilitate a more efficient environmental review process by being 

responsive to the Final Report recommendations, and to the continued input of tribal leaders. 

The BUIILD Act would expand tribes’ ability to assume responsibility for environmental review, decisionmaking, and action to include all federal agency funded actions associated with a NAHASDA section 202 funded project. This would facilitate 

a more efficient environmental review process since tribes are already authorized 

to complete the review process on behalf of HUD, which is typically the largest 

58 

source of funding for these projects. The environmental review would include the 

HUD review requirements, plus any additional laws and authorities that are required for the other funding agencies. 

Additionally the BUIILD Act provides that Indian Housing Block Grant (IHBG) 

funds may be used to meet matching or cost participation requirements of other 

Federal and non-Federal programs; as well as extend the maximum period that 

trust or restricted Indian lands can be leased for residential purposes from 50 years 

to 99 years. We look forward to working with Congress to develop these ideas. 

HUD recognizes the importance of assisting tribes and their housing entities to 

increase their capacity and technical expertise. HUD is committed to exploring ways 

to use its technical assistance to help tribes enhance their development efforts and 

to better leverage the assistance they receive through the dissemination of successful tribal strategies that meet the urgent housing needs of tribal communities. The 

BUIILD Act would authorize technical assistance funding to a broader range of TA 

providers than is currently authorized by NAHASDA. 

The BUIILD Act provides continued authorization of the Section 184 Indian Home 

Loan Guarantee Program. HUD continues to be the largest single source of financing for housing in tribal communities. The Section 184 program is the primary vehicle to access mortgage capital in Indian communities. As of December 31, 2016, the 

program has guaranteed a cumulative total of 36,324 loans with a principal balance 

of more than $6 billion. In January 2017, as part of the congressionally mandated 

Assessment of American Indian, Alaska Native, and Native Hawaiian Housing 

Needs, HUD published, Mortgage Lending on Tribal Land: A Report from the Assessment of American Indian, Alaska Native, and Native Hawaiian Housing Needs. The report finds that the Section 184 program successfully eliminates the functional 

market barrier to private lending presented by tribal trust land. 

The Section 184 program is the primary vehicle to access mortgage capital in Indian communities. The program helps tribes promote the development of sustainable reservation communities by making homeownership a realistic option for tribal 

members. It provides access to market-rate, private mortgage capital, and is not 

subject to income restrictions. The Section 184 program does not have minimum requirements for credit scores, and allows for alternative forms of credit and non-traditional income to address specific issues within the Native American communities. 

The program gives Native Americans from across the income spectrum the choice 

of living in their native community. In addition to individual Indians, tribes and 

tribally designated housing entities (TDHE) are eligible borrowers. This benefit of 

the program makes it possible for tribes and TDHEs to address housing shortages 

by developing and financing rental housing or by promoting homeownership opportunities for tribal members through lease purchase programs. 

As of June 1, 2017, the Tribal HUD–VASH demonstration program has housed 

103 veterans in tribal areas who were homeless or at-risk of becoming homeless. Approximately 201 Native American veterans are in case management with VA and 

may soon receive housing assistance under this program. Tribal HUD–VASH is an 

offshoot of the standard HUD–VASH program, which has been successful in many 

communities across the country but unable to reach eligible Native American veterans living on tribal lands, largely because tribes and TDHEs were not eligible to 

administer the program. HUD is committed to serving this population and looks forward to working with Congress to ensure they are well-served. 

HUD has been working tirelessly with VA to coordinate services and case management with housing. The program is housing families and helping veterans struggling with substance abuse and other mental health issues. One of the first veterans 

who was housed and received supportive services was a female veteran with a 

young daughter living in a trailer in severely overcrowded conditions. She and her 

daughter moved into their new home and for the first time in her life her daughter 

had her own room and a quiet place to do her homework. 

Another very moving story is about a veteran who had struggled with substance 

abuse for many years. Through Tribal HUD–VASH she was able to access safe affordable housing and support services to help her combat her addiction. The other 

veterans living nearby looked out for her and protected her sobriety by helping prevent contact from people who might trigger a relapse. She now is employed and is 

maintaining her sobriety. 

Some of the challenges HUD and VA have faced in implementation are identifying 

adequate housing stock and locating veterans who are eligible for and need access 

to the HUD–VASH program. Given the overall shortage of housing units in Indian 

County and the limited number of private rental units, many tribes have found it 

difficult to find units for their veterans and are using their own NAHASDA housing 

stock to house the veterans. While this approach provides a home for a Veteran who 

has experienced homelessness, it does not create a net increase in the number of 

59 

affordable housing options available to tribal members and means that the unit is 

not available as an opportunity for another household on the tribe’s waiting list. Attempts to house veterans in private rental units near tribal lands are mixed. Some 

veterans, predominately younger veterans, are willing to move off tribal lands to obtain housing. Many, especially elderly veterans, are not willing to leave their community to obtain housing. 

Some tribes are using project-based rental subsidies to develop new units; however, many are reluctant to leverage the funding provided by the program for new 

units since the program continues to be a ‘‘demonstration.’’ 

Finding eligible veterans who are experiencing or at-risk of homelessness in Indian Country can be difficult because they are often in overcrowded and transient 

situations. In Indian Country, there are rarely emergency shelters for people who 

are experiencing homelessness which can be used as a way to identify homeless veterans. There are also typically few people experiencing unsheltered homelessness in 

Indian Country, as community members take in veterans experiencing homelessness, oftentimes creating overcrowded situations, and those veterans often have to 

‘‘couch surf’’ from one family member’s home to another. 

To fully leverage Senate bill 1333, HUD seeks to strengthen its partnership with 

the Indian Health Service (IHS), and continue to work with VA to better identify 

veterans experiencing homelessness in Indian Country. IHS serves eligible American Indian/Alaska Native veterans in IHS operated health care facilities and programs. Through an agreement between IHS and VA’s Veterans Health Administration, VA reimburses IHS for the direct health care services of these veterans. An 

enhanced partnership could help identify eligible veterans by linking veterans who 

are being served by IHS health facilities with the Tribal HUD–VASH program. Another potential outcome of an IHS, HUD, and VA partnership is to explore the possibility of using IHS’s telemedicine network to deliver VA case management to more 

remote locations. 

In conclusion, HUD’s Indian Housing programs, including IHBG, Section 184, and 

the Tribal HUD–VASH program are all successful examples of federal programs 

that provide local choice, under streamlined governmental requirements, and leverage private market investment while respecting tribal self-governance. 

Thank you again for this opportunity to appear before you today. I would be 

happy to answer any questions you may have. 

Senator MURKOWSKI. Dr. Harris. 

STATEMENT OF DR. KEITH HARRIS, DIRECTOR OF CLINICAL 

OPERATIONS, HOMELESS PROGRAMS OFFICE, U.S. 

DEPARTMENT OF VETERANS AFFAIRS 

Dr. HARRIS. Thank you, Madam Chair Murkowski, Vice Chair 

Udall and members of the Committee. 

I want to thank you for the opportunity to discuss the Tribal 

HUD–VASH Act of 2017 and our experience at VA of implementing 

this demonstration program. 

I would like to begin by stating emphatically it remains a key 

priority for VA to end veteran homelessness, especially as it applies 

to our homeless and at risk Native Americans living in their tribal 

communities. 

I think my comments will be most useful if I focus on VA’s experience in implementing the demonstration program, some lessons 

learned there, as well as how they might apply to the new bill. 

The current status, as you just heard in testimony, there are approximately 200 veterans in their demonstration program now, 103 

of them as of June 1, are housed. The remainder, about two-thirds, 

are essentially holding a voucher as we would say in the standard 

program and the remaining one-third entered into case management and were referred to the tribal housing authority. 

I want to speak to VA hiring and case management. I know that 

is an interest, especially in Alaska, of the Committee and I assume 

of my fellow panel members. 

60 

Of the 25 active sites, 21 have a case manager onboard either 

through VA hiring or contract. Two others have been selected and 

are in the on-boarding process and/or moving to their location. That 

leaves two vacancies. One is in Montana and the other, as you 

know, Senator Murkowski, is in Bethel, Alaska. 

In both of those remaining cases, they have been very difficult 

to fill because of the remote nature of the location. I am pleased 

to report a couple of things. One is that both medical centers have 

agreed to search for broader disciplines than social work only. They 

are looking at licensed marriage and family therapists, for instance, and clinical mental health counselors. 

Both medical centers have also, at our urging, agreed to introduce recruitment incentives into the recruitment process. I am very 

pleased to say I actually just today authorized funding from our office for both recruitment incentives and permanent change of station to Bethel. We are hopeful that by broadening the disciplines 

and increasing the incentives, we can get those positions filled. 

All medical centers are also working on providing temporary case 

management in the case of vacancies so that we can move veterans 

forward in the program even in those areas. 

I wanted to touch on a couple of lessons we have learned. First 

is, partnership is necessary and critical in this program. We have 

an excellent collaborative relationship with our partners at HUD; 

within VA, with the Office of Government and Tribal Relations; 

and certainly, with all of the tribes we have worked with. 

This has been particularly important in developing new policies. 

We built this program from the ground up. There are differences 

in this model and some of the rules with tribal entities especially 

regarding substance use. There is a lot of work and a lot of negotiation around that. Partnership has been excellent. 

On the flip side, despite a lot of work, I think on both sides, we 

were unable to achieve a partnership with IHS to enter an agency 

agreement. We worked for several months on that. I am pleased to 

see language in the bill bringing IHS back to the table. We are excited to work with them and hope to achieve further partnership 

with them as this program expands. 

I will touch on other challenges just briefly. People are well 

aware of this already. Housing stock is a very difficult challenge, 

especially on reservations. Finding eligible veterans is a challenge 

both at a macro and micro level. It is difficult to quantify need. The 

typical way is the Federal Government does this through its standard PIT count, point in time count, and it doesn’t necessarily work 

or apply on Federal lands. 

At a micro level, some of the tribes and some of the medical centers have had trouble finding enough eligible veterans for this program. I know that VA hiring, especially in remote areas, is particularly challenging. 

I just want share really quickly, I reviewed feedback from all the 

medical centers running this program. It really was striking to me 

the number of them that noted the value and importance of permanent housing and the case management tied to that. 

We have seen many stories of people gaining employment, education or training, family reunification and stabilization of mental 

health and substance use symptoms. I think it is a testament to 

61 

the housing, first, the model this program was based on and I 

think it is great evidence for continuing and expanding it in the future. 

Thank you very much for the opportunity today. I look forward 

to any questions. 

[The prepared statement of Dr. Harris follows:] 

PREPARED STATEMENT OF DR. KEITH HARRIS, DIRECTOR OF CLINICAL OPERATIONS, 

HOMELESS PROGRAMS OFFICE, U.S. DEPARTMENT OF VETERANS AFFAIRS

Good afternoon, Chairman Hoeven, Vice Chairman Udall, and distinguished Members of the Committee. Thank you for the opportunity to discuss the Department 

of Veterans Affairs’ (VA) efforts to end homelessness among Veterans and specifically Native American Veterans, including legislation regarding the U.S. Department of Housing and Urban Development-VA Supportive Housing (HUD–VASH) 

Program. Unfortunately, VA did not receive the draft bill regarding this program 

in sufficient time to fully coordinate views on the bill. We will follow up with the 

Committee as quickly as possible to provide comments on the draft bill. 

Ending homelessness among all Veterans, including Native American Veterans, is 

a VA priority. The HUD–VASH Program is a collaborative program between HUD 

and VA which combines HUD housing choice vouchers with VA supportive services 

to help Veterans experiencing homelessness and their families find and sustain permanent housing. Through public housing authorities, HUD provides rental assistance vouchers for privately owned housing to Veterans eligible for VA healthcare 

services who are experiencing homelessness. VA case managers connect these Veterans with support services such as health care, mental health treatment, and substance use counseling to help them in their recovery process and with their ability 

to maintain housing in the community. Among the VA programs addressing Veteran 

homelessness, HUD–VASH enrolls the largest number and largest percentage of 

Veterans who have experienced long-term or repeated homelessness. Since 2008, 

HUD–VASH has admitted over 180,000 homeless Veterans to case management. 

Historically, legal rules have prevented Tribes or Tribally Designated Housing Entities (TDHE) from participating in the HUD–VASH program. In December 2014, 

Congress authorized funding for a Tribal HUD–VASH demonstration program, 

which targets housing and supportive services to Native American Veterans who are 

homeless or at risk of homelessness and who are living on or near a reservation or 

other Indian areas. Under the first-ever Tribal HUD–VASH Program, 26 tribes 

share $5.9 million in funding for rental assistance. Case management and supportive services are primarily provided by VA for participating Native American 

Veterans. 

Tribal HUD–VASH is modeled on the standard HUD–VASH program, which combines HUD rental assistance for homeless Veterans with VA case management and 

clinical services. In the program’s first year, HUD and VA are working to implement 

the program and have begun to lease the 500 housing subsidies allocated for the 

demonstration program and to provide supportive services. Some of the rental assistance will be used as project based unit subsidies, supporting development of affordable housing stock on tribal lands. Consistent with other project based housing, 

some of these units are in development or otherwise not yet active. 

Implementation of Tribal HUD–VASH 

Tribal HUD–VASH is a program that requires strong collaborative and coordinated efforts from the involved partners, including VA, HUD, the tribes and tribal 

housing authorities, as well as the tribal Veterans Service Officers and other community partners. In implementing this program, VA and tribal entities 

havedeveloped policies and procedures related to assessment, screening, referral, 

and entry into the program, and have worked together to identify and engage eligible Veterans. Community partnerships are needed to ensure that additional resources are available for supports that VA is not able to provide, such as services 

for the Veteran’s family members. 

When a potentially eligible Veteran is identified, VA conducts the initial screening 

to determine if the Veteran meets basic eligibility criteria, including determination 

of homelessness or at risk of homelessness status, eligibility for VA health care, and 

the clinical need for case management services. As in the standard HUD–VASH program, eligible Veterans must agree to participate in VA case management to receive 

Tribal HUD–VASH assistance as one of the eligibility criteria, particularly as this 

program provides permanent supportive housing, not housing only. The tribally desVerDate Mar 15 2010 13:50 Nov 30, 2017 Jkt 027650 PO 00000 Frm 00065 Fmt 6633 Sfmt 6621 S:\DOCS\27650.TXT JACK
62 

ignated housing entity (TDHE) makes its own eligibility determination after VA referral. TDHE eligibility includes meeting Native American criteria, income threshold, and state lifetime sex offender prohibitions. 

Goals of Tribal HUD–VASH include improved physical and/or mental health, employment, education, and/or goals the Veteran chooses for himself/herself. Substance 

use can have a significant impact on Veterans’ ability to achieve and sustain housing stability and related goals, addressing substance use is a significant focus of the 

services provided to Veterans within the Tribal HUD–VASH program. Through Veteran-centered services, HUD–VASH case managers support Veterans to achieve 

their goals regarding substance use and recovery, and Veterans are provided access 

to VA behavioral health care services and substance use treatment. 

Tribes and TDHEs deliver tenant- or project-based rental assistance to eligible 

Native American Veterans who have been screened for eligibility by VA and the 

Tribe or TDHE. VA prioritizes eligible Native American Veterans with the greatest 

need for case management. VA must document the assessment and screening process in the Veteran’s medical record and in VA’s Homeless Operations Management 

and Evaluation System (HOMES). The tribe or TDHE must maintain written documentation of all referrals and housing eligibility screening in the Veteran’s file, as 

well as electronically report participant data as required in the Federal Register implementation notice, Vol. 80, No. 203. VA may provide case management services 

directly or via contract with a Tribal health care provider for service delivery. A 

Tribe or TDHE may partner with VA to provide office space for the VA case manager, or VA, in coordination with the Tribe, or TDHE may partner with IHS to provide space for VA case management at an IHS facility. Services may include substance use treatment, mental health care, health care, job training, and education 

about tenancy rights and responsibilities. 

Similar to the standard HUD–VASH program, Native Americans are housed 

under Tribal HUD–VASH based on a Housing First approach. This means that Veterans are provided housing assistance, along with case management and supportive 

services to foster long-term stability to prevent a return to homelessness. Housing 

First provides immediate access to housing without prerequisites, such as sobriety 

or the demonstrated absence of current substance use. This approach targets those 

who are homeless and have complex clinical needs. There are two main components 

to Housing First: permanent housing and wrap around services to support continued 

tenancy. Housing First uses a treatment philosophy that is consumer-directed and 

Veteran-centric. 

Housing First is a research-based approach based on the premise that supportive 

services are more effective when the daily stress of being homeless is relieved. The 

key principles of Housing First as it is applied under HUD–VASH policy are: respect, warmth, and compassion for all Veterans; Veteran choice and self-determination; a recovery-oriented approach; and utilization of Harm Reduction strategies to 

assist Veterans to understand and reduce the impact any substance use may be 

having on their housing stability and the achievement of their goals. 

Informed by the evidence that housing stability enhances the ability of Veterans 

to seek and engage in appropriate health and behavioral health care services including substance use treatment, Housing First approaches do not require sobriety as 

a precondition for obtaining or sustaining tenancy, and such criteria are not required within leases. With a focus on Veteran-driven services, mandatory testing for 

substance use is not implemented, but assisting Veterans to achieve and sustain recovery is a significant focus of the case management and other supportive services 

delivered, and Veterans are linked to appropriate treatment and behavioral health 

care services as needed. VA and tribal grantees work together to establish eligibility, case management, outreach strategies and next steps. All partners work to 

develop processes that obtain and sustain housing for eligible Veterans. Every partner provides points of contact for all involved agencies. Additionally, VA and tribal 

grantees work with community agencies such as tribal Veterans’ services/offices, 

tribal law enforcement, health agencies, drug and alcohol service providers, and others to let them know about this potential resource for Native American Veterans 

who are homeless or at risk of homelessness. 

Eligible Native American Veterans and their families pay no more than 30 percent of their monthly-adjusted income, as outlined in the Tribal HUD–VASH implementation notice. Tribes or TDHEs pay the difference between the rent and the Veteran’s rent contribution with the Tribal HUD–VASH rental assistance. Tribes or 

TDHEs may also negotiate the inclusion of utilities in payment contracts with housing owners. Funds may cover any additional costs related to housing Native American Veterans under this program. 

To date, Tribal HUD–VASH has 103 Veterans housed, with another 98 Veterans 

currently enrolled and in the process of becoming housed. Many of these Veterans 

63 

are married or have children residing with them. In addition, several Veterans have 

engaged in employment opportunities, or have enrolled in education or training programs, now that they are housed. 

With regard to other bills on the agenda, S. 1250, the Restoring Accountability 

in the Indian Health Service Act of 2017, we defer to the Department of Health and 

Human Services, Indian Health Service, for views and comments. We note for that 

same bill certain portions of the text reflects the language in 38 U.S.C. § 713(e), the 

constitutionality of which was successfully challenged in Helman v. Department of 

Veterans Affairs, case 2015–3085 (Fed. Cir. May 9, 2017). We defer to the Department of Justice for further comment on that issue. We defer to the Department of 

Housing and Urban Development with respect to S. 1275, the Bringing Useful Initiatives for Indian Land Development Act of 2017 or BUIILD Act of 2017. 

VA remains steadfast in our commitment to end homelessness among all Veterans, no matter their circumstance or background, with recognition of the special 

efforts needed to reach especially vulnerable Native American Veteran populations. 

We are fortunate to have robust partnerships with HUD, other Federal agencies, 

and tribal organizations in that effort. Thank you and I look forward to your questions. 

Senator MURKOWSKI. Thank you, Dr. Harris. 

Ms. Onnen, welcome. 

STATEMENT OF HON. LIANA ONNEN, VICE PRESIDENT, 

SOUTHERN PLAINS REGION, NATIONAL CONGRESS OF 

AMERICAN INDIANS (NCAI) 

Ms. ONNEN. Good afternoon, Madam Chairwoman, Mr. Vice 

Chair and members of the Committee. 

My name is Liana Onnen. I am an Area Vice President for the 

National Congress of American Indians, Chairwoman of the Prairie 

Band Potawatomi Nation, and a former housing director for my 

tribe. 

I want to thank you for holding this important hearing and allowing me to testify specifically on two important pieces of legislation that will address housing issues throughout Indian Country. 

The first bill focuses on reauthorization of the Native American 

Housing Assistance and Self-Determination Act which has not been 

reauthorized since 2013. The second addresses the important issue 

of providing housing opportunities for our Native veterans. 

The housing needs in Indian Country are great. I would even say 

that the lack of housing is at a crisis point. I know this because 

in Indian Country, we are well aware of the lack of basic housing 

in our communities. 

We are aware of the overcrowding that often means multiple 

families are living under one roof in a three-bedroom house. We 

know that in many of our communities, we lack the basic infrastructure to provide for housing, even when we can afford to build 

the houses. 

At NCAI, we have long advocated for increased attention to housing programs. We have long supported reauthorization of 

NAHASDA but we are also aware that to truly address the housing 

needs in tribal communities, we also need to look at innovative 

ways to not only address the basic needs of our tribal citizens, but 

also to provide homes for teachers, public safety professionals and 

health care providers. It is not possible for us to recruit and retain 

these vital services to our communities if we lack basic housing. 

The recently released Housing Needs Assessment highlighted the 

housing needs we are addressing today. That report, based on a 

small sampling of individual households, tribes, tribally-designated 

64 

housing entities, and Native Hawaiians focused on three factors: 

one, demographics, social and economic conditions; two, housing 

conditions and needs; and three, housing policies and programs. 

That study is beneficial to illustrate the need in Indian Country, 

but it was only a small sampling, so we strongly recommend that 

Congress request a more comprehensive study of the housing needs 

in tribal communities. Without accurate data about the true need, 

we will continue to be under funded. 

You and your colleagues in Congress rely on data to show need 

and more importantly, to show results when scarce Federal funding 

is provided to Federal programs. The NAHASDA funding has been 

stagnant for nearly a decade, while the housing need only continues to grow. 

NCAI supports the reauthorization of NAHASDA as well as the 

comprehensive review of other programs and innovative ways to 

address the housing needs in tribal communities. We stand ready 

to assist you in engaging tribal leaders across Indian Country to 

bring solutions to housing needs. 

NCAI’s membership has strongly supported reauthorization of 

NAHASDA and passed a resolution to that effect at our 2013 midyear conference in Reno. That resolution is entitled, Support for the 

Immediate Reauthorization of the Native American Housing Assistance and Self-Determination Act. 

NCAI resolutions remain the standing policy of NCAI until withdrawn or modified by subsequent resolution. Therefore, we continue to strongly advocate for reauthorization of NAHASDA during 

this Congress. 

NCAI also has a resolution passed during the same mid-year conference that supports reauthorization of the Native Hawaiian programs as part of the overall NAHASDA reauthorization. Support 

reauthorization of the Title VIII part of the overall reauthorization 

of NAHASDA programs is the name of that resolution. 

NCAI’s membership has also strongly spoken on the need to ensure that any overall reauthorization also includes the Native Hawaiian programs. This is important to our membership because the 

housing needs of our Native Hawaiian brothers and sisters are just 

as critical as those throughout Indian Country. 

There are other provisions contained in the bill that NCAI will 

seek additional tribal input on. NCAI is encouraged that the bill 

contains provisions to streamline NEPA requirements by affirming 

a lead agency to assist tribes and remove bureaucratic hurdles for 

environmental reviews. NCAI is consulting with tribal leaders this 

week to seek their views on this provision. 

In addition, we are seeking additional tribal input on the 99-year 

leasehold interest in trust or restricted land for housing purposes. 

We are encouraging this Committee to consult with tribes so that 

we can ensure this provision would not create unintended hardship 

for tribes at the end of these leasing terms. 

In closing, I would again like to thank you for allowing NCAI to 

be here to discuss the housing needs in Indian Country. We stand 

ready to assist you as this legislation moves forward for consideration by this Committee and this Congress. 

I am happy to answer any questions you may have. 

[The prepared statement of Ms. Onnen follows:] 

65 

PREPARED STATEMENT OF HON. LIANA ONNEN, VICE PRESIDENT, SOUTHERN PLAINS

REGION, NATIONAL CONGRESS OF AMERICAN INDIANS (NCAI) 

Good Afternoon. On behalf of the National Congress of American Indians (NCAI), 

I would like to thank the Chairman Hoeven, Vice-Chairman Udall and other distinguished members of the Committee for the opportunity to provide testimony about 

our views on S. 1275, and HUD–VASH. NCAI is the oldest and largest national organization representing American Indian and Alaska Native tribal governments in 

the United States. We are steadfastly dedicated to protecting the rights of tribal 

governments and the achievement of self-determination and self-sufficiency. NCAI 

looks forward to working with this Committee to ensure that the recommendations 

from the Committee’s hearing process today take into account the unique needs of 

Indian Country. 

NCAI has been working diligently with tribal governments and other national 

tribal organizations to find solutions to protect and improve the infrastructure, 

health and welfare of Indian Country. Reauthorization of housing programs for tribal governments and citizens is a key component of meeting the infrastructure needs 

of tribal communities. 

The accessibility and condition of housing and other related physical infrastructure needed in American Indian, Alaska Native and Native Hawaiian communities 

continues to lag far behind that in all other segments of the U.S. population. Providing quality and safe housing within tribal communities for members and essential employees is crucial for the health and welfare of those communities. Without 

a vibrant housing sector, tribal governments cannot recruit or retain essential employees such as doctors and nurses, law enforcement personnel and teachers who 

are vital to ensuring the health, safety and education of their members and a thriving community. Moreover, given the shortage of supply and problem of undersized 

homes for Indian households, many families are forced to live in overcrowded conditions that negatively impact the lives of Native families, children and elders virtually all areas of their lives. 

S. 1275: Bringing Useful Initiatives for Indian Land Development Act of 

2017 

NCAI agrees with and is willing to work with the Committee on the reauthorization of NAHASDA. NCAI’s comments regarding S. 1275, Bringing Useful Initiatives 

for Indian Land Development Act of 2017 (Build Act of 2017) are outlined below by 

Section. 

Section 2: Environmental Review 

Tribes have requested a streamlined approach to NEPA requirements that are already authorized in statute, and request identification of a lead agency when there 

are multiple federal agencies in one project. It has been difficult to get the federal 

agencies to remove the barriers that keep their work in silos and to agree to accept 

the review and determination of another agency. HUD issued a notice entitled PIH– 

201622 Environmental Review Requirements for Public Housing Agencies that aims 

to implement a lead agency for environmental review to address the inter-agency 

coordination. 

NCAI is encouraged that this section affirms the lead agency provision and allows 

the governmental review requirements to be satisfied by the tribe or its tribal housing authority. NCAI will review this provision as drafted with tribes at our midyear conference this week and we will be glad to share the comments we receive 

with the Committee. 

Section 4: 99-Year Leasehold Interest in Trust or Restricted land for Housing Proposes 

The legislation authorizes all tribal trust or restricted lands to be leased for up 

to 99 years for residential purposes and NCAI urges further consultation with tribal 

leaders on this issue. Before 1955, except in rare and localized circumstances (for 

example, Salamanca and the congressional villages on the Seneca Nation’s Allegany 

Reservation), surface leasing of Indian lands had been limited to 5- or 10-year periods, which are appropriate for agricultural leases, but not for commercial, residential, industrial and other uses promising major economic returns. In 1955, Congress 

passed a statute (now codified as 25 U.S.C. 415) allowing all tribes and individual 

Indians to lease trust and restricted lands for up to 25 years, with the possibility 

of an additional renewal term of 25 years while retaining shorter limits for agricultural leases. Amendments to the 1955 Act have allowed longer lease terms for business purposes, usually up to 99 years, for over two dozen specified tribes. 

We urge further consultation with tribal leaders on the concept of 99 year leasing 

for residential purposes, particularly where large tracts of land could be leased for 

66 

non-Indian residential leasing. Even if a 99 year lease may be authorized, the Tribe 

should retain the right to a term of less than 99 years. 

Section 6: Loan Guarantees for Indian Housing 

NCAI supports the reauthorization of Section 184, and it is vital for Congress to 

continue this program which increases tribal homeownership. However, the Committee needs to be aware of the small percentages of acquiring home loans on Indian reservation land. 

Native Community Development Financial Institutions, or CDFIs, are critical to 

closing the homeownership gap in tribal communities. A recently released study Access to Capital and Credit in Native Communities concluded that Native people residing in tribal communities ‘‘who wish to buy a home. . .have much better options 

now than they did [in 2001]: they have access to a [Native CDFI] that can help 

them realize their ambitions.’’ 

Loan guarantees enable Native CDFIs to leverage the financing necessary to provide low-interest mortgage loans to Native people who otherwise would not have any 

other affordable options. Native CDFIs also provide mortgage loan recipients with 

credit counseling, home ownership preparedness training, and the ongoing support 

they need to stay in the homes that they purchase. 

Section 7: Leveraging 

NCAI supports the clarification that all NAHASDA funds meet the full faith and 

credit for leveraging funding from other federal programs and is essential to the 

leveraging needs in Indian Country. 

Native Hawaiian Housing Programs 

As much as the need for housing is a priority for Indian Country, NCAI is concerned with the S. 1275, the Build Act, because this proposed legislation leaves out 

the Native Hawaiian Housing Block Grant and Native Hawaiian Guarantee Home 

Loan Programs within the NAHASDA reauthorization title. The exclusion of the Native Hawaiian housing programs sets a harmful precedent for federal programs 

serving American Indians, Alaska Natives, and Native Hawaiians. NCAI stands 

with our Native Hawaiian brothers and sisters and requests the committee to include Native Hawaiians in the NAHASDA Reauthorization. Please refer to NCAI’s 

resolution #REN–13–017, Support Reauthorization of Title VIII Part of the Overall 

Reauthorization of NAHASDA Programs. 

Housing Needs Assessment 

Earlier this year, the U.S. Department of Housing and Urban Development 

(HUD) released a study entitled, ‘‘Housing Needs of American Indians and Alaska 

Natives in Tribal Areas: A Report From the Assessment of American Indian, Alaska 

Native, and Native Hawaiian Housing Needs.’’ This report provided the results of 

a multi-year study based on interviews of individual households, tribes and Tribally 

Designated Housing Entities (TDHE), and Native Hawaiians. The report focused on 

three factors related to housing needs: (1) demographic, social and economic conditions; (2) housing conditions and needs; and (3) housing policies and programs. 

The study confirmed what we already know about the needs and barriers to adequate housing in Indian Country. The main housing needs are tied to: structural 

deficiencies (i.e. plumbing, kitchen, heating and electrical); inadequate housing conditions; overcrowding; and the need for Congress to provide funding that will enable, 

and not hinder, tribes from meeting the needs for their communities. According to 

the study, 33,000 new housing units are needed to alleviate housing overcrowding 

and an additional 35,000 housing units are needed to replace existing housing units 

in severe condition. The estimate to construct new and replace existing housing totals over $33 billion (based on a HUD calculation of the average construction costs 

of a three-bedroom house). 

NCAI encourages Congress to work with tribal governments to find solutions to 

ensure adequate funding and oversight that enables tribes and federal agencies to 

have the data and other resources needed to truly determine the need for housing 

throughout Indian Country. We are confident that once there is consistent housing 

needs data, it will provide much needed information that shows the relative housing 

needs and tribal government accountability. This report is the only current study 

that identifies the data, information and needs of housing in Indian Country. However, the study was limited in scope, and the comprehensive needs in Indian Country have yet to be determined. this needs data will enable this Committee and Indian Country to advocate for the appropriations and policy considerations necessary 

to bring adequate housing to Indian Country. 

67 

S. lll HUD/VA Veterans Affairs Supporting Housing, and for other 

purposes 

NCAI and its members strongly support the Tribal HUD-Veterans Affairs Supportive Housing Program (HUD–VASH) program and expansion of HUD–VASH on 

tribal lands. American Indians serve in their country’s armed forces in greater numbers per capita than any other racial and ethnic group, and they have served with 

distinction in every major conflict for over 200 years. Homelessness among Native 

Veterans is a serious issue throughout Indian Country. However, the current HUD– 

VASH program does not include its impact on tribal lands. In 2015, the HUD– 

VASH demonstration program was created to address at-risk and homeless Veterans on tribal lands. For the first time, tribes and tribal Veterans organization 

were eligible to apply for HUD–VASH funding. Funding for the HUD–VASH program increased from $5.9 million to its current funding level of $7 million for enacted FY 2017. 

The HUD–VASH program is a successful program nationwide. However, without 

providing funding for tribes, it is virtually impossible for tribes to utilize this program. Tribes request the same opportunity given to all of America’s local municipal 

governments. According to a 2016 HUD Annual Report on Homelessness that estimated the number of homeless Veterans, ‘‘the remaining five percent were of Native 

Americans, Pacific Islander, or Asian descent.’’ Please refer to NCAI resolution # 

ECWS–14–001, Support for Indian Veterans Housing Rental Assistance Demonstration Program in the Native American Housing and Self-Determination on Act Reauthorization. 

Conclusion 

NCAI thanks the Committee for its commitment to the important goals of tribal 

self-determination through flexible and effective housing policy for American Indians, Alaska Natives, Native Hawaiians and Native Veterans. We look forward to 

working with the Committee to take the necessary steps to support tribes as they 

improve the housing conditions in their communities and to effectively respond to 

the changing economic environment. 

Senator MURKOWSKI. Thank you, Ms. Onnen. 

Mr. Charlie, welcome to the Committee. 

STATEMENT OF MARK CHARLIE, PRESIDENT/CEO, 

ASSOCIATION OF VILLAGE COUNCIL PRESIDENTS (AVCP) 

REGIONAL HOUSING 

Mr. CHARLIE. Good afternoon, Chairman and other members of 

the Committee. Thank you for the opportunity to appear. 

In respect of time, I offer my full written testimony to the Committee for the record. 

My name is Mark Charlie. I am a Yupik Eskimo and an enrolled 

member of the Native Village of Tununak. I have the privilege and 

honor of serving as the President and CEO of the Association of 

Village Council Presidents Regional Housing Authority. 

AVCP RHA is the regional housing authority for the AVCP region in Southwest Alaska and the Tribally Designated Housing Entity for 51 tribes out of 56 in our region. We are also one of the 

three PTHEs participating in the Tribal HUD–VASH Program. 

As you know, housing conditions in Native communities remain 

far worse than those of non-Native communities. Housing conditions in Native communities are five times more likely to have 

plumbing deficiencies, six times more likely to have heating deficiencies, and seven times more likely to be overcrowded. 

Substandard and overcrowded housing conditions imperils Native 

communities and exposes Native families to health, social, and economic conditions that impede their ability to become permanently 

self sufficient. A recent HUD study estimates that 68 new homes 

68 

are needed in tribal communities and that figure does not include 

estimates for much of Alaska. 

Although our housing needs remain substantial, NAHASDA has 

had a profoundly positive impact in Native communities. Tribes 

have used block grant funding to build, acquire, and renovate more 

than 123 homes and to operate and maintain 43,000 homes built 

before NAHASDA as well as potential thousands of additional 

homes built since NAHASDA. 

Today, IHBG remains the single most critical tool for developing 

safe, affordable housing in Native communities. Thank you, Chairman Hoeven, for introducing the BUILD Act which represents a 

streamlined effort to reauthorize the Indian Block Grant. Passage 

of the BUILD Act is a critical step toward ensuring that the good 

work being done by tribal housing programs will continue. 

Unfortunately, reauthorizing IHGB is not enough. As noted in 

HUD’s recent report, flat funding and inflation have seriously eroded the purchasing power of the IHGB Program. Without additional 

appropriations, development in Native communities will decline. 

This is, in part, due to higher development costs, but also because 

tribes must use a large portion of the IHGB to support the housing 

we have built. 

Without reasonable funding adjustment, development activity 

will continue to decline and Native families will fall further behind 

their non-Native counterparts. 

Allow me to turn to the Tribal HUD–VASH Demonstration Program. 

We in Alaska admit to being frustrated by the program’s slow 

implementation. However, we see the program’s potential since one 

region in our State has begun implementing the program. 

In one instance, a program participant Native veteran had a serious medical issue that required immediate attention and was taken 

to a hospital emergency room. He was admitted and treated and 

that veteran has recovered. 

An innovative aspect of the Tribal HUD–VASH Demonstration 

Program is that it allows tribes to serve both Native veterans and 

their families. This approach respects traditional family structures 

and empowers tribes to reunite veterans with their families, to find 

permanent housing for a Native veteran and his family of five including three young children. 

The veteran’s wife had been battling a serious illness. Sadly, she 

died soon after her family moved into their new home. Before she 

passed away, she expressed happiness and relief that her family 

had found a safe place to live. 

External barriers have made achieving the program’s potential 

difficult. Two Tribal HUD–VASH recipients in Alaska continue to 

struggle with implementation. In our experience, the primary barriers to VA credentialing requirements exceed those of similar positions in many communities for case managers making it difficult to 

recruit case managers. 

We believe VA and HUD have the authority to reconsider the 

VA’s credentialing requirements. If not, we would appreciate congressional efforts to give the agencies that flexibility. 

We have reviewed the recently circulated Tribal HUD–VASH bill 

and believe it will have a positive impact on tribal communities. It 

69 

would enhance program stability and give tribes the opportunity to 

engage in direct consultation with VA leadership about barriers to 

program implementation. 

On behalf of The Association of Village Council Presidents, The 

Association of Alaska Housing Authorities, and tribes across the 

United States, thank you for your efforts to improve housing conditions in tribal communities and for the privilege of speaking with 

you today. 

[The prepared statement of Mr. Charlie follows:] 

PREPARED STATEMENT OF MARK CHARLIE, PRESIDENT/CEO, ASSOCIATION OF VILLAGE

COUNCIL PRESIDENTS (AVCP) REGIONAL HOUSING

Good afternoon Chairman Hoeven, Vice-Chairman Udall, and distinguished members of the Senate Committee on Indian Affairs. Thank you for the opportunity to 

appear today as the Committee examines two bills intended to strengthen American 

Indian and Alaska Native communities and improve housing conditions for Native 

families. 

My name is Mark Charlie. I am a Yupik Eskimo and an enrolled member of Native Village of Tununak. I serve as the President and CEO of the Association of Village Council Presidents Regional Housing Authority (AVCP RHA). AVCP RHA is 

the regional housing authority for the AVCP region in Southwest Alaska and the 

Tribally Designated Housing Entity for 51 tribes. The AVCP region, approximately 

the size of the state of Illinois, has 48 remote communities. Access to our region is 

by air year round and by barge from May to October. Use of a barge is mainly for 

delivery of building materials and petroleum (heating fuel and gasoline). 

The AVCP region is home to many thousands of Alaska Native people. Many of 

our families lack safe and decent housing or housing that is affordable. Unfortunately, this problem is not isolated to the AVCP region but is experienced in the 

remainder of Alaska and throughout Indian country. 

S. 1275 (The Build Act) and NAHASDA 

Housing Needs in Native Communities 

In January 2017, HUD published the results of a comprehensive national study 

on the housing needs of American Indians and Alaska Natives living in tribal communities. The study confirmed that the housing problems experienced by Native 

peoples in tribal areas are extremely severe and considerably worse than the housing conditions of non-Native populations. 

For example, the study found that physical deficiencies in plumbing, kitchen, 

heating, electrical, and maintenance issues were found in 23 percent of households 

in tribal areas but only five percent of U.S. households overall. Compared to the 

general population, homes in Native communities are five times more likely to have 

plumbing deficiencies, six times more likely to have heating deficiencies, and seven 

times more likely to be overcrowded. The study estimated that between 42,000 and 

85,000 Native Americans are ‘‘doubled up,’’ meaning that they live with family or 

friends because they have no place else to stay and would otherwise reside in a 

homeless shelter or on the streets. 

HUD’s report, Housing Needs of American Indians and Alaska Natives in Tribal 

Areas, estimates that 68,000 units of new affordable housing are needed to replace 

substandard or overcrowded units in tribal communities nationwide. Further, the 

Report estimates that an additional 30,000 homes in tribal communities are candidates for rehabilitation. It must be noted that these figures do not capture the 

housing needs of all Indian areas served by tribal housing providers, including significant portions of the Alaska Native population. While we applaud HUD’s diligent 

efforts to quantify and describe the housing needs of Alaska Native and American 

Indian people, the Association of Alaska Housing Authorities estimates that the 

methodology used by the study team has caused housing needs in Alaska to be 

underrepresented by thousands of units. 

The availability of safe, affordable housing is crucial for the survival of Native cultures. Tribal communities that lack decent housing often cannot recruit the health 

care providers, law enforcement officers, and teachers needed to ensure the health, 

safety, and education of their tribal members. Substandard housing also negatively 

impacts health and wellness outcomes for the families who live in them. The World 

Health Organization has identified respiratory and cardiovascular disease stemming 

70 

from poor indoor air quality and the spread of communicable disease due to poor 

living conditions as key health risks caused by substandard housing. 

In rural Alaska, respiratory diseases are responsible for two-thirds of child hospitalizations. Recently, a study evaluated the effect of home ventilation improvements on 68 homes in eight villages in Southwest Alaska, having a combined population of 211 children. When outcomes were monitored one year later, hospitalizations had decreased from ten cases to zero, health clinic visits had decreased from 

36 to 12, and school absences had decreased from 18 to three. 

There remains a significant disparity in housing conditions for Alaska Native and 

American Indian people compared to non-Native populations in the United States. 

This inequtiy imperils Native communities and exposes Native families to health, 

social, and economic conditions that impede their ability to achieve permanent selfsufficiency. For these reasons, federal investment in housing programs for low-income Alaska Native and American Indian families remains of critical importance. 

The Native American Housing Assistance and Self-Determination Act (NAHASDA) 

Prior to NAHASDA, housing assistance for Alaska Natives and American Indians 

was provided by various programs under the Housing Act of 1937 and other legislation. While these programs provided a broad range of assistance, they were administratively cumbersome and inefficient when used in tribal communities. They required separate applications and program administration, and eligibility requirements differed from one program to the next. The programs were an extension of 

urban-oriented housing programs and failed to recognize the unique social, cultural, 

and economic needs of Alaska Native and American Indian communities. 

In 1994, HUD articulated its intent to strengthen the unique government-to-government relationship between the United States and federally recognized Native 

American tribes and Alaska Native villages. This created momentum toward the development of NAHASDA, which was introduced in the U.S. House of Representatives by Congressman Rick Lazio. In his remarks, Congressman Lazio explained: 

Tribal governments and housing authorities should also have the ability and responsibility to strategically plan their own communities’ development, focusing 

on the long-term health of the community and the results of their work, not 

over burdened by excessive regulation. Providing the maximum amount of flexibility in the use of housing dollars, within strict accountability standards, is not 

only a further affirmation of the self-determination of tribes, it allows for innovation and local problem-solving capabilities that are crucial to the success of 

any community-based strategy. 

Congress enacted NAHASDA in 1996, establishing an Indian Housing Block 

Grant (IHBG) program specifically for the benefit of Alaska Native and American 

Indian communities. NAHASDA represents an affirmation of the unique relationship between the Federal government and Indian tribes. Acknowledging the Federal 

government’s trust obligation to promote the wellbeing of Native peoples, it for the 

first time addressed the distinct affordable housing needs of low-income Alaska Natives and American Indians. NAHASDA authorizes tribes to address their specific 

housing needs using the strategies that are most effective in their own tribal communities, rather than strategies mandated by federal officials working in offices 

thousands of miles away. 

Although our housing needs remain substantial, NAHASDA has had a profoundly 

positive impact in American Indian and Alaska Native communities. Recipients 

have used IHBG funding to build, acquire, or rehabilitate more than 123,000 homes. 

We have developed new housing; modernized, weatherized, and rehabilitated old 

homes; provided rental assistance; created home loan programs; delivered housing 

and financial literacy counseling; offered down payment assistance; prevented crime; 

and revitalized blighted communities. In addition, tribes continue to operate, maintain, and renovate about 43,000 homes developed under the 1937 Housing Act and 

the tens of thousands of additional homes that we have built since the passage of 

NAHASDA. HUD’s recent report on Native American housing needs confirms that 

NAHASDA has enabled tribal housing providers to match or exceed the rate of 

housing production under previous HUD programs. 

The Indian Housing Block Grant remains the single most significant source of 

funding for affordable housing in Alaska Native and American Indian areas. The 

program helps to stabilize Native communities and makes it easier to grow their 

economies. Although HUD monitors grantees to ensure compliance with applicable 

statutes and regulations, the flexibility inherent in NAHASDA also allows tribes to 

design, develop, and operate the affordable housing programs that best address 

their local needs. 

71 

Support for NAHASDA is strong throughout Indian Country. According to the 

Government Accountability Office, 89 percent of tribal housing providers hold positive views toward the effectiveness of NAHASDA. 

IHBG Case Study—Hooper Bay, Alaska 

The village of Hooper Bay is located in remote western Alaska. In 2006, the village was ravaged by a fire, which destroyed 15 acres of the old section of town, including 13 residential homes, six units of teacher housing, the grocery store, the 

school, the water and sewer treatment plant, warehouses, food caches, and vital 

equipment such as boats, outboard motors, and snow machines. As the TDHE for 

Hooper Bay, AVCP RHA began to identify solutions to rebuild. One potential solution was the use of Low Income Housing Tax Credits (LIHTC), but at the time 

AVCP RHA did not have experience developing or operating LIHTC properties. 

We reached out to Cook Inlet Housing Authority, a tribal housing provider that 

had the necessary experience. Together, our two organizations secured an allocation 

of Low Income Housing Tax Credits, sold the credits to an investor to generate equity for the project, and built a 19-unit apartment building for a community in the 

midst of a housing crisis. 

The Hooper Bay partnership between AVCP Regional Housing Authority and 

Cook Inlet Housing demonstrates the importance of leveraging both money and capacity. Our investment of IHBG funds, which were just 13 percent of the total 

project cost, made it possible to secure other sources, including tax credit equity, 

while our willingness to collaborate produced timely results and a mutually beneficial relationship that continues to this day. 

HUD Section 184 Loan Guarantee Program 

The Section 184 Loan Guarantee Program was created by the Housing and Community Development Act of 1992 to address the lack of mortgage lending and homeownership in Native communities. The program offers a loan guarantee to private 

lenders, who then make mortgage loans to American Indian and Alaska Native families, tribes, and Tribally Designated Housing Entities. As of March 2016, the Section 184 program has guaranteed over 33,000 loans, representing over $5.4 billion 

dollars in increased capital into Native American Communities. 

Several characteristics of the Section 184 loan guarantee make it a particularly 

powerful leveraging tool. For example, new construction can be financed with a ‘‘single close’’ loan that provides permanent guaranteed financing before construction begins. This eliminates the need to procure separate construction financing, which 

typically carries a high interest rate. Additionally, the required down payment (2.25 

percent) is achievable for both families and smaller tribal entities that may not have 

the financial capacity to make a large down payment. Because there are no income 

limitations for the 184 program, tribes are also able to serve a broader range of families and build healthier, more economically diverse tribal communities. 

Positive Impact of the BUILD Act 

On behalf of AVCP RHA and the Association of Alaska Housing Authorities, 

thank you, Chairman Hoeven, for introducing S. 1275, the BUILD Act. The BUILD 

Act represents a streamlined effort to reauthorize the single most critical tool for 

developing safe, affordable housing in Alaska Native and American Indian communities—the Indian Housing Block Grant. 

When the IHBG operates under an expired authorization the unintended result 

is that potential investors in Native housing developments become anxious. Frequently, their investments are predicated on the assumption that IHBG funding will 

be available in the long-term, often to subsidize property operations in future years. 

Extended periods of expired authorization send the message that Congress is not 

an enthusiastic investor in the IHBG program, despite its historical success. This 

uncertainty worries some potential housing investors and makes them reluctant to 

invest in Alaska Native and American Indian communities. Passage of the BUILD 

Act will resolve this issue. Further, we deeply appreciate the extended period of authorization for the IHBG in the BUILD Act, which run through 2025. 

AVCP RHA is also pleased that the BUILD Act will reauthorize the HUD Section 

184 program for the same extended period. Reauthorization of the Section 184 program sends a clear message that Congress is committed to meeting its trust obligations to Alaska Native and American Indian tribes, and will continue to encourage 

private investors to deploy capital to Native communities. 

IHBG Funding 

Reauthorizing the Indian Housing Block Grant program is critical. However, the 

potential impact of NAHASDA has been undercut by flat funding over nearly twenty 

years. HUD’s recent report on Native American housing needs noted, ‘‘Congress has 

72 

provided a fairly consistent level of funding for the [IHBG] in nominal terms, but 

this flow has been seriously eroded by inflation.’’ 

Without additional appropriations to inflation-proof the IHBG program, the 

amount of new affordable housing developed in Alaska Native and American Indian 

communities is likely to decline in future years. This is in part attributable to higher development costs, but it is also because tribes must now use a more significant 

portion of their grants to support the housing they previously developed. Because 

NAHASDA severely limits the rents recipients can charge under the IHBG program, 

many tribes must use more of their annual housing block grant to fund the operations of existing housing. In other words, IHBG recipients are increasingly focused 

on just keeping the lights on. 

Without a reasonable adjustment to IHBG funding, development activity under 

the IHBG program will continue to slow and families in Native American communities will fall farther behind their non-Native counterparts. On behalf of AVCP 

RHA and the Association of Alaska Housing Authorities, I implore the members of 

this Committee to educate Senate appropriators regarding the critical importance 

of adequately funding the Indian Housing Block Grant program. 

Tribal HUD–VASH Demonstration Program 

In January 2015, HUD and the VA announced a demonstration program to offer 

rental assistance and supportive services to Native American veterans who experience or are at risk of experiencing homelessness. One year later, in January 2016, 

HUD and the VA awarded $5.9 million to 26 tribes, effectively launching the Tribal 

HUD–VASH demonstration program. 

Tribal HUD–VASH Successes and Program Potential 

The demonstration program has faced challenges during initial implementation, 

which are described below. However, the Tribal HUD–VASH has tremendous potential. With a few sensible adjustments, the program has the ability to permanently 

change the lives of Alaska Native and American Indian veterans and their families, 

lifting them from homelessness or near homelessness and offering them permanent 

access to safe, stable housing. 

Three Alaska tribes were selected to participate in the Tribal HUD–VASH demonstration program: 

• The Association of Village Council Presidents Regional Housing Authority is 

headquartered in Bethel, Alaska, and serves 51 tribes in 48 remote communities spread over an area of Western Alaska the size of the state of Illinois. 

• Tlingit and Haida Regional Housing Authority (THRHA), headquartered in Juneau, Alaska, serves Alaska Native people living in twelve Southeast Alaska 

tribal communities and Juneau. Similar to AVCP RHA, the communities 

THRHA serves are inaccessible from the road system and spread over a vast 

geographic area. 

• Cook Inlet Housing Authority is headquartered in Anchorage, Alaska. In addition to serving Alaska Native and American Indian people in Alaska’s largest 

urban center, Cook Inlet Housing provides housing assistance in tribal communities scattered throughout Southcentral Alaska. 

In Alaska, one of the three tribes selected to participate in the Tribal HUD–VASH 

program has begun placing veterans in stable housing. Cook Inlet Housing Authority, based in Anchorage, has benefitted from access to a qualified and credentialed 

workforce, as described below, and its Tribal HUD–VASH program has begun to realize the outcomes Congress intended when it authorized the Tribal HUD–VASH 

demonstration. 

To date, Cook Inlet Housing has issued all twenty of its tribal HUD–VASH vouchers to Alaska Native veterans. They have been able to secure housing for nine veteran families totaling 23 individuals, and they anticipate that the remaining 11 Native veteran households will be housed this summer and early fall. 

Cook Inlet Housing has found that the impact of the Tribal HUD–VASH program 

goes beyond simply sheltering Alaska Native and American Indian veterans. For example, it has already helped to stabilize the health of Native veterans. Cook Inlet 

Housing was able to find housing for ‘‘James,’’ a 75-year-old veteran who had been 

homeless for many years. Once James was housed, his VA case manager was able 

to arrange personal care services that help James meet his basic needs, including 

eating, bathing, and dressing. In another instance, the Tribal HUD VASH case manager realized during an appointment that ‘‘Susan,’’ a female veteran, had a serious 

medical issue that required immediate attention. The case manager took Susan to 

a hospital emergency room, where she was admitted and treated. Susan has since 

recovered. 

73 

One of the most innovative aspects of the Tribal HUD–VASH demonstration program is that program eligibility is sensibly expanded. Whereas the traditional 

VASH program limits eligibility to chronically homeless veterans, the Tribal HUD– 

VASH demonstration program allows tribes to serve Native veterans who are homeless or at risk of homelessness, as well as their families. This approach respects traditional Alaska Native and American Indian family structures and empowers tribes 

to reunite veterans who lack stable housing with their families. This program flexibility has led to several noteworthy success stories in Alaska’s Cook Inlet region: 

• Cook Inlet Housing received an inquiry from ‘‘Steven,’’ a veteran whose family 

spanned three generations, including a grandmother, Steven and his wife, and 

their five children. Their eight-person family was living with another three-person family in a small two-bedroom home. Cook Inlet Housing was able to qualify Steven and his family under the Tribal HUD–VASH program, and they have 

since relocated to a larger four-bedroom duplex. 

• ‘‘Mark,’’ an Alaska Native veteran, was referred to Cook Inlet Housing’s Tribal 

HUD–VASH program after being homeless for some time. He was determined 

to be eligible, which allowed him to reconnect with his family, including his 

young child. Mark’s family has been reunified and is now the recipient of a 

Tribal HUD–VASH voucher for a two-bedroom home. 

• Cook Inlet Housing was able to find housing for a Native Veteran and his family of five, which includes three young children. The veteran’s wife, ‘‘Karen,’’ had 

been battling a serious illness, and sadly, she died soon after her family moved 

in to their new home. Before she passed away, Karen told the Tribal HUD– 

VASH case manager that she was happy her family had found a safe place to 

live and that it gave her peace of mind in the end. 

As these stories demonstrate, the Tribal HUD–VASH program has the potential 

to truly and permanently change the lives of homeless and at-risk Native veterans 

and their families. However, external barriers have made achieving the program’s 

potential difficult for many tribes. 

Tribal HUD–VASH Program Barriers 

Two of the three Tribal HUD–VASH demonstration program participants in Alaska continue to struggle with program implementation. My organization, AVCP Regional Housing Authority, has been unable to deploy our vouchers, and in Southeast 

Alaska, Tlingit and Haida Regional Housing Authority has also been unable to deploy its vouchers. Even Cook Inlet Housing Authority, based in Anchorage, experienced a lengthy delay before eventual deployment. 

The primary barrier to the timely deployment of Tribal HUD–VASH vouchers in 

Alaska has been the process of filling the required case management positions under 

VA specifications. When the VA hires a case manager, it does so under Office of Personnel Management classification 0185 (Social Worker). That classification requires 

a ‘‘master’s degree in social work.’’ In Alaska, however, most non-institutional case 

management is performed by clinical associates—people with knowledge of community resources and the training to work with the focus population but who do not 

necessarily have a graduate degree in a clinical mental health professional field. Put 

simply, the VA’s required case management credentials exceed those required for 

comparable positions in Alaska, and they have made it extremely difficult to recruit 

qualified case managers for the Tribal HUD–VASH demonstration program. 

This issue became apparent to Alaska’s Tribal HUD–VASH recipients in the early 

months of 2016, after the VA notified us that it would not provide case management 

services directly. Instead, the VA required the three Alaska recipients to secure 

independently contracted case management services. 

After months of exhaustive efforts, none of the three Alaska Tribal HUD–VASH 

recipients were able to identify any organization willing to provide case management services under the VA’s contract specifications. One of the primary reasons potential contractors cited for declining to participate in the program was the VA’s credential requirements for case managers. One large, extremely capable tribal 

healthcare organization considered the VA’s educational and licensure requirements 

to be unnecessary, unduly restrictive, and out of alignment with professional standards in Alaska. 

In July 2016, the VA recognized that the three Alaska Tribal HUD–VASH recipients had exhausted all reasonable efforts to secure third-party case management 

services under the VA’s contract specifications and informed the recipients that it 

would fill the case management positions internally within the VA. However, like 

the recipients themselves, the VA found it difficult to recruit case managers with 

the VA’s preferred credentials. In September 2016, the Alaska VA was able to leverage staff time from other VA programs to begin providing part-time case manageVerDate Mar 15 2010 13:50 Nov 30, 2017 Jkt 027650 PO 00000 Frm 00077 Fmt 6633 Sfmt 6621 S:\DOCS\27650.TXT JACK
74 

ment services in the Cook Inlet Region, and in November 2016, the VA was finally 

able to hire a full-time case manager position for Cook Inlet Housing’s tribal HUD– 

VASH program. 

In Southeast Alaska, THRHA located a counselor who it believed would be a suitable case manager. The individual held a master’s degree in secondary education, 

was a licensed professional and chemical dependency counselor, and had received 

a statewide Counselor of the Year Award. Because the candidate’s master’s degree 

was not in ‘‘social work,’’ the VA informed THRHA that he could not be hired. 

Another candidate for the THRHA case manager position subsequently began the 

VA’s vetting process this spring. However, the VA’s recruitment, credentialing, 

boarding, and offer process can be cumbersome, and the candidate has not yet been 

hired. THRHA and the Alaska VA are hopeful that the VA will be able to make 

a final offer to the candidate by mid-June. Once a hire is made and a case manager 

begins work, THRHA can finally begin connecting homeless Alaska Native Veterans 

with the case management services that will help prepare them to transition into 

permanent housing. 

Sadly, in the AVCP region of Southwestern Alaska, little progress has been made 

toward the hiring of a VA case manager. We credit the VA with recently adding 

Licensed Professional Mental Health Counselors and Licensed Marriage and Family 

Therapists to the list of licensed professionals it will deem to meet their credential 

requirements. However, we are not optimistic that this step will be sufficient to secure the case management services that our homeless veterans so desperately need 

in order to access the Tribal HUD–VASH demonstration program. 

We believe that there is more that the VA and HUD can do to address this significant impediment to implementation. The simplest solution would be for the VA to 

proactively reconsider its credential requirements and more appropriately align 

them with the professional standards for ‘‘clinical associates,’’ para-professionals 

who frequently provide case management services in many communities. 

Alternatively, Congress could explicitly require the VA to waive or specify reasonable alternative requirements for its case management credentials. When Congress 

authorized the Tribal HUD–VASH demonstration via P.L. 113–235, it required that 

the program be modeled after the general HUD–VASH program, but ‘‘with necessary and appropriate adjustments for Native American grant recipients and veterans.’’ Congress further required that HUD, in coordination with the VA, ‘‘ensure 

the effective delivery of supportive services to Native American veterans that are 

homeless or at-risk of homelessness. . .’’ When Tribal VASH recipients, because of 

their remoteness, economic conditions or other factors, do not have access to personnel meeting the VA’s case manager credentials, the VA should be compelled to 

adjust those credentials to align them with the standard qualifications of other positions, such as clinical associates, that capably perform case management functions 

in similar communities. 

Draft Tribal HUD–VASH Bill 

I appreciate the opportunity to review and offer comment regarding the recently 

circulated draft Tribal HUD–VASH bill. We in Alaska believe the draft bill would, 

if passed, have a positive impact on tribal communities by strengthening the Tribal 

HUD VASH Program. 

The draft bill would enhance program stability by setting aside a small portion 

of the funding provided for the general HUD–VASH Program on a permanent basis. 

Veteran families that have been successfully housed under the Tribal HUD–VASH 

demonstration would be at less risk of losing their assistance and once again struggling to find safe, affordable housing. Additionally, the added sense of program permanency could make it easier to attract qualified case managers, who may be less 

concerned that their position will evaporate at the conclusion of the Tribal HUD– 

VASH demonstration. 

The draft bill also requires consultation between HUD, the VA, the Tribal HUD– 

VASH recipients, and other appropriate tribal organizations on program design. The 

three Alaska recipients, as well as the Association of Alaska Housing Authorities, 

would welcome the opportunity to share our observations and recommendations 

with high-level leadership from the VA, in particular. While we have expressed our 

thoughts and concerns to the Alaska VA Healthcare System, it can sometimes be 

difficult for local VA officials to communicate our local perspective to VA leadership 

at the national level. We believe that the opportunity to engage in direct tribal consultation with the VA will prove beneficial to all stakeholders. 

Finally, we appreciate that the draft bill includes provisions that give administrative flexibility to HUD and the VA. These provisions empower HUD and the VA to 

make necessary and appropriate modifications to the program after engaging in consultation with recipients and tribal organizations. Additionally, HUD is provided auVerDate Mar 15 2010 13:50 Nov 30, 2017 Jkt 027650 PO 00000 Frm 00078 Fmt 6633 Sfmt 6621 S:\DOCS\27650.TXT JACK
75 

thorization to waive or specify alternative requirements for any provision of law 

when doing so is necessary for the effective delivery and administration of rental 

assistance under the Tribal HUD–VASH program. Provisions of this nature leave 

open the possibility that HUD and VA will help address future issues that impact 

program implementation without the need for a legislative fix. 

Conclusion 

Housing conditions in Alaska Native and American Indian communities remain 

far worse than the conditions experienced by America’s non-Native populations. This 

persistent inequtiy imperils Native communities and exposes Native families to 

health, social, and economic conditions that present a barrier to the attainment permanent self-sufficiency. 

The Indian Housing Block Grant program has successfully empowered tribes to 

address their housing conditions using strategies developed and implemented at the 

local level. S. 1275, the BUILD Act, would reauthorize the IHBG, a critical step toward ensuring that the good work being done by tribal housing providers will continue. However, simply reauthorizing the IHBG is not enough. Without a reasonable 

funding adjustment, development activity under the IHBG program will continue to 

slow and families in Native American communities will fall farther behind their 

non-Native counterparts. 

In Alaska, we admit to being frustrated by the unacceptably slow implementation 

of the Tribal HUD–VASH program. However, we are also beginning to see the program’s impacts in one region of our state, and the outcomes have been impressive. 

We believe that the primary barrier to program implementation in many Native 

communities has been the VA’s credential requirements for case managers, which 

exceed those required for comparable positions in many communities and make it 

extremely difficult to recruit qualified case management personnel. 

It appears that the current legislative authorization for the Tribal HUD–VASH 

demonstration program allows the VA and HUD to reconsider the VA’s credential 

requirements for case managers and more appropriately align them with the professional standards for ‘‘clinical associates,’’ which frequently provide case management 

services in many communities. Alternatively, Congress could explicitly require the 

VA to waive or specify reasonable alternative requirements for its case management 

credentials. 

Finally, we in Alaska believe the draft Tribal HUD–VASH bill would, if passed, 

have a positive impact on tribal communities by strengthening the Tribal HUD 

VASH Program. It would enhance program stability and provide the opportunity for 

recipients to engage in direct tribal consultation with the VA about current barriers 

to program implementation. 

On behalf of The Association of Village Council Presidents, The Association of 

Alaska Housing Authorities, and tribes across the United States, thank you for your 

efforts to improve housing conditions in tribal communities and for the privilege of 

speaking with you today. 

Senator MURKOWSKI. Thank you. Again, thank you for coming so 

far to provide your testimony today. 

Ms. Difuntorum. I hope I am pronouncing that correctly. 

Ms. DIFUNTORUM. That is about as close as it gets. 

STATEMENT OF SAMI JO DIFUNTORUM, CHAIRWOMAN, 

NATIONAL AMERICAN INDIAN HOUSING COUNCIL 

Ms. DIFUNTORUM. Good afternoon. 

My name is Sami Jo Difuntorum. I am the Chairwoman of the 

National American Indian Housing Council. I am a member of the 

Kwekaeke Band of Shasta Indians of California, and I am the 

Housing Director for the Confederated Tribes of Siletz Indians in 

the beautiful State of Oregon. 

I appreciate the opportunity to testify before you today. I would 

like to thank Chairman Hoeven, Ranking Member Udall and members of the Committee for having this hearing today and for staying 

engaged on tribal housing issues. 

The NAIHC is comprised of 267 voting members that represent 

nearly 471 tribes and tribally-designated housing entities across 

76 

the United States. We were established 43 years ago and our core 

functions are advocacy and capacity building to our training and 

technical assistance program. 

In addition to the comments I will make today, I have submitted 

a formal written statement for the record. Today, I want to focus 

on the two bills I have been asked to speak about and discuss a 

tribal housing issue we have identified with the new Administration. 

First, with respect to S. 1275, the BUILD Act, I would like to 

thank Senator Hoeven for introducing the bill and for focusing on 

NAHASDA reauthorization. I would also like to thank Committee 

staff. We have had several reauthorization bills introduced in the 

last couple of sessions to no avail. I was encouraged to hear people 

on the Committee commit to working together to get this done this 

year. I hope that happens. 

To be clear, NAIHC supported the past reauthorization efforts 

that included Title VIII and will continue to advocate for Title VIII 

reauthorization. I am encouraged that members of the Committee 

pledged to one another to find a solution to reauthorize or authorize Title VIII. Whether it is in NAHASDA or not, I do not know, 

but I am encouraged with the commitment of the people on the 

Committee to do that. 

There are a number of things that we really like in the bill. We 

strongly support reauthorization of both the Indian Housing Block 

Grant and the 184 Loan Guarantee Program, the backbone of tribal 

housing programs across the Country. The Indian Housing Block 

Grant Program is the third largest source of Federal funds on Indian reservations and the primary source for Indian housing development. 

We also support the longer, seven-year authorization. As you can 

tell by how long it has taken to not get it authorized so far, it 

would be nice not to have this pressure every five years. 

The environmental review process, as in the past, we supported 

provisions to streamline environment reviews. The BUILD Act has 

a provision that goes in the right direction. We think it could be 

a little bit better. We are committed to helping work on refining 

that a little bit. 

Section 703, as I mentioned before, capacity building, is one of 

the core functions of NAIHC. We are mainly concerned that the 

BUILD Act proposes to change Section 703 Training and Technical 

Assistance provisions. 

As part of negotiations in 2000, tribal leadership understood the 

need for quality training and technical assistance in housing programs. Tribal leaders also understood that for T/TA to be effective, 

it should be delivered by an organization that represents and understands housing issues and the complexity of housing development on tribal lands. 

The provisions of the BUILD Act would strip away the requirements that the T/TA be provided by an organization knowledgeable 

in tribal housing. We don’t think that is in Indian Country’s best 

interest. Tribes have not asked for this change and, frankly, we 

don’t support it. 

There are a number of provisions that the BUILD Act leaves out 

that we would like to see enacted. If you get to the point that you 

77 

are looking at mark up, obviously, we would like to see Title VIII 

enacted, Title VIII authorized in some way, shape or form. We 

would like to see elevation of the ONAP that position to an assistant secretary position. That was in S. 710 introduced in the last 

Congress by then-Chairman Barrasso. 

We think it is important to elevate Indian Country to where it 

needs to be within HUD and some relief from the 30 percent rule. 

It is not part of the BUILD Act so I am not going belabor the discussion here, but that is something we have worked very hard on 

for a number of years to try and get some change and relief. We 

hope, going forward, that is a discussion we can take up with all 

of you. 

We support the efforts of all members of the Committee and Congress to reach these goals and we stand ready to work with each 

of you to secure their inclusion and passage of the BUILD Act. 

I am already out of time. I thought I was talking fast. 

The CHAIRMAN. [Presiding]. You are doing just fine. 

Ms. DIFUNTORUM. Thank you. 

With respect to the HUD–VASH bill, NAIHC generally supports 

efforts to improve housing conditions and opportunities for Native 

veterans. We believe the HUD–VASH Program is a step in the 

right direction. 

We support making HUD–VASH a permanent program and we 

also support the provision within the larger HUD–VASH Program 

for a five percent minimum set aside for Indian Country. Every 

time we have a conference, I ask people in the room how many of 

you have veterans on your reservation. Every single person in the 

room raises their hand. All tribes have vets and we have homeless 

vets. 

We think expansion of this program is really important. I think 

it is doing a lot of good in Indian Country. 

Funding is the last issue on which I want to touch. I realize this 

is not an appropriations hearing or an appropriations committee, 

but I would be remiss in my duty as chairwoman if I did not bring 

this up. 

The President’s budget request proposes to reduce the Indian 

Housing Block Grant by $54 million from the 2017 enacted level. 

That is 30 percent. That would be devastating to tribes. It zeroes 

out the Native Hawaiian Block Grant entirely. 

I know a lot of people on this Committee are also on appropriations committees, so I want you to think about this when you start 

doing appropriations work. 

It completely eliminates the Community Development Block 

Grant. The Indian Community Development Block Grant is a component of the larger CDBG. If that goes away, ICDBG goes away. 

That is one of our primary mechanisms and funding streams for 

developing infrastructure on tribal land. I hope those of you who 

are part of appropriations will take a close look at that. 

Earlier this year, a HUD Needs Assessment Study showed tribal 

rates of substandard housing and overcrowded homes well in excess of the national average. This is not new. This isn’t news. 

The report indicates that 68,000 new units are needed in Indian 

Country. I would suggest that is probably a low estimate. We have 

a lot of hidden homeless not on the radar a lot of the time. 

78 

1There are 567 federally recognized Indian tribes and Alaska Native villages in the United 

States, all of which are eligible for membership in NAIHC. Other NAIHC members include 

state-recognized tribes eligible for housing assistance under the 1937 Housing Act and that were 

subsequently grandfathered in under the Native American Housing Assistance and Self-Determination Act of 1996, and the Department of Hawaiian Home Lands, the state agency that administers the Native Hawaiian Housing Block Grant program. 

We recognize the budget constraints the Federal Government is 

in. However, that does not diminish the trust and treaty responsibilities the United States has towards tribes. Tribal programs 

have been operating with severe unmet needs for decades. Tribal 

programs are certainly not the cause of this Country’s fiscal issues 

and cuts to these programs should certainly not be a part of any 

solution. 

I would like to thank the Committee again for its attention to 

tribal housing. Thank you, Chairman Hoeven, for introducing the 

BUILD Act. I look forward to answering any questions you have 

before I have to leave for the airport. 

Thank you. 

[The prepared statement of Ms. Difuntorum follows:] 

PREPARED STATEMENT OF SAMI JO DIFUNTORUM, CHAIRWOMAN, NATIONAL AMERICAN

INDIAN HOUSING COUNCIL

Good Afternoon. My name is Sami Jo Difuntorum, and I am the Chairwoman of 

the National American Indian Housing Council. I am a member of the Kwekaeke 

Band of Shasta Indians of California, and I am currently the Executive Director of 

the Siletz Tribal Housing Department in Oregon. I would like to thank Chairman 

Hoeven, Ranking Member Udall and committee members for having this hearing 

today and for staying engaged on tribal housing issues. 

The NAIHC is comprised of 255 voting members that represent nearly 470 tribes 

and tribally-designated housing entities across the United States. The NAIHC was 

established 43 years ago to advocate on behalf of tribal housing programs and now 

also provides vital training and technical assistance to increase the managerial and 

administrative capacity of tribal housing programs. 

Background on the National American Indian Housing Council 

The NAIHC was founded in 1974 and for over four decades has provided invaluable Training and Technical Assistance (T&TA) to all tribes and tribal housing entities; provided information to Congress regarding the issues and challenges that 

tribes face in their housing, infrastructure, and community development efforts; and 

worked with key federal agencies to ensure their effectiveness in native communities. Overall, NAIHC’s primary mission is to support tribal housing entities in 

their efforts to provide safe, decent, affordable, and culturally appropriate housing 

for Native people. 

The membership of NAIHC is comprised of 255 members representing 478 1 tribes 

and tribal housing organizations. NAIHC’s membership includes tribes and groups 

throughout the United States, including Alaska and Hawaii. Every member of this 

Committee serves constituents that are members of NAIHC. Our members are deeply appreciative of the consistent leadership this Committee provides in Congress related to issues affecting tribal communities. 

Profile of Indian Country 

There are 567 federally-recognized Indian tribes in the United States. Despite 

progress over the last few decades, many tribal communities continue to suffer from 

some of the highest unemployment and poverty rates in the United States. Historically, Native Americans in the United States have experienced higher rates of substandard housing and overcrowded homes than other demographics. 

The U.S. Census Bureau reported in the 2015 American Community Survey that 

American Indians and Alaska Natives were almost twice as likely to live in poverty 

as the rest of the population—26.6 percent compared with 14.7 percent. The median 

income for an American Indian Alaska Native household is 31 percent less than the 

national average ($38,530 versus $55,775) 

In addition, overcrowding, substandard housing, and homelessness are far more 

common in Native American communities. In January of this year, the Department 

79 

of Housing and Urban Development (HUD) published an updated housing needs assessment. According to the assessment, 5.6 percent of homes on Native American 

lands lacked complete plumbing and 6.6 percent lacked complete kitchens. These 

are nearly four times than the national average, which saw rates of 1.3 percent and 

1.7 percent, respectively. The assessment found that 12 percent of tribal homes 

lacked sufficient heating. 

The assessment also highlighted the issue of overcrowded homes in Indian Country, finding that 15.9 percent of tribal homes were overcrowded, compared to only 

2.2 percent of homes nationally. The assessment concluded that to alleviate the substandard and overcrowded homes in Indian Country, 68,000 new units need to be 

built. 

Since NAHASDA was enacted, tribes have built over 37,000 new units according 

to HUD. However, as the IHBG appropriations have remained level for a number 

of years, inflation has diminished the purchasing power of those dollars, and new 

unit construction has diminished as tribes focus their efforts on unit rehabilitation. 

While averaging over 2,400 new unit construction between FY2007 and 2010, new 

unit construction has dropped in recent years with only 2,000 new units between 

2011 and 2014, and HUD estimating less than 1,000 new units in future years as 

tribes maintain existing housing stock. 

S. 1275, the Bringing Useful Initiatives for Indian Land Development Act 

of 2017 

First and foremost, the NAIHC would like to thank Senator Hoeven for introducing S. 1275 and for focusing on NAHASDA reauthorization. This is the fourth 

year now that the program has been left unauthorized, and our membership continues to grow more concerned as discussions in Washington, DC focus on cutting 

spending and eliminating unauthorized programs. 

While NAHASDA may be currently unauthorized, the United States’ trust and 

treaty responsibilities towards Native peoples remain and will not go away. The 

members of this Committee know these commitments well and NAIHC is very appreciative of all your efforts in supporting tribal programs and tribal self-determination. 

There are a number of provisions in S. 1275 that NAIHC supports, and the following section-by-section outlines area we support and those with which we have 

concerns. 

Section 3 and 6: Reauthorizations of the IHBG and 184 Loan Guarantee Programs 

NAIHC strongly supports the re-authorization of both the Indian Housing Block 

Grant and the 184 Loan Guarantee program. We also support the longer term of 

authorization of 7 years, as it recognizes the complexity in reauthorizing these types 

of programs. 

Section 2: Environment Reviews 

As in the past, NAIHC supports provisions to streamline environmental reviews. 

Completing multiple reviews adds additional time and cost to housing projects that 

are already complex enough due to the number of parties involved in tribal projects. 

Section 2 of the BUIILD Act would eliminate some of those costs and delays. While 

NAIHC believes the language could be further simplified, we understand the provisions in the BUIILD Act were crafted to address practical concerns expressed by 

HUD. We would be happy to offer further technical assistance to ensure the provisions are effective. 

Section 5: Training and Technical Assistance 

The NAIHC remains concerned that the BUIILD Act proposes changes to the 

NAHASDA section 703 Training and Technical Assistance (T/TA) provisions. As part 

of the original negotiations leading up to NAHASDA’s enactment, tribal leadership 

understood the need for a national organization to provide quality technical assistance and training opportunities to tribal housing programs. Tribal leaders also understood that for the T/TA to be effective it should be delivered by an organization 

that specifically understands tribal housing issues and the complexity of housing development on tribal lands. 

Furthermore, tribal leadership negotiated the provision with the understanding 

that the funds would come out of the Indian Housing Block Grant, which would otherwise go directly to tribal housing programs. Without a mandate from tribal leaders to change these provisions, NAIHC cannot support a change that would open 

up funds from the Indian Housing Block Grant to organizations that do not have 

a strong background or specific expertise in tribal housing, which the BUIILD Act 

does not currently require. 

80 

If a consensus of tribal leaders indicates that the current language of section 703 

is no longer useful in fulfilling the T/TA needs of tribal housing programs, NAIHC 

would support such a change. But until that happens, we would ask members of 

this Committee to leave section 703 of NAHASDA unaltered. 

Section 7: Leveraging 

NAIHC supports the provision that clarifies that NAHASDA funds can be used 

to meet matching or cost-sharing requirements of other federal or non-federal programs. This provision is common in other tribal self-determination programs, and 

provides tribes greater flexibility and leveraging opportunities. 

Other NAHASDA provisions 

S. 1275 represents a departure from past NAHASDA reauthorization efforts in 

that it leaves out many provisions found in past bills in an effort to secure passage. 

However, it is unclear at this time to NAIHC that the changes found in the BUIILD 

Act provide a clearer path to enactment. 

In particular, the BUIILD Act does not include a reauthorization for Title VIII 

programs for Native Hawaiians. Past versions of NAHASDA reauthorization bills included reauthorization of these programs. Notably in the 114th Congress, both H.R. 

360, which passed out of the House of Representatives, and S. 710, introduced by 

Senator Barrasso and reported unanimously out of this Committee, contained language reauthorizing Title VIII. 

In December of last year, NAIHC provided a letter to Congress that indicated it 

could support a bill that only reauthorized the Indian Housing Block Grant. However, that approach contemplated a two-prong approach where a second more substantive and thorough tribal housing bill (likely including Title VIII programs) 

would also be developed and moved forward. NAIHC is concerned that we have not 

seen movement on the second prong of that approach, and are worried the lack of 

such progress will diminish broader Congressional support of the BUIILD Act itself. 

To be clear, NAIHC supports reauthorization of IHBG, reauthorization of Title 

VIII Native Hawaiian housing assistance programs, and a host of other tribal housing related provisions. We support the efforts of all members of this Committee and 

Congress to reach those goals, and stand ready to work with each of you to secure 

their inclusion and passage in the BUIILD Act or other legislative vehicle. 

S. lll, the HUD–VASH bill 

NAIHC has not been able to fully analyze S. lll but generally supports efforts 

to improve housing conditions and opportunities for Native American veterans. In 

addition to making the HUD–VASH program permanent, the draft bill appears to 

provide the Secretaries of HUD and the VA the necessary flexibility to improve implementation of HUD–VASH on tribal lands. 

Two of the primary concerns that NAIHC has heard regarding HUD–VASH implementation are the lack of case managers the VA can identify willing to work in 

tribal areas, and the restrictions placed on certain tribal housing units by HUD that 

make them ineligible for VASH vouchers. The flexibility provided to the agencies by 

the bill could allow the VA and HUD to address these concerns. However, the restrictions on certain tribal housing units being eligible for VASH vouchers could be 

addressed more directly in the bill, as we believe HUD has too narrowly restricted 

which tribal housing units should be eligible. Many communities have housing 

shortages, and limiting the housing stock that can be used in the tribal HUD–VASH 

program forces some of the participating tribes to house their tribal veterans in 

nearby urban areas, rather than the tribal community as intended by the program. 

While that concludes NAIHC’s statement on the bills placed on today’s hearing 

agenda, the NAIHC believes it must raise the issue of several troubling developments made by the new Administration. 

Concerns with the Administration’s FY 2017 Omnibus Signing Statement 

On May 5, when President Trump signed into law the FY 2017 omnibus spending 

bill, the President issued a signing statement that characterized the ‘‘Native American Housing Block Grants’’ as quote ‘‘a program that allocated benefits on the basis 

of race.’’ 

All of the members of this Committee know full well that tribal programs are not 

based on race, but on the political relationship that have existed between Native 

peoples and the United States for over two hundred years. 

The relationship is grounded in the United States Constitution and treaties, Congressional statutes and numerous Supreme Court decisions. So we ask that members of Congress work with the new Administration to ensure it knows the history 

and importance of tribal programs. 

81 

There are numerous Supreme Court cases that can be cited upholding this principle of federal Indian Law and countless legal articles that chronicle this background. NAIHC is happy to provide documentation to the Committee if necessary, 

but believes the question is well settled and did not see the need to include such 

information here. 

Concerns with the Administration’s FY 2018 Budget Proposal 

While the signing statement could be dismissed as not fully understanding the 

background of federal Indian law, the Administration’s FY 2018 funding proposals 

is much more concerning. In short, NAIHC believes that the budget, if enacted, 

would devastate tribal housing programs across the country. 

The budget provides substantial cuts or completely eliminates the Community Development Block Grant at HUD, the CDFI Fund at Treasury, and Rural Development programs at the USDA. 

The proposed budget would also cut the Indian Housing Block Grant to $600 million, which is essentially the same level of funding tribal housing programs received 

in 1996. However adjusting for inflation, the proposal represents a cut of about onethird compared to 1996 funding levels. 

The HUD tribal housing needs assessment released in January showed that tribes 

have rates of substandard housing and overcrowded homes well in excess of the national average. The report indicated that 68,000 new units are needed in Indian 

Country. As the ability of tribes to develop new housing units has diminished in the 

last few years due to inflation, the problem cannot be compounded by the severe 

program funding cuts proposed in the Administration’s FY 2018 budget. 

NAIHC asks that members of this Committee, particularly those who also sit on 

the Appropriations Committee, support adequate funding of the Indian Housing 

Block Grant and other tribal housing programs. Funding the IHBG at $900 million 

would provide tribes relatively the same purchasing power it had in 1996 and 

NAIHC requests no less than $700 million for FY 2018. Congress should also reject 

the proposed cuts to the other programs listed above, as they provide tribes additional resources for their housing programs. Funding tribal housing programs not 

only fulfills Congressional trust and treaty responsibilities, but does so in a way 

that spurs economic development, creates jobs and builds credit in tribal communities. 

The CHAIRMAN. Thank you for your outstanding testimony. I 

thought yours was excellent and I am sorry I missed some of the 

others. I do thank all of you very much for being here. 

Madam Chairwoman, in previous Indian Affairs Committee hearings, we had one entitled, Accessing Capital in Indian Country. 

Witnesses from NAIHC provided testimony recommending that 

NAHASDA dollars, the BUILD dollars, should be allowed for 

leveraging investment opportunities in Indian Country, combining 

and leveraging those investments. 

We have included some of those leveraging authorities. I am just 

wondering if you think that would be helpful in terms of the housing challenges? 

Ms. DIFUNTORUM. Chairman Hoeven, the short answer is yes. I 

do think that would be helpful. I also think being able to use Indian Housing Block Grant dollars for matching funds, which is a 

provision in the BUILD Act, would help us to leverage as well. 

The CHAIRMAN. You mentioned the appropriations process. I am 

on appropriations and yes, we have a lot of work to do there. We 

will be hard at work. 

Also, do you think the HUD–VASH bill addresses some of the 

problems the National American Indian Housing Council has heard 

from the tribes, the feedback they are getting? Are we getting to 

some of their priorities and concerns? 

Ms. DIFUNTORUM. I do think so. There are two concerns I consistently hear from our membership. One is the education level required for the counselors in remote areas. It is very difficult to get 

82 

people with Master’s degrees as counselors. I think Alaska had suggested maybe remote counseling and lowering the requirement to 

Bachelor degrees. I think that is helpful. 

The other that surfaced recently, I have only heard from one of 

our members, is that they cannot use the HUD–VASH in what we 

call formula current assistance stock which is our 37 Act units. I 

have not been able to delve into that and it is not addressed in the 

BUILD Act. Ms. Frechette might be able to speak to that. 

The CHAIRMAN. I am going to turn to her next and ask that. 

I also want to ask about the remote counseling. Is anyone doing 

that? If so, how is it working? How can we try to implement something like that? You express a very real challenge. Maybe the telecounseling is something that can be done. Are you doing it and, if 

so, how do you think it is working? What can we do to try to make 

it work? 

Ms. FRECHETTE. I will invite Keith to comment on this also because he is in charge of the case management. 

This is an opportunity that we see in the Indian Health Service 

to become a strong partner with VA and HUD, to look at ways to 

use their telemedicine system. This is something we have talked 

about for a while. We would be able to access folks in rural and 

remote areas. 

The CHAIRMAN. Has anyone done it? 

Ms. FRECHETTE. We have with telemedicine but I don’t know 

about case management. 

The CHAIRMAN. No, I mean counseling, particularly in regard to 

veterans in remote areas and so forth? 

Dr. HARRIS. Not in the tribal programs specifically. We have 

done it more generally in HUD–VASH. Telemedicine and tele-mental health are both big pushes. 

The CHAIRMAN. You have not done it in the tribal community? 

Dr. HARRIS. Not in the tribal community. It is one of the things 

we wanted to try. 

The CHAIRMAN. Do you have the ability to do it in any tribal 

community? 

Dr. HARRIS. It requires infrastructure. That is one of the things 

we are hoping to get from IHS in an interagency agreement. We 

hope to restart those conversations but certainly we could. 

The CHAIRMAN. You could maybe link with VA and IHS to try 

to do it? 

Dr. HARRIS. Yes. 

The CHAIRMAN. It seems like that would be a really good idea, 

would it not? 

Dr. HARRIS. That is the goal. 

The CHAIRMAN. It would pose some challenges also because it is 

challenging work, right? You would have to figure out how to do 

it so it is sensitive and effective and you get some kind of feedback 

as to whether you are accomplishing something. 

Dr. HARRIS. That is right. 

The CHAIRMAN. It is such a challenge in these remote areas. It 

is not easily solvable either in terms of time and resources, getting 

people in place, and going where you need to go. It seems to me 

this is something we need to really pursue. 

Senator Schatz. 

83 

Senator SCHATZ. Thank you, Mr. Chairman. 

This is a question for all witnesses. I will start on my left and 

go down the line. 

If this bill marked up in Committee, the BUILD Act, would any 

of you object to an amendment that included Native Hawaiians? 

Ms. FRECHETTE. Thank you for your question. I am career staff 

at HUD, so I don’t comment on what vehicles are appropriate and 

stuff like that. 

Senator SCHATZ. Dr. Harris? 

Dr. HARRIS. The same answer, unfortunately. Sorry, sir. 

Ms. ONNEN. I am within CAI, and you missed part of my testimony, but we would support that. 

Senator SCHATZ. Thank you. 

Mr. CHARLIE. We would support that. 

Ms. DIFUNTORUM. We support authorization of Title VIII. If it 

happens through Committee, we would support that. 

Senator SCHATZ. Thank you. 

The next question is for NCAI and Ms. Onnen. 

For decades, as you know, Native communities have stood together fighting off divide and conquer. Could you give us a little 

bit of historical context for why this bill is a departure from the 

way we have done business both on the Committee with NCAI and 

Native communities generally? 

Ms. ONNEN. I think what I could comment on is our concern at 

NCAI about the legal precedent this would set. We have always 

worked in partnership with the Native Hawaiian community. It 

has a special political and trust relationship with the United States 

and it has been reaffirmed through Congress through over 150 

statutes, as well as the message it sends. 

I think the concern is the message it sends by condoning separate treatment of Native communities by this Committee. I think 

that is our concern at NCAI. 

Senator SCHATZ. Thank you very much. 

Ms. Difuntorum, am I getting your name right? 

Ms. DIFUNTORUM. Yes, thank you. 

Senator SCHATZ. I have good staff. 

You have Native Hawaiian members, right? 

Ms. DIFUNTORUM. Members? 

Senator SCHATZ. Of your housing council? 

Ms. DIFUNTORUM. Let me answer that. The Department of Hawaiian Homelands is the voting member and we also have an associate member which is a different level. That is the way our bylaws read. The short answer is yes, but it is a bit more complicated 

than that. 

Senator SCHATZ. Could you quickly elucidate what the impact 

would be for the Department of Hawaiian Homelands’ Hawaiian 

housing generally if this bill were to be enacted without taking care 

of Native Hawaiians? What would be the impact of passing 

NAHASDA without including Hawaiians? 

Ms. DIFUNTORUM. I don’t know that means; there would not be 

funding or the Native Hawaiian Housing Block Grant Program. 

That is the piece that would be devastated. On a political level, I 

think it is a very different question for Hawaiians in general. I am 

sure you know the answer to that. It is in everyone’s best interest 

84 

to include them in reauthorization. Does that answer your question? 

Senator SCHATZ. Yes, thank you. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Vice Chairman Udall. 

Senator UDALL. Thank you, Mr. Chairman. 

President Trump’s recent signing statement called into doubt the 

legality of Federal housing programs for Native Americans, Alaska 

Natives and Native Hawaiians. He also questioned the constitutionality of Native Hawaiian and Alaska Native education programs. 

For Mr. Charlie, as an Alaska Native leader, are you concerned 

about the President’s statement questioning the legality of programs benefitting Alaska Natives and Native Hawaiians? 

Mr. CHARLIE. Yes, I am. 

Senator UDALL. Are you similarly concerned that it supports the 

idea that Alaska Natives and Native Hawaiians have weaker 

claims to the Federal trust responsibility than American Indians? 

Mr. CHARLIE. The way I understand your question, yes, I think 

it weakens that responsibility, that understanding, that relationship. 

Senator UDALL. You believe it weakens the trust responsibility to 

those tribes? 

Mr. CHARLIE. Yes. 

Senator UDALL. Ms. Onnen, you represent the oldest, largest and 

most representative tribal organization in the Country. I understand that NCAI has a resolution supporting the reauthorization of 

the Native Hawaiian Housing Block Grant Program as a part of 

the overall reauthorization of NAHASDA, is that correct? 

Ms. ONNEN. That is correct. 

Senator UDALL. Why did your organization take such a strong 

position and why hasn’t it changed its position? 

Ms. ONNEN. I think the answer to that question is very similar 

to the answer that I just gave. We are concerned about the message that it may send by condoning separate treatment of different 

Native communities within the United States. 

It begins, in essence, to create potential classes of Native Americans. I think that is a concern at NCAI. The membership has stood 

behind the Native Hawaiians and the reauthorization of that piece. 

We have discussed this a couple times at our conventions and that 

stance has not yet changed. The resolution on file from 2013 stands 

and that is where we stand right now. 

Senator UDALL. Thank you. 

Ms. Difuntorum, you represent the housing interests of more 

than 277 tribally-designated housing entities providing housing 

services to approximately 450 tribes, Alaska Natives and Native 

Hawaiians. 

Your organization has a resolution supporting the reauthorization of the Native Hawaiian Housing Block Grant Program as part 

of the overall reauthorization of NAHASDA. Do you stand by this 

resolution? 

Ms. DIFUNTORUM. Yes. 

Senator UDALL. Thank you. 

85 

ABCP is a member of your organization. So are the Department 

of Hawaiian Homelands and the Hawaiian Homestead Community 

Development Corporation. Does it concern you that S. 1275 seeks 

to divide the interests of your membership? 

Ms. DIFUNTORUM. Was that a question for me? I am sorry. 

Senator UDALL. Yes, that was. 

Ms. DIFUNTORUM. I am sorry, would you repeat the question? I 

thought you were talking to Mark Charlie. 

Senator UDALL. No. ABCP is a member of your organization. So 

are the Department of Hawaiian Homelands and the Hawaiian 

Homestead Community Development Corporation. Does it concern 

you that S. 1275 seeks to divide the interests of your membership? 

Ms. DIFUNTORUM. I wouldn’t characterize it quite like that. 

Senator UDALL. How would you characterize it? 

Ms. DIFUNTORUM. I would say, again, Committee staff has 

worked very hard for several sessions of Congress to get a reauthorization bill, including Title VIII. We support authorization of 

Title VIII even though they have never been authorized under a 

NAHASDA reauthorization, right? Everybody knows that. 

We support the Hawaiian program. Chairman Hoeven spoke to 

this at the very beginning in his opening remarks that there has 

not been any success in getting any authorization done. Unfortunately, Title VIII has been a big barrier. That does not mean that 

we do not support authorization of that program. We do and if 

there is a way to do NAHASDA and have Title VIII included, absolutely, we support that. 

I do not know if that answers your question but that is our position. We support including Title VIII if we can get reauthorization 

done in its entirety with Title VIII intact, absolutely we would support that. 

Senator UDALL. Let me ask it just a little bit differently. Would 

you support passage of a NAHASDA reauthorization bill that does 

not include Native Hawaiian housing programs? 

Ms. DIFUNTORUM. Okay, that is a different question. What I am 

going to say is I do not think that is a fair question to ask me. The 

Department of Hawaiian Homelands is a member of the Housing 

Council. We also have a lot of other members and I would really 

have to consult with the Board of Directors and our membership 

before I would be willing to go there. 

Senator UDALL. Thank you. 

I am well over time here, Mr. Chairman. 

The CHAIRMAN. That is fine. I did not have any other questions 

but I think Chairwoman Difuntorum, you are getting at what we 

are trying to do. That is to pass the BUILD Act, pass NAHASDA, 

and reauthorize the Indian Housing Program. We have been stuck 

for the last two Congresses so it is just to figure out how we can 

move forward. 

I appreciate your responses because I think what you are making 

clear and what I am trying to make clear is we are looking for solutions and trying to find ways to get things done. I would it would 

not be characterized as splitting the group in any way. That is not 

it. 

86 

If we decide as a Committee to include it and we remain stuck, 

we cannot move it through the Congress. Then we are in the same 

situation we have been for the last two Congresses. 

Further, I would add it is not that the Native Hawaiians are just 

not included in BUILD, at the same time we made an offer to provide their funding through the appropriations process. I would not 

want that to get left out. I am a little concerned that those questions kind of left that out. That is why I think you answered it in 

the right way. Look, we are trying to find a solution that gets it 

accomplished. NAHASDA is about $650 million in reauthorization for housing programs. My understanding is about $2 million goes to Native Hawaiians. That is why we were talking about trying to maybe do 

something through appropriations so we could advance the ball. 

Simply put, the effort is not to leave anyone behind. The effort is 

trying to find a way to advance but it may take some creativity. 

I am open, as I said at the outset. That is the only concern I have 

with the question as put to you by the Ranking Member. It was 

kind of like this splits the BUILD. No, it is trying to find a creative 

way to get reauthorization done. Maybe there is another way to do 

it, maybe there isn’t, but aren’t we here to try to see if there is 

some possibilities that we could come up with? We are just working 

on trying to find a way to get something done. Anyway, I appreciate your answers. 

Yes, Chairwoman, you had a comment? 

Ms. DIFUNTORUM. I do have a comment. 

At the beginning of the hearing, you also made comments on the 

record and several of your colleagues on the Committee have also 

commented that they were committed to working on a solution to 

see Title VIII authorized. 

I don’t know what that is going to look like but I do hope that 

isn’t lost in the shuffle. We would like to have Title VIII included. 

At the end of the day, people can ask me my opinion about it, I 

don’t get to vote on it. I am not actually a legislator. I don’t have 

a magic pen to sign things into law. 

This is the work you all are going to have to do. I was really encouraged by the comments and what sounded like a commitment 

from people on the Committee to try and get this done with Title 

VIII intact. I want to leave it at that. 

The CHAIRMAN. Thank you. 

Ranking Member, are there other questions you might have? 

Senator UDALL. Yes. Mr. Chairman, let me first say that I very 

much appreciate your very sincere effort to reach a resolution. 

Those questions were not asked in any way to reflect on your effort. They were asked to try to clarify, as best we can, the positions 

of the people before us. 

As you know, Senator Schatz has objections. I very much appreciate your trying to work with him and we are trying to work, in 

a bipartisan way, through these issues. Unfortunately, when you 

appear before us with issues like this, I think it is important that 

we try to glean as far as possible what your positions are. We understand the positions the first two witnesses are in. 

The CHAIRMAN. I appreciate that and I think we are all trying 

to find a path forward. 

87 

Senator UDALL. Mr. Chairman, I have just a couple of questions 

on HUD–VASH but if you are really pressed, we can submit these 

for the record. 

The CHAIRMAN. No, go ahead. 

Senator UDALL. This Committee agrees that we want to ensure 

that the Tribal HUD–VASH Demonstration Program is achieving 

maximum efficiency. That means that an all hands on deck effort 

from the Administration and Congress. We need to work collaboratively to take care of our veterans. 

Dr. Harris, could you highlight any other services the VA is providing for Native veterans? 

Dr. HARRIS. I oversee operations in the Homeless Program Office. 

I would much prefer to take that back to VA and provide written 

response if that is okay with you? 

Senator UDALL. Yes, please do. 

Dr. HARRIS. Thank you. 

Senator UDALL. Thank you very much. 

I have a follow up for the panel for our tribal witnesses today. 

How do you feel these additional VA services are working in Indian 

Country? Is there more the Department could do to engage with Indian Country? For example, I have heard that the VA’s Home Loan 

Guarantee Program does not reach a lot of reservations. Do you 

feel that is the case? 

Dr. HARRIS. I can say a little bit about that. I have heard the 

same feedback, that the ideal candidate for the home guarantee 

loan, for instance, is more of a middle-class level Native American 

which is not the case, unfortunately, in too many cases. There is 

more that could be done there. I would defer to other panel members. 

Mr. CHARLIE. In response to that question, I learned about the 

Native Veteran Home Loan Program. One of the things it states is 

it has to be in trust land. In Alaska, we have very few or no trust 

lands. The question becomes how do we apply to the Native Home 

Loan Program in our region where we do not have trust land? 

Senator UDALL. Thank you very much. 

Let me thank all the panelists today for your testimony and your 

patience. It has taken a while to get to you and we very much appreciate the time and effort. 

I would say again to my Chairman, it has been such a pleasure 

working with him. He is one of the most bipartisan Senators I 

know in the United States Senate. I know he is making an incredibly sincere effort to try to reach resolution on some of these contentious issues. I really look forward to working with him and making sure that we can get something done. 

Thank you very much. 

The CHAIRMAN. Thank you. Hopefully, we will get there. 

Thanks to all of the witnesses. We appreciate so much your being 

here today. I want to remind you that your full written testimony 

will made a part of the official record. 

At this point, if there are no more questions, members may submit follow-up questions for the record. The hearing record will be 

open for two weeks. 

Again, thanks so much for being here. We appreciate it. 

We are adjourned. 

88 

[Whereupon, at 5:35 p.m., the Committee was adjourned.] 

(89) 

A P P E N D I X 

PREPARED STATEMENT OF THE AMERICAN ACADEMY OF PAS

On behalf of the more than 115,000 nationally-certified PAs (physician assistants) 

represented by the American Academy of PAs (AAPA), we appreciate the Senate Indian Affairs Committee’s work to ensure high quality healthcare is available to Native Americans though Indian Health Services. 

AAPA appreciates efforts by the committee to improve the quality of care offered 

to American Indians and Native Alaskans at Indian Health Service (IHS) facilities 

and to ensure that IHS can recruit and retain needed medical providers. Currently, 

over 250 PAs are working to meet the healthcare needs of American Indians and 

Alaska Natives at Indian Health Services facilities. PAs practice medicine on 

healthcare teams with physicians and other providers. Within IHS, PAs work in 

emergency and family practice settings, as well as specialty clinics and programs, 

such as orthopedics, diabetes care, surgery, geriatric, pediatric, women’s health, 

hospitalist and community health. 

AAPA respects the effort made by Senators Barrasso, Thune, and Chairman 

Hoeven to improve recruitment and retention for needed healthcare providers at 

IHS in S. 1250, the Restoring Accountability in the Indian Health Service Act of 

2017. However, we would like to work with the authors and the committee to ensure 

this legislation reaches its full potential to help IHS attract and retain needed 

healthcare providers, including PAs. 

As introduced, S. 1250 seeks to improve the ability of IHS to recruit and retain 

providers by requiring the agency to establish pay scales where health providers are 

paid ‘‘to the maximum extent practicable’’ comparable to what such providers would 

make under the pay scales that apply to health providers at facilities operated by 

the Department of Veterans’ Affairs (VA). While the VA generally takes into consideration wages for providers in local geographic markets, the VA has a flawed process in relation to PAs that does not consistently take into consideration local market 

compensation. Under the flawed compensation system at the VA, it is not uncommon for PAs in the VA to be compensated by as much as $30,000 less than other 

providers performing the exact same job. This flawed approach to compensation 

within the VA has resulted in VA facilities having difficulty recruiting PAs and provides PAs practicing at the VA a significant financial incentive to take positions 

with private employers. Recent reports by the VA Office of Inspector General consistently recognized the importance of PAs as part of VHA’s healthcare team and 

identify PAs as one of the five critical occupations with the ‘‘largest staffing shortages.’’ Because of problems the flawed formula has caused the VA in recruiting and 

retaining needed providers, Senators Tester and Moran have introduced S. 426 that 

would ensure PA salaries at the VA take into consideration private pay rates in 

local markets. AAPA feels strongly that it is important to make sure any legislation 

intended to help IHS recruit and retain providers does not replicate inequities that 

exist at the VA. 

AAPA is committed to working to improve access to care at IHS facilities, and we 

look forward to working with the Committee on this critical issue. 

PREPARED STATEMENT OF THE HAWAII CONGRESSIONAL DELEGATION

Chairman Hoeven and Vice Chairman Udall, please accept this written testimony 

in opposition to S. 1275, the Bringing Useful Initiatives for Indian Development 

(BUIILD) Act of 2017. While we have and continue to support reauthorizing the Native American Housing Assistance and Self-Determination Act (NAHASDA) programs, we strongly oppose this bill in its current form because it fails to include 

Native Hawaiian Housing Block Grants (NHHBG) and Section 184A Native Hawaiian Home Loan Guarantee programs, as set forth in Title VIII of NAHASDA. 

The housing needs faced by our Native communities are among the worst in our 

country. In recognition of the Federal Government’s trust responsibility to Native 

90 

1Public Law 106–569 

2The Hawaiian Homes Commission Act was passed by Congress and signed into law by President Warren Harding on July 9, 1921. 3 Hawaiian Homes Commission Act of 1920, § 201.5 4 U.S. Census Bureau, 2015 American Community Survey 1–Year Estimates, Selected Population Profile in the United States, Hawaii http://files.hawaii.gov/dbedt/census/acs/ACS2015/ 

ACS2015l1lYear/SelectlPoplProfiles/majorlracelaoc.pdf 

Americans, including Alaska Natives, Congress passed the Native American Housing Assistance and Self-Determination Act in 1996. In 2000, the American Homeownership and Economic Opportunity Act of 2000 1 inserted Title VIII in NAHASDA 

and created the NHHBG and Section 184A programs to provide resources for affordable housing programs for Native Hawaiians, pursuant to the Hawaiian Homes 

Commission Act of 1920 (HHCA). 2

HHCA recognizes the Federal Government’s ‘‘unique trust responsibility to promote the welfare of the aboriginal, indigenous people of the State [of Hawaii].’’ 3

This law created the Hawaiian Home Land Trust, which includes more than 

200,000 acres of land managed by the Department of Hawaiian Home Lands 

(DHHL). The purpose of the HHCA is to improve the lives of Native Hawaiians, who 

continue to be more economically disadvantaged and lag behind in education and 

health, compared to other Hawaii residents. The trust lands create a land base 

where beneficiaries are able to reestablish connections to their native lands and cultural traditions that are vital in maintaining their identity and foundation. 

While many Native Hawaiian families benefit from the HHCA, there are a large 

number of low-income families who are unable to take advantage of these lands because obtaining and managing a property is not within their financial means. To 

put this into perspective, DHHL recently reported that there were more than 27,000 

applicant families on the waitlist to reside on Hawaiian homesteads and the latest 

U.S. Census numbers indicate that approximately 16.8 percent of Native Hawaiians 

live in poverty in the State of Hawaii. 4 The NHHBG and Section 184A programs 

are crucial in bridging the gap between low-income Native Hawaiian families and 

their ability to live on homestead lands. 

Congress has recognized the special relationship between the U.S. government 

and Native Hawaiians, and a responsibility to continue promoting programs that 

counter these sobering figures. NAHASDA’s Title VIII programs provide vital tools 

that promote safe and affordable housing for Native Hawaiians. Healthy, sustainable homeownership is also fostered through the provision of funds for direct loans, 

housing counseling, self-help housing, and home rehabilitation programs. These resources focus on developing strong communities that serve as foundations for Native 

Hawaiian families to improve their collective quality of life. 

In 2015, the U.S. House of Representatives passed legislation to reauthorize 

NAHASDA with overwhelming bipartisan support. Also in 2015, this committee favorably reported a Senate version to reauthorize NAHASDA. Both versions included 

improvements to allow for NAHASDA programs to have a greater ability to self-determine—as is stated in the title of the law we are discussing—how to efficiently 

meet local housing needs. To abandon this bipartisan progress and Title VIII entirely—as the BUIILD Act does—would be a grave mistake and disservice to our 

Native communities. This is simply not the way forward. 

It is incumbent upon Congress to continue to acknowledge our responsibility to 

protect and improve the lives of Native Americans, Alaska Natives, and Native Hawaiians, which the BUIILD Act, in its present form, does not do. As such, we urge 

members of this committee to oppose the BUIILD Act and to continue to work to 

improve on the progress made on NAHASDA reauthorization in the last several 

years. 

We look forward to working with this Committee on how we can continue to work 

toward meeting the dire housing needs of all our Native people. 

PREPARED STATEMENT OF ANEVA J. YAZZIE, CEO, NAVAJO HOUSING AUTHORITY

On behalf of the Navajo Housing Authority (NHA) and our NHA Board of Commissioners (BOC), I am grateful and appreciate the opportunity to provide this written statement to the United States Senate Committee on Indian Affairs for review 

of the following legislative bills: S. 1250, a bill to amend the Indian Health Care 

Improvement Act; S. 1275, the ‘‘Bringing Useful Initiatives for Indian Land Development,’’ (BUILD Act of 2017); and a bill relating to the HUD/VA Veterans Affairs 

Supporting Housing (HUD–VASH) program. It is NHA’s goal to work with Congress 

in addressing our mutual interests in advancing effective policies to build economic 

91 

and community development opportunities through addressing healthcare, housing 

and comprehensively support our Native Veterans. 

Background on NHA 

The Navajo Housing Authority is the Tribally Designated Housing Entity (TDHE) 

for the Navajo Nation. NHA is the largest Indian housing authority and is nearly 

the eighth largest public housing authority in the United States. NHA is comparable 

in size to the public housing agency for the City of Atlanta. The Navajo Nation is 

the largest Indian tribe in the United States, with a total enrollment of approximately 320,000 tribal members, a land base of 26,897 square miles (larger than 

West Virginia) that extends into the states of Arizona, New Mexico, and Utah. 

Comprised of 365 employees headquartered in Window Rock, Arizona and 15 field 

offices across the reservation, NHA manages 9,200 rental and homeownership units 

including 43 administrative facilities, and oversees an additional 1,800 units from 

sub-recipients. The 15 field offices deliver housing services to tribal members that 

reside within 110 Chapters (local regional government units) and the surrounding 

communities. 

Success of the NHA 5-Year Expenditure Plan 

In 2012, following a three-year HUD-imposed moratorium on development, NHA 

had accumulated approximately $470 million in unspent Indian Housing Block 

Grant (IHBG) funds. NHA developed and implemented an aggressive five-year expenditure plan to timely and responsibly expend a large accumulated balance. 

Over the past four years, NHA has proven that it has the sustained capacity to 

effectively and responsibly expend its allocated IHBG funds; over $600 million in 

the past four years (an average of $143 million per year). Since the beginning of 

2012, the NHA delivered housing services to over 10,592 households, built 538 new 

housing units, modernized 878 older housing units, funded the development of 7 bed 

group homes and emergency shelters, and oversaw the acquisition and transition of 

29 housing units for persons with disabilities. NHA is in its final year of the expenditure plan and is on target for a consecutive 5th year in meeting its spending goal 

by the end of Fiscal 2017. 

S. 1250 Indian Health Care Improvement Act 

Indian Healthcare Service (IHS) programs, administered by the Department of 

Health and Human Services, are the single largest investment into tribal communities at $3.5 billion annually. From this amount, $446 million is used to fund sanitation facility infrastructure. As NHA and many tribal housing programs have previously mentioned, those sanitation funds are impeded by appropriations language 

that restricts IHS funds from being comingled with the funds received through the 

Native American Housing Assistance and Self-Determination Act (NAHASDA). In 

short, this limits a tribe’s ability to maximize the federal investment. 

The Administration and Congress have vowed to spur growth into the economy 

by funding infrastructure, however a key challenge to providing housing in tribal 

communities is the lack of infrastructure, especially in rural areas. Development 

costs in rural areas are higher and can easily double the price tag or even make 

housing development impossible in many places. On Navajo, there is often no sanitation infrastructure and using NAHASDA funds alone for development, although 

authorized for infrastructure, significantly eats into housing funds which is unnecessary. Tribes should be allowed to leverage federal funding sources (NAHASDA and 

IHS sanitation funds) for developing the necessary sanitation infrastructure. NHA 

respectfully requests this Committee to seriously consider language that would 

statutorily allow the co-mingling of IHS sanitations funds so that the federal investment into infrastructure could be maximized. 

S. 1275 the ‘‘Bringing Useful Initiatives for Indian Land Development,’’ or 

BUILD Act of 2017 

The Build Act has 6 sections that re-authorizes and amends the Native American 

Housing Assistance and Self-Determination. On December 16, 2016, the NHA BOC 

passed Resolution NHA–4677–2016, this resolution authorizes the support of key 

provisions for any NAHASDA Reauthorization bill. 

Section 2: Consolidated Environmental Review (ER), this section authorizes a 

tribe who co-mingles federal funds from different agencies will discharge the tribe 

from other applicable environmental review requirements of the other applicable 

agencies under Federal law if the largest source of federal funding is from HUD. 

NHA supports this provision. 

Section 3: Reauthorizes NAHASDA from 2018 through 2025. NHA supports this 

provision. 

92 

Section 4: Extension of Leasehold interest for housing from 50 years to 99 years. 

NHA takes no position on this provision. 

Section 5: Reauthorizes Training and Technical assistance from 2018 through 

2025. NHA supports this provision. 

Section 6: Reauthorizes the Indian Loan Guarantee program (commonly known as 

the 184 loan program) from 2018 through 2025, with a limitation on funding at 

$12.2 Million. NHA supports the reauthorization of the 184 Loan Program but does 

not support a limitation on funding. 

Section 7: Authorizing Leveraging: Allows for all grants funds under NAHASDA 

to be used for purposes of meeting matching or cost participation requirements 

under any other Federal or non-Federal programs. NHA supports this provision. 

NAHASDA outlined dual roles for Indian housing, to build safe homes and sustainable communities while spurring economic development. Under the IHBG, funding must first cover the continuing support of the remaining housing stock that was 

funded under the 1937 Housing Act. NAHASDA includes other eligible activities 

such as new construction, acquisition and rehabilitation, thus in addition to the 

above sections in the Build Act, NHA supports additional provisions in the Re-authorization of NAHASDA which are outlined in Resolution NHA–4677–2016. These 

additional provisions were identified to stream-line the administrative workload of 

housing authorities and to reduce the duplication of rules and regulations between 

federal agencies. Tribes need these provisions so that they can focus on the important task of building houses instead of working tirelessly to meet burdensome administrative rules. 

HUD/VA-Veterans Affairs Supportive Housing 

NHA Success with HUD–VASH Program 

Tribal HUD–VASH recipients are having success placing tribal veterans into local 

supportive housing but we need the program to be permanently authorized or else 

we risk leaving those homeless Native Veterans without affordable housing options 

that include critical supportive services. 

HUD approved 20 HUD–VASH vouchers for NHA in the amount of $268,835 on 

January 6, 2016. NHA has prioritized and incorporated the 20 VASH vouchers for 

homeless Navajo Veterans and to date we have issued nine vouchers (four have 

found housing) in Arizona and New Mexico. These homeless Navajo Veterans were 

reviewed by case-managers and determined eligible for the program and were immediately issued a voucher. Further NHA took efforts a step further and instituted its 

own Veterans Housing Assistance Policy. This policy goes above and beyond Federal 

legislative authority and has helped over 120 veterans become homeowners and has 

extended $8.8 million in veteran debt forgiveness and assisted 17 widowers/mothers 

of service men and women through NHA’s veterans housing assistance program. 

Project Coordination 

NHA partners with Veterans of the Armed Services residing on the Navajo Nation 

and are eligible to receive housing assistance services through the Department of 

Navajo Veterans Affairs (DNVA). The DNVA partners with Federal, state and local 

services, but the amount of case management that is needed to service our veteran 

population is large and added federal resources are need. Navajo has one case manager for the HUD–VASH program to handle cases that cover the entire Navajo reservation (Navajo extends into three states: Arizona, New Mexico and Utah). Moreover, the remote location of the reservation is not conducive to providing adequate 

case-management unless that case-management can be provided in their community 

as opposed to off the reservation. NHA believes a solution is to provide for more 

case-managers to meet the needs in the Navajo community. 

Place-based Vouchers 

The biggest problem with using the tenant based rental assistance vouchers on 

the Navajo Nation is the lack of private or non-profit housing for renters. Therefore, 

the HUD–VASH program should allow rental assistance vouchers to be used for 

housing currently included in the housing stock of the tribal housing program. 

NHA’s only option for using our HUD–VASH rental vouchers is to use Section 8 approved properties off the reservation. This solution will not help veterans who are 

needing supportive services who wish to stay on the reservation close to their family 

who are helping in their recovery. Thus, creating a place based voucher system that 

stays on the reservation, where most tribal veterans reside is the best option to alleviate our TDHE’s lack of public and non-profit housing. 

93 

1MSPB administrative judges are federal employees under the General Schedule System employed by MSPB. They are not ‘‘administrative law judges’’ appointed under 5 U.S.C. § 3105 nor 

federal judges. 

Conclusion 

It is the goal of NHA to help build safe sustainable homes for the Navajo People 

while strengthening the socio-economic fabric of the Navajo Nation. The re-authorization of NAHASDA, development of sanitation infrastructure and expansion of 

HUD–VASH coordination and program is critical in maintaining the growth of NHA 

and sustaining the progress of the Navajo People. We hope our testimony can assist 

this Committee in expanding each of these programs for the benefit of NHA and 

all Tribal TDHE’s. Thank you for this opportunity. 

PREPARED STATEMENT OF THE UNITED STATES MERIT SYSTEMS PROTECTION BOARD

(MSPB) 

Chairman Hoeven, Vice Chairman Udall and distinguished Members of the 

United States Senate Committee on Indian Affairs (‘‘Committee’’). Thank you for the 

invitation to present a written statement on behalf of the United States Merit Systems Protection Board (MSPB) in connection with the Committee’s legislative hearing to receive testimony on S. 1250, the ‘‘Restoring Accountability in the Indian 

Health Service Act of 2017’’ and other legislation which was held on June 13, 2017. 

As an initial matter, I would like to note that under statute, MSPB is prohibited 

from providing advisory opinions on any hypothetical or future personnel action 

within the executive branch of the federal government. 5 U.S.C. § 1204(h) (‘‘The 

Board shall not issue advisory opinions.’’). Accordingly, this statement should not be 

construed as an indication of how I, any other presidentially appointed, Senate-confirmed Member of the Merit Systems Protection Board (‘‘Board’’), an MSPB administrative judge, or an administrative law judge acting on behalf of the MSPB would 

rule in any pending or future matter before the agency. Moreover, at this time, 

MSPB is not taking a policy position on this legislation. Accordingly, I would respectfully request that the Committee consider the substance of my statement to be 

technical in nature. 

The Potential Impact of S. 1250 on MSPB’s Adjudicatory Function 

MSPB’s views on S. 1250 derive from its statutory responsibility to adjudicate appeals filed by federal employees in connection with certain adverse employment actions. Generally, after a federal agency imposes an adverse personnel action upon 

a federal employee, such as removal or demotion, and the federal employee chooses 

to exercise his or her statutory right to file an appeal with MSPB, MSPB will begin 

the adjudication process. In the case of a federal employee who is removed from his 

or her position, that individual is no longer employed by the Federal Government, 

and is not receiving pay at the time he or she files an appeal with MSPB or at any 

point during the subsequent MSPB adjudication process. 

Once an appeal is filed, an MSPB administrative judge 1 in one of MSPB’s regional or field offices will first determine whether MSPB has jurisdiction to adjudicate the appeal. If MSPB has jurisdiction, the administrative judge may conduct 

a hearing on the merits and then issue an initial decision addressing the federal 

agency’s case and the appellant’s defenses and claims. Thereafter, either the appellant or the named federal agency may file a petition for review of the MSPB administrative judge’s initial decision to the 3-Member Board. The Board Members constitute an administrative appellate body that reviews the administrative judge’s decision and issues a final decision of the MSPB. Both the Board Members and MSPB 

administrative judges adjudicate appeals in accordance with statutory law, federal 

regulations, precedent from United States federal courts, including the Supreme 

Court of the United States and the United States Court of Appeals for the Federal 

Circuit, and MSPB precedent. 

S. 1250 contains similar language to Section 707 of the Veterans Access, Choice, 

and Accountability Act of 2014, which was enacted into law and became effective 

in August 2014. (Public Law No. 113–146; 38 U.S.C § 713). In pertinent part, S. 

1250 would allow the Secretary of Health and Human Services (‘‘Secretary’’), acting 

through the Director of the Service, to remove, demote, or transfer employees, including Senior Executive Service employees, of the Indian Health Service (‘‘Service’’) 

if the Secretary determines the performance or misconduct of the employee warrants such a personnel action. If the Secretary removes or demotes such an employee, the Secretary may: 

• Remove the employee from the civil service altogether; 

94 

2 Under 5 U.S.C. § 7513(b)(1)-(4) and (d), a federal employee against whom certain adverse actions are proposed is generally entitled to: (1) at least 30 days advance written notice stating 

the specific reasons for the federal agency’s proposed action; (2) not less than 7 days to respond 

to the proposed adverse action; (3) be represented by an attorney or other representative before 

the federal agency; (4) a written decision and the specific reasons therefor by the federal agency; 

and (5) file an appeal to MSPB under 5 U.S.C. § 7701. 

Under 5 U.S.C. § 4303(b)(1), a federal employee who is subject to removal or a reduction in 

grade for unacceptable performance is generally entitled to: 1) at least 30 days advance written 

notice of the federal agency’s proposed action identifying certain information; 2) be represented 

by an attorney or other representative before the federal agency; 3) a reasonable time to answer 

orally and in writing to the proposed adverse action; 4) a written decision by the federal agency 

specifying the instances of unacceptable performance which has been concurred in by an employee who is in a higher position that proposes the removal or reduction in grade; and 5) appeal 

to MSPB under 5 U.S.C. § 7701. Moreover, under 5 U.S.C. § 4302(b)(5), before a federal agency 

can take a personnel action based on performance, the employee whose performance is in question shall be provided an opportunity to improve his or her unacceptable performance. 3Generally, under current law, an appeal must be filed at MSPB no later than 30 days after 

the effective date, if any, of the action being appealed, or 30 days after the date of the appellant’s receipt of the agency’s decision, whichever is later. 5 C.F.R. § 1201.22(b). 4MSPB does not directly employ any administrative law judges, but can retain the services 

of administrative law judges via contract. Thus, if S. 1250 were to become law without amendment, and MSPB was required to retain the services of administrative law judges to adjudicate 

appeals covered by this legislation instead of using MSPB administrative judges, MSPB would 

likely incur significant operating costs. 5 In addition to adjudicating appeals filed by federal employees, MSPB is required under statute to: 6This report can be found at: http://www.mspb.gov/netsearch/ 

viewdocs.aspx?docnumber=1166935&version=1171499&application=ACROBAT 

Conduct, from time to time, special studies relating to the civil service and to the other merit 

systems in the executive branch, and report to the President and to Congress as to whether the 

public interest in a civil service free of prohibited personnel practices is being adequately protected. 5 U.S.C. § 1204(a)(3). 

• Regarding SES employees, transfer the employee from the SES to a position 

in the General Schedule at any grade of the General Schedule for which the 

employee is qualified and that the Secretary determines is appropriate; and 

• Regarding managers and supervisors, reduce the grade of these employees to 

any other grade for which the employee is qualified and the Secretary determines is appropriate. 

With respect to the above-referenced personnel actions, S. 1250 provides that ‘‘the 

procedures under chapters 43 and 75 of title 5, United States Code, shall not 

apply.’’ 2 Instead, S. 1250 provides that ‘‘before an employee may be subject to a personnel action, he or she must be provided with: (1) written notice of the proposed 

personnel action not less than 10 days before the personnel action is taken; and (2) 

an ‘‘opportunity and reasonable time’’ to answer orally or in writing. 

Expedited MSPB Appeal Rights Under S. 1250 

Employees who are either removed or demoted by the Secretary may appeal that 

personnel action to MSPB ‘‘under section 7701 of title 5.’’ Any appeal must be filed 

with MSPB ‘‘not later than seven days after the date of the personnel action’’ 3 and 

the MSPB will be required to refer the appeal to an administrative law judge 4 for 

adjudication. An administrative law judge would be required to issue a decision ‘‘not 

later than 21 days after the date of the appeal,’’ and that decision ‘‘shall be final’’ 

and not subject to further review, either by the Board or a United States federal 

court. In the event that an administrative law judge does not issue a final decision 

within 21 days, the decision of the Secretary to remove or demote the employee becomes final and the employee has no further right to appeal. 

Possible Constitutional Defects of S. 1250 

In May 2015, MSPB released a study 5 entitled: What is Due Process in Federal 

Civil Service Employment? The report provides an overview of current civil service 

laws for adverse actions and, perhaps more importantly, the history and considerations behind the formation of those laws. It also explains why, according to the Supreme Court of the United States, the Constitution requires that any system which 

provides that a public employee may only be removed for specified causes must also 

include an opportunity for the employee—prior to his or her termination—to be 

made aware of the charges the employer will make, present a defense to those 

charges, and appeal the removal decision to an impartial adjudicator. We encourage 

Members of the Committee and their staff who have interest in these issues to read 

this report. 6

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7The Loudermill case involved a state employee, not a federal employee. Nevertheless, while 

the Federal Government is covered by the Fifth Amendment and the states by the Fourteenth 

Amendment, the effect is the same. See Lachance v. Erickson, 522 U.S. 262, 266 (1998); Stone 

v. Federal Deposit Insurance Corp., 179 F.3d 1368, 1375–76 (Fed. Cir. 1999). 

In the landmark decision of Cleveland Board of Education v. Loudermill, 470 U.S. 

532 (1985) the Supreme Court held that while Congress (through statutes) or the 

president (through executive orders) may decide whether to grant protections to employees, they lack the authority to decide whether they will grant due process rights 

once those protections are granted. Stated differently, when Congress establishes 

the circumstances under which employees may be removed from positions (such as 

for misconduct or malfeasance), employees have a property interest in those positions. Loudermill, 470 U.S. at 538–39. 7 Specifically, the Loudermill Court stated: 

Property cannot be defined by the procedures provided for its deprivation any 

more than can life or liberty. The right to due process is conferred, not by legislative grace, but by constitutional guarantee. While the legislature may elect 

not to confer a property interest in public employment, it may not constitutionally authorize the deprivation of such an interest, once conferred, without 

the appropriate procedural safeguards. 

Id. at 541. 

The Court explained that the ‘‘root requirement’’ of the Due Process Clause is that 

‘‘an individual be given an opportunity for a hearing before he is deprived of any 

significant property interest,’’ and that ‘‘this principle requires some kind of a hearing prior to the discharge of an employee who has a constitutionally protected property interest in his employment.’’ Id. at 542. 

According to the Court, one reason for this due process right is the possibility that 

‘‘[e]ven where the facts are clear, the appropriateness or necessity of the discharge 

may not be; in such cases, the only meaningful opportunity to invoke the discretion 

of the decisionmaker is likely to be before the termination takes effect.’’ Id. at 542. 

The Court further held that ‘‘the right to a hearing does not depend on a demonstration of certain success.’’ Id. at 544. 

I further note that the requirements of the Constitution have shaped the rules 

under which federal agencies may take adverse actions against federal employees, 

as explained by the Supreme Court, U.S. Courts of Appeal, and U.S. District Courts. 

Accordingly, should Congress consider modifications to these rules, many of which 

have been in place for more than one hundred years, MSPB respectfully submits 

that the discussion be an informed one, and that all Constitutional requirements be 

considered. 

As stated above, S. 1250 provides ten days’ notice to an employee prior to a personnel action, a ‘‘reasonable time’’ to respond, and the right to an expedited appeal 

at MSPB. Whether these rights—taken as a whole—satisfy constitutional due process requirements would depend on the various factors and the circumstances of a 

given appeal, and it would be inappropriate for me to address that issue at this 

point. 

Finally, and significantly, I note that a panel of judges on the United States Court 

of Appeals for the Federal Circuit—MSPB’s primary reviewing court—recently 

issued a decision that casts serious doubt on the constitutionality of at least one provision of S. 1250. In Helman v. Dep’t of Veterans Affairs, 856 F.3d 920, 929 (Fed. 

Cir. May 9, 2017), a panel of the Federal Circuit ruled that the provision of Section 

707 of the Veterans Access, Choice, and Accountability Act of 2014 that allowed 

MSPB administrative judges to issue final decisions on behalf of the MSPB—without allowing review of those decisions by MSPB Board members—was unconstitutional. Specifically, the court found that this provision of Section 707 (as codified at 

5 U.S.C. § 713(e)(2)) violated the Appointments Clause of Article II of the United 

States Constitution: 

Thus, we conclude that the authority to render a final decision, affirming or 

overturning the Secretary of the DVA’s removal decision, is a significant duty 

that can only be performed by officers of the United States. Through [38 U.S.C.] 

§ 713, Congress purports to vest this significant authority in [MSPB] administrative judges who are hired as employees. This is unconstitutional under the 

Appointments Clause. Accordingly, we declare invalid those portions of § 713. 

See, Helman at 929 (Fed. Cir. May 9, 2017) 

The Court also struck down the provision of Section 707 (38 U.S.C. § 713(e)(3)) 

that provided that the Secretary’s decision became final in the event that an MSPB 

AJ was unable to issue a decision within the 21 day period provided for in that section. Helman, 856 F.3d at 929 n.4. We recommend that the Committee consider the 

96 

Federal Circuit’s decision in Helman before approving S. 1250 to the extent that it 

prohibits MSPB Board members from reviewing the decisions of MSPB administrative judges and provides that decisions shall be final in the event that any MSPB 

administrative judge does not meet any arbitrary deadline to decide an appeal. 

Permitting Appeals to MSPB ‘‘Under 5 U.S.C. § 7701′′ 

S. 1250 would permit covered employees to appeal to MSPB ‘‘under 5 U.S.C. 

§ 7701.’’ Section 7701 of title 5, United States Code, provides in pertinent part that 

‘‘the decision of an agency shall be sustained. . .only if the agency’s decision. . .is 

supported by a preponderance of the evidence.’’ 5 U.S.C. § 7701(c)(1)(B). The term 

‘‘preponderance of the evidence’’ is defined as ‘‘the degree of relevant evidence that 

a reasonable person, considering the record as a whole, would accept as sufficient 

to find that a contested fact is more likely to be true than untrue.’’ 5 C.F.R. 

§ 1201.4(q). 

Additionally, 5 U.S.C. § 7701(c)(2)(B) provides that ‘‘an agency’s decision may not 

be sustained. . .if the employee or applicant for employment shows that the decision was based on any prohibited personnel practice described in section 2302(b) [of 

title 5, United States Code].’’ Among the ‘‘prohibited personnel practices’’ described 

in section 2302(b) are illegal discrimination, 5 U.S.C. § 2302(b)(1)(A)-(E), coercion of 

political activity or reprisal for refusal to engage in political activity, 5 U.S.C. 

§ 2302(b)(3), and reprisal for lawful ‘‘whistleblowing,’’ 5 U.S.C. § 2302(b)(8). Thus, if 

such issues are raised by appellants as defenses in any appeal filed pursuant to the 

language contained in S. 1250, an administrative law judge acting on behalf of the 

MSPB will be required under law to consider those defenses prior to issuing a final 

decision. 

Restriction on the Issuance of Stays of Personnel Actions 

S. 1250 provides that the ‘‘Merit Systems Protection Board or any administrative 

law judge may not stay any personnel action.’’ While I take no policy position on 

this language, I note that it appears to be in direct conflict with 5 U.S.C. 

§ 1214(b)(1)(a)(i) and (ii), which allows the Office of Special Counsel to seek, and the 

MSPB to grant, a stay of any personnel action ‘‘if the Special Counsel [and the 

MSPB] determines that there are reasonable grounds to believe that the personnel 

action was taken as a result of a prohibited personnel practice,’’ including illegal retaliation for lawful whistleblowing. I would recommend that the Committee make 

clear whether it wishes to prohibit OSC from seeking—and the MSPB from granting, in appropriate circumstances—stays of personnel actions that may be the result 

of prohibited personnel practices with respect to the agency and employees covered 

by this legislation. 

This concludes my written statement. I am happy to address any questions for 

the record that Members of the Committee may have. 

PREPARED STATEMENT OF HON. W. RON ALLEN, CHAIRMAN, SELF-GOVERNANCE

COMMUNICATION & EDUCATION TRIBAL CONSORTIUM; TRIBAL CHAIRMAN/CEO, 

JAMESTOWN S’KLALLAM TRIBE

On behalf of the Self-Governance Communication & Education Tribal Consortium 

(SGCETC), I am pleased to provide the following written testimony regarding Senate Bill 1250 (S. 1250), Restoring Accountability in the Indian Health Service Act 

of 2017. SGCETC appreciates the time, attention and effort this Committee and others have devoted to improving the quality and access to health care for all American 

Indians and Alaska Natives (AI/ANs). While we agree that legislation offers new opportunities for IHS, Self-Governance Tribes cannot support the legislation as introduced. 

Today, 352 Federally-recognized Tribes and Tribal Organizations exercise SelfGovernance authority to operate and manage health programs previously managed 

by the Indian Health Service (IHS), while many more continue to evaluate their opportunities. As Tribes assume greater authority over the delivery of health care in 

their communities, legislation like S. 1250 is increasingly important to us as we 

seek to gain more autonomy in the management and delivery of health care programs in partnership with the IHS. This collaboration has proven successful and 

has improved the Indian health system that existed prior to the passage of the Indian Self-Determination and Education Assistance Act (ISDEAA). 

Over the last decade, this Committee, in partnership with Tribes, has passed several pieces of legislation that provided opportunities to modernize IHS, support selfdetermination, and permanently reauthorize the Indian Health Care Improvement 

Act (IHCIA). Similarly, shared efforts and continued partnerships will be required 

to successfully correct the health care quality challenges that IHS faces. 

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We would be remiss without first reiterating that the agency is chronically underfunded, and receives a fixed amount of appropriations each year to provide health 

care for 2.2 million AI/AN people, a per capita spending level that is the lowest of 

any healthcare system. AI/AN have the right to have quality health care services, 

but without proper resources put behind these intentions, it is unlikely to be fully 

successful. We appreciate Congress expanding health programs in the Indian Health 

Care Improvement Act to increase access to health care services in Tribal communities, but more is needed to both appropriately fund these initiatives and further 

incorporate new and innovative ways to modernize IHS health delivery. Without 

funding to address the information technology gap, to treat critically diagnosed patients with specialized care, and improve the facilities to maintain accreditation and 

accommodate the diverse cultural health needs of native people, IHS will remain an 

outdated system that is locked in a ‘‘time capsule’’ and unable to achieve its mission 

of ‘‘raising the health status of AI/AN to the highest possible level.’’ 

We offer the following recommendations for the Committee to consider and hope 

that additional Tribal input will improve the legislation to make meaningful 

progress toward modernization of the IHS. 

General Recommendations 

This legislation offers many solutions to some of IHS’ leading challenges, including provider recruitment and retention and filling shortages, improving quality care 

and increasing Tribal engagement and culture in the system. While we have some 

specific comments below to provide additional insight and to identify potential unintended consequences of certain provisions, we also recommend that specific legislation be considered to advance the Federal policy that has proven to improve quality, 

increase access to care for Tribal citizens and reduce the federal bureaucracy—SelfGovernance. 

Self-Governance is the most successful partnership between the Federal and Tribal governments to ever exist. S. 1250 does articulate protections for Tribes to assume programs, services, functions, and activities at any time. However, it does not 

encourage or create additional opportunities for Tribes to assume these responsibilities. We hope that in future legislation, the Committee will consider legislation to 

expand Self-Governance and assure Tribal rights to assume management of their 

health care. 

Additionally, Self-Governance Tribes note that the legislation does not authorize 

additional appropriations to support the new initiatives. We strongly believe that 

overlooking the funding necessary to properly implement the proposed programs 

will likely result in diminished returns on the Committee’s efforts. In fact, even 

though IHCIA was permanently reauthorized seven years ago, more than 20 provisions remain unfunded and therefore unimplemented. As this legislation moves forward, we recommend and offer any support to Senators who can seek additional appropriations for IHS to improve the quality and access to care for all AI/ANs. 

Creating Parity between IHS and Veterans Health Administration 

Many of the programs which stand to remain unimplemented are those that seek 

to address IHS’ provider shortage and vacancies. Self-Governance Tribes were heartened by the efforts this legislation makes to bring parity between the Veterans 

Health Administration (VHA) and IHS in provider compensation and personnel policy, to expand the IHS Loan Repayment Program, and to create demonstration 

projects to employ successful recruitment and retention strategies. However, some 

of the proposals do not recognize the challenges that exist in Indian Country. For 

instance, the housing voucher program included in Section 101 is limited to three 

years and does not acknowledge that the real challenge in Tribal communities is 

that there is a housing shortage. Recognizing that appropriations for IHS-constructed provider housing are far below need, granting IHS authority and flexibility 

to explore innovative means for addressing housing shortages would be extremely 

helpful. At a minimum, we ask that the Committee considers extending the termination date for this program as well as authorizing appropriations so that IHS and 

Tribes can properly support such a voucher program. 

Similar to VHA, this legislation also provides IHS additional flexibility to take 

personnel actions or to remove employees when necessary. Self-Governance Tribes 

agree that additional authority to manage employee performance is essential to improving quality of care over time. These practices also more closely mirror private 

industry standards for personnel management. 

Addressing Provider and Administrator Vacancies 

This legislation responds to long-standing Tribal requests to modify IHS authorities to increase qualified providers and health administrators through expansion of 

the IHS Loan Repayment Program in Section 104. Self-Governance Tribes support 

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the increased flexibility in eligibility for the Loan Repayment Program, as it is an 

important tool for recruitment and retention. We recommend that this section be expanded further to provide the IHS with flexibility to repay student loans for shortages of providers in geographic areas with chronic vacancies as long as the provider 

agrees to serve at least 4 years in that location. 

Though we appreciate the efforts to better include Tribal leadership in important 

hiring decisions, we are concerned that the legislation may have inadvertently included too many positions for Tribal notification. The legislation includes the ‘‘position of a manager at an Area office or Service unit’’ under the Tribal notification 

requirement in Section 105(a). Self-Governance Tribes are concerned that this could 

be interpreted quite broadly and that a ‘‘too’’ general interpretation of this language 

could include an overwhelming number of positions at the local and area levels— 

creating significant administrative burdens for IHS Human Resources staff. This 

may lead to unintended consequences, including further delays in the hiring process 

for critical day-to-day program management and vacancy rate increases. The highest-level managers should have Tribal support; however, program level management 

decisions should be left to the Senior Executive Service (SES) positions and service 

unit Chief Executive Officers (CEOs) so as not to interfere with their autonomy, accountability and ability to fill vacancies at the earliest opportunity. 

With regard to the waiver of Indian Preference in hiring in Section 105(b), we are 

unclear of the intention to allow waivers in order to consider former employees that 

have been removed from employment or demoted for performance or misconduct. 

This would seem to be at odds with our collective goals to provide quality health 

care services. 

S. 1250 offers a few solutions to improve the Service’s ability to hire employees, 

including centralization of medical credentialing and direct hire authority. Self-Governance Tribes know all too well that an efficient hiring process will increase quality and access to care. We fully support shared credentialing throughout the IHSoperated facilities as proposed in Section 102, allowing IHS to efficiently deploy and 

assign providers to facilities as needed. A centralized medical credentialing process 

has been initiated by the IHS through Tribal Consultation under a Quality Framework, and is currently being implemented. We support full implementation of the 

Framework, and while IHS has created a small staff to implement the Framework 

by reallocating existing resources, implementation would be expedited and enhanced 

by appropriately funding this effort through additional appropriations. We further 

recommend that the Committee protect current and future Self-Governance Tribes’ 

rights to choose to operate their own credentialing systems or leverage the efficiency 

of a centralized credentialing system and quality standards administered by IHS. 

Another opportunity the bill offers IHS is the Staffing Demonstration Project included in Section 109. Self-Governance Tribes know the value that demonstration 

projects can create in Indian Country. Demonstration projects often establish best 

practices and scalability of a program. However, the proposed project seems overlimiting in that it only includes Federally-operated sites with significant third-party 

resources. Staffing shortages are a challenge for all rural health care systems. SelfGovernance Tribes recommend that access should be broad enough to include Tribes 

who are managing their health services and wish to exercise their right to participate. The provisions should address cases when Tribes wish to exercise their SelfGovernance authority during the demonstration project. Self-Governance Tribes also 

recommend that an option be available to Tribal Health Programs to extend the liability protections for health professional volunteers under Section 103. 

The legislation does not address one common recommendation Tribes previously 

made to this Committee to improve recruitment and retention of providers. The loan 

repayment program has proven to be the IHS’s best recruitment and retention tool 

to ensure an adequate health workforce to serve in the many remote IHS locations. 

Self-Governance Tribes recommend that the Committee included a provision that 

would provide IHS loan repayment program the same tax free status enjoyed by 

those who receive National Health Service Corps (NHSC) loan repayments. Under 

the IHS and NHSC programs, health care professionals provide needed care and 

services to underserved populations. However, the IHS uses a large portion of its 

resources to pay the taxes that are assessed on its loan recipients. Currently, the 

Service is spending 29.7 percent of its Health Professions’ account for taxes. Making 

the IHS loan repayments tax free would save the agency $7.21 million, funding an 

additional 232 awards. Changing the tax status of the IHS loans to make them tax 

free would enable the agency to fill two-thirds or more of the loan repayment requests without increasing the IHS Health Professions’ account. 

99 

Improving Timeliness of Care 

Self-Governance Tribes recognize that access to care can be partially measured by 

evaluating patient wait times. We appreciate the efforts by the proposed legislation 

in Section 107 to require measurement and accountability for patient wait times. 

The Improving Patient Care (IPC) initiative, which began in 2008, provides a good 

foundation for measuring wait times as well as other measures, and we would recommend the IHS implement IPC in all of its facilities. However, additional time 

may be necessary to develop the rule. One hundred and eighty days would likely 

not allow for the proper development of a policy and required Tribal consultation. 

We would recommend additional time to develop a new set of standards. Further 

we hope the Committee will consider requiring Consultation prior to implementation and that data collected be available to impacted Tribes on a regular basis. 

Establishing a Formal Tribal Consultation Policy 

In the Department of Health and Human Services, IHS has set the gold standard 

for government-to-government consultation. The IHS policy has undergone many revisions and continues to be updated as the relationship between Tribes and IHS 

changes. Tribes have been an active partner with the IHS in the development and 

subsequent changes of the IHS Tribal Consultation Policy. If a negotiated rule is 

required as described in Section 110, it may unnecessarily limit future Tribal engagement or restrict the flexibility the agency requires to serve the best interest of 

Tribes. Generally, Self-Governance Tribes agree there is always room to improve implementation of the IHS Tribal Consultation Policy, but we are unsure that development of a rule will create the enforcement and results the Committee is seeking. 

Fiscal Accountability 

While Self-Governance Tribes are supportive of the Committee’s effort to ensure 

that valuable resources are committed to improving patient care, we believe this is 

a provision that needs additional consideration before passage. The current language in Section 202 is significantly more restrictive than current regulations and 

could inadvertently impact both the ability of the IHS to meet its obligations to provide care, as well as current and future Self-Governance opportunities. 

Specifically, narrowing the use of unobligated funds may negatively impact the 

ability of IHS and Tribes to meet accreditation standards and requirements in the 

future such as technology requirements, which may include additional spending categories other than those included in this Section. The language also does not take 

into account specific appropriations for Facilities and Contract Support Costs, which 

are limited to those appropriations accounts, and much of this funding is intentionally available until expended. These provisions would also seem to limit IHS’ 

ability to pay funds to a Tribe under a Title I or Title V contract that were collected 

associated with a Program, Service, Function or Activity that is being assumed for 

operation by a Tribe. These provisions could also complicate IHS service delivery 

when there are delays in the appropriations process. Finally, the Section should be 

clarified to apply only to the IHS directly-operated program. 

With regard to the reporting requirements of Section 202, it appears as though 

the fiscal year reporting required under this section would also include Title I and 

Title V contracts and funding agreements. Under current law, IHS would not have 

the ability to obtain information to accurately report the requested information, because the fiscal data is reported by Tribes under their required audits. 

In closing, SGCETC would like to thank the Committee for the opportunity to 

submit testimony and feedback. We look forward to working with you to improve 

the quality and access to care at IHS. 

PREPARED STATEMENT OF THE NAVAJO HOUSING AUTHORITY BOARD OF

COMMISSIONERS

Honorable Chairman Hoeven and Vice Chairman Udall, and members of the committee, thank you for the opportunity to provide written comments on a crucial legislative proposal aimed at improving the state of housing in Indian Country. The 

Navajo Housing Authority (NHA) Board of Commissioners, the President of the 

Navajo Nation, and the Navajo Nation Speaker recognize your commitment to Indian Country. We greatly appreciate your efforts to improve housing in Indian 

Country. We are grateful for the opportunity to provide this written statement to 

the United States Senate Committee on Indian Affairs for review of the following 

legislative bills: S. 1250, a bill to amend the Indian Health Care Improvement Act; 

S. 1275, the ‘‘Bringing Useful Initiatives for Indian Land Development,’’ (BUILD Act 

of 2017); and a bill relating to the HUD/VA Veterans Affairs Supporting Housing 

100 

(HUD–VASH) program. It is NHA’s and the Navajo Nation’s goal to work with Congress in addressing our mutual interests in advancing effective policies to build economic and community development by addressing healthcare and housing. 

Background on NHA 

The Navajo Housing Authority is the Tribally Designated Housing Entity (TDHE) 

for the Navajo Nation. NHA is the largest Indian housing authority and is nearly 

the eighth largest public housing authority in the United States. NHA is comparable 

in size to the public housing agency for the City of Atlanta. The Navajo Nation is 

the largest Indian tribe in the United States, with a total enrollment of approximately 320,000 tribal members, a land base of 26,897 square miles (larger than 

West Virginia) that extends into the states of Arizona, New Mexico, and Utah. 

Comprised of 365 employees headquartered in Window Rock, Arizona and 15 field 

offices across the reservation, NHA manages 9,200 rental and homeownership units 

including 43 administrative facilities, and oversees an additional 1,800 units from 

sub-recipients. The 15 field offices deliver housing services to tribal members that 

reside within 110 Chapters (local regional government units) and the surrounding 

communities. 

S. 1250 Indian Health Care Improvement Act 

Indian Healthcare Service (IHS) programs, administered by the Department of 

Health and Human Services, are the single largest investment into tribal communities at $3.5 billion annually. From this amount, $446 million is used to fund sanitation facility infrastructure. As NHA and many tribal housing programs have previously mentioned, those sanitation funds are impeded by appropriations language 

that restricts IHS funds from being comingled with the funds received through the 

Native American Housing Assistance and Self-Determination Act (NAHASDA). In 

short, this limits a tribe’s ability to maximize the federal investment. 

The Administration and Congress have vowed to spur growth into the economy 

by funding infrastructure, however a key challenge to providing housing in tribal 

communities is the lack of infrastructure, especially in rural areas. Development 

costs in rural areas are higher and can easily double the price tag or even make 

housing development impossible in many places. On Navajo, there is often no sanitation infrastructure and using NAHASDA funds alone for development, although 

authorized for infrastructure, significantly eats into housing funds which is unnecessary. Tribes should be allowed to leverage federal funding sources (NAHASDA and 

IHS sanitation funds) for developing the necessary sanitation infrastructure. NHA 

respectfully requests this Committee to seriously consider language that would 

statutorily allow the co-mingling of IHS sanitations funds so that the federal investment into infrastructure could be maximized. 

S. 1275 the ‘‘Bringing Useful Initiatives for Indian Land Development,’’ or 

BUILD Act of 2017 

NAHASDA was passed in 1996 with the Congressional intent to empower tribes 

to build homes for low-income families in Indian Country. We hope this intent continues in the BUILD Act, while also eliminating any duplicative requirements to 

streamline the building of homes. 

The Build Act has 6 sections that re-authorizes and amends the Native American 

Housing Assistance and Self-Determination. 

Section 2: Consolidated Environmental Review (ER), this section authorizes a 

tribe who comingles federal funds from different agencies will discharge the tribe 

from other applicable environmental review requirements of the other applicable 

agencies under Federal law if the largest source of federal funding is from HUD. 

NHA and Navajo Nation support this provision. 

Section 3: Reauthorizes NAHASDA from 2018 through 2025. NHA and Navajo 

Nation support this provision. 

Section 4: Extension of Leasehold interest for housing from 50 years to 99 years. 

NHA takes no position on this provision. 

Section 5: Reauthorizes Training and Technical assistance from 2018 through 

2025. NHA and Navajo Nation support this provision. 

Section 6: Reauthorizes the Indian Loan Guarantee program (commonly known as 

the 184 loan program) from 2018 through 2025, with a limitation on funding at 

$12.2 Million. NHA and the Navajo Nation support the reauthorization of the 184 

Loan Program but do not support a limitation on funding. 

Section 7: Authorizing Leveraging: Allows for all grants funds under NAHASDA 

to be used for purposes of meeting matching or cost participation requirements 

under any other Federal or non-Federal programs. NHA and the Navajo Nation support this provision. 

101 

NAHASDA outlined dual roles for Indian housing, to build safe homes and sustainable communities while spurring economic development. Under the Indian 

Housing Block Grant (IHBG), funding must first cover the continuing support of the 

remaining housing stock that was funded under the 1937 Housing Act. NAHASDA 

includes other eligible activities such as new construction, acquisition and rehabilitation, thus in addition to the above sections in the Build Act, NHA supports additional provisions in the Re-authorization of NAHASDA. These additional provisions 

will stream-line the administrative workload of tribal housing entities and reduce 

the duplication of rules and regulations between federal agencies. This will help 

TDHE’s focus on building new homes efficiently and effectively. 

NAHASDA expired on September 30, 2013. Since its expiration, the act’s funds 

have been reauthorized on a yearly basis. This has caused uncertainty for Tribally 

Designated Housing Entities (TDHE) to meet the construction timelines, which furthers the delay of building any new homes. Reauthorizing NAHASDA through the 

BUILD Act will eliminate any uncertainty for funding housing projects in Indian 

Country. 

S. 1333 HUD/VA-Veterans Affairs Supportive Housing 

NHA Success with HUD–VASH Program 

Tribal HUD–VASH recipients are having success placing tribal veterans into local 

supportive housing but we need the program to be permanently authorized or else 

we risk leaving those homeless Native Veterans without affordable housing options 

that include critical supportive services. 

HUD approved 20 HUD–VASH vouchers for NHA in the amount of $268,835 on 

January 6, 2016. NHA has prioritized and incorporated the 20 VASH vouchers for 

homeless Navajo Veterans and to date we have issued nine vouchers (four have 

found housing) in Arizona and New Mexico. These homeless Navajo Veterans were 

reviewed by case-managers and determined eligible for the program and were immediately issued a voucher. Furthermore, NHA took efforts and instituted its own Veterans Housing Assistance Policy. This policy goes above and beyond Federal legislative authority and has helped over 120 veterans become homeowners and has extended $8.8 million in veteran debt forgiveness and assisted 17 widowers/mothers 

of service men and women through NHA’s veterans housing assistance program. 

Project Coordination 

NHA partners with Veterans of the Armed Services residing on the Navajo Nation 

and are eligible to receive housing assistance services through the Department of 

Navajo Veterans Affairs (DNVA). The DNVA partners with Federal, state and local 

services, but the amount of case management that is needed to service our veteran 

population is large and additional federal resources are needed. Navajo has one case 

manager for the HUD–VASH program to handle cases that cover the entire Navajo 

reservation (Navajo extends into three states: Arizona, New Mexico and Utah). 

Moreover, the remote location of the reservation is not conducive to providing adequate case-management unless that casemanagement can be provided in their community as opposed to off the reservation. NHA believes a solution is to provide for 

more case-managers to meet the needs in the Navajo community. 

Place-based Vouchers 

The biggest problem with using the tenant based rental assistance vouchers on 

the Navajo Nation is the lack of private or non-profit housing for renters. Therefore, 

the HUD–VASH program should allow rental assistance vouchers to be used for 

housing currently included in the housing stock of the tribal housing program. 

NHA’s only option for using our HUD–VASH rental vouchers is to use Section 8 approved properties off the reservation. This solution will not help veterans who are 

needing supportive services who wish to stay on the reservation close to their family 

who are helping in their recovery. Thus, creating a place based voucher system that 

stays on the reservation, where most tribal veterans reside is the best option to alleviate our TDHE’s lack of public and non-profit housing. 

Conclusion 

It is the goal of NHA and the Navajo Nation to help build safe sustainable homes 

for the Navajo People. The re-authorization of NAHASDA through the BUILD Act, 

the development of sanitation infrastructure through Restoring Accountability in 

the Indian Health Service Act, and expansion of HUDVASH coordination and program is critical in maintaining the growth of the Navajo Nation and sustaining the 

progress of the Navajo People. We hope our testimony can assist this Committee in 

expanding each of these programs for the benefit of the Navajo Nation and all Tribal TDHE’s. Thank you for this opportunity. 

102 

1 IHS 2016 Profile. https://www.ihs.gov/newsroom/factsheets/ihsprofile/ 

JOINT PREPARED STATEMENT OF HON. RUSSELL BEGAYE, PRESIDENT, NAVAJO NATION

AND JONATHAN HALE, CHAIRMAN, HEALTH, EDUCATION & HUMAN SERVICES, NAVAJO NATION COUNCIL

As President of the Navajo Nation and Chairman of the 23rd Navajo Nation 

Council Health, Education, and Human Services Committee, we are submitting the 

following written testimony to the Senate Committee on Indian Affairs (SCIA) in response to the June 13, 2017 legislative hearing on the Senate Bill 1250 ‘‘Restoring 

Accountability in the Indian Health Service Act of 2017.’’ We support the overall legislative goals of this bill to improve the quality, access, and delivery of health care 

services through the Indian Health Service (IHS). However, we remain concerned 

about several provisions, which are outlined in this testimony. Finally, we have concerns regarding the funding of this bill and support a commensurate increase in appropriations to support increased operations. 

The Navajo Nation is the largest land based Indian tribe in the United States 

spanning over 27,000 square miles across three states: Arizona, New Mexico, and 

Utah. We have over 300,000 enrolled tribal members, with nearly 180,000 members 

living on the Navajo Nation. The Navajo Nation easily comprises the largest IHS 

footprint in Indian Country. Therefore, any changes to the IHS system will have an 

overwhelmingly significant effect on our Navajo people. 

The health care system on Navajo Nation includes five Indian Health Service direct service units, five tribal health organizations, and the Navajo Department of 

Health. The Navajo Area Indian Health Service (NAIHS) is the primary health care 

provider that serves two federally recognized Indian tribes—the Navajo Nation and 

the San Juan Southern Paiute Tribe. NAIHS is responsible for providing health care 

services to nearly 246,776 users through inpatient, outpatient, purchase referred 

care for specialized services, contract providers, and an urban Indian health program. The NAIHS system includes five hospitals, six health centers, fifteen health 

stations and twentytwo dental clinics. In 2016, as a result of limited funding, the 

IHS per capita expenditure rate for patient health services was just $3,688, compared to $9,523 per person nationally. 1 In order to more fully serve the quarter of 

a million individuals within the Navajo Area, IHS must be fully funded to appropriately deliver critical services. Therefore, any proposed changes should be accompanied by increased funding to fully implement new programs and functions, and 

to reduce the strain on the insufficiently funded IHS system. 

Employee Compensation 

The Navajo Nation supports section 101 with the intent to create parity of employee compensation between the Veterans Administration and Indian Health Service. We also support the creation of a Housing Voucher program for critical health 

professionals. However, the proposed voucher program is limited to three years, 

which does not address the long-term shortage of adequate housing on the Navajo 

Nation and may inadvertently create a temporary workforce. In order to invest in 

long-term workforce solutions, we suggest establishing a permanent program to create more permanent employment opportunities to attract quality health care professionals into the IHS system. 

Centralized Credentialing 

We understand that IHS is piloting a similar credentialing system. We believe examining the results of the IHS pilot system and further tribal consultation will better inform all IHS stakeholders of the possible benefits and concerns associated with 

such a system. As stated earlier, we cannot support the creation and implementation of the proposed credentialing system if adequate funds are not appropriated. 

Loan Repayment Program 

The Navajo Nation supports Section 104 to increase eligibility for the Loan Repayment Program for health administration-related degrees, an important tool for the 

recruitment and retention of qualified health care professionals. Health administration-related degrees should be considered under the IHS Scholarship program as 

well. However, it is imperative that Congress appropriates new funding to cover 

these programs, as IHS is already severely underfunded. 

Direct Hiring Authority 

The Navajo Nation has grave concerns regarding Section 105, which provides the 

Secretary of HHS with direct hiring authority. We do not support waiving Indian 

Preference in hiring within IHS, as we believe there are qualified AI/AN candidates 

for all IHS positions, including Navajo tribal members. 

103 

3 Helman v. Department of Veterans Affairs. http://www.cafc.uscourts.gov/sites/default/files/ 

opinionsorders/15-3086.Opinion.5-5-2017.1.PDF 3 15 N.N.C. 604(B)(11) 

Employee Removal 

The Navajo Nation understands the need to refine current human resources practices to remove ineffective employees. However, in Helman v. Department of Veterans Affairs (Fed. Cir.), the proposed process has been deemed questionable by the 

United States Court of Appeals for the Federal Circuit. 2 Therefore, we are opposed 

to this method, which may result in costly litigation further burdening the IHS 

budget intended for health care. 

Standards to Improve Timeliness of Care 

The Navajo Nation supports Section 107, which requires IHS to establish standards to improve the timeliness of care in order to provide faster care for patients. 

Wait times at NAIHS facilities are notoriously high. 

For example, the Gallup Indian Medical Center (GIMC) provides dental exams 

three days per week. GIMC policy only allows for one patient per household per day 

to receive a dental exam. As a result, families are forced to make multiple trips to 

the facility so that various family members can receive critical dental services. Currently, GIMC only treats four dental patients per day, which has resulted in families arriving well before the opening hours of the facility in hopes of receiving care. 

Patients must then endure wait times greater than one hour. Due to the outstanding need of dental services within this service region, and the limited resources 

at GIMC, many patients are turned away daily, leaving them without necessary oral 

health services. 

We support the proposed data collection and establishment of timeliness of care 

standards to improve this challenge; however, we encourage Congress to appropriate 

additional funds to support this effort. 

Tribal Culture and History Training Programs 

We fully support the development and implementation of tribal culture and history training programs for all employees in a particular service area. Currently, 

Navajo employment practices mandate such training on the Navajo Nation. The Office of Navajo Labor Relations enforces Section 604 of the Navajo Preference in Employment Act, which mandates that: 

An employer-sponsored cross-cultural program shall be an essential part of the 

affirmative action plans required under the Act. Such program shall primarily 

focus on the education of non-Navajo employees, including management and supervisory personnel, regarding the cultural and religious traditions or beliefs of 

Navajos and their relationship to the development of employment policies which 

accommodate such traditions and beliefs. The cross-cultural program shall be 

developed and implemented through a process which involves the substantial 

and continuing participation of an employer’s Navajo employees, or representative Navajo employees. 3

Again, we encourage Congress to appropriate funding for this activity, which complements current requirements on the Nation. 

Staffing Demonstration Project 

The Navajo Nation understands and supports the overall goals of addressing 

workforce shortages through the development of staffing demonstration projects for 

federally managed health care facilities. However, the requirement for tribal contribution for construction funds will prevent Tribes from accessing this potential resource. Therefore, we believe that this requirement should not be a factor for selection. Additionally, we suggest that tribally operated health care facilities be considered for participation, such as the 2 tribally contracted and 3 compacted facilities 

on the Navajo Nation. The inclusion of these facilities fully supports the aims of the 

Indian Self Determination Act (P.L. 93–638). 

Tribal Consultation 

Direct, meaningful Tribal consultation is a crucial part of the relationship between Tribal Nations and the Federal Government. In current practice, IHS drives 

the consultation efforts. While the proposed legislation is designed to improve consultation, we are concerned that a negotiated rulemaking committee may hinder or 

restrict future Tribal consultation. As proposed, potential negotiated rulemaking 

could likely result in a time-consuming and costly process. Alternatively, we recommend that the current IHS consultation policy be reexamined for improvements 

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1 USET SPF member Tribal Nations include: Alabama-Coushatta Tribe of Texas (TX), Aroostook Band of Micmac Indians (ME), Catawba Indian Nation (SC), Cayuga Nation (NY), 

Chitimacha Tribe of Louisiana (LA), Coushatta Tribe of Louisiana (LA), Eastern Band of Cherokee Indians (NC), Houlton Band of Maliseet Indians (ME), Jena Band of Choctaw Indians (LA), 

Mashantucket Pequot Indian Tribe (CT), Mashpee Wampanoag Tribe (MA), Miccosukee Tribe 

of Indians of Florida (FL), Mississippi Band of Choctaw Indians (MS), Mohegan Tribe of Indians 

of Connecticut (CT), Narragansett Indian Tribe (RI), Oneida Indian Nation (NY), Passamaquoddy Tribe at Indian Township (ME), Passamaquoddy Tribe at Pleasant Point (ME), Penobscot Indian Nation (ME), Poarch Band of Creek Indians (AL), Saint Regis Mohawk Tribe (NY), 

Seminole Tribe of Florida (FL), Seneca Nation of Indians (NY), Shinnecock Indian Nation (NY), 

Tunica-Biloxi Tribe of Louisiana (LA), and the Wampanoag Tribe of Gay Head (Aquinnah) (MA). 

and be recommitted to engaging in meaningful consultation. Additionally, we suggest that a greater emphasis be placed on Tribal concerns as they arise, and this 

must result in meaningful and timely consultation. 

Proposed Reports 

The Navajo Nation supports the directive for the additional reporting contained 

within sections 302–304. To be most effective, reports should be developed in collaboration with Tribes. Reports should then be presented to affected Tribes for comment before the final version is officially released. 

CMS Survey 

The Navajo Nation supports the call for a CMS compliance survey. Again, to be 

most effective, the proposed survey should be developed in collaboration with Tribes. 

Reports should be presented for Tribal input before the final version is officially released. 

Conclusion 

In conclusion, we would like to thank the Senate Committee on Indian Affairs for 

the opportunity to submit testimony and feedback. As it is the goal of the Navajo 

Nation to ensure delivery of quality health care for our Navajo people, we appreciate 

Senators Barrasso, Thune, and Hoeven’s efforts to improve health services within 

the IHS. It is critical that we find successful, lasting solutions to the current challenges facing Indian health care system, including the recruitment and retention of 

employees and unacceptable standards of care. We hope this testimony can assist 

the Committee in improving the quality, access, and delivery of health care services 

through the Indian Health Service (IHS). Thank you. 

PREPARED STATEMENT OF UNITED SOUTH AND EASTERN TRIBES SOVEREIGNTY

PROTECTION FUND

On behalf of the United South and Eastern Tribes Sovereignty Protection Fund 

(USET SPF) we write to provide the Senate Committee on Indian Affairs with the 

following testimony for the record of its June 13, 2017 legislative hearing on S.R. 

1250, the Restoring Accountability to Indian Health Service Act of 2017. 

USET SPF is a non-profit, inter-tribal organization representing 26 federally recognized Tribal Nations from Texas across to Florida and up to Maine. 1 Both individually, as well as collectively through USET SPF, our member Tribal Nations work 

to improve health care services for American Indians. Our member Tribal Nations 

operate in the Nashville Area of the Indian Health Service, which contains 36 IHS 

and Tribal health care facilities. Our citizens receive health care services both directly at IHS facilities, as well as in Tribally-operated facilities under contracts with 

IHS pursuant to the Indian Self-Determination and Education Assistance Act 

(ISDEAA), P.L. 93–638. 

While we appreciate efforts to address the healthcare disparities identified within 

the Great Plains Area of the Indian Health Service (IHS), we feel a broad, one-sizefits-all approach to addressing these problems is unwarranted. Not all IHS Areas 

are experiencing these same types of failures, and there are lessons to be learned 

from the best practices they employ. In addition, despite Tribal concerns with similar legislation last Congress, this bill was introduced without broad Tribal consultation. Any attempts to reform IHS, through Congressional action or otherwise, must 

be accomplished through extensive Tribal consultation. Finally, we maintain that 

until Congress fully funds the IHS, the Indian Health System will never be able to 

fully overcome its challenges and fulfill its trust obligations. Although USET SPF 

supports reforms that will improve the quality of service delivered by the IHS, we 

continue to underscore the obligation of Congress to meet its trust responsibility by 

providing full funding to IHS and support additional innovative legislative solutions 

to improve the Indian Health System. 

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Uphold the Trust Responsibility to Tribal Nations 

The United States has a trust responsibility to Tribal Nations that has been reaffirmed time and time again. The most recent reaffirmation came though the permanent reauthorization of the Indian Health Care Improvement Act when, ‘‘Congress declare[d] that it is the policy of this nation, in fulfillment of its special trust 

responsibilities and legal obligations to Indians to ensure the highest possible health 

status for Indians and urban Indians and to provide all resources necessary to effect 

that policy.’’ This trust responsibility obligates the federal government to provide 

quality healthcare to Tribal Nations. Providing quality healthcare can only be accomplished when these programs are fully funded. We further recommend the inclusion of language directing the IHS to request a budget that is reflective of its full 

demonstrated financial obligation, as this is the only way to determine the amount 

of resources required to deliver comprehensive and quality care. 

As long as IHS remains dramatically underfunded, the root causes of the failures 

in the Great Plains and IHS will not be addressed. In FY 2015, the IHS medical 

expenditure per patient was $3,136 while the Veteran’s Administration, the only 

other federal provider of direct health care services, spent $8,760 per patient—a 36 

percent difference. Disparities in financing for health care such as these lead to disparities in health outcomes. Congress must authorize full funding for the IHS in 

order to make meaningful progress on the chronic challenges faced by IHS. We remain hopeful that Congress will take necessary actions to fulfill its federal trust responsibility and obligation to provide quality health care to Tribal Nations, by providing adequate funding to the IHS. 

Authorize Advanced Appropriations 

On top of chronic underfunding, IHS and Tribal Nations face the problem of discretionary funding that is almost always delayed. Stability in program funding is 

a critical element in the effective management and delivery of health services. Since 

FY 1998, there has only been one year (FY 2006) in which appropriated funds for 

the IHS were released prior to the beginning of the new fiscal year. The FY 2016 

omnibus bill was not enacted until 79 days into the Fiscal Year, on December 18, 

2015. Delays in funding only amplify challenges in providing adequate salaries and 

hiring of qualified professionals, particularly in areas with high Health Professional 

Shortage Areas where many Tribal Nations are located. 

Budgeting, recruitment, retention, provision of services, facility maintenance, and 

construction efforts all depend on annual appropriated funds. As Congress seeks to 

improve IHS’ ability to attract and retain quality employees, as well as promote an 

environment conducive to effective health care administration and management, we 

urge the inclusion of language that would extend advance appropriations to the IHS. 

Clarification for Tribal Health Programs 

When it comes to Tribal Nations operating facilities pursuant to the Indian SelfDetermination and Education Assistance Act (ISDEAA), P.L. 93–638, the current 

language is ambiguous. We recognize that many provisions contain a ‘‘rule of construction’’ clause that appears to be intended to ensure that the new obligations 

placed on the IHS in these areas would not interfere with Tribal health programs’ 

ability to enter into or maintain contracts or compacts under the Indian Self-Determination and Education Assistance Act. We believe that such a rule of construction 

is helpful, but are concerned that the precise language used does not achieve its 

goal. Instead, these provisions should be revised to simply state they do not apply 

to Tribally-operated health programs. Tribal Nations should have a clear sense of 

which provisions apply to our Tribally-operated programs and which do not. 

Section-by-Section Comments 

Below, USET SPF offers section-by-section comments and concerns. Again, S. 

1250 should not move forward without additional, thorough Tribal Consultation on 

a national basis. 

Section 101—Incentives for Recruitment and Retention 

In order to address the ongoing challenges with the recruitment and retention of 

IHS staff, the legislation would allow HHS to provide housing vouchers or reimburse the costs for those relocating to an area experiencing a high level of need for 

employment. Though this provision provides the Secretary discretion to determine 

whether a location is experiencing a high level of need, USET SPF suggests including language for positions that are ‘‘difficult to fill in the absence of an incentive.’’ 

This addition would allow IHS more flexibility when determining when to offer relocation compensation. 

USET SPF agrees that there is a need for recruitment and retention programs. 

However, the establishment of these programs should not come at the cost of health 

106 

care services. USET SPF recommends that additional appropriations be authorized 

for the proposed recruitment and retention programs. 

Additionally, it is unclear why the bill includes a sunset date on the housing 

voucher program. It is unlikely that IHS staff housing needs will be fully addressed 

in only a 3-year period. USET SPF suggests that the sunset date be stricken. 

Section 102—Medical Credentialing System 

USET SPF has deep concerns about the centralization of any Area Office functions, including credentialing. Nashville Area Tribal Nations have consistently advocated for Area Office presence and for services to be administered at the Area level. 

Collectively, we have worked hard to establish the strong and high functioning Area 

Office we have today. Taking away functions from Area offices causes significant 

backlogs in services, and disrupts an established and trusted relationship between 

the Area Office and Tribal Nations. We believe credentialing should be kept at the 

Area level, utilizing established best practices. 

Section 103—Liability Protections for Health Professional Volunteers at 

IHS 

While USET SPF understands that providing an incentive for healthcare professionals to volunteer at IHS facilities by protecting them from liability would aid in 

delivering quality healthcare to Indian Country, we believe this provision needs further technical evaluation to ensure patients and healthcare providers are adequately 

protected. In addition, USET SPF recommends adding language to ensure similar 

protections are available at Tribally-operated facilities. 

Section 104—Clarification Regarding Eligibility for IHS Loan Repayment 

Program 

USET SPF encourages efforts that would expand the Indian Health Service Loan 

Repayment Program to include degrees in business administration, health administration, hospital administration, or public health professions as eligible for awards. 

We recommend including language that would expand these degrees as eligible 

under the IHS Scholarship Program as well. Allowing for comprehensive eligibility 

under these programs would increase the number of AI/AN individuals seeking business and health administration degrees, as well as increase the pool of qualified 

health professionals within Indian Country. 

Section 105—Improvements in Hiring Practices 

When it comes to improvements in hiring, three provisions are included in S. 

1250. On the first of these, Direct Hire Authority, language should be included that 

would require the Secretary to consult with the Tribal Nations served by the Area 

office where the position will be filled prior to any secretarial action. 

On the second provision, we appreciate the inclusion of Tribal Notification of individuals who have been appointed, hired, promoted, transferred or reassigned within 

IHS. However, language should also be included that would provide notification to 

Area Tribal Nations on removals based on performance or misconduct. This would 

supplement the effort of this legislation in increasing transparency and allow Tribal 

Nations to have greater knowledge and confidence in healthcare professionals providing services to their citizens. 

On Waivers of Indian Preference, USET SPF firmly believes that the providers 

best suited to care for our communities are ones that come from the communities 

themselves. Therefore, we cannot support the inclusion of this provision, which 

would set a dangerous precedent throughout other federal agencies that serve Tribal 

communities. The aims of this provision can be achieved by modifying hiring practices within the current legal framework. There is room for improvements in hiring 

practices to ensure that positions are being filled in a timely manner with qualified 

candidates. We recommend directing the Secretary to update and streamline Indian 

preference hiring practices to ensure that qualified non-Indian applicants will be 

considered in cases where no qualified Indian applicants are available, at the sole 

discretion of the Tribal Nations served. 

Section 106—Removal or Demotion of IHS Employees Based on 

Performance or Misconduct 

While USET SPF understands the purposes of including language that would expand the Secretary’s authority to remove or demote IHS employees based on performance or misconduct, we believe Tribal governments must also be notified when 

IHS employees within their Service Area become subject to a personnel action such 

as removal, transfer or demotion. In under Sec. 606 (d) ‘‘Notice to Congress’’, we recommend including ‘‘Tribal Governments located in the affected service area’’ to the 

107 

list of entities the Secretary would be required to provide notification to 30 days 

after the Secretary takes a personnel action on an IHS employee. 

Section 107—Standards to Improve Timeliness of Care 

It is imperative that any timeliness of care standards are developed in consultation with Tribal Nations. We note that IHS is currently implementing a timeliness 

standard in accordance with its Improving Patient Care (IPC) Initiatives. We urge 

consultation with the 170 IHS and Tribally-operated sites that have chosen to participate in the IPC Initiative, as well as aligning with these standards with IPC to 

ensure that the standards and reporting are not overly burdensome for Tribal 

health programs. 

In addition, we request that any data collected under the provision be provided 

to Tribal Nations as well as the Secretary. 

Section 108—Tribal Culture and History 

We support the inclusion of Section 108 that would require annual and mandatory 

cultural competency trainings for IHS employees, including contractors. However, 

because each Tribal Nation is unique, language should be included that would require IHS to compile these trainings through consultation with the Tribal Nations 

they serve, on a regional basis. 

Section 110—Rule Establishing Tribal Consultation Policy 

While IHS is currently operating under an existing Tribal Consultation Policy, it 

may be appropriate for Tribal Nations to reexamine and reevaluate its efficacy. 

Tribal consultation is a cornerstone of the relationship between federally recognized 

Tribal Nations and the federal government. We do, however, have concerns about 

the functionality of a negotiated rulemaking and its potential to divert attention and 

resources away from patient care. USET SPF encourages the use of a Tribal/Federal 

workgroup to examine, evaluate and update the existing policy and approve through 

the Public Comment procedures versus official negotiated rulemaking. 

Section 202—Fiscal Accountability 

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

order to assess its true impact. 

Section 302–304—Reports by the Secretary of HHS, Comptroller General, 

Inspector General 

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

Tribal Nations for consultation prior to their release to Congress or the public. 

Section 305—Transparency in CMS Surveys 

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

Tribal Nations prior to their public release. 

Conclusion 

USET SPF acknowledges the efforts of the Committee and others within Congress 

in seeking to address the long-standing challenges within IHS. However, we believes 

that S.1250 fails to recognize the deep disparities in funding faced by IHS and how 

these disparities contribute to failures at the Area level. We maintain that until 

Congress fully funds the IHS, the Indian Health System will never be able to fully 

overcome its challenges and fulfill its trust obligations. Finally, a number of provisions within S. 1250 seem to be responding to Area-specific concerns. While we 

stand with our brothers and sisters who are experiencing these failures, we ask that 

the Committee strongly consider the national (rather than regional) implications of 

S. 1250, and work with Tribal Nations to ensure its impact is positive in all IHS 

Areas. We thank the Committee for the opportunity to provide comments on this 

bill and look forward to further consultation on S. 1250, as well as an ongoing dialogue to address the complex challenges of health care delivery in Indian Country. 

PREPARED STATEMENT OF THE DEPARTMENT OF HAWAIIAN HOME LANDS

Chairman Hoeven, Vice-Chairman Udall, Senator Schatz and Members of the 

Senate Committee on Indian Affairs, we thank you for the opportunity to submit 

written testimony for the Committee’s June 13th, 2017 hearing on S. 1275. 

108 

We want to express our deep appreciation to Chairman Hoeven and the members 

of this Committee for your continuing leadership in seeking to address the housing 

needs of Native American communities. 

Your efforts are a vital part of a long history of congressional initiatives—beginning in 1920, when the United States Congress recognized the dire circumstances 

in which native Hawaiians were living and enacted legislation to authorize the designation of approximately 203,500 acres of some of the worst available lands in the 

Hawaiian Islands for homesteading. These lands were intended to provide permanent, safe and secure home lands for the indigenous people of what was later to become the 50th state of America’s union of states. 

The Hawaiian Homes Commission Act of 1920 did not, however, provide for an 

appropriation of funds to develop those designated lands, and from that time to the 

present day, the Hawaiian Homes Commission and the Department of Hawaiian 

Home Lands have struggled mightily to secure the financial resources needed to 

clear forested lands and difficult terrain for the development of housing; to assure 

that roads, clean water resources and sources of power, including access to coal-produced power as well as solar- and wind-produced energy, can be supplied to those 

housing areas; and to provide for the rehabilitation of the native peoples of these 

islands while celebrating their traditional knowledge, language and culture. 

Title VIII of the Native American Housing and Self Determination Act 

(NAHASDA) was the response of the Congress to address the critical housing needs 

of Native Hawaiians. Title VIII moneys have provided opportunities for many families over the years: 

• The single father of four who lost his job and could not qualify for a conventional loan to convert his rental to home ownership. With the help of Title VIII 

funds paying for case management services and homeowner financing, a year 

later he is employed and providing for his four children as a homeowner 

• The autistic young man living in rural Molokai that now owns his own home 

using NAHASDA mortgage financing and a Section 8 home ownership voucher. 

In 15 years the home will be his, permanently affordable. 

• The elderly grandmother in Maui on a fixed income who received a ready-tobuild lot with roads, water, electrical, (etc.) financed by NAHASDA. Her son 

and grandsons, all employed in the construction industry, plan to help build the 

home. 

Today, while significant progress has been made in carrying out the Congress’ 

1920 statutory directive, challenges remain and the goals of 1920 Act have yet to 

be fully realized, as documented by the recently-released 2017 report of the U.S. Department of Housing and Urban Development (HUD) on housing needs in Native 

America. 

According to the May 2017 Housing Needs of Native Hawaiians: A Report From 

the Assessment of American Indian, Alaska Native, and Native Hawaiian Housing 

Needs HUD study (the study) , Native Hawaiians comprise approximately 10 percent of the Native American population of the United States. Of this number, approximately 27,000 Native Hawaiian households are on DHHL’s waitlists. 

While Native Hawaiians living in Hawaii continue to have lower incomes, need 

higher rates of assistance, and experience higher poverty rates than other residents 

of Hawaii, it is not because they are not working. In fact, Native Hawaiians participate in the civilian labor force (either working or looking for work) at higher rates 

than do other residents of Hawaii, however, the jobs that are available are low wage 

service industry jobs that do not pay enough to keep up with the sky-high cost of 

living in Hawaii. 

The study highlights that within the Native Hawaiian population, the Native Hawaiian households on DHHL’s waiting list (DHHL applicant households) are more 

economically disadvantaged than are (1) Native Hawaiian households overall, (2) 

residents of Hawaii households, and (3) Native Hawaiian households already located 

on the home lands (DHHL lessees). Compared to those groups, DHHL applicant 

households also experience substantially higher rates of overcrowding and significantly higher rates of substandard housing. 

Specifically: 

• DHHL applicant households have the lowest median income of the four groups: 

$48,000 compared with more than $60,000 for the three comparison groups; 

• One in five of DHHL applicant households receive public cash assistance compared to 7 percent of Native Hawaiians and DHHL lessees and 3 percent for 

residents of Hawaii; 

109 

• Nearly 40 percent of DHHL applicant households are overcrowded compared 

to 15 percent of Native Hawaiian households and 8 percent of resident of Hawaii households; and 

• 10 percent of DHHL applicant households lack complete plumbing compared 

with one percent for all other comparison groups. 

The study identifies one key area affecting all resident households living in Hawaii: housing affordability. 

Cost burden rates for residents of the State of Hawaii of 40 percent surpass the 

national rate of 36 percent. Again, Native Hawaiian residents experience a higher 

rate than the state as a whole with Native Hawaiian rates at 42 percent. Consistent 

with the earlier trends, DHHL applicant household rates are the worst off—experiencing cost burden rates of 46 percent. 

However, for residents of the home lands (DHHL lessees), the cost burden is very 

different. DHHL lessees experience a substantially lower rate of cost burden (21 percent) in the Hawaiian home lands communities that were sampled. This is due in 

part to the financial benefits of living on the home lands, including substantiallyreduced housing cost burdens. 

For a family and a community, lower housing costs and a permanent home eases 

the pressures on parents to seek and hold multiple jobs to support their families, 

provides the opportunity for new households to form, and enhances the well-being 

of an entire native people. 

NAHASDA funding has enabled DHHL to address and target those Native Hawaiian households most in-need: those waiting to reside on the home lands. During the 

fiscal year ending June 30, 2016, 150 families participated in homebuyer and financial literacy education workshops and received case management services to help 

prepare them for homeownership as roads, water, drainage, electrical, and other infrastructure investments were being made to the home lands with NAHASDA resources to prepare housing lots for building. 

During the fiscal year ending June 30, 2017, 98 ready-to-build lots were awarded 

to families on Oahu, Maui, and Kauai. Working with selfhelp providers, contractors 

selected by the families, their own family and friends, and home-builders certified 

by DHHL, these families are now building their own homes that address their needs 

at a level they can afford. Another 211 lots are ready to be awarded in fiscal year 

2018, available to families now because of NAHASDA. 

With NAHASDA monies, DHHL has had the financial ability to address those 

usually left behind. In Hoolimalima, a rental project on the home lands that converted to homeownership in the state fiscal year ending June 30, 2017, nearly 50 

percent of the families were able to successfully purchase their homes because of 

financing offered by DHHL using NAHASDA resources. Without NAHASDA, the 

dream of homeownership may never have become a reality for these families. 

Over the years, we have come to know much more about the similar challenges 

that our brothers and sisters in Indian country face—our lands are also held in 

trust—making it difficult to secure loan guarantees and mortgage financing in the 

absence of Federal incentives that recognize and seek to address the unique circumstances of trust lands. 

We also share with our relatives and friends in the Alaska Native community the 

barriers of the distance of our lands from urban areas, creating extremely high construction costs for housing. 

For Native Hawaiians, perhaps most heart-breaking, is to see their beloved Hawaii Nei be priced out of their reach as land prices and construction expenses soar 

and new housing is built not for residents but for off-shore investors seeking a vacation home or a luxury residence. The Hawaiian home lands may be the most important, if not only, opportunity for Native Hawaiian families to stay in Hawaii in a 

permanently affordable home on land that will never be sold. 

We endeavor to address the housing needs of a hard-working Native population 

whose families often have incomes below the poverty level; who are forced to live 

in overcrowded conditions simply because the housing costs off the home lands are 

too-expensive; who must work two or more jobs just to pay for basic expenses: food, 

transportation, shelter, and utilities. Through financial literacy programs, self-help 

housing projects, and by providing a greater range of housing options we are seeking to reduce the burden of housing costs, as well as reducing overcrowded households and homelessness for working Native Hawaiian families by placing an increasing number of families on the home lands. 

We recognize that the resources needed to achieve this goal are substantial. For 

the state fiscal year 2018, DHHL requested over $148 million from the Hawaii state 

legislature to address development costs associated with the development of new 

lots and the necessary capital for loans for just one fiscal year. Of the requested 

110 

amount, the State provided $34 million or 23 percent of the amount requested. The 

$2 million in NAHASDA funds appropriated by the Congress represents a little over 

1 percent of the amount needed. Clearly, we recognize that public resources alone 

cannot meet the need. 

Accordingly, we have reached out to partners in the private and commercial markets who have assisted us in the means of leveraging our resources to attract lenders and developers who understand that with the development of homes and communities, comes the potential for greater economic development for all—as neighborhoods, community centers, schools, health care facilities, police and fire protection 

services, grocery supplies, service industries and stores locate in newly-developed 

areas on, near and around housing developments on the home lands. 

Housing programs under the authority of Title VIII of NAHASDA, including the 

Native Hawaiian Housing Block Grant, and the section 184(A) Native Hawaiian 

Home Loan Guarantee programs, have made the dream of home-ownership possible 

for thousands of native Hawaiians who, for generations, have long thought that access to decent, affordable housing would never be part of their future. 

We well understand that today, there are those who harbor constitutional concerns about the provision of housing to America’s native people. We believe that 

those concerns have been answered by the Congress in its enactment of over 160 

laws, signed by the President of the United States, and designed to address the conditions of Native Hawaiians, as well as the enactment of hundreds of Federal laws 

addressing conditions in Indian country and Alaska Native communities. 

Like other Native Americans, we seek only to improve the lives of our people— 

loyal Native Americans who have served our country in defense of our nation in proportionally greater numbers—we are veterans and families of veterans, and we are 

citizens of the United States. Like many Americans, our people simply want to be 

able to live in the land of their forefathers, and provide a good life for their children 

and grandchildren. 

We firmly believe that if we work together, we can together forge a legislative 

path forward which will address the housing needs of all Native Americans—always 

keeping in the forefront of our minds the knowledge that throughout its history, our 

great nation has endeavored to assure the highest quality of life for all of its people, 

including America’s first indigenous citizens. 

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PREPARED STATEMENT OF MIKE HODSON, CHAIRMAN, BOARD OF COMMISSIONERS, 

HOMESTEAD HOUSING AUTHORITY


613a11.eps
112 

PREPARED STATEMENT OF THE OFFICE OF HAWAIIAN AFFAIRS (OHA) 


613b1.eps

Aloha c Chainmm :ij~;a:W!l u me Vic~Ch~irmuf! Udall: 

The Office of Hawaiian Affairs (OHA) 1S"'gtateful for the opportmiicy lo provide writ len 

lestirnouy OilS. 1215, the Bringing Useful ,{uitiatives for lndiahLand Developm~nt Act of2017, 

o~ BUITLD A~t. The: Office of Huwaiian Mfairs is a quasi-independent, semi-autonomous 

agency of the State of HtlWai'i established tfirouE;h our SLI.tte's constiwtion. Hll.wlli'l state law 

recoJP!izcs OHA, "as the prlndp!e public agcm .. -y -in lhi~ State re:lponsible fOr" the pMformanco, 

development, and·coordinatlon [)f progr.~ms-and <1\::liVitit:~ n=laliDg to nutive- Hawaiiiws." OHA is 

also dircctc~ by srore-law to review polioi~s and practices that imp~clthe indigeuow; people of 

Hall(!li'i. As 1\ nntJ,•c ~erving organizntion, OHA- ~up_ports initiatives tllat allow native 

commimitie's opportuliitles to grow and sttengihen. As such, we support rc.authoriz~tion Qf tlte 

Nativ.e American HouSing Assiiit"nCe and Self-~tciD'Iination Aet (NAHASDA). 

Howev~. we write to share our oonc;:rns with lilt: CommilfCC .regarding the CJ:Clusion of 

'I:itle VIII'ofNARA.SDA, lht: Native Hnwniiart Housing ]lock Grant (NHHBG) and the 184A 

Natir.'e Hawaii~!! I-liJtllC Loan GuaJ:llnte~ p~graro, from the BUllLD Act. As n ~chicle for 

l"CaLLthorii'.ing native hou~ing pmgrllms supported by t:he fed~ral gowrnment, the BUULD Acl 

provides. an opportunitY ·to SUJ1Pon.nU natiVe-cnmmunitins. The decision to exdude one is, ill tlle 

end, a tktrimcnt 1o ~11. The Office ofHaWliiinn Affai.s strongly urges the Committee to restore 

Title Vlll in full, lhereby-renffinning Congr<:Ss's longstanding commitment 10 its obligations to 

in:digenoi.ls people. 

Though OHA i~ not the ng_eney directly {"l;f"'OSibtc \or ndminisle<:ing the Huwailiu 

Homos Cornmis~i6n Att (a-tesponsibilily which belongs to o~r sister agency, the DcpRrtment of 

H;~,waiian Home. Lands) nlllt~y t'lf our bcoeficilllies" rue ~\so Hnwniian Homes b'enefl<:larics who 
113 


613b2.eps

.lfC ~ifbor )"CSidi~ on or wailing for a Jea5e of.:Hn.wn.iian Rorpe Lands. There ure roushly 9,000 

fumilkS Livin~ on wbat w'e refer tO as h~lc~d 'landS, and the!'!! are nno(h~· 27,800 an the 

wnitlilll . .BaSed on these numbei:s·altme, which do not em:ompass !lie total number of Hawaiian 

ltomes bWteficiaries, we oDie lha~ the BUill.D Act i$ choosing llJ ignore rough:ly 37,000 

ini:liviilunls und their families. 

A brief ltistory of the Native Hawoiian housing 11rogrom~ may here be wammted. ln 

192G, H~w.ii'i'l; -delegal<.' lo COn~s. Prince. Jonah KUhiiJ IUolaniana'ole, put foilh n bill aimed 

at a~dres~lng !he de.vastnting impa~l. W{!Slem C~(act b:ul inflicted on !h~ Hawaiirw people. At 

tht:: lime of tm;t tDntact in 1778, estimates put the Hawaiian population 11.1 as high as l,OOIJ,OUO 

~op:e:, l:ly 1920, e~timates had the Mlive popti!ation at between 20,000to 30,000 ~pie. I'rinre 

Krlh!O, reoogniz.ing_ that his people were dying, made a faidy £1raightforwil:J:d proposal: allow 

WllfW Hnw.o!Hms the oppt>ttullity· to (ee'stablislt themselvoo by providiDg a~co::.~.~-to r""idenlial, 

agriculturnl, ~nd y.rsturult..nU fOillltily heW by the· Native- Hawaiirm-esta0li~1ocd Kingdom of 

Hnwai'l. \Y!Jen ·congress contemvlnred the-HHO\, they diS\lusscd which landS to ~e\ aside, and 

set!IOO on the proposal of resttll'lng some pan .of these crown laud~. which WcrtJ heW in tnm for 

the ffiw.ili3ti pcopte.ln 1\!Zt, tl1e proposed Hawilian Homes Conunission A~t (liHCA) lru~= 

bw. The HHCA s~t ~.side ~03.50(} acres in }]aw~i'i im 99 year l~<~st:S to. HaW<tlian Home.1 

beneficiru:les, or native. Bawaiians. with 11. blood- qu:llltum of 50 percent or more. 'l'he passa~ of 

Jhe HHCI\, nnd Hs oon;ldemtion by Congress ever nenrly a c'inrury, demonstrates' CongresS's 

view that the wc1f~rc Df'tltesB indigenous peop]!i is in pnrt u.fede.ra\ responslbj]\ty, 

Since its creation, .Congress has oonfinuoosly octed on the_Hawalian Homes Commission 

Act. When Hawai'i was udmitted in!O the UniQn as a Stote In 1959, n collditlon of admission was that the S!.Jte of Hnwal'i ;tdopt. the HHCA as pa't of'its constitution ~nd continue to adminisfer 

the lnw. TJ\e U11ited Slates retained the respomib1lity Of providing t:onsent to lillY cllan~es llll!dc 

to lhe ffi-ICA by the Hawai'.iStatetegislllt.ure th~t could alter the cluss efbcncficiarics Dr c~rtain 

trmt flll1ds. k; tlic IDiwni'i Stnrc_LI.'gig]ature made changes to the HHCA, Congl'cSs continued 10 

pmvide consent lo lhose ilm\\!!dmenls. In 1996, -~fler decades of cxtucssing cOWlent to chan~ 

millie by the Hnw_ai'i St_nte. Legislature, Cangrcss pns~~d t~e Hawaiinn Home L:mds- Recovery A~t (HHLRA}. Th!! HHLR'A set Jhe puromctcrn [or =tain Scttlcm~lllli owed to tf.e Sute of 

Hawai'i by !hJ: Uuircd State.!; ~s well as how amcndruents made to 1hc llliCA by the Hnwlli'i 

Stare Legis)aiu:re would be handled, ln 2000, Congress nmendcd NAHASDA to create n Title 

VIII, ¢0Jlipriscd or both the Nilti.vc Ifuwtt.ii:m Housing 13lD~k Grnnt, to. nssist the State ofJJawai'i 

in meeting the needs of HHCA Jx;neficinrtes, nnd the. I84A NatiVe Hnwniian Home Loon 

Guru;nntee program, wltich provided ao:c•ss to capitnl that hild. prevkmsly been dlffloull for 

le~sees to oblnin, 

'rha~ the NHH'BG' and 1E4Apr0J.rram w= includ'cdin NAHASDA is no aL:Cident. Tbey 

represent Cong'ressiow\ action to supprxt the Nntive·B'awaihm oolllll1llnily which, like American 

lndi;:rru; and Alaska Natives, continues 'lo lag Jehind our non-il)digcnous poore in terms of 

~oeioeoonomia indicnmr.<. According to the 2010 Ceit!)US, Native Hnwnilonsmnl."e up ne:rrly on~­

quartcr ofHawai'i'S population, Almost !I pcn:ml oi Native Hawaiians in Hawai'i live below 

the poverty level, cQmp:!i'ed to 1 percent statewide-. I-Iousin.g costs ill Hawaf'i arc the highcsr in 

the nafion, with th,; medinn price fat: n single-family home on o•_ahu, the smte's most populon~ 

island, hovering .at $.720,000 in 2016. In camparison, a.ccording tD the Ce!lSus Burcan, Ute 

mtdiDn cost of a .home nati01_1~fde· Is roUghlY. $300;000. Ilawill'i's homeless population is iili;o on 
114 


613b3.eps

lht- r}se, am!. som~ estl_mntcs -nrguc that th~ Native HawuiiruJ cwmuunlt}' make,> up a signiflcan~_ 

percentage of-the state's homeless fmllviduals and: fnroi.Jleo. 

lbese facts: bear out in- Jbe housing n~ed!; of'the Hnwl\ii:m p~ulil.tion. Actord:ing 'to lhe 

D~paranent of ROUsing and Urbnn Dcve!opmenl, relying on the 201.0 Census: "27.2 percent of 

native Hawaiian (ori>lhm' Padfiu bill~t!L7) houscliolds in tile State of Hnwai'i arc 6\'crerowded, 

co.rop!)l'ed to ~-:'i perc~ntoft~ll house]lol(ls·in Hawrri'i," Further: 

"Si;>:ty-cight percenf of low"lneo~e nn(ive Hawaiian hwse:ho!ds e](peritm~e some 

kind ·at housing problem Such as afford~bllify, _overcrowding, 81l1lclural quality, 

availability. or sorile COmbination of th~se'·pmblel11ll. FOr very loW-income native 

H.1waililn household~ (n<:>t ex<::e«ting 5Q pmenl of ru:e~. median .income), '!ho 

ueeds are more severe, with 75 v~rccnt ofhau5ehol~s in-this eateg_ory facing oome. 

kind ofhou;;ln,g" probli=." 

The Nnti.ve HilV.'Uiluu HotJSin_g Block Grant (NHHBG) wa.• created to ,Wre~~s these 

issues. First, the program p.rovldes. funding for housing llevelop.menL "Tile HHCA clearly 

delincatc;d whi"h )~nd" would !:& set aside as Jiawaiian Home Lands, and in a story .1imil~r to 

tbat lived by Alaska Natives nud American Jndi~ns, they were gen~raUy remote, ~rid, and 

difficult to ncvclt~p. Most lands -musl 00 oleared of fore:;t and leveled. Roatls ~nd other 

infrastructure mQ~t .be boUt be:fpre tbe ac"tua.l p.rocess of puuiug up h11rne.~ crnt begin. Providin£ 

the Depaltltlont of Hawaiian Home Lands with funding to support IDe development -ofhouslng 

h!!s hclpOO ·huodrcds tJf Hawaiian Home.~ Mneficim'ies. Beyond thi:s, NHHBG money has also 

gooe to liousiui coons cling programs.tbnl huv.; assi_slcd over 1,000 Hawaiians who may not have 

t~thcrwise qualified fGra mortsagE~ or olhCI" frnarwing to purchaSe thcir homes. 

11JC L84A Nntiuc l1awaiian Housing LOJln Guarantt:~ Progmm has as~i~Lcd .numcmu~ 

benefu:iru-ies in at:ccs~ing needed oopital fur purclu: .. ~ing,-n:finrnJcing, nhd rehaWlitating homes. 

Agai11, in :a.stgry f~mili~r to our American Indian and Alaska Native brethren, natiVe Hnwaiian; 

living on F;aw(!iinn Ifome Lands bnvc tradlticnally had difficulty a~~esslng capital. Beamoo 

Hawallnn Home Land~ are leMed tltlots thru:· cannot be cucwnbered or othenvise ·used as 

ca!Iqtt:r!il, treditional lenders were reluctant 10 pt(widc loanS tO Hawaiian Homes behefioiaties. 

The IS!IA program offer~ knd_ers c guaranttc in the case of default, providing thosro: Hawaiilllls 

mOJst in nCCtl wlth actcs"S to more-traditional mortgnges. 

The !'!ffilBG ®d 184A progrnms,ur~ thol\glltful progmms creaaed 'by Congress to assist 

the Sl!lte.ofHl!waf'i in ealrying outtbe-ruponslbllities o(.admlnismring n pror:rrun Utat.Congress 

created. They b.:tve_provided Hnwaiilm Homes beneficiaries, wiiether currently rcliding on Home 

L~nds or wailing fora J'ea;e, wii:h the_opport).m.lt.y to realize one of the greatest American dreams 

- home_ownen;hip. This i~·an especially poignant hPpe for Native Hawaiians, Who have too of(en 

been pric~d out of thil housing market and [On::ed to leuvc our :ancc::stral home. NHHBG fun& 

hay;:. cre~ied_oew Hnwnli(lll Homes ·C~Jmm\.ll,lides, supported' innovative WO)'ll!O se<:ure homes 

includ-itlg se\f~hclp housing, nod provided the kind of housing C<lnnscling that prevents 

foteclosure Md debt. Througb the 184A progmm, numerous· lcss~~s have !Jcen able to secure 

lonn.s they ha\!e u·aditioually .stroggled. with due !o t!\c nature of Hawaiian Home Lands; 

rehabllil<lte severely dilapidated homes~aud find some u:curicy through refina:noing, 
115 


613b4.eps

The. need for th~e prpgram& is ~lear, Yet, we often hear from oppon~nls that they may 

not be. npprbpriare because:. they are urace. ba5cdu pro,grams. This is an odious ~nd _crrnn<ious 

Rrgument that OHA vrould 111::e to addre~s. The Native Hawaii!ln community "is the indigenous 

CO!l;lrnunity _of the Huwuii<m [\l;Chipelago, V!hi~ll now makes. up the StJte of Haw;li'i. Oar 

nncestbrs were those inhabiti.n,g -the islrlndS when Briti~h e;>;plorer Cnptain James Cook first 

''discoVered" whu'l he- narn~d tbe San·dwich hbiuds. By the time CUptain Cook arrived in 

Hawai'i, the )>~n~ka m;!Oli, o~eof-scv'<fl'l names for oorllomrnunity, had reside{i in Hawai'i fur n 

rnillcnnia. Ourcn:lltion 8torics conVey that these:- islands are·tlie elder siblings of our people, and 

that H.'\WUiinn~ nnd Hnwni'l have tleeil to_geth~r from thB bBginning. · -

Our 1111e<:stral goi'¢J:WU1Ce StrllCIU!'i: ?aried from istnnd m ls.L."\\ld bnt shnred similar trait~; 

ch.iefs, or ali'i, ruled scp~rnll'.]and <livisil)ns_from·mQkll, or cnfuu islands, \a ahupua'a, districts 

on eUdLfiland whieh ran fr91n mou.ntai_n to sea. The m;tka'ainana, commoners nnd citlzenr:y, 

Wlltklld the land and sea ITt a Comniuo~r structure. This (ih~ng~d iu l-810,. wh"n ~[t~r a l"rtgthy 

~b:Uggle, Kam~hameha the Great, whose ·birtlt we recently haoared in tlte ·hnlls- of the U.S. 

CaJ?ital,- at tl.le siatc Capitol .in -Hr1.wai'i, and at liis 'birth pl~ce on Ha.wal'i Island, trnited !he 

Hm>.'<liimt Jslands into one kingdom. While the kinl:dom itllow~o:l dtizensltip to all people, our 

!homm:hs were llll_.descen(j"ants ofKa_mellllllleha-1. Our governance s"tructures changed in !YIX' but 

miliutalned pC!Iitical iotluence and aulhori~y over the Hawuliftn community. 

~awai'i rema.in.ed a kingdom \J,ntll 18~3, when our last ~vereign monarch, Queen 

Lili'nokahuti, w.as. overthrown by a·provisioo111 ,government with strong lies to the United StateS. 

Jn li'>9IS, th~ R<:pobli~ ofJrawai'i wils iinnext:d by tlri:: Uhiteil Staks. Despite this, however, the 

"HnWuililll people CDll_linued t!) exp!(!~~ an<~·ctemonslrnte communal ties .and political organization. 

We fo"rmed Qllf.o.wl! party, to stand in ~:cmtl:~st to iheDemo~rnt~ nnd Republicru1s !ilected to our 

Territorial Legislature. We sffit lfawtillan -delegates, first Roberr Wikox, ~ N~tivc Hawa\ian 

descended from our clii!lfS, thcn.Prl~~;e-Kfihiq, to l'l,lpm_sent the Territory ofHawni'i in Congress, 

Soni.e· bthtr flm;hpoirtt· e;wmp!es in recoot Haw~iian histor_y demonstrate that we have 

mairituinad our C(ll!ectiv~ cultusal tics; working to stop the bomlllng of:Kaho'oluwe, an cl'fo;t led 

by Nutive Hawaiians til protect a ~acred island; With the aSsiStance of other Pacific peoples 

croating the Polynesian Vllyaging Society,_ which dcmo.nsb:ated that HaWiliilllls could :md did 

navigate the P:acific Oceal). withol!t the I,!Se-of modern, Ellropeill1-tecllnology; the resJ,Ora.tion of 

the_ Unwniiao lM!!Jlate. which had nearly tiied out; ill.,_l9'18 Hawai'i Collstimtional Couycntion 

wltlch l~d to the creation of the Office" Of Hawaiian Aff.U.r.'<. We cuntinuc lo exiSt liS ll distind 

cotllliQlnity, as we have since time l.!ume1110rinL 

COf!Yes!i has. repeatedly rccogp.il;cd and affu:med nl)'! only the United Strltes' relatioruhlp 

[(] the Native I:Iaw~ii~!l -com!IUloity Out how that reffitio.c.ship is akin· to the !~!lalionship lh<! 

United State"s has with Ala~ka N"ati"""-~IJd·Amcric:nn JndiaiLS.ln short, Native Hawaiian.-lire M 

indigenciu~ corolllU1lity·wtth which the United States has a unique, specta:J trusr relalio~ship. 11JC 

Native Hn\vnijnn houSing program! ootlined in this testimony are modd~d 11fu:r the. In{lian 

-·Housiog II lock Gt:ant a!)d the 184 Jmlian Hom~ Lo~n Guarant"c pro,gnnn becaust:, not in spiw, of 

!IIi!; fuel. 

As this Commiuee is Slr\lctur.-:d to· ctmsid_cr polici~:s thlll uffcct Alaslm Native, Junerlcan 

lndimt, ahd Native Hawaiian Corilmunities, we Would like to resmte·our original _premise for tbe 
116 

PREPARED STATEMENT OF ROBIN PUANANI DANNER, CHAIRMAN, SOVEREIGN

COUNCILS OF THE HAWAIIAN HOMELAND ASSEMBLY (SCHHA) 


613b5.eps 613c1.eps
117 


613c2.eps

In 1959, our trust lands under the HHCA were directed by 11J,eCongn:ss lhrouglt theHawnii Sl:rt:ehood 

_ACJ, to bc-admiuistcn:d by ~w State_of.}lawaii, with fcd_~ral ovcrai]llt. Ag n result, the Srnte of Hawaii lws 

bi:c:ri delegntbd administratiVe-· _functions to i!llplew<;nt the 1-U·ICA with.omr~lght ]>y tho fi:denr' 

Dcy~artment oflriterior, !llld.~~Naiiv~)lC{)jll\'(1-ill HawnH, we engage "l'lltll both our State and Fe-deral 

govemml!hts "" issues-involvh:lg the Hf!CA, to fulfillitsc purpose and intent. 

In 1995, the Congr(!ss enad<lii the H~iou Ii_QmeL~ IW::overy Ac~ whith settled land~1ost frownsc 

in Qur.larul ttust·Jbr a spccifrud"period of time, butil: olso reaffirmed the role of the federal government in 

its. direct trus.t rel~liOilshlp !o liiiCA eligible na_tive trawuiiuns, and 'further defin~d ril'spODliible parties 

within the federal Department nfintrnior to luad t:hc ovcrnll federal govemmenttrust rel.!ltionship. 

In 1!196., the Congress enacted the Natfve Amerk~n tlousingAs>i5lauce anrl SJlffDcterminntion Act 

(NAHASDA), and four ye<lis 4Jtt:r:in20DO.-~le C011gwss added tftlc'Vill to propmly inolndeHHCA 

eligible ndtive Ha.waHuns :md ourtnmtlunds to-be 0"1! (lar 'vith Amorleen Indians and Aluska jl)utive~. 

The Sringint: {J.mful ]!11/laliJII'..• jQr IndiQn L<md D~opment (BUIILD) Acr of20l7 fu<':uSl:H on 

NAHASDA, addressing ~~:authorhation, sln;:umlined environmental M~~ssment processes, technical 

.as!'iis~'l" resourc~> and leveragingaull)ority. 

S, liZ75BUOLD A~t Comm~nt~ &Reeo"rrmiendulfuns 

Wo.: maltalo ScnQtorHoeve'n ·for-tk intr<Jduntion ors. 1275' to prlmarlly "'authorize NAHASDA. We 

offcr'tM fui!o-wing ~mments: 

I, In dude T!Ue vm. Wc-.ll<Jmmcut tbut Title VlUofN:AHASDA, sp~cific~lly fir. !he tn1st 

land!l ~slljb!ishod fur HHCA c\igi&lo nat<~ Hawaiians byColit:rcss i'n 1!.121, which were 

included in 'NAHASDA in2000, ~llould be included inS. 127$. 

1l1c emiss.ion ofTitl~ Vl!l would debililate the efforts of our -federal government, state 

govom1nent, sdf-govemii.Ig:hom~ead nssadatiens. nod the Homestead Housing A11thority to 

v"(jdi"<;So ~ever~ homel~sness,·and lnoJ.:: ofnffordnble housing in Hawaii nod more !!J>Ccifically, 

oo.thcl!HCA lJU~t l~qd:;. ~p'addilion,thc~missfon ofTi_tle VII1 undccruines the ~bility IU. 

fu1fi11 thep\lqm&e.s aftbe HHCA, enucted nearly!OOyeai"s a~o. 

Trust lands are unique, as. is lh<Jit\Og-esUJblisltcd trust relationship wfth Americ3n Indians, 

Alaska.Nativepm(j Nnth'" H:nvailans, as w11 know lhe memb'en of !he committee. ~rc-a ware 

from y.our-own cxpcricnccs in your home sl!tte>; Where both exisl 

Jt il; impcra)ive-that Title Vll[ be in"ludcd in the BUJ!LD Act:-of20l7. 

2.. $elfDciermlnation. we con:iment on improYlmlllllls Iequested to "flUe VIII U!ron_gh the 

BU!lLD Actof201?, to be!~r reflect the Self Determination goals ofNAHASDA. that truly 

_bring us [:.fill iuilialivesfor land d~vcloprn~nt on our trust land.\. Afi"Jmnrethan 15 years of 

el-;periencc w.itl0'1ARASDA, lh~ are 3 mnjor imwovcmc~ls that we offerta improve on 

rileeling !hc:sflf.detetmination goals intendetl hy the Coogross and indeed the words 'sclf- detcimi:n~timJ"' in tho title ac:ronym ofthe NAifASDA lnW: 

a. On or Nur -Adl:llo th~tligibility oflhcJIUD 1S4n lonn gna~antce progrnm under 

Tl!lp VIII, tho words "on or M~r'' ti:ust latrd,_ to e011b!erobu.;t engogemont by HIICA 

"Cl.iglblo n~liVD Hawaiians in !he ~en ltousiug marketplace with mortguge lcnd==d 

~welopor~, r~-gardless·ofwltelher a unit is lOCll!C'd on lnm 1and~, or -IJeilfhy nil fee-

.,;mpilll<md.:. 
118 


613c3.eps

This simple imptovement to NAHASDA 'ritle VJ'Jl, will cm:tgizc 1hc realest ate market 

to address th_e· lack ofhousing inv(:Jltory onlru:;llno-ds by creo.tingpurchase: 

trti11Silctions and oppO!jUnities off trust !a.nds. 

And finally, tl1ls1mprovemeot Q_riQg~ p~rity to the (rust lands in Haweii, with trust 

lands in·lndiau Country and Alaska where-the-'on vr ncmr' ilmguagc h~s been 

iii-lpTt::ll)eliled. 

b. Cons'ultation- Add a basic-requirement that any granfrecipicnt ofTitl~ VIII 

NAHAsDA funds,ls-m~nd~tOO to cot)dnc: consultltion will:i bomEl!ltead associations 

~Dd HFiCA'cligiblc.tmlive H:l~·ailllllS before BUD ~!!'approve annual Ho~ing_ Plans 

usingNAHASDA fillldiug. 

This il);lprovcm~mt will c;us\l!e thai_NAl!ASDA 1'itle-VUI .funds benefi:t '!Torn lhe direct 

knowlcd,!!c ~ml expertise ofJQcally go vented homestead associations in every region nf 

oilr land trust-, CFJ.Cb ofwhieb art unlqu~,just as iOCividualtriba:L areas are unique. 

t. GruntRC~ipient-Rt::p\aD;:lbeStute ofHuwuii U:;-the NAHASDA Tit!!!: VITI grant 

recipient, with the lp~illy cCllnlra1led and gov~medHomcslcitdHoll:ling AuU10rity. to 

bring p·arity with th~ more than2.00 Tribal and Nath•e nonprofit Housi.ng.Authr.rities 

uoross tl;le country. Hawl'ii.lls tbe only rr.cation in the country where NAHASDA funds 

ara direcled to a s~ate_governm~t, irn;tead of a housing authority governed by tb~ 

Native people themselyes. 

Tbis Improvement is tim~ly, given the incredible C-lpac:ity developed over the fi!St 2 

decade.~ 11)' bomestead associations to implementlmst-land based economic and 

alioxdable lwu~ing proje'cts, In 2009, home-stead association elootfld leaders·from 

atross the state, convened to ineorponltc a.dcdieatcd bollicslead l.'Qillmunity 

de.volopmoot i!orpomtion nonprQfrt to be wholly dedicated to job crea,ttonand 

·ll_fford_abh.: 'hoy.sing. 

Today. simil~~t to hundu:d!l- oftdbal mld Indinn housing ~uthorltios receiving 

NA:HASDA funding, 'the Homc~'Je~d Hou~1ng Authority iS govemcd by a 5-p=n 

Board of Commissioners, with hQmestead leader3 serving from the iSland ofKuu~i. 

Mani; Oahu, Molo~i and_ Hawaii Island. Th~ ho11.~ing authority owns and operotos 

tnlll'~tplace proje~ts, a oortificd kitch~n and ·caft!, slllons and.retuil sput:e~. on 

'enterprise cen:ter, and OtJeretes businessincubatot programs. It has also·dcvcloptd 

affordable hou~ing on 'two islands,11nd is irrthe p,rocess of a 54-l!nit_rental prtljec'l on 

th~:.il!hiilcl W.O.dtu. 

This;improvement 1o Title Vffiis also timely, given the cllallenge!i.cxperi(!J]ccd by tllc 

currently 11amed giallt fu'cipient, the slnto-governm~nt age;JGy, to Rdequately~ efficiently 

and economini!Y, sp~nd (l.owni:-IAHASDA Title YDI h!nding to address tlie homeless 

'and affurdablellousingn~ed& ofHHCA eligible native H!iwDfiarut. 

The time has come fQr the trus!lands m1d fhc HHCA eligible native Huwaiiuus 

Congress. intended to irnpact-near1y 100 yMrs a _go with the cDactrn(!J]t of the HHCA, 

and 17" y!l;Jn:·ngo wil;h the emu;tmentofTitle VTIINAHASDA, lo rak;eon'thc 

respimsibHily and IICtivitie~·that ·embody the· go11ls of seif-d~terminction. 

The SCHHA fully supports the tramitlon of the re~pient Qf'Title VIII NAHASDA 

Junds to b~ on-pai- w~tlt over 200' lribal housin:g ~uthodtfes, from a state government 
119 


613c4.eps

ngene_y to theH'omeste.;~d HuusingAull!ority. Tllis JlCfll~ps, is the most imp~ctful 

a,spcct that the BUIIl..D Act pf2017 rould acoomplish an our trust lauds to brlll$U~efu1 

lnnd devol<'l)lmen\ to OW' hu-melauds. 

3~ Leverafine. We SDJlp_m1 section_1 of the B_UIILD·Act that au\horilles NAHASDA fund~ tQ ~~ 

applic;l Wl rnnlcld\mdin~ with. otllerfcd~ml ornon-fudMJ! pro!il"~ms ~nd pn:;>jcds, and !'(:quest 

!bat lhis ex""lknllang,u~M be included in Tille Vni. 

4. Tl'nbilng & T.e!1lnlcn1Ji:ss1Strmce- Resources. T~~hnical as~istance and training is such an 

important~sp.:ct.ofany progmmming, WllllPJ'l'CCinte Olnt ih~ BUIJLD Act co.ntains u secti<m 

en 'this. We c!Jrnw'Onl fuat bc;1 pniCiicoe mtabli>ilied p•rticulotly for trustlond areo~. •hou1d 

.reqoire :l)ly prQViders of-sttch servi C'IS to hav~ a spe<;i!ic mi~ion and expertise in Nativ~ land~, 

N;ltivc peOples, and indeed, tbe b~~~ provitl= nte.otganizationS-lhatare governed by Natives 

tMm!«!IVCS with nn ncutc·undotslllnding eoffederal unO: I~<~lio~~<Jl In~ian policies. C~p•cily in 11 

~ll\3je~tmattenucb as houliing:llftbe useoftax credits for Cl:alflple, t:an many time=; be 

irrelevnot, if tliere is no. expertise iD Indian .his lucy, Indian lands, Iudiah n]Jpmnches to 

nho.U-..ngc;, and the praelical iljipli<iation n[lndian law. 

Fedeml rr-ngram for- Native. Peuples Som~ cnga$Cd in n\lliOllal ctm-vcnmlinns-on Jndlatl ond Native publi()po\iey have opined tllat Indian 

Housing, including Native.H~waiian h~nsingprogr~ms ~RY he ''race-based". Honom'blc memb&s, -your 

o:brnmittee is. wet! vet.ed o:n tile •tondiug'ofNativc p~opl~• in ilii~ country, and tlic.)ll<m•rypowors of1hc 

U.S. Ccmgn::~s tc address thenc;::d.~ of America's Indigcnous peopJes. 

Arncricrro Jnt!iillls 1ndig<elious !{l!he-48 strJ\es, AlasKa Natives indigenous to fue 49111 awe, and :indeed 

N~liw Hawaiians indigenous lo the so"' staW, are willlout quGstioo, Amerien's Judig<=nous ~eo plcs, 

Spealt:lng'fortbb SCHHA, our-ttust·Jnnds an~ Jl"\!Pl•, defined under the 1921 HRCA, the 1959 :tf~waii 

Admissions Act, lhe:Jlt951-IHLR.o\. arid ofcOu:rsc lhe-2000 NAI'IASDA Tit Ia Vill, tkU,S. Congress lltlS 

"'[l"atedly m,.ffirmed ils \rus1.rdationihip wi£h us, enacting fed<m~l policy and progrants bnsed {Ill the 

UUlqUC po\iti~aJ rcJallo(\slJi]l. Witfi US, lll)d plher indigennw; population~ thai pruda!e uw- U,S. CWJ5tiltilioll, 

nnd not fl$ H l'f!CCOfjJCQple. As member~ Qf1he oomm!rtee know, Jhis is fundamsnl111 civics. 

Honorabl'emembe;s-, thank you for tho 9PPO!tunity to submit tesl.imQIIY on S.1275,_the BUIILD Act of" 

201?. PI=~ doil.ot hc:lilato to tOolac! nle.al BO!I-652-0140 oral •clr~a.associations@gn>ail.con> to 

provide nnyaddltion~llr\funnotion, 
120 

PREPARED STATEMENT OF HON. TROY ‘‘SCOTT’’ WESTON, PRESIDENT, OGLALA SIOUX

TRIBE


613d1.eps
121 


613d2.eps

The United States has tasked the illS with C!lllying oul the federal duty to provide 

health ~arc sen<i.ccs to olli' Tribe and others, but tht: TI-JS is fuiling ll.l this tusk. Our Pine 

Ridge Hospilal ils nut a fun~Lianing facilily capable of meeting even d1e basic hl;a).th care 

needs of our people, and the Centers for Medicare & Medicaid Services (CMS) bas 

n:pc!!tcdly found the fadlity deficient. The Sioux Sllll Hospital m:ur our reservation had its 

cmr:rgency room shut down la:.t year. Meanwhile, our citizens face infant mortality, obesity, 

dillhetes, und hewtdisease in staggering proportions; nnd the average life expectnnoy on our 

Reservation is only 50. TI1is is uuacceptable. 

What is more, these problems are not new. !n 2003, the U.S. Commission on Civil 

Rights shined a light 011 Indian. CoWltry'S unmet heald1 Deeds an.d ronny of the problems 

fucing IHS, such us difficulty recruiting and training emplo~·ees.2 In 2010, this Committee 

held a hearing exploring the urgent need to reform IHS in the Creal Plains Area, prompted 

by years of complaints of mismanagement and substandard care. The hearing followed up 

on u formal investigntion of the rns Arefl, which resulted in a report by then-Committee 

Chair Byron Dorgan confirming and documenting the deplorable condition of the Area's 

h~Wth care servic~:> tu lndiWJ3.3 Nearly two years have passed since the W'IIlDebago 

Hospital in our Great Plains Aree.lost its certification-the first of our Area hospitals to do 

so. Nevertheless, years pass while our uibal members continue to suffer from shamefully 

inadequate IHS services, gross mismanagement, and u nearly complete lack oftranspareney. 

We tllank the Commillee for its aUentiou to the grave situation our Tribe and others 

face. It is time fur the United St11teS to fulfill this importwlt treaty and trust obligmion. 

Employee Rr!cntilment, Retention, Training, A~corm!nbility a11d Termination 

We strongly supportS. 1250's provisions to address IHS staffing challenges. As we have 

previously testified, insufficient staffing is a serious problem impacting both access to and 

quality of care for the Great Plains Area. The bill's loan repayment program and its 

authorization of competitive pay scales are critical to recruiting qualified professionals to 

our region. We also appreciate the bill's attempt to address the need for housing assistance 

by providing relocation assistance and housing vouchers. However, on our Reservation, 

housing vouchers !!lone are insufficient to address this significant recruitment challenge 

because we lack adequate housing infrastrucrure near our hospital and clinic facilities. Our 

en\in: RI:SeiVl!tion is presently in a housing crisis, and we desperately need assistance 

developing housing infrastructure for bo.spital and dinic staff. 

Om Tribe also supports the bill's efforts to increase the quality and accountability of!HS 

stnff. We support the medical crcdcntialing system the bill would authorize and its slllndarOO 

1 A Quiet Crisis: Federal FWldingand Unnoet Needs in Indian Country, U.S. Commission on Chi\ Ril,>hts (July 

2003), 

'ln Critical Condition: Tlle Urgent Need lo Rerorm t~e lndien Health Service·~ Aberdeen Area, Report of 

Cbainnan Byron L. Dorgan to the Commiru:ecm Indian AIThir5, \11th Cong. (Q<,c. 28, 2010). 
122 


613d3.eps

to improve timeliness of care. The bill would also expand requirements for tribal culrure 

and history training. lbis is a step Utat is desperately needed, and we encoUfllge Congress 

to ensure that there are penalties for non-participation in the f'J111Ual training and that training 

materials are developed in consultation with the particular tribes served. We !l]so request 

that this provision be exp11nded to apply to all IHS employees, not just ones with regular 

patientcorrtact, The knowledge and cultural sensitivity of employees at all levels of the II-IS 

affects the agency's relationship with our Tribe and the way it fulfills, or fails to fulfil, its 

treaty and trust obligations. 

We also welcome the Inspector General report required by Section 304, which would 

monitmqualityofcare. We have repea1edly testified on the shockingly substandard quality 

of care in the Great Plains Area. Section 304 would provide much-needed data regarding 

the quality of care and require an audit of IHS reporting systems. Our Tribe also supports 

oth~r reporl.l! requir~d by the bill, including GAO and HHS reports regardins housing and 

~111ffing needs. 

Gcncrclly, vrc support S. 1250's intention to improv~ hiring practices !llld speed up 

demotioru and tenninutions when necessary. In particular, we have previously testified that 

poor management practices and the "recycling" m shuffling of problem employees p~rsists 

in the Great Plains Area, as does the USt;: of admini5trativc lcav~ in lieu of more appropriate 

sanction:l. However, we believeS. 1250 m:eds to require tribal cnnsnltation regarding key 

employment decisions. Ser.:tion 105 provides that the Secretary of Health and Human 

Services (HHS) would be required to notify Tribes of the appointment, hiring, promotion, 

transfer, or reassignment of a Senior Executive position or manager at llil Area Office or 

Service Unit. Similorly, Section 106 would allow the Secretary to remove or transfer an 

employee based on performance or misconduct, but lhc Secretary would only be required 

to notifY Congress, not the Tribes. These employmeut decisions greatly effect Ute quality 

of our care, and we must: have a voice in the decisio.n-makh!g process. Additionally, IHS 

employees should be held accountable not only to th~ agency but also to the Tribe nnd our 

members. 

Section 1 09 of the bill provides a staffing demonstration project. which we- do not support 

in its current fonn. As frequently happens, our Tribe's grave statistics and dispru.i.ties fuel 

the creation of a demonstration project and then we are excluded from participation because 

we lnck resour~cs or infrastructure. The staffing demonstration project in the current bill, 

for instance, require!! thnt a Tribe have contributed substantial ftmds to construct a health 

fucility and be located in a Medicaid cxpllllfiion state. Tribes like ours that are in the poorest: 

end most vulnero.ble position3 would not benefit from such a d~monstration. The Great 

Pbins is in cdsis as we speak, Wld all necessary resources should he going to addressing 

this crisis. Further, theexplanatioo for staffing shortages at our hospitnls and clinics are not 

complic-ated-qualified professionals do Dot Wllllt to live in remote areas without adequate 

infrll:;tructure, housing, schools, and roads. Further, they do not want to receive inadequate 

pay, hnve alack lhc resources they need to do their jobs, and be subject to dysfunctional 
123 

PREPARED STATEMENT OF HON. BRIAN CLADOOSBY, CHAIRMAN, SWINOMISH INDIAN

TRIBAL COMMUNITY

On behalf of the Swinomish Indian Tribal Community (‘‘Tribe’’), thank you for 

convening the June 13, 2017, hearing on S.1250, the Restoring Accountability in the 

Indian Health Service Act. The legislation would amend the Indian Health Care Improvement Act in several ways and would increase transparency and accountability 

at the Indian Health Service (IHS), streamline the hiring of medical staff, provide 

incentives for doctors and nurses to stay on the job, and protect whistle-blowers who 

report violations of health and safety rules. Of course, all of these are laudable goals 

designed to address the many disparities in medical and dental health in Indian 

Country. 

During the hearing, one of the non-tribal witnesses provided testimony on Section 

102 of the legislation. That section would standardize and streamline credentialing 

at IHS facilities. The Tribe would like to provide additional context to ensure that 

the Committee understands that while streamlining credentialing is important, volunteers are not a long term solution to health care needs in Indian country. 

The Swinomish Tribe and I have a particular passion for improving oral health 

and oral health care in Indian Country. Oral disease is the most widespread chronic 


613d4.eps
124 

disease, despite being highly preventable and manageable. Oral health is essential 

to overall health and well-being at every stage of life. Like any other infection or 

disease, oral disease must be managed. What is needed to best do this is a workforce of skilled and culturally-competent oral health providers who have a long-term 

and consistent presence in tribal communities. 

Dental professionals have recognized the unmet need for oral health providers in 

Indian Country, and have proposed volunteer or other short term providers as a solution. We appreciate the commitment of volunteers in Indian Country. But this is 

not an effective way to manage any infection or disease, and it has not been successful in tribal communities. Instead of looking to volunteers providing surgical or 

other short-term solutions, tribes want to replicate long-term strategies that follow 

a more medical model for oral disease management and utilize more members of 

the dental team. 

In short, we need to think about oral disease and health care differently, and that 

is just what we have done at Swinomish. We looked north to Alaska, where for ten 

years Dental Health Aide Therapists have been an integral party of the dental 

team, providing long-term, consistent and culturally-competent care to remote Alaska Native populations. The Swinomish Tribe established its own program for integrating Dental Therapists into our Dental Clinic team, where all dental providers 

are licensed and regulated under Swinomish Tribal law. The State of Washington 

recently passed legislation explicitly recognizing as practitioners Dental Health Aide 

Therapists who are licensed under Tribal law and practicing in tribal communities. 

For more than a year the Dental Therapist at our Swinomish Dental Clinic has 

been successfully working as a member of our oral health team. Just like the midlevel providers in our medical clinic, expanding the dental team with Dental Health 

Aide Therapists and more efficiently utilizing all members of the dental team has 

shown strong results in Alaska and here at Swinomish for improving oral health. 

Swinomish takes an evidence-based approach to health care. Researchers from the 

University of Washington presented a paper at the National Oral Health Conference 

this year that shows that over a 10 year period, children and adults living in villages in Alaska with Dental Health Aide Therapists had fewer extractions and more 

access to preventive care than villages without Dental Health Aide Therapists. 

There has been a nearly 300 percent decrease in extractions of the first four front 

teeth for children under age three in villages with Dental Health Aide Therapists. 

That is nearly 300 percent more happy and healthy smiles—and that is real 

progress. 

This demonstrated success is the result of consistent, high quality, community 

based oral health care provided by culturally competent staff. It was just this success that prompted the Swinomish Tribe to license and hire Dental Therapists as 

part of its team. 

We urge the Committee in its work on this important legislation to be cognizant 

of the need to provide sustained health care for Indian country, including oral 

health. Volunteers are welcome and standardizing credentialing will make it more 

efficient to deploy them. Volunteers, however, will never be a long term solution to 

Indian country’s unmet health care needs. 

PREPARED STATEMENT OF GUNDERSEN HEALTH SYSTEM

On behalf of Gundersen Health System we are writing to provide testimony in response to the committee hearing held June 13th to express support for Senate Bill 

1250, (and companion bill H.R. 2662), the Restoring Accountability in the Indian 

Health Service Act. Specifically, we are supportive of Section 102, relating to medical 

credentialing systems, and Section 103 applying liability protections for professional 

volunteers. 

Gundersen Health System is an integrated health system located in nineteen 

counties throughout western Wisconsin, southeastern Minnesota and northeastern 

Iowa. Our system includes a primary hospital in La Crosse, four critical access hospitals and over 50 clinics throughout the region. With over 7,000 employees, we are 

the largest employer in the area. As a Healthgrades Top 50 hospital in overall care, 

many clinical specialty services, and patient experience, we are committed to supporting public policy that helps to enrich every life through improved community 

health, outstanding experience of care, and decreased cost burden. 

Gundersen Health System is firmly committed to providing services to improve 

the health and wellbeing of communities both near and far. Gundersen is proud to 

have established the Global Partners program that has provided needed healthcare 

services to critical areas both in U.S. and throughout the world. Since 2008 

Gundersen Health System has collaborated with the Pine Ridge Service Unit of the 

125 

Indian Health Service in South Dakota to provide healthcare services to residents 

on the reservation. Throughout this partnership, Gundersen Global Partners has 

continuously sent volunteer physicians, nurses, and staff for week-long periods at 

IHS clinics on the reservation, providing clinical, diagnostic, and even surgical services. The volunteers at Gundersen have logged thousands of hours of complimentary 

services for members of the Oglala Sioux Tribe, and is proud to continue in this 

partnership. 

However, administrative barriers have prevented teams from volunteering on a 

consistent basis. Procedures for credentialing of healthcare providers for the Indian 

Health Service have become challenging to meeting the needs of individuals and 

families at Pine Ridge. We are very pleased Section 102 establishes a uniform process for medical credentialing, including the consultation with existing services that 

would meet the guidelines of the Indian Health Services, and efficiently credential 

volunteer professionals. Removing unnecessary duplication, especially for volunteer 

healthcare providers and nurses would provide much needed relief and improve our 

existing partnership. 

In addition, we are supportive of liability protections provided in Section 103 of 

the legislation. We appreciate this provision that recognizes the volunteer efforts of 

our providers by deeming them public health service professionals while serving Indian Health Service individuals and families. 

On behalf of Gundersen Health System, and our Global Partners Program, we 

greatly appreciate the opportunity to provide comments on S. 1250, Restoring Accountability in the Indian Health Service Act. This bill would help address administrative barriers and improve our ability to provide services for those in need. We 

thank the Committee for holding this hearing and ask the Committee to advance 

the legislation forward. 

Please feel free to contact us with any questions or if you would like to learn more 

about Global Partners Program and partnership with the Pine Ridge Reservation. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. JON TESTER TO

DR. KEITH HARRIS

Question 1. The Blackfeet reservation is approximately 180 miles one way from 

the nearest VA facility. How is the VA ensuring homeless veterans of the Blackfeet 

reservation or any extremely rural tribe are receiving the required direct services 

under the program? 

Answer. The Department of Veterans Affairs (VA) is ensuring that Veterans enrolled in the Tribal Department of Housing and Urban Development-VA Supportive 

Housing (HUD–VASH) program are receiving the required direct services under the 

program. VA case managers are located in or near communities served by the tribe. 

Case managers coordinate and provide VA care, including psychosocial services, including mental health and substance use disorder care, and also connect Veterans 

to needed services that are available locally. VA also has technology capabilities enabling case managers to provide services remotely, augmenting the face to face services described above. 

VA case managers are also working collaboratively to ensure that the supportive 

services and resources are available to Veterans. Most HUD–VASH programs have 

sought licensed clinical social workers, who provide a wide range of clinical services 

directly to the Veteran, from skill building to substance use disorder treatment to 

psychotherapy, if needed and appropriate. On or near many reservations, VA has 

community-based outpatient clinics (CBOC) that can provide primary care, mental 

health, and substance use disorder assistance. VA also connects Veterans to local 

service providers for assistance that VA cannot provide, such as assistance with employment, food or other support. The Indian Health Service (IHS) within the Department of Health and Human Services, or a tribally operated health program, may 

also offer primary care and specialty services that can be provided locally. In circumstances in which VA medical center specialty care is needed, the VA case manager can assist in securing transportation for associated appointments. VA case 

managers also have connections with groups such as the Elks Club, Military Outreach USA, or Home Depot, who can provide furniture and other household items. 

Specific to the Blackfeet Nation, VA has a temporary case manager in place until 

a permanent case manager is hired. The case manager travels to the Blackfeet Nation monthly and is available to travel more frequently as needed. The current case 

manager ensures that Veterans are connected with the CBOC in Cut Bank, Montana, which provides primary care, mental health, and substance use disorders services. The case manager also ensures the Veterans are connected with the local IHS 

facility. Additionally, ‘‘Manpower,’’ a local community center,is located nearby and 

126 

offers a range of co-located social services, including employment services. The Manpower community center also provides an opportunity for the case manager to educate key stakeholders on VA services, how to coordinate referrals, and promote service utilization between VA and the service providers. 

Question 2. How does the VA identify or locate eligible veterans in areas with vast 

geographical challenges such as the Blackfeet Tribe of Montana, who are one of the 

10 largest tribes in the United States, and sit on a reservation of approximately oneand-a-half million acres in the remote northwestern part of Montana? 

Answer. VA has found success in identifying or locating eligible Veterans by ensuring that the tribal government is part of the solution. The tribal government and 

the tribal designated housing entity (TDHE), along with the case manager, are collaboratively working on recruitment for eligible Veteran participants. The tribe has 

a central role in referring Veterans, as they are most familiar with which Veteran 

members are homeless or at-risk of homelessness. As one example, to enhance the 

identification of eligible Veterans, the VA Portland Health Care System (HCS) Director and the VA Office of Tribal Government Relations Specialist met with the 

Warm Springs tribal government, and developed a collaborative approach that has 

resulted in a significant increase in referrals. 

VA case managers are working with the VA Public Relations staff and tribes to 

engage the tribes and other local media (such as: https:// 

cheyennearapahotribal.tribune.wordpress.com/2017/05/11/a-veterans-guide-to-thehud-vash-tribal-program-oklahoma-city-ok-va-health-care-system/ or http:// 

www.kfyrtv.com/content/news/Iraq-veteran-receives-new-home-thanks-to-HUD-VAhousing-grant-387033601.html) in marketing the program. The tribal government 

and TDHEs also directly refer Veterans to the VA case manager. 

VA case managers participate in various events hosted by the tribe and/or Tribal 

Veterans Service Officer. VA holds Homeless Veteran Stand Downs in tribal communities to meet and speak with Veterans who are homeless or at risk of homelessness. The HUD–VASH program office holds calls with the Tribal HUD–VASH case 

managers twice each month, at which innovative practices and successful engagement strategies are shared. As part of the joint training led by HUD and VA with 

the tribes and VA case managers, there have been modules focused on marketing 

and engagement strategies. Tribal entities and case managers worked together in 

these sessions to develop outreach and marketing strategies. 

Question 3. What has VA done to address these specific challenges since you wrote 

me that response letter? 

Answer. VA has been working on the noted challenges including: 

• recruiting qualified applicants who are able to work independently and have 

the required clinical skills 

• lack of available housing for case managers working on or near the reservations 

• lack of available office space for case managers 

• safety and work related challenges 

• transportation challenges 

• locating eligible Veterans 

• educating TDHEs on the implementation of the principles of Housing First, the 

required model of care for Tribal HUD–VASH 

• concerns expressed by tribes regarding program longevity 

In March, there were seven locations that did not have a VA case manager hired. 

Today, there are five locations, but of those, two have case managers expected to 

begin in August, and one is a recent vacancy after the case manager accepted another position. Additionally, the VA Montana Health Care System (HCS) has a temporary case manager assigned until a permanent case manager is hired. 

At this time, there are only two positions that remain difficult to fill, Blackfeet 

Nation in Montana and the Association of Village Council Presidents (AVCP) in 

Alaska. They both were approved for fiscal incentives, such as retention and relocation expenses. These positions have ongoing open announcements posted on USA 

Jobs. The case manager position for the Blackfeet Nation had two applicants, who 

interviewed on July 18, 2017, and a provisional offer was recently made to one of 

the candidates. While there is no housing available in Browning, case managers 

may live in Cut Bank or potentially in smaller communities or farmland areas close 

to the tribe. The AVCP position has several applicants and interviewing will be completed during the week of August 14, 2017. VA medical centers may elect to expand 

the range of disciplines to include Licensed Marriage and Family Therapists, LiVerDate Mar 15 2010 13:50 Nov 30, 2017 Jkt 027650 PO 00000 Frm 00130 Fmt 6601 Sfmt 6621 S:\DOCS\27650.TXT JACK
127 

censed Professional Counselors, Registered Nurses, Licensed Mental Health Counselors, and Licensed Master Social Workers in addition to the standard Licensed 

Clinical Social Workers, particularly in those remote or frontier locations where 

other services may be more limited. 

VA facilities have been working to ensure the implementation of Tribal HUD– 

VASH. Office space continues to be a challenge, but VA case managers are teleworking as needed. Additionally, they meet with Veterans in community locations 

and at the TDHE. Some case managers are working in space provided by the tribe. 

Case managers may travel to VA CBOC locations for meetings, for Veteran assistance, and to ensure Veterans’ documentation is submitted electronically. Black Hills 

VA HCS purchased cell phone boosters for their staff to ensure cell coverage 

throughout the reservation, and they also obtained four-wheel drive vehicles to account for terrain and weather. This information has been shared with other sites. 

VA is actively collaborating with tribes and tribal Veteran Service Organizations on 

outreach, the referral process, and marketing strategies to ensure that tribal members are aware of and informed about the Tribal HUD–VASH program. Notably, 

twenty tribes are now housing Veterans and two tribes have Veterans in case management who are actively seeking housing. While the limited stock of viable rental 

housing continues to be a concern; tribes are demonstrating creativity and flexibility 

to ensure that housing is available for the program. For example, tribes are housing 

Veterans in communities within their service area but off of the reservation, are 

electing to forgo funding for currently unoccupied Formula Current Assisted Stock 

(FCAS) under the Indian Housing Block Grant (IHBG) program, so that the Tribal 

HUD–VASH assistance can be used on that housing unit instead , and developing 

housing with tax credit programs. Tribes have also investigated potentially using 

Federal Emergency Management Agency trailers. The recent renewal funding provided by Congress in the budget for fiscal year 2017 demonstrates Federal commitment to the program, supporting tribes’ continuing investment in the Tribal HUD– 

VASH program. 

Question 4. Why has it generally been so difficult to hire case managers to provide 

wrap-around services to homeless Native American veterans that are receiving Tribal HUD–VASH vouchers? 

Answer. Case manager recruitment has been challenging in some locations, primarily due to the rural/frontier location of the tribe, affordable housing challenges 

for some staff considering a move to a location (such as in South Dakota with the 

Bakken oil and gas field), and in a few cases, tribal governance changes such as 

with Leech Lake, which elected a new tribal government; VA was asked by the 

tribe’s interim government to stand down hiring until the new government determined their interest in program participation. Delays in the hiring process have also 

been a contributing factor. 

The two positions that have been particularly challenging to fill are with the Alaska VA HCS associated with the AVCP TDHE, and the VA Montana HCS associated 

with the Blackfeet Nation. VA approved financial incentives to facilitate recruitment 

and retention, including fiscal relocation support for case managers for AVCP with 

the Alaska VA HCS and Blackfeet Nation with the VA Montana HCS. The VA medical centers also have options for broadening the pool of potential applicants. The 

Alaska VA HCS has opened recruitment to Licensed Marriage and Family Therapists and Licensed Master Social Workers, in addition to Licensed Clinical Social 

Workers. At this time, the Montana VA HCS has tentatively offered a position to 

a candidate, and the Alaska VA HCS is conducting interviews with applicants. 

As indicated earlier, VA has expanded the pool of clinical professions for case 

manager positions to help recruit qualified candidates. This expansion considers the 

degree of independent practice expected of the case manager. VA expects the clinical 

case manager to be able to provide clinically sound mental health and substance use 

services directly to Veterans, particularly when there are regional challenges to obtaining those services elsewhere. Case managers in this program treat Veterans 

with high mental health and substance use acuity. VA medical centers are responsible for ensuring that the scope of practice for each employee is appropriate for the 

population being served, which may require a particular education level, a specific 

number of years of experience, and/or a clinical license. 

Question 5. What are the other challenges that you have seen in implementing 

the Tribal HUD–VASH program, particularly to the extremely rural tribes such as 

the Blackfeet Tribe of Montana? What would you do to fix them? 

Answer. The greatest challenge VA has experienced with implementing the Tribal 

HUD–VASH program is the limited amount of housing stock. In Montana, more 

Veterans could be admitted to the Blackfeet Nation’s Tribal HUD–VASH program, 

but the case manager is waiting for housing to be built and pass the housing quality 

128 

standards inspections that must be completed before the units can be available. 

Some tribes are developing or rehabilitating housing, which similarly creates delay 

in placement. 

Zuni, Hopi, Tohono O’odham, Spokane, Osage and others allow Tribal HUD– 

VASH Veterans to live outside of the reservation due to the shortage of housing 

stock in their tribal communities. While the Tribal HUD–VASH program was specifically designed to serve American Indian and Alaska Native Veterans in their 

tribal communities, those sites that have been able to most expeditiously implement 

the program are those utilizing housing off of the reservation. The exception 

isYakama, which repurposed existing housing units from a different, previously terminated project. Tribes also report that the primary barrier is a lack of appropriately sized, decent, sanitary housing stock. 

Some tribes have had difficulty locating Veterans appropriate for the program. In 

response, a number of tribes have opened their tribal preference to allow any Native 

American Veteran who is a member of any tribe, living in their tribal area, to utilize 

the program; which has enhanced utilization of their grant resources. 

In areas where the tribe is fully committed to the program and a VA case manager is on staff, referrals have been steady and Veterans are being housed and are 

receiving services. Extensive marketing activities to recruit additional Veterans are 

also in place in these areas. There are Tribal HUD–VASH locations that have sufficient Veterans to completely utilize their grant: Oneida of Wisconsin, Cook Inlet, 

and Tohono O’odham. Additionally, Navajo, Zuni, Osage, Muscogee (Creek), Rosebud 

Sioux, and Lumbee are more than half-way to filling the units their grants support. 

Please see Attachment 1 for additional information. 

Question 6. How will you ensure that tribes and tribal entities are properly consulted about the implementation of the program? What will that consultation look 

like? 

Answer. VA and TDHEs have identified points of contact (POC) that meet and 

collaboratively discuss the program. VA case managers are encouraged to collaborate extensively with the tribes and TDHEs that they support. In some locations, 

the tribe has provided space for the case manager to work, which facilitates communication and relationship building, while demonstrating the partnership involved 

with program implementation. 

During initial implementation of the program, VA POCs interacted extensively 

with the tribe in program execution. There was an initial meeting to discuss implementation and the tribes were engaged in case manager recruitment. Specifically, 

tribes were consulted about ways to obtain a case manager. VA offered to develop 

a contract for case management or allow the tribe to request VA obtain a full time 

VA employee as the case manager. VA contracted with one tribe for case management. Some tribes were actively engaged in the hiring process and participated in 

the selection of the VA case manager. VA is committed to ensuring eligible tribal 

members or Native American candidates are selected, where possible, to further 

support collaboration and consultation. Currently, seven of the twenty case managers VA has hired have Native American ancestry, and of those, four are members 

of the tribe with whom they collaborate. One of the case managers that we expect 

to start work in August 2017 is also Native American and, while not a member of 

that tribe, is a descendant of the tribe. 

The earlier question regarding how the case managers are able to recruit eligible 

Veterans provides an example of consultative conversations with the tribes. VA 

worked with HUD to provide technical assistance and training for both the case 

managers and TDHEs, connecting them as a team to work on implementation. VA 

needs the tribal government and TDHE to not only help the case managers with 

marketing and referrals, but to also provide their wisdom and experience to help 

locate and engage Veterans through other local resources. VA continually looks for 

ways to engage, collaborate and consult with tribes on the program. 

Question 7. How does VA currently work with IHS? Can inter-agency collaboration over Tribal HUD–VASH be easily worked into existing agreements? 

Answer. VA currently collaborates with IHS in several regards, one of which is 

the 2010 Memorandum of Understanding between VA and IHS and pursuant to the 

VHA–IHS Reimbursement Agreement, under which VHA reimburses IHS for direct 

care services provided to eligible American Indian/Alaska Native Veterans at IHS 

facilities. Expanding our relationship with IHS would be beneficial to the Tribal 

HUD–VASH program and the Veterans and tribes that it serves. VA has an excellent working relationship with HUD and is confident that collaboration involving 

VA, IHS, and HUD would be beneficial and provide an opportunity for VA and IHS 

to assess the scope, capacity, and ability to collaborate at the specific Tribal HUD– 

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VASH locations. VA recommends that IHS be consulted to determine the ability to 

collaborate regarding Tribal HUD–VASH within existing agreements. 

Question 8. Once this bill requires them to help support Tribal HUD–VASH, how 

do you envision VA working with IHS to better provide supportive services to Native 

American veterans receiving Section 8 vouchers? 

Answer. As IHS has existing relationships with tribes, VA is confident that there 

is excellent potential for IHS and VA to collaborate. IHS has significant knowledge 

and experience understanding the cultural differences of each tribe, and would be 

a meaningful, collaborative partner for this program. VA had discussions with IHS 

that preceded the administration change that did not yield final conclusions. We believe that new discussions, with current leadership in both agencies, about how VA 

and IHS can collaborate and identify ways to work together in serving Veterans in 

Tribal HUD–VASH are needed. As appropriate, HUD should also be a part of these 

discussions. 

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RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. JON TESTER TO

HEIDI FRECHETTE

Question 1. The Blackfeet reservation is approximately 180 miles one way from 

the nearest VA facility. How is the VA ensuring homeless veterans of the Blackfeet 

reservation or any extremely rural tribe, are receiving the required direct services 

under the program? 


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131 

Answer. This question is best answered by VA. HUD has forwarded this question 

to VA and VA will respond under separate cover. 

Question 2. What are the other challenges (aside from long distance to the nearest 

VA facility) that you have seen in implementing the Tribal HUD–VASH program, 

particularly to the extremely rural tribes such as the Blackfeet Tribe of Montana? 

What would you do to fix them? 

Answer. The Tribal HUD–VASH pilot program was created to provide access to 

the HUD–VASH benefit for veterans who are Native American and homeless or atrisk of homelessness and living in or near Indian Country. When the Tribal HUD– 

VASH pilot program was designed and implemented, HUD essentially created a new 

program, administered by Indian Housing Block Grant recipients and operating primarily in a rural setting. This was accomplished by working closely with the tribes 

and VA to address challenges unique to rural and remote tribal communities. The 

two main challenges HUD and tribes have encountered in implementing and administering the pilot program are the lack of housing stock, and the length of time it 

can take to identify eligible veterans. 

Lack of Housing Stock 

One of the main challenges with implementing HUD–VASH in Indian Country is 

the lack of available housing stock in the tribal communities. Many Tribal HUD– 

VASH grantees house veterans in the community or in nearby locations; however, 

other Tribal HUD–VASH grantee tribes simply do not have available housing stock, 

or have veterans who do not want to move outside of their community to receive 

housing. 

When the Tribal HUD–VASH pilot program was being considered, it was contemplated that where there was not adequate housing stock, tribes would leverage 

funding for new units. However, only a handful of tribes are adding new units with 

their Tribal HUD–VASH funding. One reason for tribes’ reluctance to develop new 

units is that the program was established as a pilot program. Tribes are concerned 

that if they leverage HUD–VASH funding for new units, and then the program is 

discontinued, they would not be able to support the new units. 

As tribes face housing shortages, HUD has encouraged tribes to leverage the 

HUD–VASH rental subsidy to buy, rehab, or construct new units. HUD continues 

to disseminate best practices, troubleshoot impediments to progress, and provide 

training and technical assistance on bi-weekly calls, webinars, and as-needed to specific tribes in close coordination with HUD’s partners at the Department of Veterans 

Affairs. 

Tribes are also working with each other to house veterans, and are seeking opportunities to house veterans in nearby communities. 

Identifying Eligible Veterans 

HUD has found that in some communities, identifying homeless veterans is taking longer than expected. Tribal communities are typically ineligible for many of 

HUD’s homeless programs, are outside the homeless continuum of care operating 

areas, and often do not have homeless shelters, all of which can be a source for identifying veterans experiencing homelessness. Homelessness is typically less visible in 

tribal communities. Veterans experiencing homelessness live mainly with family or 

extended family in overcrowded housing, or ‘‘couch surf’’ among friends and relatives. Therefore, it can be difficult to locate and identify veterans who are homeless 

or at-risk of homelessness. Further, it takes time for the VA case manager to become known in the community, which is especially important since he or she will 

be going into people’s homes to locate and work with eligible veterans. 

HUD is working closely with tribes and VA to build a network of partners to assist in identifying veterans eligible for the HUD–VASH program, including working 

with tribal Veterans Departments, and encouraging known tribal veterans to help 

identify and recruit their fellow veterans who may be eligible. Potential beneficiaries 

may be more likely to seek out the program if a fellow tribal veteran serves as an 

intermediary between them and the VA case manager. HUD continues to share best 

practices with tribes on effective marketing and recruitment methods that other 

tribes have found successful. And finally, HUD and VA continue to find ways to engage the Indian Health Service to help identify Native veterans, because the IHS 

serves this population at its facilities in Indian Country. 

Question 3. How will you ensure that tribes and tribal entities are properly consulted about the implementation of the program? What will that consultation look 

like? 

The demonstration program was designed based on comments received from tribes 

in both regional and national consultation sessions, and through an open public 

comment period. HUD has a website dedicated to the program, has provided a series 

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of trainings, has sent ‘‘Dear Tribal Leader’’ letters to tribes with program information and to solicit feedback, and has issued program guidance and a list of ‘‘Frequently Asked Questions’’ that are responsive to tribal input to keep tribes abreast 

of the program and to solicit additional input. 

Currently, HUD staff directly coordinates with Tribal HUD–VASH points of contact (both the tribal contacts and the VA case managers) on no less than a bi-weekly 

basis. Tribes and TDHEs participated in HUD’s and VA’s face-to-face regional technical assistance trainings, which were open to questions and discussion amongst the 

participants, trainers and HUD and VA subject matter experts. HUD’s Area Offices 

of Native American Programs communicate this feedback to HUD Headquarters 

through written reports and meetings. HUD carefully considers this input from 

tribes and has adjusted its trainings, program guidance and implementation strategy based on tribal comments. 

HUD will continue with its existing level of tribal consultation by keeping tribes 

abreast of program changes, having a robust webpage with recorded trainings, and 

actively soliciting feedback from tribes on ways to improve and refine the program. 

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