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H.R. 5406, HELPING ENSURE 

ACCOUNTABILITY, LEADERSHIP, AND TRUST IN TRIBAL 

HEALTHCARE ACT, ‘‘HEALTTH 

ACT’’ 

LEGISLATIVE HEARING 

BEFORE THE

SUBCOMMITTEE ON INDIAN, INSULAR AND 

ALASKA NATIVE AFFAIRS 

OF THE

COMMITTEE ON NATURAL RESOURCES 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

Tuesday, July 12, 2016 

Serial No. 114–50 

Printed for the use of the Committee on Natural Resources 

( 

Available via the World Wide Web: http://www.fdsys.gov 

or 

Committee address: http://naturalresources.house.gov 

(II) 

COMMITTEE ON NATURAL RESOURCES 

ROB BISHOP, UT, Chairman 

RAU ́ L M. GRIJALVA, AZ, Ranking Democratic Member 

Don Young, AK 

Louie Gohmert, TX 

Doug Lamborn, CO 

Robert J. Wittman, VA 

John Fleming, LA 

Tom McClintock, CA 

Glenn Thompson, PA 

Cynthia M. Lummis, WY 

Dan Benishek, MI 

Jeff Duncan, SC 

Paul A. Gosar, AZ 

Rau ́l R. Labrador, ID 

Doug LaMalfa, CA 

Jeff Denham, CA 

Paul Cook, CA 

Bruce Westerman, AR 

Garret Graves, LA 

Dan Newhouse, WA 

Ryan K. Zinke, MT 

Jody B. Hice, GA 

Aumua Amata Coleman Radewagen, AS 

Thomas MacArthur, NJ 

Alexander X. Mooney, WV 

Cresent Hardy, NV 

Darin LaHood, IL 

Grace F. Napolitano, CA 

Madeleine Z. Bordallo, GU 

Jim Costa, CA 

Gregorio Kilili Camacho Sablan, CNMI 

Niki Tsongas, MA 

Pedro R. Pierluisi, PR 

Jared Huffman, CA 

Raul Ruiz, CA 

Alan S. Lowenthal, CA 

Matt Cartwright, PA 

Donald S. Beyer, Jr., VA 

Norma J. Torres, CA 

Debbie Dingell, MI 

Ruben Gallego, AZ 

Lois Capps, CA 

Jared Polis, CO 

Wm. Lacy Clay, MO 

Jason Knox, Chief of Staff 

Lisa Pittman, Chief Counsel 

David Watkins, Democratic Staff Director 

Sarah Lim, Democratic Chief Counsel 

SUBCOMMITTEE ON INDIAN, INSULAR AND ALASKA NATIVE AFFAIRS 

DON YOUNG, AK, Chairman 

RAUL RUIZ, CA, Ranking Democratic Member 

Dan Benishek, MI 

Paul A. Gosar, AZ 

Doug LaMalfa, CA 

Jeff Denham, CA 

Paul Cook, CA 

Aumua Amata Coleman Radewagen, AS 

Rob Bishop, UT, ex officio 

Madeleine Z. Bordallo, GU 

Gregorio Kilili Camacho Sablan, CNMI 

Pedro R. Pierluisi, PR 

Norma J. Torres, CA 

Rau ́l M. Grijalva, AZ, ex officio 

(III) 

CONTENTS 

Page 

Hearing held on Tuesday, July 12, 2016 ............................................................... 1 

Statement of Members: 

Noem, Hon. Kristi L., a Representative in Congress from the State of 

South Dakota ................................................................................................. 5 

Prepared statement of ............................................................................... 7 

Ruiz, Hon. Raul, a Representative in Congress from the State of 

California ....................................................................................................... 3 

Prepared statement of ............................................................................... 4 

Young, Hon. Don, a Representative in Congress from the State of Alaska . 1 

Prepared statement of ............................................................................... 2 

Statement of Witnesses: 

Bohlen, Stacy, Executive Director, National Indian Health Board, 

Washington, DC ............................................................................................ 38 

Prepared statement of ............................................................................... 40 

Church, Jerilyn, Chief Executive Officer, Great Plains Tribal Chairmen’s 

Health Board, Rapid City, South Dakota ................................................... 46 

Prepared statement of ............................................................................... 48 

Kitcheyan, Victoria, Treasurer, Winnebago Tribe of Nebraska, 

Winnebago, Nebraska ................................................................................... 32 

Prepared statement of ............................................................................... 34 

Miller, Hon. Vernon, Chairman, Omaha Tribe of Nebraska, Macy, 

Nebraska ........................................................................................................ 26 

Prepared statement of ............................................................................... 28 

Shield, Hon. William Bear, Chairman, Rosebud Sioux Tribal Health 

Board, Rosebud, South Dakota .................................................................... 23 

Prepared statement of ............................................................................... 25 

Smith, Mary, Principal Deputy Director, Indian Health Service, U.S. 

Department of Health and Human Services, Rockville, Maryland .......... 14 

Prepared statement of ............................................................................... 16 

Questions submitted for the record ......................................................... 22 

Additional Materials Submitted for the Record: 

Avera Health, Deb Fischer-Clemens, Sr. Vice President, Prepared 

statement of ................................................................................................... 58 

Confederated Tribes of the Colville Reservation, Hon. Michael Marchand, 

Chairman, Prepared statement of ............................................................... 58 

Oglala Sioux Tribe, John Yellow Bird Steele, President, Prepared 

statement of ................................................................................................... 60 

South Dakota Organization of Healthcare Association, Scott A. Duke, 

CEO, Prepared statement of ........................................................................ 68 

United South and Eastern Tribes Sovereignty Protection Fund and SelfGovernance Communication and Education Tribal Consortium, 

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

(1) 

LEGISLATIVE HEARING ON H.R. 5406, TO 

AMEND THE INDIAN HEALTH CARE 

IMPROVEMENT ACT TO IMPROVE ACCESS 

TO TRIBAL HEALTH CARE BY PROVIDING 

FOR SYSTEMIC INDIAN HEALTH SERVICE 

WORKFORCE AND FUNDING ALLOCATION 

REFORMS, AND FOR OTHER PURPOSES, 

‘‘HELPING ENSURE ACCOUNTABILITY, LEADERSHIP, AND TRUST IN TRIBAL 

HEALTHCARE ACT,’’ OR ‘‘HEALTTH ACT’’ 

Tuesday, July 12, 2016 

U.S. House of Representatives 

Subcommittee on Indian, Insular and Alaska Native Affairs 

Committee on Natural Resources 

Washington, DC 

The subcommittee met, pursuant to notice, at 2:04 p.m., in room 

1334, Longworth House Office Building, Hon. Don Young 

[Chairman of the Subcommittee] presiding. 

Present: Representatives Young, Benishek, Gosar, LaMalfa; Ruiz, 

Bordallo, and Sablan. 

Also present: Representative Noem. 

Mr. YOUNG. The Subcommittee on Indian, Insular and Alaska 

Native Affairs will come to order. 

The subcommittee is meeting today to hear testimony on the following bill: H.R. 5406 from Congressman Kristi Noem to amend 

the Indian Health Care Improvement Act to improve access to tribal health care by providing for systematic Indian Health Service 

workforce and funding allocation reforms, and other purposes, or 

the ‘‘Helping Ensure Accountability, Leadership, and Trust in 

Tribal Healthcare Act.’’ 

Under Committee Rules, opening statements will be issued by 

myself and the Ranking Member. This will allow us time to hear 

from our witnesses. Therefore, I ask unanimous consent that all 

other Members who have opening statements be made part of the 

record if they are submitted to the Subcommittee Clerk by 5:00 

p.m. today, or at the close of the hearing, whichever comes first. 

And I ask unanimous consent that the gentlewoman from South 

Dakota, Mrs. Noem, be allowed to join us at the dais to be recognized and participate in today’s hearing. Hearing no objection, so 

ordered. 

STATEMENT OF HON. DON YOUNG, A REPRESENTATIVE IN 

CONGRESS FROM THE STATE OF ALASKA 

Mr. YOUNG. We are here today to take testimony on a bill intended to address a severe problem in Indian Country. Adequate 

2 

health care is one of the most important issues to American 

Indians and Alaska Natives. However, the Indian Health System 

(IHS) direct care system is deficient, inadequate, and simply fails 

in areas of the country that need help the most. 

In 2010, a Senate investigation report brought to light some very 

severe problems plaguing 1 of the 12 regions in the Indian Health 

Care Service, the Great Plains region. After the report was released, the agency repeatedly assured Congress that issues were 

being addressed. Then, roughly a year ago, the same IHS region 

experienced a termination of a provider agreement with Centers for 

Medicare and Medicaid Services (CMS) at the Winnebago IHS 

hospital located in Winnebago, Nebraska. CMS found repeated deficiencies at the hospital ‘‘had caused actual harm and is likely to 

cause more harm’’ to persons seeking examination or treatment. 

Since 2015, CMS has found deficiencies in other hospitals in the 

Great Plains region. Emergency department services have been diverted to hospitals that are 45 miles away. This leaves some tribes 

asking not ‘if,’ but ‘when’ other hospitals may lose CMS provider 

agreements. 

H.R. 5406, the Healthcare Act, is intended to make reforms to 

the Indian Health Service to help their broken system. This bill 

does not fix every problem in IHS; however, it is a step in the right 

direction for Indian County. 

And again, I would like to thank the sponsor of the bill for being 

here today, and she will be one of our witnesses. 

Before we turn to our witness, though, I want to acknowledge a 

group of students that I understand are here in the audience, who 

are part of the NCAI’s Health Fellowship program, which I had the 

privilege of speaking to in Spokane, all of which are looking to pursue careers in the health field. I am encouraged by your interest, 

as I think many here in this room are, and I recognize you will 

play a role in the future of health care in Indian Country. 

So, if you are a student, would you raise your hands, please? 

That is not bad. One, two, three, four, five—five? Where are the 

rest of you? Six? OK. Anyway, welcome to the healthcare field and 

this hearing, by the way. 

[The prepared statement of Mr. Young follows:] 

PREPARED STATEMENT OF THE HON. DON YOUNG, CHAIRMAN, SUBCOMMITTEE ON

INDIAN, INSULAR AND ALASKA NATIVE AFFAIRS

We are here today to take testimony on a bill intended to address a severe problem in Indian Country. Adequate healthcare is one of the most important issues to 

American Indians and Alaska Natives; however the IHS direct care system is deficient, inadequate, and is simply failing areas of the country that need help the most. 

In 2010, a Senate investigation report brought to light some very severe problems 

plaguing 1 of the 12 regions of the Indian Health Service, The Great Plains region. 

After the report was released, the agency repeatedly assured Congress that issues 

were being addressed. Then, roughly a year ago, the same IHS region experienced 

the termination of a provider agreement with Centers for Medicare and Medicaid 

Services at the Winnebago IHS hospital located in Winnebago, Nebraska. CMS 

found that repeated deficiencies at the hospital ‘‘had caused actual harm and is 

likely to cause harm’’ to persons seeking examination or treatment. 

Since 2015, CMS has found deficiencies in other hospitals in the Great Plains 

region. Emergency Department services have been diverted to hospitals that are 45 

miles away. This leaves some tribes asking not ‘‘if’’ but ‘‘when’’ other hospitals may 

lose CMS provider agreements. 

3 

H.R. 5406, the HEALTTH Act, is intended to make reforms to the Indian Health 

Service to help a broken system. This bill does not fix every problem in the IHS; 

however, it is a step in the right direction for Indian Country. 

I want to thank the Sponsor of the bill and our witnesses for being here today. 

But before we turn to our witnesses, I want to acknowledge a group of students 

here in the audience who are part of NCAI’s Health Fellowship program—all of 

which are looking to pursue careers in the health field. I am encouraged by your 

interest and I think many here in this room and elsewhere recognize you will play 

a role in the future of healthcare in Indian Country. 

Mr. YOUNG. With that, I will turn to the Ranking Member for his 

opening statement. 

STATEMENT OF HON. RAUL RUIZ, A REPRESENTATIVE IN 

CONGRESS FROM THE STATE OF CALIFORNIA 

Dr. RUIZ. Thank you, Mr. Chairman. I also want to congratulate 

the students and encourage you to continue to reach your dreams 

and your goals, with a passion and compassion that you have, to 

serve in healthcare capacity. I am an emergency physician, and I 

have been in your shoes. I can tell you that it is doable, it is absolutely doable, and you can do it. 

I also want to thank Congresswoman Noem for being here and 

discussing your bill, and to thank our other witnesses for taking 

the time to testify. We are here to talk about one thing, and that 

is health care in Indian Country. This is a chance to not only hear 

about the current issues at the Indian Health Services facilities 

and proposed solutions to address them, but to also take a hard 

look at the future of health care in Indian Country. 

Where do we want to be when it comes to our trust responsibility 

to ensure the health and well-being of our Native brothers and sisters? We do know where we have been, and the results speak for 

themselves. American Indian and Alaska Native people have long 

experienced a desperate health status when compared with other 

Americans, including a lower life expectancy and a disproportionate 

disease burden. 

American Indians and Alaska Natives born today have a life expectancy that is 4.4 years less than the rest of the U.S. population. 

American Indians and Alaska Natives continue to die at a higher 

rate than other Americans in many categories, including chronic 

liver disease and cirrhosis, diabetes, unintentional injuries, assault, 

homicide, suicide, and chronic lower respiratory diseases. 

There are many reasons for these health disparities, and we 

know that one of the contributing factors is the adequacy of the 

Indian health care delivery system. A recent GAO study found that 

the IHS has never conducted an agency-wide oversight on the timeliness of their care. Even the facilities that do attempt to track 

wait times are hampered by an outdated electronic health record 

system. 

We all agree on the seriousness of the deficiencies outlined by 

CMS in their survey of the four Great Plains area hospitals and 

the effects they have had on the communities they serve. I am saddened and angry to hear about the victims of those deficiencies. 

And while this is just the Great Plains area, I know that we will 

probably hear many of the same stories from other service units in 

other areas; this is not unique to the Great Plains area. 

4 

We cannot provide competent, quality health care to Native 

American and Alaska Natives when we allow this inadequate level 

of facilities, management, and care. There are long-standing systemic issues at IHS that must be addressed, whether regulatory 

and legislatively, and the entire system needs to be brought into 

the 21st century. 

This includes an investment in infrastructure and information 

technology. It includes recruitment and retention of high-quality 

medical professionals and administrators, starting from grade 

school all the way to residency and fellowship training. And it includes the ability for tribes to control their own destinies through 

self-governance, while guaranteeing that the Federal Government 

lives up to its end of the bargain. 

This is the vision I see for the future of Native health care and 

the IHS, and I think many of my colleagues, both in Congress and 

the healthcare industry, would agree with me. I appreciate the effort that Acting Director Mary Smith has put forth in an attempt 

to address the current issues at these Great Plain area hospitals, 

and to establish a more proactive approach through mock surveys 

and other measures to prevent these issues from cropping up at 

other service units. 

I want to thank our colleague, Rep. Noem, for shining a light on 

the concerns at IHS, and bringing this legislation forward. I agree 

with some of the proposals—in fact, most—in H.R. 5406, and I disagree with others. The fact is that we need to start talking about 

permanent solutions that comprehensively address long-standing 

issues at IHS. And I also think we need to seriously talk about finally adequately funding IHS, which includes exempting IHS and 

its programs from sequestration. 

It strikes me as hypocritical to complain about the level of service that is provided, and then turn around and consistently underfund the very agency responsible for providing it. And I know you 

agree with me, as well. 

There are actual lives in the balance, and they deserve better; we 

can do better as a community and as a country. In the end, I know 

that we all want the same thing. Everybody on this dais, everybody 

in the audience, we all want the same thing, the best healthcare 

system for our Native American communities. 

So, I want to yield back my time and thank you, Mr. Chairman, 

for addressing some of these issues in the past, and bringing this 

to light now. 

[The prepared statement of Dr. Ruiz follows:] 

PREPARED STATEMENT OF HON. RAUL RUIZ, RANKING MEMBER, SUBCOMMITTEE ON

INDIAN, INSULAR AND ALASKA NATIVE AFFAIRS

Thank you, Mr. Chairman. I want to thank our witnesses for taking the time to 

testify today. We are here today to talk about one thing—Healthcare in Indian 

Country. 

This is a chance to not only hear about current issues at IHS facilities and proposed solutions to address them, but to also take a hard look at the future of 

healthcare in Indian Country. 

Where do we want to be when it comes to our trust responsibility to ensure the 

health and well-being of our Native brothers and sisters? We do know where we 

have been, and the results speak for themselves. American Indian and Alaska 

Native people have long experienced a disparate health status when compared with 

other Americans, including a lower life expectancy and a disproportionate disease 

burden. 

5 

American Indians and Alaska Natives born today have a life expectancy that is 

4.4 years less than the U.S. all races population. American Indians and Alaska 

Natives continue to die at higher rates than other Americans in many categories, 

including chronic liver disease and cirrhosis, diabetes, unintentional injuries, assault, homicide, suicide, and chronic lower respiratory diseases. 

There are many reasons for these health disparities, and we know that one of the 

contributing factors is the adequacy of the Indian health care delivery system. A 

recent GAO study found that the IHS has not ever conducted any agency-wide 

oversight on the timelines of their care. Even the facilities that do attempt to track 

wait times are hampered by an outdated electronic health record system. 

We all agree on the seriousness of the deficiencies outlined by CMS in their survey of the four Great Plains area hospitals, and the effects they have had on the 

communities they serve. Like us all, I am saddened and angry to hear about the 

victims of those deficiencies. And while this is just the Great Plains area, I fear that 

we could probably hear many of the same stories from other service units in other 

areas. We cannot provide competent, quality healthcare to Native American and Alaska 

Natives when we allow this inadequate level of facilities, management and care. 

There are long-standing systemic issues at IHS that must be addressed, whether 

regulatory and legislatively, and the entire system needs to be brought into the 21st 

century. 

This includes an investment in infrastructure and information technology. It includes recruitment and retention of high quality medical professionals and administrators. And it includes the ability for tribes to control their own destinies through 

self-governance, while guaranteeing that the Federal Government lives up to its end 

of the bargain. 

This is the vision I see for the future of Native healthcare and the IHS, and I 

think many of my colleagues, both in Congress and the healthcare industry, would 

agree with me. I appreciate the effort that Acting Director Mary Smith has put forth 

in an attempt to address the current issues at these Great Plain area hospitals, and 

to establish a more proactive approach through mock surveys and other measures 

to prevent these issues from cropping up at other service units. 

I want to thank our colleague, Rep. Noem, for shining a light on the concerns at 

IHS, and bringing this legislation forward. I agree with some of the proposals in 

H.R. 5406, and I disagree with others. The fact is that we need to start talking 

about permanent solutions that comprehensively address the long-standing issues at 

IHS. And I also think we need to seriously talk about finally adequately funding 

IHS, which includes exempting IHS and its programs from sequestration. 

It strikes me as hypocritical to complain about the level of service that is provided, and then turn around and consistently underfund the very agency responsible 

for providing it. 

There are actual lives in the balance, and they deserve better. We can do better. 

In the end, I know that we all want the same thing—the absolute best heath care 

system for our Native peoples. 

Thank you, Mr. Chairman, and I yield back. 

Mr. YOUNG. I thank the gentleman, and one thing that I want 

to make clear—in Alaska, I believe—I may be wrong—the IHS role 

with contracting is only with the Native organizations, and it 

works very well, and I think we ought to look at that. We have 

probably the best Native healthcare system in the United States 

right now. I am a little proud of that, and I should be. 

So, our first witness, Congresswoman Noem, you are up. Thank 

you for your bill, and thank you for taking the time to be here. We 

gladly look forward to your testimony. 

STATEMENT OF HON. KRISTI L. NOEM, A REPRESENTATIVE IN 

CONGRESS FROM THE STATE OF SOUTH DAKOTA 

Mrs. NOEM. Thank you, Chairman Young and Ranking Member 

Ruiz, and the members of the subcommittee. I appreciate you having this hearing today and inviting me to testify in support of my 

bipartisan bill, H.R. 5406. Maybe by the end of this committee 

6 

hearing, I will have you on board, as well, Representative Ruiz, 

with all parts of the bill. 

This bill is called the Helping Ensure Accountability, Leadership, 

and Trust in Tribal Healthcare, the HEALTTH Act. And I want to 

thank today’s witnesses who have traveled a long way to be with 

us. Mr. Bear Shield and Ms. Church, who are here from my home 

state of South Dakota; we have Mr. Miller and Mrs. Kitcheyan, 

who are here from Nebraska. And thanks also to Ms. Bohlen and 

Ms. Smith for being here today to add their perspective. 

I don’t want to make any mistakes today in telling you clearly 

we are here because of a crisis. The Indian Health Service is beyond broken. Fixing it is literally a matter of life and death. 

Nowhere is this truer than in the Great Plains region. The Great 

Plains service area is home to some of America’s most remote and 

most impoverished tribal communities. Unemployment rates, substance abuse rates, and suicide rates are far above national averages. In fact, many of the unemployment rates in these areas are 

80 to 90 percent. 

At the center of it all is a healthcare system so deficient that providers are offering care with expired licenses. Their surgical instruments are being washed by hand. Opioids and other drugs are 

being stolen by the thousands, and premature babies are being 

born on hospital bathroom floors with no physician present. 

Last year, CMS terminated its accreditation of the Winnebago 

Hospital in Nebraska, which serves the Omaha and the Winnebago 

Tribes. CMS then cited the Rosebud, Pine Ridge, and Sioux San 

Hospitals in South Dakota. In Rosebud, the situation is by far the 

worst. Without warning, IHS closed the facility’s emergency room 

and diverted patients to hospitals located over 50 miles away. In 

the 7 months that the ER has been closed, five babies have been 

born in ambulances, and nine people have died in transit to these 

other hospitals. So, literally, we are talking life and death. 

I want everybody to think of this perspective, too, because I 

think it is important to know—IHS is a subset under HHS, as is 

CMS. CMS actually refused to reimburse the kind of care that was 

being delivered at IHS facilities, both under the same umbrella of 

HHS, which tells you—we have one Federal agency pointing out 

how terrible of a job another Federal agency is doing—literally, 

every single day it is important that we recognize how terrible this 

situation is. 

In the years since the 2010 Senate Indian Affairs Committee report that outlined many of the most shocking problems, the IHS 

has promised again and again to make changes. But it has failed 

to do so, even at the most basic levels. If you thumb through the 

past IHS budget requests, you will find the same promises copied 

and pasted from one year to the next. This is the very definition 

of status quo. 

What has changed is the funding. Congress has delivered funding increases to IHS almost every year since the Senate report, 

bringing the annual IHS budget almost $1 billion over 2010 levels. 

Yet the situation is just as bad as it has ever been. So, we know 

for a fact that money alone is not going to fix the problem. 

The HEALTTH Act reforms an agency that is desperately in 

need of an overhaul. Many tribes are considering self-governance, 

7 

which you indicated, Mr. Chairman, works well in Alaska. But for 

a number of reasons, many of my tribes are not quite ready to administer a hospital when they are so impoverished and lack so 

many resources. They want to eventually end up there, though, 

that is the goal. 

My bill creates a pilot project in which hospitals can be controlled by tribal-led boards, rather than IHS. This new model will 

give tribes more control over their hospitals, and equip them with 

the expertise that they need for self-governance. The IHS’s chief 

obstacle in the Great Plains is staffing. To improve recruitment 

and retention, my bill extends the agency student loan repayment 

program to administrators, as well as medical staff, and makes this 

financial support tax-free, like other government programs that are 

already out there designed to attract providers to under-served 

areas. This will make the repayment program a more valuable tool 

to recruit more competent administrative and medical staff. 

We also require cultural competency training to ensure that IHS 

employees understand the people that they are serving. We ask the 

agency to report their wait times, and we eliminate barriers that 

currently prevent medical and dental providers from being able to 

volunteer at IHS facilities. And finally, the HEALTTH Act reforms 

the purchased referred care program, which currently operates 

under an unfair funding allocation formula. My bill would require 

that IHS update this formula and ensure that the money is getting 

to those people who need it the most. 

As I said before, I believe IHS should get out of the hospital business. I think they are terrible at it. My bill takes us a step in that 

direction, under this pilot program. We have received widespread 

support, including from the Rosebud Sioux Tribe, the National 

Indian Health Board, all the major health systems in South 

Dakota, and national and state health organizations. But we are 

not done. 

I look forward to a robust discussion today, and I welcome all of 

the input from the subcommittee, the witnesses, and the tribes 

across the country. 

Chairman Young, Ranking Member Ruiz, and members of the 

committee, thank you for allowing me to testify today. I truly 

thank you for your commitment to improving tribal health care. 

With that, I will yield back. 

[The prepared statement of Mrs. Noem follows:] 

PREPARED STATEMENT OF THE HON. KRISTI L. NOEM, A REPRESENTATIVE IN

CONGRESS FROM THE STATE OF SOUTH DAKOTA

Chairman Young, Ranking Member Ruiz, and members of the subcommittee, 

thank you for inviting me to testify in support of my bipartisan bill, H.R. 5406, the 

Helping Ensure Accountability, Leadership, and Trust in Tribal Healthcare—or 

HEALTTH Act. 

I thank today’s witnesses, especially Mr. Bear Shield and Ms. Church, who traveled from my home state of South Dakota, and Mr. Miller and Ms. Kitcheyan, who 

are here from Nebraska. Thanks also to Ms. Bohlen and Ms. Smith for being here 

today. 

We are here today because of a crisis. The Indian Health Service is beyond broken, and fixing it is literally a matter of life and death. Nowhere is this truer than 

in the Great Plains. The Great Plains service area is home to some of America’s 

most remote and impoverished communities. Unemployment rates, substance abuse 

rates, and suicide rates are above national averages. At the center of it all is a 

healthcare system so deficient that providers are offering care with expired licenses, 

8 

surgical instruments are being washed by hand, opioids and other drugs are being 

stolen by the thousands, and premature babies are being born on hospital bathroom 

floors with no physician present. 

Last year, CMS terminated its accreditation of the Winnebago hospital in 

Nebraska, which serves the Omaha and Winnebago Tribes. CMS then cited the 

Rosebud, Pine Ridge, and Sioux San hospitals in South Dakota. In Rosebud, the situation is particularly dire. Without warning, the IHS closed the facility’s emergency 

room, diverting patients to hospitals located over 50 miles away. In the 7 months 

the ER has been diverted, five babies have been born in ambulances while in transit 

to these other hospitals, and nine people have died. 

In the years since a 2010 Senate Indian Affairs Committee report that outlined 

many of the most shocking problems, the IHS has promised time and again to make 

changes. But it has failed to do so at even the most basic levels. If you thumb 

through past IHS budget requests, you will find the same promises copied and 

pasted from one year to the next. This is the very definition of status quo. 

What has changed is funding. Congress has delivered funding increases to the 

IHS almost every year since the Senate report, bringing the annual IHS budget almost $1 billion over 2010 levels, and yet, the situation is as bad as it has ever been. 

Money alone will not fix the problems. 

The HEALTTH Act reforms an agency in desperate need of change. 

Many tribes are considering self-governance, but for a number of reasons, aren’t 

yet ready to administer a hospital. My bill creates a pilot project in which hospitals 

can be controlled by tribal-led boards, rather than IHS. This new model would give 

tribes unprecedented control over their hospitals, and equip them with the expertise 

needed for self-governance. 

The IHS’s chief obstacle in the Great Plains is staffing. To improve recruitment 

and retention, my bill extends the agency’s student loan repayment program to administrators as well as medical staff and makes that financial support tax-free, like 

other government programs designed to attract providers to underserved areas. This 

will make the repayment program a more valuable tool to recruit more competent 

administrative and medical staff. 

We also require cultural competency training to ensure IHS employees understand the people they serve. We ask the agency to report wait times. And we eliminate barriers that currently prevent medical and dental providers from volunteering 

at IHS facilities. 

Finally, the HEALTTH Act reforms the Purchased/Referred Care program, which 

currently operates under an unfair funding allocation formula. My bill would require the IHS to update this formula and ensure the money is getting to people who 

need it most. 

As I have said before, I believe the IHS should get out of the hospital business, 

and my bill is a step in that direction. 

We have received widespread support, including from the Rosebud Sioux Tribe, 

the National Indian Health Board, all the major health systems in South Dakota, 

and national and state health associations. But we’re not done. I look forward to 

a robust discussion today and I welcome input from the subcommittee, the witnesses, and tribes across the country. 

Chairman Young and Ranking Member Ruiz, thank you again for inviting me to 

testify. I thank you for your commitment to improving tribal healthcare. Because 

this is such a critical issue for my constituents in South Dakota, I respectfully request that the members of the subcommittee allow me to join them on the dais for 

the remainder of the hearing. 

Mr. YOUNG. Thank you, Congresswoman. Ranking Member, do 

you have any questions? 

Just out of curiosity, did you write this bill, or did you have help 

from the people directly affected? 

Mrs. NOEM. We had help from many of the tribes that are impacted directly. We even got technical assistance from IHS originally. The thing that has been the most frustrating for me is that, 

as you will hear in the testimony today of the IHS’s Acting 

Director, they have some criticisms of our bill, which we have been 

waiting weeks now for more technical assistance. 

9 

So, some of the criticisms that you will hear in testimony today 

I think are unwarranted, when we did consult with them in 

drafting the legislation. Our tribes are very happy with the legislation, and recognize that these needed reforms have to be put in 

place as soon as possible. Every day that emergency department is 

closed down and services are diverted, their people are dying. IHS 

doesn’t recognize the emergency situation we have on our hands. 

Mr. YOUNG. You just led an opening to me, Kristi. We did not 

get their testimony until last night at 8:00. 

Mrs. NOEM. I know. 

Mr. YOUNG. I have checked it over, and if I really wanted to be 

nasty, I would have the Senate testimony and this testimony, and 

there are just some words that have been transferred. 

Mrs. NOEM. Except for the criticisms of this bill. 

Mr. YOUNG. That is right. 

Mrs. NOEM. That was added on at the end. The rest of it was 

identical. 

Mr. YOUNG. That is right. And I am just saying that is a no-no, 

so thank you for your legislation. 

Mr. Benishek. 

Dr. BENISHEK. Well, I want to thank Mrs. Noem for bringing this 

to my attention. I, frankly, was not aware of the severity of the 

problem. And looking over the briefing here, it is just remarkable 

what has been going on. How can there be any defense of this action? I don’t know, and I think your legislation is long overdue. I 

can’t wait to hear from the tribal people. 

So, this hospital is run by the IHS, is that the story? 

Mrs. NOEM. Our hospitals in the Great Plains region, except for 

one—but all the ones in South Dakota are run by direct service, 

which means IHS Federal employees deliver the health care in 

these facilities. Other tribes in other parts of the country operate 

under a 638, which means that they do not have Federal employees 

running it, but they receive the funds to run the facilities. 

But for us, I think we are in such a tragic situation because we 

have IHS running these facilities, and you will hear stories from 

the tribal members today that you would not believe could happen 

in America. The quality of health care that is being delivered in my 

tribal communities is third-world health care, and it should not be 

happening in this country, especially when the Federal Government is responsible for providing health care to them. 

Under our treaty obligations—these are treaty tribes that we 

need to honor by treating them with the respect they deserve and 

the health care that we have promised them, and we are failing. 

And the agency is slow-walking fixes. They will tell you in the 

testimony today that they have the authority to do some of the 

things in the bill. Well, the tribal members will tell you if they 

have had the authority to do this all along, then shame on them 

because they should have been doing it. Our legislation is making 

sure that they follow through on delivering the kind of health care 

that our tribes deserve. 

Dr. BENISHEK. Thank you. I yield back. 

Mr. YOUNG. Mr. Gosar. 

Dr. GOSAR. Sure. One of the things the Office of IHS is supposed 

to work in consultation with the tribes, and that is foremost and 

10 

inadequate in that discovery. We have seen the 638. In fact, in 

Arizona we have seen the 638 take off. I mean the Navajos were 

one of the first ones to use the 638. There were some complications, 

granted, but I am hoping there is a way that what we can do is 

teach the tribes to take that onus and the transitional factor, so 

that they have more of the leadership role in that application to 

health care, but also have the accountability, as well. 

So, from that standpoint, I applaud your efforts in that regard. 

There will be some things that I will have some concerns about, because I want the same type of care from auxiliaries. That has to 

be mandated differently. 

My one question for you is—did you have any input from the 

Pew Foundation? 

Mrs. NOEM. Not that I am aware of, but I will request from my 

staff and clarify later with you if we did. 

Dr. GOSAR. I appreciate it. Thanks. 

Dr. BENISHEK. Will you yield for a minute? 

Dr. GOSAR. I will yield to the gentleman from Michigan. 

Dr. BENISHEK. I thought of another question. 

Mrs. NOEM. Sure. 

Dr. BENISHEK. Do you know how much the IHS was spending on 

this hospital? 

Mrs. NOEM. One of the problems that we have had with IHS is 

we cannot get the exact dollar amounts that flow to the Great 

Plains region and what actually meets the tribes. The tribes will 

testify to you that they believe a lot of the dollars disappear at the 

regional center in Aberdeen, that it never quite flows down to the 

people or actually results in delivered health care to the people. 

So, the purchased referred care that I reform within my bill, that 

money runs out by June every year. In fact, it is common knowledge and there is a saying in Indian Country in South Dakota, 

‘‘Don’t get sick after June,’’ because if you get sick after June, you 

are just not going to receive care, you will be—— 

Dr. BENISHEK. This hospital that was closed down, the IHS ran 

it, but you don’t really know how much money they spent there per 

patient, or the total amount, or any of those numbers. That is all, 

like—— 

Mrs. NOEM. Exactly. 

Dr. BENISHEK. All right, thank you. I yield back. 

Dr. GOSAR. I am going to reclaim my time, because Dr. Benishek 

actually gave me another question. 

One of the things that would—and I mean this is not my first 

rodeo with problems with IHS and application to the tribes. Part 

of the reason is credentialing. And dentistry is also a big issue 

within the tribes. IHS refused to have a core central credentialing 

protocol in which those that want to volunteer for extended periods 

of time can do so. I hope that is a real prominent aspect of this 

bill. 

Mrs. NOEM. It is. 

Dr. GOSAR. I will spend a little more time with that. 

Credentialing is a problem. And I would alert the tribes to tell 

them that, once again, the consultation process—IHS has to function on consultation with a tribe. So, I would beg that the tribes 

become very affluent and forceful in that regard, to have transVerDate Mar 15 2010 11:11 Dec 02, 2016 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6602 J:\114TH CONGRESS\INDIAN, INSULAR & ALASKA NATIVE AFFAIRS\07-12-16\20919.TXT
11 

parency and have them answer directly to them, because that is 

the way it is supposed to function; and Congress should back that. 

Mrs. NOEM. Representative Gosar, I wholeheartedly agree with 

you. My tribes will tell you that they feel as though no consultation 

happens and that virtually they are left out of the decisionmaking 

process, they are informed when something has already been implemented. When we do have problems with employees, they are 

shuffled around to other positions, nobody is ever fired. 

The consultation piece is one of the biggest complaints that I 

hear out of my tribes. 

Dr. GOSAR. Yes, and I once again would re-acknowledge the point 

that there are some 638s out there that are becoming very sophisticated in application, not just for tribal members, but off tribal. In 

Flagstaff, there are some outreach clinics that are associated with 

the 638s, so there is a lot of possibility that actually works within 

this. 

I appreciate the gentlelady’s interest and—— 

Mrs. NOEM. Well, my tribes would like to get there, they just do 

not have the resources to get there tomorrow. That is their goal. 

Mr. YOUNG. I am going to use my prerogative, Mr. Ruiz. 

Dr. RUIZ. Thank you, Mr. Chairman. 

Congresswoman Noem, I just want to give a warning that there 

is no one size that fits all in Indian Country. There are a lot of dynamics and complexities within the different regions, within the 

different tribes. There is a difference between rural health and 

urban health. There is a difference within the states, of course. So, 

sometimes IHS can work within a certain region, within a certain 

population. Perhaps, in Great Plains, it is not working with the big 

hospital model, however there have been partnerships with hospitals with IHS and local tribes working together. 

So, I think that this is not a one-size-fits-all or this one particular bill is going to fix the entire IHS. We should be flexible in 

understanding the local unique dynamics within the different regions and the different types of health care and the different types 

of risk factors that exist in those. 

The other thing is that we should really focus on making sure 

that there are incentives for recruitment. I know this bill has some 

of those, and also prevent the disincentives for retention, because 

there are some barriers that are unique in Indian Country in terms 

of trying to get, as you mentioned, administrators, doctors, and 

nurses to serve there that we need to address. So, I think it is important that we keep those things in mind and I thank you for your 

attempt in doing that. 

Mrs. NOEM. Thank you. I think that is why you will see that the 

bill is drafted as a pilot program for the Great Plains region, because we know that we face a different situation than other regions 

in the country. This is specifically to test this kind of implementation process in our region, where the situation is so terrible. 

And also, one of the challenges that we face is the vacancy rates 

of positions of nurses, doctors, and administration officials. That is 

why, in the bill, we try to address that through provisions that will 

help us recruit, but also allow individuals to stay in these communities, become a part of the community, and maybe even train 

12 

members of the community, so that they continue to better their 

lifestyle and livelihood, as well. Thank you. 

Mr. YOUNG. Mr. LaMalfa. 

Mr. LAMALFA. Thank you, Mr. Chairman. Mrs. Noem, you 

mentioned a pretty horrific situation there. I wasn’t sure if you 

said that was at Rosebud on the ER closure? 

Mrs. NOEM. Yes, for 7 months the emergency department has 

been closed. 

Mr. LAMALFA. And it is still closed? 

Mrs. NOEM. Yes. 

Mr. LAMALFA. All right. What was the condition of why they 

chose to close it? Was it the right decision to close it? 

Mrs. NOEM. Well, what created the situation was CMS coming in 

and saying they would no longer reimburse for services provided in 

that emergency department because of conditions that were occurring there. And what IHS identified and has fixed, some of it was 

construction, some of it was adding new technology or new medical 

devices, lack of staff. 

But they also put new security measures in on protecting their 

drugs and—— 

Mr. LAMALFA. Some of that was done, or was being done—— 

Mrs. NOEM. That has been done. Then they contracted the emergency department out to a staffing agency that has been hiring and 

trying to fill positions before they reopen. 

I have been told for weeks that it will reopen soon. But every 

time I have asked IHS, ‘‘When will this emergency department 

open because lives depend on it,’’ I have never gotten an answer. 

I understand that CMS is there today conducting a survey; so potentially that is coming soon, and that should be the final step before it reopens. The problem I have had is it has taken them 7 

months to get their act together, to get it done, hire staff, and that 

I never once was given a date on when this emergency department 

would reopen—and I don’t believe my tribes were ever given any 

kind of an indication. Even if we asked them today, I am not sure 

they would tell us what day it would open. 

But what we need to realize is that we are transporting people 

across very rural areas of South Dakota, and they are dying in ambulances on the way there—— 

Mr. LAMALFA. You said five baby deliveries and nine deaths—— 

Mrs. NOEM. Nine deaths. 

Mr. LAMALFA [continuing]. They could attribute to maybe lack of 

timing? 

Mrs. NOEM. Lack of care when they needed it. 

Mr. LAMALFA. And was actual closure really necessary, or could 

they have restaffed a little ongoing? I mean shutting something 

completely down—— 

Mrs. NOEM. It was a dangerous situation. 

Mr. LAMALFA [continuing]. Versus trying to do something in a 

couple weeks that would take care of this cleanliness issue, or get 

one—I mean it would seem like with the cost involved to the community in its convenience or proximity, or whatever you would call 

it, that is a pretty big cost. 

Mrs. NOEM. That is a great question for the Acting Director. 

13 

Mr. LAMALFA. The next panel? OK. In the bill, how do you feel 

about the allocation formula and capping being placed on the PRC. 

How is that going to play out? 

Mrs. NOEM. The PRC funding formula does not currently work, 

because my tribes run out of money by June. So, for the rest of the 

year, they cannot get care. Unless they are dying on the table, they 

might get care. But other than that, those reimbursements or payments are not made to other facilities that are providing care to 

Natives that IHS should be doing. 

Mr. LAMALFA. Because there is a fund somewhere that runs out 

by June instead of it being properly funded? 

Mrs. NOEM. Yes. 

Mr. LAMALFA. Or is there a higher cost involved or something 

that is blowing up the fund, or what? 

Mrs. NOEM. Yes. What my legislation does is that it reimburses 

at Medicare rates, so that it stretches the dollars farther, so that 

they are not paying astronomical rates to other providers to take 

care of Native Americans. 

And then also what it does is it allocates the formula according 

to need. Some tribes are getting more dollars than what they can 

really utilize and have plenty of money to make it through the 

year. My tribes run out by June because it has never been changed 

according to population. As population grows in these tribes, I am 

just asking IHS to redo this formula to make sure that needs are 

being met. 

Mr. LAMALFA. Are you getting any pushback on the Medicare 

cap? 

Mrs. NOEM. I have not. 

Mr. LAMALFA. OK. So maybe smooth sailing? 

Mrs. NOEM. I am sure there is somebody that is unhappy with 

it, but it certainly will help my tribes receive care for more months 

out of the year. 

Mr. LAMALFA. And it is probably commensurate with a lot of 

other medical facilities that maybe are not as tribe-oriented. 

Mrs. NOEM. Well, my medical facilities that are providing care to 

Native Americans today that are not getting paid for that, they are 

doing it as charity care, sure, they would like to get something. 

Mr. LAMALFA. Yes, well, certainly. OK. Very good. Thank you for 

your testimony. 

Mr. YOUNG. I have been informed there are no other questions 

at this time. We want to hear from the other witnesses, is that 

correct? 

We thank you Congresswoman, very much so, and thanks for 

bringing this bill forward. We will have Mary Smith, Principal 

Deputy Director, Indian Health Service; the Honorable William 

Bear Shield, Chairman of the Rosebud Sioux Tribal Health Board; 

Ms. Victoria Kitcheyan—I have to say that, Victoria, because it is 

not Ketchikan; it is very nearly Ketchikan, though, I can tell you 

that, so you know—a city in Alaska; and the Honorable Vernon 

Miller, take the witness stand, please. 

Which one? Two more? OK. Jerilyn Church and Stacy Bohlen. I 

think most of you recognize or have testified before. You have 5 

minutes. I am pretty lenient if you are making good presentation. 

14 

I have to say that because if you start rambling I will enforce the 

5-minute rule. So, just keep that in mind. 

But I try to give you time. I have never liked the 5-minute rule. 

But it is because of time. And, unfortunately, you cannot present 

your real case in 5 minutes, nor can we ask questions in 5 minutes. 

But because of time we can’t. 

And Ms. Mary, I have to say that we are not picking on you, we 

are picking on the system. This is not new. This has been going on 

for years, and we are just trying to ensure—the congresswoman is 

trying to arrive at a solution, and we are willing to listen to all 

sides of this issue and see if we can’t get something done for those 

that have not been served. 

So, Ms. Mary, you are up. 

STATEMENT OF MARY SMITH, PRINCIPAL DEPUTY DIRECTOR, 

INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH 

AND HUMAN SERVICES, ROCKVILLE, MARYLAND 

Ms. SMITH. Thank you. Good afternoon, Chairman Young, 

Ranking Member Ruiz, and members of the committee. I want to 

thank you all for the invitation to join you today to testify on 

H.R. 5406, the Helping Ensure Accountability, Leadership, and 

Trust in Tribal Healthcare Act. 

And, Mr. Chairman, I do want to apologize personally on the 

timing of the testimony. I am sorry. 

Mr. Chairman, I appreciate and thank you and the committee for 

your leadership in elevating the importance of delivering quality 

care at the Indian Health Service. I would also like to thank 

Representative Noem for her partnership and for focusing attention 

on the critical needs of health care for Native Americans, and for 

her participation at the recent field hearing in Rapid City, South 

Dakota. Finally, I would like to thank my fellow witnesses for all 

their work and partnership in this important area. 

All of us share the goals reflected in this legislation: driving accountability, strengthening the workforce, and improving the quality of care for the Native American communities we serve. I think, 

while we are sitting on different sides of the table, I think we are 

all on the same side. We all want to improve the quality of health 

care for Native Americans. 

While the Administration has some concerns with some of the 

provisions in the bill as drafted, we look forward to working with 

the committee to improve the bill as it moves through the legislative process. 

At the outset, I want to thank the many dedicated staff and providers we have at IHS. They work under difficult conditions to 

deliver care in some of the poorest and most remote areas of our 

country. Nonetheless, IHS faces severe operational and staffing 

challenges, challenges not unlike those shared by other healthcare 

systems that provide care in rural communities, such as nursing 

and provider shortages. And, unfortunately, these challenges did 

not occur overnight. They are long-standing and systemic. 

Over the past several years, IHS has encountered challenges 

with a number of our direct service facilities in the Great Plains 

area. And more recently, these long-standing challenges have 

gained attention from Congress, including this committee. We 

15 

welcome this attention and momentum that it creates for lasting 

quality improvements for these facilities because we are on the 

front lines of medical care in some of the most remote parts of our 

country. 

To underscore, our challenges are daunting. But I am committed, 

along with the rest of the team at IHS, and with the support of 

the Department of Health and Human Services, to creating a culture of quality, leadership, and accountability. Since I was asked 

to lead IHS just a few months ago, I have moved aggressively toward this goal, meeting with tribal leaders to hear their concerns 

firsthand, visiting facilities, and launching agreements to make improvements in the IHS delivery system that will be sustainable 

over time. 

One area of focus is staffing and the retention of qualified staff. 

Across the system, IHS is committed to supporting staff with the 

necessary resources and tools to perform their jobs. For example, 

IHS is ensuring that living quarters are allocated efficiently to support the retention of health professionals, as a lack of housing is 

a serious barrier to recruitment. Retaining dedicated IHS staff 

members is important and essential for the continuity of operations. This year we began executing an aggressive strategy to improve the quality of care at IHS, and we are focusing on a 5-point 

strategy. 

First, we are focusing on assessment. We are taking a close look 

at the quality of care delivered through our direct-service hospitals. 

We are beginning a system-wide mock survey initiative for all 27 

IHS hospitals to assess compliance with Medicare and readiness for 

re-accreditation. 

Second, we are immediately strengthening service delivery. IHS 

is working diligently to stem local staff shortages and build a pipeline for staff training and deployment. Already more than 60 

clinicians from the U.S. Public Health Service Commissioned Corps 

have deployed to hospitals in the Great Plains. We are expanding 

our outpatient hours and we are using telehealth to bring hard-tofind specialty care right to the patient. 

Third, we are strengthening IHS management. We are assessing 

a number of staffing and management office options, including 

finding innovative ways to compete and retain talent. 

Fourth, we are infusing quality expertise. We recently joined a 

hospital engagement network to reach across all 27 IHS hospitals 

and share strategies on how to reduce avoidable re-admissions and 

hospital-acquired infections. We are bringing in experts from different parts of HHS to consult with IHS hospitals to ensure that 

our improvements are real and measurable. 

Fifth, we are engaging local resources. Some of the most helpful 

expertise and effective leadership are the tribal communities we 

work with daily. We are committed to strengthening these relationships and engaging further with partners from the community like 

local and regional healthcare systems, local colleges and universities, and the leadership of our direct-service hospitals. 

At IHS, we are committed to making meaningful and measurable 

progress to improve the health and well-being of all American 

Indians and Alaska Natives. It is not business as usual. It is not 

simply pointing out the challenges, but focusing on solutions and 

16 

about how we all have been entrusted with providing access to 

health care for Native people, and how we can work together to 

tackle these issues to make sustainable improvements so that we 

can move forward toward solving the long-standing systemic issues 

and deliver the quality of care that our patients deserve. 

Thank you, Mr. Chairman. 

[The prepared statement of Ms. Smith follows:] 

PREPARED STATEMENT OF MARY SMITH, PRINCIPAL DEPUTY DIRECTOR, INDIAN HEALTH SERVICE

INTRODUCTION

Good afternoon, Chairman Young, Ranking Member Ruiz, and members of the 

committee. Thank you for the invitation to join you today to testify on H.R. 5406, 

the Helping Ensure Accountability, Leadership, and Trust in Tribal Healthcare Act 

(HEALTTH Act). We would like to start by thanking you and the committee for your 

leadership and for elevating the importance of delivering quality care through the 

Indian Health Service. I would also like to thank Representative Noem for her leadership and partnership in focusing attention on the critical needs of health care for 

Native Americans. This committee, IHS, and HHS share common goals of providing 

consistent, quality health care to the American Indian and Alaska Native communities. The Administration has concerns with some provisions in H.R. 5406 as drafted and looks forward to working with the committee to improve the bill as it moves 

through the legislative process. 

Earlier this year, we strengthened and refocused our resources within the IHS as 

part of an aggressive strategy to improve the overall quality of care in the Great 

Plains area, and across the country. IHS is working to instill a culture of quality 

care, leadership, and accountability across the agency. We are committed to hearing 

directly from you and the communities we serve to focus sharply on how to best improve access to quality health care and, most importantly, improve the health status 

of American Indian and Alaska Native families and communities. 

To be clear, the acute problems we are seeing right now are largely tied to chronic, long-standing issues, often spanning decades. Recognizing that, the focus of our 

work this year is to move aggressively to develop both systemic changes even while 

we’re addressing immediate, short-term needs. We have significant efforts underway 

on both fronts. 

It is not business as usual at IHS. Under my leadership, IHS is changing the way 

it approaches long-standing challenges. We are working to transform the process by 

which we recruit and retain staff; to create an organizational structure that supports sustained improvement and accountability; and to strengthen our financial 

management infrastructure. 

To ensure that dependable, quality care is delivered consistently across IHS facilities, 3 months ago, Secretary Burwell created the Executive Council on Quality Care 

and asked Acting Deputy Secretary Wakefield to lead it. This Council includes senior executives from across HHS and draws on expertise from across the Department. 

We have some of HHS’s top managers, clinicians, and program experts taking a 

fresh look at long-standing obstacles like workforce supply, housing, challenges to 

delivering quality of care, and addressing key operations issues. The Council provides the framework to ensure that we are leveraging all the resources we can on 

behalf of tribal communities and the patients we serve. 

IHS, in conjunction with the work of this Council, for the past 3 months, has been 

engaging our work through a five-prong strategy to address these challenges—many 

of the same obstacles like sufficient workforce, human resources issues, and care 

quality, that this legislation seeks to address. With this strategy, IHS and the 

Department are working to (1) surface issues so that we can work to resolve them; 

(2) improve service delivery; (3) strengthen IHS Area management; (4) infuse 

quality expertise; and (5) engage with local resources. 

Surfacing Issues 

First, we are assessing and surfacing issues so that we can work to resolve them. 

We are taking a very close look at the quality of care delivered through directservice hospitals at IHS facilities across the Great Plains area as well as throughout 

Indian Country. We want to affirm and support facilities that are delivering quality 

care and work closely with facilities that need improvement. It is important that 

IHS leadership from Headquarters to Area offices to our service units work closely 

with both tribal leadership and direct service hospitals in a transparent way that 

17 

encourages open information exchange about improvement opportunities. We know 

from decades of experience across the health care continuum, that problems that are 

not acknowledged and fixed put patients at risk. For the past 20 years, health care 

systems across the Nation have been embracing new models of improvement, and 

we are working to embrace those models through the assets of IHS and other HHS 

operating divisions. 

For example, IHS has begun a system-wide mock survey initiative at all 27 of its 

hospitals to assess compliance with the Centers for Medicare and Medicaid Services 

(CMS) Conditions of Participation and readiness for re-accreditation. These mock 

surveys will be conducted by survey teams from outside each respective area to reduce potential bias. The new mock survey initiative is being coordinated through the 

IHS Quality Consortium as a unified effort to reinforce standardization of processes. 

We are beginning in the Great Plains area with assessments and, when appropriate, 

interventions through the provision of on-site assistance to hospital staff. Although 

some direct service hospitals currently conduct self-assessments, IHS is standardizing and improving this process so that direct-service hospitals receive a consistent 

assessment within the next few months and performance data is centrally tracked, 

not just at individual facilities but across all facilities. 

Through this and other targeted strategies, IHS will move from being reactive to 

proactive in identifying and addressing performance issues early. Our first efforts 

were piloted May 10, 2016, at the Rosebud Hospital, and we will continue to do 

quality surveys at all direct service hospitals, excluding those that have been surveyed in the past year or are scheduled to be formally surveyed through other mechanisms during this time frame. When our survey teams identify problems, we will 

work swiftly to address these local problems and work to put systems changes in 

place to resolve the problems. Additionally, best practices that are identified will be 

shared across IHS facilities. 

Another example of surfacing and addressing problems is IHS’ enhanced drug 

testing interim policy. This policy was released on June 6, 2016, and it focuses on 

drug testing based on reasonable suspicion. The interim policy provides guidance to 

supervisors and managers on drug testing based on a reasonable suspicion of drug 

use. This effort was informed by tribal leaders’ calls for additional IHS administrative actions in this area. 

Improve Service Delivery 

Second, we are working to improve service delivery by focusing on workforce and 

clinical support infrastructure. 

Workforce 

The IHS continues to face significant workforce challenges with a chronic shortage 

of health care providers. While we have taken immediate steps to address some 

local shortages, and are in the process of adding more, such as telemedicine, these 

long-standing challenges require bolstering and expanding the training and deployment pipelines and full use of innovative approaches to delivering care. In the nearterm, with Secretary Burwell, Deputy Secretary Wakefield, and the U.S. Surgeon 

General’s support, over 60 Commissioned Corps clinicians have been deployed for 

temporary placements into the Great Plains hospitals with CMS findings. In addition, the National Institutes for Health (NIH) and the Health Resources and 

Services Administration (HRSA) have been helping IHS deploy strategies they have 

used to recruit applicants. IHS is also revising job announcements and deploying 

more comprehensive recruitment plans around key positions, in an effort to recruit 

a greater number of qualified candidates. IHS is utilizing Title 38 pay increases for 

high-demand Emergency Department clinicians and has established eligibility for 

payment of relocation expenses for GS–12 and lower graded clinical positions. However, even with these and a number of other strategies that have been utilized during the past few months or that are in development right now, there is still much 

more work that needs to be done to attract and retain an adequate health care 

workforce. Some of these changes may require legislative action. In addition, we are 

working with Office of Personnel Management (OPM), the Office of Management 

and Budget (OMB), and other affected agencies to explore ways to enhance our current flexibilities. We are also are combining efforts that leverage collaboration between tribal, public, and private academic institutions. 

One of the most challenging areas to support is the availability of emergency services, particularly in the Great Plains area. Because of this, on May 17, 2016, IHS 

initiated a new strategy through a contract award to provide both emergency department staffing and operations support and management services at three hospitals: Rosebud Hospital and Pine Ridge Hospital in South Dakota and Omaha 

Winnebago Hospital in Nebraska. This contractor will provide health care in these 

18 

hospital emergency rooms while IHS reviews the administrative and clinical 

operations of its facilities across the region to develop long-term solutions. IHS’s 

leadership both in the hospitals and at headquarters have direct oversight of this 

contractor and is responsible for holding this contractor accountable for providing 

consistent quality health care. However, because this is a new approach to 

Emergency Department staffing and management combined, a team of clinicians 

and attorneys, as well as the CEOs of the facilities, are tracking this initiative 

weekly to ensure that performance expectations are met. 

As part of a longer-term strategy, we are re-examining the scholarship and loan 

repayments program to make sure that we are maximizing their impact as well as 

introducing new strategies as well. We are working with the Peace Corps’ Global 

Health Services program that fields clinicians to areas of critical workforce needs 

and most immediately, we are building communication channels about service to 

Indian Country to returning volunteers. By the end of last month, for example, 60 

returning volunteers learned about opportunities to work in IHS direct service hospitals even as we are engaging other longer-term communication strategies with the 

broader Global Health Services program. Additionally, the U.S. Public Health 

Service Commissioned Corps has prioritized assignment of new officers to IHS with 

a particular focus on the Great Plains area. 

On a related front, on June 1, IHS proposed to expand its Community Health 

Aide Program. Partnership and collaboration are part of our ongoing work to deliver 

quality health care to patients. Increased access to care is a top priority, which is 

why IHS is engaging in consultation with tribal leaders on this expanded effort. 

Community health aides are proven partners, and this important proposed change 

would bring more health workers directly into American Indian and Alaska Native 

communities. 

Infrastructure 

In addition to addressing workforce challenges, the IHS is trying to lessen the 

loads on our emergency departments by establishing alternative avenues of care, 

such as urgent care clinics and telehealth services. IHS is working aggressively to 

reopen the Rosebud Emergency Department as soon as possible. In the meantime, 

in order to fill the temporary gap, the IHS has re-purposed existing ambulatory care 

space into an Urgent Care clinic staffed with emergency department and ambulatory providers. Given the types of illnesses that individuals present with to the 

Rosebud Emergency Department, the Urgent Care clinic can manage the majority 

of non-emergent care needs. 

Specialty services like behavioral health, cardiology, and diabetes care can be difficult to find in rural areas. IHS will also be using telehealth contracts to bring specialty services into the communities where individuals live so they do not need to 

travel. IHS issued a Telemedicine Request for Proposal on May 5, 2016. Proposals 

were originally due June 6, 2016; however, at the request of prospective offerors 

who needed more time to prepare comprehensive proposals, IHS extended the deadline to respond by 30 days. 

Strengthening Area Management 

Third, we are working to strengthen area management. While we support the 

workforce at each hospital, we are taking a broader view to strengthen Great Plains 

area management through the temporary deployment of high-quality managers from 

within other areas of IHS as well as deploying HHS experts to both IHS headquarters and the field to assist with finance, contracting, and management functions. IHS also established a Human Resources (HR) Steering Committee, which 

provides oversight and guidance on the implementation of system-wide HR improvements in IHS. 

As part of these efforts, Rear Admiral Kevin Meeks spent 3 months leading the 

Area Office, and he continues to support the Great Plains area in order to provide 

continuity of leadership. Captain Chris Buchanan joined the Great Plains area leadership team in May and is serving as the Acting Director of the Great Plains Area 

Office. Captain Buchanan has extensive expertise working with complex health systems which are IHS directly operated facilities as well as tribally managed programs. In the longer term, the IHS is actively looking to find the best possible 

candidate for the Great Plains Area Director position. We have taken steps to attract as broad a pool of well-qualified candidates as possible. We have also implemented a stronger search committee process for recruiting highly qualified 

managers and executives. This committee is charged with candidate outreach, assessment, and vetting. IHS is also more widely advertising vacancies through 

Federal, state, and non-profit partners, and is actively seeking additional venues to 

help attract a broad and diverse applicant pool. Additionally, going forward, we 

19 

have expanded tribal participation in filling vacant Area Director positions and 

members of a tribe from each area will, for the first time, play a role in these search 

committees at the outset of the hiring process on these key positions. 

Finally, IHS recently announced it is conducting a 90-day consultation with tribal 

leaders to discuss the organization and operation of the Great Plains Area Office, 

to, in partnership with the tribes, identify new approaches to better support patients and tribal community health in the area. The first telephonic consultation 

was held on June 22, and the first in-person consultation will be held in Rapid City 

later this week on July 15. 

Infusing Quality Expertise 

Fourth, we are infusing substantial quality expertise into informing and improving care quality in direct service facilities. In partnership with CMS, we have 

launched a Hospital Engagement Network (HEN) to provide evidence-based efforts 

in quality improvement. As we announced on May 13, 2016, this HEN is now available to all IHS direct service facilities and focuses on quality improvement methods 

intended to reduce avoidable readmissions and hospital acquired conditions (e.g. 

central line blood infections, pressure ulcers, falls, etc.). Hospitals in the network 

share successful practices and lessons learned to accelerate learning and change. 

The HEN will prioritize working with the three Great Plains area hospitals and 

is currently working with each hospital to schedule on-site meetings. 

Additionally, we are bringing in targeted quality improvement assistance through 

CMS’ Quality Improvement Organization (QIO) infrastructure. Among other support 

and training functions, QIOs assist with root cause analysis of identified problems, 

assist with the development of improvement plans, establish baseline data, and 

monitor data to ensure improvement plans are successful and sustained over time. 

Also through Secretary Burwell’s Executive Council on Quality Care, HHS is deploying quality experts, as needed, from throughout the Department to consult with and 

help our IHS direct-service hospitals that are currently out of compliance with CMS 

Conditions of Participation and to monitor progress as the facilities come into 

compliance. 

Engaging Local Resources 

And fifth, we aim to engage more robustly with local resources. We know that, 

in addition to our strong partnerships with tribes and their leadership, local academic and health systems organizations can be valuable sources of expertise and 

partnership. We intend to strengthen our relationships with local and regional 

health care systems, local colleges and universities and tribal colleges, direct-service 

hospital leadership and tribal leadership to build stronger academic pipelines and 

health care connections to ensure we are working collaboratively and effectively to 

produce health related workers and health care services. 

We also recognize that the health of communities is tied to the economic health 

of communities. Rates of unemployment and poverty matter. Consequently, we are 

committed to advancing the success of small businesses in tribal communities. The 

Department’s Office of Small and Disadvantaged Business Utilization, in collaboration with the U.S. Small Business Administration, is working to coordinate meetings 

with tribal leaders and small businesses owned by Native Americans, Indian tribes, 

and the Native American community at large. 

Our team plans to have these meetings in or near the 12 Indian Health Service 

Area Offices and the events will focus on how to effectively pursue contract opportunities with HHS, IHS, and other Federal agencies. 

STRENGTHENING IHS

We have been working to address challenges using new approaches on our end. 

First, we appreciate 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 our current authorities to provide more tools to recruit 

and retain high-quality staff. 

Second, we are seeking tax treatment, similar to the treatment provided to recipients of National Health Service Corps (NHSC) and Armed Forces Health 

Professions scholarships. Currently, IHS loan repayment/scholarship awards are 

taxable, reducing their value. In contrast, participants in the NHSC scholarship program and Armed Forces Health Professions may exclude scholarship amounts used 

for qualifying expenses from income, and participants in the NHSC loan repayment 

program may exclude NHSC loan repayment amounts paid on their behalf from income. We recommend adopting the Administration’s Fiscal Year 2017 Budget 

proposal which would conform the tax treatment of IHS repayments/scholarships to 

20 

the tax treatment for NHSC and Armed Forces Health Professions repayments/ 

scholarships. 

Third, the Indian Health Care Improvement Act requires employees who receive 

IHS scholarships or loan repayments to provide clinical services on a full-time basis. 

However, the Affordable Care Act permits certain NHSC loan repayment and 

scholarship recipients to satisfy their service obligations through half-time clinical 

practice for double the amount of time or, for NHSC loan repayment recipients, to 

accept half the loan repayment award amount in exchange for a 2-year service 

obligation. We would like similar flexibility in order to attract health care professionals who may not be able to work full-time to fulfill their service obligations. 

Being able to access resources is key to amplifying our work. It is critically important that we receive the funding the President requested in his Fiscal Year (FY) 

2017 Budget, which includes: an increase of $159 million above FY 2016 to fund 

medical inflation, pay costs, and accommodate population growth for direct health 

care services; an increase of $20 million for health information technology to fund 

the development, modernization, and enhancement of IHS’ critical health information technology systems; $2 million to create a new program which will focus on reducing medical errors that adversely affect patients; and $12 million specifically for 

staff quarters at current facilities, in addition to staff quarters associated with new 

facilities. 

H.R. 5406 

H.R. 5406 addresses three broad areas and the paragraphs below include our 

feedback on various sections of the bill. 

Title I—Expanding Authorities and Improving Access to Care 

Section 101 of the bill would establish a 7-year pilot project for long-term 

contracts to fully staff three hospitals. This is a concept IHS is exploring through 

our sources sought notice for at least two hospitals in the Great Plains that includes 

the option of contracting out the top senior management of the facility or the option 

to contract out the entire hospital. This section of the bill presents a third way between the current two methods of providing care through IHS funding, either full 

direct service or full self-governance. 

IHS supports a tribe’s decision to receive services directly from IHS or to contract 

under the Indian Self-Determination and Education Assistance Act (ISDEAA). However, the agency is concerned that this provision while not impacting the right of 

a tribe to contract under ISDEAA would not absolve IHS from contractual liability 

to the private sector contractor for up to 7 years. While IHS has the current authority to contract out both the management and staffing of an entire hospital, IHS is 

concerned with the language in this section that IHS could be expected to fund both 

a private sector contractor and an ISDEAA tribal contractor, using the same source 

of funding. We suggest language be added to clarify that, in this situation, a tribe 

would take over the contract, not be paid in addition. Finally, IHS would be open 

to further discussing a long-term pilot, and associated funding needs, with the impacted tribes and the committee. 

Subsection (d) establishes governance boards for the selected hospitals made up 

of representatives from IHS, tribes, and experts in health care administration. IHS 

is concerned that such boards vest authority in individuals (elected tribal officials 

and other health care experts) who would not be accountable to IHS or the 

Secretary, who would retain the legal responsibility for running the hospitals. 

Tribes who want to assume full responsibility for the operation of their hospitals 

already have this authority under the ISDEAA. Instead, creation of an Advisory 

Board could ensure that tribes have input into hospital operations and access to information about how the hospital is operated. Advisory boards could also bring in 

the perspective of outside health experts, benefiting both IHS and tribes. 

Section 102 would expand IHS’s authorities under chapter 74 of title 38 to help 

IHS offer more flexible and competitive benefits to recruit employees. 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 our current authorities to provide more tools to recruit and retain 

high-quality staff. 

Section 103 addresses IHS authority to remove or demote employees. The specific 

provisions on removing or demoting an employee appear unnecessary as IHS 

already has authorities to implement adverse employment actions as contemplated 

by this section. While IHS already has these authorities, in an effort to bolster effective leadership and management accountability in addressing employee issues, we 

have taken the following actions during the past few months: issued a new drug 

testing policy based on reasonable suspicion; established that a new performance 

21 

requirement focused on providing quality health-care be added to all applicable performance plans during the mid-year performance reviews; started providing 

Employee Relations and Labor Relations training to our managers beginning with 

the IHS Senior Staff; and issued policy guidance and expectations on reporting of 

any suspected fraud, waste, and abuse, and Whistleblower protection rights to all 

IHS employees. In addition, the Department of Justice (DOJ) advised us that it has 

serious constitutional concerns with the procedures in section 103, which appear to 

derive from section 707 of the Veterans Access, Choice, and Accountability Act of 

2014, codified at 38 U.S.C. § 713. The Attorney General notified Congress in a recent 

letter that DOJ could not defend section 707 in litigation challenging that provision 

on Appointments Clause grounds. Section 103 could present similar concerns if 

enacted in its present form. 

Finally, we believe there may be technical issues with some of the bill’s language 

pertaining to applicability to the U.S. Public Health Service (USPHS) Commissioned 

Corps, and definitions and references to current personnel practices. We would be 

happy to provide any technical comments. 

On expedited appeals, revoking Federal employee protections could lead to the 

unintended consequence of making IHS a less desirable place to work and thus compound staffing problems. 

Section 104 requires IHS to develop and implement standards to measure the 

timeliness of care at direct-service IHS facilities. IHS believes this provision is unnecessary as IHS already is cascading annual Senior Executive Service performance 

standards that specifically address improving access to patient care by establishing 

accountability for all senior managers to implement at least two activities to improve wait times and access to quality health care for patients that are based on 

enhanced implementation of current quality initiatives or new quality initiatives 

and that have measurable goals, measures, and outcomes, and requiring improvements to be documented at Headquarters, Area Office and facility levels. In addition, IHS is developing a quality framework that will take action on timeliness of 

care and provide data analytics. 

Title II—Indian Health Service Recruitment and Workforce 

Section 201 would provide tax treatment, similar to the treatment provided to recipients of NHSC and Armed Forces Health Professions scholarships, to allow scholarship funds for qualified tuition and related expenses received under the Indian 

Health Services Health Professions Scholarships to be excluded from gross income 

under Section 117(c)(2) of the Internal Revenue Code (IRC) and to allow participants in the IHS Loan Repayment Program to exclude from gross income student 

loan amounts that are forgiven by the IHS Loan Repayment program under Section 

108(f)(4) of the IRC. IHS appreciates the inclusion of this provision as it was requested as part of the President’s FY 2017 Budget request. 

Section 202 includes health care management or health care executive positions 

as eligible professions for loan repayment awards, including non-clinical service obligations. Management expertise is very important in a health system as large as 

IHS. 

Section 203 adds specific requirements for implementation of annual mandatory 

cultural competency training programs for IHS employees, locum tenens providers, 

and other contracted employees engaged in direct patient care. Cultural competency 

in the IHS workforce is essential to the provision of quality care. 

Section 204 addresses relocation reimbursement. IHS currently has ability to provide payment of relocation expenses. This section appears to combine payment of 

relocation expenses and relocation incentives. IHS already has the authority to pay 

Relocation expenses included in 5 CFR part 572 and in accordance with the Federal 

Travel Regulations, Chapter 302, Relocation Allowances. The authorized allowances 

are outlined in Chapter 302. We would like the opportunity to better understand 

why payments of 50–75 percent of an employee’s salary would be required under 

this section of the bill. 

IHS also has the authority to pay relocation incentives under 5 CFR part 575— 

Recruitment, Relocation, and Retention (3Rs) Incentives. To help with difficult-tofill positions, agencies may authorize an incentive of up to 25 percent of an 

employee’s annual rate of basic pay times the number of years in a service agreement, which could amount to an incentive of as much as 100 percent of an annual 

salary for 4 years of service. Only OPM can authorize incentive payments above 25 

percent based on a critical agency need so that larger incentives may be approved 

for shorter service obligations. Relocation incentives also can be paid in addition to 

providing reimbursement of relocation expenses. We would be happy to provide any 

technical comments in coordination with OPM. 

22 

Section 205, which permits a limited waiver of Indian preference, is more restrictive than current law. Impacted Indian tribes and tribal organizations are already 

permitted to waive Indian preference laws with respect to personnel actions 

pursuant to 25 U.S.C. § 472a(c)(1). Current waiver authority is unconditional, unlike 

section 205, which requires the IHS service unit to have a personnel vacancy rate 

of at least 20 percent. 

Section 206 requires a Service-wide centralized credentialing system to credential 

licensed health professionals who seek to volunteer at a Service facility. IHS shares 

the goal of this section to streamline and standardize credentialing across the entire 

IHS system. IHS is exploring options for either installing an enterprise IT system 

for tracking credentialing and privileging across IHS or for contracting out the 

credentialing function to a third party. It appears the intent of the bill is for the 

Secretary to establish a separate and different credentialing system for volunteers. 

IHS’s preference is to pursue the implementation of a single credentialing system 

for the entire agency, which would include volunteers. 

Title III—Purchase/Referred Care Program Reforms 

Section 301 is similar to our Final Rule Medicare-like Rate payment for non-IHS, 

Tribal, or Urban (non-ITU) physician and other health care professional services associated with either outpatient or inpatient care provided at non-ITU facilities. If 

the intent of the legislation is to codify this regulation, we suggest using the 

language of the regulation, as there are a number of subtle changes that could drastically impact the meaning and implementation. However, if the intent is reinforcement of the rule then drafters could consider codified enforcement mechanisms, such 

as civil monetary penalties. 

Section 302 requires that the Secretary promulgate regulations to develop and implement a revised distribution formula for the purchase/referred care program 

(PRC). To the extent that this provision is optional for 638 contractors and not optional for direct service tribes, this proposed legislation will provide incentives for 

tribes to enter into 638 contracts to run their own PRC programs and essentially 

cause a race to contract for PRC in order to avoid a revised distribution formula. 

The Federal Government’s legal responsibility is to all AI/ANs, regardless of whether the services are provided directly or through a 638 contractor. The direct service 

tribes have a right to contract under the ISDEAA, but they also have a right not 

to do so and there is no basis in the law to penalize them for choosing to stay a 

direct service tribe. 

CONCLUSION

IHS and HHS are committed to making meaningful and measurable progress in 

the way that IHS delivers care and to ensuring that this progress is sustainable 

over time. We have already taken significant steps, but there is much more work 

ahead, including the intense work underway to strengthen and stabilize the hospitals in South Dakota and Nebraska. We look forward to addressing those challenges and making lasting progress in close partnership with you. We look forward 

to working with the committee on this legislation as it moves through the legislative 

process. Thank you, and we are happy to take your questions. 

QUESTIONS SUBMITTED FOR THE RECORD BY THE HON. DON YOUNG TO MS. MARY

SMITH, PRINCIPAL DEPUTY DIRECTOR, INDIAN HEALTH SERVICE, U.S. DEPARTMENT

OF HEALTH AND HUMAN SERVICES

Ms. Smith did not submit responses to the Committee by the appropriate 

deadline for inclusion in the printed record. 

Question 1. Section 121 of the Indian Health Care Improvement Reauthorization 

and Extension Act of 2009, enacted into law as part of P.L. 111–148, required the 

Secretary of the Department of Health and Human Services to submit to Congress 

a report on the current health status and resource deficiencies of the Indian Health 

Service for each service unit, including newly recognized or acknowledged tribes. 

Has the Department finalized this report? If not, when can Congress expect to 

receive the report? 

23 

Question 2. 25 U.S.C. § 1680h includes the authorization the Indian Health 

Service to establish joint venture projects under which tribes or tribal organizations 

would acquire, construct, or renovate a health care facility. 

a. For direct service tribes that have not any health facilities constructed under 

either the health care facility priority system or the Joint Venture Construction 

Program, does any way exist for those tribes to renegotiate or bring current 

their facility staffing ratios within the Indian Health Service system? 

b. For Joint Venture Construction Program solicitations dating back to 2009, 

please provide for each the solicitation information that identifies: 

• the tribes that submitted applications; 

• the applications that progressed beyond the initial round of review and the 

level of review they progressed to before being denied, and 

• the applications that Indian Health Service ultimately selected. 

Mr. YOUNG. Thank you, Mary. 

The Honorable William Bear Shield, Chairman, Rosebud Sioux 

Tribal Health Board. 

STATEMENT OF HON. WILLIAM BEAR SHIELD, CHAIRMAN, 

ROSEBUD SIOUX TRIBAL HEALTH BOARD, ROSEBUD, SOUTH 

DAKOTA 

Mr. BEAR SHIELD. Greetings, Chairman Young and Ranking 

Member Ruiz. I would also like to acknowledge our South Dakota 

Congresswoman, Kristi Noem, and offer the gratitude and support 

of the Rosebud Sioux Tribe for her crafting and introducing 

H.R. 5406, the Helping Ensure Accountability, Leadership, and 

Trust in Tribal Healthcare Act. 

My name is William Bear Shield, and I am a Council Representative for the Rosebud Sioux Tribe, representing the Milks Camp 

Community, 1 of our 20 communities. I am also the Chairman of 

our Health Board, the Vice-Chairman of the Great Plains Tribal 

Chairman’s Health Board, and the Chairman of the Unified Tribal 

Health Board for the Sioux San Hospital in Rapid City, South 

Dakota, which consists of the Cheyenne River, Oglala and Rosebud 

Sioux Tribes as members of the governing body. 

Sioux San also provides health care to tribal members from all 

Sioux Tribes and from over 200 federally recognized tribes. 

For over the past 2 years, basic health care has declined to an 

all-time low at the Winnebago, Omaha, Rosebud, Pine Ridge, and 

Sioux San IHS facilities, as reported by the tribes and confirmed 

by CMS, that has caused the deaths of tribal members and created 

other life-threatening issues. 

While Director Smith and other IHS officials seem to view the 

current and ongoing diversion of the emergency room in Rosebud 

with rose-colored glasses, nine tribal members have died in ambulances and five babies have been born in ambulances while being 

transported more than 50 miles or, in some instances, up to a 2- 

hour one-way trip to other off-reservation hospitals, since 

December 5, 2015 over the past 7 months. 

This cries for an investigation by someone other than IHS. Let 

me repeat: nine tribal members have died while riding in ambulances, and five babies have been born in ambulances while being 

transported over 50 miles to other hospitals. 

24 

Let’s highlight another less-than-rosy fact, that Indian Health 

Service official that suggested that two babies being born on the 

bathroom floor at the Rosebud IHS hospital in 8 years was ‘‘not 

doing too badly’’ was the choice of Director Smith to be the Chief 

Medical Officer of the Great Plains region. No tribal leaders were 

consulted. Rosebud certainly was not. And, that official clearly has 

disdain for our people and should work elsewhere. 

The Rosebud Sioux Tribe signed a treaty of peace with the 

United States and promised no more wars between our nations. I 

bring this to your attention because our treaty is different than 

others in that it specifically addressed our health care. By 1982 

there were 360 federally recognized tribes in Alaska that Natives 

recognized, and even then funding was not provided fairly by 

treaty, land base, and population, nor fully. 

Since Congress passed the Indian Gaming Regulatory Act, or 

IGRA, in 1988, the number of federally recognized tribes has increased to 567. As of today, 209 additional tribes have been federally recognized. Of those, none have even a fraction of our land 

base or population. 

We do not object to Congress recognizing other tribes, but we do 

want a fair formula to address health care needs in accordance 

with our treaties, land base, and populations. IHS has reported 

about 67 percent of the IHS budget is administered by 114 tribes, 

primarily through the authority provided to them under the Indian 

Self-Determination and Education Assistance Act, leaving approximately 37 percent for the remaining 453 tribes, which, in many 

cases, are large land-based and large population tribes. 

Quite simply, the U.S. Government must live up to its obligations. That means acceptable and quality health care. That means 

reform, and with reform, additional Federal funding. We recognize 

this is an authorization bill, but at heart this is an appropriation 

issue. Congress must not walk away from the obligation to fully 

fund these treaty and trust responsibilities. A purely private-sector 

solution is simply not appropriate. 

Another challenging issue we wanted to raise before the 

committee is the tribal employer mandate of the Affordable Care 

Act, which we oppose along with other large land-based tribes. This 

law will result in over $2 million in fines from the Internal 

Revenue Service annually, for just the Rosebud Sioux Tribe alone. 

We will have to cut elder and youth programs, social assistance for 

low to no-income tribal members, and let go tribal members who 

work for the Rosebud Sioux Tribe. Congress needs to fix this law 

now. 

As of this moment, the Rosebud Sioux Tribe, through its 

economic arm, which is the Rosebud Economic Development 

Corporation, or REDCo, is working with Avera Hospital in Sioux 

Falls, South Dakota, to contract the key management positions of 

the Indian Health Service hospital by utilizing our 8a Native program, and asking IHS to issue a sole-source contract to us. By 

doing so, this follows the spirit of Section 833, the Service Hospital 

Long-Term Contract 9 Pilot Program in the proposed legislation. As 

of this date, IHS has not responded to our request. 

These are only some of the examples of why we support this bill, 

and we ask that IHS justify the funding formula that it is 

25 

currently using and why the South Dakota and Great Plains area 

tribes’ budgets are far below that of small land-based and large 

population-based tribes. 

We support direction of the legislation and look forward to working with members of this committee and your staff as you move forward to a legislative markup. We urge that you work to reform and 

move robust funding. 

Last, I would again express appreciation for the leadership of 

Congresswoman Noem for introducing this legislation and to 

Chairman Young and Ranking Member Ruiz for holding today’s 

hearing. Thank you. 

[The prepared statement of Mr. Bear Shield follows:] 

PREPARED STATEMENT OF WILLIAM BEAR SHIELD, CHAIRMAN, ROSEBUD SIOUX

TRIBAL HEALTH BOARD

OPENING

Greetings Chairman Young and Ranking Member Ruiz. I would also like to acknowledge our South Dakota Congresswoman Kristi Noem and offer the gratitude 

and support of the Rosebud Sioux Tribe for her crafting and introducing H.R. 5406 

the ‘‘Helping Ensure Accountability, Leadership, and Trust in Tribal Healthcare 

Act.’’ 

My name is William (Willie) Bear Shield and I am a Council Representative for 

the Rosebud Sioux Tribe representing the Milks Camp Community, 1 of our 20 communities. I am also the Chairman of our Health Board, the Vice-Chairman of the 

Great Plains Tribal Chairman’s Health Board, and the Chairman of the Unified 

Tribal Health Board for the Sioux San Hospital in Rapid City South Dakota which 

consist the Cheyenne River, Oglala and Rosebud Sioux Tribes as members of the 

governing body. Sioux San provides health care to tribal members from all Sioux 

Tribes and from over 200 federally recognized tribes. 

PROBLEMS

For over the past 2 years basic health care has declined to an all-time low at the 

Winnebago-Omaha, Rosebud, Pine Ridge and Sioux San IHS facilities as reported 

by the tribes and confirmed by CMS that has caused the death of tribal members 

and created other life threatening issues. 

While Director Smith and other IHS officials seem to view the current and 

ongoing diversion of the Rosebud Emergency Room with rose-colored glasses, nine 

tribal members have died in ambulances and five babies have been born in ambulances while being transported more than 50 miles (up to a 2-hour one-way trip) 

to other off reservation hospitals since December 5, 2015—over the last 7 months. 

This cries out for an investigation—by someone other than IHS. Let me repeat— 

nine tribal members have died while riding in ambulances and five babies have 

been born in ambulances while being transported over 50 miles to other hospitals. 

And, let us highlight another less than rosy fact. The IHS official that suggested 

that two babies being born on the bathroom floor at the Rosebud IHS Hospital in 

8 years was not doing too badly—was the choice of Director Smith to be the Chief 

Medical Officer of the Great Plains Region. No tribal leaders were consulted— 

Rosebud certainly was not. That official clearly has disdain for our people and 

should work elsewhere. 

The Rosebud Sioux Tribe signed a treaty of peace with the United States and 

promised no more wars between our Nations. I bring this to your attention because 

our treaty is different than others, in that it specifically addressed our health care. 

By 1982, there were 360 federally recognized tribes and Alaska Natives recognized 

and even then funding was not provided fairly by treaty, land base and population, 

nor fully. Since Congress passed the Indian Gaming Regulatory Act (IGRA) in 1988, 

the number of federally recognized tribes has increased to 567, so as of today 209 

additional tribes have been federally recognized and of those none have even a fraction of our land base or population. 

We do not object to Congress recognizing other tribes, but we do want a fair formula to address health care needs in accordance with our treaties, land base and 

populations. 

IHS has reported about 67 percent of the IHS budget is administered by 114 

tribes primarily through the authority provided to them under the Indian Self 

26 

Determination and Education Assistance Act, leaving approximately 37 percent for 

the remaining 453 tribes, which in many cases are large land-based and large population tribes. Quite simply, the U.S. Government must live up to its obligations— 

that means acceptable, quality health care. That means reform, and with reform, 

additional Federal funding. We recognize this is an authorization bill, but at heart 

this is an appropriation issue. Congress must not walk away from the obligation to 

fully fund these Treaty and Trust responsibilities. A purely private sector solution 

simply is not appropriate. 

A SIDELINE ISSUE

Another challenging issue we wanted to raise before the committee is the Tribal 

Employer Mandate of the Affordable Care Act which we oppose, along with other 

large land based tribes. 

This law will result in over $2 million in fines from the Internal Revenue Service 

annually for just the Rosebud Sioux Tribe. We will have to cut elder and youth programs, social assistance for low to no income tribal members—and fire (let go) tribal 

members who work for the Rosebud Sioux Tribe. Congress need to fix this law now. 

SOLUTIONS

As of this moment the Rosebud Sioux Tribe through its economic arm (Rosebud 

Economic Development Corporation, REDCO) is working with the Avera Hospital in 

Sioux Falls, SD to contract the key management positions of the IHS Hospital by 

utilizing our 8a Native program and asking IHS to issue a sole source contract to 

us and by doing so follows the spirit of ‘‘SEC. 833. SERVICE HOSPITAL LONGTERM CONTRACT 9 PILOT PROGRAM in the proposed legislation. As of this date 

IHS has not responded to our request. These are only some of the examples of why 

we support this bill and ask that IHS justify its funding formula that it is currently 

using and why the South Dakota and Great Plains Area Tribes’ budget is far below 

that of small land-based and large population-based tribes. 

WORK WITH COMMITTEE AND WRAP UP

We support the direction of the legislation and look forward to working with members of the committee and your staff as you move toward a legislative markup. We 

urge that you work to pair reform with more robust funding. 

Last, I would again express appreciation for the leadership of Congresswoman 

Noem for introducing this legislation and to Chairman Young and Ranking Member 

Ruiz for holding today’s hearing. 

Mr. YOUNG. Thank you, Mr. Bear. 

Now we are going to Mr. Miller. 

STATEMENT OF HON. VERNON MILLER, CHAIRMAN, OMAHA 

TRIBE OF NEBRASKA, MACY, NEBRASKA 

Mr. MILLER. Thank you, Chairman Young, Ranking Member 

Ruiz, and members of the subcommittee. I want to thank you for 

inviting me here to testify regarding Representative Noem’s 

H.R. 5406, HEALTTH Act. Also, I wanted to further discuss with 

you the immediate need for substantive and effective change on 

delivery of healthcare services by the IHS. 

My name is Vernon Miller, and I am Chairman of the Omaha 

Tribe of Nebraska. The Omaha Tribe is located in the northeast 

corner of Nebraska, right along the Nebraska and Iowa border. Our 

facility is the Omaha Winnebago Hospital, which is a facility that 

is utilized by both the Winnebago Tribes and the Omaha Tribes 

within Nebraska. A week from today, it will be a full year since 

CMS came into our facility and determined that our healthcare 

services were not adequate for our tribal members, and for tribal 

members from other tribes, as well. 

27 

What this is indicative of is 1 full year of an acknowledgment by 

an HHS agency that that hospital does not provide adequate care. 

And it is not an acknowledgment from a year, but it is years of inadequate health care that CMS has finally made that designation 

a year ago. It was not the only facility within the Great Plains region that does not have that certification, so as a result of that we 

are going to be seeing some pretty big impacts of that financially 

from the hospital being able to operate and further even function. 

The stories from the Omaha Winnebago Hospital and other IHS 

facilities in the Pine Ridge and Rosebud Reservations sound like 

scenes from the third-world countries because they are. Our members routinely seek to avoid the hospital because of its poor services, but often end up there because of an emergency, and we do 

not have the resources or the means to go elsewhere. I am a prime 

example. I was born in the late seventies, and even back then my 

family chose to have me born in Pender, Nebraska, rather than 

that facility. So that is an indicative example almost four decades 

of inadequate services that I am a proof of, by not being born in 

that facility. And that is only 10 miles from where I live. 

With the emergency rooms, we have constantly talked about the 

failures that are within existence within those facilities. Within the 

Omaha Tribe, we have several committee members who do utilize 

the ER as a result of not being able to utilize it elsewhere, and we 

have numerous stories that we could share. I can go on and on, but 

I will refrain from doing that. 

Within our own tribe, we have a dialysis facility as well as a 

nursing home where we provide long-term healthcare services. As 

a tribe, we have made it a designation to avoid the hospital and 

so we use our own tribal resources to divert the facility and go directly to the Sioux City, Iowa facility or even to Ottawa, Iowa, 

which is over 30 miles away from our community, to have our 

health care and ER services met. 

I want to thank the subcommittee for having this important 

hearing on this critical issue. I also want to give particular thanks 

to Representative Noem for introducing this Act, and for spearheading this initiative to really take a hard-hitting look at the 

health care being provided within the Great Plains area and, more 

specifically, within the Omaha and Winnebago Hospital, how that 

really is indicative of the designation it does deserve. 

I want to talk about some of the issues within the HEALTTH 

Act. With long-term contract pilot program, it would create that 7- 

year program and the Omaha Tribe is definitely interested in 

pursuing that option. The Omaha Tribe supports the concept of 

blending tribal and IHS governance within the private operation of 

direct-service hospitals. Within the hospital itself, the governing 

board is a group of individuals who sit in Aberdeen, South Dakota, 

which is about 4 hours away, and through a video monitor, they 

make decisions based on the health care and the policies that are 

provided from that facility. 

As a result of that, the Chairman from the Winnebago Tribe and 

I do sit in those meetings, but there is no one there from the community that is able to provide that feedback, provide that narrative 

that is needed to these individuals, and they are the same 

28 

governing board for the rest of the IHS hospitals within the Great 

Plains region. 

So, there definitely needs to be some reform in how the governing process is actually provided, because as a community member and as a tribal leader, we are directly in the field where tribe 

members come to and bring their complaints and bring their concerns to, and that input is not adequately provided, because we are 

pretty much just sitting there and listening to their concerns, and 

we cannot really take action. 

I also want to talk about the recycling problem that we have 

been having with the contractor that has been identified and has 

been awarded a contract for 4 years, but they are using it for 1 

year in our facility. AB Contracting Services has been providing the 

ER staffing needs, and their whole staff—IHS cannot hire anybody 

to work there. As a result of that, you see a lot of these issues with 

our hospital, the Omaha Winnebago Hospital, and the loss of that 

CMS certification. 

And, as a result of that, the bid was announced. Unfortunately, 

AB Contracting was the contractor that got it again, so we are recycling this problem. I can tell you today of two examples last 

week, two more examples from the weeks before, of constant inadequate health care that is being provided in that facility. And unfortunately, like I said, the problem has just been recycling, and I 

would not be surprised if CMS came in and found those same 

issues today that were existent a year ago when that certification 

was taken away. 

I also want to talk about the need to really monitor that contractor, because now they are expanded to nursing, and that is 

really a concern within that facility for the inpatient beds, as well 

as the ER. 

I do want to also mention the expanded hiring authority. The 

Omaha Tribe supports this initiative. We recommend the subcommittee work with Representative Noem to locate authorities 

that will put IHS’s process at the front of the pack, and not just 

a small step ahead. 

In regards to the removal and demotion of employees, the tribe 

supports provisions enabling the Secretary of HHS to more easily 

remove or demote employees. We recommend that language be 

added to this section that any cost for litigation—— 

Mr. YOUNG. I don’t want to cut you off, you are doing well, but 

we have a vote on. 

[The prepared statement of Mr. Miller follows:] 

PREPARED STATEMENT OF THE HONORABLE VERNON MILLER, CHAIRMAN, OMAHA TRIBE OF NEBRASKA

Chairman Young, Ranking Member Ruiz, and members of the subcommittee, 

thank you for inviting me here to testify regarding Representative Noem’s 

H.R. 5406, the Helping Ensure Accountability, Leadership, and Trust in Tribal 

Healthcare Act (the HEALTTH Act), and to discuss with you the immediate need 

for substantive and effective change in the delivery of healthcare services by the 

Indian Health Service, particularly in the Great Plains area. My name is Vernon 

Miller, and I am the Chairman of the Omaha Tribe of Nebraska. I am part of the 

Thunder Clan and the former Business Teacher at Umonhon (Omaha) Nation Public 

Schools on the Omaha Tribal Reservation in Macy, Nebraska. 

The Omaha Tribe is located in the northeastern corner of Nebraska and, along 

with our neighbors in the Winnebago Tribe, we receive healthcare services from the 

Indian Health Service at the Omaha/Winnebago Hospital located in Winnebago, 

29 

Nebraska. In just a week from today, it will have been a full year since the Centers 

for Medicare and Medicaid Services (CMS) ceased payment for services at the hospital because the facility failed to provide for patient safety, failed to combat negligence that resulted in injuries and deaths, and failed to provide adequate care to 

patients. For us in the Omaha Tribe and our members, the IHS has failed to live 

up to its treaty and trust obligations to furnish healthcare and failed to treat us 

with respect and decency. 

The stories from the Omaha/Winnebago Hospital and other IHS facilities serving 

the Pine Ridge and Rosebud Reservations sound like scenes from Third World countries, not the American heartland. Our members routinely seek to avoid the hospital 

because of its poor services, but often end up there because of an emergency or they 

do not have the means to go elsewhere. But, the emergency rooms at these hospitals 

are renowned for their failures. In the Omaha/Winnebago Hospital, the emergency 

room staff received one of our tribe’s members who was complaining of severe back 

pain. The hospital sent him home, and later left a single voicemail with the man 

telling him his kidneys were failing. The hospital attempted no further contact, and 

the man died at a relative’s house 2 days later. Another one of our tribal members, 

a pregnant woman, came to the hospital only to be discharged after the staff could 

not find a heartbeat for her baby. They told her to drive herself to Sioux City to 

another hospital to receive care. We’ve heard stories from our neighbors in South 

Dakota that their IHS facilities have gone 6 months without sterilization machines 

so their workers were hand washing medical equipment. We have heard stories of 

women giving birth on the floor of IHS facilities’ bathrooms and people dying of 

heart attacks with no intervention from staff. 

In 2010, Senator Dorgan and the Senate Indian Affairs Committee reported on 

the Great Plains region’s failures. Unfortunately, the problems identified in the 

Dorgan Report have only gotten worse, and the care our tribal members receive still 

does not meet minimum standards of quality. 

We thank the subcommittee for having this important hearing on this critical 

issue. We would also like to give particular thanks to Representative Noem for introducing the HEALTTH Act. The HEALTTH Act is a critically important piece of 

legislation that we hope will empower the Secretary to begin to address the fundamental structural issues that have plagued the IHS in the Great Plains area for far 

too long. The Omaha Tribe strongly supports it, and urges this committee to consider it favorably. 

The issues facing the IHS are not only structural in nature however. The IHS continues to suffer from inadequate funding, and many of the problems it faces stem 

from the fact that it has always been funded at only a fraction of need. The average 

spending for an IHS patient is only 25 percent of that for an average Medicare beneficiary. Even if the IHS had no structural issues, the lack of adequate funding would 

still result in inadequate care. While the HEALTTH Act provides important and 

needed reforms for the IHS, we are concerned that without additional funding true 

reform is unlikely to be realized. The problems with the Great Plains area require 

a two-pronged solution: structural reform and adequate funding. One cannot succeed 

without the other. 

We thus urge you to consider providing additional funding as well. One important 

change you can make right away is to ensure that the IHS will be held harmless 

in the event of a sequestration or a government shutdown, just as the Veterans 

Affairs’ health facilities are (through provisions like advanced appropriations and 

exceptions in shutdown orders). It is unacceptable for our members’ health care to 

get wrapped up in these battles. 

THE HEALTTH ACT

The Omaha Tribe generally supports the HEALTTH Act and the reforms at IHS 

it seeks to achieve. We offer the following comments on specific aspects of the bill, 

and urge the committee to consider it favorably. 

Long-Term Contract Pilot Program 

H.R. 5406 would create a 7-year contracting pilot program ‘‘to test the viability 

and advisability of entering into long-term contracts for the operation of eligible 

Service hospitals with governance structures that include tribal input.’’ For the pilot 

program, the Secretary of Health and Human Services would be required to select 

three direct-service IHS hospitals in rural areas, with the permission of the tribes 

served by those hospitals, and, in consultation with those tribes, to create a governing board for each hospital that includes IHS, hospital, tribal, and expert health 

care administration and delivery representatives. 

The Omaha Tribe supports the concept of blending tribal and IHS governance 

with private operation of direct service hospitals. The IHS has proven unable to 

30 

operate the services it provides, so—as long as private contractors are able to handle 

the job—we are not opposed to the IHS contracting with another entity to fulfill its 

treaty and trust obligations so long as IHS and the United States retain ultimate 

responsibility. We hope the subcommittee agrees that, though this provision calls for 

a long-term contract, the intent is not to lock the IHS and the tribes into a contract 

if the contractor fails. Language clarifying that intent in a report may be helpful. 

We also want to ensure that tribally run programs through self-governance that operate in our hospitals (like some programs at the Omaha/Winnebago facility) that 

are working are not subject to takeover in these contracts. We also support a strong 

tribal role in the governance of hospitals under this pilot program, including having 

say in the selection of the contractor and the hiring and placement of key leadership 

positions. 

We note that the IHS must not be allowed to ‘‘recycle’’ problem contractors. The 

IHS has hired ‘‘AB Staffing’’ to fill the gap in its services at our hospital and those 

at Pine Ridge and Rosebud. This company was already providing services when 

CMS terminated payment at the Omaha/Winnebago Hospital, and now their role 

has been expanded to include nursing. IHS must look farther afield, including within the Great Plains region, to find providers with expertise in rural health care 

delivery. 

Expanded Hiring Authority 

The House bill would permit the Secretary to choose to waive civil service requirements for employees providing healthcare delivery, and to instead exercise statutory 

and regulatory personnel authorities utilized by the Veterans Health Administration. This option would not apply with respect to senior executive service positions 

and positions that do not involve health care responsibilities. 

The tribe supports the efforts to streamline and speed hiring. Vacancies in health 

care provisions plague service delivery. However, we believe vacancies in leadership 

cause similar problems, and believe these provisions should be expanded to include 

leadership positions even if those are not in service delivery. Further, we would like 

to see the provisions of S. 2953 requiring consultation with tribes located in the 

service area included in this legislation. 

We do have some concern about using the Veterans Health Administration’s personnel provisions for streamlined hiring. Just 2 weeks ago, Representative 

Wenstrup introduced legislation to reform the hiring process at the VA, calling the 

process ‘‘lengthy and inefficient.’’ Congressman O’Rourke and Congresswoman 

Stefanik have other legislation aimed at improving the process to increase access 

to doctors. The Commission on Care’s final report of June 30, 2016 recommends 

many changes to the VA’s hiring process. We recommend that this subcommittee 

work with Representative Noem to locate authority that will put IHS’ process at the 

front of the pack, not just a small step ahead. 

Removal and Demotion of Employees 

The tribe supports the provisions enabling the Secretary of HHS to more easily 

remove or demote employees. 

Some staff and providers are doing fantastic work with few resources to provide 

what they can to our people. But, those good workers are cut off at the knees by 

employees who are unwilling to work or fulfill their duties. The IHS’s answer to this 

is often to transfer the employees or put them on lengthy paid leave. The problem 

will not be solved by shipping it elsewhere or shutting it out. 

We note that some have raised due process concerns about a process that will 

result in more rapid firing or demotion. We urge the subcommittee and Representative Noem to ensure this authority will not result in lengthy, unwinnable litigation 

by the IHS, or a practice of the IHS paying settlements to fired employees to avoid 

such litigation. We recommend that language be added to this section that any costs 

for litigation arising from these personnel practices and payments resulting to lost 

cases or settlements be taken from somewhere other than IHS program or services 

funds, and from either Departmental administrative funds or the Judgment Fund. 

We cannot afford services money being diverted for legal settlements. 

Timeliness of Care 

H.R. 5406 includes provisions in response to long wait times for services at IHS 

facilities. Section 104 of the bill would require the IHS to promulgate regulations 

establishing standards to measure timeliness of the provision of health care services 

at IHS facilities and to develop a process for IHS facilities to submit data under 

those standards to the Secretary. The Omaha Tribe supports these provisions. 

31 

Student Loan Provisions 

As an employment incentive, the bill would exclude payments made by the IHS 

student loan repayment program from taxable income, and permit health administration employees to participate in the IHS student loan repayment program by 

adding health care management and administration degrees to the list of eligible 

degrees for the program. It would also permit part-time employees to participate in 

the program, with a longer time commitment. The Omaha Tribe supports these 

provisions. 

Cultural Competency Program 

The bill would require the IHS, in consultation with tribal representatives, to develop and implement a mandatory cultural competency training program in each 

Service area for all employees, locum tenens providers, and contracted employees 

whose jobs require regular direct patient access. Participation in the cultural competency training program would be mandatory for all employees on an annual basis. 

The Omaha Tribe supports these provisions. 

Relocation Reimbursement 

The bill would permit the Secretary to provide between 50 percent and 75 percent 

of base pay for relocation reimbursement to IHS employees who relocate to serve 

in a different capacity or position within the IHS, if they relocate to a rural or medically underserved area to fill a position that has not been filled by a full-time noncontractor for at least 6 months, or if the relocation is to fill a hospital management 

or administration position. The Omaha Tribe supports these provisions provided 

that relocation costs do not adversely affect the provision of health care services. 

Medical Volunteer Credentialing 

The bill would require the IHS to implement a uniform credentialing system to 

credential licensed health professionals who seek to volunteer at an IHS facility. 

The bill would permit the Secretary to consult with public and private medical provider associations in developing the credentialing system. The bill summary states 

that the purpose of this provision is to ‘‘centralize its licensed health professional 

volunteer credentialing procedures at the agency level rather than the facility level 

to reduce the paperwork burden on licensed health professionals who wish to volunteer at IHS direct-service facilities.’’ The Omaha Tribe supports these provisions for 

the IHS, but is concerned that the provisions apply equally to tribally operated programs, who are already empowered to do their own credentialing of volunteer medical providers. This provision would be strengthened by limiting its applicability to 

the IHS only. 

Waiver of Indian Preference Laws 

H.R. 5406 would permit waiver of Indian preference laws. The House bill would 

permit the Secretary to waive Indian preference laws with respect to a personnel 

action if it relates to (1) a facility that has a personnel vacancy rate of at least 20 

percent, or (2) a former IHS or tribal employee who was removed or demoted from 

that former employment for misconduct that occurred within the previous 5 years. 

In order to exercise that authority, the Secretary would be required to first obtain 

a written request or resolution from an Indian tribe located within the Service unit. 

Indian Preference is critically important to the Omaha Tribe, though we support 

providing the IHS with some flexibility as contemplated here. We recommend that 

the provision be amended to require that a waiver only be operative if the IHS gets 

a written request or resolution from all Indian tribes located in the Service unit, 

not just one. Further, the waiver of preference should be limited in nature, and not 

provide a blanket lifting of preference. Adding a provision that the IHS present a 

limited staffing plan or action to which the waiver applies would help avoid the IHS 

treating requests or resolutions as long-lasting without the tribes’ intent that they 

be. 

Financial Stability Reports 

The bill would require the Comptroller General, within 1 year, to submit a report 

to Congress on the financial stability of IHS hospitals and facilities that have experienced sanction or threat of sanction by the Centers for Medicare and Medicaid 

Services, including any revenues lost as a result and recommendations for legislative action. The Omaha Tribe supports these provisions. 

32 

CONCLUSION

On behalf of my tribe, I thank the subcommittee and Representative Noem for 

their efforts to improve the IHS and the quality of care for Native people in the 

Great Plains. If there is any way I or my tribe can further assist with these efforts, 

please do not hesitate to contact me. 

Mr. YOUNG. I am going to suggest that you go ahead and testify. 

It is going to be an hour before we get back here. I guess that is 

the way we will run it. Eleven votes will be an hour, at least. I 

hate to do that to the witnesses. This shows you how we run this 

silly place, I can tell you that right now. It is not good. 

Why don’t you take over while I am gone—no, no, OK. 

Mrs. Noem, would that be OK with you, to just come back? 

Mrs. NOEM. If the committee members would come back, I think 

that the witnesses have really compelling testimony, and I think it 

would be beneficial, as this legislation moves forward. 

Mr. YOUNG. Yes, I—— 

Mrs. NOEM. So if you will come back, and if they don’t mind 

staying for an hour—— 

Mr. SABLAN. Mr. Chairman? 

Mr. YOUNG. Yes? 

Mrs. NOEM. Go get a coffee. 

Mr. SABLAN. I have just one question to Ms. Smith, if I may, 

please. 

Mr. YOUNG. Well, go ahead—— 

Mr. SABLAN. I will make it short. 

Mr. YOUNG. You don’t vote, so—— 

Mr. SABLAN. Yes, yes, I know. 

Ms. Smith, how prevalent is this problem throughout Native 

American communities? 

Ms. SMITH. Thank you. I think we have challenges throughout 

the system. Some of them are for any rural healthcare provider and 

some are unique to IHS in tribal communities. 

Mr. YOUNG. OK. We will recess now. And I do apologize to you 

guys. It is not correct, but that is the way this system works right 

now. 

[Recess.] 

Mr. YOUNG. The witnesses can all take the stand, and again I 

do apologize. Ms. Kitcheyan, you can go ahead and testify. 

STATEMENT OF VICTORIA KITCHEYAN, TREASURER, 

WINNEBAGO TRIBE OF NEBRASKA, WINNEBAGO, NEBRASKA 

Ms. KITCHEYAN. Good afternoon, Chairman and members of the 

committee. My name is Victoria Kitcheyan, and I am a member of 

the Winnebago Tribe of Nebraska. I serve as the Tribal Treasurer 

on the Tribal Council, and I want to thank you for holding this 

hearing on this piece of legislation that is the logical first step in 

adjusting the systematic changes that need to be made that are 

present. They have been allowed to go on for far too long. We think 

that the findings in Winnebago are so profound that only a longterm plan that implements organizational change with the financial resources to match are going to make any concrete changes to 

the crisis. 

33 

The Winnebago Tribe, as background information, is located in 

northeast Nebraska. We have a 13-bed inpatient IHS facility with 

a clinic and an ER department. That facility serves the Ponca, 

Winnebago, and Omaha Tribes, as well as many individual Indians 

from other tribes living in the area. So, collectively, it has a patient 

load of about 10,000 patients. Those are 10,000 patients that deserve quality health care. 

Since at least 2007, Winnebago Hospital has been operating with 

demonstrated deficiencies that have been so numerous and so disturbing that in 2015 we actually became the first federally operated facility—and, to our knowledge, the only one—to lose our 

Medicaid and Medicare reimbursement certification. And to this 

day we still are without that certification. 

Those findings go back to 2007, but have continued through the 

years. In 2011, there was a re-certification and more findings were 

uncovered. My Aunt Debbie was a victim of those deficiencies. She 

was over-medicated, left unsupervised, and died. She died in that 

hospital, and we questioned the circumstances surrounding that. 

And before all these CMS findings had come to light, we had no 

answers. We questioned how long she laid on the floor. We questioned the documentation. We questioned the cold-blooded nurses 

that covered up the incident. 

Debbie’s story and countless others need to be told. This example 

of sub-standard care and numerous documented CMS findings are 

indicative of the Federal Government’s loose commitment to its 

trust responsibility. 

When some of the findings became public, IHS publicly committed to fixing those deficiencies, but just 2 years later in 2014, 

we had four more unnecessary deaths identified by CMS. In April 

2014, a 35-year-old man died of cardiac arrest because the nurses 

did not know how to call a code blue or operate a crash cart. A 

female died because they could not load her on the medivac. A 17- 

year-old female died because they could not administer a dopamine 

drip. These things are happening at a place of healing, a place that 

is supposed to be there for the people, yet their health and safety 

is in jeopardy. 

A fourth survey was conducted in 2014, and it had been cited 

that the facility had caused actual harm and was likely to cause 

harm to all individuals that come to the hospital for examination 

and/or treatment of a medical condition. Keep in mind that when 

CMS comes, they only sample a small portion of the record so we 

will never know how many people died unnecessarily. We will 

never know how many people were misdiagnosed. 

It is these changes that need to be made, and it is these changes 

that led up to our certification termination. Throughout this period, 

IHS assured the tribe that these things were being corrected, yet 

we were still terminated in July of 2015. We have heard reports 

for years from tribal members of the notorious reputation, and we 

go there, as well, so we know how bad it is. But until CMS came 

in, our complaints fell on deaf ears. CMS was able to provide an 

independent, verifiable documentation of what was going on. The 

sister agency put their foot down. 

After these five deaths occurred, we asked the central office, 

‘‘What happens with unusual circumstances? What happens with 

34 

questionable death? ’’ And we found that there is no procedure to 

look into these. When we pressed the issue further, it is the governing body, which is non-existent. Governance was also cited by 

CMS. So, you have a governing body made up of non-medical 

professionals overseeing the actions of the physicians, the nurses, 

and the anesthesiologist. 

It is important to note also that Winnebago Hospital has become 

a short-term stop for a number of IHS contractors. These physicians coming in many times are not Federal employees, they are 

private contractors who rotate in and out of the facility for 2 to 3 

weeks at a time. They are heavily counting on the nursing staff to 

provide that continuity of care. And with the nursing staff being 

under-trained and cited in the reports, even if we had the best 

physician, how are they going to be supported by a poor nursing 

staff with a poor attitude? 

Many of these things have been cited in multiple reports. Finally, 

in 2015, after the certification had already been lost, IHS commissioned their own consultant, and they came up with 97 deficiencies 

at that hospital that had not even been identified by CMS. 

With that, they came up with a corrective action plan. The tribe 

has been working hand in hand with IHS to ensure those deficiencies are corrected, but the tribe has no real way of measuring 

if that mark has been met. That nurse watched a video; does that 

mean she can operate a crash cart? Things like that, we really 

have no control over that process. 

It is clear that management, recruitment, transparency, and also 

accountability are major issues. A full year has passed and we are 

still without a full-time CEO, we are still without a full-time 

director. We have acting administrators coming in. Without consistent leadership, it is very hard to have consistent health care. 

Mr. Chairman, these are the reasons why we support this bill. 

I must say that we encourage you to pass this legislation, but I 

implore you do not abandon us after this. It is going to take a team 

effort, additional resources, and consistent congressional oversight. 

And, furthermore, we have 10,000 people back at home who need 

their hope restored. You cannot bring back those lost lives, but we 

can honor them by passing this legislation and fully supporting it. 

But until those systematic changes are made within the IHS 

system, Winnebago Hospital will continue to be the only place 

where you can legally kill an Indian. 

My family has experienced this, countless families in my community have experienced this, and the trauma is so deep that it is beyond repair. It is going to take something outside of the scope of 

what IHS is accustomed to doing, that culture ingrained in them 

of self-preservation. We need to restore the patient care, the 

quality. 

[The prepared statement of Ms. Kitcheyan follows:] 

PREPARED STATEMENT OF VICTORIA KITCHEYAN, TREASURER, WINNEBAGO

TRIBE OF NEBRASKA

Good afternoon Mr. Chairman and members of the subcommittee, 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. Thank you for holding 

this hearing on this very important piece of legislation which presents a logical first 

step toward addressing systemic problems in the IHS system which have been 

35 

allowed to continue for far too long. I say first step because, as my testimony will 

document, the problems in the current IHS system at Winnebago are so profound 

that only a long-term plan, which implements organizational changes and comes 

with additional financial resources, is required to make real concrete changes in our 

current situation. In order to help you understand my point, allow me to provide 

you with some background information. 

The Winnebago Tribe is located in rural northeast Nebraska. The tribe is served 

by a thirteen (13) bed Indian Health Service (IHS) 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 individual Indians from other tribes who reside in the area. 

Collectively, the hospital has a current service population of approximately 10,000 

people. 

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 CMS deficiencies that have been uncovered are so numerous and so life threatening that in July of 2015, the IHS operated hospital in Winnebago became what 

is, to the best of our knowledge, the only federally operated hospital ever to lose 

its Medicare/Medicaid Certification. 

Here is a synopsis of the events that led to this decision: 

In 2011, CMS conducted a re-certification survey of the hospital and detailed 

serious deficiencies in nine areas, including Nursing and Emergency Services. My 

wonderful aunt, Debra Free, was one of the victims of those deficiencies. She died 

in the Winnebago Hospital in 2011 when she was overmedicated, left unsupervised 

and fell from her bed in the inpatient area. After her death, a nurse at the hospital 

told my family that Debra had fallen during the night. She said that nurses from 

the emergency room had to be called to the inpatient ward to get Debra back into 

bed because there was inadequate staff and inadequate equipment on the in-patient 

floor to address that emergency. 

While the hospital insisted that they did everything possible to revive her and 

save her life, we question just how long she remained on the floor and what actually 

happened. Among those questioning was Debra’s sister, Shelly, who was a nurse at 

the hospital during that period. Unfortunately, my Aunt Shelly was not on duty 

when this occurred, but she did know enough from her professional training to question the circumstances of the death. 

When my Aunt Shelly and the family requested to see the charts to determine 

what actually happened, we were met with immediate resistance. First, my mother, 

also Debra’s sister, was told she was not authorized to request the chart. Then my 

grandmother, Aunt Debra’s own mother, Lydia Whitebeaver, submitted a request 

and was denied the information. In fact, the whole family and the attorney that we 

were forced to hire were all told that the chart was ‘‘in the hands of the Aberdeen 

Area Office’s attorneys’’ and was not available to us. 

Because she demanded answers to our very reasonable questions, my Aunt Shelly 

was retaliated against in the worst way. As an IHS employed nurse at the hospital 

she was regularly intimidated by her supervisors and colleagues, and generally 

treated in the most horrific way by the Director of Nursing and her cronies. One 

of those nurses even reported Shelly to the State Licensing Board. Thank goodness 

the State Licensing Board’s Members saw that report for what it was and dismissed 

the inquiry almost immediately, but this is a prime example of why we have been 

unable to get the proof of these incidents before the CMS Reports were released. 

Fear of retaliation within the IHS system is real. One former IHS employee of the 

hospital has said that those employees who threaten to speak out are regularly 

reminded to ‘‘remember who you work for.’’ 

My aunt, Debra Free, left behind a 9-year-old daughter and a loving family. She 

should not have been allowed to die like this. Her story and those of countless others need to be told. This example of substandard care and the numerous other examples documented by the CMS Reports are indicative of the Federal Government’s 

loose commitment to upholding its Federal trust responsibility. The Great Plains 

Service Area is in a state of emergency and the patients who seek care at the 

Winnebago Service Unit are in jeopardy as we speak! 

My ancestors made many sacrifices so that our people’s livelihood would continue. 

As a tribal member and tribal leader, it is my responsibility to carry their efforts 

forward to protect my people. Neither the Winnebago Tribe, nor I, will stand idle 

as Indian Health Service kills our people, patient by patient. 

In addition to my aunt’s case, the 2011 CMS Report also found that during that 

year: patients who were suicidal were released without adequate protection; that a 

number of patients who sought care were sent home without being seen, or with 

36 

just a nurse’s visit, were never documented in any electronic medical records; that 

out of twenty-two (22) patient files surveyed by CMS, four (4) of those patients were 

not provided with an examination which was sufficient enough to determine if an 

emergency existed, and that at least one of those patients suffered an undiagnosed 

stroke and was sent home from the emergency room without any follow-up care 

whatsoever. 

When some of the findings of the CMS 2011 Report became public, in early 2012, 

former IHS Director Roubideaux publicly promised improvements. While some 

minor issues were addressed, many other things got worse. In just the past 2 years, 

four additional potentially unnecessary patient deaths and numerous additional deficiencies have been cited and documented by CMS. These incidents and reports 

include: 

• April 2014. A 35-year-old male tribal member died of cardiac arrest. CMS 

found that the Winnebago Hospital’s lack of equipment, staff knowledge, staff 

supervision and training contributed to his death. Specifically, the nursing 

staff did not know how to call a Code Blue, were unfamiliar with and unable 

to operate the crash cart equipment, and failed to assure that the cart 

contained all the necessary equipment. CMS concluded in its report that conditions at the hospital ‘‘pose an immediate and serious threat’’ mandating a 

termination of the hospital’s CMS certification unless they were corrected 

immediately. 

• May 2014. A second CMS survey found that a number of the conditions which 

pose immediate jeopardy to patients had not been corrected, and that the hospital was out of compliance with CMS Conditions of Participation for Nursing 

Service. 

• June 2014. A female patient died from cardiac arrest while in the care of the 

hospital. This time the death occurred when the staff was unable to correctly 

board her on the medivac helicopter. The conditions leading to the unnecessary death are documented in the July 2014 CMS report. This young woman 

was employed by the Tribe’s Health Department and played an active role in 

the lives of many youth, who often referred to her as ‘‘Mother Goose.’’ 

• July 2014. A 17-year-old female patient died from cardiac arrest because the 

nursing staff did not know how to administer the dopamine drip ordered by 

the doctor. CMS also documented this event in detail in its July 2014 report 

and found that numerous nursing deficiencies remained uncorrected. This resulted in the issuance of a continuing Immediate Jeopardy citation for the 

hospital on the Condition of Participation for Nursing Services. 

• August 2014. In its fourth survey conducted in 2014, CMS concluded that failure to provide appropriate medical screening or stabilizing treatment ‘‘had 

caused actual harm and is likely to cause harm to all individuals that come 

to the hospital for examination and/or treatment of a medical condition.’’ 

• September 2014. CMS survey jurisdiction over the Winnebago IHS hospital 

was transferred from the Kansas City regional office to Region VI in Dallas, 

TX, when IHS attempted to forum shop the next CMS review, but in 

November 2014, that new CMS office identified more than 25 deficiencies. 

• January 2015. Another death occurred when a man was sent home from the 

Emergency Department with severe back pain. A practitioner later left him 

a voicemail after discovering, too late, that his lab reports showed critical lab 

values. The call advised him to return in 2 days. The patient died at home 

from renal failure before the 2 days were up. This situation is documented 

in the May 2015 CMS report. 

• May 2015. CMS conducted another follow-up survey. In addition to documenting the January 2015 death noted above, the report states that seven 

CMS Conditions of Participation and EMTALA requirements were found out 

of compliance at the hospital. 

• July 2015. CMS terminated the Winnebago IHS Hospital provider agreement. 

CMS stated that the hospital ‘‘no longer meets the requirements for participation in the Medicare program because of deficiencies that represent an 

immediate jeopardy to patient health and safety.’’ 

Keep in mind that the deaths and findings cited by CMS are only the ones that 

have been documented by CMS. When CMS conducts a survey, only a small sampling of patient records are reviewed. We have no way of knowing how many more 

unnecessary deaths and misdiagnosis have occurred at the hands of IHS personnel. 

There is also no way that we can portray the tremendous pain and loss that has 

been suffered by our families and our community in these few pages. These things 

37 

are happening not only in Winnebago, but they are also happening in Rosebud, Pine 

Ridge and Rapid City. Our people are devastated, angry and demanding change. 

The totality of these circumstances finally led CMS to notify the Indian Health 

Service in April of 2015 that it was pulling its certification of the Winnebago IHS 

Hospital, unless substantial changes were made. Changes were not made and CMS 

terminated that certification on July 23, 2015. 

Throughout this period the IHS assured the Winnebago Tribal Council that the 

CMS findings, most of which were never provided to the Winnebago Tribe at least 

in their totality, were being addressed. In fact, less than 2 weeks before CMS actually pulled the Certification, the IHS Regional Director was still telling the Tribal 

Council that IHS was talking to its lawyers and planning an appeal. There was in 

fact no basis for an appeal and, 1 year later, the hospital remains without a permanent qualified CEO and is still not ready to submit an application to CMS for 

recertification. 

When the termination happened and the Winnebago Tribe and its attorneys asked 

to see a copy of the latest CMS report, they were told by the IHS Regional Office 

that it needed to be reviewed for privacy concerns before it could be released to us. 

We finally obtained a copy and also learned that the CMS oversight of Winnebago 

IHS Hospital was transferred from Kansas City to the Dallas Office. When we asked 

one CMS employee why this transfer had occurred, he was fairly quick to suggest 

that, in his opinion, this was forum shopping. Whether there is any truth to this 

or not, this transfer of CMS oversight certainly raises questions. 

While the Winnebago Tribe had heard and reported stories of these atrocities for 

years, the CMS reports have provided independent verifiable documentation of what 

was really going on. What we have learned since then is equally disturbing. 

When we asked former Acting Director McSwain about the professional medical 

review that the IHS had engaged in after each of these five deaths occurred, and 

what role the Central Office played in those reviews, we were shocked to learn that 

the IHS does not appear to have an established procedure for dealing with questionable deaths or other unusual events that occur in its hospital. In fact, if there was 

ever a professional peer review of any of those five incidents of questionable death, 

we can’t find it! 

When we pushed harder on this issue we were told that this review should have 

been conducted by the ‘‘Governing Body’’ of the hospital. This basically means that 

a body, composed largely of other IHS employees who are not doctors or other medical professionals, were supposed to review the actions of the physicians, nurses and 

anesthesiologists in the emergency room. The end result, however, is that—to the 

best of our knowledge—no one was fired, no one was reprimanded, no one was suspended pending a medical investigation and no one was reported to the licensing 

board. This is outrageous! 

The Governing Body for the Winnebago IHS Hospital has also basically been nonfunctional. The area of governance was cited numerous times in the CMS reports. 

The Governing Body is comprised primarily of IHS management officials, many of 

whom are from the regional office and have no direct personal knowledge of the 

community, the facility, the staff or the patients served by the hospital. And while 

there is supposed to be a voting seat on the board from the two primary tribes 

served by the hospital, we have found that the tribal representatives are not afforded access to all of the same information as other members of the board, or the 

information is not timely. Furthermore, training has been inadequate and there is 

no regular meeting schedule for the Governing Body. 

It is also important to note that the Winnebago IHS Hospital has become a shortterm stop for a number of IHS contractors. Many of the doctors who take care of 

our needs are not Federal employees, they are private contractors who rotate in and 

out of our facility. This forces even the best of those physicians to rely heavily on 

the nursing staff who remain at the facility, many of whom have been found by 

CMS to be seriously undertrained. Most recently, the IHS advertised to find one 

contractor to operate the Emergency Departments at three hospitals in the Great 

Plains region, including Winnebago. The contractor selected by IHS is one of the 

same problem contractors that has been around for years and that was working at 

Winnebago during the period of review by CMS. This action was supposedly taken 

to help improve the quality of services but it was done without consultation with 

the tribes and not only did we end up with one of the same companies that failed 

us in the past, the few permanent providers who did work in the Emergency 

Department were forced to either leave or transfer to other positions. 

In the fall of 2015, the IHS hired an outside consultant to perform its own review 

of the facility. This review was conducted applying standard Federal and state medical standards. During this review, this independent consultant found 97 deficiencies, many of which were never uncovered, or at least never reported, by CMS. 

38 

The IHS consultant helped to develop a corrective action plan for the Winnebago 

facility, and the hospital staff is still continuing to work on implementation of this 

plan. This is obviously necessary, but the process is slow and it is difficult to trust 

that checking an item off a list is getting us the real change that we need to see 

or that those changes will be sustained. 

It is clear that management, recruitment, accountability and transparency are all 

major issues that need to be addressed. One full year has passed since the CMS 

certification was terminated at Winnebago—and 1 year later, the CEO position at 

the hospital and the Director of the Regional Office are still being held by individuals detailed from other IHS positions for 30 or 60 days at a time. Real change and 

the rebuilding of this organization cannot happen without permanent qualified 

personnel and the funding necessary to carry out the mission. 

Mr. Chairman, these are the reasons that the Winnebago Tribe supports the immediate passage of this legislation. But, I must state clearly and bluntly, that while 

everything in this bill is needed, this 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. So, while I 

encourage you to pass this legislation, please do so as an initial first step. I implore 

you not to abandon us after this bill is passed because correcting this situation is 

going to require a 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. 

Mr. YOUNG. Thank you, ma’am. We have another witness, I 

believe. Is that Ms. Bohlen? 

Ms. BOHLEN. Yes, sir. 

Mr. YOUNG. Ms. Bohlen, you are welcome. Sorry you got caught 

in a lock-down. Come on in. 

STATEMENT OF STACY BOHLEN, EXECUTIVE DIRECTOR, 

NATIONAL INDIAN HEALTH BOARD, WASHINGTON, DC 

Ms. BOHLEN. Thank you, sir. My name is Stacy Bohlen. I am the 

Executive Director of the National Indian Health Board in 

Washington, DC. I am also an enrolled member of the Sault St. 

Marie Tribe of Chippewa Indians, and on behalf of the National 

Indian Health Board, thank you for allowing us to be here today. 

Our organization was founded in 1972 by the federally recognized tribes, both American Indian and Alaska Native, to ensure 

that the Federal Government upholds its trust responsibility and 

honors the treaties of our people for the provision of health care. 

We also support the sovereignty and self-governance, selfdetermination of the tribes. 

On behalf of the 567 federally recognized tribes, I am honored to 

be here today. Of course, the hearing today is on the proposed legislation that we have had a quick review of today—the legislation 

attempting to address long-standing tribal concerns about the 

Indian Health Service and outlining how to move forward with better staffing practices, improving timeliness of service, increasing 

cultural competency, and reforming the purchase-referred care 

system, these are needed changes. 

The National Indian Health Board would just like to ensure that 

in the review of this legislation, and as it moves forward in a bipartisan manner, that it is recognized that the legislation is amending 

the Indian Health Care Improvement Act that is the foundation of 

the delivery of health care to all American Indians and Alaska 

Natives in the United States. 

39 

We want to make sure that there is a national voice and presence forming, reviewing, and imparting opinion and knowledge into 

the system of creating what the final bill will look like. 

The solutions that we are looking at, we believe that there are 

five key areas to improving the Indian Health System. But I want 

to start with saying that the Number-one thing that the Indian 

Health System could benefit from is implementing standard business practices. 

Medicine is a business. In the United States of America, health 

systems are a business. There are standard business practices, 

there are standard accountability practices, and quality improvement measures, patient advocacy, and so forth that are done 

throughout this country that work very well. And we believe that 

the Indian Health Service, especially through some of the 

provisions that are allowed in the Indian Health Care Improvement Act, has the authority to do innovative work. And some of 

these innovations are the things that I just mentioned. 

There needs to be structural and administrative reform, quality 

assurance, recruitment and retention of qualified medical and administrative personnel, increase in medical literacy and medical 

health knowledge among American Indians and Alaska Natives, as 

well, and greater investment in our systems, our recruitment and 

retention systems that start in kindergarten to grow a cadre of 

American Indian and Alaska Native health professionals who will 

serve their own communities or our tribal communities. 

We know that there are unique challenges to delivering health 

care in any rural setting. However, there are unique challenges to 

the Indian Health System. As the Chairman knows from Alaska, 

we are talking about incredibly rural and remote areas in some 

cases. And certainly with the Great Plains, while it is not 

Kotzebue, it is very remote for Americans, and it is a place where 

something as simple as a housing shortage for healthcare providers 

and teachers can keep the tribes from having the kind of 

healthcare professionals they have. 

There is a chronic lack of funding that the IHS has been experiencing for some time. Even now, it is only funded below 50 percent 

of need. With that is the reality that the tribes fought for years for 

the Indian Health Care Improvement Act to be reauthorized. 

Congress was with us. We finally achieved that. And only about 40 

to 60 percent of that Act has been implemented because of a lack 

of funding. 

I want to call attention also to a voice in this system that can 

be very, very beneficial. Today, three American Indian physicians 

are with us in the hearing room. They are an emergency physician, 

a primary care physician, and an OB/GYN. They are from the 

Association of American Indian Physicians. Organizations like that, 

and the professions and the people they represent, have an additive 

value to the voice and the consideration of what we are trying to 

do to improve the Indian Health System. 

I could talk more about purchase-referred care and some of the 

other provisions, but I see that I am just about out of time. So, the 

National Indian Health Board does support Congresswoman 

Noem’s legislation, and we look forward to working with her, 

40 

Congress, and the tribes to forming it into a solution that works 

for all of Indian Country. Thank you. 

[The prepared statement of Ms. Bohlen follows:] 

PREPARED STATEMENT OF STACY A. BOHLEN, EXECUTIVE DIRECTOR, NATIONAL

INDIAN HEALTH BOARD

Good afternoon, my name is Stacy Bohlen, and I am the Executive Director of the 

National Indian Health Board (NIHB). Chairman Young, Vice Chairwoman 

Coleman Radewagen, and members of the subcommittee, thank you for holding this 

important hearing on the Helping Ensure Accountability, Leadership, and Trust in 

Tribal Healthcare (HEALTTH) Act. 

The National Health Board (NIHB) is a 501(c)3 not for profit, charitable organization providing health care advocacy services, facilitating tribal budget consultation 

and providing timely information and other services to tribal governments. Whether 

tribes operate their own health care delivery systems through contracting and compacting or receive health care directly from the Indian Health Service (IHS), NIHB 

is their advocate. Because the NIHB serves all federally recognized tribes, it is 

important that the work of the NIHB reflect the unity and diversity of tribal values 

and opinions in an accurate, fair, and culturally sensitive manner. It is our mission 

to be the one voice affirming and empowering American Indian and Alaska Native 

(AI/AN) peoples to protect and improve health and reduce the health disparities our 

people face. I appreciate the opportunity to provide this testimony before the 

Subcommittee on Indian, Insular and Alaska Native Affairs today. I am here today 

to offer the national perspective of all 567 federally recognized Indian tribes. 

This hearing today, and the proposed legislation we are here to discuss, have 

arisen because of long-standing, systemic issues within the IHS that have led to crisis situations—especially, in the Great Plains Service Area. In the last year, several 

hospitals in this region have lost, (or received threats of revocation) their ability to 

bill Centers for Medicare and Medicaid Services (CMS) due to the failure of federally run sites to comply with basic safety and regulatory procedures. However, many 

of the issues now coming to light are not new to American Indian and Alaska 

Natives that rely on the Indian Health Service as their primary source of health 

care and health information. At least 5 years ago, then-Senator Dorgan released a 

report exposing the chronic mismanagement occurring at both the IHS regional 

(Area Office) level and the Headquarters level of the Agency. A 2011 report by a 

separate U.S. Department of Health and Human Services (HHS) task force specifically noted that: ‘‘. . . the lack of an agency-wide, systematic approach makes it 

virtually impossible to hold managers and staff accountable for performance and to 

correct problems before they reach crisis proportions.’’ 

Now that we are in such crises situations, there must be two separate courses of 

action taken. First and foremost, immediate corrective action must be taken to rectify the closing and cutting of IHS services so there are no more unnecessary deaths 

of our people, not just in the Great Plains area, but at the national level as well. 

Once the crisis is stabilized, we must then address the fundamental and systemic 

issues that have been occurring within the Agency for decades. These reforms may 

start in the Great Plains area; but they must be implemented nationally in order 

for all American Indians and Alaska Natives to have access to safe, reliable and 

quality health care. 

The HEALTTH Act (H.R. 5406), proposed by Representative Kristi Noem, is attempting to address long-standing tribal concerns about the IHS, and outlining how 

to move forward with better staffing practices, improving the timeliness of services, 

increasing cultural competency and reforming the Purchased/Referred Care program. The spirit and intent of this legislation is clearly aimed at responding to the 

call of tribal leaders, patients and the families of those who have had adverse experiences within the IHS system. The National Indian Health Board stands ready to 

work with the committee as the bill is shaped and formed through a tribally engaged and informed process. 

Many of the provisions within this bill will provide the IHS with the authorizations they need to improve the quality of health care services delivered at IHS facilities. However, especially because this legislation proposes to amend the Indian 

Health Care Improvement Act (IHCIA), it is the position of the National Indian 

Health Board that the bill must be vetted further with a process similar to that utilized during the IHCIA reauthorization. During the years that Indian Country and 

Congress worked to achieve the reauthorization of IHCIA, the NIHB facilitated a 

tribal leader led committee. Furthermore, it is the hope of the NIHB that this legislation, and the similar Senate bill (S. 2953), the IHS Accountability Act of 2016, are 

41 

the keys that this Congress needs to move into an era where the Indian Health 

Service can be fully funded at the level of need year after year. While the provisions 

in these bills that will improve transparency, accountability, and administrative 

functions are absolutely necessary, increased funding to carry out health care services in parity with the general U.S. population is just as, if not more so, necessary 

to erase the severe health disparities experienced in tribal communities. 

FEDERAL TRUST RESPONSIBILITY

The Federal trust responsibility for health is a sacred promise, grounded in law 

and honor, which our ancestors made with the United States. In exchange for land 

and peaceful co-existence, American Indians and Alaska Natives were promised access to certain remunerations, including health care. Since the earliest days of the 

Republic, all branches of the Federal Government have acknowledged the Nation’s 

obligations to the tribes and the special trust relationship between the United 

States and American Indians and Alaska Natives. The Snyder Act of 1921 (25 

U.S.C. § 13) further affirmed this trust responsibility, as numerous other documents, 

pieces of legislation, and court cases have. As part of upholding its responsibility, 

the Federal Government created the Indian Health Service and tasked the Agency 

with providing health services to AI/ANs. Since its creation in 1955, IHS has worked 

to provide health care to Native people. As recently as 2010, when Congress renewed the Indian Health Care Improvement Act, it was legislatively affirmed that, 

‘‘it is the policy of this Nation, to ensure the highest possible health status for Indians 

. . . and to provide all resources necessary to effect that policy.’’ 

DISPARITIES

While some statistics have improved for American Indians and Alaska Natives 

over the years, they are still alarming and not improving fast enough. Across almost 

all diseases, American Indians and Alaska Native are at greater risk than other 

Americans. For example, American Indians and Alaska Natives are 520 percent 

more likely to suffer from alcohol-related deaths; 207 percent greater to die in motor 

vehicle crashes; and 177 percent more likely to die from complications due to diabetes. Most recently, a report has come out reporting that American Indian and 

Alaska Natives are disproportionately affected by the hepatitis C virus (HCV). Furthermore, Natives have the highest HCV-related mortality rate of any U.S. racial 

or ethnic group—resulting in 324 deaths in 2013. And, most devastatingly to our 

tribal communities, suicide rates are nearly 50 percent higher in American Indian 

and Alaska Natives compared to non-Hispanic whites. 

Although the statistics highlight the severity of the problem, behind each statistic 

is the story of an individual, a family and a community lacking access to adequate 

behavioral health and health care services or traditional healing practices, and traditional family models that have been interrupted by historically traumatic events. 

Devastating risks from historical trauma, poverty, and a lack of adequate treatment 

resources continue to plague tribal communities. American Indians and Alaska 

Natives have a life expectancy 4.8 years less than other Americans. But in some 

areas, it is even lower. For instance, in South Dakota, for white residents the 

median age is 81, compared to only 58 for American Indians. 

STRUCTURAL REFORM

There are unique challenges to delivering health care in any rural area, including 

provider shortages, isolation, long travel distances, scarcity of specialty care, and 

under-resourced infrastructure. However, there are successful rural health systems 

operating all around the country that are able to deliver especially innovative and 

locally responsive care. A pressing need and opportunity exists within the Indian 

Health Service, and its many rural, geographically isolated hospitals and clinics, to 

reform the structure in its administrative oversight of Service Units and Area 

offices. 

The HEALTTH Act would provide one unique approach to rethinking the way current IHS federally run and tribally run facilities are structured. The Act would provide authority to the Agency to conduct a pilot program for a ‘‘third way’’ of health 

care delivery—in addition to Direct Service and Self-Governance. The NIHB supports piloting this proposed program, as it would create joint hospital boards consisting of IHS, tribal representatives, hospital administration experts and private 

contractors. The proposed program is written in a way that honors tribal sovereignty by placing decisionmaking authority in tribal leadership and providing 

resources to prepare tribes to take on self-governance of their clinics and/or 

hospitals if that is what they choose. 

42 

We believe that rather than reinventing a health system out of whole cloth, or 

reform around the edges of a system desperately in need of dramatic and deep reforms, IHS should aspire to achieve parity with mainstream, successful medical and 

health systems. The long-term contract pilot program would be a good start to improving administrative oversight and, hopefully, lead to strengthened partnerships 

between the tribes; the IHS Area and Service Unit employees; and the private 

healthcare providers within the region. However, other elements absolutely necessary to such an aspiration are dramatic increases in the current funding levels 

and the adoption of standard and generally accepted business practices. NIHB believes that creating partnerships with mainstream and private entities will help 

IHS improve operations and systems and perhaps provide a learning laboratory for 

system-wide reform. 

QUALITY ASSURANCE

Many reports attribute the deplorable quality of care at IHS-operated facilities to 

poor agency management at all levels. We know that hiring decisions are often 

lengthy, and poor performing employees at both the Service Unit, clinic and hospital 

administration and Headquarters are not terminated, but rather moved to other 

positions within IHS—often to a position of equal or higher responsibility level. The 

cyclical chronic lack of funding and mismanagement of funds also means that 

managers are often doing more than one job, and managerial oversight of medical 

conditions is compromised. In addition to the staffing and accountability provisions 

included in the newly proposed legislation we are discussing here today, attention 

must be directed at improving the quality of care provided at federally run IHS 

facilities. This can be done by strengthening agency-wide standards for hiring qualified individuals who are capable of fulfilling the role as expected and improving the 

timeliness of care. 

On April 28, 2016, the Government Accountability Office (GAO) released a report 

on patient wait times at the Indian Health Service (IHS). As part of this report, 

GAO found that ‘‘IHS has not conducted any systematic, agency-wide oversight of 

the timeliness of primary care provided in its federally operated facilities.’’ The report further found that the electronic health record system used by IHS does not 

‘‘provide complete information on patient wait times,’’ making it harder for staff to 

track the wait times. The GAO recommended that IHS ‘‘(1) communicate specific 

agency-wide standards for patient wait times, and (2) monitor patient wait times 

in its federally operated facilities, and ensure corrective actions are taken when 

standards are not met.’’ The NIHB supports these recommendations and applauds 

the HEALTTH Act for including provisions that would do just that. 

Quality would also be increased through implementing and nurturing a culture 

and practice of continuous quality improvement, management and supervisory 

training and setting performance benchmarks that are reviewed twice-yearly. If employees are not performing, generally accepted management practices and principals 

must be in place, respected and consistently upheld. The HEALTTH Act does include provisions that would expand the hiring authority of IHS to that of other 

Federal medical care services like the U.S. Department of Veterans Affairs, as well 

as provide expanded authorities to fire or demote underperforming employees. However, before IHS is given greater authority to remove problem employees, the NIHB 

would like remind Congress that there are procedures already in place to remove 

problem employees; the real question is whether IHS is using those authorities. We 

recommend that this committee request a report from IHS documenting the number 

of times it has exercised its authority to do just that. 

RECRUITING AND RETENTION OF PERSONNEL

Title II—the Indian Health Service Recruitment and Workforce of the HEALTTH 

Act would greatly strengthen the Agency’s ability to recruit qualified health professionals by excluding the IHS student loan repayment program from gross income 

payments, essentially making the scholarship payments tax free. The Agency has 

asked for years to have similar authorizations as the National Health Service Corps, 

in order to recruit qualified health professionals to work in Indian Country. Additionally, we are pleased to see the list of degrees that qualify for the loan repayment 

program would be expanded to include health administrators. One of the inherent 

flaws in the Indian Health System is the lack of qualified hospital administrators 

and lack of basic business acumen in the management, leadership and operation of 

health systems. This provision within the bill will help to recruit, retain and fund 

students to enter Masters of Business Administration, Hospital Administration and 

43 

related professions necessary to achieving and sustaining meaningful reforms in the 

IHS system. 

While we understand that it can be challenging to recruit medical professionals 

and health administrators to remote areas, it is critical that IHS, and other related 

agencies within HHS, employ all tools at their disposal to do so. Although there are 

strong provisions within this bill to improve recruitment practices, there is little 

that would help with chronic retention issues that we see in all IHS Service Areas— 

especially in our more remote tribal communities. We have long heard from 

healthcare professionals on isolated reservations that a lack of housing and quality 

education are barriers to long-term tenure at Indian health facilities. To rectify this, 

there will need to be further collaboration among the tribes, government agencies 

such as HHS and the U.S. Department of Housing and Urban Development (HUD), 

and Congress to make investments in housing so that people working in IHS facilities have adequate living quarters available. It is also critical to provide support for 

schools so that the families of medical providers will have access to adequate educational opportunities. 

Many policymakers do not realize that the system the United States employs to 

train medical residents, as well as dentists and some nurses, is through an entitlement program, Graduate Medical Education, within Medicare. The GME program 

exceeds $15 billion annually. Congress capped the number of residency training positions in the United States as part of the Omnibus Budget Reconciliation Act of 

1997. Since 1997, several legislative amendments and changes have occurred to 

make slight increases and variances on the resident limit; however, the medical 

specialties remain highly motivated to increase the number of residency training positions within their various colleges and academies. One potential opportunity to increase the number of physicians serving in Indian Country is to set aside a certain 

number of new residency training positions for those willing to serve in Indian 

Country. The number of years of service in Indian Country following completion of 

residency training would be equal to the number of years the resident took to complete the residency. In states like Connecticut, where residency training positions 

are approximately $155,000 per resident per year, that is an astonishing incentive 

to complete service to Indian Country. Likewise, since most of the GME funding is 

in Indirect Medical Education expenses—paid directly to the training institution, 

perhaps a similar incentive could attach to the training institute if the resident does 

not fulfill the commitment. Further, there are very limited numbers of residency 

training programs in IHS facilities—and exceptions to the caps on new residency positions include rural or medically underserved communities or if a residency training program has never before existed in the training center. The Secretary of HHS 

has the authority to approve such growth: indeed, is this not the very definition of 

Indian Country? 

Tribes and the NIHB also advocate that a long-term solution to addressing 

American Indian and Alaska Native health disparities lies in investing in our youth. 

We can improve the future of the Indian health care workforce by developing a culturally and linguistically competent workforce of Native health professionals and administrators. We know that AI/AN providers are more likely to remain in their own 

communities long-term and to provide culturally appropriate care. Therefore, 

Congress and the IHS should prioritize resources and relationship building with 

academic institutions and national health professional organizations to engage 

Native youth in cultivating interest and capability in pursuing medical and health 

professions. 

PURCHASED/REFERRED CARE REFORM

In addition to the direct healthcare services provided by the Indian Health 

Service, eligible American Indians and Alaska Natives can also access healthcare 

services by non-IHS providers through the Purchased/Referred Care Program (PRC). 

PRC funds are used to supplement and complement other health care resources 

available to eligible Indian people. The funding for PRC is distributed among the 

12 IHS Service Areas through a formula that was created through consultation with 

the Director’s Workgroup on Purchased/Referred Care and Tribal consultation. Regional and national priorities were taken into account when the formula was created 

and the section of the HEALTTH Act that requires the IHS to develop and implement a new allocation formula within three (3) years, needs to be further consulted 

on with tribes all across the Nation. The National IHS Tribal Budget Formulation 

Workgroup, reported to the Secretary of the HHS on June 20, 2016, that ‘‘a major 

concern for tribal leadership is that PRC policies have not been updated in years. 

The current policies were written during a time when the IHS had to restrict access 

44 

to services by creating limits to eligibility and scope of services provided. Tribes 

have asked the IHS to update these policies and bring them up to today’s standard 

of quality care in order to have a better picture of what the true funding need is 

for PRC services. The truth is that these needs have been understated for at least 

40 years.’’ The HEALTTH Act provides a good opportunity for the Agency to continue working with tribes and the Director’s Workgroup to assess and improve the 

program and allocation formula. 

As with the rest of the IHS budget, PRC funds have not kept pace with the health 

needs of tribal members, the cost of health care and the growth of tribal populations. As a result, PRC funds, which are managed by the IHS, are typically reserved for emergency and specialty services based on a priority schedule developed 

by the IHS. However, self-governance tribes are able to develop their own priority 

schedules, so the provision within the HEALTTH Act that would freeze the funding 

level of facilities who have achieved Priority Level III–V for a 3-year transition period, could disparately impact self-governance tribes and would be a disincentive for 

high performing facilities. An alternative solution may be to allow IHS facilities or 

Service Units the same flexibility as tribally operated facilities for developing their 

own, locally responsive priority schedules. 

Furthermore, the provision of the HEALTTH Act that codifies the recent IHS 

Purchased/Referred Care Final Rule that was published on March 21, 2016, needs 

to take into account some of the tribal concerns with the final rules. While the rules 

were created with tribal consultation and input, some concerns remain such as private providers refusing to see AI/AN patients that utilize PRC funds, that implementing PRC rates will increase the volume of services being sought and decrease 

the quality and length of visits, and that the software systems needed to calculate 

payment rates are too costly for the already underfunded Federal and tribal run 

health facilities. 

CONCLUSION

In conclusion, the NIHB overall supports the recent efforts made by both the 

Indian Health Service and Congress to address long-standing issues that our people 

have faced for far too long. Since issues have come to light in the Great Plains 

Service Area in the past year, the IHS has sought new leadership and pursued innovative policies and programs. Most recently, the IHS issued a new policy on opioid 

prescribing that is the first of its kind for a government agency that provides direct 

medical care. Additionally, law makers have been engaged with tribes across the 

country and, very much so, with the tribes of the Great Plains region. 

Finally, because this legislation seeks to amend the Indian Health Care Improvement Act, the National Indian Health Board would like to take this opportunity to 

remind the committee that the Indian Health Care Improvement Reauthorization 

and Extension Act (S. 1790, enacted in H.R. 3590) permanently reauthorized and 

made several amendments to the Indian Health Care Improvement Act (IHCIA). 

Numerous provisions of S. 1790 have not yet been fully implemented. Below is a 

summary of the progress in implementing these provisions. The strides we have already made to achieve quality improvement will remain unfulfilled and continued 

or future efforts will not be successful without full funding and implementation of 

these important authorizations for improved Indian health. 

45 

46 

Mr. YOUNG. If I may, the Indian Health Care Act that was in the 

Obamacare Act was my bill. It was written by Senator Hirono. It 

took her 15 years to get that done. It is the only good thing in the 

whole Obamacare package, by the way. I want you to be aware of 

that. 

And I will say we have not done our job, but we have done pretty 

good. We are asking for a 5 percent increase, $5.1 billion, this year. 

May not be enough, but I was interested in what you had to say 

about management, and we will talk about that later. 

Ms. Church, I am glad you made it back. I am sorry if anything 

happened. 

STATEMENT OF JERILYN CHURCH, CHIEF EXECUTIVE 

OFFICER, GREAT PLAINS TRIBAL CHAIRMEN’S HEALTH 

BOARD, RAPID CITY, SOUTH DAKOTA 

Ms. CHURCH. Good afternoon, Honorable Representative Young, 

Ranking Member Ruiz, and members of the committee. And thank 

you, Representative Noem, for your time and your commitment to 

address the serious quality of care concerns in our region. 

My name is Jerilyn Church, and I am a member of the Cheyenne 

River Sioux Tribe. I was born and raised on the Cheyenne River 

Reservation. I received my primary care through IHS growing up, 

and I choose to receive my care from IHS today. 

I also serve as the Chief Executive Officer for the Great Plains 

Tribal Chairman’s Health Board. We are a non-profit tribal organization that serves as a vehicle for appointed tribal leaders who are 

consulted within HHS, including IHS. These representatives represent the 18 tribes in North Dakota, South Dakota, Nebraska, and 

Iowa. We provide public health messaging and support to our tribal 

health departments, technical assistance to tribal leaders on topics 

of health care advocacy, provide training and education opportunities, and provide epidemiologic technical assistance, including disease surveillance, and increasing tribal capacity to develop data 

products and assist with other emerging health priorities. 

In addition to my written testimony, for your consideration I 

appreciate the opportunity to summarize some of my insights and 

recommendations, which I hope will serve to strengthen the intent 

of this Act. 

Under Title I, one of the most promising opportunities that I see 

is the opportunity to create an alternative delivery of care system. 

The health board’s leadership is in early discussions with many 

tribes and tribal health authorities regarding the opportunities and 

feasibilities of tribes assuming their programs under the selfdetermination authority. But resources are needed to explore alternative delivery systems and establish models that ensure healthy 

financial systems. We do not want our tribes to assume programs 

that are broken and assume failing programs. 

We believe that the pilot project that is recommended under Title 

I needs to stay under the authority of tribes. But the private sector 

has a lot to offer. They are experts in delivery of care, and their 

contractual involvement should be to provide management, 

mentorship in order for tribes to build their own capacity, rather 

than providing the direct operational role. 

47 

Title I is also designed to provide consistency and parity between 

the authorities of the VA and IHS, but I would also advocate that 

that would include protection of IHS funding from sequestration. 

Many of the recommendations outlined in Title II serve to address Indian Health Service recruitment and workforce needs in 

the Great Plains. However, many of the preference laws are imperative to tribal self-determination efforts and developing capacity of 

tribal health programs. So, I don’t know that a statutory change to 

Indian preference is necessary, however, there needs to be ability 

for tribes and the IHS to exercise flexibility when it is appropriate, 

and case by case. 

For example, when a position is advertised within IHS, how the 

Indian preference is currently interpreted is that those that meet 

the criteria for Indian preference are raised to the top, as they 

should be, for consideration and for interviews. However, those applicants that do not meet Indian preference criteria are not 

included in that pool. 

So, if it is determined that candidates that meet Indian preference do not have the qualifications or the experience for the 

position, IHS goes back and then they have to re-advertise, and 

anybody that is worth their salt who may not make Indian preference criteria probably has moved on to other opportunities. That 

is an example of where that interpretation could be changed to 

where we look at all candidates, but still exercise Indian 

preference. 

Expanding scholarship opportunities under Title II is a positive 

step, but there are many punitive measures for poor performance 

under Title II, which is important for accountability. I think an 

even more proactive and effective approach would be to also invest 

in advanced education and training for the many committed, highperforming staff who are members of our communities and who 

have dedicated their lives to serving our tribal members. I think 

they get forgotten and overlooked, especially in a time of crisis. 

Title III attempts to address many of the shortfalls of the 

purchased and referred care program. One of the greatest opportunities that IHS has to improve the PRC program is to implement 

the authority under the Indian Health Care Improvement Act to 

recognize North Dakota and South Dakota as one contract support 

service delivery area. 

Currently, IHS continues to operate under the old system that 

limits care to a limited service delivery area, impeding access and 

coverage of tribal members who need specialty care that is not 

available at their local service units. 

And while I understand this committee does not have appropriation authority, I would be remiss if I did not stress the importance 

of funding fundamental change of the IHS. To implement law without adequate funding is paramount to continued failure. There are 

several other authorities under the Indian Health Care Improvement Act that, if funded, would greatly improve the quality of 

service and care. 

I thank you today for your time. 

[The prepared statement of Ms. Church follows:] 

48 

PREPARED STATEMENT OF JERILYN CHURCH, CHIEF EXECUTIVE OFFICER, 

GREAT PLAINS TRIBAL CHAIRMEN’S HEALTH BOARD

Good afternoon Chairman Young, Ranking Member Ruiz, and members of the 

committee. Thank you, Representative Noem for your time and commitment to address the serious quality of care concerns in the Great Plains Area Indian Health 

Service. 

My name is Jerilyn LeBeau Church; I am a member of the Cheyenne River Sioux 

Tribe, I was born and raised on Cheyenne River, received my primary care through 

IHS growing up and I choose to receive my care from IHS today. 

I also serve as the Chief Executive Officer for the Great Plains Tribal Chairmen’s 

Health Board. We are a non-profit tribal organization that serves as a vehicle for 

appointed tribal leaders who consultation with HHS, including the IHS, who represent the 18 tribes in North Dakota, South Dakota, Nebraska and Iowa. We 

provide public health messaging and support to our tribal health departments, technical assistance to tribal leaders on topics of healthcare advocacy, provide training 

and educational opportunities and provide epidemiologic technical assistance, 

including disease surveillance, increasing tribal capacity to develop data products 

and assist with other emerging health priorities. 

In addition to a detailed written testimony for your consideration, I appreciate the 

opportunity to summarize my insights and recommendations which I hope serve to 

strengthen the intent of H.R. 5406. 

Title I—‘‘Expanding Authorities and Improving Access to Care’’ provides a promising opportunity to create an alternative delivery of care. GPTCHB leadership is 

in early discussions with tribal health authorities regarding the opportunities and 

feasibility of tribes assuming and successfully implementing their health programs 

through the self-determination authority. Resources are needed to explore alternative delivery systems and to establish models that ensure healthy financial systems. Under any pilot project, the tribe must remain the primary authority to 

preserve the ‘‘IHS’’ provider status. Private Health Systems are experts in the delivery care, and their contractual involvement should be to provide management 

mentorship to build capacity rather than providing a direct operational role. 

Title I is also designed to provide consistency and parity between the authorities 

of the VA and IHS, I would also advocate that that would include protection of IHS 

funding from sequestration. 

Many of the recommendations outlined in Title II will serve to address Indian 

Health Service Recruitment and Workforce needs in the Great Plains. However, 

Indian Preference Laws are imperative to Tribal Self-Determination efforts and developing the capacity of tribal health programs. Rather than a statutory change to 

Indian Preference, tribes should have sole authority to exercise regulatory flexibility 

when appropriate and on a case-by-case basis. 

Expanding scholarship opportunities under Title II are a positive step. However, 

much of the focus on under Title II are punitive measures for poor performance 

which is important for accountability. A more proactive and effective approach 

would be to also invest in advanced education and training of the many committed 

high performing staff who are members of our communities and who dedicated their 

lives to serving our tribal members. 

Title III attempts to address the many shortfalls of the Purchased and Referred 

Care Program. One of the greatest opportunities that IHS has to improve the PRC 

program is to implement the authority under the Indian Healthcare Improvement 

Act to recognize North Dakota and South Dakota as one Contract Support Service 

Delivery Area. Currently, IHS continues to operate under the old system that limits 

care to a limited service delivery area, impeding access to and coverage of tribal 

members who need specialty care that is not available at their local service units. 

While I understand this committee does not have allocation authority, I would be 

remiss if I didn’t stress the importance of funding a fundamental change of the IHS. 

To implement the law without adequate funding is paramount to continued failure. 

There are several other authorities under the Indian Healthcare Improvement Act 

if funded would greatly improve the quality of service and care. 

Mr. YOUNG. Thank you, Ms. Church. Good testimony, and I will 

have some questions, but Ms. Kristi, I want to let you go first, it 

is your bill. If you have questions—they are all in support of it, so 

be careful. Don’t ruin that, you know? No, go ahead. 

49 

Mrs. NOEM. Thank you, Mr. Chairman, I appreciate that. I wanted to speak specifically with Chairman Bear Shield because I know 

you have stayed and actually might be missing a flight to stay here 

and testify on this bill, because it is so important to your tribe. 

The Rosebud Emergency Department has now been diverted for 

7 months. I am pleased that we are here today to the point that 

CMS is now re-surveying the emergency department. But according 

to the recent article in the Argus Leader, in Sioux Falls nine people 

have died in ambulances on their way to the hospital. Do you confirm these numbers? You have said that in your testimony today. 

Mr. BEAR SHIELD. Yes, I just spoke with our ambulance service 

director this morning, and there were nine deaths. 

Mrs. NOEM. Did they believe that those deaths could have been 

preventable, if the emergency department had been open? 

Mr. BEAR SHIELD. I guess they happened during the diversion. 

We can’t say yes, they could have been, but we can’t say just the 

opposite of that. So, our tribe looks at it as being a part of the 

diversion of the ER. 

Mrs. NOEM. Well, I think that if there is going to be an investigation, which you also talked about in your testimony, part of that 

should be on whether those were preventable. And I believe that 

it should be done by an unbiased entity like the HHS Inspector 

General. Is that what you were recommending when you were 

talking in your testimony? 

Mr. BEAR SHIELD. Yes, exactly, somebody from a different 

agency. 

Mrs. NOEM. OK, I appreciate that. 

Ms. Smith, will you commit to join me in asking for the HHS 

Inspector General to investigate those nine deaths? 

Ms. SMITH. Yes, Congresswoman, I will. 

Mrs. NOEM. OK. I appreciate that very much, because that is 

really why we have an emergency situation on our hands. I appreciate you being willing to do that. 

And the HEALTTH Act also provides authorities for IHS to discipline and fire under-performing employees. One of the things I 

have heard over the last several years is, oftentimes, when we have 

a problem with somebody who is providing care or within administration of IHS, they are removed and then they are just rehired 

somewhere else. They are not necessarily ever punished, there are 

no consequences for not doing their job properly. I have heard this 

since I have been in office and have been trying to get to the bottom of it. I have that addressed in my legislation, yet in your testimony you say that that is not needed, you already have those 

authorities. 

So, I would like to know why that has not been done. I have not 

heard of a single person being fired from IHS because of the poor 

care that has been delivered in the facilities in the Great Plains 

region. I have heard of people being moved, and we have had leadership moved, but we have not had anybody pay any consequences. 

So, when you say it is not necessary in my bill, obviously, for the 

last couple of decades that we have had this situation going on, and 

since I have become aware of it, since I have come into office in 

the last few years, as we have been able to get all the tribes on 

the same page and pushing, and then we have had this crisis 

50 

situation, now that I have it addressed in my bill you say it is not 

necessary. Tell me why nothing has been done. 

Ms. SMITH. Thank you, Congresswoman Noem. I appreciate the 

efforts, and I think that at IHS we are committed to providing 

high-quality care. And to the extent that someone is not meeting 

that standard, there should be accountability. And you know, in 

cases that are warranted, people should be disciplined. 

Mrs. NOEM. Has anybody been disciplined or fired? 

Ms. SMITH. Yes, people have been disciplined. 

Mrs. NOEM. Could you get me those names and information? 

Ms. SMITH. I am happy to talk to you separately about personnel 

matters. 

Mrs. NOEM. Nobody fired? Do you think anybody has been fired, 

removed from IHS employment? 

Mr. YOUNG. Will the gentlelady yield? 

Mrs. NOEM. Yes. 

Mr. YOUNG. I think under the personnel laws, you cannot fire 

anybody. It is like the VA. 

Mrs. NOEM. Well, we are asking for the same provisions that the 

VA has recently received and changes that—— 

Mr. YOUNG. OK. See, but that—— 

Mrs. NOEM. That is what we are asking. 

Mr. YOUNG [continuing]. Has to be in your legislation. 

Mrs. NOEM. Yes. But you indicated in your testimony that it 

wasn’t necessary to have those provisions, so that is why I want 

to know if that is in place. We can talk about that offline, but I 

also want it dealt with, too. 

You also say that about my requirements for dealing with wait 

times. Mr. Bear Shield, do people wait a long time in the hospital 

for appointments and for emergency room treatment when it is 

open? 

Mr. BEAR SHIELD. Oh, yes. They have for many years. Yes. 

Mrs. NOEM. And again, Ms. Smith, you say that it is not necessary for us to require you to assess that and fix that problem because you already have those authorities. How come it hasn’t been 

done before? How come it hasn’t been fixed before? 

Ms. SMITH. I have only been in the job for a few months, but we 

are working aggressively on that. It is a very important issue. I 

totally agree with you, Congresswoman. 

And two things I can tell you that we are doing—well, actually 

three things. One, in all the senior executive service performance 

measures they are supposed to account for two concrete measures 

on wait times. We are implementing things at different facilities. 

One thing that has worked is that leaving same-day appointments 

open so there is flexibility for people to see that, and then third, 

we are going to be working on coming up with different models to 

address the wait times. And then, obviously, fourth, one of the 

issues that ties into that is having full staffing. We are working on 

a number of recruitment tools. So again, I appreciate your efforts 

on this important issue. 

Mrs. NOEM. I can appreciate the fact that you have only been in 

your position a few months; but unfortunately, for years we have 

watched this revolving door happen. And you may not be here longterm in this position, somebody else may come in and they may not 

51 

be—that is why we are trying to get certainty in health care here, 

because we look at the situation we are at today, and people are 

dying. 

So having somebody say, ‘‘You don’t need to do that, we are going 

to fix it,’’ we have heard that for years, and that is why we need— 

I am sorry, Mr. Chairman. I will yield back. 

Mr. YOUNG. You can hang around again. I just want to recognize 

the Ranking Member. 

Dr. RUIZ. Thank you. 

Ms. Bohlen, I understand that many of the proposals instituted 

in the permanent reauthorization of the Indian Health Care 

Improvement Act are still being implemented at the Indian Health 

Services. In your written testimony, you supplied us with a breakdown of that progress. In your opinion, will the proposals in the 

HEALTTH Act complement that effort? 

Ms. BOHLEN. In the legislation we are talking about today? I 

think it would complement it, yes. But I also think that there is 

a level of funding that is not available. If you look at the percentages of the programs that were authorized in the Indian Health 

Care Improvement Act that have not been implemented, it 

matches, kind of tracks side by side with, the level of funding that 

is not there. 

Of course, it is true that Congress, led by this House of 

Representatives, has done an excellent job of increasing funding to 

the Indian Health Service over the past several years, and that is 

to be lauded, especially in the budgetary environment we—— 

Dr. RUIZ. Are the fundings targeted specifically for this problem, 

or are there fundings for other problems but not this one? 

Ms. BOHLEN. I am not the one who can speak to that. The Indian 

Health Service would know best where those monies are being 

targeted. 

Dr. RUIZ. OK. And you mentioned that an avenue for recruitment 

for physicians could be through the GME program by setting aside 

a certain number of residency training positions for those who 

choose to serve in Indian Country. Can you further explain to us 

how this could help alleviate the problems with recruitment? And 

what do you need to make this goal a reality? 

Ms. BOHLEN. Thank you for asking that question, because that 

is an exciting opportunity. 

In the Omnibus Budget Reconciliation Act of 1997, Congress put 

caps on the number of graduate residency training positions that 

could exist in the United States for the first time since the program 

was implemented in 1965. And the important thing to understand 

is that the graduate medical education program of this country is 

an entitlement program through Medicare, somewhat through 

Medicaid. There is a direct medical education expense and an indirect medical education expense. 

In a residency position that could be reimbursed, like at the 

University of Michigan, I believe it is about $160,000 per resident 

per year. Maybe $110,000 of that goes into the institution to pay 

the indirect expenses to build that residency program, to have the 

physicians to do the training, and so forth. Yet, in Indian Country, 

I just learned of a successful program at the Choctaw Nation of 

52 

Oklahoma. They are experimenting with this, and they are being 

very successful. 

But where the money goes to build institution and build these 

residents is where all or substantially all of—— 

Dr. RUIZ. I think the point here is that a physician is most likely 

going to practice where they are from originally and they have a 

family member, and where they last trained. So, if we want more 

physicians in the recruitment process in under-served communities 

like in reservations, then we need to take students from the reservation, put them in a program, and then have them trained, their 

last location of training in the reservation and practicing community health. 

I think that is a pipeline program that I have developed with my 

Future Physician Leaders program in the most under-served area 

in Southern California, and I think it is important that when we 

look at a system of recruitment that is comprehensive, that grabs 

him from the high school, puts him into a pipeline program, and 

sends him back into the community for training. 

Ms. Smith, so we have heard from tribal nations, including the 

ones before us today, that Indian Health Service regional leadership has not properly informed the DC IHS leadership about problems and deficiencies. What are you doing from the top to 

proactively manage and monitor the different regions and their 

facilities? 

Ms. SMITH. Thank you, Congressman, for asking that question. 

We are working aggressively on new reporting methods from all 

the areas on finances, HR, and other communication methods. And 

it is important that—I think the one thing that is a priority for me 

is that there is oversight over all the areas, and that people recognize that we are all one IHS, and we are all working together for 

the common goal of providing access to health care for Native people. And we will—— 

Dr. RUIZ. What are your plans on holding the management 

accountable for consistently implementing these new procedures 

and using best practices that are shared amongst the different 

management? 

Ms. SMITH. We are working on holding people accountable. One 

example that has recently been done is there is a new performance 

standard in all the performance reviews which is holding people accountable for maintaining the conditions of participation with the 

Centers for Medicare and Medicaid Services. 

We are also doing training on practices for managers, so that 

they know how to document incidents, and that training has already started with senior staff, and it is going to go down to all 

the staff. 

But I will also say, in addition to holding people accountable, it 

is very important that we are also working on a culture where people feel free that they must report issues. They cannot hide them. 

They need to present the issue and a solution, and we all need to 

work together. We are also working on measures in that regard. 

Mr. YOUNG. Mr. Benishek. 

Dr. BENISHEK. Thank you, Mr. Chairman. 

Ms. Smith, how long have you been on the job? 

Ms. SMITH. I think it is a little over 3 months. 

53 

Dr. BENISHEK. So you are just new to all this, and this huge 

problem that we have here, the Indian Health Service. 

Frankly, Mrs. Noem was right, this sounds very much like the 

VA, you know, government-run healthcare. Sometimes it does not 

work. 

There are 27 health facilities that the Indian Health Care 

Service—is that the number that I heard? Is that correct? 

Ms. SMITH. That is the number of our hospitals. We have over 

160 clinics, as well, that we run. 

Dr. BENISHEK. OK. How many of the hospitals have you been to? 

Ms. SMITH. How many hospitals have I been to? 

Dr. BENISHEK. Yes. 

Ms. SMITH. I have been to four of them. 

Dr. BENISHEK. Have you been to the one that they are talking 

about here that had the emergency room closed? 

Ms. SMITH. I have been to every hospital that we are talking 

about today. I have been to Omaha Winnebago, Rosebud, Pine 

Ridge, and Sioux San. 

Dr. BENISHEK. Are these places inspected by JCAHO? 

Ms. SMITH. I think that, prior to my arrival, the accrediting body 

that was being used in the Great Plains and is currently being 

used is DNV. 

Dr. BENISHEK. What is that? 

Ms. SMITH. DNV, Doss Veritas—— 

Dr. BENISHEK. I don’t know. The 99 percent of hospitals in the 

country are certified by JCAHO. It is a foundation—or it is a nonprofit founded by the American College of Surgeons, of which I am 

a member, to inspect hospitals because the types of things that we 

have seen here I find pretty amazing that have actually occurred 

in a hospital in America. 

I just find it very disconcerting to even hear that this stuff is 

going on. Mrs. Noem’s testimony earlier today was unbelievable. 

And, I know you have only been on the job for 3 months, but this 

is a huge issue. And frankly, I am not sure that political appointees 

is the way this should be done. There should be a long-term 

management of this with a regular board, just like proposed for the 

VA. All right? We should not have political appointees coming in 

every 2 weeks or 2 months and then be responsible for an organization that they don’t really understand how it all works. 

I mean, you are a manager, but you have a pretty important job 

here, billions of dollars in funding, health care, people are dying, 

and we do not have a good answer for it. 

So, I think that this is a good step for making things move, but 

having political appointments, there should be a body, a board of 

directors that is appointed by the President and Congress. There 

should be a CEO so that there is continuity and skill involved in 

this management process. The way this is being done is a disaster. 

Mrs. Noem kind of gets to it, but what do you have to say about 

my idea there, Ms. Smith? 

Ms. SMITH. Well, Congressman, I agree that this is a serious situation and a lot of this is just unacceptable. And I certainly agree 

with you that one of the key things that makes a facility successful 

is continuity of leadership, strong leadership, and strong governing 

board organization. 

54 

Dr. BENISHEK. All right, good. Well, I have one more question, 

and that is—you have a balance sheet for every facility so that you 

know how much you are spending and how much money is coming 

in so that there is an accountability as to how much money is being 

spent on administration, on supplies, per facility? Do you do that 

kind of accounting? They don’t do that at the VA very well. 

Ms. SMITH. Congressman, thank you so much for asking that. 

That is actually one of the things we are implementing on the 

finances. We are wanting to get reports from the areas—— 

Dr. BENISHEK. So you don’t do that now; is that the answer? You 

are going to start doing that? Is that what you are telling me? 

Ms. SMITH. I have been there for a couple months, and we will 

start doing that. We have already put the process into place. 

Dr. BENISHEK. All right. My—— 

Mr. YOUNG. No, you have 49 seconds. 

Dr. BENISHEK. Yes, that is what I thought. I thought I heard you 

knock—— 

Mr. YOUNG. No, I am a little nervous. I have to go out and testify 

in another committee; you are going to take over here in a minute. 

Dr. BENISHEK. These are the kind of things that it is pretty 

amazing for people in the healthcare field to actually listen to, the 

fact that you are not even taking care of the numbers like that, and 

yet you are running a multi-billion dollar operation. You see what 

I am saying? Because a regular hospital could never operate that 

way. They know exactly how much money is coming in, they know 

actually where it is going. And you don’t. 

And we talk about funding levels. Well, the efficient spending of 

the taxpayer dollar is a pretty important thing. And it doesn’t seem 

to me that this agency is actually doing that. So, I think I will yield 

back. Thank you. 

Mr. YOUNG. Thank you. And you will take over the Chair in a 

moment here. I have to go down and testify. 

One thing I would like to suggest. Chief Bear, you mentioned 

something about the tribes and the potential fines would be 

$2 million if you don’t participate in the Obamacare bill? 

Mr. BEAR SHIELD. It is cheaper for us to pay the fine than it is 

to pay nearly $400,000 a month in insurance fees for our tribal 

employees. 

Mr. YOUNG. But that is still taking, what you said, about 

$2 million a year out of your cash-flow that could be used for other 

purposes? 

Mr. BEAR SHIELD. Exactly. And if you understand, in listening to 

the questions from the committee earlier, there needs to be some 

education, I feel. And that will be an ongoing process. Just remember the population that we are talking about with these facilities 

are historically in the top five poorest counties in the Nation; so 

that is where we are at in the Great Plains area. 

Mr. YOUNG. One of my biggest problems personally is that we 

are doing a pretty good job in Alaska. And the IHS is supporting 

it financially, but they are not running them. I believe in that selfdetermination concept, and you do a much better job. And I encourage you—I know what you have said, you do not have the ability 

right now. And I don’t know how we do it, but the sooner we can 

55 

get the government out of it and let you run it, I think it would 

be a lot better off. 

Ms. Smith, I want to thank you. I am going to have to let Mr. 

Benishek take over this deal in a minute. This has not been comfortable for you. And I want to ask you—you have been here 3 

months—to use this committee; don’t listen to your boss. We are 

really the boss, because like Mrs. Noem said, this has been going 

on. It is not just you, or not just this Administration. This has been 

going on, and it is a very discouraging thing. I have walked 

through some very interesting places in my life, including some 

quicksand areas, and you try to get out of it, and the more you 

struggle, the bigger you get into it, and pretty soon nobody is paying any attention because you are already under the quicksand. 

And we need to help. I mean you need help. 

Ms. SMITH. Yes. 

Mr. YOUNG. We cannot do this by ourselves. I want to move this 

legislation. 

Mrs. NOEM. Mr. Chairman? 

Mr. YOUNG. Yes. 

Mrs. NOEM. Over here. 

Mr. YOUNG. Yes. 

Mrs. NOEM. Can I just ask you for a favor? The bill that Mr. 

Bear Shield was talking about is one that penalizes tribal businesses for not complying with the Obamacare mandate, which our 

tribal businesses should not be bound to. In Obamacare, it exempted tribal members from the mandate. Our tribal businesses employ 

tribal members, so they are penalizing our tribal businesses in our 

tribes for not covering people in insurance that the government is 

responsible to cover their insurance and health care costs. That is 

how crazy that thing is. That is another bill that I need your help 

getting done, too, that is devastating. 

Mr. YOUNG. Well, I—— 

Mrs. NOEM. It has passed through Ways and Means, and we 

need to get it across the House Floor. 

Mr. YOUNG. Well, let’s do that. And the second thing I can tell 

you, respectfully, that if I was the Chief of those tribes, I wouldn’t 

do it and would tell the government to go suck an egg. 

I can say that because I probably would not go to jail. But the 

reality is that is inappropriate, because that was the intent, that 

you were not to have to pay this. And now they are making you. 

That is a challenge all over the Nation, as far as the American 

Indian and Alaska Natives go. And that is something to work on. 

Mr. Benishek, would you please take the Chair? I want to thank 

the witnesses for your input. I like the idea of a business platform, 

run it right. I don’t believe it has been run right. And unfortunately, over the years, it has probably gotten a little rotten. No disrespect, that is probably what has happened. It is a natural 

phenomenon. 

So, with this bill and the help of Ms. Smith, we will be able to 

try to solve some of these problems, try to get health care to those 

constituents. We can hear all the sad stories we want, we just do 

not want it to happen again. What happened yesterday is yesterday. What is going to happen tomorrow is what we have a role in 

trying to do. 

56 

So, Mr. Benishek, would you take the Chair? All right. Behave 

yourself, too. 

Dr. BENISHEK [presiding]. Mr. Ruiz, do you have any questions? 

Mrs. Noem, do you have any further questions? 

Mrs. NOEM. Just one, if you don’t mind. 

Ms. Smith, I know we have talked about the fact that it has not 

been on your watch that a lot of this happened, but this is one instance in which I want to explain to you why there is so much concern and why there is legislation here today, is because last year, 

in discussion with IHS officials, my staff expressed concern—and 

Mr. Bear Shield referenced this incident before, as well—but we 

talked about CMS findings at Rosebud, pointing out a baby was 

born on the floor, comparing it to the 2010 Senate report, where 

something like that had happened, as well. And the IHS’s Chief 

Medical Officer had said, ‘‘Well, if you have two babies hitting the 

floor in 8 years, that is pretty good.’’ And I understand that now 

that individual has been moved and made Acting Chief Medical 

Officer of the Great Plains. 

So, that is the fundamental question that I have—how are we 

supposed to trust this person to care for people when he makes 

statements like that? I would have removed the individual for a 

statement like that. But now they are the Acting Chief Medical 

Officer of this entire region. How can I trust them with the safety 

and care of the 122,000 tribal members in the Great Plains? 

When was he moved to Acting Chief Medical Officer of the Great 

Plains? When did that happen? 

Ms. SMITH. Thank you, Congresswoman, and I will just say that 

those comments are unacceptable. And that was made clear that it 

was unacceptable. I believe that the individual in question has publicly apologized for those comments. 

So, I certainly agree that our tribal patients and partners need 

to have respect and rapport with medical staff at each of our facilities. That is very important to us. And I am happy to talk with you 

any time and with any of the people here about any issues they 

have with people, because I think one of the fundamental things 

is the quality of health care that you have. 

Mrs. NOEM. Do you know when that person was moved into that 

position? 

Ms. SMITH. I believe it was probably about a month ago. 

Mrs. NOEM. So, that was on your watch. 

Ms. SMITH. Yes. And, like I said, the person in question has publicly apologized. I know that she is committed to caring for the patients. And to explain the decision, there was no Chief Medical 

Officer in the Great Plains, and there was no full-time person. As 

I have said at this hearing, we have very serious recruitment and 

retention problems. We have lots of vacancies. 

And I can tell you that, personally, I am committed to quality 

health care in the Great Plains. I spend a lot of time working on 

that. I know we don’t move as fast as people would like. We are 

not moving as fast as I would like. And I think, from my perspective, that it was important to have a full-time Chief Medical Officer 

there. So that was the basis of the thinking for that. 

57 

And like I said, if there are issues, I am happy to further discuss. 

But I did feel that it was important to have a Chief Medical Officer 

full time in the Great Plains to try to assist our patients there. 

Mrs. NOEM. One last thing, Ms. Bohlen, your staff was incredibly 

helpful to us as we drafted this legislation, so I appreciate that. 

I know I don’t have much time, but can you please tell me a little 

bit about your alternate idea for the PRC transition provision in 

the bill? You have an alternate idea? 

Ms. BOHLEN. I am trying to think of what our alternate idea is. 

Mrs. NOEM. Well, that’s all right. If you don’t—but I did think 

that you had another idea for how we could transition the PRC 

provision in the bill. 

I want to just maybe leave this discussion so that everybody 

knows our hope is to continue to work on this bill. I am not married to this bill exactly the way that it is. I want to pass a bill that 

fixes problems and that everybody can get behind and recognize is 

a huge change that was needed in IHS and meets the needs of the 

tribes in the Great Plains region. And I think it is time to think 

outside of the box, and it is time for everybody to get on board, because I am not going to quit. So, we need to get on board, and we 

all need to pull the same direction and fix the problems that we 

have. 

And with that, Mr. Chairman, I yield back. 

Dr. BENISHEK. All right. Thank you, Mrs. Noem. I have one more 

question, because we are talking about this funding issue, and it 

always comes to funding. We want to be sure that the funding is 

appropriately spent, and apparently the IHS entered into an $80 

million settlement with the employee unions for overtime-related 

claims at the IHS-operated facilities. Were any of the funds that 

were used to pay these claims staffing monies? Do you know anything about that? 

Ms. SMITH. The settlement was entered into before I took this 

position, but my understanding is that the settlement was over 

back pay for people who do provide care at these facilities. 

Dr. BENISHEK. Well, the information that I have says that the 

funding was not paid out of a judgment fund, it came out of the 

staffing fund, directly from the money that would go to staff these 

facilities. And there is a separate judgment fund—would you look 

into that for me, please, and find out what the story is with that? 

Ms. SMITH. We are happy to get back to you, Congressman. 

Dr. BENISHEK. All right. That was the last question that I had. 

So, thank you, Ms. Smith. You know, this is not that easy. And 

I have a lot of experience in the VA Committee with very similar 

issues. We have sincere, newly appointed people in the Department 

who have to explain bad behavior for a long time. And that is, unfortunately, your job here today. And we need sincere people to actually change the way things happen, and not come here to tell us 

how hard you are working to make a change, and then nothing 

happens. I am used to that, I am used to the Administration people 

coming to me and saying, ‘‘We really want to fix it,’’ but then, over 

the course of years, nothing changes. 

That is what we are all frustrated about. These people out here 

have a bad hospital and nobody seems to be responsible. And you 

58 

are telling them, ‘‘Well, we are doing the best we can,’’ and that 

does not work any more. 

So, anyway, I am sorry about all the comments, but I want to 

thank the witnesses today for your valuable testimony, and for the 

Members for their questions. 

The members of the committee may have some additional 

questions for the witnesses, and we will ask you to respond to 

these in writing. 

Under Committee Rule 4(h), the hearing record will be open for 

10 business days for these responses. 

If there are no further questions, then, without objection, the 

committee stands adjourned. 

[Whereupon, at 5:25 p.m., the subcommittee was adjourned.] 

[ADDITIONAL MATERIALS SUBMITTED FOR THE RECORD]

PREPARED STATEMENT OF DEB FISCHER-CLEMENS, SENIOR VICE PRESIDENT, 

AVERA HEALTH

Good afternoon Chairman Young and members of the Subcommittee on Indian, 

Insular and Alaska Native Affairs. Avera, the health ministry of the Benedictine 

and Presentation Sisters, is a regional partnership of health professionals who share 

support services to maintain excellent care at more than 300 locations in 100 communities throughout eastern South Dakota and surrounding states. On behalf of our 

health care providers in hospitals, post-acute centers, clinics, Avera Health appreciates the opportunity to submit a statement of record for Congresswoman Kristi 

Noem’s bill, the Helping Ensure Accountability, Leadership, and Trust in Tribal 

Healthcare (HEALTTH) Act of 2016 (H.R. 5406). 

Avera greatly appreciates the Congresswoman’s work to improve health care for 

Native Americans and believe the proposed legislation contains many needed steps. 

After reviewing the HEALTTH Act, Avera would suggest the following concerns 

be addressed in an amendment to the legislation: 

The Indian Health Service relies on a number of manual processes for Purchased 

Referred Care (PRC) service authorization, claims processing and payment functions. It would be to the benefit of PRC beneficiaries and health care providers if 

the IHS would bring its administrative transactions up to the standards specified 

by the Health Insurance Portability and Accountability Act (HIPAA) and as implemented by Medicare, Medicaid and private sector health care insurers, administrators and providers. Extended processing time frames due to manual processes, and 

the potential for lost records directly jeopardize an individual’s access to needed 

health care and/or unanticipated medical expenses. Additionally, it means providers 

are at risk for non-payment or delayed payment for authorized services. 

In short, though these technology updates would cost money, they are important 

to improve the referral and billing process. 

Thank you again for considering this input and allowing Avera Health to provide 

feedback on the HEALTTH Act. 

PREPARED STATEMENT OF THE HON. MICHAEL MARCHAND, CHAIRMAN, 

CONFEDERATED TRIBES OF THE COLVILLE RESERVATION

The Confederated Tribes of the Colville Reservation (‘‘Colville Tribes’’ or the 

‘‘CCT’’) appreciates the opportunity to provide this statement on H.R. 5406, the 

‘‘Helping Ensure Accountability, Leadership, and Trust in Tribal Healthcare Act’’ 

(‘‘HEALTTH Act’’). The CCT would like to express its thanks to Congresswoman 

Noem for introducing this important bill that will address long-standing issues with 

the Indian Health Service (‘‘IHS’’), both in the Great Plains and in other IHS 

regions. 

The CCT is one of six direct service tribes in the IHS’s Portland Area. The 

Portland Area oversees 43 Indian tribes in the states of Washington, Oregon, and 

Idaho. Similar to the tribes in the Great Plains, the CCT has struggled with chronically low staffing levels in its IHS-operated facilities. In the CCT’s case, the lack 

of staff is primarily the result of the absence of a mechanism for tribes that have 

59 

not been fortunate enough to construct a new health care facility through the IHS 

system to bring their staffing levels current. Like the Great Plains, some is also attributable to the challenges of attracting qualified health professionals to work in 

rural areas. 

This statement provides background on these issues and three recommendations 

on how they can be addressed in the HEALTTH Act. The CCT believes the 

HEALTTH Act, particularly its provisions relating to staff recruitment and re-examining Purchased-Referred Care funds distribution, is a needed and overdue fresh 

look at these long-standing issues. 

BACKGROUND ON THE COLVILLE TRIBES

Although now considered a single Indian tribe, the Confederated Tribes of the 

Colville Reservation is, as the name states, a confederation of 12 aboriginal tribes 

and bands from across the plateau region of the Northwest and extending into 

Canada. The present-day Colville Reservation is approximately 1.4 million acres and 

occupies a geographic area in north central Washington State that is slightly larger 

than the state of Delaware. The CCT has more than 9,500 enrolled members, about 

half of whom live on the Colville Reservation. In terms of both land base and tribal 

membership, the Colville Tribes is one of the largest Indian tribes in the Pacific 

Northwest. 

Most of the Colville Reservation is rural timberland and rangeland and most residents live in one of four communities on the Reservation: Nespelem, Omak, Keller, 

and Inchelium. These communities are separated by significant drive times. 

FACILITY NEEDS AND HISTORICALLY LOW STAFFING LEVELS

Like other Indian tribes with large service delivery areas, the Colville Tribes face 

a health care delivery crisis. The CCT’s original clinic in Nespelem, was built by 

the U.S. Department of War in the 1920s and was converted into an IHS facility 

in the late 1930s. From the information that we have been able to obtain from IHS, 

the staffing ratios at the Colville IHS Service Unit were established when the 

Nespelem clinic went into service in the 1930s. While funding levels have increased 

incrementally with IHS’s base budget in the intervening decades, the initial staffing 

ratios have not changed. 

The only way for direct service tribes like the CCT to bring staffing levels current 

under the IHS system is to construct a new facility under the IHS system. There 

are currently two ways to accomplish this. The first is the priority list system, which 

has been in effect since the early 1990s and provides funding for construction of the 

facilities included on the list as well as 80 percent of the annual staffing costs. The 

second is the joint venture (JV) program, which requires an Indian tribe to pay the 

entire up-front cost of construction of a facility in exchange for IHS providing a portion of the annual staffing costs. The priority list has been closed since the early 

1990s and the JV program is extraordinarily competitive and has been funded only 

sporadically during the past decade. Unless a facility is built under either of these 

two programs, IHS will not update the staffing ratios for a given IHS service unit. 

The CCT sought in the 1980s and the early 1990s to replace the Nespelem facility 

with a new facility through the IHS priority list system. We understand that at one 

point, the CCT’s request for a new clinic in Nespelem was near the top of the priority list but was removed because of concerns that the facility was a historical site. 

None of the more than 40 tribes in the IHS Portland Area, of which the CCT is 

a part, have ever had a facility constructed under the priority list system. 

Because the CCT’s need for a new facility in Nespelem was so great and the priority list had been closed, the CCT was ultimately forced to take matters into its 

own hands and construct a new Nespelem facility primarily using tribal funds. 

Since the facility was not on the priority list and the CCT was not selected for the 

JV program, IHS did not provide any additional staff or otherwise update the antiquated staffing ratios for the Colville Service Unit. This means that, despite paying 

to construct our own facilities, we continue in a sometimes futile effort to provide 

modern health delivery to approximately 5,000 tribal citizens using 1930s staffing 

ratios. 

In response to a congressional inquiry, in 2013 IHS calculated that the Colville 

Service Unit had less than one-third of the required number of clinical staff and 

only one-quarter of the required number of dental staff. Later that year, on 

December 17, 2013, the CCT adopted a resolution declaring a state of emergency 

in response to the continued lack of healthcare provided by the IHS and vacancies 

that threatened delivery of healthcare on the Colville Reservation altogether. 

The CCT has been doing everything it can to find creative ways to address these 

issues. For example, we are currently examining the feasibility of deploying Dental 

60 

Health Aide Therapists (DHATs) to help bridge the gap in oral health care on the 

Colville Reservation. The lack of available dentists in Omak (the largest population 

center on the Reservation) sometimes forces those residents to drive nearly 3 hours 

to Inchelium for dental services. The CCT is encouraged by the IHS’s recent overtures to Indian country to expand the use of DHATs and is fully supportive of this 

effort. 

RECOMMENDATIONS TO ADDRESS STAFFING INEQUITIES IN THE HEALTTH ACT

The CCT has three recommendations on how the HEALTTH Act could address 

the CCT and other similarly situated tribes’ staffing issues. The first would be to 

provide direction for IHS to provide some pathway for tribes that self-funded and 

constructed their own health facilities outside the IHS system to obtain staffing 

packages, whether short term or permanent. Lack of adequate staffing not only 

means fewer health care providers and longer wait times for our tribal members, 

it also means that we are unable to maximize third party reimbursements because 

of lack of administrative support. The limited number of providers are not able to 

see as many patients, which negatively impacts the CCT’s service population and, 

by domino effect, the Purchased-Referred Care funds allocated to the Colville 

Service Unit. 

Although permanent staffing would be desired, even shorter term staffing would 

be beneficial. With the 2010 reauthorization of the Indian Health Care Improvement 

Act, more opportunities exist for tribes to generate additional revenue to pay for 

staff through third party reimbursements. Providing even a short-term infusion of 

staff to tribes in this situation would empower those tribes to make these reimbursements and staff self-sustaining. 

Another benefit of providing a path forward for tribes to update staffing levels is 

that it would allow for increased preventative care, which would reduce the need 

for Purchased-Referred Care by ensuring that minor health conditions do not become severe. 

Another recommendation the CCT would like to explore would be to direct IHS 

to prioritize or provide some enhanced consideration to tribes that are currently operating under historic staffing levels when IHS allocates any increases that 

Congress may provide to IHS for staffing. If implemented, this would provide some 

equity to those tribes that have been operating under antiquated historic staffing 

levels. 

Finally, the CCT would also like to see Congress direct IHS to consult with Indian 

country and provide information to Congress on those IHS service units that are operating under historic staffing levels. Such information could include the volume of 

third party reimbursements between service units with low staffing levels compared 

to those with updated staffing ratios, impact on patient care, and other 

considerations. 

The CCT looks forward to working with Congresswoman Noem, this committee, 

and the other committees of jurisdiction on these issues and assisting in advancing 

the HEALTTH Act to House approval. 

PREPARED STATEMENT OF JOHN YELLOW BIRD STEELE, PRESIDENT, 

OGLALA SIOUX TRIBE

My name is John Yellow Bird Steele and I serve as the President of the Oglala 

Sioux Tribal Council. The Oglala Sioux Tribe is pleased to see that Congress and 

this subcommittee recognizes the urgent need for action to address the current 

Indian health care crisis in the Great Plains region and throughout the Country. 

I appreciate the opportunity to submit this testimony on behalf of the Oglala Sioux 

Tribe to provide the subcommittee with the tribe’s views on H.R. 5406, the Helping 

Ensure Accountability, Leadership, and Trust in Tribal Healthcare (HEALTTH) Act. 

THE URGENT NEED FOR ACTION

The United States owes a trust duty to all tribes and a specific treaty obligation 

to the Oglala Sioux Tribe to ensure the health and well-being of our Indian people. 

In the Sioux Treaty of 1868 (known as the Fort Laramie Treaty), the Great Sioux 

Nation and the United States agreed on a quid pro quo: by the terms of the treaty, 

the United States promised to provide certain benefits and annuities to the Sioux 

Bands each year, including health care services, in exchange for the right to occupy 

vast areas of Sioux territory. The IHS is tasked with carrying out this duty by providing quality health care services in our communities, though the responsibility 

61 

belongs to the U.S. Federal Government as a whole. The evidence is clear that the 

IHS—and as a result, the United States—is failing at that task. 

Congressional action is sorely needed to address this very serious emergency. As 

it stands, the Pine Ridge Hospital is not a functioning facility that is capable of 

meeting even the basic health care needs of our community. On top of the mismanagement problems that have been well highlighted by government reports, witness testimonies, and even news reports, our hospital facility is only utilizing a 

portion of our inpatient beds, and our intensive care unit is not even operational 

due to funding, staffing, and equipment shortages and despite the high level of 

unmet health care needs on our reservation. This situation is unacceptable; falls far 

short of the Federal Government’s treaty obligations to our tribe; and must be 

addressed. 

The Oglala Sioux Tribe appreciates the ongoing efforts of this subcommittee to 

hold the IHS—and indeed the Federal Government as a whole—accountable to 

deliver on the promise of quality health care for our people. We believe that 

H.R. 5406 would take important steps to implement needed reforms, and we would 

like to comment on the specific provisions of the bill and offer our suggestions to 

strengthen the bill and its impact even further. 

Sec. 101: Service hospital long-term contracting pilot program 

H.R. 5406 would create a 7-year contracting pilot program ‘‘to test the viability 

and advisability of entering into long-term contracts for the operation of eligible 

Service hospitals with governance structures that include tribal input.’’ The pilot 

program is also designed as ‘‘an alternative to full direct-service and full selfgovernance, with an emphasis on preparing tribes for self-governance.’’ 

The Oglala Sioux Tribe is not opposed to the consideration of new and innovative 

ideas to address deep-rooted and systemic problems, including long-term contracting. Fundamentally, the Oglala Sioux Tribe simply wants a health care system 

that works and that results in the best possible health outcomes for our communities. The tribe also appreciates efforts to provide an alternative to full direct service and full self-governance. However, we emphasize that the trust and treaty 

responsibility to provide health care to our tribal people belongs to the U.S. Federal 

Government and cannot itself be contracted out or privatized. Accordingly, the 

Federal Government must always remain ultimately responsible and accountable for 

Indian health programs. With respect to the pilot program proposal, that means 

that the contracts and governing board for each hospital must be structured in such 

a way that the IHS is not relieved of its ultimate responsibility of ensuring quality 

healthcare for our people. Private involvement should be geared toward capacitybuilding and systems improvement so that direct service tribes are better served 

and tribes that eventually choose to contract under the ISDEAA do not inherit a 

dysfunctional and ineffective system. Further, in addition to leveraging private sector expertise, the Federal Government must commit to providing Federal resources 

at the full level of need in order to make tribal self-governance a meaningful option 

for tribes. With these caveats, the tribe supports the proposed pilot project in 

H.R. 5406. 

Sec. 102: Expanded hiring authority for the Indian Health Service 

We are also happy to see that H.R. 5406 seeks to address the need to improve 

and streamline the hiring process within the IHS. H.R. 5406 would allow the 

Secretary to utilize, in place of the civil service requirements, VA hiring authorities 

with respect to positions involving direct patient services or services incident to direct patient-care services. The IHS has represented that it already has the ability 

to exercise at least some of these authorities, and it is not clear to the tribe that 

these authorities have permitted the VA itself to succeed in resolving the recruitment problems it has faced. Moreover, the bill as currently drafted focuses primarily 

on recruitment and less on retention, which is equally important. Thus, further consideration should be given to whether the VA authorities are the best substitute for 

current IHS authorities, and additional measures may be necessary to make a 

meaningful impact on IHS recruitment and retention. 

There are many factors that contribute to the hiring and retention challenges 

faced by the IHS in the Great Plains area and elsewhere, including mismanagement, uncompetitive salaries, unattractive and underequipped facilities, the rural 

and isolated location of our facilities combined with the economically depressed 

character of our communities, and the lack of housing and other infrastructure. As 

one example, the Oglala Sioux Tribe is in serious need of housing for its health care 

professionals given the shortage of housing options in the vicinity of our hospital 

62 

1The Pine Ridge Hospital has 450 positions but only 104 housing units. Likewise, the Kyle 

Health Center has 86 positions but only 20 housing units; the Wanblee Health Center has 35 

positions but only 5 housing units; and the LaCreek District Clinic has 6 positions but no housing units. There are few alternative housing options within a reasonable distance of any of these 

facilities, so staff housing specifically associated with IHS facilities is critical. 2The IHS Service Unit profile shows that the Service Unit currently services a user 

population of 51,227 in a space designed for a user population of 22,000. 

and clinics—an issue that directly impacts our ability to attract and retain health 

care professionals and administrators.1

The Oglala Sioux Tribe believes that meaningful improvement in recruitment and 

retention at the IHS depends in large part on resolving these interwoven issues. We 

agree with other testimony that collaboration between the tribes, the IHS, and other 

Federal agencies—including the U.S. Department of Housing and Urban Development, the Bureau of Indian Affairs, the Bureau of Indian Education, the U.S. 

Department of Education, and the U.S. Treasury Department, among others—is 

needed to ensure that attractive housing, education, and economic opportunities are 

available to health care professionals considering employment with the IHS in our 

communities, and to their families. It is exceedingly difficult to attract and retain 

qualified professionals while asking them to forego quality education for their children or meaningful employment prospects for their spouse. The tribe also supports 

efforts to recruit and train a Native health care workforce, so that we can staff our 

health care facilities with tribal members who already have strong ties with and 

commitments to our communities. 

Funding for facilities and equipment also impacts recruitment and retention. 

Competent, qualified staff do not want to work in a facility where they lack the tools 

necessary to do their job or where their job is made harder (or even impossible) by 

a lack of resources. But the Pine Ridge Service Unit has documented a need for, 

among other things: fetal monitoring systems, telemetry systems, surgery lights, a 

nurse call system, dental chairs and equipment, and IV pumps, to name a few. 

Equipment needs are so dire that, as one example, earlier this year we were told 

that the hospital was waiting for one of its IV Service Unit Pumps to finally stop 

working so they could take parts from it to fix another one. Some of this equipment 

is critical and could mean the difference between life or death in a patient emergency, but there is no additional funding for equipment purchases. Additionally, the 

facility is inadequate to handle the hospital’s user population.2 Even so, not all of 

the existing space is even being utilized because we lack the necessary staff and 

equipment. Very few health care or management professionals would want to work 

in such an environment, even with loan repayment and other incentives, and these 

realities have a very real impact on IHS recruitment efforts. 

Additionally, the tribe feels strongly that key IHS hiring decisions ought to be 

made with tribal consultation. A bill to reform the IHS currently pending in the 

Senate, S. 2953, would require the Secretary to consult with Indian tribes located 

in the service area before hiring or transferring senior executives or top managers, 

and we believe a similar provision would be appropriate in H.R. 5406. 

Sec. 103: Removal or demotion of employees 

Poor management practices and the ‘‘recycling’’ or shuffling of problem employees 

has been a long-standing problem within the Great Plains area, as has the use of 

administrative leave in lieu of more appropriate action like demotion and firing. 

H.R. 5406 seeks to address this mismanagement problem by enhancing the 

Secretary’s authority to hire, fire, demote, and reward employees based on performance; by limiting the use of paid administrative leave; and by requiring expedited 

review of removal and demotion decisions. 

The Oglala Sioux Tribe generally supports these reforms, and emphasizes the 

importance of qualified and accountable leadership within the IHS and the Department of Health and Human Services, as well as strong ongoing congressional oversight, to ensure that these authorities are appropriately used to fulfill the United 

States’ trust responsibility to provide our tribal members with quality health care. 

Indeed, as the IHS points out in its own testimony, authorities and procedures 

already exist to remove problem employees, but they have not been used in a consistent or effective manner. 

We support the enhanced authorities in H.R. 5406, and recommend that the IHS 

develop a policy for how it is to use these and existing authorities. Such policy 

should be developed in consultation with tribes and congressional committees of jurisdiction. This would help to ensure that existing and expanded authorities are utilized as intended by Congress and to the benefit of tribes with meaningful results. 

IHS testified that removal of employee protections could impact recruitment by 

making IHS a less desirable place to work. Our view is that most employees want 

63 

a well-thought out policy that is objectively and consistently applied, not an ad hoc, 

subjective modus operandi. 

We also agree with other testimony that any reform measures relating to adverse 

action against employees should be carefully vetted for constitutional due process 

concerns to avoid the prospect of copious, lengthy, or costly litigation against the 

IHS, and that these provisions should specify that the costs of such litigation and 

any resulting settlements be paid from sources other than IHS program or service 

funds, such as the United States Judgment Fund. 

Finally, the tribe supports the use of mandatory random drug testing for all IHS 

employees as a key accountability measure. Representative Noem recently introduced H.R. 5437 to implement such a program, and we suggest that the provisions 

of H.R. 5437 be incorporated into H.R. 5406 to require random drug testing not just 

for IHS management, but for all IHS employees. We understand that the VA uses 

pre-employment drug testing as well as random employee drug testing in its facilities, and the same should be true of the IHS. Health professionals should not be 

reporting for duty while under the influence of illegal substances. 

Sec. 104: Improving timeliness of care 

Long wait times are a major barrier to care at IHS facilities within the Great 

Plains area and a serious problem at the Pine Ridge Hospital, where emergency patients wait for hours and sometimes leave without ever being seen. H.R. 5406 would 

require the IHS to promulgate regulations establishing standards to measure timeliness of the provision of health care services at IHS facilities and to develop a process for IHS facilities to submit data under those standards to the Secretary. 

However, the draft bill stops short of requiring any particular action in response to 

those reports. The tribe suggests that the bill be amended to require negotiated 

rulemaking and to specify that the topics to be addressed in the negotiated 

rulemakings include follow-up steps to be taken by the IHS, in consultation with 

affected tribes, to reduce patient wait times in response to the reported data 

wherever possible. 

Sec. 201: Exclusion from gross income for payments made under Indian 

Health Service Loan Repayment Program 

The tribe supports this proposal, which was requested by the IHS in the Administration’s Fiscal Year 2017 Budget request and would bring the Indian Health 

Service loan repayment program into parity with the National Health Service Corps 

and Armed Forces Health Professions scholarship programs with respect to income 

tax treatment. 

Sec. 202: Clarifying that certain degrees qualify individuals for eligibility 

in the Indian Health Service Loan Repayment Program 

The tribe supports this proposal as a means of improving the IHS’s ability to 

attract health care management and executive professionals. The IHS has long 

struggled to attract and retain qualified management personnel. 

Sec. 203: Cultural competency programs 

The tribe supports the bill’s provision to require cultural competency training in 

each service area for all employees. 

Sec. 204: Relocation reimbursement 

The tribe supports the use of relocation reimbursement and incentives to attract 

high-quality employees to the IHS, provided funding is not diverted from needed 

health services. The IHS has testified that it already has authority to provide relocation reimbursement and incentives, again pointing to the need for accountable 

IHS leadership and strong congressional oversight, as well as adequate funding, to 

ensure that existing authorities are appropriately utilized. 

Sec. 205: Authority to waive Indian preference laws 

The tribe appreciates the intent behind this provision to provide greater hiring 

flexibility while leaving the ultimate decision to waive Indian preference laws to the 

impacted tribe. Any provision seeking to waive Indian preference should be carefully 

crafted and fully vetted as Indian preference is an important tool that has been used 

to strengthen the Indian health care system and build tribal capacity. Furthermore, 

we note that similar authority already exists under 25 U.S.C. § 472a(c)(1). 

Sec. 206: Streamlining medical volunteer credentialing process 

The tribe supports the creation of a centralized credentialing system within the 

IHS to credential volunteer health professionals at direct-service IHS facilities. 

64 

Sec. 301: Codification of limitation on charges for health care professional 

services and non-hospital-based care 

The tribe appreciates efforts to improve the Purchased/Referred Care (‘‘PRC’’) 

program. The PRC program is designed to ensure access to primary and specialty 

health care services that the IHS is unable to provide in its own facilities and must 

purchase from outside providers. Funding for the PRC program is so limited, however, that care is frequently rationed and limited to emergency ‘‘life or limb’’ situations. On Pine Ridge, even these emergency ‘‘priority 1’’ cases are sometimes 

rejected by the IHS due to funding constraints. Oglala Sioux tribal members routinely forego necessary medical care because the IHS refuses to pay through PRC. 

In the alternative, if these patients do seek the care, they often find themselves in 

financial crisis because the IHS will not cover the costs. 

The Oglala Sioux Tribe appreciates the fact that H.R. 5406 seeks to extend 

Medicare-Like Rates to all PRC services. Currently, only payments for hospitalbased services are capped at the Medicare-Like Rate by statute, and Medicareparticipating hospitals are required to accept those rates as a condition of 

participation. Extending Medicare-Like Rates to non-hospital PRC services in the 

same manner would greatly increase the efficiency of the PRC program: in 2013, 

the GAO released a report finding that extending Medicare-Like Rates to nonhospital PRC services would save the IHS approximately $32 million per year, 

which could be used to pay for needed services that the IHS must now deny. However, the Tribe believes that the approach taken in the current draft bill could be 

improved. 

Specifically, the bill would limit PRC payments to providers and suppliers by essentially codifying the recently released IHS regulations capping PRC rates for nonhospital services. This approach would cap the IHS or tribal health program’s ability 

to pay (if the tribal health program chooses to opt in), but would not provide any 

enforcement mechanism or consequences to the provider or supplier if the provider 

or supplier refuses to accept the capped payment rates. Tribes have argued that, 

in order for Medicare-Like Rates to be effective, they must be a condition of provider 

participation in the Medicaid program, as is the case for the existing Medicare-Like 

Rate caps on payments for hospital services. The IHS regulations do not include this 

enforcement mechanism because the IHS did not have the authority to impose those 

requirements, and as a result the regulations have been viewed by tribes as a ‘‘nextbest’’ alternative to legislation. Congress, of course, does have the authority to 

enforce Medicare-Like Rates, and should do so. 

A bill was introduced in the last Congress by Senator Betty McCollum 

(H.R. 4843, 113th Cong.) that would have extended Medicare-Like Rates to nonhospital PRC services by amending the Social Security Act and requiring providers 

and suppliers to accept the lower rates as a condition of their participation in 

Medicare. That bill had strong support from Indian Country, and the Oglala Sioux 

Tribe strongly recommends that H.R. 5406 take the same approach with respect to 

Medicare-Like Rates. 

Sec. 302: Allocation of Purchased/Referred Care program funds 

Section 302 would require the Secretary, through negotiated rulemaking with 

tribes, to develop and implement a revised distribution formula for PRC funding and 

would prioritize PRC funding increases in service areas where the majority of PRC 

services currently provided are priority level I or II—in other words, in service areas 

where only the most serious health care emergencies are funded. First, what is 

needed and in fact required by the Federal Government’s treaty and trust responsibilities is full PRC funding for all medically necessary care at every level of care. 

It is incumbent on the United States as our trustee to ensure that preventive, primary, and specialty care is available to our patients before their conditions become 

chronic or life-threatening, not just after. Not only is that the only humane and responsible approach to reduce human suffering, but it is also far more efficient and 

fiscally responsible: rationing and delaying care until a health condition becomes an 

emergency means that condition will be significantly more costly and difficult to 

treat. The tribe cannot emphasize strongly enough the importance of fully funding 

the PRC program. 

An associated problem faced by our tribal members is the cost of transportation 

to receive PRC services for primary and specialty care that cannot be provided at 

our hospitals and clinics. Again, due to funding constraints, the IHS does not always 

pay for these costs and our patients do not have the financial resources. The tribe 

frequently ends up covering transportation costs associated with medical care, which 

diverts tribal funding that is badly needed for other purposes. Dedicated, full funding for transportation for health care referrals is necessary to assure access to care. 

In addition, enhancing the capacity of local IHS facilities like the Pine Ridge 

65 

Hospital to provide the full range of primary care services to their full patient population and expanding the scope of specialty care available at those local facilities— 

especially for specialty care that is in particularly high demand, like psychiatric and 

respiratory care—would cut down significantly on expensive patient travel. This, of 

course, would require funding for increased staffing, improved facilities, and necessary medical equipment at the local level. Another strategy for reducing the costs 

and other burdens associated with patient travel is the development and support 

of telemedicine. Developing our telemedicine and telehealth capacity has been a priority for the tribe and could be an important feature of a reformed, more responsive, 

and higher quality health care delivery system in the IHS. The IHS is already exploring telemedicine possibilities, but legislative support—including authorizations 

for appropriations, pilot projects or programs, and dedicated funding—would help to 

ensure that these efforts bear fruit. 

Improving and fully funding the PRC system, including travel costs associated 

with PRC referrals, is a top priority for the Oglala Sioux Tribe and must be a part 

of comprehensive reform efforts. Though fully funding the PRC system would 

require an up-front investment, the return would be substantial in terms of health 

outcomes and system efficiency. 

Improve the PRC Program through Implementation of 25 U.S.C. § 1678a 

The PRC program in the Great Plains area would also be significantly improved 

through implementation of 25 U.S.C. § 1678a, enacted as part of the permanent reauthorization of the Indian Health Care Improvement Act in 2010, which requires 

the IHS to designate South Dakota and North Dakota as a single contract health 

service delivery area (CHSDA). Subsection (b) of that provision further states: 

The Service shall not curtail any health care services provided to Indians 

residing on any reservation, or in any county that has a common boundary 

with any reservation, in the state of North Dakota or South Dakota if the 

curtailment is due to the provision of contract services in those states pursuant to the designation of the states as a contract health service delivery 

area by subsection (a). 

However, the IHS is not implementing this provision, and IHS’s regulations do 

not include the states of South Dakota and North Dakota in its list of CHSDAs. See 

42 CFR § 136.22. 

Implementation of 25 U.S.C. § 1678a is not discretionary. Congress mandated that 

North Dakota and South Dakota be designated a single CHSDA and, as a result, 

any action by IHS to deny services to any individual based on its pre-existing 

CHSDAs in those states is unlawful. Yet, IHS continues to deny services to individuals throughout both states based on the geographic limitations in the CHSDAs it 

established in those states prior to the enactment of 25 U.S.C. § 1678a. This has had 

multiple negative effects throughout both states: because the IHS continues to deny 

PRC authorizations for American Indians living outside the pre-existing CHSDAs, 

those individuals are forced to either forgo needed care or seek care even if they 

lack the resources to pay for it. When there is no valid PRC authorization, those 

individuals may be liable for the cost of that care. If they cannot afford the care, 

both they and their non-IHS provider suffer. The patient’s credit may be affected 

by bill collectors, and the non-IHS provider cannot receive payment for the services 

they have provided. The issue is compounded for emergency services because 

hospitals are required under EMTALA to provide such services even when the individual seeking them cannot pay. 

The IHS has taken the position that it cannot implement 25 U.S.C. § 1678a without further appropriations. While additional funding is certainly needed for PRC 

programs, 25 U.S.C. § 1678a is not dependent on additional funding. Rather, it imposes a mandatory statutory duty on the IHS to designate both North Dakota and 

South Dakota as a single CHSDA and ensure that there is no curtailment of services to individuals living on or near a reservation in North Dakota or South Dakota 

as result of carrying out Congress’s directive that those states should encompass a 

single CHSDA, 25 U.S.C. § 1678a(b). The tribe, therefore, suggests that H.R. 5406 

include a provision that directs the IHS to implement 25 U.S.C. § 1678a. Additionally, as the Pine Ridge Reservation includes a portion of Nebraska, we note that 

the CHSDA for Nebraska remains the same. 

66 

3The settlement had two categories: $60 million for back pay and back pay-related costs (such 

as payroll taxes), and $20 million for administrative costs and attorneys’ fees. $50 million of 

the $60 million amount was paid from third party collections and $10 million from expired 

appropriations. The $20 million was paid from then current fiscal year 2015 appropriations. 

Sec. 304: Report on financial stability of Service hospitals and facilities 

The tribe supports the proposal in H.R. 5406 to require the Comptroller General 

to submit a report to Congress within 1 year on the financial stability of IHS hospitals and facilities that have experienced sanction or threat of sanction by the 

Centers for Medicare and Medicaid Services, including any revenues lost as a result 

and recommendations for legislative action. 

The tribe also believes that additional measures to ensure transparency in financial management would be helpful. For example, S. 2953 would require the 

Secretary to provide a report to Congress and tribes each quarter of a fiscal year 

describing spending and outlays at each level of the IHS, and would require the 

Secretary to consult with Indian tribes before spending unobligated funds at the end 

of the fiscal year, except with respect to specific categories of expenditures. In addition, the Oglala Sioux Tribe would like to see tribal consultation on the allocation 

of funding for the Pine Ridge Service Unit. 

Additionally, the IHS should be required to provide a full accounting of the 

funding received by the Area Office, how it is allocated, its employees, programs, 

and what functions the Area Office serves. The tribe believes that a fundamental 

reorganization of the Great Plains area—including quite possibly the elimination of 

the IHS Area Office altogether—may be needed. We suspect that most of the Area 

Office functions could be delegated to the service unit level and that the Area Office 

could operate with only a skeleton crew. Though legislation is not necessary to 

undergo such reorganization, the tribe has in the past had difficulty obtaining information it needs from the Area Office to fully assess this question. We do note that 

the IHS has recently initiated consultation on this question and appears open to discussing the possibility of reorganization. We appreciate that step, but a congressionally mandated comprehensive accounting of the Area Office could be a great help. 

Finally, to promote fiscal transparency and accountability, H.R. 5406 should include a requirement that IHS report on the amount of third party resources 

collected by facility and service unit, and how those funds are being used to improve 

patient care in that service unit. Section 401(c) of the Indian Health Care 

Improvement Act, 25 U.S.C. § 1641(c), requires the IHS to ensure that each service 

unit receive 100 percent of any third party resources it collects. Per 25 U.S.C. 

§ 1641(c)(1)(B), third party collections are primarily to be used ‘‘to achieve or maintain compliance with the applicable conditions and requirements’’ of Medicaid and 

Medicare programs. If there are amounts collected in excess of what is needed for 

this purpose, such collections shall be used ‘‘subject to consultation with the Indian 

tribes being served by the Service unit . . . for reducing the health resource 

deficiencies (as determined in section 1621(c) of this title) of such Indian tribes.’’ In 

addition, Section 207 of the Indian Health Care Improvement Act, 25 U.S.C. § 1621f, 

requires third party resources collected at the service unit level to be credited to 

the service unit and used for the provision of health services. 

The tribe has reason to doubt that third party collections at the Pine Ridge 

Service Unit have been left at the Service Unit and used to provide health services 

at the service unit level and to meet Medicare and Medicaid conditions of participation. First, as has been well documented, the Pine Ridge Hospital is not currently 

meeting Medicare conditions of participation despite the fact that we understand 

that it does collect third party resources from the Medicaid and Medicare programs. 

Second, the IHS recently used $50 million in third party collections to pay an administrative settlement of a union grievance in arbitration.3 The tribe is gravely 

concerned by the fact that there was such a large amount of third party collections 

readily available to the IHS that was not being used for maintaining compliance or 

for reducing health resource deficiencies at the service unit level as mandated by 

Congress in Sections 207 and 401 of the IHCIA. Thus, we ask that H.R. 5406 

require the IHS to include an accounting of third party resource collections and 

expenditures at the service unit level. 

Adequate Funding is a Necessary Component of Meaningful Reform 

One of the most significant impediments to successful reform of the IHS and 

achieving quality health care for Indian people is the severe funding shortage faced 

by the system. The National Tribal Budget Formulation Workgroup recently estimated that the full funding need of the IHS is approximately $30.8 billion, but the 

agency’s fiscal year 2016 enacted funding level was only $4.8 billion. Though 

67 

reforms to IHS management practices, hiring, transparency and accountability 

measures are critical, we cannot expect the system to function well with only a fraction of the resources it truly needs. Authorizations and appropriations are needed 

to fully fund the PRC program; to cover transportation costs when patients must 

be referred out to far-away facilities; to bring our facilities and equipment up to date 

and in line with the level of need; to fund recruitment and retention measures including housing, salaries and bonuses so that the IHS is able to attract and maintain qualified professionals; and to increase the scope of services the IHS is able to 

provide at a local level. All of these are costs, but they are part of the Federal 

Government’s trust and treaty responsibilities to Indian people and they are necessary to achieve anything more than a quick-fix, Band-Aid response to this dire crisis. Moreover, they will reduce suffering and result in significant long-run savings 

by creating healthier tribal communities and reducing the high-cost chronic and 

emergency health conditions that are so prevalent among our people today. Our current approach is not sustainable and must be remedied. Though many helpful authorities already exist in law, they cannot be implemented without sufficient 

funding. 

While the Oglala Sioux Tribe recognizes that H.R. 5406 is not an appropriations 

bill, its drafters must recognize the significance of IHS funding needs in order to 

carry out the reforms the bill seeks to implement. We ask for continued leadership 

and support from this subcommittee and individual Members throughout the appropriations process. In the meantime, there are non-appropriations measures that 

could be included in H.R. 5406 to take small but meaningful steps to ease the IHS 

funding crisis: 

Advance Appropriations. Although advance appropriations alone would not increase IHS resources, it would promote stability and permit better budgetary 

planning and help to insulate our health care services from the devastating impacts of continuing resolutions and government shutdowns. It would also help 

with hiring and retention as the IHS would know what funding is available for 

those purposes ahead of time, and employees would not be impacted by agency 

funding interruptions to the same degree. For all of these reasons, tribes have 

been advocating for advance appropriations for IHS for several years. Our treaty rights are not contingent on Congress’ ability to enact a timely budget, nor 

should the health of our people suffer on that basis. 

Exempt IHS from Sequestration. Likewise, neither our treaty rights nor the inherent value of our tribal members’ lives should be diminished on the basis of 

mandatory, indiscriminate budget cuts or ‘‘sequestration.’’ Other key Federal 

programs, including health care programs like Medicaid and VA health benefits, 

are exempt from sequestration, and IHS must also be protected. 

Leveraging other Federal funding. Various other measures could also help to 

ease the funding burden on the IHS system. Directing resources to maximize 

Affordable Care Act enrollment, for example, would provide a return by boosting 

third party revenues to the IHS. So would Medicaid expansion under the 

Affordable Care Act or state waiver or demonstration programs that leverage 

the newly expanded CMS policy on 100 percent Federal matching for services 

to American Indians and Alaska Natives. In fact, this subcommittee could investigate whether CMS is doing everything it can to allocate its resources to improve health care for American Indian and Alaska Native beneficiaries and to 

assist the IHS in doing so. Are there additional Medicare and Medicaid resources that CMS or Congress could direct to the Indian Health System to help 

it meet CMS standards and Federal treaty responsibilities? 

Ensure that the IHS is Maximizing Third Party Revenues. Finally, the Oglala 

Sioux Tribe is not convinced that IHS staff are sufficiently trained in the collection of third party revenues, and we are concerned that service unit income and 

budgets suffer because of that. We would propose a study and report to determine whether the IHS is maximizing the recovery of third party resources at 

all of its facilities, and if not, why not, and what steps can and should be taken 

to ensure that reimbursement dollars are not left on the table. 

Improve Tribal Consultation for Meaningful Reform 

Executive Order 13175 mandates that each Federal agency shall have an accountable process to ensure meaningful and timely input by tribal officials in the development of regulatory policies that have tribal implications. Every president has 

reinstated Executive Order 13175 since President Clinton initially issued it in 2000. 

This Executive Order is regularly cited by tribal governments to keep agencies 

68 

accountable and engaging with tribes as agencies develop policies that will affect 

tribes. However, the consultation process is not always effective or followed to the 

letter. For instance, Section 3(c) of the Executive Order states: 

When undertaking to formulate and implement policies that have tribal 

implications, agencies shall: (1) encourage Indian tribes to develop their 

own policies to achieve program objectives; (2) where possible, defer to 

Indian tribes to establish standards; . . . 

This Section calls for deferring to tribes, where possible, to establish standards. 

This provision, however, has been routinely overlooked by the IHS, particularly at 

the Great Plains Area Office. A recent example was the tribe’s effort to incorporate 

language into the Systems Improvement Agreement (SIA) between IHS and CMS 

to address IHS’s deficiencies in operating the Pine Ridge Hospital Emergency 

Department. We, as the beneficiary of the SIA, submitted several edits for the SIA, 

but the IHS did not accept them and they did not appear in the final executed SIA. 

Furthermore, Section 5(d) of the Executive Order states: 

On issues relating to tribal self-government, tribal trust resources, or 

Indian tribal treaty and other rights, each agency should explore and, 

where appropriate, use consensual mechanisms for developing regulations, 

including negotiated rulemaking. 

We highlight the use of consensual mechanisms for developing regulations. As 

health care is a treaty right, IHS should be implementing the use of consensual 

mechanisms as we move forward to fix the IHS’s provision of health care in the 

Great Plains. 

H.R. 5379, the RESPECT Act, is currently pending in the House. It would essentially codify Executive Order 13175, which would ensure that its provisions have 

teeth. Provisions of the RESPECT Act could be incorporated within H.R. 5406 to 

ensure that the IHS carries out effective and meaningful consultation. We highlight 

Section 401 of the RESPECT Act which provides a remedy for egregious failures of 

consultation requirements. Per this section a tribe would have the same judicial enforcement remedies as provided in the Administrative Procedures Act. We believe 

this would work well for holding IHS accountable to its consultation requirements. 

CONCLUSION

The Oglala Sioux Tribe thanks Chairman Young, Ranking Member Ruiz, members of the subcommittee and, in particular, Representative Noem for their leadership on this issue and for the opportunity to submit this testimony. We stand ready 

and willing to offer any assistance we are able to provide as you consider H.R. 5406 

and move forward to hold the IHS accountable for ensuring that our people have 

the meaningful access to quality health care that was promised in our treaties with 

the U.S. Federal Government. 

PREPARED STATEMENT OF SCOTT A. DUKE, CEO, SOUTH DAKOTA ORGANIZATION OF

HEALTHCARE ASSOCIATION

Good afternoon Chairman Young and members of the Subcommittee on Indian, 

Insular and Alaska Native Affairs. On behalf of our hospitals, health systems, postacute care providers and our 63,000 individual members, the South Dakota 

Organization of Healthcare Association appreciates the opportunity to submit a 

statement of record supporting Congresswoman Kristi Noem’s bill, the Helping 

Ensure Accountability, Leadership, and Trust in Tribal Healthcare (HEALTTH) Act 

of 2016 (H.R. 5406). 

South Dakota tribal members are suffering. Indian Health Services (IHS) has 

failed—both in its treaty obligation and moral duty—to provide the quality care that 

Native Americans across the Great Plains deserve. South Dakota tribal members 

have the second highest infant mortality rate among IHS regions, the highest diabetes death rates, the second highest alcohol related death rates, the highest TB death 

rates, the lowest life expectancy rates and the highest age adjusted death rates. 

For years, Federal reports have documented shocking cases of mismanagement 

and poorly delivered care. Over time IHS has failed to make improvements on their 

own even though their funding was increased almost every year. Tragically the recent IHS crisis in South Dakota at several IHS hospitals has resulted in loss of life. 

For many months the Emergency Department at Rosebud has been shut down because of the unsafe conditions. IHS facilities in Pine Ridge, Rosebud, and Rapid City 

69 

have been in jeopardy as well. This is unacceptable. IHS must meet the same 

quality, safety, and operational standards as all other hospitals. 

The effects of the current dire situation have a profound impact on South Dakota 

and the region. SDAHO member hospitals are actively assisting, but have seen a 

dramatic increase in Emergency Department (ED) patient volumes and other 

services. These situations are unpredictable and difficult to manage. 

The proposed legislation introduces comprehensive reform by addressing systematic failures in the Great Plains area. To ensure contracts are designed to serve 

those they are intended to help, the HEALTTH Act requires a partnership between 

IHS, with tribal input and engagement from independent health care experts. In addition, ensuring the Purchased/Referred Care Program formula is based on factors 

that impact access to care and match where health care support is needed. Moreover, the bill includes provisions to help drive down prices and stretch every 

Purchased/Referred Care dollar further. The bill seeks to make the hiring of medical 

professionals and administrators easier by paying back their student loans. Last, 

the bill provides critical accountability requirements to ensure ongoing monitoring 

of what is happening in IHS facilities. 

SDAHO’s support of the HEALTTH Act, would be strengthened by addressing 

additional concerns to ensure the delivery of quality health care for our tribal communities. These include: 

• IHS facilities should be required to have electronic billing and electronic 

referral as this will expedite patient care when communicating with non-IHS 

facilities. 

• IHS facilities must be required to reimburse care when referring American 

Indians to non-IHS facilities. 

• South Dakota community hospitals should not have to write off more than 

$10 million annually because IHS refuses to pay. 

• Contract negotiation must have meaningful input from the tribal communities to ensure that selected providers are culturally sensitive to their needs. 

• Contract awards must contemplate efficiency and integration of care. A step 

toward achieving this patient-centered objective is implementing contracting 

terms that allow providers to offer services to individual IHS facilities in a 

more comprehensive manner. 

IHS and its leaders must be held accountable. The passage of the HEALTTH Act 

will ensure sustainable improvements are achieved. This legislation is urgently 

needed to ensure sustainable improvements are achieved. We support the innovative 

and forward thinking of the HEALTTH Act with the additional proposed amendments. We urge your support as well. 

PREPARED STATEMENT OF THE UNITED SOUTH AND EASTERN TRIBES SOVEREIGNTY

PROTECTION FUND AND SELF-GOVERNANCE COMMUNICATION AND EDUCATION

TRIBAL CONSORTIUM

On behalf of the United South and Eastern Tribes Sovereignty Protection Fund 

(USET SPF) and the Self-Governance Communication and Education Tribal 

Consortium, we write to provide the House Committee on Natural Resources 

Subcommittee on Indian, Insular and Alaska Native Affairs with the following testimony for the record of its July 12, 2016, legislative hearing on H.R. 5406, Helping 

Ensure Accountability, Leadership, and Trust in Tribal Healthcare (HEALTTH) Act. 

Our organizations stand with Tribal Nations across the country in sharing our deep 

concern regarding the deplorable conditions in the Great Plains area. We appreciate 

Rep. Noem and the subcommittee’s efforts to address the systemic issues which 

have persisted in the Great Plains region and throughout the Indian Health System 

for decades, and offer section-by-section recommendations intended to strengthen 

the provisions of the bill. It is in this spirit that we ask Rep. Noem and the subcommittee to strongly consider the national (rather than regional) implications of 

H.R. 5406, and to work with Tribal Nations to ensure its impact is positive in all 

IHS Areas. In particular, we encourage Rep. Noem and the subcommittee to reexamine provisions related to the Purchased/Referred Care (PRC) program. Moreover, we maintain that until Congress fully funds the Indian Health Service (IHS), 

the Indian Health System will never be able to fully overcome its challenges and 

fulfill its trust obligations While our organizations support reforms that will improve the quality of service delivered by the IHS, we underscore the obligation of 

Congress to meet its trust responsibility by providing full funding to IHS and 

70 

support additional innovative legislative solutions to improve the Indian Health 

System. 

UPHOLD THE TRUST RESPONSIBILITY TO TRIBAL NATIONS

Through the permanent reauthorization of the Indian Health Care Improvement 

Act, ‘‘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.’’ As long as IHS remains dramatically underfunded, 

the root causes of the failures in the Great Plains and the Indian Health System 

will not be addressed, and Congress will not live up to its stated policy and responsibilities. In fiscal year 2015, the IHS medical expenditure per patient was only 

$3,136 while the Veteran’s Administration, the only other Federal provider of direct 

care services, spent $8,760 per patient. Disparities in health financing 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 the Indian 

Health System. 

Additionally, we recommend the inclusion of language directing the IHS to request a budget that is reflective of its full demonstrated financial need obligation, 

as this is the only way to determine the amount of resources required to deliver 

comprehensive and quality care. 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 AND EXEMPT THE IHS BUDGET

FROM SEQUESTRATION

Stability in program funding is a critical element in the effective management and 

delivery of health services. On top of chronic underfunding, IHS and Tribal Nations 

face the problem of discretionary funding that is almost always delayed. In fact, 

since Fiscal Year (FY) 1998, there has only been 1 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. Budgeting, recruitment, retention, provision of services, facility maintenance, and construction efforts all depend on annual appropriated funds. 

Many Tribal Nations reside in areas with high Health Professional Shortage Areas 

and delays in funding only amplify challenges in providing adequate salaries and 

hiring of qualified professionals. 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. 

Additionally, IHS and Tribal Nations continue to face the specter of sequestration. 

Through the Budget Control Act of 2011 and subsequent failure of the Joint Select 

Committee on Deficit Reduction, the IHS budget was subjected to Federal spending 

caps and across-the-board reductions, despite Congress’ Federal trust responsibility 

to finance health care services to Tribal Nations. As a result of the discretionary 

budget cuts, in FY 2013, IHS lost approximately $220 million from its already underfunded budget. These cuts required the IHS and Tribal Nations to reduce the 

availability of health services to tribal citizens who already face severe health disparities and are legally entitled to care through IHS. Reductions in funding and the 

overall instability of the IHS budget sustain conditions which lead to the crises observed in the Great Plains area and throughout the Indian Health System. Restoring these budget cuts and preventing future budgets from harmful reductions will 

be critical to advancing and improving the care delivered through IHS. We continue 

to assert that the IHS budget, and all funding for Federal Indian programs, must 

be exempt from sequestration. 

TRIBAL CONSULTATION

We appreciate Rep. Noem’s initiative to take action in response to failures in the 

provision of health care in the Great Plains area. H.R. 5460 seeks to address many 

of these issues and will have nationwide implications for the Indian Health System. 

In order to account for the diversity of management structures, including selfgovernance compacting and self-determination contracting, across the 12 IHS Areas 

as well as in patient access and experiences among these areas, ongoing tribal consultation must be inclusive of all Tribal Nations impacted. First, we request that 

Rep. Noem and this subcommittee consider holding an open listening session and 

soliciting additional comments from Tribal Nations across the country. Second, we 

request that additional language be inserted into H.R. 5406 requiring tribal conVerDate Mar 15 2010 11:11 Dec 02, 2016 Jkt 000000 PO 00000 Frm 00074 Fmt 6633 Sfmt 6621 J:\114TH CONGRESS\INDIAN, INSULAR & ALASKA NATIVE AFFAIRS\07-12-16\20919.TXT
71 

sultation on all provisions of the law, as it is implemented, to ensure Tribal Nations 

have a voice in accordance with the IHS Tribal Consultation Policy. Ongoing, meaningful tribal consultation is essential to mitigating current challenges, preventing 

future crises, and increasing the health status of American Indians and Alaska 

Natives (AI/AN). 

SECTION-BY-SECTION COMMENTS

In addition to urging the inclusion of the above proposals, we offer the following 

recommendations to strengthen the existing provisions of H.R. 5406. If implemented together, we believe these policies will provide the necessary framework for 

IHS and Tribal Nations to improve patient health outcomes the quality of care 

delivered through the Indian Health System. 

Title I—Expanding Authorities and Improving Access to Care 

Section 101. Service hospital long-term contract pilot program 

As Congress considers reform for the Indian Health System, we support initiatives 

which empower Tribal Nations to make their own decisions regarding their health 

care. Through the Indian Self-Determination and Education Assistance Act 

(ISDEAA) Tribal Nations have made considerable gains in health program administration, patient experience, and community health outcomes. We fully support 

Tribal Nations that choose to assume health and other programming under this authority. We do, however, want to ensure that Tribal Nations have the adequate infrastructure to assume these functions and that the programs being transferred are 

not in disrepair. We believe the interim option which would provide Tribal Nations 

with the authority to pilot self-governance by contracting with the private sector 

could be a good first step on the path to full self-governance. However, we believe 

this partnership should be one that fosters mentorship and capacity building in 

order to ensure these arrangements do not have the adverse effect of diminishing 

tribal governance. 

To that end, we recommend the inclusion of language to clarify that Tribal 

Nations have the authority to exercise their right to assume programs under the 

ISDEAA at any time, notwithstanding the duration of any contracts with private 

entities. This language will ensure Tribal Nations do not unintentionally forfeit 

their right to assume programs under the ISDEAA while remaining under contract 

with a private entity. Further, we request additional language which would clarify 

provider-based status when a tribal hospital is contracted with a private group. This 

provider-based status is critical to the collection of third party revenue and any disruption could further harm the hospital. Finally, we request ongoing consultation 

on this specific provision to ensure that this pilot truly provides greater tools and 

opportunities to enter into self-governance. 

Section 102. Expanded hiring authority for the Indian Health Service 

Over the course of dialogue regarding this provision and similar language in 

S. 2953, many have expressed concerns about its constitutionality. Some have suggested that the Department of Justice may be unable to represent the Indian Health 

Service in cases where the Agency is sued pursuant to action taken under this language. If this is the case, we believe this provision has the potential to destabilize 

the Indian Health System, rather than strengthen it. Our organizations urge Rep. 

Noem and the subcommittee to provide Indian Country with more information regarding the potential impact of Section 102. We further ask that this section, including whether to strike the language from the bill, be subject to tribal consultation 

prior to further legislative action. 

Section 103. Removal or demotion of employees 

We support expanding the Secretary’s authority to remove or demote IHS employees based on performance or misconduct. However, in addition to the Secretary, 

Tribal Leadership must also be notified when employees within their Service Area 

become subject to a personnel action. In under Sec. 603(c) ‘‘Notice to Secretary,’’ we 

recommend inserting ‘‘Tribal Governments located in the affected service area.’’ 

Further we recommend inserting similar language included in which S. 2953 establishes ‘‘Employment Record Transparency’’ which ensures that prior to employee 

personnel actions are adequately notated and considered in future hiring processes. 

Increasing transparency and access to information for Tribal Nations will be essential to rebuilding the confidence and trust in the IHS. 

Section 104. Improving timeliness of care 

This provision would establish standards to measure the timeliness of care and 

develop processes for submitting data to the Secretary on these measures. It is 

72 

imperative that these measures and standards are developed in consultation with 

Tribal Nations. Further, for approximately 170 IHS and tribally operated sites that 

have chosen to participate in the Improving Patient Care (IPC) initiative, many 

have already taken steps to improve timeliness of care. We suggest aligning the 

standards with existing IPC activities and ensuring that standards or reporting are 

not overly burdensome for tribal health programs. In addition, we request that any 

data regarding timeliness of care be provided to Tribal Nations, as well as the 

Secretary. 

Title II—Indian Health Service Recruitment and Workforce 

Section 201. Exclusion from gross income for payments made under Indian health 

service loan repayment program 

We fully support the provisions which would exempt payments from the Indian 

Health Service Loan Repayment Program (LRP) from an awardee’s taxable income. 

This will help reduce barriers to recruitment and achieve parity with other Federal 

health workforce programs, such as loan repayment under National Health Service 

Corps. Additionally, language should be inserted to ensure that IHS Scholarship 

Awards receive similar treatment under the Internal Revenue Service Code. Exemptions like this already exist for the Armed Forces and this will assist IHS with 

creating a pipeline of providers into the Indian Health System. 

LRP, and the IHS Scholarship Program, however, are severely underfunded, 

which has weakened efforts to improve recruitment and retention in the IHS. In 

FY 2015, LRP was unable to provide loan repayment funding to 613 health 

professionals who applied, of which only 200 accepted employment at an IHS or 

tribally operated health facility. IHS estimates that it would need an additional 

$30.39 million to fund all the health professional applicants from that year. Until 

Congress moves to adequately fund these accounts, the IHS and Tribal Nations will 

continue to have challenges attracting qualified providers and there will be gaps in 

the continuity and quality of care. 

Finally, we request that additional funding be made available to assist in the recruitment of AI/AN health professionals from within local tribal communities. We 

believe that the best way to care for our citizens is to ensure that health professionals are deeply connected to the communities they serve. In order to promote 

pathways to AI/AN entrance into health professions, we request additional funding, 

beyond the President’s FY 2017 budget request, be made available for the Health 

Professions Scholarship Program, American Indians into Nursing Program, Indians 

into Medicine (INMED) program and American Indians into Psychology Program. 

Section 202. Clarifying that certain degrees qualify individuals for eligibility in the 

Indian Health Service Loan Repayment Program 

We support the provision of the bill which would recognize degrees in business 

administration, health administration, hospital administration or public health as 

eligible for awards under IHS LRP. However, we also recommend inserting similar 

language to recognize these degrees as eligible under the IHS Scholarship Program. 

We believe including these degree types into the IHS Scholarship Program will increase the number of AI/AN seeking business and health administration degrees 

and increase the pool of qualified health professionals. 

Section 204. Relocation reimbursement 

In order to fight ongoing challenges with recruiting qualified providers into the 

Indian Health System, we support the provision allowing for reimbursement of reasonable costs associated with relocation. In addition to the criteria listed in the provision, we suggest broadening the language to include positions that are ‘‘difficult 

to fill in the absence of an incentive.’’ This language will allow IHS more flexibility 

when determining when to offer relocation awards. 

In addition to relocation benefits, we recommend the inclusion of language which 

would authorize IHS to provide other incentives such as housing vouchers, performance based bonuses, and increased pay scales. Especially in the Great Plains and 

the other medically underserved areas where many of our Tribal Nations exist, access to housing for providers is a major barrier to recruitment. Providing IHS with 

the authority to offer a variety of benefits will help improve recruitment efforts. We 

suggest inserting similar language to the provision that exists in the S. 2953 bill 

under ‘‘Sec. 607 Incentives for Recruitment and Retention.’’ 

Although we support the proposed incentives, the IHS is not equipped to implement these initiatives without additional appropriations. With IHS funding not 

meeting demonstrated financial need, we are concerned any initiatives to provide 

housing vouchers, relocation costs, or increase pay scales must be funded using patient care dollars. While the attraction of qualified staff is critically important, it 

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must not be done by diverting precious resources from health care services. For this 

reason, we request that H.R. 5604 include the authorization of additional funding 

to support these incentives without impacting patient care. 

Section 205. Authority to waive Indian preference laws 

Although we understand the need to seek ways to recruit qualified candidates, we 

have concerns regarding the waiver of Indian Preference laws. We firmly believe the 

providers best suited to care for our communities are ones that come from the communities themselves, and we cannot support efforts that would undermine Indian 

Preference. As we note above, our vision for a stronger Indian Health System includes a robust pipeline of AI/AN into health professions. In the meantime, we believe that the aims of this provision can be achieved by modifying hiring practices 

within the current legal framework. We understand the law may be applied in a 

way that does not provide for timely reviews or hiring of qualified non-Indian candidates where no qualified AI/AN candidate is available. Rather than waiving the 

laws completely, we think there is room for improvement 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. 

Title III—Purchased/Referred Care Program Reforms 

Section 301. Limitation on charges for certain Purchased/Referred Care Program 

services 

Although we appreciate the language which would codify existing IHS regulation 

extending Medicare-Like Rates payment methodology to non-hospital based services, 

in absence of an enforcement mechanism, we believe this could create major access 

to care issues. Through the 2003 authorization of the Medicare Prescription Drug, 

Improvement, and Modernization Act, hospital-based Medicare providers and suppliers were required to accept Medicare-Like Rates from IHS and tribally operated 

facilities as a condition of their participation in the Medicare program. This law has 

allowed PRC programs to extend their limited resources, while preserving access to 

care for AI/AN patients by ensuring providers accept the lower rate of payment. 

Because IHS does not have jurisdiction over Medicare Conditions of Participation, 

they could not include a similar enforcement mechanism. In cases where physicians 

or other providers do not wish to accept lower payments from PRC programs, they 

may refuse to see AI/AN patients and gaps in access will continue to persist. We 

recommend that language be inserted to this section which would require the acceptance of the MLR for all services authorized by IHS PRC programs as a condition 

of participation in the Medicare program. 

Section 302. Allocation of Purchased/Referred Care Program funds 

While we agree that ‘‘life and limb’’ PRC priority levels 1 and 2 provide woefully 

inadequate levels of care to IHS patients, we assert that rather than redistributing 

funding, Congress should simply fully fund the PRC account. Consistent underfunding results in the denial and deferral of medically necessary care. In Fiscal 

Year (FY) 2015, IHS reported 132,200 denied or deferred services, which amounted 

to $639,177,512 in unmet health care obligations. As a result, medically necessary 

services are denied by PRC departments and health conditions worsen, quite possibly contributing to many of the issues in the Great Plains. The PRC Medical 

Priority Level system itself, which forces Tribal Health Programs to ration care 

based on health condition as a result of underfunding, substantiates the need for 

Congress to fully fund the account. 

We are concerned with the HEALTTH Act’s current language, which would impose funding freezes for IHS programs which authorize care at priority level 3 and 

redistribute funding increases to programs treating only more emergent cases. This 

will not improve access to care for AI/AN patients, but rather, will spread financial 

inadequacies across the Indian Health System. Although PRC funding is inadequate, some PRC departments are able to extend their resources through effective 

financial planning. This provision could penalize PRC programs which have created 

these types of efficiencies through negotiating competitive rates with providers and 

have been successful in funding higher levels of care. Further, the care delivered 

at priorities 3 and below is more likely to be preventive care. A critical element in 

the fight against the types of emergent and chronic health problems treated at priorities 1 and 2 is preventive care. Treating health problems early avoids more 

difficult and expensive treatment down the road. 

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Additionally, we note that the current formula employed by IHS was established 

in consultation with Tribal Nations. The formula was crafted in recognition of area 

differences in cost of services, number of patients, access to hospitals, inflation and 

a number of other factors. In fact, the PRC funding formula is regularly reviewed 

in consultation with the PRC workgroup and Tribal Nations, so additional work to 

evaluate the formula is unnecessary at this time. Further, H.R. 5604 lists a number 

of factors the Secretary must consider in the redevelopment of the formula, which, 

to our knowledge, were not formulated in consultation with all Tribal Nations. 

Section 303. Purchased/Referred Care Program backlog 

While we understand that backlogged payments are a major concern in the Great 

Plains area, this is not true across the Indian Health System. Many Tribal Nations 

have instituted or agreed to prompt payments. We recommend that the language 

in this section be amended to exempt tribally operated facilities and limit the review 

to IHS Areas and direct service sites. 

Additionally, we contend that the PRC backlog is not simply the result of delayed 

payment due to inefficiencies within the IHS. Many PRC providers are unfamiliar 

with the IHS system and the laws that govern the provision of health care to AI/ 

AN. First, there are the payer of last resort provisions which require private insurance, and other coverage through Medicare and Medicaid, to pay claims prior to IHS 

PRC programs. In cases where a patient does not have an alternate resource, the 

determination process may take weeks. Similarly, in cases where a patient fails to 

attain prior authorization for a service, the PRC department will not pay on the 

claim and financial liability will go to the patient. Last, some PRC services may 

meet medical priority but be denied due to lack of funding. In emergent cases, patients will need to receive this care regardless of ability to pay. These scenarios can 

happen frequently which result in delays or denials of payment of PRC providers. 

With this in mind, we recommend the inclusion of language call for a Government 

Accountability Office report on the causes of the PRC backlog, as well as 

recommendations regarding PRC provider education. 

CONCLUSION

Our organizations appreciate congressional efforts to seek solutions to the longstanding challenges within the Indian Health System. However, we note the initiatives proposed in H.R. 5604 do not address the root cause of these issues: the 

chronic underfunding of the IHS. Only when Congress acts to uphold the Federal 

trust responsibility by providing full funding and parity for the Agency will the 

Indian Health System be equipped to provide an adequate level of care to AI/AN 

people. We thank the subcommittee for the opportunity to provide comments on this 

bill and look forward to an ongoing dialogue to address the complex challenges of 

health care delivery in Indian Country. 

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