```

[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]

H.R. 2662, ``RESTORING ACCOUNTABILITY IN THE INDIAN HEALTH SERVICE ACT 
                               OF 2017''

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

                          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 FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        Wednesday, June 21, 2017

                               __________

                           Serial No. 115-10

                               __________

       Printed for the use of the Committee on Natural Resources

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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

                         U.S. GOVERNMENT PUBLISHING OFFICE 

25-969 PDF                     WASHINGTON : 2017 
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                          Washington, DC 20402-0001

                     COMMITTEE ON NATURAL RESOURCES

                        ROB BISHOP, UT, Chairman
            RAUL M. GRIJALVA, AZ, Ranking Democratic Member

Don Young, AK                        Grace F. Napolitano, CA
  Chairman Emeritus                  Madeleine Z. Bordallo, GU
Louie Gohmert, TX                    Jim Costa, CA
  Vice Chairman                      Gregorio Kilili Camacho Sablan, 
Doug Lamborn, CO                         CNMI
Robert J. Wittman, VA                Niki Tsongas, MA
Tom McClintock, CA                   Jared Huffman, CA
Stevan Pearce, NM                      Vice Ranking Member
Glenn Thompson, PA                   Alan S. Lowenthal, CA
Paul A. Gosar, AZ                    Donald S. Beyer, Jr., VA
Raul R. Labrador, ID                 Norma J. Torres, CA
Scott R. Tipton, CO                  Ruben Gallego, AZ
Doug LaMalfa, CA                     Colleen Hanabusa, HI
Jeff Denham, CA                      Nanette Diaz Barragan, CA
Paul Cook, CA                        Darren Soto, FL
Bruce Westerman, AR                  Jimmy Panetta, CA
Garret Graves, LA                    A. Donald McEachin, VA
Jody B. Hice, GA                     Anthony G. Brown, MD
Aumua Amata Coleman Radewagen, AS    Wm. Lacy Clay, MO
Darin LaHood, IL
Daniel Webster, FL
David Rouzer, NC
Jack Bergman, MI
Liz Cheney, WY
Mike Johnson, LA
Jenniffer Gonzalez-Colon, PR

                       Jason Knox, Chief of Staff
                      Lisa Pittman, Chief Counsel
                David Watkins, Democratic Staff Director
                                 ------                                

       SUBCOMMITTEE ON INDIAN, INSULAR AND ALASKA NATIVE AFFAIRS

                       DOUG LaMALFA, CA, Chairman
             NORMA J. TORRES, CA, Ranking Democratic Member

Don Young, AK                        Madeleine Z. Bordallo, GU
Jeff Denham, CA                      Gregorio Kilili Camacho Sablan, 
Paul Cook, CA                            CNMI
Aumua Amata Coleman Radewagen, AS    Ruben Gallego, AZ
Darin LaHood, IL                     Darren Soto, FL
Jack Bergman, MI                     Colleen Hanabusa, HI
Jenniffer Gonzalez-Colon, PR         Raul M. Grijalva, AZ, ex officio
  Vice Chairman
Rob Bishop, UT, ex officio

                                 ------    
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                CONTENTS

                              ----------                              
                                                                   Page

Hearing held on Wednesday, June 21, 2017.........................     1

Statement of Members:
    LaMalfa, Hon. Doug, a Representative in Congress from the 
      State of California........................................     1
        Prepared statement of....................................     2
    Torres, Hon. Norma J., a Representative in Congress from the 
      State of California........................................     3
        Prepared statement of....................................     4

Statement of Witnesses:
    Buchanan, Chris, REHS, MPH, Rear Admiral, Assistant Surgeon 
      General, USPHS; Deputy Director, Indian Health Service, 
      Rockville, Maryland........................................    10
        Prepared statement of....................................    11
        Questions submitted for the record.......................    14
    Joseph, Hon. Andy, Business Council Member, Confederated 
      Tribes of the Colville Reservation, Nespelem, Washington...    18
        Prepared statement of....................................    20
    Kitcheyan, Victoria, Great Plains Area Representative, 
      National Indian Health Board, Washington, DC...............    26
        Prepared statement of....................................    28
    Noem, Hon. Kristi L., a Representative in Congress from the 
      State of South Dakota......................................     5
        Prepared statement of....................................     7
    Shield, Hon. William Bear, Chairman, Rosebud Sioux Tribal 
      Health Board, Rosebud, South Dakota........................    15
        Prepared statement of....................................    16
    TwoBears, Robert, District V Representative, Ho-Chunk Nation 
      Legislature, Black River Falls, Wisconsin..................    22
        Prepared statement of....................................    24

Additional Materials Submitted for the Record:
    List of documents submitted for the record retained in the 
      Committee's official files.................................    39
 
   LEGISLATIVE HEARING ON H.R. 2662, TO AMEND THE INDIAN HEALTH CARE 
 IMPROVEMENT ACT TO IMPROVE THE RECRUITMENT AND RETENTION OF EMPLOYEES 
  IN THE INDIAN HEALTH SERVICE, RESTORE ACCOUNTABILITY IN THE INDIAN 
   HEALTH SERVICE, IMPROVE HEALTH SERVICES, AND FOR OTHER PURPOSES, 
 ``RESTORING ACCOUNTABILITY IN THE INDIAN HEALTH SERVICE ACT OF 2017''

                              ----------                              

                        Wednesday, June 21, 2017

                     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 2:48 p.m., in 
room 1324, Longworth House Office Building, Hon. Doug LaMalfa 
[Chairman of the Subcommittee] presiding.
    Present: Representatives LaMalfa, Radewagen, Gonzalez-
Colon; and Torres.
    Mr. LaMalfa. Good afternoon. The Subcommittee on Indian, 
Insular and Alaska Native Affairs will come to order. The 
Subcommittee is meeting today to hear testimony on H.R. 2662, 
by Representative Kristi Noem, to amend the Indian Health Care 
Improvement Act to improve the recruitment and retention of 
employees in the Indian Health Service, restore accountability 
in the Indian Health Service, improve health services, and for 
other purposes; or known as the ``Restoring Accountability in 
the Indian Health Service Act of 2017.''
    Under Committee Rule 4(f), any oral opening statements at 
hearings are limited to the Chairman, the Ranking Minority 
Member, and the Vice Chair. This will allow us to hear from our 
witnesses sooner, and help Members keep to their schedules. 
Therefore, I ask unanimous consent that all other Members' 
opening statements be made part of the hearing record if they 
are submitted to the Subcommittee Clerk by 5:00 p.m. today.
    Without objection, so ordered.

    STATEMENT OF THE HON. DOUG LaMALFA, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Mr. LaMalfa. Today, we are here to take testimony on the 
bill intended to address a severe problem in Indian Country. 
Adequate health care is one of the most important issues to 
American Indian 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 
IHS: the Great Plains area. After the report was released, the 
agency repeatedly assured Congress that issues were being 
addressed.
    Then, in 2015, the same IHS region experienced the 
termination of a provider agreement with Centers for Medicare 
and Medicaid Services at the Winnebago IHS Hospital in 
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, the 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.
    Congress has continued to increase IHS funding almost each 
year since 2010, and it continues to increase it. In Fiscal 
Year 2014 and Fiscal Year 2015, Congress exceeded President 
Obama's budget.
    Since 2008, funding for the IHS has increased by more than 
50 percent. The House's Fiscal Year 2017 proposal appropriation 
is at approximately $1 billion over Fiscal Year 2010 levels, 
yet the dangerous situation in the Great Plains area and the 
staffing shortage problem throughout the 12 IHS areas continues 
to exist, if not to grow.
    In March of 2017, and despite funding increases, the 
Government Accountability Office added Indian health care to 
its biennial high-risk report for programs that are most 
susceptible to waste, fraud, and abuse.
    H.R. 2662, the Restoring Accountability in the Indian 
Health Service Act, is intended to make reforms to the Indian 
Health Service to help a broken system. This bill would amend 
the Indian Health Care Improvement Act to improve the IHS by 
reforming the agency's personnel processes, timeliness 
standards, and other operations.
    The bill also includes accountability language similar to 
what Congress has enacted to help the Veterans Affairs 
Administration make it easier to discipline and fire 
underperforming employees.
    The bill is a continuation of the work in the 114th 
Congress found in H.R. 5406, Helping Ensure Accountability, 
Leadership, and Trust in Tribal Healthcare Act, commonly known 
as the ``HEALTTH Act.'' 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.
    [The prepared statement of Mr. LaMalfa follows:]
Prepared Statement of the Hon. Doug LaMalfa, 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 health care is one of the 
most important issues to American Indian 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 area. After the report was released the 
agency repeatedly assured Congress that issues were being addressed.
    Then in 2015, the same IHS region experienced the termination of a 
provider agreement with Centers for Medicare and Medicaid Services at 
the Winnebago IHS Hospital 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.
    Congress has continued increase IHS funding almost each year since 
the 2010, and it continues to increase. In FY14 and FY15, Congress 
exceeded President Obama's budget.
    Since 2008, funding for the Indian Health Service has increased by 
more than 50 percent. The House's FY17 proposed appropriation is at 
approximately $1 billion over FY10 levels, yet the dangerous situation 
in the Great Plains area and the staffing shortage problem throughout 
the 12 IHS areas continues to exist if not grow.
    In March of 2017, and despite funding increases, the Government 
Accountability office added Indian health care to its biennial high 
risk report, for programs that are most susceptible to waste, fraud and 
abuse.
    H.R. 2662, the Restoring Accountability in the Indian Health 
Service Act is intended to make reforms to the Indian Health Service to 
help a broken system.
    This bill would amend the Indian Health Care Improvement Act to 
improve the Indian Health Service by reforming the agency's personnel 
processes, timeliness standards, and other operations.
    The bill also includes accountability language similar to what 
Congress has enacted to help the Veterans Affairs Administration making 
it easier to discipline and fire underperforming employees.
    This bill is a continuation of the work in the 114th Congress found 
in H.R. 5406, the Helping Ensure Accountability, Leadership, and Trust 
in Tribal Healthcare Act, commonly known as the ``HEALTTH Act.''
    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.

                                 ______
                                 

    Mr. LaMalfa. I would now like to recognize our Ranking 
Member for any opening statement.

  STATEMENT OF THE HON. NORMA J. TORRES, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Mrs. Torres. Thank you so much, Mr. Chairman, and good 
afternoon to everyone here, and our witnesses.
    Today is our opportunity to take a hard look at the current 
state and possible future of health care in Indian Country.
    American Indian and Alaska Native people have long 
experienced health disparities when compared with other 
Americans, including a lower life expectancy and higher rates 
of disease. There are many reasons for this, but we know that 
one of the factors has been the chronic underfunding of the 
Indian Health Service. These issues have been brought back to 
the forefront after what occurred with the Great Plains area 
hospitals, but I worry that we will hear many of the same 
stories from IHS facilities throughout the country.
    The fact is that we cannot provide competent, quality 
health care to Native American and Alaska Natives when we allow 
inadequate facilities and substandard levels of care to 
continue to exist. I am glad to have this discussion today, 
because we need to start talking about permanent solutions that 
will address the long-standing issues at IHS.
    We have to acknowledge that to bring about true 
transformation at IHS facilities, we need to start funding IHS 
appropriately. IHS has been shamefully underfunded for years, 
and the President's proposed Fiscal Year 2018 budget looks to 
cut another $59 million.
    Mr. Chairman, the hospitals are old, their technology is 
outdated, and they face major hurdles when hiring and keeping 
quality healthcare professionals.
    So, yes, we do need reforms at IHS, but even with the best-
intentioned reforms, we will just be giving lip service if we 
do not supply the funding to implement real change.
    I want to thank our colleague, Representative Noem, for 
bringing this legislation forward; and I thank all of our 
witnesses for taking time today to share your thoughts on this 
legislation.
    Thank you, Mr. Chairman, and I yield back.
    [The prepared statement of Mrs. Torres follows:]
    Prepared Statement of the Hon. Norma J. Torres, Ranking Member, 
       Subcommittee on Indian, Insular and Alaska Native Affairs
    Thank you, Mr. Chairman.
    Today is our chance to take a hard look at the current state and 
possible future of health care in Indian Country. American Indian and 
Alaska Native people have long experienced health disparities when 
compared with other Americans, including a lower life expectancy and 
higher rates of diseases.
    There are many reasons for this, but we know that one of the 
factors has been the chronic underfunding of the Indian Health Service. 
These issues have been brought back to the forefront after what 
occurred with the Great Plains area hospitals, but I worry we'll hear 
many of the same stories from IHS facilities throughout the country.
    The fact is that we cannot provide competent, quality health care 
to Native American and Alaska Natives when we allow inadequate 
facilities and sub-standard levels of care to exist.
    I'm glad to have this discussion today, because we need to start 
talking about permanent solutions that will address the long-standing 
issues at IHS. We have to acknowledge that to bring about a true 
transformation at IHS facilities, we need to start funding IHS at an 
appropriate level.
    IHS has been shamefully underfunded for years, and the President's 
proposed FY2018 budget looks to cut another $59 million.
    Mr. Chairman, the hospitals are old, their technology is outdated, 
and they face major hurtles when hiring and keeping quality healthcare 
professionals. So, yes, we do need reforms at IHS, but even the best 
intentioned reforms will just be lip service if we don't supply the 
funding to implement real change. There are actual lives in the 
balance, and they deserve better.
    I want to thank our colleague Rep. Noem for bringing this 
legislation forward, and I thank all our witnesses for taking the time 
today to share your thoughts on this legislation.
    Thank you Mr. Chairman, and I yield back.

                                 ______
                                 

    Mr. LaMalfa. Thank you. It is now up to me to introduce our 
witness for our first panel, the Honorable Kristi Noem, U.S. 
Congresswoman for the state of South Dakota.
    We remind the witness that under Committee Rules, there is 
a 5-minute limit to the statement, but the entire statement 
will appear in the record.
    So, allow me to recognize you, Congresswoman Noem, for your 
testimony. Thank you for appearing here.

   STATEMENT OF THE HON. KRISTI L. NOEM, A REPRESENTATIVE IN 
            CONGRESS FROM THE STATE OF SOUTH DAKOTA

    Mrs. Noem. Thank you, Chairman. And thank you also, Ranking 
Member Torres, as well, and the rest of the members of the 
Subcommittee, for allowing me to be here today to talk about 
the Indian Health Service. Many of the items that you discussed 
in your opening statements are very true. I couldn't find 
anything in there that I would disagree with.
    I do want to point out that we have increased funding for 
Indian health services over many, many years. And since I have 
been in Congress we have done that, but we still have not seen 
improvements. In fact, the situation has only gotten worse. And 
that is one of the reasons you have this bill before you today.
    I appreciate the opportunity to talk about H.R. 2662. It is 
the Restoring Accountability in the Indian Health Service Act. 
And before I begin, I wanted to also inform you that yesterday 
I was told the HHS senior staff are traveling to South Dakota 
this week. They are going to visit the IHS hospital at the Pine 
Ridge Indian Reservation, which is the home to the Oglala Sioux 
Tribe.
    That is one of the areas that has been the worst in the 
Nation. The Great Plains District has been a disaster. We have 
had third-world care being delivered there, and just a few 
weeks ago I had asked Secretary Price for his leadership and 
his help in addressing the situations that we are currently 
facing. So, I want to thank him and his team for his quick 
action in going there this week to look at the situation on the 
ground. I look forward to working with them to find solutions 
to the many issues that we face in Indian Country.
    Now, turning to our hearing today, I personally thank the 
witnesses who traveled here to Washington, DC to be at this 
hearing, especially Mr. William Bear Shield from the Rosebud 
Sioux Tribe. Mr. Bear Shield has testified before you before. 
In fact, he was here to testify on the legislation that I had 
last Congress. He is here to offer his critical insights into 
what the situation is on the ground.
    Last year, I, too, sat before this Subcommittee, testifying 
on the same issue. I told you that the state of Indian health 
care in South Dakota had fallen to emergency levels. Today, I 
could report to you that in some areas we have seen a little 
bit of progress, but it is not enough. We need to get help to 
these people that are relying on this agency for health care, 
and they are failing them dramatically.
    Since this most recent crisis has begun, the Centers for 
Medicare and Medicaid Services has found three IHS hospitals in 
South Dakota to be deficient, which resulted in the closure of 
two emergency rooms. One has since reopened, but nonetheless, 
these closures have put a serious strain on local community 
hospitals and has drastically curtailed access to care for my 
constituents. Many of them are traveling much farther in 
situations. In fact, I believe Mr. Bear Shield will talk today 
about how they believe they have lost lives because of the 
situation of IHS not delivering care that is needed.
    And it is not just South Dakota that has been affected; it 
is a nationwide issue. The hospital serving the Winnebago and 
Omaha Tribes had its relationship with CMS almost completely 
severed. And most recently, a hospital in Minnesota was cited 
by CMS, as well. In fact, my constituents tell me that the only 
reason that some IHS facilities are open today is because CMS 
just hasn't visited them yet.
    I am working hard to produce legislative solutions to this 
problem. Last year, I introduced the Helping Ensure 
Accountability, Leadership, and Trust in Tribal Healthcare Act, 
and this Subcommittee held a hearing. Today the bill looks a 
little bit different, and I will tell you why. It is because I 
have worked together with my colleagues in the Senate to craft 
a bill that includes elements of that bill that I had last 
Congress, but also a bill that Senator Barrasso introduced last 
year. His bill was called the IHS Accountability Act. The 
result of our cooperation is identical bills in the House and 
the Senate, and I am pleased that we are working together to 
address the serious deficiencies in the agency.
    The Restoring Accountability in the Indian Health Service 
Act contains several meaningful provisions and ensures that the 
agency's employees are held accountable.
    For example, the bill requires regular reporting from IHS, 
as well as GAO and the HHS Inspector General. New reporting is 
going to be critical. In our discussions with IHS over the last 
several years, the agency has been unable to even provide us 
with basic data related to its regular operations, which seemed 
pretty basic to us, but we realized they had not done any kind 
of data collection or reporting. The reporting will ensure that 
Congress has the information it needs to conduct oversight and 
make good decisions in the future.
    The bill also improves recruitment and retention by 
allowing the agency to look at employees and how they get them 
to come and serve at these facilities.
    The bill also will help IHS attract new management talent 
by allowing those managers to participate in the student loan 
repayment program. This is just an overview, but the bill 
contains several other provisions to improve patient care and 
streamline IHS processes.
    This bill, while important, I want to be clear is just a 
first step. There is so much to do in Indian Country to address 
substance abuse, domestic abuse, violent crime, child abuse, 
and, most tragically, the youth suicide situation that we are 
seeing in our tribes in South Dakota. Tribes in South Dakota 
are affected by all of these issues, and I look forward to 
working with you on them in the future.
    Again, these are situations that, if they can't get basic 
health care, you can see why none of the other needs are being 
met. I want to get this right. I have already reached out to 
HHS and IHS for technical assistance on this bill. So, that has 
been done, and I have worked with stakeholders across Indian 
Country--patients, tribal leaders, IHS employees, healthcare 
providers, private hospitals--to submit testimony for the 
record and give us feedback on the bill.
    I am excited to work with you and our tribes and thank you 
for the opportunity to discuss this bill with you today.
    [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 LaMalfa, Ranking Member Torres, and members of the 
Subcommittee, thank you for inviting me to testify at today's hearing 
about my bill, H.R. 2662, the Restoring Accountability in the Indian 
Health Service Act.
    Before I begin, I want to inform you that I was notified yesterday 
that HHS senior staff are traveling to South Dakota this week to visit 
the IHS hospital at Pine Ridge, which is home to the Oglala Sioux 
Tribe.
    Just a few weeks ago, I asked Secretary Price for his leadership 
and help in addressing this situation, and I thank him and his team for 
their quick action. I look forward to working with Secretary Price and 
the Administration on this and the many issues facing Indian Country.
    Now, turning to our hearing today: I personally thank the witnesses 
who traveled here to Washington, DC to testify today, especially Mr. 
William Bear Shield of the Rosebud Sioux Tribe. Mr. Bear Shield 
testified before you last year, and I am pleased he is here to offer 
his critical insights.
    Last year, I too, sat before this Subcommittee testifying on this 
same issue. I told you that the state of Indian health care in South 
Dakota had fallen to emergency levels. Today I can report to you that 
some progress has been made, but it's not enough, and it's not 
happening fast enough.
    Since this most recent crisis began, the Centers for Medicare and 
Medicaid Services has found three IHS hospitals in South Dakota to be 
deficient, which resulted in the closure of two emergency rooms. One 
has since reopened, but nevertheless, these closures have put serious 
strain on local community hospitals and drastically curtailed access to 
care for my constituents.
    And it's not just South Dakota that is affected. This is a 
nationwide issue.
    The hospital serving the Winnebago and Omaha Tribes had its 
relationship with CMS almost completely severed, and most recently, a 
hospital in Minnesota was cited by CMS as well. In fact, my 
constituents tell me that the only reason some IHS facilities remain 
open today is because CMS just hasn't visited them yet.
    I am working hard to produce legislative solutions to this problem. 
Last year, I introduced the Helping Ensure Accountability, Leadership, 
and Trust in Tribal Healthcare Act, and this Subcommittee held a 
hearing on the bill. Today's bill looks slightly different.
    That's because I have worked together with my colleagues in the 
Senate to craft a bill that includes elements from my HEALTTH Act and a 
bill Senator Barrasso introduced last year, the IHS Accountability Act. 
The result of our cooperation is identical bills in both the House and 
the Senate, and I am pleased that we are working together to address 
the serious deficiencies in the agency.
    The Restoring Accountability in the IHS Act contains several 
meaningful provisions that would streamline the agency's bureaucracy 
and ensure that the agency's employees are held accountable. For 
example, the bill would require regular reporting from the IHS, as well 
as GAO and the HHS Inspector General.
    New reporting is critical. In our discussions with the IHS over the 
past couple of years, the agency has been unable to provide us basic 
data related to its regular operations. This reporting will ensure 
Congress has all the information it needs to conduct thorough oversight 
of the agency.
    The bill would also improve recruitment and retention by allowing 
the agency to offer more robust benefits for employees. The bill would 
help the IHS attract new management talent by allowing managers to 
participate in the student loan repayment program.
    That's just an overview--the bill contains several other provisions 
to improve patient care and streamline IHS processes.
    This bill, while important, is only a first step. There's so much 
more to do to in Indian Country to address substance abuse, domestic 
abuse, violent crime, child abuse, and most tragically, youth suicide. 
Tribes in South Dakota are affected by all of these issues and I look 
forward to working with all of you on them in the future.
    In closing, let me be clear: I want to get this right. I have 
already reached out to HHS and IHS to obtain technical assistance for 
this bill, and I hope to get it this week.
    I encourage stakeholders across Indian Country--patients, tribal 
leaders, IHS employees, healthcare providers, private hospitals--to 
submit testimony for the record and give us feedback on the bill.
    I am excited to work closely with the Committee, tribes, and other 
stakeholders to pass this critical legislation. Thank you again for the 
opportunity to discuss the Restoring Accountability in the IHS Act.

                                 ______
                                 

    Mr. LaMalfa. Thank you, Mrs. Noem, for that. I appreciate 
your testimony.
    Would there be any questions of our panel up here? OK.
    You do? OK. Recognizing our Vice Chair.
    Miss Gonzalez-Colon. Thank you, Mr. Chairman. I want to 
commend my colleague for her noteworthy efforts to deliver 
improved health care to her constituents. Much of the IHS user 
population struggles in accessing timely quality care.
    While those facilities suffer from serious deficiencies 
memorialized in the 2010 Dorgan Report, they are still having 
those problems, and unfortunately, many of these challenges 
continue. I look forward to addressing those issues in the next 
panel.
    I have just two questions for you. One is the interest of 
H.R. 2662 to apply tribally operated facilities and recommend 
that these facilities shall have the ability to opt in and opt 
out of certain provisions of the bill. Do you think this bill 
will make it available to opt in, opt out for certain services, 
or not?
    Mrs. Noem. It will be, and it allows us to really meet the 
needs of those local communities that it is going to serve, and 
give us the opportunity--some of the reforms that we put into 
the legislation are ones that we have considered and debated 
when it comes to reforms in the VA.
    We looked at what was working there, as far as reforms. And 
some of the same problems that we have had in the VA, we are 
seeing in IHS as well. Some of them have to do with being able 
to fire employees that were not doing their job. Some of them 
had to do with recruitment issues that we are having. So, some 
of those abilities, to bring reforms to that federally run 
healthcare system of the VA, we put in this legislation as 
well, to meet some of the reforms that we believe are necessary 
within IHS.
    Miss Gonzalez-Colon. I made that question because some of 
the witnesses that are going to be here in the next panel just 
expressed that option of having opt in or opt out. And as a 
sponsor of the bill, I want to have your input about having 
that option or not.
    Mrs. Noem. Yes.
    Miss Gonzalez-Colon. The other question is, the deputy 
director of the Indian Health Service, Mr. Buchanan, mentions 
in his testimony that Section 110 of the bill requires to 
establish a tribal consultation policy. And he thinks that it 
is unnecessary, because the IHS already has a tribal 
consultation policy. What is your consideration?
    Mrs. Noem. I would encourage you to ask the others who are 
going to testify today about what consultation has been in the 
past. They will tell you that there has been no consultation. 
What IHS deems is called consultation with the tribe is non-
existent, so that is why it is required within the legislation, 
so that we now, as Members of Congress--and it is in statute--
that oversight has to happen on how that consultation piece is 
put into place, so that they have some input into what kind of 
health care is delivered to their communities.
    This is something that I have heard over and over, dozens 
and dozens of times through the years, that IHS has ignored 
many of the protocols that they have been encouraged to do, and 
consultation is one of the biggest things that they have failed 
at.
    Miss Gonzalez-Colon. Thank you. I yield back the rest of my 
time, Chairman.
    Mr. LaMalfa. Thank you. Anybody else on the panel wish to 
question?
    OK. Well, Mrs. Noem, you have answered it very well. I see 
a lot of parallels with the Veterans Administration and IHS 
here, and so the reforms you are pushing for I hope can be a 
template--one for the other--whichever one can get it done 
sooner.
    Is there anything else you would wish to elaborate on, on 
that parallel there?
    Mrs. Noem. Just the dire situation that we face. I would 
encourage all of you, if you have the opportunity, to come to 
the Great Plains region and see some of these facilities that 
have been affected. It really is like delivering health care in 
a third-world country. We have had babies born on the floor, we 
have had providers delivering care while they are on alcohol or 
drugs. We have had non-compliance on even just basic safety 
issues.
    And then we have no consistency in leadership or in 
providers. And many employees are left--they are understaffed, 
under-supported. And in the past, when we have given more money 
to IHS, the problems still have not been fixed. I believe that 
is why you see HHS on the ground today in South Dakota, because 
even in light of what has happened in the last couple of years, 
of shining some more light on this situation, IHS still has not 
made the changes that they promised to us that they would make.
    We held a hearing in South Dakota. We have had hearings 
here. We have been extremely vocal about this. This is why you 
see legislation today. We have tried to work with IHS in the 
past, and that has failed, and that is why we are pushing to 
have these reforms put in place. And listening to those who 
will testify on the next panel is critically important for you 
to get a clear picture as to the situation and the emergency 
situation that we have on the ground. Thank you.
    Mr. LaMalfa. All right. Congresswoman Noem, thank you for 
again bringing this bill forward, and for your strong efforts 
this year and last year in shining the light on this, and 
working toward an important solution for, in some cases, a 
pretty shameful situation.
    Thank you, and we will go ahead and seat the next panel. If 
you wish to stay along or do other duties--again, thank you for 
being here.
    [Pause.]
    Mr. LaMalfa. OK, I will introduce our second panel of 
witnesses as they come up to the dais.
    We have Rear Admiral Chris Buchanan, who is Assistant 
Surgeon General, U.S. Public Health Service, and the Deputy 
Director of Indian Health Service; we have the Honorable 
William Bear Shield, Chairman, Rosebud Sioux Tribal Health 
Board; we have the Honorable Andy Joseph, Business Council 
Member of the Confederated Tribes of the Colville Reservation; 
Mr. Robert TwoBears, District V Representative, Ho-Chunk Nation 
Legislature; and we have Ms. Victoria Kitcheyan, Great Plains 
Area Representative, National Indian Health Board.
    So, as you are seated, I will remind the witnesses again 
that under our Committee Rules, oral statements are limited to 
5 minutes. Their entire statement will appear in the hearing 
record.
    I think you all know the drill on the microphones, but they 
are not automatic. You need to press the button when you begin 
your testimony as we go down the line. A green light will turn 
on, which will allow you 4 minutes. The yellow light will allow 
you 1 additional minute, and your time will expire when the red 
light comes on, which we ask you to sum up and complete.
    We will have the entire panel give their testimony before 
the questioning will happen for the panel, as well. So, the 
Chair now recognizes Rear Admiral Buchanan to testify.

STATEMENT OF CHRIS BUCHANAN, REHS, MPH, REAR ADMIRAL, ASSISTANT 
 SURGEON GENERAL, USPHS; DEPUTY DIRECTOR, INDIAN HEALTH SERVICE

    Admiral Buchanan. Good afternoon, Chairman LaMalfa, Ranking 
Member Torres, and members of the Subcommittee, I am Chris 
Buchanan, I am an enrolled member of the Seminole Nation of 
Oklahoma, and Deputy Director of the Indian Health Service. I 
am pleased to have the opportunity to testify before the 
Subcommittee on H.R. 2662, the Restoring Accountability in the 
Indian Health Service Act of 2017.
    The mission of Indian Health Service, in partnership with 
American Indians and Alaska Natives, is to raise the physical, 
mental, social, and spiritual health of American Indians and 
Alaska Natives to the highest level. Providing quality health 
care is our highest priority. We share the urgency of 
addressing the long-standing systemic problems that hamper our 
ability to fully carry out the IHS mission.
    In November of 2016, we launched our Quality Framework and 
Implementation Plan to strengthen the quality of care that IHS 
delivers to the patients we serve. Since November of 2016, IHS 
has made substantial progress in implementing the Quality 
Framework and addressing many of the challenges you have 
identified in your proposed legislation.
    The Quality Framework guides how we develop, implement, and 
sustain an effective quality program that improves patient 
experience and outcomes. We are doing this by strengthening our 
organizational capacity, and ensuring the delivery of reliable, 
high-quality health care at IHS direct-service facilities.
    The new IHS credentialing system will streamline 
credentialing and facilitate the hiring of qualified 
practitioners, as well as privileging and performance 
evaluations of IHS practitioners. It will allow the local and 
area offices to perform these functions in alignment with the 
Centers for Medicare and Medicaid Services' conditions of 
participation, and accreditation standards for governance of 
hospitals and ambulatory care facilities. We will pilot it in 
four IHS areas in July, and implement it across the remaining 
IHS areas by the end of 2017.
    Ensuring timely access to care requires that we develop 
standards for waiting times for appointments, as well as for 
the time spent in providers' offices, and that we benchmark 
against clear standards. Agency-wide standards for wait times 
are also in development. To ensure accountability at the 
highest level, and to improve transparency about access to and 
quality of care, IHS is implementing a performance 
accountability dashboard. This includes reporting on patient 
wait times. Pilot testing of the dashboard and associated data 
collection is targeted for this summer.
    Strengthening governance and leadership at all levels of 
IHS is essential for assuring quality health care. IHS now 
requires a standardized governance process and use of a 
standard governing board agenda across all IHS areas with 
federally operated facilities.
    The first leadership training class to prepare selected 
individuals to serve in leadership positions at the service 
unit, area, and headquarters levels was launched June 6, with 
34 participants. IHS faces significant recruitment challenges 
due to the remote, rural locations of our healthcare facilities 
and area offices.
    IHS is implementing various strategies to increase 
recruitment and retention. Global recruitment is one strategy 
that we have implemented for a streamlined approach to filling 
critical provider vacancies at multiple locations. Applicants 
only need to apply to a single vacancy announcement, and can be 
considered for multiple positions throughout the country. 
Recruiting for critical positions by using a single 
announcement to recruit for multiple positions is showing 
promise.
    Now, IHS has priority access to new commissioned corps 
applicants. This allows IHS to make first contact with these 
applicants in efforts to recruit them to fill health 
professional vacancies throughout IHS.
    Also, IHS facilities can use the National Health Service 
Corps scholarship and loan repayment incentives to recruit and 
retain primary care providers. As of April 2017, 472 National 
Health Service Corps recipients are currently part of our 
workforce serving in IHS tribal and urban facilities. These 
actions demonstrate that IHS is taking challenges seriously, 
and is continuing to take assertive and proactive steps to 
address them.
    IHS is prepared to provide the Subcommittee technical 
assistance on specific authorities proposed by H.R. 2662. 
Despite all of the challenges, I am firmly committed to 
improving quality, safety, and access to health care for 
American Indians and Alaska Natives.
    In collaboration with HHS, our partners across Indian 
Country, and Congress, we look forward to working with the 
Subcommittee on this legislation as it moves through the 
legislative process, and I am happy to answer any questions the 
Subcommittee may have. Thank you.
    [The prepared statement of Admiral Buchanan follows:]
   Prepared Statement of Chris Buchanan, R.E.H.S., M.P.H., Assistant 
 Surgeon General, USPHS; Deputy Director, Indian Health Service, U.S. 
                Department of Health and Human Services
    Good afternoon, Chairman LaMalfa, Ranking Member Torres, and 
members of the Subcommittee. I am Chris Buchanan, an enrolled member of 
the Seminole Nation of Oklahoma and Deputy Director of the Indian 
Health Service (IHS). I am pleased to have the opportunity to testify 
before the House Natural Resources Committee's Subcommittee on Indian, 
Insular and Alaska Native Affairs on H.R. 2662, the ``Restoring 
Accountability in the Indian Health Service Act of 2017.'' I would like 
to thank you, Chairman LaMalfa and members of the Subcommittee for 
elevating the importance of delivering quality care through the IHS.
    IHS plays a unique role in the Department of Health and Human 
Services (HHS) because it was established to carry out the 
responsibilities, authorities, and functions of the United States to 
provide healthcare services to American Indians and Alaska Natives. The 
mission of IHS, in partnership with American Indian and Alaska Native 
people, is to raise the physical, mental, social, and spiritual health 
of American Indians and Alaska Natives to the highest level. IHS 
provides comprehensive health care delivery to approximately 2.2 
million American Indians and Alaska Natives through 26 hospitals, 59 
health centers, 32 health stations, and 9 school health centers. Tribes 
also provide health care access through an additional 19 hospitals, 284 
health centers, 163 Alaska Village Clinics, 79 health stations, and 8 
school health centers.
    Providing quality health care is our highest priority. We share the 
urgency of addressing long-standing systemic problems that hamper our 
ability to fully carry out the IHS mission. In November 2016, we 
launched our 2016-2017 Quality Framework and Implementation Plan to 
strengthen the quality of care that IHS delivers to the patients we 
serve. Implementation of the Quality Framework is intended to 
strengthen organizational capacity to improve quality of care, improve 
our ability to meet and maintain accreditation for IHS direct-service 
facilities, align service delivery processes to improve the patient 
experience, ensure patient safety, and improve processes and strengthen 
communications for early identification of risks. The Quality Framework 
will be reviewed and updated at least annually in partnership with 
tribes.
    The HHS Executive Council on Quality Care (the Council), which was 
stood up in November 2016, provides support to IHS by identifying and 
facilitating collaborative, action-oriented approaches from across the 
Department to address issues that affect the quality of health care 
provided to American Indians and Alaska Natives we serve. The Council 
includes leadership from 12 HHS Staff and Operating Divisions. The 
Council's mission is to support IHS' efforts to develop, enact, and 
sustain an effective quality program--to improve quality and patient 
safety in the hospitals and clinics that IHS administers. This may 
include providing technical assistance to bolster quality and safety, 
identifying solutions to address workforce recruitment and retention 
challenges, seeking creative solutions to infrastructure needs, and 
enhancing stakeholder engagement. The Council partners with HHS 
leadership and staff in policy implementation.
    Since November 2016, IHS has made substantial progress in 
implementing the Quality Framework and in addressing many of the 
challenges you have identified in your proposed legislation.
                 strengthening organizational capacity
    The Quality Framework guides how we develop, implement, and sustain 
an effective quality program that improves patient experience and 
outcomes. We are doing this by strengthening our organizational 
capacity, and ensuring the delivery of reliable, high quality health 
care at IHS direct-service facilities.
    We recently awarded a contract for credentialing software that will 
provide enhanced capabilities and standardize the credentialing process 
across IHS. The new system will streamline credentialing and facilitate 
the hiring of qualified practitioners as well as, privileging and 
performance evaluations of IHS practitioners. This will help ensure the 
quality and safety of care delivered in IHS Federal Government 
hospitals and health centers. We are on course with the implementation 
of this medical credentialing system. We expect to test it in four IHS 
Areas in July 2017, and plan to implement it across the remaining IHS 
Areas by the end of 2017. Our agency credentialing policy is in the 
process of being updated.
    Ensuring timely access to care requires that we develop standards 
for waiting times for appointments, as well as for the time spent in 
the provider's office, and that we benchmark against clear standards. 
IHS Service Units currently collect patient wait time data to track the 
patient care experience as part of the Improving Patient Care program. 
Agency-wide standards for wait times are also in development. To ensure 
accountability at the highest level, and to improve transparency about 
access to and quality of care, IHS is implementing a performance 
accountability dashboard. This includes reporting on patient wait 
times. Pilot testing of the dashboard and associated data collection is 
targeted for this summer.
    Strengthening governance and leadership at all levels of the IHS 
system is essential to assuring quality health care. IHS now requires a 
standardized governance process and use of a standard governing board 
agenda across all IHS Areas with federally operated facilities. The 
first leadership training class to prepare selected individuals to 
serve in leadership positions at the Service unit, Area, and 
Headquarters levels was launched June 6 with 34 participants. In 
addition, IHS has begun implementing a leadership coaching and 
mentoring program in the Great Plains area as new leaders are 
recruited.
                          workforce strategies
    IHS faces significant recruitment challenges due to the remote, 
rural location of our healthcare facilities and Area offices. To make a 
career in IHS more attractive to modern healthcare practitioners, IHS 
is implementing various strategies to increase recruitment and 
retention. Global recruitment is one strategy we have implemented that 
allows for a streamlined approach to filling critical provider 
vacancies at multiple locations. Applicants only need to apply to a 
single vacancy announcement and can be considered for multiple 
positions throughout the country. Recruiting for critical positions by 
using a single announcement to recruit for multiple positions is 
showing promise.
    IHS continues the successful partnership with the Office of the 
Surgeon General to increase the recruitment and retention of 
Commissioned Corps officers, and most recently the IHS has been given 
priority access to new Commissioned Corps applicants. This allows IHS 
to make the first contact with these applicants in an effort to recruit 
them to fill health professional vacancies throughout IHS. This new 
effort began in May, and we can provide periodic updates on this 
effort. IHS also continues to partner with the National Health Service 
Corps (NHSC). Use of NHSC allows IHS facilities to recruit and retain 
primary care providers by using NHSC scholarship and loan repayment 
incentives. As of April 2017, 472 NHSC recipients are currently part of 
our workforce serving in IHS, tribal and urban facilities.
    These actions demonstrate that IHS is taking its challenges 
seriously, and is continuing to take assertive and proactive steps to 
address them.
                               h.r. 2662
    H.R. 2662 proposes specific authorities to aid us in elevating the 
health of American Indians and Alaska Natives to the highest level. IHS 
is prepared to provide the Subcommittee technical assistance on the 
legislation and I would like to provide additional technical comments 
on various sections of the bill.
    Section 101 would address the need for IHS to offer more flexible 
and competitive benefits to recruit employees by establishing a 
comparable pay system as allowed under Chapter 74 of Title 38. IHS 
appreciates the authority we already have to use the pay flexibilities 
under Chapter 74 of Title 38. We are working with OPM, OMB, and other 
affected agencies to explore ways to enhance utilization of our current 
pay authorities to enhance our ability to recruit and retain high 
quality staff.
    Section 102 requires a Service-wide centralized credentialing 
system to credential licensed health professionals who seek to provide 
healthcare services at any Service facility. IHS supports the use of a 
standard system for credentialing. We are implementing a national 
system for credentialing as well as privileging and evaluating 
performance of IHS practitioners. Our new system will allow the local 
and/or Area offices to perform these functions in alignment with the 
Centers for Medicare and Medicaid Services (CMS) Conditions of 
Participation and external accreditation standards for governance of 
hospitals and ambulatory care facilities.
    Section 104 would make certain healthcare management or healthcare 
executive positions eligible professions for loan repayment awards, in 
exchange for non-clinical service obligations. Management expertise is 
very important in a health system as large as IHS.
    Section 106 addresses IHS authority to remove or demote employees. 
IHS has existing authorities to implement adverse employment actions.
    Section 107 requires IHS to develop and implement standards to 
measure the timeliness of care at direct-service IHS facilities. As 
described above, IHS is in the process of establishing agency-wide 
standards for wait times to each federally operated service unit. A 
process for uniform data collection and reporting is also being 
established.
    Section 108 adds specific requirements for implementation of annual 
mandatory cultural competency training programs for IHS employees, and 
other contracted employees engaged in direct patient care. Cultural 
competency in the IHS workforce is essential to the provision of 
quality care and is a requirement under the accreditation standards for 
hospitals. I have recently issued direction for all IHS employees to 
complete training, which will become an annual requirement.
    Section 110 requires IHS to establish a tribal consultation policy. 
The specific provision is unnecessary as IHS already has a tribal 
consultation policy in place. The requirements for consultation are 
contained in statutes and various Presidential Executive Orders 
including: the Indian Self-Determination and Education Assistance Act, 
Indian Health Care Improvement Act, Presidential Memoranda in 1994 and 
2004, and Executive Orders in 1998 and 2000. It is the policy of HHS 
and IHS that consultation with American Indian and Alaska Native tribes 
will occur to the extent practicable and permitted by law before any 
action is taken that will significantly affect Indian tribes. IHS is 
committed to regular and meaningful tribal consultation and 
collaboration as an essential element for a sound and productive 
relationship with tribes.
    Despite all of the challenges, I am firmly committed to improving 
quality, safety, and access to health care for American Indians and 
Alaska Natives, in collaboration with HHS, our partners across Indian 
Country, and Congress. I appreciate all your efforts in helping us 
provide the best possible healthcare services to the people we serve to 
ensure a healthier future for all American Indians and Alaska Natives.
    We look forward to working with the Subcommittee on this 
legislation as it moves through the legislative process. Thank you for 
your commitment to improving quality, safety, and access to health care 
for American Indians and Alaska Natives. I am happy to answer any 
questions the Subcommittee may have.

                                 ______
                                 

   Questions Submitted for the Record by Rep. LaMalfa to RADM Chris 
            Buchanan, Deputy Director, Indian Health Service

    Question 1. The Indian Health Service (IHS) operates the Joint 
Venture Construction Program, allowing tribes to expend tribal, 
private, or other available non-IHS funds to acquire or construct a 
healthcare facility, usually clinics.

    In exchange, IHS agrees to request congressional appropriations for 
additional staff and operation costs to maintain the facility under a 
no-cost lease for a minimum of 20 years.

    While this program is yielding some success, funding for the 
construction of healthcare facilities has been limited to clinics and 
fails to address the challenge of providing physician care to those 
areas of Indian Country which are most in need.

    How would the IHS respond to the idea of modifying the Join Venture 
model by tasking the Federal Government to build, perhaps with the 
involvement of private investment, 20-30 bed micro hospitals and then 
allowing willing tribes take on the task of equipping and staffing the 
facility?

    Answer. The current Joint Venture Construction Program (JVCP) is a 
way for the IHS to bring new healthcare facilities into the IHS system. 
Tribes strongly support the JVCP because it provides them the 
opportunity to use their own capital on a one-time basis to acquire or 
construct a facility. In exchange, IHS agrees to submit requests to 
Congress for initial and recurring staffing and operation funding for 
that facility. The last solicitation for the JVCP yielded 37 
applications. Seven of those applicants were approved to proceed with 
planning on variously sized ambulatory and inpatient facilities.
    The IHS currently does not have the authority to fund construction 
of Joint Venture Construction projects. If Congress provided IHS with 
construction authority for such projects, it would likely impact IHS's 
ability to fund the construction of other new and replacement 
healthcare facilities that have been identified by the Secretary as 
priorities under the Health Care Facility Priority System (HCFPS). 
Generally, IHS appropriations for construction are limited to the 
amounts required to construct new and replacement healthcare facilities 
identified as HCFPS priorities.
    The HCFPS list was last updated in 1992, identifying 27 facilities 
that need to be completed before new facilities are added. Today, there 
are 11 healthcare facilities that remain on the list that have either 
received funds for design and construction or are waiting to be funded. 
The rate of funding to date has been approximately one facility per 
year. IHS funding the construction of other facilities would delay 
continued progress on addressing the HCFPS list.
    In summary, the IHS is open to working with tribal leaders to 
explore how we can utilize existing authorities within the IHS and 
other resources to maximize resources for Indian Country.

                                 ______
                                 

    Miss. Gonzalez-Colon [presiding]. Thank you. Now the Chair 
recognizes Chairman Bear Shield to testify.

 STATEMENT OF THE HON. WILLIAM BEAR SHIELD, CHAIRMAN, ROSEBUD 
        SIOUX TRIBAL HEALTH BOARD, ROSEBUD, SOUTH DAKOTA

    Mr. Shield. Good afternoon. Thank you, Committee, for once 
again allowing me to be here to testify about H.R. 2662. I want 
to acknowledge our South Dakota Congresswoman, Mrs. Kristi 
Noem, and our gratitude for her reaching out to us on working 
together on creating this legislation.
    I am William Bear Shield, a member of the Rosebud Sioux 
Tribal Council. I am also the Chairman of our Rosebud Sioux 
Health Board and the Unified Health Board that serves the Sioux 
San IHS Hospital in Rapid City, South Dakota, as well as the 
Vice Chairman of our Great Plains Tribal Chairman's Health 
Board, and I sit on the Health and Human Service's Secretary's 
Tribal Advisory Committee.
    The problems within IHS did not happen overnight. In fact, 
in 2010, former U.S. Senator Dorgan from North Dakota released 
the Dorgan Report that identified most of the same issues. The 
difference is something is now being done to correct those 
issues.
    The fundamental problem found in the Dorgan Report in 2010 
and the findings now before the House is IHS leadership was 
failing then, as it is failing now. So, before I talk about 
this bill, I first feel the need to stress the appointment of a 
new principal director of IHS. The Rosebud Sioux Tribe has 
endorsed a candidate that we believe will bring a new 
perspective, and is not a member of PHS. We believe this is 
necessary if the rebuilding of IHS is to have any change at 
all.
    We strongly urge the Members to press for the nomination of 
a permanent director of IHS as soon as possible. Along with the 
naming of a permanent director, the position must be given 
authority to deal with rebuilding IHS, which H.R. 2662 does.
    We feel that IHS needs a deputy secretary-level position at 
the Health and Human Services level. It is appropriate and 
necessary that tribal health care be given the priority and 
status it deserves, and this helps in creating positive change.
    As a starting point for commenting on any legislation, it 
must be acknowledged that the current structure, systems, and 
management of IHS are outdated, broken, and cannot be fixed. It 
has reached a point where only adding tools and 
responsibilities will not help. The IHS must be set aside and 
be completely rebuilt from the ground up. If this is not the 
view, we will be back here next year and in the following years 
talking about the same issues and more tribal members will have 
needlessly perished.
    Specifically, it is our view that this legislation 
accomplishes the following: This legislation respects our 
treaty rights--this means always recognizing and affirming the 
obligations of the U.S. Government to provide the highest 
quality of health care to every tribal member.
    This legislation allows the delivery of patient-focused 
health care, and this should be the first and truly only 
priority of IHS. Regardless of what may be said or reported, 
this is not the case now and it has not been for a very long 
time.
    This legislation mandates the required meaningful 
communication at all levels between the IHS and tribes. You may 
hear that there is a consultation policy in place and that it 
is working. It is not working, and I am here to tell you that. 
Consultation only works when there is a direct and substantial 
dialogue. It only works when the dialogue leads to better care, 
solves real problems, and is accountable. Because of this, we 
ask Congress to direct IHS to work with tribes, and we are 
included in developing the consultation policies as directed in 
the proposed legislation.
    We applaud the task force set up by the House. It is our 
hope that this signals the rebuilding efforts we advocate are 
supported by the Members. We will work with the task force in 
continuing to advocate for real, meaningful recommendations 
that rebuild and strengthen IHS.
    As we move forward, there are other areas we need to focus 
on: Drug pricing--allow the IHS to use existing Federal 
authority to negotiate prices to better deploy IHS budgeted 
funds.
    PRC--focus on better systems and processes, so that tribes 
can access Medicaid and third-party dollars. We ask that 
Congress work with us and the Centers for Medicare and Medicaid 
Services to update a policy on funding 100 percent of funds for 
Medicaid-eligible American Indians through the Indian Health 
Service and/or tribes.
    HIPAA changes--explore amendments to HIPAA that would give 
access to records and accountability for all Indian healthcare 
facilities and operations.
    We would also favor the President using an Executive Order, 
very like the one he issued for the VA. It could be possibly 
titled, ``Improving Accountability and Whistleblower Protection 
at IHS.''
    Create a modern, state-of-the-art healthcare delivery and 
administrative system for tribal health care. There are many 
examples in the private sector and the direction the VA is 
moving may be worth examining. At a minimum, modern systems 
address credentialing, waiting times, and quality of service.
    Miss Gonzalez-Colon. Chairman, could you summarize?
    Mr. Shield. Yes. Last, again, it may be said that there are 
plans being implemented to address this issue. How long has IHS 
been in this planning mode? We still need to see that 
implemented. When there are no leadership and no systems, plans 
are all that can be talked about. We look forward to this bill 
in changing those systems within IHS. Thank you.
    [The prepared statement of Mr. Shield follows:]
  Prepared Statement of Councilman William Bear Shield, Rosebud Sioux 
                          Tribal Health Board
    Thank you for inviting me to testify about H.R. 2662. I want to 
acknowledge our South Dakota Congresswoman Kristi Noem, and give our 
gratitude to her for reaching out to us on working together in creating 
this legislation.
    I am Willie Bear Shield. I am a member of the Rosebud Sioux Tribal 
Council, I am also the Chairman of the Rosebud Sioux Health Board and 
Unified Health Board that serves the Sioux San IHS Hospital in Rapid 
City, South Dakota, as well as the Vice-Chairman of the Great Plains 
Tribal Chairman's Health Board and I sit on the HHS Secretary's Tribal 
Advisory Committee.
    The problems within IHS did not happen overnight, in fact in 2010 
former U.S. Senator Dorgan from North Dakota released the Dorgan report 
that identified most of these same issues, the difference is something 
is now being done to correct the problems.
    The fundamental problem found in the Dorgan report in 2010 and the 
findings now before the House is IHS, LEADERSHIP was failing then as it 
is failing now. So, before I talk more about the bill, I feel the first 
thing we must do is appoint a new Principle Director of IHS. The 
Rosebud Sioux Tribe has endorsed a candidate that we believe will bring 
a new perspective and is not a member of PHS. We believe this is 
necessary if the rebuilding of IHS is to have any change at all.
    We strongly urge the members to press for the nomination of a 
permanent Director of IHS as soon as possible. Along with the naming of 
a permanent Director, the position must be given authority to deal with 
rebuilding IHS, which H.R. 2662 does. We feel that IHS needs a Deputy 
Secretary level position at HHS. It is appropriate and necessary that 
tribal health care be given the priority and status it deserves and 
this helps in creating positive change.
    As a starting point for commenting on any legislation it must be 
acknowledged that the current structure, systems and management of IHS 
are outdated, broken and cannot be fixed. It has reached a point where 
only adding tools and responsibilities will not help. The IHS must be 
set aside and be completely rebuilt from the ground up. If this is not 
the view, we will be back here next year and the years following 
talking about the same issues and more tribal members will have 
needlessly died.

    Specifically, it is our view that this legislation accomplishes the 
following:

     This legislation, Respects Treaty Rights--this means 
            always recognizing and affirming the obligations of the 
            U.S. Government to provide the highest quality health care 
            to every tribal member.

     This legislation allows the delivery of patient focused 
            health care and this should be the first and truly only 
            priority of IHS. Regardless of what may be said or reported 
            this is not the case now and has not been for a very long 
            time.

     This legislation mandates the required meaningful 
            communication at all levels between the IHS and tribes. You 
            may hear that there is a Consultation Policy in place and 
            that it is working. It is not working. Consultation only 
            works when there is a direct and substantial dialogue. It 
            only works when the dialogue leads to better care, solves 
            real problems and is accountable. Because of this we ask 
            Congress to direct IHS to work with tribes and we are 
            included in developing the consultation policies as 
            directed in the proposed legislation.

    We applaud the task force set up by the House. It is our hope that 
this signals the rebuilding efforts we advocate are supported by the 
Members. We will work with the task force and continue to advocate for 
real meaningful recommendations that rebuild and strengthen IHS.

    As we move forward there are other areas we need to focus on:

    Drug pricing--Allow the IHS to use existing Federal authority to 
negotiate prices to better deploy IHS budgeted funds.

    PRC--Focus on better systems and processes so that tribes can 
access Medicaid and third-party money. We ask that Congress work with 
us and the Centers for Medicare and Medicaid Services (CMS) to update a 
policy on funding 100 percent of funds for Medicaid-eligible American 
Indians through the Indian Health Service or tribes.

    HIPPA changes--Explore amendments to HIPPA that would give access 
to records and accountability for all Indian healthcare facilities and 
operations.

    We would also favor the President issuing an Executive Order very 
like the one issued for the VA. It could be possibly titled, Improving 
Accountability and Whistleblower Protection at IHS.

    Create a modern state-of-the-art healthcare delivery and 
administrative system for tribal health care. There are many examples 
in the private sector and the direction the VA is moving may be worth 
examining. At a minimum, modern systems address credentialing, wait 
times and quality of service.

    For example:

     We all hear how terrible the credentialing systems are at 
            IHS. The reason is because of the lack of leadership 
            practically every service unit within IHS uses its own 
            method of credentialing. This means that a doctor at IHS 
            Pine Ridge cannot easily come to IHS Rosebud and provide 
            service. It may take 30, 60, 90 days or longer. Also, if a 
            bad doctor is moved out of any given IHS facility they can 
            be credentialed at another because of the lack of systems 
            that track and are accessible system wide in the IHS. An 
            $85 million contract does not solve this, because it 
            requires leadership to make it work.

     At the Rosebud ER, and others, the lack of standing orders 
            and other processes that are standard in most every other 
            healthcare system in the United States has killed our 
            people. Let me explain--It is common and best practice for 
            an ER to have standing orders issued by a doctor. This 
            enable the staff to quickly treat and otherwise deal with 
            incidents. The orders follow well established medical 
            practice and allow staff to administer drugs and other 
            treatments if an attending or on call doctor is not 
            immediately available. This then allows for effective 
            service, evaluations, and assessments as well as saving 
            lives. Why is it that IHS leadership does not require that 
            this fundamental medical practice be implemented 
            everywhere? It is beyond me.

    Again, it may be said that there are plans being implemented to 
address this issue. How long has IHS been in the planning mode. When 
there is no leadership and no systems--plans are all that can be talked 
about!
    Once again, I want to thank you for the opportunity to testify 
before you and want to advise you that we strongly support this 
legislation and ask that all Members of Congress do the same to start 
the rebuilding of a broken system into one that provides quality health 
care.
    We strongly urge the Members to press for the nomination of a 
permanent Director of IHS as soon as possible. Along with the naming of 
a permanent Director, the position must be given authority to deal with 
the rebuild. H.R. 2662 does some of that. Let me suggest that the IHS 
needs a Deputy Secretary level position at HHS. It is appropriate and 
necessary that tribal health care be given the priority and status it 
deserves this change within HHS would bring.
    As to the rebuild, we applaud the task force set up by the House of 
Representatives. It is our hope that this signals the rebuilding 
efforts we advocate are supported by the Members. We will work with the 
task force and continue to advocate for real meaningful recommendations 
that rebuild and strengthen IHS.

    There are other areas for the Members to focus on:

     Drug pricing--Allow the IHS to use existing Federal 
            authority to negotiate prices to better deploy IHS budgeted 
            funds.

     PRC--Focus on better systems and processes so that tribes 
            can access Medicaid and third-party money.

     HIPPA changes--Explore amendments to HIPPA that would give 
            access to records and accountability for all Indian 
            healthcare facilities and operations.

    We recognize the provision of health care is complicated. We see 
the national demand for change in delivery, service and financing of 
the healthcare system. We ask that Members focus on the rebuilding of 
the IHS as both a way to meet the obligations of the U.S. Government to 
tribes and to make sure that tribes have a place at the table as the 
overall national debate on health care moves forward.

                                 ______
                                 

    Miss. Gonzalez-Colon. Thank you, Chairman. The Chair now 
recognizes the Honorable Andy Joseph, Business Council Member 
of the Confederated Tribes of the Colville Reservation.

  STATEMENT OF THE HON. ANDY JOSEPH, BUSINESS COUNCIL MEMBER, 
  CONFEDERATED TRIBES OF THE COLVILLE RESERVATION, NESPELEM, 
                           WASHINGTON

    Mr. Joseph. Good afternoon, members of the Subcommittee. 
[Speaking native language.] My name is Andy Joseph, Jr. I am a 
member of the Colville Business Council, the governing body of 
the Confederated Tribes of the Colville Reservation. I serve as 
the Chair of the Council's Health and Human Services Committee.
    H.R. 2662 addresses several long-standing problems with IHS 
service. The Colville is a direct-service tribe, and the bill 
would benefit us and other direct-service tribes in several 
ways. We strongly support H.R. 2662 and urge the Committee to 
move the legislation forward.
    I would like to express the Colville Tribes' thanks to 
Congresswoman Kristi Noem and her staff for their work in 
developing this legislation. I would also like to thank this 
Committee for its work in outreach on the bill.
    Last year, your staff toured the health facilities on the 
Colville Reservation and heard firsthand about the challenges 
we face in providing care for our members. I would also like to 
thank Rear Admiral Chris Buchanan for him and his staff who 
came to our reservation and toured our clinics.
    For decades, the Colville Tribes have endured chronically 
low staffing levels. On December 17, 2013, the Colville 
Business Council adopted a resolution declaring a state of 
emergency because of IHS staffing shortages. After that 
declaration, IHS calculated that the Colville Tribe 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.
    For direct-service tribes, facility staffing ratios are 
established when the initial IHS health facility opens for 
operations. Those levels may increase slightly as the IHS base 
budget increases, but they can never be brought anywhere close 
to what is needed in modern times.
    There are two ways for direct-service tribes to update 
their staffing levels. One is to construct a new facility with 
IHS funds under the Facility Construction Priority System. The 
other is to build the facility using tribal funds under a joint 
venture program. The priority list has been closed since 1992, 
and applicants for joint venture programs are offered rarely 
and are highly competitive.
    Direct-service tribes that have not been able to update 
their staffing ratios through these two IHS programs are frozen 
in time for staffing purposes. For the Colville Tribes, this 
historic staffing ratio dates back to 1938. That is when the 
U.S. Public Health Service converted a Department of War 
building for use as the Colville service unit's health clinic. 
Former IHS officials have told us that this facility was 
removed from the priority list in the 1980s because of its 
historical significance. This building was used as a tribe's 
primary health clinic until the tribe used its own tribal funds 
to construct a new facility.
    Staffing shortages increase the waiting times for patients 
and have other consequences. Lack of staffing has also resulted 
in fewer patient encounters. Fewer encounters means our user 
population decreases, which means our allocation of purchased 
and referred care funding decreases.
    The staffing shortages have also driven our healthcare 
providers to seek other employment. Many of their patients have 
chronic illnesses that multiply the number of visits in their 
annual workload. Despite increases in the IHS base budget in 
recent years, the Colville Tribes' staffing ratios have not 
improved. This is because the increases for IHS staffing in the 
President's budget request are almost always earmarked to staff 
new facilities that come on-line under the priority list or the 
joint venture program.
    For direct-service tribes like the Colville that have been 
unable to build anything under these programs, our staffing 
ratios are frozen in time. In our case, time was 70 years ago.
    The staffing demonstration project in Section 109 would 
provide a way to address these inequities. It would authorize 
IHS to provide additional staffing resources to the Indian 
Health Service units on a temporary basis. A deployment----
    Miss Gonzalez-Colon. Mr. Joseph, can you summarize?
    Mr. Joseph. Yes. I just have a couple more--this would 
enable staffing to be self-sustaining and permanent.
    Section 109 would address a much-needed void in the Indian 
Health System. It would provide a path to direct-service tribes 
with historically low staffing ratios to update their ratios. 
This could be a model to address staffing inequities throughout 
the IHS system for well-managed IHS service units.
    My written testimony is in for the record. Thank you for 
this time.
    [The prepared statement of Mr. Joseph follows:]
Prepared Statement of the Honorable Andrew Joseph, Jr., Council Member, 
    Colville Business Council, Confederated Tribes of the Colville 
                              Reservation
    On behalf of the Confederated Tribes of the Colville Reservation 
(``Colville Tribes'' or the ``CCT''), I thank you for this opportunity 
to provide testimony on the ``Restoring Accountability in the Indian 
Service Act of 2017,'' H.R. 2662.
    My name is Andy Joseph, Jr., and I am a member of the Colville 
Business Council, the governing body of the Colville Tribes, and serve 
as the Chair of the Council's Human Services Committee. I also serve as 
the President of the Portland Northwest Area Indian Health Board, which 
has 43 federally recognized member tribes in Oregon, Washington and 
Idaho and serves as the health advocacy organization for the Northwest 
region. I provide this testimony in my capacity as a representative of 
the Colville Tribes.
    As an initial matter, I would like to express the Colville Tribes' 
thanks to Congresswoman Kristi Noem and her staff for their work over 
the past year in developing this legislation. I would also like to 
thank the staff for this Committee, who toured the health facilities on 
the Colville Reservation last year and heard directly from our staff 
about the challenges they face in providing care to our members.
    H.R. 2662 addresses several long-standing issues with the Indian 
Health Service (``IHS'') and would benefit the Colville Tribes and 
other tribes in many ways. The Colville Tribes supports H.R. 2662 and 
urges the Committee to move the legislation forward through the 
legislative process. We offer some specific recommendations on how the 
bill can be clarified to garner even broader Indian Country support.
                   background on the colville tribes
    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 Colville Tribes 
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. The Colville Tribes has a large 
IHS service area and these communities are separated by significant 
drive times. The CCT's primary IHS facility is in Nespelem, WA, and 
residents from Inchelium that require care must drive, in many cases, 
more than 90 minutes through two mountain passes. Although the CCT has 
contracted some discrete IHS activities under Pub. L. 93-638, the IHS 
directly provides most of the healthcare services on the Colville 
Reservation.
                 staffing inequities in the ihs system
    The Colville Tribes has, for decades, endured chronically low 
staffing levels. On December 17, 2013, the Colville Business Council 
adopted a resolution declaring a state of emergency on the Colville 
Reservation in response to immediate IHS staffing shortages and a large 
number of current and forecasted vacancies. In response to a 
congressional inquiry resulting from that declaration, the 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.
    For the Colville Tribes and similarly situated direct-service 
tribes, facility staffing ratios are essentially set when the initial 
IHS health facility opens for operation. These levels may increase 
incrementally as the IHS base budget increases, but they can never be 
brought anywhere close to what is needed in modern times.
    The only way for a tribe to update its staffing levels to reflect 
growth and modern health delivery needs is to either construct a new 
facility with IHS funds under the Health Care Facility Construction 
Priority List (``Priority List'') or construct a facility using tribal 
funds under the Joint Venture construction program. The Priority List 
has been closed since 1992 and solicitations for the Joint Venture 
program are offered very infrequently and are extraordinarily 
competitive.
    Direct service tribes that have not been able to update their 
staffing ratios through these two IHS programs are essentially frozen 
in time for staffing ratio purposes. For the Colville Tribes, these 
historic staffing ratios date back to the late 1930s when the U.S. 
Public Health Service converted a Department of War building for use as 
the Colville Service Unit's health clinic. This historic facility--
which the CCT understands from former IHS officials was removed from 
the Priority List in the 1980s because of its historical significance--
was used as the CCT's primary health clinic until the CCT used its own 
tribal funds to construct a new facility. That facility opened in June 
2007.
    Staffing shortages not only increase the wait times for patients, 
but in the CCT's case, they have also had other consequences. Lack of 
health providers has resulted in fewer patient encounters, which has 
had a negative domino effect on the CCT's Purchased/Referred Care 
funding and user population. The staffing shortages have also prompted 
other healthcare providers to seek other employment because many of the 
patients in their respective panels have chronic illnesses that 
multiply the number of visits in their annual workloads.
    Despite increases to the IHS's base budget in recent years, the 
Colville Tribes' staffing ratios have not improved. This is because 
increases for IHS staffing in the President's Budget request have been 
earmarked to staff new facilities that come on-line that were 
constructed under either the Priority List or the Joint Venture 
programs. Again, for direct-service tribes like the CCT that have been 
unable to build anything under those IHS construction programs, our 
staffing ratios are frozen in time. In our case, the 1930s.
 the section 109 staffing demonstration project provides an innovative 
               approach to addressing staffing inequities
    The Staffing Demonstration Project in Section 109 would provide a 
mechanism to address these inequities by authorizing the IHS to deploy 
an infusion of staffing resources to federally managed IHS Service 
Units. While temporary, the deployment of staff is intended to enable 
Service Units to incorporate the additional staff into their billing 
and collection processes to enable the staff to be self-sustaining and 
permanent. The Staffing Demonstration Project could be funded 
separately but, as drafted, it is intended to allow the IHS to utilize 
carryover or other available funds.
    Section 109 would address a much-needed void in the IHS system by 
providing a path for tribes with historically low staffing ratios to 
update those ratios. With the advances in opportunities for third party 
billing in the last reauthorization of the Indian Health Care 
Improvement Act, if successful, the Staffing Demonstration Project 
could be a model to address staffing inequities throughout the IHS 
system. We greatly appreciate that this language was included in the 
bill and strongly support it.
                   other comments and recommendations
    Although the CCT is primarily a direct-service tribe and most of 
H.R. 2662 is intended to address issues applicable to direct-service 
tribes, we recommend that language be added that clarifies the 
applicability of H.R. 2662 to tribally operated facilities. We believe 
that tribally operated facilities would likely want the opportunity to 
opt-in to certain provisions of the Act, such as the parity in pay 
requirements in Section 101, but might also want to opt out of certain 
provisions as well. We encourage further discussion with tribes and 
tribal organizations to clarify application of H.R. 2662 to tribally 
operated facilities.
Sec. 101. Incentives for Recruitment and Retention
    The Colville Tribes strongly supports Section 101, which would 
direct the Secretary to establish a pay system for physicians, 
dentists, nurses, and other healthcare professionals employed by the 
IHS comparable to the pay provided by the Department of Veterans 
Affairs. We also support authorizing the IHS to reimburse relocation 
costs. Despite whatever recruiting challenges might exist, the IHS has 
an obligation to provide adequate care to federally managed service 
units. The Colville Service Unit is in a rural area and these tools are 
necessary to attract and incentivize health providers to take jobs 
there.
Sec. 102. Medical Credentialing System
    This section would direct the Secretary to consult with Indian 
tribes and any public or private association of medical providers, 
government agencies, or relevant experts in developing an IHS-wide 
credentialing system. While the CCT appreciates the need to standardize 
credentialing, we are concerned that directing the Secretary to consult 
with private associations may provide an opportunity for those 
associations that do not share tribal goals to cause mischief or erect 
barriers in developing credentialing standards.
Sec. 105. Improvements in Hiring Practices
    Section 105 would amend the IHCIA to authorize the Secretary to 
directly hire candidates to vacant positions within the IHS. The 
section also directs the Secretary to notify each Indian tribe located 
within a geographic Service Area and, in some instances, obtain a 
waiver of Indian preference laws from each Indian tribe concerned. The 
CCT is concerned about the directive for the Secretary to obtain a 
waiver of Indian preference from tribes. We recommend additional 
discussion on this provision with Indian tribes and tribal 
organizations.
Sec. 106. Removal or Demotion of IHS Employees Based on Performance or 
        Misconduct
    The Colville Tribes strongly supports this section. While the 
Colville Service Unit has not experienced the personnel issues that 
other IHS areas have reported regarding problem personnel, these tools 
should be available for all IHS areas.
Sec. 202. Fiscal Accountability
    The Colville Tribes strongly supports Section 202, which would 
direct the Secretary to use unobligated or unexpended funding to 
support essential medical equipment, purchased or referred care, or 
staffing. The Colville Tribes is troubled by reports that the IHS has 
carried over significant funds from year to year. The CCT was also 
disturbed that in 2015, the IHS paid $80 million from funds that could 
have otherwise been used for staffing to the Laborers' International 
Union of North America to settle overtime claims.
    There has long been a lack of transparency in how the IHS spends 
its appropriated funds. Had Indian Country known that this $80 million 
was available, it could have used it for needed programs and services. 
The IHS needs congressional direction on how it should use unobligated 
or unexpended funds and Section 202 is a good start.
Sec. 303. Reports by the Comptroller General
    The Colville Tribes strongly supports Section 303, which would 
direct the U.S. Comptroller General to develop and submit to Congress 
three reports. With regard to the staffing report in Section 303(b)(2), 
the CCT recommends additional specificity be added to ensure that the 
formulas or methodologies that the IHS has previously used and 
currently uses to assess staffing needs are identified in the report. 
The Colville Tribes has received conflicting information from the IHS 
about these issues in past years when it was attempting to ascertain 
what its needed staffing levels should be.

    This concludes my testimony. Thank you for allowing the Colville 
Tribes to testify today. I would be happy to answer any questions that 
the members of the Committee may have.

                                 ______
                                 

    Miss Gonzalez-Colon. Thank you, Mr. Joseph. Now the Chair 
recognized the Honorable Robert TwoBears.

 STATEMENT OF TWO BEARS, ROBERT, DISTRICT V REPRESENTATIVE, HO-
     CHUNK NATION LEGISLATURE, BLACK RIVER FALLS, WISCONSIN

    Mr. TwoBears. I would like to thank you for the invitation 
to appear before you today to discuss H.R. 2662, the Restoring 
Accountability in the Indian Health Service Act of 2017.
    My name is Robert TwoBears. I am a District V 
Representative of the Ho-Chunk Nation Legislature. The Ho-Chunk 
Nation has over 7,000 tribal members spread across 18 counties 
in the state of Wisconsin. We have a diverse and strong tribal 
economy that employs thousands of tribal members in the 
surrounding communities.
    The Nation operates two health facilities, one in Black 
River Falls and one in Wisconsin Dells. The Black River Falls 
facility has 23 exam rooms and 6 operatories. The Wisconsin 
Dells facility has 11 exam rooms and 3 dental operatories.
    The facilities in itself are very similar to community 
health centers. They handle a pharmacy, optometry, and also 
community health departments.
    You have read our written statement, so I would just like 
to highlight a few provisions the Nation believes are most 
important.
    Section 100 requires Indian Health Service doctors, 
dentists, and other professionals have a pay parity and 
relocation cost with their counterparts, similar to the 
Department of Veterans Affairs.
    Section 104 expands a loan repayment program for 
administrators, health managers, and the like. These sections 
will help attract and retain high-quality professionals to 
Indian lands.
    Section 109 would allow staffing demonstration pilot to 
increase staffing resources for federally run health units with 
an emphasis on those tribes that have contributed substantially 
to the constrictions of the facility.
    Last, a word about consultation. I know that there are two 
different types of tribal consultations being considered under 
this bill. Section 110--the first being the previous tribal 
consultation, as mandated by the Indian Health Service, in 
which Indian Health Service is utilized in dealing with the 
Indian tribes. This policy was endorsed by Executive Orders and 
formalized by CMS. The policy that Indian Health Service 
utilizes requires tribes to be contacted, consulted at any 
point during a rulemaking or Federal planning decision where a 
tribe could be affected.
    In his extended remarks on the final negotiated rulemaking 
process on October 23, 1990, he indicated that this Act was not 
intended to apply to policy decisions. I think early in the 
earlier testimonies they were talking about consultations, and 
I actually attended the consultation for the Midwest region. We 
met with the Health and Human Services region, and we actually 
have a work plan that we reviewed with the appropriate staff 
from the region, CMS, Indian Health Service, HRSA, SAMHSA.
    And just to really kind of clarify from a tribal 
perspective is we talk about issues that are affecting the 
tribes. When we were having these consultations, we sit in a 
room similar to this. The tribes are on this side, similar to 
this, and the Feds are on one side. And then we actually just 
ask questions and look for guidance and assistance to help us 
with some of our health disparities, whether it is substance 
abuse, diabetes, and so forth.
    But really, what doesn't happen is that when the tribes are 
requesting this assistance, we just get the looks back from the 
Feds, looking for us. So, in a sense they give us, the tribes, 
an opportunity to talk about their issues. But on the back end 
is we never get the answers that we are looking for.
    So, in a sense, that consultation does work. We are at the 
table with the appropriate people. As far as any actionable 
items that we request back from the Feds, the tribes still have 
that work plan in place, and it is never addressed.
    This concludes my testimony. I will be happy to answer any 
questions. Thank you.
    [The prepared statement of Mr. TwoBears follows:]
 Prepared Statement of the Honorable Robert TwoBears, Ho-Chunk Nation, 
  Legislative Representative, District V, Black River Falls, Wisconsin
    Greetings Chairman LaMalfa, Ranking Member Torres, and esteemed 
members of the Subcommittee. My name is Robert TwoBears, and once 
again, I am one of the acting Legislative Representatives for District 
V of the Ho-Chunk Nation (the ``Nation'').
    Please allow me to extend some previous-stated background on the 
Ho-Chunk Nation. The Nation has nearly 7,000 tribal members, and while 
it does not have a reservation, its land base consists of trust lands 
and fee simple lands spread across eighteen (18) counties in the state 
of Wisconsin. The Nation also maintains fee simple lands in the states 
of Minnesota and Illinois. Further, the Nation has a diverse economy 
that includes forestry, gaming, agriculture services, and a number of 
retail outlets. The Nation employs approximately 4,000 individuals, and 
is the largest employer in Sauk and Jackson counties in Wisconsin. As a 
Legislative Representative for District V of the Nation, I represent 
the at-large tribal population residing outside of Wisconsin.
    For years the Nation has received direct healthcare services from 
the Indian Health Service (``IHS'') but recently, the Nation has 
finalized negotiations with IHS under its annual funding agreement, and 
now proudly operates its health facilities through the Self-Governance 
Compact and Funding Agreement under Title V of the Indian Self-
Determination and Education Assistance Act (``ISDEAA'') 25 U.S.C. 
Sec. 5381.
    Again, we applaud H.R. 2662, ``Restoring Accountability in the 
Indian Health Service Act of 2017'', as it provides workable measures 
for the success and betterment of employee recruitment, employee 
hiring, and employee retention in the Indian Health Service (``IHS'') 
workforce. We again note that H.R. 2662 takes affirmative steps to 
restore accountability in the standards and timeliness of care that IHS 
provides to its Native People. A significant obstacle H.R. 2662 
undertakes, which is essential to providing adequate health to Native 
Americans, is imposing firmer reporting requirements for the Federal 
Government to utilize, that if followed, would report with better 
clarity and accuracy, on the true state of all Indian Health Service 
Units.
    Although not applicable to all service units, Section 833 of H.R. 
2662, proposes the creation of a staffing demonstration project. This 
project would provide federally managed service units with additional 
staffing resources. The hope is, that in providing these additional 
resources to a tribe, the additionally staffed service area will become 
a self-sustaining source of revenue for the unit at the end of a 3-5 
year period. The staffing demonstration project is ambitious, to say 
the least, as it would indicate upon completion, whether giving tribes 
additional staffing resources could generate sufficient service revenue 
for the unit to retain the staffed service area on a permanent basis.
    In essence, this is the start of a self-help formula for federally 
managed tribal service units to identify their unmet needs, and then 
seek to relieve those needs by placing government provided additional 
staffing resources toward identified areas of concern, with the hoped-
for-wish that the provision of additional resources creates self-
sustaining sources of internal revenue. However, such a project cannot 
be initiated and completed without appropriate tribal consultation.
    In submitting testimony on H.R. 2662, the Nation is not in support 
of H.R. 2662's amendment, as proposed under Section 834, to replace the 
tribal consultation policy under Circular No. 2006-01 of IHS, with the 
Negotiated Rulemaking Act of 1990. In providing health care to its 
People, the Nation has consistently relied on the deictic channels of 
communication as provided by the tribal consultation policy under 
Circular No. 2006-01.
    On September 1, 2016, the Nation submitted a Comment on the 
Proposed Rule for ``Medicare Program: Payment Policies under the 
Physician Fee Schedule and Other Revisions to Part B for CY 2017; 
Proposed Expansion of Medicare Diabetes Prevention. The Nation urged 
the Centers for Medicare and Medicaid Services (``CMS'') to take into 
account the unique position of tribes, and requested that consultation 
occur at all stages where there could be a substantial effect on a 
tribe, which mirrors the standards as set forth under Circular No. 
2006-01.
    Whether any relief the Nation requested was provided, remains 
undetermined, however the tribal consultation policy, as utilized by 
the Service, provides the only viable notice to the Nation, and to all 
tribes, to assert standing and express all and any concerns regarding 
their health care as serviced by IHS and the Federal Government at 
large.
    Additionally, the Nation would like to remind the Committee that, 
in his extended remarks on the Final Passage of the Negotiated 
Rulemaking Act of 1990, Speaker Donald J. Pease, then stated that he 
does not ``. . . intend that negotiated rulemaking be employed to 
establish fundamental policy directives or to permit Federal agencies 
to frustrate the will of the Congress.'' (See attached Exhibit A. Final 
Passage of The Negotiated Rulemaking Act of 1990, 136 Cong Rec E 3414). 
Speaker Donald J. Pease was the first to introduce the Negotiated 
Rulemaking Act, and was a strong supporter of this legislation from its 
creation to its enactment.
    Given the special relationship that exists between tribes and the 
Federal Government, as well as the promulgations long-established in 
the then-titled Indian Health Care Improvement Act of 1976, as since 
amended, Congress spoke quite clearly when it found that ``. . . a goal 
of the United States is to provide the quantity and quality of health 
services which will permit the health status of Indians to be raised to 
the highest possible level and to encourage the maximum participation 
of Indians in the planning and management of those services.''(See 
attached Exhibit B. 94 P.L. 437, 90 Stat. 1400).
    Although the Indian Health Care Improvement Act has undergone many 
transformations since its inception, congressional intent for tribes to 
be meaningfully engaged and consulted regarding their health services 
as provided by the Federal Government, remains intact. Adopting the 
Negotiated Rulemaking Act of 1990 to determine or guide tribal 
consultation for services through IHS, under H.R. 2662, frustrates this 
congressional intent, and is a misapplication of the legislative intent 
of the Negotiated Rulemaking Act.
    The Ho-Chunk Nation wishes for the tribal consultation policy under 
Circular No. 2006-01 to remain and continue under H.R. 2662. Although 
by no means perfect, this policy at the very least, recognizes and 
meets the unique consultation needs of Indian tribes, as recognized by 
Congress.
    In considering the unique position of tribes, and the consequent 
need for tribal consultation, the Nation wishes to expand its 
commentary regarding the legislation's intent to increase physician 
retention rate under the service by offering the following insight. 
Upon reading H.R. 2662, and reviewing the testimony that was offered, 
Executive Director of the Ho-Chunk Nation Department of Health, Ona M. 
Garvin, found that physician retention rate in Indian Country would be 
better served by IHS receiving and funding tribes with more monies to 
hire physicians with a pay-rate that is commensurate with physicians in 
private practice, specifically in the 330k-range.
    Once again, I appreciate your kind invitation to testify and appear 
before you to discuss the Ho-Chunk Nation's commentary regarding H.R. 
2662, ``Restoring Accountability in the Indian Health Service Act of 
2017.'' I would like to thank Congresswoman Kristi Noem for introducing 
this important bill, as well as Chairman LaMalfa, the Full Committee, 
Chairman Rob Bishop, and others, for co-sponsoring this proposed 
legislation.
    I look forward to working together with all concerned parties to 
further ``Restoring Accountability in the Indian Health Service Act of 
2017.'' Thank you again for this kind invitation to the Ho-Chunk Nation 
to offer testimony on H.R. 2662.

                                 *****

The following documents were submitted as supplements to Mr. TwoBears' 
testimony. These documents are part of the hearing record and are being 
retained in the Committee's official files:

    --Exhibit A: Final Passage of The Negotiated Rulemaking Act of 
            1990, 136 Cong Rec E 3414

    --Exhibit B. 94 P.L. 437, 90 Stat. 1400

                                 ______
                                 

    Miss Gonzalez-Colon. I want to thank you, Representative 
TwoBears, for your statement. Now the Chair recognizes Ms. 
Victoria Kitcheyan, representative of the Great Plains Area 
National Indian Health Board.

      STATEMENT OF VICTORIA KITCHEYAN, GREAT PLAINS AREA 
  REPRESENTATIVE, NATIONAL INDIAN HEALTH BOARD, WASHINGTON, DC

    Ms. Kitcheyan. Good afternoon, Committee members and 
Ranking Member Torres. Thank you for the opportunity to offer 
testimony on this important bill. My name is Victoria 
Kitcheyan, and I serve as the Great Plains area rep for the 
National Indian Health Board. I am also a Winnebago tribal 
member and I serve on the Tribal Council as Treasurer.
    We appreciate the commitment of this Committee to find 
lasting solutions to the long-faced challenges in the health 
care delivery in Indian Country. Legislative efforts to address 
these issues should be conducted in conjunction with increased 
oversight and scrutiny of the agency. We need to get this 
right. I have heard from my colleagues today, and some of our 
supportive representatives, that our people need help. And some 
of the quality care issues found in my tribe and elsewhere 
within the Great Plains have been going on for far too long.
    But I want to, I guess, kindly remind the Committee that we 
need to do this in tandem with all of Indian Country, because 
this is going to affect us all. And we need to work together so 
we have the best possible outcome and product for the whole IHS 
agency and Indian Country. This includes making the legislation 
work for direct-service tribes as well as self-governance 
tribes, and we look forward to working with this Committee and 
Indian Country in the coming weeks to further engage in this 
consultation on the bill.
    As I have shared in previous testimonies with this 
Committee, as documented since 2007, that we have had these 
demonstrated deficiencies in Winnebago. And it is our feeling 
that these should not exist at any facility run by the Federal 
Government. And Winnebago still remains the only Federal 
facility to lose its CMS certification. We lost that in July of 
2015. Two years later we are still without that certification. 
Other tribes in our region continue to experience similar 
circumstances, although they have not lost their certification.
    So, we are looking for both long-term and short-term 
solutions that would improve the quality of services delivered 
at these IHS hospitals that would improve staffing and 
management.
    Though this bill addresses crucial care issues, it is 
important that we consider that it will affect the whole Indian 
healthcare system. For instance, savings clauses in the bill 
should be more clear in how they intend to exempt self-
governance tribes.
    There are a few other items in the legislation I would like 
to address so that it works for all of us.
    First and foremost, I again want to emphasize that 
legislation should not be enacted without thorough input and 
agreement of Indian Country. The legislation will affect 
everyone, and we want to ensure that all voices are heard. This 
remains a high priority for the National Indian Health Board.
    There are many provisions that address new programs and 
functions for IHS, which will be beneficial if they receive 
adequate resources and oversight. We want to make sure that 
this legislation put forward is something that is not going to 
become an unfunded mandate. Many of the provisions within the 
Indian Health Care Improvement Act passed 7 years ago remain to 
be unfunded. So, I just ask that this bill be funded so that it 
is not another broken promise to Indian Country.
    NIHB also appreciates the intent to streamline the system 
for licensed healthcare professionals' credentialing 
procedures. However, we do not want that to be mistaken as the 
replacement to providing permanent healthcare providers to the 
tribes and the IHS. We are striving for permanent providers 
here, and we just want to make sure that there is a commitment.
    Tribes in some of the areas have already come up with some 
creative solutions to gain that commitment at the local level, 
and I think that there is value there, and we can mimic those 
throughout Indian Country and replicate those models. We look 
forward to further developing some of those concepts and 
creative solutions to address the change that is much needed.
    When it comes to hiring authorities outlined in the 
legislation, NIHB appreciates the streamlining of Federal 
hiring authority. However, we believe that changes to the 
legislative language are needed to include more tribal input, 
again, and most notably when it comes to waiving the Indian 
hiring preference. And we want to make sure that that is not an 
erosion of that as a distinct political people--it is important 
that that stays intact.
    Section 110 establishes rules regarding a tribal 
consultation policy. We are in complete agreement that this 
consultation policy needs to be strengthened so it is 
meaningful for the tribes. And had this been done from the 
beginning, many of the Great Plains issues and deficiencies may 
have been identified sooner and not have risen to this crisis 
level.
    We believe increasing fiscal accountability for IHS 
outlined in the bill makes sense. However, we want to make sure 
that in Section 202, that the tribes are involved so that those 
third-party revenue dollars are spent at the local level, so 
the tribes can identify where those services are needed the 
most.
    Finally, we are glad to see some of the reporting 
requirements outlined on the quality of care, but we also want 
to include purchase-referred care. In addition, tribes should 
have input on how those reports are released.

    Again, we thank the Committee for its genuine interest to 
elevate our problems--alleviate, not elevate--I think they have 
been elevated. It is clear that management, recruitment, 
accountability, and transparency are still issues within the 
agency. I thank you for the increased efforts that this 
Committee has made, so that the tribes can be consulted with 
and we can make effective change for long-term care for Indian 
tribes and Alaska Natives.

    [The prepared statement of Ms. Kitcheyan follows:]
      Prepared Statement of Victoria Kitcheyan, Great Plains Area 
              Representative, National Indian Health Board
    Chairman LaMalfa, Ranking Member Torres and members of the 
Committee, thank you for holding this hearing on this very important 
piece of legislation. My name is Victoria Kitcheyan. I am a member of 
the Winnebago Tribe of Nebraska and I currently serve as Treasurer of 
the Winnebago Tribal Council. I also serve as the Great Plains Area 
Representative of the National Indian Health Board. The National Indian 
Health Board serves all 567 federally recognized tribal nations when it 
comes to health. This means we serve both tribes who receive care 
directly from the Indian Health Service (IHS) and those who operate 
their health systems through self-governance compacts and contracts.
    The Federal Government has a duty, agreed to long ago and 
reaffirmed many times by all three branches of government, to provide 
health care to tribes and their members throughout the country. Yet, 
the Federal Government has never lived up to that trust responsibility 
to provide adequate health services to our Nation's indigenous peoples. 
Historical trauma, poverty, lack of access to healthy foods, loss of 
culture and many other social, economic and environmental determinants 
of health as well as lack of a developed public health infrastructure 
in Indian Country all contribute to the poor state of American Indian 
and Alaska Native (AI/AN) health. AI/ANs suffer some of the worst 
health disparities of all Americans. We live 4.5 years less than other 
Americans. In some states, life expectancy is 20 years less, and in 
some counties, the disparity is even more severe. With these 
statistics, it is unconscionable that some IHS-operated facilities 
continue to deliver a poor quality of care to our people.
    We appreciate the commitment of this Committee to find lasting 
change at IHS which has long-faced challenges in the delivery of health 
care. Legislative efforts to address these issues should be conducted 
in tandem with increased oversight and scrutiny over the administration 
of the delivery of care at service units operated by the Indian Health 
Service. The current legal framework for IHS provides much of the 
necessary guidelines for the operation of the agency.
    While we appreciate the speed at which the House is considering the 
legislation given the critical situation going on in the Great Plains 
region, we need to make sure we get this right. It is true, our people 
need help. These issues surrounding quality of care cannot go on any 
longer. However, it is also important that these changes are 
accompanied by input from all tribal nations to ensure the best 
possible outcome and product. Tribes across the country would have 
appreciated the time to review any draft legislative language before 
H.R. 2662 was introduced. NIHB is ready and willing to lead a 
legislative consultation on this bill and we intend to do so in the 
coming weeks and months. This step must happen first before anything 
can be enacted.
                        ihs hospital operations
    Quality of care issues at IHS-operated hospitals and facilities are 
well documented. Since at least 2007, the Winnebago IHS Hospital has 
been operating with demonstrated deficiencies which should not exist at 
any hospital in the United States. The Centers for Medicare and 
Medicaid Services (CMS) deficiencies were so numerous and so life-
threatening that in July 2015 the IHS Hospital in Winnebago became what 
still is, to the best of our knowledge, the only federally operated 
hospital ever to lose its CMS certification. Other IHS facilities in 
the Great Plains region such as Rosebud Indian Hospital and Pine Ridge 
Hospital have been experiencing similar quality of care issues 
throughout this time and are also under threat of decertification by 
CMS. These facilities continue to have quality of care issues, and it 
is unclear if the actions the agency has taken are substantially 
improving the situation. This situation is especially troubling 
considering the challenges that have been identified are not new. In 
2010, for example, then-Chairman of the Senate Committee on Indian 
Affairs, Byron Dorgan (D-ND) issued a report detailing issues in the 
Great Plains area that sound similar to those still experienced today. 
As recently as October 2016, the Department of Health and Human 
Services' Office of the Inspector General published a report that 
highlighted the long-standing challenges IHS-operated hospitals 
experience across the system.\1\
---------------------------------------------------------------------------
    \1\ Indian Health Service Hospitals: Longstanding Challenges 
Warrant Focused Attention to Support Quality Care. Department of Health 
and Human Services, Office of the Inspector General. October 2016. OEI-
06-14-00011, p. 14-15.
---------------------------------------------------------------------------
                         comments on h.r. 2662
    Though we continue to express the need for more review and comment 
by the tribes, we have some general areas of concern regarding the 
proposed legislation. There are provisions in the bill that create new 
programs and functions for the IHS, which will be beneficial if they 
are actually funded. We want to make sure the legislation does not put 
forward programs that become in essence unfunded mandates. We urge this 
Committee to work with the Appropriations Committee to ensure that 
these provisions are funded so they do not end up just being lip 
service to tribal communities. The Indian Health Care Improvement Act 
was permanently enacted in 2010 and contained many provisions designed 
to modernize the provision of care, such as the development of new 
health care delivery demonstration projects and expansion of the types 
of health professionals available within the Indian health system. Yet 
many of those provisions remain unimplemented due to lack of adequate 
funding. We do not want to see the same type of thing happen with this 
legislation. Congress cannot continue to starve the Indian health 
system and expect major change.
    About 60 percent of the IHS budget is delivered directly to the 
tribes through contracts and compacts. We are concerned that the 
proposed legislation does not do an adequate job of stating which 
provisions of the legislation pertain to self-governance tribes and 
which do not. The legislation provides a ``Savings Clause'' that 
appears to ensure the legislation does not interfere with tribal 
contracting or compacting. Yet the provision at 607(e) of the proposed 
legislation is not clear on what provision or provisions that Savings 
Clause language pertains. This language does not clearly state that the 
provision it is contained in does not apply to tribal health programs. 
Instead, it just states that it cannot be construed to interfere with 
tribes' rights under the Indian Self-Determination and Education 
Assistance Act (ISDEAA). If enacted, it is entirely possible that IHS 
or others could interpret the operative position to apply to self-
governance tribes because, in their view, compliance with that 
provision would not inhibit the authority of a tribe to exercise its 
ISDEAA rights. As a result, we think it important that the rule of 
construction be clarified throughout the bill so as to clearly state 
that the provision does not apply to tribal health programs. Similarly, 
we believe that language should be constructed in such a way that self-
governance tribes could opt into some of the provisions if they so 
choose or would be eligible for new programs in the bill such as 
liability protections for health professional volunteers as described 
in Section 103.
    NIHB understands the intent to make a streamlined system for 
licensed healthcare professional credentialing procedures, including 
volunteers, as outlined in Section 102 and provisions in Section 103 
that support liability protections for health professional volunteers 
at IHS that would allow for healthcare professionals who volunteer at 
an IHS service unit to be considered an employee of the IHS in order to 
receive liability protections.
    However, we note that these provisions should not be considered a 
substitute or final step for increasing available providers to the IHS 
and tribes throughout the country. For example, NIHB and a large 
majority of tribes support the expansion of the dental therapy model, 
which was first brought to the United States by tribes in Alaska in 
2004. It is a highly effective way to provide reliable, safe, and 
quality dental care providers to underserved areas. We urge the 
Committee to consider models such as these to address the chronic 
staffing shortages in the Indian health system, rather than exclusively 
relying on a patchwork of volunteers. Additionally, NIHB supports 
provisions included in similar legislation introduced in the 114th 
Congress (H.R. 5406) that would provide tax-exempt status for IHS 
student loan repayment. Because IHS is paying the necessary taxes on 
the loan payments to the medical professionals, this provision would 
allow IHS to fund more medical professionals for loan repayment, 
thereby increase the amount of practitioners in the IHS system.
    Section 105 addresses improvement in hiring practices. While we 
certainly agree that hiring practices need drastic improvement, we are 
concerned that some of the proposals in the bill do not adequately 
involve the tribes, which has been a central concern with some of the 
issues in the Great Plains region. Furthermore, this provision 
indicates that the Secretary has direct hire authority, but Tribal 
Preference should not be ignored in this process. This provision of the 
proposed legislation goes on to note that the Secretary shall notify 
each tribe in the service area prior to the direct hire taking place 
without further guidance on how or why. While notice is appreciated, 
tribes should be able to file objections to any hire, especially if the 
new hire is somebody who has been recycled through the system 
previously and has not performed well with other tribes in the Region, 
which has been a common practice at IHS. Last, this provision provides 
that the Secretary may seek waivers to Indian preference from each 
Indian tribe concerned if certain criteria are met. Tribes are 
concerned about diminishing Indian preference in the hiring process. 
Further, consultation on this provision is needed to ensure that IHS 
receives a more streamlined hiring system, but also that Indian hiring 
preference is respected across the agency, as is current practice.
    We are pleased to see a provision addressing the Timeliness of Care 
in Section 107. We believe that timeliness of care has been an issue 
for many years and that additional standards to improve the reporting 
and tracking of timeliness are necessary. It should be noted that 
underfunding also contributes to the inadequate and untimely care. 
There is currently a system in place that, if implemented, correctly 
tracks these important care initiatives. However, if a region does 
nothing to implement the current system or inadequate staffing impedes 
the ability to track these initiatives, then it becomes a major 
problem. We feel that additional congressional oversight over this 
particular area may be necessary. Section 107 also states that 
regulations and standards to measure the timeliness of the provisions 
of healthcare services must be done within 180 days of the enactment of 
this legislation. We are concerned that 180 days may not be enough time 
to develop the regulations and standards if proper consultation with 
the tribes is used to develop said regulations and standards. Last, we 
request that any data gathered regarding the timeliness of care be 
provided to the tribes as well as the Secretary.
    NIHB believes that Section 108 regarding training programs in 
tribal culture and history is of utmost importance. Meaningful cultural 
training will help IHS employees as they learn the history and culture 
of the people they are serving on a daily basis. We think this training 
should be mandatory and it should not only include medical 
professionals but also include all IHS employees from headquarters to 
all staff at the service unit facilities, who have daily interaction 
with Native American people. It would be even more useful if the 
training was specifically developed by the tribes and was tailored 
specifically for the tribes in the service area.
    Section 110 establishes rules regarding a tribal consultation 
policy. We are in complete agreement that a consultation policy should 
exist and that tribes should have input into the way services are 
provided to tribal communities. However, it is imperative that the 
consultation policy developed under this section mandate to IHS staff 
that consultation shall be more than simple lip service or a listening 
session with the tribes. It should be viewed as a true partnership and 
collaborative effort. Tribal input is key to IHS in providing high 
quality services and must be taken seriously. The problems in the Great 
Plains area would have never have risen to the current critical level 
if there was true consultation and collaboration at every step in this 
process; and these issues never would have received the attention they 
have if not for tribal oversight and actions.
    Fiscal accountability is never a bad thing, but the provision in 
Section 202, subsection (b) that addresses the prioritization of 
patient care is concerning due to the specific guidelines provided. 
This section explains that IHS should only use certain dollars for 
patient care directly and limits their use to essential medical 
equipment; purchased/referred care; and staffing. While it is 
understandable the agency should have more scrutiny over these funds, 
we worry that the criteria may end up being too constraining. IHS 
should consult with the tribes in their service area before making 
decisions on what can be done with the funds pertaining to this 
section. With consultation, the money can go to the most needed 
programs in a particular service area.
    Most of Title III of the proposed legislation outlines a series of 
reports. One report that drew our attention was the Inspector General 
reports on patient care in Section 304. We agree that reports on the 
quality of care and patient harm at IHS are necessary. However, we want 
to draw attention to the fact that many tribal members end up receiving 
their care outside of the IHS system through the Purchased/Referred 
Care program. For example, in South Dakota, approximately 70 percent of 
care is referred outside of IHS facilities. It would be useful to also 
have information on quality of care once a patient has left the IHS 
facility as part of reporting. Additionally, we believe that any and 
all reports that come as a result of this legislation be first shared 
with the tribes for review and comment before they are made public.
    Again, we thank the Committee for its genuine interest in trying to 
alleviate problems within IHS. It is clear that management, 
recruitment, accountability and transparency are all still issues that 
need to be addressed at IHS-operated facilities. Real change and the 
rebuilding of many of the areas in the Great Plains region cannot 
happen without permanent qualified personnel and the funding necessary 
to carry out the mission. However, we reiterate our request that 
additional time be taken to review the legislation with Indian Country 
before the legislation moves forward in the legislative process. It is 
critical that we are able to more fully understand the implications of 
the bill.
    Legislation alone will not solve issues in the IHS. Proper training 
of hospital staff costs money, new equipment costs money, and 
recruitment under these circumstances is also going to cost money. 
Correcting this situation is going to require a continuous team effort, 
additional resources, and consistent congressional oversight of IHS 
activity.
    Thank you again for allowing me to testify, I will be happy to 
answer any questions you may have.

                                 ______
                                 

    Miss Gonzalez-Colon. Thank you, Ms. Kitcheyan. I want to 
thank the panel for their testimony.
    And I remind the Members that Committee Rule 3(d) imposes a 
5-minute limit on questions. Right now the Chair will recognize 
Members for questions, and I will recognize myself for 5 
minutes.
    First of all, I want to begin with you, our last witness. 
You said about Section 110, regarding the consultation policy 
with the IHS, you said that the fear that mandate will result 
in lip service or listening sessions with the tribes, could you 
provide more examples of, or specifics about what kind of 
recommendation we can include in the bill to make that policy 
be a true help to the Indian tribes?
    Ms. Kitcheyan. Thank you for that question. We certainly 
view consultation as our voice in the process, and we want to 
be taken seriously. So, when the tribes, at a very 
sophisticated level, engage with IHS and have the technical 
assistance to ask the right questions, we expect an answer. And 
there are many resources brought together from the tribes, from 
the regional health boards, that bring that technical 
assistance.
    When we come to the meeting, we come prepared and ready to 
engage. And when IHS comes, we just don't feel like they are 
ready to truly engage with us, or we are not given the 
information that we have asked for time and time again.
    So, I would just cite that as an example that I have 
experienced in the Great Plains. And some of it may come down 
to some miscommunications. But all in all, I feel like the 
tribes have put their best foot forward in gathering our issues 
and our concerns that we need addressed and need answered 
through data-driven information, not just, like, hey, we are 
here, and to have some face-to-face----
    Miss Gonzalez-Colon. Can you make specific recommendations 
about exercise or initiatives that can truly make this a true 
partnership? To enhance the bill we would need to have what 
kind of experience or exercise, do you think, that will improve 
that kind of relation?
    You can provide that in writing after this hearing. You 
don't have to write it right now. You may have some days to 
provide that.
    Ms. Kitcheyan. I just had a note from my colleague, and it 
may sound crazy, but increased consultation on the 
consultation, because we are not getting the answers, and it 
feels like a press release when we engage in this consultation. 
So, anything that is brought forward is not really factored 
into the decision or the next roll-out. It is just they had to 
do it, they checked that they engaged with the tribe.
    I would just say this word ``meaningful'' is so overused, 
but it needs to be meaningful to tribes so that they felt like 
they were heard, and that whatever recommendations or input was 
actually incorporated, not just dismissed.
    Miss Gonzalez-Colon. Thank you. Question to Mr. Buchanan.
    Section 202 of the bill will direct the Secretary of HHS to 
use unobligated or unexpected funding to support essential 
medical equipment, or refer care for staffing. This raises the 
long-term issue of transparency on how IHS spends its 
appropriated funds. Do you believe that IHS suffers from lack 
of transparency?
    Admiral Buchanan. With the budget, we are--with the 
resources that we get, we are extremely prudent with those. We 
try to manage those as best as we can, going forward. Is there 
a specific question that I can----
    Miss Gonzalez-Colon. I am just referring to Section 202, in 
terms of the transparency of the use of those funds. I was 
referring you about how you use the funds of the long-term 
issue of the funding for the equipment. Do you have any 
specific feedback of how this Committee can use or address the 
transparency issue in IHS?
    Admiral Buchanan. All right. As far as funding and 
transparency, we look at all opportunities to provide 
transparency related to funding and budget activities. A lot of 
our funds and--are located on our IHS website. And we also have 
other websites that they are located at.
    We have been providing training across the agency by doing 
some all-tribes calls so that we can explain where those funds 
are located. We just recently held an all-tribes call--I 
believe it was back in May--related to where you can find 
those.
    One of the things, kind of getting back to the tribal 
consultation issues, is providing that information. For me it 
is really technical; I have to rely on my experts to explain 
that to me. So, providing information that is meaningful is one 
of the goals that we have been trying to implement. And also 
providing information at the local level that is meaningful and 
useful. We are rolling out templates to provide information at 
the local level so that we can have those communications with 
the tribes on an ongoing basis.
    Miss Gonzalez-Colon. Thank you. The Chair now recognizes 
Ranking Member Torres.
    Mrs. Torres. Thank you.
    Mr. Buchanan, I would like to go back to what Ms. Victoria 
Kitcheyan was talking about regarding what sounds like 
wonderful meet-and-greet meetings, but with absolutely no 
follow-up. Can you respond to that? What do you do? What is the 
purpose of wasting time and money traveling and pretend that 
you actually care about what they are saying to you, and there 
is no followup from IHS?
    Admiral Buchanan. Thank you for the question. Our tribal 
consultation--we are committed to regular consultation----
    Mrs. Torres. Well, that commitment hasn't shown, sir. It is 
obvious to me by all of the witnesses that they have tried time 
and time again to provide to you, to your department, feedback. 
And yet that feedback has fallen to deaf ears.
    Admiral Buchanan. I hear the concerns that you are 
expressing. I hear the concerns that the tribes have expressed.
    Meaningful consultation, I get that. The agency gets that. 
We are open to improving. When we think we have consulted 
enough, we know that we have not. We can always do better. We 
can always continue to improve. We are open to revising our 
consultation policy, going forward, hearing those concerns----
    Mrs. Torres. How is this bill going to help you improve 
what you haven't been able to improve to date?
    Admiral Buchanan. Well, some of the things that we have 
done to improve the consultation process is having all-tribes 
calls, providing information and being more transparent.
    With the Quality Framework and Implementation Plan, we have 
identified five priority areas, specifically organizational 
capacity, accreditation, patient experience, patient safety, 
and last but not least is transparency and communication. So, 
that is one of the priorities, going forward with IHS.
    Mrs. Torres. Let's talk about Section 106. It is my 
understanding that Section 106 of this bill is based on 
language found in the Veterans Access Choice, an accountability 
act of 2014. In May of this year, the U.S. Court of Appeals for 
the Federal Circuit held that some provision from the 2014 
statute to be unconstitutional.
    In light of this ruling, how do you think enactment of 
Section 106 would impact IHS?
    Admiral Buchanan. I don't have the bill in front of me--106 
specifically relates to?
    Mrs. Torres. The authority for hiring and firing, or 
dismissing personnel.
    Admiral Buchanan. Right. We have lots of hiring 
authorities, and we also have authorities in place that allow 
us to discipline problem employees. But specifically, we have 
15,000 employees across the agency that are hard-working 
employees that are mission-focused related to Indian Health 
Service. We have those authorities in place to address that----
    Mrs. Torres. I understand that. In your statement you say 
IHS has existing authorities to implement adverse employment 
actions. I am reading that from your statement. Yet, what I am 
telling you is that DoJ has already weighed in on this, stating 
that they will not defend that position.
    Could enactment of Section 106 open IHS up to potential 
costly litigation that would further take away funding from the 
program to defend?
    Admiral Buchanan. Great question, a question for DoJ. DoJ 
represents us in litigation issues, so I would have to defer to 
DoJ.
    Mrs. Torres. OK, because it could also lead to the 
possibility of having the ongoing bad employees continue to 
stay on the payroll. We don't want the bad employees, we want 
to help recruit more people.
    Walk me through that process. What are some of the 
incentives to recruit new candidates? Have you met with HUD?
    And I understand that housing is part of the problem. How 
are you incorporating other agencies, and ensuring that you are 
able to have proper housing for good candidates? I mean I don't 
want to move to an area and bring children and a spouse if they 
don't have proper housing for them. So, what incentives have 
you provided?
    Admiral Buchanan. Great question. Again, recruitment and 
retention is a challenge, not only in Indian Health Service, 
but rural America, rural healthcare systems across the country.
    Some of the things that we have done specifically related 
to housing, we have used models in other areas, and we are 
incorporating those in places like the Great Plains, 
specifically Rosebud----
    Mrs. Torres. My time has expired. I hope that you would 
follow up with a written statement on that.
    Admiral Buchanan. Yes, ma'am. Sure will.
    Mrs. Torres. I yield back.
    Mr. LaMalfa [presiding]. Thank you. I will recognize myself 
for up to 5 minutes here. Let me start with Admiral Buchanan.
    I understand that when the South Dakota delegation met with 
your predecessor and asked questions about staffing needs, the 
agency was not able to produce reliable data on that. How do 
you determine what staffing levels will be needed at the 
facilities?
    Admiral Buchanan. So, specifically related to staffing 
levels at the facilities? Having been a former CEO, I would 
know the staffing levels associated within my facility, within 
Indian Health Service. We have a vacancy rate of 20 percent. 
Some of the facilities that we are talking about today, 
including Rosebud, we have vacancy levels at 22 percent. Pine 
Ridge, we have vacancy levels at 22 percent. Rapid City, we 
have 11 percent vacancy levels. Omaha Winnebago we have 29 
percent vacancy levels--lots of those physicians, chief 
executive officers, chief of nursing officers, operation 
officers.
    So, definitely a challenge. Recruitment and retention, as 
Mrs. Torres had mentioned earlier, is a challenge across IHS in 
our rural, remote locations.
    Mr. LaMalfa. OK, thank you. Let me shift over to Andy 
Joseph for a moment here.
    Your testimony indicated that in 2013, IHS determined that 
the Colville service unit had fewer than one-third of the 
required number of clinical staff. Not just short 20 percent, 
but that would be over 60 percent required number of clinical 
staff, and one-quarter of the required number of dental staff.
    Is that consistent with what we are understanding here? And 
then, what is the effect on the Colville Reservation with that 
kind of staffing?
    Mr. Joseph. The effect is a lot of our patients that go 
there, they have to wait for a chance to actually get in to see 
one of the providers that we have. So, by not having the 
providers there, they are not really getting the basic health 
care needs taken care of.
    And a lot of times what happens is our patients end up 
really hurting, and they will go into emergency and find out 
they might have Stage 3 or Stage 4 cancer, or they might be a 
diabetic, or they might need some kind of surgery procedure 
done, and then that ends up costing the government a whole lot 
more money.
    If we had the adequate amount of basic healthcare 
providers, we would be able probably to keep our patients out 
of the hospital.
    So, what we are really looking at is staffing for basic 
health care needs to keep us from burying our people. We have 
lost so many of our people due to not having those needs and 
going into emergency. Thank you.
    Mr. LaMalfa. Thank you. So, you feel, according to your 
testimony, that you really have about one-third of the required 
staff. But Admiral Buchanan, do you know what that is, 
specifically to Colville? Or is that kind of an average across 
the region, when you said numbers between 20 to 29 percent 
short of a full staff?
    Admiral Buchanan. I do not have Colville-specific numbers 
in front of me, but I am happy to provide those for the record.
    Mr. LaMalfa. You believe that is probably likely, too, as 
what Mr. Joseph is saying? It could be as low as one-third?
    Admiral Buchanan. Not knowing specifically what Colville is 
like, I----
    Mr. LaMalfa. That is a problem at that kind of level.
    Mr. Joseph. I could give you an example. One of our 
districts, Omak District, was going to get a joint venture. If 
we would have did a joint venture, that community, that 
district, would have got 115 new staff that would have came 
with that project. Right now, they are borrowing from our main 
clinic, I believe, 12 or 13 staff. There are two doctors that 
are there.
    So, that is where the inequity is, I guess, for staffing. 
We built three of our four clinics with our dollars, but have 
never been given a staffing increase from clear back in the 
1930s. So, it is based on our population back then, which was 
probably about 3,000; now we are almost 10,000 members. So, the 
user population goes backwards. It has been going that way with 
Colville for quite a few years now.
    Mr. LaMalfa. OK, thank you. My time has expired. If the 
Committee cares to have a second round--oh, I am sorry, I need 
to recognize Mrs. Radewagen on the first round. I was away for 
a little bit. So, thank you, please, 5 minutes.
    Mrs. Radewagen. I want to thank you, Chairman LaMalfa and 
Ranking Member Torres, for holding this hearing. I especially 
want to thank the panel for taking the time to be here today.
    And I particularly want to acknowledge my colleague, 
Representative Noem, for her bill, H.R. 2662. This much-needed 
legislation will make important changes to the Indian Health 
Service, and I look forward to seeing the bill added to the 
markup schedule in the near future.
    I have a couple of questions for you, Admiral Buchanan. 
Your predecessor, Mary Smith, testified before this 
Subcommittee last year about a previous version of the bill we 
are considering today. In her testimony, she agreed to sign on 
to a request to the HHS Inspector General to investigate the 
deaths at Rosebud Hospital that occurred during the diversion. 
Unfortunately, that never occurred.
    Here is my question. Will you commit to helping Mrs. Noem 
in co-signing a request to the HHS Inspector General to 
investigate the deaths?
    Admiral Buchanan. That is a great question. Actually, 
Indian Health Service is already engaged with the Office of the 
Inspector General. I am not able to comment much more because 
of the investigation that is currently going on.
    Mrs. Radewagen. Thank you. Admiral Buchanan, one of the 
chief concerns about the situation at Pine Ridge Hospital is 
that a revolving door of leadership staff has resulted in 
inconsistent leadership, and led ultimately to the most recent 
immediate jeopardy findings by CMS.
    My question is how many CEOs has Pine Ridge had in the last 
2 years? And does the facility now have permanent leadership?
    Admiral Buchanan. Great question. I don't know the specific 
number of CEOs we have had in the last 2 years. I was the 
acting area director in the Great Plains. I can recall two in 
hiring the permanent one, Mr. Mark Meersman, who is currently 
the CEO at Pine Ridge.
    Mrs. Radewagen. I would appreciate you following up and 
getting that information to us.
    And last, Admiral Buchanan, clearly our most immediate goal 
in the Great Plains is to get these Federal facilities in a 
state in which they are fully functional and safe. What is the 
long-term goal in the Great Plains? What is our ultimate 
aspiration beyond simply ensuring these facilities are safe?
    Admiral Buchanan. Our ultimate goal is to provide good, 
quality health care for the Great Plains area. Not only the 
Great Plains area, but all of IHS areas. All of our patients 
deserve that.
    To meet the mission of Indian Health Service, to raise the 
physical, mental, social, and spiritual health of American 
Indians and Alaska Natives to the highest level is something 
that all of our 15,000 employees are striving to do.
    We are implementing the Quality Framework. That is our 
long-range goal. In that framework, we have several things that 
we are implementing that are related to this bill. Talking 
about the credentialing aspect, we are going to be rolling that 
out for pilot sites in July. A policy that is going to be 
rolling out with that, also in July. So, we are excited about 
that.
    We will be establishing wait times. That was something that 
was identified in some of the GAO reports and also in this 
bill. So, we will be rolling those out, will definitely have 
that in July, and we are excited about the progress that we are 
making there.
    That is not enough. I mean when we continue to, like I 
mentioned earlier, think we are providing good-quality care, we 
can always do better. So, that is the long-term goal, the 
Quality Framework, providing performance metrics so that we can 
measure if we are making true progress when we come to hearings 
like this, when we meet with tribal leaders, to show them that 
here are the areas that we are having challenges with, here are 
the areas that we are improving with, get input at those local 
levels.
    Part of that framework is a governance process, where we 
can meet on a regular basis to make sure that our health 
centers and our hospitals are providing good, quality care to 
our patients.
    Mrs. Radewagen. Thank you, Mr. Chairman. I yield back.
    Mr. LaMalfa. OK, thank you. You can hear the buzz. We are 
going to have to go back for votes here any minute, but we can 
go for a brief second round of questions or comments.
    Let me go ahead and recognize our Ranking Member for the 
second round, for a statement, and then----
    Mrs. Torres. Thank you, Mr. Chairman. I simply want to say 
that we have heard over and over in this meeting that there was 
very little tribal consultation before introducing this 
legislation. While there might have been some meet-and-greet 
opportunities thereafter, the tribes still feel that they have 
not been heard and their concerns have not been addressed or 
even replied to, which means that you have not acknowledged 
that they have real issues. And that is tragic.
    Additionally, many of these new provisions in this bill 
would require funding for implementation. Yet, there is no 
authorized funding found anywhere in the bill; and, as I stated 
in my opening statement, IHS is already chronically 
underfunded, and we must not impose new unfunded mandates on 
IHS or Indian Country.
    As we know, many of the Indian Health Care Improvement Act 
provisions from 2010 still remain unimplemented, due to lack of 
adequate funding. Unless we want the same outcome for this 
bill, we need to finally fund IHS at an appropriate level.
    I would suggest that you sit down with rural communities, 
counties, because they have a lot of the same issues, and try 
to maximize funding so that you can address some of these 
issues, if funding continues to be an issue for you.
    Finally, let me say that I think that this bill is a good 
starting point with some good provisions. And I want to again 
thank Mrs. Noem for putting pressure on this issue. But we have 
one chance at this, and we need to make sure that we get it 
right this time.
    So, before we move forward, I recommend that tribes be 
consulted--and not just sitting down and meeting with them, but 
actually listening to them. And not just the tribes that are 
here today, but tribes across the country. Their ideas, they 
have a lot of great ideas, and we need to hear them.
    Then we can come back together, in a bipartisan fashion, 
and amend this bill so that we have a workable solution. And I 
look to you for this leadership. I yield back, Mr. Chairman, 
thank you.
    Mr. LaMalfa. Thank you. All right. I will wrap up with just 
a couple more questions here. I want to come back to Admiral 
Buchanan, please.
    Do you have in place a reliable way to measure the number 
of full-time equivalents needed at a given facility to meet the 
need of that facility at this point? And please be brief, 
because we have----
    Admiral Buchanan. For sure. As Chair Joseph was talking 
about, we use a process called, I believe, RRM. The acronym 
escapes me right now, but it is a process that we typically use 
to staff facilities, as he was referencing earlier.
    Mr. LaMalfa. So, you believe that that method will be 
accurate for the number of full-time equivalents that will be 
needed as you work toward that?
    Admiral Buchanan. We typically use that process when we 
staff and build a new facility.
    Mr. LaMalfa. OK. Let me jump to a couple more questions 
here.
    Chairman William Bear Shield--again, I have to go faster, 
so maybe a little more yes or no, if you don't mind--would you 
say that the Federal employees at the Rosebud Hospital are 
accountable to you?
    Mr. Shield. Excuse me?
    Mr. LaMalfa. Are the Federal employees at the Rosebud 
Hospital accountable?
    Mr. Shield. There are several good employees, as was 
pointed out, of Indian Health Service. As far as accountable, 
there are still issues that were mentioned today with 
credentialing. And the ones that need to be held accountable, 
seemingly, are moved throughout the system.
    Mr. LaMalfa. How would you feel about that at the Aberdeen 
office? Are they accountable, on the ball for you?
    Mr. Shield. Well, we have different issues with the 
Aberdeen area office and, really, the need for it there. A lot 
of decisions are not made there, they are made up at the 
headquarters level. And----
    Mr. LaMalfa. What is the relationship like with that area 
office?
    Mr. Shield. It all falls back on meaningful consultation.
    Mr. LaMalfa. Yes.
    Mr. Shield. And the non-existence of it. And it is hard to 
win trust back when we are not afforded meaningful consultation 
or our questions are not answered, especially when it comes to 
the budget.
    Mr. LaMalfa. OK, all right. Do you believe that the Federal 
Government and its employees can effectively spend the dollars 
that would improve patient care at this point? Do you see the 
seeds of improvement?
    Mr. Shield. Yes, I do, in a revamping of the whole system. 
But it is going to take strong leadership, starting at the 
Health and Human Services Secretary level and the incoming 
Indian Health Director.
    Mr. LaMalfa. OK, thank you. As was mentioned earlier, I 
believe, in our Ranking Member's line of questioning, some 
tribal leaders--this is for Ms. Kitcheyan--that the only reason 
some IHS facilities in the Great Plains remain open--maybe that 
was in Mrs. Noem's testimony, as well--is because CMS simply 
has not visited them recently. Do you believe that is an 
accurate statement?
    Ms. Kitcheyan. I believe that is very accurate. I believe 
across the whole country there are probably facilities that are 
in jeopardy, and they just have not been identified yet. So, 
our problem is not just in the Great Plains, it is agency-wide, 
and that is why it is so important that the solutions that come 
out of this bill are going to affect positive change across 
Indian Country.
    Mr. LaMalfa. OK. And the problems outlined earlier on a 
more individual basis--Winnebago, Rosebud, et cetera--do you 
think it is widespread across the entire Great Plains area?
    Ms. Kitcheyan. Yes, I do. And we are finding that, as we 
think we can look toward our area office for some of these 
answers and solutions, we are finding, unfortunately, that that 
capacity is not there. And I don't mean to be disrespectful to 
our area office, but the tribes are very frustrated with the 
services that are coming out of that to the extent that we want 
to dismantle it. It is just not serving our needs.
    Mr. LaMalfa. Yes, OK. That is unfortunate, but this 
Committee is committed toward vastly improving the situation, 
as Mrs. Noem is, and carrying the legislation, so I expect 
positive results coming from our efforts here in the Committee, 
and the Committee as a whole.
    With that, again, the clock is running fast here, so I do 
want to thank the panel for your travel, for your effort to be 
here, and to share your important testimony with us today, 
informing this Committee.
    I would remind that the members of the Committee may have 
additional questions for the witnesses, and we will ask you to 
respond to those in writing later on. Under Committee Rule 
3(o), members of the Committee must submit witness questions 
within 3 business days following the hearing, and the hearing 
record will be held open for 10 business days for these 
responses.
    If there is no further business, without objection, the 
Subcommittee stands adjourned.

    [Whereupon, at 4:06 p.m., the Subcommittee was adjourned.]

[LIST OF DOCUMENTS SUBMITTED FOR THE RECORD RETAINED IN THE COMMITTEE'S 
                            OFFICIAL FILES]

    --  Letter from Chairman William Bear Shield, Rosebud Sioux 
            Tribe to the Hon. Kristi Noem dated June 20, 2017.

Rep. Gosar Submission

    --  Statement of the American Dental Association to the 
            Subcommittee on Indian, Insular and Alaska Native 
            Affairs on ``Restoring Accountability in the Indian 
            Health Service Act of 2017, H.R. 2662'' dated June 
            21, 2017.

Rep. Grijalva Submissions

    --  Written Testimony of the Hon. W. Ron Allen, Chairman, 
            Self-Governance Communication & Education Tribal 
            Consortium and Tribal Chairman/CEO, Jamestown 
            S'Klallam Tribe to the House Committee on Natural 
            Resources, Subcommittee on Indian Insular and 
            Alaska Native Affairs. H.R. 2662, ``Restoring 
            Accountability in the Indian Health Service Act of 
            2017'' dated June 21, 2017.

    --  Written Testimony of United South and Eastern Tribes 
            Sovereignty Protection Fund to the House Committee 
            on Natural Resources, Subcommittee on Indian, 
            Insular and Alaska Native Affairs on ``Restoring 
            Accountability in the Indian Health Service Act of 
            2017,'' dated July 5, 2017.

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