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S. HRG. 114–522 

IMPROVING ACCOUNTABILITY AND QUALITY OF 

CARE AT THE INDIAN HEALTH SERVICE 

THROUGH S. 2953 

FIELD HEARING 

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

JUNE 17, 2016 

Printed for the use of the Committee on Indian Affairs 

( 

(II) 

COMMITTEE ON INDIAN AFFAIRS 

JOHN BARRASSO, Wyoming, Chairman 

JON TESTER, Montana, Vice Chairman 

JOHN MCCAIN, Arizona 

LISA MURKOWSKI, Alaska 

JOHN HOEVEN, North Dakota 

JAMES LANKFORD, Oklahoma 

STEVE DAINES, Montana 

MIKE CRAPO, Idaho 

JERRY MORAN, Kansas 

MARIA CANTWELL, Washington 

TOM UDALL, New Mexico 

AL FRANKEN, Minnesota 

BRIAN SCHATZ, Hawaii 

HEIDI HEITKAMP, North Dakota 

T. MICHAEL ANDREWS, Majority Staff Director and Chief Counsel 

ANTHONY WALTERS, Minority Staff Director and Chief Counsel 

(III) 

C O N T E N T S 

Page 

Field Hearing held on June 17, 2016 ..................................................................... 1 

Statement of Senator Barrasso ............................................................................... 1 

Statement of Senator Rounds ................................................................................. 6 

Statement of Senator Thume .................................................................................. 4 

WITNESSES

Bear Shield, Hon. William, Chairman, Rosebud Sioux Tribal Health Board ..... 15 

Bohlen, Stacy A., Executive Director, National Indian Health Board ................ 24 

Prepared statement .......................................................................................... 27 

Blueshield, Ardell, Health Director, Spirit Lake Tribe ........................................ 21 

Prepared statement .......................................................................................... 22 

Noem, Hon. Kristi Lynn, U.S. Representative from South Dakota ..................... 7 

Stabler, Wehnona, CEO, Carl T. Curtis Health and Education Center, Omaha 

Tribe of Nebraska ................................................................................................ 17 

Prepared statement .......................................................................................... 19 

Wakefield, Mary, Ph.D., R.N., Acting Deputy Secretary, U.S. Department 

of Health and Human Services; accompanied by Mary Smith, Principal 

Deputy Director, Indian Health Service ............................................................. 9 

Prepared statement .......................................................................................... 11 

APPENDIX

Grundmann, Susan T., Chairman, U.S. Merit Systems Protection Board 

(MSPB), prepared statement ............................................................................... 52 

Lerner, Hon. Carolyn N., Special Counsel, U.S. Office of Special Counsel, 

prepared statement .............................................................................................. 49 

Response to written questions submitted by Hon. Mike Rounds to Mary 

Wakefield .............................................................................................................. 100 

Spotted Eagle, Faith, Treaty Chairwoman, Yankton Sioux/Ihanktonwan 

Tribe, prepared statement ................................................................................... 49 

Steele, Hon. John Yellow Bird, President, Oglala Sioux Tribe, prepared statement ...................................................................................................................... 63 

Stier, Max, President/CEO, Partnership for Public Service, prepared statement ...................................................................................................................... 56 

United South and Eastern Tribes Sovereignty Protection Fund, prepared 

statement .............................................................................................................. 73 

Yankton Sioux Tribe, prepared statement ............................................................ 76 

Additional information submitted for the record................................................... 78–99 

(1) 

IMPROVING ACCOUNTABILITY AND QUALITY 

OF CARE AT THE INDIAN HEALTH SERVICE 

THROUGH S. 2953 

FRIDAY, JUNE 17, 2016 

U.S. SENATE, 

COMMITTEE ON INDIAN AFFAIRS, 

Rapid City, SD. 

The Committee met, pursuant to notice, at 10:30 a.m. in the Central High School Auditorium, Hon. John Barrasso, Chairman of the 

Committee, presiding. 

[Opening prayer, by Robert Flying Hawk spoken in Lakota.] 

OPENING STATEMENT OF HON. JOHN BARRASSO, 

U.S. SENATOR FROM WYOMING 

The CHAIRMAN. Well, good morning, everyone, and welcome to 

this oversight legislative hearing on improving accountability and 

quality of care at the Indian Health Service, and we have a piece 

of legislation to do that. I’m John Barrasso. I’m a physician from 

Wyoming. I’m also the United States Senator from Wyoming and 

Chairman of the Senate Indian Affairs Committee, and I’m delighted to be here with Senator Thune, Senator Rounds, and Congresswoman Noem, who have worked tirelessly on this effort and 

I’m so happy that you’ve all joined us today. 

The first order of business this morning is to recognize the tribal 

leaders here today. I’d like to thank all of them for your continued 

leadership and your dedication to making your people stronger and 

healthier. The progress we’ve made so far is a direct result of your 

hard work and the feedback, and I greatly appreciate the important role you’ve played in this entire process. 

So I look forward to working with each and every one of you to 

improve the legislation that’s before us today and to move it forward for the betterment of Indian health in this region and for the 

entire country. 

Now, I know our work isn’t finished, and I’d also like to thank, 

obviously, the congressional delegation of South Dakota for its significant dedication to Indian health and providing us with a warm 

welcome here in Rapid City today. And, of course, we want to 

thank our friends here at Central High School for hosting us. 

Today the Committee is basically examining one specific piece of 

legislation called S. 2953, the Indian Health Service Accountability 

Act. 

2 

So let me just stop there and ask if you or your family relies on 

the Indian Health Service for medical care, please stand. 

[Members of the audience stood.] 

This is why we are here today. This is why we’re here today. For 

everyone standing, for all of the IHS patients, we must get this 

right. We cannot accept failure or complacency, and, as a doctor, 

I know that quality health care is about putting the patient first. 

This is the mentality we need to see at every level of the Indian 

Health Service, and I thank each and every one of you for being 

here today. 

So on May 19th Senator Thune and I introduced a piece of legislation, S. 2953, the Indian Health Service Accountability Act. Senator Rounds is also a cosponsor. Congresswoman Noem is also 

working on similar legislation in the House. 

This Committee held an oversight hearing, a listening session, on 

February 3rd. We examined what we saw as substandard quality 

of Indian health care in the Great Plains Area. Many of you were 

part of that hearing, the listening session we held in Washington 

D.C. 

What was clear from listening to each and every one of you was 

the tremendous amount of pain and frustration that you have had 

with the Indian Health Service. You shared many tragic stories, 

tragic events with the Committee that day, and the sad reality is 

that many of these problems were identified, that we identified earlier this past year, were also identified in 2010 when Senator Dorgan from North Dakota was chairman of the Committee and he did 

his report. So some of these problems I believe have gotten worse, 

new issues have developed over time, and, as you all recall his 

words, the services provided by the Indian Health Service as malpractice, and I stand by those words. 

As a physician for more than 20 years I know this can only be 

rectified by significant improvements in delivering medicine, accountability, transparency and compassion for patients. And I see 

people on the panel shaking their head yes. So the bill that Senator 

Thune and I introduced does just that. 

This bill, the Indian Health Service Accountability Act, is the 

critical first step on the road to reform because it targets the issues 

we believe are at the core of the dysfunction of the Indian Health 

Service. It will lay a sound foundation for the Indian Health Service to actually deliver the health care that tribal members need and 

deserve. 

Now before going any further, I want to emphasize that this bill 

will basically bring together what we’ve heard from you, the problems that you say are there and the solutions that you’ve all shared 

as ways to fix them. All the provisions in this Indian Health Service Accountability Act are tied directly to the feedback that we 

have already received from you. So this bill is really a series of solutions designed to solve specific problems. 

For example, the Indian Health Service Accountability Act will 

provide expanded removal and disciplinary authority for the Indian 

Health Service to ensure that it has all the tools it needs to address problem employees. This expanded authority enhances accountability and transparency within the Indian Health Service to 

better reporting mechanisms and increased compliance. We’ve also 

3 

heard the Indian tribes describe a lack of basic tribal consultation. 

We heard it then and we heard it this morning in our listening session. We heard it yesterday. This legislation will increase consultation between the Indian Health Service and tribes and require this 

consultation be meaningful and timely. It would also ensure that 

the basic budget and spending information is available to the tribe. 

We heard about that this morning. And also available to Congress 

so the Indian Health Service funds are spent on patient care instead of union settlements that you brought up today. 

To address severe staffing shortfalls, this legislation would enhance the Indian Health Service’s ability to recruit and retain 

qualified employees by offering more incentives to work in Indian 

country. The bill will also reward employees who deliver quality 

care and innovative ideas to the tribal communities that they 

serve. 

The bill includes a number of provisions that will help determine 

housing needs and staffing needs in the agency so that we are all 

in a position to make informed decisions about what resources are 

needed and how they should be spent. 

The Indian Health Service Accountability Act will increase patient safety through quality measures and monitoring, and requires 

regular oversight by other Health and Human Services agencies. 

Among other things, it would help ensure that cases don’t fall 

through the cracks by requiring HHS’s Inspector General to investigate suspect patient deaths. 

This bill will also help ensure that Indian Health Service employees who see something wrong feel comfortable coming forward to 

report problems. Increasing accountability and transparency will 

help ensure the problems are resolved rather than repeated and 

covered up. That’s what we need to do to improve patient safety 

and quality of care. 

So this legislation of the Indian Health Service Accountability 

Act is a step in the right direction. Too many lives have been lost 

that could have been saved, and it’s my hope the administration 

listens and responds to testimony today so that one day these 

tribes can trust and again seek services from a well- functioning 

Indian Health Service hospital in all areas of the country. 

So the feedback we receive today will help the Indian Health 

Service Accountability Act and will make it stronger before we consider it in our Committee in Washington. 

I would also like have it known the Human Services Deputy Secretary, Mary Wakefield, made the trip to South Dakota. Dr. Wakefield, I know you had a scheduling conflict earlier and you cleared 

the calendar so you could be here to attend the hearing today and 

I’m grateful you’ve done that. 

So I appreciate your attention to this important matter, and 

thank you for coming here to testify, but also I want to take a 

break from me talking and turn this over to Senator Thune for an 

opening statement. 

Senator Thune. 

4 

STATEMENT OF HON. JOHN THUNE, 

U.S. SENATOR FROM SOUTH DAKOTA 

Senator THUNE. Well, thank you, Mr. Chairman, for holding this 

important hearing in South Dakota, and I want to speak out to the 

commission and those who are affected most by the Indian Health 

Services and those are who are part of the communities. I also 

want to thank Chairman Barrasso, who has been terrific on these 

issues, and, as he mentioned, we had a hearing back in February. 

This is a follow-up hearing to that, but, most importantly, right 

here in South Dakota where we will hear directly from people who 

are impacted. 

And it’s nice having someone like Senator Barrasso chairing the 

Indian Affairs Committee as a neighbor of Wyoming so he understands our issues. He also, as he said, is a physician, an orthopedic 

surgeon, so those of us in our 50s who are always looking for medical advice in the Senate turn to him quite often. He doesn’t do surgery—— 

The CHAIRMAN. Free advice. 

Senator THUNE. Yes, that’s right. That’s the best type of advice. 

He doesn’t do surgeries in the cloak room, and a lot of times I’m 

told, take two aspirin. 

But, anyway, it’s great to have somebody with his background 

and expertise addressing issues to health care. 

The reason that we’re doing this, and, you know, we held, what 

I feel, was a very necessary oversight hearing back in February regarding the chronic failures of the IHS, failures that, frankly, are 

just unacceptable; and, you know, we heard some pretty stunning 

stories, and at that time I think you, Mr. Chairman, heard the 

same stories, and Senator Rounds participated in that hearing 

along with us heard, and you continued that oversight into an 

agency that seemingly just doesn’t have accountability to anyone. 

CMS’s findings, as terrible and horrific as they were, brought 

forth evidence of reprehensible practices that were occurring at the 

Indian Health Service. Practices that did not match information 

that was provided to members of Congress, including myself. 

CMS’s findings have, once again, provided a public window in these 

facilities to view the substandard care that’s being delivered to our 

states by its citizens. The stories have been detailed time and 

again, and it’s time to take action. 

After these reports were released in the hearing in February, 

Chairman Barrasso and I immediately began to explore ways to reform the agency. The result of our efforts, combined with tribal 

input, culminated with the introduction of the IHS Accountability 

Act of 2016, which attempts to tackle this crisis from all sides. 

Senator Rounds was very active in that process and is also a cosponsor of the legislation. The legislation which we are here to discuss today increases accountability, improves hiring practices, enhances recruitment and retention, protects whistle-blowers, increases fiscal accountability and creates greater transparency of 

the agency. 

In an effort to improve accountability, the legislation provides 

the Secretary of Health and Human Services with a streamlined 

ability to remove underperforming managers and executives. As 

I’ve said many times, leadership starts at the top, and if IHS leadVerDate Mar 15 2010 10:23 Jan 05, 2017 Jkt 023226 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 S:\DOCS\23226.TXT JACK
5 

ers are a barrier to delivering quality care, then they should look 

for another job, not simply be moved to a different area. 

While we need strong leadership, it is also no secret that providing care in remote rural locations is difficult, which is why we 

have included provisions to streamline hiring demands and 

incentivize improvement of providers. One of the largest fears of 

change currently plaguing IHS is the lack of transparency. Unfortunately, IHS is simply unable to answer straightforward questions 

regarding funding allocations and outlays. 

For example, the agency estimates that it spends $50 million a 

year in the Great Plains Area on temporary, non-full-time staff. 

What the agency does not know is whether that number is accurate 

and how much it would save IHS if they were able to achieve permanent staffing, and full-time employees. 

What’s even more troubling is the question of where the agency 

is taking this money from in order to paper over this problem. This 

brings me to our bill’s next point, fiscal transparency and long-term 

planning. Our legislation requires IHS to issue spending reports to 

tribes and to Congress and requires the agency to release a staffing 

plan. Creating a spending plan is essential to understanding exactly how IHS allocates funding, not only nationally, but within 

each area. 

Last, and most importantly, we want to ensure increased tribal 

consultation when IHS hires senior staff. One of the major complaints that we hear constantly from tribes is the lack of meaningful consultation. 

I hope to continue discussions regarding what meaningful consultation means to our tribal members and what we can do to improve it. While there’s no doubt that more oversight is necessary 

and will be conducted, today’s hearing allows us the opportunity to 

explore changes to this failing agency, and provides us with chance, 

with input from our clients, to change the status quo. 

I’d like to acknowledge and thank the administration’s willingness to work with us and to engage with us on these issues and 

look forward to continued collaboration. 

I also want to thank, particularly, our tribal leaders, tribal representatives, and the individuals who reached out with their concerns and solutions for IHS. Your continued input and suggestions 

are still needed, and I am committed, along with the delegation, 

Senator Rounds and Congresswoman Noem and others who want 

to take on this battle with us to working with you to bring forth 

positive solutions. 

So thank you, Mr. Chairman, for being here in South Dakota. 

Thank you for bringing the Indian Affairs Committee to this state 

and to giving intense focus to the issue, and, frankly, to something 

that has become and reached, I think, a crisis stage and desperately demands a solution. Thank you. 

The CHAIRMAN. Thank you, Senator Thune, for your thoughtful 

leadership. 

Senator Rounds. 

6 

STATEMENT OF HON. MIKE ROUNDS, 

U.S. SENATOR FROM SOUTH DAKOTA 

Senator ROUNDS. Thank you, Mr. Chairman. First, let me just 

say to the Chairman, I most certainly appreciate you taking the 

time to hold today’s field hearing in South Dakota where our tribal 

members are all too familiar with the failures of the Indian Health 

Service. I’d also like to thank Senator Thune and Congresswoman 

Kristi Noem for their tireless work to address the problems plaguing IHS. 

In South Dakota we know all too well of these ongoing problems. 

Nearly every week, if not every day, our newspaper headlines tell 

the tale of new problems. Let me just read you some of the headlines that we’ve seen in just the last month: IHS Hospital in Immediate Jeopardy; Feds Deal Blow to Rosebud IHS Hospital; Man 

Won’t Return to, As He Quotes, Death Hospital; Tribal Leaders Say 

They Were Left Out of IHS Call For Help; Health Care Crisis Hits 

South Dakota Reservations. 

I can spend my entire time reading headlines, but it’s important 

to understand the impact that it’s having on real people, our tribal 

members. The Great Plains Area IHS, which covers South Dakota, 

North Dakota, Nebraska, and Iowa, has the second highest mortality rate among all IHS regions. We also have the highest diabetes death rate. It’s five times the U.S. average, almost double the 

average among all IHS regions. Our life expectancy rate is the lowest of all IHS regions at 68.1 years. Compare this to the U.S. average of 77.7 years. 

It is clear the IHS is failing our tribal members who are suffering and even dying due to this inadequate and disgraceful care. 

As we all know, Rosebud has had its emergency department on diversion status for 195 days as of today, meaning tribal members 

are having to drive over 50 miles to receive emergency care. The 

same is true with their OB and surgical departments as well. 

These circumstances are going to continue to occur until we demand thorough review and reform of IHS. We need an independent 

audit. 

I had the opportunity to deal with the Great Plains Tribal Chairman’s Association in April. We discussed an in-depth analysis on 

IHS and my office researched in an attempt to seek answers and 

gain a better understanding. We talked about the administrative 

imbalance, that there are 15,000 employees at IHS, only 750 doctors, yet nearly 4,000 are administrative medical billers. 

We also found that IHS employees and administrators can’t explain or don’t understand their own budget. After reviewing the 

data with me, the Great Plains Tribal Chairman voted on a resolution that supported an audit of the IHS. The IHS needs major reform. More taxpayer money won’t solve the dysfunction because 

what IHS lacks is an efficient system and accountability. 

Consider this: If the President proposed and Congress supported 

doubling the IHS budget, based on IHS’s current template, they 

would have 20,000 administrative employees, 7,400 bureaucrats 

billing Medicaid, and still only 1500 doctors. The imbalance and 

priorities would still exist, just at a greater level. 

From my standpoint, investing more taxpayer money in a dysfunctional system will only compound the problem. This is a seriVerDate Mar 15 2010 10:23 Jan 05, 2017 Jkt 023226 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 S:\DOCS\23226.TXT JACK
7 

ous issue that requires tangible solutions, not mandates. There are 

significant administrative management, financial management, 

and quality of care issues that must be addressed. Today’s hearing 

will help us better understand where the problems lie and steps 

forward to fix these problems. 

Once again, we need the audit. Ultimately, today’s hearing is to 

fix the poor quality of health care for our people. IHS will never 

be able to deliver quality timely care the federal government has 

a trust responsibility to deliver without broad reforms. 

I want to take this opportunity to thank Chairman Barrasso, 

Senator Thune, and Representative Noem for being here today, and 

also their ongoing work to address these issues. Thank you, Mr. 

Chairman. 

The CHAIRMAN. Well, thank you, Senator Rounds, for your leadership and for your intense focus on this. We’re very grateful. 

Now Representative Noem. 

STATEMENT OF HON. KRISTI LYNN NOEM, U.S. 

REPRESENTATIVE FROM SOUTH DAKOTA 

Congresswoman NOEM. Thank you, Chairman Barrasso, and the 

Committee, and I appreciate your input today and this opportunity 

to attend today’s hearing. I’m a member of the House, and, obviously, this is a Senate Committee Hearing, so it is very humbling 

to be a part of this process and to be invited to join the group at 

the table today and listening to our testimony that we’ll hear. 

I also thank Senators Thune and Rounds for being great partners in having ongoing monitoring of HHS, IHS, CMS as we’ve 

gone through this crisis and over the years as we’ve dealt with this 

before, as well. 

Thank you all for coming here to testify today. Mr. Bear Shield, 

you’ve been very candid with me and you always speak with great 

truthfulness, and I know that the words that you speak are factual 

and very helpful to me when I’ve been dealing with drafting legislation and hearing the testimony of your tribe. The frank analysis 

that you gave me is extremely helpful. 

And, Dr. Wakefield, I do appreciate you making this a priority. 

It certainly is for all of us here at the table, and the fact that you 

came here today means a lot. 

Ms. Stabler, Ms. Blue Shield, Ms. Bohlen, thank you, as well, for 

coming. It’s just wonderful. And, Ms. Smith, thank you for being 

here, as well. I wasn’t quite sure that you’d make it, and I’m glad 

that you have. It means the world to me that you recognize how 

important this is. 

And I’m grateful that we’re all here today to shed some light on 

the ongoing tribal health care crisis that we have going on in South 

Dakota, but, frankly, throughout Great Plains regions with tribes 

that include Nebraska, as well. We need comprehensive reform, 

and, frankly, I’m just going to put it very simply, I believe that IHS 

should get out of the hospital business. I think they’re terrible at 

it. I don’t think they know what they’re doing. 

[Audience applause.] 

I believe this for two different reasons. First, as everyone in this 

room is aware, the medical care that we receive at IHS in the 

Great Plains region is like getting health care in a third-world 

8 

country. The mismanagement of fiscal stability that is lacking in 

the area and the agency have just completely eliminated my confidence in the agency. 

We found that the agency is devoid of transparency and openness. We found it keeps patients and tribal leaders in the dark. It’s 

extremely discouraging to me and it’s incredibly difficult to get answers to the simplest questions. 

For example, IHS told us that it needs more people. We asked 

them how many employees the IHS needs and were told by the 

agency that it has no way of finding out this information. How do 

you make a request without knowing what you’re requesting? 

And if you’re a tribal leader, timely and accurate information is 

even harder to come by. To give one recent example, IHS notified 

Great Plains Tribal Leadership of an important conference call regarding the contracting problem by attending a Microsoft Outlook 

meeting invitation 1 hour before the call was to begin. 

Now we all describe the term ‘‘tribal consultation’’ differently, 

but I tell you that is certainly not it. 

On my most recent visit down to the Rosebud hospital, which 

was just a couple weeks ago, every single conversation that I had, 

those people are sick and tired of the decades of corruption, the 

mismanagement, and the life-threatening care provided by Indian 

Health Services. They’re done with the bureaucratic mess, and that 

they are tired of watching underperforming employees risk their 

lives of brothers and sisters and family. 

Enough is enough, and that’s what we’re here to talk about 

today. What do we do when enough is enough? For years IHS has 

been asked to make improvements. Congress has increased the 

agency’s funding nearly every year that I’ve been in office, and yet 

the situation is as bad as it’s been. And let me be very clear, I do 

believe that Native American health care is underfunded, but I also 

believe that money is not going to fix the broken management system that we have in the Great Plains region. So let’s talk about solutions. 

I thank the Chairman and the Senators for introducing the IHS 

Accountability Act in the Senate. Like the bill that I introduced in 

the House, this legislation attacks serious personnel problems that 

are flooding IHS, including the agency’s hiring, firing, and disciplinary practices. It also includes many incentives for improvement 

and retention of high-quality employees. 

My bipartisan Health Act that I’ve introduced in the House has 

many sponsors on it already. We’ll be having a hearing in the coming weeks, but it also takes a similar approach, but I also added 

something that is a third rail of delivering high-quality health care 

to people in Indian country. It’s the Purchase/Referred program, 

and we’ve already talked about that today when we had some questions from tribal leaders. Don’t get sick after June has become a 

common phrase in Indian country. And it’s because purchase referred care program runs out of money in June every year, and 

after that the only way that you’re going to get any kind of treatment or care is if you’re dying or losing a limb in Indian country. 

It’s unacceptable. It’s jeopardized tribal members’ lives, personal 

well-being, as well as their financial health. 

9 

The reforms in my bill ensures that funding is fairly distributed 

among tribal communities and ensures that South Dakotans can 

get the care that they need. 

So, Mr. Chairman, I am encouraged by the fact that we’ve already got broad agreement between the House and the Senate on 

solutions that remediates these problems. I’m looking forward to 

working with you and my delegation colleagues in the House, Natural Resources Committee, the Energy and Commerce Committee, 

Ways and Means Committee in uniting to approach this and unite 

to find a solution so we can put it on the President’s desk. And 

that’s what I fully intend to do is to get solutions signed into law 

so we can fix this problem. I yield back and I want to thank you 

again for allowing me to participate today. 

The CHAIRMAN. Thank you, Congresswoman Noem. Ladies and 

Gentlemen, there are 100 United States Senators. You’ve got three 

of us here. There are 435 members in the House of Representatives 

and I will tell you, people of South Dakota, you are looking at 

somebody who shows incredible leadership and a very forceful voice 

in the House of Representatives. Thank you very much, Congresswoman Noem. 

Now our witnesses. We are going to start with Mary Wakefield, 

who is also a Ph.D., but also a registered nurse. She’s the acting 

Deputy Secretary of the U.S. Department of Health and Human 

Services from Washington D.C. I just want to remind all witnesses 

that your full written testimony will be made part of the hearing 

record, so we want to please keep your statements to 5 minutes or 

less so that we may have time for questioning. 

And I look forward to hearing your testimony. Let’s us start with 

you. 

STATEMENT OF MARY WAKEFIELD, PH.D., R.N., ACTING 

DEPUTY SECRETARY, U.S. DEPARTMENT OF HEALTH AND 

HUMAN SERVICES; ACCOMPANIED BY MARY SMITH, 

PRINCIPAL DEPUTY DIRECTOR, INDIAN HEALTH SERVICE 

Dr. WAKEFIELD. Thank you very much, Mr. Chairman, Senator 

Thune, Senator Rounds, Congresswoman Noem. Thank you for the 

opportunity to participate in today’s very important hearing on the 

IHS Accountability Act of 2016. 

I wanted to say at the outset of this hearing that we, in the administration, certainly share the goals reflected in your legislation. 

Your focus on accountability, strengthening the workforce, and improving the quality of our native communities that we serve are extremely important and we share those goals. Each goal that’s reflected in your bill is important, as we confront acute and chronic 

problems like those that we are facing right now in some of our facilities here in the Great Plains Area, which are, in no small part, 

due to the product of longstanding issues. 

Today, under our current leadership, it is not business as usual 

at Indian Health Service, and with support from the Department 

of Health and Human Services we are doing critically important 

work on moving aggressively to strengthen the delivery of quality 

care at IHS facilities long term, while at the same time working 

to address immediate short-term needs. 

10 

Four months ago Secretary Burwell created the Executive Council on Quality Care, and she asked me to lead this effort. I come 

from the Great Plains. I’m from North Dakota, which I say softly 

here in the Great State of South Dakota. But I have some firsthand 

knowledge of the challenges facing Indian Country, and I view the 

responsibilities the secretary gave me as incredibly important and 

as an opportunity to make meaningful and needed changes. 

The council, the executive council, includes some of HHS’s top 

management and program experts, and together we are taking a 

deep look at longstanding obstacles like workforce retention, providing housing, care quality, and even the organization structure of 

the IHS, itself. With executive council engagement and support, 

IHS is applying a five-part strategy to create lasting change. 

First, we’re focusing on surfacing problems and addressing them 

as quickly as we can with the resources that we have. One effort 

underway is IHS’s system-wide survey initiative that includes all 

of its direct service hospitals. 

Second, we are focused on strengthening health care services to 

patients and communities. Recruiting and retaining health care 

providers is one of our biggest challenges. In the short-term we 

have already deployed more than two dozen U.S. Public Health 

Service Commissioned Corps clinicians to the Great Plains area. 

And right now, for example, we have the National Institute of 

Health helping IHS implement innovative nursing recruitment 

strategies. 

In addition, I do want to mention today that it is through the 

work of the Executive Council that we have identified an additional 

approximately $50 million in funding for Indian Health Service to 

help strengthen service delivery, the second goal over the long 

term. About 30 million of those dollars will support much-needed 

projects right here in South Dakota. This funding will be applied 

to some of the biggest needs, such as construction for provider 

housing. Lack of housing is a longstanding obstacle to recruiting 

and retaining staff. 

IHS will also be able to purchase equipment to make much needed IT upgrades, including to enhance hospital telehealth in historically hard to access specialties. 

As part of a long-term strategy we are working to find new ways 

to recruit and train more individuals with connections to the communities that IHS serves, and also connecting those with demonstrated commitment to service. 

For example, we’re now recruiting committed U.S. clinicians to 

the Peace Corps, as well as a Global Health Services program. It’s 

a new initiative. 

Third, we’re focused on strengthening area management through 

a number of strategies, from improving recruitment efforts for area 

directors to IHS’s recently announced consultation around the organization and structure of the Great Plains Area office. 

Fourth, we are infusing substantial quality expertise into the 

IHS system. IHS has joined with CMS supported hospital engagement network which shares approaches that we know improve care 

quality. Going forward CMS is in the process of contracting this 

fall for the first quality improvement organization that will focus 

exclusively on strengthening quality of care within IHS hospitals. 

11 

And, fifth, we’re working to collaborate with local resources. 

Local communities are valuable sources of expertise and collaboration. We plan to work with leaders from tribal colleges to other academic institutions, as well as regional health providers to further 

develop health care workers and services. 

We also know that the health of communities is tied to the 

health of the local economy, and that’s why we’re committed to 

doing what we can to advance the success of small businesses in 

the tribal communities. I’ve asked our HHS Department Office of 

Small and Disadvantaged Business working in cooperation with 

the U.S. Small Business Administration to coordinate technical assistance events for small businesses that are owned by Native 

American Indian Tribes and the native community at large. One of 

these is planned to occur here in South Dakota. 

As I mentioned, we know the health of our community is tied to 

the health of our local economy. 

IHS and all of HHS are committed to working hard to make 

meaningful and measurable progress. We’ve taken significant steps 

since the last hearing, and there is much more work ahead, including intense work ongoing now to strengthen and stabilize the hospitals in South Dakota and Nebraska. 

We look forward to addressing these challenges and making 

meaningful progress in partnership with you and the tribal leadership. Thank you. 

[The prepared statement of Ms. Wakefield follows:] 

PREPARED STATEMENT OF MARY WAKEFIELD, PH.D., R.N., ACTING DEPUTY

SECRETARY, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES; ACCOMPANIED

BY MARY SMITH, PRINCIPAL DEPUTY DIRECTOR, INDIAN HEALTH SERVICE

Introduction 

Good morning. Chairman Barrasso and Members of the Committee, thank you for 

the invitation to join you today here in Rapid City, South Dakota and to testify on 

S. 2953, the IHS Accountability Act of 2016. We would like to start by thanking you 

and Senator Thune for your leadership on the Committee and for elevating the importance of delivering quality care through the Indian Health Service. This Committee, IHS, and HHS share a common goal of providing consistent, quality health 

care to the American Indian and Alaska Native communities we serve. The Administration has concerns with some provisions in S. 2953 as drafted and looks forward 

to working with the Committee to improve the bill as it moves through the legislative process. 

Earlier this year, we strengthened and refocused our resources within the Department as part of an aggressive strategy to improve the overall quality of care in the 

Great Plains Area, and across the country. HHS and IHS are working to instill a 

culture of quality care and accountability across the agency. We are committed to 

hearing directly from you and the communities we serve to focus sharply on how 

to best improve access to quality health care and most importantly improve the 

health status of American Indian and Alaska Native families and communities. 

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

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

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

on both fronts. 

With new leadership at IHS, we are not accepting business as usual. IHS’s Principal Deputy Director, Mary Smith, has made it crystal clear that change is the new 

status quo at IHS. And the leadership at HHS is reinforcing and amplifying that 

message. Under her leadership, IHS is changing the way it approaches long-standing challenges. IHS is working to reengineer its human resources, create an organizational structure that supports sustained improvement and accountability, and is 

focused on strengthening its financial management infrastructure. 

12 

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

Care and asked Acting Deputy Secretary Wakefield to lead it. This council includes 

senior executives from across HHS and thus draws on expertise from across the Department. We have some of HHS’s top managers, clinicians, and program experts 

taking a fresh look at long-standing obstacles like workforce supply, housing, challenges to delivering quality of care, and addressing key operations issues. The council ensures that we are leveraging all the resources we can on behalf of American 

Indian families and communities. 

Through the work of this Council, in tandem with IHS, for the past two months, 

we have been engaging our work through a five-prong strategy to address these 

challenges—many of the same obstacles like sufficient workforce, personnel issues, 

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

the Department are working to (1) surface existing problems so that we can work 

to resolve them; (2) improve service delivery; (3) strengthen IHS Area management; 

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

Surfacing Problems 

First, we are assessing and surfacing problems so that we can work to resolve 

them. We are taking a very close look at the quality of care delivered through direct 

service hospitals at IHS facilities across the Great Plains Area as well as throughout across Indian Country. We want to affirm and support facilities that are delivering quality care and work closely with facilities that need improvement. It is important that IHS leadership from headquarters to Area offices work closely with 

both tribal leadership and direct service hospitals in a transparent way that encourages open information exchange about improvement opportunities. We know from 

decades of experience across the health care continuum, that problems that are not 

acknowledged and fixed put even more patients at risk. For the past 20 years, 

health care systems across the nation have been embracing new models of improvement, and it is that orientation that we are working to further strengthen with in 

IHS through the assets of IHS and other divisions in HHS. 

For example, IHS is beginning a system-wide mock survey initiative at all 27 of 

its hospitals to assess compliance with CMS Conditions of Participation and readiness for re-accreditation. These mock surveys will be conducted by survey teams 

from outside each respective Area to reduce potential bias. The new mock survey 

initiative is being coordinated through the IHS Quality Consortium as a unified effort to reinforce standardization of processes. We are beginning in the Great Plains 

Area with assessments and, when appropriate, interventions through the provision 

of on-site assistance to hospital staff. Although some direct service hospitals currently conduct self-assessments, IHS is standardizing and improving this process so 

that all Direct Service hospitals receive an assessment within the next three months 

and performance data tracked, not just at individual facilities but across all facilities. 

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

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

were piloted May 10, 2016, at the Rosebud Hospital and we will continue to do quality surveys at all direct service hospitals, excluding those that have been surveyed 

in the past year or are scheduled to be formally surveyed through other mechanisms 

during this timeframe. When our survey teams identify problems, we will work 

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

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

shared across IHS facilities. 

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

testing interim policy. This policy was released on June 6th and focuses on drug 

testing based on reasonable suspicion, and expands the HHS drug testing policy 

that already applies to IHS employees. The interim policy provides guidance to supervisors and managers on drug testing based on a reasonable suspicion of drug 

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

Improve Service Delivery 

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

clinical support infrastructure. 

Workforce 

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

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

shortages and are in the process of adding more, such as telemedicine, these longstanding challenges require building up and expanding the training and deployment 

13 

pipelines and full use of innovative approaches to delivering care. In the near-term, 

with Secretary Burwell, Deputy Secretary Wakefield, and the U.S. Surgeon General’s support, over two dozen Commissioned Corps clinicians have been deployed 

for temporary placements into the Great Plains hospitals with CMS findings. In addition, NIH has been helping IHS deploy strategies it has used to recruit nurses 

into its clinical program. These include providing new recruitment language and accessing web-based resumes of South Dakota nurses for the IHS, as well as using 

new web-based places to advertise. IHS is also revising position descriptions and deploying more comprehensive recruitment plans around key positions, in an effort to 

recruit a greater number of qualified candidates. IHS is also deploying Title 38 pay 

increases for high-demand clinicians and has established eligibility for payment of 

relocation expenses for GS–12 and lower graded clinical positions. However, even 

with these and a number of other strategies that have been deployed during the 

past two months or that are in development right now, there is still much more 

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

Some of these changes will require legislative action. In addition, we are working 

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

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

initiated a new strategy through a contract award to provide both emergency department staffing and operations support and management services at three hospitals: Rosebud Hospital and Pine Ridge Hospital in South Dakota and Omaha Winnebago Hospital in Nebraska. This will provide health care in these hospital emergency rooms while IHS reviews the administrative and clinical operations of its facilities across the region to develop long-term solutions. IHS’s leadership both in the 

hospitals and at headquarters have direct oversight of this contractor and is responsible for holding this contractor accountable for providing consistent quality health 

care. However, because this is a new approach to Emergency Department staffing 

and management combined, a team of clinicians and attorneys, as well as the CEOs 

of the facilities, are tracking this initiative weekly to ensure that performance expectations are met. 

As part of a longer term strategy, we are reexamining the scholarship and loan 

repayments program to make sure that we are maximizing their impact and we are 

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

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

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

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

60 returning volunteers will be learning about opportunities to work in direct service IHS hospitals even as we are engaging other longer term communication strategies with the broader Global Health Services program. Additionally, the U.S. Public 

Health Service Commissioned Corps has prioritized new officers to IHS with a particular focus on the Great Plains Area. 

On a related front, on June 1st, IHS proposed to expand its community health 

aide program and is slated to engage consultation with tribal leaders over the next 

months on this expanded effort. This important proposed change would bring more 

health workers directly into American Indian and Alaska Native communities. 

Infrastructure 

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

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

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

reopen the Rosebud Emergency Department as soon as it is safe for the patients. 

In the meantime, in order to fill the temporary gap, the IHS has re-purposed existing ambulatory care space into an Urgent Care clinic staffed with emergency department and ambulatory providers. Given the types of illnesses that individuals 

present with to the Rosebud Emergency Department, the Urgent Care clinic can 

manage the majority of these non-emergent care needs. 

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

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

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

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

14 

Strengthening Area Management 

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

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

Plains Area management through the temporary deployment of high-quality managers from within other areas of IHS as well as deploying HHS experts to both IHS 

headquarters and the field to assist with finance, contracting, and management 

functions. IHS also established a Human Resources (HR) Steering Committee, 

which provides oversight and guidance on the implementation of system-wide HR 

improvements in IHS. 

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

the Area Office. Captain Christopher Buchanan joined the Great Plains Area leadership team in May and is serving as the Acting Director of the Great Plains Area 

Office. Captain Buchanan has extensive expertise working with complex health systems which are IHS directly-operated facilities as well as tribally-managed programs assumed under the authority of the Indian Self-Determination and Education 

Assistance Act. In the longer term, the IHS is actively looking to find the best possible candidate for the Great Plains Area Director position. We revised technical 

qualification requirements for the position description in order to attract a broader 

pool of well qualified candidates. We have also implemented a stronger search committee process for recruiting highly qualified managers and executives. This committee is charged with candidate outreach, assessment, and vetting. IHS is also 

more widely advertising vacancies through federal, state, and non-profit partners, 

and is actively seeking additional venues to help attract a broad and diverse applicant pool. Additionally, going forward, we have expanded tribal participation in filling vacant Area Director positions and members of a tribe from each area will, for 

the first time, play a role in these search committees at the outset of the hiring 

process on these key positions. 

Finally, IHS recently announced conducting a 90-day consultation with Tribal 

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

to, in partnership with the Tribes, identify new approaches to better support patients and tribal community health in the Area. 

Infusing Quality Expertise 

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

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

in quality improvement. As we announced on May 13, 2016, the Premier HEN is 

now available to all IHS direct service facilities and focuses on quality improvement 

methods intended to reduce avoidable readmissions and hospital acquired conditions 

(e.g. central line blood infections, pressure ulcers, falls, etc.). Hospitals in the network share successful practices and lessons learned to accelerate learning and 

change. The HEN will prioritize working with the three Great Plains Area hospitals 

and is currently working with each hospital to schedule onsite meetings. 

Additionally, we are bringing in targeted quality improvement assistance through 

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

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

problems, assists with the development of improvement plans, establish baseline 

data, and monitor data to ensure improvement plans are successful and improvements are sustained over time. Also through Secretary Burwell’s Executive Council 

on Quality Care, HHS is deploying quality experts, as needed, from throughout the 

Department to consult with and help our IHS direct service hospitals that are currently out of compliance with CMS Conditions of Participation and to monitor 

progress as the facilities come into compliance. 

Engaging Local Resources 

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

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

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

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

hospital leadership and tribal leadership to build stronger academic pipelines and 

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

produce health related workers and health care services. 

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

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

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

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

15 

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

and the Native American community at large. 

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

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

Strengthening IHS 

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

First, we appreciate the authority we already have to use the pay flexibilities under 

chapter 74 of title 38. We are working with OPM, OMB, and other affected agencies 

to explore ways to enhance our current authorities to provide more tools to recruit 

and retain high quality staff. 

Second, we are seeking tax treatment, similar to the treatment provided to recipients of National Health Service Corps (NHSC) and Armed Forces Health Professions scholarships. Currently, IHS loan repayment/scholarship awards are taxable, 

reducing their value. In contrast, participants in the NHSC scholarship program 

and Armed Forces Health Professions may exclude scholarship amounts used for 

qualifying expenses from income, and participants in the NHSC loan program may 

exclude any loan amounts repaid on their behalf from income. We recommend 

adopting the Administration’s Fiscal Year 2017 Budget proposal which would conform the tax treatment of IHS repayments/scholarships to the tax treatment for 

NHSC and Armed Forces Health Professions repayments/scholarships. 

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

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

However, the Affordable Care Act permits certain NHSC loan repayment and scholarship recipients to satisfy their service obligations through half-time clinical practice for double the amount of time or, for NHSC loan repayment recipients, to accept 

half the loan repayment award amount in exchange for a two-year service obligation. We would like similar flexibility. 

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

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

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

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

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

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

facilities. 

Conclusion 

Our entire Department is committed to making meaningful and measurable 

progress in the way that IHS delivers care. While the Administration has concerns 

about this bill, we look forward to working with the Committee to improve it as it 

moves through the legislative process. Thank you, and we are happy to take your 

questions. 

The CHAIRMAN. Thanks so much for your testimony. I appreciate 

you being here and making the trip. Thank you. 

Let me just now turn to the honorable William Bear Shield, who 

is the Chairman of the Rosebud Sioux Tribal Health Board of 

South Dakota. 

STATEMENT OF HON. WILLIAM BEAR SHIELD, CHAIRMAN, 

ROSEBUD SIOUX TRIBAL HEALTH BOARD 

Mr. BEAR SHIELD. Good morning. Thank you, Chairman 

Barrasso. Good morning, Senator Thune, Senator Rounds, Representative Noem. Thank you for the kind words. 

First of all, I want to say [phrase in Lakota.] Welcome to the 

Hesapa Senate Indian Affairs Committee. It is the home of the 

great Sioux nation; Mount Rushmore; and, more importantly, 

Crazy Horse monument, which is our fierce warrior. 

As Chairman Barrasso has said, I’m also a member of the Rosebud Sioux Tribe. I serve as our chairman of our health board comVerDate Mar 15 2010 10:23 Jan 05, 2017 Jkt 023226 PO 00000 Frm 00019 Fmt 6633 Sfmt 6601 S:\DOCS\23226.TXT JACK
16 

mittee there. I’m also the chairman of Unified Tribal Health Board 

here for people that utilize Sioux San Hospital. I’m also vice chairman of the Great Plains Tribal Chairman’s Health Board here. 

As you’re aware, Rosebud IHS hospital has been the subject to 

multiple CMS findings that have left our hospital without emergency rooms since December 15, 2015 resulting in a CMS notification to terminate the hospital’s provider agreement effective March 

16, 2016, and as recently as this past week we learned that our 

tribal members who need surgical and health care services are now 

required to be diverted to other facilities. 

I would like to thank you for your commitment and your actions 

in assisting the Rosebud Sioux Tribe, and not only other tribes of 

the Great Plains to address these issues. Many of you visited Rosebud and have shown a sincere interest in finding a solution, and 

we can only do that working as a team. 

We believe in the IHS Accountability Act, along with Senator 

Rounds calling for an internal audit, and Representative Noem’s 

bill to accept tribes from the ACA employer mandate are important 

steps towards improving health care for Indian people in the Great 

Plains. 

The IHS Accountability Act of 2016 calls for fiscal accountability. 

We ask that the legislation includes a prohibition of the IHS from 

using the third-party revenue to settle any types of litigation. Recently IHS used over $900,000 of Rosebud IHS third-party billing to pay a national labor claims settlement. Additionally, we ask 

this Committee’s support and of the Great Plains tribes’ requests 

to IHS for a comprehensive budget of the area office, including tribal shares so that the Great Plains tribes, with the assistance of the 

Great Plains Tribal Chairman’s Health Board can begin developing 

an alternative model to the area office. 

We also believe that fiscal accountability must include adequate 

funding to ensure success. The Rosebud Sioux Tribe is currently 

teamed with capable health care management to pursue the sole 

source contracting of the Rosebud Indian Health management positions. However, when we informed IHS headquarters of this intent, 

we were told that the tribe could not sole source the proposed contract. When, in fact, didn’t they do the same thing when they 

awarded the contract for the ED? 

We ask this Committee to recognize that Rosebud and other 

tribes that want to assume programs right now are working under 

a handicap because the funding stream from third party have been 

disrupted and the costs have gone due to increased efforts to assume compliance. 

Furthermore, we also need meaningful and productive consultation, which is currently absent. 

We ask that Congress support and encourage tribal assumptions 

by creating a pool of funds to offset these challenges immediately 

so that the tribes do not have to use its own resources to overcome 

the deficits IHS causes. 

Funding will also be needed to support increased recruitment 

and retention. They should also be able to have the tribes utilize 

and assume IHS programs since they are affected. We are aware 

that there is no changing the past, but we hope that the proposed 

legislation supported by adequate funding, we can all move forward 

17 

in a positive way to provide quality health care as our ancestors 

envisioned upon signing of our treaties. 

Thank you again for your efforts on behalf of the Rosebud Sioux 

tribe and other tribes of the Great Plains. We look forward to continuing participation and partnership to drive these changes forward. 

The CHAIRMAN. Thank you for your testimony and sharing that 

with us. 

We’re next going to turn to Wehnona Stabler, who’s the Tribal 

Health Director from the Omaha Tribe of Nebraska. 

STATEMENT OF WEHNONA STABLER, CEO, CARL T. CURTIS 

HEALTH AND EDUCATION CENTER, OMAHA TRIBE OF 

NEBRASKA 

Ms. STABLER. Yes, good morning. I’d like to say thank you to my 

Tribal Council this morning that has accompanied me, and my 

nephew who said a little prayer this morning. I want to thank him. 

I’m not here representing the council, though. I’m here representing the many patients that suffer, and one recently who has 

died. A 40-year-old that went to the Omaha Winnebago hospital, 9 

miles up the road. We were promised in the treaty that’s provided, 

and she went in and she was a diabetic. It was clearly recorded. 

Nobody ever checked her blood sugar. Sent her home, next day she 

came in with 1,500 and she died. 

So in February when I testified, I wanted to relay the suffering; 

and yesterday I had to cry at the end of the day. It was one after 

the other after the other. And so, this morning I wanted to have 

the right words to say to you, but it’s very difficult because these 

are people that I know. These are relatives that I’m going to watch 

these children grow up without a mother. Her daughter just graduated from high school. I almost sent it to all the IHS people, you 

should have seen what she wrote. I’m not sharing this with my 

mother, and it was a simple finger stick. And they’re spending $6 

million to buy a central monitoring system for our ER’s, but if the 

people aren’t there to push the buttons and to do the readings, this 

is what’s happening today still in our hospitals. 

And I left the Indian Health Service after 31 years because I 

could not be a part. I could not be a part of a system that was failing my people. And I see this every day. And we’re trying our best, 

and I have to thank CMS for doing their job. It seemed like they 

were trying to go around the systems. They were trying to figure 

out ways to not comply, instead of just giving us what we deserve 

and what we’ve already paid for, and what has been promised to 

the Omahas by the treaty. 

We have five treaties with the government. We are the indigenous tribe there. We’ve always been a very peaceful tribe on the 

river, never declared the government as an enemy, but I am right 

now doing that because I’ve been in this battle for a long time, and 

we’re losing it. We’re losing it. 

And the reality is they want the tribes to take it over, but the 

Omahas have done this for 38 years. We have a public law 93–638 

contract. We’ve done everything except ER and inpatient care. 

Those are the two services, ER and inpatient care, that we rely on 

IHS for and they’ve failed us miserably. 

18 

So I do thank CMS for doing their job. And it is not a mission 

impossible, you know. I run three hospitals for IHS and numerous 

clinics when I was at the Pine Ridge service unit recently, like 

three and a half years ago we removed the immediate jeopardy. 

But it takes a CEO that will go into the ER. And I had a new area 

director tell me in February CEO’s should not have to go into the 

emergency room. 

I’m sorry. That was a necessity for me to do that to make sure 

those contract doctors, which are still in our ER’s, give our patients 

the care they deserve. Nurses won’t do it. Other staff won’t do it. 

Doctors won’t listen to people. 

Doctor, you know we were sent a dentist when we were failing. 

A dentist from Pine Ridge as our medical officer. 

You, as an orthopedic surgeon, know that there’s no board certified ER doc that’s going to listen to a dentist. That is the reality, 

but yet they argued with me every meeting and said it was legal. 

But we don’t care if it’s legal. We want the right thing to be done 

for us. 

So today I’m here representing those people that have not had 

a voice, or just take that care and never say anything. Sit all day 

and wait in those hospitals for care, and then sent home with 

Motrin. Those are the people that I’m here for today. 

And I have to say that this is a start, that you are building a 

beginning. Because you know what? When you asked that question, 

I stood up; chairman stood up; Ardell stood up; but none of the IHS 

people stood up. They don’t get their care from IHS. 

As a CEO, that’s the first thing I did, I made a chart. I thought 

if I’m going to be the CEO of this hospital or clinic, I need to get 

my care here. I need to be satisfied. If I go there, then I know 

what’s happening in that facility. And I expect the best for the patients that I serve. 

This is why I’m sitting here today. I’m from Nebraska, and I 

don’t have a representative at this table, so I’m depending on this 

Senate Committee investigation to move our voices forward. The 

bill is great. It’s a start. There are some missing pieces, though, 

and I would just like to ask you to consider, including telemedicine, 

because the states are trying to figure out how to bill and how to 

set things up. But telemedicine would be an answer to these remote areas, and we would have access to board certified ER physician if we had telemedicine, rather than mid-level contractors or 

mid-level M.D.’s that they’re contractors for a reason, you know. 

Otherwise they’d be in full-time positions somewhere. They all 

have their quirks. 

Also, quarters, even though we’ve given up our quarters at 

Omaha Winnebago hospital, we need them to recruit. Consider 

funding that. So that’s a part of your bill, but broaden it for the 

ones that have given up their quarters. Give us a second chance 

to rethink that for recruitment efforts. 

We need authorities like the V.A. has, two-year funding. And 

president Steele talked about that this morning. We’re still suffering from the shutdowns. We shouldn’t have been shut down. We 

shouldn’t have been included in that. All these things that the 

V.A.—we’re the first Americans and they’re our veterans and we 

have high, high rates, and there’s veterans still in my tribe and so, 

19 

oftentimes, I send them to the V.A. because, unfortunately, they 

get better care there. That should not be the case. Our vets and 

us should be on the same playing field, I believe all the authorities 

that the VA has, we should too. 

So what’s the next step? I think the audit, because we need to 

know where our money is. We don’t know. They don’t share that 

information with us. There is no transparency when you start talking about funding. Those old accounts, those old discretionaries, 

where are they? We see things that the money is allocated, but 

they’re not even in existence, so we know there’s money available. 

So the audit would be the next step, and then include us 

throughout these processes. The tribes have been left out. We’re 

the patients. We’re the stakeholders. Include us through the whole. 

So I think that would be the next step. 

And then I’m going to start to close my comments, but I have to 

say I have to put it back on Congress, if Congress would fund us 

at 100 percent. We’re only funded at 50, 40, 30 percent. You can 

go to any facility, they don’t have 100 percent funding. 

[Applause.] 

Thank you. 

This is why we’re having to deal with CMS. If we were funded 

at 100 percent, you know, we would not have to do third-party billing. But, again, I thank CMS for being here and keeping us accountable for patient care issues. But fund us at 100 percent and 

uphold our treaty rights. I ask HHS and IHS, please uphold our 

treaty rights. 

[Applause.] 

Keep us, the patients, at the center of all your decisions and actions. Keep us in mind. We’re real people. 

Yesterday the man could barely stand. Did you see him? He was 

sweating and he just got out of the hospital, but he felt so strongly. 

He stood there for almost 20 minutes at the podium relaying his 

barriers and all the things that went wrong with his care. And I 

thought for sure he was going to pass out, but that’s the kind of 

passion, and I think I even have PTSD from running three hospitals for a little bit. This is why we get so passionate, and if we 

cry and we carry on it’s because we have that inside us, you know. 

We give up a lot for this. We’re just asking. And so I thank you 

all for the opportunity today and may God be with you. 

[The prepared statement of Ms. Stabler follows:] 

PREPARED STATEMENT OF WEHNONA STABLER, CEO, CARL T. CURTIS HEALTH AND

EDUCATION CENTER, OMAHA TRIBE OF NEBRASKA

Good morning esteemed members of the Senate Select Committee on Indian Affairs. My name is Wehnona Stabler and I am the Chief Executive Officer of the 

Omaha Tribe of Nebraska’s Carl T. Curtis Health Center and an enrolled member 

of the Omaha Tribe. 

We operate Indian Health Service (IHS) programs, which are crucial to our tribal 

members. In addition to providing needed services, these programs offer sorely needed employment for both Indian and non-Indians. These programs are offered 365 

days a year using federal funds and our limited tribal income, with very little assistance from the State of Nebraska. Current and past IHS funding has never met our 

full basic needs and that leads me into my initial, general comments about the matter at hand. 

I understand that the IHS Accountability Act does not include more funding for 

our troubled facilities in the Great Plains Region. But it should. In sum, for too long, 

faced with federal shortfalls, IHS has leaned on the states and CMS to fund its opVerDate Mar 15 2010 10:23 Jan 05, 2017 Jkt 023226 PO 00000 Frm 00023 Fmt 6633 Sfmt 6621 S:\DOCS\23226.TXT JACK
20 

erations. And while I appreciate the intent of the Accountability Act—and will speak 

to its provisions—I believe Congress needs to be held accountable too. So let’s not 

stop here. 

Turning to the Accountability Act, I will begin with Section 3, regarding removal 

of IHS employees based on performance or misconduct. As a former employee of 

IHS, I personally welcome—and my Tribe welcomes—this language that fast tracks 

IHS’ authority to fire or demote underperforming employees while also not allowing 

an individual transferred to a general schedule position or a reduction in pay grade 

to be placed on administrative or paid leave unless they’re performing a primary 

or alternative primary duty. However, I submit that for the sake of transparency, 

Notice of the Personnel Action and of the results of employee appeals should also 

be submitted to the Tribes within the respective IHS service area 

Section 4 concerns improvements in hiring practices. Here, the proposed direct 

hiring authority is welcome, so too, are the provisions requiring tribal consultation. 

However, with regard to the required GAO report relating to staffing needs, I note 

the report to be submitted by the Comptroller General includes an assessment of 

the use of independent contractors instead of full time equivalent employees, yet 

lacks any required analysis of the fiscal impact of such use of independent contractors. In my experience, the expense of hiring independent contractors is far more 

than use of FTE. Accordingly, such analysis should be included. 

Moreover, based on experience with the Omaha-Winnebago Hospital, I have concerns regarding what I will call the ‘‘recycling’’ of the independent contractors. For 

example, ‘‘AB Staffing’’ recently entered into a contract with IHS to run the Emergency Department at the Omaha-Winnebago Hospital. This is the same company 

that was at the helm when the hospital was terminated by CMS. In fact, their role 

has been expanded to include nursing. Why bring back a company that was part 

of the problem? 

Section 5 regards Incentives for Recruitment and Retention. My comments concern the requirement that the GAO provide a report on IHS professional housing 

needs and the housing plan to be submitted by the Secretary based on that report. 

The draft bill proposes that the GAO has up to a year to provide the report and 

up to another year for the housing plan to be submitted to Congress. Given that 

Congress may take another year—if not years—to act, I suggest the respective reports should have a deadline of six months; that is, the report by IHS is due within 

six months of the passage of the bill and the subsequent report to Congress should 

be due within six months of the GAO report. 

Next, I turn to Section 9: Fiscal Accountability. Section 9 (c) calls for status reports to be provided by the Secretary each quarter of a fiscal year describing the 

expenditures, outlays, transfers, reprogramming, obligations, and other spending of 

each level of the Service, including the headquarters, each Area office, each Service 

unit, and each facility to governmental entities, including tribes. I suggest this report should include a report detailing when, how, and for what purposes funds were 

diverted from one service unit to another. For example, additional funds were diverted to the hospitals with CMS issues in the amount of $60 million: O/W Hospital, 

Pine Ridge and Rosebud. But instead of consulting with the Tribes, IHS decided to 

purchase a Central Monitoring Unit for the Emergency Departments at each hospital. The question the Omaha’s have is ‘‘Will this machine do finger sticks?’’ and 

the answer is ‘‘NO’’. We ask that question because we had a 40-year-old Diabetic 

die and no one ever checked her blood sugar. We do not need new gadgets if we 

have no qualified staff to operate them; we need permanent Board Certified, compassionate providers and staff to take care of us. The O/W Hospital is all we have. 

Finally, Section 10 addresses Transparency and Accountability for Patient Safety. 

This section requires the Secretary to post surveys, reports and other CMS materials relating to patient safety on websites of IHS operated hospitals and clinics. 

Section 10 (b) makes CMS responsible for conducting surveys at least every two 

years to assess the compliance of each hospital or skilled nursing facility of IHS and 

publish the results on the same websites. The Omaha Tribe strongly suggests that 

CMS should further be responsible for immediately publishing to those websites any 

citations issued by CMS to an IHS facility stating that the facility is in ‘‘Immediate 

Jeopardy’’. 

Thank you for allowing me this time to speak. The Omaha Tribe will continue 

to stand ready to improve IHS as a partner to see the Quality of Care finally realized. 

The CHAIRMAN. Thank you so much, Ms. Stabler. You started by 

saying that yesterday, as we were listening, that you hoped you 

21 

would be able to find your words, and I think we all agree that you 

have most certainly found your words. 

Next we’re going to hear from Ms. Ardell Blueshield, who’s the 

Tribal Health Director from the Spirit Lake Tribal Health in North 

Dakota. 

STATEMENT OF ARDELL BLUESHIELD, HEALTH DIRECTOR, 

SPIRT LAKE TRIBE 

Ms. BLUESHIELD. Good morning, Mr. Chairman, and members of 

the Committee. I am honored to be here today to discuss the Spirit 

Lake Tribe’s recent assumption of the Spirit Lake Health Center 

in Forth Totten, North Dakota from Indian Health Service. 

We are proud to be the first tribe in the Great Plains Area area 

to exercise our self-governance rights to provide for our people’s 

health care. In response to patient concerns and after conducting 

a patient survey and numerous community meetings, the tribe decided, in 2015, to assume operation of the Spirit Lake Health Center. The tribe and IHS concluded negotiations in early May, and 

the compact and funding agreement became effective June 1st of 

this year. 

I want to add that the complaints that we received, the responses 

of them were long waiting times, they wanted more providers, 

there was no patient transportation, and they wanted more services at the clinic. But it fell on deaf ears. 

So the council, the Tribal Council, and the people were tired of 

it, so they wanted to do this. They wanted to take the health care 

into their own hands. For a smooth transition, the tribe offered 

IHS employees the option to continue to work at the health center 

under the interpersonal agreements with IHS, and 48 IHS employees are detailed to the health center under these agreements. 

The tribe hired a chief executive officer and is working hard to 

fill the 24 vacancies inherited from IHS. The tribe is actively recruiting, including a job fair held just this week. The tribe’s goal 

is to have a single integrated system of care for its tribal citizens 

using the flexibility of self-governance to tailor health programs to 

address the specific needs of our communities. The tribe has only 

begun its journey over its health care and its future, but it is excited about the opportunities and promise afforded by self-governance to improve health care for its people. 

The tribe would like to express its gratitude to Indian Health 

Service in the Area Office, and the Office of Tribal Self-Governance 

for their technical assistance and cooperation as the tribe gathered 

information and negotiated the agreement. The tribe looks forward 

to a collaborative relationship for the future to provide the highest 

quality health care for our people. We deserve it. We deserve everything that everybody else has. 

I offer a few reflections based on the tribe’s experience to date. 

The Spirit Lake Tribe found a tribal survey to be a useful tool to 

learn about patient experiences at the Spirit Lake Health Center. 

The Tribe intends to continue the use of surveys in order to evaluate the health care programs and services that it provides. We recommend that IHS increase its use of surveys. 

The tribe also recommends that IHS expand its efforts to interact 

with tribal government of the communities which it serves through 

22 

regular meetings, consultations, and a tribal liaison function at the 

service unit level. 

At the time when we took it over, that we have that and it needs 

to be stronger in all Indian Country. The provisions in Section 4 

of S. 2953 requiring consultation with affected tribes regarding certain IHS personnel decisions are consistent with this recommendation and the tribe’s experience. Enhanced communication between 

IHS and tribal government will improve accountability, IHS responsiveness to local needs, and the quality of care. 

The tribe also believes that Section 5, provisions for incentives 

for improvement and retention of IHS employees would be beneficial. 

The reasons for the tribe’s decision to assume the Spirit Lake 

Health Center includes the tribe’s greater ability, compared with 

IHS, to develop packages of compensation and other employment 

terms to attract and retain quality medical providers and other 

staff. Section 5 appears to improve IHS’s flexibility in this regard 

as well. 

I thank the Committee for inviting me to give testimony this 

morning today. Thank you. 

[The prepared statement of Ms. Blueshield follows:] 

PREPARED STATEMENT OF ARDELL BLUESHIELD, HEALTH DIRECTOR, SPIRIT LAKE

TRIBE

Chairman Barraso, Vice-Chairman Tester and Members of the Committee, 

I am honored to be here today to discuss the Spirit Lake Tribe’s recent assumption of the Spirit Lake Health Center in Fort Totten, North Dakota from Indian 

Health Service. On June 1 the Tribe assumed the Health Center under the self-governance provisions in Title V of the Indian Self-Determination and Education Assistance Act. We are proud to be the first Tribe in the Great Plains Area to enter 

into the Indian Health Service Tribal Self-Governance Program and to exercise our 

sovereign rights to provide for our people’s health care under self-governance. 

The people of the Spirit Lake Tribe are Dakota. The Spirit Lake Reservation is 

comprised of approximately 405 square miles in eastern North Dakota and has four 

districts: Mission District (St. Michaels), Woodlake District (Tokio), Fort Totten District, and Crowhill District. The total population of the Reservation is 4,238 of whom 

3,794 are tribal members. The total tribal enrollment is 7,839. According to recent 

census data, the economic conditions on the Reservation are difficult, with per capita income totaling only 37 percent of the statewide average and 35 percent of the 

national average, and 47.8 percent of reservation residents and 57 percent of children on the reservation living below the poverty level. The Spirit Lake community 

faces a number of health care challenges, including a high rate of diabetes. A 2015 

community assessment found health care needs were eight of the community’s top 

ten needs, in particular behavioral health issues and chronic disease. 

The Spirit Lake Health Center is an outpatient facility on the Spirit Lake Reservation with over 70 staff positions serving IHS beneficiaries. Until June 1 IHS operated the Health Center. In recent years the Tribe noticed an increase in dissatisfaction among patients of the Health Center. In early 2015 the Tribe began 

evaluating whether it should assume administration of the Health Center under the 

Indian Self-Determination and Education Assistance Act. The Tribe conducted numerous community meetings in 2015 and 2016 to receive input from tribal members 

about the care provided at the Health Center and to discuss possible tribal assumption of the Health Center. The Tribe developed a patient survey and circulated it 

among patients. The results of that survey confirmed dissatisfaction with customer 

service and the care provided at the Health Center. The survey results also reflected 

concerns about the number of physicians and other providers available at the 

Health Center to serve patients and limited patient transportation services. In addition to the patient complaints, the Tribe was concerned about the high vacancy rate 

among IHS staff of the Health Center. 

For many years, the Spirit Lake Tribe has operated a number of health programs 

under Title I of the Indian Self-Determination and Education Assistance Act, includVerDate Mar 15 2010 10:23 Jan 05, 2017 Jkt 023226 PO 00000 Frm 00026 Fmt 6633 Sfmt 6621 S:\DOCS\23226.TXT JACK
23 

ing programs addressing mental health, diabetes, women’s health, alcohol and substance abuse, public health, community health, environmental health, and emergency medical services. Assuming the Health Center would facilitate integration of 

the Tribe’s programs with care provided at the Health Center. 

The IHS Office of Tribal Self-Governance confirmed that the Tribe was eligible 

for self-governance, and the Tribe determined to assume the Health Center. The 

Tribe and IHS concluded negotiations in early May 2016, the Compact and Funding 

Agreement for the Tribe’s existing Title I programs and the assumption of the 

Health Center was approved later in the month, and they became effective June 1, 

2016. 

In order to ensure the smoothest possible transition, the Tribe offered the current 

IHS employees the option to continue to work at the Health Center under Intergovernmental Personnel Act agreements or Memoranda of Agreement (for Commissioned Corps officers). As a result, 48 IHS employees are detailed to the Health Center under such agreements. The Tribe has hired a Chief Executive Officer of the 

Health Center and is working hard to fill the 24 vacancies inherited from IHS. The 

Tribe is actively engaged in recruitment activities, including a job fair held just this 

week. 

The Tribe’s goal is to have a single integrated system of care for its tribal citizens. 

The Spirit Lake Tribe believes that it can use the flexibility of self-governance to 

redesign the health care programs and funding at the Spirit Lake Health Center 

in order to address the specific needs of our community and to be accountable to 

tribal citizens in a way that IHS cannot. The Tribe has only begun its journey to 

assume greater control over its health programs and its future, but it is excited 

about the opportunities and promise afforded by self-governance to improve health 

care for its people. 

While it has not been easy, the Tribe would like to express its gratitude to Indian 

Health Service, in the Area Office and Headquarters, particularly the Office of Tribal Self-Governance, for their technical assistance and cooperation as the Tribe gathered information about the Health Center and negotiated the Compact and Funding 

Agreement. The Tribe looks forward to a collaborative relationship with IHS in the 

future to provide the highest quality health care for our people. 

I offer a few reflections based on the Tribe’s experience to date. 

The Spirit Lake Tribe found the tribal survey to be a useful tool to learn about 

patient experiences at the Spirit Lake Health Center. The Tribe intends to continue 

to use surveys in order to evaluate the health care programs and services that it 

provides. We recommend that IHS increase its use of surveys. 

The Tribe also recommends that IHS expand its efforts to interact with tribal government of the communities which it serves, through regular meetings, consultations and a tribal liaison function at the Service Unit level. 

The Tribe is still reviewing S. 2953 and reserves the right to submit additional 

comments later. However, in light of the Tribe’s experience, I offer comment on certain provisions. For example, Section 4 would provide that before appointing, hiring, 

promoting or transferring a candidate to a senior position or a management position 

in an Area office or Service unit, IHS must, except in certain emergencies, consult 

with affected Indian tribes. The Tribe believes that this provision would be an improvement as it would enhance information provided to tribal government about important personnel decisions affecting the health care program serving the tribal 

community. Such communication between IHS and the tribal government representing the patients whom IHS serves should improve accountability, IHS responsiveness to local needs and the quality of care. The Tribe recommends that the Committee and IHS continue to search for ways to incorporate tribal input into IHS decisionmaking. 

The Tribe also believes that the provisions in Section 5 for incentives for recruitment and retention, including authority for granting or rescinding bonuses to promote patient safety, employee performance or for recruitment, performance-based 

retention bonuses, and reimbursement to employees of relocation costs, would be 

beneficial. The reasons for the Tribe’s decision to assume the Spirit Lake Health 

Center include the Tribe’s greater ability—compared with IHS—to develop packages 

of compensation and other employment terms to attract and retain quality medical 

providers and other staff. Section 5 appears like to improve IHS’s flexibility in this 

regard as well. The Tribe is studying the proposed changes regarding the pay scale 

for IHS providers. 

I thank the Committee for inviting me to give testimony today. I am available to 

answer questions. 

The CHAIRMAN. And thank you very much, Ms. Blueshield. 

24 

Now we turn to Ms. Stacy Bohlen, who is the Executive Director 

of the National Indian Health Board in Washington D.C. 

STATEMENT OF STACY A. BOHLEN, EXECUTIVE DIRECTOR, 

NATIONAL INDIAN HEALTH BOARD 

Ms. BOHLEN. Thank you, Mr. Chairman, and members of the 

Committee, and Congresswoman Noem. My native name is [spoke 

in Lakota.] and that name means turtle woman, and that name 

carries responsibility to speak the truth for all people, and it’s with 

that being that I’m very honored to be here today on behalf of the 

National Indian Health Board. Thank you for inviting us to be 

here. 

I’m a member of the Sault Sainte Marie Tribe Chippewa Indians 

from Michigan, but my father was born and raised here in Milbank 

and Crow, South Dakota. I spent most of my childhood here in 

South Dakota, so I have a strong-rooted affinity in my heart for the 

place and the people here. 

The National Indian Health Board is a nonprofit organization. It 

serves all 567 federally-recognized tribes to provide policy analysis 

and advocacy for all of the tribes of this nation. It was founded by 

the tribes to serve as one voice affirming and empowering American Indian an Alaskan Native peoples, to protect and improve 

health, reduce health disparities, and ensure the Federal Government upholds its trust responsibilities for the health care of our 

people. 

Unfortunately, we’re all here today because of long-standing systemic issues within the Indian Health Service that have led to crises situation in the Great Plains, but other crises in other areas 

are on the cusp of showing themselves, as well, and it is from a 

national perspective that I believe that the NIHB was asked to be 

here. 

Now that we are in a crisis situation, we believe there are two 

separate courses of action that must be taken. First and for most, 

immediate corrective action must be taken to rectify the closing 

and cutting off of IHS services so that there are no more unnecessary deaths of our people in this region or anywhere in this country. Once this crisis is stabilized, we must address the fundamental 

and systemic issues that have been occurring within the agency for 

decades. These reforms may start in the Great Plains; however, 

they must be implemented nationally so that all tribes and tribal 

citizens receiving their health care from IHS are assured safe, reliable, and quality health services. 

The legislation proposed by Chairman Barrasso and Senator 

Thune, the Indian Health Service Accountability Act of 2016, is attempting to address long-standing tribal concerns and the move 

forward in attempt to improve the overall accountability and transparency of IHS. It is admirable and appreciated and necessary for 

staff. The spirit and intent of this legislation is clearly aimed at responding to the call of tribal leaders, patients, and families like all 

of those we heard yesterday and that we’ve heard down through 

the decades. 

Many folks here have already testified about a variety of concerns included in the NIHB testimony, so if you don’t mind, I’m 

25 

going to skip forward to a couple of things that I believe will add 

to the discussion. 

First of all, we believe that structure reform of the agency is 

needed. There are unique challenges to delivering health care in 

any rural setting in the United States. These include provider 

shortages, isolation, long travel distances, scarcity of specialty care, 

and under-resourced infrastructure. However, there are successfully run rural health care systems operating all over the United 

States. A pressing need and opportunity exists within the Indian 

health and it’s many rural, geographically isolated hospitals and 

clinics to reform the structure in administration oversight of the 

service units and the area to more reflect what’s happening in the 

private sector. 

Medicine is business. It is the business of medicine, and it works 

in many, many areas of this country. The examples are all around 

us of what is successful and what will work, and we, at NIHB, believe that IHS has the authority to innovate. There are dramatic 

efforts underway right now to reach for and achieve innovation and 

we encourage those to continue and be, perhaps, even more aggressive and more dramatic. 

While one element that is absolutely necessary to such an aspiration is a dramatic increase in the funding that is currently held by 

the Indian Health Service; however, that is hand in hand with 

adopting standard and generally accepted business practices 

throughout the service, and NIHB too, believes that creating partnerships with mainstream and private entities will help IHS improve operations and systems, and, in fact, provide a learning laboratory for system-wide reform. 

The National Rural Hospital Association, the American Hospital 

Association, and the many—wow, it really goes fast—sorry. That 

just took another 20 seconds off my time. 

The CHAIRMAN. Go ahead. 

Ms. BOHLEN. Thank you, Senator. Sorry. Now I’m having a hot 

flash. Jeez. 

[Audience laughter.] 

Okay. All right. let’s get back to it. 

Your bill, of course, mandates the Secretary of HHS to report 

each quarter of the fiscal year describing expenditures, outlays, 

transfers, programming obligations, and other spending at each 

level of the service to Congress, tribes and the IHS. It does not 

have substantive measures in place to ensure that the mismanagement of these resources does not continue. 

And, to make it quick, we believe at NIHB that these quarterly 

reports should have a few measurable standards that are transparent to everyone. The tribes can see them, where is the money 

going, where is the third-party billing coming in, where is it going 

out, where is the federal expenditure of dollars taking place, and 

what is being achieved with that outlay; quality assurance and 

transparency. 

Many reports attribute to deplorable quality of health care at 

IHS, to poor agency management at all levels. We know that the 

hiring decisions are often lengthy, and poor performing employees 

at both the service unit clinic, and hospital administration and 

headquarters are not terminated, but moved around or moved up. 

26 

We know that this needs to be reformed, because without patients 

there’s no hospital. That was a quote from a tribal leader during 

a town hall that IHS held earlier this year. Without the patients, 

there’s no hospital. So the patients become so disenchanted with 

the system that they just won’t go there, which is already widespread. You don’t have a hospital, you don’t have a system. You 

have a whole lot of people waiting until they are so sick that of the 

top five services that people come in for, septicemia is one of them. 

Because you’re so sick by the time you go for care that it’s like 

very, very, very, very serious. 

So I’m going to skip ahead to recruitment and retention of personnel. While we understand that it can be challenging to achieve 

this, we think that HHS has additional tools already at its disposal 

to do so. The proposed legislation at hand provides for improved incentives to recruit and retain a quality health care workforce. It begins to address setting competitive pay scales for IHS employees 

and so forth. But wouldn’t it be something to imagine and possibly 

achieve in the housing shortages that we have to bring our doctors 

in. 

For example, a mainstream company like Walgreen’s, which resides at the ‘‘Corner of healthy and happy,’’ to come forward, make 

it healthy and happy forgive me, as an example, what if we had 

the corner of healthy and happy at Pine Ridge and right in the 

middle of it the Walgreen’s house of healing for doctors so that our 

tribes have a chance. That would be an interesting undertaking. 

Finally, many policy makers do not realize that the system of the 

United States that we employ to train medical residents, as well 

as dentists and some nurses, is an entitlement program paid for 

through Medicare called Graduate Medical Education. The GME 

program exceeds $15 billion annually. Congress capped the number 

of residency training positions in the United States as part of the 

Omnibus Budget Reconciliation Act of 1997. There’s been some 

amendments since then to allow for more residency training; however, the limit never existed where there were never residency 

trainings or where they were trying to be built in a place that was 

medically underserved, that’s Indian Country. 

Medical specialties remain highly motivated to increase the number of residency training positions within their various colleges and 

academies. That creates partnership opportunity. A win/win would 

be the potential, perhaps, for increasing the number of physicians 

serving in Indian Country to set aside some of the residency training positions, create new ones that can only be filled by people who 

will commit to working in Indian Country when they finish. 

I know you want to me to stop. I’m almost done. I swear. So let 

me finish. 

Here’s the deal, and, Chairman, you’re aware, as obviously an orthopedic surgeon who went to school 700 years, maybe a few less, 

but it probably felt like 700. 

So, the thing is, say a resident goes into family practice and it’s 

a three-year internship, a three-year residency training program. 

The indirect medical costs, which is the majority of the money for 

that resident’s training goes to the hospital. That would be a great 

thing for our facilities to have. You have ten residents, a hundred 

thousand dollars each, the indirect medical education comes into 

27 

1The National Health Board (NIHB) is a 501(c) 3 not for profit, charitable organization providing health care advocacy services, facilitating Tribal budget consultation and providing timely 

information and other services to all Tribal Governments. Whether Tribes operate their own 

health care delivery systems through contracting and compacting or receive health care directly 

from the Indian Health Services (IHS), NIHB is their advocate. Because the NIHB serves all 

federally-recognized Tribes, it is important that the work of the NIHB reflect the unity and diversity of Tribal values and opinions in an accurate, fair, and culturally-sensitive manner. The 

NIHB is governed by a Board of Directors consisting of representatives elected by the Tribes 

in each of the twelve IHS Areas. Each Area Health Board elects a representative and an alternate to sit on the NIHB Board of Directors. 

our system per placement or training, but in this scenario we’re increasing the number of residency training positions working with 

American Academy of Orthopedic Surgeons, College of OBGYN, pediatrics, emergency physicians, they all want their residency positions to increase. So they come and they have residents who fulfill 

these American Indian and Alaskan Native positions with the stipulation that if they don’t serve the exact number of years in Indian 

Country, that that residency training consumed and was paid for 

by the American people, they get to pay that money back to the 

United States and the institution gets to pay it back to the United 

States. That’s pretty highly incentivized to be successful. Nobody 

wants to pay that back. 

So, sorry if I went a little over time. I’m past my time. There’s 

words to be said by better people than me, so in close, thank you. 

[The prepared statement of Ms. Bohlen follows:] 

PREPARED STATEMENT OF STACY A. BOHLEN, EXECUTIVE DIRECTOR, NATIONAL

INDIAN HEALTH BOARD

Good morning, my name is Stacy Bohlen, and I am the Executive Director of the 

National Indian Health Board (NIHB). 1 Chairman Barrasso, Vice Chairman Tester 

and Members of the Committee, thank you for holding this important hearing on 

‘‘Improving Accountability and Quality of Care at the Indian Health Service 

Through S. 2953’’. And, furthermore, thank you for honoring the Tribal leaders and 

Tribal members of the Indian Health Service (IHS) Great Plains Service Area by 

traveling to their traditional lands to hold one of many hearings and meetings to 

examine the state of the Indian health system. 

The National Indian Health Board is a non-profit organization that serves all 567 

federally recognized Tribes to provide policy analysis and advocacy, program development and assessment, and training and technical assistance in Indian healthcare 

and public health policy and programs. It is our mission to be the one voice affirming and empowering American Indian and Alaska Native (AI/AN) peoples to protect 

and improve health and reduce the health disparities our people face. I appreciate 

the opportunity to provide this testimony before the Committee today. The NIHB 

stands with and supports the Tribes of the Great Plains IHS Service Area in this 

time of crisis and I’ll conclude my testimony today with specifics on what action 

NIHB is taking outside of working with both the Administration and Congress to 

do so. I am here today to offer the national perspective of all 567 federally recognized Indian Tribes—both those that receive direct services from the Indian Health 

Service, and those that have chosen to compact or contract with the Service to provide their own services. 

Unfortunately, we are all here today because of longstanding, systemic issues 

within the IHS that have lead to crises situations in the Great Plains Area. In the 

last year, several hospitals in this region have lost, (or received threats of revocation) their ability to bill Centers of Medicare and Medicaid Services (CMS) due to 

the failure of federally run sites to comply with basic safety and regulatory procedures. As early as this week, an IHS facility, the Rosebud Hospital on the Rosebud 

Sioux Reservation here in South Dakota, closed their surgical and obstetrics care 

services division. Now, patients seeking surgical and obstetrics care must go to privately owned facilities over 40–50 miles away. This is unacceptable. 

Many of the issues now coming to light are not new to American Indian and Alaska Natives that rely on the Indian Health Service as their primary source of health 

care and health information. At least five years ago then-Senator Dorgan released 

a report exposing the chronic mismanagement occurring at both the IHS regional 

28 

2 Indian Health Care Improvement Act, § 103(2009). 3 Ibid, p 5. 

(Area office) level and the Headquarters level of the Agency. A 2011 report by a separate U.S. Department of Health and Human Services (HHS) task force specifically 

noted that: ‘‘. . .the lack of an agency-wide, systematic approach makes it virtually 

impossible to hold managers and staff accountable for performance and to correct 

problems before they reach crisis proportions.’’ 

Now that we are in such crises situations there must be two separate courses of 

action taken. First and foremost, immediate corrective action must be taken to rectify the closing and cutting of IHS services so there are no more unnecessary deaths 

of our people in this region and nationally. Once the crisis is stabilized, we must 

then to address the fundamental and systemic issues that have been occurring within the agency for years. These reforms may start in the Great Plains Area; however, 

they must be implemented nationally so that all Tribes and Tribal citizens receiving 

their health care from IHS are assured safe, reliable and quality health service. 

The legislation proposed by Chairman Barrasso and Senator John Thune, S. 2953 

‘‘The Indian Health Service Accountability Act of 2016’’, is attempting to address 

long-standing Tribal concerns about the IHS, and the move forward to attempt improving the overall accountability and transparency of the Indian Health Service is 

admirable and appreciated. The spirit and intent of this legislation is clearly aimed 

at responding to the call of Tribal leaders, patients and the families of those who 

have had adverse experiences within the IHS system. Significant and structural 

changes are needed and this this bill boldly steps into that arena as a first attempt 

to open the dialogue of change. We stand ready to work with the Committee as the 

bill is shaped and formed through a Tribally-engaged and informed process. During 

the years that Indian Country and Congress worked to achieve the reauthorization 

of the Indian Health Care Improvement Act (IHCIA) NIHB facilitated a national, 

Tribal Leader Lead committee on the IHCIA Reauthorization. Many of the details 

of this bill attempt to achieve reforms that will provide the Service with the authorizations they need to improve the quality and quantity of health care services delivered at IHS facilities. However, especially because this legislation proposes to 

amend IHCIA, it is the position of the National Indian Health Board that the bill 

must be vetted further with a process similar to that utilized during the IHCIA reauthorization. Resources will be required to facilitate such a process and the time 

is now to engage the Tribes and Tribal consumers of IHS services in order to 

achieve meaningful, lasting and effective reforms to the system set up to fulfill the 

Treaty and Trust promise and obligations of the Federal Government. 

Federal Trust Responsibility 

The federal trust responsibility for health is a sacred promise, grounded in law, 

which our ancestors made with the United States. In exchange for land and peaceful 

co-existence, American Indians and Alaska Natives were promised access to certain 

paybacks, including health care. Since the earliest days of the Republic, all branches 

of the federal government have acknowledged the nation’s obligations to the Tribes 

and the special trust relationship between the United States and American Indians 

and Alaska Natives. The Snyder Act of 1921 (25 USC 13) further affirmed this trust 

responsibility, as numerous other documents, pieces of legislation, and court cases 

have. As part of upholding its responsibility, the federal government created the Indian Health Service (IHS) and tasked the agency with providing health services to 

AI/ANs. Since its creation in 1955, IHS has worked to provide health care to Native 

people. As recently as 2010, when Congress renewed the Indian Health Care Improvement Act, it was legislatively affirmed that, ‘‘it is the policy of this Nation, to 

ensure the highest possible health status for Indians. . .and to provide all resources 

necessary to effect that policy.’’ 2

Disparities 

While some statistics have improved for American Indians and Alaska Natives 

over the years, they are still alarming and not improving fast enough. Still, across 

almost all diseases, American Indians and Alaska Native are at greater risk than 

other Americans. For example, American Indians and Alaska Natives are 520 percent more likely to suffer from alcohol-related deaths; 207 percent greater to die in 

motor vehicle crashes; and 177 percent more likely to die from complications due 

to diabetes. 3 Most recently, a report has come out reporting that American Indian 

and Alaska Natives are disproportionately affected by the hepatitis C virus (HCV). 

Furthermore, Natives have the highest HCV-related mortality rate of any US racial 

or ethnic group—resulting in 324 deaths in 2013. And, most devastatingly to our 

29 

Tribal communities, suicide rates are nearly 50 percent higher in American Indian 

and Alaska Natives compared to non-Hispanic whites. 

Although the statistics give an idea of the problem, behind each statistic is the 

story of an individual, a family and a community lacking access to adequate behavioral health and health care services or traditional healing practices, and traditional 

family models that have been interrupted by historically traumatic events. Devastating risks from historical trauma, poverty, and a lack of adequate treatment resources continue to plague Tribal communities. American Indians and Alaska Natives have a life expectancy 4.8 years less than other Americans. But in some areas, 

it is even lower. For instance, here in South Dakota, for white residents the median 

age is 81, compared to only 58 for American Indians. 

What more will it take for the U.S. government to fulfill its promise of providing 

the highest possible health status for Indians and to provide all resources necessary 

to effect that policy? How many more horror stories must we share, and how many 

more hearings like this must we endure? Clearly, the current system is not working. 

Our health care delivery is not even safe and reliable, let alone moving us toward 

the ‘‘highest possible health status’’ in Indian Country. 

Structural Reform 

There are unique challenges to delivering health care in any rural area, including 

provider shortages, isolation, long travel distances, scarcity of specialty care, and 

under-resourced infrastructure. However, there are successful rural health systems 

operating all around the country that are able to deliver especially innovative and 

locally responsive and coordinated care. A pressing need and opportunity exists 

within the Indian Health Service, and its many rural, geographically isolated hospitals and clinics, to reform the structure in administrative oversight of the Service 

Units and Service Area offices. We believe that rather than reinventing a health 

system out of whole cloth, or reform around the edges of a system desperately in 

need of dramatic and deep reforms, IHS should aspire to achieve parity with mainstream, successful medical and health systems. One element absolutely necessary 

to such an aspiration is dramatic increases in the current funding levels of the Indian Health Service; however, adopting standard and generally accepted business 

practices is also necessary. NIHB believes that creating partnerships with mainstream and private entities will help IHS improve operations and systems and perhaps provide a learning laboratory for system-wide reform. The Rural Hospital Association and the American Hospital Association are just two places to examine for 

potential collaboration and learning. 

While S. 2953 would mandate the Secretary of HHS to provide a report each quarter of a fiscal year describing expenditures, outlays, transfers, programming, obligations, and other spending of each level of the Service to Congress, Tribes and the 

IHS, it does not have substantive measures in place to ensure that the mismanagement of these resources does not continue. In May 2015, the then Acting Director 

of the IHS, Mr. Robert McSwain, wrote a Dear Tribal Leader Letter informing 

Tribes of a settlement IHS reached with employee unions, costing the Service a total 

of $80million. The settlement was reported to have resolved claims by IHS employees for overtime compensation for work they performed in federally operated hospitals, clinics and facilities—overtime work that was done to cover shifts in the 

health care facilities that would have otherwise gone uncovered and left countless 

American Indian and Alaska Native patients without care. The claims began being 

filed in 2008 and settlement awards covered several years of back-pay for this overtime work that employees performed due to long-term staffing shortages and general mismanagement of staff, facilities, and funding. A significant portion of the 

funding used for the settlement payment came from both third party collections and 

funds obligated for employee positions that went unfulfilled. The Dear Tribal Leader 

Letter stated, ‘‘IHS is also working to address the management of overtime work 

performed by IHS employees.’’, but as far as we know, no further action or reporting 

has occurred on this blatant malpractice that could have many unseen and unreported consequences on both employees and patients of the IHS. This failure to appropriately staff facilities and compensate employees shows a break down in the 

multi-layered administrative system within IHS. Both the local Service Unit and 

the Area Office would have had to have known that these issues persisted over several years, and yet, no immediate corrective action was taken to improve the quality 

of care provided or quality of workplace for employees at the facilities. More must 

be done to ensure accountability at both the Service Unit and the Area Office level 

of the Agency. 

30 

Quality Assurance 

Many reports attribute the deplorable quality of care at IHS-operated facilities to 

poor agency management at all levels. We know that hiring decisions are often 

lengthy, and poor performing employees at both the service unit, clinic and hospital 

administration and Headquarters are not terminated, but rather moved to other positions within IHS—often to a position of equal or higher responsibility level. The 

cyclical chronic lack of funding and mismanagement of funds also means that managers are often doing more than one job, and managerial oversight of medical conditions is compromised. However, as the National Indian Health Board heard from 

Tribal leaders when visiting the Great Plains Area in April 2016, Tribal leaders and 

members acknowledge the staffing shortages and other issues, but consistently demand that focus remain on improving the quality of patient care, first and foremost. 

As one Tribal leader said during a town-hall style discussion with IHS leadership, 

‘‘Without patients, there is no hospital.’’ 

So, in addition to the staffing and accountability provisions included in the newly 

proposed legislation we are discussing here today, attention must also be directed 

at improving the quality of care provided at federally run IHS facilities. This can 

be done by strengthening agency-wide standards for hiring quality and qualified individuals who are capable of fulfilling the role as expected; for example, hiring a 

qualified Hospital Administrator to run a hospital or clinic and implementing quality and performance improvement measures from the top down. Quality would also 

be furthered through implementing and nurturing a culture and practice of Continuous Quality Improvement, management and supervisory training and setting performance benchmarks that are reviewed twice-yearly. If employees are not performing, generally accepted management practices and principals must be in place, 

respected and consistently upheld. Creating and sustaining a culture where quality 

and compassion are expected from all IHS employees is an absolute must. 

The IHS currently has a hospital and health center accreditation policy requiring 

facilities to comply with at least one of any nationally accepted accrediting or certifying bodies, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or by the Accreditation Association for Ambulatory Health Care 

(AAAHC). The responsibility for assuring compliance rests with both the Area and 

Service Unit Director, who through this IHS policy, are required to report to IHS 

Headquarters annually on the status of compliance with their accrediting body. As 

we have seen in the closures of services and service units in the Great Plains Service Area, this current model of reporting is inadequate for ensuring that accreditation, and therefore, full ability to bill to private insurance, Medicaid, and Medicare 

remains intact. Therefore, these reports must be made transparent and public, perhaps posted quarterly on a web-based dashboard so that both lawmakers, Tribal 

leaders, patients and IHS may view them and assess the status of whether the facility is meeting quality and accreditation measures. 

Improving care delivery and reducing costs are critical in today’s healthcare environment, especially in the underfunded Indian health system. There needs to be 

more accountability in the accrediting process and more measures put in place that 

will allow IHS facilities to more consistently assess and implement quality and performance improvements. There are resources both within the federal government 

and private sector that exist to assist in these processes. For example, the American 

Hospital Association’s performance improvement entity, the Hospitals in Pursuit of 

Excellence, exists to accelerate performance improvement in hospitals around the 

nation, and has specific resources and support for rural hospitals and clinic—like 

so many in Indian Country are. The Health Resources and Services Administration 

(HRSA), another agency of the U.S. Department of Health and Human Services, is 

the primary federal agency for improving health and achieving health equity 

through access to quality services, a skilled health workforce and innovative programs. More intentional partnership and sharing of resources between HRSA and 

the IHS could aid in improving access to care for American Indian and Alaska Native patients and retaining skilled health professionals in Tribal communities. Overall, we know the hospitals and health systems that make quality and performance 

improvement a high priority will be rewarded with improved efficiency, better patient outcomes, and the ability to attract and retain the best people. 

Recruiting and Retention of Personnel 

While we understand that it can be challenging to recruit medical professionals 

and health administrators to remote areas, it is critical that IHS, and other related 

agencies within HHS, employ all tools at their disposal to do so. 

The proposed legislation at hand, provides for improved incentives to recruit and 

retain a quality health care workforce. It begins to address setting competitive pay 

scales for IHS employees that would be comparable to other physicians, dentists, 

31 

nurses, and other health professionals, and the bill also attempts to address housing 

issues that Tribes and the agency have long said deters qualified medical professionals from moving into remote locations to work at IHS. However, while the bill 

seeks to provide housing vouchers and relocation assistance to new employees, it 

does not fully address the lack of housing available in these areas. It is often not 

just the cost of housing that deters employees, but the lack of nearby housing available. To rectify this, there will need to be further collaboration among the Tribes, 

government agencies such as HHS and the U.S. Department of Housing and Urban 

Development (HUD), and Congress to make investments in housing so that people 

working in IHS facilities have adequate housing. It is also critical to provide support 

for schools so that the families of medical providers will have access to adequate 

educational opportunities. Public/private partnerships should be sought as an innovative solution, rather than just assuming it cannot be done. Wouldn’t it be something to imagine and possibly achieve, for example, a Walgreen’s House of Health 

housing health care providers at the ‘‘Corner of Happy and Healthy’’ on the Pidge 

Ridge or Rosebud Indian Reservation? 

Many policymakers do not realize that the system the United States employs to 

train medical residents, as well as dentists and some nurses, is through an entitlement program, Graduate Medical Education, within Medicare. The GME program 

exceeds $15 billion annually. Congress capped the number of residency training positions in the United States as part of the Omnibus Budget Reconciliation Act of 

1997. Since 1997, several legislative amendments and changes have occurred to 

make slight increases and variances on the resident limit; however, the medical specialties remain highly motivated to increase the number of residency training positions within their various colleges and academies. One potential opportunity to increase the number of physicians serving in Indian Country is to set aside a certain 

number of new residency training positions for those willing to serve in Indian 

Country. The number of years of service in Indian Country following completion of 

residency training would be equal to the number of years the resident took to complete the residency. In states like Connecticut, where residency training positions 

are approximately $155.000 per resident per year, that is an astonishing incentive 

to complete service to Indian Country. Likewise, since most of the GME funding is 

in Indirect Medical Education expenses—paid directly to the training institution, 

perhaps a similar incentive could attach to the training institute if the resident does 

not fulfill the commitment. Further, there are very limited numbers of residency 

training programs in IHS facilities—and among the exceptions to the caps on new 

residency positions is if the new program were to be in a rural or medically underserved community or if a residency training program has never before existed in the 

training center. The Secretary of Health and Human Service has the authority to 

approve such growth: indeed, is this not the very definition of Indian Country? 

We must also expand the ability of IHS to offer student loan repayment with already appropriated funds by passing S. 536—The Indian Health Service Health Professions Tax Fairness Act. The S. 2953 bill does not address this issue, despite the 

Agency having asked for years to have similar authorizations as the National 

Health Service Corps in order to recruit qualified health professionals to work in 

Indian Country. 

Likewise, one of the inherent flaws in the Indian Health system is the lack of 

qualified hospital administrators and lack of basic business acumen in the management, leadership and operation of health systems. We, therefore, also advocate for 

measures to recruit, retain and fund students to enter Masters of Business Administration, Hospital Administration and related professions necessary to any chance of 

achieving and sustaining meaningful reforms in the IHS system. 

But most importantly, we must make IHS a desirable place to work. Time and 

again, NIHB hears from physicians who leave IHS and cite the obstacles to working 

at these poorly-operated facilities. One of the most common reasons physicians leave 

is because they can’t practice medicine with the resources available. Too many of 

them have had their hands tied by budget constraints and other bureaucratic obstacles. In addition to the compensation incentives outlined in the proposed legislation, 

the Administration needs to engage Tribes in the process of onboarding new physicians and health professionals, to create a more welcoming environment that makes 

both the new employees, and the Tribal members and patients feel safe and a part 

of the community. 

Additionally, a long-term solution to addressing American Indian and Alaska Native health disparities lies in investing in our youth. We can improve the future of 

the Indian health care workforce by developing a culturally and linguistically competent workforce of Native health professionals and administrators. We know that 

AI/AN providers are more likely to remain in their own communities long-term and 

to provide culturally appropriate care. Therefore, Congress and the Service should 

32 

prioritize resources and relationship building with academic institutions and national health professional organizations to engage Native youth in cultivating interest and capability in pursuing medical and health professions. 

Medical Literacy for Patients, Patient Advocacy 

According to the National Assessment of Adult Literacy, only 12 percent of the 

U.S. population has a proficient health literacy level, and a total of 25 percent of 

American Indian and Alaska Native respondents scored at a ‘‘below basic’’ level. A 

white paper published by the IHS Health Literacy Workgroup in 2009 stated, 

‘‘While low health literacy affects people from all facets of life, it is disproportionately burdensome on vulnerable populations, such as American Indian and Alaska 

Native people and their elders. Persons with limited health literacy skills make 

greater use of services designed to treat complications of disease and less use of 

services designed to prevent complications.’’ The Agency for Health Care Research 

and Quality further reports that low health literacy is linked to higher risk of death 

and more emergency room visits and hospitalizations. 

Given the disproportionate levels of low health literacy in AI/AN communities, 

and its direct impact on health outcomes and need for care, it is clear that more 

resources and training are needed within the Indian health system to improve patients’ understanding of their own health and health care delivery. As well, those 

currently receiving their health care from IHS are the 3d Generation being cared 

for within this system. It is very important that such individuals have a scope of 

perception that includes what an average American expects from a medical encounter in mainstream America. Only then will patients within the IHS system have a 

clear understanding of their rights within the health system. And NIHB believes 

that Americans, including American Indian and Alaska Natives, have health care 

rights and among those rights is engaging in one’s own personal health advocacy 

in a meaningful and informed manner. NIHB believes it is the right entity to engage in a national health literacy campaign with American Indians and Alaska Natives and requests support from Congress to undertake this crucial initiative. 

Finally, we have heard numerous reports from patients who are afraid to report 

their negative patient encounters for fear of retaliation against themselves or their 

families. We believe it is vital to have a safe method for patients to share their comments and experiences with the IHS system. Therefore, we believe a system that 

values feedback to improve the patient experience is a necessary component of quality. An anonymous, third party service that engages IHS patients about their care 

experiences would offer very valuable insights to inform the quality improvement 

process. 

In Conclusion 

The National Indian Health Board stands with and supports the Tribes of the 

Great Plains IHS Service Area in this time of crisis. The NIHB will continue to 

work on behalf of all Tribes, in coordination with both the Administration and Congress, to rectify these longstanding, unacceptable conditions of health care delivery 

at IHS federally run hospitals and clinics. As evidenced by the stories I and others 

have and will share today, areas most in need of improvement include funding, 

staffing, culturally appropriate care, and most importantly, health outcomes. 

We are pleased that the Senate Committee on Indian Affairs, and other legislators 

in both the House and Senate, have heard our stories and are now taking real, actionable steps to correct the issues within IHS that have been worsening over the 

past decade. In addition to Senator Barrasso and Senator Thune’s Indian Health 

Service Accountability Act of 2016, several other bills to address accountability and 

transparency within the IHS have been introduced in the past several weeks. Most 

notably, the Helping Ensure Accountability, Leadership, and Trust in Tribal 

Healthcare (HEALTTH) Act (H.R. 5406) introduced on June 8, 2016 by Representative Kristi Noem (R–SD) that seeks to address many of the same issues as S. 2953 

such as fiscal accountability, transparency of funding and compliance surveys, lack 

of quality of care, and mismanagement of resources. 

The National Indian Health Board will be convening a special task force to further study the systemic challenges of the IHS, and make policy recommendations 

for long-term, sustainable reform of IHS. We are eager to work with this Committee 

and other policymakers to continue building on the legislation proposed and to 

meaningfully engage Tribal leaders, members and allies in these efforts to ensure 

truly holistic and appropriate reforms to the Indian health system. 

Finally, because this legislation seeks to amend the Indian Health Care Improvement Act, the National Indian Health Board would like to take this opportunity to 

remind the Committee that the Indian Health Care Improvement Reauthorization 

and Extension Act (S. 1790, enacted in H.R. 3590) permanently reauthorized and 

33 

made several amendments to the Indian Health Care Improvement Act (IHCIA). 

Numerous provisions of S. 1790 have not yet been fully implemented. Below is a 

summary of the progress in implementing these provisions. Without full funding 

and implementation the strides we have already made to achieve quality improvement remain unfulfilled. 

Attachment 

I. INDIAN HEALTH MANPOWER—67 PERCENT OF PROVISIONS NOT YET FULLY

IMPLEMENTED

Sec. 119. Community Health Aide Program—Authorizes the Secretary to establish 

a national Community Health Aide Program (CHAP).—Sufficient funds not yet appropriated. 

Sec. 123. Health Professional Chronic Shortage Demonstration Project—Authorizes demonstration programs for Indian health programs to address chronic health 

professional shortages.—Sufficient funds not yet appropriated. 

II. HEALTH SERVICES—47 PERCENT OF PROVISIONS NOT YET FULLY IMPLEMENTED

Sec. 106. Continuing Education Allowances—Authorizes new education allowances 

and stipends for professional development.—Sufficient funds not yet appropriated. 

Sec. 201. Indian Health Care Improvement Fund—Authorizes expenditure of 

funds to address health status and resource deficiencies, in consultation with 

tribes.—After consultation, IHS decided to make no change in use of funds at this 

time. 

Sec. 204. Diabetes Prevention, Treatment, and Control—Authorizes dialysis programs.—Sufficient funds not yet appropriated. 

Sec. 205. Other Authority for Provision of Services—Authorizes new programs including hospice care, long-term care, and home- and community-based care.—Sufficient funds not yet appropriated for long term care programs. 

Sec. 209. Behavioral Health Training and Community Education Programs—Requires IHS and DOI to identify staff positions whose qualifications should include 

behavioral health training and to provide such training or funds to complete such 

training.—Identification of positions has occurred, but IHS and DOI have lacked 

funds to provide required training. 

Sec. 217. American Indians into Psychology Program—Increases institutions to be 

awarded grants.—Sufficient funding not yet appropriated for additional grants. 

Sec. 218. Prevention, Control, and Elimination of Communicable and Infectious 

Diseases—Authorizes new grants and demonstration projects.—Sufficient funds not 

yet appropriated. 

Sec. 223. Offices of Indian Men’s Health and Indian Women’s Health—Authorizes 

establishment of office on Indian men’s health, maintains authorization of office on 

Indian women’s health.—New offices have not yet been created due to lack of funds. 

III. HEALTH FACILITIES 43—PERCENT OF PROVISIONS NOT YET FULLY IMPLEMENTED

Sec. 307. Indian Health Care Delivery Demonstration Projects—Authorizes demonstration projects to test new models/means of health care delivery.—Sufficient 

funds not yet appropriated. 

Sec. 312. Indian Country Modular Component Facilities Demonstration Program—Directs the Secretary to establish a demonstration program with no less than 

3 grants for modular facilities.—IHS has not yet established the program due to 

lack of funds. 

Sec. 313. Mobile Health Stations Demonstration Program—Directs the Secretary 

to establish a demonstration program with at least 3 mobile health station 

projects.—IHS has not yet established the program due to lack of funds. 

IV. ACCESS TO HEALTH SERVICES—11 PERCENT OF PROVISIONS NOT YET FULLY

IMPLEMENTED

Sec. 404. Grants and Contracts to Facilitate Outreach, Enrollment, and Coverage 

Under Social Security Act and Other Programs—Directs IHS to make grants or 

enter contracts with tribes and tribal organizations to assist in enrolling Indians in 

Social Security Act and other health benefit programs—IHS has not yet established 

the grants due to lack of funds. 

V. URBAN INDIANS—67 PERCENT OF PROVISIONS NOT YET FULLY IMPLEMENTED

Sec. 509. Facilities Renovation—Authorizes funds for construction or expansion.— 

Sufficient funds not yet appropriated. 

34 

Sec. 515. Expand Program Authority for Urban Indian Organizations—Authorizes 

programs for urban Indian organizations regarding communicable disease and behavioral health.—Sufficient funds not yet appropriated. 

Sec. 516. Community Health Representatives—Authorizes Community Health 

Representative program to train and employ Indians to provide services.—Sufficient 

funds not yet appropriated. 

Sec. 517–18. Use of Federal Government Facilities and Sources of Supply; Health 

Information Technology—Authorizes access to federal property to meet needs of 

urban Indian organizations.—Protocols developed, but property transfer costs require additional funding. 

—Authorizes grants to develop, adopt, and implement health information technology.—Sufficient funds not yet appropriated. 

VI. ORGANIZATIONAL IMPROVEMENTS—0 PERCENT OF PROVISIONS NOT YET FULLY

IMPLEMENTED

VII. BEHAVIORAL HEALTH—57 PERCENT OF PROVISIONS NOT YET FULLY IMPLEMENTED

Sec. 702. Behavioral Health prevention and Treatment Services—Authorizes programs to create a comprehensive continuum of care.—Sufficient funds not yet appropriated. 

Sec. 704. Comprehensive Behavioral Health Prevention and Treatment Program— 

Authorizes expanded behavioral health prevention and treatment programs, including detoxification, community-based rehabilitation, and other programs.—Sufficient 

funds not yet appropriated. 

Sec. 705. Mental Health Technician Program—Directs IHS to establish a mental 

health technician program.—IHS has yet not established the program due to lack 

of funds. 

Sec. 707. Indian Women Treatment Programs—Authorizes grants to develop and 

implement programs specifically addressing the cultural, historical, social, and 

childcare needs of Indian women.—Sufficient funds not yet appropriated. 

Sec. 708. Indian Youth Program—Authorizes expansion of detoxification programs.—Sufficient funds not yet appropriated. 

Sec. 709. Inpatient and Community Health Facilities Design, Construction, and 

Staffing—Authorizes construction and staffing for one inpatient mental health care 

facility per IHS Area.—Sufficient funds not yet appropriated. 

Sec. 710. Training and Community Education—Directs Secretary, in cooperation 

with Interior, to develop and implement or assist tribes and tribal organizations in 

developing and implementing community education program for tribal leadership.— 

Comprehensive community education program has not been implemented due to 

lack of funds, although IHS and agencies do provide some trainings. 

Sec. 711. Behavioral Health Program—Authorizes new competitive grant program 

for innovative community-based behavioral health programs.—Sufficient funds not 

yet appropriated. 

Sec. 712. Fetal Alcohol Spectrum Disorders—Authorizes new comprehensive training for fetal alcohol spectrum disorders.—Sufficient funds not yet appropriated. 

Sec. 713. Child Sexual Abuse and Prevention Treatment Programs—Authorized 

new regional demonstration projects and treatment programs.—Sufficient funds not 

yet appropriated. 

Sec. 715. Behavioral Health Research—Authorizes grants to research Indian behavioral health issues, including causes of youth suicides—Sufficient funds not yet 

appropriated. 

Sec. 723. Indian Youth Tele-Mental Health Demonstration Project—Authorizes 

new demonstration projects to develop tele-mental health approaches to youth suicide and other problems.—Sufficient funds not yet appropriated. 

VIII. MISCELLANEOUS—9 PERCENT OF PROVISIONS NOT YET FULLY IMPLEMENTED

Sec. 808A. North Dakota and South Dakota as Contract Health Service Delivery 

Areas—Provides that North Dakota and South Dakota shall be designated as a contract health service delivery area.—IHS has not yet implemented citing lack of 

funds. 

The CHAIRMAN. Well, thank you very much. 

Dr. Wakefield, I appreciated the fact that you listened closely to 

each person’s testimony, and I can see that you were watching 

closely as to what was happening. The concern that I have, and it 

was mentioned at the hearing back in February, we visited about 

35 

how apalled people were to learn that the acting Chief Medical Officer, Susie Carol, statements came up in the Committee about babies being born on the bathroom floor and it was an unfortunate 

situation. 

And the other thing that came up in the Committee was the fact 

that we heard people who maybe shouldn’t be working within the 

system simply just get moved, get shuffled around from one place 

to another place. And I recently learned that this doctor had been 

appointed by HHS to be the Chief Medical Officer through the 

Great Plains Area, so I think we’re all worried about tribal consultation and accountability and, you know, the tribes weren’t consulted on that decision to kind of move a person from one place to 

another within the region when, you know, there were real concerns about the person and their performance. 

Dr. WAKEFIELD. I cannot speak to the specific question that you 

asked about tribal consultation with regard to that individual. I 

can say that we have—we certainly have been focusing intensively 

on improving accountability using our performance evaluation 

structures that we have for evaluating our personnel in IHS. 

And to give you one example, we have embedded within our performance appraisals our annual evaluations of the individuals that 

are working in the Great Plains Area expectations that, in the hospitals where they work, they are held responsible for meeting conditions of participation, for example, that are the CMS’s conditions 

of participation. 

The accountability piece that you’ve identified in your bill, we 

certainly agree, is extremely important and we have other strategies we talked about, to hold providers accountable, as a whole. I’ll 

stop there. 

The CHAIRMAN. The concern that we’ve heard in D.C. and in 

talking with people here today and yesterday, as well, is a performance approval, if the people who are judging the performance are 

not actually the patients and the families who are being taken care 

of under that system, where there’s just one provider saying, you’re 

real good, and then the other provider saying, you’re really good, 

that doesn’t give the accountability that, I think, we’re looking for. 

Performance approval, in my mind, should have members of the 

tribe, the patients, consulted as well, and that was very much a 

concern. 

[Audience applause.] 

Dr. WAKEFIELD. Thank you for that recommendation. We’ll be 

happy to take that into consideration and see how we can incorporate exactly patient feedback back into the processes. 

The CHAIRMAN. I think it’s critical. There was another provision 

of the bill that talked about how unobligated funds would be used, 

and one provision says the secretary shall only use unobligated 

funds from the fiscal year to support patient care specifically. And 

I think you raised that, Ms. Stabler, costs of central medical equipment, purchase of preferred care, purchase approved by the secretary after consultation with the appropriate tribe. I’m sure you 

support that you use that money in that way. 

The concern that Ms. Stabler raised earlier had to do with there 

was a settlement where HHS allowed $80 million in Indian Health 

Service funds to be used for union settlements. That the money 

36 

came from funds allocated for staffing needs and for patient care. 

To make matters of even greater concern to all of us is the attorneys, you know, get a percentage of settlement. The attorneys in 

this settlement got an estimated $20 million that should have been 

used for patient care. 

In the meanwhile you have hospitals in the Great Plaines that 

are understaffed, lack of basic medical equipment, the patients are 

dying, and my question is are tribes consulted on those sorts of decisions to take that kind of money away from the patient care to 

be used for a union settlement and their lawyers? 

Dr. WAKEFIELD. So it’s you, Senator, you, Mr. Chairman, have 

raised with us the need that you’ve identified and expressed to me 

very directly for IHS to be more forthcoming in terms of additional 

consultation. As a matter of fact, other members of this panel, Senator Thune, Senator Rounds, Congress- woman Noem have all expressed concern about and interest in IHS engaging in more robust 

and more frequent consultation. 

Based on the conversations that I’ve had with each of you, because you’ve made that very clear to me. I’ve taken your recommendations back. I’ve shared them with Mary Smith and they 

are advancing strategies to accomplish just that. 

We’ve also heard the same from tribal leadership. Between what 

we’ve heard from you and also tribal leadership, it is clear to us 

that there’s more to be done in terms of improved consultation. I 

would say Mary Smith has been in the Great Plains Area, specifically in South Dakota now. This is her third trip here. She’s engaged in a number of consultations with the Great Plains Area 

tribal leadership. 

Having said that, it’s clear there’s more that we need to do on 

all of our parts in terms of engaging consultation, and you, Mr. 

Chairman, have made that clear to us. I take that recommendation 

seriously, and we are acting on it. 

The CHAIRMAN. Thank you. Ms. Bohlen, I don’t know if there was 

some additional things that you wanted to get out that you didn’t 

feel you had the chance to, but I just feel—I’m so impressed with 

your testimony. You talked about what must be done to ensure accountability. 

Ms. BOHLEN. Yes, sir. 

The CHAIRMAN. And you see it as somebody being born and 

raised here, but also what you do in Washington and across the 

country. But we want this bill to be as strong as possible. 

So, for the record, could you expand on some specifics that you 

might have that we could do with this bill to be sure that the dollars are getting to the patients who need it? Do you have additional 

thoughts? 

Ms. BOHLEN. Yes, sir, I do. May I share something else first? 

The CHAIRMAN. Go ahead, yes. 

Ms. BOHLEN. I wanted to, especially in this setting, I wanted to 

acknowledge Congresswoman Noem for alleviation of the employer 

mandate from the tribes. That bill never would have gotten 

through Weighs and Means this week without her and input from 

the tribes and I want to make sure to mention that acknowledgement. Thank you, Congresswoman Noem. 

Congresswoman NOEM. I appreciate that. Thank you. 

37 

Ms. BOHLEN. Accountability, one of the things that we say, if you 

can’t measure it, you can’t manage it. And with the ongoing research that all of us have been doing to try to find good answers 

for IHS in the future, before we can even get to the point of accountability, we have to know what we’re talking about. 

The audit that Senator Thune has been discussing, and all of you 

have been discussing, is essential to that being possible. Once we 

can get our arms around what it is that we—you know, measuring 

what it is that we’re talking about, we’ll be able to better manage 

it. 

I will share with you that the National Indian Health Board also 

believes that the tribe needs to be engaged in all of the decisionmaking about their health care and their dollars. The third-party 

billing revenue in 2015 from the Great Plains was $134 million. 

The Great Plains tribes, largely through Medicaid and Medicare, 

and about 33 million from third-party billing came through because 

the tenacity of the tribes to use that opportunity as additional income and resources and, as the questions have implied, they are 

not always able to be part of the decisionmaking in making sure 

that those dollars are spent the way they’d like to see them spent. 

We believe that there should be some medical literacy training 

that goes on in Indian Country. For three generations the IHS has 

been the only health system that many people in Indian Country 

are familiar with, and in order for tribes to be able to uniquely engage in their own decisions and their own care, we believe there 

has to be more light brought to bear on what the law is, how it 

works, what their rights are, what all the cards are that are on the 

table, because if you don’t know what all the pieces are on each 

side of the table, you’re not playing the same game. 

So we believe that given disproportionate levels of low literacy in 

Indian Country, that it has direct impact on the health outcomes 

and their need for care, and it is absolutely clear that more resources and training are needed within the Indian Health system 

to improve the patients’ understanding of their own health care 

and their own health delivery system. 

One of the other stories that we consistently hear is that patients—I stumbled upon this when I was invited to Winnebago in 

2014 to meet with their Tribal Council and learned what was going 

on, and one of the things that was the most resonating for me at 

that time was when council members said they are afraid to speak 

up, because if they speak up, they will not get health care and neither will their families. 

Well, there’s an easy way around that. We know that one of the 

greatest quality improvement measures is patient direct surveying. 

My tribe, the Sault Sioux St. Marie tribe, uses a company in Ann 

Arbor, Michigan. It’s a private third-party that keeps patient confidentiality, and after every patient encounter, those patients are 

called and surveyed about their experience. 

If we had a system like that where the patients could engage in 

a safe way, where they really felt that they could talk freely, we 

would probably find out some good things that are happening, too. 

So, you know, those kind of efforts to increase transparency, increase knowledge base of the tribes, empower tribes to be able to 

make their own decisions, and nothing empowers like knowledge. 

38 

Open up the data to the tribes so they can see what is here and 

be a true partner with the tribes and understand that at the end 

of the day it is their people and their health that is at stake. Thank 

you. 

The CHAIRMAN. Thank you very much. Senator Thune. 

Senator THUNE. Thank you, Mr. Chairman. And, again, thank 

you all to our panelists who were here today for sharing their insights. 

And, you know, the one thing, I guess, that I’ve, in looking at 

these issues, have sort of concluded is that—and we were talking 

earlier this morning in an earlier meeting Evie Espinosa, who is 

the Tribal Health Director for the Rosebud Sioux Tribe was talking 

about is that the psychological toll that the negativity surrounding 

these stories and this narrative just perpetuates year after year 

after year, the effect that has on people. And what I concluded is 

we can’t fix the problem here by a tweak here or a fine tune here. 

This requires systemic change. You can’t fix this by changing the 

oil and replacing the tires. We need a whole new car. I mean, the 

problems that are here are very deep seated. They are fundamental, and they require something that really does represent systemic change. 

And so the Chairman, in listening to everybody this morning and 

others who have shared with us over the past several months, try 

to get at in this bill, and, again, it’s a starting point, some of those 

issues. You know, for one, how do we get change? We start with 

leadership, making it easier to replace leadership; to get medical 

professionals who are willing to serve and recruit and retain reservation hiring incentives, bonuses, competitive pay, temporary 

housing and housing costs, that sort of thing. Getting accountability both on the spending side, on the staffing side, so people 

know where money’s going. I mean, $80 million. $80 million, Mr. 

Chairman, that went for litigation that was taken from patient 

care in the Great Plains Area. $6.2 million came out of this region 

and a million out of Rosebud. 1.3 out of Pine Ridge. That just can’t 

continue. And so there’s got to be the fiscal accountability piece of 

this. 

There’s got to be whistleblower protection so when things go 

wrong and people report it, they aren’t retaliated against, which is 

what you were getting at. 

[Audience applause.] 

And there’s got to be the consultation, which my impression is, 

just doesn’t and hasn’t existed in the past. And so, I mean, these 

are big systemic things that we need to do to fix this problem. 

And, unfortunately, It took a crisis to kind of get us to this point, 

and, unfortunately, IHS has not been transparent and they have 

not been forthcoming about these issues, and they’ve asked these 

questions in the recent past and not gotten straight answers. 

And so December 5th of last year, IHS had conversations with 

my staff in which they said that everything is okay, the problems 

have been abated. That very day, later that day, we got notified 

that CMS had put the Rosebud Emergency Department on emergency status. There is a huge disconnect in communication. 

So I guess I want to just, Mr. Bear Shield, ask you in the course 

of last six or seven months, because we had this conversation, we 

39 

had it several times, but we had this conversation in February, has 

consultation improved between the tribes and IHS? 

Mr. BEAR SHIELD. First of all, getting back to, real quick, to the 

Act, before I forget, I’d really like to give thanks to the people sitting behind you, the staff. They’ve really done a great job coming 

to the tribe, getting to the tribe, everything—Ms. Noem’s and your 

bills are exactly what we’ve been telling them, and a big thank you 

to them. Every morning I usually wake up to text or e-mails from 

them. 

But, Senator Thune, getting back to your question, you know, I 

have a hard time trying to—every time I—every day I pray and 

think that it’s getting better. Something is going to break today 

where things are going to get better, and then it doesn’t. You know, 

take for instance these contracts that were let out over for consultation for our ED. There’s a young lady that has been calling 

me, asking me, a reporter, and I was at home and she calls me one 

day to—she says, Mr. Bear Shield, what do you think of the contracting company that contracted your ER? And I said, What? I 

said, What do you know? I’m sure you probably know more than 

I do. 

So then I call Ms. Espinosa and I say, Hey, have you heard? She 

said, Yeah, it’s on the news, you know. And I’m not—the Chairman, Mr. Kindle and Ms. Espinosa and myself, we’re usually the 

first ones to know, but that’s the kind of stuff that still goes on 

today. 

And you know what Ms. Stabler and Ms. Blueshield and Ms. 

Bohlen were saying about, you know, contracts, there’s some up 

and coming and we really need to be a part of. You know, we need 

to get away from this type of consultation which definitely isn’t in 

our favor, you know. We’ve got the telehealth coming, we’ve got the 

sole sources sought, you know, five positions within IHS facilities, 

you know, we need help with those because the tribes need to be 

involved in those. 

And not only that, we send e-mails and calls up the line and 

they’re not getting answered back. 

And even with Sioux San’s current situation, we don’t know 

what’s going on there. You know, the last we knew that they 

worked out a—they got off immediate jeopardy status and they are 

working on an SIA agreement, I guess, and corrective action plan 

or what have you, but we sent e-mails also asking, you know, 

what’s the status, and how can we assist and we need to be involved there. Rosebud, Pine Ridge, and Cheyenne River being the 

governing body there, you know, it concerns us. It’s always concerned us. 

So, it isn’t there. You know, on the tribe’s part, ever since the 

last hearing, and you heard them, you know, just like today, we 

just heard that, you know, communities are important to us. Well, 

if that was the case, why didn’t they let South Dakota providers 

in on the ED contract, you know? 

That doesn’t make no sense to me. 

So, you know, with that being said now, I’m very confident that 

these bills will pass. Once they’re passed and part of the law, the 

shoe needs to go on the other foot this time. We do not need IHS 

40 

to define what that bill means to the tribes. Tribes need to define 

to them. They say, This is our bill, this is what this means to us. 

The CHAIRMAN. Thank you, Mr. Bear Shield. 

Senator THUNE. So I’ll assume the same as Ms. Blueshield, that 

the similar type of experiences on the consultation issue, but I 

guess what I would say, Secretary Wakefield and Ms. Smith, to 

that point there’s got to be a way in which we can create a mechanism formalized so that consultation can take place. And the bill 

requires when it comes to major hires, if it’s an area director or 

service unit, that there’s consultation with the tribes, but I’m looking to you. We, I think, are all looking to you to work with us and 

with the tribes to create a way in which that happens so that we 

don’t get these news bulletins about a contractor being hired and, 

frankly, a contractor that is, sounds like, from all we’ve been able 

to ascertain, pretty suspect based on the record with regard to previous work they’ve done for the tribes. 

And so that being said, I would just say to all of you, and, again, 

CMS, IHS are both under and that they seem to be operating on 

very different tracks, and where is the coordination, the conversations and consultation that we need to have; and, please, I would 

just say to you, I know the time is up, but work with us on getting 

that coordinated. 

Ms. Blueshield. 

Ms. BLUESHIELD. When I was putting this together, I was thinking about everything that happened, all the years, and I thought, 

you know what? Why isn’t there a tribal liaison or somebody that’s 

in between the IHS and the people and the Tribal Council, and 

why isn’t there somebody that advocates for us, that can explain 

things to the Tribal Council, or they can bring a message to the 

Tribal Council from IHS or somebody from IHS or something. But 

that was what was missing in our clinic and the things that we 

were doing, because we e-mailed all the time. I mean, we had 

phone calls, and once in a while we had somebody come and meet 

with us, but I think initially having somebody that was an advocate that could go both ways and talk to both sides, somebody in 

the middle that could be objective would be a possibility. 

The CHAIRMAN. Senator Rounds. 

Senator ROUNDS. Thank you, Mr. Chairman. And let me just 

share with everybody one of the rules in the Senate in terms of 

presenting testimony. When we ask questions, that we’re normally 

limited by Committee to 5 minutes to do it, and so I would just 

thank the Chairman for the understanding and patience as each of 

us have kind of worked our way through. So thank you, Mr. Chairman, for that. 

Dr. Wakefield, I want to just preface my questions to you with 

this. Currently we’re still experiencing underfunding with IHS and 

so forth, and I spoke earlier about the fact that I want the money 

to go in and get results. I want it to go directly to places where 

it’s going to help people, but let me just put into perspective just 

exactly what we’re talking about in terms of underfunding. At the 

federal level right now, the Bureau of Prisons currently spends 

about $5,100 per inmate on health care. Through IHS we spend 

$3,099, or about $2,000 less per individual on IHS funding than we 

41 

do for the inmates in the Bureau of Prisons, and so we recognize 

that there is a discrepancy here in terms of focus. 

But at the same time if you put more money into this process 

and we don’t know where it’s going, and if we can’t point to where 

it’s being used successfully, then we’re not going to get the results 

we want and we’ll end up with more problems than we’ve got right 

now. In fact, I know you’re aware, because we discussed this previously, Dr. Wakefield came in and spoke with all of us, we had 

a very good meeting, and there were several things that we committed at that time. I just want to walk through this in the public 

record on this. 

You’re aware, because we discussed previously, but, again, I 

would like to raise my concerns about the financial discrepancies 

in the Department of Health and Human Services fiscal year budget specifically over IHS. The FY 17 budget intended to spend $40 

million more on tribally operated facilities compared to federally 

operated facilities in the Great Plains Area. Given the Great Plains 

Area only has 17 tribally operated facilities versus 35 federally operated, I repeatedly asked for explanation. Although my office has 

never received a response, we found that your website published a 

correction indicating that you had misreported the appropriation 

amount the IHS facilities in the Great Plains Area by $80 million. 

Now this is disturbing. 

If your budget analyst and your IHS national directors and your 

agency officials did not notice these very extreme inaccuracies, how 

do acting directors, some of who only have three months on the job, 

have any understanding on how to distribute this money between 

the 52 facilities when there are inaccuracies in your annually published budget of at least funds of as much as $80 million? 

And just as a real quick follow-up, would you, once again, commit 

to that independent audit to make sure that IHS can developed a 

transparent, clear and accurate budget? 

Dr. WAKEFIELD. Thank you very much, Senator. And I said it at 

the very beginning, but, again, I want to tell you how much we appreciate the administration’s intense interest and focus and leadership of the Chairman and of the three representatives, the members of Congress from South Dakota. You have been focused so intensively on ensuring access to quality care for American Indian 

populations and we appreciate the working relationship that we 

have with you to achieve a shared goal. So thank you for your willingness to spend time with me as we work through what are very 

significant challenges. 

In terms of the specific issues that you’ve raised, I would defer 

to Mary Smith about that because you raised that with me and 

that brought back immediately, the information was updated on 

that website after you flagged it. Thank you for flagging it. And, 

in addition to an audit, as we had discussed, you’ve raised that 

with me when we met. I said to you then, and I’ll say it again for 

public record, you’re certainly welcome to that. In the five-part 

strategy that we shared with you and Mary shared with the Great 

Plains Area leaders, the very first part of that five-part strategy is 

on our expectation to improve our transparency. It’s critically important that we surface problems and that we work immediately to 

address those problems with the resources that we have. 

42 

Transparency also involves consultation, which all of you have 

spoke about and we’re trying to drive forward in a much more 

meaningful way than we have historically. So I agree with you 

about welcoming the audit. That’s part of transparency, and we 

will do our level best, as we have been and continue to drive strategies forward that inprove surfacing problems and immediately addressing them. 

Senator ROUNDS. Let me just follow up on that then, please. 

We’re talking about improving accountability at IHS. You’ve already heard a number of questions about CMS issues and our region’s staffing concerns. While I certainly echo the concerns, we 

want to remain consistent through all these, the IHS inadequacies, 

poor communication, and literally no consultation. 

I want to illustrate this for you just in terms of what we’ve 

learned so far. The Great Plains Area IHS leadership hosted a call 

on December 4th regarding Pine Ridge and Rosebud CMS issues. 

Within three hours of the call, IHS sent out a press release outlying upcoming Rosebud Emergency Department diversion. Despite 

knowing that diversion was a possibility, IHS did not notify tribal 

leadership until they were issuing the press release. 

Secondly, with the revolving door of Great Plains Area directors, 

IHS has not been forthcoming about changes. Ron Cornelius was 

reassigned without notice hours before the February 3rd Senate 

Committee Indian Affairs hearing. When Rear Admiral Meeks 

signed on to serve as acting director, his commitment was for three 

months, but the tribes were not told this until his final days. 

We were pleased when IHS Principal Deputy Director Mary 

Smith, who is here with us today, visited South Dakota hoping for 

true discussion and consultation. Director Smith explicitly mentioned the means for better communication and promised improvement. Unfortunately, while you were here making that promise, 

the Emergency Department RFP had been issued; however, our 

tribes in South Dakotas three major health care systems, were not 

properly notified, did not receive timely responses to inquiries, and 

simply did not have enough information to consider these major 

contracts. 

A month after Director Smith’s visit, local media outlets reported 

that another Great Plains Area hospital, Sioux San, was facing 

CMS violations. This newspaper headline came after days of tribes 

inquiring to IHS officials about such rumors, but our tribal leaders 

never received a response. 

So I’d like your commitment to reforming the culture in IHS to 

insisting that agency leaders treat their constituency with the dignity and the respect that they deserve. Do I have a commitment? 

And if I do have that commitment, I’d like you to share with us 

how you would execute it to make this change. 

Ms. SMITH. Thank you, Chairman Barrasso, Senator Thune, Senator Rounds, and Congresswoman Noem. I really appreciate the opportunity and your interest and your leadership on bringing this 

field hearing today. I also want to thank all the tribal leaders and 

everyone here today to address this important issue. To me, there’s 

nothing more important than health care in Indian Country. 

We’ve heard a lot of issues discussed today, and I know one of 

the issues, Senator Rounds, that you’re raising is the issue of being 

43 

transparent and open communication, and I fully agree with you on 

that. And, obviously, you know, there are more things we need to 

do, and I guess, you know, you asked how would we do that. 

The first thing I want to do is reach out to you all and the tribes, 

I think that open and honest communication occurs not only just 

with our tribal partners, the people we serve, but also Congress. 

And so I guess we are happy to continue talking with both the tribal leaders and yourselves as to what would be meaningful communication to you, because you do have my commitment that we will 

do whatever it takes to ensure that you get the information and we 

have the dialogue with you to do this. 

Senator ROUNDS. Mr. Chairman, you’ve been very kind with your 

time, and let me just finish with this very quickly. It seems like 

every time we have an emergency that comes up and there’s an obvious layout program, we find out more things are a problem and 

it brings in the public attention, but what we end up doing is we 

provided a band-aid. In December we provided spending $2 million 

to go directly into the contracting work. What I think we have to 

do is to focus on the long-term issues surrounding IHS and provide 

more transparency so the tribes can actually make a decision about 

whether they want IHS to provide the services directly or if they 

want to look at doing independent activity among the tribes, themselves. And the only way that that’s going to happen, I believe, is 

if we simply have systemically in place a plan that does not let us 

get focused on the emergency only, and let the big picture get 

away. 

And this time, unlike previous attempts, I think you’re going to 

find that Congress is not going to let this get away again, and that 

we’re going to continue to ask the hard questions and refocus on 

whether or not the job is getting done. 

[Audience applause.] 

The CHAIRMAN. Congresswoman Noem—I know you all have 

questions—but you can go ahead at this time. 

Congresswoman NOEM. Thank you. I appreciate that, Mr. Chairman. And I’ve got a lot of questions so we’re going to move kind 

of fast. I hope your answers are brief, but factual, if that’s okay, 

and I will do that as well. 

Willy, we talked about before the culture that’s ongoing within 

IHS, the fear, nepotism, corruption, and we can make a lot of 

changes in legislation, but it’s hard to change attitudes and character in office. And, Willy, could you just speak a little bit about 

what that—in reality that is, because we have protection in U.S. 

law for whistle blowers, but, frankly, I have had whistle blowers 

contact my office that are scared of retaliation when they tell the 

truth about what’s going on in IHS. 

So I want Willy to tell us a little bit about some of the culture 

that they see in IHS facilities and what it means to people, and 

then I want to get your commitment that whistle blowers will be 

protected and that there is not an environment of retaliation within IHS. 

Willy, do you have anything you can share with us about what 

it’s like? 

Mr. BEAR SHIELD. The other day I know we had visited—you 

know, backing up even to Chairman Barrasso’s initial statement 

44 

about the whole issue with the Indian Health Service, Mr. Andrews, your chief staffer came and visited a coalition of large tribes 

two weeks after initially hearing a representative of our tribe was 

there, Chairman Old Coyote from Crow Agency Montana Senate of 

Indian Affairs Committee for their work in coming to the Great 

Plains and having the hearing, but he said, Don’t stop there. Come 

to the Billings area because the same thing is happening there. So 

I’m telling you how widespread it is. 

Now going back to Ms. Noem, there was an individual that came 

from there, you know, a provider in the past that had told me that, 

you know, he tried to make some changes himself, as a provider 

within the IHS system, and he pretty much got ran out of town. 

Work started getting audited, he was hounded, you know, quite 

often concerning his work because of the issues that he brought up, 

and he said ever since that day he’s been afraid to do that. 

You know, the culture of people I do know. I think they may 

have—I was told the other day that, you know, they were going to 

make a video for recruiting or retention or a brochure, what have 

you. I don’t know what people said, but, you know, I know tribal 

members, I think, that work in the facility weren’t asked to be a 

part of it, but I do hope that they brought up our culture, our community, those type of issues because we are a very proud people, 

you know, rich in land and also in our own culture, and we’re very 

proud of that fact. 

Going back to the initial questions of some of the disparity and 

frustration that this has caused us since we’ve been on diversion 

status, I do know I had an elder, his daughter called me from Valentine, and he said, Call Willy Bear Shield. I’m having a heart attack. He told me that I’ll probably have to pay for it. This is even 

after December 5th, after Mr. Cornelius reporting this, I specifically stood up, and he was standing behind me in Tribal Council 

chambers, and I said, Okay, for the record, does this mean everything will get paid for while we’re on this diversion status, and I 

mean everything? If they can’t be fixed in Rosebud, no matter 

where you’re sent, it’s going to be paid for? And he said, Yes. 

So now we’re running into purchase referred care dollars that 

aren’t there. So what does that mean? And this elder gentleman 

just said, I don’t want you kids to be riddled with a flight bill if 

I die anyway, so I’m not going to go. So I just said, Go, we’ll take 

care of it. We’ll take care of it. So those kind of issues. 

We have people that—even Chairman Flying Hawk, the other 

day at a chairman’s association meeting, you know, they have a 

hard time waiting until the community hospital or clinic opens up 

so they get referred just across town because it’s not going to get 

paid for there either. So there’s a lot of issues. Even these people 

know about it, and it’s disheartening to them to get their health 

care or even think about it. 

Congresswoman NOEM. Thank you. Well, I appreciate that Senator Thune’s bill, he has some more whistle blower protections, and 

I just I want everyone to know, and I want you to know that we’re 

obviously aware that there are people scared of retaliation. And I 

want your commitment that we won’t see that while we’re going 

through this emergency situation. People are willing to tell the 

truth about what’s really going on in facilities. 

45 

Dr. WAKEFIELD. Congresswoman, this is critically important. We 

cannot surface problems—— 

Congresswoman NOEM. Right. 

Dr. WAKEFIELD. Right, if people are uncomfortable with flagging 

those problems for us. We cannot solve those problems if people 

don’t identify them so that we can begin to work to address them. 

Under Mary Smith’s leadership we are committed wholly to a culture that is designed to improve transparency with the expectation 

that people are supported in bringing their concerns, problems, 

challenges forward. Whistle blower protection isn’t an option, it’s 

an obligation. 

Congresswoman NOEM. Thank you. 

Dr. WAKEFIELD. It is critically important to control—[Applause.] 

we’re totally supportive of that, and, in fact, I would just say that 

HHS and IHS have recently wrote to Office of Inspector General 

on facets of this very issue. Through Mary Smith’s leadership, she 

recently released a memo to all staff of IHS, not just the supervisors, but the employees, as well, basically letting them know it’s 

not an option, it’s an obligation that if you see examples of waste, 

fraud, abuse, we expect you to report them and to feel comfortable 

to report them to the IG. 

Congresswoman NOEM. Thank you. 

Dr. WAKEFIELD. And we provide them the information about who 

called and—— 

Congresswoman NOEM. Could you quickly tell me why AB Staffing, which was considered for the contract, when their employees 

were previously a part of the problems that were ongoing in these 

facilities, why were they—— 

[Applause.] 

Dr. WAKEFIELD. So what I can tell you, first of all, is that obviously Emergency Department Services are critically important 

and—— 

Congresswoman NOEM. But some of the same employees are 

even in the positions, and that’s what I really don’t really understand is that if you continue working with a company that has 

failed us in the past and you put them on an even playing field 

with other contracting firms and allowed them to have a position 

to come in and bid for these contracts—my legislation deals in 

changing the contracting process, which I think needs to happen. 

I think we’ve discussed long-term contracts with local providers 

that understand the challenges of servicing health care and serving 

people in rural America, and especially in rural South Dakota. I’d 

much rather see Avera, Sanford, Rapid City Regional Health in 

these hospitals than AB Staffing solutions. 

[Applause.] 

So I just want to question why there is not a red flag at any 

point with you when somebody fails and has a problem that we 

don’t kick them out of the pool of people who can bid for contracts? 

Dr. WAKEFIELD. First of all, with regard to ED, you did flag for 

us, you and I had that conversation and you directed—— 

Congresswoman NOEM. But I didn’t really get an answer on what 

happens, I mean, when people fail — 

Dr. WAKEFIELD. You flagged for me the importance of engaging 

and ensuring that local, regional facilities have an opportunity to 

46 

bid on contracts, and certainly that was the case with the ED contract. Part of the challenge was the lack of familiarity that that opportunity was even available, I think, was part of the issue here, 

and so what you saw certainly with the telemedicine contract was 

additional efforts to share the information about the availability of 

that bidding process. 

Having said that, the federal procurement process that we are 

required to follow was followed in the awarding of that contract, so 

I can tell you that, because I went back to ensure that that process 

was followed. 

With regard to the specifics of that contract, I would ask Mary 

to speak to that. But I can tell you on the front end that the expectations around the awarding of contracts, those policies and procedures were followed. That, I can assure you of. 

Congresswoman NOEM. I’ll just close with this, that I also understand that IHS relies on a Norwegian accrediting body, DNV GL, 

to maintain your accreditation at some of these hospitals throughout the region and it includes Pine Ridge, Rosebud, and Sioux San, 

and I know many of the witnesses here today reference CMS for 

finding problems and I think they deserve to know why their accrediting body has clearly failed in the past. 

Has IHS, CMS, HHS, and you can respond—I know I’m out of 

time—you can respond to me later about this, but I want to know 

if you had conversations with DNV GL regarding the accreditation 

issues at these Great Plains hospitals, because I want to know 

whether they visited these facilities or did they come ever to these 

facilities and do a proper accreditation program, and will IHS’s contract with DNV GL, will it expire, and will you renew it, because 

they’ve obviously failed, and I need to know if you’ll consider 

changing to something like a joint commission on these accreditation processes. But I’ll leave it at that. Thank you. 

The CHAIRMAN. Thank you. In addition to our follow-up questions, the tribes have asked for a copy of the contract. And can we 

get it from you, a copy of the contracts? 

Ms. STABLER. We were told we had to follow them. We think we 

should have a copy though. 

The CHAIRMAN. We all think we should have a copy. 

Dr. WAKEFIELD. Mr. Chairman, yes. Yes is the answer to that. 

There is a process with which we can make the contract available, 

yes. Yes, there is a way to get. 

The CHAIRMAN. But will we be able to use that process to actually successfully get a copy of it or not? 

Dr. WAKEFIELD. Yes. 

The CHAIRMAN. Thank you. 

Senator THUNE. Chairman Barrasso, one quick follow-up on that 

point. And I fully appreciate the fact, Secretary Wakefield, that you 

followed the protocols and whatever the bidding requirements to 

award that contract, but, my gosh, there has got to be some recognition of past performance. I mean, if what we hear from the 

tribes is true about the contractor, how could you contemplate reissuing a contract? Even if it meets the, you know, that just, to me, 

it’s almost incomprehensible. 

[Applause.] 

The CHAIRMAN. Senator Rounds. 

47 

Senator ROUNDS. Just to clarify the Chairman’s request. The contracts that are there that the tribes have not been able to get, how 

long will it take for this Committee to receive those copies of the 

contracts? 

Ms. SMITH. It’s my understanding that the Committee has already received a copy of the contract, and we are happy to provide 

them to the tribes after the request is made as expeditiously as 

possible within a few days. 

Dr. WAKEFIELD. So, bottom line, Mr. Chairman, we’ll make those 

contract copies available to you. But because they are contracts, 

there is an additional step that outside groups need to go through. 

It’s a requirement, but they absolutely can be made available, and 

we’ll work with the individuals for requesting them to ensure that 

they know what that process is, and I will commit that we will expedite that process. 

The CHAIRMAN. Thank you. I appreciate that commitment. Members of the Committee—yes, I’m sorry, Mr. Bear Shield. 

Mr. BEAR SHIELD. One more thing, I guess, we’d like to know if 

we’re going to be a part of upcoming contracting, the telehealth, 

the positions of the sources sought, five positions, you know, I 

guess, we need to enter that for the record if we’re going to be able 

to have a say-so in those, and those need to be immediate. I mean, 

because if you can have a mediocre provider sitting somewhere, all 

he has to do is push a button and he could be hooked up to Sioux 

Falls or Rapid City somewhere and at least get a second opinion 

and save lives. 

The CHAIRMAN. And that’s exactly why we’re here today. That’s 

why we’ve written this piece of legislation on improving accountability. We want all of these things, is why we asked the specifics 

of what do we need to put in here so you get everything you need. 

That’s why we’ve come here today. That’s why we’ve had the listening sessions. We want to get all of that and we want to get it into 

the law. 

Mr. BEAR SHIELD. And, lastly, we just heard them say they’re 

committed to waste, fraud, and abuse. I guess if that’s the case, 

you helped the Great Plains Tribal Chairman’s Association and 

Health Board, they just passed a resolution, you know, for years 

we’ve been saying we don’t get any leadership or technical assistance out of the area office. We want to do away with that. That 

money needs to come down to the local units and go to health care 

for the people, and we’ll just deal with the headquarters. Thank 

you. 

The CHAIRMAN. Yes, Ms. Bohlen. 

Ms. BOHLEN. Mr. Chairman, I know you’re not supposed to speak 

impromptu at these kind of things, but I can’t fight my nature. So 

the National Indian Health Board has believed that the $80 million 

that was used on third-party revenues to pay off the legal settlement that should have maybe come from the Department of Justice 

instead of the third-party billing, is there any way to try to get the 

money back? 

[Applause.] 

Could you maybe look at a process for which maybe that cost could be shifted to DOJ and the tribes could recapture that $80 

million? 

48 

The CHAIRMAN. We’ll certainly have to look into that. 

Ms. BOHLEN. Thank you, sir. 

The CHAIRMAN. I appreciate everyone who has come out to be 

with us today. Thank you. Thank you so very much for coming, and 

yesterday, and sharing your stories. The hearing record is going to 

be open for another two weeks—we may ask you to come up with 

your input to some additional questions, we’re going ask that you 

provide and get to those and so I want to thank all the witnesses 

for coming, for traveling here from so many different places, but I 

want to thank the audience as well, the Senators; the dedicated 

members of the South Dakota; congressional delegation, Senator 

Thune, Senator Rounds, Congresswoman Noem. Thank you so 

much with all of your help, and thank you. 

With that, this hearing is adjourned. 

[Whereupon, at 12:25 m., the hearing concluded.] 

(49) 

A P P E N D I X 

PREPARED STATEMENT OF HON. CAROLYN N. LERNER, SPECIAL COUNSEL, U.S. 

OFFICE OF SPECIAL COUNSEL

Chairman Barrasso, Ranking Member Tester, and Members of the Committee: 

Thank you for the opportunity to submit written testimony on behalf of the Office 

of Special Counsel (OSC). OSC protects the merit system for over 2 million civilian 

employees in the federal government, with a particular focus on investigating and 

prosecuting allegations of whistleblower retaliation. We appreciate the Committee’s 

efforts to support whistleblowers and promote accountability within the Indian 

Health Service (IHS), and we offer the following views on S. 2953, the Indian Health 

Service Accountability Act (‘‘the Act’’). 

Section 6 of the Act establishes a new ‘‘mandatory reporting’’ procedure for IHS 

employees who witness retaliation or other misconduct. This new mandatory reporting procedure will restrict, rather than expand, existing channels for whistleblower 

disclosures. Under current law, IHS employees may choose to disclose information 

directly to their chain of command, to an Inspector General, to OSC, or through 

other avenues. Employees should have the flexibility, as they do under current law, 

to determine the best avenue for making a disclosure. However, Section 6 would require IHS employees to disclose the information to an official designated by the Secretary of Health and Human Services (HHS). Section 6’s procedure does not include 

rules on confidentiality for the designated HHS official, and does not clearly define 

the terms that trigger the automatic reporting requirement to HHS. As stated, since 

IHS employees can already disclose information directly to the OIG, the benefit of 

establishing a new designated official to forward employee reports to the OIG is unclear. Reinforcing the existing channels for reporting concerns will result in better 

protections and outcomes for IHS whistleblowers. It would be appropriate to require 

HHS or IHS to provide additional information to IHS employees on available options for reporting wrongdoing. 

Additionally, Section 3 of the Act establishes a new process for the removal of IHS 

employees based on performance or misconduct. We understand that the intent of 

this provision is to promote accountability within IHS by providing the Secretary 

of HHS with an additional, expedited process for disciplining IHS employees. We 

note, however, that the new process is modeled, without modification, on a similar 

provision adopted by Congress to discipline senior executives within the Department 

of Veterans Affairs (VA). The VA provision has been subject to constitutional attack 

in federal court. The constitutional challenge has significantly delayed final resolution of disciplinary actions taken against senior VA officials. If the goal of this legislation is to expedite disciplinary actions against IHS employees, the Committee may 

wish to consider modifying the provision to ensure the constitutionality of the process. 

PREPARED STATEMENT OF FAITH SPOTTED EAGLE, TREATY CHAIRWOMAN, YANKTON

SIOUX/IHANKTONWAN TRIBE

Introduction 

The elected Treaty Committee, the formal elected officials of the Business and 

Claims Committee; the Tribal Chairman, Robert Flying Hawk; and Michael Horned 

Eagle, Wagner Service Unit Director have all established a positive partnership consistent with the mission of the Indian Health Service to raise the physical, mental, 

social and spiritual health, of American Indians and Alaska Natives to the highest 

level possible, and in this case the Yankton Sioux Reservation in the Aberdeen Area 

Healthy Service Unit. This partnership must remind us of the Indian Health Service 

priorities which are supported by the foundation of treaty rights delineating delivery 

of health, education and welfare to Native nations. These agency priorities are: 

50 

• Renew and strengthen partnerships with tribes and Urban Indian Healthy Programs 

• Improve the Indian Health Service 

• Improve the quality and access to care 

• Ensure that work is transparent, accountable, fair and inclusive 

Treaty rights and trust responsibility 

As clearly outlined in the Position statement of the National Congress of American Indians regarding health care; the treaties signed by the Native nations created 

the clear trust responsibility of the government to the individual Nations in health 

care on what we call Turtle Island, or in this case the United States, located on Indigenous lands. 

When the Treaty of 1858 was signed under duress by the Yankton, it created the 

current reservation; the boundaries of which have been even further diminished by 

state and county action in an attempt to disestablish the reservation. The descendants of these immigrant families have short memories, as the Yankton shared our 

land with them to an extreme. The Supreme Court declined to hear the 

disestalishment case; thus the Yankton have retained their boundaries in a close 

call. However, despite the sad history of treaties, it was clear that treaty signatories 

had future generations in mind, by essentially creating a form of pre-paid health 

care. For this promise of health, education and welfare the Yankton signators essentially granted almost the entire half of eastern South Dakota to the US and immigrants through the Dawes Act, the Treaty of 1858 and the 1894 Act. In later years, 

the Pipestone Quarry was also lost; although guaranteed in the 1858 Treaty. 

In the case of the Yankton/Ihanktonwan; there were three large land actions 

which almost decimated the Yankton. 

• The first was the coerced Treaty of 1858, which was signed under duress and 

military captivity with the coming of Ft. Randall. Prior to the signing of this 

Treaty, the tribes domain was greater than 11 million. Per the 1858 Treaty, the 

tribe ceded more than 11 million acres. The Yankton retained a reduced amount 

of 430,400 acres which was further reduced by subsequent US government actions. 

• Following the cessions of the 1894 Act, the reservations was reduced to 262,300 

acres. The 1894 Act was designed to obtain more Indian land even after treaties 

were done away with by the US government. 

• The Pick Sloan Act took even more land from the Yanktons and destroyed highly productive farmlands on the Missouri River and created further homelessness. Only recently has legislation occurred to try to correct this. 

• The tribe now has a mere 37,600 acres held in trust. 

In light of the tremendous land losses and subsequent impact of historical trauma 

faced by our people through impacts of attempted assimilation; it is even more important that these historical sacrifices receive justice through quality health care for 

not only future generations but a population made vulnerable through cultural loss 

and infrastructure destruction. It is obvious that the massive historical trauma inflicted on the Yankton and Native nations has resulted in stress related diseases 

such as cancer, diabetes and lupus. Now we have the opportunity to right these 

human rights infringements and wrongs and create just health care, funded at an 

effective level. 

Challenges faced by the Wagner Service Unit 

• Inadequate staff composition and staff to cover an extremely large population 

area: The Unit website states that the Wagner location provides care from 7 

am—11 pm; with 6 Primary Care Providers and 2 PA–C’s. Although it is located 

on the Yankton Sioux Reservation, it provides services to patients from surrounding reservations and communities throughout South Dakota, Iowa, Minnesota and Nebraska. Unit director Mike Horned Eagle, has stated to us that 

the largest population area that Wagner provides service to is Sioux Falls, SD 

which is two hours ago. He also stated that each month, the unit has 39,000 

contacts which is totally overwhelming when compared to funding, staff and capability. This creates added stress to a small system and can set up scenarios 

of vulnerability for an overloaded system. 

• Need for full emergency room: In past years, Wagner had a full fledged emergency room, however due to Indian Health actions and lack of congressional 

funding and support, this ended. Currently what exists is an urgent care unit. 

Recently the writer of this testimony had a first-hand experience at the urgent 

51 

care unit this June 2016, when a young relative was taken in for an impending 

miscarriage. It took 45 minutes for the doctor to arrive; it took another 50 minutes for staff to arrive to do bloodwork and start the analysis machines and another 45 minutes for the ambulance to arrive and another hour to transport the 

young mother to Sacred Heart hospital in Yankton, SD; not counting how much 

it took for intake at the receiving facility. The mother subsequently suffered a 

miscarriage. This is a systemic problem, not necessarily always a staff problem 

although they could be related due to low levels of funding. 

• The Wagner Unit Diabetes Program has identified 634 diabetics receiving care 

at this clinic. This is roughly 20 percent of an on-reservation population of approximately 3000 rounded up to the nearest thousand out of a total Yankton/ 

Ihanktonwan Sioux Tribal population of 9,000 again rounded off at the nearest 

thousand according to the tribal enrollment office. The current staffing could be 

potentially detailed to care only for the high number of diabetics who usually 

have systemic health problems way beyond high blood sugar. 

• The National Center for Health Workforce Analysis has identified that among 

rural residents, there are proportionately more providers in occupations that require fewer years of education and training than providers in occupations which 

require more years of expertise. For example there are EMT’s and paramedics 

per capita residing in rural as opposed to urban areas, and more physicians and 

surgeons per capita residing in urban as opposed to rural areas. This is already 

a problem for rural areas such as the Yankton Reservation. 

• The same data center has identified that prison populations receive better care 

than Indian Health service populations, further compromising the future of our 

children, elders and families. 

• Increased Indian Health Service funding has to be a priority to meet the treaty 

rights of Native nations. In the current situation, priority is given to those suffering from potential loss of life and limb, thus compromising preventive health 

care which in the long run will save money. 

• Increased use of meth amphetamines and prescriptions are contributing to early 

organ, teeth and systemic failure. This is a national epidemic that has special 

consequences for an already rural compromised locale that has high poverty 

rates. 

Strengths of the Wagner Unit 

• This past spring, the Yankton Sioux Tribe is very proud of its partnership with 

Indian Health and other providers with the opening of a ground breaking local 

dialysis unit adjacent to the Indian Health Service Clinic. This has taken years 

to develop and funding must continue. 

• The Wagner Unit has developed a competent systemic track record of cooperative billing via medicare/Medicaid and other sources. They are to be commended 

for maintaining but further funding must continue for updated software and 

input staff who are always at a shortage, thus creating staff stress. 

• The Director, Mike Horned Eagle has developed a positive working relationship 

with the Ihanktonwan/Yankton leadership and is willing to jointly partake in 

the following recommendations and plan. 

Proposed Basic Plan for Solution Improvement at the Wagner Unit 

The answer is those who have an emic perspective on what is needed, or those 

who are intimate users of the system being examined that will be impacted by the 

Indian Health Care Improvement bill. 

1. Tribal users of the Wagner IHS Clinic are ideally situated to provide problem 

areas they experience and solutions they propose and these should be documented. Importantly, their perspective on local IHS Wagner staff members is 

needed because they can identify who is helpful and who embodies the mission 

of the IHS. 

Therefore, a focus group of 10 diverse IHS Wagner users should be convened 

to list problems/concerns. Also, to identify a list of 10 IHS Wagner staff they 

perceive as most helpful and dedicated to the mission. 

2. A focus group of 10 IHS Wagner staff will be convened as identified by the 

Tribal user group. They too will identify the top problem areas they see from 

the inside perspective on service delivery. In addition, they will identify what 

they perceive as priority solutions. 

3. A report will be completed by the IHS Wagner Facility Director to delineate 

his inside or emic perspective on solutions. 

52 

4. An appropriate tribal member from Yankton should lead the IHS consumer 

group with staff support to document notes and generate a qualitative report 

, which would be determined by the leadership team of Mr. Horned Eagle, Treaty Committee and Business and Claims Committee. 

5. An appropriate outside healthcare professional should lead the IHS staff 

group along with a Yankton Tribal Member. 

6. The appropriate healthcare professional can generate the final report to Senator Thune and the tribe, determined by the tribal leadership team who will 

then present the findings in hearings to the Ihanktonwan/Yankton Sioux Tribe. 

7. All parties, with the strong support of Thune to seek restoration of funding 

for a FULL FLEDGED EMERGENCY ROOM AT THE WAGNER UNIT, TO 

PREVENT FURTHER UNTIMELY DEATHS. 

8. We will provide joint leadership from the tribe, Senator Thune, the Chairman, the Treaty Committee and the Business and Claims Committee to revisit 

and clearly define and explore the best benefits for both parties in regard to the 

Veteran’s Administration and Indian Health Service and seek technical assistance from the Veteran’s Administration for a more balanced relationship. At the 

current time, the Wagner Unit is giving more than receiving from the VA. 

9. Senator Thune will take actions to obtain appropriate funding to implement 

the findings. The IHS Wagner Facility Director will measure the outcomes and 

providing follow reporting per protocol. This is encouraged by Mr. Thune’s statement below. 

10. Lastly, we strongly urge Senator Thune to seek INCREASED NEW FUNDING TO ACCOMPLISH THE PROPOSED FOLLOWING THREE ITEMS IN 

THE NEW LEGISLATION AND THAT THEY NOT BE FUNDED BY EXISTING LEVELS, WHICH ARE INADEQUATE FOR ALL OTHER AREAS. 

• Improving protections for employees who report violations of patient safety 

requirements. 

• Mandating that the secretary of HHS provide timely Indian Health Service 

spending reports to Congress; and 

• Ensuring the Inspector General of HHS investigates patient deaths in which 

the Indian Health Service is alleged to be involved. 

‘‘. . .We need a willing partner at IHS who takes these issues as seriously as I 

do. As far as I’m concerned, this conversation is far from over.’’ 

A part of this conversation can be an emic viewpoint from those who receive 

healthcare services and those who deliver them. This is organizational wisdom from 

a Dakota culturally based foundation. 

PREPARED STATEMENT OF SUSAN T. GRUNDMANN, CHAIRMAN, U.S. MERIT SYSTEMS

PROTECTION BOARD (MSPB) 

Chairman Barrasso, Vice Chairman Tester, and distinguished Members of the 

United States Senate Committee on Indian Affairs. Thank you for the invitation to 

present a written statement on behalf of the United States Merit Systems Protection Board (MSPB) in connection with the Committee’s June 17, 2016 hearing entitled: ‘‘Improving Accountability and Quality of Care at the Indian Health Service 

through S. 2953.’’ 

As an initial matter, I would like to note that under statute, MSPB is prohibited 

from providing advisory opinions on any hypothetical or future personnel action 

within the executive branch of the federal government. 5 U.S.C. § 1204(h) (‘‘The 

Board shall not issue advisory opinions.’’). Accordingly, this statement should not be 

construed as an indication of how I, any other presidentially appointed, Senate-confirmed Member of the Merit Systems Protection Board (‘‘Board’’), or an MSPB administrative judge would rule in any pending or future matter before the agency. 

Moreover, during my time as Chairman, MSPB has not taken policy positions on 

legislation pending before Congress. Generally, I view MSPB’s role in the federal 

civil service as an independent adjudicator of appeals in accordance with legislation 

passed by Congress and signed into law by the president. Accordingly, I would respectfully request that the Committee consider the substance of my statement to be 

technical in nature. 

MSPB’s Adjudication Function 

MSPB’s views on S. 2953—the Indian Health Service Accountability Act of 2016, 

or the ‘‘IHS Accountability Act of 2016’’—derive from its statutory responsibility to 

adjudicate appeals filed by federal employees in connection with certain adverse emVerDate Mar 15 2010 10:23 Jan 05, 2017 Jkt 023226 PO 00000 Frm 00056 Fmt 6601 Sfmt 6621 S:\DOCS\23226.TXT JACK
53 

1MSPB administrative judges are federal employees under the General Schedule System employed by MSPB. They are not ‘‘administrative law judges’’ appointed under 5 U.S.C. § 3105 nor 

federal judges. 2 Under 5 U.S.C. § 7513(b)(1)-(4) and (d), a federal employee against whom certain adverse actions are proposed is generally entitled to: 1) at least 30 days advance written notice stating 

the specific reasons for the federal agency’s proposed action; 2) not less than 7 days to respond 

to the proposed adverse action; 3) be represented by an attorney or other representative before 

the federal agency; 4) a written decision and the specific reasons therefor by the federal agency; 

and 5) file an appeal to MSPB under 5 U.S.C. § 7701. Under 5 U.S.C. § 4303(b)(1), a federal 

employee who is subject to removal or a reduction in grade for unacceptable performance is generally entitled to: 1) at least 30 days advance written notice of the federal agency’s proposed 

action identifying certain information; 2) be represented by an attorney or other representative 

before the federal agency; 3) a reasonable time to answer orally and in writing to the proposed 

adverse action; 4) a written decision by the federal agency specifying the instances of unacceptable performance which has been concurred in by an employee who is in a higher position that 

proposes the removal or reduction in grade; and 5) appeal to MSPB under 5 U.S.C. § 7701. Moreover, under 5 U.S.C. § 4302(b)(5), before a federal agency can take a personnel action based on 

performance, the employee whose performance is in question shall be provided an opportunity 

to improve his or her unacceptable performance. 

ployment actions. Generally, after a federal agency imposes an adverse personnel 

action upon a federal employee, such as removal or demotion, and the federal employee chooses to exercise his or her statutory right to file an appeal with MSPB, 

MSPB will begin the adjudication process. In the case of a federal employee who 

is removed from his or her position, that individual is no longer employed by the 

federal government, and is not receiving pay at the time he or she files an appeal 

with MSPB or at any point during the subsequent MSPB adjudication process. 

Once an appeal is filed, an MSPB administrative judge 1 in one of MSPB’s regional or field offices will first determine whether MSPB has jurisdiction to adjudicate the appeal. If MSPB has jurisdiction, the administrative judge may conduct 

a hearing on the merits and then issue an initial decision addressing the federal 

agency’s case and the appellant’s defenses and claims. Thereafter, either the appellant or the named federal agency may file a petition for review of the MSPB administrative judge’s initial decision to the three-Member Board. The Board Members 

constitute an administrative appellate body that reviews the administrative judge’s 

decision and issues a final decision of the MSPB. Both the Board Members and 

MSPB administrative judges adjudicate appeals in accordance with statutory law, 

federal regulations, precedent from United States federal courts, including the Supreme Court of the United States and the United States Court of Appeals for the 

Federal Circuit, and MSPB precedent. 

Requirements of S. 2953 

S. 2953 contains language that is virtually identical to Section 707 of the Veterans 

Access, Choice, and Accountability Act of 2014 (‘‘the 2014 Act’’), which was enacted 

into law and became effective in August 2014. (Public Law No. 113–146). In pertinent part, S. 2953 would allow the Secretary of Health and Human Services (‘‘Secretary’’), acting through the Director of Service, to remove, demote, or transfer employees, including Senior Executive Service (‘‘SES’’) employees, of the Indian Health 

Service (‘‘Service’’) if the Secretary determines the performance or misconduct of the 

employee warrants such a personnel action. Specifically, S. 2953 would allow the 

Secretary to take the following personnel actions: 

• Remove the employee from the civil service altogether; 

• Regarding SES employees, transfer the employee from the SES to a position in 

the General Schedule at any grade of the General Schedule for which the employee is qualified and that the Secretary determines is appropriate; and 

• Regarding managers and supervisors, reduce the grade of these employees to 

any other grade for which the employee is qualified and the Secretary determines is appropriate. 

With respect to the above-referenced personnel actions, S. 2953 provides that ‘‘the 

procedures under chapters 43 and 75 of title 5, United States Code, shall not 

apply.’’ 2 Instead, S. 2953 provides that ‘‘before an employee may be subject to a personnel action. he or she must be provided with: (1) written notice of the proposed 

personnel action not less than 10 days before the personnel action is taken; and (2) 

an ‘‘opportunity and reasonable time’’ to answer orally or in writing. Finally, with 

respect to SES employees who are transferred to a General Schedule position and 

managers/supervisors whose grades have been reduced, S. 2953 provides that they 

54 

3This provision appears to prohibit a federal employee from using any accrued annual or sick 

leave if he or she chooses exercise his or her right to appeal the adverse action of a transfer 

or demotion. Unlike employees who are removed from the civil service, employees who are transferred and/or demoted remain federal employees during the pendency of an MSPB appeal. Thus, 

this provision would appear to prohibit a federal employee from using leave which he or she 

has earned and—in most circumstances—is entitled to use, while employed. It is also possible 

that this provision could have a chilling effect on employees who seek to file MSPB appeals, 

per their statutory rights. 4Generally, under current law, an appeal must be filed at MSPB no later than 30 days after 

the effective date, if any, of the action being appealed, or 30 days after the date of the appellant’s receipt of the agency’s decision, whichever is later. 5 C.F.R. § 1201.22(b). 5MSPB does not directly employ any administrative law judges, but can retain the services 

of administrative law judges via service contracts with other federal agencies. Thus, if S. 2953 

were to become law, and MSPB were required to retain the services of administrative law judges 

to adjudicate appeals covered by this legislation—instead of using MSPB administrative 

judges—MSPB would likely incur significant operating costs. Moreover, MSPB has no supervisory authority over administrative law judges and could not ensure that they issue final decisions within 21 days. MSPB recommends amending S. 2953 to address this matter. 6 In addition to adjudicating appeals filed by federal employees, MSPB is required under statute to: Conduct, from time to time, special studies relating to the civil service and to the other 

merit systems in the executive branch, and report to the President and to Congress as to whether the public interest in a civil service free of prohibited personnel practices is being adequately 

protected. 5 U.S.C. § 1204(a)(3). 7This report can be found at: http://www.mspb.gov/netsearch/ 

viewdocs.aspx?docnumber=1166935&version=1171499&application=ACROBAT 8The Loudermill case involved a state employee, not a federal employee. Nevertheless, while 

the Federal Government is covered by the Fifth Amendment and the states by the Fourteenth 

Amendment, the effect is the same. See Lachance v. Erickson, 522 U.S. 262, 266 (1998); Stone 

v. Federal Deposit Insurance Corp., 179 F.3d 1368, 1375–76 (Fed. Cir. 1999). 

may not be placed on administrative leave or ‘‘any other category of paid leave’’ 3

during the period during which an MSPB appeal is ongoing. 

Expedited MSPB Appeal Rights Under S. 2953 

Employees who are either removed or demoted by the Secretary may appeal that 

personnel action to MSPB ‘‘under section 7701 of title 5.’’ Any appeal must be filed 

with MSPB ‘‘not later than seven days after the date of the personnel action’’ 4 and 

the MSPB will be required to refer the appeal to an ‘‘administrative law judge’’ 5

for adjudication. An administrative law judge would be required to issue a decision 

‘‘not later than 21 days after the date of the appeal,’’ and that decision ‘‘shall be 

final’’ and not subject to further review, either by the Board or a United States federal court. In the event that an administrative law judge does not issue a final decision within 21 days, the decision of the Secretary to remove or demote the employee 

becomes final and the employee has no further right to appeal. 

Possible Constitutional Defects of S. 2953 

In May 2015, MSPB released a study 6 entitled: What is Due Process in Federal 

Civil Service Employment? The report provides an overview of current civil service 

laws for adverse actions and, perhaps more importantly, the history and considerations behind the formation of those laws. It also explains why, according to the Supreme Court of the United States, the Constitution requires that any system which 

provides that a public employee may only be removed for specified causes must also 

include an opportunity for the employee—prior to his or her termination—to be 

made aware of the charges the employer will make, present a defense to those 

charges, and appeal the removal decision to an impartial adjudicator. We encourage 

Members of the Committee and their staff who have interest in these issues to read 

this report. 7

In the landmark decision of Cleveland Board of Education v. Loudermill, 470 U.S. 

532 (1985) the Supreme Court held that while Congress (through statutes) or the 

president (through executive orders) may decide whether to grant protections to employees, they lack the authority to decide whether they will grant due process rights 

once those protections are granted. Stated differently, when Congress establishes 

the circumstances under which employees may be removed from positions (such as 

for misconduct or malfeasance), employees have a property interest in those positions. Loudermill, 470 U.S. at 538–39. 8 Specifically, the Loudermill Court stated: 

Property cannot be defined by the procedures provided for its deprivation any 

more than can life or liberty. The right to due process is conferred, not by legislative grace, but by constitutional guarantee. While the legislature may elect 

not to confer a property interest in public employment, it may not constitutionally authorize the deprivation of such an interest, once conferred, without 

the appropriate procedural safeguards. 

55 

Id. at 541. 

The Court explained that the ‘‘root requirement’’ of the Due Process Clause is that 

‘‘an individual be given an opportunity for a hearing before he is deprived of any 

significant property interest,’’ and that ‘‘this principle requires some kind of a hearing prior to the discharge of an employee who has a constitutionally protected property interest in his employment.’’ Id. at 542. 

According to the Court, one reason for this due process right is the possibility that 

‘‘[e]ven where the facts are clear, the appropriateness or necessity of the discharge 

may not be; in such cases, the only meaningful opportunity to invoke the discretion 

of the decisionmaker is likely to be before the termination takes effect.’’ Id. at 542. 

The Court further held that ‘‘the right to a hearing does not depend on a demonstration of certain success.’’ Id. at 544. 

I further note that the requirements of the Constitution have shaped the rules 

under which federal agencies may take adverse actions against federal employees, 

as explained by the Supreme Court, U.S. Courts of Appeal, and U.S. District Courts. 

Accordingly, should Congress consider modifications to these rules, many of which 

have been in place for more than one hundred years, MSPB respectfully submits 

that the discussion be an informed one, and that all Constitutional requirements be 

considered. 

As stated above, S. 2953 provides ten days’ notice to an employee prior to a personnel action, a ‘‘reasonable time’’ to respond, and the right to an expedited appeal 

at MSPB. Whether these rights—taken as a whole—satisfy constitutional due process requirements would depend on the various factors and the circumstances of a 

given appeal, and it would be inappropriate for me to address that issue here. I 

note, however, that the constitutionality of Section 707 of the 2014 Veterans Access, 

Choice, and Accountability Act is currently the subject of litigation at the United 

States Court of Appeals for the Federal Circuit. Helman v. Dep’t. of Veterans Affairs, 

Case No. 15–3086 (Fed. Cir. 2015). The plaintiff in that litigation is alleging that 

Section 707 is unconstitutional primarily on two grounds: 

• By permitting the Department to remove a tenured federal employee without 

any pre-removal notice or an opportunity to respond, and by severely limiting 

post-removal appeal rights, Section 707 violates an employee’s right to constitutional due process as articulated by the Supreme Court; and 

• By removing the Board from the MSPB appellate review process and permitting 

MSPB administrative judges to make a final decision binding an executive 

branch agency which is not reviewable by a presidential appointee, Section 707 

violates the Appointments Clause contained in Article II, Section 2 of the 

United States Constitution. 

Significantly, on June 1, 2016, the United States Department of Justice filed a 

brief with the Federal Circuit in Helman stating that it was declining to defend the 

constitutionality of the provision of Section 707 that removed the Board members 

from the MSPB adjudication process and permitted MSPB administrative judges to 

have final decisionmaking authority in appeals on behalf of the MSPB. According 

to the Department of Justice, the ‘‘final authority to interpret and apply the civil 

service laws of the United States’’ must remain in the hands of officials properly 

appointed under the Appointments Clause of Article II of the Constitution. It noted 

that MSPB administrative judges are ‘‘regular government employees’’ who—under 

the 2014 Act—are provided ‘‘the significant authority’’ that is properly exercised by 

the presidentially-appointed, Senate-confirmed ‘‘members of the Merit Systems Protection Board.’’ Consequently, the Department of Justice moved the Federal Circuit 

to declare that provision of law invalid and remand Ms. Helman’s appeal back to 

MSPB for further proceedings. On June 17, 2016, the Department of Veterans Affairs announced that it would no longer use the personnel authority provided by the 

2014 Act as a result of the Department of Justice’s determination that the abovereferenced provision of the Act was unconstitutional. 

Finally, I note that the provision of S. 2953 that states that the Secretary’s decision with respect to the personnel action in question becomes ‘‘final’’ in the event 

that an administrative law judge does not issue a decision within 21 days may very 

well be on weak constitutional footing. This provision could be interpreted to suggest that a federal employee—who unquestionably possesses a federal property interest in his or her federal employment -loses his or her right to due process if the 

MSPB (a government actor) fails to hold a hearing and issue a final decision within 

21 days. 

In Logan v. Zimmerman Brush Co., 455 U.S. 422 (1982), the Supreme Court noted 

that ‘‘the Due Process Clause grants the aggrieved party the opportunity to present 

his case and have its merits fairly judged. Thus it has become a truism that ‘some 

56 

1The Best Places to Work in the Federal Government rankings are produced in partnership 

with Deloitte Consulting. 

form of hearing’ is required before the owner is finally deprived of a protected property interest.’’ Id. at 433, citing Board of Regents v. Roth, 408 U.S. 564, 570–571, 

n.8. The Logan Court considered whether Mr. Logan lost his due process right to 

a hearing and final decision on his claims because the State of Illinois failed— 

through its own fault—to comply with a 120 day procedural requirement required 

under Illinois statute. It held that he did not. 

The Court emphasized that the Fourteenth Amendment requires ‘‘an opportunity. . . .granted at meaningful time and in a meaningful manner. . . .for a 

hearing appropriate to the nature of the case.’’ Id. at 437 (internal citations omitted) 

(emphasis added). Thus, under Logan, an individual who possesses a federal property interest in his or her federal employment must be provided a meaningful hearing prior to that deprivation of that property, and the failure of a government actor 

to comply with certain procedural requirements—such as a time requirement in connection with a hearing—likely does not eliminate that individual’s constitutional 

rights. In light of Logan, I urge the Committee to consider whether any time limit 

with respect to the issuance of a final MSPB decision is proper. 

Permitting Appeals to MSPB ‘‘Under 5 U.S.C. § 7701′′ 

Similar to the 2014 Act, S. 2953 would permit covered employees to appeal to 

MSPB ‘‘under 5 U.S.C. § 7701.’’ Section 7701 of title 5, United States Code, provides 

in pertinent part that ‘‘the decision of an agency shall be sustained. . . only if the 

agency’s decision. . . is supported by a preponderance of the evidence.’’ 5 U.S.C. 

§ 7701(c)(1)(B). The term ‘‘preponderance of the evidence’’ is defined as ‘‘the degree 

of relevant evidence that a reasonable person, considering the record as a whole, 

would accept as sufficient to find that a contested fact is more likely to be true than 

untrue.’’ 5 C.F.R. § 1201.4(q). 

Additionally, 5 U.S.C. § 7701(c)(2)(B) provides that ‘‘an agency’s decision may not 

be sustained. . .if the employee or applicant for employment shows that the decision was based on any prohibited personnel practice described in section 2302(b) [of 

title 5, United States Code].’’ Among the ‘‘prohibited personnel practices’’ described 

in section 2302(b) are illegal discrimination, 5 U.S.C. § 2302(b)(1)(A)-(E), coercion of 

political activity or reprisal for refusal to engage in political activity, 5 U.S.C. 

§ 2302(b)(3), and reprisal for lawful ‘‘whistleblowing,’’ 5 U.S.C. § 2302(b)(8). Thus, if 

such issues are raised by appellants as defenses in appeals filed pursuant to the 

language contained in S. 2953, MSPB administrative judges will be required under 

law to consider those defenses—which often are fact intensive and complicated— 

prior to issuing a final decision within 21 days. 

This concludes my written statement. I am happy to address any questions for 

the record that Members of the Committee may have. 

PREPARED STATEMENT OF MAX STIER, PRESIDENT/CEO, PARTNERSHIP FOR PUBLIC

SERVICE

Chairman Barrasso, Vice Chairman Tester, Members of the Senate Committee on 

Indian Affairs, thank you for the opportunity to provide a statement for the record 

on S. 2953, the Indian Health Service Accountability Act of 2016. 

I am Max Stier, President and CEO of the Partnership for Public Service. The 

Partnership is a nonpartisan, nonprofit organization dedicated to revitalizing our 

federal government by inspiring a new generation to enter public service and transforming the way government works. We believe that making our government more 

efficient, effective, and accountable begins with smart hiring practices, engaged employees and strong, competent leaders. Congress has entrusted the Indian Health 

Service (IHS) with making good our country’s obligations to native peoples. If the 

agency is to do so, it must be able to recruit, hire and retain talented employees, 

hold those employees accountable for their performance, and provide them with the 

resources and tools to necessary to achieve their unique and rewarding mission of 

delivering quality health care to American Indians and Alaska Natives. In this 

statement, I will focus on the proposed legislation’s accountability, performance and 

hiring provisions. 

The good news is that, as a whole, employees of the Indian Health Service are 

highly connected to the mission of the agency, as measured by the Partnership’s, 

Best Places to Work in the Federal Government rankings®. 1 The rankings, based on 

data from the Federal Employee Viewpoint Survey (FEVS) administered by the Office of Personnel Management (OPM), are the most comprehensive and authoritative 

57 

2 ‘‘Department of Health and Human Services.’’ Best Places to Work in the Federal Government. Accessed June 24, 2016. http://bestplacestowork.org/BPTW/rankings/detail/HE37. 3The workplace category of ‘‘Effective Leadership’’ measures the extent to which employees 

believe leadership at all levels of the organization generates motivation and commitment, encourages integrity and manages people fairly, while also promoting the professional development, creativity and empowerment of employees. ‘‘Teamwork’’ measures the extent to which employees believe they communicate effectively both inside and outside their team organizations, 

creating a friendly work atmosphere and producing high-quality work products. The ‘‘Support 

for Diversity’’ category measures the extent to which employees believe that actions and policies 

of leadership and management promote and respect diversity. 4 United States of America. United States Senate Committee on Indian Affairs. In Critical 

Condition: The Urgent Need to Reform the Indian Health Service’s Aberdeen Area. Washington, 

DC: United States Senate Committee on Indian Affairs, 2010. 5 ‘‘Department of Health and Human Services.’’ Best Places to Work in the Federal Government. Accessed June 24, 2016. http://bestplacestowork.org/BPTW/rankings/detail/HE37. 6 Ibid. 

7 United States of America. Congressional Research Service. The Indian Health Service (IHS): 

An Overview. By Elayne J. Heisler. Washington, DC: Congressional Reserach Service, 2016. 

rating of employee satisfaction and commitment in the federal government. They 

consist of an ‘‘index score’’, which measures employees’ satisfaction and commitment, and 10 ‘‘workplace categories’’ which measure employees’ views on particular 

aspects of the workplace. In 2015, IHS scored 79.9 out of 100 in the workplace category of ‘‘Employee Skill-Mission Match’’, which measures the extent to which employees feel that the agency uses their skills and talents effectively. 2 The category 

also assesses the level of which employees get satisfaction from their work and understand how their jobs are relevant to the organizational mission. This score was 

relatively high with a ranking of 57 out of 319 ranked agency subcomponents, putting the IHS in the group’s top quartile. According to the 2015 FEVS, IHS employees also score above government as a whole on specific questions including ‘‘I like 

the kind of work I do,’’ and ‘‘My talents are well used in the workplace.’’ 

The Indian Health Service faces challenges as well. The agency scored near the 

bottom of all agencies in the workplace categories of ‘‘Effective Leadership’’, ‘‘Teamwork’’, and ‘‘Support for Diversity.’’ 3 The IHS ranked 301 out of 318 agency subcomponents in employee views of leadership, 317 out of 319 in employee views of 

teamwork in their agency and 313 out of 319 in employee views of how their agency 

promotes and respects diversity. These data are consistent with the findings of the 

Committee’s 2010 report, ‘‘In Critical Condition: The Urgent Need to Reform the Indian Health Service’s Aberdeen Area’’ as well as more recent investigations. 4 Particularly troubling is how poorly the IHS fares in the category of ‘‘Effective Leadership’’ and especially the subcategory measuring employee opinions of their immediate supervisor, including how well supervisors give employees the opportunity to 

demonstrate leadership, support employee development, and provide worthwhile 

feedback about job performance. The Partnership’s research has consistently found 

that employee views of leadership are the single biggest driver of satisfaction with 

their organization. The IHS ranked 315 out of 318 subcomponents with a score of 

53.2 out of 100 in the ‘‘Effective Leadership: Supervisors’’ subcategory. To put this 

in context, the highest scoring subcomponent in this subcategory in 2015 was the 

Federal Energy Regulatory Commission’s Office of the General Counsel with a score 

of 86.1. 5 The state of leadership at the Indian Health Service should, therefore, continue to be a priority for this Committee. The IHS significantly underperforms government as a whole in positive responses to FEVS questions including ‘‘Supervisors 

work well with employees of different backgrounds’’, ‘‘I have trust and confidence 

in my supervisor’’, ‘‘My supervisor treats me with respect’’, and ‘‘Employees in my 

work unit share job knowledge with each other.’’ In the overall measure of employee 

satisfaction and commitment, the Indian Health Service ranked 248 out of 320 total 

agency subcomponents with an index score of 54.5. 6

This committee is right to be troubled by the reports coming out of particular Indian Health Service facilities, and the Partnership shares your concern. It is unfortunate that the actions of a few can do so much to tarnish the work of the many 

thousands of employees who have dedicated their careers to serving Native communities. However, firing a few bad actors is not a long-term solution to systemic management problems; the IHS will never be able to fire its way to excellence. The Partnership believes that the most effective way to address the performance and talent 

challenges of the IHS and other agencies is a comprehensive overhaul of the civil 

service system, and we outlined a framework to achieve this goal in 2014. 7 We understand that this kind of reform is outside the committee’s purview. In its absence, 

there is still much you can do to hold poor performers accountable, as well as attract 

new talent, reward and recognize the best employees, and set them up for success 

58 

8 United States of America. Merit Systems Protection Board. The Probationary Period: A Critical Assessment Opportunity. Washington, DC: Merit Systems Protection Board, 2005. i. 9 Ibid ii. 

without jeopardizing due process or moving towards an ‘‘at-will’’ system of employment that would undermine our non-political civil service. 

Faster Firing Is Not the Answer 

The goal of an accountable and well-equipped Indian Health Service workforce is 

an important one. As the Committee considers the Indian Health Service Accountability Act of 2016, we urge you to think carefully about whether these proposed 

changes to due process and employment rights are the best way to achieve this goal. 

In the Partnership’s view, they are not the answer; in fact, the changes considered 

here may have unintended consequences that reduce protection for whistleblowers 

and diminish incentives for experienced and dedicated employees to join an agency 

already struggling to recruit the talent it needs. Though well intentioned, S. 2953 

severely undermines due process protections for employees and could lead to removals for partisan or discriminatory reasons. 

We believe strongly that the Indian Health Service has the authorities needed to 

take corrective action, up to and including removing an employee from the civil 

service when warranted. If it is to tackle these problems in a sustainable and lasting way, the IHS needs empowered managers who are willing to take action to deal 

with poor performers and senior leadership and human resources staff willing to 

support them. The agency also needs employees who are engaged in the work and 

mission of their agency, communicate effectively, and work together toward common 

goals. 

While accomplishing these things will take time, there is much that the Committee can do to move the Indian Health Service in the right direction. For example, 

requiring more training on the disciplinary process and how to deal with poor performers would better equip frontline managers and supervisors to manage the performance of their employees and engage in difficult conversations that many now 

choose to avoid. This training should include how to motivate, engage and reward 

employees. Managers should then be held accountable for the performance of their 

employees and their efforts to keep their teams satisfied and engaged. The Committee should also strengthen the probationary period at the IHS for both frontline 

employees and new supervisors and managers. In the federal government, newlyhired employees and new supervisors undergo a probationary period, typically of one 

year, to evaluate the employee’s conduct and performance to determine if the employee’s appointment to the civil service should become final. 8 In the IHS, as in 

most other federal agencies, the probationary period is considered a formality rather 

than an extension of the assessment process as it was originally intended to be. 9

By requiring supervisors to make an affirmative decision to keep an employee past 

the employee’s probationary period, you can ensure agencies are using this time to 

evaluate new employees and determine whether they have earned a permanent 

place in the workforce. 

Finally, the Committee should require the Indian Health Service to collect and 

report data on disciplinary process outcomes. Significant changes to the law should 

be based on measurable data rather than on anecdotes and individual cases. It is 

critically important that in considering further legislative changes, the Committee 

takes care to make reforms after fully deliberating their potential impact. The Committee can better understand the disciplinary process at the IHS by requiring the 

agency to report on the number of disciplinary actions proposed, the result of those 

actions, the average length of the disciplinary process, the extent to which administrative leave is used in disciplinary cases, and the number of decisions overturned 

or settled. These data would allow the IHS and the Committee to understand better 

the state of the disciplinary process, process outcomes, and where breakdowns occur, 

and could inform future oversight. We would be pleased to provide legislative language to the Committee to this effect. 

Recommendations 

Beyond the ideas offered above, I include here several additional recommendations for improving S. 2953 as currently drafted: 

• Handle Appeals at the Level of the Full Merit Systems Protection Board—Employees and executives slated for demotion or removal under the Indian Health 

Service Accountability Act of 2016 would have their appeal heard by an MSPB 

administrative law judge (ALJ). Such an appeals structure is problematic. As 

a recent decision by the U.S. Department of Justice (DOJ) relating to nearly 

identical language in Section 707 of the Veterans Access, Choice, and AccountVerDate Mar 15 2010 10:23 Jan 05, 2017 Jkt 023226 PO 00000 Frm 00062 Fmt 6601 Sfmt 6621 S:\DOCS\23226.TXT JACK
59 

10 ‘‘Helman v. Department of Veterans Affairs, No. 15–3086 (Fed. Cir.).’’ Loretta E. Lynch to 

Patricia Bryan, Senate Legal Counsel. May 31, 2016. Office of the Attorney General, Washington, DC. 11 5 U.S. Code § 7513 12 Ibid. 

ability Act of 2014 found that vesting final decisionmaking authority in an ALJ 

violates the Constitution’s Appointments Clause and is, therefore, invalid. 10

Given this recent decision, we recommend amending the language in S. 2953 

to send appeals to the full Merit Systems Protection Board. This change will 

sidestep the current legal challenges as well as bring to bear greater resources 

in the adjudication of IHS appeals. 

• Align Accountability Provisions with Current Law—We believe the bill can better address concerns over fairness through greater alignment with existing law. 

First, an employee facing a major adverse action such as demotion and removal 

from the civil service should have 30 rather than ten days of written notice. 

This change would align the bill with current law and provide employees more 

time to prepare a meaningful response to the agency’s action. 11 Second, the language granting the Secretary authority to remove an employee from the civil 

service, if the Secretary determines that the performance or misconduct of the 

employee warrants removal, should be amended to state that the personnel action will promote the efficiency of the service. This addition will align the bill 

with current statute. 12

• Provide More Flexibility in the Use of Administrative Leave—The Act states that 

the agency cannot place an employee appealing a personnel action on administrative leave. We recommend changing this language to allow the agency to 

place an employee on administrative leave with the approval of the Director of 

the Indian Health Service. There may be rare instances when it makes sense 

to use administrative leave, such as if an employee poses a threat to themselves 

or other employees, if their presence would result in loss or damage to government property, or if the employee otherwise jeopardizes legitimate government 

interests. It also may be appropriate to remove an employee from the worksite 

in situations where an investigation is taking place and the agency does not 

have all the facts. In any case, the use of leave should be limited and transparent. 

• Sharing of Senior Executive Personnel Files Raises Privacy Concerns—We are 

concerned that language in Section 4 of the proposed legislation making available a senior executive’s employment record to tribal organizations may present 

privacy concerns. Further, the knowledge that individuals from outside the 

agency will review an executive’s records may lead to a reduced willingness on 

the part of managers to put clear and candid information in files. We do recognize, however, the importance of transparency with the customers of the IHS, 

and urge the Committee to consider alternate ways to transmit and share information about the senior executives responsible for leading Area offices or Service units with tribes in a manner that does not compromise privacy. 

• Require a Performance Plan for the Director of the Indian Health Service and 

Other Political Appointees—Career employees and executives undergo a performance planning and appraisal process every year. Political appointees should 

be required to participate in a similar process. For example, as the highest level 

of leadership in the Indian Health Service, the Director plays a crucial role in 

providing leadership and setting priorities. In 2015, the Indian Health Service 

ranked just 271 out of 318 agency subcomponents in employee satisfaction with 

senior leaders. Appraising political leadership on and holding senior leaders accountable for setting expectations and developing an empowered and engaged 

workforce can improve satisfaction and help accountability cascade throughout 

the organization. Leaders should be rated on efforts to promote best practices 

and efforts to recruit, select and retain talent, engage and motivate employees, 

train and develop future leaders, and hold managers accountable for managing 

performance and dealing with poor performers. 

Hiring Reforms are a Good Start, and the Committee Should Go Further 

We are pleased to see the Committee demonstrate a strong commitment to addressing the Indian Health Service’s long-standing workforce challenges. Inspiring 

and hiring a new generation into public service is a core part of the Partnership’s 

mission; we believe agencies must have a more flexible and responsive hiring process that more effectively locates and assesses talent. For this reason, we believe the 

ideal solution is comprehensive hiring reform that places agencies on a level playing 

60 

13 United States of America. Government Accountability Office. Indian Health Service: Actions 

Needed to Improve Oversight of Patient Wait Times. Washington, DC: Government Accountability Office, 2016. 21. 14 ‘‘Reexamining the Substandard Quality of Indian Health Care in the Great Plains’’, 114th 

Cong., 9 (2016) (testimony of Robert McSwain, Principal Deputy Director, Indian Health Service). 15 United States of America. Congressional Research Service. The Indian Health Service (IHS): 

An Overview. By Elayne J. Heisler. Washington, DC: Congressional Reserach Service, 2016. 16 United States of America. Government Accountability Office. Indian Health Service: Actions 

Needed to Improve Oversight of Patient Wait Times. Washington, DC: Government Accountability Office, 2016. 23. 17 United States of America. Government Accountability Office. Health Care Workforce: Federally Funded Training Programs in Fiscal Year 2012. Washington, DC: Government Accountability Office, 2016. 21. 18 United States of America. Government Accountability Office. Indian Health Service: Actions 

Needed to Improve Oversight of Patient Wait Times. Washington, DC: Government Accountability Office, 2016. 23. 19 2011 Clinical Staffing and Recruiting Survey. Report. Merritt Hawkins. Rockville, MD: Indian Health Service, 2011. 20 United States of America. Government Accountability Office. Indian Health Service: Actions 

Needed to Improve Oversight of Patient Wait Times. Washington, DC: Government Accountability Office, 2016. 23. 21 ‘‘Human Capital Management Hiring Reform.’’ U.S. Office of Personnel Management. 

Accessed June 27, 2016. https://www.opm.gov/policy-data-oversight/human-capital-management/hiring-reform/#url=Hiring. 22 ‘‘Improving Accountability and Quality of Care at the Indian Health Service Through 

S.2953’’, 114th Cong., 11 (2016) (testimony of Mary Smith, Principal Deputy Director, Indian 

Health Service). 

field with each other and, to the extent possible, with the private sector. Hiring improvements should be combined with marketbased compensation that grants agencies the flexibility to set salaries the way any private sector organization would. 

While the Indian Health Service is not alone in its struggles to recruit, hire and 

retain specialized talent—organizations such as the Department of Veterans Affairs 

face similar difficulties—its challenges are nonetheless significant and require action. 

The Indian Health Service faces two major hurdles in bringing in the talent it 

needs: recruiting medical professionals to remote locations and compensation below 

comparable private sector levels. The numbers paint an alarming picture of the Indian Health Service’s success in addressing these challenges. GAO’s March 2016 report, Indian Health Service: Actions Needed to Improve Oversight of Patient Wait 

Times, reported that according to the IHS 2016 budget justification, the agency had 

over 1,550 healthcare professional vacancies in the system. 13 In testimony before 

this Committee in February, Robert McSwain, Principal Deputy Director of the Indian Health Service, reported that the Great Plains Area is facing a physician vacancy rate of 37 percent. 14 In 2014, the system-wide vacancy rate for physicians and 

nurses was 20 percent, and 650 separate IHS facilities reported provider shortages. 15 On the compensation side, the IHS starting salary is roughly a third of what 

providers can earn elsewhere. 16 And while IHS offers some loan repayment and 

scholarship programs for medical professionals, they are underfunded and underutilized; in fiscal year 2014, over 500 applications for loan repayments were denied due 

to 17 limited funds. 18

The Indian Health Service faces recruitment and hiring difficulties by nature of 

the location of its facilities and compensation structure, but the agency’s hiring process exacerbates these challenges. A 2011 report by Merritt Hawkins found that ‘‘paperwork/red tape’’ was the factor having the most negative effect on clinician turnover at IHS facilities. 19 The Department of Health and Human Services FY 2016 

Annual Performance Plan and Report stated that the IHS average time to hire was 

114 days as of 2014. GAO found that at one Navajo area facility, the length of the 

hiring process averaged 190 days, with some hires taking as long as 738 days. 20

These figures are well above the target of 80 days laid out by the administration 

as part of its 2010 hiring reform effort. 21 The most recent FEVS data shows that 

only just over a third of IHS employees believe their work unit can recruit people 

with the right skills—below the government-wide score. IHS is reportedly working 

to re-engineer its human resources, deploy new strategies and tools to recruit medical professionals, and better utilize external partners to build its workforce. 22

These are, taken together, an important step in the right direction, and we encourage the Committee to maintain its focus on the organization’s human capital needs. 

The Indian Health Service Accountability Act of 2016 includes some important 

and meaningful reforms that we believe will have a positive impact on the agency’s 

outstanding recruitment and hiring challenges. In particular, we applaud the ComVerDate Mar 15 2010 10:23 Jan 05, 2017 Jkt 023226 PO 00000 Frm 00064 Fmt 6601 Sfmt 6621 S:\DOCS\23226.TXT JACK
61 

23 Ibid. 

mittee for authorizing direct hiring at the Indian Health Service and expanding 

market pay under Title 38 to IHS medical professionals. The Partnership advocated 

for both reforms in our 2014 civil service reform report. Allowing the IHS to request 

waivers for Indian Preference if the agency cannot otherwise access the talent it 

needs is also a good idea, and the Committee should consider offering this flexibility 

to other agencies, such as the Bureau of Indian Education, with similar recruitment 

and hiring difficulties. The additional recruitment and relocation incentives should 

be helpful tools as well. 

To further improve the bill’s hiring provisions, we urge you to think about what 

more can be done. We recommend the Committee consider language allowing the 

IHS to rehire former employees noncompetitively at any grade for which they qualify. Currently, agencies can only reinstate former employees at the last grade they 

held or below. This limited reinstatement authority means that qualified medical 

professionals who have left the agency and gained valuable experience outside of 

government may not be considered for noncompetitive reinstatement to a higher 

grade. It is in the government’s interest to allow the IHS to have this option as an 

additional weapon in its arsenal to recruit former employees who may otherwise not 

return to federal service. Finally, the IHS should work with OPM to figure out how 

the agency can utilize the Competitive Service Act of 2015, enacted into law earlier 

this year, to reach talented individuals who were interviewed and rated by other 

agencies but not hired. This law gives the IHS the ability to access a broad pool 

of vetted talent from across government. 

Recommendations 

In addition to the ideas offered above, we would like to make the following recommendations to strengthen the recruitment, hiring and retention provisions of 

S.2953: 

• Expand upon GAO Report on IHS Staffing Needs—The Partnership supports 

the bill’s provision requiring a GAO report on Indian Health Service staffing 

needs. Making wellinformed decisions about how to address IHS workforce challenges requires accurate and up-todate information. Towards this end, we believe GAO’s report could be made even more useful. The Committee should request that the report also look at current legislative and regulatory barriers to 

more effective hiring at the IHS, current demographics of the organization’s 

workforce, use of existing recruitment and retention tools and the state of workforce and succession planning at the agency. Specifically, does the IHS know 

who in the workforce is most likely to leave, what actions the agency is taking 

to address skills gaps and retain key talent, and what the agency is doing to 

transfer institutional knowledge? 

• Use the IHS Staffing Plan as an Accountability Mechanism—Requiring the 

agency to develop a plan to address its staffing needs is a useful initial step. 

We believe the Committee can increase the value of this plan further. First, the 

IHS should be required to deliver the report within three to six months of the 

completion of GAO’s study, rather than a full year. Given the need for drastic 

and immediate change at the IHS, a year is simply too long to wait. Second, 

the report should be recurring either for a set number of years or until the 

agency reaches a milestone determined by the Committee. Regular reporting on 

the recruiting, hiring and retention strategies of the IHS, combined with data 

on the agency’s success in meeting the goals it has set for itself, will act as a 

meaningful measure of accountability both for the organization and for this 

Committee. The IHS staffing plan should also include, in addition to the responses to GAO’s recommendations, how the IHS plans to work with other federal agencies and external organizations to improve recruitment and hiring, an 

evaluation of the agency’s success in meeting hiring goals, and how the organization will utilize local talent sources. The IHS is reportedly looking at how to 

do these things already, and should integrate this information into into the 

staffing plan. 23

• Implement an Exit Survey at the IHS—One of the best ways an agency can inform its recruitment and retention strategies is to understand why employees 

are leaving in the first place. We believe a voluntary exit survey would provide 

the IHS with useful data to help it retain key talent. These data should then 

be made available to all IHS human resources staff and hiring managers. IHS 

could also be required to report survey data to the Committee and held accountable for taking actions to improve. 

62 

24 Ibid. 25 ‘‘Hiring Excellence.’’ U.S. Office of Personnel Management. Accessed June 24, 2016. http:// 

www.opm.gov/policy-data-oversight/hiring-information/hiring-excellence/. 26 ‘‘U.S. Office of Personnel Management—Ensuring the Federal Government Has an Effective 

Civilian Workforce.’’ FedScope Home Page. Accessed June 24, 2016. https:// 

www.fedscope.opm.gov/. 27 Rein, Lisa. ‘‘Millennials Exit the Federal Workforce as Government Jobs Lose Their Allure.’’ 

The Washington Post. 16 Dec. 2014. Web. 2016. 

• Collect Data on Hiring Process Outcomes—If the Indian Health Service is to improve its hiring process, it must be able to measure outcomes and hold itself 

accountable for improvement. There are several sets of data which the Partnership believes are key to the IHS wrapping its arms around the state of its hiring process: information on the use of special hiring authorities and flexibilities, 

time-to-hire data disaggregated by internal and external hires, manager satisfaction with the quality of applicants and new hires, and satisfaction of applicants and new hires with the hiring process. The IHS should ensure that this 

data is being collected and shared consistently, and is being used to make 

meaningful process improvements. The IHS is reportedly taking proactive steps 

to ensure broad and diverse applicant pools, and we believe this data will greatly enhance that effort. 24

• Provide Training to Managers and Supervisors on Hiring Authorities and Flexibilities—The Committee should consider language requiring training for both 

human resources staff and hiring managers on how to use these new tools, as 

well as how to maximize current authorities and navigate Indian Preference, to 

enhance the effectiveness of its hiring process. As part of this, the agency 

should identify ways that it will educate its staff on how to improve recruitment 

and hiring practices. OPM’s ‘‘Hiring Excellence’’ campaign is already traveling 

the country offering in-person and virtual sessions to help federal agencies ‘‘foster collaboration and the strategic use of recruitment and hiring tools.’’ 25 However, given the unique nature of the Service’s work and its many agency-specific 

hiring authorities, additional training and education for employees would be 

warranted. Managers should then be held accountable for their efforts to bring 

talent into the organization; other agencies, such as the National Protection and 

Programs Directorate within the Department of Homeland Security, already do 

this. 

• Better Utilize Student Interns as a Pipeline for Entry-Level Talent—According 

to data from the OPM FedScope database, just under seven percent of IHS employees are under the age of 30. 26 Compare this to the US workforce as a 

whole, in which workers under 30 make up 23 percent of the total. 27 The Pathways internship programs, created in 2010, allow agencies like the Indian 

Health Service to noncompetitively convert program participants to full-time 

federal employment from any federal agency as long as the individual meets the 

eligibility requirements for conversion. Given this authority, we recommend 

that the IHS work with the Department of Health and Human Resources and 

other agencies to create lists or platforms that allow it to access this talent pool. 

The Committee should also codify Pathways conversion authority for third-party 

and unpaid interns in undergraduate and graduate programs at the IHS. As of 

now, interns hired to work in government agencies through third-parties like 

the Washington Internships for Native Students Summer program hosted by 

American University can only credit half their hours towards conversion to a 

full-time position, despite the fact that they are performing substantially the 

same work; unpaid interns receive no credit at all towards conversion. The 

Committee should also look at expanding AmeriCorps noncompetitive hiring eligibility to encourage former AmeriCorps members to join IHS. Each of these reforms would expand the pipeline of proven entry-level talent entering the IHS 

and are especially critical given the overall lack of young talent at the agency. 

Chairman Barrasso, Vice Chairman Tester, Members of the Committee, thank 

you for providing me the opportunity to share the views of the Partnership for Public Service on this important piece of legislation. I look forward to further engagement with this Committee on how to strengthen the workforce of the Indian Health 

Service. 

63 

PREPARED STATEMENT OF HON. JOHN YELLOW BIRD STEELE, PRESIDENT, OGLALA

SIOUX TRIBE


617b1.eps
64 


617b2.eps

respon~ibility belongs to the Unito:d Stales federal government as a wholt:. The evidence is clear 

that the JH3--and as a result, the United States-is failing at that task. 

w~ thank th~ Committee for holding this field hearing, and we applaud Chairman 

Barrasso and Senator Thune for the introduction ofS. 2953, the Indian Health Service 

Ac~ounta.bility Act of2016. Th~s~ steps and your leaderehip arc sorely noodcd to address this 

very serious emergency, and the Oglala Sioux Tribe appreciates your efforts to bold the IHStmd indeed the federal government as a whole-accountable to deliver on the promise of qllality 

health care for our people. As it smnds, the Pine Ridge Hospital is not a functioning facility that 

is cnpable of meeting even the ba.~ic health care needs of Ollr community. On top of the 

mismanag~ment problems that have been well highlighted by reports and witness testimonies 

before this Committee, our hospiml fudlity is only utilizing a portion of our inpatient beds, and 

our intensive care unit is not even operational, due to funding, staffing, EU!d equipment shortages 

and despite tho high level ofunmot health care needs on our Reservation. This situation is 

unacceptable; falls far short of the federal government's treaty obligations to our Tribe; and must 

be addressed. 

S. 2953 wuu{d take impoFtUJ111'iteps to implement needed reformr. 

We are ple~sed to see th~t S. 2953 seeks to address several of the specific problem~ thllt 

the Oglala Siou;.: Trib~ hrus rai~ed in past testimony b~fore this Commillee. 

EmployeeAcr:ountability. Th~ Oglala Sioux Tribe testified in February, for example, 

that poor management practices and the "recycling" or shuffling of problem employees persists 

\IIi thin the Great Plains Area, rus docs the usc of administrative leave in lieu of more appropriate 

action like demotion and firing. Simply put, the !HS is not accountable if its employees ure not 

held accountable. S. 2953 seeks to address this mismEli!agement problem by enhancing the 

Secretary's authority to hire, fire, demote, !l.lld reward employees based on po;:rformancc; by 

prohibiting any f0l111 of paid administrative leave during an appeal ofWJy demotion, or payment 

of any rntc increase, award, bonus, or other benefit during an appeal of any removal; and by 

assessing and beefing up whistlcblowlll' protections within the IHS. The Oglala Siollx Tribe 

supports thew reforms, and emphasizes the imporl3llce oflJualified EU!d accmmmble leaderehip 

within the OIS and the Department of Health and Human Services, ns well ns strong ongoing 

Congressional oversight, to ensure that these authorities are appropriately utilized to fulfill the 

United Stntes' trust responsibility to provide our tribal members with quality health care. 

Stoffmg and HotJSitrg. The Oglala Sioux Tribe bas also testified that insufficient staffing 

is a serious problem impacting both access to and tho qu~lity of health care services in the Great 

Plains Area. There are many factors that contribute to this staffing problem, including 

mlsmunugement, uncompctitive salarie~, unattrective and underequipped facilities, the rural and 

isolated location of our facllltics, Jack of housing Wld other infrastrucwre, and many others. S. 

2953 wollld take steps to address some of the~~ 8p~cific factors--including staff housing, 

through a GAO study and housing pb:m as wdlas a housing voucher program in shortage 

areas--and by commissioning a GAO srudy on IHS staffing needs. We believe such a report 

could be an important tool in improving patient care, provided the report considers all ofthe 

intem:lated factors contributing to the staffing problem within the JHS, is completed promptly, 
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and i~ followed by concrete steps to address those contributing factors. We would also refer this 

Committe" to our Fcbrufll)' tc5timony, which notes the lack of housing on the Pine Ridge 

Reservation ror health care and other professionals. While a housing voucher program could be 

useful, it will only be successful in combil1lltion with the development ofhousing infr<IStructure 

in the vicinity of our hospital and clinic fucilities, as well as our schools, which are also in need 

of nurses und mental and behavioral health professionals. 

Streamlinetli!iring Aut!Jorit;J!. We are nlso happy to see that S. 2953 recognizes the 

need to streamline the hiring process within the JHS. We are somewhat concerned that. whileS. 

2953 removes time·consuming civil service hiring requirements for IHS employees, it does not 

provide an alternate system to ensure that the IHS fdlows a fair and impartial procllSS to hire 

qualified candidates, ;md may be overbroad by including all categories of employees (e.g., 

groundskeepers, maintenance, accounting stam. We note till! H.R. 5406, the Helping Ensure 

Acoountability, Leadership, and Trust in Tribal Hcalthcarc (HEAL TTl!) Act, V.'Ould ai!QW the 

Secretary to utilize, in place of the civil servkc requirements, VA hiring authorities set out in 

existing law in the hiring of employees for positions involving direct patient services or services 

incident to direct patient-care services (in other wtJTds, health care professionals). We nrc not 

certain that these authorities have succeeded in resolving recruitment ;md retention problems for 

the VA, but we do believe that careful attention should be paid to the question of what alternative 

hiring processes and procedure::; should be followed by the Secretary, and it may be helpful to 

draw from existing models. 

Consultation in Hiring. S. 2953 would also rBquire the Secretary to c(lnsult with Indian 

tribes located in the service area before hiring or transferring senior executives or top managers. 

This is a very importnnl step to emurc transparency ami accountability in IHS hiring decisions. 

Tho Oglala Sioux Tribe has testified previously to the need for the Tribe to be notified of;md 

involved in ti1c candidatl! ~election process when the Area Office is listing and filling job 

vncnncies. 

Transparency in Fbzancial MllJlagemeNt. The Oglala Sioux Tribe has similarly testified 

thrrt the IHS must improve tr;mspar~ncy with respect to finMcial mrmo.gcmcnt. From the Tribe's 

perspective, we !mow only that very little funding seems to reach the facility level for direct 

patient care. \Vhat we currently lack is information necessary to deterrnirn:: the extent to which 

those funding inadequacies are the result of poor mMagement decisions at the Area Office level 

and whether the Area Office is appropriately managing its funding to maximize patient care. S. 

2953 responds to these concerns by requiring the Secretary to provide a report to Congre~s and 

Tribes each quarter of a fiscal year describing spending and outlays at each level ofthe 11-!S, and 

by limiting how the Secretary can spend unobligated funds at the end of the fiscal yllar. 

In addition to these measures., the Oglola Sioux Tribe would like to see tribal oonsultation 

on the allocation of funding for the Pine Ridge Sen•ice Unit, not just unobligated funds. 

Furthermore, the report provided to Congress in Section 9 (609) (c) of the bill must also include 

a requirement that ITJS report on the amount oflhird party resources collectr.:d by facility and 

service unit, and how those f1mds lire being used to improve patient care in that service unit. 

Section 40i(c) of the Indian Health Care Improvement Act, 25 U.S.C. 1641 (c) requires the IllS 

to ensure that each service unit receive 100 percent of an>' third party resources it collects. 
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Pcr25 U.S.C. § !64l(c)(l)(B), third party collections are ptimruily to be used "to achieve 

or maintain compliance with applicable conditions and requirements" of the Medicaid and 

Medicare program:;, Ifthere are amounts collected in excess of what is needed for this purpose, 

such collections shall be used "subject to consultation with the Indian tribes being served by the 

service unit ... , for reducing the heEilth resource deficiencies (as determined in section 162l(c) of 

this Iitle) ofs1wh Indian tribes." In addition, Section 207 of the IHCTA, 25 U.S.C. 162lfrequircs 

third party resources collected at the ~ervice unit level to be credited to the service unit and used 

for the provision of health services. 

TI1e Tribe has reason to doubt that third party collections at the Pine Ridge Service Unit 

have been left at the Service Unit and used to pwvklc hc·olth ~ervices at the service unit level nnd 

to meet Medicare and Medicaid conditions ofparticipation. First, as has been well documented, 

the Pine Ridge Hospital is not currently meeting Medicare conditions afpnrtieipation dc~pite the 

fact that we understand that it does collect third pllrly resource~ from the Medicaid and Medicare 

prosrams. Second, the lHS recently used $50 million in third p!irty colle~tions to pay an 

administrative senlement of a union srievance in arbitration. 1 The Tribe challenged the IHS in 

court over the use of the $50 million in third party collections to pay for the settlement as 

unlawful under the !HCIA. Unfortunately, we did not prevail on the temporary restrainins ord~r 

and the IHS moved forward !Uld e:-:pended the funds to settle its union grievance. We remain 

gravely concerned by the fact that there was such a large ammmt ofthird party collootions 

readily available to the IIIS that was not being used for maintaining compliance or ror reducing 

health resource deficiencies at the service uni1level as already mandated by Congress in Sections 

207 and 401 of the IHCIA. Thus, we ask that S.2953 require the IHS to include an accounting of 

third party re~o= collections and expenditures 3\ the service unit level in the reports required 

by Section 9 of the bill. 

Mrmitoring Quality of Care. Much of the Oglnla Sioux Tribe's prior testimony, of 

course, has focused on the shockingly substandard quality of care provided in the Great Plain~ 

Aroa. Part of the quality of care problem nt the Pine Ridge Hospital has bun the lack of any 

transparent or functioning system to handle patient grievances. S. 2953 would require the 

Secretary, in consultation with the Inspector Gcn~ral, to establish a program within the rHS to 

monitor !he quality of patient care, and would require the Office of the Inspector General to 

conduct an audit of!HS reporting systems and lo provide recommendntions and teclmical 

assist!UlCe to improve those systems. The bill also addresses transparency by requiring the 

Secretary to provide quarterly reports to Congress and Tribes on the safety, billing, certification, 

credential, and compliance statuses of each IHS f3cility llnd to publicly post materials relating to 

patient snfety nnd compliance. The Oglala Sioux Tribe supports these measures, and hopes thltt 

quality improvement efforu will in~orporate re~ponsive patient grievance processes and 

procedures at the facility level. 

1 The serrtemenl had two eolegaries: $'60 million for hack pay !ltld baek pay-rol•tod eos1s (such as payrollloxes), and 

S20 million for adminisln!tive coots and anomoys' foos. $SO mfllion oflhe$60 million omo"nlwos poid fron11ilird 

panycollections ond SIC million from =piN<! appropriations. Tho S20 million W"" paid !'rem then ourronl FY2015 

approprialiono. 
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Funding is o. necessary anrl inlegral compo11entofsucr::es!>ful IHS refonn. 

Of course, we are anxious to share with you severn! additional meusure.~ we woulll like to 

ace taken to improve accountability and quality within the IHS system, some ofwhieh are 

absolutely critkcl to the health and safety of our tribal members. w~ understand that your goal is 

to take a comprehensive approi\Ch to address this crilis, and we hope th:!t this testimony will help 

you to achieve that goal. 

One oflhc most significant impelliments to successful reform of the IHS and achieving 

qmUity health care for Indian people is the severe funding shortage faced by the system. The 

National Tribal Budget Formulation Workgroup recently estimuted that the full funding need of 

the IT-IS is appro;dm!ltely $30.8 billion, but the agency's FY 2016 enacted funding level was only 

S4.8 billion. Though reforms to IHS management practices, hiring, transparency and 

accountability measures are critical, we cannot expect the system to function well with only a 

fraction of the resources it truly needs. The impacts ofinsufficicnt funding arc felt throughout 

the system-from r~ruitrnent and ret~ntion, to faciEties and equipment, to the SC()])e and quality 

of care. Quit~ simply, the system is star~ing. Whllc the Oglala Sioux Tribe recognizes that S. 

295J is not an appropriations bill, it must recognize the significance oflHS funding needs by 

authorizing sufficient funding to carry out the refonns it soxks to implement in a successful 

manner and by taking other measures to ease the IHS funding burden where possible. Moreover, 

w~ ask fur lt:adership and support from this Commill~e and individual Members throughout the 

appropriations procesf:. The fund!ng problem is part and parcel of these reform efforts and cannot 

be ignored. 

Purchased/Referred Care mus1 befu/Jyfunded. For example, the Purchased/Referred 

Care or "PRC" program is a crucial aspect ofthe IHS system, but it is failing our patients, at 

least in the Great Plains Area. Again, a large part of this problem is funding. ·n1e PRC program 

is intended to eru;ure access to primary and specialty health care services that the IHS is unable 

to provide in its own facilities ami must purchase from outside providers. Funding for the PRC 

program is so limited, however, that care is frequently ratio;med and limited to ~mergency "life or 

limb" situations. On Pine Ridge, even these emergency "priority 1" cas~~ arc ~om climes rejected 

by the IHS due to funding constraints. The Oglala Sioux Tribe has previously testified that tribal 

members routinely fOrego necessary medical care because the illS refu~es to p~y through PRC. 

In the alternative, if these patients do seek the care. they often find themselves in fmandal crisis 

because the lHS will nuL ~over the costs. 

This is no way to run a health care sy!>1em. It incumbent on the Unit ell States as our 

trustee to ensure that preventive and primary and specialty care ls available to our pntients before 

their conditions become chronic or life-threatening. Not only is that the only humane lllld 

rc~-ponsible approach, but rntioning and delaying nan: until a health condition becomes an 

em~rgency me110s that condition will be significantly more costly Wld difficult to trent. 

Improving i'llld fully funding the PRC system is a tQp priority for thB- Tribe and must be a 

part of comprehensive reform efforts. "Prioritizing" Jlmited funding is not enough. llmugh 

fully funding the PRC system would require an up-front invt)!;\ment, the return would be 

substantial in terms of health outcomes :md system efficiency. 
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M!!dir:a~Lik~ Rar~.r. Increased PRC appropriations are absolutely necessary, but there 

are other legislative measures that could help, Extending Medicare-Like Rates W non-hospital 

PRC services, for example, would greatly increase the efficiency of the PRC program. In 2013, 

the GAO released a report finding !bat extending Medicare-like rates to non-hospital PRC 

services would save the IHS approximately $32 million per year, which could be us~d to pay for 

nocdcd services that the IHS must now deny. The IHS has recently adopted and is now 

impl=.enting regulations to this effect, but they have no teeth because the IHS cannot condition 

provider participation in Medicare on the acceptance of these mtes fi:om the IHS. In the absence 

ofthot enforcement mechanism, which only Congress can provide, access to eru-e concerns arise 

in aro::as where providers may simply decline to see PRC patients at the lower r,;tes. A bill to 

extend Mcdiclll'll-Like Rates was introduced in the last Congress, H.R. 4843, that was strongly 

supported by Tribes and would be appropriate for inclusion in a comprehensive IHS reform bill. 

Fundi11g is needed for transportation and expanding the )'COP~ oflocalliervice.r, 

Another significnntpmblcm for health care in our area is transportation. The Oglala Sioux Tribe 

lrns previously testified before this Committee on the high costs assrteiated with transporting 

patients to locations where primary and specialty care that cannot be provided at our hospitals 

and clinics is available. Again, due to funding constraints, the IHS docs not alwa:r.; pay for these 

costs and our patients do not have the resources. The Tribe frequently ends up covering 

transportation costs associated with medical care, which diverts tribal funding that is badly 

needed for other purposes. Dedicated, full funding for transportation for health care referrals is 

necessary to assure ucc~ to cure. In addition, enhancing the capacity of local 11-!S facilities like 

the Pine Ridge Hospital to provide the full range of primary care se:rvices to their fidl patient 

population and expanding the scope of specialty 011re avoilable ot those local facilities wo\lld cut 

down significantly on e:-:pcnsive patient travel. This, of course, would require funding fOr 

increased staffing, improved facilities, and n~cessary medical equipment. 

Funding i\' ne~de:dfvr medical equiPmenr andjacf((tle.r, In February Councilwoman 

Little Hawk-Weston testified to the fact that the Pine Ridge Hospital lacb not only staff, b11t also 

lhcility space and equipment nr;!Cessary to meet health care demands. The Pine Ridge Service 

Unit has docwnented a need for, among other things: fetal monitoring systems, telemetry 

systems, wrgery light~, a nur~e call system, dentcl choirs nnd equipment, and IV pumps. Some 

of this equipment is critical and could mean the diffcrene<! between life or death in a patient 

emergency. Additionally, the space is inadequate to hnndlc the hospital'~ user population. The 

IHS Service Unit profile shows that the Service Unit currently services a user population of 

51,227 in a space designed for a user populruion of22,000. And, as noted previously, not all of 

the existing space is even being utilized, because we lock the stoffand equipment nectiSS~ry for 

operations. 

Funding to ensure that our Il-lS facilities ru-e edequate and hove the necessary equipment 

to provide needed services is an integml part ofen~uring that the IHS is meeting its duty to 

provide competent, quality care. The Tribe has also pointed out in prior testimony that these 

facility and equipment shortcomings are yet another contributing factor to the shortage of 

qualified staff, which is something that S. 2953 specifically seeks to address. Competent, 

qualified staff do not want to work in a facility when:: they lack the tools necessary to do their job 
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or wh~r~ their job is m~de harder (or even impossible) by alack ofresources. Again, these issues 

arc. interrelated, 1Uid must a!! be considered together if comprehensive reform of the II·JS is to 

become n reality. 

Authorizations and appropriations are needed to fully fund the PRC progrnm; to cover 

transportation costs when p~tients must be referred out to far-away facilities; to bring cur 

facilities and equipment up to dalll and in line with th~ level of need; to fund recruitment 1Uid 

retention measures including housing, salaries and bonuses so the IHS is able to attract and 

maintain qualified professionals; and lO incre!!Se the scope of services the IHS is able to provide 

at a local level. All ofthEl!le are costs, but they are purl ofthe Fed em! Government's trust and 

treaty responsibilities to Indian people and they are necessary ta achieve anything more than a 

quick-fix, Band-Aid rcsporure to this dire crisis. Moreover, they will reduce suffering and result 

in ~ignificnnt long-run savings by creating healthier tribal communities and reducing the highcost chronic ;md emergency health conditions that me so prevalent among our P\JOplc today. Our 

current approach is not sustainable and must be remedied. 

Leveraging otlrer federalfrmlling woufd help. Variou~ other measure~ ~ould aiso help 

to ease the funding burden on the IHS system. Dire<:ting resources to maximi~e Affordable Care 

Act enrollment, for exnmple, would provide a return by boosting third party revenues to the IllS. 

So would Medicaid expansion under the Affordable Care Act or State waiver or demonstmtion 

programs that leverage the newly-expanded CMS policy on I ml"A> federal matching for service.> 

to American Indians and Alaska Natives. In fact, this Committee could hold ;m oversight 

hearing to invcstigatll whether CMS is doing everything it can to allocate its resources to 

improve health care for American Indian and Alaska Native ben~liciaries and to assist then-IS in 

doing so. We have seen CMS criticize and penalize the IHS for compliance violations-action~ 

that are wammted-but is CMS, another federal agency that also owes n trust duty to Tribes, 

doing aU it can to help remedy the situation? rue there additional Medicare and Medicaid 

resources that CMS or Congress could direct to the [ndian health system, like the recent 

expansion of 100% federnl matching ta cover certain trans])\Jrtation costs? 

Advance Appropriations wrmfd assist lnjlnanclal planning and stability. Furtlu:r, 

although advance appropriatio!lll alone would not increase IHS resources, it would promote 

stability and permit bcller, smarter budg6llll'Y planning. It would also help with hiring and 

retention as the JHS would know what funding is availablo for those purposes ahead of time, and 

employees would not be impacted by agency funding interruptions to the same degree, For all of 

thes~ reasons, Tribes have been advocating for advance appropriations for IHS for several years. 

Maximi.zUlg third party n<Wnue mu£1 be a priority. Finally, the Oglala Sioux Tribe is 

not convinced that IHS staff are sufficiently trnincd in collection of third party revenues, and is 

o;:on~emed that service unit inoome and budgets suffer because of that, We would propose a 

study and report to determine whether the IHS is maximizing the recovery ofthlrd pnrty 

resour<:es at all a fits fudlities, and if not, why not, and wh~t steps can and 5hould be laken to 

ensure that reimbur5ement dollar5 are not left on the table. 
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AdditWnal metESures must be taken to improve ucccuntabiJjty and quulity uf cure. 

Though a Jack of funding pcnncates every .aspect of our health care crisis, there are other 

specific measures that are not currently addressed inS. 2953 that the Tribe feels should be part of 

comprehensive reform. 

Expand local uccen- to lligh-demand services. Again, we need to expand local access to 

scrvkcs, including specialty care for which there is~ high level of need in our community. 

Psychiatric care is a prime example: in February, CouncilwomWJ Little Hawk-Weston testified 

before this Committee thnt the Pine Ridge Hospilull~cks adequate psychiatric facilities to serve 

the patients with severe Md immediate psychiatric n2eds that come into the hospital on a daily 

basis. In light ofthe suicide crisis, trauma, lll!d substance abuse challenges affecting our 

RcscrYation population, it is hard to see how the IHS can expect to deliver comprehensive health 

care to our people without a psychiatric component. The same is tru~ for other specialties, such 

as respiratory care, which is in high d~mand but not available in our local facilities. 

Support for telemedicine, One way of dealing with the lack of access to specinlty cnre 

Md other challenges posed by our remote location istclcmcdicino. Duveloping our telemedidne 

and teleheahh capacity has boon a priority for the Trib~ WJd could be an important feature cfn 

reformed, more responsive, and higher quality hcaltb care dcliv~ry syst~m in the IHS. The !l-IS 

is already exploring telemlldicine possibilities, but legislative support Including authorizations 

fer appropriations, pilot projects or programs, and dtdicated funding would help to ensure that 

these efforts bear fruit. 

Ar!l!ounl/ug of tile Great Plains Area Office. The Tribe also believes that a fundamental 

reorganization of the Great Plains Area, including qdte possibly the elimination of the JHS Area 

Office altogether, may be needed, 1110n£h legislation is not n~coos~ary to undergo such 

reorganization, the Tribe has in the past had difficulty obtaining informution it needs from the 

Area Office to assess this question. For example, tb~ Area Office has refused to provide specific 

and acCurdte infonnation on how funding is allocated by the Office and why funding is withheld 

from the Service units, We need a full accounting of the funding received by the Area Office, 

how it i~ alloGatcd, it:> emp\oyc::C!i, programs, and whnt fWlcliuus th~ A.-<.:u OOiu.: :;crvcs. \Vc 

suspect that most of the Area Office functions could be delegated to the service lll1it level and 

tbat the Area Office could operate with only a skeleton crew. We do note that the IHS has 

recently initiated ronsultation on tllis question and appears open to discussing the possibility of 

r~orgnnization. We appreciate that step, but a Congr::ssiona11y·mandated Cl)mprehensive 

accotmting of the Area Office could be a great help. 

I would also like to briefly address some ideas that have been raised by otlt~rs for 

inclusion In IHS reform legislotion that the Oglala Sioux Tribe would support: 

Mandatory employee drug testbzg. Last week, Representativ~ Nollm introdnced H.R. 

5437 to implement a mandatory random drug te~tingprogram for IHS employees. While we 

have not had an opportunity to review the text ofH.R. 5437, the Oglnla Sioux Tribe strongly 

suppruts mandatory drug testing not just for IHS ma~agcment, but fur allJHS employees, We 

understand that the VA nti!izes pre-employment drug testing as well as rMdom employee drug 
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testing in its fucilities, and the same slmuld be tnlc of the lHS, Health profcssionnls should not 

be reporting for duty while under the influence of illegal substances. 

Addressing pmient wait times. Representat:ve No em has also introduced an IHS reform 

bill, H.R. 5406, which includes provisions in respr:mse to long wuit timt:s for servict:s ~t!HS 

hospitals. This has been !I major problem at Pine R:dge and is not directly addressed inS. 2953 

as currently drafted. H.R. 5406 would require the IHS to promulgate regulations establishing 

standards to measure timeliness of the provision ofJ~alth care Sffi'ices at IHS facilities and to 

develop a process for lHS facilities to submit data under those standards to the Secretary. The 

Oglala Sioux Tribe supports this requirement and mmld suggest that the Secretary be required to 

promulgate such regulations throU[;h negotiated rulemaking, to ensure that Tribes have 

meaningful input into those regulations. 

Exploring contracting optitJns wltiic mafntalni11gjedera/ responslbilJty. H.R. 5406 

would also create u pilot program to explore long-term contracting of JHS facilities, and S. 2953 

directs the GAO to consider the use ofindependentcontmetors to replace full-time equivalent 

employees nt the IHS in its report on staffinr: needs. The Oglala Sioux Tribe is not opposed to 

the consideration of new and innovative ideas to address deep-rooted and systemic problems, nnd 

perhaps other federal health cme contractin[: modt:!s exist and could offer solutions. However, 

we emphasize that the trust and treaty responsibility to provide health care to our tribal people 

belongs to the United Slates Federal Government 1111d cannot be contrncted out or privatized. 

Accordingly, while the Oglala Sioux Tribe wants a :1ealth care system thot work!- ond would be 

happy to see changes to the system that produce me:mingful results, the federal government must 

always remain nccountable to our Tribe and is ultimately responsible for carrying out it< xolemn 

t.rust duties and treaty commitments. 

Fin!!lly, we must recognize the eKtent to which our health core crisis is impacted by the 

other challenges we fuce in providing economic opportunity and other social services to our 

community members, W~ know that systemic poverty leads to poor health outcomes, and that 

our physical health is Impacted by our psychological health 11nd wel!beiug. Morwver, it is 

difficult to run a high-quality medical facility with tJp-notch staff in an isolated and 

economically depressed area. Though this bill focuses specifically on reforms within the JHS 

system, we must not lose sight of the importance of the federal government's other trust and 

treaty obligations to Tribes and tc the interrelationship nmong those obligations. 

Implemenrailon of15 U.S.C.1678a. The de>ignation of South Dakota und North Dakota 

as a single contract he11lth service delivery area (CIJSDA) is already in statute. However, the 

IHS is not implementing this provision. IHS's mgulations do not include the StHtes of South 

Dakota and North Dakota in its list ofCHSDAs. See Title 42 C.F.R. Section 136.22. 

25 U.S.C. 1678a, which was enacted over six years ago as part nfthe permanent authorization of 

tlu: Indian Health Care Tmprovement Act states; 

(a) In general 

The States of North Da.~ota and South Dakota shall be designated a.s a contract health service 

delivery area by the Service for the purpose of providing contract health care services to 

members of Indian tribes in th~;: States ofNorth Dakolll and South Dakota. 
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(b) Maiuten11nce of services 

Tite Ser~icc shall not curtail any health care ~ervices provided to Indians residins on any 

reservation, or in any oounty th~! has a ~ammon boundary with any reservation, in the State of 

North Dllko!a or South Dakota ifthe curtailment is due to the provision of contract services in 

those States pursuant to the designation of the States as a contract heEllth service delivery area 

by subsection (a), 

Implementation of this provision is not discretionary. Congress mandated that North 

Dakota and South Dakota be designated a single CHSDA, and as a result any action by JHS to 

deny services to any individu~l based on its pre-BXisting CHSDAs in those states is unlawful. 

Yet, IHS oontinues to deny services to in:lividuals throughout both States based on the 

geographic limitations in tho CHSD.As it established in those States prior to the ena<:tment of25 

U.S.C. §167En. 

The IHS has taken the position that it cannot implement 25 U.S.C. 1678a without further 

appropriations. But 25 U.S.C. 1678a is not dependent on additional funding. Rather, it imposes 

a mandatory statutory duty on the JHS to des.ign~le both North Dllkota !!Ild South Dakota a single 

CHSDA, 25 U.S.C. 1678a(a), and ellliure that there is no curtailment of service; to individuals 

living on or ncar a reservation in North Dakota or South Dakota as result of carrying ont 

Congress' directive that those stati!S should encamp= a single C[·[SDA, 25 U.S.C. \67Bo(b). 

The lHS's failure to implement 25 U.S.C. 1678a has had multiple negative effects 

throughout both States. Because the IHS continues to deny PRC authoriZI'Itions for Americen 

Indians living outside the pre-e:<isting CHSDAs, those iudividu~ls are forced to either forgo 

needed care, or seek care even if they lock the resources to pay for it. When there is no valid 

PRC authorization, those individuals may be Hable for the cost ofthat care. If they Cilllnot afford 

thll care, bo-th they and theirnon-IHS provider suffer. The American Indian's credit may be 

affcc!OO by bill collectors, and the non-IHS provider cannot receive payment for the services 

they have provided. The issue is compounded for emergency services because hospitals arc 

required under EMTALA to provide such services even when the individual seeking them cannot 

pay. 

S. 2953 should include a provision that directs the IHS to implement 25 U.S.C. 167Ba. 

Additionally, as the Pine Ridge Reservation inclndes a portion ofNcbraska we !lOW that the 

CHSDA for Nebraska remains the same. 

ImproYiug Consultation. Executive Order 13175 mandates that each federnl agency 

shall have an accountable proce~s to ~nsure meaningful and timely input by tribnl officials in the 

development of regulatory policies that ha~e tribal implications. Every President has reinstated 

E"'ecutive Order 13175 since President Clinton initially is:sued it in 2000. This Executive Order 

is regularly cited by Tribal governments to keep ngencles accountable and engaging with trib~s 

113 agencies develop policies that will affect tribes. However, the consultation proce~s is not 

always effective or followed to th~ l~ll.t:r. For instan~e. Section 3(c) of the Executive Order 

states: 
73 

1 USET SPF member Tribal Nations include: Alabama-Coushatta Tribe of Texas (TX), Aroostook Band of Micmac Indians (ME), Catawba Indian Nation (SC), Cayuga Nation (NY), 

Chitimacha Tribe of Louisiana (LA), Coushatta Tribe of Louisiana (LA), Eastern Band of Cherokee Indians (NC), Houlton Band of Maliseet Indians (ME), Jena Band of Choctaw Indians (LA), 

Mashantucket Pequot Indian Tribe (CT), Mashpee Wampanoag Tribe (MA), Miccosukee Tribe 

of Indians of Florida (FL), Mississippi Band of Choctaw Indians (MS), Mohegan Tribe of Indians 

of Connecticut (CT), Narragansett Indian Tribe (RI), Oneida Indian Nation (NY), Passamaquoddy Tribe at Indian Township (ME), Passamaquoddy Tribe at Pleasant Point (ME), Penobscot Indian Nation (ME), Poarch Band of Creek Indians (AL), Saint Regis Mohawk Tribe (NY), 

Seminole Tribe of Florida (FL), Seneca Nation of Indians (NY), Shinnecock Indian Nation (NY), 

Tunica-Biloxi Tribe of Louisiana (LA), and the Wampanoag Tribe of Gay Head (Aquinnah) (MA). 

PREPARED STATEMENT OF THE UNITED SOUTH AND EASTERN TRIBES SOVEREIGNTY

PROTECTION FUND

The United South and Eastern Tribes Sovereignty Protection Fund (USET SPF) 

is pleased to provide the Senate Committee on Indian Affairs (SCIA) with the following testimony for the record of its June 16, 2016, field hearing on, ‘‘Improving 

Accountability and Quality of Care at the Indian Health Service through S. 2953.’’ 

USET SPF acknowledges the long standing and systemic challenges faced in the 

Great Plains Area and throughout the Indian Health System. We appreciate the 

Committee’s commitment to addressing issues in the Great Plains Area and 

throughout the IHS with the introduction of S. 2953, and offer section by section 

recommendations to further strengthen the provisions of the bill. USET SPF maintains, however, that until Congress fully funds the Indian Health Service (IHS), the 

Indian Health System will never be able to fully overcome its challenges. While 

USET SPF supports the intent of S. 2953, The Indian Health Service Accountability 

Act of 2016, we reiterate the obligation of Congress to meet its trust responsibility 

by providing full funding to IHS and support additional innovative legislative solutions to improve the Indian Health System. 

USET SPF is a non-profit, inter-tribal organization representing 26 federally recognized Tribal Nations from Texas across to Florida and up to Maine. 1 Both individually, as well as collectively through USET SPF, our member Tribal Nations work 

to improve health care services for American Indians. Our member Tribal Nations 


617b11.eps
74 

operate in the Nashville Area of the Indian Health Service, which contains 36 IHS 

and Tribal health care facilities. Our citizens receive health care services both directly at IHS facilities, as well as in Tribally-operated facilities operated under contracts with IHS pursuant to the Indian Self-Determination and Education Assistance Act (ISDEAA), P.L. 93–638. 

Uphold the Federal Trust Responsibility to Tribal Nations 

We again remind SCIA that through the permanent reauthorization of the Indian 

Health Care Improvement Act, ‘‘Congress declare[d] that it is the policy of this Nation, in fulfillment of its special trust responsibilities and legal obligations to Indians to ensure the highest possible health status for Indians and urban Indians and 

to provide all resources necessary to effect that policy.’’ As long as IHS is so dramatically underfunded, the root causes of the failures in the Great Plains will not 

be addressed, and Congress will not live up to its own stated policy and responsibilities. USET SPF urges this Committee to consider carefully the level of funding it 

will support for IHS and its impact on the Agency’s ability to provide quality care 

as it considers S. 2953. Further, we recommend the inclusion of language directing 

the IHS to request a budget that is reflective of its full demonstrated financial need, 

as this is the only way to determine the amount of resources required to deliver 

comprehensive and quality care. USET SPF remains hopeful that Congress will take 

necessary actions to fulfill its federal trust responsibility and obligation to provide 

quality health care to Tribal Nations, including providing adequate funding to the 

IHS. 

Need for Tribal Consultation 

We agree with members of the Committee and with Tribal witnesses calling for 

increased transparency and accountability within the IHS. We are very concerned 

that conditions in the Great Plains area have resulted in severe gaps in access to 

care for American Indian/Alaska Native (AI/AN) patients. These gaps in access will 

only continue to widen the disparity in health status between AI/AN and the general U.S. population if not addressed. While we seek comprehensive solutions to the 

complex and multifaceted issues within the Indian Health System, we seek the empowerment of Tribal Nations in decisions regarding health care. We request that additional language be inserted into S.2953 requiring Tribal consultation on all provisions of the law, as it is implemented. On-going, meaningful Tribal consultation is 

essential to mitigating current challenges, preventing future crises, and increasing 

the health status of AI/AN. 

Implement Advance Appropriations for the IHS 

In order to address the challenges facing health care delivery in Indian Country, 

SCIA should work to ensure funding is received on time by authorizing advance appropriations for IHS. 

On top of chronic underfunding, IHS and Tribal Nations face the problem of discretionary funding that is almost always delayed. In fact, since FY 1998, there has 

only been one year (FY 2006) in which appropriated funds for the IHS were released 

prior to the beginning of the new fiscal year. The FY 2016 Omnibus bill was not 

enacted until 79 days into the Fiscal Year, on December 18, 2015. Budgeting, recruitment, retention, the provision of services, facility maintenance, and construction efforts all depend on annual appropriated funds. Many of our USET SPF member Tribal Nations reside in areas with high Health Professional Shortage Areas 

and delays in funding only amplify challenges in providing adequate salaries and 

hiring of qualified professionals. 

As this Committee seeks to improve IHS’ ability to attract and retain quality employees, USET SPF urges the inclusions of language that would extend advance appropriations to the IHS. 

Addressing Health Professional Shortages in the Indian Health System 

One of the major ways that the IHS and Tribal Nations seek to combat persistent 

provider shortages is through the IHS Scholarship Program and Loan Repayment 

Program (LRP). Although these programs have helped to increase the amount of 

provider placements in the Indian Health System, they are significantly limited by 

the level of funding available to make awards and by the treatment of these awards 

under the Internal Revenue Service Tax Code. In FY 2015, a total of 1,211 health 

professionals including physicians and behavioral health providers received IHS 

loan repayment. During the same fiscal year, the LRP was unable to provide loan 

repayment funding to 613 health professionals who applied for funding, of which 

only 200 still accepted employment at an IHS or Tribally Operated Health facility. 

IHS estimates that it would need an additional $30.39 million to fund all the health 

professional applicants from that year. 

75 

Additionally, payments to Indian health care providers through the LRP and IHS 

Scholarship are currently considered taxable income under the Internal Revenue 

Service (IRS) Tax Code for awardees. However, an exemption exists for benefits paid 

to providers under similar programs like the Armed Forces Health Professions 

Scholarships and loan repayment under the National Health Service Corps. S.2953, 

as written, does not address this discrepancy. We request that language be included 

in the S.2953 to create parity for IHS with other federal health professions incentive 

programs and provide IHS with the greatest amount of tools to recruit quality providers. 

Finally, we request that additional funding be made available to assist in the recruitment AI/AN health professionals from within local Tribal communities. We believe that the best way to care for our citizens is to ensure that health professionals 

are deeply connected to the communities they serve. In order to promote pathways 

to increase AI/ANs entering health professions, we request additional funding, beyond the IHS’ Budget Request, be made available for the American Indians into 

Nursing Program, Indians into Medicine (INMED) program and American Indians 

into Psychology Program. 

Section-by-Section Comments 

In addition to urging the inclusion of the above proposals, USET SPF provides 

several recommendations to strengthen the existing provisions of S.2953. If implemented together, we believe that the IHS and Tribal Nations can begin to make 

gains in the quality of care delivered through the Indian Health System and improve AI/AN patient outcomes. 

Sec. 3. Removal of Indian Health Service Employees Based on Performance or Misconduct 

We support strengthening the Secretary’s authority to remove or demote IHS employees based on performance or misconduct. We also support the ‘‘Employment 

Record Transparency’’ language which will ensure that prior employee personnel actions are adequately notated and considered in future hiring processes. However, in 

addition to Congressional leadership, Tribal Leadership must also be notified when 

employees within their Service Area become subject to a personnel action. In Section 

3 under Sec. 603(d), we recommend inserting ‘‘Tribal Governments located in the 

affected service area’’. Increasing transparency and access to information for Tribal 

Nations will be essential to rebuilding the confidence and trust in the IHS. 

Sec. 4. Improvements in Hiring Practices 

We recommend adding additional language to the ‘‘Notice of Removal Based on 

Performance or Misconduct’’ in Section 4 which would broaden access to records, 

available to Tribal Governments upon request, to include all clinical IHS employees. 

As the draft is currently written, access to personnel records is limited to Senior 

Executive, manager and supervisor level positions. Increasing transparency and access to records including clinical positions will allow Tribal Nations to have greater 

knowledge about and confidence in the clinicians delivering care to their citizens. 

Sec. 5 Incentives for Recruitment and Retention 

While USET SPF agrees that addressing the provider shortages across Indian 

Country requires innovative solutions and incentives, the IHS is not equipped to implement these initiatives without additional appropriations. With IHS funded at 59 

percent of demonstrated need, any mandate to provide housing vouchers, relocation 

costs, or increase pay scales must be funded using patient care dollars. While the 

attraction of qualified staff is critically important, it must not be done by diverting 

precious resources from health care services. For this reason, we request that S. 

2953 include additional funding to support these incentives without impacting patient care. 

Sec. 10. Transparency and Accountability for Patient Safety 

USET SPF has concerns regarding the lack of specificity in Section 10, as well 

as its feasibility. Although we support transparency and accountability in patient 

care, we believe that requiring an investigation of all patient deaths, ‘‘in which the 

Service is alleged to be involved by act or omission,’’ is unnecessary and will merely 

result in an investigations backlog. Due to the risks inherent to the delivery of medical care, patient death is a sad reality for all medical systems, with many patient 

deaths occurring through no fault of the provider or facility. We urge SCIA to consider narrowing the language of Section 10 to require an investigation only into 

deaths where there is an allegation of negligence or malpractice on the part of the 

IHS. In addition, we seek additional Tribal consultation on this section, in particular, to assist in providing further clarity on the criteria for investigation. 

76 

Conclusion 

USET SPF appreciates SCIA’s efforts to seek solutions to the long-standing challenges within the Indian Health System. However, we note the initiatives proposed 

in S. 2953 do not address the root cause of these issues: the chronic underfunding 

of the IHS. Only when Congress acts to uphold the federal trust responsibility by 

providing full funding and parity for the Agency will the Indian Health System be 

equipped to provide an adequate level of care to AI/AN people. Nonetheless, with 

some targeted changes, we believe that S. 2953 could be an important step in this 

direction. We appreciate the opportunity to provide comments on this bill and look 

forward to an ongoing dialogue to address the complex challenges of health care delivery in Indian Country. 

PREPARED STATEMENT OF THE YANKTON SIOUX TRIBE


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617a4.eps

mean to "monitor'' the quality of patient care in rHS, as called for in Section 10? Funds 

need tc be direcred to these importrult proposed ptograms to ensure they actually pan out 

but we hc,~itate to support such initiatives until we C!W. be as SlUed the ftmds that will support 

these program.s will actuaUy be provided <md will noi b~ Ulken from the elready 

U.ll\krfunded Hell.dqunrters and Aberdeen Area budgets that serve our mcmbl:r>~. And 

wi!houtll!ly idootified funding, the pmvhlions of the Bill could continue ttl be ignored along 

with the rest of our programs so we question whether this Bill, in the long run, would only 

b.:: Elll empty gesture, or wlrether it will aotmilly improve health care for OU1' memb~. 

The only discussion of prioritization of patient care comes near the cud of the Bill in 

Se\..1.ion 9, which culls fur tile Secretnry to use wlltlfever i's lafl over after the fiscal year to 

supJXlrl patient can:. Tribal heaJih needs to be higher on the Corrunittee's list of priorities, 

not merely an ottrufuou_ghl. 

We all !mow that thclHS h a severely underfunded agency and the Abclrdeen Service Area 

l!as historically received a disproportionately low perc~ntage of the JHS budget. In fuel ,I 

the Great Plains Region is underfunded by a staggerin~ $243 million following 

acqucstration a few years ago. That is why I would like to emph!lllize that -there are stiU 

funding problems with TI-IS that the Commiuce net:ds to tnke into account with this BilJ; 

The Committee needs to ex:pJain, M the B!ll does not answer, wh~o:rc the money will come 

from. The Headquarters in DC, the Area Office. the Servjoe Unit? Will it be enough and 

will existing programs, then,. have to compete with the new programs included in the llili 

crwill the new prcgrru:ns receive sepamte fundin&? 

Ytmkton bas other program-related and budget-rclated concerns with IRS that we 

eucourage \he Committee aud Sen mar Thune to address in the Bill. Because we only have 

a small ulinic on our reservation, every day our people receive "referrals" from IRS 

:physicians to specialists, labs, ami hospitals. Trihal members used to go to thoseref>mals 

assuming that any costs imutted would be borne by the IUS. U.nforUmately, llmt is nat the 

<=e. At Yani,tnn, v.-e have anev~rincrcruingmunbcroftriba! members whohavereceived 

thousands of dollars in medical bills in tho mail that they did not expect, and lhat they 

cannot pay. This has become so pr<walent that we nnw have tribal m~mben; V!.ilo ~ 

refusing to seek the rcfcrrnl care that is ~essary to proteettheirhealth, and in some cases, 

even their life, bnGIIIISa they fear tlw JlOSsibility of being bankrupted by unpaid medical 

e:'tpenses. 

We feel strongly 1he.tthe referrals or purchase referred C!U'e program J.'C{jUires attention an 

a program and budget level. The referred cure budget has to be examined against the actual 

need in the Aberdeen Area, taking into 11cemmt distance, our Jack of quality hospitnls, Md 

the number oflndiau p~oplc who require this service. Also, the IHS should be mandated 

to notifY a patient in advance when it is oot prepar;,;:dla pay far a referral eare visit and 

rela!ed casts. The IHS needs to acknowledge that unpaid medical billll can literally 

bankru]Jta family, and our people have a right to make an informed decision about1hecare 

that they choose to seek. This is esP£cially true in the case of our veterans. A vctemnmay 

not initially want to drive 100 miles or wait three months to sec a specialist, especially 

when the IHS is offering him a specitdist which is only 30 miles uway and au appointment 

in4B 1wnrs. He might fed differently, however, if he knew that he was going to receive a 

$20,000 bill furtakinglHS up on its offer. Pleasc,justdircctlheiHS to upfrcnt and trtlthful 

when making the referrals. and sel aut, in writiug, what amount oflhe purchased Ieferred 
78 


617a5.eps 617c1.eps

care IHS will or will nof pay in arlvanw of the treatment Wid preferably at the time the 

referral is mt~de. 

In addition to calling your attention to the issue of funding and program operation, we 

\\'Ould also po.itt. out that years ago, the JHS hospital and emergc:ncy room "llurt servell tJ1e 

Yankton Sioux Tribe and its members was closed. We now only have a clinic. We wuuld 

like to work with Congrllss and tbe ageru::y to 1:e-open lhc IHS hospital ancl emergency 

room at 1he Wagner Service Unit. Without an IHS hospital and ER uvcilElllle, tribal 

members are forced to decide whether il will seek care at the local non·IHS hospitul uml 

ER .and potentially fuce thousands of dollurs of merlical bliis or not seek tJw nccru;sary 

heallhcare. We have bad tribal mcmbcrn pnss away or suffet n1ajor medical emerge11cies 

in the parking lot of the IHS clinic while waiting for it to open after bcing fuccd wilh 1his 

dilemma. 

We praise the trib.o.l. consultation mqutroment included in the bill for the hiring of key 

lcadcisbip pollition~ provided for in Section 4. We appreciate tbe transpa!cncy and 

accountability expressly provided for in Section 10, ami we like the requirement of 

spending reports and SW.tus reporm of each level ofiHS- including each facility- being 

sent"lo the Indian tribes as well as the R:lcvant Sc!Uitc and House committees, keeping u~ 

all on the same page. Additionally, we support. the provisioo in Section 9 forthclnsp:!ctor 

General ofHHS investigating eacb pntient death associated with IHS's t~ct or omission, 

end bope thlll will b;;: enough. to prevent !lit~ neglect that bas led to too many patient rnishap3 

and innocent deaths at the hands of poor qua1ity rns faoilitie:ror lack of facilities. 

We very much uppreciate the direction in "Whieh SeAAtor Thune and B!lml9SO are trying to 

lead IHS wilh this Bill- more towards tribal interests. However, the Bill do~s not go far 

enough. Though wr. agr<:c t11at "prioritizing patients aud.Iestoring fhltlt in the health care 

system of the Indian Health Service requires greater tmnsparency, accountability, and 

strong lcadersllip," there is no doubt that to achieve this, all of the programs 1111d 

improvements envisioned in tlw Bill must be supported by the proper funding. Th~k you 

nod we look forv.".lrd to working with you on improving health cere fol' our members. 

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....}· -;{Miij ;;l·f.&.i;M:ut iniw·d tVJ :~h W.,.. 7:3M"'""''t:JitfU>.ZtJ/(,. 

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+·""'"" lo,()( ~ d,·c-...1... 
79 


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6/10/2016 

To Whom it Ma.y Concern; 

On May 18,2016 atapprox!m~tcly 2:00-2:30 a.m.! stalled to have a, what I th.oughtwns a 

mlgraineheadtlche, followed by il sh~rp pnln in my neck.. blurred vision, and naus~a/vomiting. 

Unable to sleep because of !:he pain! walked to the Fort Thompson Ambulance D~partment. r 

kno&ed several tim~ before myon~ answ~d. The two individuals working at the fune toc>k 

my vital~ In which they said were .ffne. Saaming vary umonmmed about how much pain I WtlS 

in the individuals told me lhllt there wasnothirlg they couldgiwrneordo for me. Theyl:h<!n 

asked rneifmy pain was re<Llly !hat had or if! would be able to drive myself to tl1e Emergency 

Room in Chm1berlain SD, which is21) mil~s away. When I told them that I did not have a 

vehide Iiley told me that the TI-15 clinic would be opming in 5 houn;. After explaining lo them 

how unb~arable the pain was they finally decided that they could trouspurtme to the hospital. 

After having a CATSCAN/MRI performed the resulls~howed a brain ancurlsm/sfroke. 

If not for me being pen;!stanl about how much pnin Iwa:; in and how in need of medical 

attentiun that I need~d the Ambulance Servim mny have 11ot transported me. 

11ravious to this incident I had been to the Fort ThornpsoniHS clinieon two other occasi.onsfor 

severe headache pain. I was IJ:eated with a shot to help wllh ll1<t poin I!Jld was instructed to wait 

in fue darkromn for an hol!l'; No X-rays or lab tests were done. I w~snotevcn prescribed 

Tylenol or Ibuprofen for th~ pain. If the Health Providers at Port Thompson lHS Oinic would 

h~vc. b<:<>~llllO<e obB~rvantand looked further in-d~plh to my symptoms tl't<l ht·afn 

aneurismjs!roke may have been defected earlier for treatment or may l1ave even been 

prevented. Nnw I am a39 year old single parent that if: at risk of having a bruin 

aneurism/stroke at any point ond timP. for the rest of my life. I live with the frightening thought 

of going lu sleep atiiight il!ld may no! ever wake up. All in IVhkh could have bee-n prevented if 

the IHS He«lth Providers would have taken my pain a little bit more serioulily, 
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Deor Committee Members ond Sonotorls); 

Welcome to Solrth Dakota and hope eVat"Jone Is well, When I took on a m~<iioal corkr position at 

the IHS Mere approximately 3 years and 8 months ago 1 wished 1 ~new then what 1 ~now now 

beoouse I would have told them no. Anyway; during the open test1mony bad In Februaty I sent the 

IJS Indian 5enate a mpy <>f a grievan<e thotth~ union filed on my bchulf since losing my brother on 

December 7, 2015, He was onl'/45. 1 just wont !hom to know tho! every day~ o,n Ol)1<>1ional bpttle 

tlla; I am y~rrentlytakiog depr~lo~~~-~~:!=.t.:T•dlcs~on.~-~~{0_"~ .. o1 ~ J_,_ ,.. tNrrU ~ ~ ""'f"<'~.,., dl-l:lwH <-'0 - ci.J't:l' l"../iiWJ'J 

When I ffO\ offered this job and found ~utwh<> mysupervlsorwoo it had mJ.'ilf9);t~rlngw y'l When~ I told my brother George he lill!Siwdandsaid oh shill eut the pay was ootljlit;:iilr-tmd we both 'J;/, !mew I had to tak~ lt. The r~asohb~ing my brother George hMn douatrterwitl1 this supeflliso~s 

sister about 17 years ago and he was only with her a fe"-' months when fight broke out In " bar 

between 111ero ""d G""'J>e had injU<ed thoir br<>thor •nd left o perm"nent mark on his fuoo. Since 

then. and they desptsed him and even lied under oath sending the wron~ person to prison so that 

lhelr niece would not lose her soon to be father. Unfortunately, he and that hrmHy never made up 

and he was notollowcd vlsit<tHon oftcrthot. Well my brother and ltolkod about tflo sii!Jation to be 

and he soid Just do your job ond 1 don't think you should rowe any [>rnblems. The pmbatlon pertod 

for two years was the worst ond she pi;kad at me CMliY chan'e she could att<l •o 1 walked on a 

million eggs shells during that tim~ Sho,klngly, I knew from doy one sh~ had problems as far as 

in,omp~teOO/ 50es. ltwos <ommon knbwledue to evet"Jone that she was woaved In be<au•e of 

fomily and cronyism but we loomed to work around her nnd come tu hor a1de wflen others picked 

on hor. 1 w""n't surprised when lleorn~cll was part of a phenomenal concept wrllten In a book 

bock In 1969. I had n<> Idea t:he theory Oven exl•ted IIIII re•d part> of lxlok titled "l'eter Principle" 

and rtaughed so hard until I flna!ly(,,U!1J1t myself and ao~M under my~mothwhatabouttM 

victims of cronyism? Did the author calculate tho;e Into hts equation? Who picks up the pieces? 

That's what I am hoping yourcommltt~ewlll do with the nowbllllntroducerl and let lh,is b"a [('<son 

that this has gone too long and people ore dv!ns or could die or be hurt terribly. ,MJI'~ ' 

. (Z~i:\'1 w1Hr Bu~~fd111e €~evcnce ap,&[ rem~mbH 1 was allrbat George had and was officially his careuker Md 

~r so dol sec~JitV'Il,;'~i1, reoeivijlg from FJ<1SI head trauma til at forced him to retir<! from 

roofing . Our filmily W.,, ro proud of hlrTI for throwing his bottle in 5arbage and €etlln~ off the 

slreets ~nd remaining sober for years without treatment. He was co;ch and manager of my son's 

softlrall te.m for years a~d recently we.le"n"d that lh<!y •re &uina to place him on their Hllll of 

P..me wall tW>I"'ar. If only I had not !:.<ken tho job I truly belie~• he '"'uld stlll be hore. I csnnol 

express the palo and suffering me and iam11y go thf\1 e;roh day •till wonderin~ 1> <hi• for re•l? 
81 


617c4.eps

Grte,.nt' CharleneJanl>, MediOill Reoordil~th 

NATLJRE OJ' GRIEVANCE: 

On or about December 6"', Bllf, Chorlen~ J~nls, ,...~ua.ted leav~ tQ oddre" an omercent Issue with her brother's 

health. BUE, Charlen~Jonls i• the cu5bldian of oaid brother ond is r~sponsible for his care. M>.Janis shared With her 

supe,..isor the critical health Issues concern I~ l1er brother. M>. Janis requested lea'«i! and supo.V.sor denk!d~nd stilled 

fuat <he would be AWOL. Following that event i!UE, Ch•rleneJant< went to meet with supe,..Tsorto take In 

dooumentatlon of brother's rlischarEe from hos[>llat papers to verlfv the serlousnes< onrs lllrm5>, brother was to ll'J 

bod< thef<>lloi'Jlng mornillJl. Supervlsorwos no \o.·here to bo fuund to get approval and employoe ~ltlrnately hod to S<lek 

approval from sewn<lline ,upo<'Jisor, Lynn rourer wn~ appmved J<.ave wlt:lumt pav. BllE, Charlene Janl>, wa• 

emotlon31, dl:rtraught and severely stresS<ld and· wanted to ensure that she received Bppravol prior to betna out of \11• 

offi"". SUp.>I'JI•or. AlbP.rto El>!d Wound, shmv~d no wml>"'•ion, «lncer~ nor did she offer hN ovallabllltytD "'sist BUE 

during thl> oritlcal, emotional tlme. Brmhor ofBUf, Charlene Janis po:;sed awav on D<!cember i"\ tl1e fDIIowlne day ln 

wl1i'h empi"l'•e was attempting to secure leave approvol. SUE, Charlene Janis at this time l> grieving the t<J;s of her 

brofuer and the aMcd emotional stre" she wos put fur<lu~h by her supervisor. 

SUporvl:;or Alllerta Bad Wound has vloloted Article 1, S•ctlon 7 and Seotto~ 16. 

1. sue, OlarleneJanis be aso;l<teri with proceSSing appropriate paperwork and appi"OVI!d for t11e Leave Shore 

Program. NotHlLO!Ion of epprov<ll af LeaV<! Share ~e sent to all employees within IHS to seek leave donOl"< to 

addre" thn period oftime in which BUE, Charlene .lllnls needs to be awav from duty durin~ this period of grief 

and tlmeofheoling. 

~- BU~, Charlene Janis, be refened to Employ;~e AS<ISI<lnce Col01"'1ing ta allow her time and the opporturu"ly to 

meet with a grlef coon..., lor. T!me allowe.d lo ~tt.nd oaunse~n~ will lie 1n attordon"' wHh pollcv For EAl' 

Counseling. U;e of Offir.iol Tim~. 

3. HUE:, f;h;orlenaJanls be asslg""d under tjle direct sYperviston oflvnn Pour!er, the stomnd l""el supervi"'rwh<l 

shm..ed real mmpa5>ion •~d concern fur the euE during this difficult time. 

Respectfully SUbm ltt!!d, 

Paulin"' aruoe, Fl~ld Rep/Org;oni>er 

LiUNA/IHSNC 
82 


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617d3.eps 617d4.eps

T11: 

Subject: 

Lisa, 

Janis, Cho~ono ~HS/ABR/RCJ-11 

wednesday, ll.larch 0~,201611:41 AM 

C.~~"'' ~iso (ll-ISJADR,IRCH) 

Leave situation. 

My husband of 24 vcars is ~urrently In Regional Wlth internal bleeding due aspirin but b~raus~ he has 

rongestlvt! heart failure alcngw/a pacemaker thevare keepl~ga dose watch an him. On MondiiJ'3.9.16 

momingSiOtJ~San tronsrmr~d him and so ltexted my supervl;or ABWwith a leave request and also asking for 

Lynn's number bO<aUse I was using my husband's phone and it wasn't on th•m•. 

That momlr>gfrom his phone and she responded with" I con'topprove ony more I wop pavforyou and you 

ar~ ~:onna need o docsl!p and hove the CEO Sorenson approve it. I asked her how ~he ~new thatwithouta 

romputcr b~ca~se J knew I had six hours of leave and It wasn't over three days? My husband read the t,.xt 

c:ousa ltwas his phone and startlld frl!aklngout thlnl:lnglwosgonml b\! ~red. I !t~ to remind her this is not 

my phone and pleas-e don't send anymore texts and I would be talking with lynn from there on ollt. She said 

OK. Lynn approved the leave request and said A8Wwas not coming In that day due sldness. Shed!d not toll 

me that that or send an order of succession te"t. 

I promise I won't pursue anythlllg on this incident but someone needs to talk to her and find o~t if she is 

~mpetent enough to stand her ground as a supervisor. J was angry at first l>~t now I am feeling a little sorry. 

Tn:Janis, CharlEne (IHS/A9R/RCH) <(horlone.J•nls@ lhuo\00 

Su~)ett:.RE: AWOL 

rmpomnr.o: Hieh 

Chorlcnc, 

.Sorrv this email w-.an error, wben you met with th~ ~W ontile03/31itwlll b~approy~ thl> tim~. T11e next tim~Y<JU 

meet with the fEO or the Union vou ne~d to let me know, so that I don't m~rl: you rk>wn os AWOL 

From:nad Wound,Aiberla {IHS/ABR/~CHJ 

:Sent: Mor>day, ApnliJol, 2015 8'43 liM 

To: Janis, Chorlene (IHS/AE!.R}RCH) <CharloneJonk@I!Js goy, 

Cc: Pourler, lynn {IHS/IIBR:/RCH) -<:lynn.Ptlurier@ih•_gnv;. 

SIJb/ect: AWOL 

Charlene, 

Pl.n>• Md 10:30·ll:OO on 0~/31 AWOL for Charlene Jatlls, for not getting prior awroval to moet w1th tho EEO 

11-IANKS, 

AlbetUB!dWOOJ>MI 

CodiooiD~•Enfl> ~"""""'"" 
85 


617d5.eps

TO: Oversil;ht Hearing Committee January 22,2016 

FROM: Rozell~ Lockwood 

Enrnll~d memOOr of the Crow Cri*>k Siom: Tnbe 

RE: Complointjlndian Health Service 

In the spring of2U15 I had my "Y"'examlned by ~n Optomatrist in Chamberlain, South Dakota who 

alweysdc.:s my~e exams. I Vli!Sdiagnosed with Dry Eye Syndrome and the doctor @ave me a 

prest:rlp~on for Restasls eye dro~s. 

The next day I took my prescription to the Indian Health Senolce dlnlchere In fottThompron, SD to have 

it filled. When I .:ailed to see If my prescription wa; re•dy, tha Ph~rma~Tst told th~t th~y would not fill 

my prescription bacause my eye exllmwasnotdone at the Indian Health 5eNioo clinic, so I talked to the 

Indian Health Service Optometrist ~nd she said If! m;;de an ~ppolntmentwith herfnran f!(e e~~m that 

she could prescribe me R~>stasis and I oould get my eye drcpsthatway. 

I made an oppolntmem with the IHS Optometristond had my eyes exomined and pkhd outwme 

eyecla~frames. The Gptorne:rist told me it would cost$146.00 ~nd l needed to bring in a moneyord~r 

before she tould order my .:yesla:;:;es,w I did that. 

Two weeks later I received <l call from IHS slijting that mvclosseswcre In,. so I went to the clinic and she 

adjusted \hefnlme.s, at which time I toW hert~at I couldn'tsee out of !hem, EMlrything was blurry. Th~ 

Doctor .said thdt I needed to wear them fora while so my eyes ~oulcl adju~tothe new settings, I tried 

wearin;: them th<:~tweelmnd, but !just wuldn'tseeoutofthem. 

Needles;,; to say, o~erthe next month, !went to ~ral pla~es im:Judlngthc Indian Health Service Clinic 

and had my glijsses adjusted to see If they just ue~d~d •n adjmtment,butno,no m~tter Mw much they 

were adjusted, 1 could not see out ofth~m. 

I called the Optometrist's office In Ch"mberl3ln, SD and asked for a copy of my eye exam rn•ults, whkh 

were faxed to me, so I took my eye exams results to the Indian H!!altllSenrioo Optometrist and asked 

her to match the one frcm Chaml>!.rhin to herex~m and see 1ft hey mstched, Well, ~he never called me 

bock so I tried calling her, but Slle never answered her telephone so llafther messages for her to call me 

back. I even wEnt to the clinic two timru:ai\d soot out5ide her office or.,, woiting for h~ror~nyoneto 

as~ mewhOJt I noodad, but nothing, so after waiting 20 mlnutusar more 1 would leove and trycalllnc 

her, buts he nel'eranswers her telephone or returns her mcss~gesl 

The third time I went to the India a Health Servke clinic the receptlonlstsaid a girl was moved Into the 

Optom~tr~t'sarea, sushe cuuid take hEr calls and appalntmonts, so I went to the bad of the cllnlcand 

S<ltuntllar<ather staff member .::arne out~nd I wt<nt ln. The sir! they hired to assist the optometrist 

asked me what I wanted, sa 1 told her I wanted to talk ta tha Optometrist, so she went into the 

optometrist's office and told ~er. The Optometrist came out and asked what I wanted •a I told h~rl 

wonted to know ifthi!y pre.~cription from th~ Ch9mberlain Optometri,;l's ey~ exam results matohM 

hers. She oaid no, they were t!iff~rent,.so I a~ked if she tould order m~ new lens with the Ch~mberlaln 

Optometrist's re~ultsand she said no, becouse it was post the slx month period foreKChonges, she said I 

would have to pay~ncther$-146.00 tfl wanted new lens put in the frnmes thotl ori~lnallypicked aut. I 

told her no, because I couldn"rafford to pay for "oother <etofGiasses a rod I told her to just keep my 

~la>se3 and give my money back, but she said she wuldn'tdo that either, so I told her just to keep those 

srasse •• 

11:illked to several people aboutlhlslnddent, I even went to see the Service Unit Oiractor, but he was in 

a moetins,so I left l1lma nate a>king him to call m<:, but he never did. I did report It to tim H~a!th Board 

Choirman also, hut nothing has been done. 
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T(l Wh(lm It May C(lnoom; June 15,2016 

I am writing to mport wmnedolng~ dane to me hythe Indian Health.Servke. Arstofal~ let ffi!! <mploin 

rrlf sit~ation. I am a fedarn! felon on probation for Theft of Government Property (excessive overtime). 

I applied for a job, Moror\'eh!cle Operator, at the Pine Ridge Indian Health Servi~e. This position 

haskallv a house~eepinc position with about 20016 of the time dedicated to MVO duties, ao was 

explained to me during the interv!~. 

I wos Informed ot the beginning of April that 1 did get th~job and than he hiring packet ond bockground 

check infurm~tion would be emailed to me. I filled thts out as soon as I mceived the email and semlt 

back. There were a few things I had to corract at 111e heglnnln~ of the process. As the weeks ·.~nt on, I 

was asked to provide Vllrious pieces of Information, which I beliew I did in a tlmcly manner. 

While o!l of thl~ was going on my mother was admitted to llapld City Regional Hospital aml was not 

el(pectijd to rrve much longer. Becouse of this 1 did Jnfu!T!l Lois cross, who at that time was my only 

contact between myself and D<lnna Belg"arde, who was req~estln~; adclitionallnfurmation periodically lJ'{ 

this time, that I wculd only be able to be ronbcled by my cell phone. She w;o more cr less the middleman. Because It wos uncertain when my mother would be making her journey, I did let her know that 

all of my spare time would be spend at herbedslclesoany cont""t would need to be macle throuBh my 

tell phon~. Sh~ had agreed, however, each attempt to reach mefullowingthis was made to my horne 

phon~. I would g>!t home late ~t night and cltack my caRer ID and see c"Hs from Pine Ridge IHS. The 

next mornlne I would <:all Lois back and she would let me know what was needed Qcltt. Again, l would 

remind her that I am only abie to be r:ontacred on my~ll. 

During this tim a, Donna Belgarde, through Lois, requesb:ld a letter from my probation officer stating that 

I have complied with all aspects of my probation and that l was in good ~tanding wilh the us Probation 

Office. At that time, I ~onta~ted my prob~tion officer who stated that he had never had o request like 

this and that he wasn'tsure thath~ could legally provid•them with anythins in writing and that he 

would meet with hl~supe<VIior togetcladfi,~tion and direction onthlsls;u~. After a few days, I 

attempted to contact my proballon officer again butwos tel~ he would ne out of the offio;~~ for another 

week. I was able to talk to his supervisor. By this poi Ill:, I ~5 clv=n deallnes;thatlfl didn't setthls 

lnfonna!lon to them by a certain time that they would withdraw the job offer. So that !illme d~y, I was 

able to make contactwltfl my probation officer's supeJ\•isor. H<l. inform~d m~ that h~ had disws.>ed this 

matterwlth my probation officer and that he al)o h~d never had such a request and that he had made 

r:ontact wllll hlssupcrlorsto getdarlflcmlon and directions on thls request also. He did Inform me that 

this would prob;Jb(y be a ~ouple more days and that he would call me back as soon as he got the 

infomatlon he wa> !O<Jklng for. 

At that time, I dJd let Lets know what was going on. She got In cont:lct with, I belle~e Donn• !lal8"rda, 

ond Lois let me know that she sot an extension to the deadline they had just given me. A couple days 

later, I received a call from my probation officer's supervisor and he Informed m~ that according to hi~ 

~uperiors, he would not be ~ble to glvc ~ letter to anyone in rcg3rds to my sJtisfm:tOI)' probation 

behavior unless he ordered to by a court order and even at that time, he would only turn such a letter 

ever to the courts. He did however stare that my probation offlo;:ercould sive a ~erbal on the stat~s of 

mv probation. 
87 


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I imrnedi~tely let lois knowofthi~ and she informed me that she would let [)Qnna know. I did clve Lois 

the name and number of my probation offrc~r'~ work phone ::snd his r.:ell pnt.ne. It wasn't until the 

Friday, the day of the l~st em:ension I W~5 given, til at I rec~ived a <:•II from Lois stat1ncthat no contact 

had been made yet, At this point, I did get in cont!lctwlth ~nna myself and she informed me that she 

could take the verbal from my probation officer, She informed me a coup I~ hours later that she was not 

able to get a hoi~ <l[ him at t<ithernumberand that lfl was able Ill cet a hold of him, he could call her 

directly. I wo~ obletc get a hold ofhlrn and he a~~ured me th~t he would call her. I did make sever;al 

atremptsto call Donna back to fallow up with her and make sure the callw.~~ mod" but forth a rest of 

the day, I was only able to reach hervokemall. Note: thlswasthe l3stdayl was able to spend with ml' 

mother befcre she passed. 

Because I had not heard from Donna or Lois the follow!~ wee~, I had assumed everything was still ~cod 

and that protB5SB5 were still beingtak<m in my hirins- I had che~:ked my email and the~aller ID to my 

home phone and my cell phone to see ifonycont~ctwasattemptlng to be madethrouchout the week. 

13ecause l was busy preparing my mother wake and funeral, I did not take the time to make a ~all but I 

assumedsfnce they didn't call me, everything must begorxl. On Monday morning, I did can lols and she 

inf<lfmed meth~t the job offer was rescinded. I asked why and she told me I oould call Donna and she 

wnuld tell m,.. I caHed Donna and she referred me to who she stated made the decision, Connla 

13ordc:ilux. I talked to Conni;, and she stared thnt she pulled th<.> job <>ff<lr beeiluse I didn't get her the 

Information that sh;, had requested. When l asked which informatinn wasn't received, she stated she 

never re<:elved the letter she requested from my prob~tioo officer. After I eKpln!~ed to her what lwos 

told from the probation offi<:e., she stated that she hod received letters In the past and that I should ha~e 

been able to provide the l~tter. I did l~t her know that my probation offltllrdid give Donna a verb"l. 

Connie said that she couldrr'ttah a verbal thmughsomMnB. else. In which caoe, I fe~l th~l she should 

have stated that from the beginning and my probation officer ~ould have contacted her directly. 

I am now at~ loss ofwhl<:h direct! on to take. I do not Fe.;l that I dl(l onvthlng wrong In r,;!l<!rdsto this 

whole process. I ff!elthat I did the best ofrrlf abll!ty to complv with the whole baderound che<:~ 

process frDm bt.gFnningto Bnd. 

Ide have four kids who are In coUege and I really need employment as Vte.all know holileXp~nsive 

college is. If there Is anyth!ngthatcan be dooo, please let me know. 

Michell. Twiss Sr. 
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COMMENTSTOS. 29S3; "THISACTMAV BE CITED AS THE HJNOIAN HEAlTH SERVlCEACCOUNTABiliTV 

ACT OF 2016", AND OTHER COMMIONTS ON I NOlAN HEALTH CARE SERVICES, 

BY !rvjng Provost OGLALA SIOUX TRIBAl MEMBER 

Aft<lr revl<lwlng 5. 2953 the prop"sed changes are sene rally b~scd on the "Dorgan Report".ln 

stating this, the proposed changes within S. 2953 are policy changes within the lndfan Health Sef'lire. A 

maj<>ritycftlw changes aretc del'<! lop overslte and compliance of lndl~n health service personnel, and 

performance, The lndl~n Trlbes must be a~t"1vity Involved In the overslteand compliance of Indian 

healti<Servio;es. Respective India" Tribes must be lndw::led In alltl<e proposed policy changes within 

S.2953. 

CONCERNS 

The iirst concern Is the pclicyforfundlr~G,. work plan actlvldes, ~nd reporting requirements by 

the Indian health servlce. Tl<e lrtdlan HealtllServicestates it <.lifers "BASIC HEALTH SERVICES". When did 

the Tribes of tile Great Plains ever accept "BASIC HEATH CARE" os a treaty obligation? This BillS. 2953 

must be a st~rtto set the fuundotion for the Great Plains Tribes to start to receive Complete H~ltli C~re 

Servl<:<ls based on ourTreal!eswll:h tile United States of America. 

• On page 15 ofs. 2953 (b) GAO Report on IHSSt~ffing Needs··-. Respective Tribes must have 

ln[M: on the rejXlrt assess"lllgstaffill.l! needslnthe Indian Health serAce, Tribes and local Indian 

Health Service units must have In )lOt, and lmplemenl<ltlon of recommended ch~nges based on the 

fact tl<at more comprehensive health t;are servkes are needel:l, 

• Within S, 2953 starting on page 15 SEC.5, SEC. 607,5EC, 7, local indian servl<:<l units and respective 

Tribes must be lrwolved IIIith the revision process, ~nd Implementation prcce:;s. 

• Within 5. 2953 starting on pa!Je 36 "SEC.GlO local service units and respective tribes must be 

involved with having input, and Implementation ofre•ommended Changes. 

ClOSING SfATEMENT 

As. stlted above S. 2953 is a start to the ~tthe foundation forC0!11plete He~lth Care within the 

Great Plains Area. 1 have wr!tten pr!Wi~;~us <:llrrllspondence tc SenatcrThune regarding Health am" 

On tl<e Pine Ridge Indian Reservation. (att~ched Is a copy], In closing I wiU share some oomments 

and statements, FEAR and DESPIRATION has always been as5(Jciatedwith health care on the Pine 

R!dge Indian Reservation, Werking together with respect, trust ~ncrwlsd<.lm, we can bring complete 

Health care to tl<e Tribes oft he Great PI< ins without the influence of hypocrisy. In ending I would I 

will share these words: "A great civili:atlon Is nr.t conquered from without until it has destroyed 

ltselffrnm within" 
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INDIVIDUAl REPORT ON INDIAN HEAL Til SERVICES PROVIDED AT ?INE RIDGE SERVICE UNIT 

INTRODUCTlON 

My name is Irving Provost I ~m ~lifelong resident of Pine Ridge Vi!l~gc,.l have hi!d 

concerns about health care on the Pine Ridce Indian Reservation for over40 plus years. J would 

like to thank former Senator Dorgan for doing an investfgatlon on overall health care within the 

Great Plains region. After reading the report I beo;ame interested in the overall health !;are that 

the Indian Health Service Is provldingtu the Oglala Sioux Tribal members. l have worked for 

over 20 years for the Oglala Slou:<Tribe and the U.S. Environmental Protection Ar:~ency as a 

FOOer.li/Triballnspector. I do have experience within the following areas: Investigations, 

Development of Strateeic Plan nine, Budeetlng (devalopment of national budget~, local budgets, 

budg.rt narratives), Work plan developmsnt, implemenhtion ofworJ.: plans, and reporting, and 

I developed Tribal environmental org;mlzatlons. 

Afterfintshlng my 2 term a; a Tribal council representative of the Oglala SlouKTribc,.l 

decided to take care of my personal health ca.re concerns. This Individual Report is ~bout how 

the lndl~n Health Sef'Jice provided se!i!lces to address my personal health care concerns, and 

other ooncerns regarding health cara being providad to the members of the Oglala Sioux Tribe. 

INVESTIGATION 

The first priority within my personal health care was migraine headaches, !seen a 

doctor who did a CAT scan, after the reslllts were reviewed the doctor informed me that I 

should get a MIR done but the hospital did not have a MRI machine and he prescribed 

medication for the mlgr.ilnes. I asked the doctor when I could get a MRI sc<ln? The doctor 

informed me that the IHS could not provide me with a MRlscan. After several months I was 

iliformed that there was going to be a mobile MRI machine at tho IHS hospital <:~t Pine Ridge. I 

did r:et a MR! scan and was informed thilt the results needed to be referred toil neuralogi5t for 

review. To thi> day I ~tl!l hav"' not been r"'ferred to see a neurologist and I still hilve misra!ne 

headaches. My tle:rt personal health care concern was a chip in my richt elbow. After seeing a 

doctor I was referred to an orthopedic doctor who Informed me I had arthritis !n my right elbow 

and scheduled mo to have surgery to remove the thip in my elbow. After the surseryto r~movc 

thechlp in my right elbow w~ ~ompleted,! talkM to the ~urg~on ::.bout my surgery he ~sked 

me why the .:hip was not removed earner, llnfonned him that 1 was told the IHS consldered this 
90 


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surge I)! was not life threating. This came as a shock to the surgeon, after myvlslt with the 

orthopedic£urgcrlll. The orthopedic surgeon started me on injet:tions for mobility and physieal 

ther~pyto OJddressthe arthritis. The sen~ice; of an orthopedk spe~ialist is limited based on the 

fact this service is avail<~blc on a limited monthly basis. Curnmtly when I went to get an 

appcintment for an eye exam I was informed to come back In about 4 weeks because the 

optometrist schedule was full. The dental services I received was for fillings and do=aning. I 

ilskad to be referred to get partials or dentures, and w~s Informed thatth~ could not referred 

based on they did not have enough financial resources to complete my dental sen~ices. During 

the time of i!ddressing my medkal concerns I di~ vllit wfth other tribal members and ask them 

how core your health earn conc~rns being addressed? I received various wmrnents but a 

majority of their concerns :~re we need more medical services not just basic health care. 

ASSESSMENT 

In researching, and interviewing other tribal members, regarding medic~! servioo~ 

currently beine provided by the Indian H~aith Servi'e at Pine Rklge. The first question concerns 

a statement by the Indian Health Service which is bosed on just providing basic health care. 

\Nhen did the Oglala Sioux Tribe officially accept~d )1st bi!slc hoalth ~;<~re? Since the Indian 

1-lealth SeJVice lsjustprovldlng basic health !:<lre currently I researched the budgets for Health 

care within Indian Country, it is generally stated that the IHS PRIORIT!ZED basic health care. For 

el¢>mplc after reviewing the dental services within the FY-17 budget. Dental serviens states they 

provide just basic care, without addre55lng and pro~ldlng rehabilitate services.lookin(l"ilt the 

goats and outputs for dental s~tviccs thase basic goals and outputs Oave been the same for 

years! This demanstrat~• th<' [>~rk nfimprouing to provide quality dentili o::ilre. Th11.10<1 go ills ""d 

outputs shows they are not IMng up to their trust r~sponsibility in providing quality d~ntal care. 

After reviewing the Budget forfy-'17 a majority of the health care sen~ires have the same goals 

and outputs fory!'!ars. This shows thil!l"riba! health eam Is not Improving within Indian ~ountry, 

while Tribal populations Increase yearly it is common sense that health care must lmprov~ to 

provideq1.1allty health care. No more BASIC HEALTH CARE SERVICES. 

RECOMMENDATIONS 

'Within this section tha starting point must b~ with the development of a data basE, 

within the data basa considaration must be on the development of tndlviduar health car~ plans 

for a if Dglsia Sioux Tribal members. With the completion of this step prioritization can be done 

by grouping health cam needs. From this ilsse;smentwe could start thc development of a 

strateglc:/manasement plan (this must ba ~ 4 year plan after l"year review amendment's 

would be addressed and implemented) which would include goals, financial budget, budcet 

nijrrative, and reporting The first priority must be a complete functioning emergency room with 

a oompreher~sivo functioning emergency room with tra.um~ surgeons, life support systems. All 

CMS certifications must be met and a compwhenslve plan implemented to maintain CMS 

certifiClltion with full comprehensive funding. This must be done immedl;;telyl All the. Indian 
91 


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Health Care servic~ units within 1he Gr~at f>lalns Region must develop their awn Individual 

Medical Management Plarl$ with full comprehensive funding !Nota: currently the funding for 

health care at the lndiVIdu~l health care service units Is within thE! discretlon~ry budget of HHS 

this mu~t be ~hanged to the fixed cost budget to meet the trust responsibility. Must ha11edirect 

fundin~ to the indi~idual health care service units I.e. direct implementation of funding) for 

complete health care services for our Tribal members. It is time we start ha~lng reSfJI:!ct for 

each other, and stop the hypo~:risy to make comprehensl~e complete health earn a reality to 

fulfill thegouemment's trust responsibility. Time has come for The Tribes to be a vital part In 

the implementation of comprehensive hcalth care within their local health care services, In 

other words must have directimp[ement~tiOil of serv!ces, funding and reporting. No more 

middle man~gement. In ending It Is time to ~t<lrtto develop comprehensiue qu~lityhealth care 

NO MORS (COMPREHENSIVE) BASIC HEALTH CARE. 
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June 13,2016 

Dear Mr. Walters: 

As the elected Chairman of the Sault Ste. Marie Tribe of Chippewa Jndi:ans.. ram 

writing on behalf nf ever 43,CO!l members of my Trib~. 

As ycu are the Minority Chief ofStafffortha Senate Committoo 1;n tnrl!an A~'l'ilirs, I 

w.antyou t{) be aware my Tribe has reql,leSted an amendment to HR54C6, "The 

Indian Health Care Improvement Act." The amendment would eumpt 'l.'rihePfrom 

tha dr;fillilion aj "opplioohle !al'ge cmplfJyer'' as thrJt term is dr:ftned in Section 

49$0H(< J(2). 

SlWl! an amendmentwt>nld have di\'et-t be-arillg oo S 1771 and S Z!)SZ.. 

The pr¢pt)Sed lcgislatiOctl, if;trQch;~ed by Represmtatin Kristi Nocm {SO) on June 81 

2016, is cllt'rcntly befo~ the HOU$e Committee on Nawral Resources, and the 

Committees en Energy and C<ltrunerce, and Ways and Means. 

Atlached, plea~e :find a copy of oor letter to Repoosentntlve Bertlshek. dated June 10. 

2016. Similarll:tl:ers wtu."C se-nt tll a![ members of the Mi1.1higan Congressional 

Peleg;ltioo. 

Jrequcsttbatyou include tlte letter in the record for the e-vents list-ed bel oM 

If you have aoy qu-estions, plCllSB contact me at (906). 6.35-6050. 

Sincerely. 

~.A-t- Aili'On Payment 

T dbal Cha!rpt:r~Qil 
93 

June 5, 2016 

To whom it may concern/Health Committee: 

I had a stroke in fall of 2011 while at work at the IHS hospital, and immediately 

walked over to the emergency room department. I was immediately assessed by a 

CNA named Jody and in a room when, one of the nurses by the name of Tess 

Conroy told the nurse to move me. CNA Jody told nurse Conroy that I was having 

stroke like symptoms and nurse Conroy got mad at her. All this happened in front 

of patients. I was walked over to the nurses’ station and sat in the doctor’s office. 

There wasn’t any equipment in there to help me if I needed any kind of medical 

care. This was at the demand of nurse Conroy, I WILL NEVER FORGET HER SAYING; ‘‘she’s not having a stroke, move her.’’ I knew I had to act quickly and my aunt 


617e6.eps
94 

who was there at the time drove me to Rapid City Regional Hospital. I am glad that 

I left the emergency room department because my situation was caught in time. I 

did have a stroke and can prove it with my medical records. At the time I also 

worked there in medical records and I had to put my two weeks’ notice in due to 

horrible treatment, nepotism, moral and ethical treatment on behalf of my supervisor and other IHS staff. I can truly say that filing a complaint against Tess 

Conroy because of the malpractice during that time ended in back lash as an employee working there. My then Manager Lynn Pouirer and acting Supervisor Alberta Bad Wound found every way to punish me through out that year. For example 

I was asked more than once what my education was. . .I knew very well, if you 

are my supervisor you have access to my employee records and you know I have 

a Bachelors degree. I was literally picked on; I tried every avenue to protect myself. 

I know now that the protocol put in place is void and useless if you are filing complaints and sending them into Aberdeen where your supervisor has more friends 

and extended family. The system does not work when you have people in place that 

sabotage the proper protocol of filing a complaint. I literally had to make a choice 

of being stress free and healthy to prevent another stroke from stress. They are all 

close friends or relatives, I just had to make the choice to win when it came to my 

health and loose when it came to financial stability. I was extremely hesitant to 

even write a statement only because nothing has been rectified or done. Statements, 

complaints are filed for action to be taken and then the employee or patient has 

hope that they will be justified in some way. Sadly in most cases it is not. I could 

have died due to negligence on the choice of the nurse; I walked away from a good 

paying job, because that nurse is very close friends with my manager and supervisor. After this statement that I am writing I greatly hope it will help to change 

how employees are trained, and how employees are treated by upper management, 

this will definitely change how patients are treated and the type of care they receive. This is my experience as an employee and patient of IHS hospital in Rapid 

City, SD. 

Thank you 

TRIVIA AFRAID OF LIGHTNING

Good afternoon, my name is Linda Green, 

A few years ago, (2012–2014) I worked at Soiux San Hospital in the Patient Registration Dept., I worked with a woman by the name of, Patty Bissonette, we got 

along very well at first, but as the months went on I noticed she didn’t like very 

many people and it was either because of their race and the past she had with 

them, some were because they were dated her ex-boyfriend. So one day I asked if 

she could please keep her opionions to herself, I explained to her that we were there 

because of the patients and not ourselves. This is one of the trainings that we had 

to take, to be professional, kind and put the patient before ourselves and that not 

to be racist or discriminate against anyone, because of their color, origin or sex. Well 

from time on I was on her bad side. There was another employee that had started 

and she was very good at doing her job and right away she noticed how, Patty’s, 

work ethics were and wrote her up every time, Patty, made a mistake or discriminated against a patient, and when several attempts of going to the supervisor, we 

had a supervisor by then, his name was, Monte Gonzalez, and he was also getting 

tired of, Patty, for awhile then when the employee who had issues with, Patty, finally filed an EEO and somehow I got involved in it and when the Mediators came 

I was also told by our supervisor to attend the EEO as well since I had issues with 

her, but I did talk to the supervisor about, Patty, being racist and rude to certain 

patients so I guess this was the reason I was told to attend to resolve all the issues 

at once. But after that all hell broke loose, Patty, got worse with her attitude, the 

supervisor took her side and although I didn’t really have a lot of issues with her, 

the supervisor and the business office manager, Colleen Steele, who was also the 

supervisors relative and Patty’s best friend, all clicked together and started trying 

to make me do things that I knew if I did I would either get reprimanded and probably terminated, which they attempted to do anyway. So this woman, Patty, does 

not like me at all, was telling people after I left Sioux San that I was fired because 

I was stupid, dumb, didn’t know how to do my job and how she hated me so much 

that she could choke the hell outta me. These are the reasons that I do not go to 

Sioux San for my appts or to get my medicines. I had a stroke in Spet of 2015 and 

had a second one in Jan of 2016, which the neurologists said was not a new stroke 

but was not going to rule out that it was not as troke because I had all the same 

symptoms. 

so anyway I had an appt at Sioux San Indian Hospital on 05/08/2016, it was a 

friday, I was running a little late so I called to ask if my sister could check me in 

95 

and the woman that answered the phone did not identify herself, she said, ‘‘appointment desk’’, not a ‘‘good afternoon’’ or ‘‘how can I help you?’’, so I just continued 

and Identified myself so she would know who I was and told her that I had an appt 

and was running so I wanted to know what my appt was? the phone was dead for 

a few seconds, longer than usual, so I said ‘‘hello?’’ and she responded, ‘‘I’m right 

here!’’ with attitude, so I said ‘‘oh I just thought I got disconnected’’, again no response in any way, then she said, ‘‘your appt is at Sioux San Indian Hospital, Rapid 

City South Dakota @ 4pm (and I think it was a little later than that), so I said ‘‘ok 

thank you’’ and was going to ask if my sister would be able check me in and she 

hung up very hard because I heard a very loud click, so I told my sister that she 

just hung up, without any ‘‘have a good day or is there anything else that I can 

help you with?’’ I was shocked at her attitude and how unprofessional and rude she 

was, but I had to call again to make sure that it was ok for my sister to check me 

in, at the time I had an injured foot and was getting around very slow so I needed 

all the help I could get, so I called her back knowing what was going to happen. 

So I tried again and she answered the phone again so I asked her if she was the 

lady that I spoke to a few minutes ago, I Identified myself again and she said 

‘‘yeah!’’, again with attitude, so I asked what her name was and she said ‘‘Patty!’’ 

so I said ‘‘thank you’’ and before I could say anything, she hung up again! same as 

before, no ‘‘have a good day, good bye or is there anything else I could help you 

with?’’ no apologies what so ever. So I asked my sister if she would come in with 

me to check in, in case she got an attitude with me, I was kind of nervous but I 

had to see a Dr or PA so we both went in and she was gone, her chair was turned 

like she ran out or something, her chair wasn’t pushed in, it was turned facing the 

door, so I checked in with the man that was there, Humphrey Long, I knew the 

man so when I walked in he was laughing but I didn’t know why? he was then only 

one in the office area, we made small talk, being cordial, and when I was finished 

checking in, I asked for a complaint form, he showed me where they were, so I took 

one, went about my way, a few days later the following week, I asked an ex co-worker if she could take the form in for me, I didn’t want to face, Patty, in case she 

was in the area, then I was told by same ex co-worker that I should go in and speak 

to supervisor in person to make sure that something was being done about it so I 

went in later that week and I visited the supervisor, she said at the time that, that, 

Patty, came in on monday, first thing in the morning and she had complained about 

how I harassed her and intimidated her when i worked with her and she was in 

fear of her safety so she went to the security office and they sat and watched me 

as I went in to check in for my appt and that they watched me as I went up to 

the third floor. But the supervisor said that it was my word against hers and that 

she couldn’t really do anything about it but that she had a talk with her and then 

she asked what I wanted done about her?. . ..isn’t it her job to take care of that 

kind of issues and make the place a peaceful, relaxing, comfortable place for the patient to come and get their medical issues taken care of? This woman had so many 

complaints wrote up on her that she shouldn’t even be allowed to come near the 

place, shes very hateful, unprofessional and rude. I need to see a Dr or PA again 

to refill some of my meds but I’m very hesitant because I don’t want the security 

sitting there watching my every move, I’m not a violent person, I was very kind to 

the patients when I worked there, as a matter of fact they were some of the people 

that told me back that Patty would talk about me when they asked where I was. 

There are some patients that she talked about when they would leave after they 

checked in for their appts. This woman needs to be made accountable for her work 

and watched very closely. There are other issues and I’m hoping that these people 

will take the time to send their complaints. 

Sincerely, 

LINDA GREEN

Hill City, SD. 

I live on crow creek IF YOUR NOT RELATED TO AN EMPLOYEE YOU GET 

PICKED ON IBILLED FOR REFERRALS. CONSTANTLY HARASSED GOD FOR 

BID IF YOU NEED PAIN CARE. THEY ARE DRUG TESTED SOME OF THEM 

AREALLY MAJOR PILL HEADS. CONTRACT HEALTH I’D JOKE RUN BY DECISIONS MADE BY A HIGH SCHOOL GRADUATE NO OTHER COLLEGE EDUCATION MAKING MAJOR HEALTH ISSUES SHE HAS NO CLUE WE SUFFER 

GET RID OF BERNIE LONG, ROBERT DOUVILLE, PHARMACY DIRECTOR 

GREY. WHERE IS HIPPA ENFORCED ALL GOSSIP. IT’S SAD WE HAVE SO 

MANY MISDIAGNOSED. 

96 

JANICE HOWE

07/02/2016 

Dear Sirs, 

My name is Randy St.Pierre and I have been an IHS employee at the Winnebago 

IHS hospital and most recently at the Rapid City IHS hospital. I just wanted to add 

my impressions and some of the experiences I have had while working in IHS and 

also being a patient at these hospitals. First of all I want to share a little of my 

background, I am 55 years old and am from Yankton SD originally currently living 

in Rapid City SD. At the present time I am not an employee at the Rapid City facility. I left in February of 2016. I am a Native American although I am not considered 

Native by some because my mother was Caucasian. While working in the IHS system I worked as a Medical Laboratory Technician (laboratory) and this involved 

working with many in the facility, particularly the medical staff. I finished my 

Bachelor’s degree in 2015 in Hospital Administration and Management and am halfway through a Master’s degree in Human Resources and Management. I wanted to 

work in IHS in the administrative area when I started my degree several years back 

but after dealing with administration in both the Aberdeen area and the Rapid City 

Hospital I have changed my mind because of the problems that plagues these offices. In my opinion there are many but not all that are there only to get a paycheck 

and do not care about anything else. While working at both the Winnebago and 

Rapid City facilities I would have to make calls to the Aberdeen area offices several 

times a year and I can probably count on one hand how many times I was actually 

able to talk to a person there. And leaving voice mails would also be problematic 

since rarely would they respond to your voice mails including emails. When there 

was something urgent that needed to be done I would have to have my supervisor 

call or email and even he had trouble getting through to someone. The same goes 

for the local administrative offices at the hospital, the staff would rarely take your 

calls. 

The point that has been made about trying to get rid of people is well known in 

IHS, an employee can almost get away with almost anything and never get fired, 

in the 9 years I was employed at IHS I never once saw anyone get fired except for 

myself. I will give a short synopsis of the event that led up to my termination at 

Winnebago. The laboratory had a lab aid that was Native American from the Winnebago tribe and I was warned when I started there that his brother was on the 

tribal council so you shouldn’t upset him. Anyway, I was also told that he did not 

like any Natives that were not from the Winnebago tribe which I found out quickly 

as he would berate me in front of the lab staff, even during our lab meetings. I took 

a complaint to the EEOC in Aberdeen and it took them about a year to finally send 

someone down to investigate and in a meeting with myself and the EEOC person 

and the Hospital CEO which the CEO stated that this was the first he had heard 

of this ‘‘untrue’’ he had been aware of the complaints for over a year and everyone 

in the lab said there was no problem. So this goes on for another year when one 

day the lab aid pushes me off a chair and I go to the lab supervisor and he just 

tells me to forget about it, I was so upset I walked out and went home, the following 

day when I returned I was told I was being fired for going AWOL. I was actually 

not that upset because I was finally not having to endure the constant abuse from 

a fellow worker. I filed for workmen’s comp and was denied because I was fired so 

I took it to court in Omaha NE and provided my testimony and won the case because no one from Winnebago came to the hearing. I was never bitter about this 

because I was never so glad to get out of a job that was so stressful every day. 

I do not agree with those that say that IHS needs more funding, I believe they 

are funded well enough they just don’t use the funds that they do receive in a way 

that is in the best interests of the people. And as for the employees, there are a 

lot of good people working in IHS but unfortunately, there are also a lot of those 

that should not be there. I have seen it numerous times that when a person becomes 

such a problem that they have to do something about them they don’t fire them they 

just transfer them to another facility. What a great way to solve a problem, this 

wouldn’t fly in the private sector. 

And finally, about the care that the people receive at IHS, I do believe for the 

most part they do get very good care but it does depend on the provider and the 

staff. The problem I have seen with the providers, Drs and PA’s is that they seem 

to not be very good at their jobs. I firmly believe that some if not many of these 

providers are those that have trouble in the private sector so they go into IHS 

where if they become a problem the hospital just transfers them to another facility 

or in most cases does not renew their short term contracts and they just go to anVerDate Mar 15 2010 10:23 Jan 05, 2017 Jkt 023226 PO 00000 Frm 00100 Fmt 6601 Sfmt 6621 S:\DOCS\23226.TXT JACK
97 

other IHS facility. There are a great many providers that I have worked with over 

the years that are very good but unfortunately they are in the minority. 

There is so much more I could say about IHS although I don’t want you to get 

the impression that I hate it because it is a very good service to the Native population. I just believe that if there was more accountability and not the attitude that 

you can never get fired from IHS then more of those people would be put in a position to be more accountable not only to their fellow workers but also the IHS system 

as a whole. In about a year when I finish my Master’s degree program I will then 

reevaluate whether or not I want to pursue a career in the IHS system, I hope that 

I can. 

RANDY ST.PIERRE

Rapid City, SD. 

Dear respected members of our South Dakota community, 

In 2008, I finished my master’s in healthcare administration and management. 

Eager to work back home I applied for a position with the nascent diabetes prevention program through the IHS. I applied repeatedly and left many messages to the 

program managers via email and telephone. I never heard anything back. The following year I read in the Rapid City Journal that those in charge of starting the 

program were embezzling funds. I am only writing this to add a single voice to the 

problem, and share some of my frustration that many younger people feel about the 

state of the state. 

Respectfully, 

ANDREW SLAMA

We have the same problem on the white earth res in Minnesota they say we 

might have to pay fore any of res medical treatment as they might not have the 

funds to pay. 

98 

LEROY STORY


617f1.eps

ROSEBUD SIOUX 'I'RIBE 

RESOLUTION NO. 20Ui-168 

WHEREAS, the Rosebud Sioux Tribe i.~ a federally rCCQgnized Indian Tribe organized 

pursuant to the Indian Reorganization Act of 1934 and aU pertinent amendments 

thereof: ilD.d 

WIIEREAS, in accordance v.-ith Arti<.:k: IV, Section l (n), the Rosebud Sioux Tribe is go,•emed 

by a Tribal Council made up uf elected representatives who act in ncconinnM 

with the powen; granted 10 it by it;: Constitution and by-laws; and 

WHEREAS, Article lV, ScG, J(v) of tile Rosebud SiouK Tribe Consti!Uiion states: "The Tribal 

Council shall develop plans and consider implications of the decisions they make 

<Jn the n~t seven generations."; and 

WHEREAS, the Tribe believes that utilizing he~l healti.J. care management practices is essential 

for the proper management of the Roso::bud health care facility; and 

WHEREAS, the Tribe believes that a private sector rnwagement approach to the 

administration of the Rosebud heahb Gare facility is in the best interest of the 

Tribe and will be most effective; nnd 

WHEREAS, the Tribe is actively engaging in a business partnership with 11 well-knall'll, 

experienced, and capable health care mana(:etn<:nl entity; 

WHEREAS, the Tribe's economic arm, the RosebmJ Economic Development Corporation's 

government contracting arm is a highly cffccth•e govenunent conlr<~ctor Hble lo 

deliver goods and services on time nnd on budget with the highest standards; and 

WlffiREAS, the lndiiUl Bcalth Service has issued a sourccs sought for thc m;mago:..~nent and 

administmtion of the Rosebud h~alth cure facility: and 

WHEREAS, the Rosebud Sioux Tribe believes that its business arm teamed with o capable 

hc~lth care management entity will 00 able l<l bcst manage the Rosebud hcalt!t 

001» fncility :>nd provide th~ b""t slanda.d ofcnre; ~nd 

WHii:RI!:AS, the South Dakota Congressional Delegation consisting of United States Senator 

John ThUll<; United States Senator Mike Rounds and House Representative Krisli 

No em has supported the Tribes attempts to provide better benlth care to our Tribal 

memb(:tS and as such we respectfully request their assishmcc in working with II-JS 

to accomplish to above criteria of this tesolution; and 

NOW THEREFORE IT BE RESOLVEll, the Tribe Rosebud officially rcquc:sts tho! the South 

Dakota Conb'TCssinnul D<:legD.lion work '1\ith the Tribe on haviul\ the Indian Health Service 

separate the Rosebud Sioux Tribe and Oglal~ in the sources sought and canccl the Indian Health 

Serviee sources sought for mam•B~"m~nt s..rvices tOr the Rosebud health care facility and ·work 

directly with the Rosebud Sioux Tribe's health uare logistics government contrnctiug arm 10 

negotiate a sole souroe contract for the manng<=ent oflhe Rosobud health Gate faGilily. 
99 


617f2.eps 617f3.eps

CERTIFICATION 

This is to certify that the above Resolution Nil. 2016-168 was duly passed by the Rosebud Sioux 

Tribal Council in session<m Juoe 14, 2016 by a vote offourtecu {14) iu favor, Z<:rO (0) opposed 

and one {1) not voting. The snid resolution was adopted pursuant to authority vested In the 

Co-ull\'lil A quorom wru; pre«>nt 

Rooehud Sioux Tribe 

ROS~DUO SJOUXT~UDE 

RESOLUTION '-iO. 2n16-173 

WHEli~AS, tim Rosebud Sfotllt Tribe ls a rederal!y- recognhe<l !r.dlan tribe ()fg>lflized !)Ufsuaflt to the 

Indian Reorganiutit:m Al::tof 1934aud all partln~nt ~mcndments the roof; ~nd 

WHEREAS, In a~oordance with Miele IV, Section 1[a!, the Rosebud Sk>ux ln'b~ is coverncd by a Tribal 

Coun~il made up ci clect<:d rcpresen~atl'leS wM ~<:tIn acrord~nre with the po>Ners gt'Ult00 to :t ty !& 

eoostlt!rtiOn and lly·Lilws; :md 

WHEiiFM, Artie~<! IV, Sel:tion l{v) of the Rosebud Sioux Trlhe con~ltut!Oil st~tes: 'Th~ Trib-a! Council 

~haU dawk>p pi~~· ""d consider irnplk:ati<>lls of th~ decisloM tll~y mah on the nex! ~even 

gener.rtions.";<:~nd 

WAEllEA.S, the T:-lba! Coundl recognlres the neW fnr o::h<!nges within the !n~ian l*alth se,vke to 

lm~ro\IC cur tribal meml:-a-'s h~oith ""'";and 

WHEREAS, the Tribal Countil on beh~\t of th~ t!ihlmern!:o>rs of the Rooebud SiouK Tribe m;p1e~ their 

support arm gr;.titude of United stares S..nato.s .l<Jhn e~rraSio, Chai11n~n of the senate Ccrrmittee on 

lndion Affairs, ~od Sern!tot Jol)n Thune; introduction of$, 2953, the Indian Health Service Acccuntability 

Actaf2016;and 

WHI;'IIfAS,. the Trfual Coun~il •m beha:i of the tlilx11 memb~n; of the Ro~bud Slow Trlb~ express their 

~~pport and J:nt~tude of llnltcd St.;tes Senator Mike Roun~s on his co;pcnsor!ng s. 2%3, the in<l!<ln 

Hc.~lth Sel'/lce AC«:untabi!itv Act ol 2011>; am! 

TH!!R!FORE BE IT RfSOLVED, that the Rosebud 5iouK Tribal Council reoognlzes ~nd e>:tend.< it:: support 

and g'<ltitude to United St:rteG Senotors John Barr.;sso, Chairman of the Senate Committee on Indian 

Aff~irs. aDd Sanator Joh~ Tlltme- ~n<.i Sen,tor Mikol. Ro<1~ds o~ S. 2959, the tndi~n Health Service 

AtC<lUntablUty Act of2tll6. 

O:R.TJFICI\TlON 

Th1sls to certify that the abwe Resolution No. ~016-ln was duly pass~d by the Rosebud S!ouKlribai 

Coun<:ll1n session on June 14, 2016, l:rf a vote oftw~lve (121ln favor, 1ero (Q] npposed and one (1) nQt 

\fotine. TkQ ••ld "''olutl.;" =• odopt~.:! pursu;nt to ~~•l"l<>rlty ,..,ot~d In 11>~ O:>unoll. A quoat!ll wo• 

presel\t. 

Rose 

WHH~ bird Slol.ll:Tribe 
100 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. MIKE ROUNDS TO

MARY WAKEFIELD

Tribal/Residual Shares for Great Plains Area 

Questions 1, 2, 3a. Can you tell us when you would be able to provide our tribal 

leaders with information about the potential allocation of shares for the Great 

Plains Area? Why isn’t this information public already? Is there a reason you are 

withholding this information or that it is not transparent? 

Answer. Consistent with the IHS Tribal Consultation policy, the Great Plains 

Area (GPA) consults annually on the IHS budget formulation activities and includes 

Tribal representation from the GPA in the IHS Budget Formulation Workgroup. In 

these meetings, IHS openly discusses and shares information related to IHS headquarters, Area, and program or Service Unit level budgets with the tribes. These 

consultations and meetings may include other topic areas, such as IHS investments, 

initiatives, human capital, etc. The availability of information may vary depending 

on the timing of annual appropriation bills or other actions impacting federal appropriations. This information cannot be shared until the full-year appropriations bill 

is enacted. 

In addition to these recurring meetings, in April and May of 2016, the GPA Office 

held meetings to specifically provide technical assistance related to tribal shares, as 

defined by the Indian Self-Determination and Education Assistance Act (ISDEAA) 

(25 U.S.C. 5301 et seq.), with the GPA Tribal Leaders and their subject matter experts. On March 23, 2016, invitations to attend these meetings were sent to all 

tribes in the GPA for those tribal consultation topics that are relevant to the respective tribes. For example, the IHS held a GPA Tribal Leaders Briefing in Sioux Falls, 

South Dakota on April 5–7, 2016 to provide an update on the progress addressing 

the delivery of health care services in the GPA, and to provide an opportunity for 

Tribal Leaders to voice their specific concerns. IHS provided a summary of this 

briefing to GPA Tribal Leaders via letter dated May 9, 2016. 

Throughout the year and at the request of a Tribe, the GPA met on an individual 

basis with several Tribes to provide tribal shares information and ISDEAA technical 

assistance. IHS informed Tribes that they may contact the GPA Office, the Office 

of Direct Service & Contracting Tribes or the Office of Tribal Self-Governance at 

headquarters to schedule individual technical assistance meetings. 

Question 3b. Why would tribes need to use FOIA to request this info? 

Answer. The IHS makes every effort to maintain a clear balance between transparency and information sharing as it relates to applicable requirements for protecting privacy. In general, information regarding tribal shares and residual is 

shared annually or through individual technical assistance as noted above. In addition, IHS provides information relating to budgets, initiatives, and updates to Tribes 

on an on-going basis throughout the year through various forums from Tribal advisory committees, workgroups, and boards to press releases, letters to Tribal Leaders, 

and Congressional reports. The IHS values transparency in parallel to its stewardship duty of safeguarding records and data. As a general practice, when information 

is not publically available, IHS adheres to the requirements of the Freedom of Information Act (FOIA). 

Question 4. Shouldn’t this information be based upon how the Great Plains Area’s 

budget is distributed today and isn’t that information readily available to you? 

Answer. The Indian Health Service, in consultation with tribes, has developed formulas for distribution of HQ, Area, and Service Unit funding known as ‘‘tribal 

shares tables.’’ These formulas are not based on actual expenditures from year to 

year. This was deliberate because tribes wanted the formulas set in order to ensure 

predictability in funding to continue to allow tribes to exercise self-determination in 

how they receive healthcare. This allows tribes to make their determinations continue to either receive services directly from the Indian Health Service or through 

an ISDEAA contract based on the tribal needs. 

This residual amount is described here in an April 1995 communication: 

https://www.ihs.gov/ihm/ 

index.cfm?module=dsplihmlsgmlmain&sgm=ihmlsgml9502 

This provides a clear distinction between the funding a Tribe or Tribal organization is entitled to under the ISDEAA and the operational budgets of an IHS Area 

Office. A residual is portion of the IHS budget related to inherently federal functions 

necessary for the execution of the agency’s programs and are not issued as shares 

to tribes. The split between residual and not inherently governmental funds are determined by IHS based on the legislative history of each appropriation act and executive branch wide definitions of inherently governmental functions. 

101 

The IHS is committed to ensuring accurate financial information is shared in a 

timely and transparent manner, through consultative processes and efforts described above. One key driver of delay in getting information to the tribes is the 

annual appropriations process. IHS cannot provide final tribal share information 

until our appropriation is enacted by Congress. These bills have been delayed from 

mid-December to as late as mid-March. Once the bill is enacted, IHS can compare 

this to the planned President’s Budget and determine the correct categorization for 

any new amounts, either eligible for tribal shares or designation as residual. This 

process involves review of the bills legislative history and potentially decisions 

issued by the IHS Director. 

Question 5. Are these shares the product of statute or administrative rule? 

Answer. The IHS implements the Indian Self-Determination and Education Assistance Act (ISDEAA), (25 U.S.C. 5301 et seq.), as amended, which recognizes the 

unique legal and political relationship between the United States and American Indian and Alaska Native peoples. Titles I and V of the ISDEAA provide Tribes the 

option to exercise the right to self-determination by assuming control and management of programs, services, functions, and activities (or portions thereof) previously 

administered by the Federal Government. 

Per the ISDEAA regulations, Tribal share means an Indian Tribe’s portion of all 

funds and resources that support secretarial PSFAs that are not required by the 

Secretary for the performance of inherent Federal function. The ISDEAA regulations and Tribal Consultation (at Headquarters and Area levels) helped shape the 

methodologies utilized today. The methodologies range: (1) Direct Shares are precisely determined when financial accounts record actual spending for PSFAs for a 

Tribe, e.g. IHS funds at a local site serving one Tribe; (2) Program Measures may 

be calculated in proportion to workloads, services, or patient counts for each Tribe. 

These formulas are most common for PSFAs associated with the Office of Environmental Health and Engineering; and (3) Proxy formula that calculates shares in 

proportion to indirect measures such as user counts, number of Tribes, or other general distributive factors. 

Question 6. Information on tribal shares are already published in the annual 

budget book for 10 of the 12 IHS service areas. Why is this information not published for the Great Plains Area? 

Answer. The IHS Congressional Justification (CJ) includes self-governance funding tables. For the first time, a Tribe from the Great Plains Area successfully entered into a self-governance compact in 2016, after the February 2016 publication 

of the FY 2017 CJ. Because of this, the Great Plains Area will be included in the 

self-governance funding tables in future years. 

Contracting/Staffing (Contracting/Quality Offices) 

We are frustrated by the lack of transparency, consultation and communication 

in the process for both issuing the RFP and selecting the vendor for the Winnebago/ 

Omaha, Pine Ridge and Rosebud Emergency Departments. We believe that had 

there been more awareness that the RFP was issued and had IHS responded to the 

interested local health care providers, a local health care entity may have submitted 

a legitimate bid for consideration. Furthermore, we understand that AB Staffing Solutions has a mediocre to poor history at being able to staff IHS facilities in the 

past, specifically: 

• The San Carlos Apache had AB Staffing at their facility in Arizona. AB Staffing 

did not meet the tribe’s expectations and were fired. 

• We have heard reports that AB Staffing supplied staff at our Pine Ridge and 

Rosebud facilities and that the staff members that AB Staffing supplied were 

responsible for the shortcomings and poor quality that led to the CMS violations. 

• We have heard reports that AB Staffing regularly recruits health care professionals from global regions that do not have the same or equal quality medical 

training and certification standards as United States medical training and certification. 

Question 7. What information can you give me about your confidence in AB 

Staffing’s ability to be successful in their contracts in the Great Plains Area? 

Answer. IHS is committed to providing quality care at its emergency facilities in 

the Great Plains Area. IHS is working to provide oversight and support to the contractor and to the hospitals served by the contractor to help facilitate a successful 

implementation. The challenges are complex in these specific areas of quality improvement. IHS is continually working to improve the quality of care provided at 

our facilities and to ensuring the improvements made can be sustained over time. 

102 

Question 8. Ultimately, if they are not able to perform successfully, what recourse 

do our tribes have in canceling and rebidding the contracts? 

Answer. A recent modification has been issued to the AB Staffing contract to more 

clearly define requirements, provide additional qualifications for health care providers, and enhance contractor accountability. The modification also provided additional funding in order to recruit and retain quality personnel. Tribes with concerns 

about AB Staffing’s performance should contact the Great Plains Areas Director who 

can notify the Contracting Officer’s Representative (COR) for the contract and Indian Health Service will assess the situation and if appropriate, take action pursuant to the Federal Acquisition Regulations. 

Vacancy info (OHR) 

Of the 846 Healthcare Professionals in the Great Plains Area, only 637 of those 

positions were filled at the time of the report this spring. This is a vacancy rate 

of 25 percent. 

Question 9. Presumably there is money allocated for the salaries of those positions 

that are not filled. How is that money allocated every year; is it redeployed and if 

so, how? 

Answer. Positions are funded through the annual appropriations allocated to the 

Area and each Service Unit. Third party collections within each Service Unit may 

also be used to fund healthcare positions. Any funds available due to vacancies are 

used for the provision of health care services including but not limited to medical 

supplies and equipment and temporary contracted healthcare providers. 

Question 10. Can you provide the vacancy rates/information as of June 17, 2016 

for the Great Plains Area? 

Answer. As of June 15, 2016, total number of vacancies and the vacancy rates for 

IHS GPA are as follows: 

• The total number of GPA positions was 2,782. Of the 2,782 GPA positions 549 

were vacant. Therefore, the overall vacancy rate for GPA was 20 percent (1936 

total non-health professional positions and 846 health professional positions). 

• The total number of health professional positions was 846. Of the 846 health 

professional positions 209 were vacant. Therefore, the vacancy rate for health 

professional positions was 25 percent. Health professional positions include, 

Medical Officers/Physicians, Nurses, CRNAs, Midwives, Nurse Practitioners, 

Dentists, Physician Assistants, and Pharmacists. 

• The total number of non-health professional positions was 1,936. Of the 1,936 

non-health professional positions 340 were vacant. Therefore, the vacancy rate 

for non-health professional positions was 18 percent. Non-health professionals 

positions include, for example, medical support staff, Area Office, admin staff, 

custodians, clerks, Engineers, Behavioral Health, HR, Finance, Business Office, 

etc.). 

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