```

[Senate Hearing 112-703]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 112-703
 
VA'S COLLABORATION WITH INDIAN HEALTH SERVICE: IMPROVING ACCESS TO CARE 
FOR NATIVE AMERICAN VETERANS BY MAXIMIZING THE EFFECTIVE USE OF FEDERAL 
                           FUNDS AND SERVICES 

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

                                HEARING

                                before a

                          SUBCOMMITTEE OF THE

            COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS

                             SECOND SESSION

                               __________

                            SPECIAL HEARING

                    AUGUST 30, 2011--RAPID CITY, SD

                               __________

         Printed for the use of the Committee on Appropriations

   Available via the World Wide Web: http://www.gpo.gov/fdsys/browse/
        committee.action?chamber=senate&committee=appropriations

                               __________

                         U.S. GOVERNMENT PRINTING OFFICE 

78-226 PDF                       WASHINGTON : 2013 

For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; 
DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC, 
Washington, DC 20402-0001 

                      COMMITTEE ON APPROPRIATIONS

                   DANIEL K. INOUYE, Hawaii, Chairman
PATRICK J. LEAHY, Vermont            THAD COCHRAN, Mississippi
TOM HARKIN, Iowa                     MITCH McCONNELL, Kentucky
BARBARA A. MIKULSKI, Maryland        RICHARD C. SHELBY, Alabama
HERB KOHL, Wisconsin                 KAY BAILEY HUTCHISON, Texas
PATTY MURRAY, Washington             LAMAR ALEXANDER, Tennessee
DIANNE FEINSTEIN, California         SUSAN COLLINS, Maine
RICHARD J. DURBIN, Illinois          LISA MURKOWSKI, Alaska
TIM JOHNSON, South Dakota            LINDSEY GRAHAM, South Carolina
MARY L. LANDRIEU, Louisiana          MARK KIRK, Illinois
JACK REED, Rhode Island              DANIEL COATS, Indiana
FRANK R. LAUTENBERG, New Jersey      ROY BLUNT, Missouri
BEN NELSON, Nebraska                 JERRY MORAN, Kansas
MARK PRYOR, Arkansas                 JOHN HOEVEN, North Dakota
JON TESTER, Montana                  RON JOHNSON, Wisconsin
SHERROD BROWN, Ohio

                    Charles J. Houy, Staff Director
                  Bruce Evans, Minority Staff Director
                                 ------                                

Subcommittee on Military Construction and Veterans Affairs, and Related 
                                Agencies

                  TIM JOHNSON, South Dakota, Chairman
DANIEL K. INOUYE, Hawaii             MARK KIRK, Illinois
MARY L. LANDRIEU, Louisiana          KAY BAILEY HUTCHISON, Texas
PATTY MURRAY, Washington             MITCH McCONNELL, Kentucky
JACK REED, Rhode Island              LISA MURKOWSKI, Alaska
BEN NELSON, Nebraska                 ROY BLUNT, Missouri
MARK PRYOR, Arkansas                 JOHN HOEVEN, North Dakota
JON TESTER, Montana                  DANIEL COATS, Indiana
                                     THAD COCHRAN, Mississippi
                                       (ex officio)

                           Professional Staff

                            Christina Evans
                             Chad Schulken
                              Michael Bain
                       Dennis Balkham (Minority)
                       D'Ann Lettieri (Minority)

                         Administrative Support

                              Rachel Meyer
                      Courtney Stevens (Minority)

                            C O N T E N T S

                              ----------                              
                                                                   Page

Opening Statement of Senator Tim Johnson.........................     1
Statement of Robert L. Jesse, M.D., Ph.D., Principal Deputy Under 
  Secretary for Health, Veterans Health Administration, 
  Department of Veterans Affairs.................................     2
    Prepared Statement of........................................     3
Funding for Rural and Native American Veterans...................     4
Indian Health Service Partnership................................     5
South Dakota Projects and Initiatives............................     6
Statement of Randy Grinnell, M.P.H., Deputy Director, Indian 
  Health Service.................................................     7
    Prepared Statement of........................................     9
American Indian/Alaska Native Veterans Dual Use of Indian Health 
  Service and Veterans Health Administration.....................     9
Department of Health and Human Services/Indian Health Service-
  Department of Veterans Affairs/Veterans Health Administration 
  Memoranda of Understanding.....................................    10
Indian Health Service-Veterans Health Administration 
  Collaborations.................................................    10
Area Director Meetings With Veterans Integrated Service Network..    10
Sharing Facilities...............................................    11
Telemedicine.....................................................    11
Outreach (Tribal Veteran Representatives)........................    11
Health Information Technology....................................    11
VistA Imaging....................................................    11
Bar Code Medication Administration...............................    12
Meaningful Use...................................................    12
Alaska Area Indian Health Service-Veterans Health Administration 
  Health Information Technology Collaborations...................    12
Consolidated Mail Outpatient Pharmacy............................    12
Future Opportunities of Partnership..............................    13
Statement of Stephanie Elaine Birdwell, Director, Office of 
  Tribal Government Relations, Department of Veterans Affairs....    13
    Prepared Statement of........................................    14
Outreach and Consultation........................................    15
Increase Access to Healthcare and Sustainable Economic 
  Opportunities..................................................    15
Indian Health Service and Department of Veterans Affairs 
  Coordination...................................................    18
Payment and Reimbursement........................................    19
Telemedicine.....................................................    20
Mental Health Telehealth.........................................    23
Tribal Consultation Sessions.....................................    23
Outreach.........................................................    24
Tribal Veteran Representative Program............................    25
Nondepartmental Witnesses........................................    27
Statement of Don Loudner, National Commander, National American 
  Indian Veterans................................................    27
Statement of Iva Good Voice Flute, Air Force Veteran, Oglala 
  Sioux Tribe....................................................    31
Material Submitted Subsequent to the Hearing.....................    35
Prepared Statement of the Cheyenne River Sioux Tribe.............    35
Prepared Statement of Geri Opsal, Tribal Veterans Service Officer 
  for the Sisseton Wahpeton Oyate, Lake Traverse Reservation.....    36
Letter From the Standing Rock Sioux Tribe........................    38

VA'S COLLABORATION WITH INDIAN HEALTH SERVICE: IMPROVING ACCESS TO CARE 
FOR NATIVE AMERICAN VETERANS BY MAXIMIZING THE EFFECTIVE USE OF FEDERAL 
                           FUNDS AND SERVICES

                              ----------                              

                        TUESDAY, AUGUST 30, 2011

                               U.S. Senate,
Subcommittee on Military Construction and Veterans 
                     Affairs, and Related Agencies,
                               Committee on Appropriations,
                                                    Rapid City, SD.
    The subcommittee met at 10 a.m., at the Journey Museum, 222 
New York Street, Rapid City, South Dakota, Hon. Tim Johnson 
(chairman) presiding.
    Present: Senator Johnson.

                opening statement of senator tim johnson

    Senator Johnson. Good morning. This hearing will come to 
order.
    I welcome everyone to Rapid City today to discuss 
collaboration between the Department of Veterans Affairs (VA) 
and the Indian Health Service (IHS).
    Present today are councilmen from Crow Creek Tribe, Oglala 
Tribe, and the chairman of the Rosebud Tribe.
    Our first panel today will be Dr. Robert Jesse, Principal 
Deputy Under Secretary for Health, Veterans Health 
Administration (VHA); Randy Grinnell, Deputy Director of the 
IHS; and Stephanie Elaine Birdwell, Director of the Office of 
Tribal Government Relations (OTGR) at the VA.
    Welcome, and I look forward to your testimony today.
    IHS and the VA have very unique responsibilities, but often 
overlap in their roles of providing care to Native American 
vets. Today's hearing is aimed at determining how the two 
departments plan to work together to deliver services in a more 
efficient manner.
    The budget climate we face today means that the Federal 
Government is going to be asked to do more with less. The VA 
and IHS will need to be more innovative and collaborative than 
ever in order to provide services in a very demanding 
environment. In particular, the VA and IHS need to be more 
proactive in their efforts to ensure that Native American vets 
receive the care that they have earned through their service in 
the Armed Forces.
    Native American vets face unique challenges in receiving VA 
benefits due to a number of factors, including a lack of access 
on tribal lands and an often confusing maze of bureaucratic 
hurdles leaving vets unsure of whether they should be receiving 
care through the IHS or the VA.
    I am hopeful that today's hearing will provide a better 
understanding of how both departments plan to address these 
problems. I am especially interested in how the VA and the IHS 
plan to leverage technology to bring services closer to where 
these vets live.
    With that said, again I welcome you to South Dakota. Thank 
you for coming, and I look forward to your testimony.
    Dr. Jesse, please proceed.
STATEMENT OF ROBERT L. JESSE, M.D., Ph.D., PRINCIPAL 
            DEPUTY UNDER SECRETARY FOR HEALTH, VETERANS 
            HEALTH ADMINISTRATION, DEPARTMENT OF 
            VETERANS AFFAIRS
    Dr. Jesse. Thank you, Senator.
    Good morning, Mr. Chairman. First, thank you for inviting 
me and Ms. Birdwell, the Director of the OTGR, to discuss the 
collaboration between the VHA and the IHS on improving access 
to care for Native American veterans by maximizing the use of 
Federal funds and services.
    I am accompanied today also by Mary Beth Skupien, who is 
the Director of the VHA Office of Rural Health, and Janet 
Murphy, who is the Director of the VA Midwest Healthcare 
Network, which is Network 23, providing services in South 
Dakota, North Dakota, Iowa, and Minnesota, Nebraska, and 
portions of Illinois, Kansas, Missouri, Wisconsin, and Wyoming.
    Increasing access for veterans is one of Secretary 
Shinseki's top priorities and has several components 
immediately relevant to the Native American and rural veterans. 
On a national level, VA is investing more than $270 million to 
improve access and quality care services to rural and highly 
rural veterans, including $43 million in telehealth.
    As of August 1, 2011, we are now operating 16 active 
telehealth programs for Native American, Alaska Native, and 
Pacific Island veterans. We continue to look for more 
opportunities to extend our reach in delivering quality 
healthcare so that Native American veterans in remote areas can 
have the same access to healthcare from national experts as 
their urban counterparts.
    In October 2010, the VA and IHS signed a new memorandum of 
understanding (MOU). Its principal goals are for VA and the IHS 
to provide patient-centered collaborations in consultation with 
tribes at regional and local levels. These efforts are already 
paying dividends.
    For example, last October, we initiated a pilot program 
here in Rapid City, South Dakota, to promote the safety and 
cost effectiveness of providing prescription refills by mail 
for veterans and other IHS patients. This program will enhance 
prescription delivery to federally recognized tribes and about 
2 million Native Americans.
    Similarly, VA collaborates with IHS and tribal governments 
to expand home-based primary care, including a number of local 
initiatives to improve access and outreach for Native Americans 
in South Dakota. The VA Black Hills Healthcare System, to name 
one example, maintains a robust noninstitutional purchased care 
program that offers eligible veterans in-home care when travel 
for healthcare is not possible or would be made difficult.
    In addition, the Wagner, Watertown, Spirit Lake, Sioux 
City, and Aberdeen clinics are planning information fairs and 
open houses to inform veterans of available services and 
benefits, to enroll eligible veterans so that they may access 
these hard-earned benefits.
    The Sioux Falls VA Healthcare System holds monthly phone 
conferences with the IHS Aberdeen area office so IHS can 
determine the potential areas of resource sharing, including 
services for radiology, audiology, laboratory, physical 
therapy, and patient transportation.
    Through local agreements, VA and IHS share technical 
training, informatics, and electronic health records (EHRs). 
VA's contract clinics at Mission, Winner, Eagle Butte, Faith, 
Pierre, and Isabel now serve veterans from Lakota, Nakota, and 
Dakota tribes in South and North Dakota. VA provides 
transportation support to the South Dakota tribes at Rosebud, 
Standing Rock, Cheyenne River, and Pine Ridge Reservations. And 
VA provides pharmacy mail order services for tribes in South 
Dakota.
    In April 2010, VA opened the Wagner community-based 
outreach clinic (CBOC), the first CBOC built on tribal land for 
a variety of primary and mental healthcare. The Wagner CBOC 
also hosts a home-based primary care team, which helps Native 
Americans remain in their homes and avoid frequent 
rehospitalizations or emergency room visits for chronic 
conditions.
    Our Readjustment Counseling Service Mobile Vet Center 
Program provides early access to returning combat veterans via 
outreach at a variety of military and community events, and 
today we want just to acknowledge and thank them for showing up 
here. And they are parked outside the museum so that veterans 
can access our services.
    And Mr. Chairman, we understand the unique difficulties 
Native Americans face when accessing care. We are committed to 
working to improve that access in partnership with IHS. We are 
introducing VA providers to traditional healing practices so 
that they can work to integrate these practices as adjuncts to 
Western medicine.

                           prepared statement

    And finally, I just really want to thank you personally for 
your support and that of the subcommittee and the Congress for 
securing VA resources that we need to deliver better, more 
accessible care to Native Americans. As you know, there has 
been a book written about the VA called ``The Best Care 
Anywhere''. It is in its second edition. And we think we 
strongly believe that the title of that next book should be 
``The Best Care Everywhere'', and VA is committed to providing 
that.
    So thank you again, and I am prepared to answer any 
questions.
    [The statement follows:]
                 Prepared Statement of Robert L. Jesse
    Good Morning, Mr. Chairman. Thank you for inviting me to discuss 
the collaboration between the Department of Veterans Affairs (VA) and 
the Indian Health Service (IHS) on improving access to care for Native 
American veterans by maximizing the use of Federal funds and services. 
I am accompanied today by Mary Beth Skupien, Director, Veterans Health 
Administration's (VHA's) Office of Rural Health, and Ms. Janet Murphy, 
Director of the VA Midwest Health Care Network (Veterans Integrated 
Service Network (VISN) 23), which provides services to veterans in 
South Dakota, North Dakota, Iowa, Minnesota, Nebraska, and portions of 
Illinois, Kansas, Missouri, Wisconsin, and Wyoming.
    Native American veterans face many of the same challenges as 
veterans living in rural and highly rural areas, such as geographic 
distance from healthcare facilities and a shortage of skilled community 
providers. Native American veterans also face unique challenges of 
their own, such as higher morbidity for certain conditions and the need 
for culturally appropriate care. Earlier this year, VA established an 
Office of Tribal Government Relations, which is working in close 
cooperation with VHA's Office of Rural Health (ORH), specifically to 
serve as an advocate within the Department for Native American veterans 
and help VA improve healthcare access and services for Native American 
veterans. Increasing access for veterans is one of the Secretary's top 
priorities for the Department and has several components immediately 
relevant to Native American and rural veterans--it means bringing care 
closer to home, sometimes even into the veteran's home; increasing the 
quality of the care we deliver; and providing veteran-centered care in 
a time and manner that is convenient to our veterans.
    My testimony will begin by reviewing VA's plans in fiscal years 
2011 and 2012 for continued support of ORH projects and other rural 
health initiatives. I will then focus on VA's memorandum of 
understanding (MOU) with IHS and our continually evolving partnership. 
My statement will conclude with a discussion of VA's efforts in South 
Dakota to ensure veterans, particularly Native American veterans, 
receive the care and benefits they have earned.
             funding for rural and native american veterans
    With the funding provided by the Congress in fiscal year 2011, VA 
will invest more than $270 million to improve the access and quality of 
healthcare services to rural and highly rural veterans, including $43 
million in telehealth programs. Telehealth involves the use of 
information technology to deliver services when the patient and 
healthcare provider are separated by geographic distance. We have seen 
a 20-percent increase in the use of telehealth services by veterans 
living in rural and highly rural areas between fiscal year 2008 and 
fiscal year 2010. VA-supported telehealth programs offer specialty 
services, including mental health, dermatology, amputee care, pharmacy, 
polytrauma, radiology, and others. As of August 1, 2011, VA operates 16 
active telehealth programs for Native American, Alaska Native, and 
Pacific Island veterans. Telehealth can reduce the need for travel by 
patients and providers, but it does not replace the need for face-to-
face care delivery. We continue to look for more opportunities to 
extend our reach in delivering quality healthcare. We are exploring the 
use of wireless technologies, mobile resources, and more accessible 
facilities so that Native American and rural veterans in remote areas 
can have the same access to healthcare from national experts as their 
urban counterparts.
    Other ORH-managed programs include Project Access Received Closer 
to Home, a pilot program authorizing the use of contractual agreements 
with non-VA providers to deliver care closer to home and three veterans 
rural health resource centers, which function as field-based clinical 
laboratories and serve as rural health experts for all VISNs. ORH also 
supports continuing projects and initiatives, including:
  --More than $70 million to support 52 rural community-based 
        outpatient clinics (CBOC);
  --Almost $26 million in home-based primary care at 21 sites;
  --$1.5 million to support treatment for substance use disorders;
  --Nearly $5 million to end homelessness among rural veterans 
        including funds to promote outreach, prevent homelessness among 
        at-risk veterans, distribute emergency housing vouchers, and 
        support grant and per diem programs. ORH-funded programs in 
        Sioux Falls and nationally are demonstrating improved 
        collaboration within the community to address homelessness in 
        rural areas and have a demonstrable impact on preventing 
        homelessness. These efforts also improve the quality of life 
        and functioning for veterans served and reduce the frequency of 
        visits by veterans within the primary care setting.
  --More than $3 million to enhance transportation options for veterans 
        in rural and highly rural areas; and
  --$91.2 million to sustain 76 additional rural health projects, such 
        as mobile health clinics, case management and mental health 
        services, geriatric care, non-institutional care, and other 
        specialty services.
    VA is addressing mental healthcare needs of rural veterans through 
ORH's support of the Mental Health Intensive Case Management program. 
This allows VA to hire staff to provide case management services to 
veterans with severe mental illness. This program has demonstrated its 
success in preventing homelessness and helping patients to set goals to 
improve their quality of life and reintegrate into the community.
    VA operates a fleet of 50 mobile vet centers that provide early 
access to returning combat veterans via outreach to a variety of 
military and community events including demobilization activities. The 
vehicles are also extending vet center outreach to more rural 
communities that are isolated from existing VA services. The vehicles 
consistently provide services to Native American reservations and are 
staffed with veterans who understand firsthand the needs of these 
communities.
    The VA Black Hills Health Care System (Hot Springs campus) is 
serving almost 300 veterans in 13 counties within a 60-mile radius of 
the facility, including much of the Pine Ridge Reservation, through a 
full home-based primary care (HBPC) team. Further enhancements are 
planned for fiscal year 2012 to provide HBPC and in-home skilled care 
for veterans in the southwestern portion of South Dakota, including 
previously unreached parts of the Pine Ridge Reservation. A second 
program is VA's Medical Foster Home, which matches veterans who are 
unable to remain in their homes with people in the community who are 
willing to care for them. This is a new program that is currently being 
marketed to veterans and the community, and we anticipate we will begin 
admitting veterans to the program later this year.
    In fiscal year 2012, VA will continue to support many of the same 
projects as in fiscal year 2011, and we look forward to initiating 
further measures to increase access to care for rural, highly rural, 
and Native American veterans. In fiscal year 2012, ORH will again 
support increased access to care by funding telehealth service 
projects, such as tele-mental health, tele-retinal care, tele-pharmacy, 
tele-radiology, tele-rehabilitation, tele-dermatology, and other 
innovative telehealth services. We will conduct outreach and marketing 
efforts to encourage veterans who need these services to access them. 
We will also support greater community collaboration and access to 
specialty services, and we will promote education programs, including 
healthcare provider training to teach providers how to care for the 
unique needs of rural and highly rural veterans, as we enhance our 
recruitment and retention efforts for providers in rural areas.
                   indian health service partnership
    Complementing our national efforts, VA and IHS signed a new MOU on 
October 1, 2010. In contrast to a February 2003 MOU, this current 
agreement includes more areas of focus and is more specific concerning 
the obligations of each party to coordinate the delivery of care for 
Native American veterans. The memorandum's principal goals are for VA 
and IHS to promote patient-centered collaborations in consultation with 
tribes at the regional and local levels. Although national in scope, 
the MOU provides the necessary flexibility to tailor programs through 
local implementation. We believe that by bringing together the 
strengths and resources of each organization, we will improve the 
health status of American Indian and Alaska Native veterans.
    We also recognize that interagency agreements are critical to our 
joint efforts. VA and IHS continue to work through payment and 
reimbursement policies and practices, including working to resolve 
legal questions resulting from new provisions in Public Law 111-148, 
the Patient Protection and Affordable Care Act.
    Another primary goal of the MOU is to promote the health of our 
veterans through disease prevention and community-based wellness 
programs. Through cultural awareness and culturally competent care, 
sharing staff and training programs, and collaborating on issues such 
as care for post-traumatic stress disorder (PTSD), suicide prevention, 
pharmacy management, and long-term care, we can deliver the care Native 
American veterans need.
    VA and IHS have established 14 workgroups to develop specific 
recommendations and action items related to the MOU. The workgroups are 
focused on areas such as services and benefits, coordination of care, 
health information technology, implementation of new technologies, 
payment and reimbursement, sharing of services, cultural competency and 
awareness, training and recruitment, and others. We have made 
significant progress in many of these areas, and will continue to 
monitor progress through weekly meetings and quarterly updates to 
leadership on the remaining items.
    The efforts of VA and IHS are already paying dividends. For 
example, last October, we initiated a pilot program in Rapid City, 
South Dakota, to improve the safety and cost effectiveness of providing 
prescription refills by mail for veterans and other IHS patients. This 
program will enhance prescription delivery to federally recognized 
tribes and about 1.9 million Native Americans. Based on initial 
reports, both veterans and staff are very pleased with the arrangement, 
which has reduced the amount of time it takes to transfer medication 
from VA to veterans and improved the ability of veterans to adhere to 
their treatment regimens.
    Similarly, VA has several collaborative projects with IHS and 
tribal governments to expand home-based primary care to Native American 
and rural veterans. In fiscal year 2011, VA supported these programs in 
11 States, including two locations in South Dakota (Rosebud and Pine 
Ridge). Hospice and Palliative Care has also received support from VA's 
ORH to partner with IHS so that all veterans will have reliable access 
to these services from a knowledgeable and skilled workforce.
                 south dakota projects and initiatives
    In addition to these collaborative efforts between VA and IHS, the 
Department is also supporting a number of local initiatives to improve 
access and outreach for Native American veterans in South Dakota. To 
this end, VA obligated approximately $4 million in fiscal year 2011 to 
expand telehealth, audiology, home-based primary care, mental 
healthcare, and medical foster homes. When we are unable to deliver 
care ourselves, VA Black Hills Health Care System maintains a robust 
non-institutional purchased care program. This service offers eligible 
veterans in-home care when travel for healthcare is not possible or 
would create a significant hardship. VA Black Hills Health Care System 
purchases home hospice, skilled nursing, skilled services, homemaker/
home health aide, and adult home day care services for more than 1,000 
rural veterans.
    For mental healthcare, two sites offer Compensated Work Therapy in 
the State of South Dakota--the Cheyenee River Miniconjou Lakota 
Reservation and the Pine Ridge Oglala Lakota Reservation. VA's 
Compensated Work Therapy programs provide paid vocational 
rehabilitation models designed to return veterans with mental health 
conditions to the highest level of functioning, living, and working in 
their communities. VHA program staff work collaboratively and 
cooperatively with tribal government leadership for reservation-based 
programming. VA also has established mental health specialty clinics 
for Native veterans. For example, the Rosebud clinic offers tele-
psychiatry, and the Standing Rock facility offers tele-psychiatry and 
live clinics for mental health conditions. Cultural outreach and other 
services include a residential alcohol and PTSD program with a VA sweat 
lodge at the Hot Springs clinic of the VA Black Hills Health Care 
System. Native Americans use the sweat lodge as a spiritual place for 
healing to be able to send prayers and thoughts to the Creator and 
grandfathers through the use of meditation, song, and prayers. A sweat 
lodge is a dome-shaped structure made of 28 willow branches, which 
represent the 28 ribs of the sacred buffalo, covered by canvas or other 
materials to hold in the heat and uses the heat and steam from the 
heated rocks for spiritual cleansing.
    Several additional efforts are underway to increase Native 
Americans' access to care in South Dakota. For example, the Wagner, 
Watertown, Spirit Lake, Sioux City, and Aberdeen clinics are planning 
information fairs and open houses to inform veterans of services and 
benefits they may be eligible for and to enroll them if needed. The 
Sioux Falls VA Health Care System holds monthly phone conferences with 
the IHS Aberdeen area office so the IHS can determine potential areas 
of resource sharing, including services for radiology, audiology, 
laboratory, physical therapy, dietetics, telehealth, outreach, and 
patient transportation. We are also developing plans to use video-
teleconferencing to provide tele-mental health services to veterans in 
the Sisseton area through an agreement between VA and IHS.
    VA provides office space and serves as a regional information 
technical support center for the Aberdeen Area Office of IHS. VA and 
IHS share technical training, informatics, and electronic health 
records through local agreements. VA Hot Springs provides IHS' Pine 
Ridge Hospital with information resource management consultation and 
other services such as use of a General Services Administration 
vehicle, phone line costs, and parts exchange-purchase. VA's contract 
clinic at Mission serves veterans from Lower Brule and Sioux tribes, 
and the Winner VA CBOC located on the Rosebud Reservation serves 
veterans from Lower Brule, Rosebud, and Yankton Sioux tribes, Eagle 
Butte, Faith, and Winner. VA provides transportation support to the 
South Dakota tribes at Rosebud, Standing Rock, Cheyenne River, and Pine 
Ridge Reservations, and VA provides pharmacy mail order services for 
tribes in South Dakota.
    In April 2010, VA opened the Wagner CBOC which is located on tribal 
land provided through an agreement with the Yankton Sioux Tribe and 
Aberdeen area IHS and is the first CBOC built on tribal land for the 
sole purpose of providing VA primary and mental healthcare. The Wagner 
CBOC hosts an HBPC team, which helps veterans remain in their homes and 
avoid frequent re-hospitalization or emergency room visits for chronic 
conditions. Similarly, care coordination/home telehealth services are 
also provided at this facility.
                               conclusion
    Mr. Chairman, we understand the unique difficulties faced by Native 
American and rural veterans in accessing care, and we are committed to 
working to improve access to care. We are introducing VA providers to 
traditional healing practices and the unique practices of local tribes 
to help them understand how these practices may be integrated as 
adjuncts to traditional care. We greatly appreciate your support, and 
the Congress' support, in securing the resources VA needs to deliver 
better, more accessible care to all of America's veterans. This 
concludes my prepared statement. I am prepared to answer your questions 
at this time.

    Senator Johnson. Thank you, Dr. Jesse.
    Mr. Grinnell, please proceed.
STATEMENT OF RANDY GRINNELL, M.P.H., DEPUTY DIRECTOR, 
            INDIAN HEALTH SERVICE
    Mr. Grinnell. Good morning, Senator Johnson.
    I am Randy Grinnell, Deputy Director of IHS. I am 
accompanied today by Rick Sorenson from the Aberdeen area 
office. Pleased to have this opportunity to testify on the IHS/
VA collaboration.
    IHS has a unique role in the Department of Health and Human 
Services because it is a healthcare system established to meet 
the Federal trust responsibility to provide healthcare to 
American Indians and Alaska Natives. Our mission is to raise 
the physical, mental, social, and spiritual health of American 
Indian and Alaska Natives to the highest level.
    IHS provides comprehensive healthcare services to 
approximately 1.9 million American Indian and Alaska Natives 
through a network of hospitals, health centers, and clinics 
located in 35 States, many of them in rural and remote areas 
where access is a challenge. We also provide care through the 
private sector, through Contract Health Service (CHS), for 
those types of services that are not available directly.
    In 2006, a joint VA/IHS study was initiated to review dual 
use of the two systems. The findings of the study indicated 
that veterans using the VHA are similar to other veterans with 
similar medical conditions, such as post-traumatic stress 
disorder (PTSD), hypertension, and diabetes. The review also 
found that dual users are more likely to receive primary care 
from IHS and general medical diagnostics and medical healthcare 
from the VHA, and they are likely to receive complex healthcare 
services from both systems.
    Many of the American Indian and Alaska Native veterans are 
eligible for healthcare services from both IHS and VHA. We 
estimate within our patient registration system that we have 
got approximately 45,000 who are identified as veterans in our 
system. Many of them live in rural areas as well and have 
trouble accessing direct facilities, and therefore, they are 
dependent upon our urban Indian health programs where they are 
located in 34 cities.
    IHS also pays for referred care outside the system for 
veterans if they meet the CHS program rules and regulations. 
The VHA is considered an alternate resource, along with 
Medicare, Medicaid, and private insurance in accordance with 
our CHS regulations.
    The MOU that Dr. Jesse talked about was recently signed in 
2010. He identified the five mutual goals of that, which I will 
talk about briefly. It was to improve access to care and 
services; improve communication between the VA, tribes, and 
IHS; encourage partnerships and sharing agreements between the 
three entities; also to ensure appropriate support for programs 
that serve American Indian and Alaska Native veterans; and also 
to improve access to health promotion and disease prevention 
services.
    The principal focus of both of these agreements is to 
provide optimal healthcare to American Indian and Alaska Native 
veterans. Examples include allowing VHA staff to utilize IHS 
and tribal facilities to provide services, opportunities that 
IHS providers take advantage of through the VA for clinical 
skills training and education.
    Dr. Jesse also talked about the traditional healing, where 
we have been working with the VHA to bring that approach into 
their delivery system. Dr. Jesse also talked about the VHA 
home-based primary care project. Right now, there are 13 
collaborative projects in States in New York, North Carolina, 
Oklahoma, Oregon, New Mexico, California, Mississippi, and 
Minnesota, as well as the Rosebud and Pine Ridge Reservations 
here in South Dakota.
    One of the other examples includes increasing mental health 
services by locating VHA social workers in healthcare 
facilities on both the Navajo and the Hopi reservations in the 
Southwest.
    Dr. Jesse also talked about the Wagner service unit, where 
the VA has opened a community-based outpatient clinic. Services 
are being shared there, include audiology, include lab, include 
dietary and radiology.
    On the Navajo reservation, an agreement is currently in 
place with the Prescott VA that allows IHS office space for VA 
PTSD counselors. Also there is work underway with Prescott to 
increase services by allowing more space so that they can 
provide services directly to Navajo veterans.
    In Montana, there are currently telepsychiatry mental 
health services provided at each of the service units 
throughout the Montana area. It is an example of success and a 
way of reaching those remote locations and providing needed 
services.
    Another example is in Alaska. Since 1995, there has been 
the Alaska Federal Healthcare Partnership, which brought 
Federal and tribal entities together to increase access of 
services both in the rural areas and the remote areas of 
Alaska, but also to bring the technology advancements that the 
VA has brought to healthcare and take advantage of it.
    There are more than 100 telemedicine equipment carts that 
are now in rural locations throughout Alaska, and they also 
have deployed digital imaging radiology services to more than 
51 Federal and tribal facilities across Alaska.
    I would like to also point out that the IHS and the VHA 
have a long history of partnering for many decades, especially 
in the health information technology arena. The IHS Resource 
and Patient Management System (RPMS) is actually a system that 
was built and designed by the VA. IHS uses that in place. Many 
of the tribes also take advantage of that.
    And Dr. Jesse mentioned about the VistA, the VistA system 
that they function with as well. The EHR that IHS currently has 
is one that came out of the RPMS system. It is in place now. 
The RPMS EHR is in place in more than 300 IHS tribal and urban 
facilities.
    There are other projects underway with the VA that will 
increase our utilization of their technology, and one of the 
results of that is that the IHS EHR has been certified for 
meaningful use, which is one of the new requirements under the 
Affordable Care Act.
    Dr. Jesse also talked about the Consolidated Mail 
Outpatient Pharmacy (CMOP) project. IHS is working with them. 
One of the pilots is right here in Rapid City. To date, we have 
had more than 20,000 prescriptions that have been filled 
through that project. It has allowed two of our pharmacists at 
our IHS facility to focus on providing direct patient care, 
which we feel is a tremendous outcome.
    Also both staff and patients have been extremely satisfied 
with this new service. So IHS and VA are pursuing utilizing the 
CMOP throughout the entire system.
    So we are committed. IHS is very committed to working with 
the VHA to improve access to services for American Indian and 
Alaska Native veterans.

                           PREPARED STATEMENT

    That concludes my remarks today, Senator, and I am happy to 
answer any questions.
    [The statement follows:]
                  Prepared Statement of Randy Grinnell
    Mr. Chairman and members of the subcommittee: Good morning. I am 
Randy Grinnell, the Deputy Director of the Indian Health Service (IHS). 
I am pleased to have the opportunity to testify on the IHS/Department 
of Veterans Affairs (VA) collaboration.
    The IHS plays a unique role in the Department of Health and Human 
Services (HHS) because it is a healthcare system that was established 
to meet the Federal trust responsibility to provide healthcare to 
American Indians and Alaska Natives (AIs/ANs). The mission of the IHS 
is to raise the physical, mental, social, and spiritual health of AIs/
ANs to the highest level. The IHS provides comprehensive health service 
delivery to approximately 1.9 million AIs/ANs through hospitals, health 
centers, and clinics located in 35 States, often representing the only 
source of healthcare for many AI/AN individuals, especially for those 
who live in the most remote and poverty-stricken areas of the United 
States. The purchase of healthcare from private providers through the 
Contract Health Services (CHS) program is also an integral component of 
the health system for services unavailable in IHS and tribal facilities 
or, in some cases, in lieu of IHS or tribal healthcare programs. IHS 
accomplishes a wide array of clinical, preventive, and public health 
objectives within a single system for AIs/ANs.
   american indian/alaska native veterans dual use of indian health 
               service and veterans health administration
    In 2006, a joint Veterans Health Administration (VHA)-IHS study was 
initiated to review dual use of the two systems by AI/AN veterans. The 
findings of this study indicate that AI/AN veterans using the VHA are 
demographically similar to other VHA users with similar medical 
conditions, such as post-traumatic stress disorder (PTSD), 
hypertension, and diabetes. The review found that dual users are more 
likely to receive primary care from IHS, and general medical diagnostic 
services and mental healthcare from the VHA. They are likely to be 
receiving complex care from both VHA and IHS.
    Many AI/AN veterans are eligible for healthcare services from both 
IHS and VHA. IHS has an estimated 45,000 Indian beneficiaries 
registered as veterans in the agency's patient registration system. 
Some AI/AN veterans who live in urban locations do not have geographic 
access to care in IHS facilities on or near reservations and must use 
the local systems of care or Urban Indian Health Programs (UIHP) where 
they are available. In some of these locations the UIHPs provide 
limited direct care and assist these patients in accessing VHA and 
other services in the local area. AI/AN veterans residing on 
reservations in some cases are not easily able to access VHA health 
facilities and services.
    IHS recognizes that the complexity of IHS-CHS program and VHA 
eligibility requirements can make it difficult for AI/AN veterans to 
access care. IHS pays for the care referred outside of IHS for AIs/ANs 
including veterans if all the CHS program rules and regulations are 
met. For the AI/AN veteran, the VHA is an alternate resource along with 
Medicare, Medicaid, and private insurance in accordance with the CHS 
regulations.
     department of health and human services/indian health service-
department of veterans affairs/veterans health administration memoranda 
                            of understanding
    A memorandum of understanding (MOU) between the HHS/IHS and the VA/
VHA was signed in 2003 to encourage cooperation and resource-sharing 
between the two Departments. The 2003 MOU outlined joint goals and 
objectives for ongoing collaboration between VA and HHS to be 
implemented primarily by IHS and VHA. The MOU advanced our common goal 
of delivering quality healthcare services to and improving the health 
of the 383,000 veterans who identified as AIs/ANs within the VHA 
system, a portion of which are served by IHS. The HHS/IHS and the VA 
entered into this MOU to further their respective missions, to serve 
AI/AN veterans who comprise a segment of the larger beneficiary 
population for which they are individually responsible.
    Tribes stressed the need to improve collaboration and coordination 
of services for veterans eligible for both the VA and IHS services. The 
IHS Director met with VA Secretary Shinseki in May 2010, and they 
agreed to update the 2003 VA-IHS MOU to improve collaboration and 
coordination of services for AI/AN veterans. The updated MOU was signed 
in October 2010 and a consultation on implementation of the MOU was 
initiated with tribes in November, 2010. Tribal leaders identified 
priorities for implementation and the VA and IHS are working on 
improvements to better coordinate care, services and benefits, State-
level agreements, implementation of new technologies, payment and 
reimbursement, health information technology, training, and cultural 
competency. IHS area directors are already working locally in some 
areas with the VHA and tribes to make improvements specific to the 
unique needs of veterans in the IHS area and local levels.
    The MOU identifies five mutual goals to:
  --Improve beneficiary access to healthcare and services;
  --Improve communication among the VA, AI/AN veterans and tribal 
        governments with IHS assistance;
  --Encourage partnerships and sharing agreements among VHA, IHS, and 
        tribal governments in support of AI/AN veterans;
  --Ensure the availability of appropriate support for programs serving 
        AI/AN veterans; and
  --Improve access to health promotion and disease prevention services 
        for AI/AN veterans.
  indian health service-veterans health administration collaborations
    The principal focus of the interagency communication and 
cooperation is to provide optimal healthcare for the AI/AN veterans who 
rely on the IHS and/or VHA for their medical needs. Together, we strive 
to achieve multiple goals outlined by the MOU by developing projects 
that, for example, improve access to VHA services by allowing VHA staff 
to utilize Indian health facilities for providing healthcare to AI/AN 
veterans while the joint working relationship expands opportunities for 
professional development of clinical skills by IHS providers. IHS' 
experience with the use of traditional healing in its system became a 
model for the VHA when it began incorporating traditional approaches to 
healing for AI/AN veterans.
    area director meetings with veterans integrated service network
    Other collaborations that meet the goals of the MOU range from 
expansion of access to VHA home-based primary care for AI/AN veterans 
through the collaboration with IHS and tribal health facilities to the 
improvement of interagency partnership on health information and the 
use of tele-health modalities. The home-based primary care program 
expansion will increase availability of services for AI/AN veterans 
with complex chronic disease and disability through 13 collaborative 
projects located in States including New York, North Carolina, 
Oklahoma, Oregon, New Mexico, California, Mississippi, and Minnesota 
and two locations in South Dakota (Rosebud and Pine Ridge). In 2010, 
this collaboration resulted in a five-fold (11 to 55 veterans) increase 
in the number of AI/AN veterans served by home-based primary care. In 
Arizona, the IHS and the VHA are working together to increase mental 
health services by locating VHA social workers in IHS health facilities 
on the Navajo and Hopi reservations.
                           sharing facilities
    The Wagner IHS facility recently opened a VA community-based 
outpatient clinic (CBOC). IHS has an audiology booth in the facility 
and the VA has an audiologist they can send to the facility to see both 
VA and service unit patients. Both agencies are also sharing lab 
services, the service unit provides onsite lower level lab services to 
the VA while the VA provides some higher level lab services at an 
alternate location. The service unit is developing the capacity to 
provide radiology services to the CBOC. The service unit also provides 
onsite dietary services to the CBOC patients.
    The Navajo Area IHS (NAIHS) is currently working on an approval for 
the Prescott VA providers to be allowed space in an IHS facility to 
increase access to VA services for veterans on the Navajo Nation. The 
NAIHS already has an agreement with Prescott VA that allows office 
space for a PTSD counselor in an IHS facility to provide counseling and 
increase access to services. The NAIHS is also working with Veterans 
Integrated Service Network (VISN) 18 to develop an IHS-VA task force to 
address specific issues to these organizations.
                              telemedicine
    In Montana, the Billings Area IHS and the VHA Montana Healthcare 
System (VHAMHCS) have ongoing collaborative efforts such as tele-
psychiatry established at each service unit to facilitate VHA mental 
health services for AI/AN veterans. Because of the geographic 
remoteness and difficulty in accessing transportation to a VHA 
facility, this service greatly benefits the AI/AN veterans. The 
Billings Area IHS and VHAMHCS have formalized a PTSD protocol that is 
utilized by the service units and Fort Harrison. Among the protocol 
elements, the VHA has created a position designated as a tribal 
outreach worker (TOW) who works on-site to actively seek and educate 
veterans who may benefit from the services provided through tele-
psychiatry clinics. Each service unit has a designated VHA liaison to 
help the AI/AN veterans needing medical services as well as working 
with the TOW and local tribal veteran representative (TVR). As the 
primary IHS contact, they can provide information, assistance, and 
guidance on VHA services and health benefits to AI/AN veterans. To 
distinguish the different roles and responsibilities, the TVRs function 
as an arm of the VA program with the IHS providing and coordinating the 
medical care for the AI/AN veteran. These collaborative efforts are 
reviewed on an on-going basis in efforts to address patient-related 
issues, improve services, outreach, and rural initiatives, and to 
assist AI/AN veterans to utilize both the IHS and VHA systems.
               outreach (tribal veteran representatives)
    VA's development and use of the TVR program has been and is 
critical to addressing issues related to communicating about and 
reducing barriers to VHA services and to the IHS-CHS program for AI/AN 
veterans through coordinated training on benefits and eligibility 
issues for each of the two programs.
                     health information technology
    The IHS and VHA have a long history of working jointly on health 
information technology that dates back to the early 1980s. The Resource 
and Patient Management System (RPMS) is the IHS' comprehensive health 
information system that is derived from and evolved alongside the VHA's 
acclaimed VistA system. IHS/tribal/UIHP (I/T/U) facilities use many 
components of VistA along with IHS-developed components that address 
the population and public health mission of IHS.
    The model for the RPMS electronic health record (EHR) is the 
Computerized Patient Record System, the EHR component of VistA. Since 
its release in 2005, the RPMS EHR has been deployed to more than 300 I/
T/U healthcare facilities nationwide. IHS continues to leverage VHA 
healthcare software development by adapting it for our use where 
possible.
                             vista imaging
    Another important example of IT sharing between VHA and IHS is 
VistA Imaging (VI), the VHA's Food and Drug Administration-certified 
system for capture, storage and viewing of diagnostic images and 
scanned documents. VI provides the multimedia component of both 
agencies' EHR systems, and has now been deployed to more than 90 I/T/U 
facilities across the country. This deployment would not have been 
possible without interagency agreements that have allowed VHA staff and 
contractors to provide implementation support and help desk services to 
our facilities. The VHA's VI program is critical to IHS.
                   bar code medication administration
    Like VI, the VHA Bar Code Medication Administration (BCMA) system 
is an integral component of modern hospital practice. BCMA ensures that 
the right patients are receiving the right doses of the right 
medications in the inpatient setting. The IHS, in cooperation with the 
VHA Bar Code Resource Office, is just beginning a joint effort to 
deploy BCMA in IHS and interested tribal hospitals. This effort will be 
modeled after the successful VI collaboration previously described.
                             meaningful use
    The Meaningful Use Initiative authorized by the HITECH Act of 2009 
has given the IHS an opportunity to materially assist the VHA with an 
important effort. In April 2011, the IHS became the first Government 
agency to have its health information system certified according to the 
requirements for Meaningful Use. The VHA is seeking to certify the 
VistA system in 2012, and has reached out to IHS staff for consultation 
on how we addressed the various certification criteria. Our staff is 
more than willing to do so, as IHS has greatly benefited from so many 
VHA innovations in health information technology for more than two 
decades.
alaska area indian health service-veterans health administration health 
                 information technology collaborations
    The Alaska Area IHS has partnered with the VHA since 1995 via the 
Alaska Federal Health Care Partnership (AFHCP) which includes IHS/
tribal, VHA, Army, Air Force, and Coast Guard partners. The AFHCP 
office's primary responsibility is to coordinate initiatives between 
the partners that result in increased quality and access to Federal 
beneficiaries, or an overall cost savings to the Federal Government. 
Current initiatives in the Alaska Area IHS include:
  --joint training offerings;
  --a neurosurgery contract services agreement;
  --a perinatology contract services agreement;
  --tele-radiology;
  --sleep studies;
  --home tele-health monitoring;
  --partner staffing needs assessment;
  --emergency planning and preparedness; and
  --tele-behavioral health.
    Past projects of AFHCP include the Alaska Federal Health Care 
Access Network (AFHCAN) which deployed network capability (backbone) 
along with hundreds of telemedicine equipment carts, the Teleradiology 
Project, deploying digital imaging radiology services to 51 federally 
and tribally managed IHS-funded facilities, video teleconferencing 
equipment to promote administrative and clinical consults, as well as 
an IT partnership bridge (``Raven Bridge''), allowing Federal and 
tribal partners to connect to each other.
    The AFHCP frequently shares workload data during its investigations 
of possible joint services analyses; a recent example is a study for 
joint-agency tele-dermatology and tele-rheumatology contracts. One of 
the AFHCP committees is the Partnership Telehealth & Technology 
Committee (PT&T) which brings together information technology staff to 
discuss partner organization needs, identify potential telehealth and 
technology applications to meet those needs, and find avenues for 
shared technology resources. PT&T members and their clinical champions 
will monitor patient results and gather feedback on the use of new 
technologies to improve clinical outcomes and access to care.
                 consolidated mail outpatient pharmacy
    The Consolidated Mail Outpatient Pharmacy (CMOP) is a VHA program 
that consolidates and automates the mailing of prescriptions and 
refills to veterans across the country, relieving workload from 
pharmacy staff at VHA facilities. The VHA has permitted IHS to use the 
CMOP facility at Leavenworth, Kansas to provide prescription mail-out 
services for IHS beneficiaries. The pilot has been going on for more 
than a year, right here in Rapid City. More than 21,000 prescriptions 
have been processed through the IHS CMOP to date, allowing two full-
time pharmacists to move from the pharmacy into the clinic where they 
can provide direct patient care services, (i.e., anti-coagulant clinic) 
and improve access to care. The program has improved patient safety by 
reducing medication errors, and has improved both patient and staff 
satisfaction. IHS use of the CMOP facilities will centralize routine 
prescription filling and increase pharmacy collections, and will 
greatly reduce travel time for patients. In addition, it will enable 
pharmacy staff to focus on patient counseling, adverse drug event 
prevention, and primary care.
                  future opportunities of partnership
    Local IHS-VHA efforts to improve access and develop formal 
partnerships have increased since 2003. IHS will continue joint efforts 
on issues related to access to healthcare for AI/AN veterans. We are 
committed to working on these issues, within the IHS, as well as with 
the VA and the VHA. AI/AN Native communities have always honored their 
veterans and we are committed to improving the health services they 
utilize and the quality of their lives.
    Mr. Chairman, this concludes my testimony. I appreciate the 
opportunity to appear before you to discuss the collaboration between 
the HHS through the IHS and the VA through the VHA. I will be happy to 
answer any questions that you may have. Thank you.

    Senator Johnson. Thank you, Mr. Grinnell.
    Ms. Birdwell.
STATEMENT OF STEPHANIE ELAINE BIRDWELL, DIRECTOR, 
            OFFICE OF TRIBAL GOVERNMENT RELATIONS, 
            DEPARTMENT OF VETERANS AFFAIRS
    Ms. Birdwell. Good morning, Chairman Johnson. Thank you for 
inviting me to discuss VA outreach to tribal governments.
    On November 5, 2009, President Obama signed the Memorandum 
on Tribal Consultation, pronouncing tribal consultations a 
critical ingredient of a sound and productive Federal/tribal 
partnership. As part of the strategy to realize the President's 
vision of regular and meaningful consultation and collaboration 
with tribal officials, VA created the OTGR, and I was appointed 
as Director of this office earlier this year.
    Guided by the tribal consultation policy signed by 
Secretary Shinseki in February 2011, the office was created to 
develop partnerships with American Indian and Alaska Native 
tribal governments for the purpose of enhancing access to 
services and benefits for Native veterans.
    We must maintain lasting bonds with tribal leaders and 
Native veterans. Meaningful consultation is absolutely vital if 
we are to effectively address the unique needs of this 
population.
    VA's OTGR serves as an entry point for American Indian and 
Alaska Native tribal government concerns. With an estimated 
383,000 Native American veterans and 565 federally recognized 
tribes, there is much work to be done.
    VA is embarking on a robust outreach and consultation 
effort that will focus on listening, aiding, and advocating. We 
believe the best way to create lasting bonds of trust is to 
meet with tribal leaders and their communities. VA has held 
listening sessions in Bethel, Alaska; Billings, Montana; and 
Bismarck, North Dakota. I am excited to hear from local tribal 
leaders and veterans right here in Rapid City and Kyle, South 
Dakota.
    The office is very grateful for the vast cooperation each 
of these tribes has provided. Without this support, it would be 
difficult for OTGR to understand the challenges Native American 
veterans are facing.
    While we are in the communities, we are aiding and training 
Native American veterans. For example, VA staff have trained 
tribal veteran representatives (TVRs) in Montana and Alaska and 
provided technical assistance to Native American veterans 
seeking home loans during a recent gathering of Northwest 
tribal leaders and veterans in Spokane, Washington.
    We can leverage these opportunities to increase Native 
American enrollment in VA's healthcare system, educate veterans 
about benefits for which they may be eligible, and connect them 
with online resources, such as eBenefits and My HealtheVet.
    VA's goal of creating a bond of trust with American Indian 
and Alaska Native tribal governments is not an end, in and of 
itself. This bond should lead to improved access to benefits 
and services, as well as economic sustainability for veterans 
in Indian Country.
    My office is working with the VHA to enhance access to 
healthcare in several ways. We are facilitating technical 
assistance and the sharing of best practices with the IHS as 
part of our effort to implement the MOU between the VA and IHS. 
Our role is to ensure tribal concerns are heard and considered.
    To this end, we will hold annual listening sessions, in 
addition to formal consultation, to obtain recommendations, 
hear local priorities, and advocate the tribes' perspectives on 
practices that will improve access to care.
    After OTGR was created, we worked with various stakeholders 
within VA to draft a vision statement. We see a future where we 
consistently demonstrate our commitment to Native American 
veterans by being culturally competent, respecting the unique 
sovereign status of tribes, and reaching out to veterans in 
their communities.
    As an enrolled member of the Cherokee Nation of Oklahoma 
with more than 15 years experience in Indian affairs, I know it 
will take time, but I believe it is a goal we can achieve. 
Serving both Indian Country and our Nation's heroes is both a 
professional and deeply personal calling.

                           PREPARED STATEMENT

    Thank you for the opportunity to discuss the work VA is 
doing to reach out to Native American veterans and tribal 
leaders. I look forward to answering any questions you may 
have.
    [The statement follows:]
            Prepared Statement of Stephanie Elaine Birdwell
                              introduction
    Good Morning, Chairman Johnson and members of the subcommittee: 
Thank you for inviting me to discuss Department of Veterans Affairs 
(VA) outreach to tribal governments.
    On November 5, 2009, President Obama signed the Memorandum on 
Tribal Consultation pronouncing tribal consultations ``a critical 
ingredient of a sound and productive Federal-tribal relationship.'' As 
part of the strategy to realize the President's vision of ``regular and 
meaningful consultation and collaboration with tribal officials,'' VA 
created the Office of Tribal Government Relations (OTGR). I was hired 
as the Director of this office earlier this year. The fiscal year 2012 
budget request includes $800,000 to support the establishment of this 
new office.
    Guided by the Tribal Consultation Policy signed by Secretary 
Shinseki in February 2011, OTGR has been charged to develop 
partnerships with American Indian and Alaska Native tribal governments 
for the purpose of enhancing access to services and benefits for Native 
veterans. We must maintain lasting bonds with tribal leaders and Native 
American veterans. Meaningful consultation is absolutely vital if we 
are to effectively address the unique needs of this population.
    Trust is the single most important aspect in our relationship with 
the tribes and Native American veterans. VA is working to earn the 
trust of tribal leaders and Native American veterans through consistent 
outreach and an open door policy. As an enrolled member of the Cherokee 
Nation of Oklahoma with more than 15 years experience in Indian 
Affairs, I know it will take time, but I believe it is a goal we can 
achieve. Serving both Indian Country and our Nation's heroes is both a 
professional and deeply personal calling.
                       outreach and consultation
    VA's OTGR serves as an entry point for American Indian and Alaskan 
Native tribal government concerns. With an estimated 383,000 Native 
American veterans and 565 federally recognized tribal entities, there 
is much work to be done. VA is embarking on a robust outreach and 
consultation effort that consists of three pillars: listening, aiding, 
and advocating.
    Listening certainly includes receiving communications from tribal 
leaders through email, phone, and social media tools, but we believe 
the best way to create lasting bonds of trust is to meet with tribal 
leaders in their communities. VA has held listening sessions in Bethel, 
Alaska; Billings, Montana; and Bismarck, North Dakota. I am excited to 
hear from local tribal leaders and veterans right here in Rapid City, 
South Dakota. OTGR has participated in conferences in Arizona, Montana, 
Idaho, Texas, Wisconsin, Oklahoma, and Washington. We have also 
conducted site visits to key locations that deliver services to Native 
American veterans, including the Consolidated Mail Outpatient Pharmacy 
in Leavenworth, Kansas, and tribal courts in Navajo Nation, Hopi and 
Laguna Pueblo Tribes. OTGR is very grateful for the vast cooperation 
each of these tribes has provided. Without this support, it would be 
difficult for OTGR to understand the challenges Native American 
veterans are facing. We will maintain an aggressive outreach schedule 
to increase the number of American Indian and Alaska Native tribal 
governments with which we are building relationships.
    While we are in the communities, we are aiding and training Native 
American veterans. For example, VA staff have trained tribal veteran 
representatives in Montana and Alaska and provided technical assistance 
to Native American veterans seeking home loans during a recent 
gathering of Northwest tribal leaders and veterans in Spokane, 
Washington. Our outreach provides a unique opportunity to deliver 
technical information to Native American veterans. We can leverage 
these opportunities to increase Native American veteran enrollment in 
VA's healthcare system, educate veterans about benefits for which they 
may be eligible, and connect them with online resources such as 
eBenefits and My HealtheVet. Every encounter with tribal leaders and 
veterans in Indian Country is an opportunity to make a difference in a 
veteran's life.
    OTGR is also advocating for tribal governments. The Secretary of 
Veterans Affairs is committed to conducting meaningful consultation 
with tribes; this means transforming words into action. We plan to 
facilitate five tribal consultation sessions in 2012 at different 
locations across the country. Tribal leaders will have an opportunity 
to voice their concerns on issues that affect the well-being of 
veterans and their families. With a direct link to the tribes through 
OTGR, we will be able to address their concerns before new policies and 
procedures are implemented. OTGR is already serving as a vital 
intergovernmental link for VA's health, benefits, and memorial 
programs.
  increase access to healthcare and sustainable economic opportunities
    OTGR's goal of creating a bond of trust with American Indian and 
Alaska Native tribal governments is not an end in itself. This bond 
should lead to improved access to benefits and services as well as 
economic sustainability for veterans in Indian Country.
    OTGR is working with the Veterans Health Administration (VHA) to 
enhance access to healthcare in several ways. First, OTGR is 
facilitating technical assistance and the sharing of best practices 
with the Indian Health Service (IHS) as part of our effort to implement 
the memorandum of understanding (MOU) between VHA and IHS. VHA's Office 
of Rural Health has made great strides in supporting the delivery of 
care to rural veterans across the country. OTGR's role is to ensure 
tribal concerns are heard and considered. To this end, OTGR will hold 
annual listening sessions in addition to formal consultation to obtain 
recommendations, hear local priorities, and advocate the tribes' 
perspectives on practices that will improve access to care. In 
addition, OTGR is working with VHA to realize opportunities to 
integrate new media and other communication tools to promote innovative 
technologies that bring care to rural communities.
    Mental healthcare is a critical component of overall healthcare, 
and Native American veterans often face unique challenges in accessing 
appropriate mental healthcare. To promote better mental healthcare in 
this population, VA has undertaken several initiatives. In Alaska, we 
are exploring a partnership with the South East Alaska Regional Health 
Consortium to provide mental health compensation and pension 
examinations. OTGR has worked closely with VHA to identify similar best 
practices and to explore options for exporting them. Currently, as part 
of the implementation of the VA/IHS MOU on enhancing services to Native 
American veterans, several new initiatives are being implemented. 
Guidance on outreach and education to tribes about VA/IHS post-
traumatic stress disorder (PTSD) services will involve further 
disseminating training materials created by VA, designed to make 
initial connections with and provide information to tribal governments 
about VA services.
    The training has been used extensively in the Western States (e.g., 
Montana, Idaho), and a current project will focus on Eastern areas, 
including those in Veterans Integrated Service Network (VISN) 6, with 
tribes such as the Lumpee, and in VISN 1. VA staff and tribal groups 
will expand the original training materials with information that 
describes local VISN 6 facility services. Information also will be 
associated with significant symbols of the local tribes. There will 
also be another satellite broadcast/DVD to support this planned 
outreach effort. In addition, the National Center for PTSD Web site, 
(www.ncptsd.va.gov) has the video: ``Wounded Spirits, Ailing Hearts: 
PTSD in Native American Veterans,'' created in 2000 with versions for 
clinicians and general audiences (http://www.ptsd.va.gov/public/videos/
wounded-spirits-ailing-hearts-vets.asp).
    To address substance abuse and mental health issues among veterans, 
VA has worked with veterans treatment courts across the country. These 
courts identify treatment options for many of our veterans with 
substance use disorders or mental health conditions. OTGR is working 
with VHA to create a veterans treatment court ``how to'' guide to help 
identify and link Native American veterans involved with the criminal 
justice system with VA resources and other providers as an alternative 
to incarceration. Our goal is to provide tribal governments the 
resources they need to incorporate, at their discretion, elements of 
the veterans treatment court model that may promote healing in their 
communities. This model may not work for every tribal justice system, 
but these practices generally are consistent with the holistic approach 
to criminal justice practiced by many tribal justice systems and may be 
a valuable tool at their disposal. Local circumstances will help define 
our ability to implement many of these best practices, but we must 
learn from our experiences and leverage our successes.
    In addition to working with VHA to increase access to care, we are 
also working with the Veterans Benefits Administration to address 
systemic economic issues within tribal communities. We can and will do 
more to increase access to and utilization of established benefits such 
as compensation and pension, vocational rehabilitation and employment 
services, and Post-9/11 GI Bill and other education benefits. Recent 
changes to the Post-9/11 GI Bill program illustrate the need for a 
direct link to Indian Country. We are using every avenue available to 
us to ensure that veterans know how changes to that program will 
directly affect them, and OTGR will be a vital resource for tribal 
leaders and a conduit for feedback.
    One area that we believe deserves special attention is the Native 
American Direct Loan Program (NADL), a vital tool in VA's efforts to 
provide permanent housing options for Native American veterans. NADL is 
available for Native American veterans and their spouses to purchase, 
construct, or improve a home on trust land or to refinance an existing 
NADL at a lower interest rate. OTGR is increasing VA's efforts in 
Indian Country and Alaska to educate eligible veterans about this 
important program. Our goal to make sure every eligible veteran 
understands the value the NADL benefit as a long-term housing solution.
    OTGR will also work with tribal leaders to address memorial issues. 
VA's first grant to establish a veterans cemetery on tribal trust land, 
as authorized in Public Law 109-461, was approved by the Secretary of 
Veterans Affairs on August 15, 2011. The amount of the grant, 
$6,948,365, is for the Rosebud Sioux Tribe, and the cemetery will be 
located in White River, South Dakota. This grant will fund the 
construction of a main entrance, an administration building, a 
maintenance facility, roads, an assembly area, a committal shelter, 
preplaced crypts, cremains burial areas, memorial areas, columbaria, 
landscaping, a memorial walkway, and supporting infrastructure. The 
project will provide services to approximately 4,036 unserved Rosebud 
Sioux Tribe veterans and their families. The project will develop 
approximately 14.40 acres. The construction will include 600 pre-placed 
crypts, 544 cremains gravesites, and 32 columbarium niches. The 
cemetery will provide improved service for veterans and their families 
of the Rosebud Sioux Tribe. The nearest VA national cemetery is Hot 
Springs National which is closed and 169 miles away in Hot Springs, 
South Dakota. The proposed cemetery will be near Mission, South Dakota 
on the Rosebud Indian Reservation.
    We must measure our progress and hold ourselves to a high standard 
of achievement if we are to accomplish our goals. This starts with 
compiling recommendations from tribal leaders and tracking these action 
items to the point of completion. We do not promise that every 
recommendation we receive will be adopted, but we do commit to ensuring 
tribal leaders' and veterans' voices are heard and considered. Our 
success will be not only be measured by the frequency of our contact 
with federally recognized tribes, but also by utilization rates for 
benefits and programs and healthcare enrollment by eligible Native 
American veterans. A stronger relationship between the tribes and VA 
will lead to better results and outcomes for Native American veterans.
                               conclusion
    After OTGR was created, we worked with the various stakeholders 
within VA to draft a vision statement. We see a future where American 
Indian and Alaska Native tribal governments view VA as an organization 
of integrity that advocates on behalf of Native American veterans for 
their needs. We see a future where VA demonstrates its commitment to 
Native American veterans by being culturally competent, respecting the 
unique sovereign status of tribes, and reaching out to veterans in 
their communities. We are committed to building a relationship with 
tribal leaders built on a culture of trust and respect. We see a bright 
future, but there is still much to be done.
    Thank you again for the opportunity to discuss work VA is doing to 
reach out to Native American veterans and tribal leaders. I look 
forward to answering any questions you may have.

    Senator Johnson. Thank you, Ms. Birdwell.
    Too often I hear stories from Native American vets that 
they show up at IHS facilities only to be told that they should 
be going to the VA and that there is no patient coordination 
occurring. The new MOU is supposed to address this issue and 
break down these barriers.
    Mr. Grinnell, can you describe in detail how this MOU will 
increase patient coordination between the IHS and VA? 
Specifically, if a vet shows up at an IHS facility with a 
service-connected disability, will they be treated at IHS or be 
told to go to the VA?
    Mr. Grinnell. Thank you for your question, Senator.
    That is probably one of the most challenging aspects of 
what we are trying to improve on. A good example is that when I 
mentioned in my opening comments that the VHA is considered an 
alternate resource for IHS, per our CHS regulations. So any 
time that a veteran does access our system and they have to be 
referred out for care, then we have to exhaust all other 
opportunities before it qualifies for CHS.
    To begin to address that, one of the things that the IHS 
and the VHA are doing is training both the IHS staff, as well 
as the VHA staff in terms of what services are available and 
also understanding the eight categories that the veterans have 
to be eligible for for consideration. Trainings have already 
taken place in a number of the service units where our staff is 
being trained so that they fully understand. And our goal at 
the end is so that the veteran itself is not being shuffled 
back and forth between the two systems, but there is good 
coordination of care.
    Further things that we are talking about is how we can 
hopefully do case management of that individual patient between 
both systems so that they don't feel like that they are being 
passed off from one system to the other.

 INDIAN HEALTH SERVICE AND DEPARTMENT OF VETERANS AFFAIRS COORDINATION

    Senator Johnson. Dr. Jesse, the VA has a good track record 
of coordination with DOD health facilities. But it seems that 
coordination with the IHS has been difficult. From the VA's 
perspective, how do you believe the MOU will give Native 
American vets better access to VA services and break down these 
bureaucratic barriers?
    Dr. Jesse. Thank you, Senator.
    I think there are several aspects to answering that 
question. First is the simple matter of coordinating the 
information related to healthcare. So that what a given 
patient's issues are, are then visible to both the VA and the 
IHS. With a shared electronic record, that is increasingly 
easier to do.
    Second is that both the IHS and the VA are actively 
implementing, I guess as a common collective term, new models 
of care, moving from a single-provider model into a team-based 
model of care, with a heavy emphasis on care coordination. 
This, I think, will allow for that level of coordination which 
occurs in any one of those services to be much more visible to 
the other in times when that is needed because it is not 
dependent on a single provider.
    Another piece I think is the great commitment that VA has 
made and is sharing, I guess is the best way to say that, in 
terms of telehealth with IHS. By combining these resources, IHS 
has been extremely accommodating in providing outlets for 
telehealth on the reservations so that we can get a lot of the 
care that would normally require people to go somewhere for 
high-level care. This includes, very importantly, mental 
healthcare, but also much of the subspecialty care, for 
instance, in cardiology or any number of the other 
subspecialties that can be managed through telehealth. It very 
much minimizes the need to have people travel long distances 
for what would be simple appointments.
    We can't do procedures by telehealth but certainly can 
determine when procedures are needed and where the best place 
for people to go when they are needed without having to have 
multiple visits prior to that. I think there is already, at the 
early stage of the deployment of telehealth, modalities through 
American healthcare with VA collaborating with IHS. We are very 
much moving this whole initiative forward.
    There are some challenges, to be sure. The technology is 
rapidly evolving. Teaching providers how to use it is at times 
challenging. Although, interestingly, our fear was that 
patients would be less accepting and have to get used to it, 
and my sense is that is not the case. You can correct me if I 
am wrong, but the patients love it. It allows them to speak to 
the people they need to speak to without having long delays for 
appointments and long travel times to do this.
    The whole notion of how healthcare is going to be delivered 
through team-based care and the use of telehealth and these 
other modalities is very important.
    One other thing I will just mention is that to my mind, one 
of my personal interests is, how do we get patients, veterans, 
and patients in the IHS, invested in their own health in ways 
that they can take greater control in managing it? Part of that 
is by having them be able to interact with their personal 
health records, so that the health record is not a mystery that 
lives in the provider's office, but something they can engage 
with on a relatively routine basis.
    VA has started this with My HealtheVet. There has been a 
lot of press recently about an innovation that we have been 
rolling out called the Blue Button, which allows patients who 
use My HealtheVet to actually download substantive parts of 
their records. Probably, I am guessing, within the year, it 
will be the entire medical record that can live in their 
possession, and they can have it with them.
    There will never be a question about what has been done, 
what prior lab results, what prior tests were done. And with 
all of these things, VA is rolling these out in collaboration 
with IHS and distributing this into the rural and highly rural 
populations.

                       PAYMENT AND REIMBURSEMENT

    Senator Johnson. Dr. Jesse, in your testimony, you 
mentioned that the VA and IHS are still working through payment 
and reimbursement policies. When do you believe these will be 
worked out?
    Dr. Jesse. I think that is actually a pretty simple 
question to answer because our respective Secretaries have made 
it very plain to staff that they expect this to be worked out 
by the end of the calendar year. We have been given marching 
orders from the Secretaries to get this resolved, to do it 
quickly, and get it right.
    Their timeline is end of the calendar year.
    Senator Johnson. Mr. Grinnell, how do you see the work with 
other private hospitals proceeding, and is it true that the 
Native American saying that ``you better get sick through June 
or it is all over with'' still holds true?
    Mr. Grinnell. The statement about ``don't get sick after 
June'' referred to--within the CHS program, there is one aspect 
that is referred to as the Catastrophic Health Emergency Fund 
account, and that account is centrally managed, and it is a 
reimbursement program to a local hospital or CHS program 
whenever they have a high-cost case.
    And those are first come, first serve. It starts on October 
1, and the funding that we receive, it is there until it is 
exhausted. At this point, we have got $48 million that we have 
in that particular account.
    In the past, before we had the increases which have--and 
over the last 5 years, that account has more than doubled. And 
so, we are able to go beyond May. This year, it looks like we 
are going to get into September before that account is 
exhausted, which is tremendous progress from prior years.
    We had a real nice increase in 2010. We had a $100 million 
program increase in CHS that every CHS program benefited from 
across the country, including an increase in the CHEF account. 
We see great progress. We have been in contact with pretty much 
all the CHS programs across the system. They have more 
resources this year and are able to provide more referrals than 
they have in the past, but we still feel like that the need is 
more than we have funding for at this point.
    Based on our estimates so far, we estimate that we receive 
almost $800 million a year in CHS overall. We estimate, based 
on the information from our locations and from some tribes, 
that the need is an additional $860 million more than the $800 
million.
    So we still have a long ways to go to where we feel like 
that we will be fully funded to be able to pay for all of our 
referred care.
    Senator Johnson. Mr. Grinnell, was that bump up in the 
income available as a result of the stimulus?
    Mr. Grinnell. No. It had to do with the President's budget 
in 2010, and actually, President Obama approved that budget and 
moved it forward as his first act against our budget. So the 
stimulus did not provide any CHS funding.

                              TELEMEDICINE

    Senator Johnson. Telemedicine offers great promise in 
closing the gap in services in remote areas and lowering 
healthcare costs. My biggest concern with telemedicine has been 
the lack of technology infrastructure in highly rural areas, 
such as access to broadband.
    Dr. Jesse, as you highlighted in your testimony, the VA has 
been moving more aggressively in its use of telemedicine. Can 
you please describe a bit more how the VA envisions 
telemedicine being deployed? For example, are these 
applications located only at IHS facilities, or is the VA 
planning to implement home-based solutions as well?
    And how does the VA plan to overcome the lack of 
infrastructure in highly rural areas and on reservations as it 
deploys new technology?
    Dr. Jesse. Our chief information officer, Mr. Roger Baker, 
says that what keeps him awake at night is bandwidth. So I will 
put that on the table first, and then I will come back and 
answer the other issues you brought up.
    It is an issue. I think the wisdom of the Federal 
Government is in understanding the value of the Internet in all 
we do in this country, not just healthcare, but in education, 
in banking, in communication, and social networking, all the 
things that are really changing the fabric of American life.
    The commitment to get broadband access into rural and 
highly rural areas is, I think, an important statement on 
behalf of the Government that we need this. It is certainly not 
something the VA can do on its own, but I do think that our 
commitment to making this an integral part of healthcare 
certainly drives the imperative to do so, more so than some of 
the other needs for broadband.
    We will push very hard to ensure that we have the ability 
to leverage our technologies through broadband access and with 
the understanding that this is a shared commitment on the part 
of the Federal, State, and local governments as well. It may 
take some time, but I think this will get done.
    In terms of the technologies being used, telehealth is a 
very broad statement, and there are a number of different 
categories that we look at. For instance, we can talk about 
telehealth as a provider in one place and a patient in another 
place so that, when we have a primary care clinic--which I had 
the honor and pleasure of visiting in the CBOC in town this 
morning--we can have an extensive primary care capability in 
that facility. If there is a question for a cardiologist or a 
pulmonologist, then having ability to contact somebody, say, in 
Minneapolis or anywhere else in the country to provide almost 
an instant referral, or consultation, is one methodology.
    Another is the ability to communicate with patients in 
their homes. We have a program, which is probably, at this 
point, the widest deployment of home telehealth, which we call 
CCHT, Coordinating Care Home Telehealth. This is where we have 
a telehealth communication box in the patient's home that can 
do some basic things like hook up to a blood pressure cuff, to 
a scale, or to a rhythm strip, and which provides vital 
information for caring for patients with multiple chronic 
disease, in particular heart failure and hypertension.
    Because rather than showing up once a month or once every 3 
months for an appointment and checking blood pressure, we can 
actually see the blood pressure every day. Then if it is going 
outside of bounds, we have triggers, and we can reach out to 
the patient to intervene.
    I am a cardiologist by training. This is extremely 
important for heart failure because patients can self-manage 
heart failure if they have that information and particularly if 
they have a little help. We have been able to markedly reduce 
admissions for patients with heart failure by being able to 
communicate with them in their home.
    Now that is interesting because, more and more, we are 
finding people who don't have land lines in their homes, and 
these things are dependent on land lines. How do you then begin 
to move a lot of this to a much more ubiquitous platform like 
the smartphone?
    I think that capability is moving forward very quickly. 
Even things like the PTSD Coach, which is an iPhone app, have 
been a great demonstration that you can leverage the simple 
telecommunications platforms that people have to improve their 
health in many novel ways, most of which we probably haven't 
even thought of yet.
    We do a lot of things that require ongoing monitoring, and 
I will use an example of that which is teleretinal imaging in 
diabetic patients. It is really important that we monitor the 
consequences of that disease, and looking at the retina is a 
view to the inside of the body in many respects. It speaks to 
the microvascular state, but also to the catastrophic 
consequences of diabetes, which is blindness.
    You can't have an ophthalmologist or an optometrist 
everywhere. But we can take those images, store them in the 
local record, and forward them off where they can be read, and 
that way the results come back locally so we can monitor for 
vision changes over time.
    We have teleradiology. So, for instance, you can have a CAT 
scanner in a facility without the advanced radiology capability 
to read them if that image can get forwarded to somewhere where 
you do have that capability. This is becoming increasingly 
important in the management of several complex diseases, where 
we can get a tech in to do the scan, but we can't have the 
radiologist available.
    In fact, VA now has a series of teleradiology reading 
centers which actually expands the time throughout the day 
where we can have studies accurately read. Likewise, you can do 
the same thing with electrocardiograms and any number of other 
tests.
    We all get very nervous about dermatology, and it is often 
difficult to discern what are bad lesions from what are ones 
that are okay. But we have teledermatology where in the clinic 
they can take an image, and it can go across the country to a 
dermatologist who can look at it and make a determination that 
this is benign or, no, this is something we need to follow.
    There are a lot of different parts of this that are 
complex. Probably the most interesting is the ability to do 
consultation in a way that actually increases the education of 
the primary care provider. There are projects that we are 
standing up as part of the patient line care team to bring 
specialty care into that mix through a project called SCAN--
Specialty Care Access Now--that gives real-time consultative 
capability in a way that actually educates the provider.
    And when we talk about telehealth--I am sorry, it is a 
rambling answer--but there are a broad number of modalities. 
The capabilities of some require a lot of bandwidth, for 
instance, moving big images around. But frankly, a lot of them 
don't, including what we to date have investment in, which is 
home telehealth, where we have the ability to reach in the 
patient's home on a daily basis to watch their weight, and 
their blood pressure, with a simple phone line.
    Senator Johnson. Mr. Grinnell, how do you see telemedicine 
being deployed and utilized in Native lands? And please comment 
on the lack of infrastructure in these areas.
    Mr. Grinnell. You mentioned earlier about the questions 
about the stimulus and the funding that came through the 
American Recovery and Reinvestment Act. The IHS did receive $85 
million that was targeted to help us to make improvements to 
the RPMS system. It was also to look at how we can expand 
telemedicine opportunities.
    As Dr. Jesse indicated as well, many of our locations in 
remote areas have issues with bandwidth. And so, our ability to 
expand telemedicine to some of those locations is going to be 
challenged until the bandwidth is made more available. IHS is 
looking at every opportunity and looking specifically with the 
VA to expand as many telemedicine opportunities as we can.
    Dr. Jesse also talked about the diabetic care specific to 
eye care. We have a very active telemedicine program with 
teleophthalmology, where we got a number of IHS and travel 
sites that actually have optometrists or other staff that take 
images of the eye, and then they are sent via telemedicine to 
an ophthalmology center where they are actually read. And then 
they are followed up with the necessary procedure.
    So we have lots of challenges. And some of them really get 
down to the bandwidth and the ability of that local facility to 
have the capability.
    Different than what Dr. Jesse talked about, we have not 
looked into going to providing home health through 
telemedicine. But right now, we have got more than 600 
facilities that we have still got to get connected and improve 
access to some of these services that he talked about.
    A couple of the other ones that we are looking into as well 
is teleradiology. We have got some areas now that have area-
wide contracts where they don't have a radiologist on staff, 
but they have got a radiology service that they contracted 
with. They take the images, store them, and then send them 
forward, get the readings that come back to our direct 
providers, and then they do the follow-up care.
    So we still have a lot of work to do. We definitely are 
counting on our partnership with the VA to help us to move that 
forward.

                        MENTAL HEALTH TELEHEALTH

    Senator Johnson. I understand that the Sisseton IHS health 
center is partnering with the Sioux City CBOC to offer mental 
health telehealth. One day a month, vets in Sisseton can meet 
with a psychologist in Sioux City.
    Dr. Jesse, can you speak to this partnership? How did this 
come to be? Is it meeting demand? Are there similar telehealth 
collaborations in the State and throughout the country?
    Dr. Jesse. With your indulgence, I will ask Jan Murphy to 
speak to that because I think she can give you the detail you 
need.
    Ms. Murphy. Sure. Thank you for the question.
    There are a number of these kinds of collaborations that we 
are very anxious to do. I am surprised to hear about Sioux City 
because we hear more about Wagner. But we are able to put a 
telemedicine unit either in the IHS clinic or we can have one 
in our clinic, and the two go back and forth.
    Sometimes we send the actual practitioners back and forth, 
too. So, really, with this sharing agreement, this is really 
very easy to do.
    The technology, if you have the bandwidth, is quite simple 
and quite successful to be able to do that. So that is an easy 
one, actually.

                      TRIBAL CONSULTATION SESSIONS

    Senator Johnson. Ms. Birdwell, in the Senate appropriations 
bill for fiscal year 2012, we have included $800,000 as 
requested to support the establishment of your office. In your 
testimony, you highlighted the critical need to build trust 
between the VA and the tribes through meaningful consultation.
    The VA is funded to conduct five tribal consultation 
sessions this year. How many of these sessions have been 
conducted to date, or are these the first of these sessions? 
Can you briefly describe what these sessions will include and 
how they will help shape future VA policy?
    Ms. Birdwell. Yes, Senator, thank you for that question.
    The five consultation sessions will be scheduled during 
fiscal year 2012. There have been currently no formal 
consultation sessions held, although we did hold three 
listening sessions in Bethel, Billings, and Bismarck.
    The purpose of the consultation sessions are really to 
engage the voice and the perspective of the tribes with respect 
to understanding regulations, grants, funding opportunities, 
and need for services that VA offers that may impact tribal 
communities and Native American veterans.
    The sessions really seek to engage the voice and 
perspectives of the tribes in informing how VA does business in 
Indian Country and delivers services and resources. Something 
that is important to note is that there have been a number of 
very dedicated leaders and employees within VA for many years 
who have worked and reached out to tribes, tribal leaders, and 
Native veterans.
    The cemetery that is coming up, that is online in Rosebud, 
the national cemetery is the effort of many years of 
collaborative hard work with the tribal leadership, and that is 
something that we are excited to see hopefully expand 
throughout Indian Country.
    It is really the goal of our office to put a face with 
respect to engaging in Government-to-government relations with 
tribal leaders. As Dr. Jesse mentioned, it is very important 
that when we are doing business with tribes and we are reaching 
our vets in rural areas that we get this right. And really, 
this is an opportunity for VA to formally engage the voice of 
the tribes in setting policy as we move forward and getting it 
right and being informed in the work that we do.
    We are talking about the possibility for expanding and 
sharing best practices and increasing sharing agreements. These 
consultation sessions and engaging the voice and perspectives 
of the tribes, hopefully, will result in that.
    And not just from the perspective of increasing access to 
healthcare, but also increasing access to benefits, all of the 
resources that our veterans have earned through their service, 
we would like to see that result from these sessions.

                                OUTREACH

    Senator Johnson. One major concern that I have has been 
outreach to educate vets on reservations as to what benefits 
they are entitled. Ms. Birdwell, outside of the consultation 
sessions and listening sessions, what specific outreach plans 
are in place to better educate Native American vets of the 
benefits available to them?
    Ms. Birdwell. Senator, a particular one that is very much 
on our front burner is Alaska. Alaska has a rural outreach 
coordinator that is working very closely with VA. When the 
rural outreach coordinator or when our tribal government 
relations specialist will be going out and meeting with tribal 
leaders or conducting any listening sessions in Indian Country, 
they will always be teaming up with representatives from across 
VA through VHA, through the Veterans Benefits Administration 
(VBA), and even the National Cemetery Administration (NCA).
    The approach is to have a coordinated approach in reaching 
out to Indian Country and really informing, educating, and 
providing onsite technical assistance with respect to benefits 
and resources that are available through the VA. We are 
partners, and our role is to enhance the role of VA with 
respect to reaching out to Indian Country. It is critical that 
we have those relationships internal to the organization, as 
well as with our external stakeholders. It is a combined 
effort.
    I have to say that Alaska is something that we have just 
recently worked on in a strategic outreach plan to reach rural 
Native veterans. That plan is going to be implemented, 
hopefully, this fall and throughout fiscal year 2012.
    We have also had contact from veterans in the Northwest and 
tribal leaders and also veterans in the Southwest and tribal 
leaders seeking technical assistance for how to bring about the 
MOU, and how to see that the MOU in action is as robust as they 
would like it to be. That involves coordinating technical 
assistance with our partners at the local level, within the 
VBA, VHA, and the NCA.
    One of the focuses of our office is to promote economic 
sustainability in Indian Country within veterans. In other 
words, by veterans are eligible for post 9/11 GI bill, the 
Native American direct home loan program, compensation and 
pension benefits.
    Our vision is to see that if there is a veteran in Indian 
Country, that veteran is at least aware of all of the benefits 
and can access all of the benefits and resources available with 
VA through their service. That is a goal and part of the 
mission of our office.

                 TRIBAL VETERAN REPRESENTATIVE PROGRAM

    Senator Johnson. The Tribal Veteran Representative Program 
was mentioned in testimony today. Dr. Jesse and Ms. Birdwell, 
can you elaborate on this program. Does the VA plan to expand 
this program in fiscal year 2012?
    Ms. Birdwell. Senator, I will be happy to respond to that. 
The Tribal Veteran Representative Program was started as a best 
practice and has expanded to Alaska. It was started as a best 
practice in Montana and is now--the TVRs, as they are called, 
in rural areas, because it is often the case in tribal 
communities there may be a lack of a local resource or 
connection with respect to veteran services and resources.
    TVRs are brought together by the VA on an annual basis, and 
they are provided training into all of the resources that are 
available through VA. There are even State representatives 
present. Basically, all of the resources that are available to 
veterans, the TVRs are trained in and made aware of them.
    The TVRs then go back home to their local community, and 
they become a local resource for vets. So, if a vet comes in 
and asks questions about benefits, the TVR knows where to 
direct and how to assist that veteran in moving forward with 
any kind of claims that they may want to or need to pursue. 
Healthcare, grants, or information that tribal governments may 
need to know about, that TVR is a resource.
    There are definitely plans of expanding that program. What 
is also important with respect to sharing resources are that 
there are some tribal locations that may not have a TVR 
presence, and there are some tribal locations that actually 
have their own tribal veterans affairs department. Some States 
actually have tribal veteran service officers.
    And it is interesting because those tribal veteran service 
officers have asked about the TVR training and have said they 
would really like to see it expanded locally so that they can 
also avail themselves of that TVR training.
    We are very excited to see that as a best practice. There 
is definitely a strong interest and a need to expand that, and 
we look forward to doing that in 2012. Strategically, we would 
probably be doing that in a way that would be consistent with, 
moving from the Northwest to the Great Plains to the Southwest 
and on to the Midwest. It is something that we would probably 
host with regional trainings and then ideally make it so that 
they are held at as local a level as we possibly can hold them.
    Senator Johnson. Dr. Jesse, did you have anything to add?
    Dr. Jesse. Yes, sir. I would just like to amplify something 
Ms. Birdwell said, and that is that healthcare, in and of 
itself, will flounder--by whatever VHA does or IHS does--
without the strong support of the broader social needs of 
patients. That support includes education, housing, and a host 
of things.
    I think the elegance of the VA is that we have the 
capability to provide much of those needed services so that the 
healthcare side of things can truly flourish. It is vital in 
order for us to do that, in addition to supporting IHS, we need 
veterans to get enrolled. Because it is not just access to the 
healthcare system, it is access to this broader base of very 
needed and very hard-earned support.
    It is very much our interest and important to us that the 
veterans are aware of how to get enrolled and are aware of 
this. We are strongly supportive of all these initiatives and 
are working with the IHS in order that we can identify the 
Native Americans who are eligible for VA benefits and get them 
enrolled. I think it is important to note that it is their 
choice of which of those benefits they wish to access, but the 
first step is the access into the system.
    If I may just go back to the first question you asked me 
about the MOU and the deadline on that? I just want to be very 
clear that IHS and VA are committed to making this work.
    There are some challenges in the law reconciling parts of 
title 38 legislation with the Affordable Care Act, but it is 
not either party being recalcitrant or creating a problem. We 
just have to get this reconciled. We are anxious to make it 
work and are working hard and diligently to do so.
    Senator Johnson. Thank you for your testimony. The 
witnesses may now be excused.
    Thank you.
    Dr. Jesse. Thank you, sir. Appreciate it.

                       NONDEPARTMENTAL WITNESSES

    Senator Johnson. I would now like to welcome our second 
panel of witnesses. I am honored to have two South Dakotans 
testify today--Don Loudner and Iva Good Voice Flute.
    Mr. Loudner served 32 years in the Army and is a veteran of 
the Korean war. He is a member of the Dakota Sioux Nation and 
has been a tireless advocate for Native American vets, 
particularly in his role as the national commander of the 
National American Indian Veterans, Inc.
    Iva Good Voice Flute is a Air Force vet, having served here 
in South Dakota at Ellsworth Air Force Base. She is a member of 
the Oglala Sioux Tribe. Ms. Good Voice Flute is a strong 
advocate for female vets and in March of this year received 
designation as the Oglala Sioux Tribe's women's tribal vets 
representative.
    Thank you both for being here today.
    Mr. Loudner, would you begin?
STATEMENT OF DON LOUDNER, NATIONAL COMMANDER, NATIONAL 
            AMERICAN INDIAN VETERANS
    Mr. Loudner. Good morning. Yes, I have with me one of my 
regional commanders that has North Dakota, South Dakota, 
Nebraska. His name is Peter Lengkeek. He is a member of the 
Crow Creek Tribal Council. He is here with me.
    And we also have in our audience some of our tribal veteran 
service officers. I am glad they are here, and I hope that they 
speak up to ask these questions that were not answered to them. 
Don't be afraid of these people. I mean, they are human like 
all of us.
    And this is the time to get them straightened out. Because 
you know, as well as I know, that the services that they are 
talking about are not being completed for us veterans.
    Senator Johnson. We need a lot of straightening out.
    Mr. Loudner. I want to thank you, Senator Johnson, for 
holding this important hearing. The last hearing that I can 
remember that was held for American Indian veterans with 
congressional people was back in the Nixon administration. And 
it is a hearing that should have been held long before. 
Hopefully, we can have more.
    Holding this important hearing to discuss the degree of 
cooperation that currently exists between the IHS and the VA to 
provide quality care to our American Indian veterans and the 
Alaska Native veterans and ways to improve the agencies' 
working relationship.
    As you can imagine, American Indians, Alaska Native 
veterans have many problems in common with other veterans. But 
because of their geographic remoteness, weak tribal economies, 
and a host of related pathologies, face challenges that are, in 
many ways, unique. I believe that the members that share with 
you, Senator Johnson, are aware of the valor and the service of 
American Indian/Alaska Native veterans to this country and that 
they have served in the highest proportion than any other 
ethnic group in the United States.
    You may also be aware that the lack of healthcare to these 
veterans upon returning home is nearly to the point of being 
unacceptable, considering for what they have done protecting 
our homeland. Especially with the event of the Afghanistan and 
Iraqi wars, the number of veterans returning with injuries, 
disabilities--physical and emotional--has increased largely.
    And as we have learned from the past wars and conflicts, 
the need for treatment of these warriors may not be revealed 
for several years after these men and women have returned home.
    The primary healthcare provider to tribal communities, 
including American Indian/Alaska Native veterans, is the IHS, 
which has always been woefully underfunded. Many veterans have 
sought healthcare from VHA hospitals because that is an option 
and their right.
    In an attempt to stretch their healthcare dollars, both IHS 
and the VA hospitals have denied services to our veterans, 
insisting that they go to the other agency for treatment. These 
proud veterans, who in some instances use their last dollars to 
travel long distances to either facility, deserve better 
treatment.
    I thought the days of transferring responsibility from one 
agency to the other were over when this MOU, between the IHS 
and the VA hospitals, was signed. It is my understanding that 
the issue is still with us, and it is my hope that this hearing 
will be a step forward in finally resolving this situation to 
prevent more veterans from additional suffering.
    In my capacity as national commander, I am in constant 
contact with these men and women in the States of Arizona, 
California, Colorado, Montana, New Mexico, Oregon, South 
Dakota, Wisconsin, Washington, and others. In fact, we just 
returned home within the last 10 days from a strong visit to 
the Alaska Natives up there, and I will send you a written 
report of what we just found out up there that needs immediate 
attention.
    Senator Johnson. Please do.
    Mr. Loudner. Since 2004, the National American Indian 
Veterans has hosted three national conferences, the most recent 
taking place in March 2009. I know that has been a couple of 
years ago, but it takes money to hold them, and we are working 
with our own dollars to do those. It was held at the Morongo 
Convention Center in California. We had more than 500 American 
Indian veterans from throughout the West and Southwest and 
Midwest in attendance.
    The National American Indian Veterans has the support of 
the National Congress of the American Indians, the National 
Association of State Directors--and I want to just elaborate a 
little something there. My chief of staff, Joey Strickland, is 
the only American Indian that serves, in all 50 States, as a 
Secretary of Veterans Affairs, and now he is in Arizona.
    There he serves for all veterans in the State of Arizona. 
Although his job is to support all of Arizona's 600,000 
veterans, Arizona is home to 21 federally recognized Indian 
tribes, and American Indian veterans regularly attend his 
commission meetings. As a result of these meetings, he relays 
to me the concerns, issues, and needs regarding the lack of 
proper medical care delivered through the VA and Indian 
veterans residing on Indian lands.
    I just wanted to stress just a little bit about the Navajo 
Nation. I heard them talk about it. The Navajo Nation 
reservation is roughly the size of West Virginia. And on that 
reservation, there are more than 12,000 veterans living today.
    To date, the Disabled American Veterans (DAV) has rejected 
repeated calls to locate a permanent community-based outpatient 
clinic within that reservation. They are claiming the number of 
veterans will not support it. The fact is the numbers will not 
support a CBOC at the Navajo reservation because the 
reservation is divided into three Veterans Integrated Service 
Networks (VISNs).
    Given this division, the VA cannot count the number of 
veterans to justify the clinic. It is precisely this type of 
bureaucratic red tape which results in inaction and, 
ultimately, inferior or a complete lack of medical care to 
American Indian veterans.
    Recently, just recently, the VA's Office of 
Intergovernmental Affairs--I say recently, but about 1 year. It 
has been more than 1 year ago. The director of VISN 18 and 
others visited the Navajo reservation and witnessed for 
themselves the urgent need for additional healthcare 
facilities.
    They graciously called on the director of VA from Arizona, 
who is a Choctaw Indian, for his input, which he, of course, 
provided. The reality is that I have seen numerous visits over 
the years throughout Navajo, the Pine Ridge Indian Reservation, 
and other Indian reservations with little or no follow-up by 
the Federal officials.
    When an American Indian veteran will get to the VA medical 
center in Prescott, Arizona; or Albuquerque, New Mexico; or 
Sioux Falls, South Dakota; or Fort Meade, the medical care is 
excellent. But few, if any, of the veterans cannot overcome the 
vast distances to use such facilities. The distances are vast, 
and transportation is not always available.
    As a result, many of the American Indian veterans' efforts 
to obtain care at IHS facilities fail because they are 
veterans. In this regard, the MOU that was entered in 2003 by 
the VA and the IHS has been ineffective because the level of 
cooperation is nowhere near where it needs to be for the 
benefit of American Indians.
    I bring that up because I brought this to the attention of 
Secretary Shinseki when you brought him out here, and we met 
with him out at Fort Meade. I told him we needed to revisit 
that, and we need to make it more effective with the use of 
American Indian veterans' input.
    Today, we have that new MOU signed. No American Indian 
veterans' input whatsoever in it. So, you know, my personal 
thought in talking with some of the tribal officials and the 
American Indian veterans is why--if not, then why do we need a 
CBOC on an Indian reservation?
    Why not use our IHS to provide all these services that they 
are providing to our Indian veterans today and have the VA 
reimburse them back for those services--for the doctors, the 
nurses, the facility, administrative services, pharmacy, and so 
on, so forth? Those monies can go to help the IHS hospitals for 
other services that are needed.
    And I turned in my statement to you, Senator, and I said I 
wasn't going to go through it all. But there are some things 
that I would like to bring up on that. I would like to conclude 
on that now, and I would answer any questions on it.
    But it has been brought to my attention from some of the 
veterans here in South Dakota, which you asked me to respond 
on, that the VA is putting many of our American Indian veterans 
on the payee system. I don't know if you are aware of that?
    But the people that brought that to my attention are very 
upset about that because the payee is being paid out of his 
benefits. And he said that now he is getting around one-half of 
what he was getting from the VA because the other one-half is 
going to pay the payee for his travels to visit him and condemn 
him from going back to the reservations to attend the American 
Indian functions, such as pow-wows and stuff, visiting his 
relations.
    When I first talked with Secretary Shinseki, I told him 
that most of our American Indian veterans, especially in South 
Dakota, are very elderly. We have World War II veterans still 
alive. But with them having to ride or rent a car or take the 
family car or if they have DAV vans are available to go to Fort 
Meade or go to Sioux Falls, it is a great distance to travel, 
and they are unable to make those long distance travels.
    You know, you talk about elderly. At one time when I was 
growing up--you know Vern Ashley like I do. Vern Ashley is 
World War II Air Corps veteran. He never went to the VA, to my 
knowledge, for help, although he needs it. Today, he is 96 
years old, 97 years old, needs hearing aids, and he is too 
proud to go ask for them. But he needs them. He told me that he 
couldn't go there.
    But today, you talk about elderly, I served during the 
Korean war in 1950. My gray hair is here because I am 80 years 
old, and I am proud to have served my country. There were 12 of 
us cousins that volunteered and went into the service. They all 
returned home.
    Off-reservation American Indian veterans; that was brought 
to my attention. When they go back to the IHS facility back on 
the reservation, because they are working off the reservation--
their families are growing up off the reservation, going to 
public schools--when they go back to IHS facilities, they are 
being denied services yet today.
    I asked one of the veterans from Sisseton to come today, 
and he couldn't make it. At least I don't see him here anyway, 
but he said he was going to try. To tell his story on how he 
was treated when he was having a heart attack at the IHS 
facility.
    Burial flags. That is one of the NCA's--I am on that board, 
and the next meeting, I am going to bring that out again.
    But burial flags are not able to be gotten by a lot of 
American Indian veterans because they are human like everybody 
else. They either lost it or delayed it or something, but they 
can't get that flag from the post offices unless they have that 
DD-214 or the discharge papers or something to prove that they 
are a veteran. And when you die, they have got only so many 
days to be buried, and they need that flag.
    I know when I served on the South Dakota Veterans 
Commission, I served on that for more than 20 years, and we 
were told that the headstones, some of the headstones were 
being held hostage by some of the funeral directors because of 
lack of payment for the burial, when they ordered the stone. We 
need to change that.
    We have our own tribal veteran service officers, and there 
is no reason in the world why those headstones can't be shipped 
directly back to that tribe itself, to the tribal veteran 
service officer.
    Senator Johnson. Don, will you please wrap it up? And let 
us go to Ms. Good Voice Flute, and then I will ask you some 
questions.
    Mr. Loudner. Okay. Thank you. Thank you.
    Senator Johnson. Ms. Good Voice Flute.
STATEMENT OF IVA GOOD VOICE FLUTE, AIR FORCE VETERAN, 
            OGLALA SIOUX TRIBE
    Ms. Good Voice Flute. Good morning, Senator Johnson. Thank 
you for allowing me this opportunity to be here today.
    Good morning, ladies and gentlemen, to the various agencies 
that are represented here to come together for our Native 
American veterans.
    I would like to recognize our tribal president, John Yellow 
Bird Steele, who is in the audience. And also our fifth member, 
Mr. Myron Pourier, is over here on my left.
    And thank you to the many Native American veterans who have 
appeared here today for this hearing.
    I would like to begin by sharing two stories from veterans 
that I have visited with regarding the service that they did 
not receive from IHS and the VA.
    ``Iva, I wish I had never let our Indian Health Service 
know that I am a veteran. They sent me to the VA hospital right 
away, only to find out that the VA hospital did not have the 
doctors I needed to address my female medical problems.''
    To this day, this woman veteran will never visit a VA 
hospital again. And she finished in the conversation with me, 
``Iva, I am a Lakota first.''
    Senator Johnson. Could you pull the microphone up closer to 
you?
    Ms. Good Voice Flute. Okay. And the other story I have is 
from a Marine Corps veteran. He traveled to the IHS, and he was 
told that he needed to update his contact information. He came 
there for a dislocated shoulder.
    And IHS told him that they could not provide services for 
him because he is a veteran and that he had to utilize other 
resources that he may qualify for. So he traveled to a VA 
hospital, and then the hospital tells him that his income is 
too high to qualify for their services. But if he writes 
``zero'' for an income, the VA can take his vital readings. And 
if he returns for medical treatment, he will have to pay for 
it.
    He never returned to the VA after that initial visit. He 
thought he deserved those VA services because he is a veteran.
    These tribal-enrolled, honorably discharged veterans 
fulfilled their commitment in serving our country, but 
experienced the cruelest of ironies when two agencies, the VA 
and IHS, tell them we cannot help you, although based on the 
facts that you are members of a tribe with whom the Federal 
Government has treaties with, and you did serve in our 
country's military.
    Why was this MOU created between the VA and IHS when it 
only hurts our veterans when it is supposed to help them? And 
these two agencies have proven that they did not 
collaboratively, effectively work toward the common goal of 
meeting our veterans' healthcare needs.
    I have never agreed to this MOU, and once again, my 
personal thoughts on this are that I feel that it is a 
situation with the intentions of one agency to be profit-making 
in nature and the other agency to become cost efficient by not 
providing services to one particular group of people.
    I believe that our Federal Government has a fiduciary 
responsibility in obligating funds to our Native American 
veterans' healthcare, to bring everyone together to 
troubleshoot the problems of this MOU, and resolve the problems 
that have existed since its inception in 2003.
    And in closing, we deserve quality healthcare, and we must 
all work together to make this happen for the generation of 
veterans now and our younger generation of veterans, who need 
to be encouraged to utilize the services meant for us.
    Senator Johnson. Thank you.
    Ms. Good Voice Flute and Mr. Loudner, I will pose this 
question to both of you. In what specific areas do you see a 
need for improved collaboration between VA and IHS? In your 
opinion, going forward, where do the VA and IHS need to be 
focusing their efforts to ensure Native American vets receive 
appropriate healthcare?
    Ms. Good Voice Flute. First of all, I would like to comment 
on the services that the VA provides, that there be more 
medical care for our women veterans. And not just Native 
American women veterans, but all women veterans, and then to 
make these services more visibly available to where we are 
aware.
    And my question is whose responsibility will that be on 
behalf of the VA to make us aware that there are doctors for 
our unique special needs?
    Mr. Loudner. Thank you, Senator Johnson.
    I think what needs to be done is we need to try to work 
together. There are a lot of us out there trying to do the same 
thing, but we are going in different ways. But our American 
Indian veterans deserve to be given the opportunity to decide, 
because of their age and stuff, where they want to have their 
treatment done.
    If an elderly American Indian veteran knows that IHS 
facilities has the capability of helping him, he should be 
allowed to go there. And if IHS doesn't have the capabilities, 
there should be a way to get him to the VA facilities, whether 
it be Fort Meade or Sioux Falls.
    Right now, some of them are saying that they have to beg, 
borrow, and steal to try to get someone to take them there. A 
lot of them don't have a VA vehicle. I am proud to say that 
with a lot of arguing and everything, we finally got a new van 
back in Crow Creek delivered back there last Friday. So they 
have the capability.
    But those are some of the things that they are bringing to 
our attention.
    Senator Johnson. It is important that the VA communicate 
with the tribes, and I appreciate the creation of the OTGR. As 
Ms. Birdwell highlighted in her testimony, the office is 
focused on meaningful outreach with tribal officials.
    How do you think the VA can improve communication and 
outreach to Native American vets, Mr. Loudner and Ms. Good 
Voice Flute?
    Mr. Loudner. Let me start on that. Thanks for the question, 
Senator.
    I personally went and met with Stephanie Birdwell in her 
office and volunteered to work with her in any way that she has 
seen possible for me to work with in providing input that is 
coming back to me as the national commander from all over the 
United States. To this day, she has never returned any calls or 
even asked me to talk to her.
    So I think what she needs to do is see the importance of 
our national organization, which is called upon by you people, 
Senator Johnson, in Washington to testify on behalf of the 
American Indian veterans. There can be only one veteran 
organization to do that, and that is our organization.
    So I feel that they need to start working with us, both VA 
and IHS, so that we can get that brought to your attention in 
the Congress.
    Senator Johnson. Ms. Good Voice Flute.
    Ms. Good Voice Flute. Yes, Senator Johnson.
    I believe that the VA can improve communication with the 
tribes by being more of a visible presence. I keep going back 
to that. And I also must add that there be a healthy balance of 
being more culturally sensitive and not so much as a clinical 
approach to our problems.
    Have a liaison within the tribe to work with the VA to 
where we can bring both worlds together to benefit the needs of 
the veterans. So that is how I believe that there can be more 
communication is for the VA to have a more visible presence on 
the reservations.
    Senator Johnson. Speaking of female vets, the VA is having 
to undergo a culture change from a department designed to treat 
male vets to one that has a growing female vet population.
    Ms. Good Voice Flute, in your opinion, what steps do you 
think the VA needs to take to better meet the unique needs of 
female vets?
    Ms. Good Voice Flute. What I think, first of all, the VA 
needs to do in the hospitals is have more doctors available for 
our medical needs, and second is make us aware that there will 
be these medical needs that will be met for the medical needs 
that we have.
    I think the VA overall and IHS need to work together to 
meet the needs of the women veterans because, since my 
separation from the military and being home on the reservation, 
women veterans are very reluctant to come forward and tell the 
service providers what they need. And a lot of it, I believe, 
is trust issues.
    Senator Johnson. Are there enough OB/GYNs to go around?
    Ms. Good Voice Flute. No, I don't think there are. I do not 
think so, Senator.
    Senator Johnson. Yes. I want to thank everyone for 
attending today's hearing, especially those who have traveled 
from out of town to be here. I believe it is important for both 
the VA and IHS to appear together routinely to update everyone 
on how a more collaborative partnership will enhance services 
for Native American vets.
    As a reminder, Ms. Birdwell will be conducting a listening 
session today at 3 p.m. at the Pejuta Haka College Center in 
Kyle, South Dakota, on the Pine Ridge Indian Reservation.

                         CONCLUSION OF HEARING

    Senator Johnson. Again, thank you to everyone, and I look 
forward to continuing this dialogue as the VA and IHS move 
forward, creating a meaningful partnership.
    This hearing is concluded. Thank you.
    [Whereupon, at 11 a.m., Tuesday, August 30, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]

              MATERIAL SUBMITTED SUBSEQUENT TO THE HEARING

    [Clerk's Note.--The following testimony was received 
subsequent to the hearing for inclusion in the record.]
          Prepared Statement of the Cheyenne River Sioux Tribe
                 executive resolution no. e-360-2011-cr
WHEREAS, the Cheyenne River Sioux Tribe of South Dakota is an 
            unincorporated tribe of Indians, having accepted the 
            provision of the act of June 18, 1934, (48 Stat. 984); and
WHEREAS, the Tribe \1\ in order to establish its tribal organizations, 
            to conserve its tribal property, to develop its common 
            resources, and to promote the general welfare of its 
            people, has ordained and established a Constitution and By-
            Laws; and
---------------------------------------------------------------------------
    \1\ Cheyenne River Sioux Tribe, Cheyenne River Reservation, Act of 
March 2, 1889, Section 4, 25 Stat. 888 (reservation boundaries).
---------------------------------------------------------------------------
WHEREAS, the Tribal Council has authority pursuant to article IV, 
            Section 1(a) of the Tribal Constitution ``[t]o enter into 
            negotiations with the Federal, State, and local Governments 
            on behalf of the tribe.'' Id.; and
WHEREAS, the Cheyenne River Sioux Tribe is the successor in interest to 
            four of the historic bands of the Great Sioux Nation 
            (Titonwan Lakota Oceti Sakowin/Seven Council Fires of the 
            Teton or Prairie-dwelling Nation of Friends or Allies), 
            i.e., Mnicoujou (Plants-by-the-Water), ltazipco (Without 
            Bows), Siha Sapa (Blackfoot) and Oohenumpa (Two Kettles or 
            Boilings) signatory to the Fort Laramie Treaties of 1851 
            (11 Stat. 749) and 1868 (15 Stat. 635); and
WHEREAS, as a stipulation of the Fort Laramie Treaty of 1868 health 
            care is right provided to enrolled members of the Cheyenne 
            River Sioux Tribe (15 Stat. 635); and
WHEREAS, American Indian Servicemen and women have the highest record 
            of service per capita of all the ethnic groups in America; 
            and
WHEREAS, American Indian people have participated with distinction in 
            United States military actions for more than 200 years, 
            their courage, determination, and fighting spirit were 
            recognized by American military leaders as early as the 
            18th century; and
WHEREAS, American Indian people have served in all our nation's wars 
            despite the fact that we were not granted citizenship until 
            1924; and
WHEREAS, American Indian veterans face unique challenges when it comes 
            to equal access to care and navigating the VA and IHS 
            systems; and
WHEREAS, the Memorandum of Understanding (MOU) Between the Department 
            of Veterans Affairs and Indian Health Service is difficult 
            to understand and makes no provision for payments made on 
            behalf of American Indians between the said two Federal 
            governmental agencies; and
WHEREAS, upon their service to the United States military the 
            Department of Veterans Affairs became the payer of first 
            resort; and
WHEREAS, American Indian people have access to the healthcare via the 
            Department of Health and Human Service office of Indian 
            Health Service (IHS), IHS becomes the payer of last resort, 
            as their service to the U.S. Armed Services supersedes the 
            initial obligation of IHS to enrolled members of Federally 
            Recognized Tribes; and
WHEREAS, the Cheyenne River Service Unit, Indian Health Service, 
            Contract Health in Eagle Butte, SD, acted in good faith in 
            preparing and issuing payment vouchers for 15 veterans of 
            the Cheyenne River Sioux Tribe to the Department of 
            Veterans Affairs, Black Hills Health Care System (BHHCS); 
            and
WHEREAS, the BHHCS have denied the payments citing no ``Sharing 
            Agreement'' between the Department of Veterans Affairs and 
            the Indian Health Service; and
WHEREAS, the Cheyenne River Sioux Tribe hereby recommends and fully 
            endorses a Sharing Agreement between the Cheyenne River 
            Service Unit, Indian Health Service, Contract Health in 
            Eagle Butte, SD; now
THEREFORE BE IT RESOLVED, that the Cheyenne River Sioux Tribal Council 
            hereby calls upon South Dakota Senator Tim Johnson, 
            Chairman, Subcommittee on Military Construction and 
            Veterans Affairs Appropriations Subcommittee, support a 
            Sharing Agreement; and
BE IT FURTHER RESOLVED, that this resolution be transmitted to the 
            South Dakota Congressional delegation;\2\ and
---------------------------------------------------------------------------
    \2\ [Addressed to U.S. Senator Tim Johnson, U.S. Senator John 
Thune, and U.S. Representative Kristi Noem.]
---------------------------------------------------------------------------
BE IT FURTHER RESOLVED, that the Cheyenne River Sioux Tribal Chairman 
            is authorized to take all necessary and appropriate actions 
            for the implementation of this Resolution; and
BE IT FINALLY RESOLVED, that nothing in this Resolution diminishes, 
            divests, alters, or otherwise affects any inherent, treaty, 
            statutory, or other rights of the Cheyenne River Sioux 
            Tribe over the property or activities described herein. The 
            Cheyenne River Sioux Tribe expressly retains all rights and 
            authority over the property and activities described 
            herein, including but not limited to legislative, 
            regulatory, adjudicatory, and taxing powers.
                             certification
This is to certify that the foregoing Executive Resolution has been 
reviewed and approved by the Executive Committee, acting under the 
Executive Authority and in the best interest of the Cheyenne River 
Sioux Tribe this 29th day of August, 2011 in Eagle Butte, South Dakota.
                                   Kevin C. Keckler,
                                           Chairman, Tribal Chairman.
                                   Ev Ann White Feather,
                                           Tribal Secretary.
                                   Benita Clark,
                                           Tribal Treasurer.
                                 ______
                                 
 Prepared Statement of Geri Opsal, Tribal Veterans Service Officer for 
         the Sisseton Wahpeton Oyate, Lake Traverse Reservation
    Chairman Johnson and members of the Subcommittee on Military 
Construction and Veterans Affairs, and Related Agencies: Good morning, 
I am Geri Opsal, tribal veterans service officer (TVSO) for the 
Sisseton Wahpeton Oyate located on the Lake Traverse Reservation.
    I want to thank you for inviting us to attend this very important 
meeting, and since our schedules conflicted due to the annual 
certification school of the TVSOs and county veterans service officers, 
we are unable to attend. We do want to provide some comments regarding 
this important issue of improving access to care for Native American 
veterans in maximizing the effective use of Federal funds and services.
    The Sisseton Wahpeton Oyate is comprised of more than 12,941 tribal 
members. Of those tribal members, we have a veteran roster that goes 
back to the scout to present--we have more than 1,250 tribal members 
that are veterans. Each year we have of our members going off to serve. 
We have more than 80-plus tribal member veterans that have served in 
the Desert Era War from 1990 to present. We have tribal members 
stationed across the United States and also overseas fighting the fight 
for our country.
    Our Tribal Veterans Service Office has met many times with our 
Indian Health Service (IHS) regarding our veterans utilizing IHS verses 
having to travel and use the Department of Veterans Affairs (VA). 
Although progress has been made in the following areas, there are other 
areas we have concern about and wish to resolve.
    The following areas that we have had success with are:
      Pharmacy.--Veterans can bring their prescriptions to the pharmacy 
        and our pharmacist will call directly to the VA and confirm. 
        Our veterans are able to get the prescriptions filled locally 
        at IHS rather than traveling to get refills, etc.
      Walk-In Clinic, Optometry, Dental-Pharmacy.--Our veterans are 
        able to utilize IHS for their medical needs. They don't have to 
        travel if they chose not to but should they need referral to a 
        specialist they are required to then go to the VA and have the 
        referral done through them.
      Co-Pays.--IHS will pay for the veterans co-pays they accumulate 
        at the VA, but they do require that either the veteran or 
        myself contact Tami Seiber, contract health specialist, and 
        notify her of the appointment ahead of time. We've had a couple 
        of veterans that had their income tax refund withheld due to 
        nonpayment. One went and appealed this and had about 90 percent 
        of it returned to him. The co-pays that aren't covered by IHS 
        are the prescription co-pays and this they say is due to the 
        fact the prescription can be filled by IHS. A prescription has 
        two meds--one is covered; one is not. One you can get through 
        the VA and one through IHS, a simple Rx that takes days to fill 
        as someone has to run back and forth determining the least 
        cost-effective way to get this filled. Why isn't their brochure 
        geared for the Native American veteran notifying them to of 
        what extent their services are covered through the VA and IHS. 
        We have found out by trial and error as each case comes up why 
        are we pieced out the information as we seek it?
    The following areas of concern for us that we would like help to 
resolve are:
      Electronic Records.--If possible to have IHS doctors as well as 
        VA doctor's access electronically each others records/labs/
        notes on the veteran. This will help eliminate duplicate care 
        and often times our veterans after going to the VA for their 
        appointment or even after discharge from a hospitalization will 
        go to the IHS and ask the doctor to explain the procedure or 
        any questions. They sometimes are so happy to get discharged 
        and get home they don't ask questions until they get back to 
        the reservation and they have all the follow-up questions.
      Co-pays being returned or not paid in a timely manner, the 
        veteran getting sent to collections, or either getting their 
        income tax taken. How are we able to correct any negative 
        credit rating they may get as a result? And is their any way to 
        flag the tribal member veteran's record so the VA automatically 
        bills the IHS first rather than sending it to the patient's 
        address and expecting them to take or forward to IHS. Co-pays 
        for prescriptions should be covered as well. How is the veteran 
        to know that they only get co-pays for appointments?
    Solution.--We have a memorandum of understanding (MOU). This says 
the VA and the IHS are working together for the benefit of the veteran. 
Have the MOU give the VA authority (a new policy) that when a Native 
American veteran utilizes the VA, the VA is given authority to document 
under the financial part that the veteran is IHS-eligible; no co-pays. 
This will eliminate co-pays for office visits, medications, or 
referrals to specialty doctors. Right now, our biggest problem for our 
veterans is navigating the VA and IHS issue. The sharing of electronic 
records would come in handy with this process as well. Who's going to 
pay; hurry-up-and-wait game for referrals and getting bills because 
they didn't know they could take their Rx to IHS if they carry the 
meds; if they don't carry them they will order them and still no co-pay 
for the patient.
    We feel as a tribal member, first, and veteran, second, that we are 
protected under treaty rights. We are considered ``dual eligible''. 
Theoretically, being dual-eligible has caused more trouble for us due 
to trying to navigate the system which we have difficulty 
understanding. The Snyder Act of 1921 (25 U.S.C. 13) and the Indian 
Health Care Improvement Act (25 U.S.C. 1601) of 1976 provide specific 
legislative authority for the Congress to appropriate funds 
specifically for the healthcare of Indian people. In addition, we also 
have treaty rights to Federal healthcare services through the 
Department of Health and Human Services. The Federal trust to uphold 
the treaty responsibility for healthcare is first, and being a veteran 
is secondary to our healthcare process--moreso, when the tribal member 
is also a veteran, as they took the oath to fight for our freedom. We 
as veterans have heard the term from IHS that they are the ``payor of 
last resort'', and, as such, the use of alternative resources is 
required when such resources are available and accessible to the 
individual. We are required to go to the VA for any referrals; 
otherwise, IHS will not cover it. Dual eligibility which has us going 
between the IHS and the VA, and we try and keep our records straight.
    Mr. Chairman, this concludes my statement. Thank you for this 
opportunity to discuss the unique challenges when it comes to access to 
care and navigating the VA and IHS. We will be happy to answer any 
questions and consult on this process and perhaps if you have another 
meeting in the future we can attend along with our tribal secretary of 
the Sisseton Wahpeton Oyate; Ms. Winfield Rondell who is a Marine Corps 
veteran as well as one of our tribal executives.
                                 ______
                                 
             Letter From the Standing Rock Sioux Tribe \1\
---------------------------------------------------------------------------
    \1\ Charles W. Murphy, Chairman; Mike Faith, Vice Chairman; and 
Adele M. White, Secretary:
       Tribal Council (At Large).--Jesse ``Jay'' Taken Alive; Ronald C. 
Brownotter; Avis Little Eagle; Dave Archambault II; Joseph McNeil Jr.; 
and Jesse McLaughlin.
      Tribal Council (Districts).--Sharon Two Bears, Cannonball 
District; Henry Harrison, Long Soldier District; Duane Claymore, 
Wakpala District; Kerby St. John, Kenel District; Errol D. Cross Ghost, 
Bear Soldier District; Milton Brown Otter, Rock Creek District; Frank 
Jamerson Jr., Running Antelope District; and Samuel B. Harrison, 
Porcupine District.
---------------------------------------------------------------------------
                                                   August 26, 2011.
Hon. Tim Johnson, 
Chairman, Subcommittee on Military Construction and Veterans Affairs, 
        and Related Agencies, Committee on Appropriations,
Washington, DC.
    Most Honorable Senator Tim Johnson: We are in receipt of your 
letter and are most honored to be invited to the hearing to be held in 
Rapid City, SD on August 30, 2011.
    We are grateful for the opportunity to express our concerns 
regarding the collaboration with the Indian Health Services and the 
Department of Veterans Affairs. The following are our primary concerns 
for the Standing Rock Sioux Tribal veterans.
    I. Standing Rock veterans would like to have x-rays, labs, 
pharmacy, referrals, and all primary care provided at the local level.
    II. Standing Rock veterans would like to have a day set aside for 
their care. One day scheduled for veterans to come in and see a doctor. 
These visits would then be put into their charts at the Veterans 
Hospital that they have been assigned to.
    III. Technological access to the Department of Veterans Affairs 
medical records would allow for all medical and pharmaceutical visits 
to be viewed by the veteran's primary care physician. This would also 
eliminate the duplication of services and medications given to the 
veteran.
    IV. Veterans would like the Indian Health Services and the 
Department of Veterans Affairs to have better communications so the 
veterans get the best care available. Such as getting veterans 
stabilized at the Indian Health Services and then transported to the VA 
for care.
    V. Veterans on the Standing Rock Reservation travel 300+ miles to 
get to their primary care provider. Services here would eliminate the 
travel time for our veterans.
    Thank you for your interest in our veterans on the Standing Rock 
Sioux Tribal reservation.
                                   Charles W. Murphy,
                                           Chairman and Vietnam 
                                               Veteran.
                                   Wenelle F. Clown,
                                           Tribal Veterans Service 
                                               Office.

                                   - 

```