U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Printing Office,

http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center,

U.S. Government Printing Office. Phone 202–512–1800, or 866–512–1800 (toll-free). E-mail, gpo@custhelp.com.

53–369 PDF 2010

S. HRG. 111–471 

HEARING ON VA AND INDIAN HEALTH SERVICE 

COOPERATION 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

NOVEMBER 5, 2009 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.access.gpo.gov/congress/senate 

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

DANIEL K. AKAKA, Hawaii, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

PATTY MURRAY, Washington 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JIM WEBB, Virginia 

JON TESTER, Montana 

MARK BEGICH, Alaska 

ROLAND W. BURRIS, Illinois 

ARLEN SPECTER, Pennsylvania 

RICHARD BURR, North Carolina, Ranking 

Member 

LINDSEY O. GRAHAM, South Carolina 

JOHNNY ISAKSON, Georgia 

ROGER F. WICKER, Mississippi 

MIKE JOHANNS, Nebraska 

WILLIAM E. BREW, Staff Director 

LUPE WISSEL, Republican Staff Director 

(III) 

C O N T E N T S 

NOVEMBER 5, 2009 

SENATORS 

Page 

Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii ........................... 1 

Tester, Hon. Jon, U.S. Senator from Montana ...................................................... 2 

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 3 

Burr, Hon. Richard, Ranking Member, U.S. Senator from North Carolina ....... 4 

Begich, Hon. Mark, U.S. Senator from Alaska ..................................................... 5 

Murkowski, Hon. Lisa, U.S. Senator from Alaska ................................................ 29 

WITNESSES 

Park, William Clayton Sam ‘‘Clay’’, Director, Native Hawaiian Veterans 

Project, Papa Ola Lokahi ..................................................................................... 6 

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

Howlett, S. Kevin, Director, Health and Human Services Department, Confederated Salish and Kootenai Tribes of the Flathead Nation .............................. 10 

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

Attachments ............................................................................................... 13 

Response to post-hearing questions submitted by Hon. Daniel K. Akaka ... 17 

Joseph, Andrew, Jr., Chairman, Northwest Portland Area Indian Health 

Board, National Indian Health Board (NIHB), and Tribal Council Member, 

Confederated Tribes of the Colville Reservation ............................................... 18 

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

Floyd, James R., FACHE, Network Director, VA Heartland Network (VISN 

15), Veterans Health Administration, U.S. Department of Veterans Affairs; 

accompanied by W.J. ‘‘Buck’’ Richardson, Minority Veterans Program Coordinator, Rocky Mountain Health Network and the Montana Health Care 

System, Helena, Montana; and James Shore, M.D., Psychiatrist and Native 

Domain Lead, Salt Lake City VA medical center .............................................. 32 

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

Response to post-hearing questions submitted by Hon. Daniel K. Akaka ... 38 

Attachments ............................................................................................... 40 

Response to requests arising during the hearing by Hon. Mark Begich .....68, 78 

Grinnell, Randy E., Deputy Director, Indian Health Service, U.S. Department 

of Health and Human Services; accompanied by Theresa Cullen, M.D., 

Director of Information Technology, Indian Health Service ............................. 56 

Prepared statement .......................................................................................... 58 

Response to post-hearing questions submitted by Hon. Daniel K. Akaka ... 61 

APPENDIX 

Burris, Hon. Roland W., U.S. Senator from Illinois; prepared statement .......... 81 

Keel, Jefferson, President, National Congress of American Indians; prepared 

statement .............................................................................................................. 81 

Loudner, Don, National Commander, National American Indian Veterans, 

Inc.; prepared statement ..................................................................................... 83 

Scott, Carol Wild, Chair, Veterans Law Section, Federal Bar Association; 

prepared statement .............................................................................................. 85 

Northwest Portland Area Indian Health Board (NPAHB); prepared statement ...................................................................................................................... 88 

(1) 

HEARING ON VA AND INDIAN HEALTH 

SERVICE COOPERATION 

THURSDAY, NOVEMBER 5, 2009 

U.S. SENATE, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 10:06 a.m., in room 

418, Russell Senate Office Building, Hon. Daniel K. Akaka, Chairman of the Committee, presiding. 

Present: Senators Akaka, Murray, Tester, Begich, and Burr. 

Also present: Senator Murkowski. 

OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 

U.S. SENATOR FROM HAWAII 

Chairman AKAKA. The hearing of the Senate Committee on Veterans’ Affairs will come to order. 

Aloha and good morning, everyone. I am delighted that the Committee is focusing on the joint efforts of the Department of Veterans Affairs and the Indian Health Service to improve care for 

Native American veterans. 

Native American veterans have a rich and storied history of service to our Nation, and like all veterans they deserve the care and 

benefits that they have earned. Many Native American veterans 

served with distinction, but returned home to a very difficult transition. Substance abuse, extreme poverty, and unemployment still 

plague parts of Indian Country. American Indian and Alaska Native veterans are nearly 50 percent more likely than other veterans 

to have a service-connected disability and twice as likely to be unemployed. And as we will hear from a witness from my home State, 

challenges also extend to other Native veterans, including the 

many Native Hawaiians who have and are serving our Nation. 

Today’s hearing focuses on health care. Despite dual eligibility 

for VA and IHS health care, American Indian and Alaska Native 

veterans report unmet health care needs at four times the rate of 

other veterans. In 2003, VA and IHS signed a Memorandum of Understanding agreeing to mutual goals and actions to improve cooperation and collaboration. I look forward to hearing from today’s 

witnesses on the progress being made toward those goals. 

Senator Tester has been a leader on this issue and an advocate 

for Native Americans in Montana and across the Nation. Indeed, 

today’s hearing is in response to his request, and I will be turning 

the gavel over to him momentarily. 

Also, I want to say that Senator Murray has also been a leader 

in this area from the State of Washington. 

2 

As I speak, Tribal leaders are gathering for a White House summit, as you know. Such summits remind us of the government-togovernment relationship the U.S. has with Tribal Nations and their 

members. Therefore, for VA to effectively serve the many Native 

Americans who have shared in our mutual defense, it must also 

collaborate with the federally-recognized Tribal governments whose 

citizens serve with pride and patriotism. 

And now, I would like to call on Senator Tester for any statement that he has to make, and I will call on Senator Murray following that. Senator Tester. 

STATEMENT OF HON. JON TESTER, 

U.S. SENATOR FROM MONTANA 

Senator TESTER. I want to thank you, Mr. Chairman. Thank you 

for your remarks, and I want to thank you for agreeing to hold this 

hearing as quickly as you did. 

I want to thank the witnesses for being here today. A special 

thanks to Kevin Howlett for being here to lend his considerable expertise on the subject of Indian health care. As the Director of Tribal Health for the Confederated Salish and Kootenai Tribes in Montana, Kevin is literally on the front lines of American Indian health 

care. 

I also want to thank Buck Richardson for being here. Mr. Chairman, I know you will do a full introduction of the witnesses, but 

let me just say this. Buck is a fine man, has a great reputation, 

and does some great work for the VA as it applies to our Native 

Americans and VA folks across the board. 

This is a critically important topic in my State. We have 11 

tribes and seven reservations—over 4,500 American Indians who 

are enrolled in the VA alone. Of course, the number of American 

Indian veterans is likely much, much higher. Over the short time 

that I have been a U.S. Senator, I have heard many VA and Defense Department officials discuss the problems that they have had 

in assuring a seamless transition of a veteran from the DOD health 

program to the VA. Many veterans have told me firsthand about 

how they have fallen through the cracks caused by imperfect 

records, transfers, and red tape. It seems to me that if an agency 

as well-funded as the DOD has problems ensuring a seamless transition with the VA, we are facing an especially tall order with Indian Health Service. 

Some of this is about resources. Everyone in the room knows how 

underfunded IHS has been. The agency actually spends less per 

American Indian for health care than the Federal Bureau of Prisons spends on Federal inmates. And it has only been in the last 

couple years that the VA has been adequately funded. 

But beyond the question of dollars and cents, it is clear that neither agency has the unique needs of the Indian veterans front and 

center. As a result, we hear the horror stories of a veteran walking 

into an IHS facility, only to be told to go to a VA hospital hundreds 

of miles away, and of the veteran walking into a VA facility, only 

to be sent to an IHS facility. This so-called ping-ponging veterans 

is at odds with each agency’s mission to care for the patient first. 

3 

We have no reliable data on the progress being made between 

VA and IHS on their 2003 Memorandum of Understanding. In the 

age of information we live in, I see this as not acceptable. 

The lines of command and the role of each agency in providing 

assistance to the veteran are not always as clear as they need to 

be. One of the most important aspects of a true government-to-government relationship is communication. Tribes, clinics, and individual Indian veterans need to know what their options are for obtaining the quality health care that they deserve. 

One of the areas that seems to be working, where we have had 

decent results is the roll-out of the telehealth capabilities. As you 

know, Mr. Chairman, telehealth is particularly important in rural 

States, like my State. Many times, it is the only opportunity for 

folks in frontier areas to see a doctor or a mental health provider. 

Many of these telehealth opportunities are the product of funding 

approved by Congress in the past year for VA rural health programs. That is a good story for both the VA and the IHS, and we 

need to build on it. We have made good progress, but the work is 

not done. 

Our goal today is to find out about some of the progress. At the 

same time, we need the VA to be a willing partner at all of its levels to work with us to find ways to improve health care and the 

quality-of-life for American Indian veterans. 

So, I look forward to this hearing very, very much. From the witnesses, we are going to hopefully gain some ground on where we 

are and move forward. We all know there is much more work to 

be done, but by working together, we can get a lot of good things 

done. 

I want to thank you again, Mr. Chairman, for calling this hearing and appreciate the witnesses for their presence here. 

Chairman AKAKA. Thank you very much, Senator Tester. 

Senator Murray, your opening statement. 

STATEMENT OF HON. PATTY MURRAY, 

U.S. SENATOR FROM WASHINGTON 

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

Burr, Senator Tester, for holding this hearing today. I am looking 

forward to a discussion on cooperation between the Department of 

Veterans Affairs and the Indian Health Service so that we can improve health care and benefits for American Indian, Native Alaskan, and Native Hawaiian veterans. 

I join in thanking all of our witnesses who are appearing before 

this Committee today. I look forward to hearing your thoughts and 

perspectives on the cooperation between these two agencies since 

the implementation of the Memorandum of Understanding. 

Mr. Chairman, I especially want to welcome and thank Councilman Andrew Joseph. He comes from the Confederated Tribes of 

Colville and has traveled all the way across the country to be here 

today to testify from my home State of Washington and I really appreciate his being here today. 

I do want to take a moment to say how proud I am of all the 

veterans in this room. All of you have sacrificed so much in service 

to our country. We owe it to you to honor the promises we have 

made to take care of you when you come home. And one of the 

4 

most important ways to do this is by making sure that veterans 

have access to a system that treats you fairly. 

Tribal veterans, in particular, have made tremendous sacrifices 

for our country. In fact, Native Americans serve in the Armed 

Forces at a higher rate per capita than any other ethnic group. And 

I also know that Tribal veterans face some of the toughest barriers 

to accessing the services they have earned. Many Tribal veterans 

don’t live anywhere near VA services. They face communication 

barriers. And too often, Tribal veterans face issues with coordination between the Indian Health Service and the VA. So, it is our 

job to do everything within our power to break down those barriers 

and help our Tribal veterans access the care they need. You fought 

for us. We need to fight for you now. 

We began moving in the right direction 6 years ago when the 

Memorandum of Understanding was signed, but enough time has 

gone by for us to see some tangible results from the cooperation 

this agreement was meant to develop. 

So, Mr. Chairman, I appreciate your holding this hearing and I 

look forward to hearing from our witnesses today on the progress 

of this cooperation. Thank you. 

Chairman AKAKA. Thank you, Senator Murray. 

And now, the Ranking Member of this Committee, Senator Burr. 

STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 

U.S. SENATOR FROM NORTH CAROLINA 

Senator BURR. Thank you, Mr. Chairman. Aloha. Welcome to our 

witnesses this morning. 

We are here today to ensure the resources of the Department of 

Veterans Affairs and the Indian Health Service are being used to 

deliver timely, quality, and coordinated care services to Native 

American veterans. 

Mr. Chairman, Native Americans have the highest record of military service per capita when compared to other ethnic groups. I believe this record of service to our Nation and to the country is rooted in their culture and their traditions. Courage, duty, honor, sacrifice—these are values that make up our military men and women 

and make them second to none, and they are the values that run 

thick in the culture of so many from Indian Country. 

And when they return from military service with medical needs, 

they should expect a well-coordinated health care system. Today, I 

hope to learn how VA and the Indian Health Service coordinate the 

health care for those enrolled in both systems. For example, the 

Tribal Hospital in Cherokee, NC, has 700 enrolled veterans. One 

hundred forty of them are also enrolled in VA care. I hope to learn 

whether the remaining 560 veterans are aware of the VA health 

care benefits they may be entitled to. 

This is just a snapshot of an issue I am sure exists for North 

Carolina’s 7,600 Native American veterans and others across the 

country. VA and IHS need to do a better job in sharing information 

to determine whether a patient is dual eligible. This information 

will lead to a more efficient allocation of resources, better planning, 

and well-informed sharing agreements. 

In 2003, VA and Indian Health Service developed a Memorandum of Understanding outlining five mutual goals. One, imVerDate Nov 24 2008 16:19 Nov 22, 2010 Jkt 000000 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 H:\ACTIVE\110509.TXT SVETS PsN: PAULIN
5 

prove access to quality care; two, improve communications; three, 

encourage the development of partnerships and sharing agreements; four, ensure appropriate resources are available; and five, 

improve health promotion, disease, and preventative services. 

Today, I hope to learn where we are meeting these important goals, 

but more importantly, where we still need work. 

It is extremely important that these goals be taken seriously. For 

too long, when it comes to fair dealing with Indian Country, our 

actions have not matched our words. We must not let this be the 

case here, especially when we are talking about those who have 

worn the uniform of our country. 

Mr. Chairman, again, I thank you for convening this hearing and 

I look forward to what our witnesses might instill with us. 

Chairman AKAKA. Thank you very much, Senator Burr. 

Now I will call on Senator Begich for any opening remarks. 

STATEMENT OF HON. MARK BEGICH, 

U.S. SENATOR FROM ALASKA 

Senator BEGICH. Thank you very much, Mr. Chairman. And to 

the first panel, thank you for being here. Thank you for patiently 

waiting as we go through our opening remarks, because to be honest with you, I am looking forward to your comments, and I really 

am looking for the next panel because we are going to have a lot 

of questions for them. 

In my State of Alaska, a huge percentage—120,000 of the population are Alaska Natives. We have the very unique problem of delivery of services to our veterans in rural parts of Alaska, which 

is much different than the Lower 48, where in some cases you can 

drive to facilities. But in Alaska, you may not even be able to get 

to a facility until the weather is correct, when you can then fly or 

snow machine, depending on the conditions of the area. 

I am interested not only in the dual enrolled recipients, but also 

for Alaska, for unique opportunities in how we deliver services to 

those veterans that are in very remote areas—literally a plane ride 

away—yet a very short distance away are Indian Health Service facilities and how they can access those. Maybe they need not be 

dual-enrolled, but may need access because we don’t have a VA 

hospital in Alaska, and also the distance travel can put great pressure onto the health issue they may be moving forward on and getting services for. So, I am anxious for that. 

I am anxious for the first panel because hopefully you will give 

us your very open thoughts on what is working, what is not, but 

also where you can see some improvements. Even though it is not 

necessarily from an Alaska perspective, I think it is very important 

from the first people’s perspective of what we need to do to improve 

a service that is earned, but also important to deliver to our veterans, especially in rural communities, and Alaska Native American Indians have unique situations. 

I can only tell you that in Alaska I hear from veteran after veteran who has served and now lives back in their home village, that 

when they need services it is very difficult at times to get that access. We have some demonstration projects up there that seem to 

have some success and we are anxious to share those. But I am 

anxious to talk to the next panel in specific regard to how do we 

6 

ensure that the veterans in rural communities, and especially in 

Alaska, access health care in a reasonable timeframe and get quality health care. 

But again, thank you to the first panel. Thank you for patiently 

listening to us giving our opening remarks. Thank you, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Begich. 

I want to welcome the witnesses on our first panel. Clay Park, 

Native Hawaiian Veterans Program Director at Papa Ola Lokahi, 

will begin our discussion by giving voice to a sometimes neglected 

portion of the Native American community, and that is the Native 

Hawaiians. 

Our second witness is Mr. Kevin Howlett, Director of the Salish 

and Kootenai Tribal Health Department. 

Our third witness, I am pleased to introduce, is Andrew Joseph, 

a Councilman from the Confederated Tribes of Colville, who is testifying on behalf of the National Indian Health Board. 

Mr. Park, we will please begin with your statement. 

STATEMENT OF WILLIAM CLAYTON SAM ‘‘CLAY’’ PARK, DIRECTOR, NATIVE AMERICAN HAWAIIAN VETERANS PROJECT, 

PAPA OLA LOKAHI 

Mr. PARK. Good morning. Welina. Chairman Akaka, members of 

the Senate Committee on Veterans’ Affairs, Papa Ola Lokahi wishes to express to you its sincere gratitude for inviting us to participate today in this important hearing. 

My name is William Clayton Sam Park, Director of Papa Ola 

Lokahi’s Native Hawaiian Veterans Project. I am a retired Master 

Sergeant with 3 years active duty, 21 years of service with the Hawaii Army National Guard. I am also retired from the Department 

of Veterans Affairs and a disabled veteran. 

Mr. Chairman, in your letter, you specifically wanted us to address Papa Ola Lokahi and the Native Hawaiian Health Care Systems collaborating with the VA and the Indian Health Service. 

Papa Ola Lokahi has had a longstanding relationship with the VA, 

going back more than 10 years to a time when Mr. David Burge, 

a Native Hawaiian, served as its Hawaii Director. We have participated in past trainings and provided training to the local VA on 

cultural trauma and other areas around cultural competency. 

Recently, we have established at each of our five Native Hawaiian Health Care Systems, which operate throughout the State, veterans ‘‘Aunties’’ and ‘‘Uncles’’ groups, which act as enablers for Native Hawaiians and other veterans with issues and/or concerns. 

These men and women serve as volunteers to hear out our veterans 

and their issues and offer advice. In turn, these groups are facilitated by health care professionals from the Native Hawaiian 

Health Care Systems, who are trained specifically in VA programs 

and, in turn, serve as links for veterans on their respective islands 

into the VA structure. 

Likewise, Papa Ola Lokahi has developed a relationship with the 

Indian Health Service over the past 15 years. This relationship has 

afforded the provision of primary care service for American Indians 

and Alaska Native residents in Hawaii. Presently, these services 

are provided through Ke Ola Mama, one of the largest Native HaVerDate Nov 24 2008 16:19 Nov 22, 2010 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 H:\ACTIVE\110509.TXT SVETS PsN: PAULIN
7 

waiian Health Care Systems, directed by Lisa Mao Ka’anoi, an 

Alaska Native of Native Hawaiian ancestry. 

Over the years the Indian Health Service has provided guidance 

to Papa Ola Lokahi on, one, formation of its Institutional Review 

Board, which currently reviews and approves all health research 

undertaken by researchers through the Native Hawaiian Health 

Care Systems and other service providers. Two, establishment of 

the Native Hawaiian Epi Center, which is similar in form and 

function to the 11 Native American Epi Centers across Indian 

Country. And three, the RPMS reporting system, which some of the 

Native Hawaiian Health Care Systems are considering adopting. 

In conclusion, these two agencies have continued to support the 

efforts of Papa Ola Lokahi in the Native Hawaiian Health Care 

Systems and we have supported their missions as well. Presently, 

we receive our base Federal support through the Native Hawaiian 

Health Care Improvement Act and the Health Resources and Services Administration, U.S. Department of Health and Human Services. 

Thank you again, Chairman Akaka and members of the Senate 

Committee on Veterans’ Affairs, for this opportunity to share with 

you my thoughts today. There is an olelo, a verse, in my traditional 

language which states, ‘‘Ke kaulana pa’a ’aina on na ali’i,’’ which 

is simply translated as ‘‘The famed landholders of the chiefs.’’ The 

meaning here is the best warriors were awarded the best lands by 

our chiefs because of their bravery and service. This is why we are 

here today. We simply want the best health care possible for our 

warriors who have given so much, often sacrificing their own 

health for this Nation’s benefit. Our recommendation for specific 

actions to accomplish this objective has been submitted in the written testimony. 

Mr. Chairman, I will be pleased to answer any questions you or 

Members of the Committee have. Mahalo. 

[The prepared statement of Mr. Park follows:] 

PREPARED STATEMENT OF WILLIAM CLAYTON SAM ‘‘CLAY’’ PARK, DIRECTOR, NATIVE

HAWAIIAN VETERANS PROJECT, PAPA OLA LOKAHI

Welina. Chairman Akaka and Members of the Senate Committee on Veterans’ Affairs, Papa Ola Lokahi wishes to express to you its sincere gratitude for inviting 

us to participate today in this important Hearing. 

My name is William Clayton Sam Park, director of Papa Ola Lokahi’s Native Hawaiian Veterans Project. I am a retired Master Sergeant with 3 years active duty 

and 21 years of service with the Hawaii Army National Guard. I am also retired 

from the DVA with 28 years of service and a disabled veteran. 

Papa Ola Lokahi is the Native Hawaiian Health Board that was established by 

the Native Hawaiian community in 1987 to plan and implement programs, coordinate projects and programs, define policy, and educate about and advocate for the 

improved health and wellbeing of Native Hawaiians, an Indigenous Peoples of the 

United States. These tasks were incorporated within U.S. policy when the U.S. Congress established its policy in 1988 ‘‘to raise the health status of Native Hawaiians 

to the highest possible level and to provide existing Native Hawaiian health care 

programs with all the resources necessary to effectuate this policy’’ (Public Law 

102–396). 

Native Hawaiians have served in the military services of the United States almost 

from the very beginning of the Nation. Young Prince George Kaumuali’i enlisted in 

the U.S. Navy and fought in the War of 1812 in the Mediterranean. In following 

conflicts including the American Civil War, the Spanish-American War, World Wars 

I and II, Korea, Vietnam, Iraq, and, now, again Iraq and Afghanistan, Native Hawaiians have continued to serve and serve with distinction. As a side note, a numVerDate Nov 24 2008 16:19 Nov 22, 2010 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6621 H:\ACTIVE\110509.TXT SVETS PsN: PAULIN
8 

ber of Native Hawaiians historically have also served in the Armed Forces of other 

countries including England and Canada. 

In 1997 when the VA released the results of the late Senator Spark Matsunagainitiated study on the impacts of exposure to war zones on Native Hawaiian and 

Asian veterans, it became clear that along with American Indians and Alaska Natives, Native Hawaiians have borne a larger burden of battle-related stress and 

trauma. More than one in every two Native Hawaiian veterans experienced war-related trauma in Vietnam. The report goes on... Upon returning home after one 

or more tours in Vietnam many Native Hawaiian veterans struggle with extremely 

severe problems that neither they nor their families, friends, or communities know 

how to understand or cope with: depression, shame, guilt, isolation and emotional 

emptiness, alienation, unable to relax, addiction. One in three Native Hawaiians 

have full or partial PTSD currently... More than one in two Native Hawaiians 

have had full or partial PTSD sometime since Vietnam. 

With conflicts in the 1990s in Iraq and now on-going conflicts in Iraq and Afghanistan, and with Reserve and National Guard units being heavily utilized along with 

regular military and the particularly brutal nature of the current warfare, these 

PTSD episodes will only greatly increase. An additional factor in these conflicts is 

the full participation of women now integrated into positions which formerly were 

all male forces. 

Current US Census data indicates that there are about 30,000 Native Hawaiian 

and Pacific Islander veterans in the United States. A large portion of this number 

is resident in Hawaii and Native Hawaiians have been actively engaged with the 

Hawai’i Office of the VA (Veterans’ Affairs) for many years. Increasingly, however, 

almost as many Native Hawaiians now live on the continental United States and 

more and more, Native Hawaiians will become part of the VA structure throughout 

the Nation. In previous testimony before this Committee, Papa Ola Lokahi provided 

historical reviews and analysis of VA activities and the Native Hawaiian community 

in Hawaii. 

Mr. Chairman, in your letter you specifically wanted us to address Papa Ola 

Lokahi and the Native Hawaiian Health Care Systems’ collaboration with the VA 

and the Indian Health Service. Papa Ola Lokahi has had a long-standing relationship with the VA going back more than ten years to a time when Mr. David Burge, 

a Native Hawaiian, served as its Hawai’i Director. We have participated in past 

trainings and provided training to the local VA in cultural trauma and other areas 

around cultural competency. Recently, we have established at each of the five Native Hawaiian Health Care Systems which operate throughout the State, veterans 

‘‘Aunties’’ and ‘‘Uncles’’ groups which act as ‘‘enablers’’ for Native Hawaiian and 

other veterans with issues and/or concerns. These men and women are Native retirees who serve as volunteers to hear out veterans and their issues and offer advice. 

In turn, these groups are facilitated by health care professionals from the Native 

Hawaiian Health Care Systems, who are trained specifically in VA programs and, 

in turn, serve as links for veterans on their respective islands into the VA structure. 

Likewise, Papa Ola Lokahi has developed a relationship with the Indian Health 

Service over the past fifteen years. This relationship has afforded the provision of 

primary care services for American Indians and Alaska Natives resident in Hawaii. 

Presently, these services are provided through Ke Ola Mama, one of the larger Native Hawaiian Health Care Systems, and directed by Lisa Mao Ka’anoi, an Alaska 

Native with Native Hawaiian ancestry. Over the years, the Indian Health Service 

has also provided guidance to Papa Ola Lokahi on (1) formation of its Institutional 

Review Board which currently reviews and approves all health research undertaken 

by researchers through the Native Hawaiian Health Care Systems and other service 

providers, (2) establishment of the Native Hawaiian Epi Center which is similar in 

form and function to the twelve Native American Epi Centers across Indian Country, and (3) the RPMS reporting System which some of the Native Hawaiian Health 

Care Systems are considering adopting. 

In conclusion, these two agencies have continued to support the efforts of Papa 

Ola Lokahi and the Native Hawaiian Health Care Systems as we have supported 

their missions as well. Presently, we receive our base Federal support through the 

Native Hawaiian Health Care Improvement Act and the Health Resources and Services Administration, US Department of Health and Human Services. 

Given our relationships and vantage point, we come before you today with the following recommendations: 

1. Enhance VA capacity to address health and wellness issues not only of the VA 

beneficiary but also those of the VA beneficiary’s family; 

While addressing the VA beneficiary’s health needs is critical to the VA mission, 

there needs to be the ability within the VA also to address the resultant health 

issues and needs of the VA beneficiary’s family. This is particularly true with those 

9 

VA beneficiaries with TBI and/or PTSD. Without this ability, there is often a family 

breakdown and a less than satisfactory outcome for the VA beneficiary, the family 

and the community. 

2. Develop VA capacity to contract with Native groups and organizations to provide outreach services to VA beneficiaries and their families; 

In Hawai’i, the VA has not been able to reach out to rural communities and provide needed services to VA beneficiaries living in these areas. We would ask that 

the VA contract with Native Hawaiian and other appropriate groups and organizations to provide outreach services to VA beneficiaries and their families. 

3. Develop VA capacity to contract with FQHCs and tribal and Native Hawaiian 

Health Care Systems to provide VA beneficiaries and their families with primary 

care services in rural areas; 

For the same reasons noted previously, the VA simply does not have the capacity 

at this time to reach out into rural areas where there are currently primary care 

service providers. It would make sense for the VA to contract for primary care services with these existing entities in these rural communities. In Hawai’i, there are 

only 3 VA community-based outpatient clinics (CBOC) while there are 14 community health centers and 5 Native Hawaiian Health Care Systems, all of which provide primary care 

4. Train VA service providers working with Native populations in history, cultural 

sensitivity, and cultural competency; 

historical context and cultural sensitivity and competency can improve VA service 

provider and VA beneficiary understanding and compliance with good outcomes. 

5. Expand VA capacity to provide traditional Native healing practices and alternative and complementary healing practices to VA beneficiaries and their families; 

Native cultures have traditional healing practices such as lomilomi (Hawaiian 

massage), ho’oponopono (counseling), and la’au lapa’au (herbal medicine) in our Native Hawaiian culture. This includes traditional practices and protocols transitioning 

the ’warrior’’ back into civilian society. All of these have demonstrated effectiveness 

for the Native VA beneficiary. The VA needs to support these traditional methods 

and practices. In addition, there are numerous alternative and complementary 

health care practices such as acupuncture, chiropractic, Chinese medicine, and naturopathy which may be of particular interest and therapeutic to VA beneficiaries. 

These, too, should be allowable and available. 

6. Support and develop specific work plans for each of the recommendations of the 

Advisory Committee on Minority Veterans’ July 1, 2008 and July 1, 2009 reports; 

In 1994, legislation was passed which established the Advisory Committee on Minority Veterans. The work and recommendations of this Committee need to be actively supported and implemented respectively. It is strongly recommended that a 

Native Hawaiian representative be added to the Committee as soon as appropriate. 

In addition, Native Hawaiians look forward to participating with the federally-chartered National American Indian Veterans group and applaud the recently produced 

DVD entitled ‘‘Native American Veterans: Storytelling for Healing,’’ which includes 

American Indian, Alaska Native, and Native Hawaiian veterans’ stories produced by 

the Administration for Native Americans, US Department of Health and Human 

Services. 

7. Collect, analyze, and report data on VA beneficiaries and their families in accordance with 1997 OMB 15 revised standards, including disaggregating Native Hawaiian from Other Pacific Islander data; 

In 1997, OMB disaggregated the Asian Pacific Islander (API) identifier and established two distinct categories; Asian (A) and Native Hawaiian and Other Pacific Islander (NHOPI). The VA needs to incorporate this disaggregation within its reporting systems. Additionally, ‘‘Native Hawaiians’’ need to be distinctively identified 

apart from ‘‘Other Pacific Islanders’’ as Native Hawaiians have put forth their selfdetermination efforts. This is critical for Native Hawaiians as, like American Indians/Alaska Natives, they need to be identified as a body of individuals with a special 

political relationship to the Federal Government. 

8. Enhance VA capacity to undertake research on ways to improve health and 

wellness outcomes for VA beneficiaries and their families. 

The VA’s research budget has been limited over the past decade. Additional funds 

need to be allocated to research how better outcomes can be accomplished for VA 

beneficiaries and their families. This is particularly critical for those with TBI and 

PTSD. 

Additionally, we strongly recommend that the VA increase its research capacity 

to investigate what the health and wellness issues are for returning Native men and 

10 

women veterans from today’s war zones. It is hoped that many of these studies 

could be undertaken by Native health researchers themselves. 

Thank you again Chairman Akaka and Members of the Senate Committee on Veterans Affairs for this opportunity to share with you my thoughts today. There is an 

‘‘olelo, a verse, in my traditional language which simply states: 

KE KAULANA PA‘A ‘ALNA ON NA ALI‘I

Which is simply translated as ‘‘The famed landholders of the chiefs.’’ The meaning 

here is that the best warriors were awarded the best lands by our chiefs because 

of their bravery and service. That is why we are here today. We simply want the 

best health care possible for our warriors who have given so much and often sacrificed their own health for this Nation’s benefit. Mahalo. 

Chairman AKAKA. Thank you very much, Mr. Park. 

Mr. Howlett, we will receive your testimony. 

STATEMENT OF S. KEVIN HOWLETT, DIRECTOR, CONFEDERATED SALISH AND KOOTENAI TRIBAL HEALTH DEPARTMENT 

Mr. HOWLETT. Mr. Chairman, Members of the Committee, I am 

pleased and honored to appear before you today to present testimony related to health care of Native American veterans. For the 

record, I am Kevin Howlett, a member of the Salish Kootenai 

Tribes, and Director of the Tribes’ Health and Human Services Department. 

I would like to thank Senator Tester for his recognition and support for my being here and his commitment to providing health 

care to Native American veterans. 

Today, I will address those areas I feel that affect the access and 

quality of care I spoke of when then-Secretary Peake visited Montana. Let me assure you that while I speak as one Tribal health 

director, the issues I will address span the universe of Indian 

Country and the needs I believe exist in every reservation community. 

Specifically, there has been a longstanding belief that health care 

for Native Americans is the responsibility of the Indian Health 

Service. While I agree that the IHS has principal responsibility as 

the Federal agency designated to provide care, I also know that as 

citizens of the States in which Indians live, they are entitled to the 

services provided to the citizens of that State. In addition, by having served our country in the Armed Services, veterans have 

earned the right to care provided by the Veterans Administration 

medical system. 

Most reservations are remotely located, underfunded, understaffed, resulting in a very real rationed care scenario. While Tribal 

or IHS clinics do the best they can, the level of care is often less 

than needed. This is amplified by a severe shortage of clinical personnel evident in virtually every clinic setting. 

When the level of care is not available in the local IHS clinic, 

IHS uses what is referred to as a Contract Health Service Program 

to refer care to outside specialty providers or inpatient facilities 

when that care is not available. The CHS program has operated on 

a shoestring budget for many years. The care that can be approved 

utilizing CHS funds must be threatened if IHS assumes financial 

responsibility. Consequently, these services are not provided. 

We are aware of the existence of a Memorandum of Understanding between the Indian Health Service and the VA. We are 

11 

also aware that it represents more symbolism than action. Without 

question, the full implementation of the existing MOU linked to 

specific Tribal recommendations would go a long way in providing 

a more comprehensive level of care to our veterans. Specifically, the 

agencies agreed to many things, including the sharing of information technology and an interagency work group to oversee proposed 

national initiatives. 

Mr. Chairman, if the agencies who are a party to this agreement 

would, as a matter of priority, establish an internal and external— 

including Tribal—work group to begin developing a strategy, then 

they could discuss how that strategy should be resourced and implemented. 

An item not covered in the existing MOU concerns payment to 

Tribal facilities for care rendered to eligible veterans in Tribal clinics. The Tribes rely heavily upon third-party collections to support 

clinic operations. It seems logical that for Medicare and Medicaid 

and privately insured individuals, the clinics can seek reimbursement. We are aware that the VA does have the ability to contract 

with the private sector to pay for the care of veterans, yet Triballyoperated clinics cannot, as we understand, seek the same. It would 

be easily incorporated into statute if this Committee were so inclined. Absent the reimbursement, we will still provide what care 

we can, but the resources or the absence of resources controls the 

scope of care. 

Mr. Chairman, I could speak for hours about the specific needs 

of the 480 veterans living on my reservation. My purpose and goal 

today is to enlighten you from my perspective about the organization, structural, and resource issues that comprise the maze of 

health care for veterans on the Flat Head Indian Reservation. I 

truly believe that the level of care that is afforded must equal the 

services they have rendered. I also believe that we can find solutions if we stay focused on the task and spend less time trying to 

point fingers. We need to utilize the tools we have and the commitment all of us have in this room share. 

I look forward to this Committee providing the guidance and direction to the VA and IHS to ensure that those who have worn the 

uniform have the best care possible, to maximize limited resources, 

and to work collectively in all areas of health care, including behavioral health. We owe these dedicated men and women nothing less. 

Mr. Chairman, I have attached the MOU to my testimony. I have 

also attached some correspondence from the manager of my behavioral health program, correspondence that she relates to me from 

her personal observations as a behavioral therapist, the issues she 

has dealt with, and I think it will give you a perspective that sometimes people in bureaucracy don’t or can’t appreciate. 

I would be happy to answer any questions the Committee may 

have. Thank you. 

[The prepared statement of Mr. Howlett follows:] 

PREPARED STATEMENT OF S. KEVIN HOWLETT, DIRECTOR, HEALTH AND HUMAN SERVICES DEPARTMENT, CONFEDERATED SALISH AND KOOTENAI TRIBES OF THE FLATHEAD NATION

Mr. Chairman and Members of the Committee: I am pleased and honored to appear before you today to present testimony related to the health care for Native 

American Veterans. 

12 

For the record, I am S. Kevin Howlett, a member of the Salish and Kootenai 

Tribes and Director of the Tribes Health & Human Services Department. 

Let me thank our Senator Jon Tester for his recognition and support for my being 

here and his commitment to providing health care to our veterans. 

Today, I will address those areas I feel that affect the access and quality of care 

I spoke of when then Secretary Peake visited Montana. Let me assure you that 

while I speak as one Tribal Health Director, the issues I will address span the universe of Indian country and the needs I believe exist in every reservation community. 

Specifically, there has been a long-standing belief that health care for Native 

Americans was the responsibility of the Indian Health Service. While I agree that 

IHS has principal responsibility as the Federal agency designated to provide care, 

I also know that as citizens of the states in which Indians live they are also entitled 

to the services provided to the citizens of that state. In addition, by having served 

our country in the armed services, veterans have earned the right to care provided 

by the Veterans Administration Medical system. 

Most reservations are remotely located, under funded and under staffed resulting 

in a very real rationed care scenario. While Tribal/IHS clinics do the best they can, 

the level of care is quite often less than needed. This is amplified by a severe shortage of clinical personnel evident in virtually every clinic setting. 

When the level of care is not available in the local clinic IHS uses what is referred 

to as the contract health services (CHS) program to refer to outside specialty care 

providers or in-patient facilities when in-patient care is not available. The CHS program has operated on a shoestring budget for many years. The care that can be approved utilizing CHS funds must be life threatening if IHS assumes financial responsibility; consequently these services are not provided. 

We are aware of the existence of a Memorandum of Understanding between the 

IHS and the VA. We are also aware that it represents more symbolism then action. 

Without question the full implementation of the existing MOU, linked with Tribal 

specific recommendations would go a long way in providing a more comprehensive 

level of care for our veterans. Specifically, the agencies agree to many things including the sharing of information technology and an interagency workgroup to oversee 

proposed national initiatives. 

Mr. Chairman, if the agencies who are a party to this agreement would as a matter of priority establish an internal and external (tribal) work group to begin developing a strategy then we could discuss how that strategy should be resourced and 

implemented. 

An item not covered in the existing MOU concerns payment to Tribal facilities for 

care rendered to eligible veterans in Tribal clinics. The tribes rely heavily upon 

third-party collections to support the clinic operations. It seems logical that for 

Medicare/Medicaid, and privately insured individuals, the clinics can seek reimbursement. We are aware that the VA does have the ability to contract with the 

private sector to pay for the care of veterans, yet tribally operated clinics cannot 

as we understand seek the same. It would be easily incorporated into statute if this 

Committee were so inclined. Absent the reimbursement, we will still provide what 

care we can, but resources or the absence of resources controls the scope of care. 

Mr. Chairman, I could speak for hours about the specific needs of the 480 veterans living on my reservation. My purpose and goal today was to enlighten you 

from my perspective about the organization, structural and resource issues that 

comprise the maze of health care for veterans on the Flathead Indian Reservation. 

I truly believe that the level of care that is afforded must be equal to the services 

they have rendered. 

I also believe that we can find solutions if we stay focused on the task, and spend 

less time trying to point fingers. We need to utilize the tools we have, and the commitment all of us in this room share. 

I look forward to this Committee providing the guidance and direction to the VA 

and IHS to ensure that those who have worn our uniform have the best care possible, to maximize limited resources, and to work collectively in all areas of health 

care including behavioral health. We owe these dedicated men and women nothing 

less. 

13 

ATTACHMENTS


115Howlett4.eps
14 


115Howlett5.eps
15 


115Howlett1.eps
16 


115Howlett2.eps
17 

RESPONSE TO POST-HEARING QUESTION SUBMITTED BY HON. DANIEL K. AKAKA TO

S. KEVIN HOWLETT, DIRECTOR, HEALTH AND HUMAN SERVICES DEPARTMENT, CONFEDERATED SALISH AND KOOTENAI TRIBES OF THE FLATHEAD NATION

Question. Mr. Howlett, you testified that the VA can contract with the private sector for services through contract health services (CHS) but not with tribally-operated clinics. If the VA were able to contract with tribally-operated clinics, would 

that greatly increase accessibility for Native American veterans? 

Response. Absolutely, in many places across the country, the only care available 

is Indian Health Service or Tribal Health Services. 

Chairman AKAKA. Thank you very much, Mr. Howlett. We will 

include the information in the record that you mentioned. 

Now, we will receive the statement of Mr. Joseph. 


115Howlett3.eps
18 

STATEMENT OF ANDREW JOSEPH, JR., CHAIRMAN, NORTHWEST PORTLAND AREA INDIAN HEALTH BOARD, NATIONAL 

INDIAN HEALTH BOARD (NIHB), AND TRIBAL COUNCIL MEMBER, CONFEDERATED TRIBES OF THE COLVILLE RESERVATION 

Mr. JOSEPH. Chairman Akaka and Ranking Member and distinguished Members of the Committee, [untranslated] is my name in 

my language. I am Andy Joseph, Jr. I chair the Health and Human 

Services Committee for the Confederated Tribes of Colville. I am 

the Chair of the Portland Area Indian Health Board and Delegate 

to the National Indian Health Board. Thank you for inviting the 

National Indian Health Board to testify today. 

NIHB serves all federally-recognized Tribes by advocating for the 

improvement of health care to all American Indians and Alaskan 

Natives. Our organization believes that the Federal Government 

must uphold its trust responsibility in the delivery of quality 

health care to Indian people, especially our Native veterans. 

Native veterans are a special part of our Tribal communities. 

American Indians and Alaskan Natives have a long history of serving the U.S. Armed Forces. Indians have volunteered to serve in 

the military at a higher percentage than any other ethnic group. 

Our Native veterans are also fellow Tribal members who are assured health care as part of the Federal Government’s trust responsibility to Tribes. As veterans, the U.S. Government has made 

a commitment to provide health care in honor for their military 

service. Therefore, our Native veterans deserve quality health care. 

The IHS and VA have collaborated to promote greater cooperation for the improvement of health care for Native veterans. In 

some areas, this coordination in care is working out well. However, 

many Native veterans report a higher rate of unmet health care 

needs and continue to deal with high rates of illness associated 

with combat service. The lack of access and coordination of care 

has created some of these issues. 

There are Native veterans who may not consider the VA as an 

option for their health care. Tribal members live in remote, rural 

areas and must travel great distances to access any medical facility, including VA. Another potential barrier is the perception that 

VA will not appreciate, understand, or accommodate the cultural 

needs of Native veterans. Some Native veterans have expressed the 

frustration when VA has not accepted a diagnosis from IHS. In 

these instances, Native veterans have to travel long distances to a 

VA hospital so the VA doctor can administer the same test and 

give the same diagnosis that the IHS provided. 

Other issues include lack of communication that exists between 

VA and IHS regarding treatment. Some Native veterans who access health care through both VA and IHS must manage their own 

care by maintaining medical records, sharing the medical diagnosis 

and care between VA and IHS. Without these agencies directly 

talking with one another, there may be increased risks, such as 

side effects from counteracting medications. 

We have provided some recommendations in our written testimony. I would like to raise a couple here. First, a key recommendation to address the health needs of Native veterans is the need for 

additional funding to provide care to Native veterans. Many times, 

19 

1See ‘‘American Indian and Alaska Native Veterans: Lasting Contributions’’ by Lindsay Holiday, Gabriel Bell, Robert Klein and Michael Wells, US Department of Veterans Affairs, Office 

of Policy Assistant Secretary for Policy, Planning, and Preparedness, September 2006. 

IHS is the only facility in the area to provide care for Native veterans. Supplemental funding to IHS and Tribal facilities for services provided to Native veterans would help ensure all the care 

needed can be provided to Native veterans. 

Second, more information must be shared about the available 

services. One option is to expand the Tribal Veterans Service Officers Program by establishing it as part of the VA with permanent 

paid positions. In many areas, these representatives help Native 

veterans navigate the VA system and serve as advocates for Native 

veterans. 

Another option is to bring VA health professionals specialized in 

behavior and mental health treatment to Tribal communities to 

treat Native veterans. Many of the IHS and Tribal facilities have 

behavior health departments, but deal with veterans returning 

home from combat requires specialized care and treatment. 

In closing, thank you for this opportunity to provide these comments and I am happy to answer any questions the Committee 

might have. 

I would like to thank each of you for serving our country, also. 

As a Tribal leader, I know you swore an oath to protect and care 

for all of our people, the same as Tribal leaders have, and your 

time is greatly appreciated. Thank you. 

[The prepared statement of Mr. Joseph follows:] 

PREPARED STATEMENT OF ANDREW JOSEPH, JR., CHAIRMAN OF THE NORTHWEST

PORTLAND AREA INDIAN HEALTH BOARD, NATIONAL INDIAN HEALTH BOARD

(NIHB), AND TRIBAL COUNCIL MEMBER, CONFEDERATED TRIBES OF THE COLVILLE

RESERVATION

Chairman Akaka, Ranking Member Burr and Distinguished Members of the Committee, I am Andrew Joseph, Jr., testifying on the behalf of the National Indian 

Health Board (NIHB). Also, I serve as a Tribal Council Member of the Confederated 

Tribes of the Colville Reservation and as the Chairman of the Northwest Portland 

Area Indian Health Board. 

Thank you for inviting the NIHB to testify today regarding the cooperation and 

coordination between the Veteran Affairs and the Indian Health Service (IHS) in 

providing care to our American Indian/Alaska Natives (AI/AN) Veterans. Since 

1972, the NIHB serves all federally recognized Tribes by advocating for the improvement of health care delivery to AI/AN. It is the belief of the NIHB that the Federal 

Government must uphold its trust responsibility to AI/AN populations in the provision and facilitation of quality health care to our people. The results that we all 

wish to achieve are the enhancement of the level and quality of health care and the 

adequacy of funding for health services that are operated by Tribal governments, 

the Indian Health Service and other Federal programs. As health care is the top 

priority of Tribes across the Nation, and delivery of health care is unique and individual to each Tribal nation and their tribal members in the United States, it is 

fitting that the NIHB provides testimony regarding the health care provided to our 

Native Veterans. Thank you for inviting us to do so. 

HEALTH CARE AVAILABLE FOR OUR AI/AN VETERANS

AI/AN who have served in the US Armed Forces are a special segment in our 

communities as they are both Tribal members and honored veterans. They are fellow members, relatives and friends of the 564 federally recognized tribal communities in United States. As well as, the long history of AI/AN serving in the United 

States Armed Forces should never be forgotten.1 AI/AN have volunteered to serve 

the United States at a higher percentage in all of America’s wars and conflicts than 

any other ethnic group on a per capita basis. In addition, 25% of AI/AN population 

serve in military, which is higher than any other in the U.S. Based on the associaVerDate Nov 24 2008 16:19 Nov 22, 2010 Jkt 000000 PO 00000 Frm 00023 Fmt 6633 Sfmt 6621 H:\ACTIVE\110509.TXT SVETS PsN: PAULIN
20 

2 Indian Health Service Year 2009 Profile. Available at http://info.ihs.gov/Profile09.asp. Assessed October 31, 2009. 3 VA Health Care Eligibility & Enrollment. Available at http://www4.va.gov/healtheligibility. 

Last accessed on October 31, 2009. 

tion with both the AI/AN and Veteran communities, AI/AN Veterans are entitled to 

health care both as a right as a tribal member and as a benefit for their military 

service. 

Indian Health Service 

As a member of federally recognized Tribe, AI/AN Veterans are entitled to health 

care. The provision of health services to AI/AN is the direct result of treaties and 

executive orders that were made between the United States and Indian Tribes. This 

Federal trust responsibility forms the basis of providing health care to AI/AN people 

and reaffirmed by judicial decisions, executive orders, and congressional law. 

The Indian Health Service (IHS) is responsible for health care to all enrolled 

members of the 564 federally recognized Indian tribes, bands, and Alaska Native 

villages in the US. The current Indian health care delivery system provides culturally competent health care to AI/AN, who reside in the most remote, isolated and 

poorest parts of this Country. There is no consistent health benefits package across 

Indian country. This health care delivery system consists of various health care facilities across the country, including 45 hospitals, 635 ambulatory facilities (288 

health centers, 15 school-based health centers, 132 health stations, 34 urban Indian 

health program, and 166 Alaska Native village clinics).2 These health care facilities 

can be grouped into three categories: those operated directly by IHS, those operated 

by the tribes via contract or compact with IHS, and those providing services to 

urban AI/AN (individuals not residing on or near an Indian reservation). 

What is consistent, however, is that there is an overwhelming lack of funding to 

support even the basic health care demands in all three delivery models. Along with 

ambulatory primary care services, Tribal, IHS or Contract Care facilities may offer 

inpatient care, sporadic medical specialties, traditional healing practices, dental 

care, child and emergency dental care, mental health care, limited eye care, and 

substance abuse assessment or treatment programs. Many tribes are also served by 

community health (e.g., childhood immunizations, home visits) and environmental 

health (e.g., sanitation, injury prevention) programs, which may be administered by 

the IHS or the Tribes. Specialty services and types of medical care that are not 

available at a given facility are often purchased from providers in the private sector 

through contract health service (CHS) program. Due to lack of adequate funding, 

the IHS and Tribes apply stringent eligibility criteria to determine which patients 

qualify for CHS funding. The severely limited pool of CHS dollars also means that 

most CHS programs limit reimbursement to those diagnostic or therapeutic services 

that are needed to prevent the immediate death or serious impairment of the health 

of the patient. Long lists of denied or deferred CHS care are commonplace at all 

IHS and Tribal facilities. 

Veteran Health Administration 

AI/AN veterans may be eligible for health care from the Department of Veterans 

Health Administration (VHA). The eligibility of Veterans to access health care 

through the VHA depends on factors such as service-connected illness, income, the 

character of discharge from active military service, and the length of active military 

service.3 VHA provides comprehensive, free or low cost health care to eligible veterans through facilities located throughout the entire country. 

Memorandum of Understanding between HHS and the Veterans’ Health 

Administration 

Since 2003, the IHS and the VHA have collaborated via a memorandum of understanding (MOU) between the two Federal agencies to promote greater cooperation 

and resource sharing to improve the health of AI/AN veterans. The MOU encourages VA and IHS programs to collaborate in numerous ways to improve beneficiary’s 

access to healthcare services, improve communications between IHS and VHA and 

to create opportunities to develop strategies for sharing information, services, and 

information technology. 

The MOU has served as an impetus for improving the coordination of care between IHS and VHA. In some areas, this coordination between IHS and VHA has 

improved but while in other areas, such coordination necessitates improvement. A 

recent study examined the AI/AN veteran’s utilization of the IHS and VHA health 

services. Based the study’s survey, 25% of AI/AN Veterans receive care through both 

IHS and VHA, while over 25% of AI/AN Veterans accessed care through VHA only 

21 

4 Veterans Health Administration and Indian Health Service—Healthcare Utilization by Indian Health Service Enrollees, by B. Josea Kramer, Mingming Wang, Stella Jouldjian, Martin 

Lee, Bruce Finke, and Debra Saliba. Medical Care, Vol 47, Number 6, June 2009Id. 5 Id. 

and nearly 50% of AI/AN Veterans accessed care through IHS only.4 Of the dual 

use AI/AN Veterans, these individuals were more likely to receive primary care from 

IHS and to receive diagnostic and behavioral healthcare from VHA. Although such 

AI/AN Veterans are eligible to receive health care from the VHA and IHS, AI/AN 

Veterans report a high rate of unmet health care needs and exhibit high rates of 

disease risk factors for Post Traumatic Stress Disorder (PTSD).5

Some of the issues that lead to the unmet health care needs of AI/AN veterans: 

Access of Care: Tribal members are located in isolated areas and must travel great 

distances to attend any medical facility—IHS or VA. AI/AN veterans who live in 

rural, remote areas pay for the cost of such travel more than cost of gas but also 

time away from their home and families. Yet the decision to travel to the nearest 

facility may also take into consideration what type of care the patient would receive 

at that facility. 

Type of Care: Although the VHA offers more specialized behavioral and mental 

health care, AI/AN veterans may not consider the VHA as an option. First, the criteria for establishing eligibility for VHA services are much more stringent than IHS, 

which acts as a disincentive for Indians to access VHA services. Whereas, an 

AI/AN Veteran, if located on his/her home tribal community, may assessed IHS with 

less paperwork. Another potential barrier is the perception that the VHA will not 

appreciate, understand or accommodate the cultural needs of AI/AN veterans. For 

example, when working with the behavioral health PTSD issue, traditional treatment should be considered as an option for tribal veterans. At some sites currently, 

if a tribal veteran comes to the facility and requests a traditional healer, the Tribal 

Veterans Representatives may provide a list of traditional healers and call a traditional healer for the veteran. However, this arrangement is not present at VA 

facilities. 

Coordination of Care: For the AI/AN Veterans who accessed care at VHA and 

IHS, many tribal veterans have expressed that the frustration of VHA not accepting 

diagnosis from IHS. To resolve this issue, the Native Veteran may travel for hours 

to a VA hospital so that the VHA doctor could administer the initial tests and provide the same diagnosis that IHS provided. In addition to the lack of communication 

of appropriate coordination of care regarding diagnosis, there is also minimal communication between VHA and IHS regarding treatment and prescriptions. Those 

who assessed the care through VHA and IHS increase the risk of receiving medications which create the risk of conflicting medicine. 

RECOMMENDATIONS

Funding: The first and obvious answer to addressing the health needs of AI/AN 

veterans is the need for additional funding providing care to AI/AN veterans. Many 

times, IHS is the only facility in the area to provide care to Indian Veterans. Supplemental funding to IHS/Tribal facilities for services provided to AI/AN veterans 

would help ensure all the care needed can be provided to AI/AN veterans. 

Coordination of Care: Shared information about the services provided and needed 

by AI/AN veterans would help facilitate improved care. One option is to expand the 

Tribal Veteran Service Officers program in VA and expand these roles into paid VA 

positions. Another option is to bring the specialized the mental professional to the 

AI/AN veterans. Many of the IHS facilities have behavioral health departments but 

dealing with Veterans returning home form combat zones requires a specialized type 

of treatment. If IHS could work with the VA on collaborating efforts to address the 

Gulf War syndrome, such efforts would benefit a majority of majority of current Veterans. For example, the VHA and IHS could share mental health providers and public health nurses who would work out of the tribal facility while treating the AI/AN 

veterans. By sharing or rotating VHA employees—the health professional would 

have the knowledge and expertise that the VA could provide in addressing these 

issues, but IHS and Tribes could house the provider in the community. Likewise, 

IHS facilities may want to consider incorporate more specialization of PTSD for current veterans coming home. 

In closing, it is exciting to be a part of the Federal/tribal partnership and all of 

us working together can improve the care offered to our veterans better. Thank you 

for this opportunity and I will be happy to respond to any question. 

Chairman AKAKA. Thank you very much, Mr. Joseph. 

22 

Let me ask one question and I will turn the gavel over. Mr. Park, 

our discussion today regarding VA and IHS cooperation revolves 

largely around an MOU, Memorandum of Understanding, signed 

by the two parties. My question is, is there any similar agreement 

between VA and the Native Hawaiian Health Care Systems? 

Mr. PARK. Mr. Chairman, at this time, there is no Memorandum 

of Understanding between the Native Hawaiian Health Systems 

and the VA in Hawaii. 

Chairman AKAKA. Would you see any benefit in that kind of 

sharing? 

Mr. PARK. We had a meeting with your VBA Director and we are 

still working on that, sir. 

Chairman AKAKA. I will be following up with you in writing, Mr. 

Park, and I have other questions. 

But at this point, I am going to turn the gavel over to Senator 

Tester, who called for this hearing, and he will be leading this 

hearing. Senator Tester, the gavel is yours. 

Senator TESTER [presiding]. Thank you, Mr. Chairman. 

I will see if the Ranking Member has any questions. Senator 

Burr? 

Senator BURR. I thank the Chair. 

Mr. Park, if I understand you correctly, there are three VA outpatient clinics in Hawaii, and 14 community health centers and 

five Native Hawaiian Health Care Systems. Is that pretty accurate? 

Mr. PARK. There are four CBOCs. 

Senator BURR. OK, four CBOCs. Your recommendation is that 

VA should do more contracting with non-VA providers. Let me ask 

you, to what degree is there contracting right now going on? 

Mr. PARK. At this point, I don’t see any partnering with the community health centers or Native Hawaiian Health Systems. 

Senator BURR. Share with us, if you can, what dialog you have 

had with VA about expanding either the use of those facilities or 

the increased use of contracting. 

Mr. PARK. We haven’t talked with them about that, sir. 

Senator BURR. Are veterans in Hawaii asking you if they can just 

simply receive care under a contract? 

Mr. PARK. The veterans are trying to seek—we are seven islands, 

and we are like Alaska in that in order to get to the VA you have 

either got to fly or you have got to take a boat. The veterans are 

looking for services that they can access on the seven islands as 

best they can. And I think the community health service—there are 

14 on all the islands—to access the community health service is 

one of the best ways to go. We have only five Native Hawaiian 

Health Systems in the State, and to access the CHS is the best way 

to go. 

So, with only four CBOCs in Hawaii—and some of the problems 

are if the veteran needs to go to Maui, to the CBOC Maui, they 

need to fly to Honolulu first and catch a plane to go to Maui. And 

there’s a clinic in Honolulu, so if they’re going to fly to Honolulu, 

why don’t they just go to the clinic in Honolulu? So, I think the 

problem we’re looking at is there are not enough services for veterans on the neighbor islands. 

23 

Senator BURR. Clearly, I understand the challenge that you have 

and that Senator Begich has in Alaska. My understanding of the 

Memorandum of Understanding is that for some Tribes it is working pretty good; for others, it is nonexistent. 

Mr. PARK. Like in Hawaii, it is nonexistent. 

Senator BURR. I guess I would ask you, or any of the three of 

you, what do you think needs to be done to look at those meaningful partnerships that are working and emulate those elsewhere? 

What would it take, Mr. Howlett? 

Mr. HOWLETT. Mr. Chairman, Senator Burr, I think, first, it 

takes a real commitment from the agency, not a piece of paper that 

says how great we are. I really feel that solutions can be found, as 

I said in my testimony. But I think that there needs to be established a framework for finding that solution, and that framework 

really needs to be an honest and candid discussion of legislative 

barriers, of policy barriers, of distance barriers, of weather barriers, 

and all these discussions are things that are going to have a reflection on the capacity to provide care. 

If you don’t factor those in or you don’t discuss those, there is 

a tendency to pretend they don’t exist, and then when you run up 

against them, you can’t deliver. I just feel like if the agencies would 

say this is a priority and they would set about a task force to really 

examine these things—and fund that task force—then I think you 

could come forward with the legislative issues that are problems or 

the policy issues that are problems. 

I think this notion of one-size-fits-all really is misguided when it 

comes to trying to provide health services in Indian Country because of location, because of remoteness, because of transportation, 

and because of weather. I mean, all of these things are really important factors. So to me, let us establish a framework for trying 

to find out what the issues are. 

Senator BURR. Would I be correct if I made the statement, it 

would be a step in the right direction if VA was just proactive? 

Mr. HOWLETT. That would be—yes, yes, for sure. I agree. 

Senator BURR. Thank you. 

One last statement, Mr. Chairman, if I may. For all the challenges we have got between VA and Indian Health, Senator Coburn 

and I met with representatives from Indian Country recently and 

pledged our commitment that if Indian Country would work with 

us—we understand it needs more money, but we didn’t feel that it 

was just money alone. We need to make Indian Health structurally 

work to provide the level of care that is expected everywhere else. 

I say this to our representatives today. That offer is still on the 

table. We look forward to working with any and all to fix the Indian Health Service and to fund it at a level that would provide 

that level of care, that quality of care for all in Indian Country. 

I thank you. 

Senator TESTER. Thank you, Senator Burr. 

Yes, Mr. Joseph? 

Mr. JOSEPH. I guess I would like to answer that question, also. 

In this building, in the White House, or anyplace where law is 

written, it is just like our treaties. They are Orders that the government is supposed to abide by. I take that very seriously. I believe the VA should take this work that you do here very serious. 

24 

You have the ability to make the law the way that you write it. 

Once you are given orders in the military, you have to abide by 

those orders—and somebody needs to give the VA orders. But I 

think that you have the power here to make things happen. Thank 

you. 

Senator TESTER. Thank you. 

Chairman Akaka has conferred to me that he is pleased with the 

progress—this is for you, Mr. Park—is pleased with the progress 

of the Hawaiian Uncles and Aunties project, having used a kinship 

model to assist transitioning and distressed veterans. The question 

to you is this. Do you believe that something like the Uncles and 

Aunties model would work outside Hawaii, perhaps as a model for 

Indian and Alaska Native communities? And if you do believe it 

would work, how would it work? 

Mr. PARK. Senator, I do believe that it is important to extend the 

Uncles and Aunties program across the Nation. I have on Maui 

three Uncles—actually four Uncles, one in a remote area called 

Hana; I have eight on Oahu; one on the Island of Lanai; one on 

the Island of Hawaii; and one on Molokai. I also have five Uncles 

from Alaska and one from Guam. So, we are expanding. And a lot 

of the Uncles, they are married. Their wives are the Aunties. So, 

we have expanded the Uncles and Aunties program within the 

State of Hawaii as well as on the Mainland. 

It will work because of the trust issue. The veterans, they don’t 

trust government, and I will give you an example. I have just been 

to Hana to talk with the Vietnam veterans there and I tell them, 

this is an insurance policy. You paid the premiums, it is time for 

you to collect. The only way you are going to do it is you need to 

put in your application, VHA and VBA applications. 

The Vietnam veterans are saying, when we came back, they 

hated us. They spat on us. They called us baby killers. Why would 

I want to go through that again? I can understand what they are 

saying, but I can also understand the hurt. So, I really try to get 

them to put in their application. 

What I tell the veterans is if you don’t put in your application, 

they are not going to see you, so you need to do that. And as far 

as the Aunties and Uncles program, I think it will work anywhere 

because of the trust issue. 

Senator TESTER. Thank you. 

Kevin, if a veteran comes to one of the facilities you oversee, 

whether he or she is eligible for care from the VA—say that he or 

she is—do you know where to direct them? If they are eligible for 

VA care, they come to one of your facilities, has anybody contacted 

you? Do you know where to send them? 

Mr. HOWLETT. Mr. Chairman, I wouldn’t want to send them anywhere. I would want to treat them. 

Senator TESTER. Right. 

Mr. HOWLETT. If we have the capacity to meet their needs, I 

would want to treat them. But, you know, in Montana, we have 

two options, Fort Harrison or Spokane, depending on where you 

live in the State. So, the answer to your question is, if they are a 

veteran, we have personal relationships, although we don’t have 

formal agreements, with both VA centers. I have visited with them 

both personally. They welcome the veterans. They do the best they 

25 

can. But there is no formal process in place. I would think that we 

could treat within our capacity their needs if they came to our particular clinic. 

Senator TESTER. You said in your testimony that the Indian 

Health Service has primary responsibility for health care, and I 

don’t want to put words in your mouth, for Native Americans that 

come in. Let me just put it this way, what determines—if you have 

a veteran that comes through the door and you know your budget 

is strapped, which for the most part you are dealing with difficult 

budgets, what do you do? I mean, whose responsibility is it then 

if you know—— 

Mr. HOWLETT. Well, they don’t get turned away. I mean, we will 

provide what care we can. And again, if it is something that requires a level of care beyond our capacity which would trigger CHS 

expenditures, then the Indian Health Service in all likelihood, unless it is life-threatening, isn’t going to pay for it. That veteran 

then—we would do everything that we could to get them connected 

to a VA center. But that is where it is at this point. 

Senator TESTER. OK. You said in your testimony that you felt 

they may be able to set up internal and external working groups. 

I think your answer to Senator Burr’s question was spot-on when 

you talked about the different kind of factors that impact the ability to provide the health care. 

In your vision for the working groups to try to, as the President 

would say, quit working in silos and start working across agency 

lines, how would you do it, by region, or would you have one working group for the entire country, or how do you envision that working out? 

Mr. HOWLETT. Somehow, I anticipated that question. I think, initially, you would look at a national group that would be comprised 

of a cross-section of people. And then I think you would, of necessity, need to dissect that a little further to deal with issues like 

Alaska and distance and weather and other things. I think, initially, you would take this work group—and it would take a lot of 

time and a lot of energy, believe me—to really sit down and analyze the issues affecting health care for Native American veterans. 

You are going to have a lot of crosswalk between health care in 

general, but it just—it is just confusing to a health administrator 

now. You know that a veteran is eligible, but you don’t know what 

an agency is going to sponsor in terms of getting them to another 

place. 

You were very instrumental in just getting mileage reimbursement increased for veterans. That was a big deal. That was a big 

deal. I mean, some of these people are having a really difficult 

time, as we well know. 

So, I would look at a national group first comprised of Tribal people, Tribal health people. You need obviously some Indian Health 

people with a willingness and a vision to solve the problem. You 

need some VA people with that same kind of capacity. 

Senator TESTER. OK. Could you just very briefly tell me, the 

MOU between VA and Indian Health Service has been referred to 

several times. There is really no lead agency, just work together 

and try to find ways you can make things better. Have you seen— 

26 

that MOU, I think, went into effect about 6 years ago. Have you 

seen any difference? 

Mr. HOWLETT. Let me say, Senator, that there are many very 

dedicated and hard-working people in the Indian Health Service. 

But the agency itself, to the best of my knowledge and as much as 

I have participated with them, has not forwarded the recommendations or the body of that agreement. 

Senator TESTER. Thanks. Before I turn it over to Senator Murray 

for questioning, I want to welcome Senator Murkowski. She serves 

on the Indian Affairs Committee. We will get to your comments as 

soon as we get through the first line of questions. 

Senator Murray? 

Senator MURRAY. Mr. Chairman, thank you very much, and let 

me just follow up on the Chairman’s last line of questioning on the 

MOU that was signed 6 years ago between the IHS and VA. I 

think it is fair to say that a lot of the goals haven’t been realized. 

Now, as the VA works over the next year, I would like to ask each 

one of you what the top three priority items you think the VA 

ought to be working on to improve Tribal health care, and Mr. 

Park, I will start with you. 

Mr. PARK. At this time in Hawaii, we don’t have an MOU with 

the VA—— 

Senator MURRAY. So it doesn’t apply to—— 

Mr. PARK. Yes. We have nothing with them. So, I think we need 

to partner with them and see where we can go with this. 

Senator MURRAY. All right. Mr. Howlett? 

Mr. HOWLETT. Senator, I would reflect back on my testimony. 

First of all, a commitment to the structure, to the organization, to 

the things that are already a part of the MOU and how they would 

go about organizing that as an agency. I think that would be first. 

The second item in terms of a priority for Native American veterans would be the whole issue of access and making sure that 

they do appropriate outreach to the Native communities in their region, and I think that could come about in a number of different 

ways. 

And probably the third item—and I am grasping here for priority—I believe it would be the prevention and wellness kinds of 

activities that I think they could put some resources behind 

through some sort of a structured document with Tribes to get 

some of these veterans, not just Iraq and Afghanistan veterans, but 

some of these veterans that are older veterans, involved in more 

preventative kinds of care. 

Senator MURRAY. OK, excellent. 

Mr. Joseph? 

Mr. JOSEPH. I think it would be really great and maybe it would 

help the VA if there was an office and a position in the VA that 

is in there for Native Americans—Native American Indian Affairs 

Office, and I would welcome the Native Hawaiians be part of that, 

also. I think that the Native Alaskans and all of us share the same 

situations. So, if we had an office in the Veterans Affairs, maybe 

then they could see how everything is working and make sure that 

we have this MOU actually working the way it was intended to. 

Second, I would say that the VA could learn from IHS. IHS 

scored the highest out of any HHS Department on their report 

27 

card. With the limited funding that we have in IHS, I believe that 

the VA could learn from how IHS is run. So I think that would be 

my second thing. 

You know, if they could help with their big budget, help fund 

IHS to help serve our veterans, I think that would be another way. 

I always wanted to see the Government utilizing Public Health 

nurses and mental health providers to come and get stationed right 

at our clinics so that they can go throughout our reservation and 

serve any of our veterans, whether they are Native or not. 

Believe me, my reservation covers two counties and the surrounding areas. I can relate to the Senator from Alaska in his 

ruralness. Some of the people on our reservation have to wait, and 

hopefully there is a ferry that is operating to get to services. They 

have to travel over 2 hours just to go to the VA, and that is if they 

can afford it to begin with. With the economy the way it is, some 

of our veterans can’t afford to even get to a VA hospital. We don’t 

have any hospitals—IHS hospitals—in our area like Alaska or 

some of the other rural areas. If there was funding to help work 

in IHS, it would be a real benefit. Thank you. 

Senator MURRAY. OK. I appreciate that. 

And just really quickly, Mr. Chairman, I did want to ask about 

cultural sensitivity. It comes up time and time again to me as I am 

traveling around my State and talking to Tribal veterans. Each of 

our 564 federally-recognized Tribes have some unique cultural traditions. In my home State, we have made some progress with 

sweat lodges, but I just wanted to ask quickly if there is anything 

else that we could be doing to really be more culturally sensitive. 

Mr. JOSEPH. Well, in our State, I know I have personally gone 

to the VA and had a sweat there. It is a place where we—I guess 

it is kind of like our own type of psychology. We can get to our 

young veterans that are having a hard time in a way that we were 

brought up and taught to respect and honor different things in life. 

It is like—I guess it is more like best practices, where we have a 

better success rate than, say, sending somebody to a talking circle 

that just makes them angrier—— 

Senator MURRAY. So, just being more aware of those issues that 

impact different Tribes differently? 

Mr. JOSEPH. Yes. It saves lives. A lot of these people were suicidal and they are living today. Thank you. 

Senator MURRAY. OK. And my time is out, so I will pass to the 

next. Thank you very much to all of you. 

Senator TESTER. Thank you, Senator Murray. 

Senator Begich? 

Senator BEGICH. Thank you very much, and thank you again for 

your testimony. 

I want to follow up, if I can, on a couple of things. Mr. Howlett, 

your idea in your commentary to Senator Tester regarding kind 

of—and I think it was your words—internal-external working 

group, or a process that could help down the road in setting up a 

better relationship in a sense. You talked about kind of a national 

model and breaking it down by regions. Do you see that in the 

process of setting that up, because I read the MOU and it is a few 

pages. It has great one-liners; they sound great. If we could achieve 

all that, the world would be fantastic. But there are no goals; there 

28 

are no measurable timelines. There is nothing that you can come 

back and say, how did you do it, when did you do it, who did you 

serve, and how many did you serve? 

I am assuming—it is kind of a leading question. Is that your 

view of kind of how you set up this external-internal work group, 

but also set some real measurable efforts here, because what I have 

learned over at least my 10 months here is we do a lot of this 

paper, but accountability is sometimes lacking. Let me—I am trying to be very polite here. So, give me your thoughts on if you could 

go one more step, how you would see that. 

Mr. HOWLETT. Well, I guess maybe a definition of where we are, 

in its truest sense is abstract at this point. But good things happen 

with ideas. So, I think you can take that and you can move it to 

the next level and say, given that, what are some realistic goals 

that could be established? But that would be part of this work 

group’s goals—— 

Senator BEGICH. So that is how you see it? 

Mr. HOWLETT. Right. It currently doesn’t define anything; so, 

yes, I really believe that you could define that, and I think that you 

have got to be honest. It took a long time to get to where we are 

and it is going to take some time to get these issues resolved. But 

I think that is a good start. 

Senator BEGICH. As you develop that, do you think there is a role 

for that working group? Let us assume they set a plan, an action 

plan. Do you see a role for that working group after the fact, in 

other words, kind of a reviewer and ensurer. Or do you see that 

more of a Congressional role like this Committee, for example, to 

ensure—— 

Mr. HOWLETT. I think, Senator, that their role would really be 

dependent upon the issues that arise from that, whether there are 

legislative barriers or there are policy barriers or whatever, because I think that, obviously, if it is legislative, there needs to be 

some input here. But, I would give it enough life to, in your best 

estimate, complete the job. But I don’t think there is a necessity 

for a committee in perpetuity. 

Senator BEGICH. Good. OK. Thank you. 

One other comment you made, and I want to explore this just for 

a couple of seconds here, and that is the reimbursement issue for 

Medicaid-Medicare. VA does it. From your perspective, you are unable to—— 

Mr. HOWLETT. We do not have the ability to collect for services 

on a fee-for-service basis for services provided in our Tribal clinics 

to veterans through the VA. We can through Medicare and Medicaid and private insurance now. 

Senator BEGICH. Right, but not the VA? 

Mr. HOWLETT. Right. 

Senator BEGICH. When I campaigned, I talked about an idea— 

because all three of you have mentioned kind of the uniqueness of 

Alaska and it is very remote, and we have a very good Indian 

Health Service delivery, but through nonprofit organizations, travel 

consortiums, in some cases, very—I just talked on the Senate floor 

about our South Central Foundation and the success they have had 

in integrating traditional as well as cultural and other medicine 

techniques. 

29 

And I have always had this idea, it seems so simple with especially dual eligible veterans that you just issue them a card that 

they, for example—the example you gave of flying from one island, 

you are going through Honolulu, and it seems so logical just to go 

in and get the service rather than extend the time. You take the 

card in. You get the service. The patient doesn’t sit there and try 

to figure out who pays, but the system manages that for them, in 

other words, makes it seamless for the patient. Is that too simplistic? One thing I have also learned around here is simple ideas 

are not the ones that usually get implemented, but let me throw 

that out to any one of you. Maybe, Mr. Park, from your example— 

that was a great example. 

Mr. PARK. I think it is too simple. 

[Laughter.] 

Senator BEGICH. I thought so. 

Mr. PARK. I think one of the problems is when the VA puts it 

onto a vendor and the VA doesn’t pay the vendor, then the vendor 

bills the veteran and now the veteran gets all amped out and what 

have we got? 

Senator BEGICH. What have we got, yes. It puts some additional 

pressure, then, on the veteran. 

Mr. PARK. Yes. 

Senator BEGICH. Mr. Howlett? Then my time is up. 

Mr. HOWLETT. I, too, think it makes too much sense. No, there 

are significant issues with Federal agencies paying their bills. In 

Indian Health Service, there are thousands of people whose personal lives have been ruined, their credit has been ruined because 

IHS hasn’t paid their bills on time. I mean, these people have been 

turned over to collection and that is just—that is the way it is. I 

don’t know about the VA. We have not worked with them. But that 

needs to be worked on. 

Senator BEGICH. Very good. Thank you very much. My time has 

expired. Thank you all. 

Senator TESTER. Thank you, Senator Begich. 

Senator Murkowski, did you have a statement? 

STATEMENT OF HON. LISA MURKOWSKI, 

U.S. SENATOR FROM ALASKA 

Senator MURKOWSKI. I do, Mr. Chairman, and I appreciate the 

indulgence of the Committee giving me the opportunity to be here 

and listen to the witnesses and to just take no more than 5 minutes this morning to put on the record a statement about some of 

the Alaska issues. I appreciate the leadership of my colleague, Senator Begich, on this Committee as we try to find solutions. 

It is interesting to hear the responses to Senator Begich’s comment about it being just too simple, just too much common sense. 

Well, I think the obligation that we owe to our veterans is to provide for that level of care that was promised then; and unfortunately, I think we find more and more that with the systems that 

we have in place we have effectively disenfranchised our veterans 

from their earned benefits. I am hopeful that with the leadership 

that we have here in this Committee with what we are attempting 

to do on the Indian Affairs Committee, that we ought to be able 

to provide for this more seamless transition within the systems. 

30 

I do appreciate, Chairman Akaka and Senator Burr, your leadership in calling attention to the plight of our Native veterans. I 

often refer to them as our forgotten veterans. What a tragedy that 

is, because we recognize that from the very beginning Native peoples throughout this country have served in the Armed Services 

and the Armed Forces in greater numbers than any other group. 

So, I hope that this hearing and what you are doing here is the 

first step in a very comprehensive examination of how well the VA 

is serving our first Americans. I encourage your Committee to work 

collaboratively with us on the Indian Affairs Committee as we also 

follow these issues. 

While I was the Vice Chairman of the Indian Affairs Committee, 

I conducted a field hearing on the difficulties that our Alaska Native veterans were encountering in accessing their veteran health 

benefits, and the focus at that time was on the Alaska National 

Guard’s Third Battalion. They come from about 81 different communities scattered around the State of Alaska, and a sizable number of these Guardsmen lived in the very small bush villages. They 

live in communities that are not connected by roads, by any connectors that we would imagine here. 

To reach the nearest VA facility in Anchorage, they would first 

have to take a single-engine or perhaps a twin-engine bush plane 

to a hub, like Bethel or Dillingham or Nome, and then they catch 

the jet into Anchorage. The total cost of the trip could exceed well 

over $1,000, way out of reach for our Native people who many of 

them live off subsistence resources of the lands and the rivers. 

But back in October 2006, the Third Battalion deployed to Kuwait and they were going off to Southern Iraq after that. They returned in October 2007, but the very notion of taking our subsistence hunters and fishermen and sending them off to the Middle 

East, I think was more than a little bit distressing to some. They 

wondered out loud whether or not the VA was going to be able to 

deal with them, to treat them with issues like PTSD and other 

service-connected injuries. How are they going to do this, are they 

going to treat them in remote Alaskan communities? I certainly 

wondered the same. 

And long before that deployment date, I called the VA in and I 

asked them. I said, let us work with the Alaska Native Tribal 

Health Consortium. Let us develop this unified plan for caring for 

our Native veterans when they return. We had an opportunity to 

discuss it with the Secretary of Veterans Affairs, Secretary Nicholson. We continued to bring the VA together with ANTHC during 

that year, and in spite of all these discussions, in spite of the 

Memorandum of Understanding between the VA and the Indian 

Health Service, there was very little progress that was made in formulating that unified plan during the year. 

We knew that they were going to be gone for a year. We had a 

whole year to put it together. But the VA took the position that it 

is the payer of last resort and it disclaimed the obligation, and to 

a large extent, the authority to reimburse our Alaska Native 

Health System, which is a Tribal-run, not a government-run, system for care that was provided to our Native veterans. 

So, you drill below the surface here and what I learned was that 

there is just a very wide distrust—and I think, Mr. Park, you menVerDate Nov 24 2008 16:19 Nov 22, 2010 Jkt 000000 PO 00000 Frm 00034 Fmt 6633 Sfmt 6601 H:\ACTIVE\110509.TXT SVETS PsN: PAULIN
31 

tioned that as I was coming in—a very wide distrust between the 

VA and the Native Health System. The VA expresses their concern 

that it would neither be able to control access to care nor the cost 

of the care delivered in the Native Health facility. The VA was concerned that the Native Health System was really asking the VA to 

subsidize Congress’s inadequate funding of IHS. And for their part, 

the Native Health System argued that, hey, we are only funded at 

50 percent of the level of need. They can’t afford to subsidize the 

better-funded VA. So, you have got this impasse going on here. 

But it became very, very clear that the situation we face is the 

needs of 6,000 of our Native veterans mired in the bureaucracies, 

which is absolutely inappropriate. But under the auspices of the 

Senate Committee on Indian Affairs, we conducted a field hearing 

back then in November 2007. I think 2 years after the fact now, 

we are seeing a slight improvement in services to our Native veterans. Senator Begich mentioned some of the great successes that 

we have with South Central. We are blessed with one of the Nation’s best telemedicine systems. The VA does make extensive use 

of this system to deliver care to our veterans using the VA personnel. They have also hired a few Native Veteran Benefits Representatives who are posted at the Tribal Health facilities, and that 

is a good idea. 

But, they also attempted to train Tribal employees to serve as 

Tribal Veterans Benefits Representatives without any compensation. I was told that a handful of Alaska’s 229 Tribes showed up 

for the training, but the problem was that the VA declined to cover 

the travel expenses of the people who were there attempting to 

train. The Tribes don’t have the money to cover those expenses. 

And the VA initially argues that, well, we don’t have the authority 

to cover those expenses. 

So, I asked whether they had considered the invitational travel 

authorities in the Federal Travel Regulation. They said they had 

never heard of the authorities. And then following consultation 

with their counsel, they came back and they admitted that they do 

have the authority to cover the travel expenses. But the VA has yet 

to implement a viable Tribal Benefits Representative program in 

the State of Alaska. It is just not happening. 

The VA has recently implemented a Rural Alaska pilot, which allows Community Health Centers and Tribal Health facilities to bill 

the VA for a closely-controlled number of primary care visits. But 

at the outset of this pilot, they didn’t include behavioral health visits, which seems incredible. So, we called this omission to the VA’s 

attention and they changed the pilot. The protocol for this pilot requires that the veterans sign up for it, and unfortunately, what we 

are hearing is the word is not sufficient to get out to them and we 

have very few veterans that have signed up. So, I don’t know 

whether there is a better way to implement the pilot. Time will tell 

on that. 

In spite of what limited progress that is out there, I regret to say 

that we are far from building this seamless relationship between 

the VA and the IHS in Alaska that I have long been working for 

and Senator Begich has, as well. And the gaps aren’t just affecting 

our Alaska Native veterans of Iraq and Afghanistan, it goes back 

to our Vietnam-era veterans that are living in rural Alaska. 

32 

Again, I appreciate the emphasis that this Committee is placing 

on this. Collaboratively, we ought to be making better progress, because we are certainly not keeping our commitment to veterans. 

Right now, you can have the benefits that you have earned as a 

veteran if you happen to live in the right spot, and that was simply 

not the promise that we made. 

Thank you, Mr. Chairman, for allowing me the opportunity to 

make some comments this morning and to work with you on this 

issue. 

Senator TESTER. Thank you, Senator Murkowski. I want to 

thank the panel for their insight and their service. Now we will call 

up the second panel. Thank you, folks, for being here. 

We will call up the second panel, and while the second panel is 

coming up, I will introduce them. It is Mr. James Floyd, Network 

Director for the VA Heartland Network, VISN 15, for the Veterans 

Health Administration. He will testify on VHA’s IHS for Native 

American veterans. He will be accompanied by Mr. Buck Richardson, Minority Veterans Program Coordinator for the Rocky Mountain Health Network and the Montana Health Care System, as 

well as Dr. James Shore, psychiatrist and Native Domain Lead, VA 

Salt Lake City Health Care System. 

We also have the pleasure on the Indian Health Service side of 

hearing from Mr. Randy Grinnell, Deputy Director of the Indian 

Health Service. He is accompanied by Dr. Theresa Cullen, IHS Director of Information Technology. 

I want to thank you all for being here. Your full written testimony will appear in the record. I have been informed that we have 

a vote at about 12:15. I personally would like to get this hearing 

wrapped up by then, so I would ask you to be concise in your testimony. I know that the Ranking Member, Senator Burr, and Senator Begich have a bevy of questions, as well as myself, and we will 

get to them as quickly as possible. 

With that, I would like to ask Mr. Floyd to begin with your testimony. Thank you all for being here. 

STATEMENT OF JAMES R. FLOYD, FACHE, NETWORK DIRECTOR, VA HEARTLAND NETWORK (VISN 15), VETERANS 

HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 

AFFAIRS; ACCOMPANIED BY W.J. ‘‘BUCK’’ RICHARDSON, MINORITY VETERANS PROGRAM COORDINATOR, ROCKY 

MOUNTAIN HEALTH NETWORK AND THE MONTANA HEALTH 

CARE SYSTEM, HELENA, MONTANA; AND JAMES SHORE, M.D., 

PSYCHIATRIST AND NATIVE DOMAIN LEAD, SALT LAKE CITY 

VA MEDICAL CENTER 

Mr. FLOYD. Thank you, Senator Tester. Again, thank you for inviting me to be here this morning at this important hearing. My 

name is James Floyd. I am Creek and Cherokee, a member of the 

Muscogee Creek Nation of Oklahoma. As a Native American, I 

have worked with my own tribe, the Muscogee Creek Nation of 

Oklahoma, and their Tribal Health Program. I have also worked 

with the Indian Health Service and currently work with the Department of Veterans Affairs since 1997. 

With me on this panel this morning, to my right, who needs no 

introduction to you, is Buck Richardson, who is the Minority VetVerDate Nov 24 2008 16:19 Nov 22, 2010 Jkt 000000 PO 00000 Frm 00036 Fmt 6633 Sfmt 6601 H:\ACTIVE\110509.TXT SVETS PsN: PAULIN
33 

erans Program Coordinator for the Rocky Mountain Health Network, based out of Helena, Montana. To his right is Dr. Jay Shore. 

Jay is the psychiatrist and Native Domain Leader from the VA Salt 

Lake City Health Care System. 

VA remains committed to working with the Department of 

Health and Human Services to provide high-quality health care for 

the thousands of American Indian, Alaska Native, and Native Hawaiian veterans who have courageously served our Nation and deserve exceptional care. My written statement, which I request to be 

submitted to the record today, provides general background information on our work with the Indian Health Service. It reviews accomplishments secured because of our collaboration and concludes 

with a discussion on the need for the VA and the Indian Health 

Service to work together to continue to care for our veterans. 

The VA and the Department of Health and Human Services, as 

mentioned earlier, signed a Memorandum of Understanding on 

February 25, 2003. The MOU expresses the commitment of both 

Departments and it expresses the need to continue to expand our 

common efforts to provide quality policy support to local planning 

and collaboration efforts and charges local leadership to be more 

innovative and engaged in discharging our responsibilities. The VA 

has encouraged its field facilities to initiate and maintain effective 

partnerships at the local level, especially in areas such as clinical 

service delivery, community-based care, health promotion, and disease prevention activities. We are also interested in promoting 

management and prevention of chronic diseases, a challenge facing 

both Departments. 

We assess whether we can achieve success through local partnerships or on a national mandate on a case-by-case basis. Both methods have proved effective and productive and these projects have 

been successful in elements of each. 

For example, we recently supported a collaborative expansion of 

home-based primary care, where 14 VA medical centers have funded to collocate home-based primary care teams at Tribal and Indian Health Service clinics and hospitals. In September of this 

year, the first veterans began receiving care through this project at 

two sites. 

Much of the progress on the objectives outlined in the MOU have 

been accomplished through local partnerships. However, national 

initiatives also influence collaboration between VA and the Indian 

Health Service. For example, the national focus on outreach in 

rural health has led both the VA and IHS to develop improved 

strategies for sharing information and services, such as educational 

resources, traditional practices, and information technology. 

Improving communication and partnerships are essential components of our collaborative efforts and we continue to nurture our 

relationships both nationally and locally. Our goals include improved access, communications, partnerships, sharing agreements, 

resources, and health promotion and disease prevention. We have 

found already incremental expansion of initiatives such as the 

Tribal Veterans Representative Program and expanded use of telehealth. We are also collaborating to offer more Welcome Home 

events for returning OEF/OIF veterans, to expand access to care 

34 

and develop approaches that address the unique physical, spiritual, 

economic, and demographic needs of these veterans. 

Using shared providers is yet another way to improve access and 

cooperation. At the local level, several VA and Indian Health Service facilities are sharing providers, including appropriate shared access to the VA’s Electronic Health Records for joint projects and patients. 

In October 2008, VA established Native Domain, an infrastructure with a Native American focus. It is a national resource on 

issues related to health care for rural Native American veterans. 

It includes policy analysis, collects best practices, supports clinical 

demonstration projects, establishes collaboration with agencies and 

Native communities, and disseminates information about these 

populations. 

The VA and the Indian Health Service need to continue to work 

together to ensure within current legal authority that veterans who 

are eligible for health care from both the VA and the Indian Health 

Service receive all needed care. The VA and the Indian Health 

Service continue to discuss changing existing policies and processes 

in regard to payment for veterans’ health care. A resource sharing 

provision was included in the MOU that I referred to earlier to encourage the development of responsible sharing services to meet 

the needs of patients and communities. 

In conclusion, Mr. Chairman, I thank you again for the opportunity to be here to discuss the importance of establishing and 

maintaining strong relationships and programs and services between the VA and the Indian Health Service. We are available to 

answer any questions you may have. 

[The prepared statement of Mr. Floyd follows:] 

PREPARED STATEMENT OF JAMES R. FLOYD, FACHE, NETWORK DIRECTOR, VA 

HEARTLAND NETWORK (VISN 15), VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

Good Morning Mr. Chairman and Members of the Committee: Thank you for inviting me here today to discuss the cooperation and collaboration between the Department of Veterans Affairs (VA) and its Veterans Health Administration (VHA) 

and the Department of Health and Human Services (HHS) and its Indian Health 

Service (IHS). Joining me today are Mr. W. J. ‘‘Buck’’ Richardson, the Minority Veterans Program Coordinator, Rocky Mountain Health Network and the Montana 

Healthcare System in Helena, Montana, and Dr. James Shore, Psychiatrist and Native Domain Lead, VA Salt Lake City Health Care System. 

VA remains committed to working internally and in partnership with HHS to provide high quality health care for the thousands of American Indian/Alaska Native 

(AI/AN), and Hawaiian Native Veterans who have courageously served our Nation 

and deserve exceptional care. This commitment, in relation to AI/ANs, is principally 

fulfilled through VHA cooperation and collaboration with IHS. My testimony will 

provide general background information on our work with the IHS, review accomplishments secured because of our collaboration, and conclude with a discussion on 

the need for VHA and IHS to work together to take care of these Veterans. I would 

like to note at the outset that VHA looks forward to working with IHS to improve 

the quality and availability of care for Native American Veterans throughout the 

country. We will strengthen our existing partnerships and build new and even 

stronger associations between VHA and IHS. 

GENERAL INFORMATION

VA and HHS signed a Memorandum of Understanding (MOU) on February 25, 

2003. In summary, the MOU: 

• Expresses the commitment of both Departments to expand our common efforts 

to improve the quality and efficiency of our programs; 

35 

1Four of the 21 VISNs are exempt from this monitor because of the small size of their 

AI/AN Veteran populations. These include VISNs 4, 5, 9 and 10. 

• Provides policy support to local planning and collaboration; and 

• Charges local leadership to be more innovative and engaged in discharging our 

responsibilities. 

We expected at that time that most of our progress would be made with effective 

local partnerships formed between IHS, VHA, and Tribal governments, because 

these would be best suited to identify local needs and develop local solutions. In this 

regard, VHA field facilities have been encouraged to initiate and maintain effective 

partnerships at the local level especially in areas such as clinical service delivery, 

community-based care, and health promotion and disease prevention. We are also 

interested in promoting the management and prevention of chronic diseases, a challenge that confronts both VHA and IHS. We anticipated the MOU would lead to creative solutions in case management, home- and community-based care, and primary 

prevention activities to improve the health of AI/AN Veterans. 

Whether success is achieved most effectively through the efforts of local partnerships or with a national mandate is assessed on a case-by-case basis. Both methods 

have been effective; the challenge is to use the appropriate tool, at the correct time, 

and in a suitable location. Many times, success is achieved with a combination of 

national and local efforts. We recently supported a collaborative expansion of homebased primary care (HBPC) that exemplifies how national initiatives can be implemented locally. In this effort, 14 VA medical centers have been funded to co-locate 

HBPC teams at Tribal and IHS clinics and hospitals. Our goals are to improve access to primary care services and to foster mentoring relationships between VHA 

staff with geriatric expertise and IHS and Tribal staff. In September, the first Veterans began receiving care through this project at two tribal sites, one in Jackson, 

MS and the other in Sacramento, CA. We expect the other facilities to be active by 

the end of the calendar year. 

Much of the progress on the objectives outlined in the MOU has been accomplished through local partnerships. However national initiatives also influence collaboration between VHA and IHS. For example, a national focus on outreach and 

rural health has led VHA and IHS to develop improved strategies for sharing information and services such as educational resources, traditional practices, and information technology (IT) sharing. 

Experts in information technology at the Department as well as the VHA and IHS 

levels are working together to enhance health-care information sharing. This April, 

representatives from the Office of Information Technology at IHS, VHA’s Office of 

Health Information, and VA’s Office of Information and Technology met to develop 

a comprehensive list of actions needed to strengthen the relationship. The group 

identified a list of specific activities for collaboration, and work continues to address 

the tasks identified on that list. 

ACCOMPLISHMENTS

VHA and IHS, as the primary implementers, have used the MOU’s goals and objectives as a framework for establishing partnerships and accomplishing individual 

achievements. Our goals include improved access, communications, partnerships 

and sharing agreements, resources, and health promotion and disease prevention. 

Access. A mutual goal of IHS and VHA is to improve beneficiaries’ access to quality health care and services. As a tool to ensure steady and effective progress, VHA 

established a performance monitor for Veterans Integrated Service Networks 

(VISNs) with significant American Indian/Alaska Native (AI/AN) populations to 

track and monitor how VISNs were achieving the goals and objectives of the MOU.1

Examples from the performance monitor reports of how VA’s local facilities have 

brought about easier access to VA services include: 

• Establishing transportation programs; 

• Using home visits to provide both clinical care and assistance with claims processing; 

• Providing supplies and equipment to clinics on Reservations; 

• Expanding VA community-based outpatient clinic hours and services; and 

• Using fee basis care to facilitate more timely, accessible care, when necessary. 

In fiscal year (FY) 2009, the Office of the Deputy Under Secretary for Health for 

Operations and Management established a new template for VISN semi-annual reporting of VHA/IHS activities. There appears to be steady, incremental expansion 

of certain types of initiatives across the country demonstrating an increased alignment with current national priorities. These initiatives include: 

36 

• Increased interest in, training for, and development of the Tribal Veteran Representative (TVR) role across the country; • Expanded use of information technology and telecommunications efforts, particularly to support telehealth initiatives and tele-mental health; • Increased number of ‘‘Welcome Home’’ events for Operation Enduring Freedom 

and Operation Iraqi Freedom Veterans, as well as education and outreach efforts; • Steady expansion of rural health care initiatives with progress toward bringing 

services closer to the Veterans being served; • Continued growth in culturally specific, holistic approaches that address the 

unique physical, spiritual, economic, age and gender specific needs of the population 

served; and • Coordinated efforts between local VHA and IHS entities to increase awareness 

and communication regarding Veterans’ needs and available VHA services, as well 

as cooperative and creative outreach efforts. 

Another tool that VHA and IHS use to improve access is telehealth. Telehealth 

uses information and communication technologies to provide health care services in 

situations in which patient and provider are separated by geographical distance. 

Telehealth, thus, provides a means of providing health care services directly to Tribal communities, obviating the need for AI/AN Veteran patients to travel long distances to receive services. It also supplements health care services available within 

Tribal communities. 

VA has been collaborating with the IHS and other Federal agencies to provide 

telehealth services in Alaska since 1997, when the Alaska Federal Health Care Access Network began. Subsequent to that first effort, the functionality of the telehealth and telecommunications technologies has improved, and research has substantiated the benefits of telehealth as a means of providing health care to the 

AI/AN Veterans VA serves. Currently there are seven operational telehealth programs providing services to Tribal communities and nine programs in deployment. 

VHA telehealth programs to Tribal communities predominantly involve clinical 

video-conferencing to provide mental health services and home telehealth services 

for diabetes and mental health conditions. 

A cultural competency training program also has been developed and is in use to 

ensure that providers are sensitive to the particular circumstances of using telehealth to reach into Tribal communities to deliver services. In addition to cultural 

awareness, other critical success factors to implementing and sustaining telehealth 

services to Tribal communities include adequate telecommunications bandwidth and 

meeting appropriate credentialing and privileging requirements. 

Using shared providers is yet another way to improve access. At the local level, 

several VHA and IHS facilities are sharing providers, including appropriate shared 

access to VA’s electronic health records for joint patients; this is demonstrated 

through the partnership between VHA’s Black Hills Health Care System and the 

Rosebud IHS facility. Nationally, VA and IHS conducted a one-year pilot to test the 

feasibility of using VA’s electronic credentialing system, VetPro, to credential IHS 

providers. Both VA and IHS participants believed the pilot met its stated goals of 

ensuring a consistent credentialing process that met all regulatory and agency requirements for IHS facilities and demonstrating the feasibility of national sharing 

agreements for information sharing between VA and IHS. Decisions about expanding the pilot are pending. 

Communications. There have been accomplishments in efforts to improve communications among VA, VHA, AI/AN, HHS, IHS, and Tribal governments and other organizations with assistance from IHS. Sharing information and improving cultural 

awareness and competencies are crucial to achieving this goal. Relevant information 

is shared through several methods, including: 

• Participation at VHA/IHS conferences and VHA/IHS/Tribal Veteran Service Organization (VSO) meetings, as well as Pow Wows and local community events; 

• Outreach to IHS organizations and Tribal Governments, including liaison with 

VA staff and leadership; and 

• Attendance at AI/AN cultural events. 

IHS and VA continue to have regular communications at the national level with 

a working group that meets regularly to exchange information and track the status 

of several national programs, such as a recent initiative to establish a pilot partnership between VHA’s Consolidated Mail Outpatient Pharmacy (CMOP) and IHS’ 

pharmacy program. This pilot will enable IHS beneficiaries to have access to pharmacy services through VHA’s nationally recognized CMOP program to process outpatient prescriptions, based upon the electronic prescription data provided from the 

IHS facilities. The possibility of IHS decreasing capitalization costs, the reduction 

of needed space to house more drugs and personnel in a centralized space, reduction 

37 

of outdated medications, and reduction in the numbers of patients entering IHS facilities on a daily basis will make the use of the CMOP programs an attractive technology for dispensing refills within the IHS. Rapid City, South Dakota and Phoenix 

Indian Medical Center are currently identified as the participating IHS locations. 

The coordinating CMOP is in Leavenworth, KS. The necessary service agreement 

is in place, and IT connectivity and testing have been accomplished. A formal interagency agreement (IAA) is being developed. The pilot will commence as soon as the 

IAA is in place. The working group ensures that projects such as this remain on 

track and also identifies other new collaborations that would lead to improvement 

of services. 

The Tribal Veteran Representative (TVR) program is another example of developing and maintaining effective communications at the local level. This program 

uses volunteers who receive training on VA’s health care services and benefits to 

educate their Tribal members. The concept used in the TVR program has been quite 

successful. VA and IHS held several coordinated training sessions this spring for 

IHS Community Health Representatives and the Contract Health Service program 

to bring the TVR concept to them. The annual TVR training was held at the Naval 

Reserve training facility at Ft. Harrison, MT during the last week of April 2009. 

Seventy-two participants from VA, IHS, and different Tribal organizations attended. 

Also, in May, VISN 7 held a training session for VA’s Transition Patient Advocates 

using the TVR model. 

Partnerships and Sharing Agreements. Encouraging partnerships and sharing 

agreements among VA Central Office and VA facilities, IHS headquarters and IHS 

facilities, and Tribal governments in support of AI/AN Veterans has been an important to improving access. Local VHA facilities use sharing agreements and partnerships to operate clinics, provide social work, offer laboratory services, and make 

available other benefits. Again, the success of these projects depends on the strength 

of local relationships. Building a strong partnership or sharing agreement depends 

on fostering a trust relationship between the AI/AN community and VHA facility 

staff and leadership. Meeting the specific needs of a particular community is best 

done by fostering communications at the local level. 

Resources. Resources needed to support programs for AI/AN Veterans include 

more than just funding projects and services. Time and staffing resources are essential elements to supporting these endeavors and helping AI/AN communities to identify needs, devise mutually agreeable solutions that meet local requirements, and 

implement projects effectively. In FY 2009, VA, through the Office of Rural Health, 

acknowledged the need for increasing resources in this area by funding specific 

projects and establishing a Native American Resource Center. 

In October 2008, the Veterans Rural Health Resource Center-Western Region established a Native Domain, an infrastructure with a Native American focus. It is 

a national resource on issues related to health care for rural Native American Veterans. It conducts policy analysis, collects best practices, supports clinical demonstration projects, establishes collaborations with agencies and Native communities, and disseminates information about these populations. 

Health Promotion and Disease Prevention. The final part of the official MOU goal 

and objective framework is to improve health promotion and disease prevention 

services to AI/ANs. This has been addressed at the local level with projects ranging 

from health fairs to diabetes prevention and other educational efforts. 

MEDICAL CARE OF DUAL ELIGIBLE VETERANS

VHA and IHS need to continue to work together to ensure, within current legal 

authority, that Veterans who are eligible for health care from both VA through VHA 

and HHS through IHS receive all needed care. VHA and IHS continue to discuss 

changing the existing policies and processes in regard to payment for Veterans’ 

health care. A resource sharing provision was included in the MOU to encourage 

the development of responsible sharing of services to meet the needs of patients and 

communities. 

There are circumstances where VA, through VHA and its local facilities, contracts 

with or enters into sharing agreements with IHS, Tribal governments, or Tribal organizations to provide health care services to AI/AN Veterans. Many of these Veterans also are eligible for services from IHS or through Tribal governments or organizations. VA endorses the use of sharing agreements in these circumstances. 

CONCLUSION

Thank you again for the opportunity to discuss the importance of establishing and 

maintaining strong relationships, programs, and services between VHA and IHS at 

both the national and local levels to effectively meet the health care needs of 

38 

AI/AN. VHA is strongly committed to continuing to make VA health care services 

more accessible to AI/AN, and Hawaiian Native Veterans. In this regard, it may be 

time to update the MOU and identify additional opportunities for collaboration between VA, IHS, Tribal governments and organizations. We are ready to do whatever 

it takes to find the best ways to serve the needs of these Veterans. Thank you again 

for the opportunity to testify. My colleagues and I are available to answer your 

questions. 

RESPONSE TO POST-HEARING QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO

JAMES R. FLOYD, FACHE, NETWORK DIRECTOR, VA HEARTLAND NETWORK (VISN 

15), VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 1. How many sharing agreements has VA entered into with tribes, tribal 

facilities and Indian Health Service (IHS) facilities? Please provide a list broken 

down by tribe, tribal and IHS facility, describing these sharing agreements. 

Response. Since the initial Memorandum of Understanding (MOU) between VA 

and IHS in 2003, the amount and variety of activities has steadily increased. Many 

of the activities are at the national level and reflect an impact on many, if not all, 

federally recognized tribes. Attached is a spreadsheet that reflects completed and 

ongoing activities as of March 2010, itemizing partnerships, projects, status, and 

where appropriate, the tribe(s) or IHS facility. 

Question 2. Please provide the Department’s best estimate of the number of dual 

eligible and dual enrolled Native American Veterans. Please also describe how these 

estimates were determined. 

Response. This information is not currently available. A match is technically possible, but extremely difficult. Challenges include, but are not limited to, getting an 

overall estimate of Native American Veterans from any source and exchanging demographic data. 

Standards defining Veterans differ in the VHA and IHS systems. VHA verifies 

past military service as a condition of enrollment and provides care on the basis of 

degree of service-connected disability and degree of impairment to determine Veteran status. In contrast, IHS records rely on self-reported Veteran identification. 

VHA and IHS continue to explore how to share clinical records and are working 

through information security, privacy and other issues. 

Question 3. Your testimony described a ‘‘comprehensive list of actions’’ to 

strengthen the VA-IHS relationship. Please provide that list. 

Response. VA and IHS have embarked on a comprehensive series of information 

technology activities as evidenced by the attached spreadsheet. (See Attachment following the response to Question 9.) The list of actions and/or activities referenced 

in Mr. Floyd’s testimony can best be seen on attachment pages 13 to 17. There are 

also other information technology projects listed throughout the document. 

Question 4. Your testimony described a ‘‘performance monitor’’ for Veterans Integrated Service Networks (VISNs) with a significant American Indians and Alaska 

Native populations to track progress toward achieving the MOU’s objectives. Please 

provide a description of that performance monitor. 

Response. A comprehensive monitor was developed in response to the signing of 

the VA/IHS MOU in 2003; it has been periodically updated since then. This performance monitor defines the MOU’s desired outcomes and currently requires the 

submission of quarterly progress reports from each VISN. The purpose of the monitor is threefold: 

• To support continuous improvement in the coordination of patient care between 

VHA and IHS; 

• To encourage referrals between IHS and VHA; and 

• To ensure that dual eligible American Indian and Alaskan Native Veterans 

have coordinated access to appropriate services from both agencies. 

For quarterly reports, VISNs are instructed to report their activities in the context of the five objectives set forth in the MOU. These objectives are: 

• Improve beneficiary’s access to quality health care and services; 

• Encourage partnerships and sharing agreements among VA Central Office and 

facilities, IHS Headquarters and facilities, and Tribal Governments in support of 

American Indian and Alaskan Native (AI/AN) Veterans; 

• Ensure appropriate organizational support for programs targeted to AI/AN Veterans; 

• Improve health promotion and disease support for programs targeted to AI/AN 

Veterans; 

39 

• Improve communication among VA, AI/AN Veterans and Tribal Governments 

with the assistance of IHS. 

Question 5. Is VA considering entering into an MOU or sharing agreement with 

Papa Ola Lokahi and/or the Native Hawaiian Health Systems or other Native Hawaiian entities, to improve care and services for Native Hawaiian Veterans? 

Response. Yes. Papa Ola Lokahi is the Governance Structure/Entity that represents the Native Hawaiian Consortium of health care programs active throughout 

the state on every island. ‘‘Papa,’’ as they are referred to, has an executive director, 

staff, and advisory board. 

At this time, VA Pacific Islands Health Care System (VAPIHCS) is exploring the 

enhancement of services to Veterans residing in the Hana area of Maui. Both a federally Qualified Health Center and a Native Hawaiian Health Care Clinic are serving the health care needs of Hana’s population. VAPICHS plans to visit Hana to 

meet with both entities and discuss their potential roles as partners with VA to care 

for Veterans. 

Question 6. Is VA considering expanding the concept of the Tribal Veteran Representative to be inclusive of Native Hawaiians? 

Response. Yes. The Tribal Veterans Representative (TVR) program is national in 

scope and the VA Pacific Islands Health Care System is identifying Native Hawaiian candidates to train as TVRs. The Native Hawaiian TVR program will likely be 

somewhat different than the AI/AN TVR program because it will serve a different 

population. 

Question 7. Please provide a description of the Native American Resource Center 

mentioned in VA’s testimony. 

Response. Over the past decade, VHA has taken important steps toward meeting 

the health care needs of Native Veterans who reside in rural areas. These have occurred nationally and at the local level as collaborations have developed between regional VHA medical centers and tribal programs. VHA’s Office of Rural Health 

(OHR) recently established the Veterans Rural Health Resources Center—Western 

Region (VRHRC-WR) with a special population focus on rural Native Veterans—the 

Native Domain. The Native Domain is intended to serve as a national resource on 

issues surrounding health care for Native rural Veterans through conducting policy 

analysis; collecting best practices; fostering clinical demonstration projects; coordinating and partnering with agencies and Native communities; and disseminating information about these populations. 

The Native Domain has defined Native Veterans to include American Indians, 

Alaska Natives, Native Hawaiians, and Pacific Islanders. Of note, Native Veterans 

comprise the largest proportion of Veterans living in rural areas. The major philosophy of the Native Domain is defined by the theme of national scope with a local 

focus. 

Given the considerable cultural, social and geographic diversity of rural Native 

Veteran populations, it is important to acknowledge that while VHA policy is national in scope by its very nature, VHA programs and activities targeted at this population may benefit from policy strategies that embrace a national scope while 

maintaining a local focus. Such programs effectively honor the cultural uniqueness 

of each tribal, village, and islander group to address their health care needs. 

Question 8. During a pre-hearing briefing, a VA representative told Committee 

staff that VA has replaced the Chaplain guidelines concerning American Indian and 

Alaska Native traditional practitioners with a more comprehensive guideline. Please 

provide a copy of that guideline. 

Response. The Revised VHA Handbook 1111.02, ‘‘Spiritual and Pastoral Care Procedures,’’ dated July 18, 2008, did not replace the Chaplain Service Guidelines concerning American Indian and Alaskan Native Practitioners. The Chaplain Service 

Guidelines and the VHA and Indian Health Service (IHS) Memorandum of Understanding from November 2005, are referenced in the Handbook, which is official 

VHA policy. Both documents are still in use by VHA and the Handbook strengthens 

the Chaplain Service Guideline document. The four references to ‘‘American Indian 

and Alaskan Native Veterans’’ are highlighted on pages 11, 13 and 24, in the attached Handbook 1111.02. The Chaplain Service Guidelines Concerning Native 

American Indian Traditional Practitioners are also attached. 

Question 9. An FY 2005 VHA-IHS issue update stated that ‘‘. . . the leadership 

of each organization has been asked to develop a joint policy for the coordination 

of health care for dual use Veterans.’’ Please comment on progress toward that joint 

policy, and whether VA and IHS are still working toward that goal. 

Response. In FY 2007, a Work Group was established to develop VHA Directive 

entitled, ‘‘VHA and IHS National Inter-Departmental Coordinated Care Policy.’’ VA 

and IHS continue to make strides toward this goal. 

40 

ATTACHMENT FOR QUESTION 3 


115q3VA-IHS1.eps
41 


115q3VA-IHS2.eps
42 


115q3VA-IHS3.eps
43 


115q3VA-IHS4.eps
44 


115q3VA-IHS5.eps
45 


115q3VA-IHS6.eps
46 


115q3VA-IHS7.eps
47 


115q3VA-IHS8.eps
48 


115q3VA-IHS9.eps
49 


115q3VA-IHS10.eps
50 


115q3VA-IHS11.eps
51 


115q3VA-IHS12.eps
52 


115q3VA-IHS13.eps
53 


115q3VA-IHS14.eps
54 


115q3VA-IHS15.eps
55 


115q3VA-IHS16.eps
56 

Senator TESTER. Thank you for your testimony, Mr. Floyd. 

Mr. Grinnell, if you would proceed with your testimony. 

STATEMENT OF RANDY E. GRINNELL, DEPUTY DIRECTOR, INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND 

HUMAN SERVICES; ACCOMPANIED BY THERESA CULLEN, 

M.D., DIRECTOR OF INFORMATION TECHNOLOGY, INDIAN 

HEALTH SERVICE 

Mr. GRINNELL. Mr. Chairman and Members of the Committee, 

good morning. I am Randy Grinnell. I am the Deputy Director for 

Indian Health Service. Today, I am accompanied by Dr. Terri 

Cullen. She is the Chief Information Officer and a family practice 


115q3VA-IHS17.eps
57 

physician, and we are pleased to have the opportunity to testify on 

the collaboration of the IHS and the Veterans Health Administration. 

The Indian Health Service in the Department of Health and 

Human Services is a health care system that was established to 

meet the Federal trust responsibility to provide health care to 

American Indians and Alaska Natives, with the mission to raise 

their physical, mental, social, and spiritual health to the highest 

level. The IHS provides the comprehensive primary care services 

and public health services through a system of IHS-operated, Tribally-operated, and urban-operated programs and facilities that 

were based on treaties, judicial determinations, and Acts of Congress. This system serves nearly 1.5 million American Indian and 

Alaska Natives through these health facilities in 35 different 

States, and in many cases, they are the only source of health care 

in many remote and poverty-stricken areas of this country. 

The partnership between the IHS and the VHA started in the 

mid-1980s in the area of health information technology. The Resource and Patient Management System, or RPMS, is the IHS’s 

comprehensive health information system that was created to support high-quality care delivered at several hundred facilities 

throughout the country. This system is a government-developed 

and owned system that evolved alongside the VHA-acclaimed 

VISTA system. 

IHS and the VHA have also collaborated in the implementation 

of the VA’s VISTA imaging system now in use in the IHS at over 

45 sites. This system allows clinicians to have access to images and 

data that assists them in making better clinical decisions. 

Several individuals today have talked about the MOU between 

the IHS and the VHA. I am not going to go into detail about that 

for time’s sake. 

I did want to mention that our system—we currently estimate 

that there are about 45,000 veterans that are registered within our 

system, and that includes both the IHS-operated facilities as well 

as the Tribally-operated facilities. In some cases, these veterans 

also live in urban locations and may not have access to these facilities that are out on the reservations and within Indian Country 

and they have to rely on limited urban health programs as well as 

any local facilities that may be available for their care. 

IHS also recognizes the complexity of the Contract Health Care 

Program that has been mentioned several times today in other testimonies. As identified, there are rules and regulations that we 

must adhere to. In many cases, this presents a challenge in addressing the care needs of both our elderly users as well as those 

Indian veterans. 

I would like to talk about some of the collaborations that have 

currently taken place. Because of the IHS’s experience with traditional healing, this has assisted the VHA in modeling how to incorporate traditional approaches into healing for Indian veterans. 

VHA’s development and use of the Tribal Veterans Representative 

Program has been and is critical to communication and reducing 

barriers for VA services as well as assisting those veterans in understanding the IHS Contract Health Service Program and its 

rules and regulations. 

58 

As mentioned earlier in some of the testimony, the Alaska area 

has partnered since 1995 via the Alaska Federal Health Care Partnership that includes not only the IHS and the Alaska Native Corporation, but the VA, Army, Air Force, and Coast Guard partners. 

They have numerous initiatives, including teleradiology, telehealth 

monitoring, and telebehavioral health, as well. Some of their past 

projects have also included the Alaska Tribal Health System Wide 

Area Network. 

In Arizona, the IHS and VHA have worked together to increase 

mental health services by the VA locating social workers in several 

of the Navajo facilities as well as the Hopi Reservation facility. 

In Montana, the Billings Area IHS and the VA have worked together to establish tele-psych at each of the service unit locations 

to provide mental health services. Each of these service units also 

have a designated VA liaison to assist the veteran in understanding and accessing the services there. 

At this time, there is a pilot project underway between the IHS 

and VHA to where we are looking at the VA’s consolidated Outpatient Pharmacy Program to assist us in processing outpatient 

prescriptions. This program, we feel like would be a real benefit to 

our eligible users because it will decrease our cost and also allow 

more time for our pharmacists to provide clinical care, as well. 

Some future opportunities between the two partnerships is intended to improve access and to increase since 2003, but IHS acknowledges that our joint efforts on issues related to access to 

health care for Indian veterans needs to continue. 

I would like to say that because Dr. Roubideaux is not available 

today—she is currently at the meeting that the President has with 

the Tribal leaders—but she is totally committed to continuing this 

partnership and looking at new ways to improve the relationship 

and also to further services to Indian veterans. 

Mr. Chairman, that concludes my testimony. We are here to answer any questions you may have. 

[The prepared statement of Mr. Grinnell follows:] 

PREPARED STATEMENT OF RANDY E. GRINNELL, DEPUTY DIRECTOR, INDIAN HEALTH

SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES

Mr. Chairman and Members of the Committee: Good afternoon. I am Randy E. 

Grinnell, the Deputy Director of the Indian Health Service (IHS). I am accompanied 

by Theresa Cullen, M.D., Director, Office of Information Technology. I am pleased 

to have the opportunity to testify on the Indian Health Service-Veterans’ Administration (VA) collaboration. 

As you know, the Indian Health Service plays a unique role in the Department 

of Health and Human Services because it is a health care system that was established to meet the Federal trust responsibility to provide health care to American 

Indians and Alaska Natives. The mission of the Indian Health Service is to raise 

the physical, mental, social, and spiritual health of American Indians and Alaska 

Natives to the highest level. The IHS provides high-quality, comprehensive primary 

care and public health services through a system of IHS, Tribal, and Urban operated facilities and programs based on treaties, judicial determinations, and acts of 

Congress. This Indian health system provides services to nearly 1.5 million American Indians and Alaska Natives through hospitals, health centers, and clinics located in 35 States, often representing the only source of health care for many American Indian and Alaska Native individuals, especially for those who live in the most 

remote and poverty-stricken areas of the United States. The purchase of health care 

from private providers through the Contract Health Services 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 health care programs. IHS accomplishes a wide array of clinical, preventive, and public health activities, operVerDate Nov 24 2008 16:19 Nov 22, 2010 Jkt 000000 PO 00000 Frm 00062 Fmt 6633 Sfmt 6621 H:\ACTIVE\110509.TXT SVETS PsN: PAULIN
59 

ations, and program elements within a single system for American Indians and 

Alaska Natives. 

AMERICAN INDIAN/ALASKA NATIVE VETERANS’ DUAL USE OF IHS AND VHA

In 2006, a joint VHA-IHS study was initiated to review dual use of the two systems by American Indians. The findings of this study indicate that American Indians and Alaska Natives using the VHA are demographically similar to other VHA 

users with similar medical conditions, such as Post Traumatic Stress Syndrome 

(PSTD), hypertension, and diabetes. To date, the review has found that dual-users 

are more likely to receive primary care from IHS, and diagnostic and mental health 

care from the VHA. They are likely to be receiving complex care from VA and IHS. 

Many American Indians and Alaska Natives are eligible for healthcare services 

from both Indian Health Service and Veterans Health Administration. IHS has an 

estimated 45,000 Indian beneficiaries registered as veterans in the agency’s patient 

registration system. Some American Indian and Alaska Native 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 clinics where 

they are available. In some of these locations Urban Indian Health Programs provide limited direct care and assist these patients in accessing VA and other services 

in the local area. Indian veterans residing on reservations in some cases are not easily able to access VA health facilities and services, as well. 

IHS recognizes that the complexity of IHS Contract Health Services and VA eligibility requirements may discourage Indian Veterans from accessing care. IHS pays 

for the care referred outside of IHS for American Indians and Alaska Natives including veterans if all rules and regulations governing the CHS program are met. 

For the Indian veteran, the VHA is an alternate resource along with Medicare, Medicaid and private insurance under the CHS regulations. Other requirements include 

membership in a federally-recognized Indian tribe, residence on the reservation or 

within an IHS Contract Health Service Delivery Area (CHSDA), meeting the CHS 

medical priority of care, exhaustion of alternative resources of coverage, and compliance with the timelines for notification of IHS. If the Indian Veteran patient is eligible for Contract Heath Services and requires services outside the IHS facility, i.e. 

specialty inpatient and outpatient services, she or he may be approved for care 

pending relevant medical priority level on same basis as any other American Indian 

and Alaska Native. 

HHS/INDIAN HEALTH SERVICE-VA/VETERANS’ HEALTH ADMINISTRATION

MEMORANDUM OF UNDERSTANDING

A Memorandum of Understanding (MOU) between the HHS/IHS and the Department of Veterans Affairs (VA)/Veterans Health Administration (VHA) was signed in 

2003 to encourage cooperation and resource sharing between the two Departments. 

It outlines joint goals and objectives for ongoing collaboration between VA and HHS 

to be implemented primarily by IHS and VHA. The MOU advances our common 

goal of delivering quality health care services to and improving the health of the 

189,000 veterans who are American Indian and Alaska Native as of 9/30/08. The 

HHS and the VA entered into this MOU to further their respective missions, in particular, to serve American Indian and Alaska Native veterans who comprise a segment of the larger beneficiary population for which they are individually responsible. 

The MOU identifies 5 mutual goals to (1) improve beneficiary access to healthcare 

and services; (2) improve communication among the VA, American Indian and Alaska Native veterans and Tribal governments with IHS assistance; (3) encourage partnerships and sharing agreements among VHA, IHS, and Tribal governments in support of American Indian and Alaska Native veterans; (4) ensure the availability of 

appropriate support for programs serving American Indian and Alaska Native veterans; and (5) improve access to health promotion and disease prevention services 

for American Indian and Alaska Native veterans. 

INDIAN HEALTH SERVICE-VETERANS HEALTH ADMINISTRATION COLLABORATIONS

The principal focus of the interagency communication and cooperation is to provide optimal health care for the American Indian and Alaska Native 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 health care to Indian 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 

60 

the VHA when it began incorporating traditional approaches to healing for Indian 

veterans. VA’s development and use of the tribal veterans’ representative (TVR) program has been and is critical to addressing issues related to communicating about 

and reducing barriers to VA services and to the IHS CHS program for Indian veterans through the coordinated training on benefits and eligibility issues for each of 

the two programs. 

Other collaborations that meet the goals of the MOU range from expansion of access to VHA home based primary care for Indian veterans through the use of IHS 

and Tribal health facilities to the improvement of interagency partnership on health 

information and use of tele-health modalities. The home based primary care program expansion will increase availability of services for Indian veterans with complex chronic disease and disability through 14 collaborative projects located in states 

including New York, North Carolina, Oklahoma, Oregon, New Mexico, South Dakota, California, Mississippi, and Minnesota. In Arizona, the IHS -VHA are working 

together to increase mental health services by locating VHA social workers in IHS 

health facilities on the Navajo and Hopi reservations. 

In Montana, the Billings Area IHS and the VA Montana Healthcare System 

(VAMHCS) have on-going collaborative efforts such as tele-psych established at each 

service unit to facilitate providing VA mental health services for American Indian 

and Alaska Native veterans. Because of the geographic remoteness and difficulty in 

accessing transportation to a VA facility, this service greatly benefits the American 

Indian and Alaska Native veterans. The Billings Area IHS and VAMHCS have formalized a PTSD protocol that is utilized by the service units and Fort Harrison. 

Among the protocol elements, the VA 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 telepsyche clinics. Each service 

unit has a designated VA liaison to help the American Indian and Alaska Native 

veterans needing medical services as well as working with the TOW and local Tribal 

Veteran Representative. As the primary IHS contact, they can provide information, 

assistance, and guidance on VA services and health benefits to American Indian and 

Alaska Native veterans. These collaborative efforts are reviewed on an on-going 

basis in efforts to address patient related issues, improved services, outreach, rural 

initiatives, and to assist American Indian and Alaska Native veterans to utilize both 

IHS/VHA systems. 

The IHS and VHA have a long history of working jointly on health information 

technology (HIT). Since the mid-1980s when the two agencies both successfully fielded the Decentralized Hospital Computer Program (DHCP) software, the VHA and 

IHS have sought opportunities to collaborate in the sharing of HIT. The Resource 

and Patient Management System (RPMS) is the IHS’ comprehensive health information system created to support the delivery of high quality health care to American Indians and Alaska Natives at several hundred Federal and Tribal hospitals 

and clinics nationwide. The RPMS is a government-developed and owned system 

that evolved alongside the Veteran’s Health Administration’s (VHA) acclaimed VistA 

system. 

In addition, the model for the RPMS Electronic Health Record (EHR) is the Veterans Health Administration (VHA) electronic medical record, the Computerized Patient Record System (CPRS). CPRS has been successfully deployed across the VHA 

hospital network over half a decade ago. The EHR utilizes a technical infrastructure 

originally developed for the VHA that displays various clinical functions in a graphical user interface (GUI) format. 

CONSOLIDATED MAIL OUTPATIENT PHARMACY (CMOP)

The IHS and VHA will soon begin a pilot-test using VA’s CMOP to process IHS 

outpatient prescriptions, based upon the electronic dispensing data provided from 

the IHS facilities. Through the IHS use of the CMOP facilities, prescription filling 

can be centralized while providing more efficient prescription delivery and increased 

pharmacy billing collections. It will also provide facilities with the capability to fill 

prescriptions for more than 30-day refills. The VA’s CMOP programs offer an attractive technology for dispensing refills within the IHS because it offers the possibility 

of decreasing capitalization costs, reduction of outdated medications, and freeing up 

significant IHS pharmacist time for patient counseling, adverse drug event prevention, and primary care. The IHS has been able to successfully transmit prescriptions 

from an IHS RPMS test system to a CMOP test system and transmit appropriate 

prescription information back to the RPMS test system. The VA’s CMOP is currently in beta testing at Haskell Indian Health Center in Lawrence, Kansas; at the 

Phoenix, AZ Indian Medical Center; and at the Indian health facility in Rapid City, 

South Dakota. 

61 

VISTA IMAGING

A Memorandum of Understanding between the IHS and the VHA has enabled 

telemedicine program coordinators from both Departments to identify key areas for 

cooperation and possible shared resource development. An example is the implementation of the VA’s VistA Imaging System (VI) in IHS, which is now up to approximately 45 RPMS systems nationwide. VistA Imaging provides the multimedia component of the VHA’s Computerized Patient Record System (CPRS) and is also offered as a multimedia tool to complement the IHS RPMS- EHR. The VI is an extension to the RPMS hospital information system. The RPMS Health Information System and Radiology Information System provide extensive support for imaging and 

contain a full image management infrastructure. VistA Imaging provides clinicians 

with access to all images and text data in an integrated manner that facilitates the 

clinician’s task of correlating the data and making patient care decisions in a timely 

and accurate way. Through this agreement, the VHA also provides the IHS with onsite VI installation and training support. 

ALASKA AREA IHS-VA HIT COLLABORATIONS

The Alaska Area IHS has partnered with the VA since 1995 via the Alaska Federal Health Care Partnership (AFHCP) which includes IHS/Tribal, VA, Army, Air 

Force and Coast Guard partners. The Alaska Federal Health Care Partnership 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 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 Alaska Tribal Health System Wide Area Network 

(ATHSAN) Telemedicine and the development of the Wide Area Network. 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. 

FUTURE OPPORTUNITIES OF PARTNERSHIP

Local HIS-VHA efforts to improve access and develop formal partnerships have 

increased since 2003 but IHS acknowledges that our joint efforts on issues related 

to access to health care for Indian veterans need to continue. We are committed to 

working on these issues, within the Indian Health system, as well as with the Department of Veterans Affairs and the Veterans Health Administrations. Indian communities have always honored their Indian 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 Department of Health and 

Human Services through the Indian Health Service and the Department of Veterans 

Affairs I will be happy to answer any questions that you may have. Thank you. 

POST-HEARING QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO RANDY E. 

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

HEALTH AND HUMAN SERVICES

Question 1. How many sharing agreements has VA entered into with tribes, tribal 

facilities and IHS facilities? Please provide a list broken down by tribe, tribal and 

IHS facility, describing these sharing agreements. 

Question 2. Please provide IHS’s best estimate of the number of dual eligible Native American veterans. Please also include a description of the methodology used 

to produce those estimates, and information regarding ongoing efforts by IHS to improve these estimates. 

Question 3. How many staff has IHS dedicated to tracking and implementing the 

VA-IHS MOU and IHS’s obligations (consultation included) to Native American vetVerDate Nov 24 2008 16:19 Nov 22, 2010 Jkt 000000 PO 00000 Frm 00065 Fmt 6633 Sfmt 6621 H:\ACTIVE\110509.TXT SVETS PsN: PAULIN
62 

erans? Please provide the names and titles of dedicated staff, and whether they 

focus on these responsibilities on a full or part-time basis. 

Question 4. In a FY2005 VHA-IHS issue update stated that ‘‘. . . the leadership 

of each organization has been asked to develop a joint policy for the coordination 

of health care for dual use veterans.’’ Please comment on progress toward that joint 

policy, and whether VA and IHS are still working toward that goal. 

[Responses were not received within the Committee’s timeframe 

for publication.] 

Senator TESTER. I thank you for that. Thank you for your testimony. We will start the first round of questions with Senator Burr. 

Senator BURR. Thank you, Mr. Chairman. 

Mr. Floyd, before I get to the issue of the day, I would like to 

touch base with you about the VA hospital in Marion, IL, that is 

now under your purview, and from the Inspector General’s report 

it is apparent there are still systemic issues which have not fully 

been addressed in the last 2 years. Some of those issues that have 

presented themselves over that period of time: providers not 

credentialed or privileged; lack of peer review; poor quality management; and not reporting adverse health effects efficiently. Can 

you share with us your level of commitment to make sure that 

these systemic problems are solved? 

Mr. FLOYD. Senator Burr, in that report, beginning on page 20, 

are my statements to address those ten recommendations made 

from that report. I would refer you and your staff to that. But I 

will also be available to discuss that in further detail, to specifically 

address any of those with you or other Members of the Committee 

at an appropriate time. 

Senator BURR. I appreciate that. Let me suggest to you that it 

was unacceptable when it happened and I find it somewhat unbelievable that we still have systemic problems. I realize you have 

only been there a short period of time—— 

Mr. FLOYD. Twelve months. 

Senator BURR [continuing]. And I hope you will take this as a 

warning shot, that this will not be the last time this Committee 

looks at those systemic problems in that facility specifically and 

across the network. 

Let me, if I could, move to a question for one or both of you. As 

I mentioned in my opening statement, the MOU between the VA 

and IHS outlines five mutual goals. Mr. Howlett on the first panel 

described the MOU as, quote, ‘‘more symbolism than action.’’ So, let 

me mention these goals, and if you will, tell me how your agencies 

are measuring the success or failure at meeting them. 

First, access to health care. How do you measure whether access 

has improved since 2003? 

Mr. FLOYD. First of all, about the MOU, it is purposefully vague 

so that we disregard work with individual areas, Indian communities, urban areas and all, so that we can address unique circumstances of each local community, Tribe, nonprofit organization 

that exists that has Native American veterans. And we have made 

strides in that. 

If I could give you an example. When I was the Director of the 

VA Salt Lake City Health Care System, we worked with the Billings Area Indian Health Service and did a comparison of databases between the VA and the Indian Health Service to identify paVerDate Nov 24 2008 16:19 Nov 22, 2010 Jkt 000000 PO 00000 Frm 00066 Fmt 6633 Sfmt 6601 H:\ACTIVE\110509.TXT SVETS PsN: PAULIN
63 

tients within the Indian Health Service system who were veterans 

who weren’t enrolled within the VA. We used that as a method of 

outreach for patients in Wyoming, Montana, Idaho, and Utah. That 

helped us increase the enrollments of these individuals into the VA 

health care system. That is one example. 

Senator BURR. Communication—how do you measure improvements since 2003? 

Mr. FLOYD. The VA and the Indian Health Service has ongoing 

conference calls between the two of us. We have a spreadsheet that 

identifies projects that we both identified as necessary for action. 

We have identified the responsible parties for that and on a monthly basis report on the progress of those. That is a method which 

we use internally within both agencies to gauge our success in improving services. 

Senator BURR. The development of partnerships and sharing 

agreements—how many existed in 2003? How many exist today? 

Mr. FLOYD. I am not sure how many existed in 2003. I can speak 

for the ones that at the present time exist, which are at least 15 

of the 21 Veterans Integrated Service Networks within the VA with 

varying levels of agreements in place, whether that is for telehealth, traditional services, direct primary care, the installation of 

the Electronic Health Record from the VA into Indian Health Service or Tribal facilities. Those are examples of where we use specific 

agreements to follow up from the MOU to improve mechanisms for 

care. 

Senator BURR. Ensuring appropriate resources are available, 

does the VA know how much it provided to Indian Health Services 

or Indian Health Service contract facilities under the sharing 

agreement in 2003 versus the level it provides today? 

Mr. FLOYD. I am aware of several agreements specifically between the VA and Indian Health Service or Tribal facilities—the 

Muscogee VA in Oklahoma, for example, their work with the Choctaw and the Cherokee Nations specifically on a contract basis. 

However, there are other agreements in place, such as what we 

have experienced in the Rocky Mountain area, where we work with 

social workers or other transfer coordinators within either Tribal or 

IHS facilities on specific cases to get them in and coordinate their 

care, either from that level, primary care, or specialty care in the 

VA system. 

Now, I am not aware of a national database that rolls all those 

up. However, I know that recently the VA has asked and received 

information from each one of the facilities of specific agreements 

that they have in place. So that information is available. 

Senator BURR. To improve health promotion and disease prevention services. How do you measure that? 

Mr. FLOYD. The VA has benefited, actually, from the development of the Indian Health Service, particularly in diabetes education and hypertension education, and collaborated on a level 

where they have actually helped train the VA in their preventive 

practices for diabetes education, hypertension, and the VA has utilized their resources to help improve the knowledge of the VA practitioners. Those are the examples that I am aware of, sir. 

64 

Senator BURR. I would like to thank the Chair, because he has 

been kind to let me go over. Let me make a statement and then 

I will end with one last question. 

The Memorandum of Understanding was meant to cover all the 

Native American geographical area. I think we have a tendency to 

focus on certain successes, certain outreaches, and certain partnerships. But I hope you got the gist I did from the first panel, that 

this is not the overriding theme of the VA, to live up to all the 

standards in that agreement. I am not sure that there is an overriding commitment on the part of VA to make sure that there is 

incredible access to quality health care within Indian Country. I 

am not sure that there is a real focus within the VA to make sure 

that the communications is open to the degree that in all areas, 

they know exactly what is available to them. And I could sort of 

go down the list. 

But let me just ask, is there a database at VA of Native American veterans? 

Mr. FLOYD. Well, within the electronic health records system of 

the VA, as a veteran enrolls in the VA health care system, there 

is a question asked of their racial designation. It is a voluntary request on their part. Those who identify Native American or Alaskan Native as their primary racial group are in our database. Yes, 

sir, we have that information. 

Senator BURR. If they are enrolled in the VA? 

Mr. FLOYD. Yes, sir. 

Senator BURR. But we don’t import into VA potentially all the 

folks who qualify for VA services that may not be enrolled? 

Mr. FLOYD. Not to my knowledge. Not yet. However, as you may 

be aware, the project especially with these soldiers who are in Afghanistan and Iraq, the War on Terror, at the present time—the 

project is called VLER, Virtual Electronic Record, which would 

transmit that information from DOD directly into the Department 

of Veterans Affairs. That project is in its initial stages, but could 

address the issue that you just asked about. 

Senator BURR. Clearly, I would think that with this Memorandum of Understanding in place, that there would have been 

some thought process at VA as to how they could proactively go 

after a population that may not be enrolled yet qualified. Likewise, 

I would hope that the Indian Health Service would push VA to do 

this. The first panel, I don’t think talked about the successes of the 

system or about the outreach or, for that fact, about the quality of 

care within the Indian Health Service. I actually think it has made 

progress, but I think it falls woefully short of what they deserve 

from the standpoint of a quality health care system. 

So, Mr. Chairman, I do hope you will be persistent that we will 

continue to follow up on this and that we will be at a point where 

we can measure progress versus just cite highlights. I think it is 

important that we have a matrix that is constructive that allows 

us to gauge what we have done. 

I thank all our witnesses. I thank the Chair. 

Senator TESTER. And I thank you, Senator Burr. 

I am going to follow up on Senator Burr’s questions here real 

quickly, on the measurement aspect. I am going to paraphrase 

what you said, but you basically merged medical records between 

65 

the VA and IHS and found which Native Americans were out there 

that were veterans that weren’t being served by the VA. Is that 

fairly accurate? 

Mr. FLOYD. Yes, sir. 

Senator TESTER. And then you said that you did outreach. How 

did you do outreach? 

Mr. FLOYD. Well, one of the things that we drew out of that was 

the address of those individuals and their zip codes so that we 

could target them with mailings. Also, as a follow-up at that time, 

Mr. Richardson and myself, we went out to areas where they had 

higher concentrations of veterans and held meetings on those reservations or Indian communities. 

Senator TESTER. And how many folks did you have? 

Mr. FLOYD. In the beginning, sir, very few, but I think with continued follow-up meetings, we began to enroll many more. I am not 

sure of the exact number. I know in one community in Utah, we 

were able to get about 300 people enrolled that hadn’t previously 

been using the VA. 

Senator TESTER. Does the VA keep metrics on the effectiveness 

of this sort of stuff? 

Mr. FLOYD. With the communication between the VA and the Indian Health Service, these types of initiatives are looked at and 

discussed in terms of specific metrics. Reporting is requested periodically from Central Office here in Washington to the respective 

networks, such as the one I am at in Kansas. 

Senator TESTER. It would just seem to me that it would be very, 

very difficult to do measurements if you do it in generalities. How 

do you measure the effectiveness of your outreach unless you 

know? I guess that is a statement. You don’t have to answer that. 

You also talked about contracting facilities with Senator Burr’s 

question, and I had the impression that you do have contracted 

services with some IHS facilities. Is that correct, or did I hear you 

wrong? 

Mr. FLOYD. Well, we have the ability to contract for primary care 

within the VA and locally within any facility. They determine 

where they have the volume of patients to support the contract. 

Senator TESTER. Can you tell me if there are any IHS facilities 

that you have contracts with and where would they be? 

Mr. FLOYD. Specifically, with the Indian Health Service, I am not 

aware of any contracts with them. 

Senator TESTER. Why is that? 

Mr. FLOYD. Because it seems to be more appropriate for us to comanage the patients, although—— 

Senator TESTER. But you do have contract agreements with private facilities, correct? 

Mr. FLOYD. Yes, sir. 

Senator TESTER. So why is there a difference? I am just curious, 

because as one of the people testified in the first panel, a lot of the 

areas that the Native Americans live in are pretty darn remote. 

Mr. FLOYD. Yes, sir. 

Senator TESTER. And one of the things that we have talked about 

on this Committee is when you are in remote areas, it makes more 

sense to deal with the veteran there than ship him a few hundred 

66 

miles, or in Alaska’s case, a lot further than that, to a CBOC or 

a hospital. 

Mr. FLOYD. The traditional usage we have seen in terms of these 

co-managed patients, if I could use that term, is that they generally 

receive their primary care locally, either in a Tribally-run facility 

or Indian Health Service facility. 

Senator TESTER. So the reason you don’t contract with them is 

that IHS is already supposed to take care of them? 

Mr. FLOYD. No, they have a choice. If they want to be exclusively 

served by the VA, then we do that. We do that with many patients. 

We co-manage patients across the country in all kinds of settings. 

Senator TESTER. OK. And I have got about a minute, so you guys 

are going to have to be concise on this. This is for both Mr. 

Grinnell and Mr. Floyd. If you were to analyze how well your two 

agencies were working together to service Native American veterans, what grade would you give yourself? 

Mr. FLOYD. Umm—— 

Senator TESTER. No talking across the aisle. [Laughter.] 

No bell curve; right? 

Mr. FLOYD. I don’t know if I can represent the agency to talk 

about that, Senator, but—— 

Senator TESTER. The point I am trying to make is that from my 

perspective as somebody who serves in the U.S. Senate that represents everybody, whether they are Native American veterans or 

regardless what their race is, I go into Indian Country—and I have 

got all the statistics right here that talk about how their health 

isn’t as good, which I have heard spoken from many agencies in the 

Obama administration, and I agree with them wholeheartedly— 

that we need to figure out ways that we can work together to maximize our ability to serve the people we are serving, because IHS 

is funded by taxpayer dollars, VA is funded by taxpayer dollars, 

and we have got an opportunity to work together and get more 

bang for the buck. 

And so that is why I want to know. Would it be accurate to say 

that we could do better? How is that, Mr. Floyd? 

Mr. FLOYD. Well, I think we can always do better, sir. 

Senator TESTER. All right. Well, I left you off the hook. 

Mr. Grinnell, what grade would you give us? 

Mr. GRINNELL. Well, I am going to punt like Mr. Floyd did and 

not give myself a grade. But in discussions with the Director, Dr. 

Roubideaux, about future partnerships, we clearly see that there is 

an opportunity for improvement and ways to bring services to the 

Indian veterans throughout Indian Country—— 

Senator TESTER. OK. If there is opportunity for improvement, 

how does that information flow up and how do you get it ultimately 

in the end to Dr. Roubideaux? 

Mr. GRINNELL. Well, one of the things that Mr. Floyd also talked 

about is that many of these agreements and these relationships are 

at the local level. 

Senator TESTER. Right. 

Mr. GRINNELL. In many cases, the agreement and the relationship is between the VA and the Tribes that now manage those programs, an example is Alaska. All the Alaskan programs are now 

under 100 percent management of the Tribes up there. I believe 

67 

that the opportunities we have before us to bring the partnership 

of the Tribes and the Alaskan Natives into that partnership in a 

more open and equal manner, I think that will help us move 

ahead. 

Dr. Roubideaux, one of her priorities is to have more consultation 

with Tribes on how we deliver health care across this country, and 

she sees that as an opportunity here, as well. 

Senator TESTER. OK. Thank you very much. 

Senator Begich? 

Senator BEGICH. Thank you very much, Mr. Chairman, and 

thanks for calling for this hearing. I think it has been very informative, but also gives us a chance to—I was trying to figure out how 

to do the grading, too. When I went to elementary school, they had 

‘‘N’’ for needs improvement, ‘‘O’’ for outstanding, ‘‘S’’ for satisfactory, and this is probably a combination, depending on where you 

are. I know in Alaska, as you just mentioned, the Tribal Consortium has done, I think, an exceptional job in advancing health care 

for Alaska Natives. Again, I went on the floor today to explain the 

great value of what they have done in improving and turning 

around the system. 

Now, saying that, I think there are some improvements that 

clearly need to be made, especially with, I will use the phrase dual 

eligible veterans. You know, they are eligible in both your systems. 

And in Alaska, again, as I said in my opening, they are in areas 

that are very difficult to access quality health care that is VA-delivered, if they live in rural Alaska, so there has to be a better way. 

But I want to go back to the Ranking Member’s comment to the 

VA, how you try to figure out who the folks are, because if you 

don’t know the number, if you can’t put that in your database—I 

understand why it is voluntary—but why can’t you have a question 

that says something like this. Are you qualified under the Indian 

Health Service for any services? Because you may be qualified for 

additional services. 

Why can’t you just ask that question, so then when they check 

that box, you can actually create a database? I understand the 

issue about asking their ethnic background, but if you are asking 

them, are you qualified under Indian Health Services today, a lot 

of folks will identify that, especially if they are a veteran. So, they 

just check the box. It then gives you the data to move forward in 

figuring out how to provide dual services. 

Mr. FLOYD. If I could answer that, Senator. The VA in its registration package asks for alternate resources information, which is 

generally third-party insurance coverage. I know the Indian Health 

Service is not an insurer—— 

Senator BEGICH. Right. 

Mr. FLOYD [continuing]. But a lot of patients do say, well, it is 

Indian Health Service. They can note Indian Health Service on 

there—— 

Senator BEGICH. But if I can interrupt you, if you ask the question from that perspective, insurance, some will view it differently. 

But if you ask, are you qualified under Indian Health Service for 

any benefits, it is a simple yes or no, and it immediately gives you 

a qualifier. 

Mr. FLOYD. We don’t ask that specific question. 

68 

Senator BEGICH. Can you be more—I mean, can you? 

Mr. FLOYD. We could, but let me give you one hesitation on my 

part to do so. Having run a medical center, I would not want any 

of my staff to turn that person away and say, then we want you 

to go to an Indian Health Service facility. 

Senator BEGICH. I am not asking that. What I am saying is it 

helps you create the database, so then as you do this MOU, you 

now can say, we have 5,000, 2,000, 100, or ten qualified based on 

the data we have collected. Now, how do we approach that group 

in order to ensure that we are giving them the benefits and the 

services earned? And then you can kind of start drilling down. I 

have done a lot of MOUs as a former mayor and I will tell you, 

if you don’t have the data, there is no way to perform on it. You 

just can’t. 

So, I would just encourage you to kind of look at how you ask 

the question in order to extract the data in order to then work together to figure out who that group is you are trying to target. 

That is just a comment. 

The other thing is, the MOU has been talked about a lot, and 

like I said, I have developed a lot of MOUs as mayor, but one of 

the things we always had was kind of, you have interagency discussions on a regular basis. But the last time, I think, that they have 

taken those issues and updated and where they are, I think, was 

maybe in 2005 or later. 

I am assuming you do this, and if you don’t, I would highly encourage you. I am assuming in your interagency group you will 

have an MOU with your 15 or so items and you will note, here are 

the action items, here is the progress. Do you have such a chart 

that shows what you all work off of? 

Mr. FLOYD. Between the—if I could answer that—— 

Senator BEGICH. Between both of you, yes. 

Mr. FLOYD. Yes. We do share our database of the projects that 

we are either working on individually or jointly. Those are identified, then the objective, the status of the actions, and who is responsible as the lead on those types of issues. And then we discuss 

those on conference calls. 

Senator BEGICH. So, you have some document where you keep 

track of these? 

Mr. FLOYD. Yes, sir, we do. 

Senator BEGICH. Is that something you can share with the Committee? 

Mr. FLOYD. Yes, I think we can provide that information. 

[The additional information requested during the hearing follows:] 

69 


115q1aFloyd1.eps
70 


115q1aFloyd2.eps
71 


115q1aFloyd3.eps
72 


115q1aFloyd4.eps
73 


115q1aFloyd5.eps
74 


115q1aFloyd6.eps
75 

[Additional information about this topic can be found under response to Question 3 from Hon. Daniel K. Akaka to Mr. James R. 

Floyd, which appears previously.] 

Senator BEGICH. Both of you? I don’t know who is the right person. Mine is a dual-eligible question, so—— 

Mr. GRINNELL. Yes. It is maintained through this National Committee that—— 

Senator BEGICH. OK. So you can provide that to us to give us a 

sense? 

In implementing that, is one of the pieces of the puzzle funding? 

It doesn’t matter if it is VA or Indian Health Service, but on both 

sides, are any of the implementations of those just a funding issue 

versus a desire or a combination? Does that make sense, the question? In other words, do you get to an item and say, we want to 

do it, but there is just no money for it? And just to make sure you 

know, my second question will be, if the answer is yes to that, then 

I would ask, are you asking for that? Is it OMB and their magical 

black box that kind of strips at the pieces and then you end up 

having to take what you get? How is that for putting you on the 

spot? I wanted to warn you of the second part of the question. 

Mr. FLOYD. The way the funds are allocated, having been in the 

Indian Health Service and now in the VA, I know how money is 

allocated in both. Within the Veterans Health Administration, it is 

a capitated system. The money follows the workload. So, the generation of the workload is going to retrospectively provide the resources to sustain that service for those individuals. So, there is 

through that system that we have within the VA a way to reimburse us for going out and getting that workload. 

Senator BEGICH. Quickly—I know my time is over—— 

Mr. GRINNELL. As far as the funding, I think that everybody is 

aware of the funding of the Indian Health Service and the programs that are administered by us and the Tribes. The 2010 budget is definitely an increase. We have 13 percent that is now in 

place. The increases are very targeted and we are going to see 

some advances in Contract Health Service, which will have an impact on veterans that access that part of the system, as well. 

The other part is within Health Information Technology. We are 

seeing some increases in our budget there that will be targeted to 

move us into more of these telemedicine partnerships that we have 

with the VHA to expand our services to those veterans in those remote locations. 

Senator BEGICH. Thank you very much. I will ask one question, 

and it is a yes or no. Does Indian Health Service believe they 

should be on a 2-year budgeting cycle like the VA? 

Mr. GRINNELL. I would have to—— 

Senator BEGICH. It is a yes or no. It is very simple. 

Mr. GRINNELL. I would have to defer on that question to the Department. I am sorry. 

Senator BEGICH. OK. No problem. Thank you. 

Senator TESTER. Thank you, Senator Begich. 

A couple more questions, and the first one is for Mr. Richardson. 

Buck, you are the guy who actually executes the goals of the MOU 

on the ground. You go out to reservations. You deal with the veterans, the IHS, and Indian Tribal Health. How do you and other 

76 

folks in the VA know what the challenges are out there and how 

do you share your ideas among your counterparts? How do you let 

them know what you are doing outside your region to influence 

folks? 

Mr. RICHARDSON. We do a combination of things, Senator. It is 

either through conference calls, and reports I do through the VISN 

Director or actually taking other VA employees out. Then Dr. Shore 

and I do a report monthly that shows what we are actually doing 

at each one of the reservations, that shows the activity that we are 

doing, and how many veterans we are seeing through the different 

clinics. And then I have got a Web site for the TVRs that shows 

what is going on with each reservation and what is going on for 

the TVR, or the Tribal Veterans Representative Program, so that 

they can see what is going on in each one of the reservations. 

Then in VISN 19 or the Rocky Mountain Health Care Network, 

I have got 23 Sovereign Nations that I work with, so I keep that 

up to date as to what is going on. So, I try to keep as much information flowing, and when I run across employees that are actually 

interested in trying to find out more about the Sovereign Nations, 

I take them out to the Nation with me. 

Senator TESTER. Thank you. 

Mr. Floyd and Mr. Grinnell, from your perspective, do you comanage patients at this point in time? 

Mr. FLOYD. Well, from my experience, yes, sir, we do. 

Mr. GRINNELL. Yes. 

Senator TESTER. OK. So, how do you effectively co-manage patients when you don’t have an interoperable recordkeeping system 

and no one in either agency is really tracking how you are doing, 

implementing these strategies? 

Mr. FLOYD. Well, my own experience, if I can answer that—— 

Senator TESTER. Sure. 

Mr. FLOYD [continuing]. And maybe Buck can follow up, is it is 

as simple as a phone call. Each VA facility has a Transfer Coordinator. A lot of times, calls are made into the Transfer Coordination 

Office or to some of us individually of the specific case. At that 

point, we get the Transfer Coordinator to work with the individual 

at the local site. They coordinate the care to get the patient where 

they need to go. 

Senator TESTER. Mr. Richardson, did you want to further respond? 

Mr. RICHARDSON. There will be occasions where maybe an OEF/ 

OIF Coordinator, either Iraq or Afghanistan, they will get phone 

calls trying to find individual veterans, and they will call me too. 

And what I will do is call the TVRs. The TVRs will actually go out 

into the field and find the veteran. 

Senator TESTER. OK. 

Mr. RICHARDSON. And once they find that veteran, a lot of times, 

there is a language barrier, so they have to get through the language issue through the family of that veteran. Once they get over 

the problem of the language and they get the veteran found, whichever reservation it might be, then they will get the veteran back 

in touch with me and then I will get the veteran in touch with the 

appropriate employee so that they can get them into whatever facility they might need to go to. 

77 

Senator TESTER. How about you, Mr. Grinnell? 

Mr. GRINNELL. I would like Dr. Cullen to answer that, if she 

could. 

Senator TESTER. Sure. 

Dr. CULLEN. If the patient is cared for primarily in our system 

and identified as a veteran, they may be referred to the VA. If they 

are referred—because we do have a similar Electronic Health 

Record to the VA, especially in terms of patient registration, we 

will have captured their veteran status, we ask the nine questions 

the VA asks. In addition, we can drill down and tick off war and 

other things like that. If they are referred, we have a contract 

health and a referred care software application that allows us to 

track the referral out. 

The question will be, can we get the records back in. At the current time, we have locations that have what we call read-only access into the VA systems, where the providers have been 

credentialed appropriately and they can dial into, with appropriate 

security, the VA VISTA system and get a read-only access to that 

patient’s chart. 

Senator TESTER. Let me restate what you just said. You are telling me that health care professionals in Indian Health Service can 

access those medical records in the VA? 

Dr. CULLEN. At certain locations where there have been local 

sharing agreements developed and the provider has been appropriately credentialed, yes. 

Senator TESTER. OK. Can the VA do the same thing, Dr. Shore? 

Can the VA do the same thing with the Indian Health Service 

records? 

Dr. SHORE. I can only speak for the series of clinics where I work 

in Montana, Wyoming, and South Dakota. I run a series of telehealth clinics for the VA mental health clinics. So in those, with 

those specific sites, we do not have read-only capacity. It depends 

on the medical record, although often, our clinics are colocated in 

the actual IHS facility. So, we do a lot of phone calling back and 

forth with the providers. 

Senator TESTER. All right. Thank you. 

Senator Begich, did you have any other questions? 

Senator BEGICH. I want to fall back in. Dr. Cullen, that is interesting, how you crafted that answer. I just want to make sure I am 

following you correctly here. If it is locally done, it has credentials 

done locally, then it is a read-only into the system, correct? 

Dr. CULLEN. Appropriate credentials and security, yes. 

Senator BEGICH. Security. If I can ask you a question, how many 

of your facilities have that, in percentage of total? 

Dr. CULLEN. We are only aware of five at the current time. 

Senator BEGICH. What about the percentage? What would that 

be—very small? 

Dr. CULLEN. Very small percentage. 

Senator BEGICH. And is it successful? 

Dr. CULLEN. Yes. 

Senator BEGICH. Why do we not model that nationally and do it? 

If you want to kick it back to Mr. Grinnell, that is fine. But if it 

is successful, why not just do it? 

Mr. GRINNELL. Resources. 

78 

Senator BEGICH. Is that the issue? Have you requested that in 

the 2010 or 2011—— 

Mr. GRINNELL. That has been part of the request that we have 

made in the health IT line, is to begin to improve the ability to increase our telemedicine capabilities. 

Senator BEGICH. OK. Do you have a plan of action if you get the 

resources? How long would it take you to convert, or not convert, 

but to ensure that this occurs in this manner? 

Mr. GRINNELL. This—— 

Senator BEGICH. And to give you the pre-warning, if you say yes, 

I will ask you for that document. [Laughter.] 

In all fairness. 

Mr. GRINNELL. I think that at this point, the talk that is going 

on nationally about the Health Information Network, I think has 

been taking precedence over anything that we are doing right now. 

Senator BEGICH. It just seems that it is working, and I think 

your request, Mr. Chairman, was really good. If it is working, 

sometimes the stuff that is working, we kind of forget about and 

we move on. But it seems like this is such a good one, and this is 

such a need, to make sure the records are back and forth. So I will 

follow that up at another time. 

One last question, if I can, Mr. Chairman, and that is it was 

asked earlier on the first panel on the ability to bill the VA. Indian 

Health Service can bill Medicare and Medicaid but they can’t bill 

the VA to get reimbursed, I guess. Is that correct? If you remember 

the earlier testimony, there was some discussion about that. 

Mr. GRINNELL. Yes, that is correct. 

Senator BEGICH. Is there a reason why we should not allow that 

to occur? Why not? Again, you can kind of flip it to Mr. Floyd if 

you would like, but whoever would like to answer that. Or no answer. 

[Laughter.] 

Mr. FLOYD. In all due respect, I am not quite sure that I know 

the exact—— 

Senator BEGICH. That is fair. 

Mr. FLOYD. I could respond to that as a follow-up for this hearing—— 

Senator BEGICH. I would appreciate that. 

Mr. FLOYD [continuing]. Question of the authority. 

Senator BEGICH. Yes, if you could just answer that question. It 

is more so that I understand it better and to consider if there is 

something that we need to be thinking about here in the process 

of how to improve that. 

Mr. Chairman, thank you very much. 

[The additional information requested during the hearing follows:] 

RESPONSE TO QUESTIONS ARISING DURING THE HEARING BY HON. MARK BEGICH TO

JAMES R. FLOYD, FACHE, NETWORK DIRECTOR, VA HEARTLAND NETWORK (VISN 

15), VETERANS HEALTH ADMINISTRATION

Question: Senator Mark Begich (D-AK) requested information about a statute that 

prohibits VA from reimbursing IHS for the cost of medical care provided to Veterans. 

Response. No statute prohibits VA from reimbursing IHS for the cost of medical 

care provided to Veterans and VA does reimburse IHS for services provided to Veterans in certain situations. VA currently reimburses eligible Veterans for health 

79 

care provided by non-VA providers only in limited circumstances whereby the care 

that VA has deemed necessary is otherwise not offered by VA Healthcare facilities. 

VA seeks to control and monitor all care that eligible Veterans receive. 

Current law provides sufficient direction and authority for the appropriate apportionment of costs for the care of Indian Veterans between IHS and VA. In the event 

that VA determines that a Veteran needs care at a non-VA facility, VA has the authority to enter into an agreement with IHS under which VA would pay for that 

care. 

Senator TESTER. Yes, thank you, Senator Begich, and I want to 

thank the panelists. 

Let me give a quick overview. We had in the first panel some 

folks that represent health care in Indian Country on the ground. 

My sense is—and it is not just a sense but I think it is reality— 

there is a level of frustration there that we could be doing more 

work and getting it to the ground to really serve the Native American veterans in a better way. 

This panel we had here, and you are all great folks, I sense much 

less attention on what is going on the ground. All I would say is 

that the question asked by grading where you were at—I mean, 

you are right, Mr. Floyd, we can always do better. But I think we 

need to really, really work at doing better. These are really tough 

issues, and sometimes it just comes down to who is paying the bill. 

But more than that, I think it comes down to working together and 

finding ways which we can service, in this case, Native American 

veterans in a way that they deserve. 

As Senator Murray said, these folks worked for the benefits. 

They served this country, in many cases, put their lives on the line. 

Promises were made. We need to make sure that those promises 

are kept. 

I want to thank each and every one of the panelists today for 

their service in their individual capacities and I want to thank you 

for taking time out of your busy schedule to come here and visit 

with us. Thank you very much. 

This meeting is adjourned. 

[Whereupon, at 12:07 p.m., the Committee was adjourned.] 

(81) 

A P P E N D I X 

PREPARED STATEMENT OF HON. ROLAND W. BURRIS, U.S. SENATOR FROM ILLINOIS

Thank you Mr. Chairman, I would like to begin by extending a ‘‘Warm Welcome’’ 

to our distinguished guests, as well as fellow colleagues from the Committee. Moreover, I would like to thank you and Senator Tester for creating this opportunity to 

further discuss the ongoing efforts in the Veterans Health Administration (VHA) to 

provide safe, effective, efficient and compassionate health care to American Indian 

and Alaska Natives (AI/AN) veterans residing in rural areas. 

It is of course my desire to see that this hearing focus on the progress between 

the VA and the Indian Health Service (IHS) in delivering quality health care to (AI/ 

AN) veterans. In particular, it is my hope that we will examine the challenge of 

making health care in rural and urban areas more accessible, as well as the VA’s 

needs to overcome cultural barriers to serve veterans in Indian Country. 

Mr. Chairman, as you know, in February 2003 the Departments of Health and 

Human Services-Indian Health Service and VA signed a memorandum of understanding (MOU) to promote cooperation and sharing between the Veterans Health 

Administration and the IHS to further each Department’s respective mission. 

It is my understanding that over the past six and a half years there has been 

limited progress made toward the goals of this MOU. That said, it is also my understanding that overall the networks have made some progress in developing closer 

relationships with IHS and the Tribes and in considering means to improve services 

and access for AI/AN veterans. This is a good start but I would like to see further 

strides established toward the original intent of the MOU. 

Furthermore Mr. Chairman, for a contributing ethnic group of the U.S. population 

(who retains dual citizenship) that has a higher percentage of people serving ‘‘per 

capita’’ in the Armed Forces than that of the general US population (24% compared 

to 19%) I think it only appropriate that these measures be carried out in an expedient manner. 

With this in mind I want to bring to this Committee’s attention a few interesting 

points that I think are relevant to this discussion and need to be factored in. To 

begin, studies and testimony from AI/AN veterans indicate that travel distance and 

a lack of coordination between the two agencies are key factors that inhibit AI/AN 

veterans’ access to health care at VHA. 

Another barrier AI/AN veterans are dealing with is the perception that VHA staff 

do not understand or accommodate the needs and unique perspectives of Indian veterans and that VHA care is not culturally or linguistically sensitive. 

In addition, AI/AN veterans have indicated that the eligibility requirements and 

application process for receiving care from VHA can be very confusing. AI/AN veterans find the process particularly baffling as many of them may have been receiving health care from the Federal Government, IHS, all their lives under a different 

system of eligibility and rules for access. 

Mr. Chairman, I close simply with this: it is my belief—as I know it is yours— 

that providing safe, effective, efficient and compassionate health care to our (AI/AN) 

veterans, regardless of where they live, should be the primary goal of the VHA and 

IHS. 

PREPARED STATEMENT OF JEFFERSON KEEL, PRESIDENT, 

NATIONAL CONGRESS OF AMERICAN INDIANS

Thank you for the opportunity for the National Congress of American Indians to 

provide testimony regarding American Indian and Alaska Native veterans and 

health care services provided by the Department of Veterans Affairs and the Indian 

Health Service. 

82 

In addition to thanking Chairman Akaka and Ranking Member Burr for the opportunity to present testimony, I want to acknowledge and thank Senator Tester for 

requesting today’s hearing and for his leadership on the Rural Veterans Health 

Care Improvement Act, which includes provisions for Native American veterans’ 

health care, through this Committee. 

I believe that the Members of this Committee are aware of the valor and service 

of American Indian, Alaska Native and Native Hawaiian veterans to this country 

and that they have served in higher proportion than any other ethnic group. You 

also may be aware that the lack of health care to these veterans upon returning 

home is appalling, considering what they have done in protecting our homelands. 

With the advent of the Afghanistan and Iraq wars, the number of veterans returning with injuries and disabilities, physically and emotionally, has significantly 

increased. And as we have learned from past wars and conflicts, the need for treatment of these warriors may not be revealed for several years after these courageous 

men and women return home. 

The primary health care provider to tribal communities, including American Indian and Alaska Native veterans, is the Indian Health Service, which has always 

been woefully underfunded. Many veterans have sought health care from Veterans 

Health Administration hospitals because that is an option and a right. In an attempt to stretch their health care dollars, both IHS and VA hospitals have denied 

services to veterans, insisting they had to go to the other agency for treatment. 

These proud veterans, who in some instances used their last dollars to travel long 

distances to either facility, deserve better treatment. 

As a tribal leader and veteran, I thought the days of transferring responsibility 

from one agency to the other were over when a Memoranda of Understanding between the IHS and Veterans Health Administration was signed in 2003. 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 or worse. 

There are far too many reports of inconsistency in delivery of health care to American Indian and Alaska Native veterans. NCAI staff members have been informed 

of concerns about delays in scheduling appointments as well as the cancellation of 

appointments without notice by both the Indian Health Service and Veterans Administration hospitals. We have been made aware of the backlog of delivery of basic 

services including dispensing eyeglasses and hearing aids. Many veterans also have 

shared their complaints that they believe their health problems have not been addressed because they met with medical staff who rushed them through medical 

exams and sent them away quickly without diagnosing problems or providing proper 

treatment including medication. 

There are some things that are under the purview of this Committee that might 

help to alleviate the problems. The Veterans Health Administration has authority 

to create Tribal Veterans Service Offices in tribal communities, which would provide 

a resource for local veterans to be informed of their best options for health, housing, 

and other benefits and what additional resources are available for specific 

assistance. 

I am hoping that there will be additional resources available that veterans will 

be able to draw from, including the reauthorization of the Indian Health Care Improvement Act that is before Congress. But any money appropriated for services authorized under the Indian Health Care Improvement Act is desperately needed for 

the overall population of tribal communities, and even though veterans may benefit, 

there still is a need for increased VA health care funding. 

Remoteness of IHS and VA health facilities will always be a problem. Native veterans are likely to have scarce financial resources to expend on travel to IHS or VA 

hospitals. The VA, perhaps in cooperation with the Department of Transportation, 

should be able to work with tribal governments to facilitate transportation from 

tribal community hubs to Veterans Health Administration hospitals, which can, in 

some instances, be over 200 miles roundtrip, and for Alaska Native veterans, much, 

much further. 

In providing services to Native American veterans, it is a basic requirement that 

the two agencies’ systems for data exchange and communication are compatible. 

One of the agreements in the 2003 VA-IHS MOU was to ‘‘[d]evelop national sharing 

agreements, as appropriate, in healthcare information technology to include electronic medical records systems, provider order entry of prescriptions, bar code medication, telemedicine, and other medical technologies . . .’’ 

We are aware that the IHS received $85 million under the American Recovery 

and Reinvestment Act for Health Information Technology. We would hope that a 

portion of this funding—to be used for electronic health record development and deployment, personal health record development, telehealth and network infrastrucVerDate Nov 24 2008 16:19 Nov 22, 2010 Jkt 000000 PO 00000 Frm 00086 Fmt 6601 Sfmt 6621 H:\ACTIVE\110509.TXT SVETS PsN: PAULIN
83 

ture, and other purposes—would benefit Native veterans through improved data exchange and patient tracking. We would also like the Committee to consider requesting that the IHS make some Recovery Act health IT dollars available to triballyadministered health programs, perhaps including Tribal Veterans Service Offices, in 

addition to internal IHS records management and infrastructure development. 

Members of the Committee can also assist American Indian and Alaska Native 

veterans by supporting current legislation. The Indian Veterans Housing Opportunity Act of 2009 (H.R. 3553) has been introduced by Representative Ann Kirkpatrick (D-AZ), which will help disabled Native American veterans and their survivors by providing eligibility for housing assistance to which they are currently denied because they are receiving veterans disability and survivor benefits. I ask that 

you support this critical legislation. 

The National Congress of American Indians (NCAI) passed a resolution (SD–02– 

079) in 2002 at their Annual Convention, calling for the development of a report 

on the health status of American Indian and Alaska Native veterans. Today’s hearing is a significant step in pointing out that both the VA and IHS have roles and 

responsibilities in the treatment and care of Native veterans. We all know that Native peoples are subject to more studies than anyone in the country, but perhaps 

a report of the nature called for in the NCAI resolution would not be an infringement or intrusion on privacy when weighed with the potential outcome and value 

of such a survey. I am offering the assistance of the NCAI in supporting this effort 

and am sure that the NCAI Veterans Committee would lend its assistance. 

Because of the government to government relationship, nearly all agencies have 

instituted an Indian affairs desk tasked with outreach and communication to tribal 

governments and organizations. The NCAI has always supported implementation of 

tribal affairs offices because they enhance and advance program delivery and implement policies that better serve tribal governments and communities. The Veterans 

Administration currently has a Native American who serves as a tribal contact in 

the Office of Minority Affairs. We strongly urge the VA to expand this position and 

move it out from the Office of Minority Affairs and establish an Office of Tribal Affairs staffed by American Indian and Alaska Native personnel who report directly 

to the VA Secretary. The creation of an Office of Tribal Affairs with VA also complies with the Memorandum of November 5, 2009 on Tribal Consultation issued by 

President Obama. 

Thank you again on behalf of the National Congress of American Indians for taking the time to conduct this hearing and to provide this opportunity to hear from 

our organization, veterans and other supporters in calling for comprehensive delivery of the best health care available for the honorable men and women who deserve 

no less than the best. 

PREPARED STATEMENT OF DON LOUDNER, NATIONAL COMMANDER, 

NATIONAL AMERICAN INDIAN VETERANS, INC. 

INTRODUCTION

Good morning Chairman Akaka, Ranking Member Burr, and Members of the 

Committee on Veterans Affairs. I am Don Loudner, the national commander of the 

National American Indian Veterans, Inc. (‘‘NAIV’’), a national not-for-profit organization dedicated to the welfare of American Indian veterans who have proudly 

served this country for generations. I am an enrolled member in the Crow Creek 

Sioux Tribe, SD, and am a veteran of the Korean War. 

I want to thank the Chairman for holding this important hearing on the degree 

of cooperation that currently exists between the Indian Health Service (‘‘IHS’’) and 

the Department of Veterans Affairs (‘‘DVA’’) when it comes to providing the best 

quality health care to our Native veterans. As you can imagine, Native veterans 

have many of the same problems other veterans do, but also face unique challenges 

of unemployment and poverty as well as living in geographically-remote areas of the 

country. 

HEALTH CARE AND AMERICAN INDIAN VETERANS

I would like to provide the Committee with information pertaining to the challenges faced by American Indian veterans regarding DVA benefits and health care, 

as well as DVA memorial services (e.g. Indian veteran’s cemeteries). While I have 

worked my entire adult life to improve the standard of care and living of these men 

and women, in my capacity as national commander of the NAIV, I am in constant 

contact with American Indian veterans in the States of Arizona, California, ColoVerDate Nov 24 2008 16:19 Nov 22, 2010 Jkt 000000 PO 00000 Frm 00087 Fmt 6601 Sfmt 6621 H:\ACTIVE\110509.TXT SVETS PsN: PAULIN
84 

rado, Montana, New Mexico, Oregon, South Dakota, Wisconsin, Washington, and 

others. 

Since 2004, the NAIV has hosted three National Conferences, the last taking 

place in March 2009 at the Morongo Convention Center in Cabazon, CA, with more 

than 500 American Indian veterans from throughout the West and Southwest in attendance. The NAIV has the support of the National Congress of American Indians, 

the National Association of State Directors of Veterans Affairs, the National Disabled American Veterans, and the National American GI Forum. 

The chief of staff for the NAIV is the only American Indian to serve as the Director of Veterans Affairs—serving the veterans of the State of Arizona. He and I travel to the many Indian reservations constantly. Although his job is to support all of 

Arizona’s 600,000 plus veterans, Arizona is home to 22 federally-recognized Indian 

tribes and American Indian veterans regularly attend his commission meetings. As 

a result of these meetings, he relays to me concerns regarding the lack of proper 

medical care delivered through the DVA to reservation-dwelling Indian veterans. 

On the Navajo Reservation, for example, there are more than 12,000 veterans, but 

DVA has rebuffed calls to locate a permanent Community-based Outpatient Clinic 

(‘‘CBOC’’) there claiming the number of veterans will not justify it. The fact is, the 

numbers will not support a CBOC at Navajo because the reservation is divided into 

3 Veteran Integrated Service Network (‘‘VISN’’) and, given this division, the DVA 

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 the DVA’s Office of Intergovernmental Affairs and the Director of VISN 

18 and others visited the Navajo Nation and witnessed for themselves the urgent 

need for additional health care facilities. They graciously called the Director of Veterans Affairs in Arizona for his input which he, of course, provided. The reality is 

that I have seen numerous visits over the years throughout Navajo, Pine Ridge and 

other Indian reservations, with little follow-up action. 

When a Navajo veteran can get to a Veterans Administration Medical Center in 

Prescott, Arizona or Albuquerque, New Mexico, or Sioux Falls, SD, the medical care 

is excellent, but few if any veterans can overcome the vast distances to use such 

facilities. The distances are vast and transportation is not always available. As a 

result, many American Indian veterans try to obtain care at IHS facilities but do 

not receive treatment because they are veterans. 

In this regard, the Memorandum of Understanding (‘‘MOU’’) that was entered in 

2003 by the DVA and the IHS has been ineffective because the level of cooperation 

is nowhere near where it needs to be for the benefit of American Indian veterans. 

The idea behind the MOU was that the American Indian veteran could receive 

the treatment she needs at an IHS facility and the DVA would reimburse IHS for 

those services. The reality is that the veteran is usually the last to be seen at an 

IHS facility. The MOU can be strengthened and this in itself would alleviate some 

of the need for Community Based Outpatient Clinics on Indian reservations. 

COMMENTS ON THE CAREGIVER AND VETERANS OMNIBUS HEALTH SERVICES ACT

(S. 1963)

Mr. Chairman, I want to thank you for sponsoring the Caregiver and Veterans 

Omnibus Health Services Act (S. 1963), which was introduced last week and is already pending on the Senate Calendar. While we are carefully studying S. 1963 in 

its entirety, there are many excellent elements included in it that I would like to 

highlight. 

The bill creates a much-needed Demonstration Project to examine the feasibility 

and advisability of expanding care for veterans in rural areas, including expanding 

coordination between the DVA and the IHS for health care for American Indian veterans. The bill would also assign an Indian Veterans Health Care Coordinator to 

each of the 10 Department Medical Centers that serve communities with the greatest number of American Indian veterans per capita, as well as an official or employee of the Department to act as the coordinator of health care for Indian veterans 

at the Medical Centers. 

In an effort to bring the benefits of information technology to the medical records 

of American Indian veterans, S. 1963 would bring real advances in two key areas: 

(1) It would establish a Memorandum of Understanding to ensure that the health 

records of Indian veterans can be transferred electronically between facilities of the 

IHS and the DVA; and (2) It would transfer and install surplus DVA medical and 

information technology equipment to the IHS. 

Perhaps most importantly, S. 1963 requires the Secretary of the DVA and the 

Secretary of the Department of Health and Human Services to jointly submit to 

85 

Congress a report on the feasibility and advisability of the joint establishment and 

operation by the Veterans Health Administration and the Indian Health Service of 

health clinics on Indian reservations to serve the populations of such reservations, 

including Indian veterans. 

NAIV AND ITS PURSUIT OF A FEDERAL CHARTER

In 2005, then-Senator Tom Daschle introduced legislation to award a Federal 

Charter to NAIV. The legislation passed unanimously in the Senate but languished 

in the House Committee on the Judiciary. At the time, there were two bills seeking 

to award Federal charters to veteran’s organizations, one for NAIV and one for the 

Korean War Veterans Association. In 2008, Congress passed legislation awarding a 

charter to the Korean War Veterans Association, but failed to consider the NAIV 

bill. 

One question that NAIV faces constantly is why does NAIV need a Federal charter? Indian veterans have come together to form their own professional veterans 

service organization which was created out of the necessity to support ourselves and 

not have to rely on other service organizations like the American Legion, the VFW, 

or others to support and advocate for them. With our own Federal charter, NAIV 

would be officially sanctioned and as national commander I would be able to testify 

before Congress on Native veteran’s issues, just as the American Legion, VFW, AmVets, and other organizations do each winter. 

Chairman Akaka, American Indian veterans have earned the right to have their 

own Federal charter and to be recognized by Congress. No other group of Americans 

serves in our Nation’s Armed Forces in proportion to their numbers as do Native 

Americans. With a Federal charter, NAIV could train and certify the required veterans benefits counselors and certify them to work on Indian reservations. This 

would alleviate some of the obstacles such as language barriers and access which 

is one of the major complaints American Indian veterans now have. Thousands of 

Indian veterans are going without claims being process for them because of cultural 

barriers. Indian veterans are dying without ever having filed a claim, leaving their 

widows destitute, and dependent on their respective tribe. 

AMERICAN INDIAN VETERANS CEMETERIES

Currently, there are no American Indian veterans cemeteries on Indian reservations and many Indian veterans are being buried in tribal cemeteries. The sad fact 

is that these tribal cemeteries are often in a horrible physical condition. For example, the cemetery at Fort Defiance, AZ is so decrepit and horrible that it brought 

me to tears and should be closed immediately but the tribe does not have the funds 

to close or rehabilitate it. Visitors from the VA’s office of Intergovernmental Affairs 

toured this cemetery and can vouch for this accuracy of my statement. 

AMERICAN INDIAN VETERAN REPRESENTATION AT THE VA

Finally, there is great unhappiness among veterans in Indian country at the lack 

of representation of Indian veterans at the VA headquarters. All other veterans 

groups are represented in the ranks of the Senior Executive Service—with the exception of Indian veterans. There is only one Indian official working in the Center 

for Minority Veterans and that person is a GS–13. The Center for Minority Veterans 

in Washington, DC, has little to no credibility with American Indian veterans, and 

for good reason: They seldom visit the reservations. I conclude this report by stating 

sadly that as the situation now stands, the American Indian veteran is the leastserved veteran in the United States by the VA and currently has no voice at the 

VA. 

Unless Secretary Shinseki, who is highly respected by American Indian veterans, 

pays special attention to this situation and directs that the VA study the plight of 

Indian veterans, or Congress changes the makeup of the Center for Minority veterans to make it more accessible, nothing will change and the American Indian veterans will continue to receive poor health and other services. 

This concludes my prepared statement Mr. Chairman. 

PREPARED STATEMENT OF CAROL WILD SCOTT, CHAIR, VETERANS LAW SECTION, 

FEDERAL BAR ASSOCIATION

The National Congress of the American Indian estimates that 22% of the Native 

American/Hawaiian and Alaskan Native population are either members or the 

Armed Services or veterans. This represents the highest level of participation of any 

identifiable group in our population in the defense of this country. The service renVerDate Nov 24 2008 16:19 Nov 22, 2010 Jkt 000000 PO 00000 Frm 00089 Fmt 6601 Sfmt 6621 H:\ACTIVE\110509.TXT SVETS PsN: PAULIN
86 

dered to this Nation is freely given by sovereign peoples among us chiefly out of 

patriotism and the warrior tradition. 

All veterans, including Native American veterans are entitled to a wide range of 

benefits and services as a result of their military service. Native American/Hawaiian 

and Alaskan Native veterans have less access to and thus receive far fewer, VA benefits and services than does the veteran population as a whole. Native American 

veterans who live west of the Mississippi and in Alaska live in great part on reservations. They do not have access to VA health care or meaningful access to the 

Veterans Benefits system though which they may seek the health care to which they 

are entitled. Accordingly, there are far fewer appeals taken from denial of pension 

and compensation. 

The estimates of the incidence of PTSD in the population of Vietnam and Southwest Asia veterans as a whole range around 50%. For many reasons grounded in 

cultural and economic circumstances, this may be a low estimate in Native American veterans. Neither VA nor IHS provides effective treatment modalities for these 

veterans. With very few exceptions, there is no culturally compliant therapy available to Native American veterans and their families, particularly in dealing with the 

secondary effects of PTSD presenting as self-medication, domestic violence and suicide. Native American women veterans particularly receive nowhere near the mental health care they need for Military Sexual Trauma (MST). Nor do they receive 

the other medical care they need for service related trauma and illnesses from either VA or IHS. Despite the existence of the MOU of 2003 between DVA and IHS 

there is insufficient effective interface between IHS and VA health care systems. 

Traditionally, Vet Centers, in urban and suburban settings have provided counseling and treatment for PTSD and other mental health issues. There is currently 

legislation pending to expand the number of these centers. The creation of ‘‘Traditional Tribal Vet Centers’’ (Centers) on the reservations, conjoined and complementing existing IHS facilities, would address a wider range of issues for the Native 

American veterans than those in urban and suburban settings. 

These Centers would be a cooperative enterprise between DVA, IHS and the Tribal governments, fully implementing the MOU of 2003 between IHS and DVA. 

Through the Centers Native American veterans would receive mental health services from Western and Traditional Healing practitioners. The availability and presence of both modalities would provide documentation for benefits purposes. In addition to the mental health services, the VA/IHS cooperation would provide readily 

available attention for medical issues arising from such matters as TBI, wound care, 

damaged prostheses as well as medication. Such issues, once identified would then 

be referred into the clinic/VAMC system. Native American women veterans would 

particularly benefit from the availability of mental health and medical care in this 

setting. Family counseling and training for family care givers for severely wounded 

veterans should also be available through these Centers. 

The availability of adequate medical care is dependent on the grant of service connection for injuries, illness and diseases incurred in or the result of military service. 

Not only must the grant of compensation be appropriate, but the rating must be 

adequate. The presence of trained representatives designated as such by the Tribal 

Councils, and most importantly, accredited and certified to the Agency on the same 

footing as state and county employees is critical to the adequate utilization of the 

Centers. This status is not provided for in the current regulatory scheme, and would 

require modification of 38 CFR Sect. 629.14(2), which currently provides only for 

state and county employees, thus by definition excluding Tribal Veterans Representatives (TVRs) as designees or employees of a sovereign entity. 

The innovative concept of ‘‘TVRs’’ was designed and implemented by James R. 

Floyd, currently Network Director of VISN 15 in Kansas City, MO. This was an effort to provide Native American veterans with a trustworthy emissary to assist in 

seeking benefits and dealing with the VA benefits and health care bureaucracy. The 

drawback is that the TVRs lack accreditation and all training is done by VA, which 

gives rise to inherent conflict of interest issues as well as a wholly unintended contribution to the inadequacy of representation because the TVRs function largely as 

intermediaries rather than accredited representatives. Provided with a training program independent of VA, culminating in accreditation to the Agency, the TVRs 

would make a tremendous contribution to the meaningful availability of compensation and benefits to Native American/Hawaiian and Alaskan Native Veterans. 

An important issue relating to the needs of Native American veterans is trust, 

or lack of it. There is a profound reluctance to discuss matters related to combat 

with anyone; including members of the same tribe. A long history of racism, distrust 

of governmental entities, and an unwillingness to approach representatives of governmental entities exacerbate the situation. Intergovernmental cooperation in establishing Traditional Tribal Native American Vet Centers would provide at least some 

87 

solutions. The establishment of an Office of Native American Affairs within the Department of Veterans Affairs would further considerably the development of programs and services for Native American/Hawaiian and Alaskan Native veterans. 

The Veterans Law Section of the Federal Bar Association urges your recognition 

of the profound needs of these veterans, and consideration and adoption of the 

measures discussed herein. The views and proposals discussed herein are those of 

the Veterans Law Section and not necessarily those of the Federal Bar Association 

as a whole. 

88 


115NPAHB1.eps
89 


115NPAHB2.eps
90 


115NPAHB3.eps
91 

Æ 


115NPAHB4.eps