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[Senate Hearing 114-185]
[From the U.S. Government Publishing Office]

 
     DEPARTMENT OF THE INTERIOR, ENVIRONMENT, AND RELATED AGENCIES 
                  APPROPRIATIONS FOR FISCAL YEAR 2016

                              ----------                              

                       WEDNESDAY, MARCH 11, 2015

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:07 a.m., in room SD-124, Dirksen 
Senate Office Building, Hon. Lisa Murkowski (chairwoman) 
presiding.
    Present: Senators Murkowski, Cochran, Daines, Cassidy, 
Udall, and Tester.

                       DEPARTMENT OF THE INTERIOR

                         INDIAN HEALTH SERVICE

STATEMENT OF DR. YVETTE ROUBIDEAUX, SENIOR ADVISOR TO 
            THE SECRETARY FOR AMERICAN INDIANS AND 
            ALASKA NATIVES

              OPENING STATEMENT OF SENATOR LISA MURKOWSKI

    Senator Murkowski. I will call to order the meeting of the 
Interior Appropriations Subcommittee. Welcome to Dr. 
Roubideaux. We understand that Mr. McSwain will be joining us 
shortly, but he along with apparently many in Washington, DC, 
this morning have been delayed due to traffic issues. So when 
he comes in, we are not going to count this as a tardy. We know 
he is making good efforts to be here. Appreciate members of the 
subcommittee joining us for our second hearing of the Interior 
Appropriations Subcommittee for fiscal year 2016.
    Today we are going to examine the budget request for the 
Indian Health Service (IHS). I want to thank Dr. Roubideaux, 
our senior advisor to the Secretary for American Indians and 
Alaska Natives, and then Mr. McSwain, the acting director of 
IHS, for appearing before us today.
    Briefly, just a reminder in terms of how we proceed here in 
the subcommittee, it is early bird rule for recognizing members 
for questions. I am going to call on members in the order in 
which they have arrived, and we will do 6-minute rounds. I see 
that Mr. McSwain has arrived. We are glad that you are here 
safely. And as I mentioned, there is no--you do not have to get 
a tardy excuse to show up here. We appreciate the efforts that 
you made, and hopefully you will have a minute here to just 
settle before we move to statements and questions.
    As I noted in my opening statement last week in this 
subcommittee, we have not marked up an interior bill in 5 
years. And likewise, it has been over 5 years since we have 
done a hearing on the IHS budget, so this hearing is long 
overdue. With over half of the federally-recognized tribes in 
Alaska and all healthcare delivered by tribal organizations 
through compacting agreements, it is impossible for me to 
overstate the significance of the Indian Health Service to the 
people of my State. And I know that Senator Udall also shares 
my view of the importance of this Agency, so I look forward to 
us exercising more oversight over IHS while we serve as 
chairman and ranking member of this subcommittee.
    Now, turning to the budget request for the Service, it is 
$5.1 billion for the programs within this subcommittee's 
jurisdiction. This is an increase of $461 million, which is 10 
percent over last year's enacted level. There are some very 
worthy increases in this budget that I certainly support. I 
support the increase of $55 million more to fully pay contract 
support costs, and $100 million more to address the $2 billion 
backlog on the current Healthcare Facilities Construction List. 
I also support the additional $25 million request to provide 
for suicide prevention and combatting substance abuse among our 
native youth.
    But as I have said at all the budget hearings that I have 
chaired, whether in this subcommittee or on the Energy 
Committee, the administration developed these budgets assuming 
that sequester would go away in fiscal year 2016. I do not 
think that this is an assumption that we can make. Even if 
there is some agreement related to the sequester, we cannot 
assume the agreement will provide the amount of resources that 
the President has requested governmentwide.
    Regardless of whether there is an overall agreement related 
to the sequester, I am committed to working with the Budget 
Committee to provide sequester relief for the IHS in the same 
fashion as the relief that is provided to the Veterans 
Administration (VA). I believe that all Federal healthcare 
providers should be placed on equal footing, particularly when 
the VA and the IHS work cooperatively to provide services to 
both veterans and Native Americans at their respective 
facilities.
    So while I appreciate the desire to increase funding to 
meet our obligations to native people, the reality is that in 
this difficult budget climate, we are likely to have roughly 
the same amount to spend as we did last year. And because that 
is the case, it is vital that we work closely with the Service 
in establishing priorities within this tight environment.
    I do want to raise a proposal in your budget that concerns 
contract support costs. You are aware how critical funding of 
these costs is to Alaska healthcare providers as they have 
compacted to provide all healthcare services for Alaska 
Natives. In fiscal year 2014, the administration proposed 
capping the amounts available for tribes for contract support 
costs. I believe that proposal was an effort to circumvent the 
tribes' victory in the Ramah case decided by the Supreme Court. 
And thankfully my colleagues on both sides of the aisle and in 
the House and Senate determined that this was not the right 
approach. We rejected that proposal.
    In the Service's current budget proposal, the 
administration has announced it will not only pay full contract 
support costs for the current fiscal year at a cost of $718 
million, but also that beginning in fiscal year 2017, contract 
support costs would become mandatory spending for 3 years. Now, 
frequently this administration has made general statements 
about providing mandatory funding for certain programs, but 
after making the statements, it fails to send up a legislative 
proposal. When it comes to this particular issue, your budget 
request does not have any specific legislative language. When 
we get to the questions that is something I want to explore in 
greater detail.
    As an appropriator, I am generally not a supporter of 
moving programs to the mandatory side of the ledger where they 
do not have to compete with other priorities each year. 
However, the Supreme Court in the Ramah case essentially made 
contract support costs an entitlement. And as appropriators, we 
have no discretion over what amounts to include in this bill 
because the Congressional Budget Office (CBO) scores are billed 
based on whatever Agency says are full support costs. So given 
the circumstances, I think that exploring mandatory funding and 
figuring out a way to responsibly pay for it is entirely 
appropriate.
    So, again, I thank our witnesses for being here. I turn to 
Ranking Member Udall for any comments that he may make.

                     STATEMENT OF SENATOR TOM UDALL

    Senator Udall. Good morning, and let me--I first want to 
welcome Dr. Roubideaux and Acting Director McSwain, and thank 
you for joining us today. And we really appreciate you coming 
to discuss the fiscal year 2016 budget request for the Indian 
Health Service.
    And I would also like to thank Chairman Murkowski for 
convening this important hearing. It has been many years since 
this subcommittee has held a hearing on the Indian Health 
Service budget, and I want to acknowledge her leadership in 
elevating this conversation. Healthcare for American Indians 
and Alaska Natives is an important issue, and I thank you for 
giving it the attention it deserves. And just like she said, it 
is a burning issue in New Mexico, and it is also one, as she 
has expressed, in Alaska, and it certainly deserves our 
attention.
    Access to quality healthcare is incredibly important for 
the 22 tribes and pueblos in my State, but there is more to it 
than that. Throughout the Nation's history, the United States 
has made a solemn commitment to provide healthcare through the 
treaties and agreements negotiated with the tribes. We have to 
honor that commitment. Support for the budget of the Indian 
Health Service helps ensure that we do that.
    Congress has stepped up and provided significant increases 
for tribal health programs over the past several years, but we 
clearly have a lot of work to do, and we will do more. The 
President's budget for the Indian Health Service includes a 10 
percent increase for health services and facilities needs, and 
I am pleased to see that. Dr. Roubideaux, I want to commend the 
administration for fully funding contract support costs, which 
I know Chairman Murkowski also mentioned, and I look forward to 
discussing your proposal to authorize mandatory funding for the 
program starting in 2017.
    The budget request also proposes an increase of $70 million 
for purchased and referred care. These funds ensure that tribes 
can access healthcare outside of the Indian Health Service, 
including preventive and specialty care. The request also 
includes new substance abuse and behavioral health investments 
for Native youth, which I look forward to discussing. And 
finally, it includes large increases for healthcare 
construction and maintenance programs. These funds are 
critically needed to repair aging hospitals and health clinics 
like those we have in my home State of New Mexico.
    This is a good budget request, but it is worth noting that 
it is only a downpayment on the needs in Indian country. Tribal 
health spending per patient continues to lag behind the 
national average for health spending. The average medical 
spending per IHS patient, according to the Indian Health 
Service, was just $3,100 in 2014. That is less than half the 
average amount spent per patient for health services on a 
national basis, according to the Centers for Medicare and 
Medicaid Services. These funding limitations are a major factor 
in health disparities faced by our Native population, including 
higher rates of diabetes, suicide, and preventable illnesses.
    We need to close this gap, and we need to close it now. 
That is why I look forward to hearing more about the details of 
how your budget can improve health outcomes. And health 
outcomes, I think we really need to be discussing more and more 
because that is what we want to see, Dr. Roubideaux. I 
appreciate you and Mr. McSwain appearing before us today, and 
thank Chairman Murkowski for working so hard on this issue.
    Senator Murkowski. Thank you, Senator Udall. I would now 
like to turn to Chairman Cochran. I understand that you have 
other committee obligations this morning, and you might like to 
make a quick opening statement before you depart the 
subcommittee.

                   STATEMENT OF SENATOR THAD COCHRAN

    Senator Cochran. Madam Chair, thank you very much. I am 
glad to be able to join you in welcoming our distinguished 
panel of witnesses this morning. Our friend who is the ranking 
member of the subcommittee, I think you have done an excellent 
job in outlining the issues that we need to be aware of and 
making a commitment that we do what is necessary to ensure that 
we continue to make available healthcare, and healthcare 
services, and related assets to be sure that the Indian Health 
Service is able to carry out its responsibilities.
    Our State, as some may know, is home to the Mississippi 
Band of Choctaw Indians. This week coincidentally marked an 
important milestone in our State as the Indian Health Service 
moved into their new health center in Mississippi. I am happy 
to join you in commending all of those responsible for the good 
work, and to thank the subcommittee for its support in this 
effort.
    I am hopeful we can continue to work together to ensure 
that the healthcare needs of Choctaws and others are enjoyed 
and benefitted as we intend. Thank you very much.
    Senator Murkowski. Thank you, Senator Cochran. And with 
that, I would like to turn to Dr. Roubideaux this morning for 
your opening comments, and welcome.

               SUMMARY STATEMENT OF DR. YVETTE ROUBIDEAUX

    Dr. Roubideaux. Thank you, Chairman Murkowski and members 
of the subcommittee. I am Dr. Yvette Roubideaux, the senior 
advisor to the Secretary for American Indians and Alaska 
Natives, and with me today is Mr. Robert McSwain, who is the 
acting director of the Indian Health Service. I am pleased to 
provide testimony on the President's fiscal year 2016 budget 
for the Indian Health Service.
    Well, since 2008, Indian Health Service appropriations have 
increased 39 percent, and thanks in part to your subcommittee 
for that hard work in helping us achieve those investments 
because they are making a substantial difference and impact in 
the quality and quantity of healthcare provided to American 
Indians and Alaska Natives. The fiscal year 2016 President's 
budget proposes to continue that progress by increasing the IHS 
budget by $460 million to a level of $5.1 billion, which, if 
appropriated, would increase the IHS budget by 53 percent since 
2008. So this budget continues the administration's commitment 
to improving healthcare for American Indians and Alaska 
Natives.
    So the budget proposes increases totaling $147 million to 
help address medical inflation, population growth, and pay 
costs to help maintain current services. The budget also 
addresses a top tribal priority by proposing an overall $70 
million increase in the Purchase and Referred Care Program, 
formerly known as Contract Health Service, which will help us 
fund more referrals for patients and result in more programs 
funding more than priority one life or limb services. And the 
recent increases in PRC have also enabled the Catastrophic 
Health Emergency Fund, or CHEF Fund, to reimburse high cost 
cases submitted through mid-September rather than only through 
June as in the past.
    The budget proposes an additional $25 million for the IHS 
to expand its successful methamphetamine and suicide prevention 
initiative to increase the number of child and adolescent 
behavioral health professionals, who will provide direct 
services and implement youth-based programming as a part of the 
President's Generation Indigenous Initiative.
    The budget also includes other increases focused on 
improving access to affordable healthcare, including improving 
third party collections, and helping IHS continue to achieve 
meaningful use of its electronic health record. The budget 
proposes to reauthorize the successful Special Diabetes Program 
for Indians, or SDPI, for another 3 years at the current $150 
million funding level to continue progress on preventing and 
treating diabetes in American Indians and Alaska Natives.
    The budget includes significant investments in IHS 
facilities, including increases for maintenance and 
improvement, sanitation facilities construction, and healthcare 
facilities construction, which will help us make significant 
progress on the IHS healthcare facilities construction priority 
list. The budget proposes $18 million to fund additional 
staffing for three newly constructed facilities that are 
opening just prior to or in fiscal year 2016.
    A top priority of IHS is to strengthen the partnership with 
tribes, and I truly believe that the only way we are going to 
improve the health of these communities is to work in 
partnership with them. This includes honoring and supporting 
tribal self-determination and self-governance. That is why I am 
so pleased to inform you that the fiscal year 2016 President's 
budget includes a two-part long-term approach to funding 
contract support costs, which is the result of our tribal 
consultation that was requested last year on a long-term 
solution for contract support costs appropriations.
    The first part of the approach is full funding of contract 
support costs that estimate a need in fiscal year 2016 for 
which the budget requests an increase of $55 million. The 
second part of this approach is a proposal to reclassify 
contract support costs as mandatory rather than discretionary, 
starting in fiscal year 2017 after tribal consultation and to 
allow time for Congress to work on this issue with us. The 
proposal is consistent with the top recommendation from tribes 
to fully fund contract support costs (CSC), but to do it 
separately from the Service budget.
    IHS also worked in partnership with tribes to improve 
estimates of CSC need and the Agency's business practices 
related to contract support cost funding. The proposal to 
reclassify contract support costs as a mandatory appropriation 
helps us continue progress on this issue, and we look forward 
to working with you on the proposed approach. IHS has also made 
progress on past contract support cost claims with offers 
extended on 1,232 claims and settlements on 889 claims for a 
total value of $699 million.
    So in summary, the fiscal year 2016 President's budget 
helps IHS continue progress in improving access to quality 
healthcare, changing and improving the Indian Health Service, 
and strengthens our partnership with tribes. I appreciate all 
of your efforts to help us ensure a healthier future for 
American Indians and Alaska Natives. So thank you, and we are 
happy to answer questions.
    [The statement follows:]
              Prepared Statement of Dr. Yvette Roubideaux
    Chairman Murkowski and members of the subcommittee:

    Good morning. I am Dr. Yvette Roubideaux, Senior Advisor to the 
Secretary for American Indians and Alaska Natives. Accompanying me is 
Mr. Robert G. McSwain, Acting Director of the Indian Health Service 
(IHS). I am pleased to provide testimony on the President's proposed 
fiscal year 2016 budget for the IHS and to describe our accomplishments 
that show the budgets enacted in recent years have made a difference in 
helping us address our agency mission to raise the physical, mental, 
social, and spiritual health of American Indians and Alaska Natives 
(AI/ANs) to the highest level.
    The IHS is an agency within the Department of Health and Human 
Services (HHS) that provides a comprehensive health service delivery 
system for approximately 2.2 million AI/ANs from 566 federally 
recognized tribes in 35 States. The IHS system consists of 12 area 
offices, which are further divided into 170 Service Units that provide 
care at the local level. Health services are provided directly by the 
IHS, through tribally contracted and operated health programs, through 
services purchased from private providers, and through urban Indian 
health programs.
    As an agency we are committed to ensuring a healthier future for 
all AI/AN people, and the IHS budget is critical to our progress in 
accomplishing this. Since 2008, IHS appropriations have increased by 39 
percent, thanks in part to your subcommittee, and these investments are 
making a substantial impact in the quantity and quality of healthcare 
we are able to provide to AI/ANs. The fiscal year 2016 President's 
budget proposes to increase the IHS budget to $5.1 billion, which will 
add $460 million to the fiscal year 2015 enacted funding level, and if 
appropriated, will increase the IHS budget by 53 percent since fiscal 
year 2008.
    The funding increases proposed in the President's budget are part 
of an ``all of government'' approach to addressing tribal needs, with a 
particular focus on AI/AN youth. For the IHS, the increases will help 
us improve the quality of and access to care for the patients we serve 
by expanding access to priority healthcare services that our patients 
need, which will result in better quality and health outcomes.
    The fiscal year 2016 President's budget proposes current services 
increases totaling $147 million, which are critical to maintain the 
base budgets of our IHS and tribal hospitals and clinics, help address 
medical inflation, population growth and pay costs, and ensure 
continued support of services that are vital to improving health 
outcomes.
    The fiscal year 2016 President's budget also addresses a top tribal 
priority by proposing an overall $70 million increase to the Purchased/
Referred Care (PRC) budget, formerly known as Contract Health Services. 
This increase includes $43.6 million in medical inflation, $1.2 million 
in additional staffing for new facilities and a $25 million program 
increase. PRC funding has increased almost every year since 2008 (58 
percent overall), which has allowed some of the IHS and tribally 
managed PRC programs to approve referrals in priority categories other 
than Medical Priority I--Emergent or Acutely Urgent Care Services (life 
or limb), including some preventive care services, thus increasing 
access to patient care services. In 2009, only four IHS-operated PRC 
programs were able to fund referrals that met PRC Medical Priority I. 
In fiscal year 2013, 23 IHS-operated PRC programs were able to purchase 
services beyond Medical Priority I. This number increased to 41 of 69 
IHS-operated PRC programs with the PRC increase in fiscal year 2014. 
The recent increases in PRC have also enabled the Catastrophic Health 
Emergency Fund (CHEF) to reimburse high cost cases submitted through 
mid-September, rather than only through June as in the past.
    The fiscal year 2016 President's budget proposes an additional $25 
million for the IHS to expand its successful Methamphetamine and 
Suicide Prevention Initiative (MSPI) to increase the number of child 
and adolescent behavioral health professionals who will provide direct 
services and implement youth based programming at IHS, tribal, and 
urban Indian health programs, school based health centers, or youth 
based programs. This funding will enable the hiring of more behavioral 
health providers specializing in child, adolescent, and family 
services, which will improve access to behavioral health prevention 
treatment services for AI/AN youth. This expansion of the MSPI is the 
central focus of the Tribal Behavioral Health Initiative for Native 
Youth, which is part of the President's comprehensive Generation 
Indigenous Initiative to remove barriers to success and to create 
opportunities for Native youth and reflects a collaborative effort 
between the IHS and the Substance Abuse and Mental Health Services 
Administration.
    The IHS and tribes have made progress in improving behavioral 
health over the past few years with both the MSPI and the Domestic 
Violence Prevention Initiative (DVPI). The MSPI has funded 130 IHS, 
tribal, and urban community developed programs since 2009 that have 
provided over 500,000 evidence-based and practice-based youth 
encounters in the first 5 years of MSPI implementation. The successes 
of the MSPI highlight the effective use of strength-based interventions 
and protective factors, such as identification with Native culture, 
increased social connectedness, and discussing problems with friends or 
family, emotional health, and connectedness to family, consistent with 
the scientific literature on prevention of suicide and substance abuse 
among AI/AN youth. The increase in services is significant; the percent 
of individuals receiving depression screening in IHS and tribal 
facilities increased from 35 percent in fiscal year 2008 to 66 percent 
in fiscal year 2014.
    The DVPI currently funds 57 projects focusing on prevention, 
intervention, and treatment of domestic and sexual violence. Together 
these services have resulted in 50,500 direct service encounters, more 
than 38,000 referrals, and the delivery of over 600 forensic evidence 
collection kits submitted to Federal, State, and tribal law 
enforcement. These are vital services. According to a 2014 Centers for 
Disease Control and Prevention report, American Indian women residing 
on Indian reservations suffer domestic and sexual violence at rates far 
exceeding women of other ethnicities and locations. Native women are 
over 2.5 times more likely to be raped or sexually assaulted compared 
to other women in the United States.
    The fiscal year 2016 President's budget also includes other 
increase focused on improving access to affordable healthcare. With the 
Affordable Care Act's Health Insurance Marketplaces and the Medicaid 
expansion, IHS has the potential to increase revenues to support more 
services through third party reimbursements when it provides services 
to eligible American Indians and Alaska Natives with other health 
insurance coverage. The fiscal year 2016 President's budget includes a 
$10 million funding increase to improve third party billing and 
collections at IHS and tribally operated facilities. Having more 
patients who are Medicaid beneficiaries or have private insurance is 
one part of increasing revenues for our hospitals and clinics. 
Improving our business practices to ensure timely and accurate billing, 
monitoring of open receivables, and follow up on unpaid bills is 
another critical component on which IHS has made progress. In fiscal 
year 2014, IHS third party collections increased by $49 million, mainly 
due to improvements in business practices and from increased third 
party reimbursements from patients with health coverage.
    Another important component necessary to improving quality and 
ensuring better outcomes for our patients is an effective, state-of-
the-art health information technology system that helps us measure 
outcomes and provide better patient care. That is why we continue to 
upgrade the capabilities of our IHS Resource and Patient Management 
System (RPMS), which includes IHS' Electronic Health Record (EHR). The 
fiscal year 2016 President's budget will help IHS to comply with the 
requirements for the 2015 EHR Certification and Stage 3 Meaningful Use 
(MU). Participation in MU is critical for the agency since it promotes 
activities to improve quality and penalties in Medicare payments will 
occur if IHS does not participate.
    IHS has implemented several major upgrades related to the 
Meaningful Use (MU) initiative. The IHS was an early adopter of EHR 
technology and achieved certification for Stage 1 Meaningful Use, 
resulting in the IHS and tribal health systems receiving over $120 
million to date from the MU incentives. IHS recently received 
certification for the 2014 Certified EHR and is developing upgrades 
that will include the ability to achieve Meaningful Use Stage 2, which 
includes the ability to share records between facilities, have patients 
view their health records online, and even have patients send direct 
secure email to providers. IRS is also preparing to implement ICD-10 
which can now proceed since IHS met the 2014 EHR Certification 
requirements. The IHS RPMS team is currently conducting testing of ICD-
10 software upgrades with four sites and with external payers. We are 
on track to meet the ICD-10 implementation date of October 1, 2015 and 
plan to begin upgrading local RPMS systems in June.
    Another successful program that is helping us improve the provision 
of quality healthcare is our Special Diabetes Program for Indians 
(SDPI). The fiscal year 2016 President's budget proposes to reauthorize 
the SDPI for another 3 years at the current $150 million funding level 
to continue progress in preventing and treating diabetes in the AI/AN 
population. This program has shown that, in partnership with our 
communities, we can prevent and treat diabetes in Indian Country with 
innovative and culturally appropriate activities. The most recent SDPI 
data reflect improvements in diabetes care throughout our system. For 
example, the rate of increase in diabetes prevalence in adults is 
slowing and there is almost no increase in diabetes prevalence in 
youth. In addition, the most recent outcomes paper for the SDPI 
Diabetes Prevention Program (DPP) suggests that the DPP may reduce new 
cases of diabetes through lifestyle changes. Preventing diabetes, 
especially among Native youth, is important since it will help them 
avoid a lifetime of diabetes and related health problems.
    Ensuring access to healthcare requires efficient and effective 
facilities and infrastructure, which contribute to improving public 
health and health outcomes. The fiscal year 2016 President's budget 
includes significant investments in IHS facilities, including increases 
for maintenance and improvement, sanitation facility construction, and 
healthcare facility construction. Since 2008 the IHS has maintained the 
facility condition of its healthcare facilities, provided sanitation 
facilities service to 159,990 Indian homes, funded 2 hospitals, 6 
health centers, and 2 youth regional treatment centers, and 
participated with tribes in 12 joint venture projects. However, the 
backlog of essential maintenance, alteration, and repair is $467 
million as of the end of fiscal year 2014, over 34,500 AI/AN homes are 
without access to safe water or adequate wastewater disposal facility 
infrastructure and over 182,500 AI/AN homes that require upgrades and/
or capital improvements to the existing sanitation facilities, and 
there remains $2 billion of construction projects still to construct on 
the IHS Health Care Facilities Construction Priority List.
    The fiscal year 2016 President's budget proposes an additional $171 
million for the Facilities appropriation to address these needs. 
Included is $35 million to address the maintenance backlog and $36 
million to provide sanitation facilities to 7,700 more homes than 
estimated to be served in fiscal year 2015. In addition, the healthcare 
facilities construction budget is proposed to be increased by $100 
million for a total funding level of $185 million, which will enable 
the IHS to complete construction of the Gila River Southeast Health 
Center, and begin construction on three other projects on the IHS 
Health Care Facility Construction Priority List including the Salt 
River Northeast Health Center in Arizona, the Rapid City Health Center 
in South Dakota, and the Dilkon Alternative Rural Health Center in 
Arizona.
    Additional staffing for newly constructed facilities is critical to 
achieving the planned increased access to healthcare. The fiscal year 
2016 President's budget proposes to fund all three of the projects that 
are opening just prior to or in fiscal year 2016. The requested amount 
is $18 million to complete the staffing packages for the Southern 
California Youth Regional Treatment Center and the Mississippi Band of 
Choctaw Indians' joint venture health center, and to begin funding of 
the staffing package for the Fort Yuma Health Center.
    A top priority of the IHS is to strengthen our partnership with 
tribes. I truly believe that the only way that we are going to improve 
the health of our communities is to work in partnership with them. This 
includes honoring and supporting tribal self-determination and self-
governance. That is why I am pleased to inform you that the fiscal year 
2016 President's budget includes a two-part, long-term approach to 
funding Contract Support Costs (CSC), which is the result of our tribal 
consultation that you requested last year on a long-term solution for 
CSC appropriations. The first part of the approach is full funding of 
the estimated CSC need in fiscal year 2016, for which the budget 
requests an increase of $55 million.
    The second part of the approach is a proposal to reclassify CSC as 
mandatory, rather than discretionary, starting in fiscal year 2017, 
after tribal consultation in fiscal year 2016. The reclassification of 
CSC as mandatory would be authorized for a 3-year period that specifies 
annual amounts that fully fund the estimated CSC need for each year for 
fiscal years 2017-2019. This proposal is consistent with the top 
recommendation in fiscal year 2014 from tribes to shift CSC to a 
mandatory account as the long-term approach to fully funding CSC, and 
will accomplish the top tribal recommendation to fully fund CSC 
separately from the services budgets.
    In the past year, IHS has worked in partnership with tribes to 
improve estimates of CSC need and the agency's business practices 
related to CSC appropriations. IHS has also made progress on past CSC 
claims, with offers extended on 1,232 past CSC claims and settlements 
on 889 claims for a total value of $699 million. The fiscal year 2016 
President's budget proposal to move CSC to a mandatory appropriation 
helps us continue progress on this issue which is a top priority of 
tribes and we look forward to working with you on this proposed 
approach.
    I want to close by emphasizing that even with all the challenges we 
face, I know that, working together with our partners in Indian Country 
and Congress, we can continue changing and improving the IHS to better 
serve tribal communities. The fiscal year 2016 President's budget helps 
IHS continue progress on improving access to quality healthcare and 
strengthens our partnership with tribes. I appreciate all your efforts 
in helping us provide the best possible healthcare services to the 
people we serve, and in helping to ensure a healthier future for 
American Indians and Alaska Natives.
    Thank you and I am happy to answer any questions you may have.

    Senator Murkowski. Thank you, Dr. Roubideaux. I understand 
that, Mr. McSwain, you are not going to be providing a 
statement. You are just here to answer questions as we hand 
them your way.
    Mr. McSwain. That is very correct. As they come to me.
    Senator Murkowski. Great.
    Mr. McSwain. We have got it worked out as to which 
questions I may ask or answer and which ones that she will 
answer.

                         CONTRACT SUPPORT COST

    Senator Murkowski. We will see where they go from here. I 
am going to start where you left off, Dr. Roubideaux, and this 
relates to the contract support costs. You have outlined what 
the administration is prepared to do with full funding and 
mandatory beginning in 2017. And I appreciate you putting that 
statement before the subcommittee here this morning.
    As I mentioned in my opening statement, oftentimes what we 
will get is we will get the statement of general support, but 
then we do not see an actual legislative proposal. Do you plan 
to send the Congress a proposal for contract support costs, and 
if so, when?
    Dr. Roubideaux. Well, the Congressional Budget 
justification includes the details for the main components of 
the proposal. And we did not want to give a detailed proposal 
because we wanted to take the time to work with Congress and 
the tribes on it and give time for consultation.
    But basically, the proposal to reclassify in 2017 is to 
make contract support costs a mandatory authorization for 3 
years with amounts for each of those 3 years that would aim to 
fully fund contract support costs, and they are set at levels 
high enough to make sure we have enough funding to do that. And 
then it would allow for revisiting the estimates and 
reauthorizing every 3 years.
    Senator Murkowski. I understand that, but I also recognize 
that given the timeline, this all happens after this 
administration is no longer in place, and so that is why I am 
curious as to whether or not we are actually going to see that 
proposal. As you have outlined, the cost for contract support 
in 2017, 2018, then in 2019--have PAYGO offsets been identified 
for the new mandatory spending?
    Dr. Roubideaux. While there is no specific PAYGO 
identified, all the proposals in the fiscal year 2016 
President's budget are paid for in the context of the budget in 
savings and investments for both fiscal year 2016 and proposals 
in the out years as well.
    Senator Murkowski. So for the proposals in 2017, 2018, 
2019, you do have that addressed in our proposal.
    Dr. Roubideaux. The overall President's budget addresses 
that through savings and other investments.
    Senator Murkowski. Just a question as to why a 3-year 
period. Why is the proposal not to make the program mandatory 
permanently? What is the magic there?
    Dr. Roubideaux. Well, we are eager to discuss this proposal 
with you, and did consider all options. This is the proposal 
that the administration is putting forward, but we do want to 
discuss it with you. And we are eager to fix this. We want to 
get full funding and contract support costs, that policy to 
continue, and we wanted to take time. As you mentioned before, 
people were mad about that proposal in 2014. Now we are 
providing time for people to actually come up with a proposal 
that can work for all of us.

                         VILLAGE BUILT CLINICS

    Senator Murkowski. Well, and it is something that if we are 
kind of revisiting this every 3 years, that can be complicated, 
too. So I will look forward to discussing it more with you.
    I am going to bring up an issue that is pretty consistent 
every time you and I visit through these hearings, and that is 
as it relates to village built clinics. I think you know how 
strongly I feel about this issue. There are about 150 village 
built clinics in the State of Alaska. Most of them are 
effectively the only local option for healthcare, have serious 
maintenance needs. And yet the Agency's view is that the tribes 
are responsible for paying the costs out of other funds that 
they get from IHS. I probably hear more about this issue than 
almost anything else when I am out in the villages. Can you 
tell me today or perhaps provide for the record what the 
projected backlog of maintenance is for the VBCs in the State?
    Dr. Roubideaux. I do not have that number with me, but we 
can go back----
    Senator Murkowski. Can you get that for me?
    Dr. Roubideaux [continuing]. And take a look at that. I 
know the tribes are looking at that as well in Alaska.
    Senator Murkowski. Well, if you can help us out with that 
information, I would appreciate it.
    [The information follows:]
    IHS routinely collects maintenance needs from IHS and tribal 
facilities and updates this list annually as the Backlog of Essential 
Maintenance and Repair (BEMAR). This priority list was developed in 
consultation with tribes from all IHS areas.
    The Village Built Clinics (VBC) are owned by the local city, 
village councils, and/or Indian Reorganization Act councils and likely 
have a backlog of maintenance, but that information has not been 
provided to the Indian Health Service, nor is it provided by any other 
vendor from whom the agency has a full service lease.
    The Alaska tribes and tribal health organizations have requested 
that funding for VBCs be increased by $8.84 million to cover operating 
and utility costs and deferred maintenance. IHS has not seen actual 
data related to this request but would be willing to review any 
information provided.

                          DEFINITION OF INDIAN

    Senator Murkowski. But I am going to ask you for what I 
have asked before, which is a commitment to work with me, to 
work with my staff, to come up with a solution to this issue. 
This is purely a budget issue, and it seems to me that there is 
no reason that we should not be able to get this resolved.
    And I am not quite sure how much more forceful and direct I 
need to be with this. We had this same conversation in 
discussion in the Indian Affairs Committee and in the 
Appropriations Subcommittee. Obviously this is the subcommittee 
that has the gavel now, so we do need to work through these 
issues. So I ask for that commitment.
    Last question for you before we move on to others, and this 
is the definition of ``Indian'' under the Affordable Health 
Care Act. This is something that I think we all know that when 
the ACA was implemented, there was not uniformity within that 
legislation that defined the term ``Indian.'' It has potential 
for, I think, significant confusion in the implementation. It 
can hurt American Indians, Native Alaskans in receiving the 
benefits to which they are entitled.
    And I have asked you to fix the issue administratively. For 
some reason it is still hanging out there. We included report 
language in the fiscal year 2015 omnibus appropriations bill 
that was pretty specific. It said, ``The committee, therefore, 
directs the Department of Health and Human Services, the IHS, 
and the Department of Treasury to work together to establish a 
consistent definition of an Indian for purposes of providing 
health benefits.'' So where are we? Have we resolved this? What 
has IHS done in response to this directive in the omnibus?
    Dr. Roubideaux. Well, we are as concerned about it as you 
are, and we actually have been working as hard as we can on it. 
We have done as much as we can do administratively, and the 
determination was that a legislative fix was needed. We 
actually worked with tribes on language, and we gave technical 
assistance to the Finance Committee.
    We do want to work with you on this. We do want to find a 
solution. We know so many people will benefit. And just like 
village built clinics as well, and I was glad to meet with your 
staff to start conversations about what some solutions might be 
there as well. So we really are willing to work with you on 
these issues. We understand they are very significant.
    Senator Murkowski. Well, and you need to understand my 
frustration here because the ACA was passed years ago. We 
identified this as an issue and a problem, and we were told do 
not worry about it because this part of the ACA does not go 
into play until 2015. Well, we are now in 2015. We are now in a 
situation where I am having Alaska Natives coming and saying, 
well, have you guys cleared this up? What is the status? What 
is going on? And now you are sitting in front of me telling me 
it is going to require a legislative fix when you have said all 
along we should be able to resolve this administratively.
    In the meantime, you have got Alaska Natives and American 
Indians that are caught up in this great washing machine of the 
ACA. This is not fair to them. This is not right. I think that 
we can do an administrative fix. And, you know, you look at the 
other areas that this executive has chosen to wave the magic 
wand, and rectify, or push back or do something to help. Well, 
if we cannot figure out how we are going to help our native 
people with this kind of self-inflicted confusion here, that is 
a shame to them. So we have got to address this.
    Dr. Roubideaux. Well, we definitely want to keep looking 
for solutions. We agree with you that this is a really 
challenging problem for the American Indians and Alaska Natives 
who do not fit the current definitions in law. So we would 
definitely like to find some solutions and continue working on 
it with you.
    Senator Murkowski. Well, know that I am going to be 
conferring directly with the Secretary of Health and Human 
Services and at Treasury to determine--there has got to be a 
way to fix this short of legislation. I have gone well over my 
time, and I apologize.
    Senator Udall. Chairman Murkowski, I am going to defer and 
allow Senator Tester to go on this round.

                     VA MEMORANDUM OF UNDERSTANDING

    Senator Tester. Thank you, Ranking Member Udall, and thank 
you, Chairman Murkowski. I would just say from the opening 
comments I look forward to working with everybody on this 
subcommittee, especially, Madam Chairwoman, to get sequester 
relief for Indian tribes. I do not know how we are going to do 
that and stay under the caps, but we will do what we can do 
because I think it is important with our trust responsibilities 
we have to Indian country.
    I want to talk about the VA for a second to Indian Health 
Service. You have, I believe, 65 memorandums of understanding 
out there with--the VA has 65--you do not have--they have 65 
memorandums of understanding with the Indian Health Service. Do 
you anticipate more coming up this year, and if so, how many?
    Dr. Roubideaux. Well, with regards to the reimbursement 
agreement, all the Federal facilities have agreements in place, 
and it is the tribal facilities where there are 65 agreements. 
And we are definitely hopeful that the VA will continue to 
enter into agreements with tribes directly on that.
    Senator Tester. Okay. And in that regard, who is the point 
of contact for Indian Health Service for the VA to set up these 
agreements?
    Dr. Roubideaux. On the VA to set up the----
    Senator Tester. Agreements with Indian Health Service.
    Dr. Roubideaux. The agreements are all set up with the 
Indian Health Service on the reimbursement part.
    Senator Tester. Yes, but who?
    Dr. Roubideaux. Dr. Susan Karol is our lead for the VA work 
that we do. And we also have the overall memorandum of 
understanding, or MOU, on the coordination of care for veterans 
as well.
    Senator Tester. Okay. And so far, how has this worked?
    Dr. Roubideaux. Well, the best thing about the MOU over the 
past couple of years is that it has brought the VA and IHS 
together in regular meetings, and we are starting to talk about 
sharing services. We actually are sharing services, training, 
providers, telemedicine.
    Senator Tester. Do you have any figures on how much it has 
saved in reduction of duplication?
    Dr. Roubideaux. That is a good question. I can refer that 
back to IHS to maybe figure that out.
    [The Information follows:]
    The Veteran Affairs (VA) and Indian Health Service (IHS) 
partnership under the 2010 Memorandum of Understanding and the 2012 
Reimbursement Agreement has saved on reduction of duplication in many 
areas. The VA-IHS partnership utilizes doctors that are already on 
staff at either IHS or tribal health programs (THP) facilities instead 
of increasing staff at VA Community Based Outpatient Clinics (CBOC). 
Facility costs are reduced by utilizing existing facilities that 
currently receive Federal dollars instead of building or contracting 
for new facilities. The IHS has also collaborated with VA to implement 
its Central Mail Order Pharmacy (CMOP). Mailing prescriptions when they 
receive care from either the VA or IHS saves veterans on travel costs 
they otherwise would have had to incur if they had to physically travel 
to the IHS or VA facility to receive their refills. In the first 
quarter of fiscal year 2015, there was no duplication of pharmacy 
services while filling 114,377 prescriptions (all at IHS sites) which 
were transmitted to CMOP. This is equivalent to 26 percent of the 
440,575 Rx's (all at IHS sites) that were transmitted to CMOP in fiscal 
year 2014, and is equivalent to 86 percent of all of the Rx's that were 
transmitted in the first 3 years of the program in fiscal year 2010-
fiscal year 2012. The VA-IHS partnership has clearly demonstrated that 
American Indian (AI) and Alaskan Native (AN) Veterans are utilizing 
IHS/THP facilities in increasing numbers. This partnership will lead to 
increased positive effects beyond the Memorandum of Understanding (MOU) 
for the IHS/THP facilities and their non-Veteran patients due to 
increased customer utilization and funding. The VA has also paid the 
IHS and tribal programs with reimbursement agreements approximately $15 
million to date for veterans receiving direct services at IHS and 
tribal facilities. Again, veterans are saving on transportation costs 
to the VA if they can be seen more locally in the IHS or tribal 
facility. All of these areas where duplication has been reduced clearly 
benefit the veteran by improving access to and coordination of care.

    Senator Tester. I would love to have that because that is 
the goal. The goal is you are serving the same population, 
Native Americans serve at a higher rate than any other minority 
in the Services, and so you are serving the same population, 
and the goal is to make the money run further for other folks.
    Dr. Roubideaux. Well, the one data that we do have is on 
the reimbursement agreement.
    Senator Tester. Yes.
    Dr. Roubideaux. Since it has been put in place in all the 
Federal facilities and with the tribal facilities to date, we 
have received a total of $17.8 million of payments from the VA, 
which help us expand services.

                          THIRD PARTY BILLING

    Senator Tester. Okay, that is good. I want to talk about 
third party billing. I had a hearing in Billings, Montana, I do 
not know, eight or 9 months ago, 10 months ago. And it was 
apparent that a lot of the local providers were not utilizing 
third party billing, and there was a lot--I mean a lot--of 
dollars being left on the table that could be brought into 
Indian Health Service, could be utilized to help expand your 
purview in Indian country. Are you doing anything about 
educating the local providers on how to third party bill?
    Dr. Roubideaux. Absolutely. So related to third party 
collections, when we--well, it goes both ways. When we provide 
the services, we are billing Medicare and Medicaid and private 
insurance to pay for us. When we refer out to other providers, 
then we work on the payments to them. We have done a lot to 
improve both of those business processes over the last few 
years, and in terms of third party collections, in the last 
year we were able to increase them by $49 million through a lot 
of improvements in the process.
    Senator Tester. So the question is, what are you doing to 
help those local providers, the one in Fort Peck, for example, 
that provides a service? There is insurance money out there. 
They are not getting it.
    Dr. Roubideaux. Oh, local, the local Indian health 
providers, yes.
    Senator Tester. Yes. Are you able to do anything?
    Dr. Roubideaux. Yes, absolutely. We have been providing 
technical assistance. We have developed a third party 
collections tool that monitors collections every month, and so 
if there are any problems, we can help them.
    Senator Tester. And how is that being received? Is it being 
received well?
    Dr. Roubideaux. I have heard it is being received well 
because what it means is people are getting more dollars to 
provide services locally.
    Senator Tester. That is right. So how much do you think is 
still being left on the table? You said it has been increased 
by 40-some----
    Dr. Roubideaux. Forty-nine million dollars last year.
    Senator Tester. How much do you think is still out there to 
be gotten?
    Dr. Roubideaux. It is hard to estimate, but it could be a 
lot more with Medicaid expansion in those States that expanded, 
with private insurance now with the Affordable Health Care Act, 
and with just the overall making sure that we are following up 
on the bills, making sure that we are addressing open 
receivables, making sure that we are getting the bills paid so 
that we have the revenues.

                           IHS STRATEGIC PLAN

    Senator Tester. Okay. When I talk to Indian country, I can 
tell you that, and it really has not changed much in the last 8 
years. The big concern is healthcare, and it is still the big 
concern. Sometimes you guys are a scapegoat, and sometimes it 
is warranted when it comes to finger pointing. Is there a 
strategic plan in place to move forward and change the 
perception of IHS in Indian country, and if so, when is going 
to be implemented, or has it already been implemented?
    Dr. Roubideaux. Well, the overall plan to change and 
improve the IHS over the past several years has been to try to 
work closer with the tribes that we serve. I mean, the first 
step is to work with our customers, and the first step is to 
try to meet their needs. You know, we are in the business of 
healthcare, to try to improve those communications. And we have 
been able to improve that at the national area levels, and now 
the focus is improving that at the local level. That is the 
first step really in improving the overall----
    Senator Tester. Communication is critical. I want to talk 
about something else that is critical, and that is mental 
health.
    Dr. Roubideaux. Yes.

                             MENTAL ILLNESS

    Senator Tester. Mental illness in Indian country. We have 
heard that local service centers are trying to incorporate, 
from your testimony, mental health screenings and for medical 
visits, checkups, wellness care. I applaud that. Can you tell 
me how successful that has been very briefly because my time is 
out, how successful that mental health incorporation has been?
    Dr. Roubideaux. Well, it is successful for the patients so 
they do not have to go other places.
    Senator Tester. Right.
    Dr. Roubideaux. In the testimony we have statistics about 
the increase in the number of people being screened for 
depression that has increased quite a bit from like the low 20s 
up into 60s.
    Senator Tester. Thank you, and thank you.
    Senator Murkowski. Thank you, Senator Tester. Senator 
Daines.

                             REIMBURSEMENTS

    Senator Daines. Thank you, Madam Chairman. Director 
McSwain, according to Northern Cheyenne tribal leaders we spent 
some time with, IHS owes over $2 million to the Northern 
Cheyenne members for healthcare received from non-IHS 
providers. Some of these tribal members get in trouble with 
bill collectors. They have got to put off paying other bills in 
order to pay healthcare costs that should be reimbursed by IHS. 
My question is, what is IHS doing to make reimbursements clear 
and understandable for the average patient who is juggling 
work, kids, and other responsibilities?
    Mr. McSwain. Thank you, Senator Daines. What we are doing 
on several fronts, and it is something that Dr. Roubideaux just 
mentioned, which is the education program that we have put in 
place. I know that we have a new acting director up in Billings 
who has really been doing some great things about orientation 
of the hospitals--she is a hospitals expert--and to really get 
out and talk to the providers.
    What we are finding out is people self-refer, and so we 
need to connect with the facilities that they are self-
referring to, and ensure that they are being referred to them 
for payments so we can ensure that they do not get caught 
outside of an authorization, because if they are going into a 
facility, our contracts are actually--it is now referred to as 
purchase referred care--has a set of requirements on referral, 
and a lot of it is just for maintaining continuity of care.
    Senator Daines. Do they track that number? Is that 
something--is a metric that people look at, and have you 
focused on it?
    Mr. McSwain. This is one that we monitored closely through 
the businesses and the like.
    Senator Daines. Yes, for example, like the Northern 
Cheyenne situation, if there is $2 million outstanding, who 
looks at that number, and who reports it, and who is held 
accountable for it?
    Mr. McSwain. Each of the area offices across the country 
that begin to face these larger amounts sit down with the 
hospitals and actually go down through the actual claims that 
are being levied against the patients, because obviously we 
want to get in front of those and resolve them.
    Senator Daines. Yes, it would be helpful, I think, for us, 
too, because we have got a Billings office there I think inside 
your Billings regional office. We could look at those numbers 
and track those with you to see is that declining. Is the 
number going down every month?
    Mr. McSwain. Yes, I made a note of it, and we follow up on 
it.
    Senator Daines. All right. I would love to see that number.
    Mr. McSwain. Yes.

                          ADMINISTRATIVE COSTS

    Senator Daines. All right. Great, thank you. Dr. 
Roubideaux, two weeks ago when you testified before the Senate 
Committee on Indian Affairs, we talked about the administrative 
costs at IHS. I know that in fiscal year 2013, $6 and half a 
million was spent on admin costs at our Billings area office 
out of $18 and a half million spent overall in the Billings 
area IHS. While I understand that it is necessary to have some 
admin costs in any organization, is this money being 
effectively spent, because that is about 35 percent of the 
total spend there out of Billings. And how exactly does this 
money help get our services to our tribal members who need it?
    Dr. Roubideaux. Well, there are statistics out there. There 
are two sets of statistics, and what I am finding is that there 
is confusion about the statistics that people are looking at, 
so we will provide you with two pictures. One is the overall 
administrative costs for the Billings area, and that is about 
11 percent. But if you look just at the area office, the area 
office is--the purpose of it is for administration, to help the 
local service units.
    So I think that there have been some charts and graphs out 
there that I think there has been some overall 
misunderstanding. But when you are running a healthcare 
program, I know that everybody sees the doctor and thinks that 
is all that needs to happen. But you definitely need to have 
some administration overall for the Indian Health Service that 
is about 10 to 11 percent. And in the Billings area, overall 
when you look at the whole area, it is only 11 percent. But the 
area office itself would have that higher proportion just 
because it is providing administrative functions to support the 
local----
    Senator Daines. Do you all have a goal to try to continue 
to reduce your admin costs as a percent of overall spend? Is 
that something you have set targets for to see reductions in 
that number?
    Dr. Roubideaux. We have worked on ways to reduce that 
number. The number will also reduce over time as more tribes 
contract and compact. But we have done things like reduce 
travel by half, we have reduced conference expenditures by a 
third, and we are always looking for ways to be more efficient 
and to save dollars.

                          PERFORMANCE OUTCOMES

    Senator Daines. And speaking of measurements, and I was 
struck by the testimony, Dr. Roubideaux, a 39 percent increase, 
I believe, in IHS funding since 2008, 53 percent with the 
President's budget versus 2008. I see we are touting increases 
in spending. I want to talk a little about what are we doing in 
terms of measuring outcomes, in terms of what are we getting 
for the investments made, in terms of improving health in 
Indian country.
    I was recently--our staff was engaged with the chairman's 
staff in Assiniboine and Sioux Tribes of the Fort Peck 
Reservation. The average age of death for tribal members over 
the last few years has been 51. As I get older, 51 sounds like 
a lot younger. The Fort Peck Reservation is larger than the 
State of Delaware, yet has only two IHS clinics. And as Senator 
Tester mentioned, I hear the same thing. I probably hear more 
complaints about IHS than anything else I hear out in Indian 
country. The challenges are enormous, and the problem is made 
worse by these huge distances to get to both IHS and non-IHS 
facilities.
    Question: what are we doing to measure outcomes from IHS? I 
mean, I heard all about increased spending--more money, more 
money. But what are we doing right now, and how are we 
measuring outcomes in terms of improving health in Indian 
country?
    Dr. Roubideaux. Well, we have actually done a lot over the 
past few years to improve and measure outcomes. We measure 
outcomes on the quality of care as how we are working, and we 
have so many examples of that when we do the Government and 
Performance Results Act or GPRA indicators.
    We also have some data that should be available soon on how 
we measure the ultimate long-term outcomes, like mortality and 
life expectancy. And, you know, the numbers are getting better 
overall. If you look at the life expectancy at birth in 1972 to 
1974, it was 63.6 years overall. Now, for 2007-2009, it is 73.7 
years, so we have gained like 10 years overall. But it is clear 
that there are some areas where when you look at the specific 
tribal data, you can see that there are disparities even among 
tribes in terms of their life expectancy, and we absolutely 
want to continue to try to get that trend of improving life 
expectancy and reducing mortality in a number of areas.
    The Special Diabetes Program for Indians is the best 
example. It is funded to be evaluated. We have not only been 
able to show improved care, we have been able to show that the 
diabetes prevalence is slowing. It is not going up as fast as 
it was. And we are able to prevent diabetes----
    Senator Daines. Yes, I am out of time, but one last follow-
up and then I yield my time. But I would love to align our 
tribal leaders, and chat with the IHS, and get on the same page 
in terms of outcomes and measurements of quality of care, so 
that these are measures that the tribal leaders will say, yes, 
that is the right way to measure the quality of care versus 
what is coming out of our centralized command and control here 
in Washington, DC bureaucracies. So thank you.
    Dr. Roubideaux. I completely agree with you on that, and 
that is what we are trying to do with the--we are encouraging 
the CEOs at the local facilities to meet regularly with the 
tribes and understand tribal priorities and develop those 
measures together----
    Senator Daines. Because ultimately that is the customer. 
That is who we are trying to help.
    Dr. Roubideaux. Love to work with you on that.
    Senator Daines. Okay, thank you.
    Senator Murkowski. Thank you, Senator Daines. Senator 
Udall.

                      PURCHASED AND REFERRED CARE

    Senator Udall. Thank you, Madam Chair. Dr. Roubideaux, your 
budget increases funding for purchased and referred care, which 
is known, I think, as the PRC, by $70 million above the fiscal 
year 2015 level, which is an 8 percent increase. Patients 
depend on the PRC program to cover the cost of services not 
provided directly by the Indian Health Service, including 
emergency and specialty care.
    Your proposed increase is only a down payment toward the 
actual need for the PRC program. In 2014, you reported that 69 
percent of PRC programs across the country were able to cover 
services beyond priority one, life and limb emergencies, and 
that means nearly one-third of the programs were unable to 
cover referrals for preventive care. That is clearly a huge 
demand for the PRC Program funds, which means that even if 
Congress is able to support your request for additional 
funding, we may also ensure that every----
    How may we also ensure that every dollar in this program 
stretches as far as it can? What progress would you expect to 
make towards expanding PRC services if Congress approves your 
budget request? Can you talk about how the funds will be 
allocated and whether they will be distributed to reflect the 
greatest needs on the ground?
    Dr. Roubideaux. Well, thank you. The need in the Purchase 
and Referred Care Program is enormous. If you look at the 
denied and deferred statistics from our Federal and our tribal 
facilities, in 2013 $761 million was denied and deferred 
because of our funding levels not being enough to pay for all 
of those. So every dollar that we can get in an increase in 
purchase and referred care will mean more referrals. Related to 
this particular proposal, the increase could fund 980 more 
hospital admissions, 19,000 outpatient visits, 1,200 patient 
travel trips over the base funding if we get that increase.
    We are doing everything we can to spend that money 
efficiently. That is why we hire a fiscal intermediary to 
review all of our referrals and payments, and make sure we are 
maximizing third party collections so that we can save 
resources for those that do not have other resources. Our 
fiscal intermediary in 2013 was able to save us $1.1 billion in 
contracts, Medicare-like rates, and alternate resource savings 
that were negotiated as well. So we know these dollars are 
precious because every bit of them can pay for referrals for 
care that patients need. So that is why it is a top priority of 
tribes, and it has always been a top priority in our budgets 
over the last few years.
    Senator Udall. Now, you mentioned Medicare-like rates, and 
I have a question there. Your budget request includes a 
legislative proposal to charge providers Medicare-like rates 
for services. And the service has also proposed a rule relating 
to this new rate structure. Can you share with us what you 
expect the impact of this proposal would be in terms of dollars 
reinvested in care and additional patients treated?
    Dr. Roubideaux. There was a Government Accountability 
Office (GAO) report that said on the Federal side the Indian 
Health Service could save around $32 million in purchased and 
referred care funds if we were able to negotiate the lower 
rates with the outside providers that we pay for services. And 
so, that is why we are trying to do everything we can on all 
levels to implement Medicare-like rates for non-hospital and 
physician services. And the notice of proposed rulemaking that 
went out in December, the comment period has closed. The Indian 
Health Service is reviewing those comments trying to find a way 
to make that work administratively as well.
    We know there is legislation pending that is actually 
better on the enforcement piece, but this is one where we are 
trying to push all the levers on this because the amount that 
we could save is millions of dollars, and that is just on the 
Federal side. I have seen tribes estimate they could save like 
$60 or more million if we were able to get these lower 
Medicare-like rates that we pay the outside providers.
    Senator Udall. Now, if you are proposing your own rule, 
could you address the need to have Congress--why you are 
requesting Congress to act on this issue, and why is the 
legislative proposal still necessary?
    Dr. Roubideaux. Well, the legislative proposal that we have 
seen does tie the Medicare-like rates to Medicare participation 
by those outside providers, so it has a much stronger lever 
than we are able to do administratively. And I know the tribes 
really prefer that legislation, but that is still working its 
way through Congress. And tribes have also asked us to try any 
and all options. So that is why the administrative solution is 
another option to be considered here.
    Senator Udall. Thank you. Thank you, Madam Chair.
    Senator Murkowski. Thank you. Senator Cassidy.

                        TRIBAL PATIENT COVERAGE

    Senator Cassidy. Thank you. Dr. Roubideaux, how many 
patients is the Indian Health Service responsible for?
    Dr. Roubideaux. The Service population is 2.2 million.
    Senator Cassidy. 2.2 million. What is the mean age of those 
served?
    Dr. Roubideaux. It is younger than the general population. 
I do not have the statistic in front of me.
    Senator Cassidy. Do you have a ballpark, a mean and a 
median? Do you have a ballpark of that?
    Dr. Roubideaux. We would have to get that for you.
    Senator Cassidy. Senator Udall mentioned that the spending 
per recipient is less than the elsewhere per Centers for 
Medicare and Medicaid Services (CMS), but obviously the younger 
your population, the less expensive. A 28-year-old man would be 
typically on average $500 a year. Ballpark it looks as if you 
do have a much younger population with relatively few people 
over age 65. I say that because if we look at funding levels, 
we have to look at obviously apples and apples, right?
    Dr. Roubideaux. Well, that is true. However, our younger 
population has a higher burden of disease, accidents, injury, 
diabetes occurring at----
    Senator Cassidy. Totally accept that you would have to 
control for disease, but nonetheless if you look at the average 
health of me, 57, versus my assistant back there, who is 25?
    Voice. Yes, sir.
    Senator Cassidy. Let us just say he is lower than me. Now, 
in your budget you mentioned a 39 percent increase. Does that 
include the increased amounts you receive from Medicaid and 
other third party recipients?
    Dr. Roubideaux. No, that is with regard to increases in 
appropriations.
    Senator Cassidy. So if you just look at--if you include 
your increase, because obviously you received a large amount 
from the stimulus package, and then there have been provisions 
in the ACA that have increased reimbursement. How much is your 
budget increased if you do all third party, the stimulus, et 
cetera? How much is your budget increase? Do you know that?
    Dr. Roubideaux. Well, we know from the statistics from 2013 
to 2014, we increased our third party collections by $49 
million. Third party collections are about $1 billion of our 
total budget. In this proposal, we are proposing----
    Senator Cassidy. So just because I have limited time, so 
really your increased funding is more like 45 percent if you 
bring in the increased amount you have brought in from Medicaid 
and perhaps even a little bit more. I am saying that off the 
top of my head, so I am trying to get a sense of the growth of 
your budget.
    Now, we just divided your total budget number by the per 
person, knowing that you have a younger population, by the 2.2 
million people whom you serve, and it looks like you are 
receiving about $2,900 per person. For a family of five that 
would be roughly $15,000, which could buy you a pretty good 
group policy, you know. It would be a very good policy 
actually. So I am not sure if we have a problem with funding 
frankly because if you control for age and you take in the 
third party, then you actually have, and knowing that children 
cost far less than adults, you have less. So I just say that 
because obviously with budgets being tight, we have to have a 
good sense of that being done.
    There have been problems in the past in 2008 and 2009 with 
your inventory control, with the GAO report very concerned. I 
know that you did not begin then, but it seemed as if in 2008, 
the report was of millions, and then in 2009 again there was 
$3.5 million reported lost in fiscal year 2009. What is the 
state of your inventory control now?
    Dr. Roubideaux. With regard to property and inventories, a 
number of improvements have been implemented since that GAO 
report. There has been a greater accountability for the 
individuals who have personal property within the Agency. There 
has been improvements in the policies. There have been 
improvements in the tracking.
    Senator Cassidy. So do you have a sense of what your loss 
ratio is or the absolute amount ratio is now relative to 
before? Is there kind of ongoing audits as to inventory?
    Dr. Roubideaux. I will ask Mr. McSwain if he knows that.
    Mr. McSwain. Yes, having lived through that period of time 
that some of you know about, the property issue. We have 
reduced it. The last count is of lost--missing property is just 
around $600,000 from $13 million.

                          INFORMATION SECURITY

    Senator Cassidy. And there was a problem with some of those 
being computers with personal information, medical information. 
And how is the control going for that?
    Mr. McSwain. Those are being controlled completely now. We 
secure them before we----
    Senator Cassidy. Great. I have just limited time, so I do 
not mean to be rude.
    Mr. McSwain. Right.

                        PROVIDER--PATIENT RATIO

    Senator Cassidy. I see that you are asking for increased 
staffing in multiple clinics. Do you have an average that you 
can make available to us, your average nurse-patient ratio at 
these clinics or all clinics and your average physician-patient 
ratio, as well as the number of visits each physician sees, 
subtracted by the no-show rate? Do you follow what I am saying?
    Dr. Roubideaux. Yes, I do. We will need to get back with 
you on that.
    [The information follows:]
    A nurse-patient ratio of 1:5 is the base staffing plan for an 
inpatient IHS Medical-Surgical Unit. Actual provider-patient staffing 
levels may vary due to staff turnover and the difficulty of recruiting 
nurses in what are often remote facilities.
    All patients are assessed an acuity level of I-IV and based upon 
the acuity level staffing requirements are adjusted to meet patient 
care demands and to provide safe and quality patient care services. IHS 
Emergency Departments, Obstetrical and Intensive Care Units adhere to a 
1:1 or 1:2, nurse-patient ratio as established by national standards. 
Primary Care Provider (PCP) workloads or panel size, no-show reports 
and provider performance are aggregated and analyzed locally to improve 
continuity of care, access to care and to identify appropriate 
physician-patient ratios to meet patient demands. IHS has been 
implementing the Improving Patient Care (IPC) initiative since 2006 
which is its patient centered medical home model to improve care. As a 
part of the IPC, facilities have been encouraged to work on improvement 
projects that are priorities at the local level. Many, but not all, 
facilities have worked on patient flow statistics and staffing pattern 
improvements, and the specific flow processes analyzed are based on 
customer input and are in general not consistent enough to nationally 
aggregate or report. IHS can provide examples about how some facilities 
have measured and improvement patient flow and staffing patterns upon 
request.

                        QUESTIONS FOR THE RECORD

    Senator Cassidy. Now, I will say in 2008, you all testified 
before Energy and Commerce, and I do not mean to be accusatory, 
but I will point out that I asked several questions for the 
record and frankly never got a response. It was frustrating, 
and you had just started, so maybe there was disorganization. 
But I will say then when you testified I asked specific 
questions for the record, did not receive answers. And, again, 
I say that only to point that out and look forward to receiving 
these.
    Dr. Roubideaux. You mean on Energy and Commerce?
    Senator Cassidy. No, I was on Natural Resources then in 
2008.
    Dr. Roubideaux. Oh, Natural Resources in 2008.
    Senator Cassidy. So I am out of time. I yield back. Thank 
you.
    Senator Murkowski. Thank you, Senator Cassidy. And I think 
your point about expecting replies to the questions for the 
record is a good reminder. And I would certainly remind not 
only you, Dr. Roubideaux and Mr. McSwain, but everyone who 
comes before the subcommittee, when we ask the questions, it is 
not just for busy work. It is because typically we run out of 
time.
    Senator Cassidy. Can I make another----
    Senator Murkowski. Senator.

                             STAFFING RATIO

    Senator Cassidy. Thank you, Madam Chair. I also say the VA 
has done something which I admire. They have given a 
spreadsheet which we can all look at that has these statistics 
per clinic. So if Senator Udall wants to look in his State at 
the particular clinic with their staffing ratios, with their 
number of visits, with the percent of those which are no-show, 
which is a failure of a system, or if Senator Murkowski wishes 
to do so in Alaska, they can do so. And that allows us and our 
staff to on a longitudinal basis see your progress. Frankly, 
that will make us your best friend if we see those numbers 
improving, but nonetheless it allows us to fulfill our 
constitutional responsibility of defending the taxpayer. I 
yield back. Thank you.

                         JOINT VENTURE PROGRAM

    Senator Murkowski. Thank you. Excellent point, and I think 
many of us were on the Approps Subcommittee yesterday when we 
were talking about these issues with the VA.
    Dr. Roubideaux, I wanted to ask about probably one of the 
more successful programs that we have within the IHS right now, 
and this is the Joint Venture Program. With the substantial 
backlog that we have with Healthcare Facilities Construction 
List, what we have seen is the ability for tribes to come 
forward, pay for the construction of a facility with the 
promise that IHS is later going to come in and provide the 
staffing packages to operate the facility.
    And we have had some enormous success in Alaska in recent 
years. We have got the facility for TCC in Fairbanks, which is 
beautiful, the South Central Foundation in Wasilla, Dena'ina, 
and Kenai, and now Alaska is on the list for a Joint Venture 
(JV) project. But one of the problems that we have run into 
that is that our tribes have been so efficient in that they 
built the facilities faster than IHS predicted, and so there 
was a gap or a lag between when the facility was ready and when 
the funds were available for staffing packages.
    So two questions for you on joint venture. First, if you 
can give me an update or current status on the Alaska project. 
And then second, and probably more importantly from a structure 
perspective, have you come up with a better model to predict 
timing when facilities are finished so that, again, we do not 
face this lag between having a great facility and not having 
the folks to go in them?
    Dr. Roubideaux. Well, thank you. And, you know, Alaska has 
really taken a lead in the Joint Venture Program and done a 
great job. And I want to thank you for your advocacy over the 
last few years to help get those staffing packages during 
difficult budget climates, and so I am really grateful for 
that. It has been great to go to Alaska and visit those 
facilities, and see how beautiful they are.
    It is a very popular program. It is extremely competitive 
because of the need. The update is that we had a more recent 
round of the Joint Venture Construction Program. We had 37 
applicants--pre-applicants. And based on exactly what you are 
saying, we do not want to get ahead of ourselves. And that is 
where we want to work together with you is making sure that the 
appropriations can be timed at the same time that they are 
opening. We anticipate that in this current round the plan was 
to notify two to three facilities to proceed each year, and 
then work closely with those tribes to determine the estimated 
date of beneficial occupancy or opening, and then we would be 
giving you the updates as quickly----
    Senator Murkowski. Is that any different than we what we 
have done in the past because it has been a smaller block, and 
I thought we were in sync. But then, again, we were efficient, 
we got it done, staffing package not there.
    Dr. Roubideaux. Well, two things happened. The first was, 
yes, the tribes were great at getting them done early, and 
there was a lull in appropriations in 2011, which sort of 
caused us to be a little bit more behind, and it is what it is. 
I think we learned some good lessons from that to make sure 
that we are timing and communicating well on what the timing 
is.
    Senator Murkowski. So where are we with Unalaska then?
    Dr. Roubideaux. Unalaska is one of the facilities from the 
last round that is working on that. I am going to refer to Mr. 
McSwain on that.
    Mr. McSwain. Yes. I think your overall question is one that 
is always a challenge for us because the tribes build them, and 
so we try to keep really track of them as to when they are 
going to open. Fortunately with Alaska, I know that we had the 
occasion where we had one that was opening really early, and we 
had one that was in the lower 48 that was opening really late.
    Senator Murkowski. We got lucky.
    Mr. McSwain. And so, we shifted money to make sure that we 
could have them open on time and not leave it vacant because 
that is the one thing we do not want to do. Unalaska is on 
schedule, and we have not signed the agreement. There is an 
agreement that goes in place where we actually say, you know, 
you will tell us when you are going to complete, and we commit 
to providing the staffing in accordance with a staffing package 
that we agree on.
    So Unalaska is technically on schedule right now because it 
is the last of the last--actually three of the first round that 
are still working. So there is one in Oklahoma, one in Alaska, 
and then we had one in Wyoming that is having problems because 
the tribes elected not to join in on the project. But anyway, 
that is where we are, but it is a good question. We just would 
like a little more engaging of time because when the tribe is 
going to build it, it is their construction that is beyond our 
control.
    Senator Murkowski. It really just comes back to very 
constant communication on this.
    Mr. McSwain. Right. Correct.

                    STAFF RECRUITMENT AND RETENTION

    Senator Murkowski. One last question for you, and this 
relates to physician recruitment and retention, because, again, 
you can build facilities that are state-of-the-art, but if you 
do not have the men and women, the professionals, and their 
teams to open the doors, it does not do any good. And there is 
nothing that is a more glaring example of, you know, Government 
not working than when you have this great facility, but you do 
not have the providers.
    I am told that the vacancy rate for physicians right now 
within IHS is 20 percent, so that means effectively that one in 
five physician positions is vacant. And furthermore, you look 
at that and you say, well, that is not acceptable, and then you 
go beyond that. The turnover rate is 18 percent. And I am told 
that these numbers are actually coming down, but that is still 
too high. I think we would agree that is still too high. So 
what are we doing within the President's budget to improve the 
recruitment and the retention, and how do we do better within 
this system?
    Dr. Roubideaux. Well, if I may, this is a significant 
problem for both Federal facilities and tribal facilities, and 
the statistics you are quoting are Federal facility statistics. 
We do not have the statistics for tribes, but we have heard 
from them. They are facing the same challenges.
    The Indian Health Service over the past few years, number 
one, has addressed more competitive salaries by using the VA 
Title 38 pay scale because of the primary care shortage----
    Senator Murkowski. That does not help us in Alaska, though, 
because we cannot get our physicians in the VA. So if we are 
going by the VA pay scale, and we heard yesterday from the 
Undersecretary that they have got to reevaluate their VA pay 
scale because they are not able to attract physicians there. So 
I do not know that I would use them as a model.
    Dr. Roubideaux. Well, it is higher than our old pay scale, 
so it is an improvement for us, but you are right. With the 
physician shortage that is looming now, right now even to get a 
physician to look at your facility, you have to pay them over 
$200,000, and if they are a specialist you are talking closer 
to $300,000. And that is hard for our facilities to pay for.
    The other thing is the Loan Repayment Program, the 
Scholarship Program. We are grateful for the introduction of 
the amendment to make them tax exempt because that would allow 
us to be able to fund more of them. The National Health Service 
Corps is so critical for us. It has helped to fund over 300 
providers, not just physicians, but like dentists and 
behavioral health providers.
    Senator Murkowski. So you are seeing more and more coming 
from the Corps?
    Dr. Roubideaux. Yes. And we are concerned because we have 
heard that they need their funding renewed either on the 
mandatory or discretionary side, and it is really critical for 
us. We would lose these--all these great new providers that our 
facilities have, so we hope you can work with us on that.
    Senator Murkowski. It is a big issue. Senator Udall.

                            PATIENT COVERAGE

    Senator Udall. Thank you, Chairman Murkowski. I really 
appreciate Senator Cassidy's comments and questions, and I hope 
that we can get the answers to those. I think it is important 
when we make comparisons, and I made the comparison about 
$3,100 a year I think approximately per patient, and how it is 
double in other circumstances around the country. And let us be 
fair with the comparison there, and try to answer the question 
thoroughly.
    But my--and clearly IHS needs to be held accountable for 
what they spend, what you all spend, but I do not think these 
are the average patients. I think they have a higher disease 
burden. They live in remote areas where the provision of health 
services is more expensive. Their referrals for basic services, 
Dr. Roubideaux, as I think you have said, are still being 
denied. So the idea that the Indian Health Service has enough 
funding at this point I think is incorrect. But I hope that you 
will help us with that, and I will probably submit a couple of 
questions, too, so that you can answer that very thoroughly, 
and give us an idea of what the comparison is.
    Senator Udall. You know, it was mentioned that if you had a 
private policy, it would be a good private policy. Well, a lot 
of these people live hundreds of miles from physicians. And so, 
if you had a private policy, then you would end up exercising 
that option, which I do not think is a very good option for 
many Native Americans.
    And, Chairman Murkowski, I am glad you talked about 
retention. I am really proud to have co-sponsored legislation 
with you on the Scholarships and Loan Repayment Programs funded 
through IHS, which I think this makes them tax exempt, and to 
try to attract and keep people there. And so, that is, I think, 
an important one, and we clearly need to do more there.

                           HEALTH FACILITIES

    Dr. Roubideaux, I would like to talk about your request for 
health facilities in Indian country. While I am pleased that 
you have requested an increase of $100 million in your budget 
for healthcare construction, I know that the request only 
scratches the surface. I believe that the Chairman said earlier 
$2 billion, $100 million of funds that the IHS needs to fully 
fund its current construction priority list.
    In New Mexico, we have been waiting for years to receive 
funding to address the four aging facilities we have on the 
priority, including the Gallup Indian Medical Center. You and I 
have both visited Gallup together, Dr. Roubideaux, and we both 
have seen firsthand how outdated the facility is. Tribes tell 
me that already it serves less than half the local needs, and 
yet we are still waiting. I know you share my frustration, and 
we are simply not making enough progress in replacing these 
facilities. So let us talk about the backlog. At your current 
rate of funding, how many years would it take to complete your 
current construction priority list?
    Dr. Roubideaux. I think I will have to get you that 
specific number. It is dependent on appropriations. It is a 
$2.2 billion remaining need on the list that the Indian Health 
Care Improvement Act says we have to complete before we get to 
the other $5 billion estimated need for facilities for everyone 
else.
    And so, I have been to Gallup Indian Medical Center. I have 
seen the condition of it. The providers working there are 
heroes to be able to do what they do with the facility there. 
This President's budget helps us make significant progress 
moving down the list, so it would get us to Gallup Indian 
Medical Center sooner.
    And just on the--I am grateful for your comments about the 
data issue, and we want to work with you all on providing more 
data and more information to help you in your decisionmaking on 
the budget. There is data and there is what we hear from the 
tribes, and the tribes tell us that there still is significant 
need, and we hear that from our providers as well. And just 
appreciate your comments on if we are looking at the data, let 
us also remember the voices of the tribes who say there is a 
huge disparity in need as well, and we will be happy to work on 
some of the data issues also.
    Senator Udall. Well, it is seems to me with the number you 
mentioned, the $2.2 billion and then the $100 extra million, 
still the Gallup facility, I think, is $500 million, so I think 
that is going to be a very, very difficult lift. And so, that 
is why I think we need to see from you some kind of outside the 
box thinking of how we are going to address these kinds of 
construction needs. And, you know, previous administrations 
have come up with a 5-year plan or whatever it is. I mean, I 
hope you give some thought to that, and then interact with us 
in terms of improvements there.
    Under the Indian Health Care Improvement Act, IHS is due to 
make annual progress reports on its construction program. When 
can we expect to see your next report, and will it include 
estimates for the funds that IHS needs to construct all 
remaining facilities on the list, including the Gallup Indian 
Medical Center I have talked about?
    Mr. McSwain. Mr. Vice Chairman, Dr. Roubideaux actually 
started an authorized Federal Appropriations Advisory Board 
made up of tribal leaders and a couple of staff people. And 
they have actually been charged with coming up with the report 
that is due next year, and they will be doing a wide search. We 
will be talking about consulting with tribes, particularly on 
the new authorities that are in the Indian Health Care 
Improvement Act. But we will have the report prepared on time 
for submission the early part of next year.
    Senator Udall. Thank you.

                         CONTRACT SUPPORT COSTS

    Senator Murkowski. I have just hopefully two quick 
questions, and we will be able to wrap up soon. I know both of 
us have many different hearings this morning, but I appreciate 
the time that our witnesses have given us.
    Dr. Roubideaux, back in 2010, I understand that you sent a 
letter to Jefferson Keel, who was then the chairman of the 
Tribal Self-Governance Advisory Committee. And effectively, the 
letter said that contract support costs would be computed on 
top of all the methamphetamine prevention and domestic violence 
funds. And then last summer IHS announced that tribes would 
have to waive all rights to additional contract support cost 
funding if they wanted to receive these same funds again. And 
in Alaska, South Central Foundation operates what I think is 
one of the country's best domestic violence programs. And the 
Agency's approach is requiring South Central to divert hundreds 
of thousands of dollars to cover overhead.
    So the question to you this morning is what authority do 
you have from Congress to change what you, I think, accurately 
said in 2010, which was a legal obligation to add contract 
support costs to those funds?
    Dr. Roubideaux. Well, while I am not able to comment on 
litigation that is in progress, I do want you to know that we 
are consulting with tribes on the issue related to the MSPI and 
how it is funded currently, and we will see what comments we 
get on that. But I cannot comment on active litigation. But I 
do want to----

                      DOMESTIC VIOLENCE PREVENTION

    Senator Murkowski. What about with the Domestic Violence 
Prevention funds?
    Dr. Roubideaux. Also we are consulting with tribes on that 
at this point, and we would like to talk about--we want to make 
sure that tribes do get the administrative costs that they need 
to run the program. It is just that we have limited funds 
available for those initiatives, and so we have to figure out a 
way to do that. And Mr. McSwain will probably make the decision 
after the consultation since he is the acting director, and, 
you know, we are hopeful to try to find a solution. But it also 
is related to litigation, which makes it difficult for us to 
talk about it at a hearing, but we would love to talk with 
you----
    Senator Murkowski. Well, and perhaps we should have further 
discussion because I think we would all agree, those of us here 
within the Interior Appropriations Committee--Senator Udall and 
I both sit on the Indian Affairs Committee. And we all know 
that our statistics as they relate to domestic violence when it 
comes to Alaska Natives and American Indians are among the 
worst in the country. And the statistics that we have are not 
only troubling, they are just unacceptable. And so, if what we 
are doing is we are limiting the ability of our providers out 
in Indian country to address some of these issues, we have got 
to look at it.
    One last point on domestic violence. As we look at the 
Agency's website, between 2010 and 2014, the Domestic Violence 
Prevention Initiative resulted in over 50,000 direct 
encounters, including crisis intervention and case management 
consulting. More than 38,000 of those referrals were made for 
domestic violence services, and then there was a total of 600 
forensic evidence collection kits that were submitted to either 
Federal, State, or tribal law enforcement.
    I find those numbers somewhat surprising. The sheer numbers 
that we are talking about are in the tens of thousands, and yet 
we are only seeing 600 rape kits submitted to various law 
enforcement agencies. I know that when we were moving the 
Violence Against Women bill through the Congress, part of the 
discussion at that time was we simply did not have sufficient 
rape kits that were distributed, certainly in my State. Is that 
still our situation? Do we have enough kits that are available 
across the agencies, various service units? Is that part of the 
problem, because if it is that basic, that is something that we 
need to be talking about, too, because you cannot get to 
prosecution if you have not collected the evidence. So have we 
addressed that aspect of the problem?
    Dr. Roubideaux. Well, I am glad you brought this up. We 
have $8.9 million total for the Domestic Violence Prevention 
Initiative, and with that we have funded more availability of 
those kits. There are other factors. Sometimes the----
    Senator Murkowski. Have we funded it to the level of need?
    Dr. Roubideaux. Well, the problem is it is difficult to 
know the level of need because some patients do not come into 
the clinic. Some patients might come in for an exam, but not 
consent to having it go to law enforcement. Some may be outside 
the timeframe where a kit would be relevant. And so, there are 
some issues for why not every encounter is associated with a 
kit.
    Senator Murkowski. Understood, and I also understand that 
one of the problems that we have, and at least in many of the 
rural places in Alaska, is we do not have the individuals that 
are trained in collecting that evidence. And so, sometimes it 
is the lack of availability of a kit. Other times it is not 
having a trained individual. I mean, there are many reasons.
    Dr. Roubideaux. This funding----
    Senator Murkowski. But we can do better.
    Dr. Roubideaux. Well, this funding has helped us increase 
our activities to provide the training necessary and forensic 
equipment to do the exams. There are SANE, SAFE, and SART 
training and activities. Unfortunately, this funding is not 
enough to fund everybody, and that is why we are trying to 
address it as best we can with the funding that we have. And we 
would love to work with you on this on such a need.
    Senator Murkowski. Well, it would be helpful, Dr. 
Roubideaux, for us to have a little bit more definition in 
terms of what you are doing with the money from this 
initiative, how it is being allocated, what it is being used 
for, where the gaps are, because, again, if this is a situation 
where the number of assaults continues at an elevated level. 
But if you have a situation where an individual knows that 
there is nobody in my village that even knows how to collect 
the evidence, or there is no kit, there is not going to be--the 
individual is going to say, why even bother going on.
    Dr. Roubideaux. I agree with you.
    Senator Murkowski. So the perpetrator goes out. It is a 
horrible cycle.
    Dr. Roubideaux. Well, I would love to have us work more 
with you on this issue and help you get you the data and 
information you need to----
    Senator Murkowski. If you can get us that data, it would be 
appreciated.
    [The information follows:]
    The Domestic Violence Prevention Initiative (DVPI) is currently 
funded at $8.9 million program and funds 65 IHS, tribal, and urban 
Indian health projects. The funding is allocated to projects in three 
categories: domestic violence (DV) community developed prevention 
models, sexual assault (SA) prevention expansion projects, and sexual 
assault examiner (SAE) programs. There are 38 DV focused projects, 19 
SA focused projects, and 8 SAE projects. The 8 SAE projects focus on 
training their providers to conduct medical forensic projects and 
establishing a coordinated response to sexual violence. The 600 
evidence collection kits have been submitted to law enforcement by 
those 8 funded projects. The number does not represent the total number 
of evidence collection kits collected or the total number of patients 
who received a medical forensic examination. The number is also not 
representative of the entire Indian health system, the number is only 
from the progress reports collected from the 8 funded SAE projects. 
Evidence collection kits are made available to IHS and tribal 
healthcare facilities at no charge from either law enforcement entities 
or State crime labs. IHS has not received recent reports of facilities 
having difficulty obtaining evidence collection kits.
    There are no current ICD-9 codes to collect data from the 
electronic health record to determine the number of evidence collection 
kits that are collected from patients system-wide. There will be more 
specificity with ICD-10, which will enable IHS to make better 
determinations in relation to the gaps in services for domestic and 
sexual violence. ICD-10 is on track to be implemented starting October 
1, 2015 and more data should be available next year.
    The funds are also used to provide medical forensic examiner 
training to IHS, tribal, urban Indian, and referral healthcare 
providers and purchase forensic equipment for IHS and tribal healthcare 
facilities. Over 290 healthcare providers have been trained to conduct 
medical forensic examinations through IHS' Tribal Forensic Healthcare 
Training Program and 90 facilities have state-of-the-art forensic 
equipment to aid in the photo-documentation of domestic and sexual 
violence cases. The training is provided through in-person and online 
courses, including Alaska specific courses for Sexual Assault Examiner, 
Pediatric Sexual Assault Examiner, and Domestic Violence Examiner.
    The allocation of funding for DVPI was determined after tribal 
consultation and the funding is distributed to the sites with highest 
need. Not all applicants are able to receive funding. The DVPI 
evaluation includes various measures to help illustrate how the 
appropriated amount of funding is used to implement the programs 
described above to selected sites.

    Senator Murkowski. Senator Udall, do you have any final 
questions here for us this morning?

                               SANITATION

    Senator Udall. Yes, thank you very much. Just a couple of 
quick ones here. Dr. Roubideaux, your budget includes $35 
million in new funds to address sanitation needs in Indian 
country, which is a 44 percent increase in the program. These 
funds are badly needed to make sure that homes in Indian 
country have proper access to clean drinking water and 
wastewater disposal, especially since your budget estimates 
that 13 percent of these homes have no connection to sanitation 
facilities at all.
    Can you share with us how you expect to use these funds to 
improve public health? How do you propose to allocate the 
funds, and how many homes do you expect you will be able to 
serve? What kind of progress will this proposed increase allow 
you to make?
    Dr. Roubideaux. Well, the need is significant. There is 
about $2 billion worth of need in projects that would be 
feasible to do. This particular increase would help us provide 
sanitation facilities to 7,700 Indian homes above the base 
funding. The Indian Health Service proposes in its 
justification to distribute this to both priority projects for 
existing homes and for new homes as well.
    And there is no doubt that any funding we can have in this 
area is going to help. You know, I had the opportunity to visit 
very rural areas in Alaska and other places, and it is just--it 
is heartbreaking to see that here we are in, you know, 2015, 
and there are people that do not have sanitation facilities, do 
not have potable water. It is heartbreaking. And so, that is 
why we are wanting to make some progress with this budget to 
propose the $35 million investment. It is not the entire need, 
but it certainly helps us get started on addressing that need.

                              DENTAL CARE

    Senator Udall. Thank you. And shifting over to a quick 
question on dental care, there was language in last year's 
omnibus that encouraged IHS to work with the Bureau of Indian 
Education to provide Native youth with preventive dental care. 
As you know, Native American youth face far higher rates of 
childhood tooth decay and dental disease compared to the 
overall U.S. population. So providing these children with 
access to good dental services is critical, and will help, I 
think, reverse these health disparities. Could you please 
update on your efforts to improve dental care in the school 
setting, and will you work with me to make this a priority?
    Dr. Roubideaux. Absolutely, it is a priority. It is so 
important, good dental care. We surveyed our dentists recently 
in light of this request, and found that in nine of 12 areas, 
we already have prevention and treatment activities with 93 
Bureau of Indian Education schools. So we have reached out to 
the BIE, and would love to work with you on making sure we can 
increase access.
    Senator Udall. Thank you. I am finished.
    Senator Murkowski. Thank you, Senator Udall, and know that 
I am happy to work with you on the oral health needs of our 
Native people. We have implemented in Alaska, I think, a great 
model with regards to our dental health therapists, kind of 
that mid-level provider. And we have encountered a little bit 
of resistance at times from the American Dental Association, 
but I think we have reached an accord with them, and the track 
record that we have seen has made a difference. When you have 
somebody in a village who is working with kids on just basic 
care--brushing your teeth, and passing out toothbrushes at the 
grocery, and being there to address cavities so that you do not 
have to pull them--it does make a difference. And I think we 
have got a very strong model going in Alaska that I would love 
to talk with you about.

                     ADDITIONAL COMMITTEE QUESTIONS

    Thank you, Dr. Roubideaux. Thank you, Mr. McSwain. I have 
some additional questions that I am going to be submitting for 
the record. One relates to the 477 Program, as well as the 
Native Youth Suicide Program that you have incorporated, the 
healthcare initiative for Native youth. Know that many of us 
are very focused on making some headway there as we deal with 
our Native youth. But I know that other members will also have 
questions that they would ask to have submitted for the record, 
and we would appreciate your timely responses to each of them.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
              Questions Submitted to Dr. Yvette Roubideaux
             Questions Submitted by Senator Lisa Murkowski
    Question. For fiscal year 2016, the administration has announced it 
will pay full contract support costs within the Indian Health Service 
(IHS) budget ($718 million). The administration has also proposed that 
beginning in fiscal year 2017 Contract Support Costs (CSC) become 
mandatory spending.
    At a recent National Congress of American Indians (NCAI) Listening 
Session, the indication was made that the administration's proposal 
would authorize up to 2 percent of the contract support cost 
appropriation to be used for overhead. How much is IHS currently 
spending to administer its annual appropriation for contract support 
costs? Please exclude funding for legal claims and include funding used 
with allocating and paying the annual contract support cost 
appropriation.
    Answer. IHS estimates spending approximately $12 million dollars in 
fiscal year 2014 to administer CSC-related activities. This includes 
costs for CSC need negotiations with each tribe, payment 
reconciliations, CSC meetings at the Area and Headquarters level, and 
contractor support to assist with ensuring consistency in process/
negotiation issues identified during claims analysis.
    Question. What is the administration's position on the lawsuit that 
Maniliilaq brought against the Indian Health Service in the U.S. 
District Court? The lawsuit concerns the tribe's Village Built Clinic 
(VBC) in Ambler which had been chronically underfunded for years under 
its Indian Self Determination Act agreement. The court ruled that the 
Self-Determination Act must be interpreted in the light that is most 
favorable to tribes and that ``Congress intended the Indian Self-
Determination and Education Assistance Act (ISDEAA) must be interpreted 
in a manner favoring flexibility in funding agreements like the one at 
issue in this case.''
    Does the administration believe the court's rationale is at odds 
with the IHS's approach to the VBC issue? Why or why not?
    Answer. Although the case referenced has been decided, the 
Department of Health and Human Services (HHS) is involved in ongoing 
litigation related to the VBC issue. As a result of ongoing litigation 
the IHS is not able to comment at this time.
    Question. What could be the impact of this case on other VBC's in 
Alaska if the tribe prevails on appeal?
    Answer. As a result of ongoing litigation the IHS is not able to 
comment at this time.
    Question. Public Law 102-477 is a self-determination statute that 
allows tribes greater control over delivery of social-welfare and 
workforce-development services from funds received through the 
Department of the Interior, Department of Labor, and the Department of 
Health and Human Services. I know that DOI is the lead agency for the 
``477'' program but obviously funds come from the Department and it 
seems that some of the flexibility that tribes have enjoyed with this 
program in the past were restricted based on new interpretations of the 
law by HHS. In fact, we addressed this issue in the fiscal year 2012 
Interior bill and asked for the administration to work with the ``477'' 
Tribal Working Group to resolve auditing requirements for tribes.
    Does the administration agree or disagree that additional 
flexibility is helpful to tribes in best managing their limited 
resources?
    Answer. The administration sees the benefit of providing the 
flexibility to adjust priorities due to local circumstances and 
changing priorities over time. However, the administration is also 
respectful of the statutory purposes for which funds are appropriated 
and the regulations associated with those programs. It is essential 
that we work collaboratively with tribes to identify opportunities to 
maximize flexibility and reduce administrative burdens wherever 
possible.
    Question. Also, my understanding is that there has never been an 
issue with the misuse of funds concerning the co-mingling of 477 funds 
to maximize results on the ground for tribes. Is that your 
understanding as well?
    Answer. The Indian Health Service is not aware of any information 
regarding co-mingling of funds. IHS programs are not included in 477 
employment and training programs.
    Question. One of the proposed increases in the budget that I'd like 
to understand more about is the $25 million aimed at suicide prevention 
and substance abuse within our Native youth. Information from the 
Alaska Department of Health and Social Services indicates that Alaska 
Native men between the ages of 15-24 have the highest rate of suicide 
of any demographic in the country. We also know the devastating impacts 
of alcohol and other drugs in our Native communities. These statistics 
are heartbreaking.
    Can the IHS outline how the additional funds would be used?
    Answer. The funds would be used to award additional Methamphetamine 
and Suicide Prevention Initiative (MSPI) projects for a 5-year funding 
cycle to hire behavioral health staff for prevention and early 
intervention of youth suicide and substance abuse, as well as other 
mental health services. Funding would be awarded through a competitive 
application process based on greatest need to those projects with plans 
to use the funding to provide services for youth in local IHS, tribal, 
and urban Indian healthcare facilities, school-based settings, or in 
other youth based programs, such as the Boys & Girls Club of America.
    Question. Increased funding for programs is one way to help address 
this issue, but is the IHS developing better strategies and identifying 
other things to do in order to help our Native youth?
    Answer. The IHS continues to support and monitor youth behavioral 
health programming provided by IHS, tribal and urban Indian health 
programs, including the Youth Regional Treatment Centers (YRTCs), the 
Methamphetamine and Suicide Prevention Initiative (MSPI) and Domestic 
Violence Prevention Initiative (DVPI). IHS develops, utilizes and 
disseminates best and promising practices, as well as culturally 
appropriate services from the current MSPI and DVPI programs to inform 
future youth specific services and programming.
    IHS also provides on-going training for its healthcare providers to 
build a competent workforce prepared to promote the health and 
wellbeing of AI/AN youth through the IHS Tele-Behavioral Health Center 
of Excellence (TBHCE). In fiscal year 2014, over 8,000 healthcare 
providers received no cost continuing education through the TBHCE. In 
the same time period, IHS hosted 59 youth-related training events with 
more than 2300 attendees.
    Question. The reauthorization of the Indian Health Care Improvement 
Act authorized the Indian Health Service to expand services to include 
dialysis services.
    How many IHS funded facilities offer dialysis?
    Answer. No IHS facilities directly provide dialysis services. 
According to the OIG report from September 2011 entitled ``Access to 
Kidney Dialysis Services at Indian Health Service and Tribal Health 
Facilities'', there are 20 tribal facilities that provide dialysis at 
their facilities: 3 have tribally operated dialysis facilities and 17 
provide dialysis services through an independent for-profit or 
nonprofit company. As the majority of IHS beneficiaries on dialysis are 
eligible for Medicare, funding for dialysis programs comes primarily by 
billing Medicare and other third party payers for services. Purchased/
Referred Care is used infrequently for dialysis services, only when 
other third party payment is not available.
    Question. What is the average distance a dialysis patient has to 
travel in Indian Country if there is not a Service facility nearby?
    Answer. IHS does not have data available on the average distance a 
dialysis patient has to travel to receive dialysis services. The 
distance can range from a few blocks to a tribally managed dialysis 
center in the community to a drive to the next city or town with a 
dialysis center. Since dialysis services are often covered by Medicare 
and many patients do not go through IHS to obtain their dialysis 
services, IHS does not have access to information to be able to 
calculate the average distance.
    Question. Does the Purchased/Referred Care money have to be used to 
pay for both this travel and this care? If so, how much of PRC funding 
goes to dialysis care?
    Answer. The Purchased/Referred Care (PRC) funding is not required 
to be used to pay for both travel and dialysis services. PRC may be 
used for transportation and dialysis services depending on eligibility, 
notification, ranking within medical priority, alternate resource use 
and funds availability. Otherwise alternate resources such as private 
insurance, Medicaid, or tribal transportation services may pay for 
travel. In general, Medicare covers the cost of dialysis services for 
most patients which saves PRC funding for other types of referrals.
    In fiscal year 2013, approximately $12,770,215 of funding for 
Federal PRC programs was spent on dialysis care. This is approximately 
3.3 percent of the total IHS Federal PRC budget and does not include 
transportation costs.
    Question. The Indian Health Service system is heavily reliant on 
the funds it gets from third party receivables whether private 
insurance or medicare/medicaid. As CEO of the Indian Health Service, 
you must hold the Service unit's accountable.
    How often do you monitor reports of 3rd party collection from the 
various Service units? Reports are that in some Service units (Billings 
Service Unit, Crow Hospital) there are providers who only see one 
patient a day. Is that accurate?
    Answer. IHS Headquarters, through the Office of Resource Access and 
Partnerships and the Unified Financial Management System, monitors 
collections by Facility (Tax ID) on a monthly basis, with any 
discrepancies or downward trends shared with the Facility/Area in 
question. Facilities and Areas are responsible for tracking collections 
specifically at the local level on a more frequent basis (weekly). 
Since this tracking is by facility, it does not track collections by 
individual provider. Neither of the facilities mentioned has providers 
that see only one patient a day. IHS facility management monitors 
monthly workload reports in addition to overall facility collections so 
that if there are providers that need to increase their workload IHS 
facility management can address those providers directly.
    Question. Is there someone assigned to diligently monitor 
collections to determine if a provider is doing his/her job in that 
facility?
    Answer. Service Unit staff and Area Office staff are responsible 
for tracking collections at the local facility level. However, IHS 
headquarters has not recommended tracking collections by individual 
provider and judging productivity for providers based on collections 
amounts because it is complex, impacted by other factors outside of the 
control of the provider and can be misleading. For example, some 
patients may not have an alternate resource that IHS may be able to 
bill for covered services. Also, providers do not manage or control 
their payer mix in IHS. Providers are required to see all IHS patients 
regardless of any additional third party coverage. For example, 
Provider A may coincidentally see more Medicaid patients (at a higher 
rate of reimbursement) than Provider B, even though they see the same 
total number of patients.
    However, IHS has implemented business planning at local Federal 
facilities to ensure that CEOs are responsible to regularly update 
their strategic planning to maximize third party collections, and that 
includes reviewing staffing patterns. In addition, implementation of 
the IHS Improving Patient Care (IPC) Program allows physicians to spend 
less of their time on administrative and other tasks that can be done 
by other members of the team which will allow them to improve their 
efficiency and have time to see more patients. This will potentially 
result in increased opportunities for third party collections for 
services provided to patients that have coverage.
    In the Billings Area, tracking of provider productivity regarding 
number of patients seen per day is extracted from the Resource Patient 
Management System (RPMS). CEOs are able to review this data over time.
    The Billings Area and Crow Hospital monitor provider productivity 
on daily/weekly basis and specifically address any issues with 
providers when needed. The Billings Area also addresses issues of 
documentation, billing, posting, and accounts receivable backlog with 
individual providers when pertaining specifically to providers.
    In order to respond to tribal input and increase access to care, an 
Express Clinic was opened at the Crow Service Unit in the past year 
that provided care after regular clinic hours. The increased volume of 
patients seen could help increase third party collections if those 
patients have coverage.
                                 ______
                                 
                Questions Submitted by Senator Tom Udall
                         contract support costs
    Question. Are you confident that the budget request you have 
proposed for fiscal year 2016 will fully cover your estimated contract 
support cost needs?
    Answer. IHS is confident that the amount proposed for fiscal year 
2016 will fully cover the estimated contract support costs needs, based 
on the information available at the time of the budget submission. 
Since CSC estimates can change over time due to a number of factors, 
IHS will provide updates to the subcommittee.
    Question. Can you tell us more about the Service's efforts to work 
with tribes to improve contract support cost budget estimates in 2016 
and going forward?
    Answer. The consultation on the long term solution after the 
Supreme Court's decision in Salazar v. Ramah Navajo Chapter was helpful 
in generating discussion and collaboration between the agencies and 
tribes on how to improve CSC estimates, and the IHS has implemented 
improved business practices and a calculation tool to use with tribes 
to provide more consistent and verifiable CSC amounts for negotiations, 
reconciliation and payments. In addition, IHS performs monthly data 
reconciliation of CSC estimates and payments. The data reconciliation 
assures that IHS is updating the CSC estimates of need for each tribe 
throughout the year as new information becomes available. This process 
of monitoring CSC activity on a regular basis, identifying additional 
amounts owed to tribes by IHS or amounts owed to IHS from tribes, and 
adjusting payments on a regular basis to assure full CSC funding, 
provides the ability to better estimate the full amount of CSC need 
during the fiscal year and ensure there is no shortfall for the 
estimate identified by the end of the fiscal year.
           recruitment and retention of health care providers
    Question. I am concerned about turnover and low morale at the 
Indian Health Service--and the agency's reported vacancy rate of 23 
percent for doctors particularly troubles me. That means you are 
operating without almost one-quarter of the doctors you need. Congress 
and IHS need to work together so that we can be sure you are hiring 
enough qualified healthcare providers to properly staff every 
facility--and to make sure that providers stay with IHS to develop 
relationships with patients and improve health outcomes. I also 
understand that every vacancy left open also costs the Service 
potential revenue from third-party billing, so there's also a case that 
filling these vacancies makes good business sense.
    What are you doing to make recruitment and retention of healthcare 
providers a priority, and how are you engaging tribes to participate in 
retention efforts--especially since they have a personal stake in the 
outcome?
    Answer. The vacancy rate represents positions that are not 
permanently filled at the time of that specific report. However, many 
facilities will hire temporary or contract providers to ensure that 
patients can get the care they need while the facility is recruiting to 
permanently fill the position. Third party billing can continue even 
with a temporary or contract provider.
    Recruitment and retention of healthcare professionals is an ongoing 
issue for the IHS and other healthcare organizations that serve rural 
and remote locations. The IHS has made it a priority and uses a number 
of incentives to assist in the recruitment and retention of health 
professionals including loan repayment, scholarships and extern 
programs, maximizing use of pay authorities, the National Health 
Service Corps, and involvement of local tribal leadership.
    Many health professionals leave school or post graduate training 
with substantial educational loan debt. The IHS Loan Repayment Program 
(LRP) allows IHS to attract individuals interested in working in Indian 
communities, but who would be unable to do so if there were not a way 
to pay their educational loans. In fiscal year 2014, the IHS LRP was 
able to award 710 healthcare professionals. In fiscal year 2014, the 
IHS Scholarship Program was able to fund 260 health professions 
students that will provide clinical services for 2 to 4 years at Indian 
health sites once they complete their training. The IHS Extern Program 
is designed to give IHS scholars and other health professions students 
the opportunity to gain clinical experience with IHS and tribal health 
professionals in their chosen discipline. The program also allows 
students the opportunity to work at sites they may want to apply to for 
employment after they complete their health professions training. This 
program is open to IHS scholars and non-IHS scholars. Students are 
employed up to 120 days annually, with most students working during the 
summer months. In fiscal year 2014, the Extern Program funded a total 
of 111 extern students. Hundreds of additional students rotate through 
Indian health facilities on academic rotations throughout the school 
year.
    IHS facilities have existing authorities for other incentives to 
assist in the recruitment and retention of health professionals. These 
include Title 5 and Title 38 Special Salary Rates, Title 38 Physician 
and Dentists Market Pay, the 3Rs (recruitment, retention and relocation 
incentive pays), and use of service credit for annual leave accrual 
rate purposes based on prior non-Federal work experience or a period of 
active duty in an uniformed service. Title 5 and 38 Special Salary 
Rates have allowed IHS facilities to recently offer more competitive 
pay that is closer to what healthcare providers would receive in the 
private sector. Title 38 Physician and Dentists Market Pay enables IHS 
to pay physicians at salary levels comparable to the VA and to hire 
specialists, such as orthopedic surgeons, that would otherwise not 
consider IHS employment for the pay and incentives offered under Title 
5.
    The IHS and Health Resources and Services Administration (HRSA) 
continue to work together to make the National Health Service Corps 
(NHSC) more accessible to fill health professional vacancies. Starting 
in 2010, the IHS and HRSA collaborated to expand the number of IHS and 
tribal facilities designated as NHSC-approved sites. This allows these 
facilities to recruit and retain primary care providers by using NHSC 
scholarship and loan repayment incentives. As of January 2015, a total 
of 648 IHS, Tribal Clinics, and Urban Indian Health Clinics are 
approved as eligible sites for NHSC scholars and LRP applicants, 
compared to 60 at the end of 2010. There are currently 197 positions at 
IHS and tribal sites listed on the NHSC Job Center Web site that serves 
as the central source for scholars and loan repayment recipients to 
find placements. As of January 2015, a total of 33 NHSC scholars and 
351 NHSC loan repayment recipients were providing healthcare services 
to Indian communities.
    Many tribes have their own health professions recruitment programs. 
The IHS works to encourage tribal leaders and the local community to 
participate in recruitment efforts. The IHS provides assistance to 
local chief executive officers, clinical directors, tribal leaders and 
prospective new hires through the development of recruitment and 
retention materials. The Applicant Support Program Guide provides 
guidance to IHS and tribal hiring officials on building relationships 
with prospective hires as they go through the hiring process. The 
Planning Your Successful Transition brochure and workbook help new 
hires and their family's transition to a new culture and rural 
community. The Community Liaisons brochure focuses on preparing a 
community liaison to work with prospective employees and new hires and 
the Organizational Onboarding guide sets the stage for continued 
employee satisfaction, thereby promoting retention of these healthcare 
professionals.
    Question. How does IHS measure its success for its recruitment and 
retention efforts--and how will you show that improvements have a 
beneficial effect on patient care?
    Answer. The goal of the IHS health professions recruitment and 
retention effort is to provide highly skilled health professionals to 
Indian health facilities to deliver high quality care to Indian people. 
At the national level, IHS conducts a comprehensive set of activities 
in support of healthcare provider recruitment and retention, including 
national advertising campaigns, marketing of the Loan Repayment and 
Scholarship Programs and development of collateral materials that are 
distributed and used by national, Area and local recruiters. The 
effectiveness of these activities is evaluated in terms of the number 
and types of activities as well as the number of individuals viewing 
advertisements, contacting recruiters and recruited to key health 
professions positions. IHS has been able to measure improvements in 
specific health professional disciplines. For example, the vacancy rate 
for dentists improved from over 30 percent prior to 2009 to less than 
10 percent recently after a coordinated push to increase a variety of 
recruitment activities, including the use of Title 38 Physician and 
Dentist Market Pay for that profession. IHS measures and routinely 
monitors vacancy rates and turnover rates at IHS Federal facilities for 
high priority health professions. IHS does not have complete 
information on tribal vacancy rates since they are not required to 
submit data on this under their Indian Self-Determination and Education 
Assistance Act (ISDEAA) contracts and compacts.
    The IHS Improving Patient Care (IPC) Program encourages greater 
continuity of care for patients through teamwork and improvements in 
processes of care. IPC has measured greater patient satisfaction with 
improved processes among participating programs. Filling vacancies 
helps improve continuity of care for patients, which can result in 
improved quality of care.
    Question. I'm proud to have sponsored legislation with Chairwoman 
Murkowski that would make scholarships and loan repayment programs 
funded through IHS tax-exempt to help you attract and I am happy to see 
your budget request proposes something similar. Can you please tell us 
what you expect the impact of making scholarships and loan repayment 
tax exempt will be on your vacancy rates?
    Answer. The IHS Scholarship Program (SP) and Loan Repayment Program 
(LRP) are invaluable tools for recruiting and retaining healthcare 
professionals. The SP assists American Indian and Alaska Native (AI/AN) 
health professions students with tuition and monthly stipend support 
while they are in school. Students must agree to a year of service for 
each year of financial support with a minimum 2 year commitment. IHS is 
not authorized to provide funding to offset tax liability for SP 
recipients, who must fund this cost from their stipend or through other 
means. The LRP offers healthcare professionals the opportunity to 
reduce their student loan debts through service to Indian health 
programs with critical staffing needs. Applicants agree to serve 2 
years at an Indian health program in exchange for up to $20,000 per 
year in loan repayment funding. Currently, for every LRP award of 
$20,000, the LRP sets aside $5,836 of its appropriated funding to 
account for taxes; $4,000 for Federal tax and $1,836 for Federal 
Insurance Contributions Act (FICA) costs. If the IHS SP had a tax 
exemption similar to that of the National Health Service Corps (NHSC) 
Scholarship Program as proposed in the President's budget, AI/AN 
students receiving scholarship support could use their entire $1,500 
monthly stipend to assist with their living expenses rather than using 
it to pay taxes on their scholarship award. If the IHS LRP were to 
receive tax exemption equivalent to the NHSC LRP, the IHS LRP could use 
the $5,711,893 of loan repayment funding currently paying taxes 
associated with LRP awards to make an additional 132 LRP awards.
                 innovation in health care construction
    Question. I believe that it's very important that you also make 
sure that the buildings you construct are flexible enough to meet 
future needs, given the construction backlog and the limited resources 
we face.
    How are you using innovation such as flexible floor plans and green 
building technologies to address your facilities' current and future 
needs?
    Answer. IHS agrees that innovation in construction techniques are 
needed to address the changing health delivery methods and green 
building technologies. Our healthcare facilities construction program 
attempts to incorporate flexibility during the design stages working 
hand in hand with our tribal partners, healthcare professionals, and 
engineers/architects with specific experience in healthcare facility 
design. IHS healthcare facilities are being constructed to incorporate 
many sustainability/``green'' features and IHS continues to investigate 
cost-effective options in the future design of planned facilities. 
Also, IHS is complying with Public Laws and Executive Orders that 
direct Federal agencies to increase energy efficiency and reduce water 
consumption in their facilities. The IHS meets sustainability 
requirements and Leadership in Energy & Environmental Design (LEED) 
Silver when constructing new healthcare facilities. Also, IHS completed 
a report on modular construction where the results revealed that 
modular facilities can be constructed to last 50 or more years. Modular 
facilities are constructed using typical construction grade materials 
such as concrete, structural steel, masonry units, found in permanent 
buildings.
                   youth behavioral health initiative
    Question. Your budget request includes $25 million in new funds to 
address suicide risk and substance abuse as part of the President's 
cross cutting initiative on Native youth, ``Generation Indigenous''. I 
understand that that funds requested through the Indian Health Service 
would be used to expand access to behavioral health professionals, and 
that these funds are complemented by increases proposed in the budgets 
of the Substance Abuse and Mental Health Administration and other 
Federal agencies.
    Your budget states that the new funds within the IHS budget would 
be used expand service for Native youth through the existing 
Methamphetamine and Suicide Prevention Initiative grants program 
(``MSPI''). The MSPI pilot program started in 2009, so I'm interested 
to learn more about its track record, as well as the expected outcomes 
in your budget proposal.
    Can you share some of the accomplishments of the current MSPI 
program and elaborate on why you believe that it's the best model to 
address mental health and substance abuse issues for Native youth? How 
do you measure success?
    Answer. The primary goals and accomplishments of the MSPI projects 
include the expansion of behavioral healthcare and services--providing 
more services and wider access--to tribal communities. The MSPI focuses 
on implementing evidence-based and practice-based strategies that are 
culturally appropriate and community based. Statistics that document 
users, or the number of individuals impacted by these services, are one 
clear indicator of accomplishment. In the course of the initiatives, 
many tribal youth and families increased their knowledge about and/or 
participated in services and treatment related to methamphetamine, drug 
use, suicidality, and depression. Over 528,000 encounters with youth 
have been provided as part of evidence-based and practice-based 
prevention activities.
    As a result of the MSPI, over 9,400 individuals entered treatment 
for methamphetamine abuse. MSPI projects also offer treatment options 
for marijuana, alcohol, and prescription drugs as the most common 
substances other than methamphetamine for which treatment was provided. 
Fifty-nine percent of MSPI projects focus on depression screening with 
a 12 percent positive rate. To help improve access to quality care for 
patients, more than 12,000 substance abuse and mental health encounters 
were delivered via tele-behavioral health. MSPI projects also deliver 
treatment options with motivational interviewing and cognitive 
behavioral health therapy as the most commonly utilized evidence-based 
practice types. MSPI projects have also trained over 13,000 
professionals and community members to respond to suicide crises.
    The model in use for MSPI demonstration projects is community 
driven and solution focused from a community needs context making its 
success the best model to address mental health and substance use and 
abuse.
    Question. How will you allocate the funds proposed in your request 
to ensure that they actually reach the youth who are at the greatest 
risk--and that they also reach the greatest number of tribes? What role 
do you see for schools and education professionals to play? What about 
tribal leaders?
    Answer. The funding formula for MSPI considers the greatest need 
based on data on population served, poverty, and disease burden. 
Determining greatest need has been based on consultation with tribes 
and includes recommendations for funding applicants to submit related 
findings from relevant community data, needs assessments, or evaluation 
to support their application and request for funding.
    Educational professionals and schools serving AI/AN youth, 
including organizations such as Boys & Girls Club of America, are vital 
participants in the success of youth directed prevention, early 
identification and intervention, treatment, and recovery services. 
Selecting projects that will provide these types of services in school 
settings are ideal since this is where youth spend much of the day and 
can more easily access services. Early identification and intervention 
is essential in the school environment. If schools do not have the 
capacity to intervene themselves, it is essential that they are able to 
engage the youth and assist in a seamless introduction and/or referral 
to a behavioral health professional. Finally, when youth are receiving 
or have received behavioral health services, it is essential for school 
professionals to encourage and support the youth as they return to the 
school in their reintegration and recovery process.
    Tribal leaders are necessary participants in the planning, 
development, implementation, and monitoring of any behavioral health 
services directed for AI/AN youth in their communities. Buy-in and 
active participation from tribal leaders is vital to the success of 
youth behavioral health programs. One element identified in the lessons 
learned from the MSPI and DVPI demonstration programs was the ability 
to garner support and participation of community members and tribal 
leaders.
    Question. Can you talk more about the overarching goals of the 
``Generation Indigenous'' proposal, and share specific details about 
how IHS plans to coordinate with other Federal agencies to implement 
these goals? If they are funded, what are the metrics that this 
administration plans to use to show that these investments are working 
to change the lives of Native youth?
    Answer. The Generation Indigenous initiative was developed after 
the President and First Lady took a historic trip to the Standing Rock 
Sioux Reservation in North Dakota in 2014 where they heard directly 
from Native youth who described significant challenges. President Obama 
launched the Generation Indigenous (Gen I) initiative at the 2014 White 
House Tribal Nations Conference which takes a comprehensive, culturally 
appropriate approach to remove barriers and help improve the lives and 
opportunities for Native youth by using new investments and 
strengthening the administration's engagement with public and private 
partners. The IHS participates in the Gen I initiative along with other 
Federal agencies.
    The major components of the overall Gen I initiative include: (1) 
White House Native Youth Report (released earlier this year); (2) 
fiscal year 2016 President's budget proposals for several agencies, 
including the Department of Education proposal for Native Youth 
Community Projects and Bureau of Indian Education reform proposals; (3) 
National Tribal Youth Network; (4) Cabinet Secretary Listening Tour; 
(5) White House Tribal Youth Gathering; and (6) Generation Indigenous 
Youth and Tribal Leader Challenges.
    IHS sees itself as a critical partner in this important work. IHS' 
initial contribution to this work is the fiscal year 2016 budget 
proposal in collaboration with the Substance Abuse and Mental Health 
Services Administration (SAMHSA). The $50 million proposal from the 
Department of Health and Human Services to address behavioral health 
issues in youth includes $25 million for SAMHSA's Tribal Behavioral 
Health Grants and $25 million for IHS to expand the Methamphetamine and 
Suicide Prevention Initiative (MSPI) to hire additional behavioral 
health providers to focus on youth services and programming. This 
collaboration represents a proposal for the agency efforts to 
compliment and not duplicate other efforts. While SAMHSA focuses in 
expanding community based services, IHS' proposal focuses on adding 
providers on the clinical side. Both proposals are needed to support 
and address behavioral health issues in youth. Improvements by other 
agencies in schools and other services are complimented by addressing 
behavioral health issues, which are often a significant challenge and 
barrier to success for Native youth.
    Evaluation of the IHS proposal will be included in the ongoing MSPI 
evaluation of the provision of services and their impact on patients 
served. This proposal meets the first goal of MSPI to increase access 
to behavioral health services. Specifically, IHS will include measures 
such as the number of new projects funded, numbers of new behavioral 
health providers hired by projects, and the numbers of and 
effectiveness of services and activities implemented for youth with 
these additional funds.
                        third party collections
    Question. Dr. Roubideaux, IHS currently collects about $1.1 billion 
in these funds each year from third-party payers such as Medicare, 
Medicaid, the Department of Veterans Affairs and private insurers.I 
understand that IHS is trying to better leverage third-party 
collections, especially with the passage of the Affordable Care Act, 
and I see that your budget request includes $10 million in new funds to 
expand collections efforts at your health facilities. The Affordable 
Care Act greatly increases the potential for expanded participation in 
Medicaid and private insurance through the health insurance 
marketplaces, allowing the Service to bill these third party payers for 
medical care.
    Can you share with us what specific impacts these changes are 
having on the IHS budget?
    Answer. The Affordable Care Act increases the potential for 
increased third party coverage for IHS patients and if they receive 
services through IHS, increases the potential for third party 
collections. IHS facilities are required to conduct regular business 
planning to assess the potential impact of the Affordable Care Act on 
their facilities and to develop strategies to maximize third party 
collections. While it is still early to determine the full impact of 
coverage expansions that began in 2014, in fiscal year 2014, IHS was 
able to increase third party collections by $49 million compared to 
fiscal year 2013, in part due to increased third party coverage of its 
patients and through improvements in business practices. In order to 
maximize outreach, education, enrollment, case management, and third 
party billing moving forward, IHS proposed the increase of $10 million 
to help provide additional support to IHS business offices, including 
additional training, technical assistance, improvements in business 
office processes and compliance. This additional funding is needed 
since the volume of business related to third party coverage and 
collections is anticipated to continue to increase as a result of the 
Affordable Care Act.
    Question. Can you tell us how exactly you plan to spend the 
additional $10 million proposed in your budget, and share with us why 
you think IHS needs additional funding to implement better collections?
    Answer. IHS and tribal business offices are the backbone of the 
Indian healthcare system. In order to maintain and increase collections 
for the services provided, the $10 million increase in the Hospital & 
Health Clinics (H&HC) budget will be used to provide support in the 
areas of training, technical assistance (TA), and business process and 
compliance issues. The training will be instrumental in increasing the 
skill sets of the employees that work directly on third party billing 
and collections. Better trained staff will make the business process 
more efficient and effective thereby making better use of resources 
available for patient care. Billing practices will improve, third party 
collections will increase and there will be better accountability of 
collections. This will be accomplished through the development of 
appropriate training materials and the establishment of TA programs 
that are tailored to IHS and tribal business office needs. This TA will 
provide needed information on regular and recent changes to the 
business process such as billing code changes, rate increases for 
Medicare and Medicaid, regulatory policy and technical changes, and new 
technology, including information technology. The additional funding is 
needed to develop and deliver this training and technical assistance 
and to increase staff ability to adapt to the anticipated increased 
workload due to the Affordable Care Act.
    Question. Are there steps that you could take to improve 
collections right now by simply improving your existing business 
practices?
    Answer. Yes, we can and we have been taking as many steps as 
possible with existing resources to improve business practices related 
to third party collections. We have just completed an update of the 
Third Party Internal Controls/Accounts Receivable Policy and are now 
taking steps to ensure its implementation in every Area and local 
hospital and clinic. This spring, we are also finishing an update of 
the IHS Revenue Operations manual, our system-wide reference resource 
for all IHS and tribal facilities across the United States, to assist 
any and all staff with any function related to business operation 
procedures and processes, including administrative Roles and 
responsibilities, patient registration, Coding, Billing, and Accounts 
management. Finally, as we prepare for ICD-10 implementation, we are 
making sure that every Area, hospital, and clinic, has received and 
reviewed our checklist for local implementation.
    Question. How much additional revenue will IHS recover through this 
proposal? What's the expected return on investment?
    Answer. IHS estimates that we will increase our collections by 2 
percent by the end of the first year of implementation if this 
investment is enacted and that this will increase in outlying years as 
implementation progresses. However, without knowing the final enacted 
funding level, it is premature to estimate an expected return on 
investment.
                            data collection
    Question. As we discussed during the hearing, I remain concerned 
that per-patient health expenditures by the Indian Health Service 
continue to lag behind spending for other Federal programs.
    Please provide updated data that compares per-patient spending by 
the Indian Health Service with the following Federal programs: (1) 
Medicare spending per beneficiary; (2) national health spending per 
capita; (3) medical spending per patient by the Department of Veterans' 
Affairs; (4) Medicaid spending per enrollee; and (5) per-patient 
spending for enrollees of the Federal Health Benefits Program.
    Answer. The 2014 IHS expenditures per capita data indicates that 
$11,910 is spent per Medicare beneficiary; $8,097 is the national 
healthcare spending per capita; $7,036 is the amount of medical 
spending per patient by the Department of Veterans' Affairs; and $5,563 
is the amount spent per Medicaid enrollee. IHS does not have data 
available for the per-patient spending for enrollees of the Federal 
Health Benefits Program (FEHB).
    However, a comparative cost benchmark linked to premiums, 
deductibles, and co-pays from the FEHB is included in annual comparison 
charts.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    See notes on next page for data. * The extent of payments by other 
sources for medical services provided to AIANs outside IHS is unknown.
---------------------------------------------------------------------------
                               2/13/2015
                               
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

 
 
 
1. $11,910--2013 AVERAGE MEDICARE BENEFIT PER ENROLLEE: Source--2014
 ANNUAL REPORT OF THE BOARDS OF TRUSTEES OF THE FEDERAL HOSPITAL
 INSURANCE AND FEDERAL SUPPLEMENTARY MEDICAL INSURANCE TRUST FUNDS;
 available at http://www.cms.gov/Research-Statistics-Data-and-Systems/
 Statistics-Trends-and-Reports/ReportsTrustFunds/downloads/tr2014.pdf in
 Table II.B1 Medicare Data for 2013, page 10.
 
2. $8,097--PROJECTED 2014 NATIONAL HEALTH CARE EXPENDITURES PER CAPITA:
 Source--Table 5 Personal Health Care Expenditures; Aggregate and per
 Capital Amounts, Percent Distribution and Annual Percent Change by
 Source of Funds: Calendar Years 2013-2023; available at http://
 www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
 Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html.
 
3. $7,036--2014 MEDICAL CARE PER VETERANS ADMINISTRATION PATIENT:
 Source--Volume II--Medical Programs and Information Technology
 Programs--Congressional Submission, available at http://www.va.gov/
 budget/docs/summary/FY2015-Volumell-
 MedicalProgramsAndInformationTechnology.pdf. Per capita spending
 estimate is calculated by dividing 6,616,963 unique VA patients (page
 VHA-7 ``Unique Patients'' table) into $46,554,000,000 total health care
 services (page VHA-8, Executive Summary of Medical Care table).
 
4. $5,563--2010 MEDICAID PAYMENTS PER BENEFICIARY. The Urban Institute
 and Kaiser Commission on Medicaid and the Uninsured estimates based on
 data from Medicaid Statistical Information System (MSIS) reports from
 the Centers for Medicare and Medicaid Services (CMS). 2010. Available
 at http://kff.org/medicaid/state-indicator/medicaid-payments-per-
 enrollee/#.
 
5. $5,296--FDI BENCHMARK PER IHS USER (Interim Inflated): The ACA
 expands health care resources potentially available to AIANs. IHS' long
 standing methodology projecting per-capita resource needs has not yet
 incorporated these factors due to unavailable data. In the interim, the
 last benchmark was inflated to 2014 pending future methodological
 adjustments for ACA effects.
 
6. $3,107--2014 IHS MEDICAL CARE EXPENDITURES PER USER: Source--IHS
 appropriations for 2014. Appropriations spent for personal health care
 services plus IHS collections from third parties are totaled and
 divided by 2014 user counts (1,597,500). IHS spends an additional $499
 per person for public health, community programs, sanitation and
 environmental projects, education, and other purposes unrelated to
 personal medical care. An unknown additional amount of spending occurs
 outside the IHS system when patients obtain a portion of their medical
 services elsewhere, e.g. payments by private insurance, Medicare and
 Medicaid to non-IHS providers for services to Indians who also use the
 IHS.
------------------------------------------------------------------------
 

    Question. We also discussed how unique challenges in Indian Country 
such as disease burden and geography further compound the challenges 
that the Service faces in providing healthcare to American Indians and 
Alaska Natives. Could you also discuss why measuring IHS spending 
against these benchmarks may not fully capture some of the additional 
challenge you face? In other words, why is an IHS patient not a 
``typical'' patient that is enrolled in Medicaid or the Federal Health 
Benefits program?
    Answer. The American Indian and Alaska Native (AI/AN) people 
continue to experience health disparities and multiple chronic 
conditions that are greater on average than those that a typical 
patient enrolled in Medicaid or the Federal Health Benefits Program may 
face. For instance, while the rate of increase in diabetes prevalence 
appears to be slowing in AI/AN adults, the current prevalence of 15.9 
percent it was still more than twice that of U.S. white adults (7.6 
percent) and more than 4 percent higher than the general U.S. adult 
population in 2012. Diabetes at least doubles the risk of 
cardiovascular disease and other complications are also common in 
patients with longstanding diabetes, including kidney, eye, and nerve 
problems. Management of patients with diabetes, diabetes complications 
and other associated chronic conditions is extremely challenging and 
requires more time and resources.
    Additionally, AI/AN people have experienced high rates of adverse 
childhood experiences (ACE), which are strongly related to many adult 
health and mental health outcomes. One study of ACE exposures in 1,660 
AI people from seven southwest tribes (Am J Prev Med 2003;25:238-244) 
found that the prevalence of adverse childhood experiences was very 
high in all 7 tribes studied. Two-thirds of participants reported 
having at least one parent with alcohol problems. The most common types 
of maltreatment were physical neglect (men: 45 percent; women: 42 
percent) and physical abuse (men: 40 percent; women: 42 percent), 
sexual abuse (men: 24 percent; women: 31 percent), emotional abuse 
(men: 23 percent; women: 36 percent), and emotional neglect (men: 20 
percent; women: 23 percent). One-third of participants had experienced 
at least 4 types of ACE exposures. In the original ACE study conducted 
with over 9,500 adult HMO enrollees in California, having experienced 
at least 4 types of childhood adversities increased the risk of 
alcoholism, drug abuse, depression, and suicide attempt by 4-12 times; 
the risk of smoking, poor self-rated health, and sexually transmitted 
disease by 2-4 times; and the risk of physical inactivity and severe 
obesity by 1.4-1.6 times (Am J Prev Med 1998;14:245-258). Further, the 
experience of chronic poverty, food insecurity, and discrimination 
compounds the effects of childhood adversities to create significant 
risks for the health and mental health of AI/AN people.
    The AI/AN population is younger, but it experiences mortality at a 
much higher rate than the overall U.S. population (U.S. All Races). 
Children aged 5-14 years comprises 21.6 percent of the AI/AN service 
population, whereas in the overall U.S. population this group accounts 
for 14.6 percent. The median age of the IHS Service Area AI/AN 
population is 25.0 years. In comparison to the overall U.S. population, 
the median age is 34.9 years.
    AI/AN persons aged 15-24 years are 17.8 percent of the population 
in the IHS Service Area, compared to 14.0 percent of the overall U.S. 
population. In four key areas, this age group experiences significantly 
higher mortality as summarized in the table below.

                                    ADJUSTED MORTALITY PER 100,000 POPULATION
                                               15-24 YEARS OF AGE
                                          IHS SERVICE AREA (2007-2009)
----------------------------------------------------------------------------------------------------------------
                   Cause of Death                            AI/AN             All Races             Ratio
----------------------------------------------------------------------------------------------------------------
Alcohol Related.....................................                5.4                 0.4                13.5
Suicide.............................................               39.7                 9.9                 4.0
Heart Disease.......................................                3.8                 2.5                 1.5
Homicide............................................               16.9                12.2                 1.4
----------------------------------------------------------------------------------------------------------------

    Mortality rates for alcohol-related deaths, suicide, heart disease 
and homicide among AI/AN persons aged 15-24 years are in excess of U.S. 
All races, ranging from 1.4 times (homicide) to 13.5 times (alcohol 
related) higher.

                          SUBCOMMITTEE RECESS

    Senator Murkowski. We look forward to working with you on 
many of these issues. And with that, the subcommittee stands 
adjourned.
    [Whereupon, at 11:26 a.m., Wednesday, March 11, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]
```