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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. 
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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. 
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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 pro-
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posal 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. 
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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 
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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 
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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 total- ing $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 pro- posing 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 IHSoperated 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 practicebased 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 
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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 
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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? 
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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? 
11 

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. 
12 

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 
13 

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. 
14 

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. 
15 

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 
16 

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. 
17 

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. 
18 

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, 
19 

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 Medicarelike 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. 
20 

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 
21 

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 MedicalSurgical 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 
22 

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 con-
23 

struction 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—preapplicants. 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 
24 

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. 
25 

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. 
26 

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? 
27 

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 
28 

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 
29 

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 
30 

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. 
31 

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 
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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 comingling 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 
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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. 
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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 
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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 
36 

$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 
37 

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 
38 

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 administra-
39 

tive 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 copays from the FEHB is included in annual comparison charts. 
40 

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 
41 

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-Trendsand-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-paymentsper-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 partici-
42 

pants 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.]