[Senate Hearing 117-]
[From the U.S. Government Publishing Office]
DEPARTMENT OF THE INTERIOR, ENVIRONMENT, AND RELATED AGENCIES
APPROPRIATIONS FOR FISCAL YEAR 2023
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WEDNESDAY, MAY 11, 2022
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 10:00 a.m. in room SD-124, Dirksen
Senate Office Building, Hon. Jeff Merkley (chairman) presiding.
Present: Senators Merkley, Tester, Van Hollen, Heinrich,
and Murkowski.
INDIAN HEALTH SERVICE
STATEMENT OF HONORABLE ELIZABETH FOWLER, ACTING
DIRECTOR
ACCOMPANIED BY JILLIAN CURTIS, CHIEF FINANCIAL OFFICER
OPENING STATEMENT OF SENATOR JEFF MERKLEY
Senator Merkley. Today, we convene this hearing at an
important time when health care remains at the forefront of our
minds as we attempt to move past the COVID-19 pandemic. We
faced a number of challenges with wave after wave of new
variants, and we continue to confront the challenges of new
variants to come.
But I'm hopeful that we're finally making progress and
emerging from this pandemic with a better understanding of the
virus and with more tools in our toolbox available to fight its
effects and the fact that we're all here in person today is a
very good sign of the progress that we have made.
Welcome, IHS Acting Director Elizabeth Fowler. Good to have
you as well as Indian Health Service (IHS) Chief Financial
Officer Jillian Curtis. Good to have both of you here today and
for your willingness to answer the questions that the Senators
may have.
I look forward to hearing from both of you on how a
combination of fiscal year 2022 funding and previously-
appropriated supplemental funding is being used to address the
pandemic's ongoing impacts in Native communities, how we are
working to improve patient outcomes, how bipartisan
infrastructure funding will make an impact on water
infrastructure, and most importantly, how we are planning to
deal with future health care challenges with your agency's
proposed fiscal year 2023 budget.
Native communities have been disproportionately affected by
the COVID-19 pandemic with Native COVID mortality rates twice
as high as non-Native populations. Native Americans and Alaska
Natives have been hospitalized due to COVID-complications at a
rate four times higher than non-Hispanic white individuals.
Unfortunately, these differences are not uncommon even
outside the context of COVID-19. These disparities in health
care have long existed. The pandemic simply highlighted and
exacerbated them.
So the work to improve health outcomes for Native American
communities remains a vital challenge that we must tackle. To
that end, this committee provided Indian Health Service with
6.6 billion in the fiscal year 2022 Omnibus, a 394 million
increase in the agency's funding.
These increases were provided in the hope that we can move
the needle towards bettering the lives of Native Americans.
This is not only a moral obligation, it's a trust and treaty
responsibility that we must never lose sight of.
We can never fully atone for the sins of the past in this
country but we can and must do our best to live up to our
responsibility for providing the best available health care as
enshrined in treaties. Because no matter who you are or where
you live, health care simply is and ought to always be a
fundamental right in America.
I am pleased to see the Biden Administration shares this
commitment and has proposed significant new investments in the
Indian Health Service. The request includes $9.1 billion in
funding for fiscal year 2023 or a 2.49 billion or 38 percent
increase, and for the first time the request includes a
proposal to move IHS from discretionary funding to mandatory
funding.
I am keeping an open mind on this proposal and look forward
to discussing this in more detail in this hearing during our
questions, but I'll say right now that I agree with the
sentiments to want to provide financial stability to the agency
and to Native communities, and I'm pleased to see ideas being
proposed to prompt discussion on how we can address chronic
problems.
I do have concerns, however, that despite the significant
important reasons to change the funding trajectory, we need to
also make sure that there is an important congressional
oversight role and so how do those two pieces fit together: the
possibility of mandatory funding and congressional oversight.
I think I speak for most, if not all, of my colleagues on
this committee when I say this is something we are not easily
willing to forego. We feel that annual appropriations is an
important tool for ensuring close oversight and a close working
relationship with agencies and the programs we oversee.
We need to learn a lot more about how this proposal would
work and I look forward to having that detailed discussion with
you in the near future.
I am pleased to see proposed IHS facilities requests of
$1.6 billion, an increase of 626 million or 67 percent, for
tribal infrastructure, medical equipment, water infrastructure
investments to improve access to drinking water and clean water
systems in Indian Country.
This investment in water infrastructure is critically
important for the health and well-being of any community. The
water infrastructure funding provided for fiscal year 2022
comes on top of the $3.5 billion that I'm proud we're able to
provide for tribal water systems in the bipartisan
infrastructure law.
There is a direct correlation between improved water and
sanitation systems and improved public health. The
infrastructure funding was, frankly, an astounding level of
investment. It cleared out a backlog that we know will soon be
replaced by other projects that are desperately needed by other
Native communities.
I look forward to hearing how all of this funding is being
spent and how we can continue to focus on these investments.
In Oregon, for example, the Confederated Tribes of Warm
Springs has 57 miles of pipes in such a state of disrepair that
much of the community is repeatedly left without running water
and are under almost perpetual instructions to have to boil
their water to make it safe to drink.
The system is operated by a computer that was established
from a landfill that's running on a very old and unsecured
version of Windows. It's been obsolete for many years, just a
symbol, if you will, of how out of date this infrastructure is,
how much it's in need of restoration.
In 2022, these are stories we shouldn't be hearing about in
the United States of America. We must do better. So there's a
lot to discuss and I look forward to that conversation.
And now I'd like to turn to our Ranking Member Senator
Murkowski for any opening remarks that she would like to make.
STATEMENT OF SENATOR LISA MURKOWSKI
Senator Murkowski. Thank you, Mr. Chairman, and good
morning. Good morning, Ms. Fowler. It's good to have you before
the committee here this morning. We had an opportunity to have
you before the Indian Affairs Committee last week, so
appreciate you coming back to the Hill, and an opportunity to
discuss the fiscal year 2023 budget proposal.
Mr. Chairman, you have noted the issue about the decision
that has been made by the Administration proposing to
reclassify the entire agency's budget and so I just want to
thank you for having a hearing on this proposal because given
that we're looking at this proposed reclassification to put the
entire agency budget for fiscal year 2023 as mandatory, really
the 2023 IHS budget proposal is technically not in the
jurisdiction of the Appropriations Committee.
So I'm glad that we are having the decision to move forward
with this hearing despite some jurisdictional issues.
While we're not completely back to pre-pandemic level of
activity, I am hopeful that we've turned the corner on COVID.
Over the course of the pandemic, IHS received approximately
nine billion in supplemental funding to address both pandemic-
related expenses and other long-term infrastructure needs, like
electronic health records, information technology, and, in
addition to the investments made by COVID supplemental
packages, the bipartisan infrastructure law enacted last year
dedicated 3.5 billion for the IHS to fund all listed wastewater
and sanitation projects, as the Chairman has mentioned.
I have consistently raised this funding as a priority in
our hearings. So it's no secret that securing the money to
address the IHS backlog was something that I worked really hard
on to make sure it was included in the final infrastructure
package.
We've heard about potential administrative cost concerns
associated with these funds. So I'll have some follow-up
questions related to this in our back and forth after
statements here.
When you consider the COVID supplemental packages, the
bipartisan infrastructure law, and the annual appropriations
bills, the IHS has received approximately 37.5 billion over the
preceding 4 years. I think that this demonstrates our
commitment to working together in a bipartisan manner to
address our shared tribal priorities across the board.
Whether working together to navigate the budget
unpredictability and instability surrounding the 105L issue,
providing money to fully fund staffing packages, or trying to
address the overall needs of the entire health delivery system
while also taking into consideration administration and
congressional interests during a pandemic, I think the work has
been together and that has been so important.
When I became Chairman of this subcommittee back in 2016,
the annual appropriations level for the agency was 4.8 billion.
An indefinite appropriation for contract support costs was
created in my first bill as Chairman. Tribal lease payments
were not a significant portion of the budget, and one of my
priority issues, sanitation construction, was funded at 99
million.
Last year in Fiscal 2022, the agency received 6.6 billion.
In 7 years, the IHS has received an approximate 37.5 percent
increase in programmatic funding while the overall allocation
of the Interior Appropriations bill received an estimated
increase of 15 percent over this same period.
So I think it's important to recognize that this could not
have been accomplished if IHS was only my priority. This had to
be a shared priority and it clearly, clearly was.
The increases the IHS has received relative to the overall
increases for the Interior bill clearly sends the signal that
this agency is of bipartisan/bicameral importance, and the fact
that this subcommittee provided significant increased funding
to the IHS even during times of budget constraints and caps
should indicate that we are all dedicated and all committed to
ensuring access and quality care for Indian Country.
So in light of all of our shared accomplishments, I was
disappointed to read the 2023 budget proposal. Last year the
Administration proposed advanced appropriations for the entire
agency as well as a budget reclassification for the contract
support costs and the highly unpredictable 105L tribal lease
payments.
Advanced appropriations, as you know, Ms. Fowler, is
something that I have personally been supportive of over the
years. I also know that when this concept was proposed in the
budget last year, many of my colleagues and staff had technical
questions that went unanswered unfortunately and unexplained
for months.
This delay likely contributed to the omission of this
concept in the final Omnibus bill, but I was hopeful that those
conversations would have carried forward in an effort to
potentially set us up for success for at least some accounts in
fiscal year 2023, but this doesn't appear to be the direction
that the Administration took.
Not only does this budget proposal fail to take a lessons
learned approach in an effort to be successful, this budget
proposal takes a series conversation and I think it makes it
less serious which is disappointing.
Another area of concern is the recent actions of the agency
related to contract support costs. As you know, a large number
of tribes and tribal organizations are concerned the agency is
attempting to change the way these costs are calculated as a
result of the Cook Inlet Tribal Council decision and the Fort
Defiance letter.
So I appreciate the answers to my letter on this topic, but
I hope that we can get some additional information here today,
and while we're glad you are here today to provide testimony
and answer questions, I think it's just so important. We need
permanent leadership. We need permanent leadership at IHS.
As we all know, the agency was first put on GAO's High Risk
List back in 2017 and it's still there. It's critical the
agency have stable executive leadership in place to make
decisions and address those high-risk concerns.
So this past March the Administration nominated Ms. Roslyn
Tso, a citizen of the Navajo Nation and current Director of the
Navajo Area Indian Health Service, as the new Director. I do
believe that this is one of the last nominations for agency
leadership positions to be received in the Senate.
So while this is welcome news for us, I am concerned about
the length of time that it has taken to receive the nomination.
The annual appropriations process is never easy or quick,
but it is one that we work on together. So as we look to fiscal
year 2023, I hope that we're able to continue this bipartisan
tradition.
With that, Mr. Chairman, back to you, and I look forward to
the discussion this morning.
Senator Merkley. Thank you very much, Senator.
Now we turn to Honorable Elizabeth Fowler. Welcome.
SUMMARY STATEMENT OF HON. ELIZABETH FOWLER
Ms. Fowler. Good morning. Chairman Merkley, Vice Chairman
Murkowski, and Members of the Committee, thank you for the
opportunity to testify on the President's fiscal year 2023
Budget Request for the Indian Health Service.
Before I turn to the fiscal year 2023 Request, I want to
first acknowledge and thank each of you for your work over the
years in growing the IHS budget and prioritizing tribal issues
within your bill.
With your support, the IHS budget has grown by 57 percent
in the last decade, and we know that type of growth is
challenging to accomplish in a constrained discretionary
funding environment.
Patients across Indian Country have benefited from your
efforts. This growth in funding has enabled us to address some
of the most critical issues facing the Indian Health System,
from addressing exponential growth and legally-required
contract support costs and Section 105(l) lease agreements to
resolving accreditation emergencies to bolstering the core
administrative functions of the agency.
We know you also fought hard to tackle urgent disparities
facing Indian Country, such as the opioid epidemic, HIV,
maternal health and suicide prevention.
Over the years this work has always been underscored by our
shared goal to improve health outcomes for all American Indians
and Alaska Natives. HHS deeply appreciates this partnership and
commitment.
It is with this shared goal in mind that the Administration
approached the fiscal year 2023 Budget Request for the Indian
Health Service. We know that despite our shared efforts, IHS is
still underfunded. Whether you look at per capita spending
rates compared to other Federal health programs or other
national health expenditure benchmarks, it is clear that
current funding is not sufficient to meet the needs of the over
2.7 million American Indians and Alaska Native patients that
IHS serves each year.
This underfunding of the Indian Health System directly
contributes to stark health disparities in tribal communities.
American Indian and Alaska Native people born today have a life
expectancy that is 5.5 years shorter than the U.S. all races
population with some tribes experiencing life expectancy as
much as 12 years shorter than the general population.
Longstanding health disparities were compounded by the
pandemic with American Indians and Alaska Natives experiencing
disproportionate rates of COVID-19 infection, hospitalization,
and death. Addressing these inequities is a moral imperative
for our nation, and it will require bold action from all of us
to ensure we are upholding our commitments to Indian Country.
IHS MANDATORY FUNDING PROPOSAL
That is why the President's fiscal year 2023 budget
proposes the first-ever mandatory budget for the Indian Health
Service. I acknowledge that this is a substantial change that
would fundamentally impact how IHS receives funding from
Congress. The Administration did not propose this change
lightly.
We believe that a change of this magnitude is needed to
deliver on the government's health care responsibility for
Indian Country.
This proposal is in line with longstanding recommendations
from tribal leaders across the nation, including in the Tribal
Consultation and Urban Confer HHS conducted last year on long-
term funding solutions for the IHS.
The fiscal year 2023 IHS budget is a starting point for
ongoing conversations with tribes and Congress to consider and
refine the proposal through the legislative process.
Just to summarize, the fiscal year 2023 budget includes a
total of $9.3 billion in mandatory funding for the Indian
Health Service which is $2.5 billion above the fiscal year
2022-enacted level.
For fiscal year 2024 to 2032, the budget would grow
automatically to account for the growing costs of providing
health care as well as population and pay growth.
This budget would address the three core issues identified
by GAO: funding stability, predictability, and adequacy. These
changes will allow IHS, tribal health programs, and urban
Indian organizations to more effectively plan and implement
health care services to best meet their community needs.
As we work towards securing stable and predictable funding
to meet the needs of Indian Country, we are committed to
working closely with our stakeholders and understand the
importance of working with partners, including Congress.
Thank you again for the opportunity to speak with you
today, happy to answer any questions that you might have.
[The statement follows:]
Prepared Statement of Hon. Elizabeth Fowler
Good afternoon Chairman Merkley, Ranking Member Murkowski, and
Members of the Committee. Thank you for your support and for inviting
me to speak with you about the President's fiscal year 2023 Budget
Request for the IHS.
The Indian Health Service (IHS) is an agency within the Department
of Health and Human Services (HHS) and our mission is to raise the
physical, mental, social, and spiritual health of American Indians and
Alaska Natives to the highest level. This mission is carried out in
partnership with American Indian and Alaska Native Tribal communities
through a network of over 687 Federal and Tribal health facilities and
41 Urban Indian Organizations (UIOs) that are located across 37 states
and provide healthcare services to approximately 2.7 million American
Indian and Alaska Native people annually.
On March 28, 2022, the White House released the President's fiscal
year 2023 Budget, which proposes the first-ever fully mandatory budget
for the IHS. The bold action taken in the fiscal year 2023 President's
Budget demonstrates the Administration's continued commitment to
strengthen the nation-to-nation relationship. This historic proposal
addresses long-standing challenges that have impacted communities
across Indian Country for decades.
The Indian Health system is chronically underfunded compared to
other healthcare systems in the U.S.\1\\2\ Despite substantial growth
in the IHS discretionary budget over the last decade, by 57 percent
from fiscal year 2012 to the current fiscal year 2022 enacted level,
the growth has not been sufficient to address the well documented
funding gaps in Indian Country. These funding deficiencies directly
contribute to stark health disparities faced by tribal communities.
American Indian and Alaska Native people born today have a life
expectancy that is 5.5 years shorter than the U.S. all-races
population, with some tribes experiencing life expectancy as much as 12
years shorter than the general population. They also experience
disproportionate rates of mortality from most major health issues,
including chronic liver disease and cirrhosis, diabetes, unintentional
injuries, assault and homicide, and suicide. The pandemic compounded
the impact of these disparities in tribal communities, with American
Indians and Alaska Natives experiencing disproportionate rates of
COVID-19 infection, hospitalization, and death.
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\1\ Government Accountability Office Report--Indian Health Service:
Spending Levels and Characteristics of IHS and Three Other Federal
Health Care Programs https://www.gao.gov/assets/gao-19-74r.pdf
\2\ U.S. Commission on Civil Rights Report--Broken Promises:
Continuing Federal Funding Shortfall for Native Americans https://
www.usccr.gov/files/pubs/2018/12-20-Broken-Promises.pdf
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long-term funding solutions
Our budget plays a critical role in advancing a healthier future
for American Indian and Alaska Native people. Growth beyond what can be
accomplished through discretionary spending is necessary to address
funding gaps and remediate health disparities. Mandatory spending is a
more appropriate avenue to provide high-quality healthcare that is
reliable and widely available for American Indians and Alaska Natives.
To address this historic underinvestment in IHS, the mandatory
budget provides $9.3 billion in fiscal year 2023, which includes $147
million in current law authorized funding for the Special Diabetes
Program for Indians. This is an increase of +$2.5 billion or 37 percent
above the fiscal year 2022 enacted level. This immediate surge of
funding is necessary to address long-standing gaps in healthcare and
tackle chronic health disparities faced across Indian Country.
Mandatory funding for the IHS provides the opportunity for
significant funding increases that could not be achieved under
discretionary funding caps. Further, this mandatory funding proposal
would authorize and appropriate funding over 10 years, through fiscal
year 2032, ensuring predictability that would allow IHS, tribal, and
urban Indian health programs the opportunity for long-term and
strategic planning. This increased stability and ability to conduct
longer-term planning will improve quality of healthcare, promote
recruitment and retention of health professionals, and enhance
management efficiencies for individual health programs and the Indian
Health system at large.
Specifically, the mandatory budget proposal culminates in a total
funding level of approximately $36.7 billion in fiscal year 2032. When
compared with the fiscal year 2022 enacted level of $6.8 billion, the
Fiscal year 2032 proposed funding level represents an increase of
nearly +$30 billion or +442 percent. In total, the 10-year budget
includes over $248 billion for the IHS.
The budget also exempts the IHS from sequestration for proposed
funding, which is the legislatively mandated process of budget control
consisting of automatic, across-the-board spending reductions to
enforce budget targets to limit Federal spending. Exempting the IHS
budget from sequestration ensures funding for direct healthcare
services for American Indians and Alaska Natives is not reduced and is
consistent with the treatment of other critical programs such as
veterans' benefits and nutrition assistance programs. The budget also
includes inflation factors to address the growing cost of providing
direct healthcare services, including pay costs, medical and non-
medical inflation, and population growth.
This request responds to the long-standing recommendations of
tribal leaders shared in consultation with HHS and IHS to make IHS
funding mandatory, and IHS will continue consulting with tribes to
inform future policy and budget requests.
prioritizing high quality health care
In fiscal year 2023, the budget prioritizes investments that
advance high quality healthcare and tackle the stark inequities that
exist in the Indian Health system. This includes a +$243 million
increase to the Indian Health Care Improvement Fund to provide
additional health services and address resource disparities across the
Indian health system. Likewise, the budget prevents a sharp reduction
in services by providing an additional +$220 million to partially
sustain the one-time American Rescue Plan Act investments that were
appropriated to expand access to mental health and substance abuse
prevention and treatment services, and to expand the public health
workforce in Indian Country.
The Budget also includes a +$215 million general increase to
Hospitals and Health Clinics to expand access to direct healthcare
services, which would provide an estimated 41 thousand inpatient
admissions and almost 16 million outpatient visits at IHS and Tribal
facilities. The Purchased/Referred Care program, which supports the
purchase of essential healthcare services not available in IHS and
Tribal healthcare facilities, is expanded by +$206 million, providing
an estimated 7,333 additional inpatient admissions; 182,319 additional
outpatient visits; and 8,006 additional patient travel trips. This
Purchased/Referred Care increase would also support establishment of an
Arizona statewide Purchased/Referred Care Designation Area, as directed
in the Indian Health Care Improvement Act, which will expand access to
care for over 67,000 IHS patients in Arizona. The Budget also expands
dental health services by supporting an additional estimated 1 million
dental visits in fiscal year 2023 through a +$48 million investment.
Expansion of these programs is essential to ensure that IHS can provide
high quality medical services and support critical healthcare services
through contracts with hospitals and other healthcare providers to
purchase specialized or critical care when IHS and tribally-managed
facilities are unable to provide the services directly.
In addition, Current Services, which offset the rising costs of
providing direct healthcare services, are fully funded at +$207
million. These resources will help the IHS to maintain services at the
fiscal year 2022 levels by shoring up base operating budgets of IHS,
Tribal, and urban Indian health programs in the face of increasing
costs. Similarly, +$102 million is provided to fully fund staffing and
operating costs for eight newly-constructed or expanded healthcare
facilities. These funds support the staffing packages for new or
expanded facilities, which will expand the availability of direct
healthcare services in areas where existing healthcare capacity is
overextended.
The budget also makes targeted investments to address our Nation's
most pressing public health challenges, which disproportionately impact
American Indian and Alaska Native communities. This includes HIV and
Hepatitis C (+$47 million), improving maternal health (+$4 million),
and addressing opioid use (+$9 million).
IHS also recognizes the importance of providing culturally
competent care to American Indians and Alaska Natives who live off-
reservation or in urban areas. To address this, the Urban Indian Health
Program is expanded by +$27 million to provide additional culturally
competent direct healthcare services through a network of 41 Urban
Indian Organizations located in urban areas across the country. This
investment will provide an estimated 1.1 additional million healthcare,
outreach, and referral services to urban Indian users in fiscal year
2023.
In fiscal year 2023, the budget also makes numerous investments in
high priority areas, such as recruitment and retention of high quality
health professionals, expansion of the successful National Community
Health Aide Program, expanding emergency medical services, and other
activities that support high quality healthcare.
While these fiscal year 2023 investments will make significant
progress to address the most urgent healthcare needs, further growth is
needed to address sustained underfunding of the Indian Health system
that has resulted in documented gaps in funding and service provision.
Over 5 years, from fiscal year 2024 to fiscal year 2028, the budget
grows to address the funding gap for direct healthcare services
documented in the fiscal year 2018 level of need funded analysis.\3\
The level of need gap analysis calculated $11.2 billion as the point in
time estimated funding shortfall identified for a baseline of health
services in fiscal year 2018. This funding increase would be
distributed across the IHS funding lines that provide direct healthcare
services, ensuring a broad benefit of this investment for all tribes,
while also seeking to address funding disparities within the Indian
Health system.
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\3\ (FY) 2018 Indian Health Care Improvement Fund Workgroup Interim
Report https://www.ihs.gov/sites/ihcif/themes/responsive2017/
display_objects/documents/2018/2018_IHCIF_WorkgroupInterimReport.pdf
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modernizing critical infrastructure
In addition to funding for direct healthcare services, additional
investments are needed to address substantial deficiencies in physical
and information technology infrastructure across the IHS system.
Outdated infrastructure can pose challenges in safely providing patient
care, recruiting and retaining staff, and meeting accreditation
standards. From fiscal year 2023 through fiscal year 2028, the budget
includes critical funding increases to reduce or eliminate existing
facilities backlogs and modernize the IHS Electronic Health Record
(EHR).
Specifically, the budget provides $285 million in fiscal year 2023
and +$6 billion from fiscal year 2024 to fiscal year 2028 to stabilize
the current system and replace IHS's EHR with a modernized system. The
current IHS EHR is over 50 years old, and the GAO identifies it as one
of the 10 most critical Federal legacy systems in need of
modernization. The IHS relies on its EHR for all aspects of patient
care, including the patient record, prescriptions, care referrals, and
billing public and private insurance for over $1 billion reimbursable
healthcare services annually. The EHR holds an extremely high degree of
mission criticality given the ability to provide much-anticipated
clinical and administrative capabilities used in modern systems for the
delivery of timely and impactful healthcare. Expected benefits from
adopting and implementing a modernized system include, but are not
limited to, improved patient safety, improved patient outcomes, better
disease management, enhanced population health, improved clinical
quality measures, opioid tracking, patient data exchange, third party
revenue generation, and agency performance reporting. Additionally, the
new system will be interoperable with the Department of Veterans
Affairs, Department of Defense, tribal and urban Indian health
programs, academic affiliates, and community partners, many of whom are
on different health information technology platforms.
The IHS system also faces substantial physical infrastructure
challenges--IHS hospitals are approximately 40 years old on average,
which is almost four times the age of the average hospital in the
United States. Infrastructure deficiencies directly contribute to
poorer health outcomes for American Indians and Alaska Natives. The
Budget addresses these needs by fully fund the 1993 Health Care
Facilities Construction Priority list. The remaining projects on the
list include the Phoenix Indian Medical Center, Phoenix, AZ; Whiteriver
Hospital, Whiteriver, AZ; Gallup Indian Medical Center, Gallup, NM;
Albuquerque West Health Center, Albuquerque, NM; Albuquerque Central
Health Center, Albuquerque, NM; and Sells Health Center, Sells, AZ.
Furthermore, the budget includes $102 million in fiscal year 2023
and +$454 million over 5 years, from fiscal year 2024 to fiscal year
2028, to ensure IHS can replace medical and laboratory equipment at the
end of its six to eight-year life cycle. Many IHS hospital
administrators reported that old or inadequate physical environments
challenged their ability to provide quality care and maintain
compliance with the Medicare Hospital Conditions of Participation. The
administrators also reported that aging buildings and equipment is a
major challenge impacting recruitment and retention of clinicians.
Maintaining reliable and efficient buildings is also challenge as
existing healthcare facilities age and the costs to operate and
properly maintain healthcare facilities increases. Many IHS and Tribal
healthcare facilities are operating at or beyond capacity, and their
designs are not efficient in the context of modern healthcare delivery.
In fiscal year 2023, the Budget tackles this challenge by including a
+$172 million increase for maintenance and improvement to reduce the
Backlog of Essential Maintenance, Alteration, and Repair, as well as
routine maintenance and repair to sustain the condition of Federal and
Tribal healthcare facilities, and environmental compliance projects to
meet changing healthcare delivery needs. The Budget proposes to fully
fund all existing projects by fiscal year 2028.
Lastly, the IHS is grateful for the additional $3.5 billion in
Sanitation Facilities Construction funding provided by the
Infrastructure Investment and Jobs Act (IIJA). These funds will make a
transformational impact in shoring up essential sanitation facilities
across Indian Country. In order to maintain existing project completion
deadlines and support IHS and Tribes in successfully implementing IIJA
resources, the budget includes +$49 million to support implementation
of the $3.5 billion provided by the IIJA for Sanitation Facilities
Construction (SFC). This funding will support additional salary,
expenses, and administrative costs beyond the 3 percent allowed in the
IIJA. These funds would also be available to Tribal Health Programs,
which is not currently permissible under the 3 percent set-aside for
administrative costs in the IIJA.
The budget also proposes a new $18 million program to recruit and
retain new public health engineers by partnering with colleges and
universities to implement a scholarship program with service
requirements in support of Sanitation Facilities Construction projects
across Indian Country. The IHS owns over 10.2 million square feet of
facilities across 2,119 buildings and 1,758 acres of Federal and trust
land. The nature of this space varies from sophisticated medical
centers to residential units and utility plants. Facilities range in
age from less than 1 year to more than 167 years. A professional and
fully- functional workforce is essential to ensure effective and
efficient operations.
supporting self-determination
IHS continues to support the self-determination of tribes to
operate their own health programs. Tribal leaders and members are best
positioned to understand the priorities and needs of their local
communities. The amount of the IHS budget that is administered directly
by tribes through Indian Self-Determination and Education Assistance
Act contracts and compacts has grown over time, with over 60 percent of
IHS funding currently administered directly by tribes. Tribes design
and manage the delivery of individual and community health services
through 22 hospitals, 319 health centers, 552 ambulatory clinics, 79
health stations, 146 Alaska village clinics, and 8 school health
centers across Indian Country. In recognition of this, the budget
includes a mandatory indefinite appropriation for Contract Support
Costs and Section 105(l) lease agreements with estimated funding levels
of $1.1 billion for Contract Support Costs and $150 million for Section
105(l) Lease Agreements in fiscal year 2023. The budget maintains
indefinite mandatory funding for these accounts across the 10-year
budget window to ensure these payments to tribes are fully funded.
covid-19 response and future emergency preparedness
Throughout the COVID-19 pandemic, the IHS has made incredible
achievements to save lives and improve the health of American Indian
and Alaska Natives across the nation. The IHS has worked closely with
our Tribal and Urban Indian Organization partners, state and local
public health officials, and our fellow Federal agencies to coordinate
a comprehensive public health response to the pandemic. Our number one
priority has been the safety of our IHS patients and staff, as well as
Tribal community members.
However, it is clear that COVID-19 has disproportionally impacted
American Indian and Alaska Natives. Deficiencies in public health
infrastructure exacerbated the impact of COVID-19 on American Indians
and Alaska Natives. Based on data from 14 states, age-adjusted COVID-19
associated mortality among American Indians and Alaska Natives was 1.8
times that of non- Hispanic Whites. In 23 states with adequate race and
ethnicity data, the cumulative incidence of laboratory-confirmed COVID-
19 among American Indians and Alaska Natives was 3.5 times that of non-
Hispanic Whites. In the state of Montana, COVID-19 incidence and
mortality rates among American Indian and Alaska Natives were 2.2 and
3.8 times those among White persons, respectively. The CDC has also
reported that 1 in every 168 American Indian and Alaska Native Children
experienced the death of a parent or primary caregiver due to COVID-19,
4.5 times more likely than non-Hispanic White children.
The budget's proposed investments proposed in direct services and
infrastructure will make substantial progress toward ensuring these
stark disparities are not repeated in future pandemics. Additionally,
to ensure that the IHS is prepared for future emergencies, the budget
requests +$10 million for emergency preparedness activities at IHS
Headquarters and Area offices to establish a dedicated emergency
preparedness workforce at IHS and support relevant training and
capacity building efforts. These additional resources will ensure IHS
has adequate emergency preparedness capacity to serve American Indian
and Alaska Native communities during future public health emergencies.
closing
The fiscal year 2023 budget makes bold strides toward the goal of
ensuring stable and predictable funding to improve the overall health
status of for American Indian and Alaska Natives. The budget is a
historic first step and the start of an ongoing conversation with
tribes to ensure the IHS system is meeting the healthcare needs in
Indian Country. HHS looks forward to working in consultation with
tribes, urban Indian organizations, and Congress to refine this
historic proposal through the legislative process to achieve sustained
improvements in health status and strengthen the Nation-to-Nation
relationship.
Senator Merkley. Thank you very much, and with your
agreement, we'll put your entire written testimony into the
record. No objections on the committee, so ordered.
And let's start with this question of the mandatory
funding. So it certainly does relate to having stable and
predictable budget, but as I mentioned in my initial testimony,
there's always some reservation on Capitol Hill to forego the
oversight function, and this is set up as a structure for a 10-
year period, and it's quite different from the advanced
appropriation request that I championed last year at the
request of IHS and that we supported in our Senate bill.
ADVANCE APPROPRIATIONS
We ultimately did not get agreement on the final
negotiations between the four corners, the final decision-
makers, but I thought that that had a lot of merit to make sure
Indian Health Services did not shut down during an government
shutdown which was a previous significant problem.
Is it the case that the Administration is dropping its
request for advanced appropriations in favor of the
reclassification of mandatory spending?
Ms. Fowler. So the mandatory proposal for the Indian Health
Service, if enacted, would eliminate the need for advanced
appropriations for the agency.
CONGRESSIONAL OVERSIGHT
Senator Merkley. Okay. So the answer is yes, and how would
you envision that there would be any congressional oversight
under that structure?
Ms. Fowler. We understand that if the mandatory proposal
were to be enacted, that we would fall under the jurisdiction
of our authorizing committees which we would work with in an
oversight role, but we also understand the need to continue to
be responsive to the Appropriations Committees, as well, and we
would be happy to work with the Appropriations Committees on
any questions or inquiries or any interests that they have in
continuing to review our budget and request information from
us.
Senator Merkley. So in partnership with our colleagues from
Indian Affairs, we've been trying to schedule a meeting with
OMB and IHS to explore the technical details and there's not
been a responsive communication from the Administration.
So can we get your assurances that this meeting will happen
shortly?
Ms. Fowler. Yes, as I understand, OMB will be leading a
briefing that we anticipate will occur next week.
Senator Merkley. Okay. Great. Because if the Administration
is not responsive, then it's clear it's not a serious proposal
and so we're ready to dive into the details and explore it, but
we need the partnership from the Executive Branch in that
regard.
COVID PREVALENCE
So let's turn to COVID. So the positive test rate remains
high, and we are seeing across the country stagnating vaccine
rates.
Are we seeing the same trends across Indian Country?
Ms. Fowler. We are. We are seeing higher positivity rates,
but we believe that is from more patients coming in who are
symptomatic for testing but a lower volume of testing and so as
an example, in January there were 12,000 COVID tests performed
and in April there were 2,000 tests performed. So the positive
test results combined with the lower denominator is resulting
in a higher positivity rate.
Senator Merkley. That makes sense. Thank you for explaining
that.
COVID VACCINES AND THERAPEUTICS
And the Administration has requested $22.5 billion for
COVID response and there was no specific request for IHS, but
it's my understanding that the funding requested by HHS, Health
and Human Services, that a certain share would be transferred
to IHS. Is that your understanding, as well?
Ms. Fowler. Yes, IHS is a jurisdiction that receives
vaccines and therapeutics from the HHS.
Senator Merkley. Okay. Do you know how much would be
transferred under the Administration's vision?
Ms. Fowler. It's not a funding amount that gets
transferred. We receive the vaccines directly and we receive
the therapeutics and some supplies directly.
Senator Merkley. So let's talk about the therapeutics.
We've got a couple companies that have produced pills, Merck
and Pfizer that seem to be significant.
Are these pills being currently distributed to IHS
facilities? Do people who need those therapeutics, can they
readily access them?
Ms. Fowler. Yes, currently we are able to meet 100 percent
of the demand from the IHS, Tribal, and Urban Facilities that
are requesting those therapeutics.
Senator Merkley. You are requesting therapeutics?
Ms. Fowler. I said we're able to meet 100 percent of the
demand from those facilities that are requesting therapeutics.
Senator Merkley. Okay. Great. We've seen interesting
reports across the nation from health care clinics that
essentially have had the therapeutics, but they don't even
prescribe them when people come in. It's been a strange
arrangement where we've got a tool that can be very helpful and
when a person is early in the phase of the infection and not
necessarily being fully utilized.
I'm not talking about Indian Health Service specifically,
more health services more broadly.
WARM SPRINGS WATER INFRASTRUCTURE
Let me turn to Warm Springs water infrastructure, and as
we've discussed in the past, they've got an ancient system of
pipes. The pressure gauges are always breaking or pressure
control valves. The pipes are splitting. It's just the
contamination results in a lot of the times the water simply is
unsafe to drink. They've been under the continuous boil
notices, meaning they have to boil their water to drink it.
So we are really pleased that the infrastructure bill had
$3.5 billion to clear the backlog on the sanitation
deficiencies list at the time of passage and we're looking
forward to seeing the projects actually get done.
Do you have a timeline for the Warm Springs project?
Ms. Fowler. So the last time we talked, there was a
preliminary engineering assessment that was going to be
completed, which has been completed. We now know that the
project will cost roughly $24 million to complete. It is a Tier
1 project. So we do anticipate that it will be funded with
fiscal year 2022 funding, whether from the Infrastructure
Investment and Jobs Act funding or the annual appropriation.
As I understand it, it will take 30 to 36 months to
complete once we have the funding available for the project,
which we anticipate will be very soon.
Senator Merkley. Great. Is very soon like within the next
couple weeks?
Ms. Fowler. I would think so, yes.
Senator Merkley. Can you personally keep me briefed on
this? It's so important to the Warm Springs Tribe in my state.
Ms. Fowler. Yes.
Senator Merkley. Thank you very much.
I'll turn to Senator Murkowski.
Senator Murkowski. Thank you, Mr. Chairman.
CHANGE IN IHS BUDGET PROPOSALS
Ms. Fowler, I'd like to go back to the discussion that the
Chairman has raised about mandatory versus the discretionary.
You confirmed to him that in fact the Administration has now
decided to take an approach on mandatory as opposed to the
advanced appropriation, and you indicated that, well, if we
move to mandatory, that means that we don't have to look to
advanced appropriations.
But I guess I'm trying to understand why, why the
Administration chose to move in this direction instead of
proposing advanced appropriations again.
Ms. Fowler. Thank you, Senator Murkowski.
I'm just going to be frank here. The Indian Health System
needs substantial funding to meet the needs that are out there
in Indian Country, and we're not able to accomplish that within
the discretionary spending caps on the mandatory side of the
budget as has been proposed for fiscal year 2023 and the 10-
year timeframe.
We're proposing that the budget will grow by almost 300
percent over that 10-year period, and so we believe that it is
an approach that is more suitable for funding Indian health
care.
MANDATORY FUNDING LEGISLATIVE PROPOSAL
Senator Murkowski. Well, as I mentioned in my statement and
as I have said over the years, I believe that IHS has been
chronically underfunded and we need to make improvements.
You and I both noted in our comments that those
improvements over the years have been dramatic in terms of the
funding, but with funding also comes the role of oversight and
that's where the committees come in.
I am in that enviable position, maybe it's not so enviable,
maybe it's just more responsibility, but I am not only the
appropriator for IHS as the Ranking Member on this subcommittee
but I'm also the authorizer as the Ranking Member on Indian
Affairs Committee, and so I appreciate what you've shared that
there's going to be a meeting with OMB coming up.
This is the first that I have heard of it. I'm asking my
staff to confirm whether they have been notified of any such
meeting because so far as I know, there is no legislative
proposal out there in terms of new authorizing language to
account for this shift and what we're trying to figure out here
is whether or not you have identified how you're going to be
paying for the shift to mandatory appropriations.
At what point do you expect that you will send to the
Indian Affairs Committee a legislative proposal to mark up a
mandatory funding bill for fiscal year 2023?
Ms. Fowler. I know that there's a supporting document that
is under development. I will have to get back to you on that
timeframe of when we'll be able to submit it.
Senator Murkowski. So I guess I have to admit a little bit
of confusion here because what we've got is technically there's
no discretionary appropriations language or money proposed for
fiscal year 2023. The discretionary funding levels for the IHS
in fiscal year 2022 was $6.6 billion.
So in theory, if there's not a discretionary proposal for
the Interior bill this year, there's $6.6 billion that is
currently unaccounted for.
So, Mr. Chairman, we're looking here at $6.6 billion in
base Indian Health Service funding that can't be used by an
authorizing committee to pay for mandatory funding on an annual
basis. It certainly wouldn't cover the scoring for a 10-year
window that you've just noted, but it's also been 2 months now
since the budget was released.
The end of the fiscal year is a little over four and a half
months away. So the clock is ticking here. So if you're
planning on sending this plan up, I don't see how you're giving
us the time as whether we are authorizing or whether we are
appropriating to consider this in a way that is viewed as a
serious proposal, and so I share the Chairman's concern here
that if this is serious coming from the Administration, if we
recognize that we've got to be doing this together, you've got
to be working with us a little bit more instead of coming to a
hearing and saying, well, we're going to sit down and talk with
you about what the plan is.
We are in the midst now of these budget and appropriations
discussions. So I don't know. Is it your proposal that there be
no IHS title in the fiscal year 2023 Interior appropriations
bill this year?
Ms. Fowler. That is the proposal, yes.
Senator Murkowski. So there would be nothing in the IHS
title?
Ms. Fowler. Correct.
APPROPRIATIONS COMMITTEE OVERSIGHT
Senator Murkowski. So oversight again absolutely key to
everything that we do around here. In fairness, I don't think
we do enough of it, but I think that this is one of the areas
within the Appropriations Committee where we are able to do
active oversight.
Will you commit to answering questions from this
Appropriations Subcommittee even though you would propose to
delete the discretionary account from the Interior bill?
Ms. Fowler. Yes, we will commit to that.
CONTRACT SUPPORT COSTS (CSC)
Senator Murkowski. Let me ask about contract support costs.
I've raised the issue of the decision in Cook Inlet Tribal and
the Fort Defiance letter. There's a lot of questions and
concerns. Again, we received your response last week, but
there's still some things that I need some clarification on.
For the record, in your letter you state that ``the agency
interprets the Cook Inlet decision and the Fort Defiance letter
as a restatement of current law and practice.'' You also say
that ``the IHS will maintain current methods for calculating
CSC and that there's no plan to change any of the
calculations.''
So the question that I would have for you this morning is
are both of those statements correct and would you support
codifying current practice in legislative text if you would
agree that those statements are correct?
Ms. Fowler. I agree that the statements are correct. We're
not changing any method of calculating contract support costs
as a result of the Cook Inlet decision. We believe the Cook
Inlet decision affirms current statute, and current
interpretation of the statute, and therefore we believe that
there's not a reason to codify the current practice of
calculating contract support costs.
Senator Murkowski. So there's some buzz out there that this
may be a situation where Cook Inlet was just one example. In
the case of the Fort Defiance letter, it stated that the
``Federal Government errantly overpaid CSC in prior years and
were seeking to correct it.''
So the discussion that is out there is whether or not the
Fort Defiance issue is the only example where the Federal
Government errantly overpaid. So the question that I would have
of you is whether you know if this is the only instance in
which IHS has made overpayments and whether or not you
conducted any type of an analysis that would lead you to that
conclusion.
Ms. Fowler. So there's a process for reconciling contract
support costs owed to tribes. We're required to fully pay the
amount of contract support costs required for a tribal
contract.
During that process of reconciliation, sometimes there are
overpayments that are identified. Sometimes there are
underpayments that are identified. The tribe can bring a
Contract Disputes Act claim for an underpayment, and IHS can do
the same for an overpayment, and there are other instances
where the Indian Health Service has identified overpayments of
contract support costs and has sought repayment or has sought
to reconcile the overpayment through the means that are
available to us.
Senator Murkowski. So, Mr. Chairman, my time is well over.
I may come back to this because I'm trying to determine whether
or not there's been any type of a comprehensive analysis of
whether or not overpayments are at issue and the extent of
that.
I'll defer now to my colleague.
Senator Merkley. Thank you.
SANITATION AND FACILITIES PROJECTS
Senator Heinrich.
Senator Heinrich. Thank you, Chairman.
Ms. Fowler, there are literally hundreds of projects
representing over $3.3 billion on the IHS fiscal year 2021
Annual Report of Sanitation Deficiency Levels. Projects in my
state alone represent nearly $200 million in water and
sanitation projects.
As you know, Congress included a total of $3.5 billion for
the IHS Sanitation and Facilities Account to be spent over the
next 5 years in the infrastructure law.
Walk us through what the current status of actually getting
that funding on the ground and how IHS is preparing agency
personnel and resources to get those projects on that list
built.
Ms. Fowler. Thank you, Senator.
When the Infrastructure Investment and Jobs Act was passed,
Indian Health Service quickly planned and implemented a
consultation process on an allocation method for that funding.
We held some sessions in December and a session in January. So
we held several consultation sessions on the funding.
Once those sessions were completed, we compiled the
comments. We reviewed the comments and considered every piece
of input that we had received from the tribes. We then began
working on a spend plan.
We also worked on a spend plan for the administrative
portion of the funding and working to identify what staffing
resources were going to be needed in order to implement the
funding and worked to identify how we were going to hire that
many staff. It's a considerable number that are going to be
needed. And so we had a couple of different tracks that were
moving, proceeding.
We're at the point now where our spend plan for the
projects is in the last stage of review, and we anticipate that
we'll be able to announce the decision that we made for which
projects are going to be funded with the fiscal year 2022
portion of the $3.5 billion very soon.
We are also putting----
Senator Heinrich. How much will that represent in actual
projects? Do you have a dollar figure yet?
Ms. Fowler. Let's see. It's $700 million per year and then
there's three percent--sorry. I'm going to ask my Chief
Financial Officer. She probably has the numbers at her
fingertips.
MS. CURTIS: Certainly. We do expect that the bulk majority
of the resources will be used specifically for project
construction. There is the $21 million for admin, of course,
and then the small portion of funding that goes to the OIG who
we have already started engaging with on oversight issues, but
we expect----
Senator Heinrich. So you're planning to largely just split
it up equally over the 5 years?
MS. CURTIS: Since we received the same $700 million each
year, we will take a similar approach each year.
TIMELINE FOR PROJECT CONSTRUCTION
Senator Heinrich. Okay. How soon do you think we can see
actual work on the ground within the projects that you've
selected? Not trying to micromanage which projects make it into
that first tranche, but when are we going to see the actual
work begin?
Ms. Fowler. I would say actual construction is actually
going to take some time. It's going to take several months
because even the Tier 1 projects, which are ready to fund,
still require some additional documentation to be completed and
so that will take some months to complete.
So before actual construction and on the groundwork begins,
I would say it's going to be into next year before that even
begins on any project.
ALBUQUERQUE IHS SYSTEM
Senator Heinrich. Okay. Let me shift gears to over the
course of the last year, the Albuquerque area IHS System closed
two hospital intensive care units, one at Acoma-Canoncito-
Laguna, another at Mescalero. They did that citing lack of
resources as a contributing factor to the closures, and IHS has
now decreased service in both locations to only business hour
urgent care centers.
As you know, Congress has passed historic funding for the
IHS through CARES, through the American Rescue Plan, and this
budget also increases overall funding for the IHS.
So I'm trying to reconcile the disconnect between the
historic funding that we've passed in the last 2 years, the
increase in the current budget, the increase that we heard of
about over the course of the last 5 years, and the disconnect
between that and the lack of service at Acoma-Canoncito-Laguna
and at the Mescalero site.
Why are we seeing those reductions in services at the same
time we're increasing overall funding?
Ms. Fowler. Let me start with the Acoma-Canoncito-Laguna
facility. The lack of resources there was the result of two of
the three tribes withdrawing and seeking to manage their own
health care programs under the Indian Self-Determination and
Education Assistance Act.
Senator Heinrich. The 638 Program?
Ms. Fowler. Yes, the 638. So the resources that were left
that were the Pueblo Acoma share of that funding of that
hospital was not enough to sustain an inpatient facility and so
we did use CARES Act funding. We did use some supplemental
funding to maintain operation, ER and inpatient services, at
that facility for a year beyond the intended closure of the
facility, but at that point there were no other resources that
were available to us to continue those services.
The Mescalero facility, the issue there is the inpatient
census had been decreasing to the point that we could not
accomplish accreditation as an inpatient facility.
The Joint Commission would not survey the facility as an
inpatient facility because there were not enough inpatients
that it would consider it to be a hospital at that point.
I don't think that that is unusual in very rural areas of
the country, and so we started to consider what is the best way
to continue to ensure access to primary health care for the
tribal members who reside in that location and taking the
resources, running an inpatient facility is very expensive
because you have the 24-hour support that's needed, and so we
began to consider what is the best approach for some of our
hospitals that were unable to achieve that accreditation that's
necessary and also to assure the quality and safety of the care
that's being provided.
And so we chose to shift to the urgent care model and the
primary health care availability during the normal business
hours of the clinic.
Senator Heinrich. Thank you, Chairman.
Senator Merkley. Senator Van Hollen.
AMERICAN INDIANS IN URBAN AREAS
Senator Van Hollen. Thank you, Mr. Chairman.
Ms. Fowler, it's great to have you here and it's great to
have a University of Maryland alum.
Let me turn to the issue of American Indians in urban areas
because in the state of Maryland, we have 40,000 individuals
who identify themselves as American Indian or part American
Indian and nearly half of that population resides in Baltimore,
and as you know nationally seven out of 10 American Indian or
Alaska Native people reside in urban areas.
In my view, this is a population that has not received the
attention or services that are deserved. That's why earlier
this year Senator Padilla and I and a few others wrote to the
President and the Vice President asking the Administration to
form an Urban Indian Interagency Workgroup. We've not gotten a
response yet. So my opportunity is to ask you about this.
Would you support the creation of such a workgroup and work
with us to focus more closely on the needs of American Indians
in urban areas?
Ms. Fowler. The Indian Health Service considers urban
Indian organizations to be a vital component of the Indian
Health System, and we would gladly participate and support any
interagency efforts to address health care for urban Indians.
Senator Van Hollen. Well, if you could do me a favor, we
can give you a copy of this letter that was sent by a number of
Senators, we would like a formal response from the
Administration as to whether they support our request to
establish this kind of workgroup which we think would be
important. Can you do that for us?
Ms. Fowler. Yes, we will.
SUPREME COURT DECISION ON ROE V. WADE
Senator Van Hollen. All right. As you know, there's lots of
concern and uncertainty with the real prospect the Supreme
Court could overturn Roe v. Wade. We don't know what the final
decision is but that's certainly what the draft decision
indicates.
As you know, the Indian Health Services are the sole
providers in many cases of reproductive health services to
American Indian populations.
We also know that the Hyde Amendment has restricted the
ability of many of these women to obtain reproductive services.
We also know that in the cases of rape where the Hyde Amendment
does permit the use of these funds that has to be reported to
the police within 60 days, and we also know and Senator
Murkowski and others have highlighted the fact that American
Indian women have been especially vulnerable and targeted for
violent crime, including rape.
So I guess my question to you is if the Supreme Court
decision does knock out the right to an abortion pursuant to
Roe v. Wade, what planning do you have in effect to ensure that
women, including victims of rape, have access to reproductive
health services?
Ms. Fowler. Great question. We've actually begun some
discussions around this topic. I don't have anything specific I
can share with you today, but we are considering there is some
regulations specific to the Indian Health Service that we're
looking at that pertain to this area and our chief medical
officer will be working with our reproductive health experts on
reviewing and examining the current Indian Health Service
policy and considering any updates that will be necessary.
Senator Van Hollen. Well, I appreciate that. We've been
looking over the current policy in light of what could come
from the Supreme Court, and I do think it requires updating to
ensure that these women have the reproductive health services
they need.
I have no further questions. Thank you.
Senator Merkley. Thank you very much, Senator. It's so rare
to leave a little bit of time on your clock. Thank you.
Senator Tester.
IHS STAFFING
Senator Tester. Thank you, Mr. Chairman, and I'll use it.
So thank you, Senator Van Hollen.
It's good to have you here. Thank you very much for being
here in front of the committee.
What would you say the biggest challenge is for IHS right
now?
Ms. Fowler. Staffing.
Senator Tester. Right answer. Thank you. You didn't have to
go down this line like I did a few years ago.
This budget puts significant money, $21 million,
additional, I believe, is that correct, into staffing? You can
correct me if I'm wrong. I'm just looking at some notes I've
made here very quickly.
Ms. Fowler. Well, when you're referring to staffing, is
that to hire staff or is that for recruitment and retention?
Senator Tester. Hopefully that's for both. Is it more than
that?
Ms. Fowler. It's more than that.
Senator Tester. Okay. Good. So the question then that I
would ask is, is that, I think your priorities are correct in
this budget. Staffing is a problem. Doctors, nurses. Do you
have a plan on how to utilize those dollars to get the biggest
bang for the buck and get the people onboard that you need
because I think there's a GAO report from a few years back that
said you were about 25 percent short?
Ms. Fowler. So the funding that we've requested in the
President's budget is there are a number of items that are
included that will be really helpful to us in addressing our
staff shortages from incentives, additional compensation.
There's a legislative proposal to exempt our loan repayment
and scholarship programs from taxes. There is not a provider,
but we are proposing $18 million to establish a scholarship
program with payback obligations for engineers.
Senator Tester. And these are new programs, correct? These
are programs that you haven't had in the past?
Ms. Fowler. They're expansion. They're either enhancing our
current programs. There are some new ones, as well.
Senator Tester. Okay. So in Montana, for example, it
doesn't matter if it's Indian Country or if it's in urban
clinics, we need more people. So how are you going to get out
to recruit those folks? How are you going to tell them that you
have these new programs out there available to them and that
IHS is a good place to work?
Ms. Fowler. Well, I think that part of the funding that
we're asking for, if it's enacted, will help us to beef up our
recruiters so that we can do more work, direct hands-on work
with students. We're working to increase our residency
programs.
We want to get students into the Indian Health Service
before they graduate, so they'll be interested and come work
for us. There's actually several strategies that we're already
employing, we hope to deploy, as well, using the new funding.
Senator Tester. That's good. My advice is to be as
aggressive as you possibly can. Otherwise, it's going to be
hard to make this happen because the doctor shortage is
everywhere and IHS, because of trust responsibilities we have
and because it provides health care to people who really need
health care, we need to make sure we're staffed up.
IHS FACILITIES
Can you talk about the facilities line items in your budget
a little bit? Are they plussed up because if you don't have
good facilities, you're not going to be able to recruit doctors
and nurses? So are the facilities line items plussed up to a
point where it's adequate and, if so, tell me why?
Ms. Fowler. Yes, as a matter of fact, the budget proposes
to complete the Health Care Facilities Construction Priority
List that was established in 1993 within the first 5 years of
this 10-year proposal. It will provide an additional $72
million for our equipment needs so that we can--when we get
providers who are just coming out of medical school and coming
to work for us, they're used to some bells and whistles, and
they don't currently see that within the Indian Health Service.
So being able to upgrade and keep our equipment updated is
going to be helpful in that regard.
Senator Tester. Okay. So you're a hundred percent correct
and with the increases in budget also comes accountability and
so I would expect that you guys will be very transparent in how
you're doing business so that we know that the dollars that are
appropriated at whatever level gets to the ground because
there's a lot of need out there, both in staffing and
facilities, as you already know.
ADVANCE APPROPRIATIONS
Can I ask, IHS did not include advanced appropriations in
the 2023 budget, is there a reason for that?
Ms. Fowler. If the mandatory budget proposal is enacted,
then advanced appropriations will not be necessary because the
mandatory proposal will automatically appropriate the funding
each year for the next 10 years.
Senator Tester. Okay. So are you advocating, just to help
educate me on this, that this entire budget be mandatory
funding?
Ms. Fowler. Yes.
Senator Tester. What percentage is mandatory funding now?
Ms. Fowler. Only $147 million for the Special Diabetes
Program for Indians.
Senator Tester. How much is the rest of the----
Ms. Fowler. The total $6 billion budget.
Senator Tester. And a $147 is mandatory?
Ms. Fowler. $147.
Senator Tester. So in the case of a potential government
shutdown, you guys have to shut down, and if there was
mandatory funding you would not?
Ms. Fowler. So let me clarify. Because we provide health
care, we don't shut down. We're considered excepted. We just
can't pay our staff if we don't have any other source of
funding.
Senator Tester. But that's a problem.
Ms. Fowler. Yes, it is.
Senator Tester. Okay. All right. Have you had consultations
with Indian tribes on the issue of mandatory versus
discretionary funding?
Ms. Fowler. Yes, we have.
Senator Tester. And on advanced appropriations, also?
Ms. Fowler. We've not consulted on advanced appropriations,
but we've been hearing for years from tribal leaders that they
desire advanced appropriations.
Senator Tester. Okay. All right. Well, I want to thank you
for being here. Thank you for your knowledge on this budget,
and I appreciate the opportunity.
Thank you, Mr. Chairman, Ranking Member Murkowski.
Senator Merkley. Thank you very much, Senator Tester.
BIPARTISAN INFRASTRUCTURE BILL
I want to turn to the bipartisan infrastructure bill and
one of the things that is in it is a limit of 3 percent for
``administrative costs,'' but administrative costs apparently
includes project critical activities, like the engineering, in
which case 3 percent doesn't make sense because the engineering
is often more than that and so like designing a new water
system is a significant undertaking.
I don't think of that as administrative costs at all. I
think of it as a core part of the construction from beginning
to end to get it designed right.
So I have pushed for a higher limit of 10 percent on this,
but from your experience, is this 3 percent limit a problem?
Ms. Fowler. It is a problem. We do not believe that it will
fully fund all of the administrative costs that are necessary
to implement the IIJA funding in a timely way.
Senator Merkley. Okay. Well, thank you. We want to keep
working with you to explore that question.
Maybe the key is that engineering shouldn't be identified
as an administrative cost. I mean, administrative costs, you
think of payroll and communications and so forth, but
engineering is not what I think of in that category.
URBAN INDIAN ORGANIZATIONS
We'll continue that conversation with your team and with
our colleagues here, and let me turn to the Urban Indian
Organizations and Senator Van Hollen mentioned the importance
of that, certainly important in my state of Oregon, and we did
have the increased funding of--well, it was 17 percent
increase.
Did more grants go out to Urban Indian Health Organizations
as a result?
Ms. Fowler. We did not fund any more, any additional Urban
Indian Organizations with that funding, but what it will do is
allow some of the programs that are currently referral-only
programs to initiate services, actual clinical services to
provide the patients.
Senator Merkley. Okay. I will submit questions for the
record to better understand how we're spending the additional
money in that account and understanding how urban Indian
population is being better served, like what specific changes
have occurred. Thank you.
STUDENT LOAN REPAYMENT PROGRAM
And Senator Tester raised the issue over staffing,
significant issue, and one of the things that you testified
last year was the Student Loan Repayment Program was the most
effective tool you have in recruiting.
Have you done specific changes to that program as a result
of the additional funding for staffing?
Ms. Fowler. We haven't made changes to the program, but
what it does is allow us to fund more providers with loan
repayment. The five million that's provided in fiscal year 2022
will fund a hundred additional providers.
Senator Merkley. Okay. So the program remains the same, but
it remains available at more locations in Indian Country?
Ms. Fowler. Yes.
Senator Merkley. Okay. Great. Thank you. Thank you.
PROVIDER ABUSE
I want to turn to the Weber Report and the Weber Report,
it's a terrible story about how there was a doctor, Dr. Weber,
who abused children within the Indian Health System and we had
an independent report that was commissioned by IHS that found
that officials at the Federal Agency on--I'm quoting now from a
New York Times article in October ``silenced and punished
whistleblowers in an effort to protect the doctor who sexually
abused boys.'' This is like the story we never want to hear.
Have those individuals who silenced and punished
whistleblowers been fired?
Ms. Fowler. So a number of those individuals that were
involved in the Weber case are no longer with the Indian Health
Service and any individuals who were found by the Office of
Inspector General who needed to be disciplined or should be
disciplined were disciplined.
Senator Merkley. Can we get details on that?
Ms. Fowler. To the extent that we're able to provide that
type of information.
Senator Merkley. Okay. The report has a number of
recommendations and other ideas have also been mentioned. So
I'll just quickly run through them.
One recommendation of the report was you put in place
whistleblower protection coordinators at 12 regional offices.
Have you done this?
Ms. Fowler. We've not done that yet.
Senator Merkley. Why not?
Ms. Fowler. Funding and it's a resource issue.
Senator Merkley. Hmm. Okay. I am kind of stunned by that
answer because if we're talking about 12 individuals in a
system as large as the Indian Health Service to make sure that
whistleblowers are protected, it seems like it should be a very
high priority, should it not?
Ms. Fowler. Well, the approach that we've taken to the
recommendations, not only to that report but to recommendations
from the OIG, from the past Administrations, White House Task
Force on Protecting Children, we've consolidated those
recommendations.
There was some overlap, but there are some differences
amongst those recommendations, as well. We currently have a
chartered committee that has reviewed each and every one of the
recommendations, determined that their status of implementation
within the agency. They're reviewing those recommendations that
have not been implemented yet, which would include the
whistleblower coordinators, and they are going to make
recommendations on the priority for implementing those
recommendations and whether or not additional resources will be
required to implement them.
Senator Merkley. All right. I'll tell you what I think why
it feels to me like this is such an important question because
in the medical community, there is a huge reluctance to report
on the conduct of any other members of the medical community
and so those who do so, it's very difficult for them to do so,
and if they are not protected, if they are essentially fired,
it sends a message that no one else will report and if no one
else will report, if no one reports, abuse occurs, and so I see
whistleblower protection as essential.
Now I will in follow up to this hearing ask about this long
list of suggestions, and I think one of them you have
implemented. There is a Hotline in place. There's a number in
place to call, is there not?
Ms. Fowler. There is a dedicated Hotline for reporting.
Senator Merkley. Great. And is that well publicized
throughout the system now?
Ms. Fowler. It has been publicized, but we are currently
planning to increase the visibility of the Hotline and make
sure that it is well publicized.
Senator Merkley. Okay. And I'll want to get details on it,
find out how many--when it went live, how many calls have come
in, are they being responded to.
Again, people will be reluctant to call if their careers
are at risk because they share information, and, you know, we
have seen this issue that arises in every institution. Yeah. I
mean, it does so much damage to every single child who is
abused, for a lifetime, that there has to be a huge priority.
Another is on training and so I'll want to get details
about what you've done to implement training for IHS employees
and contractors. Stronger patient safety protocols that are
recommended, I'll want to get details on that.
The preservation of records, which apparently were very
poorly done in the past, I'll want to get details on that, and
the Blackfeet Nation in Montana, which was very directly
affected by Mr. Weber's abuse, is asking for an apology from
IHS, and I'll want to get details on whether IHS has responded
to that request or if perhaps you know now, you can tell me.
Ms. Fowler. I don't know the status of that request.
Senator Merkley. Okay. Thank you. This should be a huge
priority. Not one more child should be at risk. I mean, we keep
seeing these horrific things that occur in organization after
organization, like, for example, the Olympic Gymnast
Association, like who would imagine, and so if people who are
sexual predators know that they will be reported on and that
those who report will be protected, it dramatically changes the
situation.
IHS MANAGEMENT
One of the things I was very struck about in this article
was that it said, ``IHS management ignored or suppressed
efforts to address this danger.'' Well, when that happens, that
means more children are abused, like a thousand percent
unacceptable.
Ms. Fowler. Senator, I agree with you 100 percent. I
believe we have taken many steps that are addressing the root
causes of the failures that occurred in the Weber case. I
believe we made many improvements and I believe the culture is
changing within the Indian Health Service, and we're happy to
provide those additional details.
Senator Merkley. Thank you.
Senator Murkowski.
Senator Murkowski. Thank you, Mr. Chairman, and know that I
absolutely agree with your concern about this.
Ms. Fowler, you mentioned that it is a matter of
resourcing. Yes, it's always about our resourcing, but it's
also a matter of prioritization, and if this was something that
had just hit the news and we were responding to it, it's one
thing, but it's not. It's been out there for awhile and again I
think this is where I still remain a little bit concerned about
the approach the Administration is taking with regards to
moving over to mandatory.
You have been on the GAO's High Risk List since 2017. I
mentioned that we are just now at a point where we're going to
be able to take up the confirmation of the Administrator for
IHS, and, you know, the fact that maybe it's just a hard
position to fill. I think it really is. I think it's very, very
hard, but still it makes me think that the Administration
doesn't place a high enough priority on it to really try to
move that, and when you're going to be implementing such a
really systemic change, when you move an entire, an entire
Indian Health System to a new approach and you don't have an
IHS Administrator in place, it makes me question whether or not
you have the talent that you need, the senior executive team
that you need to make some really important decisions that will
need to be implemented and implemented in such a way that it
gives members who have been around these issues a long time.
Senator Tester, as you know, was formerly Chairman of the
Indian Affairs Committee. I've been on the Indian Affairs
Committee for 20 years now and have served as the Ranking
Member now several different times.
These are issues that we all care very deeply about, but
this is leadership and when leadership is saying a
whistleblowing protection is not going to be prioritized as it
needs to be doesn't give me the degree of confidence where I
can say all right, as the appropriators, we're not going to be
in there on an annual basis and having the input that the
appropriators do.
I appreciate what you said, but you'll come back to the
committee, but I know for a fact that we oftentimes have to use
the hammer, if you will, of we're going to bring in front of
the committee to answer to you about where these funding
priorities have been.
FOLLOW-UP IHS MANDATORY PROPOSAL BRIEFING
I just want to add that I did check with my folks on Indian
Affairs and have been made aware that OMB is having a tribal
consultation on the fiscal year 2023 budget with tribes, but
we're not aware of any other meeting out there and recognize
that OMB tribal consultation and a meeting to discuss this
shift to mandatory in my view would be very, very different. So
again I just raise this to underscore my concern.
CONTRACT SUPPORT COSTS
I was talking about contract support costs before I
deferred to my colleague here, and I wanted to just ask a
further question in this vein.
The issues of contract support costs and the situation with
Cook Inlet Tribal and Fort Defiance arose during a
renegotiation. So what guidance have you given tribes or tribal
organizations who are expected to renegotiate agreements with
IHS and do you anticipate that those agreements are going to
have to go through an added level of scrutiny now, now that
this has all transpired?
What's the situation with these renegotiations in light of
Fort Defiance?
Ms. Fowler. The process for negotiating contract support
costs is outlined in our Contract Support Cost policy, which
was developed with a tribal workgroup, tribal Federal
workgroup, and then we did full consultation on that policy.
So we do have a policy that has been agreed upon with
tribes for addressing when a contract is coming to an end, how
we look at the terms of the contract, including contract
support costs.
Senator Murkowski. Including whether or not overpayments
have been made?
Ms. Fowler. And it includes a process for reconciling the
contract support costs because the way the process works, we
pay contract support costs at the beginning of the period of
performance, at the beginning of the fiscal year, if that's the
period of performance, based on the budgeted amounts, and then
it's reconciled against what the actual contract support costs
need was once that need is known which is after the end of the
fiscal year.
So there's a process in place that where it's routine and
it's normal to identify whether there's an underpayment or
overpayment that exists for that contract, for contract support
costs.
Senator Murkowski. So you don't see that there would be any
additional scrutiny or anything that would slow or hinder these
renegotiations then?
Ms. Fowler. No additional scrutiny than the current process
that we currently use.
105(L) TRIBAL LEASES
Senator Murkowski. Okay. Let me ask about 105 tribal lease
payments. This is something that I raise every year before the
committee, that and village-built clinics.
In the fiscal year 2021 Omni, we all agreed to separate out
the 105(l) costs. We created a separate appropriations account
similar to what we did with contract support.
Additionally, there was a general provision that was
included that directed both IHS and Interior to begin this
process to establish guidelines regarding the parameters for
which lease agreements could be structured and paid for.
But since the 105(l)s have started being paid, we've seen
estimates really kind of all over the board, I think wildly
unpredictable, and they have certainly injected some budget
uncertainty into the process.
Do you consider that the 105(l) leases are stable and are
predictable?
Ms. Fowler. I would say no and that makes it very difficult
for us to identify the amount that's needed to fund them.
Senator Murkowski. Which has been a frustration of mine
because again we've got to figure it out here and we're all
trying to look into that crystal ball to understand where we're
going, what is it going to look like, and we've asked for a
more reliable schedule.
So then going to the Administration's fiscal year 2023
mandatory appropriations proposal, you have a $150 million
proposed there. So is that the current up-to-date estimate for
the tribal leases because again you and I have both recognized
we haven't seen a level of stability and it's hard to predict.
We've seen estimates that are shifting anywhere from $10
million to $50 million in a matter of months. So what are you
basing the $150 million on, and do you think that that is a
figure that you can actually rely on then by the time that IHS
would submit mandatory funding text?
Ms. Fowler. So the $150 million was based on the best
information available at the time. So we don't know what the
final amount is going to be. We don't know if there are going
to be any additional tribal leases that are proposed. So it is
going to be very difficult to provide a firm number for the
amount that's needed.
However, we do expect that the amount for both contract
support costs and the 105(l) lease agreements would remain an
indefinite appropriation because of the very nature of those
two funding accounts.
Senator Murkowski. So, I mean, this has been the challenge,
is the ability to understand and predict what we can anticipate
year over year. So if you've got a new account structure,
105(l) has been separated from the village-built clinics but
both provide funding for lease agreements.
So the question for you is whether or not the village-built
clinics should be funded from the same account as 105(l)s,
recognizing that they both provide for funding for lease
agreements, because in last year's Omni we included report
language for the IHS to include an analysis or a study on the
funding levels for village-built clinics. We're trying to get a
handle on that one, as well.
So your thoughts on whether you separate them out and can
you tell me where you may be on this report for village-built
clinics (VBCs)?
Ms. Fowler. We're currently gathering the information for
the report, and we do anticipate meeting the deadline that was
in the bill which I believe was 270 days we were provided.
Regarding the two programs, village-built clinics, as you
stated, is separate from the 105(l) lease agreements account.
It's funded within the services appropriation. It operates in a
different way. It's under a different authority and so there
are some village-built clinic leases that are not eligible to
be funded through a 105(l) lease.
In addition, there are some tribal programs who prefer to
continue to have the VBC versus a 105(l) because the VBC leases
are part of their self-determination agreement on a recurring
basis, they get paid on a recurring basis, versus the 105(1)
process which requires a proposal and some negotiation
regarding what's in the proposal.
So I think there's going to continue to be a need for both
the village-built clinics program and the 105(l) lease account.
IHS BUDGET PROPOSAL CHANGE
Senator Murkowski. Well, I don't know. I'm listening to
this, Mr. Chairman, and the more we have discussions on some of
these very granular details that are very, very budget-
specific, again it brings me back to what the committee had
thought was a pretty workable proposal in terms of advanced
appropriations and so I'm still trying to reconcile with the
fact that we've seen a pretty dramatic shift in the
Administration's views on how they want to address the IHS
budget and moving it completely to mandatory, completely
eliminating the discretionary aspect of it, and also given that
there's some very technical things, like we're talking about
the distinction between the 105Ls and the VBCs, I'm concerned
about the proposal that we have out there and don't believe
that it is fleshed out enough.
Certainly we will look forward to having conversations with
folks in the Administration.
ELECTRONIC HEALTH RECORDS (EHR)
The last point that I will raise is we've been talking
about electronic medical records for forever, it seems. Last
year finally IHS did a data call with tribes and I think that
that was good, but again we now have to make sure that our
systems are talking with one another, whether it's IHS through
VA, which is a big deal for us in Alaska.
We need to understand who's going to pay for any necessary
upgrades to the system, whether tribes are responsible for the
cost or whether IHS is planning to do this. So there's a lot
more to do with implementation, but again I think that that
will help with some of the efficiency that we need within IHS.
Thank you, Mr. Chairman.
Senator Merkley. Thank you, Senator Murkowski, and I so
much appreciate your attention to detail on these programs
because how they get implemented makes a big difference on the
ground to so many people in Indian Country.
PURCHASE AND REFERRED CARE
I want to note a last issue before we adjourn. I had
requested information about purchase and referred care, the PRC
Program, and was supplied with a chart that I'll ask consent to
put into the record.
So ordered.
[The information follows:]
Senator Merkley. I looked at it and I just went my
goodness, this is a nightmare for how a person, a member of a
tribe in a place like Washington, D.C., accesses medical care,
and if they have a medical emergency and they have to go to the
emergency room, they have to give notice within 72 hours after.
They might still be very, very sick or still be in the hospital
at that point to have a chance to apply and this chart says,
you know, the PRC fundings are not sufficient to pay for all
needed services and so it's basically saying we're not sure
even if you get a setup, that notice in 72 hours that you're
going to get helped and this is what's wrong with health care
in America.
When accessing medical services requires a complicated
chart like this going through like, I don't know, what is it,
about 12 different bubbles of checks and while you're trying to
recover from an illness or an injury.
So I will have questions to follow on with about this. One
of the fellows on my team is a tribal member who has brought to
my attention this real-life example of here in Washington,
D.C., that he would have to go to New York or North Carolina to
receive care or to get a referral to another facility.
So I will be exploring with you how we can make this system
work better, and one of the questions I will ask about is
whether tribal members are given equivalent insurance card to
be able to submit when they need to get medical services or
emergency services in a location where there is not an IHS
facility.
ADDITIONAL COMMITTEE QUESTIONS
So with that, thank you, Senator Murkowski and Members of
the Committee, and if there are no other statements, the
hearing record will be open until close of business on May
18th, 2022.
Thank you. Thank you, Director Fowler, and thank you, Ms.
Curtis, for your expertise and hard work to make this system
work well all across Indian Country.
SUBCOMMITTEE RECESS
[Whereupon, at 11:27 a.m., Wednesday, May 11, the
subcommittee was recessed to reconvene subject to the call of
the Chair.]