▶ 0:07:34Insular affairs will come to order. Without objection, the chair is authorized to declare recess of the subcommittee at any time. The subcommittee's meeting today to hear testimony for an oversight hearing entitled modernizing the implementation of 638 contracting at the indian health service under committee rule for any oral opening. Statements at hearings are limited to the chairman and the ranking minority member.
▶ 0:07:56I therefore ask unanimous consent that all of the members opening statements be made part of the hearing record if they are submitted in accordance with committee rule three. Oh, without objection, so ordered. I ask unanimous consent that the gentleman from montana, Mr. downing, be allowed to sit and participate in today's hearing. Without objection, so ordered. I will now recognize myself for an opening statement. Good morning, and thank you to our witness and witnesses in the second panel for being here today.
▶ 0:08:25We are holding an oversight hearing titled modernizing the implementation of 638 contracting at the indian health service. 50 years ago, congress passed the indian self-determination and education assistance act. The law empowered tribes to take control of federal programs that directly affect their communities. In the health context, that means title one contracts and title five self-governance compacts what we collectively refer to as 638 contracts and compacts.
▶ 0:08:53Today, tribes and tribal organizations manage the majority of the ihs budget through 638 contracts. This is a testament to the success of self-determination and self-governance, but it also means ihs mission has fundamentally changed.
▶ 0:09:11Instead of serving primarily as a direct provider, ihs must now negotiate hundreds of complex agreements, process amendments, pay support costs, and support increasingly sophisticated tribal health systems. How ihs can meet that modern mission is the core oversight mission is the core oversight issue before us. We know there are serious challenges.
▶ 0:09:37Tribes regularly, regularly report delays and uncertainty in basic 638 administration. Slow action on contract amendments, lack of clear process maps and long waits on 105 leases. Ihs does not publish standard metrics or review timelines or pending actions without consistency or information sharing. Tribes cannot plan effectively, and delays ultimately affect health services on the ground.
▶ 0:10:03The government accountability office, or gao, has raised similar concerns. Ihs has been on the gao high risk list since 2017 for deficiencies in capacity oversight and demonstrated progress. The most recent iteration of the list acknowledges some effort, but concludes the agency still fails to meet key criteria for removal. That finding aligns with what tribes often experience on the ground.
▶ 0:10:31Too many delays that turn self-governance into negotiation rather than a predictable process variation across the ihs area offices remains one of the biggest challenges. Some areas maintain strong collaborative relationships with tribes. Others are known for slow responses and unclear guidance.
▶ 0:10:55Unlike the bureau of indian affairs, which recently updated its self-governance manual and and standardized its policies, ihs still lacks uniform guidance. That absence contributes to uneven performance and prevents tribes from receiving consistent federal partnership. Another major structural issue is electronic health record, or ehr modernization. Tribes and ihs still rely on rpms, a legacy system that is now more than 40 years old.
▶ 0:11:23Ihs has selected a new ehr system and is working on deploying it, and we appreciate the administration's efforts in this area. Finally, we are meeting at a moment when ihs is proposing a major strategic realignment of its structure. The stated goal of creating a more accountable, efficient and self-determination driven agency is one all of us share.
▶ 0:11:48In principle, if done thoughtfully, this realignment could reduce variation across areas and strengthen technical support. Our responsibility today is straightforward to assess whether ihs is equipped to support the self-governance system that congress created, and which tribes have embraced.
▶ 0:12:07That means clear guidance, transparent data, timely contract processing, consistent area office performance, and modern systems that work for tribal governments. But tribes have made clear that they need more detail, more transparency, and more assurance that promised reforms will translate into real improvements.
▶ 0:12:27Our responsibility is something that is critical, and I look forward to hearing from our witnesses on the importance of these important issues, and making sure that federal implementation is as strong as the self-determination principles that is meant to uphold. The chair now recognizes the ranking minority member for any statement. >> thank you, chair, and good morning to everybody out there.
▶ 0:12:56Uh, wonderful to see our tribal leaders and some of the experts and visionaries in the field of self-governance in the audience. I look forward to hearing your testimony.
▶ 0:13:09And, deputy director smith, it was marvelous seeing you at santo domingo last week, where we were able to celebrate what happens when a tribe takes over and operates its own systems, where you're able to bring together the mission. In that case, the early child care education mission that a tribe has with its cultural values.
▶ 0:13:39So it is rooted in both providing the trust responsibility to the tribe, but rooted in the tribes direction and self-determination and cultural preservation. It was wonderful to see you there.
▶ 0:13:54And, uh, I love being able to look out at the audience and see some of the people that we heard from at our hearing in oklahoma city to evaluate the indian self-determination and education assistance act as we celebrate its 50th year. The witnesses at the hearing, including principal chief hoskin and Mr.
▶ 0:14:18Span, illustrated how vital, uh, the indian self-determination act has been for indian country. It's such a foundational law because it's rooted in not the idea, but the knowledge, the knowledge that tribes know their needs and how to address them best.
▶ 0:14:42You've been doing it since time immemorial, and the federal government needs to celebrate that, recognize that and make it possible so that you can do it all the time in health care and in other areas, because health care is indeed one of the best examples of how self-determination and self-governance can transform a community and save lives.
▶ 0:15:07And we saw in oklahoma that you are saving lives not just of your own community members, but of those in the community around you. It benefits the tribe and the local communities. I am a bit concerned because the trump administration has acted in ways that undermine health care services and self-determination.
▶ 0:15:31In march, president trump rescinded executive order 14 1112 that directed agencies to increase accessibility and flexibility of federal funding, promote compacting, contracting, co-management and co stewardship with tribes to administer federal programs and services. Recent reporting showed that workforce had a 30% vacancy rate.
▶ 0:15:55The administration's attacks on federal workers hinders its ability to provide health care for native americans. Because you can't provide the services, all of those increase compacting and contracting that the chair mentioned requires people to process those compacts. And these issues, uh, have become even more pressing after the ihs announced in june that they are proposing a significant realignment of the agency.
▶ 0:16:23Now, listen, everybody in this room knows that we need to do better, that I can do better. Deputy director, I appreciate you smiling and nodding at that, because we all agree we must make improvements. And I think they need to be significant improvements. But I would suggest that we need to make sure that those are done in better alignment for native americans.
▶ 0:16:51First, ihs must, um, hold future consultations in geographical, diverse locations so all tribes can participate. You must give tribes detailed information on the alignment before each consultation so that it's productive. We have heard that the past consultations were not as productive as they could have been, because the tribes didn't have advanced knowledge to be able to respond to what the proposals are.
▶ 0:17:17And, uh, you know me, I'm a huge supporter of self-governance. I worked in, uh, worked in negotiated self-governance contracts and compacting. But we need to remember that not all tribes are in a position to enter into compacts or contracts. So we do need to ensure that providing health services, as is required, needs to continue.
▶ 0:17:43For those tribes who choose not to compact or contract, we need to make sure that there is adequate staffing at the regional and area office and that the staff at the local office who best understands the needs and practices of a particular tribe, are equipped to negotiate and partner with them.
▶ 0:18:06Centralizing power and decision making in dc could potentially slow down responses to tribes and make things more inefficient. But if we get things right, there's great promise for improving health care in indian country. As you know, I'm working on legislation to expand the self-determination act to other hhs programs that tribes utilize. It would enable tribes to blend together.
▶ 0:18:32Behavioral health funding from samhsa, public health funding from cdc and ihs money to provide more comprehensive care. It would cut bureaucracy and give tribes more of a say in running their own health care systems. I hope this legislation can be considered and that we work on it on a bipartisan basis.
▶ 0:18:51I truly appreciate the bipartisan support for tribal self-determination and self-governance, and appreciate that it is one of our major priorities in this committee. I look forward to hearing directly from the tribes doing this incredible work. And, Mr. chairman, I yield back. >> thank you very much. Ranking member leger fernandez, the chair now recognizes the ranking member of the house natural resources committee. The gentleman from california, Mr. huffman, for any statement. Mr. huffman.
▶ 0:19:22>> thank you, Mr. chairman. I have a unanimous consent request. Before we begin, I'd like to enter into the record a recent report from the energy and climate intelligence unit. It is entitled ten years post paris, a decade that defied predictions. And it is about the amazing progress. 90% of new electricity capacity being wind and solar globally, renewables overtaking coal and saving around 467 billion in fossil fuel costs.
▶ 0:19:51This is part of the benefits of a clean energy future, a climate reality, the committee should note in the record. >> without objection. >> thank you, Mr. chairman, and welcome, folks. I appreciate everyone who's traveled here and look forward to the testimony. This is an important hearing. And of course, we know that 50 years ago, congress passed the indian self-determination and education assistance act is dia.
▶ 0:20:17Uh, this is a cornerstone of federal indian law, and it has provided tribes with flexibility to develop and administer programs that administer, um, that address unique needs of their communities while strengthening tribal self-determination. It's been utilized across law enforcement, natural resources, education and health care, which, of course is the focus of today's hearing.
▶ 0:20:39The indian health service is the primary agency providing health care in indian country, and this law has allowed important partnerships with tribal governments, uh, and urban indian organizations through self-determination and self-government. Um compacts to better administer services. In fact, I'm impressed that tribes now administer over 60% of ihs budget through these title one contracts and title five contracts.
▶ 0:21:09And this shows that they have the ability to effectively manage programs and meet community needs. And while 638 agreements have provided greater autonomy, uh, obviously there are persistent challenges that remain with this implementation and ihs operations. So, Mr. chairman, thank you for choosing to hold a hearing on this subject. We know that staff recruitment and retention have long been issues at ihs.
▶ 0:21:38Um, these are familiar issues, certainly to everyone on this subcommittee. But under the trump administration, we have seen it, uh, get a lot worse, frankly, uh, many more challenges, widespread chaos at the agency and the administration, um, as they've worked to dismantle the federal workforce. We know earlier this year, they tried to lay off 2200 probation, so-called probationary employees. Right. Um, but this included doctors, nurses and other critical care staff.
▶ 0:22:08And when they quickly realized this was a terrible idea, um, they backtracked, exempting, uh, those folks while attempting to move forward with laying off about 950 other employees. And literally within a few hours, they realized that too was a terrible idea and ultimately rescinded the layoffs. But the damage was done.
▶ 0:22:30Uh, because of this chaos, the since the administration took office, we've seen over a thousand employees leave, either through early retirement or voluntary termination. Uh, combined with long standing, chronic understaffing that predated all of this chaos. Uh, we now have a 30% vacancy rate and historically low acceptance rates. So you put those together.
▶ 0:22:57And that's just a serious problem that we have to acknowledge part of the context, essential context for this whole conversation. Now, I know the department is deploying public health service officers into the ihs system to fill gaps.
▶ 0:23:10Um, that's fine, but it's certainly not a permanent solution for the many problems we're seeing, uh, increasing vacancy rates and declining acceptance offers combined with preexisting chronic understaffing, means that we've, uh, we're at serious risk when it comes to tribal health care and health disparities, which we know, uh, already existed for american indians and alaska natives. So, um, I'm glad we're talking about pursuing modernization efforts.
▶ 0:23:40We all support improving health care delivery in indian country. But for modernization to succeed, we have to be driven by tribal leaders and health care professionals who work in the system every day. And we're hearing concerns that some of the consultation that's been conducted so far, uh, on modernization is inadequate, with some regions lacking meaningful in-person options. So I hope we can work on that.
▶ 0:24:10Um, and I also hope that we can include funding. We have to include funding if we're going to get this right. But it's an important conversation, Mr. chairman, and I look forward to hearing more from the witnesses, and I yield back. >> thank you very much. Ranking member huffman. Now, I'm going to introduce the witness for our first panel, Mr. benjamin smith, deputy director, indian health service, us department of health and human services here in washington, dc. Uh, Mr.
▶ 0:24:37Smith, you and I spoke before, and I know you've mentioned you've done this before testifying, but I just want to remind you that under committee rules, you are to limit your opening statement to five minutes, but your entire statement will appear in the hearing record. Uh, to begin your testimony, just press that talk button on the microphone. We do use timing lights. Uh, green means go. Yellow means you've got one minute left, and red means, uh. Please wrap up any answer as quickly as possible.
▶ 0:25:03Uh, I will also allow you to testify before, obviously, before the members begin their questioning. And that will be the same for the second panel as well. And so, Mr. smith, uh, I now recognize you for five minutes. >> thank you. And good morning, chairman, ranking member leger fernandez. Likewise.
▶ 0:25:23It was an amazing event out of new mexico and really a clear demonstration of self-determination and self-governance targeting youth and how that fits into the theme of today's oversight hearing. I also want to thank the members of the subcommittee and our tribal leaders who are in the room with us. My name is benjamin smith. I serve as the deputy director at the indian health service.
▶ 0:25:47And thank you for the opportunity to present testimony at today's hearing on the critical matter of 638 contracting and compacting within the indian health service. The indian health service is an agency within the department of health and human services, and our mission is to raise the physical, mental, social and spiritual health of american indians and alaska natives to the highest level.
▶ 0:26:12We carry out this mission in partnership with tribal communities, through a network of more than 600 federal and tribal health facilities, as well as 41 urban indian organizations across 37 states. Together, these systems provide healthcare services to approximately 2.8 million american indians and alaska natives each year. The indian health service is the 18th largest healthcare system in this country.
▶ 0:26:35Our system includes 12 area offices that oversee 170 service units, which are the facilities that provide care in local communities. Health services are delivered in three main ways within our system. They can be managed directly by the indian health service through tribal health programs, meaning a tribe or tribal organization operating under titles one or title five of the indian self-determination and education assistance act, or through contracts and grants to urban indian organizations as
▶ 0:27:05Authorized under the indian health care improvement act. As was mentioned 50 years ago, the indian self-determination education assistance act marked a monumental turning point in federal indian policy. It empowered tribal nations to reclaim authority over essential services, and to make decisions about matters that directly affect their communities. I want to thank the subcommittee for holding a field hearing earlier this year to commemorate the 50th anniversary of this landmark law.
▶ 0:27:35Both title one and title five of the isda authorize the secretary of health and human services to enter into contracts or compacts with tribes or tribal organizations upon their request. The key distinction between self-determination contracts and self-governance compacts is the degree of tribal flexibility. Both of these authorities transfer programs, services, functions, or activities that would have otherwise been provided by the indian health service.
▶ 0:28:03But one key difference under title one in particular, the indian health service must approve any substantial changes to a contract where, under title five, a tribe may consolidate any of those programs, services, functions or activities or portions thereof and reallocate funding under their compact and funding agreement without indian health service approval, provided that the redesign does not deny eligibility for services.
▶ 0:28:30We do have a growing volume of the work, as was mentioned. In fact, in fiscal year 24 for title one self-determination contracts, we had a portfolio of 247 contracts reflective of 232 tribes and tribal organizations under self-determination, title or self-governance. Title five excuse me.
▶ 0:28:55Ihs was party to 114 compacts and 141 funding agreements. Through both mechanisms, we transfer approximately $3 billion of ihs budget to tribal tribes and tribal organizations.
▶ 0:29:10Today's hearing, modernizing the implementation of 638 contracting at the indian health service is absolutely important to recognize that public law 93 638, in itself, continues to evolve in practice, particularly through the distinctions between title one and title five that I mentioned earlier. Although not all tribes choose to enter into contracts or compacts, those that do have meaningful options that reflect their unique priorities and circumstances.
▶ 0:29:41The steady increase in tribes electing to contract or compacts since the enactment of the isda is another sign of modernization. We have moved from a time when the indian health service was the primary provider of health care and programs in indian countries to a system which approximately now has 62% of the indian health service budget that's tribally managed and operated.
▶ 0:30:03As we contemplate moving in towards modernization, we do need to acknowledge the recent supreme court decision in becerra versus san carlos apache, the level of work that contract support costs in section 105 l has added to the agency's statutory requirements. Secondly, electronic health record modernization. We can't leave indian health health system or indian country behind.
▶ 0:30:30And finally, addressing some of the challenges of infrastructure and workforce. I have details included in my testimony, but with that, thank you for your commitment to improving healthcare for all american indians, alaska natives, and I'm happy to answer any questions. >> thank you very much, Mr. smith, for your testimony. The chair will now recognize members for five minutes of questions. We're going to start with the gentleman from american samoa, miss radewagen, for five minutes. Mr. hogan. >> Mr. chairman, thank you for holding this important hearing.
▶ 0:31:01Uh, the committee does support broader 638 participation in. Many tribes are preparing to assume new programs. Deputy director smith, from the agency's perspective, what are the most important steps ihs can take operationally or structurally to support more widespread 638 implementation across indian country? >> thank you very much for the question.
▶ 0:31:30First and foremost is that this is not a one sided deal. This is government to government. There are two parties that come together. Partnership is absolutely essential. And whether we rely upon the tools of tribal consultation to make sure that as the federal government, we are making informed decisions and positions on our side, that's absolutely essential. And likewise, we need to show up as as in a government to government manner.
▶ 0:31:58Because of this shift in, um, our portfolio with 62% of our budget that's now tribally managed and operated, that does not diminish in any way the federal trust responsibility or federal duties that exist for the federal government. So I would say it starts off with the conversation in that tribal consultation format to identify those critical, critical issues and path and develop a plan to move forward.
▶ 0:32:26>> are there specific resources, statutory changes or administrative reforms that would help ihs better support tribes ready to take on additional programs? >> thank you for the question. I, as was stated earlier, the government accountability office has identified, uh, some of the long standing issues that face our system under chronic underfunding facility, infrastructure, workforce.
▶ 0:32:55These are not only, uh, root causes of the federal side of the system, but tribes and tribal organizations that are assuming program services, functions, activities that are otherwise provided by the indian health service are also encountering these issues. And so collectively targeting and finding strategies to bring in new facilities. In fact, our facilities today have an average age of 41 years old.
▶ 0:33:24That's three times older than a facility that you would see in the private sector. And, uh, as well as workforce, uh, there's a huge competition across this country and a huge workforce shortage when it comes to healthcare providers. Collectively, we need to work together. >> Mr. smith, you mentioned the flexibility differences in istea.
▶ 0:33:49Are there opportunities to highlight or track these flexibilities at ihs or with partnering tribes, tribal organizations or urban indian organizations? >> thank you so much for the question.
▶ 0:34:05Tribal self-determination, tribal self-governance, our tribally driven to the extent we learn and are informed about, uh, the innovations inroads tribes and tribal organizations are making and operating their programs, um, and changing them. We can certainly learn from those.
▶ 0:34:26Uh, over the years, we have been working not only with tribes, but also with organizations to collect some of the best practices and incorporate them into our own systems. That is really made. Benefits come into the system as a, as a whole. So in terms of looking at flexibilities, uh, it really does take both governments coming to the table.
▶ 0:34:49And I look forward to the tribal witnesses who will share some of the burdens that they're facing on their side. Certainly for the federal government, we want to make sure that we're upholding our statutory requirements.
▶ 0:35:02And this means timely payments, making sure that whatever we agree to in a compact or or contract is being met, uh, despite growing, uh, volumes of work, we still hold that, um, at heart within the indian health service. >> thank you, Mr. chairman. I yield back. >> gentleman yields at this time. The chair recognizes the ranking member from the state of new mexico. Miss leger fernandez for five minutes. Miss leger fernandez.
▶ 0:35:32>> uh. Thank you. Chairman. Chairman. Um, Mr. smith, we have heard from tribes, including some of the tribes that will testify today that there is indeed this inconsistency, uh, across the areas. But some area offices work.
▶ 0:35:49Well, uh, we have also received testimony that, uh, sometimes having to come up to dc and negotiate with dc is problematic because there have been, um, a slowdown in the ability of ihs to respond. Don't know what all the reasons of that are, but centralizing everything in dc can sometimes be a problem.
▶ 0:36:16Perhaps it would be great if ihs would make sure that there is uniformity in all of its regional offices so that tribes, whether you're in alaska or wisconsin and new mexico or new mexico or oklahoma, know that you're going to be treated just as well as a high performing regional office.
▶ 0:36:39Um, for those tribes that wish to continue working closely with the area offices, will you commit to make sure that the area office staff have decision making authority? >> thank you. Ranking member leger fernandez for the question.
▶ 0:36:58When it comes to authorized or designated federal officials who are authorized to negotiate these agreements on behalf of the secretary, as delegated down to the indian health service, it is important that we have a clear understanding of who those individuals are. Um, our experience throughout the indian health service has changed and evolved over time.
▶ 0:37:24In fact, when the indian health service was in demonstration authority for self-governance, we did have a centralized, uh, process for negotiations which required tribes to come and negotiate here in the washington, dc area.
▶ 0:37:38Um, we did learn that, you know, being able to negotiate, uh, throughout our system, especially with members of teams that are familiar with the local, uh, nuances, aspects or, or plans that tribes are carrying out has been beneficial.
▶ 0:37:56Um, today, uh, with our workforce challenges that we're facing, uh, coupled against an significant increase in volume of managing, um, indian self-determination education assistance act agreements, we need to realign ourselves.
▶ 0:38:13Part of what occurs under self-governance and self-determination is that there is a natural, uh, reduction in federal footprint, as tribes assume, um, program services, functions and activities. However, the inherent federal functions still need to be carried out, and indian health service is at a point to make sure that we are looking at all of our existing resources to be be able to carry out those inherent federal functions.
▶ 0:38:43>> so the question was, will you commit? And I am, uh, I haven't heard a yes or no on that question. Um. >> I will say it depends. And the reason I say it depends is because we are currently in active tribal consultation and urban confer on the ihs realignment. I don't want to preclude. >> I'll go on to another question. I think.
▶ 0:39:04I think you touched on an important piece, which is it's important to have understanding of the local conditions and the ability to build trust. Now, you mentioned that you are under an active process of receiving comments. I looked at the list of in-person consultation sites. Washington, minnesota. Wisconsin. Great. Those are great places to go to.
▶ 0:39:25New mexico is not on the list, even though, as you know, there are 21 tribes, uh, 81 self-determination contracts, uh, and seven self-governance compacts. Uh, will you commit to holding an in-person consultation on the realignment in new mexico? >> thank you. We'll certainly take that under consideration.
▶ 0:39:50I do want to share with you that just yesterday we have published, uh, tribal consultation website on ihs realignment that not only carries identifies all the locations and opportunities, both in-person and virtually, but also provides a list of frequently asked questions as well as materials. >> as, as you well know, uh, in all of your different work and, uh, your own background, tribes like to be able to talk to you directly.
▶ 0:40:19They want to be able to look you in the eye, to ask you the questions, to do those follow ups. I think that using the multiple ways of getting input is useful, but it cannot substitute for in-person consultation and in-person, um, uh, feedback and that feedback loop that happens like we're doing right now.
▶ 0:40:46So I'd like for you to commit to holding a consultation in new mexico. >> thank you. We'll take that under consideration. >> the gentleman's time has expired at this time. >> Mr. chair. >> the chair recognizes the gentleman from north carolina, Mr. mcdowell, for five minutes. Mr. mcdowell. >> thank you, Mr. chairman. And thank you, uh, deputy director smith, for for being here to testify before the subcommittee today.
▶ 0:41:14Uh, today's discussion on modern or on modernizing the implementation of of, uh, 638 contracting at, uh, the ihs goes to the heart of two principles that are very important to me. Uh, local control and federal efficiency and modernizing. 638 implementation is not about expanding federal programs. It's about letting tribes take responsibility for their own health care without washington getting in the way.
▶ 0:41:41When tribes do manage their own hospitals and clinics, the results are clear accountability, faster decision making, and better use of taxpayer dollars. The problem is not the law. The the problem is the bureaucracy. In my opinion, and tribes that step forward to manage their own hospitals and clinics.
▶ 0:42:05They often face slow approvals, inconsistent guidance, delayed funding, administrative hurdles, and these are things that would never happen or be tolerated in the private sector.
▶ 0:42:18And now in north carolina, with the lumbee tribe, uh, about to be federally recognized, modernization becomes even more important because as lumbee gain access to hhs programs and begin shaping their own health systems, they should be met with with streamlined, consistent processes and not outdated bureaucracy, especially when you have a university like the university of north carolina at pembroke that is producing students in
▶ 0:42:49Nursing, occupational therapy, uh, and the list goes on and on. But they need to have somewhere to go where they're not going to be pulling their hair out because of the federal government that won't let them do their job. Uh, this is especially important, uh, for states like mine in north carolina, where our tribes have already demonstrated what self-determination looks like, well-run facilities, a strong tribal workforce, uh, and programs that are designed by the community that they serve.
▶ 0:43:21So I look forward to working with all of my colleagues, uh, to ensure that we deliver a contracting process that respects tribes and respects taxpayers. And it gets the federal government out of the way. Uh, for those who can do the job better. Uh, and so, deputy director smith, where do you see the biggest bureaucratic delays or inconsistencies in ihs, uh, contracting process? And how do those delays impact healthcare on the ground?
▶ 0:43:53>> thank you very much for the question. And we agree with, um, your points on local control and decision making. That must absolutely occur. As I mentioned, within our system, 170 service units. That's a lot to manage. And things play out differently, um, across across the country.
▶ 0:44:13So, um, making sure that that's occurring with what's at play, not only with our our realignment is absolutely essential, but also creating those efficiencies. And this is what realignment is permitting us to do, is looking at how to bring in those system wide supports or enterprise wide resources in a manner that that makes sense. And we'll get the get the needs met specifically on our side.
▶ 0:44:40Our challenge again, is the volume of work without a growing workforce to carry out those inherent federal functions of managing contracts and compacts, the work is getting done. But could it be done quicker? Probably.
▶ 0:44:58Um, to give you an example, uh, with our section 105 l leases, we're managing over 1200 leases annually, and you might find this shocking, but there's three staff dedicated to doing that. That's and it's only growing. So this is certainly something that is on our radar. Um, what can be done about it is look into partnerships.
▶ 0:45:24We want to find ways to tap into academic academic institutions or tribal colleges and universities to build and create pipelines and pathways to bring in workers not only health care workers, but administrators, you know, finance, legal, you name it across the board.
▶ 0:45:42This is going to take a concerted effort or using authorities such as the intergovernmental personnel act to bring in subject matter expertise into our system to help bridge those gaps as we build capacity. But I really appreciate you raising this, because it really pinpoints to the work that's at play within the indian health service and across the country today in our realignment consultations and urban confer. >> sure. Well, thank you very much. And, Mr. chairman, I yield back the balance of my time.
▶ 0:46:11>> the gentleman yields at this time. The chair recognizes the gentleman from the state of washington, miss randall, for five minutes. Mr. randall. >> thank you so much, Mr. chair. And thank you, deputy director smith, for joining us. You know, I have to say, I'm concerned by ihs proposed realignment that would move functions and personnel from area offices to ihs headquarters, especially consider the shortened tribal consultation window.
▶ 0:46:35Um, where tribes were notified of the realignment december 5th, just one week before they were to be consulted. Considering that tribes may not have had adequate time to prepare for consultation, what evidence does ihs have that centralizing all indian health, indian self-determination and education assistance act negotiations at headquarters will improve negotiation timelines?
▶ 0:47:04>> thank you very much for the question. I do want to clarify that no concrete decisions have been made. It is a proposal, uh, which is in part why we are engaging in a second round of tribal consultation and confer a lot of these concerns came up initially, and we want to learn more about them. So, um, how that's going to end?
▶ 0:47:27I don't want to draw any conclusions at this point, but what I, what I do want to share is that, you know, in creating those efficiencies in meeting our statutory requirements of the isda is absolutely essential, meeting our statutory requirements as a federal agency to provide healthcare oversight and management of the facilities that we oversee. We want to accomplish that.
▶ 0:47:52We also want to make sure that we're meeting our statutory requirements to maintain an electronic health record. It needs to be modernized. The gao has told us this. That is the path we're moving forward on, and this is the opportunity that we have at this point in taking a look and a question that hasn't been touched on in over two decades within the indian health service, what does the indian health service need to look like as a whole? And that's where we're moving.
▶ 0:48:23>> thank you so much. Um, I think I maintain some concerns, but we will keep watching. Um, you know, it's my understanding that long before this proposed realignment plan, ihs had trouble recruiting area negotiating leads. And I'm not convinced that moving these positions to headquarters will solve this issue. You mentioned the importance of, um, building a pipeline and recruiting.
▶ 0:48:48Um, I think I have to mention that the rate of college admissions for native americans has been steadily declining and is currently nationwide at about 24%, as compared to 41% of the overall population. Um, none of which will be helped by the dismantling of the department of education and the realignment there.
▶ 0:49:14So be very clear eyed about what that recruitment and support looks like as we build a pipeline. Um, but given the persistent workforce shortages in ihs, what concrete steps do you plan to take to recruit and retain experienced lead negotiators, especially individuals with strong tribal tribal ties, so that these positions don't remain vacant longer? >> thank you so much.
▶ 0:49:38I love this question because it is really, um, affording us an opportunity to highlight the work that is ongoing and in play right now in bolstering up our technical assistance, improving our training not only for our existing staff, but creating materials that will help a workforce that comes into play self-governance, self-determination negotiations.
▶ 0:50:04There's not a lot of places you can find outside of the system to learn about it. Um, you'll hear about some from some of the witnesses today, uh, of some academic partnerships that, um, are starting to build that curriculum. And we really hope to see it grow down the road.
▶ 0:50:24But sharing best practices has been key, and this has really been the successful approach that indian health service and tribes have used, not only through our tribal advisory bodies like the tribal self-governance advisory committee, but through organizations such that such as the tribal self-governance. >> thank you. As you know, the isda goals require ihs to act promptly on proposed amendments.
▶ 0:50:47Yet tribes, probably because of staffing shortages, among other reasons, continue to encounter significant delays, which I am worried will only increase when all area lead negotiators move to headquarters. Um. Particularly, I'm thinking of the nisqually tribe, not in my district, but very close. Submitted an amendment in march 2025 without a response from ihs.
▶ 0:51:11For more than six months, they conveyed an expected opening date of october 1st in march, and did not hear anything back from ihs headquarters until september 5th. Approval for the amendment is still outstanding, preventing the opening of a much needed residential treatment facility, something that I think we can agree across both sides of the aisle is an important need in communities, tribal and otherwise.
▶ 0:51:35How does ihs justify these ongoing delays, and what immediate actions will you commit to. >> really quickly, if you could, Mr. smith, very quick in the answer. We're over time. >> thank you. We're happy to follow up with you, um, separately on that issue. >> great. Thank you, Mr. smith. Uh, the gentleman's time has expired at this time. The chair recognizes the gentleman from montana. Uh, Mr. downing for five minutes. Mr. downing.
▶ 0:52:00>> chairman, first I ask unanimous consent that this letter from the little shell band of chippewa indians of great falls, montana, be entered into the record. >> without objection. >> well, thank you, Mr. chairman. Uh, for, uh, allowing hosting this event and this hearing, modernizing the implementation of indian health services. And I appreciate you allowing me to to wave on to this committee. I represent montana's second district, representing more than half dozen tribes, including the little shell band of chippewa indians.
▶ 0:52:28And, uh, you know, little shell is a model example of assuming operations of health services for its members. As of july 1st, 2025, the little shell tribe assumed management of the little shell health clinic through the title five self-governance compact and funding agreement, providing high quality care for little shell uh citizens. And I have personally, um, toured with chairman gray from from the tribe and been very impressed at what they've been able to do with this and appreciate those opportunities.
▶ 0:52:59But these accomplishments underscore the tribe's readiness and their eagerness to assume the health obligations of its citizens. The the success proves that congress should work with ihs to allow for greater tribal self-governance in health care, and little shell was able to assume operations of its health clinic through extensive effort and determination, ihs is undergoing a strategic realignment to better serve tribes ambitions and allow for tribal self-governance and reduce barriers for access to
▶ 0:53:29Capital. And so, Mr. smith, I'm going to start out with how a question, how will the ihs realignment balance the need for standardized processes with the importance of understanding regional differences and sentiments for tribes across the united states? >> thank you very much for the question. The ihs realignment is exactly that. It's a realignment. It's not a reduction.
▶ 0:53:56I think we've talked a lot about the current vacancy rates that needs to be addressed. We want to grow staff. We want to fill those vacancy rates. But at the same time, we want to ensure consistency in practice, whether it's in the state of montana, whether it's in the state of oklahoma or washington. We want our negotiators to be able to, um, uniformly negotiate terms and conditions of the contracts and compacts.
▶ 0:54:27So by bringing in the resources and again, the resources are all throughout the system. I'm getting a sense that there's a notion that centralization means moving people into a different location. We are going to draw upon our existing resources that currently reside throughout the country. >> well thank you. Yeah. Um, just moving on. To interest of time, you noted in your testimony that the ihs realignment aims to create a more accountable, efficient, responsive agency.
▶ 0:54:56I appreciate your comments there, but how will the proposed realignment directly support increased? 638 implementation, and how will it help reduce the variation tribes experience across different area offices? >> again, thank you for the question. Well, this aligns well with just modernization efforts.
▶ 0:55:17We need to update our systems, you know, in lieu of of doing manual data calls, by bringing in and fixing the system where you have automated data that can show you timelines of amendment, execution, contract or compact execution, and allow us and permit us to put ambitious targets in place. We'll do that.
▶ 0:55:43In fact, one that happened just this year as this fiscal year opened up, um, as a result of advanced appropriations, we were able to meet the statutory requirement to make payments to all tribes and tribal organizations within ten days of omb apportionment. That was a transfer of approximately $2.5 billion. That's what this realignment is seeking to do, is to bring in those performance metrics and improve operations within the capacity. >> that we have for that answer.
▶ 0:56:13Well, any elements of the new structure explicitly focus on elevating strong regional practices and bringing underperforming areas up to the standard. >> absolutely. That is our goal. >> thank you. So gao was kept ihs on the high risk list for issues in planning, monitoring and internal controls. You know, some of the modernization initiatives you've described seem relevant to those gaps.
▶ 0:56:35Are there particular gao criteria where you feel the agency agency is closest to demonstrating measurable, uh, measurable progress? >> again, thank you for the question. Part of the challenge is these have been chronic issues, and they are going to take a concerted effort to move forward.
▶ 0:56:55But whether it's electronic health record modernization, facility infrastructure, we look forward to working with congress, with this administration, with the tribes and tribal organizations across the country to address these. I do want to share with you that we have posted on our indian health service website for the first time, our gao action plan. This is going to be a living document, but it will provide some insight to those strategies of how we plan to accomplish this. >> outstanding. Well, I thank you for your time. Thank you for your responses.
▶ 0:57:25Unfortunately, I've run out of time. So on that, Mr. chair, thanks for allowing me to be here and I yield. >> thank you. The gentleman from montana yields at this time. The chair recognizes the gentleman from the state of oregon. Miss hoyle, for five minutes, miss hoyle. >> thank you, Mr. chair. Um, sorry. Um. So.
▶ 0:57:42And again, thank you, deputy director smith, um, for being here in western oregon, our tribes rely on 638 contracting to provide health care to tribal members. And thanks to 638 contracting, the ihs provides tribes the funding to open tribal clinics, often in rural communities with health care shortages.
▶ 0:58:08These clinics support the health of tribal members and can also serve the community at large. The purchased and referred care program at ihs also allows tribes to pay their members to receive medical care from third party providers when need be. As you know, I'm strongly supportive of the 638 authority for health care, and I see it as a necessary part of upholding the federal government's trust responsibility to tribal nations. Now, today, we're discussing how to modernize.
▶ 0:58:38638 contracting, and I support that. I'm happy to have the discussion. As long as we have the same end goal, which is upholding tribal self-determination and expanding access to affordable, quality, appropriate health care for native people, consistent funding is an important part of that, as is adequate staffing at the ihs have great concerns about that. But I'd like to ask you about a related issue.
▶ 0:59:06Tribes in my district were terminated by congress in 1954. That was wrong. And it took decades for five western oregon tribes to be finally be restored. Many of their members moved to different parts of oregon when they didn't know whether or not that recognition would happen, and it's an ongoing process, um, to make our western oregon tribes truly whole again.
▶ 0:59:28Several tribes have shared that it's an ongoing challenge to provide affordable health care to the many tribal members who live outside the tribes purchased and referred care delivery area. So a couple of questions. Um, so you can pull it all together. Could you outline the process for tribes seeking to expand its purchase and referred care delivery area?
▶ 0:59:52Number one two, is there a way we could allow tribes to expand where it can use its own funds, not federal funds, to provide health care to its members at medicare like rates that the ihs um, has, has contracts for? Because wouldn't that be of no cost to the federal government? It's a win win situation.
▶ 1:00:14And then finally, we commit to working with me to identify low or no cost ways to make it easier for the restored tribes to deliver health care for their members statewide. >> thank you, representative, for the questions. Um, the last one. Yes, absolutely. We will commit to working with you. Um, those goals are things that we're trying to achieve across the board.
▶ 1:00:40Um, your second question about the medicare rates, um, I would like to follow up and get additional details on on that, but with the purchase referred care, um, designation areas. Again, these are there is a process. It's outlined in the code of federal regulations on, um, what tribes can do to expand or request the agency to expand that.
▶ 1:01:08>> so just just so that we can have your answer go in the right direction. There is a process. It is complicated. It is convoluted, it is difficult and needs streamlined. >> so okay. Yes. And we have already made some, uh, a few efforts to streamline the process. Um, in that one, being able to review multiple requests and take action simultaneously. Uh, we've seen a lot of results in moving that forward.
▶ 1:01:36Um, we're also drawing upon the, um, revisions that were made or the updates to the indian health care improvement act in 2010 that designated some states as statewide, um, purchase referred care delivery areas. In fact, we're consulting on some of those right now. Uh, the dakotas for, for example, and the state of arizona. But we we are if we can follow up with you and share the detailed, um, process flows and maps.
▶ 1:02:03But those do start locally, uh, with the tribe and the respective area director. >> thank you very much. And I yield back. >> the gentleman yields at this time. The chair recognizes himself for five minutes. Uh, Mr. smith, how does ihs track timelines and capacity at area offices? >> we have internal teams that are monitoring those through our, uh, one financial systems. Um, as you know, some trackings are easier.
▶ 1:02:32Uh, I only bring this up as an example, but at all costs, we try to avoid these. But if there are dispute mechanisms, such as a final offer, um, there's a 45 day statutory time clock that gets set. So we do have, um, systems to monitor those. Likewise under the title one, um, uh, side of things, the law is very prescriptive in terms of timelines, whether it's acknowledging.
▶ 1:03:00>> the same for title five as well. >> uh, no. Title five. Uh, once it became a permanent program at the indian health service outside of the demonstration authority, the demonstration project did have concrete timelines of negotiations. But today, uh, there are no set timelines for negotiating self-governance agreements. >> so in the there's a variation among the area offices. What where are the bottlenecks?
▶ 1:03:26What's what are the staffing constraints or workload constraints that you see? There are variation, at least we've heard there's variations among the area offices. What is it that's causing those variations. And why are some offices, um, working more efficiently or working differently than others? >> the variation. >> are they better staffed? Are they better? They have more resources? What is it that's leading to a variation among the area offices? Yeah. >> thank you.
▶ 1:03:55The short answer is it depends. Um, you know, some areas are engaged in some very complicated, um, negotiations. Perhaps it involves a multi tribal service unit. What does that look like? If one tribe is seeking to negotiate its share of those programs, services, functions, activities outside of facility, others may be retained. Um, in fact, we have some tribes in, in, um, in our california area that haven't come to negotiations in several years.
▶ 1:04:26They rely on the indefinite terms of, uh, of a title five self-governance compact and funding agreement, and we'll check in on occasion. So looking at the variation, how it plays out, not only, uh, to, to the routine work, but, um, looking at the cycles. So some tribes have, have uh have and. >> title one or title five right now, are we talking title one or title five? >> uh, both.
▶ 1:04:53Some can negotiate on fiscal year cycles starting in october 1st of each year. Some, um, start on the calendar year with the january cycle so that workload distribution can differ. And then some may have other cycles. Um, uh, to give you an example, one starts at the very last day of the fiscal year. >> okay. Um, ihs 14,000, 15,000 employees. Does that sound right? >> yeah, a little over 14,000. >> at this point.
▶ 1:05:20How many of those are assigned to six, 38 contracts and compacts in the 12 area offices and in dc? Do you have just a guess? Just general I'm curious. >> yeah. So so in total, in terms of, uh, what's you're hired for in duties, I would I'll have to get back to you on a, on a number. But what I do want to point out. >> what should it be. >> uh, we, we do have some projections that are on the table.
▶ 1:05:47Um, I think one of our areas that most recently went through a reorganization, which is helping to inform this realignment, is our intergovernmental and external affairs component that really looked at meeting the statutory requirements of the isda, not only the administrative work, but the negotiation work and, um, other items such as contract support costs and 105 l. >> and are the employees that are in the 638 contract and contracting.
▶ 1:06:14Are they only doing those duties in that area, or are they also doing other things outside of that area. >> as you suspect, they're carrying out multiple duties? Okay. In fact, some may be public health analysts. Um, some can be engineers in some cases, uh, they're carrying they're wearing multiple hats. >> how should we measure success? How should we, as policymakers and congress know whether or not ihs is headed in the right direction when it comes to 638 contracting and contracting?
▶ 1:06:42What are the external things that we could look to to say you are on the right track and that we would know at the end of this fiscal year it's either happened or it hasn't. Is it timelines? Is it? How do we how do we know if it's working? >> uh, there's multiple factors. I think at the highest level, and this has always been most concerning for us is just the the recent data that shows that american indians and alaska natives are living almost 11, 11 years fewer than the general population.
▶ 1:07:12There's something wrong with that that needs to change. >> but that's pretty broad. 638 contracting and compacting seems more like it's I would expect it to be timelines or and my time has expired. And I want to let you know that I appreciate you being here and and your testimony. This is something that's really important. And I know all of all of us here on this dais care about improving these results and these outcomes and and increasing the effectiveness of the. 638 contracting and compacting. I my time has expired.
▶ 1:07:40And at this point. I'm going to thank you, Mr. smith, for your valuable testimony and thank my colleagues up here for their their questions. We are are we going to go to a second panel? Okay. So members of the committee may have some additional questions for you, Mr. smith. Uh, and we would ask that you respond to those in writing. And right now I'm going to ask the clerk to reset the table.
▶ 1:08:06And while that is happening, I am going to introduce the witnesses for our second panel. Okay.
▶ 1:08:34Our witnesses are here. You're welcome to take your seats at the table. Thank you. To our witnesses. Welcome to the second panel.
▶ 1:09:01Uh, for this morning's hearing, I'm going to start by introducing the honorable chuck hoskin jr, principal chief of the cherokee nation in tahlequah, oklahoma. It's nice to see you again. Uh, chief hoskin, next is the honorable greg abramson, who is chairman of the spokane tribe of indians and wellpinit washington. And last is Mr. jay spahn. Sorry. Second to last is Mr.
▶ 1:09:27Jay spahn, executive director of self-governance and communication education and tribal, uh, at the self-governance communication education tribal consortium in tulsa, oklahoma. And last is the honorable victoria kitchen, council member of the winnebago tribe of nebraska in winnebago, nebraska. Welcome. Witnesses, as you heard before, under committee rules.
▶ 1:09:50Um, I'm going to ask you to limit your oral statements, your oral opening statements to five minutes, but your entire written statement will appear on the hearing record. To begin your testimony, you should see a talk button in front of you. Green talk button. Uh, we do use timing lights, as you saw with Mr. smith. When you begin the lights going to turn green, when you have one minute to go, it will turn yellow. And then when it turns red, I would ask you to wrap up either your statement or your answer to the question as quickly as possible.
▶ 1:10:18Um, I'm also going to allow each of you to testify before member questioning begins. And with that, if you are ready, the chair will now recognize the honorable Mr. hoskin for five minutes. Mr. hoskin. >> chairman hurd, members of the committee subcommittee. Uh, I appreciate the opportunity to testify on the modernization and implementation of the 638 contracting an indian health service.
▶ 1:10:43Uh, I have the honor of representing the largest tribe in the united states, cherokee nation, with over 470,000 citizens nationwide. We have an unbroken treaty relationship with the united states and exclusive tribal jurisdiction over our 7000 square mile reservation. Across that reservation, we operate the largest tribally run health system in indian country. Last year, our hospitals and clinics handled more than 2 million patient visits.
▶ 1:11:11That equates to 3 million patient services across 11 health facilities. We deliver first class service instead of the art facilities. All of that is possible because of 638 self-governance. 638 has been transformational. We've replaced outdated facilities.
▶ 1:11:33Those facilities include the largest joint venture facility in the country, which also happens to be the largest outpatient facility in indian country. We're building indian country's largest hospital on a campus that includes the oklahoma state university college of osteopathic medicine, which is only on that campus because of our 638 self-governance activities. It is a med school, by the way, that is shattering records for native student graduates.
▶ 1:12:03And most recently, 638 enabled us to assume operation of the claremore indian hospital. We took over on october the 1st. We immediately invested $11 million to take that neglected facility from the ihs standard to the cherokee standard. We will replace that facility with a $244 million state of the art health campus in claremore.
▶ 1:12:31These successes demonstrate a clear truth when the government of the united states returns control of health care to native peoples and their tribal governments. Health care for tribal citizens is demonstrably better, and federal dollars are used more efficiently. 638 unshackled the cherokee nation. We designed our health system around patients.
▶ 1:12:54We made decisions like integrating behavioral health, investing in public health, and focusing on prevention. We are building towards a world class system of wellness. On a bipartisan basis federal leaders should be proud of. 638 it is the most successful federal indian policy in history.
▶ 1:13:17Modernization of 638 should include more focus on predictability, transparency, and coordination across the indian health service. Above all, it must include a renewed commitment to tribal consultation. Modernization should lean on the policies that work, including the joint venture program and the 477 program. Those programs increase efficiency and empower tribes to focus on local needs.
▶ 1:13:46Modernization should recognize that most ihs funding today goes through programs operated under is dia, is dia has enabled us to improve access, quality and workforce. Modernization also means aligning the federal budget with trust and treaty obligations. Those obligations are best met by making ihs appropriations mandatory, and that includes contract support costs and 105 l leases.
▶ 1:14:11But at a minimum, congress should continue the practice of advanced appropriations, which it embraced in fy 24, 25, and 26. No tribal citizen should lose healthcare when the federal government fails to enact a budget due to dysfunction. Tribal health systems deserve. Taxpayers deserve certainty and predictability. Some recent issues unique to cherokee nation have exposed some structural concerns at ihs that undermine.
▶ 1:14:40638 contracting two days ago, after more than a year of working on our end, ihs announced a new process for transferring the land title at claremore from federal enclave status to tribal ownership. This will impact operations and public safety.
▶ 1:14:58We've seen ihs headquarters make decisions that lack statutory authority, lack precedent and lack logic, and they produce funding disparities that are impossible to reconcile. They've even overruled area office leadership. We've seen actions on our reservation, providing funding to a tribe within our reservation to duplicate our system.
▶ 1:15:23Any member of this committee concerned about the fleecing of taxpayer dollars in the shortchanging of indian country, should investigate the duplication of services that's happening right now within our reservation. Modernization should include safeguards to prevent this in the future. Appreciate the opportunity to testify. Modernization led by this committee should reinforce the principles that make. 638 a success.
▶ 1:15:48Clarity, respect for tribal governance and federal actions that strengthen, not disrupt, tribal health system. 638 works and cherokee nation proves it. Thank you. >> thank you very much, chief hoskin. At this time, I'd like to recognize Mr. abramson for five minutes, Mr. abramson. >> uh, has expressed. Chairman heard, ranking member leger fernandez and other distinguished members of the subcommittee.
▶ 1:16:16It is an honor to be before you today and among other tribal, honorable tribal leaders. Thank you for inviting me to testify on such an important and crucial topic there for our people there. My name is greg abramson, and I serve as chair of the spokane tribal business council, vice chair for the northwest portland area health board, and former chair for the direct service tribe advisory committee. Spokane tribe is located in northeastern washington, washington state.
▶ 1:16:43We have around 3030 enrolled tribal citizens, with about 55% of the living on the reservation and 35% living in eastern washington, with the remainder living elsewhere. And approximately 50% of our people are 30 years old and younger. Our ancestors inhabited approximately 3 million acres in much of northeastern washington, washington state.
▶ 1:17:08Uh, now our reservation is close to 160,000 acres there, with lands in stevens and spokane county there. So since, uh, indian self-determination and education assistance act was enacted and self-determination contract and process has allowed tribes to carry out functions and activities according to their needs, as he heard. And you do will hear more.
▶ 1:17:32And, um, before they can take care of their customers desires and ushering, they see a change from the traditional direct service model and many of the roles have occupied over the years. I've seen that tribally operated health centers can better tailor services for their citizens, expanded care, reduce workforce shortages while many federally operated indian health service facilities continue to struggle with high vacancy rates and even tribal patients without
▶ 1:18:02Timely access to care. For more than 25 years, the spokane tribe has contracted behavioral health portion of our service unit under title one, public law 93 638. Building on that experience, in february 2024, our tribal council decided to move forward with a full title five compact to both the medical and behavioral health services.
▶ 1:18:24Over the next year, we engaged consultants and tribal staff to plan and negotiate the transition from federally operated hhs clinic to a tribally operated health center so we could exercise our inherent right to self-determination, close long standing gaps in care, and ensure that spokane citizens receive the high quality and wide range of health care services. On april 1st, 2025, spokane tribe formally assumed operation of our health clinic.
▶ 1:18:54Many ihs staff at the area and service unit levels demonstrated professionalism and worked hard to support the successful transition. At the same time, staffing shortages, administrative turnover, and delays in responding to critical requests that made the process more difficult than needed to be at, and risked undermining our ability to meet deadlines under the ihs. Development and tribal self-governance negotiation grants.
▶ 1:19:20These challenges show why any modernization of 638 implementation must include adequate staffing and capacity to both headquarters and area offices. The most serious challenges we faced involved information technology and the transfer of electronic health records. Ihs reliance on age and resource and patient management system rpms meant that when our compact went into effect, the systems could not reliably communicate.
▶ 1:19:48This disrupted patient care by crippling our pharmacy operations, third party billing and referrals, and delaying to transfer the complete patient records into our new system, and is supposed to improve care coordination, not put patients at risk.
▶ 1:20:05Our experience makes clear that he must either fully fund tribal transition to modern, commercial, off the shelf ehr systems, or fully fund the true modernization rpms and must prioritize continuity of care during any transition. Thank you for this opportunity to testify.
▶ 1:20:24As more tribes move from direct service to contracting and compacting, I look forward to working with this subcommittee and indian health service to modernize the implementation of the public law 93 638, so that every transition puts patients first and honors the united states trust and treaty responsibilities to our people. Thank you. >> thank you very much, chairman abramson. At this time, the chair recognizes Mr. spahn for five minutes. Mr. spahn.
▶ 1:20:56>> chairman and members of the committee, thank you for the opportunity to testify today. My name is jay spahn. I'm a citizen of the cherokee nation and serve as executive director of the tribal self-governance consortium. Congress passed the indian self-determination and education assistance act in 1975 to affirm that tribal nations have the right to govern their own affairs and run the federal programs that serve their communities. Over the years, tribes and congress strengthened the law, and in 2000, congress made title five self-governance a permanent option for the indian health service.
▶ 1:21:24Today, nearly every tribe uses this authority directly, administering 65% of the ihs budget. Ihs is a very different agency today than it was 20 years ago, not because its mission changed, but because tribal nations stepped up, delivered strong results, and changed what tribal federal partnership looks like in practice, as ihs considers the largest organizational realignment in two decades, modernization is understandable and necessary.
▶ 1:21:50The agency faces workforce shortages, growing healthcare demands, and the reality that tribal nations now manage most of the system. But modernization must build on what already works, and it must strengthen, not weaken, tribal self-governance and the federal trust responsibility. I'm going to focus on three of the key areas identified in the ihs proposal that need greater attention. First, meaningful tribal consultation must guide any major restructuring.
▶ 1:22:17Consultation works when tribes have the full picture and enough time to evaluate the impacts. Ihs released a high level executive summary describing the proposed realignment on december 5th, a little more than just one week before the first consultation. Tribes need complete details to understand how the realignment would affect istea implementation, funding processes, agency responsibilities and the government to government relationship. Sharing more information earlier would improve consultation and lead to stronger modernization plans.
▶ 1:22:44After consultation, ihs should work side by side with tribal leaders to shape implementation. And when tribes do not support support certain elements of the realignment, the agency should be ready to make changes. This is what meaningful consultation requires. Second, the proposal to centralize isda negotiations raises concerns. Ihs is proposing a new national office that would coordinate all title one and title five negotiations.
▶ 1:23:09While consistency across areas is a reasonable goal, centralizing negotiations could introduce new delays, reduce flexibility, and shift the process from a relationship based approach to a more distant, more distant transactional one. We are already hearing from tribes that routine matters are taking longer because area offices must wait for approval from headquarters. It's not clear whether the additional approvals are needed because of reduced area office authority, limited legal resources or inexperience of area lead negotiators.
▶ 1:23:39But the slowdown is frustrating and hinders self-determination and self-governance. Many tribes also note that area offices often provide faster and more accurate information, because they know the communities they serve. At the same time, we recognize that some areas are under-resourced and not meeting tribal expectations. For that reason, tribes should be able to work with either area office or a headquarters strike team until area office performance is consistently meeting tribal obligations and expectations.
▶ 1:24:05Strengthening negotiation process is essential, and ihs needs to make meaningful changes, such as establishing performance metrics tied to communication timelines and using its proposed new office for training and mentorship. But centralizing these functions may weaken isda implementation rather than improve it. Third, decision making authority must remain connected to tribal communities. The plan to convert area offices into tribal relations offices and remove their authorities represents a major shift. Area.
▶ 1:24:31Directors currently play a critical role because they know the histories, priorities and needs of the tribes they serve. Removing decision making from the local level risks weakening accountability and reducing responsiveness. Again, area performance is not consistent and improvements are needed, but modernization should lift up underperforming areas, not pull authority away from those that have strong relations and proven success. Modernization must keep decision making as close as possible to tribal communities.
▶ 1:24:58Finally, modernization requires attention to issues outside of reorganization itself. Ihs still faces a 35% vacancy rate. Several ihs behavioral health programs cannot yet be compacted under isda. Ipa agreement terms were recently changed without tribal consultation, and some ihs manuals and policies are outdated and do not reflect how tribal health systems operate today. These issues must be addressed to make modernization complete.
▶ 1:25:23Congress also plays a vital role, making ihs funding mandatory, extending advance appropriations to all ihs accounts, and expanding isda authority to more hhs programs would give ihs and tribes the stability and additional tools they need to carry self-governance into into the next generation. Tribal nations and ihs share the same goal a modern, a strong, modern health system that delivers high quality care and supports tribal self-governance. We want this effort to succeed.
▶ 1:25:51If done right, realignment can help ihs become more responsive, more effective, and better prepared. Thank you for the opportunity to testify. I'm happy to answer any questions. >> thank you very much. Mr. spohn. At this time, the chair recognizes council member kitchen for five minutes. Council member kitchen. >> good morning. Excuse me. Good morning. Good morning, chairman hurd and ranking member leger fernandez. Who? My name is victoria kitchen, and I serve as the tribal council member at the winnebago tribe of nebraska.
▶ 1:26:21And it's an honor to testify today. The winnebago tribe's experience both shows the consequences of failing health system and the transformative power of tribal self-determination. When tribes take control of their health care systems through 6 or 8 contracting and compacting, we restore trust, we save lives, and we build the kind of care our people deserve. When I testified before congress in 2016, the ihs hospital serving our community had been operating with life threatening deficiencies for nearly a decade.
▶ 1:26:50Cms found immediate jeopardy violations. Nurses weren't trained in emergency to administer emergency medications, and patients were sent home, only to be life flighted later. Families who lost loved ones, even to preventable deaths, were prevented from receiving those medical records. And in 2015, the hospital lost its cms medicaid certification and our community's trust.
▶ 1:27:14After years of urging ihs to fix these deficiencies, the tribal council made the difficult decision to assume control of a troubled hospital, and through a self-governance compact, we were able to restore that certification. In july 2018, we formally took over what had become a deeply troubled hospital. We renamed it 12 clans hospital and built the winnebago comprehensive health care system, and we brought together tribal health programs under one unified, culturally grounded organization.
▶ 1:27:40We established a governing body, a board of directors, a leadership team, and new policies. Everything was on the table. We began the long process of regaining cms certification. And within 18 months, with expert documented major improvements, we regained cms certification in april 2023. Since taking over, we have dramatically improved care for roughly 10,000 tribal members and patients.
▶ 1:28:06Some of the examples include 2020 net revenue for patient services were $6 million. We have grown that to nearly $30 million in 2026. We project for the first time. We're budgeting for third party revenue to exceed the compact. Medicaid makes up for 50% of those revenue collections, while private insurance makes up for 40 to 45% of those collections.
▶ 1:28:31Also, by 2024, nearly all our medical staff were permanent employees rather than short term contract employees. We created a 24 over seven sexual assault nurse examiner program in 2025. Our emergency room received nebraska's level four trauma designation. Our quality metrics continue to rise. Hypertension control is up from 53 to 70%.
▶ 1:28:53Our emergency room nurse satisfaction reached the 94th percentile nationally, and we launched a modern electronic medical health record system. We brought we brought specialty service home, including ob gyn, dermatology, orthopedics, podiatry, nephrology and urology. We use telehealth to expand services like psychiatry, behavioral health, endocrinology and other services for rural tribal nation. This is transformational.
▶ 1:29:21On the public health side, our community trust has grown each year. We protected our people through covid 19. In 2025, our public health department received national accreditation. Only the eighth tribe to do that for their public health department. And finally, based on these experiences, I want to offer some recommendations for 638 modernization. Develop and publish uniform performance metrics.
▶ 1:29:46Tribes ihs and congress need consistent data on approval, timelines, staffing, and pending contract actions. Create a comprehensive 638 implementation manual. Just like the bia needs clear, standardized procedures so tribes are not navigating inconsistent guidance across areas. Strengthen area office capacity and accountability. This is a big one for the winnebago tribe. Gao has repeatedly identified deficiencies.
▶ 1:30:10Addressing this is essential to getting off the high risk reduction of the federal footprint does not alleviate the responsibility or accountability to self-governance. Tribes, and in fact, in my area on the great plains area, the area director told my tribe that 90% of his time is spent on direct service tribes. And so capacity needs to be built, accountability needs to be built and maintained for self-governance tribes, and there needs to be a willingness to.
▶ 1:30:35Work with the tribe as they take on these roles and, um, excel, improve transparency and communication with tribes. Regularly structured engagement will reduce uncertainty and support better decision making. Clarify and fully fund inherently federal functions. Restructure and distribute distribution of program funds new and existing resources, especially in behavioral health and public health. Those should flow through the contracts and not through a grant program.
▶ 1:31:03A grant is not a fulfillment of the trust responsibility. And I just want to say that broadly, not just with ihs, all of hhs, a grant program is not a fulfillment of the trust responsibility. When you have $1 and all the tribes have to go after it. It's just very sad. Um, in conclusion, I just want to say that the winnebago tribe took a struggling hospital and turned it into a model of excellence. We did this through self-determination and self-governance.
▶ 1:31:31Modernizing the 638 process is a central pathway to saving lives, restoring dignity for tribal nations. We thank you for the opportunity to testify and look forward to answering your questions and working closely with you to not only improve and strengthen 638 contracting, but possibly expand it. >> thank you. Council member. The chair will now recognize members for five minutes for questions, and we'll begin by recognizing the gentleman from american samoa, miss radewagen for five minutes. Miss radwagon. >> thank you, mister chairman.
▶ 1:32:04I want to thank the witnesses for being here today. Chief hoskin, many smaller or mid-sized tribes look to cherokee nation for technical assistance and guidance. Based on that experience, what reforms would most help tribes with limited administrative capacity succeed under istea? >> thank you. Congresswoman. I appreciate the question because I'm recalling the days of chief mankiller.
▶ 1:32:34Although the cherokee nation was a large tribe, then we needed technical assistance. All of her successors, myself included, needed technical assistance. A small tribe with a limited capacity, just in terms of people power certainly needs that so structured ihs technical assistance program to deliver it in partnership with experienced self-governance tribes with which cherokee nation is, and I have to say, my friend jay spohn and his organization can be instrumental to that and is instrumental to that, uh, would be important for smaller tribes,
▶ 1:33:05Uh, streamlining, uh, redesign approvals and compact amendments can reduce administrative barriers. Those tend to disproportionately affect small tribes and of course, advanced appropriation and mandatory funding is good for all of us. But you can imagine having that hedge against uncertainty is much more important if you're a smaller tribe that has less ability than the cherokee nation does, to look at our own resources to get through the storms of periodic funding lapses.
▶ 1:33:35Uh, training, of course, is important in areas like billing, workforce development, facility planning. Those are things that took cherokee nation a great deal of time to develop our own expertise. And we had, of course, more people to do it with. So those are some areas that I think small tribes could benefit from. Thank you. >> council member kitchen. What do you need to see from ihs for this realignment to genuinely support more effective? 638 implementation.
▶ 1:34:04And are there aspects of the current area structure that you believe must be changed to improve responsiveness? >> thank you for the question. Yes. I think that the the capacity building is essential in each area. And it's been, um, set across the panel that they're inconsistent, um, expertise in some of the areas.
▶ 1:34:28And when you don't have the capacity to help an and nurture a young, um, self-governance tribe like the winnebago tribe, we need that technical support, and we need the buy in from the area and from headquarters down to the area that the support is there for the tribe to be successful. >> so, council member kitchen, if ihs could fix one thing tomorrow, that would have the widest impact across indian country.
▶ 1:34:57What what do you think it would be? >> it would be to streamline processes, expand. 638 and tribes have been able to do much more with limited resources, and it would just, um, be taking what the lessons we've learned and expanding. >> 630. Uh, chairman, uh, abrahamson, your testimony discusses the spokane tribe's interest in assuming control of the wellpinit service unit.
▶ 1:35:29What are the primary reasons the tribe believes that taking over wellpinit under 638 authority improves care for your citizens? And what outcomes do you hope tribal management will achieve that? The current federal structure has not. >> thank you. Congresswoman. That's a great question, because that's what, uh, as I traveled across the nation when I was a direct service tribe, uh, chair.
▶ 1:35:56And, and as we visited a lot of these, uh, other facilities and in the northwest, we have, uh, some of the most innovative health systems out there that the tribes that have assumed, uh, their operations, uh, furthered health care for their people. And along with that, we can be able to offer more with the federal government has restrictions on what they're able to pay their providers.
▶ 1:36:25And, uh, they have locals that come in a lot of times they're to we can provide, uh, providers that may stay there for a long time, offer more things that, uh, as anybody would like to have as a doctor that's going to be there and continued care for our people and be able to expand services for podiatry care for different functions of dentistry that can help, uh, health out for our people, for both the young and the older, to be able to, uh, even offer more preventive care
▶ 1:36:57To so our people can live longer, as you heard earlier there, too, that our people live less than what they should. There's. >> thank you, Mr. chairman. I yield back. >> the gentleman yields at this time. The chair recognizes the gentleman from the state of washington. Miss randall, for five minutes, Mr. randall. >> thank you, Mr. chair. Mr. swan, as we discussed in the prior panel and you alluded to in your remarks, ihs is considering large organizational realignment where more functions and staff will be centralized at headquarters.
▶ 1:37:26Tribes across the country are worried that this realignment will further delay services and response times, as positions like area lead negotiators are move farther from the tribes that they serve and are encouraged to maintain strong relationships with. It's my understanding that ihs notified tribes of the realignment just last week on december 5th, with one week to go before consultation.
▶ 1:37:50Yet ihs tribal consultation policy states generally, every effort will be made to provide at least 30 days notice prior to a scheduled consultation. Mr. what are the consequences for tribal health care of improper consultation for large agency realignment, like the one ihs has proposed? >> thank you for that question. Uh, with this consultation, it has been multi-year.
▶ 1:38:19There's been a number of moving parts. So ihs did initially schedule a consultation, um, much further in advance. And that was for a limited number of locations and sites. Uh, when that tribal leader came out announcing it, it was more of a here's the locations that we're going to have it. Here's the date, uh, with very minimal information shared. It was december 5th before ihs provided any meaningful information to tribes to prepare for those consultations. And then they added additional dates as well at that time.
▶ 1:38:47So so our concern was that in that initial letter, in that initial preparing time, it was basically we're going to have a consultation, but tribes didn't have anything to review or evaluate to comment on. Uh, and so the short time frame been able to look at this high level executive summary and understand it, uh, and then consider what impacts it's going to have really hinder's tribes abilities to provide meaningful input. Uh, 638 implementation is tribally driven. It's tribally driven by law, by congress.
▶ 1:39:14Is the intended for it to be tribally, um, driven approach that is not a one size fits all. This is where tribes have the opportunity to decide what works best for them. And so having them as part of any realignment is critical, specifically, now that nearly every tribe is participating in istea. >> absolutely. Thank you. I think it's always important for us to remember that tribal consultation isn't a box to check in the process. It is.
▶ 1:39:37It is the work of determining how we move forward in a way that honors sovereignty and our treaty and trust responsibilities. Um, I also understand that ihs has proposed centralizing the area lead negotiators under newly created office of agency negotiations, rather than under the ihs director.
▶ 1:39:57And as mentioned previously, the lead negotiators are, um, being in an area office allows them to have strong working relationships with the tribes that they serve. Proximity, the ability to connect in-person, face to face. As um, ranking member fernandez shared earlier. Um, and I, I worry that the centralization at headquarters will reduce timely communication.
▶ 1:40:22And we have heard that, you know, it may not happen exactly as we think it might happen, but I want us to be clear eyed about what what could happen if that centralization looks like it might, um, area lead negotiators also have delegated authority to act on behalf of ihs, the ihs director. But I'm concerned that this proposal to create an office of agency negotiations will shortchange tribes in that regard. Can you talk to us, Mr.
▶ 1:40:51Span a little bit about the negotiation process and what the consequences are when those negotiations are not properly carried out for tribes to get the health care to their members that they need? >> yes. Thank you for the question. And tribal negotiations is, again, a tribally driven process where tribes are deciding the terms and how they want to move forward in negotiating with the agency and redefining that relationship.
▶ 1:41:13What's worked really well in some areas is having that local team that knows the community, that knows the tribes, that has a history, and tribes have built up those relationships over time. Uh, it also ensures that any of those decision making activities that impact the tribe and the patients that are being served are being made closest to where they are located, that these are local individuals that know the communities, know the areas. So we do have a great concern about centralizing. And even if it doesn't mean moving people to D.C.
▶ 1:41:41That if you have this centralized process where you're pulling, uh, from one from alaska to work with the tribe in alaska and in oklahoma, and you're pulling general counsel from a different area that you start weakening that relationship, and it becomes very transactional based versus relationship based, whereas the local people know what the community needs, and they're invested in making sure the health care for that community. >> thank you so much for your testimony and answers. And, Mr. chair, I yield back.
▶ 1:42:12>> the gentleman yields at this time. The chair recognizes the gentleman from utah, Mr. kennedy, for five minutes. Mr. kennedy. >> thank you, Mr. chair, for convening this. And thanks to the witnesses for being here. And I'm grateful for your testimony. Today's subcommittee meets to support a clear and necessary goal, and that's to modernize indian health services. And as a physician, I know how important it is that we have timely action and reliable systems to deliver the quality of care for our native american populations.
▶ 1:42:37Too often, ihs is held back by outdated processes, slow contracting and persistent staffing gaps that delay the services tribal communities depend on and deserve. We've heard testimony from councilwoman kitchen on the initial, life threatening deficiencies of their facility. Let me be clear no hospital or health facility in the united states should have their services, or lack thereof, described as life threatening.
▶ 1:43:02As such, while we should acknowledge that great lengths ihs has progressed in their quality of service and encourage its continuance, we must maintain this trajectory through careful congressional oversight. So I'll start with chief hoskin, thank you for your willingness to be here and answer the questions. But the cherokee nation runs one of the largest tribal health systems in the country. With that scale, predictability is essential.
▶ 1:43:25So how do inconsistencies, inconsistencies among ihs area offices affect long term planning for tribal, for the for tribal system of the cherokee nation's size? >> thank you. Congressman. It is critical that we have consistency among agency offices. And it's critical that agency offices, first of all, exist because the relationship we have close to people that are close to on the ground activities is indispensable.
▶ 1:43:55But they have to be empowered and they cannot be undercut. And we've actually seen that in the cherokee nation's experience, where decisions by area office leadership has been undercut, in fact, by headquarters. Um, and so it's important, though, to have that direct line of communication, quite simply, area office folks know the tribal lands, they know our systems, they sort of have grown up with us. And that's really important because they know what's going on.
▶ 1:44:24And oftentimes and again, this isn't directed to any particular administration. Oftentimes headquarters is a bit detached from what's really going on on the ground. And there's a bit of reeducation that has to happen. But I've heard about inconsistencies between offices, and we've had a really great experience with the oklahoma city area office. And I would I would want that experience across the country and standardization would be important. >> how do you coordinate, though, with your local office?
▶ 1:44:54What's the best way to make sure that that happens? >> well, I think frequent interaction, I mean, there's no substitute for in-person interaction in oklahoma. We have of the five large tribes, the inter-tribal council and the area office representative invariably shows up not only to speak to us, but is there to talk with us. And you can't replace that with memoranda.
▶ 1:45:18You can't replace that even with virtual meetings with headquarter folks, even though there's very wonderful folks that work in headquarters, having people that you're familiar with show up is important and it can't be substituted with other means. >> thank you for that response, miss kitchen. You've emphasized that tribes often face very different experiences depending on which ihs area office they work with. How has the area level variation affected the winnebago tribe as you've implemented and expanded your. 638 authority.
▶ 1:45:49>> thank you for the question. The winnebago tribe assumed was the first tribe to assume a hospital in the great plains area. Only one other tribe had assumed management of a clinic, so my area lacked capacity. And and I can, quite frankly, the willingness to, um, not only triage a broken hospital, but also walk with the winnebago tribe as we took over that hospital. And so this whole process has been, um, challenging.
▶ 1:46:14And the winnebago tribe advocated for special appropriation to for hospitals that find themselves in jeopardy. And even through that path, we had to after we advocated for that appropriation, we had to work with ihs to receive a portion of appropriation. And so it's really on the the the onus is on the tribe when you do not have the capacity or the willingness in your area to to support the self-governance tribes.
▶ 1:46:40And so as we step into this modernization, I think some of the areas need more attention than others. And I think that there should be a priority list from either the tribes experience or from some type of assessment. And having these metrics that were mentioned earlier, those are a wonderful start. >> excellent response. Thank you very much to the witnesses yet again. And mister chair, thanks. This is an important hearing and we stand ready to help wherever we can to make sure that these services are delivered effectively. And with that, I yield back.
▶ 1:47:10>> I agree completely. >> with that sentiment. Um, representative kennedy, the gentleman yields back at this time. The chair would like to recognize himself for five minutes of questions. Uh, councilmember kitchen, I loved what you had to say about uniform performance metrics, a 638 implementation manual. It's not clear to me why the bia has one, and, um, ihs does not strengthen accountability and accompanying capacity improvements also with accountability.
▶ 1:47:36If a tribe was considering moving from direct service to 638, what's one piece of advice you'd offer them? >> thank you for the question. I would offer the tribe to educate themselves, themselves, as well as their tribal members and on what 638 is, and that it's actually an exercise of sovereignty rather than a diminishment of sovereignty.
▶ 1:47:58And we are not letting the federal government off the hook, per se, for our treaty rights, but rather this is a mechanism to, um, deliver quality and better health care services at the local level, with local control and the care that, um, only the relatives can provide. >> thank you very much. Um, uh, chief hoskin, it's great to see you again.
▶ 1:48:24You mentioned in your testimony, um, health care is better when it's managed within the tribe and behavioral health issues as well. I think you mentioned that. Can you give us some specific examples of how this works and how through the 638 contracting or compacting? Um, you've seen improvements in health care delivery compared to what would happen in a, in a direct situation? >> absolutely, chairman. Thank you.
▶ 1:48:53And it is good to see you again. The, uh, the integration of behavioral health into our health system is probably been one of the the best things that's happened in our health system. We're not in an era in which patients come in and then they're on their own to seek those behavioral health services, or there's some disconnect. It is all in one system. So that is something cherokee nation decided to do because we put the patient at the center.
▶ 1:49:18And so if I were to come in and for some other ailment but need behavioral health services, it is really a holistic approach and in some cases, maybe a handholding approach to get someone to that service. One of the things that, uh, we're very concerned about, the cherokee nation is making sure some of our population that may live in the shadows, particularly on behavioral health, stay in the shadows. And what can we do?
▶ 1:49:41So, because we control our health system under 638, our health program, working with our language program to make sure we're reaching some of these fluent speakers, cherokee speakers of which are on average over the age of 70. Many are living economically, marginally, many of living remote locations. Uh, and some of them aren't getting the health care they need.
▶ 1:50:05It is opening up things like a peer recovery program for fluent speakers with health program, working with our language programs. It turns out good health care, adequate health care, excellent health care is not just inherently good. It turns out to be a great program for language preservation and revitalization. Getting those two departments to work together probably wasn't something decades ago, ihs was even equipped to understand or execute on. But the cherokee nation is. Why?
▶ 1:50:37Because 638 has put all of that in our control. Uh, there's many other examples, but that fluent speaker peer recovery program is probably the most powerful one I've seen lately. >> that's a very interesting example that is truly comprehensive, uh, integrated care there. Um, and I assume it's led to better health care utilization, more efficient use of health care dollars. Is that fair to say, compared to what it would be in a different context? >> absolutely. It's fair to say. I mean, just this week we had an issue where a patient needed some medical equipment.
▶ 1:51:06And there, again, in our fluent speaker population, that turned into making sure that person, maybe for the first time in a long time, got primary health care. That only happens when we're over our health care system. We're able to bring in multidisciplinary approaches, multi-department approaches within the cherokee nation only because of 638. >> great. Thank you, chief hoskin.
▶ 1:51:29Uh, chairman abramson, are there any support mechanisms that ihs could provide upfront technical assistance, staff detail, planning funds that would accelerate tribal readiness? >> yes. Thank you.
▶ 1:51:41And yes, there is, uh, we got a couple of grants there, but I think more, uh, support out front would definitely help the tribe as they got ready to transition over, uh, with getting the proper staff and proper consultants and actually even being able to, uh, visit the best practice on some of these tribes that have gone through that and stuff.
▶ 1:52:05So you don't end up with, uh, as we did after we assumed it with the, uh, system of rpms there of not talking. I was actually back here in dc, and I might have been testifying or something there, but I was getting phone calls and people couldn't get their, uh, their pharmacies there. And they said, how are we going to do this? So they had to go back to old thing of trying to write it down, and they'd have to try to bring it to these, uh, places to get it there and stuff.
▶ 1:52:34And it was very difficult there. And being able to get referrals out. >> thank you. Thank you very much, chairman abramson. And I see my time has expired. Um, at this time, um, I would like to recognize the gentleman from the state of oregon, miss hoyle, for five minutes. Miss hoyle. >> thank you very much, Mr. chair. And I want to thank the panel for traveling to be with us here today. Um, each of you spoke about the importance of 638 contracting.
▶ 1:53:01And, of course, I hear from my tribes all the time about the importance of this program. And it's a great tool, but it's only as effective as the resources available for tribes to carry it out. I mean, it's the the basic no money, no mission, right? Um, mister hoskin, in your testimony, you mentioned the importance of predictable and stable funding for the indian health service.
▶ 1:53:28And congress previously provided ihs with advance appropriations for fiscal years 24 through 26, which I strongly support. But the authority will expire soon. Could you elaborate on, you know, why and how this funding stability has been important? Uh, especially during the recent government shutdown. And what's at risk if we don't re-up this funding? >> thank you. Congresswoman.
▶ 1:53:59Yes, advanced appropriations is critical. We just experienced the longest federal government shutdown in the history of this country. Timing is everything. Had that happened in 1975 when I was born in the claremore indian hospital, I'm not sure what my mother would have done had that happened when I was younger. And my grandfather was going to claremore indian hospital, or cherokee nation's health system was small and had great ambitions.
▶ 1:54:26I don't know what they would have done, but it would have been some lapse in service. It would have been someone not getting health care. And so advanced appropriations was perfectly timed. I mean, the congress didn't know we would experience the longest shutdown in the history of the country, but because that was in place, I could be in a room with tribal leaders in which we were talking with some glee about the fact that our tribal nations were balanced, budget tribes continuing in our operations, and our citizens
▶ 1:54:58Weren't fearful of a lapse in funding. Now, cherokee nation size has been a hedge against ups and downs of federal funding, and even continuing resolutions and funding lapses. But I worry in particular about some of the smaller tribes out there. But even cherokee nation can't weather every storm. Advanced appropriation is a minimum. Mandatory appropriation should be the goal. >> perfect. Thank you so much.
▶ 1:55:21Um, and I agree, you know, that ihs funding shouldn't be subject to budget instability in congress, and I'm confident we can work in a bipartisan way to make that happen. Um, Mr. spann, if you know, as you know, the supreme court ruled in 2024 that ihs must pay the contract support costs that tribes incur. But I've heard from many tribes in my district that these costs are taking up a large share of the annual appropriations for ihs.
▶ 1:55:49So in your testimony, you expressed support for providing mandatory appropriations to cover these contract support costs. Could you share more about this issue and how mandatory appropriations would help tribes provide more affordable health care to its citizens? >> sure. Thank you so much for the question. Uh, as you know, the contract support costs are a critical piece of the success of tribes. Whenever they take over these federal programs, these federal responsibilities provide services.
▶ 1:56:17There is an administrative piece that comes along with it. And this funding is what helps to ensure that the programs get fully funded and that the administration doesn't cut into those program costs. Uh, the courts have found that csc is an obligation of the united states, and there's a responsibility to do so. We definitely fully support making csc mandatory so that there isn't this risk within ihs of cutting into program funds.
▶ 1:56:43Uh, nobody wants to see programs suffer because of csc, but csc is as much critical as those program funds are. >> thank you so much. And I yield back. >> the gentleman yields. At this time. I wanted to just take a quick minute, a quick moment to, uh, to say that I'm pleased to welcome another, uh, grijalva to the house committee on natural resources, specifically the subcommittee on indian insular affairs. Um, this is representative grijalva.
▶ 1:57:14You'll see as we try to be strive to be a serious subcommittee focused on bipartisan principles that, uh, strengthen tribal sovereignty, that respect the government to government relationship that we have with our tribal partners, and that promotes self-determination in indian country. And we also work with our our insular partners on critical issues of economic and national security. And so I just want to say, welcome, uh, representative grijalva, to the subcommittee on indian insular affairs. It's great to have you here.
▶ 1:57:41And with that, the chair now recognizes the gentlewoman from the state of arizona, miss grijalva, for five minutes. Miss grijalva. >> thank you, Mr. chairman. I appreciate that. And thank you to all the witnesses for being here today. As we've heard, the united states has a trust responsibility and trust obligation to uphold the treaty, um, for healthcare to the american indians and alaska natives.
▶ 1:58:04This is accomplished by consulting with tribes and then actively advocating for policy, legislative, budgetary planning, and for appropriate health care. I believe it is clear that often our federal government falls short, and what we should and what we should do is be clear, comprehensive and fair consultation process. I think we all can appreciate the desire to increase efficiency.
▶ 1:58:29Unfortunately, under this administration, we have mainly seen confusion, chaos and backlogs created in the name of efficiency. Tribes in arizona have demonstrated their ability to effectively deliver health care services, often doing more with less, while strengthening local economies and providing culturally appropriate care. I do agree that there are areas for improvement.
▶ 1:58:50For instance, currently only the um, only the indian health service ihs is required to confer with urban indian organizations on healthcare policies and initiatives for american indians and alaska natives living in urban areas. This despite the fact that the vast majority of american indians and alaska natives, roughly 70%, live and seek health care in urban areas outside of ihs jurisdictions.
▶ 1:59:18However, I am concerned that when this administration talks about modernizing the 638 contract program, the end result will be slash staffing for critical job functions. So, Mr. spahn, you note in your testimony, tribal administration of health programs can lead to better results, stronger accountability, and more effective use of federal resources.
▶ 1:59:42Part of this realignment plan is to nationalize the isd negotiations, which you note has potential downfalls. Can you talk about the end result of a failure to have a full and fair consultation process, and describe how it will, how providers and patients will be impacted? >> yes. Thank you so much for the question. Uh, consultation is critical.
▶ 2:00:06It is a system that serves tribal communities, tribal nations, native american people, and making sure that they have a voice in any realignment is essential for the success. It's challenging whenever federal agencies, particularly located in a headquarters office, hold that decision making authority and don't understand or know the communities that are actually being served on the ground.
▶ 2:00:30And so that consultation process is critical to make sure that that input is received and that those voices are not only heard, but that part of the solution to put together a realignment plan. We definitely agree that there's opportunity for more effective ihs, a more efficient ihs, but we think that creating that realignment can only be successful if it's done hand in hand with tribal governments and with those that are receiving the care from ihs. >> yeah.
▶ 2:00:55So, as you know, some tribes report that area offices when compared to headquarters, provide faster, clearer and more accurate information. Are there any ways to improve area offices for 638 contracting needs, rather than nationalizing or centralizing the process? >> yes. Thank you for the question. Um, we there is a great deal of inconsistency across ihs area offices.
▶ 2:01:20There are some area offices that are very high performing and have very good relationships and are very effective in responding to tribal requests and moving forward with the negotiations in a very timely manner. Uh, there's others that are underperforming, and we hear tribes that have concerns about that. So we do propose that one ihs learn from the successes within those high performing areas, see how it can duplicate it for the underperforming.
▶ 2:01:45In the meantime, while they're trying to make a national standard within the area offices for performance, that they could use things like a strike team and give that as a tribal choice or a tribal option, that the tribe can either opt to work with their area office or choose to bring in the strike team. That can also help build capacity within the underperforming area. We also think that the new office of area negotiations is being created. Not all functions that are listed in there would be problematic. We think there's some really great things.
▶ 2:02:11The opportunity for more training, for more mentorship, we think that makes sense on a national level to ensure that agency negotiators within the areas have the same capacity. >> yeah. Any of the other witnesses want to add anything? I have 26 whole seconds. Council member thank you. >> thank you for the question. I would say that the areas that have the least amount of self-governance tribes need the most help.
▶ 2:02:40And we've watched and witnessed the success of strong sovereign self-governance. Tribes and organizations like the self-governance, communications, education, um, where j leads is a mecca of information, and we need to support the work there and help. If ihs can't take it on, then we need to support the work where it's taken place. Thank you. >> thank you so much I yield back.
▶ 2:03:05>> gentleman yields I want to thank the witnesses, each of you, for your valuable testimony today and my fellow colleagues for your valuable questions. Members of this committee may have some additional questions for the witnesses, and we would ask that you respond to those in writing. Under committee rule three, members of the committee must submit any of those questions to the committee clerk by 5 p.m. On tuesday, december 16th, 2025. The hearing record will be held open for ten business days for these responses. If there is no further business.
▶ 2:03:32Without objection, the committee stands adjourned.