Indian Health Bills: Southcentral Foundation Land, Emergency Notice, PRC Payment

Good afternoon. The committee will come to order. We're here to receive testimony today on three bills that will improve health care delivery across Native communities. The first bill I want to highlight is S two zero nine eight. This is a land transfer bill that I introduced with Senator Sullivan. It would transfer approximately three point four acres of federal land in Anchorage for the IHS to the South Central Foundation. This is an Alaska Native tribal health organization that already provides health care to IHS beneficiaries under a self-governance compact. On this site, SEF oper operates the Kweana Clubhouse, which serves adults over twenty-one with serious mental health needs, through culturally grounded behavioral health services. SEF is ready to expand the facility and offer more intensive outpatient programming. We heard a lot about it this morning. But they cannot move forward until they own the property, so this bill would make that possible. The other two bills before us were introduced by our colleague, Senator Rounds, and they focus on fixing real challenges. I want to thank Senator Rounds for for advancing these and really prioritizing these issues. Tribal members face uh uh issues, so many issues with purchased and referred care, PRC. The PRC allows the Indian Health Service to purchase care from private providers for tribal members when the needed care is S ten fifty five, the Indian Health Services Emergency Claims Parity Act would give patients more time to notify the PRC after receiving emergency care, from seventy-two hours to fifteen days. Right now, many tribal members are expected to meet a tight reporting deadline while dealing with a medical emergency and this bill would bring fairness and common sense to that process. Uh S six nine nine, the Purchase and Refere Referred Care Improvement Act of twenty twenty five addresses reimbursement delays for the purchased and referred care. When IHS payments to non-IHS providers are late, patients can end up facing collections or find themselves saddled with unexpected medical debt. S six nine nine strengthens liability protections and requires procedures to be developed for IHS to reimburse patients, who paid out of pocket for PRC approved care. I'd like to acknowledge and thank our witnesses for being here. Uh it is very important that we hear from the IHS on these bills, so thank you. I'm also grateful to Vice President Ross and Councilmember Seymour for traveling from Alaska and and and Washington State to share their testimony. We appreciate that. Um we do have one more vote after this series, so we're gonna be popping in and out and and committee meetings as well, so we apologize for a little bit of the disruption, but uh we're making good progress and I now turn to my colleague and the ranking member, uh, Schatz. The Vice Chairman, excuse me.

Uh, thank you, uh, Chairman, uh, Murkowski for convening today's hearing on legislation to improve health services and facilities for Native communities. The federal government has a fundamental trust responsibility to provide health care to American Indians Native Hawaiians and Alaska Natives. This obligation is not and cannot be an aspiration. It is a duty grounded in federal laws, treaties, and the federal government's own promises. When it fails, native families pay the price. And yet lofty promises from Secretary Kennedy to quote " protect healthcare access and strengthen delivery systems across Indian country" have not come to fruition. We've seen the opposite. Tribes and their advocates have consistently raised alarms about HHS's, office closures, budget cuts, and new administrative processes that delay healthcare delivery. I've sent letters to Secretary Kennedy seeking basic information that tribes and the Native Hawaiian community need to know. In these letters, the chair and I asked about reorganization and reduction in force plans. We asked about IHS staffing levels, hiring freezes, and the practical impact of delays in filling vacancies. And I asked about the changes to grant review processes and what those changes mean for tribal and urban Indian health programs, trying to plan a year or even a month ahead. This committee even held an oversight hearing last May, highlighting all HHS programs serving Native communities and the agency's obligations. But we have struggled to get timely, straightforward information. Responses often come late, are often incomplete, and use carefully worded generalities rather than providing real answers. Let me be clear, it should not take repeated letters to get plain English explanations of what is changing at HHS, why it's changing, and how and whether tribes were consulted before decisions were made. This is not an unreasonable ask, it's not even a partisan ask. It is Congress doing its job and the tribes demanding the respect that they are owed. Tribes need a federal partner that provides concrete information, answers questions, and treats consultation as a real process, not a box checking exercise. The consequence of this failure to communicate are not abstract. IHS civilian workforce is at a ten year low, clinics struggle to operate without staff, and patients cannot access the care that they need. Tribes can't reach agency staff for solutions to urgent problems that they face. So going forward I hope IHS will agree to come prepared to talk to our community, excuse me, our committee and answer questions about basic matters of accountability and real steps that the agency is is taking to improve access to health care. And while I'm glad that IHS announced an effort to begin a new hiring initiative for medical professionals, the details are scarce again. The agency press release vaguely cited a comprehensive workforce plan, but Congress has not seen it. And the tribes were not consulted. And so my message today is straightforward. HHS has to begin to restore a basic level of trust by sharing facts, timelines, and clear commitments to Congress and to Indian country. Tribes will keep advocating for their citizens as they always have. We in Congress will keep doing our job. But the agency needs to meet these actions by doing theirs with transparency and accountability. I wanna thank you for convening this meeting and thank the witnesses.

Thank you, Vice Chair. Senator Rounds, did you care to make an opening statement?

Madam Chair, if you would allow, I would appreciate that.

Please, go ahead.

Thank you. And first of all, thank you to Chairman Murkowski and Vice Chairman Schatz for this hearing today. The purchased and referred care program is an important part of how health care is supposed to be delivered for tribal members who have no access to direct care at an IHS facility. However, tribal members in my home state of South Dakota routinely encounter obstacles when attempting to seek payment for health care services outside of an IHS facility. Under current law, most tribal members receiving emergency care outside of the IHS network must report that care within seventy-two hours or IHS will not provide reimbursement for their care. This is perhaps one of the shortest windows to submit emergency claims out of any health care system in the world. My bill, S one O five, the Indian Health Service Emergency Claims Parity Act would fix this by moving the emergency notification requirements of IHS's PRC program from seventy-two hours to fifteen days. This will allow patients the necessary time to seek care at the closest facility that can adequately address their emergency needs without worrying that the IHS won't reimburse costs. However, even properly submitted PRC claims may not be paid in a timely manner. A twenty twenty report by the Department of Health and Human Services found that between October of twenty thirteen and June of twenty sixteen, an estimated thirty-two thousand claims were not paid within a thirty day time period during this time frame. My bill, S six nine nine, Purchased and Referred Care Improvement Act of twenty twenty five would help fix this. It would require IHS to develop procedures to reimburse beneficiaries for approved PRC services within thirty days and make sure that IHS addresses any unintended costs for beneficiaries with approved PRC claims. It would also allow a beneficiary to submit documentation to the agency electronically or at a service unit. And finally, it would strengthen liability provisions of the Indian Healthcare Improvement Act, making it clear beneficiaries with approved PRC claims are protected from outside providers and third parties attempting to collect wrongfully charged debt. Combined, these bills would provide needed reforms to IHS's PRC program And I ask for my colleagues' support as we work towards a mark-up. And once again, Madam Chairman, I thank you and uh the Vice Chair for your um privilege of allowing me to speak at this time.

Absolutely. And uh a- again uh Senator Reynolds, thank you for your leadership on these issues. We'll now turn to the witnesses. Uh we will first hear from the Honorable Darrell LaRoche. He is the Deputy Director for Management Operations at IHS here in Washington DC. Uh he will be followed by the Honorable Dana Seymour um from Inchilum uh the district the Inchilum District Representative and Health and Human Services Chair uh at the Colville Tribal Business Council uh the Confederated Tribes of the Colville Reservation out in Washington State and uh Ms. Leandra Ross. Leandra is the Vice President uh of Executive and Tribal Services at South Central Foundation in Anchorage, Alaska. I will just remind our witnesses that we do have your full written testimony, so we would uh encourage you to try to keep your written uh your your verbal statements to uh about five minutes and uh then we'll have an opportunity for questions following that. So, Mr. LaRoche, please uh with your testimony please and uh thank you.

Good afternoon, Chair Murkowski, Vice Chairman Schatz and members of the committee. I'm Darryl LaRoche, I'm the Deputy Director for operations at the Indian Health Service. Thank you for the opportunity to provide testimony on S two zero nine eight, the South Central Foundation Land Transfer Act of twenty twenty five, uh S one zero five five, the Indian Health Service Emergency Claims Parity Act, and S six nine nine, the Purchase and Referred Care Improvement Act of two thousand twenty five. If I may restate the mission of the Indian Health Service, which is to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level. This mesh mission is carried out in partnership with American Indian and Alaska Native communities. The first bill before the committee, S two zero nine eight, the South Central Foundation Land Transfer Act of two thousand twenty five would authorize the Secretary of Health and Human Services to transfer certain land in Anchorage, Alaska to the South Central Foundation by warranty deed without requiring consideration to the federal government. The bill would also require the conveyance to be completed as soon as practical but no later than two years after enactment. Additional details are included in my written statement. As you know, Chair Murkowski and members of the committee, Congress has considered similar legislation in previous years that mandated land rather than by quit claim deed. And the department has the same concerns with uh S two zero nine eight. As noted in my written testimony, HHS has identified certain preferences and with those cons concerns in mind, the department supports the propose uh the purpose of the bill to convey the property to South Central Foundation. S one zero five five and S six nine nine both relate to the Indian Health Service purchase referred care program, the administration and the department's goals to improve health outcomes for American families and protect uh patients from medical debt. Therefore, I think it is very important to note that patients are not liable for PRC costs under section two two two of the Indian Health Care Improvement Act and patients should not be forced into collections. because of the unpaid medical bills. The PRC Improvement Act seeks to address liability for payment of charges, or costs associated with the provision of PRC services. It would require the secretary of HHS to notify a PRC provider and any patient who receives PRC by IHS that the patient is not liable to any provider, debt collector, or any other persons for the payment of any charges, or costs associated with the provision of the PRC services. It would further require the secretary through IHS and in consultation with Indian tribes to establish and implement procedures to allow a patient that paid out of pocket for PRC authorized by IHS to be reimbursed by the IHS for that payment. When patients when the patient submits uh documentation to the IHS consistent with the procedures established under the PRC Improvement Act. Simply put, patients should not be expected to pay out of pocket for PRC authorized services, consistent with the patient protections in section two twenty-two. However, if a patient chooses to pay in anticipation of an reimbursement under the new subsection D of the PRC Improvement Act, the patient should be cautious not to pay before alternate resources are exhausted, or in uh excess of the PRC rates. Thus as drafted, the bill may cause additional uncertainty for patients seeking care. S one zero five five, the IHS Emergency Claims Parity Act seeks to modify the notification requirements for emergency PRC services. The current time frame for non-elderly or disa disabled individuals' notifications must be within seventy-two hours, per current uh PRC regulation. The only concern with the bill is flexibility. If there's ever a need to change the time frames for notification of treatment or admissions to more than fifteen days, such would need to be an amendment to a statutory limitation if the bill were to be passed by Congress and signed into law. All things considered, the department shares the same goals as the drafter to improve PRC program, protect patients from medical debt, and ensure American Indians and Alaska Natives throughout Indian country have access to high quality and affordable care. We look forward to continuing our work with Congress on these bills, and as always welcome the opportunity to provide technical assistance as requested by the committee or its members. Thank you again for this opportunity to testify.

Thank you, uh, Mr. LaRoche. We next turn to, uh, Dana Seymour. Welcome.

Good afternoon. Good afternoon, Chair Murkowski, Vice-Chairman Schatz and members of the committee. My name is Dana Seymour and I'm a member of the Colville Business Council, the governing body of the Colville tribes. Thank you for inviting me to testify on the Purchase and Referred Care Improvement Act. Purchase and Referred Care, or PRC, is a program where IHS beneficiaries receive care from private non-IHS health providers when IHS is unable to provide the care at its own facilities. As discussed in more detail in my written statement, for years IHS mismanaged the purchase referred care program at the Colville service unit. Our local IHS personnel, most of whom are Colville tribal members, went to great efforts to try to get PRC services for our tribal members, and otherwise make the PRC program workable. The IHS Portland area office, however, would impose new obstacles at every turn. Addressing PRC was the main reason that on October first, twenty twenty five, we contracted all IHS functions under the Indian Self-Determination Education Assistance Act. From two thousand and seventeen to two thousand and twenty two, the IHS Portland area office administered the PRC program at the Colville service unit. During this time, the PRC program was administered so poorly that we can trace it to deaths in our community. IHS required on an annual basis our members to produce utility bills, certificates of Indian blood, other proof of tribal enrollment, and other information not required by the IHS regulations or the IHS handbook to get PRC services. Those who were unable to produce this information either went without care or obtained care on their own and faced collection agencies when IHS refused to pay for the services. If IHS did approve PRC services, there was no way to predict if IHS would pay the provider. When ICHESS does not pay PRC providers, the providers will assign the debt to third-party debt collectors and pursue tribal members for payment. Even though the Indian Healthcare Improvement Act generally states that individuals are not liable for bills associated with authorized PRC services, PRC providers rely on the boilerplate consent forms that they require all patients to sign as an alternative basis to pursue the debt. IHS's mismanagement of the PRC program has resulted in many Colville tribal members avoiding IHS care altogether, out of fear of being saddled with medical bills and having their credit negatively affected. Near the end of our negotiations with IHS, we were shocked to learn that the Colville service unit had forty-two million dollars in carryover PRC funds. This money should have been spent on health care for Colville tribal members had IHS, administered our PRC program properly. Some tribal members have paid medical bills for PRC services out of pocket because they feared having their credit damaged by being sent to collection agencies. There is nothing in the law or regulations that prohibits IHS from reimbursing beneficiaries when they pay out of pocket. IHS however has indicated that it is unable to reimburse for reasons that they have never explained to the Colville tribes. The PRC Improvement Act would clarify that individuals that receive PRC care that is authorized by IHS shall not be liable to any provider or debt collector. The bill would also preempt the use of boiler plate consent forms that providers require patients to sign from being used to target tribal members through collection agencies. Finally, S six ninety-nine would require IHS to reimburse tribal members who paid medical bills for IHS authorized PRC services within thirty days. This is only fair because PRC bills are IHS obligations and tribal members should be made whole when they pay out of p- out of their own pockets to avoid collection, activities through no fault of their own. For those tribal members who paid a medical bill out of pocket, the money that IHS would reimburse would be in the PRC carry-over funds for that service unit. In other words, the reimbursement requirement would not cost taxpayers anything because that money is sitting in the IHS system as unreconciled PRC funds. For Colville tribal members, any amounts they paid out of pocket would be reflected in the forty-two million dollar carryover at the Colville service unit that I mentioned earlier. The Colville tribes urges the committee to take whatever steps are necessary to secure the enactment of S six ninety nine into law. And the Colville tribes also fully supports S ten fifty five Indian Health Service Emergency Claims Parity Act extending the time frame from seventy two hours to fifteen days for reporting PRC emergency care services to IHS. This will minimize instances of PRK PRC care being denied for emergency care. This concludes my testimony and I'm happy to answer any questions that the committee may have. Thank you.

Thank you so much, Ms. Seymour, and thank you for the very concrete examples you've provided the committee. Uh, and next we go to Ms. Leandra Ross. Welcome.

Good afternoon. My name is Leandra Ross and I am the Vice President of Executive and Tribal Services at South Central Foundation. I'm a Hlingut and Haida citizen and a Salamatof tribal member. I wanna thank the committee and Chairwoman Murkowski and Vice Chairman Schatz for the opportunity to testify today. and for your work on b- on behalf of tribes, tribal organizations, and Alaska Native and American Indian people all around the country. Gunuschish. I also wanna thank the staff that have been so helpful working on S twenty ninety eight. South Central Foundation, or SCF, is the Alaska Native tribal health organization under the tribal authority of Siri and designated by twelve federally recognized tribes. We provide health care services to beneficiaries of the IHS who we refer to as customer owners, as we're both customers and owners of our own healthcare. SCF is one of the largest employers in Alaska, with three thousand employees that support the physical, mental, emotional, and spiritual wellness of over seventy thousand customer owners, including residents of fifty-five rural villages in a service area that's over a hundred thousand square miles. SCF has over eight hundred and fifty thousand unique encounters a year with ninety-plus programs and is a model of how self-determination is successful in providing quality health care. Today, I'm here to testify on the South Central Foundation Land Transfer Act. This bill will transfer the title of land that the IHS currently owns and on which SCF operates the Koyana Clubhouse. This land transfer is necessary for SCF to build a new forty-four thousand square foot building for two critical programs. The buildings we are using now for the Koyana Club House are some of the oldest the IHS has in Alaska, and were not built to provide direct services to customer owners. In fact, the space currently used as an arts room was the old IHS hospital morgue. With the new building, we'll be able to expand services to some of Anchorage's most vulnerable individuals who experience chronic mental illness and adults with complex behavioral health and substance misuse needs. The Koyana Clubhouse, operating for more than thirty years, is an answer to the ongoing needs of adults with chronic mental illness to live a stable, healthy, supportive life in community. Koyana Clubhouse is a day treatment program that blends integrated behavioral health and primary care services to further meet individualized treatment goals, done through the provision of support, including medication and case management, individual and group therapy, and cultural and wellness activities. Today SCF has a hundred and fourteen customer owners in the program. The success of Koyana Clubhouse is evidenced by the fact that all participants are living in stable housing. In Anchorage where sadly many Alaska Native people are unhoused, it is remarkable that with supportive services such as those offered at Koyana Clubhouse customer owners can overcome this hurdle. I'm also pleased to share that eight customer owners currently participating in the program have achieved their goal of employment. We're proud to support Koyana Clubhouse participants with over eighty-seven percent reporting ownership in their own health care, some of which are Alaska Native veterans. The do- n- the new building will not only double the capacity, but it will allow us to align and co-locate SCF's intensive case management services into the same building. The ICM program is a community-based program focusing on outreach, engagement, intensive community case management, and linkages to other critical services, such as housing, that assist individuals to increase their level of independence and develop a community support network. Think of ICM as one precursor to participating in the Koyana Clubhouse. ICM works with customer owners where they're at, whether that's in a homeless camp or living with family members to grow on their journey towards wellness. S twenty ninety eight will make possible the expansion of both programs in a state-of-the-art facility by giving SCF ownership of the land to build the building needed for our customer owners SCF is ready to take advantage of the short building season and begin this project this summer with passage of this bill to that end we hope that the transfer can happen expeditiously. Again, thank you for the opportunity to testify today. And I'm also happy to answer any questions that you may have.

Thank you, Miss Ross. Um, let me begin, let me begin with you, um, uh, Leandra, about the South Central Foundation Land Transfer Act. You you have shared with the committee the current conditions of the Kweana, uh, clubhouse. We understand that. Um, uh, can you just share what the challenges are then uh with maintaining or upgrading the facilities when South Central does not own the land or facilities. And then I'd also ask you to to give a little more clarity to what you just said at the end which was, you're prepared to um to to to move quickly and if you could just describe um what quickly means in terms of your ability to move should this land conveyance um

Thank you, chairwoman. Um, I appreciate the question. Thank you. Uh, the Koyana Clubhouse is in a fifty year old building and it has many of the challenges, as you can imagine, that uh, three closely connected buildings would have. Heating systems are difficult to maintain. Um, there's just, uh, pe- uh, participants walking outside to get to uh the different services located on the facility. Um this facility um is one that we would love to see increase for our customer owners. We'd love to be able to uh s- build this summer. We are at currently a thirty-five percent design in for th for the building. We're ready to build and Um, it will.

So if I can just ask on that, you're ready to build thirty-five percent design,

Mm-hmm.

but the thing that is holding you back is you do not have the warranty title.

Right. We do not have ownership to the land. Yes. And so we just would like the ownership through this land transfer, uh, to be able to build.

And and if that is to come through this conveyance, you are prepared to move uh to to um

Yes.

start construction this year.

We're excited.

I I can tell you're excited and and and rightly so and I know

Yes. Yes.

that those who serve are probably equally excited and the importance in in terms of being able to to be more responsive for the increasing demand for behavioral health services in this area I think is so important so I just wanted to make it clear for the record that you are ready to go the only thing that is holding you up is is the full ownership of of the property it itself. And that, let me ask one other question because it's always important that you have stakeholder buy-in whether it's from the community um can you just speak to the

Yes.

efforts to work with local stakeholders to prepare for the land transfer?

Um yes thank you, good question. We have many partners and the community in the area is very excited about the new building. We've gone to community councils, we've shared uh with the municipality our uh plans to move forward, we have letters of support from community partners um and I think that uh we've been a good neighbor in this area and so uh we'll continue to be a good neighbor in this area.

Good, I appreciate that.

Thank you.

Let let me ask you uh, Mister Laroche, because um y- you have mentioned that well you support um uh the the conveyance uh you you noted uh a concern here. Congress has already passed several bills transferring federal land uh to tribal health organizations um in twenty twenty-two we were able to pass legislation that conveyed IHS land to the tribal uh Tanana uh tribal council TTC uh TCC um to the Southeast Alaska Region Hall Consortium as well as ANTHC. So you you've mentioned that you have some some concerns, but can you tell the committee when IHS carried out these transfers um three years ago now, back in twenty twenty-two, did the agency have any administrative difficulties in executing on them?

Thank you for that question. I d no, we had not had any administrative uh problems with with that.

So so

We we prefer the quit claim, but

Sure.

but we uh enacted in law we will g- uh go through with the warranty deed.

So so I just I just wanna make clear then, well, we get what the preference is, um, even though you didn't have that preference uh with these other transfers, um, the administ the agency didn't encounter any um difficulties then with with that legislation,

No, Senator.

with with how how the uh how the deeds were were were titled. Okay. Um let me let me move to you um, Miss Seymour. Um you you have shared a great deal in your testimony today, the uh the the issues when you have PRC payment delays leading to these unexpected bills uh medical debt uh credit score impact um Uh, and, and you, you went further to say that, uh, in an effort to, to perhaps avoid this, you actually have some of your Colville tribal members avoid seeking medical medical care altogether, which is, which is absolutely, um, the wrong direction for any of this. So, you, uh, you made a decision, um, you made a decision back in October of of twenty, twenty-five to assume all IHS functions through a six thirty-eight agreement. Um to what extent did these concerns that you have raised, people who were fearful of of of debt collection issues, um and thus delaying um perhaps medical medical care or treatment, Um, uh, you you have also, um, just just detailed, um, how how this, uh, this concern about what it's gonna mean to me when I have when I have the bills coming to my house, um, I'm dealing with a bureaucracy that I may or may not be very comfortable dealing with. To what extent did, um, these debt collection issues affect the decision to contract IHS functions and take on the management and and the provision of health care services yourself?

Uh, it had a huge impact on that decision. We looked at we were getting complaints, we were losing our people because they were not getting the care that they needed in a timely manner or not at all. And we, I believe um the council has been looking at it for years and finally took the stance of, you know what, we can do better, we can, if we contract this and bring this under our our uh supervision, we can provide our members with the healthcare that's needed, but like in the statement it says we can trace this back to to deaths in our communities. Um I can give you one example of um, some issues, I had a family member who was awaiting a specialist's referral and her appointment I believe had had to be cancelled. She was going to have the follow-up that Monday. She died over the weekend of a massive heart attack because she couldn't get to the doctor soon enough to be checked out.

Mm.

And she wasn't the only one. There were many instances where that happened on our reservation and And we decided that, you know what, enough is enough, we can't continue to lose our people. So that's why we made the decision to contract not only that, but also um I myself have been sent to collections. I have bills, my husband has bills right now that are in collections, uh my daughter does because b and we diligently turned them in time after time, but they're, they weren't being taken care of. And so what do you do? You don't want your your credit to be affected. So if you have the means, you pay it. And a lot of our patients are elderly and they were paying these bills out of pocket when they couldn't afford to do so. So

So even though we've heard uh Mister Laroche say, look the patient is not going to be liable that reimbursement comes, you still have a situation where um you're you're the debt collector is is the one that comes before the reimbursement. comes. Um and so there is there is concern about whether or not the reimbursement is is going to be made, whether it's gonna be made timely. Mister Laroche, you said something um uh about uh on this issue of reimbursement, that uh it's reimbursed to the extent of the PRC. And that the patient should be cautious in not exceeding the amount of the PRC. How do I know what that amount is?

Yeah, and i i that's a great question. Uh, it it would have to do with uh whatever that service is that they were sent out for as far as um usually the PRC program is paying providers, so that's what we're used to doing,

Right.

so the yes, the the patient one necessarily know what that reimbursement rate is.

Yeah, and that's, you know, that's the that's the heartburn that I've got with all of this, is you're putting the burden on on the patient. If I'm gonna go in for I'm gonna go in for a mammogram, all right? And I I don't necessarily check to see if the cost for that procedure in the area that I'm in is within the scope of what is is approved. um uh within the within the PRC um and you're saying, all right, you're not gonna be on the hook um ultimately, but it could be a situation where we don't know how long that reimbursement is gonna take, and in the meantime who knows, it gets sent to a debt collector, I we don't know. Um but then you find out that not the full amount is going to be covered, and it just seems to me that we are doing a huge disservice if we're saying There is a uh there is a a re a a a federal trust responsibility here when we're talking about about health care for native peoples and you've got a program that um for for for reimbursement um for care that assumes an awful lot that is not very clear. Um you you're you're nodding that you don't disagree that this is confusing to the patient. Um, do you have any good suggestions as to how within the department this can be addressed? I think that perhaps Senator Round's uh two bills could be very, very helpful to that.

It definitely, the PRC program at IHS has always been set up to deal directly from IHS to a provider, so that's why it's a little bit more confusing when we start talking about uh a patient having to uh to pay on that, but I I think this is a opportunity for us to it will be more than happy to work with the committee and the drafters to come up with some technical assistance and uh, come up with a solution on that.

Okay. Um, Ms. LaRoche made the the the observation that there's nothing in statute or regulation that prohibits reimbursement. Um, Uh, CBO apparently thinks that uh there is some budget authority that is required. Um is th this is something that uh uh again I think needs to be made much more clear than we currently have in statute. Is that we're in agreement on that? Um I'm gonna ask my last questions and I'm gonna turn to my colleagues who have just come back because they've done their second vote and I have not. Um, uh, the, you, you have mentioned the issues that the, the burden of a seventy-two hour window creates. Senator Rounds had mentioned that as well. Um, is there, is there, uh, do you think that people understand that this seventy-two hour reporting issue is a problem for them? provi uh an issue with the providers themselves. Yes, please, thank you.

So it it's an issue for I don't think everybody understands, and I think that's where it would be helpful for more education to the patient, but I think uh it's very cumbersome, like Senator Rounds had said, because if you have somebody who is in an accident and they're in ICU for two weeks, that you're limited to a seventy-two hour, but within those first seventy-two hours your family's so focused on if you're going to live or not, the last thing on their mind is calling IHS to report to the PRC department that they're in the ER. And at that point you don't know if they're gonna stay at that hospital or be shipped to another and then there's repeated calls that have to be made so I think the fifteen days would give a lot more grace time for the families and for the patients because I think the first seventy-two hours of any illness is critical to taking care of yourself or your family member who's in the critical illness and in that time frame. Um but I think it part of it is that patients don't quite understand that and so it doesn't get reported and then they get release from the hospital, say it's in four days and then they call and then it's too late, so now they're stuck with this. astronomical, you know, ER or hospital stay bill that they have. Cuz attached to those bills also, like we're in a rural rural area, so if you get life flighted or ambulance, that's attached to that bill as well too. So if you don't report that, I mean, that could be two to four hundred thousand dollars, depending on where you're flown to. So

Thank you for that. And uh uh Senator Cantwell, we'll turn to you and then Senator Lujan. Senator Shots is coming back. I'm gonna go vote. Um, but I think Senator Rounds has presented a couple really strong bills on how we can improve purchased and referred, um, care. But we've heard some, some really very interesting testimony here today in terms of how a system that, uh, uh, that should work better, that should ensure that, um, uh, Native American, uh, patients when they go to seek care, um, uh, are not ultimately, um, uh, on the hook, but it's, it's some, some pretty troubling stories. So I think we've got some good suggestions out there. And then, uh, Ms. Ross from South Central Foundation working on great initiatives, uh, when it comes to, uh, the opportunities for access for mental and behavioral health. So I'm gonna turn it to Senator Cantwell next, and, uh,

Thank you, uh, Chair Murkowski. Thank you for you and Vice Chair Schatz for holding this legislative hearing. And the chair just mentioned Senate Bill six nine nine, the Purchase and Referred Care Improvement Act. I'm just glad to join Senator Rounds on that. I wanna thank Councilmember Seymour for traveling all the way from Colville to be here in Northeast Washington so very challenging to, um get all the way across the country, particularly we just had some people in the office from Oroville and I was like, how'd you get here? So everybody, a lot of traveling this week. So um I teamed up with Senator Rounds because introducing this purchase referred care improvement act really after hearing from the Colville tribe. I mean it was just really clear, the pervasive problems. If you're in this rural part of the state and I just is supposed to deliver care but I just doesn't deliver care and then your people end up getting um credit score deterioration. How are you supposed to get health care? And it's all because Indian Health Services were not paying its bills. So as we already heard from the council member um the Colville Reservation which encompasses one point four million acres, so no small area of geographic uh r- area to serve, in the northeast corner of our state there are no full service I H H hospitals and a sixty percent vacancy rate at Colville IHS service unit. Now that's basically abdication of duty, if you ask me. It's just abdicating the duty that we are supposed to provide for healthcare. This means tribal members often travel long distances to seek the healthcare providers outside of the IHS system. And the IHS system is supposed to re- reimburse the healthcare provider for those services provided to those tribal members. Unfortunately, when this doesn't happen, IHS does not reimburse the healthcare provider, and then the provider is not paid, and then they seek payment from the tribal members. So that's what we're here to try to say. It's got to stop. It's got to stop. We can't be putting this on the backs of individual tribal members. This is crazy. Live up to our responsibilities in delivering care, either through the IHS system or let us go get care and pay for it. That's the role and responsibility here of the federal government. So tribal members, including elders and elected officials, have been sent to collection debt creditors. So literally, we're not providing the health care, but then we're letting debt collectors prey on individuals. So the Colville tribe recently learned that there was a forty-two million dollars in funds that should have been spent on health care for tribal members, if only IHS had administered the program properly. Recently the Colville tribe assumed all IHS functions under the Self-Determination Act. And, and I must say, I'm so proud of our state where we have become the primary provider under self-governance of clinics around the state of Washington. Not only are they great tribal clinics, they are serving the larger population within a region. Oftentimes they're in some of our m- remote parts of our state, like um, you know, uh, the Macaw or the Lummi or something of that nature. And not only are they providing great Indian health services, but they are providing care to the larger community and really becomes a stabilizing force for health care within the region. And obviously Indian country because it's been preyed on for the most egregious abuses of narcotics with people locating big fentanyl centers. Why do they locate in Indian country? Well I just said the vast land that basically is there at Colville or somewhere else It's because you can't cover all that land.

Mm-hmm.

You can't cover all that tribal land. You can't cover, they know that tribal law enforcement is challenged to deliver and root them out. And so we've said had horrific, horrific challenges just dealing with the attack on Indian country by the scourge of fentanyl. So, Councilmember Seymour, again, thank you so much for being here to illuminate this. Um, I wanted to, um, talk about how the Purchase and Referred Care Act does support Indian country and since IHL's health care service services, since the tribe has taken over and has your own relationships, are tribal members financially getting better protection?

So, tribal members are financially better protected under the Colville tribal health care authority, because our purchase referred care payments are issued faster and more reliably than under the IHS system. which is reducing delays, denials, and unexpected patient bills. We're also able to build and maintain financial reserves for our programs, which strengthens long-term sustainability and protects services during funding challenges or emergencies. So that combined with stronger revenue cycle oversight and local decision making, tribal control has shifted financial risk away from our members and towards an a c a more accountable and sustainable health care system.

Thank you. Thank you for that leadership that Colville has has demonstrated.

Yes, thank you.

And again, if we can just continue to empower, I think through self-governance, the delivery of a system, I think we're gonna get a better system. And but on this issue, Mister LaRoche, is there any legal impediments to IHS reimbursing tribal members who pay PRC bills out of pocket so that they can stop being harassed by collection agency? Is there any legal impediment to that?

Great question. I'd have to take that back to the legal as far as from the legal side of things, but I do know one of the things that's challenging for us is we are bound by the federal acquisition regulations and sometimes that's a little bit cumbersome for uh providing payments for healthcare and still complying with that.

Burdened by what, the

The federal acquisition regulations, the four,

Oh.

uh requires a purchase order, so it's a a little bit more cumbersome when you Uh, d- we'd have to really work with the tribes, uh, in IHS to come up with a mechanism to actually

Okay, so why why haven't we done that yet?

pay.

That's my question.

That, uh, that's one of the things that this is past. We can go ahead and do that.

Why why can't we do that right now?

Um, they

We know that we have a broken system in a big part of our state, and why can't we figure out why can't IHS, if they're not gonna deliver the care, I mean, obviously these are choices, right, that people made a long time ago. Uh, I I'm assuming, I see, I know lots of lawyers in the audience who know this, are back here on the dais who know this better than I do,

Mm-hmm.

but I mean, different parts of states made different choices, right, uh, whether through self-governance or IHS, but if IHS now can't deliver the care and the tribe is now taking on the financial responsibility of delivering the care and, and you have a direct relationship I'm assuming because you can't deliver the care at IHS, that you are then contracting with them. So if you're contracting with them, why can't you just protect them from being preyed upon by creditors?

I uh the uh IHS PRC program wa- was really set up for the the payments between us and the providers. So so that's one of the things. And we are working to we do have a director's work group to improve PRC and things like this have been uh talked about there, so we can take those um suggestions and the recommendations that

Yeah. Let's let's yeah, I will go I will get with you. You should get go back, get an answer and figure out why we can't do this sooner.

Oh. Okay.

All right. Um I'm not really cheering, but I'm passing on down to Senator Lujan. Senator Lujan.

Thank you, Senator Quintelon. Um last year I just made the decision to move funding away from at least two New Mexico tribal health facility projects on IHS's list of facilities that need to be replaced. One is in Albuquerque, um it's the Albuquerque West facility, a priority for Santa Ana Pueblo, and one serving the Navajo Nation in Gallup, which is one of IHS's largest facilities, serving a large portion of the Navajo Nation. Actions like this depriving the tribes of these funds creates uncertainty, and hinders negotiations and planning. Worse, the tribes, the Pueblo and the nation had no explanation as to why the funds were moved, allowing them no opportunity to resolve any issues and maintain their funding. Last year I met with the leadership of San Fernando Pueblo and they told me the Pueblo had broken ground on a new facility and it is shovel ready. I believe funding has been restored there and want to be sure that it will not be removed again. Mister LaRouche, yes or no, will you commit to prioritizing projects and using the encouraged six thirty-eight authorities where possible.

It definitely all of the facilities that are on our grandfathered lists are our priorities and we do uh encourage the six thirty-eight.

Appreciate and just to be clear, Mr. LaRouche, both those projects are on that list.

Correct.

Appreciate that. Mr. LaRouche, yes or no, will you commit to meaningful consultation with sovereign nations before IHS chooses to move their funds out of their projects?

The d we do uh realize that we do need to discuss that with them. I believe the uh within that um authority or the funding authority or whatever, we are able to kind of move things around, but we do need to make sure that we contact and and uh work with the tribes, whenever something's done like that.

And are you comfortable with

So

committing to meaningful consultation with these sovereign nations, if that's a decision that IHS is making.

Uh, it will follow the, uh, tribal consultation policy.

I appreciate that. Ju- just because when discuss versus meaningful consultation, as we know, two different things. So I I very much appreciate that, Mr. LaRouche. Lastly, Secretary Kennedy visited the Navajo Nation last year and specifically mentioned access to water as a priority. But just yesterday, There are signs that remain at the Gallup Indian Medical Center stating that the water in the hospital is not safe for human consumption. So there were letters or there were signs that were up when the secretary was in New Mexico. He he didn't go, but I asked the same question. All of a sudden those signs were taken down. Well now there's new signs that are up. And the sign's different, so to the credit of the staff. They didn't put the same signs signs up if they were reprimanded for saying the water is not drinkable. But now it's a picture. And it says the water is for hand washing only. Now, the little bit that I know about water is when you can't drink it, you're not supposed to wash your hands with it either. It's a hospital. So, my question, Mister LaRoche, is when will I just restore safe drinking water at the Gallup Indian Medical Center? And what is your plan to do so?

Uh, I don't have the details on that. I will need to go back to our office of uh environmental health and engineering and check on their plans for them.

I I appreciate I I'd like to hear back as soon as possible and see if if you need authorities if they're whatever is needed to work with my colleagues if there are any IHS facilities in the country where they it's a hospital they don't have drinking water I don't think there's gonna be disagreement to say no they should have clean safe drinking water um mister La Roche La Roche I apologize, I said that I I told myself I was not going to say your name incorrectly today, sir. Mister LaRouche, last week IHS announced it's launching a major hiring push to rebuild and strengthen the IHS workforce. I appreciate that and this is welcome news, I think, by all of us. My question though is how do you plan to implement the hiring push and actually get health providers into facilities? Because I've heard from my constituents that they've been unable to hire staff because they face red tape and background checks that can take six to nine months for some of these positions. Now, I appreciate saying that there's gonna be a major push. My question to you is, what are you going to do to address the foundational issues that have held up hiring?

Tha- i- i- that's a great question with bringing on uh over three thousand people is our goal for this uh this next year. We have brought together our HR team as well as what what you had mentioned as the other people who are involved with getting people on board and getting the recruiting and and so forth. So we have uh had a meeting on that to approach it in a comprehensive way so that we can have all the parts of our organization ready for that big hiring.

Is it fair to say, Mister LaRoche, that that six to nine month backlog, that time line, that will be condensed, they'll look for inefficiencies in there, see what needs to be done to make sure that we're not losing healthcare providers when they're recruited. They say they wanna go move there and then they're told, " Well, in nine months you have a job."

We're, uh, we're definitely working on that,

Yeah.

the reduced site time thing,

I appreciate that.

definitely.

What I'd be interested, sir, is if you could detail for me, and you, we could work with the teams, um, why the background checks are taking so long, so if there's things that we need to do together, that we look at that as well. And then what is the concrete problem problem that needs to be fixed to speed up the background checks? I'm very interested in that. Um, there were a few providers that were identified for a few small facilities in New Mexico, and they lost them because of the six to nine month delay. And they, they need a paycheck as well. They need to take care of their families and they had other opportunities, even though they were ready to move. And so there's something we could do there. I I'd be very interested in working with you.

Thank you.

Yeah. Thank you for that. With that, um, I recognize Senator Cortez Masta.

Thank you. Uh, welcome to the panel members. Thank you very much. Um, I I do wanna focus most of my questions on S ten fifty five, which is the Indian Health Service Emergency Claims Parity Act. Currently, Indian Health uh services beneficiaries um are required to notify the Purchased Referred Care commonly known as PRC, uh the office within seventy-two hours of receiving outside care during a medical emergency. Now, the last thing patients should be thinking about during an emergency is having to file out file the paperwork uh to make sure their hospital visit is properly covered within the seventy-two hours of that emergency. Um so for me, and I think this is why um Senator Rounds I was so pleased that he introduced this legislation and I uh joined him on it, I think there's an opportunity here to do make common sense here, right? So is there this legislation that we introduced um the Emergency Claims Parity Act It extends the reporting deadline for IHS patients who seek emergency care outside of those IHS facilities from seventy-two hours to fifteen days, fifteen days. Now, um, Deputy Dec Director LaRoche, uh, in your testimony you indicated concerns over flexibility, noting that S ten fifty-five would limit the Indian Health Services' authority to a period of fifteen days. Could you are are those concerns? Could you elaborate? On the concerns?

I d I'll say that we we do support the fifteen days, but if uh it what we are saying is if it is uh put into law, that if we ever wanted to even extend it longer than the fifteen days, go to twenty-one days or something, that we'd have to come back and and go through uh the the federal process.

Is there, uh, and because uh for seniors and um people with disabilities, they have thirty days.

Correct.

Is there a reason why we shouldn't look at thirty days just for everyone?

I if we could take that back for consideration.

But right now you do suppose you do support the legislation, the fifteen days,

Correct.

your only concern is the flexibility if you want to make it longer.

Longer, correct.

Hmm. Okay, we might be able to work with that. Thank you, I appreciate that, that's very helpful. Um, let me ask you this. Uh, yesterday uh uh I introduced a piece of legislation the Stronger Engagement for Indian Health Needs Act, again with um Senator Rounds. This bill would elevate the director of IHS position to an assistant secretary at HHS, uh granting greater authority over recruitment, retention and inter-agency coordination. In fact, Secretary Kennedy in testimony at his nomination hearing before the Senate's Health, Education, Labor and Pensions Committee expressed support for this idea. Uh, it's not new. Senator John McCain previously introduced the bill, and it has passed the Senate before. Um, given the recent introduction on the bill, um, uh, and I s- understand you probably need more time to review it and take it back. But I would just appreciate, uh, your review and your thoughts on it. Uh, it, not now but in the future at any point in time, uh, I obviously it's not new legislation but it, I think it is important and I would love your feedback at some point in time. Would you be willing to work with me?

Thank you. Yes.

Great. Thank you. Um At the end of the day, let me just say this. I I think for many of us, um particularly those that have um Native American communities, tribal communities in our state, uh we gotta do a better job uh of providing them opportunities for care for uh Indian health services. I hear it in my state, we're hearing it, we're hearing the conversations and the concerns um today on these three bills. Can I ask the other panel members, is there anything else that we should be aware of that we haven't addressed today, that you would like to make us aware of, uh concerning um whether it's the bills that we heard or or the concern just in in, uh health services in Indian country or Native American Alaskan country as well.

So I think regarding the bills that you heard today, um especially the PRC, the two PRC bills for us is IHS looking at their PRC program as a whole because the forty-two million dollar carryover that we had at the callable service unit

Mm-hmm.

was um I as well as our other counsel and staff were there at the negotiations were dumbfounded when we heard how much money was there, and and it was very disheartening because when you have people dying daily because they're not getting the health care that they need, and then you find out that IHS has been hoarding forty-two million dollars that could have sent them to get the care they needed, it's heartbreaking and gut-wrenching. So I think if that is something that can be looked into with the PRC program, um I've worked for the PRC program myself. Um earlier on in my career I worked with um A big part of the problem is the fiscal intermediary not paying the bills as well. Um, we were using New Mexico Blue Cross Blue Shield, I believe at the time is who we were going.

Not paying the bills, they were denying the claims or just not paying them,

They just were not paying them.

just not denying everything,

So,

not there's nothing that you could do that you've seen that

yeah. They weren't paying them and that's why they were getting sent to collection some of the time was because the fiscal intermediary wasn't taken care of for whatever reason. Um. And our staff at the local level tried to work with them,

Okay.

like what can we do, what do you need, what documentation can we submit to get those bills paid, but it it's just so such a cumbersome process, so I think to help that process for others, you know, we have our own FI now, 'cause we're contracting, but to help the other um tribes that are still with IHS and their PRC, that would be something that I would recommend looking into.

Okay. Okay.

Miss Ross, anything else?

Thank you for the question. I would just add that um the support of self-determination that tribes tribal organizations have within them, the ability to manage their own programs and funds successfully, innovatively, and um with quality. So just the support of expansion of s of self-determination. Thank you.

Thank you, and thank you. And then, Deputy Director, anything else that you would like to

D uh again uh supportive of the the bills and uh really looking forward to working with the the tribe the South Central Foundation and the tribes and I I will say our PRC program we've been going through a lot of improvement efforts over the past couple of years to to do exactly what was brought up here with uh working with the fiscal intermediary and trying to remedy those so we're still working on that so continuous improvement.

Thank you. Thank you all for being here.

Thank you, Senator. I just have a a a couple quick follow-ups here. Um, Mister LaRoche, you you note in your testimony that IHS has seen what we're referring to as bad actors in the PRC space when it comes to private providers not um following section uh two twenty-two the provision prohibiting prohibiting them from seeking payment from a patient um And you you also know that this legislation doesn't uh provide any mechanism for consequences. Has has IHS taken any steps to end agreements um with or or otherwise discourage these bad actors?

It definitely where the bad actors have been uh identified, we have been working directly with them to go through and make sure that it's not just that they don't understand the process or they're looking Sorry, you have to repeat?

Right.

uh continue with them, but one of the challenges is sometimes those uh providers may be the only ones within a reasonable area.

Mm.

And then that ends up um we have to look for people kinda outside of a closer area.

Yeah, that's not a good outcome. You keep keep somebody that you know is has got a bad track record, that's not helping um improve the system at all. So so I'm at Seymour. Um It's my understanding that because of what we're seeing with IHS's, um, uh, poor management of the PRC program, you're actually seeing fewer local health providers who are willing to participate in in the program. So to your point, Mister LaRoche, you're saying you might not have anybody in the area, and then because you've got things that are poorly run, you have providers that say, no, um, uh, I'm, I'm interested in participating? Or do you have non-IHS uh providers that have refused to perhaps schedule appointments with with members that have unpaid uh prior balances, um from previous PRC claims? I mean I I just I look at this and this situation just does not get any better. You're you're just making it harder to get access to care, even if it's even if it's bad. With the provider situation.

So So from um Calvel's perspective, we have seen providers who have canceled contracts with us because they haven't gotten paid we've had patients go to their appointments and not be able to be seen because they don't have a purchase order or they have an outstanding bill that wasn't paid.

So on on that last point, so w would if if I'm that person and I have an outstanding balance, w If I have a condition that I need to be seen for now, am I flagged? Because I have this unpaid prior balance? So I go in, I check in for an appointment, and I'm told, sorry, we can't see you for this appointment?

Yeah, basically that's what has happened, and and sadly we've even had people turned away for cancer treatments and oxygen and different things like that because they have outstanding bills.

And so the only alternative for me in that situation would be to say, " Well, I'll just pay out of pocket."

Yeah, basically some of them, if they have the means, we'll make a payment at that time so they can be seen.

Yeah. Yeah.

And that's how we end up in this situation is, you know, they should be reimbursed, but IHS won't tell us why, but that they can't, they just keep saying they can't reimburse patients. But it's, and you know, some of them, like I said, are elders or We live in a a high poverty area, so most the people that we provide services to can't afford to take a hundred dollars out of their pocket to pay on a medical bill so that they can be seen by their provider that day.

So, um, you last year, so you you're not even you're not even six months into your um six thirty eight uh agreement here. Do you are you hearing from those who um uh are are are part of Colville tribe that the situation is better now? Do they know that um they're they're not going to be turned away at their appointment? Um uh because of of unpaid prior balance with it? I guess I I wanna know whether or not you have seen improvements because of the direction that you've taken.

We have seen improvements and um some of that has come from patient communication, but it's also came from our staff who are initiating the payments and making sure um that the payments are being paid timely they've worked in um diligently to make sure that they're establishing contracts with all the providers we use communicating with the providers so they know the process that they need to follow to make sure that we get payment taken care of and

Are you seeing more providers that are perhaps now interested and and are popping up there?

Yes, we've actually had providers reach out to us to say, " Hey, we would love to work with you guys, um, who had previously canceled due to IHS non-payment." But now that they're hearing that we have our Colville Tribal Health Care Authority administering that program, they're more willing to work with us because they're, they trust that they will get paid.

Yeah. And I think this is, this is where you really see, um, self-determination play out in a way that is meaningful, um, uh provides for that that balance and and the and those true results. Um uh and and I think just having um uh Miss Ross from South Central Foundation on the panel here today is an example of of what you really can what you really can do when it comes to uh tribal health organizations, coming together and um and and working to to meet the needs of folks where they are, um, not being, not being, um, uh, as as directed or controlled by by operations four thousand miles away. But I think we see, uh, very strong examples, um, uh, where, uh, uh, not only are we, we, we, we talking about, um, those principles of delt self-determination, but we're seeing them in action. And You know, my my hope is that uh those in in the Colville uh Business um uh Council are going to see positive results as you uh as you assume this direction and and to you, Mister LaRoche, I think you've heard um some really good examples of the challenges that are being faced. Um we've talked about this in this committee for a long time and um I'm in a different situation than than my colleague in South South Dakota, and I'm I'm very proud of what Alaska natives have have come together to develop, um, through our tribal health organizations. Um, in many ways we're leading the model when it comes to health care delivery, and that's exciting. But to know that so many in Indian country, um, are are struggling with a system that is clearly, clearly not working for them um and in in many ways is is just punitive on a on on many different levels. When you are choosing to not access care because you're fearful that you don't know how this whole reimbursement process is gonna work or if it's gonna be reimbursed, or if you're gonna get sent to the the the debt collector, it just it's not a place that we should be. So I'm really thankful that the committee is is going to engage um in these uh legislative initiatives and look forward to working with, with colleagues to help advance them, as well as with the department. And I think, I think I'm, I'm reading body language here and you have not given me serious frowns or no. You're, you're kind of acknowledging some of the um the deficiencies, the real deficiencies within the department and and an acknowledgement that we need to address them. So, look forward to doing that. And with that, the committee stands adjourned. Um, we'll be taking we'll be taking uh testam- or uh questions for the record for two weeks after this. Thank you.