Testimony from RADM Chris Buchanan on The President’s FY 2020 Budget Request for Indian Programs before Committee on Indian Affairs

Good afternoon, Chairman Hoeven, Vice-Chairman Udall, and Members of the Senate Committee on Indian Affairs. I am RADM Chris Buchanan, Deputy Director of the Indian Health Service (IHS). Thank you for your support and for the opportunity to testify on the President's Fiscal Year (FY) 2020 Budget. The Budget advances our mission to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level. As an agency within the Department of Health and Human Services, the IHS provides federal health services to approximately 2.6 million American Indians and Alaska Natives from 573 federally recognized tribes in 37 states, through a network of over 605 hospitals, clinics and health stations.

The President's FY 2020 Budget proposes $5.9 billion in total for IHS, which is $392 million above the FY 2019 annualized continuing resolution funding level, or $140 million above the FY 2019 Consolidated Appropriations Act. The President's Budget grows the resources available to meet the nation's commitment to American Indians and Alaska Natives in a constrained budget environment, reflecting a strong commitment to Indian Country. Specifically, the budget prioritizes direct clinical health care, providing a 7 percent increase and makes crucial investments in the fight against Hepatitis C and HIV/AIDS, launches a national expansion of our health paraprofessional program and provides resources for planning and key infrastructure improvements for a replacement electronic health record system (EHR). The Budget also proposes to extend our successful Special Diabetes Program for Indians (SDPI) through FY 2021, at $150 million per year.

The President's Budget provides $25 million to expand partnerships between IHS and Native communities to eliminate Hepatitis C and end the HIV epidemic in Indian Country. With the resources and tools we have available today, we have an unprecedented opportunity to make a real difference in reducing hepatitis and HIV transmission. I'm pleased that IHS is taking part in the "Ending the HIV Epidemic: A Plan for America" initiative.

The Budget also provides $25 million to begin transition to a new and modernized replacement of IHS's electronic health record system, Resource and Patient Management System (RPMS). These resources are critical to allow IHS to conduct planning for this transition and address key infrastructure gaps necessary to implement a modern EHR. Our current system exists as more than 400 separate local instances rather than a single system, hobbling our efforts to share medical information efficiently, improve monitoring of medical quality, and recover critical third party financial resources.

A modern system would enable IHS to enhance medical quality, maximize the time our doctors, nurses and other health professionals are providing direct patient care, and increase the security of our patients' medical records. I believe this transition represents an opportunity to meaningfully impact the care received by our patients.

We have also requested $20 million to launch a national expansion of our paraprofessional program, the Community Health Aide Program (CHAP). This program of certified health, behavioral health, and dental aides will enable us to fill critical care gaps. This program has been used for decades in Alaska to great success and I believe its expansion into the rest of the country will be beneficial and an important tool in meeting the health needs of American Indians and Alaska Natives, as part of a mix of services determined at the local level.

In addition to these key initiatives, our FY 2020 Budget includes:

• $147 million to expand direct clinical health services, including dental, mental health, alcohol and substance abuse services;
• $8 million to recruit and retain medical professionals, critical to addressing gaps in care;
• $2 million to bolster the Office of Quality;
• $11 million to fund the health care of six newly federally recognized tribes;
• $98 million to fully fund staffing at four newly completed or expanded health care facilities, including 3 joint venture facilities and a youth regional treatment center;
• $69 million to support current services, including pay costs, inflation, and population growth;
• $855 million for contract support costs, which currently aligns with our estimate of those costs.

The Budget prioritizes funding for key investments in support of direct clinical health services, and in doing so, proposes some program adjustments. A net reduction of $66 million in Facilities ensures continued priority focus on maintaining existing facilities and addressing continuing sanitation facilities construction projects. Phase out of funding for the CHR program is contemplated with a funding level of $24 million, as part of proposed reforms to current community-based care. The President's Budget also proposes two program discontinuations, including the Health Education and Tribal Management Grants programs, which total $23 million.

The Budget will enable us to implement our newly released Indian Health Service Strategic Plan for fiscal year 2019-2023. The Strategic Plan will improve the management and administration of the IHS and sets the strategic direction of the agency over the next five years. The Strategic Plan includes three goals that will guide our efforts – access to care, quality of care, and strengthening management and operations. The final plan is the result of collaboration with our tribal and urban Indian organization partners who offered their feedback and expertise.

Aligning with the IHS Strategic Plan, four legislative proposals are included within the Budget to increase access to care by: providing tax exemption for IHS scholarship and loan repayment programs, providing discretionary use of all Title 38 personnel authorities, meeting loan repayment and scholarship service obligations on a half-time basis, and providing Federal Tort Claims Act coverage for IHS volunteers. These proposals focus on parity with authorities provided to other federal agencies providing health care services and seek to strengthen agency efforts to recruit and retain healthcare professionals.

The IHS has also realized significant improvements to quality care for American Indians and Alaska Natives, including:

• Establishing the Office of Quality as an elevated national oversight component within IHS Headquarters;
• Implementing a new standardized professional provider credentialing and privileging software agency-wide for all applicants;
• Awarding a new contract for an adverse events reporting and tracking system that replaces an older legacy system.

I can also report to you that since October 2018, 16 IHS health care facilities have had surveys by either the Centers for Medicare & Medicaid Services (CMS), the Joint Commission (TJC) or the Accreditation Association for Ambulatory Health Care (AAAHC). All surveys have resulted in CMS certification or TJC and AAAHC accreditation. This includes both Rosebud and Rapid City hospitals, and the IHS is preparing to send a request to CMS for a certification of the Pine Ridge Hospital.

Lastly, I want to take this opportunity to talk about an important issue to all of us at the IHS. Regarding the recent media reports on patient abuse by a former IHS employee, we have taken every opportunity to speak with our tribal and urban partners, as well as our federal employees, about how this conduct is unacceptable and will absolutely not be tolerated at IHS.

Recently, RADM Weahkee met with the Oglala Sioux Tribal Council in Pine Ridge, South Dakota, to discuss steps IHS has taken to ensure the protection of patients at IHS health care facilities. He expressed his sincere regret that children were victimized by those entrusted to care for them and made it absolutely clear that IHS will not tolerate sexual assault and abuse in its facilities.

This opportunity followed a similar meeting RADM Weahkee had in February with the Blackfeet Nation in Montana. These two communities were victimized by the actions of the former IHS employee. I want to thank the leadership of the Oglala Sioux Tribe and the Blackfeet Nation for their partnership as we work to re-establish trust with our patients.

As shared in an October 2018 letter to tribal leaders, I can promise you that IHS will continue our efforts to ensure safe and quality care for our patients. We are committed to doing whatever it takes and will continue to work closely with our tribal and urban Indian partners in transforming health care for American Indians and Alaska Natives across the Country. Some of the actions already taken include implementing new professional standards and stronger requirements for IHS employees to report suspected sexual abuse and exploitation of children. The implementation of our new centralized credentialing system will enable us to monitor the practice history of licensed health care professionals across the agency.

The Presidential Task Force on Protecting Native American Children in the Indian Health Service System announced last month will complement our ongoing efforts to identify areas for improvement and implement changes to strengthen our systems. IHS is in the process of identifying an outside, independent contractor to conduct a medical quality assurance review to examine whether laws, policies and procedures have been followed, and to identify any further improvements IHS can implement to better protect patients. The HHS Office of the Inspector General has also been tasked with reviewing the effectiveness of the actions we have taken.

I assure you that our workforce understands how serious this issue is, and I am proud of the efforts and commitment of our staff for the progress we've made, and we continue to press forward. We remain firmly committed to improving quality, safety, and access to health care for American Indians and Alaska Natives, in collaboration with our partners in HHS, across Indian country, and Congress. We appreciate all your efforts in helping us provide the best possible health care services to the people we serve.

Thank you, and I am happy to answer any questions you may have.