Testimony from Benjamin Smith on Native Veterans' Access to Healthcare before Committee on Veterans' Affairs

Good morning, Chairwoman Brownley, Ranking Member Dunn, and Members of the Subcommittee. I am Benjamin Smith, Deputy Director for Intergovernmental Affairs, Indian Health Service (IHS). Thank you for the opportunity to testify on native veterans' access to health care. The IHS mission is 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 (Department), 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 health care facilities, including hospitals, clinics, health stations, and other facility types.

The American Indian and Alaska Native population experiences health and other disparities that disproportionally affect their quality of life. American Indians and Alaska Natives have an average life expectancy of five years shorter than that of the general U.S. population and are more likely than people of other races or ethnicities to experience social and economic difficulties that may impact their health or wellness, such as lower income, lower education levels, and higher unemployment.1

As health needs change and new approaches to care emerge, the IHS, Department of Veterans Affairs (VA), and their tribal partners will continue to combine their expertise, resources, and efforts to help the nearly 145,000 American Indian and Alaska Native veterans living in the United States.2 The IHS and VA's Veterans Health Administration (VHA) continue work to provide eligible American Indian and Alaska Native veterans with access to care closer to their homes, promote cultural competence and quality health care, and focus on increasing care coordination, collaboration, and resource-sharing between the agencies. Revising the IHS-VA Memorandum of Understanding (MOU) signed in 2010 will help accomplish this goal. Our plan to complete revisions to the MOU and its related performance measures by fall 2020 includes tribal consultation with tribal leaders and native veterans, and conferring with urban Indian organizations.

In the late 1980's, Congress directed the IHS and VA to explore the feasibility of entering into an arrangement for sharing of medical facilities and services, as required by the Indian Health Care Improvement Act (IHCIA).3 The results of this collaboration led to our initial MOU in 2003. The Patient Protection and Affordable Care Act of 2010 permanently reauthorized the IHCIA, and authorized IHS to enter into (or expand) arrangements for the sharing of medical facilities and services between IHS, Indian tribes, and tribal organizations and the VA.4 The law also directs the VA to reimburse the IHS, Indian tribes, or tribal organizations for the services provided to eligible beneficiaries of either Department in the respective facility.

Since implementing this provision in 2012, VA has reimbursed over $103 million for direct care services provided by IHS and Tribal Health Programs (THP), covering approximately 10,645 unique American Indian and Alaska Native veterans. Currently, IHS and VA operate under a national reimbursement agreement, inclusive of 75 IHS federal facilities. Likewise, the VA has entered into 114 individual reimbursement agreements with THP. We are aware of an additional 42 tribes working with VA's Office of Community Care to enter into a reimbursement agreement for direct care services.

In March 2019, the Government Accountability Office (GAO) released a report entitled, VA and Indian Health Service: Actions Needed to Strengthen Oversight and Coordination of Health Care for American Indian and Alaska Native Veterans (GAO-19-291). In its report, GAO recommended that VA and IHS revise the MOU and related performance measures to ensure consistency with key attributes of successful performance measures, including having measurable targets.

IHS-VA MOU

In 2003, IHS and VA entered into the initial MOU to improve access and health outcomes for American Indian and Alaska Native veterans. To maximize resources and deliver an integrated approach that supports the health and well-being of the American Indian and Alaska Native veterans living in the United States, the IHS and VA signed a revised MOU in 2010.5 The updated MOU built upon a decade of successful collaboration and further established mutual goals to advance collaboration, coordination and resource-sharing between VA and IHS "to improve the health status of American Indian and Alaska Native Veterans." The IHCIA affirms the goals of the MOU.6

Together, the IHS and the VA Veterans Office of Tribal Government Relations and Office of Rural Health form a MOU leadership team. The leadership team meets quarterly and is responsible for review and oversight of the MOU collaboration on care coordination, reimbursement, workforce training, and cultural competency that align with the five overarching goals to:

1. Increase access to care and services for American Indian and Alaska Native veterans.
2. Promote patient-centered collaboration and communication.
3. Improve health-promotion and disease prevention.
4. Consult with tribes at the regional and local levels.
5. Ensure appropriate resources are identified and available.

In fiscal year (FY) 2018, the VA-IHS MOU leadership team conducted an in-depth revision of the existing MOU to reflect changes in law, as well as, the evolving health care and health information technology landscape. The VA-IHS MOU leadership team focused on areas concerning health and its social determinants for Native Veterans, including prescription services, transportation, housing services, workforce training and consultation with tribal communities. In addition, the team concentrated on revising the 2010 MOU to reflect progress made to date under the new Administration's leadership priorities. Our vision of a revised MOU contemplates a more comprehensive and flexible structure to support and adopt to the needs of both agencies and the veterans they serve well into the future.

The IHS-VA workgroups completed several MOU-related activities, which are now a routine part of each department's operations, including:

• Workforce Training: To better coordinate on training and recruitment efforts, VA and IHS opened their training resources to each organization's staff. In FY18, they shared 256 online and in-person training events focused on mental health, clinical support, oral health, diabetes and more.
• Access to Care: Since their inception in FY 2012, the VA-IHS and VA-THP reimbursement agreements provided $103 million to IHS and THP for care of approximately 10,645 unique American Indian and Alaska Native veterans. In FY18 alone, VA paid IHS and THP $20 million for the care of nearly 5,300 enrolled American Indian and Alaska Native veterans.
• Access to Medication: The VA Consolidated Mail Outpatient Pharmacy Program (CMOP) processed 840,000 prescriptions, an increase of 17 percent from 2017. Since its inception in FY10, CMOP processed more than 3.6 million prescriptions for VA-IHS patients.
• Housing Assistance: The Tribal Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program increased tribal engagement in FY18 from 23 to 26 tribes that used the program to find homes for Veterans. As a result, the program found homes for 130 American Indian and Alaska Native veterans.

As part of the process for revising the MOU, the IHS and VA conducted an initial listening session to solicit tribal input for the MOU on May 15, 2019, as part of the National Indian Health Board's 10th Annual National Public Health Summit. On September 4, 2019, IHS sent a letter to tribal and urban Indian organization leaders to initiate tribal consultation and urban confer on the MOU and related performance measures. The IHS and VHA held their first in-person session on September 16, 2019 in Temecula, California in conjunction with the National Indian Health Board's Tribal Health Conference. The IHS and VHA continue to deliberate on adjusting consultation and confer plans to increase national awareness of the goals of the MOU in order to gather meaningful input.

The IHS remains firmly committed to improving quality and access to health care for American Indian and Alaska Native veterans. We appreciate all your efforts in helping us provide the best possible health care services to the veterans we serve. Thank you, and I am happy to answer any questions you may have.

• 1. IHS Disparities Fact Sheet, April 2018: https://www.ihs.gov/newsroom/factsheets/disparities/.
• 2. VA Veteran Population Projection Model, 2018: https://www.va.gov/vetdata/veteran_population.asp.
• 3. Indian Health Service and Department of Veterans Affairs health facilities and services sharing (25 U.S.C. § 1680f).
• 4. Sharing arrangements with Federal agencies (25 U.S.C. § 1645).
• 5. IHS-VA Memorandum of Understanding, October 2010: https://www.ihs.gov/sites/vaihsmou/themes/responsive2017/display_objects/documents/VA_IHS_MOU_508c.pdf.
• 6. See 25 U.S.C. § 1647(a)(2).