With a collaborative, ongoing, ever-deepening spirit of partnership, we can continue to strengthen the federal government’s relationship with tribal governments—and most important, use that relationship to improve the health and well-being of every American Indian and Alaska Native.
As Prepared for Delivery
Thank you, Juana [Majel-Dixon] for that introduction. Good morning, everyone, and thank you all for having me here today. Thank you, in particular, to the leadership of the National Congress of American Indians, including President Jefferson Keel, for inviting me to address you.
Jefferson, I’m grateful for the chance I’ve had to work with you over the years on tribal health issues.
The experiences I had working with you and other tribal leaders when I was Deputy Secretary in the 2000s, on trips to Alaska and other parts of Indian Country, were some of the most meaningful learning experiences I had during my time at HHS.
The communities I visited hold fond memories for me, from Navajo Nation and San Diego County to just about every corner of Alaska, from the Aleut community on St. Paul Island and the Metlakatla Indian Community, to Barrow, Nome, Kotzebue, Hope, Sitka, Ketchikan, Shishmaref, Point Hope, Minto, Bethel, and a few more places besides.
In fact, I am probably lucky enough to have become HHS secretary with more experience traveling in Indian Country, offering a firsthand perspective about the challenges and successes on the ground, than any recent secretary.
I was also pleased to learn recently that Jefferson, a Vietnam Veteran and retired Army Ranger, is also helping to co-chair the effort to build a National Native American Veterans memorial, an effort many others among you are involved in.
As you know, that memorial will be located right by HHS headquarters, near the National Museum of the American Indian.
The memorial’s establishment is a long overdue recognition of the heroic service that American Indians and Alaska Natives have rendered to America in the field of battle—serving in the U.S. military at higher rates, as many of you know, than any other ethnic group.
It is fitting and right that there will now be a formal recognition of Native heroism, so close to the U.S. Capitol. I strongly hope that Native American veterans of the U.S. Public Health Service Commissioned Corps will be recognized as part of the memorial.
I also want to heartily congratulate all members of NCAI on the 75th anniversary of its founding, which you began celebrating last fall.
As the largest single umbrella organization for tribal governments, NCAI has played a vital role over the years in bringing together Native voices, sharing perspectives, and assessing the state of Indian Country.
NCAI was formed at a time when the federal government was a great deal less respectful of tribal governments—it was, in fact, seeking to terminate them.
We are in a very different place today.
The Trump Administration and the entire federal government are not only committed to engaging with tribal governments as equals—we are working with many of you on a path toward greater self-determination and self-sufficiency.
In our health programs, in particular, recent years have seen tribal governments work toward having greater control over IHS facilities, and we have been highly supportive of tribes who decide that transition makes sense for their people.
Today, I want to address several aspects of how we are working to advance tribal health, through collaborative engagement with all of you. I’ll first mention two acute public health challenges in Indian Country, HIV and the opioid crisis, which President Trump has made top priorities.
I then want to discuss the work that the Indian Health Service is doing to improve quality across its facilities.
In closing, I want to talk about how, on every shared policy issue, we are committed to constantly extending and deepening our consultation with tribes.
First, I want to share a bit about the role that tribal communities will play in the historic public health effort President Trump announced in his State of the Union last week: ending the HIV epidemic in America.
For a number of reasons, this is an especially important effort for the public health of Indian Country.
HIV infections among American Indians and Alaska Natives actually rose from 2011 to 2015—the only population where we are headed in the wrong direction. Tackling this epidemic with the plan we’ve put forth will be a historic victory for public health across the United States—but it will be an especially important victory for Indian Country, too.
That is why Admiral Weahkee and leadership at IHS were a key part of the team that helped develop the administration’s plan for ending the epidemic in America and in Indian Country.
As soon as it was announced, a number of leaders in this room were some of the first to hear more details first-hand from Admiral Weahkee and Admiral Brett Giroir, our Assistant Secretary for Health.
The plan will involve large new investments in programs that already work at connecting patients with HIV to treatment, including at IHS, as well as new public health resources deployed on the ground where the disease continues to spread.
The plan puts a particular focus on geographic areas and communities where HIV imposes the greatest burden.
That includes the 48 counties where 50 percent of HIV infections now occur each year, but also seven states with a high rural burden of HIV, including Oklahoma, and particular demographic communities, including gay men, black and Latino Americans, and American Indians and Alaska Natives.
Admiral Weahkee and other leadership at IHS were involved in the early planning for this initiative, which was developed by a small team of our top infectious disease and public health experts at HHS.
Now that we have announced the plan publicly, we look forward to engaging with tribal leaders and tribal communities to inform the plan’s implementation.
We already know there are some great lessons to be learned from Indian Country. This week, Surgeon General Jerome Adams and IHS Chief Medical Officer Michael Toedt will be visiting the HIV Center of Excellence at the Phoenix Indian Medical Center.
The Center of Excellence is located in one of the 48 counties where we see half of the new infections across America, Maricopa County.
But we have also, happily, seen success there: Patients at the Center of Excellence have a 92 percent viral suppression rate, which means they can not only lead normal, healthy lives, but they also pose virtually no chance of transmitting the disease.
Translating successes like that across Indian Country, and across America, will be a key piece of our work on HIV.
Defeating the HIV epidemic requires connecting patients to treatment and connecting people at risk of contracting HIV to prevention strategies.
This kind of work requires people on the ground, raising awareness and working closely with the community. One barrier to this can be the unacceptable stigma that still tragically surrounds HIV. You all know best how to combat this stigma in your communities, and your contributions and perspectives will be invaluable.
Another potential barrier to HIV care is lack of healthcare providers in rural areas. But no one knows better how to promote public health in that kind of environment than tribal health providers.
We continue to hear about the success of the Alaska Community Health Aide Program, which uses community health aides to connect patients in remote areas to care when they may not have immediate access to any other healthcare practitioners.
I had the chance to witness this work first hand in Alaska during my time in the Bush administration, and we’re proud that IHS is looking to understand how the community health aide program can be extended in the lower 48.
We are always eager to hear about any local barriers that may be standing in the way of tribal health innovations like I’ve just described.
The second public health challenge I want to touch on is our country’s crisis of opioid addiction and overdose. The opioid crisis is an American crisis, and it’s an Indian Country crisis.
We know rates of opioid overdoses are as high among American Indians and Alaska Natives as they are any other demographic group.
That is why HHS has made it a priority to ensure that all of our opioid efforts take into account the special needs of Indian Country.
You know best how to tackle the challenges of substance misuse in your communities, but we know we need to assist you with the resources to do it. That is why we were so pleased that Congress created a specific set-aside within the new $1 billion State Opioid Response program to provide grants to tribal governments, through what was very creatively dubbed the Tribal Opioid Response program.
In deciding how to distribute the Tribal Opioid Response money, we heard from members of the Secretary’s Tribal Advisory Committee, and we talked about this matter across HHS. Consultations were led by the agency that distributes these grants, the Substance Abuse and Mental Health Services Administration, or SAMHSA, and the Deputy Secretary himself was personally involved in deliberations as well.
After consultation, we recognized it was best to distribute the money by formula, rather than by a competitive process, so that the greatest number of tribes can stand to benefit.
Our head of SAMHSA, Assistant Secretary Elinore McCance-Katz, has worked to ensure tribal communities are included in all of the rest of the work the agency does.
Last year, after we heard concerns that state governments hadn’t adequately consulted tribal communities on another large opioid grant program, Assistant Secretary McCance-Katz wrote a letter to all 50 governors, making it clear that we expect them to consult tribal communities in implementing these state-based grant programs. In total, she has now worked to create tribal set-asides in nine different grant programs.
Thankfully, we have seen some encouraging trends: In 2018, we finally saw the national provisional drug overdose death count, reported by the CDC, flatten and begin to drop. Alaska’s state government also recently reported that the number of overdose deaths in the state dropped significantly from 2017 to 2018—an achievement that Alaska Native communities should find especially encouraging.
We believe that these successes are in part because of the concerted efforts, from the federal government on down to local communities, to embrace the best evidence-based practices around addiction, which includes offering medication-assisted treatment for those with opioid use disorder and providing holistic supports for those in recovery. IHS has joined the rest of HHS at the forefront of this work, creating a new program for prescribing medication-assisted treatment through telehealth, and we’ve seen tribal communities continue to think creatively about how to support people in recovery.
Quality
The other health issue I want to discuss today is the broad goal of improving the quality of care across our Indian health facilities.
For all of the amazing work done by IHS employees and tribal health facilities every day, we know that the quality of care at IHS facilities has not always met the standards we set—and that kind of outcome is totally unacceptable.
I first want to assure you that you’ll always receive an honest, frank assessment from HHS, the department in charge of these facilities, and that we are always working aggressively to improve the situation.
Recently, most tragically, some of you may have seen media reports about patient abuse several years ago by one former employee at IHS. I want to reiterate, to all of you, the message that Admiral Weahkee delivered to every employee of IHS last week: This conduct is utterly unacceptable and will not be tolerated at IHS.
The leadership team at IHS has also been working for some time now to put in place new agency policies to ensure this kind of horrific event cannot occur again. That includes the implementation of new professional standards and a new centralized credentialing system that will help share information across IHS on clinician qualifications and practice history.
To provide additional assurance in this area, I have asked HHS’s Office of Inspector General to conduct a review of the policies and procedures we’ve put in place for handling allegations of abuse at an IHS facility or by an IHS provider.
These kinds of reforms fit into broader efforts across IHS to improve the management of the healthcare facilities in Indian Country.
Admiral Weahkee has made a formal commitment to this work through the creation of the first-ever Office of Quality at IHS, which builds on what IHS has been doing around quality for a few years now. Any top-tier health system has a quality leader and a quality office; IHS deserves the same.
The Office of Quality has four divisions, which will work to improve the quality of both clinical care and management across IHS. That will include helping to address instances where facilities face challenges participating in Medicare and Medicaid, which we recognize are important to the financing of care in Indian Country. The Office of Quality will work toward rapidly addressing quality issues raised by CMS oversight and building the most productive, collaborative relationship possible between IHS and CMS.
Higher quality care at IHS facilities also means embracing the latest technology, and IHS is hard at work on examining options for a next-generation health IT system.
High quality health IT, which can put useful health information in the hands of both patients and physicians, is a top priority across HHS. We’ve heard from practitioners in the field that a high-quality electronic health records system can be one of the single most valuable tools they have for clinical care—and we’re committed to delivering that for IHS.
We are tremendously proud of Admiral Weahkee’s leadership on these issues. Management at IHS has seen important advances under his leadership as Acting Director and now Principal Deputy Director.
But we also recognize the need for permanent, presidentially appointed leadership at the top of IHS, and securing a nominee as IHS director remains a top priority for the administration.
Consultation
The final topic I want to touch on today is the vital importance of engagement between the federal government and tribal governments. Consultation is a formal recognition that our relationship with tribal governments is a cooperative one, a relationship of equals. But we also see it as a vital way to improve our policies.
Productive, positive consultation means better policy, better services, and better outcomes for Indian Country.
For instance, at a 2017 STAC meeting, Secretary Price learned that capital projects funded with solely tribal or congressionally appropriated dollars still required HHS approval, even when they were of relatively modest size.
In response, after consultation with tribes and across the federal government, we substantially raised the threshold for which HHS approval is needed on these kinds of projects.
We were also pleased that a collaborative process among tribal governments, state governments, and HHS has helped reach a resolution regarding community engagement requirements in Arizona’s Medicaid program.
As many of you know, it is a priority of this administration to ensure that our federal programs promote long-term health, economic independence, and self-sufficiency. The connection between health and economic independence is the reason we invited state governments to propose ways to incorporate requirements for community engagement, including work, in the Medicaid program—to help make that program more than just an insurance card, but a pathway out of poverty.
This vision is best implemented locally, where governments know the needs of the people best.
As many of you know, Arizona applied for and received a waiver to implement community engagement requirements. In recognition of the unique needs of tribal communities in the state, they decided to categorically exempt members of tribes.
Going forward, we’ve reminded states that they are required to consult with the federally recognized tribes within their borders in crafting these requirements.
I want to commit to you that we will not just maintain the level of engagement we’ve had with tribal governments—we will constantly seek to deepen this relationship. I am proud that HHS carries on more regular, more extensive consultation with tribal governments than any other part of the federal government, but we can always do better.
This is in part thanks to the hard work of our Office of Intergovernmental and External Affairs, which Secretary Leavitt used to call “the front door” of the department.
I hope you see that office and their tribal team as exactly that: a way to reach out to us and get in touch with whatever area of the department you need.
Consultations have allowed HHS leadership, myself included, to be strong advocates for budgetary investments in Indian Country: As some of you know, last year, HHS worked with OMB to request from Congress a major capital investment for IHS, nearly $4 billion to address facilities backlogs.
That would have entirely cleared IHS’s Health Care Facilities Construction Priority list. We look forward to continued work with Congress to address these capital needs.
We are also aware, as President Keel explained in his State of Tribal Nations address this week, that the recent government shutdown caused particularly acute challenges in Indian Country. We understand that, especially after the shutdown, many tribal leaders have asked Congress to consider the advanced appropriations for the Indian Health Service.
We are aware of this proposal, and I want to assure everyone that we are doing everything we can to minimize disruption for Indian Country in the event of future interruptions in government funding.
In addition to the budget consultations out in Indian Country, I am pleased to announce to all of you today that this administration is committing to hosting a meeting of the Secretary’s Tribal Advisory Committee each year in Indian Country.
In 2017, Secretary Price held the first STAC meeting in Indian Country, in Cherokee Nation.
Last year, Deputy Secretary Hargan held the STAC meeting in interior Alaska, which was graciously hosted by the Tanana Chiefs Conference. Deputy Secretary Hargan and a number of HHS senior leaders visited 7 villages in the Alaska interior and multiple organizations in Fairbanks and Anchorage. This series of meetings, I’m told, is the most comprehensive HHS visit to Indian Country in anyone’s memory.
This year, the Deputy Secretary will be traveling to Arizona for the next STAC meeting, which will be hosted by Tohono O’Odham Nation, home to the current STAC chairman, Chester Antone.
While the STAC didn’t exist when I was at HHS in the Bush administration, I have been so pleased to see how it provides not just a venue for dialogue between federal leaders and tribal leaders, but also an opportunity to foster better cooperation across HHS.
I want to conclude by reemphasizing why I’m glad to be here—and honored to run a department that plays such a key role in tribal work.
A meeting like this, of NCAI, is an important chance for tribal leaders to come to Washington and dialogue with our leadership at HHS and across the Trump Administration.
But we are going to keep expanding our opportunities for engagement in the ways I mentioned because the government-to-government relationship shouldn’t just take form in STAC meetings or Washington conference rooms.
It should be an ongoing, rich partnership between your governments and the federal government—between Indian Country and the United States.
From the hundreds of tribes in coastal and interior Alaska, to the huge, storied tribes and lands on the Great Plains, all the way to the newly recognized tribes on Virginia’s coast, the perspectives of every American Indian and Alaska Native matter to us.
We cannot accomplish HHS’s mission to improve the health and well-being of every American, and we cannot fulfill our special obligations to American Indians and Alaska Natives, without understanding your perspective.
We are committed to listening to and working with you.
With a collaborative, ongoing, ever-deepening spirit of partnership, we can continue to strengthen the federal government’s relationship with tribal governments—and most important, use that relationship to improve the health and well-being of every American Indian and Alaska Native.
Thank you so much for having me here today, and I look forward to years of successful partnership with all of you.
