S. HRG.

112703

VAS COLLABORATION WITH INDIAN HEALTH

SERVICE: IMPROVING ACCESS TO CARE FOR
NATIVE AMERICAN VETERANS BY MAXIMIZING
THE EFFECTIVE USE OF FEDERAL FUNDS AND
SERVICES

HEARING
BEFORE A

SUBCOMMITTEE OF THE

COMMITTEE ON APPROPRIATIONS
UNITED STATES SENATE
ONE HUNDRED TWELFTH CONGRESS
SECOND SESSION

SPECIAL HEARING
AUGUST 30, 2011RAPID CITY, SD

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COMMITTEE ON APPROPRIATIONS
DANIEL K. INOUYE, Hawaii, Chairman
PATRICK J. LEAHY, Vermont
THAD COCHRAN, Mississippi
TOM HARKIN, Iowa
MITCH MCCONNELL, Kentucky
RICHARD C. SHELBY, Alabama
BARBARA A. MIKULSKI, Maryland
KAY BAILEY HUTCHISON, Texas
HERB KOHL, Wisconsin
LAMAR ALEXANDER, Tennessee
PATTY MURRAY, Washington
SUSAN COLLINS, Maine
DIANNE FEINSTEIN, California
LISA MURKOWSKI, Alaska
RICHARD J. DURBIN, Illinois
LINDSEY GRAHAM, South Carolina
TIM JOHNSON, South Dakota
MARK KIRK, Illinois
MARY L. LANDRIEU, Louisiana
DANIEL COATS, Indiana
JACK REED, Rhode Island
ROY BLUNT, Missouri
FRANK R. LAUTENBERG, New Jersey
JERRY MORAN, Kansas
BEN NELSON, Nebraska
JOHN HOEVEN, North Dakota
MARK PRYOR, Arkansas
RON JOHNSON, Wisconsin
JON TESTER, Montana
SHERROD BROWN, Ohio
CHARLES J. HOUY, Staff Director
BRUCE EVANS, Minority Staff Director

SUBCOMMITTEE

ON

MILITARY CONSTRUCTION AND VETERANS AFFAIRS,

RELATED AGENCIES

TIM JOHNSON, South Dakota, Chairman

DANIEL K. INOUYE, Hawaii
MARK KIRK, Illinois
MARY L. LANDRIEU, Louisiana
KAY BAILEY HUTCHISON, Texas
PATTY MURRAY, Washington
MITCH MCCONNELL, Kentucky
LISA MURKOWSKI, Alaska
JACK REED, Rhode Island
ROY BLUNT, Missouri
BEN NELSON, Nebraska
JOHN HOEVEN, North Dakota
MARK PRYOR, Arkansas
DANIEL COATS, Indiana
JON TESTER, Montana
THAD COCHRAN, Mississippi
(ex officio)
Professional Staff
CHRISTINA EVANS
CHAD SCHULKEN
MICHAEL BAIN
DENNIS BALKHAM (Minority)
DANN LETTIERI (Minority)
Administrative Support
RACHEL MEYER
COURTNEY STEVENS (Minority)

(II)

AND

CONTENTS
Page

Opening Statement of Senator Tim Johnson ........................................................

Statement of Robert L. Jesse, M.D., Ph.D., Principal Deputy Under Secretary
for Health, Veterans Health Administration, Department of Veterans Affairs .......................................................................................................................
Prepared Statement of .....................................................................................
Funding for Rural and Native American Veterans ...............................................
Indian Health Service Partnership ........................................................................
South Dakota Projects and Initiatives ...................................................................
Statement of Randy Grinnell, M.P.H., Deputy Director, Indian Health Service ..........................................................................................................................
Prepared Statement of .....................................................................................
American Indian/Alaska Native Veterans Dual Use of Indian Health Service
and Veterans Health Administration .................................................................
Department of Health and Human Services/Indian Health ServiceDepartment of Veterans Affairs/Veterans Health Administration Memoranda of
Understanding ......................................................................................................
Indian Health ServiceVeterans Health Administration Collaborations ............
Area Director Meetings With Veterans Integrated Service Network ..................
Sharing Facilities .....................................................................................................
Telemedicine ............................................................................................................
Outreach (Tribal Veteran Representatives) ..........................................................
Health Information Technology ..............................................................................
VistA Imaging ..........................................................................................................
Bar Code Medication Administration ....................................................................
Meaningful Use ........................................................................................................
Alaska Area Indian Health ServiceVeterans Health Administration Health
Information Technology Collaborations ..............................................................
Consolidated Mail Outpatient Pharmacy ..............................................................
Future Opportunities of Partnership .....................................................................
Statement of Stephanie Elaine Birdwell, Director, Office of Tribal Government Relations, Department of Veterans Affairs ..............................................
Prepared Statement of .....................................................................................
Outreach and Consultation .....................................................................................
Increase Access to Healthcare and Sustainable Economic Opportunities ..........
Indian Health Service and Department of Veterans Affairs Coordination .........
Payment and Reimbursement ................................................................................
Telemedicine ............................................................................................................
Mental Health Telehealth .......................................................................................
Tribal Consultation Sessions ..................................................................................
Outreach ...................................................................................................................
Tribal Veteran Representative Program ................................................................
Nondepartmental Witnesses ...................................................................................
Statement of Don Loudner, National Commander, National American Indian
Veterans ................................................................................................................
Statement of Iva Good Voice Flute, Air Force Veteran, Oglala Sioux Tribe ......
Material Submitted Subsequent to the Hearing ...................................................
Prepared Statement of the Cheyenne River Sioux Tribe .....................................
Prepared Statement of Geri Opsal, Tribal Veterans Service Officer for the
Sisseton Wahpeton Oyate, Lake Traverse Reservation ....................................
Letter From the Standing Rock Sioux Tribe .........................................................

(III)

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VAS COLLABORATION WITH INDIAN HEALTH

SERVICE: IMPROVING ACCESS TO CARE
FOR NATIVE AMERICAN VETERANS BY
MAXIMIZING THE EFFECTIVE USE OF FEDERAL FUNDS AND SERVICES
TUESDAY, AUGUST 30, 2011

U.S. SENATE,
SUBCOMMITTEE ON MILITARY CONSTRUCTION AND
VETERANS AFFAIRS, AND RELATED AGENCIES,
COMMITTEE ON APPROPRIATIONS,
Rapid City, SD.
The subcommittee met at 10 a.m., at the Journey Museum, 222
New York Street, Rapid City, South Dakota, Hon. Tim Johnson
(chairman) presiding.
Present: Senator Johnson.
OPENING STATEMENT OF SENATOR TIM JOHNSON

Senator JOHNSON. Good morning. This hearing will come to

order.
I welcome everyone to Rapid City today to discuss collaboration
between the Department of Veterans Affairs (VA) and the Indian
Health Service (IHS).
Present today are councilmen from Crow Creek Tribe, Oglala
Tribe, and the chairman of the Rosebud Tribe.
Our first panel today will be Dr. Robert Jesse, Principal Deputy
Under Secretary for Health, Veterans Health Administration
(VHA); Randy Grinnell, Deputy Director of the IHS; and Stephanie
Elaine Birdwell, Director of the Office of Tribal Government Relations (OTGR) at the VA.
Welcome, and I look forward to your testimony today.
IHS and the VA have very unique responsibilities, but often overlap in their roles of providing care to Native American vets. Todays hearing is aimed at determining how the two departments
plan to work together to deliver services in a more efficient manner.
The budget climate we face today means that the Federal Government is going to be asked to do more with less. The VA and IHS
will need to be more innovative and collaborative than ever in
order to provide services in a very demanding environment. In particular, the VA and IHS need to be more proactive in their efforts
to ensure that Native American vets receive the care that they
have earned through their service in the Armed Forces.
(1)

2
Native American vets face unique challenges in receiving VA
benefits due to a number of factors, including a lack of access on
tribal lands and an often confusing maze of bureaucratic hurdles
leaving vets unsure of whether they should be receiving care
through the IHS or the VA.
I am hopeful that todays hearing will provide a better understanding of how both departments plan to address these problems.
I am especially interested in how the VA and the IHS plan to leverage technology to bring services closer to where these vets live.
With that said, again I welcome you to South Dakota. Thank you
for coming, and I look forward to your testimony.
Dr. Jesse, please proceed.
STATEMENT OF ROBERT L. JESSE, M.D., Ph.D., PRINCIPAL DEPUTY
UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS

Dr. JESSE. Thank you, Senator.

Good morning, Mr. Chairman. First, thank you for inviting me
and Ms. Birdwell, the Director of the OTGR, to discuss the collaboration between the VHA and the IHS on improving access to care
for Native American veterans by maximizing the use of Federal
funds and services.
I am accompanied today also by Mary Beth Skupien, who is the
Director of the VHA Office of Rural Health, and Janet Murphy,
who is the Director of the VA Midwest Healthcare Network, which
is Network 23, providing services in South Dakota, North Dakota,
Iowa, and Minnesota, Nebraska, and portions of Illinois, Kansas,
Missouri, Wisconsin, and Wyoming.
Increasing access for veterans is one of Secretary Shinsekis top
priorities and has several components immediately relevant to the
Native American and rural veterans. On a national level, VA is investing more than $270 million to improve access and quality care
services to rural and highly rural veterans, including $43 million
in telehealth.
As of August 1, 2011, we are now operating 16 active telehealth
programs for Native American, Alaska Native, and Pacific Island
veterans. We continue to look for more opportunities to extend our
reach in delivering quality healthcare so that Native American veterans in remote areas can have the same access to healthcare from
national experts as their urban counterparts.
In October 2010, the VA and IHS signed a new memorandum of
understanding (MOU). Its principal goals are for VA and the IHS
to provide patient-centered collaborations in consultation with
tribes at regional and local levels. These efforts are already paying
dividends.
For example, last October, we initiated a pilot program here in
Rapid City, South Dakota, to promote the safety and cost effectiveness of providing prescription refills by mail for veterans and other
IHS patients. This program will enhance prescription delivery to
federally recognized tribes and about 2 million Native Americans.
Similarly, VA collaborates with IHS and tribal governments to
expand home-based primary care, including a number of local initiatives to improve access and outreach for Native Americans in
South Dakota. The VA Black Hills Healthcare System, to name one
example, maintains a robust noninstitutional purchased care pro-

3
gram that offers eligible veterans in-home care when travel for
healthcare is not possible or would be made difficult.
In addition, the Wagner, Watertown, Spirit Lake, Sioux City, and
Aberdeen clinics are planning information fairs and open houses to
inform veterans of available services and benefits, to enroll eligible
veterans so that they may access these hard-earned benefits.
The Sioux Falls VA Healthcare System holds monthly phone conferences with the IHS Aberdeen area office so IHS can determine
the potential areas of resource sharing, including services for radiology, audiology, laboratory, physical therapy, and patient transportation.
Through local agreements, VA and IHS share technical training,
informatics, and electronic health records (EHRs). VAs contract
clinics at Mission, Winner, Eagle Butte, Faith, Pierre, and Isabel
now serve veterans from Lakota, Nakota, and Dakota tribes in
South and North Dakota. VA provides transportation support to
the South Dakota tribes at Rosebud, Standing Rock, Cheyenne
River, and Pine Ridge Reservations. And VA provides pharmacy
mail order services for tribes in South Dakota.
In April 2010, VA opened the Wagner community-based outreach
clinic (CBOC), the first CBOC built on tribal land for a variety of
primary and mental healthcare. The Wagner CBOC also hosts a
home-based primary care team, which helps Native Americans remain in their homes and avoid frequent rehospitalizations or emergency room visits for chronic conditions.
Our Readjustment Counseling Service Mobile Vet Center Program provides early access to returning combat veterans via outreach at a variety of military and community events, and today we
want just to acknowledge and thank them for showing up here.
And they are parked outside the museum so that veterans can access our services.
And Mr. Chairman, we understand the unique difficulties Native
Americans face when accessing care. We are committed to working
to improve that access in partnership with IHS. We are introducing
VA providers to traditional healing practices so that they can work
to integrate these practices as adjuncts to Western medicine.
PREPARED STATEMENT

And finally, I just really want to thank you personally for your
support and that of the subcommittee and the Congress for securing VA resources that we need to deliver better, more accessible
care to Native Americans. As you know, there has been a book
written about the VA called The Best Care Anywhere. It is in its
second edition. And we think we strongly believe that the title of
that next book should be The Best Care Everywhere, and VA is
committed to providing that.
So thank you again, and I am prepared to answer any questions.
[The statement follows:]
PREPARED STATEMENT

OF

ROBERT L. JESSE

Good Morning, Mr. Chairman. Thank you for inviting me to discuss the collaboration between the Department of Veterans Affairs (VA) and the Indian Health Service (IHS) on improving access to care for Native American veterans by maximizing
the use of Federal funds and services. I am accompanied today by Mary Beth
Skupien, Director, Veterans Health Administrations (VHAs) Office of Rural Health,

4
and Ms. Janet Murphy, Director of the VA Midwest Health Care Network (Veterans
Integrated Service Network (VISN) 23), which provides services to veterans in
South Dakota, North Dakota, Iowa, Minnesota, Nebraska, and portions of Illinois,
Kansas, Missouri, Wisconsin, and Wyoming.
Native American veterans face many of the same challenges as veterans living in
rural and highly rural areas, such as geographic distance from healthcare facilities
and a shortage of skilled community providers. Native American veterans also face
unique challenges of their own, such as higher morbidity for certain conditions and
the need for culturally appropriate care. Earlier this year, VA established an Office
of Tribal Government Relations, which is working in close cooperation with VHAs
Office of Rural Health (ORH), specifically to serve as an advocate within the Department for Native American veterans and help VA improve healthcare access and
services for Native American veterans. Increasing access for veterans is one of the
Secretarys top priorities for the Department and has several components immediately relevant to Native American and rural veteransit means bringing care
closer to home, sometimes even into the veterans home; increasing the quality of
the care we deliver; and providing veteran-centered care in a time and manner that
is convenient to our veterans.
My testimony will begin by reviewing VAs plans in fiscal years 2011 and 2012
for continued support of ORH projects and other rural health initiatives. I will then
focus on VAs memorandum of understanding (MOU) with IHS and our continually
evolving partnership. My statement will conclude with a discussion of VAs efforts
in South Dakota to ensure veterans, particularly Native American veterans, receive
the care and benefits they have earned.
FUNDING FOR RURAL AND NATIVE AMERICAN VETERANS

With the funding provided by the Congress in fiscal year 2011, VA will invest
more than $270 million to improve the access and quality of healthcare services to
rural and highly rural veterans, including $43 million in telehealth programs. Telehealth involves the use of information technology to deliver services when the patient and healthcare provider are separated by geographic distance. We have seen
a 20-percent increase in the use of telehealth services by veterans living in rural
and highly rural areas between fiscal year 2008 and fiscal year 2010. VA-supported
telehealth programs offer specialty services, including mental health, dermatology,
amputee care, pharmacy, polytrauma, radiology, and others. As of August 1, 2011,
VA operates 16 active telehealth programs for Native American, Alaska Native, and
Pacific Island veterans. Telehealth can reduce the need for travel by patients and
providers, but it does not replace the need for face-to-face care delivery. We continue
to look for more opportunities to extend our reach in delivering quality healthcare.
We are exploring the use of wireless technologies, mobile resources, and more accessible facilities so that Native American and rural veterans in remote areas can have
the same access to healthcare from national experts as their urban counterparts.
Other ORH-managed programs include Project Access Received Closer to Home,
a pilot program authorizing the use of contractual agreements with non-VA providers to deliver care closer to home and three veterans rural health resource centers, which function as field-based clinical laboratories and serve as rural health experts for all VISNs. ORH also supports continuing projects and initiatives, including:
More than $70 million to support 52 rural community-based outpatient clinics
(CBOC);
Almost $26 million in home-based primary care at 21 sites;
$1.5 million to support treatment for substance use disorders;
Nearly $5 million to end homelessness among rural veterans including funds to
promote outreach, prevent homelessness among at-risk veterans, distribute
emergency housing vouchers, and support grant and per diem programs. ORHfunded programs in Sioux Falls and nationally are demonstrating improved collaboration within the community to address homelessness in rural areas and
have a demonstrable impact on preventing homelessness. These efforts also improve the quality of life and functioning for veterans served and reduce the frequency of visits by veterans within the primary care setting.
More than $3 million to enhance transportation options for veterans in rural
and highly rural areas; and
$91.2 million to sustain 76 additional rural health projects, such as mobile
health clinics, case management and mental health services, geriatric care, noninstitutional care, and other specialty services.
VA is addressing mental healthcare needs of rural veterans through ORHs support of the Mental Health Intensive Case Management program. This allows VA to

5
hire staff to provide case management services to veterans with severe mental illness. This program has demonstrated its success in preventing homelessness and
helping patients to set goals to improve their quality of life and reintegrate into the
community.
VA operates a fleet of 50 mobile vet centers that provide early access to returning
combat veterans via outreach to a variety of military and community events including demobilization activities. The vehicles are also extending vet center outreach to
more rural communities that are isolated from existing VA services. The vehicles
consistently provide services to Native American reservations and are staffed with
veterans who understand firsthand the needs of these communities.
The VA Black Hills Health Care System (Hot Springs campus) is serving almost
300 veterans in 13 counties within a 60-mile radius of the facility, including much
of the Pine Ridge Reservation, through a full home-based primary care (HBPC)
team. Further enhancements are planned for fiscal year 2012 to provide HBPC and
in-home skilled care for veterans in the southwestern portion of South Dakota, including previously unreached parts of the Pine Ridge Reservation. A second program
is VAs Medical Foster Home, which matches veterans who are unable to remain
in their homes with people in the community who are willing to care for them. This
is a new program that is currently being marketed to veterans and the community,
and we anticipate we will begin admitting veterans to the program later this year.
In fiscal year 2012, VA will continue to support many of the same projects as in
fiscal year 2011, and we look forward to initiating further measures to increase access to care for rural, highly rural, and Native American veterans. In fiscal year
2012, ORH will again support increased access to care by funding telehealth service
projects, such as tele-mental health, tele-retinal care, tele-pharmacy, tele-radiology,
tele-rehabilitation, tele-dermatology, and other innovative telehealth services. We
will conduct outreach and marketing efforts to encourage veterans who need these
services to access them. We will also support greater community collaboration and
access to specialty services, and we will promote education programs, including
healthcare provider training to teach providers how to care for the unique needs of
rural and highly rural veterans, as we enhance our recruitment and retention efforts for providers in rural areas.
INDIAN HEALTH SERVICE PARTNERSHIP

Complementing our national efforts, VA and IHS signed a new MOU on October
1, 2010. In contrast to a February 2003 MOU, this current agreement includes more
areas of focus and is more specific concerning the obligations of each party to coordinate the delivery of care for Native American veterans. The memorandums principal goals are for VA and IHS to promote patient-centered collaborations in consultation with tribes at the regional and local levels. Although national in scope, the
MOU provides the necessary flexibility to tailor programs through local implementation. We believe that by bringing together the strengths and resources of each organization, we will improve the health status of American Indian and Alaska Native
veterans.
We also recognize that interagency agreements are critical to our joint efforts. VA
and IHS continue to work through payment and reimbursement policies and practices, including working to resolve legal questions resulting from new provisions in
Public Law 111148, the Patient Protection and Affordable Care Act.
Another primary goal of the MOU is to promote the health of our veterans
through disease prevention and community-based wellness programs. Through cultural awareness and culturally competent care, sharing staff and training programs,
and collaborating on issues such as care for post-traumatic stress disorder (PTSD),
suicide prevention, pharmacy management, and long-term care, we can deliver the
care Native American veterans need.
VA and IHS have established 14 workgroups to develop specific recommendations
and action items related to the MOU. The workgroups are focused on areas such
as services and benefits, coordination of care, health information technology, implementation of new technologies, payment and reimbursement, sharing of services,
cultural competency and awareness, training and recruitment, and others. We have
made significant progress in many of these areas, and will continue to monitor
progress through weekly meetings and quarterly updates to leadership on the remaining items.
The efforts of VA and IHS are already paying dividends. For example, last October, we initiated a pilot program in Rapid City, South Dakota, to improve the safety
and cost effectiveness of providing prescription refills by mail for veterans and other
IHS patients. This program will enhance prescription delivery to federally recognized tribes and about 1.9 million Native Americans. Based on initial reports, both

6
veterans and staff are very pleased with the arrangement, which has reduced the
amount of time it takes to transfer medication from VA to veterans and improved
the ability of veterans to adhere to their treatment regimens.
Similarly, VA has several collaborative projects with IHS and tribal governments
to expand home-based primary care to Native American and rural veterans. In fiscal
year 2011, VA supported these programs in 11 States, including two locations in
South Dakota (Rosebud and Pine Ridge). Hospice and Palliative Care has also received support from VAs ORH to partner with IHS so that all veterans will have
reliable access to these services from a knowledgeable and skilled workforce.
SOUTH DAKOTA PROJECTS AND INITIATIVES

In addition to these collaborative efforts between VA and IHS, the Department

is also supporting a number of local initiatives to improve access and outreach for
Native American veterans in South Dakota. To this end, VA obligated approximately $4 million in fiscal year 2011 to expand telehealth, audiology, home-based
primary care, mental healthcare, and medical foster homes. When we are unable to
deliver care ourselves, VA Black Hills Health Care System maintains a robust noninstitutional purchased care program. This service offers eligible veterans in-home
care when travel for healthcare is not possible or would create a significant hardship. VA Black Hills Health Care System purchases home hospice, skilled nursing,
skilled services, homemaker/home health aide, and adult home day care services for
more than 1,000 rural veterans.
For mental healthcare, two sites offer Compensated Work Therapy in the State
of South Dakotathe Cheyenee River Miniconjou Lakota Reservation and the Pine
Ridge Oglala Lakota Reservation. VAs Compensated Work Therapy programs provide paid vocational rehabilitation models designed to return veterans with mental
health conditions to the highest level of functioning, living, and working in their
communities. VHA program staff work collaboratively and cooperatively with tribal
government leadership for reservation-based programming. VA also has established
mental health specialty clinics for Native veterans. For example, the Rosebud clinic
offers tele-psychiatry, and the Standing Rock facility offers tele-psychiatry and live
clinics for mental health conditions. Cultural outreach and other services include a
residential alcohol and PTSD program with a VA sweat lodge at the Hot Springs
clinic of the VA Black Hills Health Care System. Native Americans use the sweat
lodge as a spiritual place for healing to be able to send prayers and thoughts to the
Creator and grandfathers through the use of meditation, song, and prayers. A sweat
lodge is a dome-shaped structure made of 28 willow branches, which represent the
28 ribs of the sacred buffalo, covered by canvas or other materials to hold in the
heat and uses the heat and steam from the heated rocks for spiritual cleansing.
Several additional efforts are underway to increase Native Americans access to
care in South Dakota. For example, the Wagner, Watertown, Spirit Lake, Sioux
City, and Aberdeen clinics are planning information fairs and open houses to inform
veterans of services and benefits they may be eligible for and to enroll them if needed. The Sioux Falls VA Health Care System holds monthly phone conferences with
the IHS Aberdeen area office so the IHS can determine potential areas of resource
sharing, including services for radiology, audiology, laboratory, physical therapy, dietetics, telehealth, outreach, and patient transportation. We are also developing
plans to use video-teleconferencing to provide tele-mental health services to veterans
in the Sisseton area through an agreement between VA and IHS.
VA provides office space and serves as a regional information technical support
center for the Aberdeen Area Office of IHS. VA and IHS share technical training,
informatics, and electronic health records through local agreements. VA Hot Springs
provides IHS Pine Ridge Hospital with information resource management consultation and other services such as use of a General Services Administration vehicle,
phone line costs, and parts exchange-purchase. VAs contract clinic at Mission
serves veterans from Lower Brule and Sioux tribes, and the Winner VA CBOC located on the Rosebud Reservation serves veterans from Lower Brule, Rosebud, and
Yankton Sioux tribes, Eagle Butte, Faith, and Winner. VA provides transportation
support to the South Dakota tribes at Rosebud, Standing Rock, Cheyenne River, and
Pine Ridge Reservations, and VA provides pharmacy mail order services for tribes
in South Dakota.
In April 2010, VA opened the Wagner CBOC which is located on tribal land provided through an agreement with the Yankton Sioux Tribe and Aberdeen area IHS
and is the first CBOC built on tribal land for the sole purpose of providing VA primary and mental healthcare. The Wagner CBOC hosts an HBPC team, which helps
veterans remain in their homes and avoid frequent re-hospitalization or emergency

7
room visits for chronic conditions. Similarly, care coordination/home telehealth services are also provided at this facility.
CONCLUSION

Mr. Chairman, we understand the unique difficulties faced by Native American

and rural veterans in accessing care, and we are committed to working to improve
access to care. We are introducing VA providers to traditional healing practices and
the unique practices of local tribes to help them understand how these practices
may be integrated as adjuncts to traditional care. We greatly appreciate your support, and the Congress support, in securing the resources VA needs to deliver better, more accessible care to all of Americas veterans. This concludes my prepared
statement. I am prepared to answer your questions at this time.

Senator JOHNSON. Thank you, Dr. Jesse.

Mr. Grinnell, please proceed.
STATEMENT OF RANDY GRINNELL, M.P.H., DEPUTY DIRECTOR, INDIAN HEALTH SERVICE

Mr. GRINNELL. Good morning, Senator Johnson.

I am Randy Grinnell, Deputy Director of IHS. I am accompanied
today by Rick Sorenson from the Aberdeen area office. Pleased to
have this opportunity to testify on the IHS/VA collaboration.
IHS has a unique role in the Department of Health and Human
Services because it is a healthcare system established to meet the
Federal trust responsibility to provide healthcare to American Indians and Alaska Natives. Our mission is to raise the physical, mental, social, and spiritual health of American Indian and Alaska Natives to the highest level.
IHS provides comprehensive healthcare services to approximately 1.9 million American Indian and Alaska Natives through a
network of hospitals, health centers, and clinics located in 35
States, many of them in rural and remote areas where access is a
challenge. We also provide care through the private sector, through
Contract Health Service (CHS), for those types of services that are
not available directly.
In 2006, a joint VA/IHS study was initiated to review dual use
of the two systems. The findings of the study indicated that veterans using the VHA are similar to other veterans with similar
medical conditions, such as post-traumatic stress disorder (PTSD),
hypertension, and diabetes. The review also found that dual users
are more likely to receive primary care from IHS and general medical diagnostics and medical healthcare from the VHA, and they
are likely to receive complex healthcare services from both systems.
Many of the American Indian and Alaska Native veterans are eligible for healthcare services from both IHS and VHA. We estimate
within our patient registration system that we have got approximately 45,000 who are identified as veterans in our system. Many
of them live in rural areas as well and have trouble accessing direct facilities, and therefore, they are dependent upon our urban
Indian health programs where they are located in 34 cities.
IHS also pays for referred care outside the system for veterans
if they meet the CHS program rules and regulations. The VHA is
considered an alternate resource, along with Medicare, Medicaid,
and private insurance in accordance with our CHS regulations.
The MOU that Dr. Jesse talked about was recently signed in
2010. He identified the five mutual goals of that, which I will talk
about briefly. It was to improve access to care and services; im-

8
prove communication between the VA, tribes, and IHS; encourage
partnerships and sharing agreements between the three entities;
also to ensure appropriate support for programs that serve American Indian and Alaska Native veterans; and also to improve access
to health promotion and disease prevention services.
The principal focus of both of these agreements is to provide optimal healthcare to American Indian and Alaska Native veterans.
Examples include allowing VHA staff to utilize IHS and tribal facilities to provide services, opportunities that IHS providers take
advantage of through the VA for clinical skills training and education.
Dr. Jesse also talked about the traditional healing, where we
have been working with the VHA to bring that approach into their
delivery system. Dr. Jesse also talked about the VHA home-based
primary care project. Right now, there are 13 collaborative projects
in States in New York, North Carolina, Oklahoma, Oregon, New
Mexico, California, Mississippi, and Minnesota, as well as the Rosebud and Pine Ridge Reservations here in South Dakota.
One of the other examples includes increasing mental health
services by locating VHA social workers in healthcare facilities on
both the Navajo and the Hopi reservations in the Southwest.
Dr. Jesse also talked about the Wagner service unit, where the
VA has opened a community-based outpatient clinic. Services are
being shared there, include audiology, include lab, include dietary
and radiology.
On the Navajo reservation, an agreement is currently in place
with the Prescott VA that allows IHS office space for VA PTSD
counselors. Also there is work underway with Prescott to increase
services by allowing more space so that they can provide services
directly to Navajo veterans.
In Montana, there are currently telepsychiatry mental health
services provided at each of the service units throughout the Montana area. It is an example of success and a way of reaching those
remote locations and providing needed services.
Another example is in Alaska. Since 1995, there has been the
Alaska Federal Healthcare Partnership, which brought Federal and
tribal entities together to increase access of services both in the
rural areas and the remote areas of Alaska, but also to bring the
technology advancements that the VA has brought to healthcare
and take advantage of it.
There are more than 100 telemedicine equipment carts that are
now in rural locations throughout Alaska, and they also have deployed digital imaging radiology services to more than 51 Federal
and tribal facilities across Alaska.
I would like to also point out that the IHS and the VHA have
a long history of partnering for many decades, especially in the
health information technology arena. The IHS Resource and Patient Management System (RPMS) is actually a system that was
built and designed by the VA. IHS uses that in place. Many of the
tribes also take advantage of that.
And Dr. Jesse mentioned about the VistA, the VistA system that
they function with as well. The EHR that IHS currently has is one
that came out of the RPMS system. It is in place now. The RPMS
EHR is in place in more than 300 IHS tribal and urban facilities.

9
There are other projects underway with the VA that will increase
our utilization of their technology, and one of the results of that is
that the IHS EHR has been certified for meaningful use, which is
one of the new requirements under the Affordable Care Act.
Dr. Jesse also talked about the Consolidated Mail Outpatient
Pharmacy (CMOP) project. IHS is working with them. One of the
pilots is right here in Rapid City. To date, we have had more than
20,000 prescriptions that have been filled through that project. It
has allowed two of our pharmacists at our IHS facility to focus on
providing direct patient care, which we feel is a tremendous outcome.
Also both staff and patients have been extremely satisfied with
this new service. So IHS and VA are pursuing utilizing the CMOP
throughout the entire system.
So we are committed. IHS is very committed to working with the
VHA to improve access to services for American Indian and Alaska
Native veterans.
PREPARED STATEMENT

That concludes my remarks today, Senator, and I am happy to

answer any questions.
[The statement follows:]
PREPARED STATEMENT

OF

RANDY GRINNELL

Mr. Chairman and members of the subcommittee: Good morning. I am Randy

Grinnell, the Deputy Director of the Indian Health Service (IHS). I am pleased to
have the opportunity to testify on the IHS/Department of Veterans Affairs (VA) collaboration.
The IHS plays a unique role in the Department of Health and Human Services
(HHS) because it is a healthcare system that was established to meet the Federal
trust responsibility to provide healthcare to American Indians and Alaska Natives
(AIs/ANs). The mission of the IHS is to raise the physical, mental, social, and spiritual health of AIs/ANs to the highest level. The IHS provides comprehensive health
service delivery to approximately 1.9 million AIs/ANs through hospitals, health centers, and clinics located in 35 States, often representing the only source of
healthcare for many AI/AN individuals, especially for those who live in the most remote and poverty-stricken areas of the United States. The purchase of healthcare
from private providers through the Contract Health Services (CHS) program is also
an integral component of the health system for services unavailable in IHS and tribal facilities or, in some cases, in lieu of IHS or tribal healthcare programs. IHS accomplishes a wide array of clinical, preventive, and public health objectives within
a single system for AIs/ANs.
AMERICAN INDIAN/ALASKA NATIVE VETERANS DUAL USE OF INDIAN HEALTH SERVICE
AND VETERANS HEALTH ADMINISTRATION

In 2006, a joint Veterans Health Administration (VHA)-IHS study was initiated

to review dual use of the two systems by AI/AN veterans. The findings of this study
indicate that AI/AN veterans using the VHA are demographically similar to other
VHA users with similar medical conditions, such as post-traumatic stress disorder
(PTSD), hypertension, and diabetes. The review found that dual users are more likely to receive primary care from IHS, and general medical diagnostic services and
mental healthcare from the VHA. They are likely to be receiving complex care from
both VHA and IHS.
Many AI/AN veterans are eligible for healthcare services from both IHS and VHA.
IHS has an estimated 45,000 Indian beneficiaries registered as veterans in the
agencys patient registration system. Some AI/AN veterans who live in urban locations do not have geographic access to care in IHS facilities on or near reservations
and must use the local systems of care or Urban Indian Health Programs (UIHP)
where they are available. In some of these locations the UIHPs provide limited direct care and assist these patients in accessing VHA and other services in the local

10
area. AI/AN veterans residing on reservations in some cases are not easily able to
access VHA health facilities and services.
IHS recognizes that the complexity of IHS-CHS program and VHA eligibility requirements can make it difficult for AI/AN veterans to access care. IHS pays for the
care referred outside of IHS for AIs/ANs including veterans if all the CHS program
rules and regulations are met. For the AI/AN veteran, the VHA is an alternate resource along with Medicare, Medicaid, and private insurance in accordance with the
CHS regulations.
DEPARTMENT OF HEALTH AND HUMAN SERVICES/INDIAN HEALTH SERVICEDEPARTMENT
OF VETERANS AFFAIRS/VETERANS HEALTH ADMINISTRATION MEMORANDA OF UNDERSTANDING

A memorandum of understanding (MOU) between the HHS/IHS and the VA/VHA

was signed in 2003 to encourage cooperation and resource-sharing between the two
Departments. The 2003 MOU outlined joint goals and objectives for ongoing collaboration between VA and HHS to be implemented primarily by IHS and VHA. The
MOU advanced our common goal of delivering quality healthcare services to and improving the health of the 383,000 veterans who identified as AIs/ANs within the
VHA system, a portion of which are served by IHS. The HHS/IHS and the VA entered into this MOU to further their respective missions, to serve AI/AN veterans
who comprise a segment of the larger beneficiary population for which they are individually responsible.
Tribes stressed the need to improve collaboration and coordination of services for
veterans eligible for both the VA and IHS services. The IHS Director met with VA
Secretary Shinseki in May 2010, and they agreed to update the 2003 VAIHS MOU
to improve collaboration and coordination of services for AI/AN veterans. The updated MOU was signed in October 2010 and a consultation on implementation of
the MOU was initiated with tribes in November, 2010. Tribal leaders identified priorities for implementation and the VA and IHS are working on improvements to
better coordinate care, services and benefits, State-level agreements, implementation of new technologies, payment and reimbursement, health information technology, training, and cultural competency. IHS area directors are already working
locally in some areas with the VHA and tribes to make improvements specific to
the unique needs of veterans in the IHS area and local levels.
The MOU identifies five mutual goals to:
Improve beneficiary access to healthcare and services;
Improve communication among the VA, AI/AN veterans and tribal governments
with IHS assistance;
Encourage partnerships and sharing agreements among VHA, IHS, and tribal
governments in support of AI/AN veterans;
Ensure the availability of appropriate support for programs serving AI/AN veterans; and
Improve access to health promotion and disease prevention services for AI/AN
veterans.
INDIAN HEALTH SERVICEVETERANS HEALTH ADMINISTRATION COLLABORATIONS

The principal focus of the interagency communication and cooperation is to provide optimal healthcare for the AI/AN veterans who rely on the IHS and/or VHA
for their medical needs. Together, we strive to achieve multiple goals outlined by
the MOU by developing projects that, for example, improve access to VHA services
by allowing VHA staff to utilize Indian health facilities for providing healthcare to
AI/AN veterans while the joint working relationship expands opportunities for professional development of clinical skills by IHS providers. IHS experience with the
use of traditional healing in its system became a model for the VHA when it began
incorporating traditional approaches to healing for AI/AN veterans.
AREA DIRECTOR MEETINGS WITH VETERANS INTEGRATED SERVICE NETWORK

Other collaborations that meet the goals of the MOU range from expansion of access to VHA home-based primary care for AI/AN veterans through the collaboration
with IHS and tribal health facilities to the improvement of interagency partnership
on health information and the use of tele-health modalities. The home-based primary care program expansion will increase availability of services for AI/AN veterans with complex chronic disease and disability through 13 collaborative projects
located in States including New York, North Carolina, Oklahoma, Oregon, New
Mexico, California, Mississippi, and Minnesota and two locations in South Dakota
(Rosebud and Pine Ridge). In 2010, this collaboration resulted in a five-fold (11 to
55 veterans) increase in the number of AI/AN veterans served by home-based pri-

11
mary care. In Arizona, the IHS and the VHA are working together to increase mental health services by locating VHA social workers in IHS health facilities on the
Navajo and Hopi reservations.
SHARING FACILITIES

The Wagner IHS facility recently opened a VA community-based outpatient clinic

(CBOC). IHS has an audiology booth in the facility and the VA has an audiologist
they can send to the facility to see both VA and service unit patients. Both agencies
are also sharing lab services, the service unit provides onsite lower level lab services
to the VA while the VA provides some higher level lab services at an alternate location. The service unit is developing the capacity to provide radiology services to the
CBOC. The service unit also provides onsite dietary services to the CBOC patients.
The Navajo Area IHS (NAIHS) is currently working on an approval for the Prescott VA providers to be allowed space in an IHS facility to increase access to VA
services for veterans on the Navajo Nation. The NAIHS already has an agreement
with Prescott VA that allows office space for a PTSD counselor in an IHS facility
to provide counseling and increase access to services. The NAIHS is also working
with Veterans Integrated Service Network (VISN) 18 to develop an IHSVA task
force to address specific issues to these organizations.
TELEMEDICINE

In Montana, the Billings Area IHS and the VHA Montana Healthcare System
(VHAMHCS) have ongoing collaborative efforts such as tele-psychiatry established
at each service unit to facilitate VHA mental health services for AI/AN veterans.
Because of the geographic remoteness and difficulty in accessing transportation to
a VHA facility, this service greatly benefits the AI/AN veterans. The Billings Area
IHS and VHAMHCS have formalized a PTSD protocol that is utilized by the service
units and Fort Harrison. Among the protocol elements, the VHA has created a position designated as a tribal outreach worker (TOW) who works on-site to actively
seek and educate veterans who may benefit from the services provided through telepsychiatry clinics. Each service unit has a designated VHA liaison to help the AI/
AN veterans needing medical services as well as working with the TOW and local
tribal veteran representative (TVR). As the primary IHS contact, they can provide
information, assistance, and guidance on VHA services and health benefits to AI/
AN veterans. To distinguish the different roles and responsibilities, the TVRs function as an arm of the VA program with the IHS providing and coordinating the medical care for the AI/AN veteran. These collaborative efforts are reviewed on an ongoing basis in efforts to address patient-related issues, improve services, outreach,
and rural initiatives, and to assist AI/AN veterans to utilize both the IHS and VHA
systems.
OUTREACH (TRIBAL VETERAN REPRESENTATIVES)

VAs development and use of the TVR program has been and is critical to addressing issues related to communicating about and reducing barriers to VHA services
and to the IHS-CHS program for AI/AN veterans through coordinated training on
benefits and eligibility issues for each of the two programs.
HEALTH INFORMATION TECHNOLOGY

The IHS and VHA have a long history of working jointly on health information
technology that dates back to the early 1980s. The Resource and Patient Management System (RPMS) is the IHS comprehensive health information system that is
derived from and evolved alongside the VHAs acclaimed VistA system. IHS/tribal/
UIHP (I/T/U) facilities use many components of VistA along with IHS-developed
components that address the population and public health mission of IHS.
The model for the RPMS electronic health record (EHR) is the Computerized Patient Record System, the EHR component of VistA. Since its release in 2005, the
RPMS EHR has been deployed to more than 300 I/T/U healthcare facilities nationwide. IHS continues to leverage VHA healthcare software development by adapting
it for our use where possible.
VISTA IMAGING

Another important example of IT sharing between VHA and IHS is VistA Imaging
(VI), the VHAs Food and Drug Administration-certified system for capture, storage
and viewing of diagnostic images and scanned documents. VI provides the multimedia component of both agencies EHR systems, and has now been deployed to
more than 90 I/T/U facilities across the country. This deployment would not have

12
been possible without interagency agreements that have allowed VHA staff and contractors to provide implementation support and help desk services to our facilities.
The VHAs VI program is critical to IHS.
BAR CODE MEDICATION ADMINISTRATION

Like VI, the VHA Bar Code Medication Administration (BCMA) system is an integral component of modern hospital practice. BCMA ensures that the right patients
are receiving the right doses of the right medications in the inpatient setting. The
IHS, in cooperation with the VHA Bar Code Resource Office, is just beginning a
joint effort to deploy BCMA in IHS and interested tribal hospitals. This effort will
be modeled after the successful VI collaboration previously described.
MEANINGFUL USE

The Meaningful Use Initiative authorized by the HITECH Act of 2009 has given
the IHS an opportunity to materially assist the VHA with an important effort. In
April 2011, the IHS became the first Government agency to have its health information system certified according to the requirements for Meaningful Use. The VHA
is seeking to certify the VistA system in 2012, and has reached out to IHS staff for
consultation on how we addressed the various certification criteria. Our staff is
more than willing to do so, as IHS has greatly benefited from so many VHA innovations in health information technology for more than two decades.
ALASKA AREA INDIAN HEALTH SERVICEVETERANS HEALTH ADMINISTRATION HEALTH
INFORMATION TECHNOLOGY COLLABORATIONS

The Alaska Area IHS has partnered with the VHA since 1995 via the Alaska Federal Health Care Partnership (AFHCP) which includes IHS/tribal, VHA, Army, Air
Force, and Coast Guard partners. The AFHCP offices primary responsibility is to
coordinate initiatives between the partners that result in increased quality and access to Federal beneficiaries, or an overall cost savings to the Federal Government.
Current initiatives in the Alaska Area IHS include:
joint training offerings;
a neurosurgery contract services agreement;
a perinatology contract services agreement;
tele-radiology;
sleep studies;
home tele-health monitoring;
partner staffing needs assessment;
emergency planning and preparedness; and
tele-behavioral health.
Past projects of AFHCP include the Alaska Federal Health Care Access Network
(AFHCAN) which deployed network capability (backbone) along with hundreds of
telemedicine equipment carts, the Teleradiology Project, deploying digital imaging
radiology services to 51 federally and tribally managed IHS-funded facilities, video
teleconferencing equipment to promote administrative and clinical consults, as well
as an IT partnership bridge (Raven Bridge), allowing Federal and tribal partners
to connect to each other.
The AFHCP frequently shares workload data during its investigations of possible
joint services analyses; a recent example is a study for joint-agency tele-dermatology
and tele-rheumatology contracts. One of the AFHCP committees is the Partnership
Telehealth & Technology Committee (PT&T) which brings together information
technology staff to discuss partner organization needs, identify potential telehealth
and technology applications to meet those needs, and find avenues for shared technology resources. PT&T members and their clinical champions will monitor patient
results and gather feedback on the use of new technologies to improve clinical outcomes and access to care.
CONSOLIDATED MAIL OUTPATIENT PHARMACY

The Consolidated Mail Outpatient Pharmacy (CMOP) is a VHA program that consolidates and automates the mailing of prescriptions and refills to veterans across
the country, relieving workload from pharmacy staff at VHA facilities. The VHA has
permitted IHS to use the CMOP facility at Leavenworth, Kansas to provide prescription mail-out services for IHS beneficiaries. The pilot has been going on for
more than a year, right here in Rapid City. More than 21,000 prescriptions have
been processed through the IHS CMOP to date, allowing two full-time pharmacists
to move from the pharmacy into the clinic where they can provide direct patient
care services, (i.e., anti-coagulant clinic) and improve access to care. The program

13
has improved patient safety by reducing medication errors, and has improved both
patient and staff satisfaction. IHS use of the CMOP facilities will centralize routine
prescription filling and increase pharmacy collections, and will greatly reduce travel
time for patients. In addition, it will enable pharmacy staff to focus on patient counseling, adverse drug event prevention, and primary care.
FUTURE OPPORTUNITIES OF PARTNERSHIP

Local IHSVHA efforts to improve access and develop formal partnerships have
increased since 2003. IHS will continue joint efforts on issues related to access to
healthcare for AI/AN veterans. We are committed to working on these issues, within
the IHS, as well as with the VA and the VHA. AI/AN Native communities have always honored their veterans and we are committed to improving the health services
they utilize and the quality of their lives.
Mr. Chairman, this concludes my testimony. I appreciate the opportunity to appear before you to discuss the collaboration between the HHS through the IHS and
the VA through the VHA. I will be happy to answer any questions that you may
have. Thank you.

Senator JOHNSON. Thank you, Mr. Grinnell.

Ms. Birdwell.
STATEMENT OF STEPHANIE ELAINE BIRDWELL, DIRECTOR, OFFICE
OF TRIBAL GOVERNMENT RELATIONS, DEPARTMENT OF VETERANS AFFAIRS

Ms. BIRDWELL. Good morning, Chairman Johnson. Thank you for

inviting me to discuss VA outreach to tribal governments.
On November 5, 2009, President Obama signed the Memorandum on Tribal Consultation, pronouncing tribal consultations a
critical ingredient of a sound and productive Federal/tribal partnership. As part of the strategy to realize the Presidents vision of regular and meaningful consultation and collaboration with tribal officials, VA created the OTGR, and I was appointed as Director of
this office earlier this year.
Guided by the tribal consultation policy signed by Secretary
Shinseki in February 2011, the office was created to develop partnerships with American Indian and Alaska Native tribal governments for the purpose of enhancing access to services and benefits
for Native veterans.
We must maintain lasting bonds with tribal leaders and Native
veterans. Meaningful consultation is absolutely vital if we are to effectively address the unique needs of this population.
VAs OTGR serves as an entry point for American Indian and
Alaska Native tribal government concerns. With an estimated
383,000 Native American veterans and 565 federally recognized
tribes, there is much work to be done.
VA is embarking on a robust outreach and consultation effort
that will focus on listening, aiding, and advocating. We believe the
best way to create lasting bonds of trust is to meet with tribal leaders and their communities. VA has held listening sessions in Bethel, Alaska; Billings, Montana; and Bismarck, North Dakota. I am
excited to hear from local tribal leaders and veterans right here in
Rapid City and Kyle, South Dakota.
The office is very grateful for the vast cooperation each of these
tribes has provided. Without this support, it would be difficult for
OTGR to understand the challenges Native American veterans are
facing.
While we are in the communities, we are aiding and training Native American veterans. For example, VA staff have trained tribal

14
veteran representatives (TVRs) in Montana and Alaska and provided technical assistance to Native American veterans seeking
home loans during a recent gathering of Northwest tribal leaders
and veterans in Spokane, Washington.
We can leverage these opportunities to increase Native American
enrollment in VAs healthcare system, educate veterans about benefits for which they may be eligible, and connect them with online
resources, such as eBenefits and My HealtheVet.
VAs goal of creating a bond of trust with American Indian and
Alaska Native tribal governments is not an end, in and of itself.
This bond should lead to improved access to benefits and services,
as well as economic sustainability for veterans in Indian Country.
My office is working with the VHA to enhance access to
healthcare in several ways. We are facilitating technical assistance
and the sharing of best practices with the IHS as part of our effort
to implement the MOU between the VA and IHS. Our role is to ensure tribal concerns are heard and considered.
To this end, we will hold annual listening sessions, in addition
to formal consultation, to obtain recommendations, hear local priorities, and advocate the tribes perspectives on practices that will
improve access to care.
After OTGR was created, we worked with various stakeholders
within VA to draft a vision statement. We see a future where we
consistently demonstrate our commitment to Native American veterans by being culturally competent, respecting the unique sovereign status of tribes, and reaching out to veterans in their communities.
As an enrolled member of the Cherokee Nation of Oklahoma with
more than 15 years experience in Indian affairs, I know it will take
time, but I believe it is a goal we can achieve. Serving both Indian
Country and our Nations heroes is both a professional and deeply
personal calling.
PREPARED STATEMENT

Thank you for the opportunity to discuss the work VA is doing

to reach out to Native American veterans and tribal leaders. I look
forward to answering any questions you may have.
[The statement follows:]
PREPARED STATEMENT

OF

STEPHANIE ELAINE BIRDWELL

INTRODUCTION

Good Morning, Chairman Johnson and members of the subcommittee: Thank you
for inviting me to discuss Department of Veterans Affairs (VA) outreach to tribal
governments.
On November 5, 2009, President Obama signed the Memorandum on Tribal Consultation pronouncing tribal consultations a critical ingredient of a sound and productive Federal-tribal relationship. As part of the strategy to realize the Presidents
vision of regular and meaningful consultation and collaboration with tribal officials, VA created the Office of Tribal Government Relations (OTGR). I was hired
as the Director of this office earlier this year. The fiscal year 2012 budget request
includes $800,000 to support the establishment of this new office.
Guided by the Tribal Consultation Policy signed by Secretary Shinseki in February 2011, OTGR has been charged to develop partnerships with American Indian
and Alaska Native tribal governments for the purpose of enhancing access to services and benefits for Native veterans. We must maintain lasting bonds with tribal
leaders and Native American veterans. Meaningful consultation is absolutely vital
if we are to effectively address the unique needs of this population.

15
Trust is the single most important aspect in our relationship with the tribes and
Native American veterans. VA is working to earn the trust of tribal leaders and Native American veterans through consistent outreach and an open door policy. As an
enrolled member of the Cherokee Nation of Oklahoma with more than 15 years experience in Indian Affairs, I know it will take time, but I believe it is a goal we
can achieve. Serving both Indian Country and our Nations heroes is both a professional and deeply personal calling.
OUTREACH AND CONSULTATION

VAs OTGR serves as an entry point for American Indian and Alaskan Native
tribal government concerns. With an estimated 383,000 Native American veterans
and 565 federally recognized tribal entities, there is much work to be done. VA is
embarking on a robust outreach and consultation effort that consists of three pillars:
listening, aiding, and advocating.
Listening certainly includes receiving communications from tribal leaders through
email, phone, and social media tools, but we believe the best way to create lasting
bonds of trust is to meet with tribal leaders in their communities. VA has held listening sessions in Bethel, Alaska; Billings, Montana; and Bismarck, North Dakota.
I am excited to hear from local tribal leaders and veterans right here in Rapid City,
South Dakota. OTGR has participated in conferences in Arizona, Montana, Idaho,
Texas, Wisconsin, Oklahoma, and Washington. We have also conducted site visits
to key locations that deliver services to Native American veterans, including the
Consolidated Mail Outpatient Pharmacy in Leavenworth, Kansas, and tribal courts
in Navajo Nation, Hopi and Laguna Pueblo Tribes. OTGR is very grateful for the
vast cooperation each of these tribes has provided. Without this support, it would
be difficult for OTGR to understand the challenges Native American veterans are
facing. We will maintain an aggressive outreach schedule to increase the number
of American Indian and Alaska Native tribal governments with which we are building relationships.
While we are in the communities, we are aiding and training Native American
veterans. For example, VA staff have trained tribal veteran representatives in Montana and Alaska and provided technical assistance to Native American veterans
seeking home loans during a recent gathering of Northwest tribal leaders and veterans in Spokane, Washington. Our outreach provides a unique opportunity to deliver technical information to Native American veterans. We can leverage these opportunities to increase Native American veteran enrollment in VAs healthcare system, educate veterans about benefits for which they may be eligible, and connect
them with online resources such as eBenefits and My HealtheVet. Every encounter
with tribal leaders and veterans in Indian Country is an opportunity to make a difference in a veterans life.
OTGR is also advocating for tribal governments. The Secretary of Veterans Affairs
is committed to conducting meaningful consultation with tribes; this means transforming words into action. We plan to facilitate five tribal consultation sessions in
2012 at different locations across the country. Tribal leaders will have an opportunity to voice their concerns on issues that affect the well-being of veterans and
their families. With a direct link to the tribes through OTGR, we will be able to
address their concerns before new policies and procedures are implemented. OTGR
is already serving as a vital intergovernmental link for VAs health, benefits, and
memorial programs.
INCREASE ACCESS TO HEALTHCARE AND SUSTAINABLE ECONOMIC OPPORTUNITIES

OTGRs goal of creating a bond of trust with American Indian and Alaska Native
tribal governments is not an end in itself. This bond should lead to improved access
to benefits and services as well as economic sustainability for veterans in Indian
Country.
OTGR is working with the Veterans Health Administration (VHA) to enhance access to healthcare in several ways. First, OTGR is facilitating technical assistance
and the sharing of best practices with the Indian Health Service (IHS) as part of
our effort to implement the memorandum of understanding (MOU) between VHA
and IHS. VHAs Office of Rural Health has made great strides in supporting the
delivery of care to rural veterans across the country. OTGRs role is to ensure tribal
concerns are heard and considered. To this end, OTGR will hold annual listening
sessions in addition to formal consultation to obtain recommendations, hear local
priorities, and advocate the tribes perspectives on practices that will improve access
to care. In addition, OTGR is working with VHA to realize opportunities to integrate
new media and other communication tools to promote innovative technologies that
bring care to rural communities.

16
Mental healthcare is a critical component of overall healthcare, and Native American veterans often face unique challenges in accessing appropriate mental
healthcare. To promote better mental healthcare in this population, VA has undertaken several initiatives. In Alaska, we are exploring a partnership with the South
East Alaska Regional Health Consortium to provide mental health compensation
and pension examinations. OTGR has worked closely with VHA to identify similar
best practices and to explore options for exporting them. Currently, as part of the
implementation of the VA/IHS MOU on enhancing services to Native American veterans, several new initiatives are being implemented. Guidance on outreach and
education to tribes about VA/IHS post-traumatic stress disorder (PTSD) services will
involve further disseminating training materials created by VA, designed to make
initial connections with and provide information to tribal governments about VA
services.
The training has been used extensively in the Western States (e.g., Montana,
Idaho), and a current project will focus on Eastern areas, including those in Veterans Integrated Service Network (VISN) 6, with tribes such as the Lumpee, and
in VISN 1. VA staff and tribal groups will expand the original training materials
with information that describes local VISN 6 facility services. Information also will
be associated with significant symbols of the local tribes. There will also be another
satellite broadcast/DVD to support this planned outreach effort. In addition, the National Center for PTSD Web site, (www.ncptsd.va.gov) has the video: Wounded
Spirits, Ailing Hearts: PTSD in Native American Veterans, created in 2000 with
versions for clinicians and general audiences (http://www.ptsd.va.gov/public/videos/
wounded-spirits-ailing-hearts-vets.asp).
To address substance abuse and mental health issues among veterans, VA has
worked with veterans treatment courts across the country. These courts identify
treatment options for many of our veterans with substance use disorders or mental
health conditions. OTGR is working with VHA to create a veterans treatment court
how to guide to help identify and link Native American veterans involved with the
criminal justice system with VA resources and other providers as an alternative to
incarceration. Our goal is to provide tribal governments the resources they need to
incorporate, at their discretion, elements of the veterans treatment court model that
may promote healing in their communities. This model may not work for every tribal justice system, but these practices generally are consistent with the holistic approach to criminal justice practiced by many tribal justice systems and may be a
valuable tool at their disposal. Local circumstances will help define our ability to
implement many of these best practices, but we must learn from our experiences
and leverage our successes.
In addition to working with VHA to increase access to care, we are also working
with the Veterans Benefits Administration to address systemic economic issues
within tribal communities. We can and will do more to increase access to and utilization of established benefits such as compensation and pension, vocational rehabilitation and employment services, and Post-9/11 GI Bill and other education benefits.
Recent changes to the Post-9/11 GI Bill program illustrate the need for a direct link
to Indian Country. We are using every avenue available to us to ensure that veterans know how changes to that program will directly affect them, and OTGR will
be a vital resource for tribal leaders and a conduit for feedback.
One area that we believe deserves special attention is the Native American Direct
Loan Program (NADL), a vital tool in VAs efforts to provide permanent housing options for Native American veterans. NADL is available for Native American veterans and their spouses to purchase, construct, or improve a home on trust land or
to refinance an existing NADL at a lower interest rate. OTGR is increasing VAs
efforts in Indian Country and Alaska to educate eligible veterans about this important program. Our goal to make sure every eligible veteran understands the value
the NADL benefit as a long-term housing solution.
OTGR will also work with tribal leaders to address memorial issues. VAs first
grant to establish a veterans cemetery on tribal trust land, as authorized in Public
Law 109461, was approved by the Secretary of Veterans Affairs on August 15,
2011. The amount of the grant, $6,948,365, is for the Rosebud Sioux Tribe, and the
cemetery will be located in White River, South Dakota. This grant will fund the construction of a main entrance, an administration building, a maintenance facility,
roads, an assembly area, a committal shelter, preplaced crypts, cremains burial
areas, memorial areas, columbaria, landscaping, a memorial walkway, and supporting infrastructure. The project will provide services to approximately 4,036
unserved Rosebud Sioux Tribe veterans and their families. The project will develop
approximately 14.40 acres. The construction will include 600 pre-placed crypts, 544
cremains gravesites, and 32 columbarium niches. The cemetery will provide improved service for veterans and their families of the Rosebud Sioux Tribe. The near-

17
est VA national cemetery is Hot Springs National which is closed and 169 miles
away in Hot Springs, South Dakota. The proposed cemetery will be near Mission,
South Dakota on the Rosebud Indian Reservation.
We must measure our progress and hold ourselves to a high standard of achievement if we are to accomplish our goals. This starts with compiling recommendations
from tribal leaders and tracking these action items to the point of completion. We
do not promise that every recommendation we receive will be adopted, but we do
commit to ensuring tribal leaders and veterans voices are heard and considered.
Our success will be not only be measured by the frequency of our contact with federally recognized tribes, but also by utilization rates for benefits and programs and
healthcare enrollment by eligible Native American veterans. A stronger relationship
between the tribes and VA will lead to better results and outcomes for Native American veterans.
CONCLUSION

After OTGR was created, we worked with the various stakeholders within VA to
draft a vision statement. We see a future where American Indian and Alaska Native
tribal governments view VA as an organization of integrity that advocates on behalf
of Native American veterans for their needs. We see a future where VA demonstrates its commitment to Native American veterans by being culturally competent, respecting the unique sovereign status of tribes, and reaching out to veterans in their communities. We are committed to building a relationship with tribal
leaders built on a culture of trust and respect. We see a bright future, but there
is still much to be done.
Thank you again for the opportunity to discuss work VA is doing to reach out to
Native American veterans and tribal leaders. I look forward to answering any questions you may have.

Senator JOHNSON. Thank you, Ms. Birdwell.

Too often I hear stories from Native American vets that they
show up at IHS facilities only to be told that they should be going
to the VA and that there is no patient coordination occurring. The
new MOU is supposed to address this issue and break down these
barriers.
Mr. Grinnell, can you describe in detail how this MOU will increase patient coordination between the IHS and VA? Specifically,
if a vet shows up at an IHS facility with a service-connected disability, will they be treated at IHS or be told to go to the VA?
Mr. GRINNELL. Thank you for your question, Senator.
That is probably one of the most challenging aspects of what we
are trying to improve on. A good example is that when I mentioned
in my opening comments that the VHA is considered an alternate
resource for IHS, per our CHS regulations. So any time that a veteran does access our system and they have to be referred out for
care, then we have to exhaust all other opportunities before it
qualifies for CHS.
To begin to address that, one of the things that the IHS and the
VHA are doing is training both the IHS staff, as well as the VHA
staff in terms of what services are available and also understanding the eight categories that the veterans have to be eligible
for for consideration. Trainings have already taken place in a number of the service units where our staff is being trained so that they
fully understand. And our goal at the end is so that the veteran
itself is not being shuffled back and forth between the two systems,
but there is good coordination of care.
Further things that we are talking about is how we can hopefully
do case management of that individual patient between both systems so that they dont feel like that they are being passed off from
one system to the other.

18
INDIAN HEALTH SERVICE AND DEPARTMENT OF VETERANS AFFAIRS
COORDINATION

Senator JOHNSON. Dr. Jesse, the VA has a good track record of

coordination with DOD health facilities. But it seems that coordination with the IHS has been difficult. From the VAs perspective,
how do you believe the MOU will give Native American vets better
access to VA services and break down these bureaucratic barriers?
Dr. JESSE. Thank you, Senator.
I think there are several aspects to answering that question.
First is the simple matter of coordinating the information related
to healthcare. So that what a given patients issues are, are then
visible to both the VA and the IHS. With a shared electronic
record, that is increasingly easier to do.
Second is that both the IHS and the VA are actively implementing, I guess as a common collective term, new models of care,
moving from a single-provider model into a team-based model of
care, with a heavy emphasis on care coordination. This, I think,
will allow for that level of coordination which occurs in any one of
those services to be much more visible to the other in times when
that is needed because it is not dependent on a single provider.
Another piece I think is the great commitment that VA has made
and is sharing, I guess is the best way to say that, in terms of telehealth with IHS. By combining these resources, IHS has been extremely accommodating in providing outlets for telehealth on the
reservations so that we can get a lot of the care that would normally require people to go somewhere for high-level care. This includes, very importantly, mental healthcare, but also much of the
subspecialty care, for instance, in cardiology or any number of the
other subspecialties that can be managed through telehealth. It
very much minimizes the need to have people travel long distances
for what would be simple appointments.
We cant do procedures by telehealth but certainly can determine
when procedures are needed and where the best place for people
to go when they are needed without having to have multiple visits
prior to that. I think there is already, at the early stage of the deployment of telehealth, modalities through American healthcare
with VA collaborating with IHS. We are very much moving this
whole initiative forward.
There are some challenges, to be sure. The technology is rapidly
evolving. Teaching providers how to use it is at times challenging.
Although, interestingly, our fear was that patients would be less
accepting and have to get used to it, and my sense is that is not
the case. You can correct me if I am wrong, but the patients love
it. It allows them to speak to the people they need to speak to without having long delays for appointments and long travel times to
do this.
The whole notion of how healthcare is going to be delivered
through team-based care and the use of telehealth and these other
modalities is very important.
One other thing I will just mention is that to my mind, one of
my personal interests is, how do we get patients, veterans, and patients in the IHS, invested in their own health in ways that they
can take greater control in managing it? Part of that is by having

19
them be able to interact with their personal health records, so that
the health record is not a mystery that lives in the providers office,
but something they can engage with on a relatively routine basis.
VA has started this with My HealtheVet. There has been a lot
of press recently about an innovation that we have been rolling out
called the Blue Button, which allows patients who use My
HealtheVet to actually download substantive parts of their records.
Probably, I am guessing, within the year, it will be the entire medical record that can live in their possession, and they can have it
with them.
There will never be a question about what has been done, what
prior lab results, what prior tests were done. And with all of these
things, VA is rolling these out in collaboration with IHS and distributing this into the rural and highly rural populations.
PAYMENT AND REIMBURSEMENT

Senator JOHNSON. Dr. Jesse, in your testimony, you mentioned

that the VA and IHS are still working through payment and reimbursement policies. When do you believe these will be worked out?
Dr. JESSE. I think that is actually a pretty simple question to answer because our respective Secretaries have made it very plain to
staff that they expect this to be worked out by the end of the calendar year. We have been given marching orders from the Secretaries to get this resolved, to do it quickly, and get it right.
Their timeline is end of the calendar year.
Senator JOHNSON. Mr. Grinnell, how do you see the work with
other private hospitals proceeding, and is it true that the Native
American saying that you better get sick through June or it is all
over with still holds true?
Mr. GRINNELL. The statement about dont get sick after June
referred towithin the CHS program, there is one aspect that is
referred to as the Catastrophic Health Emergency Fund account,
and that account is centrally managed, and it is a reimbursement
program to a local hospital or CHS program whenever they have
a high-cost case.
And those are first come, first serve. It starts on October 1, and
the funding that we receive, it is there until it is exhausted. At this
point, we have got $48 million that we have in that particular account.
In the past, before we had the increases which haveand over
the last 5 years, that account has more than doubled. And so, we
are able to go beyond May. This year, it looks like we are going
to get into September before that account is exhausted, which is
tremendous progress from prior years.
We had a real nice increase in 2010. We had a $100 million program increase in CHS that every CHS program benefited from
across the country, including an increase in the CHEF account. We
see great progress. We have been in contact with pretty much all
the CHS programs across the system. They have more resources
this year and are able to provide more referrals than they have in
the past, but we still feel like that the need is more than we have
funding for at this point.
Based on our estimates so far, we estimate that we receive almost $800 million a year in CHS overall. We estimate, based on

20
the information from our locations and from some tribes, that the
need is an additional $860 million more than the $800 million.
So we still have a long ways to go to where we feel like that we
will be fully funded to be able to pay for all of our referred care.
Senator JOHNSON. Mr. Grinnell, was that bump up in the income
available as a result of the stimulus?
Mr. GRINNELL. No. It had to do with the Presidents budget in
2010, and actually, President Obama approved that budget and
moved it forward as his first act against our budget. So the stimulus did not provide any CHS funding.
TELEMEDICINE

Senator JOHNSON. Telemedicine offers great promise in closing

the gap in services in remote areas and lowering healthcare costs.
My biggest concern with telemedicine has been the lack of technology infrastructure in highly rural areas, such as access to
broadband.
Dr. Jesse, as you highlighted in your testimony, the VA has been
moving more aggressively in its use of telemedicine. Can you please
describe a bit more how the VA envisions telemedicine being deployed? For example, are these applications located only at IHS facilities, or is the VA planning to implement home-based solutions
as well?
And how does the VA plan to overcome the lack of infrastructure
in highly rural areas and on reservations as it deploys new technology?
Dr. JESSE. Our chief information officer, Mr. Roger Baker, says
that what keeps him awake at night is bandwidth. So I will put
that on the table first, and then I will come back and answer the
other issues you brought up.
It is an issue. I think the wisdom of the Federal Government is
in understanding the value of the Internet in all we do in this
country, not just healthcare, but in education, in banking, in communication, and social networking, all the things that are really
changing the fabric of American life.
The commitment to get broadband access into rural and highly
rural areas is, I think, an important statement on behalf of the
Government that we need this. It is certainly not something the VA
can do on its own, but I do think that our commitment to making
this an integral part of healthcare certainly drives the imperative
to do so, more so than some of the other needs for broadband.
We will push very hard to ensure that we have the ability to leverage our technologies through broadband access and with the understanding that this is a shared commitment on the part of the
Federal, State, and local governments as well. It may take some
time, but I think this will get done.
In terms of the technologies being used, telehealth is a very
broad statement, and there are a number of different categories
that we look at. For instance, we can talk about telehealth as a
provider in one place and a patient in another place so that, when
we have a primary care clinicwhich I had the honor and pleasure
of visiting in the CBOC in town this morningwe can have an extensive primary care capability in that facility. If there is a question for a cardiologist or a pulmonologist, then having ability to

21
contact somebody, say, in Minneapolis or anywhere else in the
country to provide almost an instant referral, or consultation, is
one methodology.
Another is the ability to communicate with patients in their
homes. We have a program, which is probably, at this point, the
widest deployment of home telehealth, which we call CCHT, Coordinating Care Home Telehealth. This is where we have a telehealth communication box in the patients home that can do some
basic things like hook up to a blood pressure cuff, to a scale, or to
a rhythm strip, and which provides vital information for caring for
patients with multiple chronic disease, in particular heart failure
and hypertension.
Because rather than showing up once a month or once every 3
months for an appointment and checking blood pressure, we can
actually see the blood pressure every day. Then if it is going outside of bounds, we have triggers, and we can reach out to the patient to intervene.
I am a cardiologist by training. This is extremely important for
heart failure because patients can self-manage heart failure if they
have that information and particularly if they have a little help.
We have been able to markedly reduce admissions for patients with
heart failure by being able to communicate with them in their
home.
Now that is interesting because, more and more, we are finding
people who dont have land lines in their homes, and these things
are dependent on land lines. How do you then begin to move a lot
of this to a much more ubiquitous platform like the smartphone?
I think that capability is moving forward very quickly. Even
things like the PTSD Coach, which is an iPhone app, have been a
great demonstration that you can leverage the simple telecommunications platforms that people have to improve their health in many
novel ways, most of which we probably havent even thought of yet.
We do a lot of things that require ongoing monitoring, and I will
use an example of that which is teleretinal imaging in diabetic patients. It is really important that we monitor the consequences of
that disease, and looking at the retina is a view to the inside of
the body in many respects. It speaks to the microvascular state,
but also to the catastrophic consequences of diabetes, which is
blindness.
You cant have an ophthalmologist or an optometrist everywhere.
But we can take those images, store them in the local record, and
forward them off where they can be read, and that way the results
come back locally so we can monitor for vision changes over time.
We have teleradiology. So, for instance, you can have a CAT
scanner in a facility without the advanced radiology capability to
read them if that image can get forwarded to somewhere where you
do have that capability. This is becoming increasingly important in
the management of several complex diseases, where we can get a
tech in to do the scan, but we cant have the radiologist available.
In fact, VA now has a series of teleradiology reading centers
which actually expands the time throughout the day where we can
have studies accurately read. Likewise, you can do the same thing
with electrocardiograms and any number of other tests.

22
We all get very nervous about dermatology, and it is often difficult to discern what are bad lesions from what are ones that are
okay. But we have teledermatology where in the clinic they can
take an image, and it can go across the country to a dermatologist
who can look at it and make a determination that this is benign
or, no, this is something we need to follow.
There are a lot of different parts of this that are complex. Probably the most interesting is the ability to do consultation in a way
that actually increases the education of the primary care provider.
There are projects that we are standing up as part of the patient
line care team to bring specialty care into that mix through a
project called SCANSpecialty Care Access Nowthat gives realtime consultative capability in a way that actually educates the
provider.
And when we talk about telehealthI am sorry, it is a rambling
answerbut there are a broad number of modalities. The capabilities of some require a lot of bandwidth, for instance, moving big images around. But frankly, a lot of them dont, including what we
to date have investment in, which is home telehealth, where we
have the ability to reach in the patients home on a daily basis to
watch their weight, and their blood pressure, with a simple phone
line.
Senator JOHNSON. Mr. Grinnell, how do you see telemedicine
being deployed and utilized in Native lands? And please comment
on the lack of infrastructure in these areas.
Mr. GRINNELL. You mentioned earlier about the questions about
the stimulus and the funding that came through the American Recovery and Reinvestment Act. The IHS did receive $85 million that
was targeted to help us to make improvements to the RPMS system. It was also to look at how we can expand telemedicine opportunities.
As Dr. Jesse indicated as well, many of our locations in remote
areas have issues with bandwidth. And so, our ability to expand
telemedicine to some of those locations is going to be challenged
until the bandwidth is made more available. IHS is looking at
every opportunity and looking specifically with the VA to expand
as many telemedicine opportunities as we can.
Dr. Jesse also talked about the diabetic care specific to eye care.
We have a very active telemedicine program with teleophthalmology, where we got a number of IHS and travel sites that actually have optometrists or other staff that take images of the eye,
and then they are sent via telemedicine to an ophthalmology center
where they are actually read. And then they are followed up with
the necessary procedure.
So we have lots of challenges. And some of them really get down
to the bandwidth and the ability of that local facility to have the
capability.
Different than what Dr. Jesse talked about, we have not looked
into going to providing home health through telemedicine. But
right now, we have got more than 600 facilities that we have still
got to get connected and improve access to some of these services
that he talked about.
A couple of the other ones that we are looking into as well is teleradiology. We have got some areas now that have area-wide con-

23
tracts where they dont have a radiologist on staff, but they have
got a radiology service that they contracted with. They take the images, store them, and then send them forward, get the readings
that come back to our direct providers, and then they do the followup care.
So we still have a lot of work to do. We definitely are counting
on our partnership with the VA to help us to move that forward.
MENTAL HEALTH TELEHEALTH

Senator JOHNSON. I understand that the Sisseton IHS health

center is partnering with the Sioux City CBOC to offer mental
health telehealth. One day a month, vets in Sisseton can meet with
a psychologist in Sioux City.
Dr. Jesse, can you speak to this partnership? How did this come
to be? Is it meeting demand? Are there similar telehealth collaborations in the State and throughout the country?
Dr. JESSE. With your indulgence, I will ask Jan Murphy to speak
to that because I think she can give you the detail you need.
Ms. MURPHY. Sure. Thank you for the question.
There are a number of these kinds of collaborations that we are
very anxious to do. I am surprised to hear about Sioux City because we hear more about Wagner. But we are able to put a telemedicine unit either in the IHS clinic or we can have one in our
clinic, and the two go back and forth.
Sometimes we send the actual practitioners back and forth, too.
So, really, with this sharing agreement, this is really very easy to
do.
The technology, if you have the bandwidth, is quite simple and
quite successful to be able to do that. So that is an easy one, actually.
TRIBAL CONSULTATION SESSIONS

Senator JOHNSON. Ms. Birdwell, in the Senate appropriations bill

for fiscal year 2012, we have included $800,000 as requested to
support the establishment of your office. In your testimony, you
highlighted the critical need to build trust between the VA and the
tribes through meaningful consultation.
The VA is funded to conduct five tribal consultation sessions this
year. How many of these sessions have been conducted to date, or
are these the first of these sessions? Can you briefly describe what
these sessions will include and how they will help shape future VA
policy?
Ms. BIRDWELL. Yes, Senator, thank you for that question.
The five consultation sessions will be scheduled during fiscal
year 2012. There have been currently no formal consultation sessions held, although we did hold three listening sessions in Bethel,
Billings, and Bismarck.
The purpose of the consultation sessions are really to engage the
voice and the perspective of the tribes with respect to understanding regulations, grants, funding opportunities, and need for
services that VA offers that may impact tribal communities and
Native American veterans.
The sessions really seek to engage the voice and perspectives of
the tribes in informing how VA does business in Indian Country

24
and delivers services and resources. Something that is important to
note is that there have been a number of very dedicated leaders
and employees within VA for many years who have worked and
reached out to tribes, tribal leaders, and Native veterans.
The cemetery that is coming up, that is online in Rosebud, the
national cemetery is the effort of many years of collaborative hard
work with the tribal leadership, and that is something that we are
excited to see hopefully expand throughout Indian Country.
It is really the goal of our office to put a face with respect to engaging in Government-to-government relations with tribal leaders.
As Dr. Jesse mentioned, it is very important that when we are
doing business with tribes and we are reaching our vets in rural
areas that we get this right. And really, this is an opportunity for
VA to formally engage the voice of the tribes in setting policy as
we move forward and getting it right and being informed in the
work that we do.
We are talking about the possibility for expanding and sharing
best practices and increasing sharing agreements. These consultation sessions and engaging the voice and perspectives of the tribes,
hopefully, will result in that.
And not just from the perspective of increasing access to
healthcare, but also increasing access to benefits, all of the resources that our veterans have earned through their service, we
would like to see that result from these sessions.
OUTREACH

Senator JOHNSON. One major concern that I have has been outreach to educate vets on reservations as to what benefits they are
entitled. Ms. Birdwell, outside of the consultation sessions and listening sessions, what specific outreach plans are in place to better
educate Native American vets of the benefits available to them?
Ms. BIRDWELL. Senator, a particular one that is very much on
our front burner is Alaska. Alaska has a rural outreach coordinator
that is working very closely with VA. When the rural outreach coordinator or when our tribal government relations specialist will be
going out and meeting with tribal leaders or conducting any listening sessions in Indian Country, they will always be teaming up
with representatives from across VA through VHA, through the
Veterans Benefits Administration (VBA), and even the National
Cemetery Administration (NCA).
The approach is to have a coordinated approach in reaching out
to Indian Country and really informing, educating, and providing
onsite technical assistance with respect to benefits and resources
that are available through the VA. We are partners, and our role
is to enhance the role of VA with respect to reaching out to Indian
Country. It is critical that we have those relationships internal to
the organization, as well as with our external stakeholders. It is a
combined effort.
I have to say that Alaska is something that we have just recently
worked on in a strategic outreach plan to reach rural Native veterans. That plan is going to be implemented, hopefully, this fall
and throughout fiscal year 2012.
We have also had contact from veterans in the Northwest and
tribal leaders and also veterans in the Southwest and tribal leaders

25
seeking technical assistance for how to bring about the MOU, and
how to see that the MOU in action is as robust as they would like
it to be. That involves coordinating technical assistance with our
partners at the local level, within the VBA, VHA, and the NCA.
One of the focuses of our office is to promote economic sustainability in Indian Country within veterans. In other words, by veterans are eligible for post 9/11 GI bill, the Native American direct
home loan program, compensation and pension benefits.
Our vision is to see that if there is a veteran in Indian Country,
that veteran is at least aware of all of the benefits and can access
all of the benefits and resources available with VA through their
service. That is a goal and part of the mission of our office.
TRIBAL VETERAN REPRESENTATIVE PROGRAM

Senator JOHNSON. The Tribal Veteran Representative Program

was mentioned in testimony today. Dr. Jesse and Ms. Birdwell, can
you elaborate on this program. Does the VA plan to expand this
program in fiscal year 2012?
Ms. BIRDWELL. Senator, I will be happy to respond to that. The
Tribal Veteran Representative Program was started as a best practice and has expanded to Alaska. It was started as a best practice
in Montana and is nowthe TVRs, as they are called, in rural
areas, because it is often the case in tribal communities there may
be a lack of a local resource or connection with respect to veteran
services and resources.
TVRs are brought together by the VA on an annual basis, and
they are provided training into all of the resources that are available through VA. There are even State representatives present. Basically, all of the resources that are available to veterans, the TVRs
are trained in and made aware of them.
The TVRs then go back home to their local community, and they
become a local resource for vets. So, if a vet comes in and asks
questions about benefits, the TVR knows where to direct and how
to assist that veteran in moving forward with any kind of claims
that they may want to or need to pursue. Healthcare, grants, or information that tribal governments may need to know about, that
TVR is a resource.
There are definitely plans of expanding that program. What is
also important with respect to sharing resources are that there are
some tribal locations that may not have a TVR presence, and there
are some tribal locations that actually have their own tribal veterans affairs department. Some States actually have tribal veteran
service officers.
And it is interesting because those tribal veteran service officers
have asked about the TVR training and have said they would really like to see it expanded locally so that they can also avail themselves of that TVR training.
We are very excited to see that as a best practice. There is definitely a strong interest and a need to expand that, and we look forward to doing that in 2012. Strategically, we would probably be
doing that in a way that would be consistent with, moving from the
Northwest to the Great Plains to the Southwest and on to the Midwest. It is something that we would probably host with regional

26
trainings and then ideally make it so that they are held at as local
a level as we possibly can hold them.
Senator JOHNSON. Dr. Jesse, did you have anything to add?
Dr. JESSE. Yes, sir. I would just like to amplify something Ms.
Birdwell said, and that is that healthcare, in and of itself, will
flounderby whatever VHA does or IHS doeswithout the strong
support of the broader social needs of patients. That support includes education, housing, and a host of things.
I think the elegance of the VA is that we have the capability to
provide much of those needed services so that the healthcare side
of things can truly flourish. It is vital in order for us to do that,
in addition to supporting IHS, we need veterans to get enrolled.
Because it is not just access to the healthcare system, it is access
to this broader base of very needed and very hard-earned support.
It is very much our interest and important to us that the veterans are aware of how to get enrolled and are aware of this. We
are strongly supportive of all these initiatives and are working with
the IHS in order that we can identify the Native Americans who
are eligible for VA benefits and get them enrolled. I think it is important to note that it is their choice of which of those benefits they
wish to access, but the first step is the access into the system.
If I may just go back to the first question you asked me about
the MOU and the deadline on that? I just want to be very clear
that IHS and VA are committed to making this work.
There are some challenges in the law reconciling parts of title 38
legislation with the Affordable Care Act, but it is not either party
being recalcitrant or creating a problem. We just have to get this
reconciled. We are anxious to make it work and are working hard
and diligently to do so.
Senator JOHNSON. Thank you for your testimony. The witnesses
may now be excused.
Thank you.
Dr. JESSE. Thank you, sir. Appreciate it.

NONDEPARTMENTAL WITNESSES
Senator JOHNSON. I would now like to welcome our second panel
of witnesses. I am honored to have two South Dakotans testify
todayDon Loudner and Iva Good Voice Flute.
Mr. Loudner served 32 years in the Army and is a veteran of the
Korean war. He is a member of the Dakota Sioux Nation and has
been a tireless advocate for Native American vets, particularly in
his role as the national commander of the National American Indian Veterans, Inc.
Iva Good Voice Flute is a Air Force vet, having served here in
South Dakota at Ellsworth Air Force Base. She is a member of the
Oglala Sioux Tribe. Ms. Good Voice Flute is a strong advocate for
female vets and in March of this year received designation as the
Oglala Sioux Tribes womens tribal vets representative.
Thank you both for being here today.
Mr. Loudner, would you begin?
STATEMENT OF DON LOUDNER, NATIONAL COMMANDER, NATIONAL
AMERICAN INDIAN VETERANS

Mr. LOUDNER. Good morning. Yes, I have with me one of my regional commanders that has North Dakota, South Dakota, Nebraska. His name is Peter Lengkeek. He is a member of the Crow
Creek Tribal Council. He is here with me.
And we also have in our audience some of our tribal veteran
service officers. I am glad they are here, and I hope that they speak
up to ask these questions that were not answered to them. Dont
be afraid of these people. I mean, they are human like all of us.
And this is the time to get them straightened out. Because you
know, as well as I know, that the services that they are talking
about are not being completed for us veterans.
Senator JOHNSON. We need a lot of straightening out.
Mr. LOUDNER. I want to thank you, Senator Johnson, for holding
this important hearing. The last hearing that I can remember that
was held for American Indian veterans with congressional people
was back in the Nixon administration. And it is a hearing that
should have been held long before. Hopefully, we can have more.
Holding this important hearing to discuss the degree of cooperation that currently exists between the IHS and the VA to provide
quality care to our American Indian veterans and the Alaska Native veterans and ways to improve the agencies working relationship.
As you can imagine, American Indians, Alaska Native veterans
have many problems in common with other veterans. But because
of their geographic remoteness, weak tribal economies, and a host
of related pathologies, face challenges that are, in many ways,
unique. I believe that the members that share with you, Senator
Johnson, are aware of the valor and the service of American In(27)

28
dian/Alaska Native veterans to this country and that they have
served in the highest proportion than any other ethnic group in the
United States.
You may also be aware that the lack of healthcare to these veterans upon returning home is nearly to the point of being unacceptable, considering for what they have done protecting our homeland.
Especially with the event of the Afghanistan and Iraqi wars, the
number of veterans returning with injuries, disabilitiesphysical
and emotionalhas increased largely.
And as we have learned from the past wars and conflicts, the
need for treatment of these warriors may not be revealed for several years after these men and women have returned home.
The primary healthcare provider to tribal communities, including
American Indian/Alaska Native veterans, is the IHS, which has always been woefully underfunded. Many veterans have sought
healthcare from VHA hospitals because that is an option and their
right.
In an attempt to stretch their healthcare dollars, both IHS and
the VA hospitals have denied services to our veterans, insisting
that they go to the other agency for treatment. These proud veterans, who in some instances use their last dollars to travel long
distances to either facility, deserve better treatment.
I thought the days of transferring responsibility from one agency
to the other were over when this MOU, between the IHS and the
VA hospitals, was signed. It is my understanding that the issue is
still with us, and it is my hope that this hearing will be a step forward in finally resolving this situation to prevent more veterans
from additional suffering.
In my capacity as national commander, I am in constant contact
with these men and women in the States of Arizona, California,
Colorado, Montana, New Mexico, Oregon, South Dakota, Wisconsin,
Washington, and others. In fact, we just returned home within the
last 10 days from a strong visit to the Alaska Natives up there, and
I will send you a written report of what we just found out up there
that needs immediate attention.
Senator JOHNSON. Please do.
Mr. LOUDNER. Since 2004, the National American Indian Veterans has hosted three national conferences, the most recent taking
place in March 2009. I know that has been a couple of years ago,
but it takes money to hold them, and we are working with our own
dollars to do those. It was held at the Morongo Convention Center
in California. We had more than 500 American Indian veterans
from throughout the West and Southwest and Midwest in attendance.
The National American Indian Veterans has the support of the
National Congress of the American Indians, the National Association of State Directorsand I want to just elaborate a little something there. My chief of staff, Joey Strickland, is the only American
Indian that serves, in all 50 States, as a Secretary of Veterans Affairs, and now he is in Arizona.
There he serves for all veterans in the State of Arizona. Although
his job is to support all of Arizonas 600,000 veterans, Arizona is
home to 21 federally recognized Indian tribes, and American Indian
veterans regularly attend his commission meetings. As a result of

29
these meetings, he relays to me the concerns, issues, and needs regarding the lack of proper medical care delivered through the VA
and Indian veterans residing on Indian lands.
I just wanted to stress just a little bit about the Navajo Nation.
I heard them talk about it. The Navajo Nation reservation is
roughly the size of West Virginia. And on that reservation, there
are more than 12,000 veterans living today.
To date, the Disabled American Veterans (DAV) has rejected repeated calls to locate a permanent community-based outpatient
clinic within that reservation. They are claiming the number of veterans will not support it. The fact is the numbers will not support
a CBOC at the Navajo reservation because the reservation is divided into three Veterans Integrated Service Networks (VISNs).
Given this division, the VA cannot count the number of veterans
to justify the clinic. It is precisely this type of bureaucratic red tape
which results in inaction and, ultimately, inferior or a complete
lack of medical care to American Indian veterans.
Recently, just recently, the VAs Office of Intergovernmental AffairsI say recently, but about 1 year. It has been more than 1
year ago. The director of VISN 18 and others visited the Navajo
reservation and witnessed for themselves the urgent need for additional healthcare facilities.
They graciously called on the director of VA from Arizona, who
is a Choctaw Indian, for his input, which he, of course, provided.
The reality is that I have seen numerous visits over the years
throughout Navajo, the Pine Ridge Indian Reservation, and other
Indian reservations with little or no follow-up by the Federal officials.
When an American Indian veteran will get to the VA medical
center in Prescott, Arizona; or Albuquerque, New Mexico; or Sioux
Falls, South Dakota; or Fort Meade, the medical care is excellent.
But few, if any, of the veterans cannot overcome the vast distances
to use such facilities. The distances are vast, and transportation is
not always available.
As a result, many of the American Indian veterans efforts to obtain care at IHS facilities fail because they are veterans. In this regard, the MOU that was entered in 2003 by the VA and the IHS
has been ineffective because the level of cooperation is nowhere
near where it needs to be for the benefit of American Indians.
I bring that up because I brought this to the attention of Secretary Shinseki when you brought him out here, and we met with
him out at Fort Meade. I told him we needed to revisit that, and
we need to make it more effective with the use of American Indian
veterans input.
Today, we have that new MOU signed. No American Indian veterans input whatsoever in it. So, you know, my personal thought
in talking with some of the tribal officials and the American Indian
veterans is whyif not, then why do we need a CBOC on an Indian reservation?
Why not use our IHS to provide all these services that they are
providing to our Indian veterans today and have the VA reimburse
them back for those servicesfor the doctors, the nurses, the facility, administrative services, pharmacy, and so on, so forth? Those

30
monies can go to help the IHS hospitals for other services that are
needed.
And I turned in my statement to you, Senator, and I said I
wasnt going to go through it all. But there are some things that
I would like to bring up on that. I would like to conclude on that
now, and I would answer any questions on it.
But it has been brought to my attention from some of the veterans here in South Dakota, which you asked me to respond on,
that the VA is putting many of our American Indian veterans on
the payee system. I dont know if you are aware of that?
But the people that brought that to my attention are very upset
about that because the payee is being paid out of his benefits. And
he said that now he is getting around one-half of what he was getting from the VA because the other one-half is going to pay the
payee for his travels to visit him and condemn him from going back
to the reservations to attend the American Indian functions, such
as pow-wows and stuff, visiting his relations.
When I first talked with Secretary Shinseki, I told him that most
of our American Indian veterans, especially in South Dakota, are
very elderly. We have World War II veterans still alive. But with
them having to ride or rent a car or take the family car or if they
have DAV vans are available to go to Fort Meade or go to Sioux
Falls, it is a great distance to travel, and they are unable to make
those long distance travels.
You know, you talk about elderly. At one time when I was growing upyou know Vern Ashley like I do. Vern Ashley is World War
II Air Corps veteran. He never went to the VA, to my knowledge,
for help, although he needs it. Today, he is 96 years old, 97 years
old, needs hearing aids, and he is too proud to go ask for them. But
he needs them. He told me that he couldnt go there.
But today, you talk about elderly, I served during the Korean
war in 1950. My gray hair is here because I am 80 years old, and
I am proud to have served my country. There were 12 of us cousins
that volunteered and went into the service. They all returned
home.
Off-reservation American Indian veterans; that was brought to
my attention. When they go back to the IHS facility back on the
reservation, because they are working off the reservationtheir
families are growing up off the reservation, going to public
schoolswhen they go back to IHS facilities, they are being denied
services yet today.
I asked one of the veterans from Sisseton to come today, and he
couldnt make it. At least I dont see him here anyway, but he said
he was going to try. To tell his story on how he was treated when
he was having a heart attack at the IHS facility.
Burial flags. That is one of the NCAsI am on that board, and
the next meeting, I am going to bring that out again.
But burial flags are not able to be gotten by a lot of American
Indian veterans because they are human like everybody else. They
either lost it or delayed it or something, but they cant get that flag
from the post offices unless they have that DD214 or the discharge papers or something to prove that they are a veteran. And
when you die, they have got only so many days to be buried, and
they need that flag.

31
I know when I served on the South Dakota Veterans Commission, I served on that for more than 20 years, and we were told
that the headstones, some of the headstones were being held hostage by some of the funeral directors because of lack of payment
for the burial, when they ordered the stone. We need to change
that.
We have our own tribal veteran service officers, and there is no
reason in the world why those headstones cant be shipped directly
back to that tribe itself, to the tribal veteran service officer.
Senator JOHNSON. Don, will you please wrap it up? And let us
go to Ms. Good Voice Flute, and then I will ask you some questions.
Mr. LOUDNER. Okay. Thank you. Thank you.
Senator JOHNSON. Ms. Good Voice Flute.
STATEMENT OF IVA GOOD VOICE FLUTE, AIR FORCE VETERAN, OGLALA SIOUX TRIBE

Ms. GOOD VOICE FLUTE. Good morning, Senator Johnson. Thank

you for allowing me this opportunity to be here today.
Good morning, ladies and gentlemen, to the various agencies that
are represented here to come together for our Native American veterans.
I would like to recognize our tribal president, John Yellow Bird
Steele, who is in the audience. And also our fifth member, Mr.
Myron Pourier, is over here on my left.
And thank you to the many Native American veterans who have
appeared here today for this hearing.
I would like to begin by sharing two stories from veterans that
I have visited with regarding the service that they did not receive
from IHS and the VA.
Iva, I wish I had never let our Indian Health Service know that
I am a veteran. They sent me to the VA hospital right away, only
to find out that the VA hospital did not have the doctors I needed
to address my female medical problems.
To this day, this woman veteran will never visit a VA hospital
again. And she finished in the conversation with me, Iva, I am a
Lakota first.
Senator JOHNSON. Could you pull the microphone up closer to
you?
Ms. GOOD VOICE FLUTE. Okay. And the other story I have is
from a Marine Corps veteran. He traveled to the IHS, and he was
told that he needed to update his contact information. He came
there for a dislocated shoulder.
And IHS told him that they could not provide services for him
because he is a veteran and that he had to utilize other resources
that he may qualify for. So he traveled to a VA hospital, and then
the hospital tells him that his income is too high to qualify for their
services. But if he writes zero for an income, the VA can take his
vital readings. And if he returns for medical treatment, he will
have to pay for it.
He never returned to the VA after that initial visit. He thought
he deserved those VA services because he is a veteran.
These tribal-enrolled, honorably discharged veterans fulfilled
their commitment in serving our country, but experienced the cruelest of ironies when two agencies, the VA and IHS, tell them we

32
cannot help you, although based on the facts that you are members
of a tribe with whom the Federal Government has treaties with,
and you did serve in our countrys military.
Why was this MOU created between the VA and IHS when it
only hurts our veterans when it is supposed to help them? And
these two agencies have proven that they did not collaboratively,
effectively work toward the common goal of meeting our veterans
healthcare needs.
I have never agreed to this MOU, and once again, my personal
thoughts on this are that I feel that it is a situation with the intentions of one agency to be profit-making in nature and the other
agency to become cost efficient by not providing services to one particular group of people.
I believe that our Federal Government has a fiduciary responsibility in obligating funds to our Native American veterans
healthcare, to bring everyone together to troubleshoot the problems
of this MOU, and resolve the problems that have existed since its
inception in 2003.
And in closing, we deserve quality healthcare, and we must all
work together to make this happen for the generation of veterans
now and our younger generation of veterans, who need to be encouraged to utilize the services meant for us.
Senator JOHNSON. Thank you.
Ms. Good Voice Flute and Mr. Loudner, I will pose this question
to both of you. In what specific areas do you see a need for improved collaboration between VA and IHS? In your opinion, going
forward, where do the VA and IHS need to be focusing their efforts
to ensure Native American vets receive appropriate healthcare?
Ms. GOOD VOICE FLUTE. First of all, I would like to comment on
the services that the VA provides, that there be more medical care
for our women veterans. And not just Native American women veterans, but all women veterans, and then to make these services
more visibly available to where we are aware.
And my question is whose responsibility will that be on behalf
of the VA to make us aware that there are doctors for our unique
special needs?
Mr. LOUDNER. Thank you, Senator Johnson.
I think what needs to be done is we need to try to work together.
There are a lot of us out there trying to do the same thing, but we
are going in different ways. But our American Indian veterans deserve to be given the opportunity to decide, because of their age
and stuff, where they want to have their treatment done.
If an elderly American Indian veteran knows that IHS facilities
has the capability of helping him, he should be allowed to go there.
And if IHS doesnt have the capabilities, there should be a way to
get him to the VA facilities, whether it be Fort Meade or Sioux
Falls.
Right now, some of them are saying that they have to beg, borrow, and steal to try to get someone to take them there. A lot of
them dont have a VA vehicle. I am proud to say that with a lot
of arguing and everything, we finally got a new van back in Crow
Creek delivered back there last Friday. So they have the capability.
But those are some of the things that they are bringing to our
attention.

33
Senator JOHNSON. It is important that the VA communicate with
the tribes, and I appreciate the creation of the OTGR. As Ms.
Birdwell highlighted in her testimony, the office is focused on
meaningful outreach with tribal officials.
How do you think the VA can improve communication and outreach to Native American vets, Mr. Loudner and Ms. Good Voice
Flute?
Mr. LOUDNER. Let me start on that. Thanks for the question,
Senator.
I personally went and met with Stephanie Birdwell in her office
and volunteered to work with her in any way that she has seen
possible for me to work with in providing input that is coming back
to me as the national commander from all over the United States.
To this day, she has never returned any calls or even asked me to
talk to her.
So I think what she needs to do is see the importance of our national organization, which is called upon by you people, Senator
Johnson, in Washington to testify on behalf of the American Indian
veterans. There can be only one veteran organization to do that,
and that is our organization.
So I feel that they need to start working with us, both VA and
IHS, so that we can get that brought to your attention in the Congress.
Senator JOHNSON. Ms. Good Voice Flute.
Ms. GOOD VOICE FLUTE. Yes, Senator Johnson.
I believe that the VA can improve communication with the tribes
by being more of a visible presence. I keep going back to that. And
I also must add that there be a healthy balance of being more culturally sensitive and not so much as a clinical approach to our
problems.
Have a liaison within the tribe to work with the VA to where we
can bring both worlds together to benefit the needs of the veterans.
So that is how I believe that there can be more communication is
for the VA to have a more visible presence on the reservations.
Senator JOHNSON. Speaking of female vets, the VA is having to
undergo a culture change from a department designed to treat
male vets to one that has a growing female vet population.
Ms. Good Voice Flute, in your opinion, what steps do you think
the VA needs to take to better meet the unique needs of female
vets?
Ms. GOOD VOICE FLUTE. What I think, first of all, the VA needs
to do in the hospitals is have more doctors available for our medical
needs, and second is make us aware that there will be these medical needs that will be met for the medical needs that we have.
I think the VA overall and IHS need to work together to meet
the needs of the women veterans because, since my separation from
the military and being home on the reservation, women veterans
are very reluctant to come forward and tell the service providers
what they need. And a lot of it, I believe, is trust issues.
Senator JOHNSON. Are there enough OB/GYNs to go around?
Ms. GOOD VOICE FLUTE. No, I dont think there are. I do not
think so, Senator.
Senator JOHNSON. Yes. I want to thank everyone for attending
todays hearing, especially those who have traveled from out of

34
town to be here. I believe it is important for both the VA and IHS
to appear together routinely to update everyone on how a more collaborative partnership will enhance services for Native American
vets.
As a reminder, Ms. Birdwell will be conducting a listening session today at 3 p.m. at the Pejuta Haka College Center in Kyle,
South Dakota, on the Pine Ridge Indian Reservation.
CONCLUSION OF HEARING

Senator JOHNSON. Again, thank you to everyone, and I look forward to continuing this dialogue as the VA and IHS move forward,
creating a meaningful partnership.
This hearing is concluded. Thank you.
[Whereupon, at 11 a.m., Tuesday, August 30, the subcommittee
was recessed, to reconvene subject to the call of the Chair.]

MATERIAL SUBMITTED SUBSEQUENT TO THE

HEARING
[CLERKS NOTE.The following testimony was received subsequent to the hearing for inclusion in the record.]
PREPARED STATEMENT

OF THE

CHEYENNE RIVER SIOUX TRIBE

EXECUTIVE RESOLUTION NO. E3602011CR

WHEREAS, the Cheyenne River Sioux Tribe of South Dakota is an unincorporated

tribe of Indians, having accepted the provision of the act of June 18, 1934,
(48 Stat. 984); and
WHEREAS, the Tribe 1 in order to establish its tribal organizations, to conserve its
tribal property, to develop its common resources, and to promote the general
welfare of its people, has ordained and established a Constitution and ByLaws; and
WHEREAS, the Tribal Council has authority pursuant to article IV, Section 1(a) of
the Tribal Constitution [t]o enter into negotiations with the Federal, State,
and local Governments on behalf of the tribe. Id.; and
WHEREAS, the Cheyenne River Sioux Tribe is the successor in interest to four of
the historic bands of the Great Sioux Nation (Titonwan Lakota Oceti
Sakowin/Seven Council Fires of the Teton or Prairie-dwelling Nation of
Friends or Allies), i.e., Mnicoujou (Plants-by-the-Water), ltazipco (Without
Bows), Siha Sapa (Blackfoot) and Oohenumpa (Two Kettles or Boilings) signatory to the Fort Laramie Treaties of 1851 (11 Stat. 749) and 1868 (15 Stat.
635); and
WHEREAS, as a stipulation of the Fort Laramie Treaty of 1868 health care is right
provided to enrolled members of the Cheyenne River Sioux Tribe (15 Stat.
635); and
WHEREAS, American Indian Servicemen and women have the highest record of
service per capita of all the ethnic groups in America; and
WHEREAS, American Indian people have participated with distinction in United
States military actions for more than 200 years, their courage, determination,
and fighting spirit were recognized by American military leaders as early as
the 18th century; and
WHEREAS, American Indian people have served in all our nations wars despite the
fact that we were not granted citizenship until 1924; and
WHEREAS, American Indian veterans face unique challenges when it comes to
equal access to care and navigating the VA and IHS systems; and
WHEREAS, the Memorandum of Understanding (MOU) Between the Department
of Veterans Affairs and Indian Health Service is difficult to understand and
makes no provision for payments made on behalf of American Indians between the said two Federal governmental agencies; and
WHEREAS, upon their service to the United States military the Department of Veterans Affairs became the payer of first resort; and
WHEREAS, American Indian people have access to the healthcare via the Department of Health and Human Service office of Indian Health Service (IHS), IHS
becomes the payer of last resort, as their service to the U.S. Armed Services
supersedes the initial obligation of IHS to enrolled members of Federally Recognized Tribes; and
WHEREAS, the Cheyenne River Service Unit, Indian Health Service, Contract
Health in Eagle Butte, SD, acted in good faith in preparing and issuing payment vouchers for 15 veterans of the Cheyenne River Sioux Tribe to the Department of Veterans Affairs, Black Hills Health Care System (BHHCS); and
1 Cheyenne River Sioux Tribe, Cheyenne River Reservation, Act of March 2, 1889, Section 4,
25 Stat. 888 (reservation boundaries).

(35)

36
WHEREAS, the BHHCS have denied the payments citing no Sharing Agreement
between the Department of Veterans Affairs and the Indian Health Service;
and
WHEREAS, the Cheyenne River Sioux Tribe hereby recommends and fully endorses
a Sharing Agreement between the Cheyenne River Service Unit, Indian
Health Service, Contract Health in Eagle Butte, SD; now
THEREFORE BE IT RESOLVED, that the Cheyenne River Sioux Tribal Council
hereby calls upon South Dakota Senator Tim Johnson, Chairman, Subcommittee on Military Construction and Veterans Affairs Appropriations Subcommittee, support a Sharing Agreement; and
BE IT FURTHER RESOLVED, that this resolution be transmitted to the South Dakota Congressional delegation;2 and
BE IT FURTHER RESOLVED, that the Cheyenne River Sioux Tribal Chairman is
authorized to take all necessary and appropriate actions for the implementation of this Resolution; and
BE IT FINALLY RESOLVED, that nothing in this Resolution diminishes, divests,
alters, or otherwise affects any inherent, treaty, statutory, or other rights of
the Cheyenne River Sioux Tribe over the property or activities described herein. The Cheyenne River Sioux Tribe expressly retains all rights and authority
over the property and activities described herein, including but not limited to
legislative, regulatory, adjudicatory, and taxing powers.
CERTIFICATION

This is to certify that the foregoing Executive Resolution has been reviewed and approved by the Executive Committee, acting under the Executive Authority and in
the best interest of the Cheyenne River Sioux Tribe this 29th day of August, 2011
in Eagle Butte, South Dakota.
KEVIN C. KECKLER,
Chairman, Tribal Chairman.
EV ANN WHITE FEATHER,
Tribal Secretary.
BENITA CLARK,
Tribal Treasurer.
PREPARED STATEMENT OF GERI OPSAL, TRIBAL VETERANS SERVICE OFFICER
SISSETON WAHPETON OYATE, LAKE TRAVERSE RESERVATION

FOR THE

Chairman Johnson and members of the Subcommittee on Military Construction

and Veterans Affairs, and Related Agencies: Good morning, I am Geri Opsal, tribal
veterans service officer (TVSO) for the Sisseton Wahpeton Oyate located on the
Lake Traverse Reservation.
I want to thank you for inviting us to attend this very important meeting, and
since our schedules conflicted due to the annual certification school of the TVSOs
and county veterans service officers, we are unable to attend. We do want to provide
some comments regarding this important issue of improving access to care for Native American veterans in maximizing the effective use of Federal funds and services.
The Sisseton Wahpeton Oyate is comprised of more than 12,941 tribal members.
Of those tribal members, we have a veteran roster that goes back to the scout to
presentwe have more than 1,250 tribal members that are veterans. Each year we
have of our members going off to serve. We have more than 80-plus tribal member
veterans that have served in the Desert Era War from 1990 to present. We have
tribal members stationed across the United States and also overseas fighting the
fight for our country.
Our Tribal Veterans Service Office has met many times with our Indian Health
Service (IHS) regarding our veterans utilizing IHS verses having to travel and use
the Department of Veterans Affairs (VA). Although progress has been made in the
following areas, there are other areas we have concern about and wish to resolve.
The following areas that we have had success with are:
Pharmacy.Veterans can bring their prescriptions to the pharmacy and our
pharmacist will call directly to the VA and confirm. Our veterans are able to
get the prescriptions filled locally at IHS rather than traveling to get refills, etc.
Walk-In Clinic, Optometry, Dental-Pharmacy.Our veterans are able to utilize IHS for their medical needs. They dont have to travel if they chose not to
2 [Addressed to U.S. Senator Tim Johnson, U.S. Senator John Thune, and U.S. Representative
Kristi Noem.]

37
but should they need referral to a specialist they are required to then go to the
VA and have the referral done through them.
Co-Pays.IHS will pay for the veterans co-pays they accumulate at the VA,
but they do require that either the veteran or myself contact Tami Seiber, contract health specialist, and notify her of the appointment ahead of time. Weve
had a couple of veterans that had their income tax refund withheld due to nonpayment. One went and appealed this and had about 90 percent of it returned
to him. The co-pays that arent covered by IHS are the prescription co-pays and
this they say is due to the fact the prescription can be filled by IHS. A prescription has two medsone is covered; one is not. One you can get through the VA
and one through IHS, a simple Rx that takes days to fill as someone has to run
back and forth determining the least cost-effective way to get this filled. Why
isnt their brochure geared for the Native American veteran notifying them to
of what extent their services are covered through the VA and IHS. We have
found out by trial and error as each case comes up why are we pieced out the
information as we seek it?
The following areas of concern for us that we would like help to resolve are:
Electronic Records.If possible to have IHS doctors as well as VA doctors access electronically each others records/labs/notes on the veteran. This will help
eliminate duplicate care and often times our veterans after going to the VA for
their appointment or even after discharge from a hospitalization will go to the
IHS and ask the doctor to explain the procedure or any questions. They sometimes are so happy to get discharged and get home they dont ask questions
until they get back to the reservation and they have all the follow-up questions.
Co-pays being returned or not paid in a timely manner, the veteran getting
sent to collections, or either getting their income tax taken. How are we able
to correct any negative credit rating they may get as a result? And is their any
way to flag the tribal member veterans record so the VA automatically bills the
IHS first rather than sending it to the patients address and expecting them to
take or forward to IHS. Co-pays for prescriptions should be covered as well.
How is the veteran to know that they only get co-pays for appointments?
Solution.We have a memorandum of understanding (MOU). This says the VA
and the IHS are working together for the benefit of the veteran. Have the MOU
give the VA authority (a new policy) that when a Native American veteran utilizes
the VA, the VA is given authority to document under the financial part that the
veteran is IHS-eligible; no co-pays. This will eliminate co-pays for office visits, medications, or referrals to specialty doctors. Right now, our biggest problem for our veterans is navigating the VA and IHS issue. The sharing of electronic records would
come in handy with this process as well. Whos going to pay; hurry-up-and-wait
game for referrals and getting bills because they didnt know they could take their
Rx to IHS if they carry the meds; if they dont carry them they will order them and
still no co-pay for the patient.
We feel as a tribal member, first, and veteran, second, that we are protected
under treaty rights. We are considered dual eligible. Theoretically, being dual-eligible has caused more trouble for us due to trying to navigate the system which we
have difficulty understanding. The Snyder Act of 1921 (25 U.S.C. 13) and the Indian
Health Care Improvement Act (25 U.S.C. 1601) of 1976 provide specific legislative
authority for the Congress to appropriate funds specifically for the healthcare of Indian people. In addition, we also have treaty rights to Federal healthcare services
through the Department of Health and Human Services. The Federal trust to uphold the treaty responsibility for healthcare is first, and being a veteran is secondary to our healthcare processmoreso, when the tribal member is also a veteran, as they took the oath to fight for our freedom. We as veterans have heard the
term from IHS that they are the payor of last resort, and, as such, the use of alternative resources is required when such resources are available and accessible to the
individual. We are required to go to the VA for any referrals; otherwise, IHS will
not cover it. Dual eligibility which has us going between the IHS and the VA, and
we try and keep our records straight.
Mr. Chairman, this concludes my statement. Thank you for this opportunity to
discuss the unique challenges when it comes to access to care and navigating the
VA and IHS. We will be happy to answer any questions and consult on this process
and perhaps if you have another meeting in the future we can attend along with
our tribal secretary of the Sisseton Wahpeton Oyate; Ms. Winfield Rondell who is
a Marine Corps veteran as well as one of our tribal executives.

38
LETTER FROM

THE

STANDING ROCK SIOUX TRIBE 1

AUGUST 26, 2011.

Hon. TIM JOHNSON,
Chairman, Subcommittee on Military Construction and Veterans Affairs, and Related Agencies, Committee on Appropriations,
Washington, DC.
MOST HONORABLE SENATOR TIM JOHNSON: We are in receipt of your letter and
are most honored to be invited to the hearing to be held in Rapid City, SD on August 30, 2011.
We are grateful for the opportunity to express our concerns regarding the collaboration with the Indian Health Services and the Department of Veterans Affairs. The
following are our primary concerns for the Standing Rock Sioux Tribal veterans.
I. Standing Rock veterans would like to have x-rays, labs, pharmacy, referrals,
and all primary care provided at the local level.
II. Standing Rock veterans would like to have a day set aside for their care. One
day scheduled for veterans to come in and see a doctor. These visits would then be
put into their charts at the Veterans Hospital that they have been assigned to.
III. Technological access to the Department of Veterans Affairs medical records
would allow for all medical and pharmaceutical visits to be viewed by the veterans
primary care physician. This would also eliminate the duplication of services and
medications given to the veteran.
IV. Veterans would like the Indian Health Services and the Department of Veterans Affairs to have better communications so the veterans get the best care available. Such as getting veterans stabilized at the Indian Health Services and then
transported to the VA for care.
V. Veterans on the Standing Rock Reservation travel 300 miles to get to their
primary care provider. Services here would eliminate the travel time for our veterans.
Thank you for your interest in our veterans on the Standing Rock Sioux Tribal
reservation.
CHARLES W. MURPHY,
Chairman and Vietnam Veteran.
WENELLE F. CLOWN,
Tribal Veterans Service Office.

1 Charles

W. Murphy, Chairman; Mike Faith, Vice Chairman; and Adele M. White, Secretary:
Tribal Council (At Large).Jesse Jay Taken Alive; Ronald C. Brownotter; Avis Little
Eagle; Dave Archambault II; Joseph McNeil Jr.; and Jesse McLaughlin.
Tribal Council (Districts).Sharon Two Bears, Cannonball District; Henry Harrison, Long
Soldier District; Duane Claymore, Wakpala District; Kerby St. John, Kenel District; Errol
D. Cross Ghost, Bear Soldier District; Milton Brown Otter, Rock Creek District; Frank
Jamerson Jr., Running Antelope District; and Samuel B. Harrison, Porcupine District.