▶ 0:28:20Don't check.
▶ 1:03:24And I apologize for being starting about an hour late. Uh, but we had votes on the floor and stuff, so I appreciate you taking the time and waiting around for us. I'd like to extend a warm welcome to the indian health services chief of staff, clayton fulton. Mr. fulton has assumed the. The delegated. Delegate. I can't say that word. Delegate, uh, duties of the hhs director.
▶ 1:03:52And I thank him for being with us today to discuss the administration's fiscal 2027 budget request. This committee, on a bipartisan basis, takes the responsibility of prioritizing and supporting indian indian health care services for american indians and alaska natives very seriously. In february 2023, congress provided advanced appropriations for the indian health services.
▶ 1:04:16For the first time, advanced appropriations continue to provide the indian health system with the certainty needed to properly serve communities, provide stability for health care providers, and improve long term planning for services in 20. In the fiscal year 2027, president's budget request includes advanced appropriations for 2028. This is a monumental step in the right direction.
▶ 1:04:38In doing so, this administration is clearly communicating its commitment to funding certain funding certainty that health care professionals and programs in indian health country so desperately need to provide quality care. For the fiscal year 2027, the president's budget requests approximately $9 billion in discretionary funding for ihs, maintaining funding for critical programs and fully funding estimates for contract support costs and 105 leases.
▶ 1:05:06It also proposes 5.6 billion in advanced appropriations for fiscal year 2028, and this funding does not begin to meet the full needs in indian country. But I am encouraged by the commitment to continue this funding that this budget represents, and believe it signals a deeper understanding of our responsibilities to uphold our trust and treaty obligations. I look forward to hearing how indian health services will embrace and fully integrate advanced appropriations to improve how it plans and operates ihs programs. Mr.
▶ 1:05:38Fulton, I really enjoyed our opportunity that we had to meet and discuss your perspective on this budget. You are doing vital work to fill the trust and treaty agreements, and to maintain and improve tribal members access to quality health care. Thank you again for being with us this morning, and I look forward to our discussion. Now, I'd like to yield to ranking member pingree for her opening statement. >> thank you, Mr. chair. And good morning, Mr. fulton. Miss curtis. Thank you for coming to meet with me earlier.
▶ 1:06:02And thank you for being with us today to discuss fiscal year 2027 budget request for the indian health service. Statistics on health disparities in indian country, as you know, are far worse than other populations in america, and we must make additional additional investments to make progress in addressing these disparities. Unfortunately, despite this committee's continued bipartisan efforts, funding has not kept pace with the need.
▶ 1:06:28Last month, as we do every year, our subcommittee held tribal witness hearings over the course of two full days, we heard from tribal leaders spanning the country who repeatedly told us about the dire need for more health care funding. To make matters worse, the nearly $1 trillion cut to medicaid in the big ugly bill would have devastated would have a devastating impact on tribal health care.
▶ 1:06:512.7 million american indians and alaska natives are enrolled in medicaid, including 49% of children. Additionally, ihs facilities rely on third party reimbursement. Your fiscal year 2027 budget request assumes collections of 1.4 billion from medicaid. So I'm greatly concerned about the impacts of medicaid reductions and what they will have on the delivery of vital health care to tribal members.
▶ 1:07:20While I'm pleased to see some much needed increases for programs in the budget request, the request also proposes cutting the sanitation facilities construction by 87%, which is completely out of touch with the reality that there is an over $1 billion backlog for sanitation facilities.
▶ 1:07:39I'm also pleased to see that the administration has, for a change, listen to congress and proposed continuing advanced appropriations for the indian health service, which will provide certainty for those who rely on ihs services. This subcommittee has been dedicated to funding solutions for addressing the health care needs of american indians and alaska natives, including. Advance appropriations is a major step forward.
▶ 1:08:03I hope we can build on that progress by working in a bipartisan way to make contract support costs and 105 l lease payments mandatory. It's ridiculous that these entitlements are not mandatory. The indian health service is not the only part of the federal government that provides services to indian country. The administration has proposed steep cuts to the bureau of indian education and the bureau of indian affairs by 32% and 27%, respectively.
▶ 1:08:32Chaos within other departments, within other parts of the department of health and human services, such as nih, cdc, and the fda affect tribal communities just as it affects us all. Mr. fulton, thank you again for being here today. Thank you for your dedication to the ihs mission. I look forward to continuing to work with chair simpson and members of the subcommittee in a bipartisan fashion to honor the united states treaty responsibilities to tribal nations. And thank you, and I yield back. >> thank you, Mr. pingree. Mr.
▶ 1:09:02Fulton, you may proceed with your opening statement. Your official statement will be submitted for the record. >> good morning. Thank you, chairman, ranking member pingree and members of the committee, thank you for the opportunity to testify on the president's fiscal year 2027 budget request for the indian health service. I want to begin by thanking this committee for its long standing support of the indian health service.
▶ 1:09:25Over the past decades, your investments have helped grow the ihs budget by 60% and have strengthened health care across indian country. That progress matters. The fy 2027 president's budget builds on that very foundation.
▶ 1:09:39It advances our mission to raise the health of american indians and alaskan native communities and fulfill the federal trust responsibility by supporting a system of over 600 facilities and 41 urban indian organizations who are collectively serving over 3 million people annually. This budget is guided by three key priorities strengthening the future of the indian health service, improving health outcomes and supporting tribal self-governance.
▶ 1:10:07First, we're working on modernizing the ihs system. Our current structure is not sustainable. As more programs are operated by tribes, we must evolve to better fit that reality. We are actively evaluating changes that streamline operations, reduce administrative burdens, and improve accountability so that our providers can focus on patient care. Second, this budget prioritizes direct health care services.
▶ 1:10:34It includes $9.1 billion in discretionary funding and continues to advance appropriations to ensure stability in the care delivered just as you previously mentioned, we're also making investments in core elements needed to deliver that high quality care. That includes $84 million to staff, new and operated expanded facilities, ensuring that those facilities serve patients as they were intended. When constructed, it includes 265 million for current services.
▶ 1:11:02That helps us keep pace with inflation, increasing workforce costs and population growth across our system. Then it also includes $5 million to strengthen ihs oversight of the hospitals we operate and improve system wide performance. Together, these investments ensure that care remains consistent and accessible in tribal communities across the country. We are also continuing to modernize our health information system.
▶ 1:11:27The budget includes $287 million for electronic health record modernization, an essential investment that is critical to improving how we deliver care efficiency and long term outcomes. At the same time, we're addressing long standing infrastructure needs. This budget includes an additional $5 million in the health care facilities construction fund.
▶ 1:11:52Right now, we have 36 of the 42 priority projects completed or underway, but six projects remain. The secretary has also committed $1 billion over the next several fiscal years in investments to complete these priority projects, who have been on the priority list since 1993. Modern facilities are critical to delivering safe, high quality health care.
▶ 1:12:17Third, this budget seeks to strengthen tribal self-governance. It fully funds contract support costs and 105 ls based on updated estimates. These investments support tribal control and long term planning in tribally controlled health care systems. The budget also includes initial funding for newly recognized tribes, including the lumbee tribe of north carolina, and statutory required funding for the united keetoowah band of cherokee indians.
▶ 1:12:45These resources ensure that access to care is there as services expand. Finally, in alignment with the secretary's goals of making america healthy again, this budget supports efforts to improve outcomes and reduce disparities through programs such as the produce prescription pilot program, which aims at tackling food insecurity, improving dietary health and health outcomes. Generally, recent investments have contributed to measurable progress.
▶ 1:13:12Right now, in 2022, we saw an increase of 2.3 years of life expectancy. We saw additional increases in 2023. That's a trend we plan to keep moving forward. And finally, I want to highlight the importance of advanced appropriations. These resources are critical to ensure that care goes uninterrupted, including during recent government shutdowns.
▶ 1:13:34The fy 2027 budget builds on that success by requesting $5.6 billion in advanced appropriations to ensure stable, predictable funding moving forward. In closing, the budget is about delivering on the fundamental commitment by ensuring that american, indian and alaska native communities have access to reliable, high quality health care.
▶ 1:13:58We appreciate this committee's continued partnership in this work, and we look forward for the opportunity to testify and answer your questions on this budget. >> thank you. And again, thank you for being here today. I apologize for the lateness that we got started, but, uh, it's important.
▶ 1:14:16But as I hear your testimony in the the need for increasing, whether it's it or whether it's the hospitals and, and those kind of things, the clinics that are run, my mind kind of goes, we kind of concentrate on indian health services because it's one of the most important. If you don't have your health, you don't have anything, you know, but there are other areas in indian country, whether it's law enforcement or whether it's indian education, where the same thing could be said.
▶ 1:14:42And we we put so much of our resources in concentration on health care that sometimes we let we leave short the other areas that we've got to do. And that's something that we're trying to address in the last few years and, and try to make sure that we get the the facilities that are necessary in indian education and stuff. But thank you for what you're doing. Uh, you talked about the, the importance of advanced appropriation. And as miss pingree said in her opening statement, we always looked at this as the first step toward, uh, making it mandatory funding.
▶ 1:15:13And I hope we get there at some point. But advanced appropriation is a huge step in the right direction. The last year's president's budget didn't, uh, didn't support advanced appropriation or didn't recommend it. We went ahead and did it anyway. This year they've came on board and said it's important. So that's important to us as a member of the as members of the subcommittee know, I've been concerned about ongoing staffing shortages at ihs hospitals and health clinics.
▶ 1:15:38I commend the ihs on the january launch of the fy 2026 hiring initiative that is streamlining the hiring process with a goal of reducing the staffing vacancy rate to historic lows. Can you tell us more about this hiring initiative and how it's going so far, and what is ihs doing under this initiative that is different from what has been done in the past?
▶ 1:16:01As I've gone out on the on reservations, they always take me to the dental clinic because I was a dentist, you know, and oftentimes there's not a dentist there. And the same thing is in other places, because a lot of these clinics are in remote areas and trying to find professionals that will go out there and, and live there. First of all, where do they live and that kind of stuff. So I appreciate you focusing on that. But tell us how that's going. >> well, thank you, chairman. When we talk about this hiring initiative, you're right.
▶ 1:16:31Delivering care is a service industry, and it is dependent on having the right people there to deliver it. So what makes this hiring initiative different? It largely comes down to structure. In the past, the indian health service has had very disjointed system. We've had 12 areas and several service units each who have been on their own to figure out hiring and recruiting.
▶ 1:16:50But several years ago, before I joined the agency, in the last few years, we have merged and unified our hr efforts and realigned it like we're looking to do with the rest of the agency. This has provided us visibility on making the first truly national hiring surge, where we're coordinating across the system, whether that's where to place scholars, recruiting efforts, announcements.
▶ 1:17:14And so far, we're seeing several positive signs from this, including having over 8000, nearly 8000 applicants. You applicants who have applied for roles in the indian health service. And we're helping connect them to where we have jobs. It's also worked very well in moving us forward. So we are seeing a significant number of efforts. Additionally, we're looking at new other unique ways of getting providers into our communities.
▶ 1:17:40One way I will highlight is our recent partnership with the us public health commission corps and the assistant secretary of health, who has instituted what the commission calling force management. But what this actually means is, at the beginning of a officer's career in the public health commission corps, they are being assigned to places of high need. That means instead of selecting where they want to go, we're putting them where care needs to be delivered.
▶ 1:18:07This has resulted in actually putting several providers or I think we have about 56 that have been placed just in the last two months into our hardest fill spaces. This is places like browning, montana, pine ridge, and we're really being able to fill those gaps by moving providers where we need them. And so that is just one of a variety of efforts we're making to find out of the box solutions, to put care where it's needed. >> well, I appreciate that and I hope it's successful.
▶ 1:18:35You know, I've come to the conclusion that the only way you're going to ultimately fill the provider need is to educate tribal members, to get them to go to college, to become doctors, dentists, nurses, whatever is necessary out there because they're more likely to come back to the roots of practice there than anybody else. And I know that's it's a big thing with tribes. I can't remember build within or something like that program that they've got started. Yeah.
▶ 1:19:04And, uh, I was very impressed that the, the cherokee nation is starting a, uh, doctor's program with is an oklahoma state, oklahoma university of oklahoma, one of one of those to us in idaho, oklahoma, oklahoma state. Yes. But starting with. >> we won't tell them that back home. >> yeah. And don't tell tom cole don't tell that tom cole either. But it is it's very impressive what they were doing. And that kind of connects with.
▶ 1:19:35We can't just concentrate on indian health services. We have to concentrate on indian education. If we're going to solve indian health services problems in in the long run and stuff. Uh, but it is very important. I appreciate what you're what you're doing, uh, on that initiative, miss pingree. >> thank you. Thanks, Mr. chair, and thanks for asking that question as well about staffing.
▶ 1:19:55Um, and I appreciate you bringing up the prescription, um, produce prescription pilot program that's, uh, you know, been a program I've been strongly supportive of just a couple other follow up questions. Um, can you give me a little bit of an update on the five year pilot program and just some examples of how grantees are responding to the community needs out there? >> wonderful. Yes. We've been very excited about this program.
▶ 1:20:20And as you're aware, one of the key highlights of that is it allows tribes to build programs tailored to their communities. So we started off with initial five sites that were awarded across the united states, including my former employer, before coming and joining the service at the muskogee creek nation. And each one of those groups have taken a different approach to how they deliver. Some have focused on providing vouchers to make food easily accessible.
▶ 1:20:46Once somebody is identified as food insecure, some have worked on meal delivery programs that have targeted elders to make sure that good food is traveling to them. Some have focused around education and identifying homes and then working on educating them. What's it like to use real foods to cook real foods? This is a real passion project of the secretary. And so we're so excited about the additional funding that was provided in fy 2026.
▶ 1:21:11And we're planning on using that funding to expand the number of tribes receiving funding, going to serving more than ten additional sites with that additional funding. >> great. Those were the things I wanted to know more about. Um, if we were able to provide more in 27, do you think you could just continue to expand the sites? >> yes, ma'am. I believe that would be our approach.
▶ 1:21:35We in our initial application cycle, we had about 60 tribes applied for the funding and we were able to do five. And so we will continue to go. Ideally, we would love to have all 60 available. Um, but we're happy to, you know. >> that's good to know that there's that much interest in need out there. And so I'm sure, and especially as people hear about the programs with certain tribes, I can imagine that number would even grow. Um, let me ask about the electronic health records.
▶ 1:22:03Um, fy 27 budget request 287 million for electronic health records. And that's an increase of 93 million. During last year's hearing, acting director smith said around 50 vacancies were directly impacting the ehr program. So could you give us a little bit of an update about how staffing is going, since that seemed like quite a significant issue? >> perfect. Thank you.
▶ 1:22:24So a significant portion of our ehr efforts are being handled by contractors, especially in this pilot phase, but it is requiring staff investment at the local level, where we have local staff who are directly engaging, receiving training on the software and being involved. It is definitely a full agency effort where employees and contractors are working together to implement that.
▶ 1:22:48I'm unaware that we've seen any significant delays in our implementation as a result of staffing. As we've continued to add, especially here in the most recent months, where we've been adding significant amount of new staff and trying to get them into the facilities. So I'm not aware of any significant delays. We still plan on wrapping up our lawton pilot site at the end of the fiscal year and getting that out, and then using our new funding to roll out a first, another cohort of sites to begin implementation.
▶ 1:23:19>> great. Thank you for that. Yield back. >> Mr. venki. >> thank you, Mr. chairman, and thank you for serving and stepping up. So just a reminder, with the blackfeet nation, a few years ago, there was a physician that was a predator. Um, he was ihs knew about it. He was then shipped to pine ridge reservation, where he did the same thing and is currently serving in prison.
▶ 1:23:46But part of the part of the the response from ihs, we couldn't get him a clinic, but we did get him a youth center. And then part of that of that the promise once again to the blackfeet was the youth center would have a nurse practitioner provided by the h.r. Ihs, particularly to address the needs of the young women. Uh, there.
▶ 1:24:12I just want to make sure that that you're aware of it and I want to hear your commitment that's still in place. >> thank you. Congressman. Yes. When that project is finished by the tribe, we stand by the commitments previously made to provide a nurse or nurse prac for that facility. >> I greatly, greatly appreciate that. So on, on the electronic records, um, the military electronic records have gone so well.
▶ 1:24:39Uh, so how, how is your, your electronic transfer transformation happening and is there things you need and what's your assessment of where, where, where it's going to be completed? Are you going to be on time? Are you going to be at budget or under budget? It kind of walk me through where, where your process is on that. Perfect. >> yes.
▶ 1:25:03So as we know, there's definitely been issues with the other ehr implementations, and we've used those largely as learning lessons. We've partnered very closely with the va on the rollout of their electronic health records and learning from a lot of the lessons as they have pioneered the process so far.
▶ 1:25:19We're seeing success, we've working forward, and we're pretty much on pace to finish our initial pilot site at the lawton indian hospital and its two outlying clinics there in southwestern oklahoma. To move forward. We have not ran into any significant delays. Um, with that so far. Things continue to march on.
▶ 1:25:44Um, and I think largely that is because of our deep partnership with va and learning from all the things that have been involved with their process, based on the amount of funding you receive, will depend on how many sites we're able to roll out to next fiscal year and how many additional sites are doing that. >> and you're on your on time. We're on time. >> we're on. Originally we had we've put about a two month delay because we understand how important it is to get right, but it's not because of any significant timelines.
▶ 1:26:12We just want to make sure that when we bring this to patients, that they are receiving top tier experience. And so we've been very diligent in strategic in the way we've approached that, working with some best in class vendors and the team at cerner in order to move forward with that, because thankfully, we're not having to build this from scratch. It's a commercial system that has been well adapted.
▶ 1:26:36We're just tailoring it towards the unique needs of our system, which includes having to provide it to tribes, urban indian organizations, and a number of nonfederal organizations. >> and shifting really quick to hiring. When secretary burgum was here, he talked about local hiring authority because oftentimes the usa jobs.gov will give the wrong outcome. It doesn't address local housing, and sometimes the local superintendent will know someone that's eminently qualified.
▶ 1:27:06They're part of the community. So you don't have to pay for housing. And and they are culturally, uh, correct. A lot, a lot of times, especially in indian country. Are you looking at, uh, providing the local, the local superintendent, that same authority rather than going through usa dot, dot dot dot jobs.gov and giving local hiring authority? >> yes, sir.
▶ 1:27:30This is something that we've been actively doing at ihs for a while through a direct examination authority, where those hires are happening locally. If we're not able to fill them through the usa hiring process and ceos are are able to do those direct evaluations. They're on site based on experiences that are running completely through the usa jobs postings. We haven't had those. >> great. I yield back. Thank you. >> Mr.
▶ 1:28:01>> I don't know that I need this. We're sitting pretty close, but. >> the rest of us want to hear. >> fine. I just have a couple of things. One, um, in utah, we have several small tribal communities, um, that generally don't rely on tribally operated clinics or the big ihs hospitals. They have tribally operated clinics, prc and outside providers. Um, can you tell me how this year's budget helps support those smaller tribes that have smaller facilities?
▶ 1:28:32>> no, that's a great question. It's something we take very seriously. So this budget and our increase, especially in the hospital and clinics line item, will help provide dollars directly to them to help expand their services. Additionally, when we think about electronic health records and what that modernization really means, it means the most to small clinics because they're usually the ones who are left on the legacy ehr system as large systems who bring in large amounts of third party revenue have been able to already make the transition to
▶ 1:29:03More modern healthcare. So by investing in ehr and rolling that out, it's going to enable them to provide 21st century care instead of being stuck with our mid 80s designed rpms system. >> okay. Well, and just worth noting that especially for these smaller communities, distance is a problem. Um, and whatever you can do to help make sure that they're, they don't just have the facility, but that they can easily access facilities be really great.
▶ 1:29:31Um, and then executive order one, three, 175 requires tribal input on this budget. Can you just tell me how that worked with this budget and where, where we can see evidence that that was considered? >> no. Wonderful. So the executive order is a great step forward, but it is something that we have been doing for several decades at the indian health service. We are statutorily required to hold annual budget consultations on our budget. And that's how we start.
▶ 1:29:57Every budget is we start off holding tribal consultations 12 across the various areas of the indian health service, which then send representatives to the national budget formulation, who then proposes numbers and priorities that they would like to see advanced in the budget. And that is the exact process that we followed this year with the development of this budget. >> thank you, and I yield. >> that's okay. >> thank you, Mr. chairman.
▶ 1:30:28Thank you, Mr. fulton and miss curtis, for being here today. Uh, you clearly love your job and the opportunity to help indian nation or indian country, and I'm glad that you do it. Um, we I don't have any tribes in my district, but we have 20,000 urban indians in the dallas fort worth area, which is where I serve. Um, and, uh, we have texas native health there that has a spectacular clinic.
▶ 1:30:53If anybody needs to come through dallas for any reason, I urge you to go visit that clinic because it really kind of sets the standard. Can you tell me how the, how you guys are helping, uh, clinics like texas native health? >> perfect. Thank you. Our urbans do incredible work for the amount of dollars that provide them each year.
▶ 1:31:13They do incredible access and we work with them and the national council on urban indian health to make sure that they are well accessed, whether that's creating access to our grant programs like behavioral health, additional grants that we have in urban programs, and securing them. So that has been primarily our partnership and continue to work with them, to be exact. In this budget.
▶ 1:31:34We, before having the fy 2026, had proposed a $4.5 million increase, but congress beat us to the punch and actually provided $5 million in fy 2026. And so that's led to some observation, some appearance issues in the budget, making it look like a small decrease. But our intent was to cover the full cost of services and keep urban secure.
▶ 1:31:59>> okay, I know ihs, on a more serious note, recognizes the missing and murdered indigenous peoples as a public health crisis. 40% of women involved in sex trafficking are identified as american indian and alaska native. 1 in 3 native american women report being raped in their lifetime, which I think is probably massively underreported, which probably makes it more than one and two.
▶ 1:32:27My guess, uh, two and a half times higher than that of other groups. And, uh, american indian women are ten times more likely to be murdered than any other group. What is ihs taken in the past year? What what steps is ihs taken in the past year to better support, uh, bia and the doj in combating this? Perfect. >> well, thank you for that question. I mean, when we think about the mini crisis across indian country, it's an extremely serious issue.
▶ 1:32:56Um, before joining the indian health service, I was worked at the muskogee creek nation office of the attorney general, and a large part of my job was working hand in hand with tribal law enforcement, with our prosecutor's team, in handling just some of the most unfortunate scenarios one can think of. Um, but we take that commitment very seriously and playing our role, what we found in criminal justice there at the tribe and working was partnerships matter. Working together matters.
▶ 1:33:25That's what provided public safety in our community was how did tribals, states, federal law enforcement and our health care partners, how did we work together to share information? And that's the commitment we make, is to be there to support and to make efforts. One way that we're putting this into practical action is by expanding education in our forensic nursing program. That is something we have 37 ihs sites that are. We have worked very diligently to put forensic nursing programs in.
▶ 1:33:54And additionally, we've been partnering with academic institutions such as the texas a&m university center for excellence in forensic nursing to make sure that system wide. People across the itu system are getting training on how to handle that and making sure that they're well equipped to deal with the emotional consequences of it, but also have the equipment to collect the evidence needed to ensure that justice is served well. >> thank you. This this is.
▶ 1:34:23>> this is a this is a multi-tiered approach that I know the chairman, the ranker and everybody on this committee, republican, democrat, as americans are addressing. We understand the delineation of the law enforcement and the laws that govern the reservations versus non res, uh, is something that we are approaching, uh, aggressively, as well as finding enough law enforcement to prevent this on the first side, but also locate them. We know the first 24 hours, uh, is critical in locating a missing person.
▶ 1:34:53And if you are underfunded by 90 or understaffed by 90% on the rez for law enforcement, your chances of, of, of getting that person back are go way down. Uh, and so we are committed to working on that on all three levels in this committee. Mr. chairman. Thank you, I yield back. >> thank you. Uh, very important subject. I was going to ask about forensic nurses, and I know that, uh, that's a priority in your budget. We'll do all we can. Uh, Mr. lee said it correctly.
▶ 1:35:22This committee is committed to addressing this issue of murdered and missing it. It is stunning to most of us. And it's unfortunate that generally, the public doesn't know how big of a problem this is, because it doesn't get reported in the press like everything else does. And that's really unfortunate. But we're going to make it, uh, we're going to make it known to people.
▶ 1:35:44Uh, let me ask you, uh, as I'm sure you're aware, the government accountability office has been directed to compare veterans affairs and indian health services, health care delivery. And we hear from tribal leaders and health care professionals that the va spends considerably more than ihs on patient care. The gao team conducted this study. Conducting. This study will try to get. At this issue. Gao actually released a similar study in 2019. Uh, but we are interested in a fresh view.
▶ 1:36:13The earlier study, without getting into too much detail, had some difficulty identifying per patient costs when patients were eligible for multiple federal programs. How can the I. How can the ihs support the gao researchers who will conduct this new analysis, and can you commit to providing them access to the ihs experts and data to help us get a better handle on the difference between the va and the ihs health care systems? >> well, thank you, chairman. We can make that commitment.
▶ 1:36:41We have always appreciated working with gao on a variety of projects, and we have teams that are making regular engagements with geo on other issues. So that is a relationship we have definitely fostered and we will continue to do. Our goal is to equip them and make sure that they have what they need to make the determination and inform this body's decision making.
▶ 1:37:00We actually have already scheduled our entrance conference with gao for may the 7th, and so we are already preparing and getting them the documents and starting that conversation to make sure that they're well equipped to inform this body of making those decisions. >> I appreciate that very much. And, you know, one thing I did learn from I, I probably learned more than one thing, but from what those was doing, some of the recommendations that they made is that, uh, in the government, one of our biggest problems, our it systems suck is what he told me.
▶ 1:37:32Uh, and we need to really upgrade those. And that's reflected in the medical records and all that kind of stuff. And I, I noticed in your opening testimony, you said you were putting $200 million into the it upgrades and stuff. And we ought to recognize that that's not going to be a one time investment. It's going to be going on forever. Uh, that's just the reality of, of how we have to keep up with these things. So, uh, I look forward to working with you on that.
▶ 1:37:57One other question that I had, though, is, uh, miss pingree brought it up in her statement, uh, changes in medicare for or for better or worse, whatever, change the reimbursements that tribes get from medicare on. So how is it affecting the tribes out there with changes that have been made in medicare? >> well, perfect. Thank you for that. When we talk about third party billing, it is essential to how we deliver care.
▶ 1:38:21It changes how we approach things such as prc, the services rendered, the facilities constructed, and that's third party across the board. The working family tax cuts legislation did provide some very unique set asides, taking the important. How important it is to the itu system in play, whether that was exemption from the community engagement requirements, not requiring as frequent reassessments on income for qualification. Those have been very helpful.
▶ 1:38:50We are actually anticipating seeing a 9% increase across our ihs hospitals in third party billings this year. So I can't speak for the itu system wide. We don't have that data in quite yet, but I can tell you, at least from the ihs hospital perspective, we're on pace to see a 9% increase in third party billings than last fiscal year. >> appreciate it, miss pingree. >> yeah, thank you for that.
▶ 1:39:15Um, well, I will continue to be worried about those third party reimbursements because I think we don't really know since that hasn't kicked in yet how that will impact you. And I'm sure you're trying to anticipate it, but the more we can, the more work you can do in advance, the more it will help us in our appropriations process to make sure there isn't a giant hole that we didn't anticipate. Um, I just wanted to follow up.
▶ 1:39:39You know, we've already talked a little bit about filling vacancies and about the education side, and I wholeheartedly agree with the chair on that. A little bit more on the graduate medical education. Um, this is a concern I've raised before about recruiting and retaining those professionals and the idea that you need those opportunities in your training process. And it seems that there continue to be lack of opportunities for physicians in training to serve and learn in tribal health centers, including in maine. So, um, what are you doing right now?
▶ 1:40:10Can you talk more about how ihs is scaling up any tribal involvement in medical elective rotations? >> perfect. Well, thank you, ranking member. So I will circle back to the chairman's statement. Previously, you were right. It's actually both oklahoma and oklahoma state have education programs at cherokee nation. I believe oklahoma state is doing the m.d. Residency programs in education. And then they just recently announced a partnership with the university of oklahoma on, um, nursing programs there at ww hastings.
▶ 1:40:41I will say, you know, I think this, uh, getting good people into rural health care and tribal health care is the one unifying issue between, uh, the university of oklahoma and oklahoma state. They may have bedlam on everything else, but they seem to be working quite well for that one. So we are definitely striving to do as much as we can.
▶ 1:40:59So one thing I will like to highlight for this body is our recent residency program between the university of new mexico and the ihs hospital at shiprock on the navajo reservation, where we have had, it turns out nine trainees come through so far, with two thirds of them going on to work either at ihs directly or in tribal health systems. And we're additionally seeing 100% baud rate. So we are getting good candidates, and they are succeeding when they leave. It is not a slackers program, but we are.
▶ 1:41:30We just had two new residents placed in that program here in just the last few months, including Mr. andrew tom kean from brown university and brian guttman from the university of colorado. We're excited to have them. Additionally, we've been working on deep partnerships with other institutions. Right now, we have 16 agreements with colleges and universities this year alone, working on expanding access to education and putting those educated individuals into service.
▶ 1:41:57And we're in we have another 19 sitting in the queue waiting for review to continue to expand those partnerships. As you mentioned, grow your own is this is largely the solution to these problems. We've been trying to recruit from outside of indian country for a long time. It has not yielded quite the results, we hope. But when we can capture those people young, when we can keep them close to their communities, their families and their ties, we're seeing that they tend to stay around. And I know that was the case for me, uh, in my service in indian country.
▶ 1:42:25And I imagine we'll see very similar things, um, across the itu system. >> this is a follow up. Um, are there more resources needed to accomplish that? I mean, I'm glad to see the number of agreements you have and that there are that many in the queue. Do you have sufficient, um, you know, staffing to deal with this? Uh, I just want to make sure we, we pick up the pace and that we follow through on all this, right? >> a lot of those initiatives are we have our scholarship program and our loan repayment program, which have been successful.
▶ 1:42:54But a lot of these internships opportunities are largely being funded through third party billing. Um, have been the key drivers in expanding those. And I think that's likewise what you're seeing across the itu system is they're using a lot of third party unrestricted dollars to fund these kinds of initiatives. Um, so one of the big goals that we're having as we look to reorg is to ask ourselves, what role does indian health service play into the future?
▶ 1:43:19And I think when we talk about pathways and pipelines, those are some of the initiatives that we think increased focus will need to be on in upcoming years to make sure that the itu system operates efficiently, even when we're no longer ihs directly involved in hospital operations. If we reached 100% compacted world. And so I think this is a critical issue, um, going forward. But right now a lot of that is being funded through third party. >> great. Well, thanks for that information.
▶ 1:43:49We'll continue to stay in conversation with you about that. With that, I yield back. Thank you. Thank you, chair. >> Mr. zink. >> no, I have no further questions. I think you're doing a great job. >> appreciate it sir. >> thank you. Uh, you know, it's kind of you can use models that have worked out there. And I think you're using some of those in in idaho, idaho, alaska, montana, uh, and washington have the what's called the witschi program and the whammy program for doctors and dentists.
▶ 1:44:18And we actually take, uh, seats in university of idaho for veterinarian science and stuff like that. But the state reserves seats in medical schools. It used to be just the university of, uh, of washington. Now we do some at the university of utah and stuff because we can't afford a medical school ourselves and it doesn't make sense. So we reserve seats for idaho students to go down there.
▶ 1:44:41And most of those students come back to idaho, same sort of thing that, uh, that we're working on here, uh, that you're, that you're working on. So I think that'll be successful. It just takes a little time to get it done. So I appreciate what you're doing. I look forward to, to working with you as we try to put together the budget for the next year. And, uh, I will tell you in all honesty, you got really good friends on this committee.
▶ 1:45:04So if there are things that come up that you need to let us know about, let us know and we'll work with you and try to solve these problems and look forward to getting a bill that we can all be proud of in indian country next year. >> well, perfect. Thank you. Chairman. Like I said in my opening remarks, we greatly appreciate the support this committee has had. You've been making investments over the last decade, and we are seeing the fruits of those.
▶ 1:45:25And as we continue to make strategic investments in infrastructure and technology and humans, care providers, I think we'll continue to see and rewarding benefits that will make impacts not just for indian country, but for rural health care generally. >> well, thank you and thank you again again for being here. And I apologize for our lateness and stuff. I know your time is as valuable as ours, but sometimes we get caught up in this voting thing. So I appreciate you waiting for us.
▶ 1:45:53>> and I was always recommend, uh, getting out of the headquarters and going to front line as much as you possibly can. We'd welcome you in montana. I'm sure the same thing in idaho. And anyone that has any indian country, we would, we would welcome a dialog face to face. >> wonderful. Congressman, I think we've got a trip to montana scheduled in montana or in july. So if your staff is available or yourself, we would love to connect. >> and if you go to montana that is so close to god's country, you know. So close.
▶ 1:46:24Yeah. >> swing and a miss. >> anyway. Thank you. With that, the hearing is adjourned.