▶ 0:28:10Chair Murkowski: Good afternoon, the committee will come to order, we are here to receive testimony on three bills that will include health care delivery across native communities. The first bill I want to highlight is s. Mr. laroche -- is s.
▶ 0:28:23Chair Murkowski: 2098 that would transfer land to the south-central foundation that already provides health care to ihs beneficiaries under a self-governance compact.
▶ 0:28:45Chair Murkowski: On this site, scf operates a clinic that serves culturally grounded behavioral health practices. They can't move forward unless they own the property. The other two bills were introduced by our colleague, senator rounds, and the focus on fixing real challenges.
▶ 0:29:18Chair Murkowski: Tribal members face issues. The emergency claims parity act would give more patients time to notify the act.
▶ 0:29:46Chair Murkowski: Right now many tribal members are expected to be meeting a type reporting deadline while dealing with a medical emergency and this bill would bring fairness and common sense to that process. S. 699 addresses reimbursement delays for the purpose of reimbursement care. Patients can end up facing collections.
▶ 0:30:17Chair Murkowski: This strengthens liability protections and requires procedures to be developed. It is very important that we hear from ihs on these bills. I'm grateful to vice president ross and councilmember seymour for traveling to share their testimony. We appreciate that.
▶ 0:30:44Chair Murkowski: We do have one more vote after this series, so we will be popping in and out and committee meetings as well so we apologize for a little bit of the disruption. But we are making good progress and I turned to my colleague in the ranking member schatz, the vice, excuse me.
▶ 0:31:06Sen. Schatz: Thank you, chairman murkowski for convening today's hearing on legislation to improve health services and facilities for native communities. The federal government has a trust responsibility. This obligation is not and cannot be an aspiration. It is a duty grounded in federal laws, treaties, and the federal government's own promises.
▶ 0:31:29Sen. Schatz: When it fails, native families pay the price and yet lofty promises from secretary kennedy to "protect health care access and strengthen delivery systems across indian country have not come to fruition. We have seen the opposite. Office closures, budget cuts and new administrative processes have delayed.
▶ 0:31:57Sen. Schatz: The tribes in the native hawaiian community need to know. In these letters, the chair and I asked about ihs staffing levels, hiring freezes and the delays in filling vacancies. What it means for tribal and urban indian health programs trying to plan a year or even a month ahead.
▶ 0:32:25Sen. Schatz: This committee even held an oversight hearing last may highlighting all hhs programs serving native communities and the agency obligations, but we have struggled to get timely, straightforward information. Responses often come late, they are often incomplete and use carefully worded generalities rather than providing real answers.
▶ 0:32:47Sen. Schatz: Let me be clear, it should not take repeated letters to get plain english explanations of what is changing at hhs, wyatt is changing, and how and whether tribes were consulted before decisions were made. The tribes demanding the respect that they are. And treats consultation is a real process.
▶ 0:33:25Sen. Schatz: Ihs's civilian workforce is that a 10 year low. Clinics struggled to operate without staff and clinics cannot operate the way they need. Tribes cannot reach agency staff for urgent problems they face. Going forward I hope ihs will agree to come prepared. And real steps that the agency is taking steps to improve access to health care.
▶ 0:34:02Sen. Schatz: Congress has not seen it. The tribes were not consulted. My message today is straightforward. Hhs has to begin to restore a basic level of trust by sharing facts, timelines to indian country. Tribes will keep advocating for citizens the way they always have. The agency needs to meet these actions with accountability.
▶ 0:34:35Sen. Schatz: I want to thank you for this meeting and the witnesses.
▶ 0:34:38Chair Murkowski: Senator rounds, would you care to make an opening statement?
▶ 0:34:43Senator Rounds: If you would allow.
▶ 0:34:45Chair Murkowski: Yes.
▶ 0:34:49Senator Rounds: Thank you to chairman murkowski advice chairman schatz for this today. Tribal members in my home state of south dakota routinely encounter obstacles when attempting to seek payment for health care services outside of an ihs facility.
▶ 0:35:15Senator Rounds: Under current law, most tribal members receiving emergency care outside of the network must report that care within 72 hours or ihs will not provide reimbursement for their care.
▶ 0:35:37Senator Rounds: My bill, the indian health service emergency claims parity act would fix this by moving the emergency notification requirements from 72 hours to 15 days. This will allow patients the necessary time to seek care at the closest facility that can adequately address their emergency needs without worrying that the ihs won't reimburse costs.
▶ 0:36:12Senator Rounds: Properly submitted p.r.c. Claims may not be paid in a timely manner. Between october of 2013 and june of 2016, an estimated 32's thousand claims were not paid within a timeframe.
▶ 0:36:41Senator Rounds: It would require ihs it would require them to approve it within 30 days and make sure ihs addresses any unintended costs with beneficiaries for approved claims that it would allow a beneficiary to submit documentation to the agency electronically or at a service unit.
▶ 0:37:11Senator Rounds: It would strengthen liability provisions making clear beneficiaries with approved p.r.c. Claims are protected from outside providers and third parties attempting to collect wrongfully charged debt. These bills would provide needed reforms to the ihs p.r.c. Program and asked for my colleagues' support as we work toward a markup.
▶ 0:37:39Senator Rounds: Madam chairman, I thank you and the vice chair for your privilege of allowing me to speak at this time.
▶ 0:37:45Chair Murkowski: Absolutely. Senator rounds, thank you for your leadership on these issues. We will turn to the witnesses and first-year from the honorable darrell laroche, the deputy director for management operations at ihs in washington, D.C.
▶ 0:38:01Chair Murkowski: He will be followed by the honorable dayna seymour, from the district representative and health and human services chair at the colville tribal business council, the confederated tribes of the colville reservation out in washington state. And Ms. leanndra ross, the vice president of executive and travel services at south-central foundation in anchorage, alaska.
▶ 0:38:30Chair Murkowski: I will remind our witnesses that we do have your full, written testimony, so we would encourage you to try to keep your verbal statements to about five minutes. And then we will have an opportunity for questions following that. Mr. laroche, please with your testimony please and thank you.
▶ 0:38:50Mr. Laroche: Good afternoon. I'm darrell roche, the deputy director for management operations at the indian health service. Thank you for the opportunity to provide testimony. The indian health service emergency claims parity act, and s.
▶ 0:39:16Mr. Laroche: 699, the purchase care and improvement act. If I may restate the mission of the indian health service, which is to raise the physical, mental, social, and spiritual health of american indians and alaska natives to the highest level, this mission is carried out in partnership with american indian and alaska native communities.
▶ 0:39:41Mr. Laroche: The first bill before the committee, the south-central foundation land transfer act of 2025 would authorize the secretary of health and human services to transfer certain land in anchorage, alaska to the south-central foundation by warranty deed without requiring consideration to the federal government. The bill would require the conveyance to be completed as soon as practical, but no later than two years after enactment.
▶ 0:40:11Mr. Laroche: Additional details are included in my written statement. As you know, chair murkowski and members of the committee, congress has considered similar legislation in previous years that mandated land transfers by warranty deed rather than by quitclaim deed and the department has the same concerns with the s 2098.
▶ 0:40:33Mr. Laroche: As noted in my written testimony , hhs has identified certain preferences and with those concerns in mind, the department supports the proposal of the bill. S. 1055 and s.
▶ 0:40:49Mr. Laroche: 699 relate to the indian health service purchase, the administration and the department's goals to improve health outcomes for american families and protect patients from medical debt, therefore I think it is very important to note that patients are not liable for p.r.c. Costs under section 222 of the indian health care improvement act.
▶ 0:41:16Mr. Laroche: A patient should not be forced into collections because of the unpaid medical bills. The p.r.c. Improvement act seeks to address liability for costs associated with p.r.c. Services. It would require the secretary of hhs to notify a p.r.c. Provider and any patient who receives p.r.c.
▶ 0:41:36Mr. Laroche: By ihs that the patient is not liable to any provider, debt collector, or any other persons for the payment of any charges or costs associated with the provision of the p.r.c. Services. It would further require the secretary through ihs and in consultation with indian tribes to establish and implement procedures to allow a patient that paid out-of-pocket for p.r.c.
▶ 0:42:02Mr. Laroche: Authorized by ihs to be reimbursed by the ihs for that payment. Simply put, patients should not be expected to pay out-of-pocket for services consistent with the patient protections in section 222.
▶ 0:42:29Mr. Laroche: However, if a patient chooses to pay in anticipation of a reimbursement under the new subsection d, the patient should because this not to pay before alternate resources are exhausted. The draft of the bill may cost additional uncertainty for those seeking care.
▶ 0:42:58Mr. Laroche: The emergency claims parity act seeks to notify p.r.c. Services. It must be within 72 hours for current p.r.c. Regulation. The only concern is flexibility.
▶ 0:43:19Mr. Laroche: If there is ever need to change time frames if the bill were to be passed by congress and signed into law. All things to consider, the department shares protecting patients from medical debt and ensuring american indians and alaska natives have access to high-quality and affordable care.
▶ 0:43:48Mr. Laroche: We look forward to continuing our work with congress on these bills and welcome the opportunity to provide technical assistance as requested by the committee or its members. Thank you again for this opportunity to testify.
▶ 0:44:01Chair Murkowski: Thank you. We next turned to dayna seymour. Welcome.
▶ 0:44:10Ms. Seymour: Good afternoon. My name is dayne my name is dayna seymour, I'm a member of the colville business council. Thank you for inviting me to testify. Purchase and referred care or prc is a program where ihs beneficiaries receive care from private non-ihs health providers when they are unable to provide the care.
▶ 0:44:38Ms. Seymour: As discussed in more detail for years ihs mismanaged the program at the service unit. Members went to great efforts to try to get p.r.c. Services and otherwise make the program workable. The ihs portland area office would impose new obstacles. Addressing p.r.c.
▶ 0:45:03Ms. Seymour: Was the main reason that we contracted all ihs functions under the indian self-determination education assistance act. From 2017 through 2022 we administered at the caldwell service unit. The p.r.c. Program was administered so poorly we can trace it to deaths in our community.
▶ 0:45:31Ms. Seymour: Ihs required on an annual basis are members to produce utility bills, certificates of indian blood, other proof of tribal enrollment and other information not required by the ihs regulations or handbook to get p.r.c. Services. Those unable to produce this information either went without care, obtained care on their own and faced collection agencies when ihs refused to pay for the services.
▶ 0:46:00Ms. Seymour: If they did produce services, there was no way to predict if they would pay the provider. The providers will assign the debt to third-party debt collectors. Even though the indian health care improvement act states individuals are not liable for bills with authorized p.r.c. Services.
▶ 0:46:24Ms. Seymour: Providers rely on the boilerplate consent forms that they require all patients to sign as an alternative basis to pursue the debt. The mismanagement of the program has resulted in many tribal members avoiding care altogether out of fear of being saddled with medical bills and having their credit affected. Near the end of our negotiations, we were shocked to learn that the service unit had $42 million in funds.
▶ 0:46:56Ms. Seymour: This money should have been spent if it was administered properly. Some have paid medical bills for services out-of-pocket because they feared having their credit damaged by being sent to collection agencies. There is nothing in the law or regulations that prohibits ihs from reimbursing beneficiaries when they pay out-of-pocket.
▶ 0:47:22Ms. Seymour: Ihs has indicated that it is unable to reimburse for reasons that they have never explained to the colville tribes. The prc improvement act would clarify the individual p.r.c. Care authorized by ihs, shall not be liable to any provider or debt collector.
▶ 0:47:41Ms. Seymour: The bill would create the use of boilerplate consent forms providers require patients to sign from being used to target tribal members through collection agencies. Finally, s. 699 word require -- would require providers to be authorized within 30 days.
▶ 0:48:08Ms. Seymour: Tribal members should be made whole when they pay out of their own pockets to avoid collection activities through no fault of their own. For those tribal members that paid a medical bill out-of-pocket, the money ihs would reimburse would be in the p.r.c. Carryover funds for that service unit. In other words, the reimbursement requirement would not cost taxpayers anything because that money is sitting in the system as unreconciled p.r.c. Funds.
▶ 0:48:40Ms. Seymour: Any amounts they paid out-of-pocket would be reflected in $42 million carryover at the service unit I mentioned earlier. The colville tribes urges the committee to take whatever steps are necessary to secure the enactment of s. 699 99 -- s. 699 into law and we also support the s. 1055 indian health service emergency claims parity act.
▶ 0:49:13Ms. Seymour: This will minimize instances of prc care being denied for emergency care. This concludes my testimony and I'm happy to answer any questions the committee may have. Thank you.
▶ 0:49:22Chair Murkowski: Thank you so much. And thank you so much for the very concrete examples you provided the committee. Next, we go to Ms. ross, welcome.
▶ 0:49:36Ms. Ross: Good afternoon, my name is leandra ross and I'm the vice president of executive and tribal services at the south-central foundation. I want to thank the committee for the opportunity to testify today and for your work on behalf of tribes, tribal organizations, and alaska native and american indian people all around the country.
▶ 0:50:02Ms. Ross: I also want to thank the staff that have been so helpful working on s. 2098. Scf is under the tribal authority and designated by 12 federally recognized tribes. We provide health care services to beneficiaries of the ihs so we referred to as customer owners as we are both customers and owners of our own health care.
▶ 0:50:28Ms. Ross: It is one of the largest employers in alaska with 3000 employees that support the physical, mental, emotional, and spiritual wellness of 70,000 customer owners.
▶ 0:50:48Ms. Ross: Scf has over 850,000 unique encounters a year with 90 plus programs and as a model of how self-determination is successful in providing quality health care. Today, I'm here to testify on the south-central foundation land transfer act. The bill will transfer the title of land the ihs currently owns.
▶ 0:51:12Ms. Ross: This land transfer is necessary for scf to build a new 44,000 square-foot building for two critical programs. The building we are using now are some of the oldest the ihs has in alaska and were not built to provide direct services to customer owners. In fact, the space currently used as an arts room was the old hospital morgue.
▶ 0:51:36Ms. Ross: With the new building, we will be able to expand services to some of anchorages most vulnerable individuals who experience chronic mental illness and adults with complex behavioral health and substance misuse needs. The clubhouse operating for more than 30 years as an answer to the ongoing needs of adults with chronic mental illness to live a stable, healthy, supportive life in community.
▶ 0:52:01Ms. Ross: It is a day treatment program that blends integrated behavioral health and primary care services to further meet individualized treatment goals done through the provision of support, including medication in cultural and wellness activities. Today, scf has 100 14 customer owners in the program. The successes evidenced by the fact that all participants are living in stable housing.
▶ 0:52:31Ms. Ross: In anchorage, were sadly many alaska native people are in housed, it is remarkable that with supportive services such as those offered, customer owners can overcome this hurdle. I'm pleased to share 80 customer owners currently participating in the program have achieved their goal of employment. We are proud to support participants with over 87% supporting ownership and health care.
▶ 0:53:00Ms. Ross: The new building will not only double the capacity, but it will allow us to align and co-locate the intensive case management services into the same building. The icm program is a community-based program focused on outreach, engagement, intensive community case program such as housing.
▶ 0:53:29Ms. Ross: Think of icm as one precursor to participating. It works with customer owners. S 2098 will make possible the expansion of both programs and a state-of-the-art facility by giving scf ownership of the land .
▶ 0:53:55Ms. Ross: Scf is ready to begin the project this summer with passage of this bill. We hope the transfer can happen expeditiously. Thank you for the opportunity to testify today and am happy to answer any questions you may have.
▶ 0:54:13Chair Murkowski: Thank you. Let me begin with you. About the south-central foundation land transfer act. You have shared with the committee the current conditions of the clubhouse.
▶ 0:54:36Chair Murkowski: Can you share with the challenges our with maintaining or upgrading the facilities when south-central does not own the land or facilities.
▶ 0:54:51Chair Murkowski: I would ask you to give a little but more clarity to what you said on the end and that you are prepared to move quickly and if you could just describe quickly what you mean so this land advance happened.
▶ 0:55:16Ms. Ross: The clubhouse is in a 50-year-old building and it has many of the challenges that three mostly connected buildings would have. Heating systems are difficult to maintain. Participants walk outside to get to different services located one of the facility.
▶ 0:55:42Ms. Ross: This facility is one that we would love to see increase for our customer owners. We would love to be able to build this summer. We are at a 35% design for the building.
▶ 0:56:08Chair Murkowski: If I can ask on that. You are ready to build, 35% design but the thing holding you back is you do not have the warranty type.
▶ 0:56:14Ms. Ross: We do not have ownership to the land so we would like the ownership through this. To be able to build.
▶ 0:56:23Chair Murkowski: If that is to come, you are prepared to move to start construction this year?
▶ 0:56:33Ms. Ross: We are excited.
▶ 0:56:35Chair Murkowski: I can tell you are excited and rightly so. The importance of being able to be more responsive to the increasing demand for behavioral health is so important so I want to make it clear for the record that the only thing holding you up as the full ownership of the property itself.
▶ 0:57:06Chair Murkowski: Let me ask one other question because it is always important that you have stakeholder buy-in. Whether it is from the community. Can you speak to the efforts to prepare for the land transfer?
▶ 0:57:19Ms. Ross: Good question, we have many partners and the community in the area is very excited. We have got to community councils. We have shared with the municipality our plans to move forward. We have letters of support for community partners. I think that we have been a good neighbor in this area and we will continue to be a good narrative -- good neighbor in this area.
▶ 0:57:48Chair Murkowski: Let me ask you, Mr. laroche, because you have mentioned that while you support the conveyance, you noted a concern here. Congress has already passed several bills transferring federal land to tribal health organizations.
▶ 0:58:11Chair Murkowski: In 2022 we were able to pass legislation that conveyed ihs land to the tribal council of tcc to the southeast alaska region health consortium as well as in thc.
▶ 0:58:30Chair Murkowski: You have mentioned that you have some concerns, so can you tell the committee, when ihs carried out these transfers three years ago now back in 2022, did the agency have any administrative difficulties in executing on them?
▶ 0:58:49Mr. Laroche: Thank you for that question. We had not had any administrative problems. We prefer the quit claim, but we enact it in law, we will go through with the warranty deed.
▶ 0:59:03Chair Murkowski: I want to make clear that while we get with the preference is, the agency didn't encounter any difficulties then with that legislation. With how the deeds were titled. Ok. Let me move to you, Ms. seymour.
▶ 0:59:37Chair Murkowski: You have shared a great deal in your testimony today. The issues. When you had delays leading to these unexpected bills, medical debt, credit score impact.
▶ 0:59:56Chair Murkowski: And you one further to say that in an effort to avoid this, you have some of your tribal members avoid seeking medical care altogether, which is absolutely the wrong direction for any of this.
▶ 1:00:16Chair Murkowski: You made a decision, you made a decision back in october of 2025 to assume all ihs functions through 638 agreement.
▶ 1:00:35Chair Murkowski: To what extent did these concerns you have raised, people who were fearful of debt collection issues and thus delaying medical care or treatment you have also just detailed how this concern about
▶ 1:01:05Chair Murkowski: What it is going to mean to me when I have the bills coming to my house. I'm dealing with the bureaucracy I may or may not be comfortable with. To what extent did these debt collection issues affect the decision to contract ihs functions and take on the management and the provision of health care services yourself?
▶ 1:01:29Ms. Seymour: It had a huge impact on that decision. We were getting complaints. We were losing our people because they were not getting the care that they needed in a timely manner or not at all. And I believe the council has been looking at it for years and finally took the stance of, you know what? We can do better.
▶ 1:01:56Ms. Seymour: If we contract this and bring this under our supervision, we can provide our members with the health care that is needed. In this statement, it says we can trace this back to deaths in our community. I can give you one example of some issues. I had a family member who was awaiting a specialist referral and her appointment I believe had to be canceled.
▶ 1:02:27Ms. Seymour: She was going to have the follow-up that monday. She died over the weekend of a massive heart attack because she good not get to the hospital soon enough to be checked out. She was not the only one. There were many instances where that happened on the reservation and we decided that we cannot continue to lose our people, so that is why we made the decision to contract. Not only that, but also I myself have been sent to collections.
▶ 1:02:58Ms. Seymour: I have bills, my husband has bills that are in collections. My daughter does. And we diligently turn them in time after time. You don't want your credit to be affected, so if you have the means, you pay it. A lot of our patients were elderly and paying these bills out of pocket when they could not afford to do so.
▶ 1:03:23Chair Murkowski: Even though we have heard Mr. laroche say the patient will not be liable, that reimbursement comes, you still have a situation where the debt collector is the one that comes before the reimbursement comes. And so there is concern about whether or not the reimbursement is going to be made.
▶ 1:03:59Chair Murkowski: They said something on this issue about reimbursement where it is reimbursed to the extent that they prc and that the patient should be cautious in not exceeding the amount of the prc. How do I know what that amount is?
▶ 1:04:21Mr. Laroche: That's a great question. It would have to do with whatever the service was they were sent out for. Usually, the prc program is paying providers. So the patient would not necessarily know what that reimbursement is.
▶ 1:04:44Chair Murkowski: That is the heartburn I've got with all of this. You are putting the burden on the patient. If I'm going to go in for a mammogram, I don't necessarily check to see if the cost for that procedure in the area that I'm in is within the scope of what is approved within the prc and you are saying, alright, you
▶ 1:05:15Chair Murkowski: Are not going to be on the hook ultimately, but it could be a situation where we don't know how long that reimbursement is going to take. It seems to me we are doing a huge disservice if we are saying there is, there is a responsibility here when we are talking about health care for
▶ 1:05:46Chair Murkowski: Native peoples and you have a program for reimbursement for care that assumes an awful lot that is not very clear. You are nodding that you don't disagree that this is confusing to the patient. Do you have any good suggestions as to how this can be addressed?
▶ 1:06:17Chair Murkowski: I think perhaps senator rounds two bills could be very helpful to that.
▶ 1:06:20Mr. Laroche: Definitely. The prc program has been set up to deal with directly from ihs to a provider so that is why it is a little bit more confusing when we talk about a patient having to pay on that, but I think this is an opportunity for us that we will be more than happy to work with the committee and the drafters to come up with some technical assistance and come up with a solution on that.
▶ 1:06:50Chair Murkowski: Ok. There is nothing in statute or regulation that prohibits reimbursement. Cbo apparently thinks that there is some budget authority that is required.
▶ 1:07:13Chair Murkowski: This is something that I think needs to be made much more clear than we currently have in statute. We are in agreement on that? I'm going to ask my last questions and I will turn to my colleagues who have just come back because they have done their second vote and I have not.
▶ 1:07:36Chair Murkowski: You have mentioned the issues that the burden of a 72 hour window creates. Senator rounds had mentioned that as well. Is there, do you think people understand that this 72 hour reporting issue is a problem for them? Or is that just an issue with the providers themselves?
▶ 1:08:06Chair Murkowski: Yes, please, thank you.
▶ 1:08:08Ms. Seymour: So it is an issue I don't think for everybody understands, and I think that is where it would be helpful for more education to the patient. I think it is very cumbersome.
▶ 1:08:24Ms. Seymour: Like senator rounds had said, because if you have somebody in an accident and they are in the icu for two weeks, you are limited to a 72 hour, but within those first 72 hours, your family is so focused on if you are going to live or not, the last thing on their mind is calling ihs to report the prc department that they are in the er and at that point you don't know if they are going to stay at that hospital or be shipped to another and then there are
▶ 1:08:55Ms. Seymour: Repeated calls that have to be made so I think the 15 days would give a lot more grace time for the families and the patient . Because I think the first 70 two hours of any illnesses critical to taking care of yourself or your family member who is in the critical illness and in that timeframe, that I think part of it is that patients don't quite understand so it doesn't get reported and then they get released from the hospital, say it is in four days and then they
▶ 1:09:26Ms. Seymour: Call and it is too late and they are stuck with this astronomical hospital stay bill that they have. Because attached to those pills also, we are in a rural area, so if you get flighted or an ambulance, that is attached to the bill as well, so if you don't report that, that could be $200,000 to $400,000 depending on where you are flown to.
▶ 1:09:54Chair Murkowski: Senator cantwell, we will turn to you. Senator chasse is coming back, I'm going to go vote. I think senator rounds has presented a couple really strong bills on how we can produce -- reduce purchase and referred care, but we heard some really very interesting testimony here today in terms of how a system that should work better, that should ensure that native
▶ 1:10:27Chair Murkowski: American patients when they go to seek care are not ultimately on the hook, but it is some pretty troubling story is so I think we got some good suggestions out there and then Ms. ross from south-central foundation working on great initiatives when it comes to the opportunities for access for mental and behavioral health. I will turn to senator cantwell next.
▶ 1:10:55Sen. Cantwell: Thank you, chair murkowski, thank you for you and vice chair shots -- schatz for holding this hearing and the chair mentioned senate bill 699, the purchased and referred care improvement act. I want to thank councilmember seymour for traveling all the way from colville to be here in northeast washington, so very challenging to get all the way across the country.
▶ 1:11:27Sen. Cantwell: We just had some people from orville. I was like, how did you get here? A lot of traveling this week. I teamed up with senator rounds because introducing this really after hearing from the caldwell tribe. It was really clear, the pervasive problems.
▶ 1:11:47Sen. Cantwell: If you are in this rural part of the state that doesn't deliver care and then your people end up getting credit score deterioration, how are you supposed to get health care? It is all because indian health services was not paying its bills.
▶ 1:12:04Sen. Cantwell: As we already heard from the councilmember, the caldwell reservation which -- the colville reservation, which is no small area of geographic area to serve in the northeast corner of our state, there are no full-service ihs hospitals and a 60% vacancy rate at caldwell ihs service unit. That is basically abdication of duty if you ask me.
▶ 1:12:32Sen. Cantwell: It is just abdicating the duty we are supposed to provide for health care. This means tribal members often travel long distances to seek health care providers outside of the system and the ihs system is supposed to reimburse the health care provider. Unfortunately when this doesn't happen, ihs does not reimburse the health care provider and then the provider is not paid and then they seek payment from the tribal members. That is what we are here to say it has got to stop.
▶ 1:13:04Sen. Cantwell: We can't be putting this on the back of individual tribal members, this is crazy. We have to live up to our responsibilities in delivering care either through the ihs system or let us pay for it. That is the role and responsibility of the federal government, so tribal members including elders and elected officials have been sent to collection dead creditors. So literally we are not providing health care and then we are letting debt collectors prey on individuals.
▶ 1:13:36Sen. Cantwell: The colville tribe learned that there was $42 million in funds that should have been spent for health care on tribal members if only ihs had admitted it properly. Recently, they assumed all functions under the self-determination act and I'm so proud of our state, where we have become the primary provider under self-governance of clinics around the state of washington. Not only are they great tribal clinics, they are serving the larger population within the region.
▶ 1:14:08Sen. Cantwell: Oftentimes, they are in more remote parts of our state, something of that nature and not only are they providing great indian health services, but they are providing care to the larger community and it really becomes a stabilizing force for health care in the region.
▶ 1:14:30Sen. Cantwell: Indian country has been prayed on for the most egregious abuses of narcotics with people locating big fentanyl centers. Why do they locate it in indian country? The vast land that is there. It is because you can't cover all that land. You can't cover all that tribal land.
▶ 1:14:57Sen. Cantwell: They know law enforcement is challenged to root them out, and so we have had horrific challenges with the attack on in country and this could--the screech of fentanyl.-- scourge of fentanyl. I want to talk about how the purchase and referred care act does support indian country.
▶ 1:15:19Sen. Cantwell: Since ihl's health care services -- since the tribe is taken over and has your own relationships, are tribal leaders financially getting a better production?
▶ 1:15:31Ms. Seymour: So tribal members are financially better protected under the caldwell tribal health care authority because our purchase of effort care payments are issued faster and more reliably than under the ihs system, which is reducing delays, denials, and unexpected patient bills. We are expected to maintain financial reserves for programs which strengthens long-term sustainability and protects services during funding challenges or emergencies.
▶ 1:16:02Ms. Seymour: That, combined with stronger revenue cycle oversight and local decision-making, tribal control has shifted financial risk away from our members and towards a more accountable and sustainable health care system.
▶ 1:16:13Sen. Cantwell: Thank you. Thank you for that leadership that caldwell has demonstrated. If we can continue to empower through self-governance the delivery of a system, we will get a better system. On this issue, Mr. laroche, is there any legal impediments to ihs reimbursing tribal members who pay bills out of pocket so they can stop being harassed by collection agencies? Is there any legal impediment to that?
▶ 1:16:41Mr. Laroche: Great question. I would have to take that back to the legal as far as the legal side of things. One of the things that is challenging for us is we are bound by the federal acquisition regulations, and that is a little bit cumbersome for providing payments for health care and still complying --
▶ 1:16:58Sen. Cantwell: Burdened by what?
▶ 1:17:01Mr. Laroche: Federal acquisition regulations that requires purchase orders. It is a little bit more cumbersome -- we would have to work with the tribes and ihs to come up with a mechanism to actually --
▶ 1:17:19Sen. Cantwell: Ok, so why haven't we done that yet is my question.
▶ 1:17:23Mr. Laroche: That is one of the things that if this is passed we can do that --
▶ 1:17:26Sen. Cantwell: Why can't we do that now? We know have a broken system in a big part of our state. Why can't ihs, if they are not going to deliver the care -- obviously these are choices, right, that people made a long time ago. I'm assuming. I see lots of lawyers in the audience who know this, back here on the dais, who know this better than I do. Different parts of states make different choices whether through self-governance or ihs.
▶ 1:17:56Sen. Cantwell: If ihs can't deliver the care and the tribe is taking on the financial responsibility of delivering the care, and you have a direct relationship because you cannot deliver the care and ihs, you are then contracting with them. If you are contracting with them, why can't you just protected them from being preyed upon by creditors?
▶ 1:18:18Mr. Laroche: The ihs p.r.c. Program was set up for the payments between us and the providers. So that's one of the things that we are working -- we have now directors workgroup to improve p.r.c., and things like this have been talked about there so we can take those suggestions --
▶ 1:18:41Sen. Cantwell: I will get with you -- you should go back and get an answer and figure out why we can't do this sooner.
▶ 1:18:47Mr. Laroche: Ok.
▶ 1:18:49Sen. Cantwell: I'm not really chairing, but I'm passing down to senator lujan. Senator lujan.
▶ 1:18:57Sen. Lujan: Thank you, senator cantwell. Last year ihs made the decision to move funding away from 2 new mexico tribal health facility projects on the list of facilities that need to be replaced. One is in albuquerque, the albuquerque west facility, and one serving the navajo nation, one of ihs's largest facilities serving a large portion of the navajo nation.
▶ 1:19:25Sen. Lujan: Actions like this depriving the tribes of these funds creates uncertainty and hinders negotiations and planning. Worse, the tribes, the poor - p - - pueblos and the nation, had no explanation for why the funds why the fu were moved. They told me the pueblo had broken ground on a new facility and it was shovel-ready.
▶ 1:19:55Sen. Lujan: Funding is restored there and I want to make sure it is not moved again. Mr. laroche, yes or no, who you commit to privatizing this project and using the encouraged 638 authorities were possible?
▶ 1:20:08Mr. Laroche: Definitely all the facilities on the grandfather list our priorities and we do encourage the 638. Sen. luján: just to be clear, Mr. laroche, both of the projects are on that list?
▶ 1:20:20Mr. Laroche: Correct. Sen. luján: appreciate that. Yes I know, will you commit to meaningful--yes or no, we're committed to meaningful consultations before ihs moves funds out of the projects?
▶ 1:20:34Mr. Laroche: We do realize that we need to discuss that with them. I believe that within that authority, the funding authority or whatever we are able to move things around, but we need to make sure that we contact and work with the tribes. Sen. luján: are you comfortable with committee to meaningful consultation with these sovereign nations if that is a decision ihs is making?
▶ 1:21:01Mr. Laroche: It will follow the tribal consultation policy. Sen. luján: I appreciate that. We are in discuss vs. Meaningful consultation, two different things. I appreciate that, Mr. laroche. Secretary kennedy visited the navajo nation last year and specifically mentioned access to water is a priority. But just yesterday there are signs that remain at the indian medical center stating that the water in the hospital is not safe for human consumption.
▶ 1:21:32Mr. Laroche: There were signs that were up when the secretary was in new mexico. He didn't go, but I asked the same question -- all of a sudden the signs were taken down. Well, now there is new signs that are up. The signs is different, so they didn't but the same signs up if they were reprimanded for saying that the water is not drinkable, but now it is a picture and it says water is for handwashing only.
▶ 1:22:00Mr. Laroche: The little bit I know about water is when you can drink it, you are not supposed to wash her hands with it--can't drink it, you are not supposed to wash her hands with it either. It is a hospital. When will ihs was josé drinking water at the gallop in the--restore safe drinking water at the gallop indian medical center and what is your plan to do so?
▶ 1:22:18Mr. Laroche: I don't have the details on that. I will have to go back to our office of environmental health and engineering and check on the plans. Sen. luján: I would like to hear back as soon as possible and see if you need authorities, whatever is needed to work with my colleagues, if there are any ihs facilities in the country, hospital without drinking water -- I don't think there is going to be disagreement to say they should have clean, safe drinking water. Mr.
▶ 1:22:46Mr. Laroche: Laroche -- I apologize, I told myself I was not going to say your name incorrectly today, sir -- last week ihs announced it is launching a major hiring push to rebuild and strengthen the ihs workforce. I appreciate that, and this is welcome news by all of us. My question is how do you plan to implement the hiring push and actually get hold providers into facilities?
▶ 1:23:13Mr. Laroche: Knowing I've heard from my constituents that they have been unable to hire staff because they face redtape and background checks that can take six to nine months for some of these positions. I appreciate saying there is going to be a major push. My question to you is what are you going to do to address the foundational issues that have held up hiring?
▶ 1:23:32Mr. Laroche: That's a great question with bringing on over 3000 people is our goal for this next year. We are brought together our hr team as well as what you mentioned as the other people who are involved with getting people on board and getting the recruiting and so forth. We have had a meeting on that to approach it in a comprehensive way so we can have all the parts of our organization ready for that big hiring. Sen.
▶ 1:24:02Mr. Laroche: Luján: is it fair to say, Mr. laroche, that the six-to-nin e-month backlog, the timeline, that will be condensed, they will look for efficiencies to make sure we are not losing health care providers when they are recruited and they say they want to move there and then they are told, well, in nine months you have a job?
▶ 1:24:21Mr. Laroche: We're definitely working on that. Sen. luján: appreciate that. What I would be interested, sir, is if you could detail for me and we can work with the teams why the background checks are taking so long. If there is things we need to do together, that we look at that as well. What is the concrete problem that needs to be fixed to speed up the background checks? I'm very interested in that.
▶ 1:24:45Mr. Laroche: There were a few providers that were identified for a few small facilities in new mexico and they lost them because of the six-to-nine-month delay. They need a paycheck as well, they need to take care of their families, and they had other opportunities even though they were ready to move. I would be interested in working with you. Thank you for that. With that, I recognize the senator cortez masto.
▶ 1:25:08Sen. Cortez Masto: Thank you. Welcome to the panel members. Thank you very much. I want to focus most of my questions on s. 1055, the emergency claims parity act. Currently indian health services beneficiaries are required to notify the purchase referred care, commonly known as poc, the office-- prc, the office within 72 hours of a medical emergency.
▶ 1:25:37Sen. Cortez Masto: The last thing patients should be thinking about during an emergency is having to file the paperwork to make sure that hospital visit is properly covered within the 72 hours of that emergency. So for me, and I think this is why senator rounds, I was so pleased he introduced this legislation and I joined him on it, I think there is an opportunity to do common sense here.
▶ 1:26:05Sen. Cortez Masto: This legislation that we introduced, the emergency claims parity act, it extends the reporting deadline for ihs patients who seek emergency care outside of those ihs facilities from 72 hours to 15 days. 15 days. Deputy director laroche, and your testimony you indicated concerns over flexibility, noting that s.
▶ 1:26:29Sen. Cortez Masto: 1055 would limit the indian health service's authority to a period of 15 days. Those concerns -- could you elaborate on the concerns/
▶ 1:26:41Mr. Laroche: We support the 15 days, but what we are saying is if it is put into law that if we ever wanted to even extend it longer than the 15 days, go to 21 days or something, that we would have to come back and go through the federal process.
▶ 1:26:59Sen. Cortez Masto: Is there -- because for seniors and people with disabilities, they have 30 days.
▶ 1:27:05Mr. Laroche: Correct.
▶ 1:27:06Sen. Cortez Masto: Is there a reason we shouldn't look at 30 days for everyone?
▶ 1:27:10Mr. Laroche: We could take that back for consideration.
▶ 1:27:13Sen. Cortez Masto: But right now you do supposed -- you do support the legislation, 15 days, the only concern is the flexibility if you want to make it longer?
▶ 1:27:21Mr. Laroche: Longer, correct.
▶ 1:27:23Sen. Cortez Masto: Hmm. Ok, we might be able to work with that. I appreciate that. That's very hopeful. Let me ask you this. Yesterday I introduced a piece of legislation, the stronger engagement for indian health needs act, again with senator rounds. This bill would elevate the director of ihs position to an assistant secretary at hhs.
▶ 1:27:52Sen. Cortez Masto: Granting greater authority over recruitment, retention, and interagency coordination. Secretary kennedy inattention money and his nomination hearing--in testimony at his nomination hearing expressed support for this idea. It's not new. Senator john mccain previously introduced the bill, and it has passed the senate before. Given the recent reintroduction of the bill, and I understand you probably need more time to review it and take it back, but I would just appreciate your review and your thoughts on it.
▶ 1:28:20Sen. Cortez Masto: Not now, but in the future, at any point in time. Obviously it is not new legislation, but it is important and I would love your feedback at some point in time. Would you be willing to work with me?
▶ 1:28:31Mr. Laroche: Thank you, yes.
▶ 1:28:34Sen. Cortez Masto: Great, thank you. At the end of the day, let me just say this. I think for many of us, particularly those that have native american communities, tribal communities in our state, we got into a better job of providing them opportunities for care for indian health services. I hear it in my state, we are hearing the conversations and the concerns today on these three bills.
▶ 1:29:02Sen. Cortez Masto: Can I ask the other panel members, is there anything else we should be aware of that we haven't addressed today that you would like to make us aware of concerning whether it is the bills that we heard or the concern just in health services in indian country, native american, alaskan country as well?
▶ 1:29:24Ms. Seymour: So I think regarding the bills that you heard today, especially the prc< th , the two prc bills for us, I just looking at the prc program-- ihs looking at the prc program is all.
▶ 1:29:44Ms. Seymour: The carryover was -- I as well as our other council and staff were dumbfounded when we heard how much money was there, and it was very disheartening. When you have people dying daily because they are not getting the health care that they need and then you find out that ihs has been hoarding $42 million that could have sent them to get the care they needed, it is heartbreaking and gutwrenching.
▶ 1:30:15Ms. Seymour: I think if that is something that can be looked into with the prc program, I have worked for the prc program myself early on in my career. I worked with a big -- a big part of the problem is the fiscal intermediary not paying the bills as well. We were using new mexico blue cross blue shield.
▶ 1:30:37Sen. Cortez Masto: Not paying the bills, they were denying the claims?
▶ 1:30:42Ms. Seymour: They just were not paying.
▶ 1:30:44Sen. Cortez Masto: There is nothing you could do --
▶ 1:30:47Ms. Seymour: That is why they were getting sent to collection some of the time, because the physical area wasn't taken care of for whatever reason. - fiscal area wasn't taken care of for whatever reason. Our staff at the local level tried to work with them, what documentation can resubmit to get those bills paid. It is such a cumbersome process.
▶ 1:31:09Ms. Seymour: I think your help that process for others, we have our own now because we are contracting, but to help the other tribes that are still with ihs and prc, that would be something I recommend looking into.
▶ 1:31:24Sen. Cortez Masto: Ok. Ms. ross, anything else?
▶ 1:31:28Ms. Ross: Thank you for the question. I would add that the support of self-determination that tribes, tribal organizations have within them, the ability to manage their own programs and funds successfully, innovatively, and with quality. Just the a point of expansion of self-determination.
▶ 1:31:49Sen. Cortez Masto: Thank you. And thank you. Deputy director, anything else you would like to respond to that you heard today that we need to be aware of as well? Mr. laroche,
▶ 1:32:00Mr. Laroche: Again, supportive of the bills and looking forward to working with the foundation and the tribes. I will say our prc program, we have been going through a lot of improvement efforts over the last couple of years to do exactly what was brought up here with working with the fiscal intermediary and trying to remedy those. We are still working on that. Continuous improvement.
▶ 1:32:25Sen. Cortez Masto: Thank you. Thank you all for being here.
▶ 1:32:28Chair Murkowski: Thank you, senator. I just have a couple quick follow-ups here. Mr. laroche, you note in your testimony that ihs has seen what we are referring to as bad actors in the prc space with private providers not following section 222.
▶ 1:32:49Chair Murkowski: The provision preventing them from seeking -- this legislation does not provide any mechanism for consequences. Has ihs taken any steps to end agreements with or otherwise discourage these bad actors?
▶ 1:33:07Mr. Laroche: Definitely where the bad actors have been identified, we have been working directly with them to go through and make sure that it's not just that they don't understand the process or they are looking for certain things that they are not receiving to be able to put those -- get paid by other -- the other payers that may be involved in things like that. We are working on that.
▶ 1:33:37Mr. Laroche: Working together with them and finding out what the problem is. If there is anybody that has been egregious, we usually don't continue with them. One of the challenges is sometimes those providers may be the only ones within a reasonable area. And then that ends up -- we have to look for people outside of the area.
▶ 1:34:02Chair Murkowski: Keep somebody that you know has got a bad track record, that's not helping improve the system at all. Ms. seymour, it's my understanding that because of what we are seeing with ihs's poor management of the prc program, you are seeing fewer local health providers who are willing to participate in the program. To your point, Mr.
▶ 1:34:30Chair Murkowski: Laroche, you are saying you might not have anybody in the area, and then because you have got things that are poorly run, you have providers that say, no, I'm not interested in participating. Or do you have non-ihs providers that have refused to perhaps schedule appointments with members that have unpaid prior balances from previous prc claims?
▶ 1:34:58Chair Murkowski: I look at this, and the situation just does not get any better. You are just making it harder to get access to care, even if it is bad, with the provider situation.
▶ 1:35:17Ms. Seymour: From colville's perspective, we have seen providers cancel contracts with us because they haven't gotten paid. We have had patients go to their appointments and not be able to be seen because they don't have a purchase order, they have an outstanding bill that wasn't paid.
▶ 1:35:32Chair Murkowski: On that last point, if I am that person and I have an outstanding balance, if I have a condition that I needed to be seen for now, am I flagged because I have this unpaid prior balance? So I go in, I check in for an appointment, and I'm told, "sorry, we can't see you for this appointment"?
▶ 1:35:57Ms. Seymour: Yeah, basically that is what is happened, and sadly we have had people turned away for cancer treatments and oxygen and things like that because they have outstanding bills.
▶ 1:36:08Chair Murkowski: And so the only alternative for me in that situation will be to say I will just pay out-of-pocket?
▶ 1:36:13Ms. Seymour: Yeah, basically, some of them if they have the means will make a payment at the time so they can be seen, and that is how we end up in this situation. They should be reimbursed, but ihs won't tell us why, they just keep saying they can't reimburse patients. Some of them, like I said, are elders.
▶ 1:36:36Ms. Seymour: We live in a high-poverty area so most of the people we provide services to cannot afford to take hundreds of dollars out of the pocket to pay medical bills so they can be seen by their provider that day.
▶ 1:36:48Chair Murkowski: So you last year -- you are not even six months into your 638 agreement here. Are you hearing from those who are part of colville tribe that the situation is better now? Today know that-- do they know that they are not going to be turned away at them appointment --there appointment because of unpaid prior balance?
▶ 1:37:19Chair Murkowski: I guess I want to know whether or not you have seen improvements because of the direction you have taken.
▶ 1:37:27Ms. Seymour: We have seen improvements. Some of that has come from patient communication, but it also came from our staff who were initiating the payments and making sure that the payments are being paid timely. They work diligently to make sure that they're establishing contracts with all the providers we use, communicating with the provider so they know the process that they need to follow to make sure we get payment taken care of.
▶ 1:37:54Chair Murkowski: Are you seeing more providers that are perhaps now interested -- Ms. seymour,: yes we have actually had providers reach out to us to say we would love to work with you guys who had previously canceled due to ihs nonpayment. Now that they are hearing that we have our tribal health care authority in ministering that program--administering the program, they are more willing to work with us because they trust they will get paid.
▶ 1:38:22Chair Murkowski: But I think this is where you really see self-determination play out in a way that is meaningful, provides for that balance and those true results. And I think just having Ms.
▶ 1:38:36Chair Murkowski: Ross from south-central foundation on the panel here today is an example of what you really can do when it comes to tribal health organizations coming together and working to meet the needs of folks where they are, not being as directed or
▶ 1:39:10Chair Murkowski: Controlled by operations of 4000 miles away. But I bequeath -- but I think we see very strong examples where not only are we talking about those principles of self-determination, but we are seeing them in action. My hope is that those in the colville business council are going to see positive results as you assume this direction.
▶ 1:39:41Chair Murkowski: Enter you,-- and to you, Mr. laroche, I think you have heard really good examples of the challenges that are being faced. We have talked about this in this committee for a long time, and I'm in a different situation than my colleague in south dakota. And I am very proud of what alaska natives have come together to develop through our tribal health organizations.
▶ 1:40:11Chair Murkowski: In many ways we are leading the model when it comes to health care delivery, and that's exciting. But to know that so many in indian country are struggling with a system that is clearly, clearly not working for them and in many ways is punitive on many different levels.
▶ 1:40:34Chair Murkowski: When you are choosing to not access care because you are fearful -- you don't know how this whole reimbursement process is going to work or if it is going to be reimbursed or if you are going to get sent to the debt collector, he is not a place we should be. I'm really thankful that the committee is going to engage in these legislative initiatives and look forward to working with colleagues to help advance them, as well as with the department.
▶ 1:41:04Chair Murkowski: And I think -- I am reading body language here, and you have not given me serious frowns or no. You are kind of acknowledging the deficiencies, the real deficiencies within the department, and at acknowledgment that we need to address them. So I look forward to doing that. And with that, the committee stands adjourned. We will be taking testimony -- questions for the record for two weeks after this. Thank you. [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy.
▶ 1:41:36Chair Murkowski: Visit ncicap.org]