i want to apologize because i've got to go. it's my turn to preside. and i've read your testimony, and i look forward to watching it later. and i want to thank you, mr. chairman, for giving me this opportunity and for your indulgence and for the ranking members indulgence as well. thank you. >> thank you very much, senator franken, for your statement. now before we go to dr. roubideaux, let me call on our vice-chairman to give his opening remarks. >> thank you very much mr. chairman, and i appreciate the patience of the members of our panel as we went through a series of roll call votes. i want to thank you for holding this important hearing. once again, congress is examining a budget request for all federal programs including indian programs.

so from within the shadow of enormous growing spending deficit, we look at the issues facing our country. as we see on both sides of the aisle an agreement there is no avoiding the problem anymore. and most, if not all agencies and programs will be called on to participate in the solution. we all recognize that the federal government has important responsibilities in indian country. safety, education, health care. just to name a few as senator franken previously mentioned. we all know carrying out these responsibilities requires money. this year and into the foreseeable future, decisions will receive ever-increasing scrutiny, as we discussed, mr. chairman. i look forward to the additional testimony on how this budget advances federal responsibilities in a meaningful and effective manner for indian country. so thank you, mr. chairman. >> thank you very much, senator.

i now call on dr. robert roubideaux. will you please proceed with your testimony. but before you do, let me say that your full statement will be made a part of the record. your testimony but before you do, let me say that your full statements will be made a part of the record. >> thank you mr. chairman, mr. vice chairman, members of the committee. i'm dr. yvette roubideaux, director of indian health service and accompanied by vice director. i'm pleased to have an opportunity to testify on the president's fiscal year 2013 request, budget request for the indian health service. for my written statement, reviews in detail what his has completed in funding that congress has appropriated for us

in the past few years. since 2008 the budget has increased and it's helped the indian health service make significant progress in our efforts to change and improve the organization as well as in addressing the priorities of our work. our partnership with tribes is fundamental to improving the health of our communities. each year we incorporate tribal budget priorities into our budget requests. we're also making progress on reforming the indian health service with an emphasis on improving the way we do business and how we lead and manage our staff, setting a strong tone at the top that we must change and improve, improving our financial controls, finding more efficient and effective ways to conduct our business matters and performance management and accountability have been very important to our progress. for example, ihs was able to demonstrate its best performance ever as a part of the hhs cfo audit in 2011.

our hiring times have improved and we're addressing pay disparities to help with recruitment and retention. the contract health services program, or how we pay for referred care, has demonstrated accomplishments in ihs reform through improved business practices and improving access to care. the contract health service budget of referred care has increased 46% since 2008. and as a result, some chs programs are able to pay for more than priority one or life and limb referrals and services. while the overall need is still significant, the funding increases are making a difference. we've also made significant progress in improving quality of and access to care with improvements in customer service, our improving patient care program, our use of health information technology, the success of the special diabetes program for indians, and the early accomplishments of the methamphetamine and suicide

prevention and domestic violence prevention initiatives. in fy 2011 for the first time ever we met all of our clinical goals. the ihs health care facilities construction program has contributed to ihs increasing care and its partnership with tribes and helping us complete health facility construction projects. when i was first appointed to be the director of the indian health service, i heard input from tribes, patients and our staff that we needed to change and improve the indian health service in many ways. and although we've made significant progress in addressing our priorities, much work remains to be done. the population we serve continues to grow and the challenges of providing health care in rural america are ever present. our data continues to show the incredible need for services by the patients we serve, and we continue to work hard to meet our mission with available resources.

the increases in ihs funding over the past few years have helped us make progress but we still have much more to do. so the 2013 president's budget request for ihs will help us address these challenges and make progress. our agency priorities through targeted investments, to increased access to care improved quality of care, support our oversight and accountability functions and address tribal management support costs. the budget request is $4.24 -- $4.42 billion, an increase of $116 million over 2012. and that includes funds to support activities that are identified by tribes as budget priorities. so the budget request includes $34 million to increase inflation costs and $20 million for program increase for the contract health service program or how we pay for referred care. that will be spent on expanding the purchase of health care from

private-sector providers outside of the indian health system. an increase of 49 million is included to staff and operate newly constructed health facilities, including our joint venture facilities constructed by tribes. a $5 million increase is included for contract support cost as priority for tribes that assumed management of our health care programs previously managed by the federal government. a $1 million increase in direct operations will help the agency continue its reforms and provide accountability and oversight in administrative areas. we also include $6 million for health information technology to support the mandatory icd-10 implementation and $1 million in support for electronic dental record programs. for facilities we have $81.5 million budget to continue construction on two facilities in progress. and an increase of $1.7 million will help us address routine maintenance and improvement needs. in closing we've shown our ability to make progress and

improving and changing the indian health service. however, we know there's still much more work to be done. we'll continue to work in partnership with tribes to make these improvements and improve the quality of and access to care for the patients that we serve. the president's budget requests help us make progress in changing and improving the indian health service. thank you for the opportunity to present on the 2013 budget. >> thank you very much, dr. roubideaux, for your statement. secretary echo hawk, the budget contemplates savings. you mention $19 million by streamlining operations across all components of the organization. my question to you, are all

aspects of the organization being considered for this reduction such as office closures, cuts to programs, reductions in force? how do you intend to consult with tribes during this process? >> mr. chairman the first point i would like to make has to do with consultation. of course, the president of the united states gave us the directive across the federal government to improve how we consult with tribes. this past december, the department of interior adopted its new consultation policy. in all of the areas that we do consultation, perhaps there's no more important part than consulting on the budget. and thus, on a quarterly basis

we assemble tribal leaders from all regions of the country to make sure that they have input on how we're crafting the budget. and i have to say that their position has been very clear to us that they do not support any cuts in spending through interior indian affairs. nevertheless they are very helpful to us in identifying what the priority areas are. one of the messages that i've heard very clearly in this consultation policy over the last three years is that when budgets are tight, and we have to be fiscally responsible, that tribal leaders say don't forget the federal government has got to take its turn too. don't just turn to tribal programs and start chopping.

and so in this 2013 request, we have proposed streamlining, which means that what we're going to do is look very carefully at what we can do more efficiently to consolidate programs, to do everything we can to tighten the federal government's belt. we're not going to do that just on our own. our plan is to move forward in a consultation process. we're not talking about reorganization here without the approval of the congress, but we're talking about identifying ways that we can save dollars in the federal bureaucracy so we can fund the priorities of tribes. and so we will be out there consulting, beginning in april, in listening to what tribes have to say about the areas where we can do that belt-tightening within the bureau of indian affairs, within the bureau of indian education and within the office of the assistant secretary. thank you. >> thank you very much.

it's good to hear that you will do it by consultation. in my rather brief experience with this area i find that somehow the indian tribes out there don't get the full message on many other things. and to hear you consulting directly, it's really great to hear. dr. roubideaux, in your testimony, you state that tribal consultation is fundamental to your budget formulation process too. please discuss how tribal consultations led to tribal priorities being reflected in the proposed budget.

>> well, tribal consultation is fundamental. i really feel the only way we're going to improve the health of our communities is to work in partnership with them. we have a tribal budget formulation process that starts first at the local level and the area level. we have the 12 ihs areas in the fall, they hold meetings with tribes, and they determine what the area level budget priorities are for tribes. and then we have a national budget consultation that occurs usually in january and february, where representatives from all the ihs areas come together and fight among each other to try to get their priorities into the list. and there's so many priorities for funding, it's a very difficult conversation for our tribes, but i'm very grateful

that they do that important work because it results in a great set of recommendations for us to use as we begin our budget formulation process. and so each year they present their budget priorities to me, and that's the first step in developing our proposals for the indian health service budget. it's an annual process so tomorrow the tribes will be presenting their recommendations on the 2014 budget and so i'm really looking forward to hearing their results as well. >> all right. thank you very much. let me know. ask vice chairman for his questions. >> thank you very much, mr. chairman. i want to talk about a couple of specific things and first for mr. echo hawk. the president's budget requests $12 million for indian irrigation projects. none of these are in the proposed area of the wind river project in wyoming.

according to a 2006 gao report there was a total of $84 million in deferred maintenance for this project. at our wyoming field hearing on irrigation last april the department of interior testified that they would begin working on a long term plan to repair the deferred maintenance on indian irrigation projects. i'm wondering what has the department done since april to reduce the deferred maintenance in the wind river irrigation project. >> senator brasso, i am not prepared to address that today, but i would be happy to look into that and working with my staff get you an immediate answer to your question. >> thank you. i want to move on to law enforcement. the high priority performance goal pilot project was implemented on the wind river reservation in wyoming to decrease violent crime rate, the goal was 5% over two years. yet after the two years the

violent crime rates on the wind river reservation has increased by 7%. i underthere was an overall downward trend so some success in the rates over the last two years on a national basis but yet what we saw was unfortunately an increase. i'm wondering what efforts will be made to work to decrease the crime rates on the wind river reservation? >> senator brasso, that's an excellent question. i'm happy to bring good news with me today, because we did achieve the overall 35% reduction across the four reservations. wind river was the largest reservation that we dealt with, and it was the area where we had to bring in the most law environment officers. i want to just emphasize that this is not a surge. these officers that were funded will be there permanently.

so it's not something where we fund it temporarily, see how it works, and then back off. and, you know, it is correct that by the end of the 24 month period, we actually had a 7% increase in crime there, but because it was large, because we had so many law enforcement officers come in there, and what happens when you bring in that large number of officers, you actually, you know, will generate more reports that come in. and then eventually, because people feel safer, they report, then we start to see a downward trend. so after the 24 months ended, given another three months, we actually decreased crime at wind river by 21%. so we knew that was probably going to be the case but we're obviously moving in the right direction there, and that's good news for the community. >> good. i look forward to additional reports. dr. roubideaux, the president's

budget request includes a $54 million increase for contract health services program. you testified at our budget hearing last year that the federal tribal work group was to review and then make recommendations to you. i asked you last year whether the formula would include a consideration of mortality and morbidity rates because both of our experience as physicians, we know how important that is. can you tell me where the rates are factored into the formula and what decisions you've made? >> thank you for the question. contract health services is such an important budget priority, it really is the top priority. tribal leaders have been helping us over the past two years to make recommendations on how to improve the way we do business and to look at how we provide funding. the work group decided that they needed to have another year to look at the impact of our recent budget increases to see how the

formula really played out so we expect them to have their discussions about the formula and whether it needs be changed in the next year. >> i appreciate your attention, your personal attention to that given your background and then if you could involve me in some of the findings i would be very grateful. thank you. senator franken mentioned some things about public safety, people needing a place to feel safe in their homes or in their workplace, and i want to talk about, if i could with you, dr. roubideaux, public safety and health care. they go hand in hand. patients and employees need to feel safe in a workplace especially in a place where pharmaceutical drugs need to be secured. at the budget hearing in 2008, before you were responsible, dr. coburn asked your predecessor, mr. mcswain that what the indian health service was doing to protect the patients and employees and it was a specific

hospital he was familiar with, claremore indian hospital in oklahoma. he indicated that the agency was working to resolve had some jurisdictional issues so local law enforcement could protect patients and staff at that facility. four years later. again, it was not something that you were charged with, you inherited this problem but it's four years later and there's still not really been an adequate resolution to the problem. can you maybe help address what needs done resolve this matter? >> yes. well, we are aware that the issue at claremore indian hospital is serious and needs to be resolved as soon as possible. i just recently was briefed by staff. it looks like we've been working very closely with the department of justice and the bureau of indian affairs and they have outlined some administrative and possible legislative options. and so the next step would be to decide what our priorities are for those options, and then to

consult with the tribes, because some of those options actually do involve whether the tribes will be helping us with this problem. we would be happy to discuss the details of those options with you and work with you on this issue. but now that i've seen we've made progress in identifying some specific options, then i will do what i can to push for resolution. >> thank you very much very much. thank you, mr. chairman. >> thank you very much, senator. my question is for the panel. the budget control act requires an enforcement mechanism called and i did mention in my opening remarks sequestration. and due to take effect in january of 2013.

my question to the panel is what would the sequestration have on the department's budget and your ability to provide core services to tribes? >> well, we are very concerned about the sequestration. for the indian health service, a portion of our budget actually is protected in that automatic decrease would be less but it still would be 2%. and 2% for our budget equates to around $88 million, and that would have to be applied to both of our accounts in services and facilities. and so we already know that our system has had to absorb a lot of costs including high medical costs and inflation and so on.

and having another $88 million to try to absorb in our budget would be very painful and would be very difficult for our health care facilities and would certainly impact services. so we're following the progress of this in congress, and i've been talking with tribes about, you know, if this occurs, what's your preferences on where we might absorb these costs. and, of course, the tribes just are not -- they are very reluctant to have that conversation because they don't want this to happen because they've told me that this will have a very significant impact on the services in their communities. so we're following this very closely, and it will have a great impact, even though indian health service does get treated a little better, it's still a significant impact. >> thank you. >> chairman akaka, we realize

we're living in this era of constrained budgets. as we've consulted with tribes, we have received some targets by omb, you know, to craft budgets. this helps us figure out what our true priorities are. for instance we had to go through exercises where we looked at 10% reduction, then 7% reduction. even at the level we are now in this proposal where it's 0.2 of 1% reduction is very painful. we try to meet the tribes' priorities, but like i said a few minutes ago we're streamlining and we're going after management efficiencies. this is painful for the federal government because we have trust responsibility to fulfill. so we have some feeling about how painful it would be to

undergo additional cuts in the budget, and i'm just hoping that, you know, things can be worked through the congress so that the sequestration does not automatically trigger because we're down to trying to solve problems that are very significant in indian country with a constrained budget already. >> thank you very much. i have further questions that i'll submit for the record. senator, are there any further questions? >> no, sir. >> well, i want to thank you so much to this panel for your responses. we do want to do the best that we can. streamlining, of course, is a difficult process. but you know, it can certainly

save and we're looking forward to things working out. the sequestration, i ask it primarily because it's something that we hope we can work out at that time. so i would like to thank our first panel very much for your patience and for being here today and look forward to working with you. thank you. now i would like to invite the second panel to the witness table.

due to the delay of this hearing, i just want you all to know that secretary thomas is unable to testify on behalf of the national congress of american indians. however, we'll include his full written statement into the hearing record. serving on our second panel is the honorable sharp, president of the affiliated tribes of northwest indians.

the on handle michell hicks, principal chief of the eastern band of cherokee indians on behalf of the united south and own tribes. and the honorable robert shepherd, chairman of the sisseton wahpeton oyate tribe on behalf of the great plains tribal chairman's association. welcome to you and thank you, again, for your patience. president sharp will you proceed with your testimony. >> thank you. on behalf of the tribe of northwest indians we're truly proud to be here and thank you for the opportunity. we believe this is another reflection of the new era of the partnership with the united states. not only do we have a relationship with the president

but now with the legislature, the congress. and we thank you for that opportunity and your leadership. i would like to begin our remarks by speaking to natural resources issues. the northwest is rich with abundant wildlife, fish, hunting, gathering, and we would like to speak to a couple of issues that relate to, first of all, the b.i.e. rights protection fund. we appreciate the increase, the proposed increase from 28 million to 32 million, but we do recognize that when you look at the entire issue across the nation, we are falling incredibly short of the other appropriations to our sister organizations, intertribal organizations throughout the united states. for example the great lakes indian fish and wildlife commission is looking at an increase of 17% ti