Questions for the Record — The Honorable Fawn Sharp, President, National Congress of American Indians
Summary
Written responses to Questions for the Record from the July 28, 2022, Legislative Hearing on H.R. 5549, Indian Health Service Advance Appropriations Act, before the Committee on Natural Resources Subcommittee for Indigenous Peoples of the United States. The responses are given by Fawn Sharp, President, National Congress of American Indians and Vice President, Quinault Indian Nation, to questions from Rep. Leger Fernández and Rep. Grijalva. They address advance appropriations for the Indian Health Service, the effect of Continuing Resolutions on funds distribution, tribal planning and construction, and trust and treaty obligations, with a supplemental answer describing examples from Tribal Nations. The document closes with a response on GAO reports and congressional oversight functions.
Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used
Cite this document
“Questions for the Record — The Honorable Fawn Sharp, President, National Congress of American Indians.”
Original at docs.house.gov. Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/hhrg-117-ii24-20220728-qfr201-c10ba5efdd04-203114c04b/
, SHA-256 c10ba5efdd04547e25bcf03a2830cedfa64b0c6af054469069234878255efbc7.Full text
United States House of Representatives
Committee on Natural Resources
Subcommittee for Indigenous Peoples of the United States
Hearing on July 28, 2022, at 1:00 p.m. ET
Legislative Hearing on H.R. 5549, Indian Health Service Advance Appropriations Act
Questions for the Record
The Honorable Fawn Sharp
President, National Congress of American Indians
Vice President, Quinault Indian Nation
Questions from Rep. Leger Fernández for Hon. Fawn Sharp, President, National Congress of American
Indians
1. Can you speak more on the need for advance appropriations for the Indian Health Service
considering ongoing tribal economic development concerns?
The operation of federal programs in tribal communities continues to be an economic
driver providing good paying jobs to the community and supporting Native families.
Simply put, adequate funding for the Indian Health Service (IHS) can help drive forward
self-determined tribal economies. Uncertainty in funding limits the ability to not only
provide service, but to support our health care professionals, plan for the future, and,
ultimately, look at ways we can best serve our people. Advance appropriations for IHS
will support Tribal Nations in recruiting and maintaining talent in our communities while
providing the stability for our families to grow and prosper, and will help build a better
future for communities by helping drive tribal economies.
Questions from Rep. Grijalva for Hon. Fawn Sharp, President, National Congress of American Indians
1. What are some stories that you’ve heard from the National Congress of American Indian’s
(NCAI) member tribal nations about their experiences during federal funding gaps for tribal
programs?
a. What about the experiences your own tribal government faced during government
shutdowns?
See the below responses.
2. In what ways would securing advance appropriations for the Indian Health Service streamline
the budget process and reduce taxpayer waste?
Regardless of whether the appropriations are full-year or partial-year funding, the funds
distribution process involves multiple federal agencies and can take well in excess of 30
days. By repeating these activities several times per year under Continuing Resolutions
(CRs) or at the very end of the budget cycle, you sink labor into both federal and tribal
budgets on duplicative calculations and processes. Advance appropriations immediately
eliminate the waste associated with these duplicative functions by eliminating the effects
of CRs on the necessary budgetary functions for both tribal and federal governments.
1
3. In your experience, how would ensuring the continuity of care for Indian Health Service clinics
and programs help tribal governments better plan for longer-term objectives?
Good budgeting and performance management involve multi-year planning and decision-
making–and this exercise is one that Tribal Nations already engage in to provide all kinds
of services to our citizens. However, when the funding is uncertain, it has a chilling effect
on the exercise of tribal sovereignty and self-determination by limiting the ability to
match multi-year planning and initiatives to the necessary resources to carry out those
plans. This chilling effect holds back progress on innovative healthcare solutions that
could reduce costs due to better community health.
Another example can be found in facilities construction and facilities improvement and
repair. Construction and repairs are costly endeavors that naturally stand to benefit from
multi-year plans and longer-term objectives. Advance appropriations for IHS facilities
accounts would assist Tribal Nations taking on much-needed construction and repair
activities that benefit from knowing how much and when funds will be available.
Tribal Nations that are prudent investors will get the money up front, allowing them to put
that money in interest-bearing accounts or other short-term investments, while
simultaneously allowing other tribal investments intact to continue to grow. When Tribal
Nations pull resources from their third-party revenue to maintain IHS operations that
would have otherwise been invested, they are losing the potential revenue from growth on
that investment. These sorts of financial coverings for trust and treaty obligations often
force tribal governments to operate paycheck-to-paycheck because they cannot position
their revenue to grow over time. This is not just an issue for Tribal Nations with third
party revenue–passive income is a path to wealth generation and operating paycheck-to-
paycheck is no way to build tribal economies.
4. As your testimony states, the Indian Health Service is the only federal health care provider that
does not receive advance appropriations.
a. How does this current system contribute to further Broken Promises?
Tribal Nations paid, in full, for the provision of payments and services—including the
promise to provide health care to tribal citizens—when they exchanged their land that
created the foundation of the bounty and wealth of the United States. An exchange was
made and memorialized, and the duty is owed. One of the most fundamental promises was
access to health care.
The current system contributes to further broken promises in three ways:
(1) by subjecting the provision of health care to the discretionary
appropriations process, it violates the fundamental agreement that was struck
by our ancestors;
(2) by subjecting the United States’ trust and treaty obligations to statutory
caps on discretionary spending, it pits IHS funding against the competing
interests under those caps, telling us each year which promise gets further
broken. We prepaid for these services and now we have to re-compete for
them against the land we prepaid with;
2
And (3) by subjecting IHS to the uncertainty and instability of the partisanship
of the regular appropriations process, it results in inefficiencies and waste that
leave those solemn promises further and further behind.
SUPPLEMENTAL ANSWER TO REP. GRIJALVA’S QUESTION 1.
What are some stories that you’ve heard from the National Congress of American Indian’s (NCAI)
member tribal nations about their experiences during federal funding gaps for tribal programs?
When Tribal Nations assume or are transferred IHS operations and facilities under the Indian Self-
Determination and Education Assistance Act (ISDEAA), they have to be certain they have the cash flow to
maintain operations and accreditation. One Tribal Nation in the west was in the middle of transferring an IHS
facility to become a tribal facility when Congress began passing CRs as opposed to full-year funding. This
disruption in funding caused by short-term CRs meant that IHS did not have money to give to the Tribal Nation
for the transfer of the facility and the Nation was forced to use their general fund to maintain sufficient cash
flow to complete the project. Before the transfer could be completed, the Tribal Nations had to affirm they
could fund operations until a budget is enacted. This is a substantial risk for any Tribal Nation that does a
transfer and does not have robust and stable government revenue.
Without advance appropriations, Tribal Nations will continue to struggle to exercise self-governance and their
administrative rights over healthcare. The provision of healthcare costs a lot, and the federal government is
obligated to fund these services. Most Tribal Nations like to take over at a fiscal year change because it makes
sense for providers and contracts. However, if the Tribal Nation has to mitigate the effects of multiple CRs
providing partial-year funding and conduct duplicative planning and cash flow analyses, then Tribal Nations
struggle to keep providers or enter into rational and cost-effective contracts.
A lot of Tribal Nations do their capital asset purchases at the beginning of the year. They order medical
equipment, and it comes in when it comes in. However, if you have a situation like COVID-19, where there
have been supply chain constraints, delivery may be delayed. A typical transaction for these capital assets
requires Tribal Nations to make a down payment on costly capital equipment—such as Magnetic Resonance
Imaging (MRI) machines—and enter into contracts to try to guarantee delivery within the accounting period
for audit and efficiency purposes. The regularity of funding disruptions from the federal government means
Tribal Nations have to gamble that their funding will be consistent and there will not be a shutdown or a CR
affecting the ability to make payment. In the alternative, Tribal Nations must secure alternate resources to make
the acquisition on a timely and reliable basis. Stable IHS funding received earlier in the year means Tribal
Nations can enter into those capital asset obligations earlier and feel more secure when negotiating the
agreements for life-saving medical equipment.
________________________________________
One Tribal Nation, which is generally fortunate enough to maintain sufficient funds from third-party billing,
still must regularly assess how to handle the effects of federal funding disruptions and the instability it creates.
Their accountants are always aware of the amount of funds needed to keep aside in the general fund in case
they have to cover costs to maintain healthcare services and operations. The uncertainty and instability of
regular IHS funding causes Tribal Nations to be more dependent on capital markets that charge interest on loans
and other grant revenue that may have more restrictions, which inhibit Tribal Nations’ ability to exercise their
sovereignty in relation to funds received pursuant to ISDEAA. If you do not have the certainty of full-year
funding to rely on, it makes it hard for Tribal Nations to plan, progress, and exercise their inherent right to
sovereignty. During disruptions in funding, Tribal Nations are at the mercy of Congress.
3
During the 2013 federal government shutdown, it was more difficult. The Tribal Nation quickly had to assess
if they had the funds to continue to provide services. They had to identify critical staff and make quick decisions
about who would be first to be furloughed. Fortunately, that government shutdown was not very long, but
having to make decisions to cut services to their people is difficult. Tribal leaders are just trying to answer to
their people and do not want to have to say, “we can’t provide you these services because the government is
shut down.” Going forward, the Tribal Nation has learned to plan around potential government shutdowns, and
they are fortunate to be in a financially secure situation to mitigate a shutdown. However, the possibility of a
future shutdown is enough to give Tribal leaders heartburn when they have to make decisions about employees'
lives and the lives of people who depend on those vital healthcare services.
When looking at healthcare in general, the costs have gone up exponentially. The dollars are not adequate the
way it is. If we put on top of that the government shutdown, it is clear Tribal Nations’ basic rights are being
failed. Tribal Nations should be able to rely on the full funding amount for IHS. As the financial standing of
Tribal Nations has become more and more sophisticated, they can handle it better, but they should not be at the
whim of the government shutdown.
Additionally, tribal leaders know that these funds could be better spent. If Tribal Nations use their general fund
to cover federal funding shortfalls, it takes away from language programs, elder care, and youth programs,
among the myriad of programs, services, functions and activities provided by tribal governments. If you have
to reallocate dollars, something else is always hurt. Advance appropriations would allow Tribal Nations to plan
better with their dollars, supporting additional critical programs in their communities.
________________________________________
The effects on Tribal Nations vary based on when the disruption in funding occurs, such as if the shutdown
takes place at the fiscal year or the calendar year. Tribal Nations will regularly have to divert funding from
other vital projects to cover their healthcare programs. This delays activities like ongoing construction, and
increases the general costs for both the health program and the programs that had their funding diverted,
contributing to the overall costs Tribal Nations face. Tribal Nations do a great job of using every resource they
have in order to ensure that their patients are not negatively impacted. However, they should not have to use
those resources to safeguard against the United States defaulting on its trust and treaty responsibilities.
For sanitation facilities construction, funding disruptions mean furloughed IHS staff struggle to get the money
out to Tribal Nations. This puts wastewater projects and drinking potable water projects on hold. These houses
or facilities will then go long spans of time without access to water. When disruptions in funding affect
construction projects, conditions change. In places with significant weather changes, like harsh winter months
or rainy seasons, it changes when and how you can continue construction, which results in duplicative costs on
planning and project delays.
Disruptions also impact other funding, like the ability to clear roads in a winter storm. For one Tribal Nation,
this meant that emergency services could not get out to the community during emergencies and lives were lost
as a result.
________________________________________
For one Tribal Nation in the northwest, government shutdowns have caused the tribal government to implement
immediate restrictions, such as on traveling and training, pauses in classes for accreditation, etc. The Nation is
resilient and, like many Tribal Nations, knows how to be resourceful, but they shouldn’t have to be, especially
when there is added stress around the rising rates of natural disasters or the COVID-19 pandemic. Last winter,
the one road leading to the clinic for this Tribal Nation washed out during a hard rain. They had people that
needed critical life-saving care, such as dialysis. The Tribal Nation began flying supplies in and using the coast
guard to transport patients to their appointments. Flying in medications was critical because supplies were
getting depleted. This Tribal Nation knew how to be resourceful and devised creative solutions to maintain
care for their people but, again, this shouldn’t be the norm.
4
During government shutdowns, this Tribal Nation is able to withstand it for the most part, but they do so by
repurposing carefully managed resources. For this Tribal Nation, what is the most frustrating is that healthcare
is in their treaty, but the funding is already only at approximately half of their current community need. During
the COVID-19 pandemic, it became apparent that certain IHS clinics and hospitals do not have the capacity to
do everything their citizens need, due to already limited staff and resources. The Tribal Nation stretched their
resources and their dollars to try to meet the needs of their patients as best they could, while sacrificing other
tribal government initiatives.
For many Tribal Nations, one extra barrier is IHS housing. Tribal Nations must provide housing for professional
staff, for counselors, for practitioners, etc. For a doctor, it is usually a temporary situation. Doctors in Indian
Country usually stay only two or three years, then move out of the community. IHS doctors are like a revolving
door, which is a result of the amount of pay, stability in pay, and availability of community infrastructure like
housing. Recent supplemental funds have helped, but for Tribal Nations stability in regular funding is critical.
Nothing can be fixed properly until funding is at a minimum, stable. Shutdowns strain the community because
funding becomes even more limited, and Tribal Nations have to supplement their health care services with
extreme and costly solutions.
The COVID-19 pandemic only amplified these issues that were already present in Indian Country. During the
pandemic, Tribal Nations lost a lot of revenue that is used to support the unmet obligations of the United States
and resiliency needed to provide services during funding disruptions. Tribal leaders have shared that enterprise
activity comes second to saving their peoples’ lives. Tribal Nations shut down their business, offices, and lands
during COVID-19 and chose to worry about revenues later. The resiliency to provide for their people is a model
for all governments throughout the world, but Tribal Nations are maintaining this resiliency by spending
carefully managed and hard-earned resources.
________________________________________
For tribal hospitals, a shutdown is riskier because they have to meet life safety protocols, and anything that is
not an emergency becomes a back burner issue. Because of staffing issues, both ongoing and due to disruptions
in federal funding, Tribal Nations cannot hold patients in their hospital unless necessary. You might see people
go home sooner with fewer wrap-around services. If you do not have purchase and referred care funding, you
might see fewer diversions where patients are diverted to another hospital. While people are not dying directly
from these decisions, breaks in the patient coordination cycle can result in life-altering complications or
additional harm that increase costs and quality of life for the patient. When tribal hospitals have their patients,
they try to hold onto them because they might be remote, or there might be personal issues which prohibit
regular visits. Providing that wrap-around care is more difficult when there are fewer available resources during
a CR or government shutdown.
Disruptions in federal funding also affect the provision of specialty care like cancer treatment or diabetes
treatment. A diabetic who is injured with a cut may not be considered an emergency under an emergency
operating plan. Meaning, that patient may not lose their limb immediately, but the reality is that they should
see a specialist to address the threat of an infection, or should be in a step down unit ensure there are no
complications. Patients are sent home as a direct result of the disruptions and IHS funding, and the next time
they are seen by a doctor it is to remove their leg.
________________________________________
For a registered nurse (RN) in the Great Plains Region, it is difficult to plan around the fall during budget
season. Working at a tribal clinic, she doesn’t frequently follow Congress or politics, except in the case of a
government shutdown. Under the furlough policy at her clinic if she takes a day for either personal or sick leave
during a government shutdown, she will be furloughed. This means, even though she is a single mom, she is
unable to stay home with children if they are ill, or to travel with her son for his basketball games. If she has to
stay home for any reason during the shutdown, she then will not be paid until the shutdown is over. If the
5
shutdown is particularly long, that can cause serious gaps in her ability to pay her bills. She works at an IHS
clinic because, as a Native woman, she cares about her people even though she might have better pay, better
hours, and more stability at a private clinic. However, to do so, disruptions in IHS funding require her to choose
between family, the cost of basic necessities, and the people she serves. It’s hard to know what might happen
to her patients if services are cut or if she must be furloughed. Today, the reality in Indian Country without IHS
Advance appropriations is that many medical professionals, like this RN, must choose between providing for
their family or serving their communities when a government shutdown occurs. This should never be a choice
that they have to make.
________________________________________
SUPPLEMENTAL INFORMATION FROM PRESIDENT SHARP:
On behalf of NCAI President Fawn Sharp, we would like to provide the following supplemental information
for two of the questions asked during the hearing.
1. Question from Chair Leger Fernández: “Do you think there is any difference in the trust obligation that
is owed to our Native American citizens than that obligation that we owe to our veterans for their
service?”
The respect for the agreements entered into by the United States and care for its citizenry are
similar—and when the United States makes a promise it must keep it. We are grateful for the
service of all veterans—including our Native American veterans who serve this country at
disproportionately higher rates than other groups. The treaty and trust obligations to Tribal
Nations have a distinct meaning in the U.S. Constitution and embody unique relationships
between sovereigns. The United States has failed to uphold what our ancestors bargained for
years ago. Our Tribal Nations bargained for healthcare in perpetuity and look at what we have
received instead—a chronically underfunded system that has cost us generations of strong and
healthy Native Americans. Our treaties and agreements are to be read pursuant to the Indian
Canons of Construction. Instead, we had those promises broken. We were put into a pool of
quicksand of continued poverty and oppression. We were left vulnerable to epidemics, sadly
costing us thousands of Native lives. We were robbed of so many promising, healthy, and strong
futures. Congress must finally uphold its end of the bargain to help the generations now and
generations to come, as our ancestors were promised.
2. Various GAO Report and Congressional Oversight Function Questions
Since advance appropriations still require a budget request from the agency and annual
inclusion in appropriations laws to maintain, Congress retains its oversight functions over
federal action; however, an important aspect of IHS operations that was not thoroughly
addressed during today’s hearing is the ability of tribal governments to exercise oversight over
the resources owed to them. Tribal Nations are the front line of defense to ensure that Indian
Country gets the best services, providers, and care for our citizens. Nearly every other health
care system in our country has a board for oversight and assurance, yet we barely have funding
to pay our healthcare workers. Full funding means that Indian Country must have the necessary
checks and balances capacity to support tribal oversight of tribal healthcare. There must be
government equity in this process, or else it remains a paternalistic practice that inhibits tribal
sovereignty.
6
File and source
- File
- hhrg-117-ii24-20220728-qfr201-c10ba5efdd04.pdf
- Size
- 179,763 bytes
- SHA-256
- c10ba5efdd04547e25bcf03a2830cedfa64b0c6af054469069234878255efbc7
- Original
- docs.house.gov