Question from Rep. Westerman for Ms. Alberta Unok, Alaska Native Health Board — August 11, 2022

Summary

A question from Rep. Westerman for Ms. Alberta Unok, President and CEO, Alaska Native Health Board, dated August 11, 2022, asks about the unique aspects of health care in Alaska that are vulnerable to uncertain appropriations. In response, the text says delays or gaps in Indian Health Service (IHS) funding impact the Alaska Tribal Health System, which serves more than 180,000 American Indian and Alaska Native people and 229 federally recognized Tribes across 586,412 square miles. It says delayed appropriations mean heating fuel cannot be purchased with IHS funding in September when barges are still running, and that over 80% of communities are not on the road system. The response adds that the short building season limits shipping of construction materials for facilities.

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                            Question from Rep. Westerman for
             Ms. Alberta Unok, President and CEO, Alaska Native Health Board
                                      August 11, 2022

Question: Could you further elaborate on the unique aspects of health care in Alaska and for
Alaska Natives that are particularly vulnerable to uncertain appropriations?

        Thank you for the question. Delays or gaps in Indian Health Service (IHS) funding impact
us in different or often dramatic ways. The Alaska Tribal Health System (ATHS) is unique in
many ways, especially when it comes to providing health care in frontier and remote areas with
great challenges with climate and geography. The ATHS is a diverse and multifaceted healthcare
system that has developed over the last 50 years. This innovative system was created out of
necessity to provide healthcare and public health services to more than 180,000 American Indian
and Alaska Native (AI/AN) people and 229 federally recognized Tribes that live across 586,412
square miles of predominantly road-less land.

        As noted on in our testimony, delayed appropriations mean that we are not able to purchase
heating fuel to support operations with IHS funding in September when barges are still running.
Over 80% of our communities are not on the road system, so without the ability to transport heating
fuel by barge, it would have to be flown in, which is significantly more expensive. Sometimes,
Tribal health programs take out a loan to buy the heating oil at the start of the winter season, which
means that there is an unnecessary cost of interest on this purchase that would otherwise be made
with program dollars.

       Tribal communities in Alaska have also taken advantage of the IHS Joint Venture
Construction Program (JVCP) where tribes invest in development of building of facilities and in
exchange, the IHS commits to requesting staffing for those facilities. Again, this creates
challenges in shipping construction materials. The building season is very short in Alaska, so
without the full funding available, we cannot ship the necessary supplies by barge to complete
construction of facilities under JVCP, the Sanitation Facilities Construction (SFC) program, or
through any other means. This delays construction, and therefore impacts improved health services
for our people. Furthermore, without guaranteed funding, lenders who work with us in the
construction of the JVCP facilities charge a higher interest rate if the funding is uncertain, and this
also impacts our credit ratings. This is especially troubling given the severe backlog of IHS
construction projects, which the agency estimates will take many years and billions of dollars to
clear. At current funding levels, a new facility built today would not be replaced for 400 years.
Continuing resolutions (CRs) exacerbate these funding delays for Tribal health facility
construction programs.

        As noted above, our communities are remote and rural. This means that hiring and
retaining the necessary medical staff is a continuous challenge. Health professional are in high
demand throughout the country, even in the best of circumstances, so enticing providers to come
work in rural and frontier clinics in Alaska can be nearly impossible. These challenges are
exacerbated by having to halt the hiring process or fill positions with expensive, short term
contracts when funding is delayed. Without knowing our yearly budget, it is difficult to recruit a
provider to relocate to our area and promise an adequate salary. We have to make long-term hiring
decisions in a competitive market, with only short-term funding guarantees. Similar challenges
exist when we are working with vendors. Again, it can be difficult to negotiate contracts with
medical suppliers to our remote and rural locations. Without being able to enter into yearly (or
longer) contracts, many vendors will not want to do business with us. And, as you know, longer
term contracts are typically more cost-effective.

        CRs also create financial burden for our staff at Tribal health organizations (THOs). We
develop our annual budgets with severe uncertainty and hope that we will be able to follow it
throughout the year. THO financial staff are constantly reevaluating what services may or may
not be available in a given year.

        The ATHS is rooted in the community, Tribally-driven, and consists of several levels of
service, including: Village Clinics, Sub-regional Services (some regions), Regional/Hub Services,
and Statewide Services. The ATHS works together to ensure all AN/AI receive the highest quality
of healthcare. This unique healthcare system provides comprehensive statewide health services
and is interconnected thru the system’s sophisticated patterns of referrals and their primary and
common mission of improving the health status of Alaska’s AI/AN people. This includes
coordination of care from local health clinics to sub-regional and regional facilities which can be
also referred on to the Alaska Native Medical Center (ANMC) the tertiary medical center in
Anchorage. Its size and reach are also reflected in the map below highlighting the typical referral
patterns.

       Our ATHS also relies on flight patterns run by experienced rural traveling airlines
throughout the state. In many rural areas of Alaska, Tribes and Tribal Health Organizations are
the only healthcare providers available. Therefore, tribal health organizations serve the general
population. The Tribal system represent a larger portion of both facilities and service providers in
Alaska than in other states.

The ATHS is a Tribal network that
provides services through:

   •   180 small community primary
       care centers
   •   25 sub-regional mid-level care
       centers
   •   4 multi-physician health
       centers
   •   6 regional hospitals
   •   Alaska Native Medical Center
       -Tertiary Care


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