Oversight hearings to examine delivering essential public health and social services to Native Americans, focusing on Federal programs serving Native Americans across the operating divisions at the Department of Health and Human Services.
Meeting•Senate Indian Affairs•May 14, 2025 · 3:30 PM
Summary
Senate Indian Affairs held a meeting on May 14, 2025 at 3:30 PM in Dirksen Senate Office Building, Room 628.
Record
The meeting has its transcript on the record.
Transcript
The transcript runs to 8,145 lines and 479,414 characters, as the Government Publishing Office printed it.
1[Senate Hearing 119-122]2[From the U.S. Government Publishing Office]34 S. Hrg. 119-12256 DELIVERING ESSENTIAL PUBLIC HEALTH AND7 SOCIAL SERVICES TO NATIVE AMERICANS_8 EXAMINING FEDERAL PROGRAMS SERVING NATIVE9 AMERICANS ACROSS THE OPERATING DIVISIONS10 AT THE U.S. DEPARTMENT OF HEALTH AND11 HUMAN SERVICES1213=======================================================================1415 HEARING1617 before the1819 COMMITTEE ON INDIAN AFFAIRS20 UNITED STATES SENATE2122 ONE HUNDRED NINETEENTH CONGRESS2324 FIRST SESSION2526 __________2728 MAY 14, 20252930 __________3132 Printed for the use of the Committee on Indian Affairs3334 GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT3536 COMMITTEE ON INDIAN AFFAIRS3738 ______3940 U.S. GOVERNMENT PUBLISHING OFFICE41 60-911 PDF WASHINGTON : 20254243 LISA MURKOWSKI, Alaska, Chairman44 BRIAN SCHATZ, Hawaii, Vice Chairman45JOHN HOEVEN, North Dakota MARIA CANTWELL, Washington46STEVE DAINES, Montana CATHERINE CORTEZ MASTO, Nevada47MARKWAYNE MULLIN, Oklahoma TINA SMITH, Minnesota48MIKE ROUNDS, South Dakota BEN RAY LUJAN, New Mexico49JERRY MORAN, Kansas5051Amber Ebarb, Majority Staff Jennifer Romero, Minority Staff52 Director Director and Chief Counsel53Lucy Murfitt, Chief Counsel Caroline Ackerman, Legislative54Anna Powers, Senior Professional Assistant55 Staff Alanna Purdy, Policy Advisor56Sarah McKinnis, Legislative57 Assistant58Katie Bante, Health Policy Fellow59 C O N T E N T S6061 ----------62 Page63Hearing held on May 14, 2025..................................... 164Statement of Senator Cortez Masto................................ 5365Statement of Senator Lujan....................................... 5466Statement of Senator Murkowski................................... 167Statement of Senator Rounds...................................... 368Statement of Senator Schatz...................................... 269Statement of Senator Smith....................................... 517071 Witnesses7273Alkire, Hon. Janet, Chairwoman, Standing Rock Sioux Tribe;74 Representative, National Indian Health Board................... 475 Prepared statement........................................... 676Charlie, Melissa, Executive Director, Fairbanks Native77 Association.................................................... 2178 Prepared statement........................................... 2379Daniels, Dr. Sheri-Ann, CEO, Papa Ola Lokahi..................... 3180 Prepared statement........................................... 3281Greninger, Hon. Loni, Vice Chairwoman, Jamestown S'Klallam Tribal82 Council........................................................ 1483 Prepared statement........................................... 1684Simpson, Lucy R., Executive Director, National Indigenous Women's85 Resource Center................................................ 2786 Prepared statement........................................... 288788 Appendix8990American Indian Higher Education Consortium, prepared statement.. 6791Baker, Hon. Melvin J., Chairman, Southern Ute Indian Tribe,92 prepared statement............................................. 8293Crevier, Francys, Algonquin/CEO, National Council of Urban Indian94 Health (NCUIH), prepared statement............................. 7095Garcia, Donnie, Chairman, Albuquerque Area Indian Health Board,96 Inc., prepared statement....................................... 6597Kana`iaupuni, Shawn M., Ph.D., President/CEO, Partners in98 Development Foundation (PIDF), prepared statement.............. 7899Knowlton, Stephanie, Program Coordinator, Fort Peck Tribal Court,100 prepared statement............................................. 69101Letters submitted for the record102103Lucero, Esther, MPP, President/CEO, Seattle Indian Health Board,104 prepared statement............................................. 80105Lujan, Eileen J., Board Member, National Indian Council on Aging,106 prepared statement............................................. 70107Pesina, Andrea, President, National Indian Head Start Directors108 Association (NIHSDA), prepared statement....................... 74109Response to written questions submitted by Hon. Ben Ray Lujan to:110 Hon. Janet Alkire............................................ 96111 Melissa Charlie.............................................. 99112 Hon. Loni Greninger.......................................... 107113Response to written questions submitted by Hon. Lisa Murkowski114 to:115 Hon. Janet Alkire............................................ 93116 Hon. Loni Greninger.......................................... 103117 Lucy R. Simpson.............................................. 107118Response to written questions submitted by Hon. Brian Schatz to:119 Hon. Janet Alkire............................................ 94120 Melissa Charlie.............................................. 97121 Dr. Sheri-Ann Daniels........................................ 99122 Hon. Loni Greninger.......................................... 105123 Lucy R. Simpson.............................................. 107124Rowland, Jennifer, prepared statement............................ 80125Sunday-Allen, Robyn, CEO, Oklahoma City Indian Clinic (OKCIC),126 prepared statement............................................. 76127United South and Eastern Tribes Sovereignty Protection Fund (USET128 SPF), prepared statement....................................... 85129130 DELIVERING ESSENTIAL PUBLIC HEALTH131132 AND SOCIAL SERVICES TO NATIVE133134 AMERICANS--EXAMINING FEDERAL135136 PROGRAMS SERVING NATIVE AMERICANS137138 ACROSS THE OPERATING DIVISIONS AT139140 THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES141142 ----------143144 WEDNESDAY, MAY 14, 2025145146 U.S. Senate,147 Committee on Indian Affairs,148 Washington, DC.149 The Committee met, pursuant to notice, at 3:39 p.m. in room150628, Dirksen Senate Office Building, Hon. Lisa Murkowski,151Chairman of the Committee, presiding.152153 OPENING STATEMENT OF HON. LISA MURKOWSKI,154 U.S. SENATOR FROM ALASKA155156 The Chairman. Good afternoon. Calling this oversight157hearing to order.158 We are here this afternoon to examine critical programs159within the U.S. Department of Health and Human Services that160are also essential to upholding the Federal Government's trust161responsibility for the health and well-being of Native162communities, but that are not under the Indian Health Service.163 As we look broadly at the programs within HHS, we have to164remember that for many Native communities, non-IHS programs are165just as important as those under the IHS. From public health166initiatives to social services, these programs often provide167the only consistent access to basic supports for the most168vulnerable members of Native communities.169 So, what programs are we talking about? It is Tribal Head170Start, that helps young children grow up healthy and rooted in171culture, it is LIHEAP, that ensures tribal elders have heat in172the winter and air conditioning in the summer. These aren't173just Federal services, they are really critical components of174the social safety net. My view is that these programs support175family stability, child development and basic dignity.176 So today, we are going to also hear about HHS programs like177FVPSA, which is the Family Violence Prevention and Services178Act. This is the primary Federal funding stream supporting179vital crisis services and shelters for those experiencing180family violence.181 We will also hear about how tribes are reducing the risk of182costly intervention and foster care removals through child183welfare services and Tribal TANF. These programs help break184intergenerational cycles of trauma, support safe housing and185equip Native families with the tools to thrive.186 Many tribes have built these effective programs over187generations, investing their own resources, training their own188workforce so that they better align with their culture and189community needs. These are models of local innovation and190sovereignty, and they deserve both protection and sustained191support.192 Given the scope and critical nature of these HHS programs,193we are hearing growing concerns from tribes and Native194communities about the executive order on optimizing the195workforce across the Federal Government and the HHS196announcements about reorganization and RIFs. I hear regularly197from constituents that are asking, how do these proposals198affect me and the delivery of essential services?199 I want to acknowledge and thank Senator Kennedy for200recognizing the importance of IHS very early on. He made clear201that they were not going to be subject to those RIFs. Now we202are asking for the same understanding for other programs at203HHS. And that starts with tribal consultation at HHS on these204programs. I think it has to occur early, be consistent and be205meaningful.206 We know that when tribes are truly engaged in shaping the207policies and programs that serve their citizens, outcomes208improve, trust deepens, and Federal resources are more209effectively aligned with local priorities. These programs work210best when they reflect the voices of the people that they are211meant to serve.212 Forums like this hearing are also important. This is your213opportunity to formally make your case for these programs to214the Legislative Branch. But we also know that HHS will take215notice, too.216 I was in a hearing that began at 1:30 before the Health217Committee, and Secretary Kennedy was there. I had alerted him218that we were having this oversight and he said, if he wasn't in219that hearing he would be here as well, which I appreciate. And220I think perhaps some of his team, if they are not here in the221room, they might be watching or listening.222 So I think what we learn today is not just going to be223confined to this room, this audience, but broader.224 I want to thank all of you for traveling with us to be here225today or if you are here in D.C., your journey is a little bit226easier. But I know your time and expertise are invaluable. The227insights that you share will help inform our continued work to228strengthen Federal programs and uphold the promises made to229Native communities. So I am looking forward to your230testimonies.231 I now turn to Vice Chair Schatz for his comments.232233 STATEMENT OF HON. BRIAN SCHATZ,234 U.S. SENATOR FROM HAWAII235236 Senator Schatz. Thank you, Chair Murkowski. I want to237extend a special warm aloha to Dr. Sherri-Ann Daniels, CEO of238Papa Ola Lokahi. Papa Ola Lokahi is the sole entity responsible239for coordinating Native Hawaiian health care services, and is a240leading voice for health care across the State of Hawaii.241Mahalo for your continued leadership on behalf of Native242Hawaiian people.243 Providing health care is one of the Federal Government's244most fundamental trust and treaty responsibilities to American245Indians, Native Hawaiians and Alaska Natives. And delivering on246that promise depends on over a dozen HHS agencies, not just the247Indian Health Service.248 For Native Hawaiians in particular, HHS's trust249responsibility extends far beyond just HRSA. But despite a lot250of promises from the Secretary from the Secretary about251strengthening Native health care and addressing longstanding252issues, we have seen that this administration is engaging in253staff layoffs, office closures, funding freezes and proposed254budget cuts that will undermine the quality of care and255overwhelm a health care system that, frankly, is already on the256brink.257 Native people are among the most vulnerable in health terms258in the Country, falling behind on almost every metric. They259experience some of the highest rates of cancer, heart disease,260respiratory illness, diabetes, overdose and suicide, and their261life expectancy is the lowest of any racial group in the United262States and nearly 10 years below the national average.263 So the status quo was insufficient to begin with. Then came264the sweeping cuts at CDC, NIH, HRSA, SAMHSA, ACF, and other265offices and programs. A CDC team supporting overdose prevention266in tribal communities was reduced from seven staffers to a267single human who is now responsible for managing millions of268dollars in funding. The Healthy Tribes Program, which is269focused on preventing certain chronic diseases, was gutted.270Five HHS regional offices, which served 461 tribes in 22271States, terminated staff and were abruptly closed in March.272 All of this means that Native communities have less support273for job training, child care, domestic violence victim274services, suicide and substance abuse prevention, and much275more. These cuts are being carried out without any tribal276consultation whatsoever in plain violation of our trust and277treaty responsibilities.278 This is not just a moral question of what we owe Native279people; it is also a question of the law. Let's be clear: the280status quo was already insufficient. The administration's281proposed cuts of nearly $1 billion to Native health care will282make matters worse.283 There is bipartisan agreement on this Committee that these284communities need more help. Now is the time to stand together285to protect Native health care.286 I want to thank our witnesses, and I look forward to the287hearing.288 The Chairman. Thank you, Senator Schatz.289 We will now turn to the witnesses. I am going to turn to290our colleague from South Dakota to do the first introduction.291292 STATEMENT OF HON. MIKE ROUNDS,293 U.S. SENATOR FROM SOUTH DAKOTA294295 Senator Rounds. Thank you, Madam Chair and Vice Chair. I296want to thank our witnesses as well for taking the time to297attend today's hearing and share your perspectives.298 Today I am proud to introduce my friend, Chairwoman Janet299Alkire, of the Standing Rock Sioux Tribe.300 After retiring as a staff sergeant in the U.S. Air Force,301Chairwoman Alkire returned home to serve the Standing Rock302Sioux Tribe. During this time, she oversaw the daily operations303of tribal government programs while serving two terms as the304Executive Director. In 2021, Janet became the first woman ever305elected by the people as Chairwoman of the Tribe.306 Chairwoman Alkire provides an important voice on several307key tribal issues, including health care, public safety and308economic development. In recognition of her leadership and309advocacy, Chairwoman Alkire was named one of USA Today's women310of the year in 2025. Not bad. Congratulations. Matter of fact,311congratulations.312 She continues to advocate for her people as a board member313of the National Indian Health Board.314 I want to again thank Chairwoman Alkire and all the other315witnesses for attending today's hearing. Thank you, Madam316Chair.317 The Chairman. Thank you.318 I will make full introduction of everyone, then we will319begin with individual statements. Following Chairman Alkire, we320have the Honorable Loni Greninger. She is the Vice Chair of321Jamestown S'Klallam Tribal Council from Sequim, Washington.322 We also have, from Fairbanks, Alaska, Melissa Charlie.323Melissa is currently the Executive Director of Fairbanks Native324Association. She is a tribal citizen of Minto, and has been325involved in many, many leadership capacities in her region.326 She is focused and committed to early childhood development327and community wellness. We really appreciate the fact that you328have traveled so far to be with us, Melissa.329 Following Melissa, we have Lucy Simpson, the Executive330Director for the National Indigenous Women's Resource Center331from Lame Deer, Montana, as well as Dr. Sheri-Ann Daniels, who332the Vice Chairman has already introduced. I am just going to333try to say it, is the Chief Executive Officer of the Papa Ola334Lokahi, from Honolulu. It is good for us to be working through335the names and doing them correctly to show that respect.336 I want to remind everyone that we do have your full337testimony that each member has. We would ask you to try to keep338your comments to five minutes so that we can have questions339following your statements.340 So Chairman Alkire, you may begin with your testimony.341342 STATEMENT OF HON. JANET ALKIRE, CHAIRWOMAN,343 STANDING ROCK SIOUX TRIBE; REPRESENTATIVE,344 NATIONAL INDIAN HEALTH BOARD345346 Ms. Alkire. Good afternoon, Chairwoman Murkowski, Ranking347Member Schatz, and distinguished members of the Committee. On348behalf of the National Indian Health Board and the 574349sovereign federally-recognized tribal nations we serve, thank350you for this opportunity to provide testimony today.351 My name is Janet Alkire. I serve as the Chairwoman of the352Standing Rock Sioux Tribe. I also serve as the Great Plains353Representative for the National Indian Health Board. I am354Hunkpapa Lakota, a descendant of the Lakota leaders who signed355the 1868 Fort Laramie Treaty.356 I am a beneficiary of the treaty and trust obligations357enshrined in that agreement, which continue to shape the rights358of our people in Indian Country.359 The Department of Health and Human Services delivers vital360programs to tribal nations and citizens from a part of the361Federal Government's trust and treaty obligations. These362services, many beyond Indian Health Service, are essential to363the health and well-being of our citizens. As tribal leaders,364we are deeply concerned about the ongoing HHS reorganization365and its far-reaching consequences for serving tribal nations366and their citizens.367 Despite chronic underfunding, tribal nations, tribal368organizations and Urban Indian Organizations rely on HHS369resources to deliver lifesaving care. Tribes have long370supported efforts to streamline Federal programs, reduce371reporting burdens and direct funding to the Indian health372system.373 However, any reorganization must honor treaty and trust374obligations, including meaningful consultation. We have urged375HHS to hold consultations to ensure programs that serve tribal376nations and citizens are protected. To date, the organization377has reduced HHS staff by 24 percent, disrupting grant access,378tribal advisory committees, and causing tribal program staff to379leave.380 This has already resulted in the cancellation of over $6381million in grants, jeopardizing critical infrastructure for the382Indian health system. The Great Plains is experiencing a383syphilis epidemic, with rates among Native people rising to3841,865 percent from 2020 to 2022, ten times the national385average. The CDC played a key role in the response, but the386recent restructuring cut nearly 20 percent of its staff,387including those staff supporting our tribal epidemiology388center.389 OASH, Office of Infectious Disease, HIV/AIDS Policy also390lost staff, ending a program that awarded $16 million to 18391tribal and Urban Indian Organizations, improved HIV outcomes by392over 90 percent at the Phoenix Medical Center. This leaves us393without essential Federal STI response support.394 Additionally, the majority of the staff operating Healthy395Tribes Program under CDC, which oversees several grants,396including good health, wellness in Indian Country, grantees are397receiving conflicting information about their grants and the398programs are in limbo. One tribal grantee has already received399notice of determination. A UIO has reported losing400communication with their project officer and grants manager,401leaving a critical gap in their program.402 CDC's Division of Reproductive Health is a huge component403for tracking maternal health and outcomes nationwide, including404Native moms. These staff were also placed on administrative405leave and updates to the pregnancy risk assessment monitoring406system, one of the few national data sources that tracks Native407maternal and infant health disparities, has been paused.408Because of this, we are losing vital tools for identifying409risks, interventions and saving lives.410 SAMHSA's Center for Mental Health Services has seen major411staffing cuts. Key tribal behavioral health grants have been412terminated or left in limbo. Even when funding has been removed413temporary disruptions in funding can destabilize programs.414 The Great Plains Tribal Leaders Health Board is connecting415with our youth program, which applies traditional Lakota values416to reduce suicide through mentorship and culturally grounded417education is at risk. This program reduced Native youth418suicides in our area by 78 percent from 2019 to 2024.419Successful outcomes like this shows what is at stake.420 In conclusion, programs serving tribal nations and their421citizens have a minimal fiscal impact, but are foundational to422improving chronic health conditions in Indian Country. Tribes423share a vision for a healthy America, but tribes must be424consulted in the first instance.425 Tribes want to work with HHS. I appreciate what the426Secretary has done so far to protect our health. We want427efficiency to reduce grant reporting, provide direct funding to428tribes instead of reliance on State block grants, expand tribal429self-governance outside the IHS.430 We must avoid barriers such as DOGE Defend the Spend, which431increased burdens and withheld funding from programs serving432tribes and its citizens. We can be the solution to a more433efficient HHS.434 I thank the Committee for this opportunity to provide this435testimony. Wopila.436 [The prepared statement of Ms. Alkire follows:]437438 Prepared Statement of Hon. Janet Alkire, Chairwoman, Standing Rock439 Sioux Tribe; Representative, National Indian Health Board440 Chairwoman Murkowski, Ranking Member Schatz, and distinguished441members of the Committee, on behalf of the National Indian Health Board442(NIHB) and the 574+ sovereign federally recognized American Indian and443Alaska Native (AI/AN) Tribal Nations we serve, thank you for this444opportunity to provide testimony on Delivering Essential Public Health445and Social Services to Native Americans. My name is Janet Alkire, and I446serve as the Chairwoman of the Standing Rock Sioux Tribe. I also serve447as the Great Plains Representative to the NIHB. I am Hunkpapa Lakota--a448descendant of the Lakota leaders who signed the 1868 Fort Laramie449Treaty. I am a beneficiary of the Treaty and Trust obligations450enshrined in that agreement, which continue to shape the rights of our451people and Indian Country as a whole. I am also a proud veteran of the452United States Air Force.453 The NIHB is concerned about the implementation of reorganization of454the Department of Health and Human Services (HHS) and its significant455implications for Tribal Nations and Tribal-serving programs. HHS456programs, including those agencies and operational divisions outside457the Indian Health Service (IHS), are a critical support to Tribal458Nations, their citizens, and their communities, and HHS programs are an459integral part of the federal trust responsibility to Tribes. For460example, in FY 24, HHS provided Great Plains Area Tribes and Tribal461organizations approximately $124 million in funding, less than 0.002462percent of the HHS budget, which supports life-saving programs that463address some of the most extreme health disparities in the nation.464Although Tribes support efforts to improve efficiency within HHS, any465reorganization, reduction in force, and changes to this funding must be466conducted in a manner that upholds the federal trust and treaty467obligations to Tribal Nations. An obligation for which Tribes have pre-468paid for centuries through land and resources. We have urged HHS to469promptly schedule a series of Tribal Consultations to discuss the470implications for Tribal Nations and ensure that Tribal-serving471programs, set-asides, and staff are preserved.472 The United States maintains a unique political, legal, and473historical relationship with Tribal Nations, established and affirmed474by the Constitution, federal law, Supreme Court rulings, and executive475orders. Born out of this relationship is the federal government's trust476responsibility--including the duty to provide the necessary resources477to deliver high-quality healthcare to AI/AN people.478 The reorganization of HHS is part of the implementation of479Executive Order 14210, ``Implementing the President's `Department of480Government Efficiency' Workforce Optimization Initiative'', signed on481February 11, 2025. The implementation of this Executive Order through482the reorganization of HHS has resulted in the immediate reduction of483full-time employees at the Department by no less than 24 percent. The484reduction in staff has impacted grant funding access and distribution485to Tribes, the operation of Tribal Technical Advisory Committees, and486is causing remaining Tribal program staff to seek opportunities outside487federal employment. Without Tribal Consultation, Tribal Nations have488already incurred significant harm, including the abrupt cancellation of489no less than $6 million in grants from various HHS agencies--490jeopardizing the sustainability of health and public health systems in491Indian Country.492 One pattern NIHB has noted is the preservation of divisions of493Tribal affairs (DTA) within HHS' agencies and operational divisions.494This is a positive recognition of the importance of these offices and495their staff. These DTAs, however, are frequently only engagement-level496offices, and do not host critical programs and funds supporting497services in Indian Country. It is the programmatic offices, discussed498in this testimony, which work to meet the trust and treaty obligations499for healthcare. All of this impacts the ability of HHS programs to500deliver on the trust and treaty obligations to Tribal Nations.501Centers for Disease Control and Prevention502 Under this reorganization, several key public health programs have503been impacted, including the National Center for Injury Prevention and504Control (NCIPC) in AI/AN Communities, Healthy Tribes, the Reproduction505Health Division (RHD), and Pregnancy Risk Assessment Monitoring System506(PRAMS). Further, the Center for Chronic Disease Prevention and Health507Promotion would face elimination, including the elimination of its508Maternal and Infant Health branch, Division of Oral Health, Division of509Diabetes Translation, the Division of Cancer Prevention and Control,510and the Office of Smoking and Health. These programs provide critical511support to Tribal providers nationwide on healthcare disparities512impacting our communities.513 We have received troubling reports that the seven-member Tribal514Support Team within the NCIPC in AI/AN communities has been reduced to515just one remaining staff member. This small team but essential team,516was responsible for managing $18 million in funding that directly517supports 15-Tribes and Tribal organizations, ten Tribal epidemiology518centers, and seven urban Indian organizations. The NCIPC was one of few519HHS divisions deeply committed to developing tribally centered injury520prevention initiatives, particularly those focused on healing from the521devastating impacts of the overdose crisis in Indian Country. Grantees522under this program have implemented culturally responsive overdose-523prevention strategies including sweat lodges, smudging, talking524circles, engaging in ceremony, and other culturally centered practices.525In many rural and remote areas, these programs represent the only526available treatment services for hundreds of miles. The Tribal Support527Team served as a lifeline for individuals and families and their528dismissal will undoubtedly harm access to treatment for AI/AN529populations.530 The proposed cancellation of Healthy Tribes funding agreements and531termination of staff as part of the agency's reduction in force has532already impacted the delivery of three critical projects, including533Good Health and Wellness in Indian Country (GHWIC), Tribal Practices534for Wellness in Indian Country, and Tribal Epidemiology Centers Public535Health Infrastructure. These programs, while representing a minimal536fraction of federal spending, are lifelines in Indian Country. In at537least one instance, a grantee has already received notice of the538termination of the Good Health and Wellness in Indian Country funding.539Some Tribal programs have already received termination notices for540their GHWIC grants.541 The dismantling of RHD and the suspension of PRAMS would decimate542the limited maternal and child health surveillance tools available to543AI/AN communities. PRAMS is already not being updated and data not544being tracked due to staff layoffs. PRAMS is one of the few national545data sources that tracks maternal and infant health disparities in AI/546AN populations. Without it, federal and Tribal health agencies will547lose a vital tool for identifying risks, informing interventions, and548saving lives. The provisional data released last month by the National549Center for Health Statistics shows that maternal mortality has started550to rise again after two years of declining mortality rates. \1\ We need551these data sets now more than ever. Likewise, the reduction of RHD552staff has stripped Tribal communities of critical technical assistance.553We are already aware of Hear Her campaign staff being let go554interrupting resources available to pregnant women, families, and555healthcare professionals. It remains unclear whether funding will556continue for Maternal Mortality Review Committees (MMRCs) which are557vital to preventing maternal deaths in local communities.558---------------------------------------------------------------------------559 \1\ CDC National Center for Health Statistics, April 9, 2025.560Maternal Mortality Surveillance, Provisional Maternal Death Rate.561Accessed 5/11/2025: https://www.cdc.gov/nchs/nvss/vsrr/provisional-562maternal-deaths-rates.htm.563---------------------------------------------------------------------------564 In reviewing the publicly available information, the new proposed565reorganization of CDC centers would focus funding and efforts into the566National Center for State, Tribal, Local, and Territorial Public Health567Infrastructure and Workforce. We commend the need to provide more568direct funding to Tribes and Tribal organizations for this work, but to569date we have not seen this. In fact, in 2022, the CDC denied Tribes570access to public health infrastructure funding, claiming that funding571had been sent to IHS which was then rescinded from IHS by Congress in5722024. Any refocusing of the agency to send more funding to States and573local governments directly must include direct funding sources to574Tribal programs.575 CDC has also seen a nearly 20 percent reduction in staffing which576has had an impact on public health response in Indian Country. CDC,577particularly Commissioned Corps staff, frequently do temporary duty578stations or tours in areas with extreme public health need. Because of579the extreme disparities in Indian Country, there are frequent tours to580address public health needs in our communities. One individual working581with the Great Plains Tribal Epidemiology Center (TEC) raised concern582about several staff from CDC who have been terminated who did several583tours with their TEC to address a public health crisis in their region.584Following the termination of these staff, the individual shared that585the response efforts would not be possible now because those586individuals' positions do not exist anymore. This also includes the587technical assistance their CDC division provides on capacity to test588samples and other clinical/lab approaches to the crisis. Those types of589positions are vital to the work that they have done related to syphilis590and other STIs that may come around again. It is quite concerning;591these positions just do not exist anymore.592 HHS also cut funding for the Strengthening Public Health System and593Services in Indian Country that was a data modernization initiative594project. We understand it was due to funding being attached to COVID595supplements, but for Indian Country this funding is vital to modernize596our healthcare infrastructure in the face of chronic underfunding.597Other COVID-linked funding has also been terminated for things598including support of Community Health Representative programs, supplies599including personal protective equipment, and funding for Tribal600vaccination programs. Many of our facilities are outdated and need new601equipment and modern electronic health record systems. Without this602funding Indian Country continues to be left out of modern advancements.603Health Resources and Services Administration604 The Health Resources and Services Administration (HRSA) is proposed605to be rolled up into a new Administration for a Healthy America (AHA).606This concerns Tribes as there are a number of programs that Tribes rely607on programs delivered across HRSA's offices and bureaus. HRSA serves as608a grant-making agency but also provides technical support across609workforce, maternal and child health, rural healthcare, and supporting610access to underserved communities, including Tribes.611 One of HRSA's primary functions is to develop and support the612healthcare workforce, and as part of that, HRSA administers the613National Health Service Corps and its loan and scholarship programs.614This is one critical source of funding to support providers who work in615Indian Country. The NHSC includes a 15 percent set aside for Tribes to616support recruitment and retention in our underserved communities. In617the middle of April, NIHB held a Tribal Townhall to get a better618understanding of the impacts of the HHS Reorganization on Tribal health619programs. The NHSC Loan Repayment program was raised as an example620where participating Tribal providers has received stop notices on their621repayments. Without the additional resources of the NHSC programs, our622communities will struggle to find providers. The Funding for Indian623Health Professions within the IHS budget is insufficient, and its loan624repayment and scholarship programs are not tax exempt like HRSA's625programs are.626 HRSA's Maternal and Child Health programs are another important627source of funding to Indian Country. The President's FY 2026 Proposed628Budget, which begins to spell out what HHS Reorganization will look629like in detail, includes a recommended $274 million reduction to630maternal and child health programs. It explains these funds as631``duplicative'' and that they should be addressed through State block632grants. Most of this funding already goes to the States with no set633asides for Tribes, and consolidating the remaining funds will only634worsen this situation. AI/AN women are three times more likely to die635from pregnancy-related causes than non-Hispanic White (NHW) women \2\636and the AI/AN mortality rate is two times the rate of NHW population.637\3\ HRSA administers the Healthy Start program, which aims to improve638maternal and infant health outcomes, reduce infant mortality, and639address adverse perinatal conditions through Tribally tailored640programming. Several Tribal health programs receive this funding641enabling screenings, nurse visits, and the Tribal Home Visiting642program. Tribes and Tribal health programs only receive small portions643of funding for maternal and child health through programs, so some644Tribes also access funding through State allocations of HRSA funding.645Instead of pushing more funding to the State, we should be creating646Tribal set asides withing the Maternal and Child Health Block Grant.647The proposal to reduce funding and centralize these services at a648critical time for maternal health in Indian Country and the United649States could cause harm to Tribal programs.650---------------------------------------------------------------------------651 \2\ Petersen EE, Davis NL, Goodman D, et al. Racial/Ethnic652Disparities in Pregnancy-Related Deaths--United States, 2007-2016. MMWR653Morb Mortal Wkly Rep 2019;68:762-765. DOI: http://dx.doi.org/10.15585/654mmwr.mm6835a3655 \3\ CDC, 2024. Infant Mortality in the United States, 2022: Data656from the Period Linked Birth/Infant Death File. National Vital657Statistics Reports, vol. 73, no. 5. Table 2.658---------------------------------------------------------------------------659 HRSA is also responsible for programs providing healthcare in660underserved communities. They do this through a series of programs661including the Health Professions Shortage Area designation process, the662section 340B program for reduce-cost pharmaceuticals, and the section663330 program which funds and provides technical assistance to Community664Health Centers (CHC) and Federally Qualified Health Centers. HHS's665proposal to dissolve HRSA into the new AHA without Tribal consultation666is concerning for the future of these programs. Specifically, 37 Tribal667and Urban Indian organizations participate in the section 330 grant668program, to ensure that their patients receive quality health services.669The proposed reorganization raises concerns about whether HRSA670programmatic support will be maintained or diminished in the671transition, which would affect continuity of care for Tribal citizens.672Some grantees have already reported delays in receiving payments or673only getting short-term grant renewals.674Office of the Assistant Secretary for Health (OASH)675 The Office of the Assistant Secretary for Health (OASH) is a676critical operating division for many public health related activities677and programs. In the initial days following the mass termination of678employees within OASH, NIHB tracked staff departures that disrupted the679Office of Minority Health (OMH) and the Office of Infectious Disease680and HIV/AIDS Policy (OIDP). NIHB has heard from numerous Tribal leaders681that their OASH funding has been paused, withheld or terminated without682clear communication or consultation. Combined with the significant683reduction in force, Tribes are concerned about their current access to684resources and technical assistance from OASH. OASH has historically685provided support that is critical for addressing region-specific health686challenges such as chronic disease prevention, maternal health, youth687wellness, and behavioral health services. OASH is also one of the few688HHS divisions with a focus on community-level engagement and cross-689agency coordination.690 For example, the OMH provided outreach and support to Tribal691communities and was working to implement a new Center for Indigenous692Innovation and Health Equity (CIIHE) to support the elimination of693health disparities in Tribal communities. This new center, created in6942021, was to help identify and disseminate evidence- and practice-based695interventions for AI/AN populations to improve public and healthcare696delivery in our communities. The CIIHE also include the Tribal advisory697committee (TAC) responsible for advising the Assistant Secretary of698Health. Without any details for what is happening to these programs,699Tribes and TAC members do not know how this program is moving forward.700Until the release of the FY 2026 President's Proposed Budget, it was701believed that OMH was eliminated in its entirety.702 The OIDP develops, coordinates, and supports a range of infectious703disease initiatives including Ending the HIV Epidemic in the U.S., the704Minority HIV/AIDS Fund (MHAF), and actions to prevent healthcare-705associated infections. In 2022, AI/AN males were 1.8 times more likely706to have a diagnosis of HIV infection than NHW males and AI/AN females707were 1.6 times more likely to have AIDS. \4\ Many staff who oversaw708HIV/AIDS programming have already been eliminated impacting local709efforts. The Reorganization has terminated staff working on MHAF and710Ending the HIV Epidemic which is undermining lifesaving care and711prevention efforts for AI/AN individuals living with or at risk of HIV/712AIDs. Since 2012, HIV screening among adults/adolescents increased from71331 percent to 57 percent. In 2024, The Phoenix Indian Medical Center714achieved viral suppression of over 90 percent for people living with715HIV, leading Arizona's viral suppression rate. IHS was also able to716develop the national HIV/HCV/STI dashboard to monitor trends and717support outbreak response. Despite these advances, AI/AN communities718remain disproportionately impacted. HCV-related mortality is highest719among Native people. Congenital syphilis has increased by over 5,000720percent in the past decade, leading to preventable infant deaths.721Further, when we look at just the Great Plains Area, from 2020 to 2022,722syphilis rates among AI/AN people surged by 1,865 percent--that is ten723times the national rate. It will now be harder to track these types of724rate changes as well. Further, the staff responsible for tracking HIV,725HCV, and Syphilis data at CDC have been let go, and these data sets are726no longer being maintained. This data has been crucial to understanding727the spread of these diseases, particularly the syphilis epidemic in the728Great Plains. Without MHAF, OIDP, and the CDC's data tracking, IHS and729Tribes are losing their only dedicated federal funding source and730support for HIV, HCV, and STI response.731---------------------------------------------------------------------------732 \4\ Centers for Disease Control and Prevention (CDC), 2024. HIV733Surveillance Report: Diagnoses, Deaths, and Prevalence of HIV in the734United States and 6 Territories and Freely Associated States, 2022,735v.35. Tables 3a and 1a. https://stacks.cdc.gov/view/cdc/156509 (Back to736top)737---------------------------------------------------------------------------738 In FY25 alone, MHAF awarded $16 million to 17 Tribal health739organizations, with funding intended through FY29. The loss of this740support would dismantle programs and destabilize essential services,741particularly because these Tribal programs largely treat all STIs742concurrently and often support screenings in clinical environments743during regular check-ups, like for expecting mothers. This is also744coupled with uncertainty for HRSA's Ryan White program to treat HIV/745AIDS, which is often part of the larger strategy on HIV/AIDS/STIs and746is slatted for ``consolidation''. \5\ These programs provide treatment,747testing, and wraparound services that help reduce the spread of HIV and748other STIs and increase access to healthcare services and screenings.749---------------------------------------------------------------------------750 \5\ Office of Management and Budget, 2025. President's Proposed FY7512026 Budget. Accessed 5/9/25: https://www.whitehouse.gov/wp-content/752uploads/2025/05/Fiscal-Year-2026-Discretionary-Budget-Request.pdf.753---------------------------------------------------------------------------754Administration for Community Living755 The Administration for Community Living (ACL) plays a critical role756in delivering essential services under the Older Americans Act (OAA)757and is a lifeline for AI/AN Elders, people with disabilities, and other758vulnerable populations. ACL's funding structure ensures that resources759reach communities through state, Tribal, and local programs, supporting760wraparound services that are vital for maintaining independence,761dignity and quality of life. The proposal to eliminating the ACL762division would create gaps in care, destabilizing systems on which763communities have come to rely.764 ACL's Office of Older Indians (OOI) oversees the OAA Title VI which765provides support for home and community-based care wrap around services766and nutritional support for Native Elders. These services are the only767direct Tribal programs to offer these important services enabling our768Elders to stay in community. Even though the Indian Health Care769Improvement Act (IHCIA) authorizes funds to support long-term services770for our Elders, Congress has never funded those provisions and no771Administration has ever requested such funding. This means that our772Elders' Programs are severely underfunded in Indian Country. Tribes773frequently turn to the State's Title III and other OAA funding to774support other wraparound services to our Elders. NIHB has heard that775the OOI staff have been preserved, but OOI staff are not responsible776for grant payment processing. As we understand it currently, ACL staff777responsible for the payment of grant awards have been let go without778notice to grantees. This has meant huge disruption to Tribes awaiting779funds.780 This means that changes to all of ACL impact Tribal programs. The781proposed HHS reorganization states intent to dissolve ACL and move782programs to the Administration for Children and Families and the783Centers for Medicare and Medicaid Services. This would dismantle core784ACL programs, eliminate the Chronic Disease Self-Management Education785(CDSME) which empowers older adults to manage chronic conditions and786avoid costly medical services, and would transfer the National787Institute on Disability, Independent Living, and Rehabilitation788Research (NIDILRR), weakening evidence-based approaches to care. It is789also unclear what will happen to funding for the Native American790Caregivers Support, a program that provides critical assistance to791families caring for Elders.792 ACL is the only agency that has programs working to keep Elders and793those with disabilities in their homes and communities. With the loss794of these programs, more and more preventable injuries and advanced795chronic conditions will fall to the Medicare and Medicaid programs--796frequently at higher costs than the preventive care being cut/reduced.797Keeping our Elders in community is also important for the preservation798of our cultures. Our Elders are the keepers of our knowledge, stories,799and culture; when they remain in community, they have stronger800relationships particularly with our youth who learn from them and carry801on our traditions. Without these programs, more of our Elders would802need to leave community--breaking these important cultural bonds. ACL's803ability to reach our vulnerable communities cannot be replicated by804transferring programs to the ACF and CMS. ACL programs are a critical805lifeline for older adults, AI/AN Elders, and individuals with806disabilities, and the transition of such programs could break the807process and institutions that currently deliver this lifeline of808funding.809National Institutes of Health810 HHS Reorganization proposes to retain a much reduced National811Institutes of Health (NIH). The detail for a reorganized NIH can be812found in the President's FY 26 Proposed Budget which proposes a 42813percent decrease from FY 2025 and would eliminates several key814programs. The preservation of the Tribal Health Research Office and815staff has been essential to providing technical assistance to Tribes816and understand the cancelations or pauses of no less than 18 grants,817including one Native American Research Center for Health (NARCH) award.818NARCH is the premier health science grant recognizing excellence in AI/819AN health science research. Of the many Institutes proposed to be820closed in the NIH reorganization, we are concerned that it includes the821National Institute of Nursing Research, National Center for822Complementary and Integrative Health, and National Institute on823Minority Health and Health Disparities, which reports out data on AI/AN824populations. The proposal would also consolidate the remaining 23825institutes into a total of eight.826 Tribal and Tribal research programs have already been impacted by827funding cuts, recissions, and direct funding cancelation. Tribes,828Tribal public health agencies, and Tribal research programs must be829exempted from any further disruptions to uphold the federal trust and830treaty obligation.831Substance Abuse and Mental Health Services Administration (SAMHSA)832 SAMHSA programs save lives in Indian Country. In the Great Plains833Area, the Great Plains Tribal Leaders Health Board's (GPTLHB)834Connecting With Our Youth (CWOY) program, funded by SAMHSA. Based in835Pennington County, South Dakota, CWOY applies traditional Lakota836values--compassion, wisdom, generosity, and respect--to reduce youth837suicide through mentorship, advocacy, and culturally grounded838interventions. Partnering with the Rapid City Police Department, the839program offers early intervention and long-term support. From 2019 to8402024, CWOY achieved a 78 percent reduction in suicide deaths among841Native youth (ages 10-24), from 9 deaths to just 2. This has resulted842in a consistent year-over-year decline in suicide mortality and an 11843percent drop in suicide-related police calls in 2024. These outcomes844illustrate what is possible when federal investments are tailored to845community needs and delivered in partnership with tribal leadership.846 SAMHSA programs also combat the substance use disorder crisis we847are facing. In 2022, 1,543 non-Hispanic AI/AN individuals died from848overdose, which was the highest overdose rate of any racial or ethnic849group. \6\ While we have successes, this data underscores the urgency850of expanding, not reducing, behavioral health resources in Indian851Country.852---------------------------------------------------------------------------853 \6\ Centers for Disease Control. (2024). Opioid Overdose Prevention854in Tribal Communities. Retrieved from: https://www.cdc.gov/injury/855budget-funding/opioid-overdose-prevention-in-tribal-communities.html856---------------------------------------------------------------------------857 SAMHSA's Center for Mental Health Services was one of the divisions858within the Agency that saw a massive staffing reduction. CMHS was859responsible for several Tribal behavioral health grant programs,860including the Circles of Care program and part of the Native861Connections grant program. Circles of Care was a program to strengthen862the mental health care infrastructure for Tribal communities. Native863Connections was a youth-focused behavioral health grant to Tribes.864While staff are no longer available, it is not clear what will happen865to these life-line programs; some Tribes have even heard from SAMHSA866staff that their Native Connections grants will be nonrenewed in the8672026 grant year.868 The elimination of CMHS is not the only concern we have tracked at869NIHB. Tribal Behavioral Health Grants for Substance Use Disorder for a870particular Tribe were also terminated as reflected on a March 31, 2025871HHS Grants Termination List. Later iterations of the HHS Grants872Termination List \7\ have removed the line-items, which does not873clarify whether these grants have been restored. However, even if such874grants were restored--the act of terminating funding and restoring it875in the middle of a grant year severely impacts the work of the grantee876and can damage the programs reliant on these funds.877---------------------------------------------------------------------------878 \7\ HHS Grants Termination List can be found at https://879taggs.hhs.gov/Content/Data/HHS_Grants_Terminated.pdf (Last Accessed 5/8809/2025).881---------------------------------------------------------------------------882 Other critical funding streams for Tribes, such as the Tribal883Opioid Response Grants, have not yet been cut. However, without further884details of the proposal to relocate SAMHSA programs in the new AHA, it885is hard to understand exactly how much further Tribes will be impacted886by the HHS Reorganization to behavioral health programs. Eliminating887these programs will result in irreversible harm during a declared888Public Health Emergency on Opioids. \8\ Tribal behavioral health889systems are already chronically underfunded, and we cannot allow890prevention and treatment programs to disappear when AI/AN populations891need them most.892---------------------------------------------------------------------------893 \8\ RENEWAL OF DETERMINATION THAT A PUBLIC HEALTH EMERGENCY EXISTS,894March 18, 2025. Accessed 5/9/2025: https://aspr.hhs.gov/legal/PHE/895Pages/Opioid-Renewal-18Mar2025.aspx.896---------------------------------------------------------------------------897Centers for Medicare and Medicaid Services898 The Centers for Medicare and Medicaid Services (CMS) is a critical899agency in supporting the delivery of the trust and treaty obligations900for healthcare to Tribal Nations. The agency does this through the901administration and regulation of the Medicare, Medicaid, Children's902Health Insurance Program, and the federal and state Marketplaces.903Although the primary mission of the agency is to delivery these904healthcare coverage programs which have up to now been unaffected by905HHS reorganization, other administrative work and activities have been906impacted.907 The CMS Office of Minority Health (OMH) had its entire staff908terminated in the days following the announcement of reorganization.909CMS OMH, like all offices of Minority Health throughout HHS, are910statutorily created by the Patient Protection and Affordable Care Act911(ACA). CMS OMH not only had programs supporting rural health and widely912used data, it also housed CMS' work on Health Equity. The CMS Framework913for Health Equity involved significant input by Tribes, particularly914through the CMS Tribal Technical Advisory Group (TTAG). The Framework915is now missing from the CMS OMH webpage, and there are no staff left to916support this work which included Tribal Nations.917 CMS Administrative funding also supports critical programs for918outreach and education to support Americans access their healthcare919coverage programs. This includes funding to Tribes to support outreach920and enrollment focused on supporting Tribal citizens accessing Medicaid921and other healthcare coverage. Tribal Nations are concerned that this922funding may be in jeopardy because in the President's Proposed FY 26923Budget proposes doing away with such funding. It reads, ``[The Budget]924eliminates health equity-focused activities and Inflation Reduction925Act-related outreach and education activities.'' Outreach and926enrollment are critical activities and resources for Tribes.927 Without additional information or context, it is hard to understand928how this will impact Tribal Nations.929Indian Health Service930 Although the Indian Health Service has not been included in public931facing details about the proposed HHS Reorganization and broad932Reduction in Force initiatives, the Agency and its staff are impacted933by the loss of contacts and partners across their sister agencies. The934IHS works with agencies and offices to implement their programs,935provide effective public health programming, support staffing936recruitment and retention, and ensure services are available and937reimbursable. IHS providers, like all physicians and extenders, rely on938the guidance documents outlining standards of care, stable staffing,939and federal health care coverage to deliver the best care to AI/AN940people. When staff at other HHS agencies are terminated, the941government-wide hiring freeze is preventing new employees to fill those942roles depriving the IHS of technical assistance and support for outside943programs.944 Although IHS staff have not been included in RIF actions, the945instability of sudden firings across the Department is creating an946environment of uncertainty which is making it even more difficult to947hire and retain providers and other healthcare professionals. The948healthcare industry in general has experienced significant attrition as949providers and healthcare professionals leave the industry, burnt out by950years of difficult work during the COVID-19 pandemic. HHS and IHS must951work to stabilize the workforce to ensure that we are able to attract952and retain the best providers. This includes the maintenance of loan953repayment programs in other federal agencies, such as the Health954Resources and Services Administration's National Health Service Corps955loan repayment opportunities. Further, the IHS has been given few956exemptions from the federal hiring freeze making this even more957difficult and threatens the ability of IHS facilities to retain958sufficient staffing to keep beds operational and accreditation959requirements met.960 Finally, the initial proposals for the HHS Reorganization included961the centralization of core functions, including ``Human Resources,962Information Technology, Procurement, External Affairs, and Policy.''963\9\ The IHS is unique because it is one of only four direct healthcare964providers in the federal government, and is the only one in HHS which965provides healthcare nationwide. In fact, IHS is the 18th largest966healthcare system in the United States. \10\ For this reason, the IHS967depends on a separate set of core functions which hire providers,968maintain accreditation, maintain electronic health records, and ensure969access to medications and supplies critical to direct healthcare970services. For this reason, Tribes believe it is inappropriate to971centralize IHS core functions with other HHS agencies. We urge HHS to972maintain IHS' independence to ensure it can continue its work to973improve their core systems and urge the Administration to request974adequate resources for IHS to operate its core functions.975---------------------------------------------------------------------------976 \9\ U.S. Department of Health and Human Services, March 27, 2025.977``HHS Announces Transformation to Make America Healthy Again''.978Accessed 5/9/2025: https://www.hhs.gov/press-room/hhs-restructuring-979doge.html.980 \10\ U.S. Department of Health and Human Services, March 27, 2025.981``Fact Sheet: HHS' Transformation to Make America Healthy Again''.982Accessed 5/9/2025: https://www.ihs.gov/newsroom/ihs-updates/january-2-9832025-ihsupdates-for-tribes-and-tribal-and-urban-indian-organizations/.984---------------------------------------------------------------------------985Restructuring of HHS Headquarters and Closure of HHS Regional Offices986 HHS regional offices have been reduced from 10 to 5, a987consolidation that now places over 400 Tribes under the jurisdiction of988a single office in the Western United States. This restructuring now989requires Tribes in remote Alaska and Southern California to work with990staff in Denver. Many Tribes have already reported losing access to991essential technical assistance, cross-agency coordination, and992localized programmatic guidance that these regional offices once993provided.994 The IHS has a 12-region structure designed to facilitate995operational efficiency and responsive engagement with Tribal996governments. HHS' initial 10-regions also provided regionally-specific997policy support, technical assistance, and trust-based relationships998that support Tribal needs. The closure of numerous regional offices999limit the government's ability to meet its legal obligations, and puts1000the health of AI/AN communities at risk. The elimination of regional1001offices without consultation violates the principles of Tribal1002sovereignty.1003 This consolidation will especially harm rural and remote Tribal1004communities, where regional offices often served as a lifeline to1005federal programs, helping Tribes navigate complex grant applications,1006interpret policies, and respond to time-sensitive funding1007opportunities. By eliminating these offices, HHS has created coverage1008gaps, increased the burden on remaining offices, and eroded local1009institutional knowledge built over years of partnership and trust.1010Tribes have already reported being redirected to regional offices in1011places like Atlanta for program guidance, an office with little-to-no1012knowledge of Tribes or their unique government-togovernment status.1013These closures will diminish quality, timeliness, and cultural1014relevance of supportive assistance.1015 These regional office closures also included announcements of the1016consolidation of HHS Office of General Counsel regional branches. This1017included the closure of the OGC offices in Seattle and San Francisco1018which were responsible for a significant portion of the Indian Self-1019Determination and Education Assistance Act (ISDEAA) compact and1020contract negotiations and review. Over 375 Tribal Nations participate1021in IHS self-governance utilizing over 60 percent of the IHS'1022appropriation to delivery culturally tailored and quality healthcare.1023The reduction of OGC staff and these offices not only removes regional1024knowledge and history of the self-governance negotiations process, it1025also places significantly more strain on OGC staff in Headquarters.1026This could severely delay the execution of ISDEAA contracts and1027compacts.1028 Other recommendations related to the Office of the Secretary will1029have impacts on Tribes. One change which stands to dramatically impact1030Tribal Nations and their relationship with HHS is the relocation of the1031Office of Intergovernmental and External Affairs (IEA). The IEA is home1032to HHS Tribal Affairs, the office responsible for supporting the HHS1033Secretary's Tribal Advisory Committee, organizing department-wide1034Tribal Consultations, and coordinating departmental policies related to1035Tribal Nations. Recent critical work from this office has included the1036development of the HHS Tribal Consultation Policy, coordination of new1037Tribal and TEC data policies, and the hosting of the Annual Tribal1038Budget Consultation where the IHS National Tribal Budget Formulation1039Workgroup's Annual Tribal Budget Recommendations are released. The1040current proposal for reorganization envisions removing this critical1041office from direct report to the Secretary to a newly created Assistant1042Secretary for External Affairs. The removal of this work from its1043current position would significantly reduce the responsiveness of its1044work to Tribes and a critical link directly to the HHS Secretary.1045Disruptions to Tribal Advisory Councils and Tribal Serving Programs1046 Tribal Advisory Councils (TACs) have also largely been paused since1047January 2025, leaving Tribal Leaders with questions about their future1048amid the changes occurring at HHS. Without Tribal Consultation on the1049HHS Reorganization, it is not clear how TACs will be structured and1050which TACs will continue related to SAMHSA, HRSA, and the OASH Center1051for Indigenous Innovation and Health Equity Tribal Advisory Committee1052slatted to be reorganized into the new AHA--but without further details1053it is hard to know. Our TACs form a critical part of the government-1054togovernment relationship and support a robust system of policy input1055and feedback as Agencies work to regulate healthcare coverage and1056programs.1057 As discussed at the Secretary's Tribal Advisory Council meeting, we1058reiterate our request for exemptions for employees within Tribal1059Affairs Offices and Tribal-serving programs. These federal staff are1060critical to delivering legally mandated services to AI/AN beneficiaries1061and are essential extensions of the government-to-government1062relationship. The dismissal of staff from the CDC's Healthy Tribes and1063SAMHSA's Circles of Care programs further erodes this relationship.1064 Current disruptions have left communication gaps between Tribal1065Nations and federal offices. Tribal Affairs Offices previously provided1066transparency and technical assistance, but today there is often delayed1067and miscommunication with federal agencies. As political entities,1068Tribal Nations deserve access to proper communication channels and a1069list of grants and programs impacted by the reorganization.1070Government-to-Goverment Relations Through Tribal Consultation1071 These Tribal-serving programs have a minimal fiscal impact on the1072federal government but are foundational to improving chronic health1073conditions in Indian Country. Without formal Tribal Consultation and1074meaningful input from Tribal leaders, the HHS Reorganization is likely1075to unintentionally impede the effectiveness of these programs and1076impinge on the government-togovernment relationship between the United1077States and Tribal Nations.1078 Tribes share the vision for a Healthy America and a more efficient1079HHS, but Tribes must be active in these discussions as they impact our1080direct relationship with HHS programs and obligated funding for HHS1081programs. Some examples of efficiency we see that could be part of the1082HHS Reorganization include the reduction of onerous grant and U.S.1083Department of Government Efficiency Services (DOGE) reporting1084requirements, providing direct funding to Tribes instead of reliance on1085State block grant pass throughs, and the expansion of Tribal self-1086governance outside the IHS. Tribal Self-Governance has time and again1087proven one of the most successful, qualityimproving, and efficient1088programs pursued by the United States. Tribes can be the solution, and1089fit well into a reorganized HHS. We welcome the opportunity to achieve1090these efficiencies and improve services to our communities. These1091programs and personnel are not only operational necessities to our1092public health systems, they are part of the federal government's legal1093and moral obligation to Tribal Nations.1094 I thank the Committee for this opportunity to provide testimony on1095this very important issue, and look forward to working with you further1096to ensure the federal government meets and upholds its trust and treaty1097obligations to Tribal Nations.10981099 The Chairman. Thank you, Chairman.1100 Next, we will go to Loni Greninger, the Vice Chair of the1101Jamestown S'Klallam Tribal Council.11021103 STATEMENT OF HON. LONI GRENINGER, VICE CHAIRWOMAN, JAMESTOWN1104 S'KLALLAM TRIBAL COUNCIL11051106 Ms. Greninger. Thank you so much. [Phrase in Native1107tongue.]1108 Honored Leaders, Chair Murkowski, Vice Chair Schatz, thank1109you so much for the opportunity, and other members of the1110Committee that I know were here. I am grateful for their time1111as well.1112 I want to acknowledge the opening comments that you said1113earlier. You are going to be hearing me repeat probably many of1114the things that both of you have said already.1115 And for Vice Chair Schatz in particular, one of the things1116I have said at other tables before is, I hate being the first1117place in everything like that. Chronic disease, all these1118negative impacts, I hate being in first place. I want to be1119able to fix that.1120 So that is one of the reasons why I am here testifying1121before you today. So thank you for this opportunity.1122 For Chair Murkowski, I have family in the great State of1123Alaska, so I get to visit your great State often on the Kenai1124Peninsula. It is beautiful there.1125 So I am the current Vice Chair of the Jamestown S'Kallam1126Tribe. We are located in Squim, Washington, in the great State1127of Washington. I serve currently as the ACF Tech Chair, so I am1128pretty intimate with the ACF programs and how those programs1129are being implemented on the ground, especially within my1130region and in my State and in my community. The Jamestown1131S'Kallam Tribe actually has a few of the ACF programs, so I get1132to see what those things are doing to my families in the most1133positive way possible.1134 My service to my community comes very honestly. I have1135seven generations worth of tribal leadership in my blood, all1136going from educational services to child welfare. So for me to1137be a social services director at my tribe for five years is one1138of my passions. I currently serve as the chair of a few1139different tables in Washington State as an Indian policy1140advisory chair, serving not only just social services in maybe1141a traditional sense but also corrections, department of1142corrections and health care authority as well.1143 I am really glad to be able to be here to speak before you1144today.1145 In ancient times, we as tribes, we have had our own1146systems, so to speak, of how we addressed the community level1147needs, then the family level needs, then of course the1148individual needs. Most of that was addressed in our ancient1149times through communal living and also through spirituality.1150Because we believe that mental health and emotional health,1151that was made whole through the spirituality.1152 As the relationship between tribal governments and the1153United States was growing and it came to be, it was born, it1154has evolved over decades and decades and decades. So we have1155been learning how to evolve our systems, what does it mean to1156blend western systems with our indigenous perspective at the1157same time and being able to serve our people with these Federal1158services.1159 So this is why we are here testifying, we are here to try1160and figure out how do we blend that all together. And you1161mentioned tribal consultation, that is essential to us figuring1162out how do we blend these systems together and make these1163programs work for us. How do we make these programs fit our1164cultural needs and then translate them into Federal-speak so1165that we can access Federal funds?1166 The huge concern of the RIFs at HHS, as well as the1167proposed funding cuts, those are the things that are1168threatening our ability to be able to do that. These RIFs1169happened without tribal consultation. The budget proposal is1170happening without tribal consultation. I have lost connections1171to my staff in Region 10 at ACF, that means TANF contacts, that1172means my ACF regional administrator, gone. Everybody is gone.1173And this was all done without consultation and with very little1174warning, not only to the tribes but also to the staff.1175 That also meant that we did not have any transition1176planning. There was nobody to tell us, hey, here is your next1177contact. For example, Regions 1, 2, 5, 9 and 10 have been1178consolidated, they have been eliminated and now they are being1179consolidated into the rest of the five.1180 So me in Washington State, my new regional office is in1181Denver, Colorado. And when you eliminate all of Region 10, just1182talking about Region 10 by yourself, that is all of Alaska's1183more than 200 tribes, Washington's 29, Idaho's 5, Oregon's 9,1184that is 250 plus tribes that now Denver is absorbing into their1185portfolio.1186 They don't know who we are, they don't know our lands. So1187we need to be able to have people on the ground who know our1188land, who know our intimate cultural nuances and our political1189nuances. That is what these HHS staff members have been for us,1190the technical advisor. They help translate our language into1191your language so we can access funds that are obligated to us1192through treaty and trust responsibility.1193 As I conclude here with my remarks, one of the things we1194want to see is just consultation. Consultation, consultation,1195consultation . We need HHS to understand the impacts that have1196already happened because of not having consultation. We know1197that there are regulation decisions to come, budget decisions1198to come, deregulation decisions to come. And we need to make1199sure that tribal voices are at the forefront, that we have our1200voices heard, our impacts are heard, so that we can minimize1201impacts and we can maybe find some different creative solution1202that meets both the Federal goal but also maintains trust and1203treaty responsibility for our tribes.1204 In conclusion, I do want to acknowledge that Secretary1205Kennedy, he seems to want to work with tribes, and I am glad1206for that. He has advocated for Head Start for us. And we saw1207that in the President's latest draft of the budget. So we are1208thankful for that. Thankful that LIHEAP is still also being1209chatted about as well.1210 Bu we want to see more. It is more than IHS, right? You1211mentioned this earlier. HHS programs as a whole, even if the1212word tribe, Native American or Indian isn't in the office name1213or in the grant name, it still serves tribes, and we want to be1214able to access that and make our communities healthy, so we1215continue to blend those systems together, and hopefully get us1216out of first place so we can be healthy again.1217 Thank you for the opportunity to speak before you today. I1218will look forward to any questions if you have any for me.1219Thank you.1220 [The prepared statement of Ms. Greninger follows:]12211222 Prepared Statement of Hon. Loni Greninger, Vice Chairwoman, Jamestown1223 S'Klallam Tribal Council1224Introduction1225 Chair Murkowski, Vice Chair Schatz, and members of the Senate1226Committee on Indian Affairs, thank you for the opportunity to testify1227in this oversight hearing regarding critical programs that serve tribal1228nations like mine, the Jamestown S'Klallam Tribe.1229 Tribal nations, as sovereign governments, have a government-to-1230government relationship with the United States. This relationship is1231based upon numerous treaties between tribal nations and the U.S.1232government and is enshrined in the U.S. Constitution, \1\ federal law,1233and numerous U.S. Supreme Court decisions. As part of the political1234relationship with tribal nations, the U.S. has a federal trust1235responsibility that is a legal obligation to protect tribal rights,1236lands, and resources, and to fulfill its obligations under treaties and1237federal laws. This includes providing for the well-being of tribal1238citizens through basic programs and services. Access to federal1239programs that support the basic needs of Native people is a critical1240element of the federal trust responsibility, which includes human1241services and behavioral health services provided by the Department of1242Health and Human Services (HHS), and an exercise of tribal sovereign1243authority to tailor programs to serve communities at the local level.1244---------------------------------------------------------------------------1245 \1\ U.S. Constitution, Article VI states, ``This Constitution, and1246the Laws of the United States which shall be made in Pursuance thereof;1247and all Treaties made, or which shall be made, under the Authority of1248the United States, shall be the supreme Law of the Land. . .''1249---------------------------------------------------------------------------1250 I have had the privilege of serving my tribe as Vice Chair since12512020 and have worked for my tribe's Social and Community Services1252Department from 2017-2022. I currently serve as the Chair of the1253Washington State Department of Social and Health Services Indian Policy1254Advisory Committee (since 2020), and the Washington State Governor's1255Tribal Leaders Social Services Council (since 2020). I also currently1256Chair the Administration for Children and Families (ACF) Tribal1257Advisory Committee (since 2022). In all of these roles, I am uniquely1258positioned to understand both the community impact of HHS's human and1259behavioral health services and the federal laws, policies, and1260implementation necessary to administer them.1261 In this testimony, I will focus on the role of human services and1262behavioral health services in tribal communities, identify federal1263programs that help tribal nations meet community needs, the role of HHS1264in providing support and assistance to tribal nations, and the impacts1265of recent reorganization efforts by HHS.1266Tribal Human Services1267 Tribal human service programs administer a range of services that1268provide core support for tribal community members to meet their basic1269needs and improve their well-being to increase their quality and1270standard of living. Federal human service programs enable tribal1271nations to ensure every citizen can meet basic needs related to1272employment, food, housing, medical care, education, and childcare. They1273also provide support to ensure community members are protected from1274harm, can develop a healthy sense of belonging, have opportunities to1275have regular social contact, and more generally, find stability in1276their lives. \2\ For people living in unstable and vulnerable1277conditions, these services can mean the difference between life and1278death in some cases. As tribal nations strive to create communities1279where children, families, and elders can thrive, human services play a1280vital role in supporting positive change that is accessible and1281sustainable.1282---------------------------------------------------------------------------1283 \2\ Mayo Health Clinic Health System. (2021). Is Having a Sense of1284Belonging Important? https://www.mayoclinichealthsystem.org/hometown-1285health/speaking-of-health/is-having-a-sense-of-belonging-important.1286---------------------------------------------------------------------------1287 While the types of human services vary widely, there are a number1288of key services that are contained within this category of services.1289They include, but are not limited to:12901291 prevention services,12921293 child, adult, and victims of crime protection,12941295 in-home family services,12961297 case management and service coordination,12981299 out of home placements for children,13001301 job training and education,13021303 childcare,13041305 housing and food assistance,13061307 participation in court hearings,13081309 intergovernmental coordination and service collaboration1310 with federal, state or county partners, and13111312 referrals and coordination with other service providers,1313 such as mental health, substance abuse treatment, child1314 welfare, juvenile justice, employment assistance and training,1315 education, food assistance, health care, childcare, housing,1316 and law enforcement.13171318 Examples of federal programs under ACF that support tribal human1319services include the following:13201321 Title IV-B, Subpart 1, Child Welfare Services \3\1322---------------------------------------------------------------------------1323 \3\ Title IV-B and Title IV-E refer to programs authorized under1324the Social Security Act.13251326---------------------------------------------------------------------------1327 Title IV-B, Subpart 2, Promoting Safe and Stable Families13281329 Title IV-E Foster Care, Adoption Assistance, Relative1330 Guardianship, and Prevention Services13311332 Chafee Independent Living Program (youth aging out of foster1333 care)13341335 Community Based Child Abuse Prevention grants13361337 Tribal Court Improvement Grant Program (tribal juvenile1338 court proceedings)13391340 Social Services Block Grant (tribes receive pass-through of1341 state allocations)13421343 Child Support Enforcement13441345 Temporary Assistance to Needy Families13461347 Tribal TANF-Child Welfare grant program (services1348 integration and coordination)13491350 Native Employment Works grant program13511352 Family Violence Prevention and Services grant program13531354 Child Care and Developmental Fund13551356 Community Services Block Grant13571358 Affordable Housing and Supportive Services Demonstration1359 grant program13601361 Rural Community Development grant program13621363 Low Income Home Energy Assistance Program grant program13641365 Community Economic Development grant program13661367 Head Start13681369 Tribal Personal Responsibility Education Program grants1370 (adolescent pregnancy prevention)13711372 Demonstration Grants for Domestic Victims of Human1373 Trafficking grants13741375 Runaway and Homeless Youth grant programs13761377 Administration for Native Americans social, economic1378 development, and language preservation grant programs13791380 Key to a well-functioning human service system is the integration1381of services from a variety of fields to create a system of programs and1382services that address families in a holistic manner. When programs or1383services are siloed and don't collaborate well, they struggle to1384communicate, adapt to changing client needs, and take advantage of1385opportunities to address issues early before crisis sets in. Tribal1386human service programs, by their nature, are well-adapted to developing1387program efficiencies and innovative ways to serving their citizens.1388 As an example, the Central Council of the Tlingit and Haida Indian1389Tribes of Alaska child welfare program understood many of the families1390that are involved with the tribal child welfare system are also1391involved with their Temporary Assistance to Needy Families (TANF)1392program. They also know that many of the families involved in their1393tribal child welfare system have been seen by the TANF program a year1394or more before they came to the attention of the tribal child welfare1395program. A number of years ago, the tribal child welfare and TANF1396programs outlined a strategy to improve the capacity of the TANF1397program to assess the risk for child maltreatment with their families1398and improve coordination with the child welfare program. The1399collaboration utilized an adapted child abuse and neglect risk1400assessment tool that TANF staff were trained to administer, which1401resulted in the identification of tribal families with child abuse and1402neglect risks earlier so they could receive child welfare services.1403This resulted in more families getting help earlier, reducing the risk1404of trauma to children and their families from foster care removal, and1405lowering the risks for more costly and intrusive interventions.1406 Tribal nations serve a critical role in providing these services1407not only for tribal citizens living within their tribal boundaries but1408also with state agencies that provide services to tribal citizens1409living off tribal lands. In child welfare, tribal assistance helps1410states reduce state costs and administrative burden, helps ensure1411appropriate and effective services are provided to Native families, and1412improves implementation of federal legal requirements, like those1413contained in the Indian Child Welfare Act. \4\ In many cases, tribal1414human service programs also serve non-Native populations on or near1415tribal lands. Tribal programs like TANF, child welfare, and childcare1416provide services and support to non-Native populations that would1417otherwise not be available in their area or would be much more1418challenging to access than state services. When tribal human service1419programs have adequate federal support, they are much more likely to be1420able to assist states and nearby non-Native communities, as well as1421tribal citizens living on tribal lands.1422---------------------------------------------------------------------------1423 \4\ U.S. Government Accountability Office (2005). Indian Child1424Welfare Act: Existing Information on Implementation Issues Could Be1425Used to Target Guidance and Assistance to States. Washington, D.C.:1426Government Printing Office. https://www.gao.gov/assets/gao-05-290.pdf1427---------------------------------------------------------------------------1428Tribal Behavioral Health Services for Children and Youth1429 Trauma is a key factor in the need for tribal human services.1430Threats to well-being like child maltreatment, substance abuse,1431domestic violence, and homelessness are highly linked to trauma.1432Exposure to trauma during childhood creates an adverse childhood1433experience (ACE). ACEs measurements help practitioners and researchers1434understand the impact of trauma in children and youth that are exposed1435to violence, abuse, or neglect. The impact of a traumatic event can1436occur through direct contact or by witnessing a traumatic event in the1437home or community. \5\ Children and youth who have ACEs can often carry1438the negative effects, especially if untreated, into adulthood, which1439creates a higher risk for poor health, mental illness, and substance1440abuse. \6\ Native populations have one of the highest rates of ACEs, in1441one study 2.3 times higher than any other racial group. \7\ Another1442measure of the critical need to better address trauma in young Native1443people is the extremely high rate of suicide among Native youth between1444the ages of 15-19 years of age. \8\ Behavioral health services are1445needed to treat existing trauma, prevent exposure to additional harm,1446and reduce the need for lengthy and repeated human services1447interventions.1448---------------------------------------------------------------------------1449 \5\ Centers for Disease Control. (2024). What is Adverse Childhood1450Experiences? https://www.cdc.gov/aces/about/index.html#:-:text=1451Adverse%20childhood%20experiences%2C%20or%20ACEs,attempt%20or%20die%20by1452%20suicide.1453 \6\ Ibid.1454 \7\ Giano Z, Camplain RL, Camplain C, Pro G, Haberstroh S, Baldwin1455JA, Wheeler DL, Hubach RD. (2021). Adverse Childhood Events in American1456Indian/Alaska Native Populations. https://pmc.ncbi.nlm.nih.gov/1457articles/PMC8098634/#:-:text=1458Results:,educational%20attainment%20reported%20lower%20scores.1459 \8\ Office of Minority Health. (2021). Mental and Behavioral1460Health--American Indians/Alaska Natives. https://1461minorityhealth.hhs.gov/mental-and-behavioral-health-american-1462indiansalaska-natives.1463---------------------------------------------------------------------------1464 In tribal communities, behavioral health services are provided1465through a combination of programs and services, such as mental health1466or substance abuse prevention and treatment. This can include services1467that are based on Western models of practice, tribal cultural models,1468or a combination of both. While the Indian Health Service (IHS) is one1469of the key providers of funding for tribal mental health services, and1470in a small number of tribal communities, directly provides mental1471health services, these funding streams are primarily designed for1472adults and not for children and youth. While the general number of1473professionally trained therapists in Indian Country is low, the number1474of child-trained therapists is even lower and well below what is needed1475to address at-risk children and youth. Access to state behavioral1476health services for Native children is also challenging, especially for1477Native children and youth that reside in remote areas of the country.1478Adding to this is the extremely limited availability of state-funded,1479child-trained therapists that have experience with Native children and1480youth. Federal programs, like those funded under the Substance Abuse1481and Mental Health Services Administration (SAMHSA), provide vital1482resources to tribal nations to develop their own community-based child1483and youth mental health and substance abuse prevention and treatment1484programs and services.1485 Examples of federal programs under SAMHSA that support tribal1486behavioral health services include the following:14871488 Tribal Behavioral Health Grants Program (two grant programs,1489 mental health and substance abuse, that seek to prevent1490 suicidal behavior and substance abuse among Native youth)14911492 Circles of Care grants (developing community based,1493 children's mental health systems)14941495 Project Launch grants (promote wellness of children ages1496 birth to eight years of age through positive mental,1497 behavioral, and cognitive development)14981499 Children's Mental Health Services grants (operate and1500 enhance community-based children's mental health systems)15011502 Numerous tribal grantees that have received these federal funds1503have gone on to develop innovative children's mental health programming1504that provides children's mental health services in communities that1505previously had none and established financial sustainability by working1506collaboratively with states to leverage other federal and state1507funding.1508HHS Reorganization Efforts and Impacts to Tribal Community Human and1509 Behavioral Services Programs1510 While tribal human services programs have demonstrated their1511ability to design and operate effective services for their communities,1512they also need assistance from federal agencies to achieve their full1513potential. The National Indian Child Welfare Association, a leading1514tribal organization working to improve tribal human services, conducted151511 listening sessions with tribal leaders and tribal human service1516directors from October of 2023 through June of 2024, where many of the1517participants shared concerns regarding tribal human service programs1518being understaffed, lacking access to appropriate training, and needing1519improved support and technical assistance to access federal funding and1520ensure tribal programs can provide community-based programs that will1521meet federal requirements.1522 Beginning in February, numerous federal staff at ACF, both in the1523regional offices and central office in Washington, DC, had their1524positions eliminated based on HHS's reduction in force goals; the1525results were eliminating probationary staff, regional offices were1526closed, or staff took the buyouts being offered by the Administration.1527In some cases, staff who were considered probationary had been working1528for many years in another federal job within HHS but were considered1529probationary because they had been promoted or had taken a different1530job within HHS within the last two years. In ACF's central office in1531Washington, DC, there were five senior advisors on tribal engagement1532that advised ACF leadership on how to improve the agency's engagement1533with tribal nations and improve tribal participation in ACF programs.1534This team worked closely with regional ACF office tribal program leads1535and was improving ACF consultation and relationships with tribal1536nations across the country. As of May, only two staff in the central1537office tribal engagement team are still employed, and all but a few of1538the regional office tribal program leads have been let go as part of1539the regional office closures in five regions. \9\1540---------------------------------------------------------------------------1541 \9\ Five regional HHS offices were abruptly closed on April 1 and1542staff put on administrative leave pending their termination. The1543regional offices closed were regions 1, 2, 5, 9, and 10.1544---------------------------------------------------------------------------1545 In addition to elimination of staff in probationary status and1546buyouts, firings of whole teams of federal program staff have crippled1547program operations for certain ACF programs. For example, it is our1548understanding that the entire central office team for the Low Income1549Home Energy Assistance Program(LIHEAP) have been dismissed, creating a1550void for tribes needing help with the operation of their LIHEAP1551programs. This includes operating under their current grant and1552preparing for submission of year-end reports and funding applications1553for the next fiscal year.1554 Another facet of HHS staff reductions has been the timing and1555process used. According to reports by former federal staff, notice of1556staff reductions has occurred with less than 24-hour notice with staff1557being ordered to leave their office the same day. This doesn't allow1558for an orderly transition of work to other staff or managers and is1559demoralizing for both the staff that are fired and for those that1560remain. While HHS has talked about rehiring staff in some agencies,1561former staff that have experienced the first round of firings are1562reporting they are not feeling inclined to return to HHS. This has also1563eroded the desire of people new to the federal service to accept1564positions at HHS, especially those with higher-level skills and1565knowledge applicable to tribal nations.1566 The HHS regional office closures occurred abruptly causing tribal1567human service programs to scramble to find answers to program and1568fiscal issues and seek assistance as they develop their new1569applications for federal grant programs. The five regions that were1570closed served 80 percent of all federally recognized tribes in the1571United States. Many tribal human services directors have reported that1572even a month later, they haven't been able to talk to a person at ACF1573or have their voicemails or emails responded to. This comes at a1574particularly difficult time as hundreds of tribes are trying to fill1575out their funding applications for next fiscal year's funding and were1576in process with regional office tribal program leads to ensure they1577could submit a successful application (e.g. Child and Family Services1578Plans, Child Care Development Fund, LIHEAP, Title IV, Child Support,1579TANF, etc.). Other tribes were working with regional office tribal1580program leads to address training needs or develop strategies to1581address tribal-state concerns in service delivery.1582 While in some cases, ACF has referred tribes to other regional1583offices, they are often referred to regional staff that already have1584full workloads and can't respond to them in a timely manner or have1585little to no experience working with tribes and the federal programs1586they participate in. The strategy of ``next man up'' in assistance to1587tribes, trivializes the necessary skills and knowledge needed to work1588effectively with tribes and the years of professional development it1589takes to competently provide assistance to tribal nations. In this1590current environment, many tribal human services directors fear that1591federal assistance will become less focused on the values of supporting1592tribal self-determination and program effectiveness, and more on1593compliance and process.1594 Besides existing program work, ACF is also responsible for guiding1595implementation of new laws that are approved by Congress. Last year, in1596an overwhelming bipartisan show of support, Congress approved the1597Supporting America's Children and Families Act (P.L. 118-258). This new1598law reauthorized Title IV-B programs under the Social Security Act to1599accomplish a variety of goals, including streamlining administrative1600requirements for states and tribes, creating new technical assistance1601opportunities for states and tribes to improve implementation of the1602Indian Child Welfare Act, and improve tribal court participation in1603state court proceedings and data collection involving Native children1604and families. This historic law will require ACF's best efforts to1605develop guidance and provide assistance to states and tribes that will1606ensure a smooth and proper implementation. With fewer ACF staff with1607experience in tribal child welfare available, especially in areas where1608regional offices were closed, there are concerns about how this will1609impact the implementation and opportunities for tribal nations under1610the Supporting America's Children and Families Act.1611 An underlying concern in all of these changes at HHS was the lack1612of consultation with tribal nations. In almost every situation, tribal1613nations found out about these changes after the fact, usually in the1614media, well after the decisions had been made. While I and many other1615tribal leaders can appreciate your desire to improve the effectiveness1616and efficiency of the federal government, something that is important1617to tribal leadership too, respecting the nation-to-nation relationship1618requires adherence to formal government-to-government protocols, which1619begin with consultation before decisions are made that impact our1620communities.1621Conclusion1622 While there is great appreciation for HHS's efforts to protect IHS1623programs and services from cuts and staff firings, attention also needs1624to be given to the implications of HHS's reorganization plans for human1625services and behavioral health services programs. None of these1626programs operate in isolation, just as our citizens don't live in1627isolation either. Our most vulnerable citizens and the programs that1628serve them need the assistance of fully qualified staff that understand1629their needs and have ongoing working relationships with our tribal1630communities. HHS's trust responsibility doesn't stop at IHS. It extends1631to all of the agencies of HHS and requires carefully planned1632consultation with tribal nations before policy decisions are made and1633the consideration of our rights as tribal people under our treaties and1634federal law. Consulting with tribal nations provides HHS with greater1635opportunities to identify and implement program efficiencies and1636establish more effective programs-in essence, tribal consultation will1637further our shared goals of achieving government efficiency and reduce1638federal bureaucracy, while maintaining the trust responsibility and1639continuing to empower tribal sovereignty.1640 Thank you for the opportunity to testify before you today.16411642 The Chairman. Thank you very much. Well said.1643 Melissa, welcome to the Committee.16441645 STATEMENT OF MELISSA CHARLIE, EXECUTIVE DIRECTOR, FAIRBANKS1646 NATIVE ASSOCIATION16471648 Ms. Charlie. Good afternoon, Chair Murkowski and Vice Chair1649Schatz and members of the Committee. Thank you for this1650opportunity to testify today. My name is Melissa Charlie, and I1651serve as the Executive Director of Fairbanks Native1652Association, FNA, a Native non-profit organization serving the1653Alaska Native community since 1967.1654 I am here today not only on behalf of FNA, but also to1655uplift the critical importance of Tribal Head Start and other1656U.S. Department of Health and Human Service programs that serve1657Native communities nationwide. At FNA, our Tribal Head Start1658program is the foundation of our investment in early childhood1659development, cultural identity and family stability. Our1660program offers not only education but nourishment, cultural1661grounding, health and intervention while offering a healthy1662foundation for families who need it the most.1663 Our classrooms honor Native idendity and language,1664instilling pride in our community while preparing children for1665academic success. For many families, Tribal Head Start is the1666first point of connection for our broader network of services1667that address health, nutrition, wellness and family support.1668Moreover, our program, like many others, integrates traditional1669knowledge, language and values into every single classroom.1670 We know Tribal Head Start and child care programs across1671the Country integrate various programs and grants to stretch1672every dollar and create a system of comprehensive community1673based services. Many of these include utilizing Head Start with1674child care development funds or connecting programs with1675language work, at the Administration for Native Americans.1676 Indian Country is the most dynamic investment that the1677Federal Government can make. Our funding is no different. In1678addition to Head Start, FNA operates several other critical1679programs under HHS, including youth and adult behavioral1680treatment programs which provide services that integrate Native1681cultural values and practices with evidence based approach1682funding from SAMHSA, child welfare community based family1683prevention emergency youth shelter services and family and1684domestic violence prevention and services under ACF.1685 And we utilize funding under the current administration for1686community living such as Administration on Aging, Title VI1687funding, which fosters a healthy and connected elder community1688by providing nutrition, support services and caregiver1689services.1690 Yet, despite decades of success, Tribal Head Start and1691other programs remain under-resourced compared to other non-1692tribal counterparts. We face challenges recruiting and1693retaining qualified staff due to wage disparities. We need1694updated facilities and modern learning materials and a more1695robust professional development, which requires an increase in1696stable Federal investment and partnership with tribal1697organizations. Now is not the time to divest these programs;1698now is the time to invest in Indian Country, the same way the1699Federal Government hopes to reinvest in States.1700 These programs work to form a safety net for our tribal1701families who too often exist in a gap where they remain1702underserved by State and local communities. Importantly, tribal1703programs like these are a direct impact for fulfilling trust1704and treaty obligations to tribes.1705 In our area, the tribes and villages have done so through1706Native organizations like FNA. Whether a tribal nation or a1707Native organization, we are the best positioned to deliver1708these services, because we understand our communities,1709histories, strengths, and our needs.1710 Tanana Chiefs Conference, TCC, is our sister organization,1711providing a large array of prevention and clinical services for1712the Alaska Native population across interior Alaska. Either in1713complement of FNA services or in collaboration with FNA, TCC,1714like FNA, relies on Federal funding guaranteed under the1715Federal Government's trust obligation to Alaska Natives and1716American Indians, which requires the United States to protect1717tribal lands, assets, resources, and treaty rights and to1718provide certain services such as health care, education, and1719housing.1720 The Federal trust obligation is not one that can simply be1721transferred to a State government. It is a legal and moral1722obligation of the Federal Government alone.1723 For FNA and the many tribes across the Country, HHS1724programs are not simply support services, they are an active1725nation-to-nation partnership, upholding the Federal trust1726responsibility to Native children, families and communities.1727 Today, I urge Congress to protect and maintain the Tribal1728Head Start program and other child care funding, and support1729such child care development funds, ensuring that these1730setasides go directly to tribes or Native organizations and1731that they are not rerouted through the States; to protect1732SAMHSA funding for tribes like the tribal behavioral health1733grants and ACF programs, including by protecting the1734Administration for Native Americans through streamlined funding1735which is directly provided to tribes and Native organizations;1736to support infrastructure investment so tribal providers can1737modernize facilities and expand reach.1738 We stand ready to work with the administration and Congress1739to streamline and strengthen these programs with quality1740investments.1741 Thank you for holding this important hearing and for your1742continued focus on the health and well-being of Native1743communities. I look forward to your questions. [Phrase in1744Native tongue.]1745 [The prepared statement of Ms. Charlie follows:]17461747 Prepared Statement of Melissa Charlie, Executive Director, Fairbanks1748 Native Association1749 On behalf of the Fairbanks Native Association (FNA), a Native non-1750profit organization based in Fairbanks, Alaska committed to improving1751the quality of life for individuals and families by promoting justice,1752healing, and wellness in our community, thank you for the opportunity1753to provide written testimony on the critical services supported by the1754U.S. Department of Health and Human Services (HHS) and the profound1755impact these services have on our Alaska Native community.1756 My name is Melissa Charlie, and I am the Executive Director of FNA.1757In addition to my role at FNA, I serve on the Advisory Board of the1758Fairbanks North Star Borough Board of Education. I am Athabascan and1759Inupiaq, and I am a Tribal member of Minto, Alaska.1760 FNA was incorporated in 1967 in direct response to the social1761service needs of Alaska Natives in Fairbanks during a time when Native1762people were increasingly moving to the area from remote villages and1763Alaska Native soldiers were returning from military service. Access to1764basic health and social services was severely limited. Educational1765outcomes were extremely low, and life expectancy for Alaska Natives was1766alarmingly short. Because of the work of our early leaders, and thanks1767to increased investment in education and healthcare, our community has1768made substantial progress across quality-of-life indicators over the1769last sixty years.1770 FNA provides services within the Fairbanks North Star Borough,1771which has an Alaska Native and American Indian population of1772approximately 10,000 people. Working with our sister organization, the1773Tanana Chiefs Conference, our combined efforts serve more than 12,0001774Alaska Natives across 42 communities in Interior Alaska.1775 With support from the U.S. Department of Health and Human Services,1776FNA serves our community through three major program areas: early1777childhood development, behavioral health services, and community1778services. The work we do at FNA is deeply rewarding. We assist1779individuals in times of great need--whether they are facing1780homelessness, substance abuse, mental health challenges, or grief. From1781the womb to the end of life, FNA is here to serve.17821783 As our late founder, Poldine Carlo, often said: ``There is no1784greater reward than serving our people.''--Poldine Carlo, founding1785member of the Fairbanks Native Association17861787 These programs are essential to addressing the needs of our Native1788population and strengthening the overall health, safety, and resilience1789of our community. Continued federal support for these HHS programs is1790critical to ensure we can meet these needs now and into the future.1791Federal Obligations1792 The federal government's trust obligation to Alaska Natives and1793American Indians is a legal and moral commitment rooted in treaties,1794statutes, executive orders, and judicial decisions. It requires the1795United States to protect tribal lands, assets, resources, and treaty1796rights, and to provide certain services, such as healthcare, education,1797and housing. This obligation stems from the historical relationship1798between tribes and the federal government, in which tribes ceded large1799portions of land in exchange for these protections and services. The1800trust responsibility may seem to be carried out primarily by federal1801agencies like the Bureau of Indian Affairs (BIA) and the Indian Health1802Service (IHS), but truly extends across the federal government, and1803outside of tribal-specific agencies. The trust obligation emphasizes1804the government's duty to act in the best interest of Tribal Nations and1805individuals with loyalty, care, and accountability.1806 FNA is only one of many Alaska Native and American Indian1807organizations providing services that are made available under the1808federal government's trust obligation. We work in lockstep with Tanana1809Chiefs Conference, our sister organization, to provide a large array of1810prevention and clinical services for the Alaska Native population1811across the Interior of Alaska. TCC's services either complement those1812offered by FNA or are provided in collaboration with FNA. Like FNA and1813many other Native entities, TCC too relies on Federal funding provided1814under federal trust obligations.1815 The federal government's trust obligation to Alaska Natives and1816American Indians involves a complex interplay of legal, financial, and1817social responsibilities. While progress has been made in certain1818areas--such as tribal self-determination and economic development--1819there are still significant challenges, particularly around1820underfunding, legal complexities, and the need for more meaningful,1821long-term investments in Native communities. The trust obligation is an1822ongoing process that requires constant attention, accountability, and1823respect for tribal sovereignty.1824 Despite this legal obligation, the federal government often fails1825to fully fund the programs and services essential to Native1826communities. This underfunding has led to significant disparities in1827health, education, and housing outcomes between Native and non-Native1828populations. Due to underfunding in the IHS, BIA, and Bureau of Indian1829Education (BIE), tribal organizations are relying on other federal1830funding like SAMHSA, HRSA, CDC and others to help support the provision1831of essential prevention, behavioral health and clinical services to1832decrease these disparities. Proposed cuts to many grants, programs and1833services currently provided through funding from these agencies, are of1834great concern to all of us and our partner organizations.1835 The federal government's trust obligation is not one that can be1836transferred to state governments. Again, it is a legal and moral1837obligation of the federal government alone, which should be honored in1838good faith and due diligence.1839Tribal Head Start and Early Childhood1840 At FNA, one of the major services we provide is our Tribal Head1841Start Program. FNA's Head Start program promotes cultural identity of1842Alaska Native and American Indian families, while equipping all1843enrolled children with the educational, physical, and social skills and1844tools for a great head start towards school readiness. Students receive1845health screening for vision, dental, hearing, physical and cognitive1846development--an important early intervention to ensure any additional1847services are prioritized. Head Start works with families to connect1848with partnering community agencies for additional resources that they1849may need to succeed.1850 While many of these services are key lifelines that Head Start1851programs provide children nationwide, there are a few key differences1852between Tribal Head Start and other Head Start programs. The main1853difference lies in who administers them and the communities they are1854designed to serve.1855 Tribal Head Start programs are administered directly by tribal1856governments or tribal organizations. Our programs incorporate Native1857culture, language, and traditions into the curriculum and daily1858operations. We design our programs to support the cultural preservation1859and educational success of our children.1860 In short, Tribal Head Start is tailored for Native communities,1861while general Head Start serves the broader population of low-income1862families.1863 Our Head Start and Early Head Start programs are a strong example1864of how Alaska Native culture is thoughtfully woven into early childhood1865education. Our children are introduced to our Native languages1866throughout these programs through songs, simple phrases, and greetings.1867Elders and cultural bearers are regularly invited to share traditional1868stories, legends, and oral histories, passing down intergenerational1869knowledge.1870 FNA's program goes beyond education--it builds identity, pride, and1871connection to Native heritage from an early age, while meeting all1872federal Head Start standards. This is also true for Head Start programs1873in rural Alaska, including the Tanana Chiefs Conference regionwide1874programs, and other Tribal Head Start programs nationwide.1875Other Critical HHS Programs1876 In addition to Head Start, FNA operates many other critical1877programs to fill gaps in services typically provided by state1878government for non-Tribal communities. These programs address the needs1879of our Native communities by providing the programs the federal1880government owes under trust and treaty obligations. Many of our1881services are funded under HHS outside of the Indian Health Service.1882 One program that has been considered for elimination by the1883Administration is the Community Services Block Grant. This grant, which1884FNA receives under the set-aside for Tribes and Tribal Organizations,1885provides services that remove obstacles to the achievement of self-1886sufficiency for low-income individuals, families, Elders, and homeless1887community members. By providing services that support self-sufficiency1888and that address emergency assistance needs, youth development, and1889health and nutrition, the program enhances the lives of low-income1890individuals with services that meet their needs and empower them with1891the resources, knowledge, and skills needed to achieve self-1892sufficiency. We urge Congress to protect this program for tribes.1893Unlike states, our communities do not have the tax revenue to pick up1894the services otherwise provided by the federal government.1895 Title VI funding through the Older Americans Act provides critical1896nutrition and supportive services for elders and caregivers, with 3621897enrolled in the program. Through the congregate meals program, FNA1898serves approximately 800 hot lunches monthly on weekdays and provides1899group programming and information about a range of health, safety, and1900nutrition topics relevant to the population. This has been an area1901identified as a critical need in the Fairbanks North Star Borough, as1902an FNA survey of local elders in 2022 found that for 57.3 percent of1903respondents it was often or sometimes true that they could not afford1904to eat balanced meals. Additionally, three out of the five most common1905chronic conditions in the population are closely linked with nutrition:1906high blood pressure, diabetes, and osteoporosis. With more than one in1907five elders reporting that they eat alone most of the time, the1908congregate meal program also serves a critical function in helping to1909reduce isolation and promote social connection among this vulnerable1910population. Title VI funding also supports caregivers by connecting1911them to information and community resources and providing training,1912specialized support, and supplemental services. Given that current1913levels of programming are not able to meet the full degree of need for1914elder nutrition and support services, the funding that is provided1915under Title VI remains a critical resource for supporting the health of1916elders in the community.1917 We also receive funds from the Family Violence Prevention and1918Services program, which supports the prevention of and response to1919incidents of domestic violence, dating violence, family violence and1920their dependents. supports the prevention of and immediate response to1921incidents of domestic violence, dating violence, family violence by1922providing emergency shelter, supplies, and services to adult victims1923and their non-abusing dependents. Domestic and/or family violence1924continues to be an area of high need among FNA's service population,1925with 58.8 percent of consumers receiving victim services through FNA1926Community Services department reporting domestic and/or family violence1927in 2024. In Interior Alaska, where housing is limited and the cost of1928living is high, Family Violence Prevention and Services funding is1929especially critical in providing immediate access to temporary housing1930and resources that allow victims and their children to escape violent1931situations and meet their basic needs, a first step to achieving1932stability, security, and self-sufficiency.1933 Our Tribal Maternal, Infant, and Early Childhood Home Visiting1934Program, which FNA has operated since 2010, except in fiscal years19352015-2017 when funding was not available, uses the evidence-based1936Parents as Teachers (PAT) model to provide American Indian and Alaska1937Native children and families services that address their critical1938maternal and child health, development, early learning, family support,1939and child abuse and neglect prevention needs. Serving 30 expectant1940families and families with young children aged birth to kindergarten1941entry, the Tribal Home Visiting Program is a critical link in the1942continuum of early childhood education and family wellness that1943coordinates with other existing resources like AIAN Head Start to1944support healthy, happy, and successful children and families. As one of1945only a few providers offering services in the home for pregnant women1946and/or families with children younger than 5 years of age to the over19476,000 children ages 0-5 in the Fairbanks North Star Borough, \1\ the1948Tribal Home Visting Program provides critical support for these1949children and families whose needs would otherwise go unmet.1950---------------------------------------------------------------------------1951 \1\ U.S. Census Bureau and State of Alaska Department of Labor and1952Workforce Development1953---------------------------------------------------------------------------1954 FNA's Domestic Violence Prevention program provides primary and1955secondary domestic and sexual violence, trafficking, and abuse1956prevention programming for youth and adults. The DVP grant funds1957support community outreach and awareness events and evidence-based1958prevention programming for youth, in collaboration with the local1959school district. The DVP program facilitates coordinated community1960response to domestic violence prevention and intervention by1961emphasizing active collaboration between FNA's Community Services1962Department and the Fairbanks Police Department, the Alaska State1963Troopers, the District Attorney's Office, a local domestic violence1964shelter, and other service providers. Without access to this program,1965the community would lose important opportunities to learn about and1966connect with services through the many well-attended outreach and1967prevention events and activities it supports, and elementary and1968secondary aged youth throughout the Fairbanks North Star Borough would1969miss out on opportunities to build important life skills and trusting1970relationships that develop resilience and set them up for healthy and1971fulfilling lives. Through comprehensive prevention and skill-building1972programming, education and awareness activities, and community outreach1973events, the DVP grant reaches more than 600 youth and more than 1,2001974adults annually.1975 Through its youth and adult services divisions, FNA's Behavioral1976Health Services (BHS) Department provides residential and outpatient,1977evidence-based prevention, intervention, and treatment services for1978more than 1,200 people annually through 18 population-specific programs1979funded by grants from the Substance Abuse and Mental Health1980Administration, Administration for Children and Families, and Indian1981Health Service. Although multiple programs are intentionally designed1982to meet the needs of AIAN community members by integrating cultural1983values and practices with evidence-based mental and behavioral health1984strategies, many BHS programs provide community-wide services for1985anyone who needs them. These lifesaving and life-changing programs1986include projects funded by 19 active grants from the U.S. Department of1987Health and Human Services, including a one one-time Health Resources1988and Services Administration Community Project Funding/Congressionally1989Directed Spending grant for construction/renovation of the BHS Women's1990and Children's residential treatment facility.1991 FNA's Women's & Children's Center is a residential substance use1992disorder and mental health treatment facility for pregnant women and1993women with children ages 0-7 years old. Serving the entire state, it is1994a four- to six-month program providing individual and group treatment1995sessions. The primary outcomes of the program are that mothers learn1996how to interact with their children in a substance-free lifestyle, and1997that children who have suffered through traumatic incidences related to1998an environment of alcohol and drug abuse receive mental health services1999to ensure a healthy lifestyle for the entire family. With Community2000Project Funding/Congressionally Directed Spending funds administered2001through the Health Resources and Services Administration, FNA will be2002able to make much-needed updates to the residential facility so that2003this unique program can continue to meet the needs of the mothers and2004children who participate from across the state of Alaska every year.2005Conclusion2006 The services provided by FNA are essential in promoting the2007independence and self-sufficiency of our community. Guided by our2008traditional values, we remain committed to serving our people in a2009respectful and meaningful way.2010 But, like other Alaska Native and American Indian tribes and2011organizations, FNA's ability to do this important work relies on the2012Federal government to uphold its trust responsibility. Adequate and2013consistent funding is essential to ensure that these critical services2014continue, as is a stable grant administration support infrastructure.2015Proposed and already executed DHHS restructuring actions such as2016closing and consolidating offices, dismissing federal program officers2017and grant managers, and/or converting existing direct grant programs2018into block grants administered by states, have very real impacts on2019tribes' and tribal organizations' abilities to implement federally2020funded programs and services and in turn, on the individuals, families,2021and communities we serve. For a person who is experiencing an acute2022mental health crisis, grappling with addiction, trapped in a violent2023living situation, or struggling to keep a family fed and sheltered, a2024temporary lapse in availability of funds or a delay in processing a2025federally required grant approval action can mean life or death.2026 The loss of any FNA programs funded by DHHS would significantly2027harm both our community and the clients we serve. Since the pandemic,2028youth and social services have struggled to fully recover, and staffing2029continues to be a major challenge. Even if programs were cut, the2030underlying needs would persist. Gaps in victim services, behavioral2031health care, education for children, and family support would place2032additional strain on already limited community resources in Fairbanks.2033 FNA has operated these programs in good faith, relying in part on2034the federal government's trust responsibility to support essential2035services. These programs are vital to the well-being of families and2036the health of our community.2037 Thank you for this opportunity to share the important and rewarding2038work that FNA is doing with Health and Human Services funding. We2039believe it is reflective of the work that is being done across the2040nation by tribes and tribal organizations. This work is critical to2041meet the needs of families, children and communities.2042 I also want to thank the Alaska delegation, particularly Senator2043Murkowski, for their continued support of and advocacy for our work.2044 Basee'.20452046 The Chairman. Thank you.2047 Next we turn to Lucy Simpson. Welcome.20482049 STATEMENT OF LUCY R. SIMPSON, EXECUTIVE DIRECTOR, NATIONAL2050 INDIGENOUS WOMEN'S RESOURCE CENTER20512052 Ms. Simpson. Thank you, Madam Chair Murkowski, Vice2053Chairman Schatz, and members of the Committee, for the2054opportunity to testify today on the critical role of HHS2055programs serving Indian Country.2056 My name is Lucy Simpson. I am a citizen of the Navajo2057Nation and the Executive Director of the National Indigenous2058Women's Resource Center. We are a Native-led nonprofit2059dedicated to restoring sovereignty and safety for Native women2060and families. We serve as the National Indian Resource Center2061Addressing Domestic Violence and Safety for Indian Women and2062the Tribal Safe Housing Capacity Building Center under the2063Family Violence Prevention and Services Act, or FVPSA.2064 I first want to ground this testimony in what must remain2065the guiding principle of the Federal Government's work: its2066trust and treaty responsibility to tribal nations. This2067responsibility is not abstract; it is a legal and moral2068obligation.2069 HHS plays a crucial role in fulfilling this obligation, not2070only by providing public health services through the Indian2071Health Service, but also in providing services that address the2072public health crisis that is violence against Native people.2073Congress reaffirmed this obligation in the Violence Against2074Women Act reauthorization of 2005, stating that ``Indian tribes2075require additional criminal justice and victim services2076resources to respond to violent assaults against women; and the2077unique legal relationship of the United States to Indian tribes2078creates a Federal trust responsibility to assist tribal2079governments in safeguarding the lives of Indian women.''2080 By investing in tribal nations and Native-led organizations2081as they design and implement community-driven, culturally2082grounded services, HHS programs become instruments of tribal2083self-determination. Such programs include those funded by2084FVPSA, which for more than 40 years has been the cornerstone of2085our Nation's response to family and domestic violence. It2086remains the only Federal funding source specifically dedicated2087to emergency shelter and related services for victims and their2088children and is especially important for tribal nations and2089American Indian and Alaska Native and Native Hawaiian victims2090of violence.2091 According to the National Institute of Justice, more than2092four in five American Indian and Alaska Native women have2093experienced violence in their lifetime, and more than half have2094experienced sexual violence and intimate partner violence.2095These statistics reflect a complex public health and safety2096crisis, which often involves jurisdictional confusion, a lack2097of law enforcement presence, geographic isolation, historical2098trauma, and distrust of systems.2099 Yet, despite the pervasive levels of violence, many tribal2100communities still lack access to the most basic safety2101services, with fewer than 60 Native-centered domestic violence2102shelters across all of Indian Country.2103 FVPSA provides essential funding to these tribal shelters,2104as well as counseling services, tribal domestic violence2105programs, the StrongHearts Native Help Line, and resource2106centers like ours, all of which ensure that culturally2107appropriate services are available where they are most needed.2108 But recent and abrupt changes within HHS, specifically the2109removal of experienced staff and leadership from agencies and2110programs that serve Indian Country, threaten to destabilize the2111progress made. Sudden changes in leadership, staffing and2112structure, especially without tribal consultation, can disrupt2113the continuity of services, erode trust, and delay funding for2114these life-saving programs.2115 At a time when Native women face the highest rates of2116murder, rape, and abuse in the Country, preserving2117institutional knowledge and maintaining stable, informed, and2118responsive leadership is not just a matter of continuity, it is2119a matter of life and death. Every day, we hear from frontline2120advocates who, with limited resources, are saving lives by2121creating safe homes, traditional healing circles, and language-2122based advocacy services that allow survivors to heal in ways2123that reflect their values and culture.2124 When we invest in Native women, we invest in the future of2125tribal nations. We respectfully urge Congress and HHS to2126fulfill your trust and treaty obligations by prioritizing,2127strengthening, and expanding all programs that impact the2128health and safety of Native peoples, and for HHS to engage in2129meaningful government-to-government consultation with tribal2130nations before making changes to program structure, leadership,2131or funding.2132 Thank you. [Phrase in Native tongue.]2133 [The prepared statement of Ms. Simpson follows:]21342135 Prepared Statement of Lucy R. Simpson, Executive Director, National2136 Indigenous Women's Resource Center2137 Thank you, Chairman Murkowski, Vice Chairman Schatz, and members of2138the Committee, for the opportunity to testify today on the critical2139role of Health and Human Services (HHS) programs serving Indian2140Country--particularly those programs that address the health and safety2141of Native women, families, and survivors of violence.2142 My name is Lucy Simpson. I am a citizen of the Navajo Nation and2143the Executive Director of the National Indigenous Women's Resource2144Center (NIWRC). NIWRC is a Native-led nonprofit organization dedicated2145to restoring sovereignty and safety for Native women and their2146families. We serve as the statutorily mandated National Indian Resource2147Center (NIRC) Addressing Domestic Violence and Safety for Indian Women2148and the Tribal Safe Housing Capacity Building Center under the Family2149Violence Prevention and Services Act (FVPSA).2150 I first want to ground this testimony in what must remain the2151guiding principle of the federal government's work: its trust and2152treaty responsibility to Tribal Nations.2153 This responsibility is not abstract; it is a legal and moral2154obligation. HHS plays a crucial role in fulfilling this obligation, not2155only by providing public health services through the Indian Health2156Service, but also in providing services ``which are necessary to raise2157the standard of living and social well-being of the Indian people to a2158level comparable to the non-Indian society,'' \1\ including those2159programs that address the public health crisis that is violence against2160Indigenous people.2161---------------------------------------------------------------------------2162 \1\ Administration for Native Americans. U.S. Department of Health2163and Human Services, Administration for Children and Families. Retrieved2164January 31, 2025, from https://www.acf.hhs.gov/ana2165---------------------------------------------------------------------------2166 Congress reaffirmed this obligation in the Violence Against Women2167Act (VAWA) reauthorization of 2005, stating that ``Indian tribes2168require additional criminal justice and victim services resources to2169respond to violent assaults against women; and the unique legal2170relationship of the United States to Indian tribes creates a Federal2171trust responsibility to assist tribal governments in safeguarding the2172lives of Indian women.'' \2\2173---------------------------------------------------------------------------2174 \2\ Violence Against Women and Department of Justice2175Reauthorization Act of 2005, Pub. L. No. 109-162, 901(6), 119 Stat.21762960, 3077 (2006).2177---------------------------------------------------------------------------2178 By investing in Tribal Nations and Native-led organizations as they2179design and implement community-driven, culturally grounded services,2180HHS programs become instruments of self-determination.2181 Such programs include the Administration for Children and Families2182(ACF) Office of Family Violence Prevention and Services (OFVPS), which2183administers FVPSA. For more than 40 years, FVPSA has been the2184cornerstone of our nation's response to family, domestic, and dating2185violence. It remains the only federal funding source specifically2186dedicated to emergency shelter and related services for victims and2187their children. FVPSA programs are essential for Tribal Nations and2188American Indian, Alaska Native, and Native Hawaiian victims of2189violence.2190 According to the National Institute of Justice, more than 4 in 52191American Indian and Alaska Native (AI/AN) women (84.3 percent) have2192experienced violence in their lifetime, and more than half have2193experienced sexual violence (56.1 percent) and intimate partner2194violence (55.5 percent). \3\ These statistics reflect a public health2195and safety crisis. One that is devastatingly complex, often involving2196jurisdictional confusion, a lack of law enforcement presence,2197geographic isolation, historical trauma, and distrust of systems.2198---------------------------------------------------------------------------2199 \3\ Rosay, Andre B., ``Violence Against American Indian and Alaska2200Native Women and Men,'' NIJ Journal 277 (2016): 38-45, available at2201National Institute of Justice, Violence against American Indians and2202Alaska Natives, National Institute of Justice, http://nij.gov/journals/2203277/Pages/violence-against-american-indians-alaska-natives.aspx..2204---------------------------------------------------------------------------2205 Yet, despite the pervasive levels of violence, many Tribal2206communities still lack access to the most basic safety services. Fewer2207than 60 Native-centered domestic violence shelters exist across all of2208Indian Country, and access to specialized legal aid and programs aimed2209at improving the mental, emotional, physical, spiritual, and cultural2210health of survivors as they seek to rebuild their lives is extremely2211limited.2212 FVPSA funding is often the only lifeline preventing Native2213survivors from falling through the cracks. Through NIWRC's role as the2214National Indian Resource Center, since 2011, we have responded to2215nearly 15,000 requests for technical assistance, hosted more than 7002216trainings and community engagement sessions, trained close to 100,0002217individuals, and distributed more than 800,000 resources to support2218survivors, advocates, and programs nationwide. Our digital resources2219have been accessed more than 6 million times, a clear indication of2220both the reach and ongoing need for culturally specific, Native-led2221solutions.2222 With continued FVPSA funding, NIWRC leads national efforts to2223implement prevention strategies that address the root causes of2224violence, promote healthy relationships, and break cycles of2225intergenerational trauma--and we are not alone in this work.2226 FVPSA provides essential funding to Tribal shelters, counseling2227services, Tribal domestic violence programs, and resource centers like2228NIWRC, including the Alaska Native Tribal Resource Center on Domestic2229Violence and the Native Hawaiian Resource Center on Domestic Violence.2230These ensure that culturally appropriate services are available where2231they are most needed.2232 Among the most vital efforts supported by FVPSA is the StrongHearts2233Native Helpline, a free, confidential, 24/7 service that connects2234Native survivors to advocacy, shelter, and support. Organizations like2235ours also fill critical data gaps by conducting research, evaluating2236program impact, and tracking trends that inform future prevention and2237response strategies. Data that too often does not exist elsewhere for2238Native communities.2239 In Fiscal Year 2024, FVPSA supported more than 230 Tribal domestic2240violence programs, most of which are the sole service providers in2241their communities. Yet, all but 36 of those programs received grants of2242just $58,000--barely enough to support one full-time advocate. The2243number of eligible Tribes has nearly doubled since 1993, but the Tribal2244set-aside has not meaningfully increased. We recommend raising the2245Tribal set-aside to 12.5 percent, both to reflect the expanded2246eligibility and to build on the proven success of existing programs.2247 Domestic violence, however, is never an isolated issue. Native2248survivors often face multiple overlapping challenges: housing2249insecurity, substance use disorders, chronic health conditions,2250poverty, and high rates of maternal and infant mortality, all of which2251are rooted in historical and intergenerational trauma. \4\ Addressing2252this requires a coordinated federal response that bridges healthcare,2253social services, and justice systems, with Native voices leading the2254way.2255---------------------------------------------------------------------------2256 \4\ Centers for Disease Control and Prevention, Health disparities2257affecting American Indian/Alaska Native people, Centers for Disease2258Control and Prevention, https://www.cdc.gov/hearher/aian/2259disparities.html.2260---------------------------------------------------------------------------2261 Programs like the Maternal, Infant, and Early Childhood Home2262Visiting (MIECHV) Program, which includes a Tribal set-aside (TMIECHV)2263administered by ACF, are a critical part of that solution. TMIECHV2264offers culturally grounded, evidence-based strategies, including2265domestic violence screening and social support connections, that2266identify and address risk factors early in the lives of Native2267families.2268 In just four years, TMIECHV grantees have demonstrated measurable2269improvements across 17 performance indicators, including screening2270child injury prevention, maternal health, and domestic violence. \5\2271These outcomes underscore the deep connection between public health and2272safety--and the vital role of Native-led, community-based programs in2273advancing both.2274---------------------------------------------------------------------------2275 \5\ Administration for Children & Families, Tribal Home Visiting2276Action Plan, 2020-2023, Administration for Children & Families, https:/2277/acf.gov/ecd/data/tribal-home-visiting-action-2020-2023.2278---------------------------------------------------------------------------2279 HHS also provides funding for Tribal Nations and Tribal2280organizations to run programs such as the Low Income Home Energy2281Assistance Program (LIHEAP) and Temporary Assistance for Needy Families2282(TANF). These programs help strengthen Native families by assisting2283low-income households in meeting the costs of home energy and helping2284needy families care for their children in their own homes or in the2285homes of relatives. Funding integrated, culturally appropriate services2286such as these is essential to protecting Native women and families and2287building healthier, more resilient Tribal communities.2288 But recent and abrupt changes within HHS, specifically the removal2289of experienced staff and leadership from agencies and programs that2290serve Indian Country, threaten to destabilize the progress made by2291these services. These programs rely on staff who have cultivated2292trusted relationships with Tribal Nations, relationships that take2293years to build, alongside cultural competence, trauma-informed2294expertise, and a deep understanding of the complex realities facing our2295communities.2296 Sudden changes in leadership and staffing, especially without2297Tribal consultation, can disrupt the continuity of services, erode2298trust, and delay funding for life-saving programs. At a time when2299Native women face the highest rates of murder, rape, and abuse in the2300country, preserving institutional knowledge and maintaining stable,2301informed, and responsive leadership is not just a matter of continuity,2302but it is a matter of life and death.2303 Since time immemorial, Native women have been leaders, caregivers,2304knowledge keepers, and protectors of our cultures, languages, and2305traditions. Every day, we hear from frontline advocates who, with2306limited resources, are saving lives. They are creating safe homes,2307traditional healing circles, and language-based advocacy services that2308allow survivors to heal in ways that reflect their values and culture.2309Most importantly, survivors are able to disclose abuse and access2310support in spaces that feel safe, familiar, and trusted. This leads to2311better healing outcomes.2312 Given the unique historical, cultural, geographic, and socio-2313economic barriers facing Native people, the federal government must2314continue to expand, not scale back, its support for Native-led2315domestic, sexual, and family violence prevention and response programs.2316These programs are best positioned to foster healing, strengthen social2317support networks, and provide trauma-informed care that reflects2318Indigenous values and healing practices.2319 When we invest in Native women, we invest in the future of Tribal2320Nations. Continued federal funding for culturally grounded, community-2321led solutions is a trust and treaty obligation.2322 We respectfully urge Congress and the Department of Health and2323Human Services to continue to prioritize, strengthen, and expand all2324programs that impact the health and safety of Native peoples, and to2325engage in meaningful government-to-government consultation with Tribal2326Nations before making changes to program structure, leadership, or2327funding.2328 The National Indigenous Women's Resource Center is honored to2329support the lifesaving work of Tribal programs across the country.2330Thank you for your commitment to safety, justice, and sovereignty. I2331welcome your questions.23322333 The Chairman. Thank you.2334 And finally, Dr. Sheri-Ann Daniels.23352336 STATEMENT OF DR. SHERI-ANN DANIELS, CEO, PAPA OLA LOKAHI23372338 Dr. Daniels. [Greeting in Native tongue.] Aloha, Chairman2339Murkowski, and Vice Chairman Schatz. Thank you for the2340introduction, and members of the Committee.2341 Thank you for inviting me today to provide remarks on2342behalf of Papa Ola Lokahi, the Native Hawaiian Health Board. We2343appreciate the Committee's legacy of strong bipartisanship in2344honoring the Federal trust responsibility. I am honored to hear2345and learn from other Native American leaders and communities on2346this panel, because the comments, stories and challenges that2347they shared are what we face as well.2348 Papa Ola Lokahi was Congressionally and statutorily created2349in 1988 to improve the health status of Native Hawaiians, and2350the named entity in the Native Hawaiian Health Care Improvement2351Act. So I want to be really clear: we are statutorily named and2352created to support and uplift the health of Native Hawaiians.2353 And as a named entity, we have the statutory responsibility2354for the coordination, implementation and updating of a2355comprehensive health care master plan, the identification and2356research of diseases, establishment of a network of health2357resources, services and infrastructure through our five-island2358community based health organizations, as well as administer a2359scholarship for health care professionals.2360 On the topic of this oversight hearing today, it is in our2361written testimony, we highlight the following key messages.2362Federal trust responsibility to Native Hawaiians is based on2363our unique political status, not on our race. So let me say2364that again. There is a trust responsibility to Native2365Hawaiians, and that is through policy, funding and consultative2366practices, which we often don't get.2367 Our unique political status is recognized in other2368Congressional acts, not just the Native Hawaiian Health Care2369Improvement Act. And this is with a population that has grown237029 percent since between the 2010 and 2020 Census. That is2371huge.2372 For almost 40 decades, Papa Ola Lokahi continues fulfilling2373our statutory responsibility including our Native Hawaiian2374health systems. We do this through funding with HHS.2375 We talk about IHS, and you are correct that we do not get2376any funding through IHS. So the bulk of our funding comes from2377HHS through HRSA. And that fulfillment of the Federal trust2378responsibility for Native Hawaiians is in the way of programs2379and funding, again, primarily through HRSA.2380 The other HHS areas, including SAMHSA, we would be impacted2381through mental health and substance abuse. And we all know what2382those statistics are.2383 In addition to that, we also currently are supporting the2384Lahaina wildfires impacted families. So over the last two2385years, over 12,000 families, 34,000 people, 3,7002386professionals, boots on the ground, and over 140 organizations2387had a role in that and continue to have a role in that.2388 We need to continue to focus on the most vulnerable of2389populations, programs that address the health, safety and self-2390sufficiency of Native Hawaiian families, and that is CMS. Our2391Native Hawaiian population in Hawaii is 21 percent. Yet for2392TANF families, 33 percent of them are Native Hawaiian. For2393victims of child abuse and neglect, 39.7 percent. Those are2394large numbers, greater than our population.2395 The total Hawaiian population currently receiving Medicaid2396equals almost 77,000. That is a lot. Thirty-four percent of2397them are children. That is not acceptable. If we talk about our2398cultural values and where we put our youngest as well as our2399oldest, that is culture. And when we remove those things, we2400create other impacts and other concerns down the line.2401 CDC, the prevention services, tobacco, chronic conditions,2402we all know diabetes. Diabetes does not discriminate. It is no2403longer just a Native issue. So cutting those services has huge2404impacts.2405 We also want to make sure we continue to advance the2406Missing and Murdered Native Hawaiian Women and Girls2407initiatives, but it is also with our tribal partners. We know2408that a quarter of the missing girls are Native Hawaiian.2409 We also want to recognize the reality of communities and2410the impact it has on health, that health policy should aim to2411reduce differences between rural and city areas. It is2412especially important because our Native communities, for many2413of us, tribes, everyone, our people live in rural areas, often2414with limited access to services.2415 Finally, we need to continue to strengthen our networks. In2416our written testimony, we highlight the Native Hawaiian health2417network collaborators across our eight major islands. It is not2418just us. We recognize it is our Native Hawaiian health systems,2419our federally qualified health centers, our community health2420centers, hospitals and especially our community based2421organizations. We are doing it with everyone, linking arms. And2422I think that is important to recognize.2423 And these are just some of the highlighted examples of the2424impacts that HHS in reduction and the things that are happening2425could have on our communities. I look forward to answering any2426further questions from the Committee.2427 Mahalo.2428 [The prepared statement of Dr. Daniels follows:]24292430 Prepared Statement of Dr. Sheri-Ann Daniels, CEO, Papa Ola Lokahi2431 Aloha e Chairman Murkowski, Vice Chairman Schatz, and Members of2432the United States Senate Committee on Indian Affairs (``Committee''),2433 Mahalo (thank you) for inviting me to provide remarks on behalf of2434Papa Ola Lokahi (POL), the Native Hawaiian Health Board (NHHB). In the2435spirit of the Committee's legacy of strong bipartisanship in honoring2436the federal trust responsibility owed to American Indians, Alaska2437Natives, and the Native Hawaiian Community (NHC), collectively ``Native2438Americans'', thank you for convening the oversight hearing, and I'm2439honored to participate, and to share our collective support with Native2440American leaders and communities.2441 POL was congressionally and statutorily created in 1988 to improve2442the health status of Native Hawaiians, through the passage of the2443Native Hawaiian Health Care Act, which was later reauthorized as the2444Native Hawaiian Health Care Improvement Act (NHHCIA). The2445implementation of the NHHCIA provides for: 1) Coordination,2446implementation and updating of a comprehensive Native Hawaiian health2447care master plan (operationally known as ``E Ola Mau''), including2448identification and research of diseases most prevalent among NH; 2)2449Establishment of a network of health resources, services, and2450infrastructure, through five island community based health2451organizations, commonly known and referred to as the Native Hawaiian2452Health Care Systems \1\ (NHHCS or ``Systems''); and 3) Administration2453of scholarships via the Native Hawaiian Health Scholarship Program2454(NHHSP).2455---------------------------------------------------------------------------2456 \1\ Comprised of Ho`ola Lahui Hawai`i--Kaua`i Community Health2457Center, a federally qualified health center; Ke Ola Mamo, island of2458O`ahu; Hui No Ke Ola Pono, island of Maui; Na Pu`uwai, islands of2459Molokai and Lana`i; and Hui Malama Ola Na `Oiwi, Hawai`i Island2460---------------------------------------------------------------------------2461 We recognize and are grateful for the commitment and work of the NH2462Health Network (NHHN) collaborators across the eight major islands of2463the State of Hawai'i, including the Systems, federally qualified health2464centers (FQHCs), community health centers (CHCs), community-based2465organizations (CBO), and Native Hawaiian serving organizations (NHO),2466and the State of Hawaii (Department of Health, Department of Human2467Services).2468 POL's response to the Committee's Oversight Hearing focuses on2469examining Federal Programs serving NHs across the Operating Divisions2470at the United States Department of Health and Human Services (HHS), and2471is divided into the following three sections:24722473 I--Federal Trust Responsibility, Unique Political Status &2474Declaration of Policy24752476 II--Impact of Delivering Essential Public Health and Social2477Services to2478Native Hawaiians24792480 A. Overview of POL's Unique Statutory Role24812482 B. Impact re: Trust & Treaty Obligations, Policy Implementation2483 for Native Hawaiians24842485 C. Summary of Delivery of Essential Public Health and Social2486 Services for Native Hawaiian Communities24872488 D. Essential Public Health and Social Services: Via Native2489 Hawaiian Health Care Systems24902491 E. Essential Public Health and Social Services: During the2492 Height of COVID-19 via HRSA24932494 F. Essential Public Health and Social Services: For Communities2495 Impacted by the Lahaina, Maui Wildfires via SAMHSA24962497 G. Essential Public Health and Social Services: For Child2498 Welfare, Domestic Violence, and Family Needs24992500 H. Essential Public Health and Social Services: Via POL and2501 Trusted Community Partners25022503 I. Essential Public Health and Social Services: Via Cultural2504 Healing Model25052506 J. Essential Public Health and Social Services: Via Traditional2507 Healers & Practitioners25082509 K. Essential Public Health and Social Services: Via Native2510 Hawaiian Health Professionals25112512 L. Essential Public Health and Social Services: Via Education2513 Collaborations25142515 III--Continuing Needs, Implementing Master Plan Recommendations and2516the Native Hawaiian Health Network25172518 A. Continuing Needs25192520 B. Implementing Recommendations of E Ola Mau--Native Hawaiian2521 Health Master Plan25222523 C. Native Hawaiian Health Network25242525 Chairman Murkowski and Vice Chairman Schatz, thank you for the2526longstanding commitment you have demonstrated individually,2527collectively and through your Committee work and leadership to ensure2528that the United States upholds its federal Trust and Treaty Obligations2529to Native Americans. We acknowledge the Committee's historic and2530bipartisan, work that has helped strengthen the overall well-being of2531Native Americans.2532I--The Federal Trust Responsibility, Unique Political Status &2533 Declaration of Policy2534A. Federal Trust Responsibility2535 Similar to American Indians and Alaska Natives, Native Hawaiians2536never relinquished the right to self-determination despite the United2537States' involvement in the illegal overthrow of Queen Lili`uokalani in25381893 and the dismantling of our Hawaiian government. As such, Native2539Hawaiians are owed the same trust responsibility as all Native groups2540in the United States. The federal trust responsibility extends to all2541Native Hawaiians, a population that grew nationwide by 29.1 percent2542from the 2010 to the 2020 census data. \2\ To meet this obligation,2543Congress--through landmark, bipartisan work of this Committee and its2544Members--created policies to promote education, health, housing, and a2545variety of other federal programs intended to build, maintain, and2546better conditions for the Native Hawaiian Community.2547---------------------------------------------------------------------------2548 \2\ https://www.census.gov/library/stories/2023/09/2020-census-dhc-2549a-nhpi-population.html, retrieved May 7, 20252550---------------------------------------------------------------------------2551B. Unique Political Status2552 Hundreds of Acts of Congress expressly acknowledge or recognize a2553special political and trust relationship to Native Hawaiians based on2554our status as the Indigenous, once-sovereign people of Hawai`i. Among2555these laws are the Hawaiian Homes Commission Act, 1920 (42 Stat. 108)2556(1921), the Native Hawaiian Education Act (20 U.S.C. 7511) (1988),2557the Native Hawaiian Health Care Improvement Act (42 U.S.C. 11701)2558(1988), and the Hawaiian Homelands Homeownership Act codified in the2559Native American Housing Assistance and Self Determination Act, Title2560VIII (25 U.S.C. 4221) (2000).2561 The first Congressional finding of the NHHCIA states, ``(1) Native2562Hawaiians comprise a distinct and unique indigenous people with a2563historical continuity to the original inhabitants of the Hawaiian2564archipelago whose society was organized as a Nation prior to the first2565nonindigenous people in 1778.'' \3\ Subsequent Congressional findings2566include: ``(17) The authority of the Congress under the United States2567Constitution to legislate in matters affecting the aboriginal or2568indigenous peoples of the United States includes the authority to2569legislate in matters affecting the native Peoples of Alaska and Hawaii;2570(18) In furtherance of the trust responsibility for the betterment of2571the conditions of Native Hawaiians, the United States has established a2572program for the provision of comprehensive health promotion and disease2573prevention services to maintain and improve the health status of the2574Hawaiian people; and (22) Despite such services, the unmet health needs2575of the Native Hawaiian people are severe and the health status of2576Native Hawaiians continues to be far below that of the general2577population of the United States.'' \4\2578---------------------------------------------------------------------------2579 \3\ The Native Hawaiian Health Care Improvement Act (42 U.S.C.258011701) (1988)2581 \4\ Ibid2582---------------------------------------------------------------------------2583C. Declaration of Policy2584 Congress declared that it is the policy of the United States in2585fulfillment of its special trust responsibilities and legal obligations2586to the indigenous people of Hawaii resulting from the unique and2587historical relationship between the United States and the Government of2588the indigenous people of Hawaii (1) to raise the health status of2589Native Hawaiians to the highest possible health level; and (2) to2590provide existing Native Hawaiian health care programs with all2591resources necessary to effectuate this policy. \5\2592---------------------------------------------------------------------------2593 \5\ The Native Hawaiian Health Care Improvement Act (42 U.S.C.259411702) (1988)2595---------------------------------------------------------------------------2596II--Impact of Delivering Essential Public Health and Social Services to2597 Native Hawaiians2598A. Overview of POL's Unique Statutory Role2599 For almost four decades, POL, the Native Hawaiian Health Board2600(NHHB), has consistently focused on raising the health status of Native2601Hawaiians, in executing its statutory charge to:26022603 1. Coordinate, implement and update a Native Hawaiian2604 comprehensive master plan designed to promote comprehensive2605 health promotion and disease prevention services to improve and2606 maintain the health status of Native Hawaiians.26072608 2. Conduct training for Native Hawaiian care practitioners,2609 community outreach workers, counselors, and cultural educators2610 to educate the Native Hawaiian population regarding health2611 promotion and disease prevention.26122613 3. Identify and perform research into diseases that are most2614 prevalent among Native Hawaiians.26152616 4. Develop an action plan outlining the contributions that each2617 member organization of Papa Ola Lokahi will make in carrying2618 out in the policy of the NHHCIA.26192620 5. Serve as a clearinghouse for (1) collecting and maintaining2621 data associated with the health status of Native Hawaiians; (2)2622 identifying and researching diseases affecting Native2623 Hawaiians; and (3) collecting and distributing information2624 about available Native Hawaiian project funds, research2625 projects and publications.26262627 6. Coordinate and assist health care programs and services2628 provided to Native Hawaiians.26292630 7. Administer special projects.26312632B. Impact re: Trust & Treaty Obligations, Policy Implementation for2633 Native Hawaiians2634 In responding to executive orders (EOs) and other policy statements2635by this Administration, HHS and the federal government, as a whole,2636must honor the federal Trust & Treaty Obligations and Responsibilities2637in policy, funding and consultation practices, specifically:26382639 1. Policy. Follow other executive departments (e.g., Interior,2640 Education, Agriculture), in articulating, via Secretary's2641 Order, that diversity, equity, inclusion, accessibility and2642 environmental justice policies do NOT apply to Tribal nations,2643 tribal citizens and the NH Community and related programs. Most2644 notably, the HHS Advisory Opinion 25-01, dated February 25,2645 2025, on ``Application of DEI Executive Orders to the2646 Department's Legal Obligations to Indian Tribes and Their2647 Citizens'' excludes NHs.26482649 2. Funding. Recognize that federal Trust responsibility, policy2650 implementation and program funding is: Congressionally and2651 statutorily authorized and appropriated; NOT discretionary2652 spending that Native Americans need to ``apply'' for; exists2653 beyond Indian Health Services (IHS); and NOT a state obligation2654 (i.e., state funding should supplement not supplant federal2655 funding).26562657 3. Consultation Practices. Implement meaningful consultation2658 practices with Tribal nations, tribal citizens and the NHC,2659 including announced HHS reorganization activities (e.g.,2660 consolidation, elimination of HRSA, SAMHSA).26612662 In practice, and by observation, HHS' policy implementation2663activities in its related operating divisions, have not been explicit2664nor in alignment with the above.2665C. Summary of Delivery of Essential Public Health and Social Services2666 for NHCs2667 1. Appropriations. Current FY26 appropriations request for the2668Native Hawaiian Health Care Program is at $27 million, via HRSA, and2669historically funded:26702671 a. Papa Ola Lokahi, Native Hawaiian Health Board--Via HRSA \6\,2672 BPHC \7\--$10,000,0002673---------------------------------------------------------------------------2674 \6\ Health Resources and Services Administration (HRSA)2675 \7\ Bureau of Primary Health Care (BPHC)26762677 b. Papa Ola Lokahi, Native Hawaiian Health Board--Native2678 Hawaiian Scholarship Program via HRSA, BHW \8\--$2,200,0002679---------------------------------------------------------------------------2680 \8\ Bureau of Health Workforce (BHW)26812682 c. Papa Ola Lokahi, Native Hawaiian Health Board--Native2683---------------------------------------------------------------------------2684 Hawaiian Health Care Systems Via HRSA BPHC--$14,800,00026852686 2. Program Commitments, Spending. Described in further detail2687below, the following table summarizes the financial program impacts by2688HHS operating divisions from 2022 to 2024 which may be at risk, pending2689further HHS' reorganization plan details--$16,572,000.26902691 a. Papa Ola Lokahi, Native Hawaiian Health Board--American2692 Rescue Plan Act (ARPA)--HRSA--$1,566,00026932694 b. Papa Ola Lokahi, Native Hawaiian Health Board--Community2695 Health Workers, Perinatal Health--HRSA--$801,00026962697 c. Papa Ola Lokahi, Native Hawaiian Health Board--Native2698 Hawaiian Health Program (NHHP), including Native--HRSA,2699 including BPHC, BHW--$9,576,00027002701 d. Papa Ola Lokahi, Native Hawaiian Health Board--SAMHSA2702 Emergency Response Grant (SERG)--SAMHSA, \9\ via the State of2703 Hawaii, Department of Health--$4,537,0002704---------------------------------------------------------------------------2705 \9\ Substance Abuse and Mental Health Services (SAMHSA)27062707 e. Papa Ola Lokahi, Native Hawaiian Health Board--Center of2708 Excellence, Tobacco, Aging, Transportation Equity Working2709---------------------------------------------------------------------------2710 Group--Via the State of Hawaii, Department of Health--$92,00027112712 Total HHS' Operating Divisions Related--$16,572,00027132714D. Essential Public Health and Social Services: Via Native Hawaiian2715 Health Care Systems2716 1. Overview. The five NHHCS offer a range of health care and other2717services, including primary care, mental health, and fitness programs,2718in a way that reflects the culture and priorities of the island2719communities they serve. The work of the NHHCSs aims to build trust in2720the Native Hawaiian Community, serving as a bridge to Western medicine,2721while integrating medical care with traditional Native Hawaiian values,2722beliefs, and practices. In the past year, the five Native Hawaiian2723Health Care Systems have made a significant impact through their2724community outreach and traditional healing efforts.2725 Collectively, based on the most recent program funding year, the2726Systems distributed over 41,900 health education materials, hosted 3762727events, and reached more than 39,400 individuals across Hawai`i.2728Traditional healing services played a vital role, with over 3,2002729people receiving care rooted in Native Hawaiian cultural practices. For2730example, Hui Malama Ola Na `Oiwi (HMONO) reached more than 17,0002731individuals through just 3 major events, while Ho`ola Lahui Hawai`i2732(HLH) provided traditional healing services to 1,571 individuals across2733131 events. Ke Ola Mamo (KOM), Na Pu`uwai, and Hui No Ke Ola Pono2734(HNKOP) also made notable contributions, with HNKOP engaging more than273515,400 community members through its 173 events, primarily a result of2736the Lahaina wildfires in August 2023. These efforts reflect a deep2737commitment to culturally grounded care and community engagement,2738strengthening health and wellness through Native Hawaiian traditions2739and values.2740 Indian Health Services (IHS) awarded a contract to KOM for2741alcoholism and related health care services and coronavirus activities2742in 2015 and 2020, respectively. POL is not aware of any other IHS2743related activities with the Systems or in the state. \10\2744---------------------------------------------------------------------------2745 \10\ KE OLA MAMO--Coronavirus Contracts--ProPublica, retrieved May274612, 20252747---------------------------------------------------------------------------2748 2. HLH (Kaua`i) provides comprehensive health services across2749Kaua`i County, including primary, dental, pharmacy (with delivery),2750behavioral health, substance abuse counseling, chronic disease2751management, physical activity and nutrition programs, health2752screenings, school-based services, mobile clinic care, family planning,2753and traditional healing. Services are delivered island-wide with2754central locations in Lihu`e, Kapa`a, and Waimea. In addition to its2755designation as a Native Hawaiian Health Care System, HLH operates as a2756Federally Qualified Health Center under Section 330 of the Public2757Health Service Act. Their culturally grounded approach emphasizes2758preventive care, cultural competence through local staffing, and2759integration of traditional practices with modern medicine. HLH's2760facilities include two clinics, mobile units, a pharmacy, and a fitness2761center.2762 3. KOM (O`ahu) is dedicated to improving the health and well-being2763of its clients, with a focus on Native Hawaiians while serving the2764entire O`ahu community. Becoming a client is simple and provides access2765to a variety of health and wellness programs. KOM offers comprehensive2766support, including medical and primary care, traditional healing such2767as lomilomi, fitness programs, cultural workshops, and health classes.2768Recognizing the disproportionate rates of heart disease, diabetes,2769stroke, and cancer among Native Hawaiians, Ke Ola Mamo integrates2770cultural values with healthcare to address these disparities. Services2771are delivered through one medical clinic, an administrative office, and2772four community-based health offices, ensuring care that honors the2773cultural and historical connections to health and well-being.2774 4. Na Pu`uwai, founded on the pillars of Native Hawaiian health2775disparity and cardiovascular disease research, serves residents of both2776Moloka`i and Lana`i. Na Pu`uwai is dedicated to delivering culturally2777responsive primary health, health education and health promotion that2778address the unique needs of these communities, its mission, informed by2779a foundation in research and advocacy, is to uplift and enhance the2780health of Native Hawaiians through an integrative healthcare delivery2781model grounded in Native Hawaiian culture, practices, tradition, and2782language. Services include primary health, in addition to traditional,2783complimentary and integrative medicine. Na Pu`uwai's community2784engagement efforts are aimed at improving healthcare access by2785informing Native Hawaiians about available services, programs and2786resources.2787 5. HNKOP (Maui) is dedicated to improving the health of Native2788Hawaiians and the greater Maui island community by empowering clients2789to become their own health advocates, blending medical care with2790traditional Hawaiian values and practices. With an emphasis on health2791promotion and prevention, HNKOP, offers enabling and wrap-around2792services to help community navigate healthcare and connect with2793resources. Clinical services include adult primary care, oral health,2794and intensive cardiac rehabilitation, supported by wellness programs2795such as the Kaiaulu Wellness & Outreach, Hale Ho`oikaika gym, Simply2796Health Cafe, and career training through the Kealaho`imai program. What2797distinguishes HNKOP is its Kua`ua`u traditional healing program, which2798provides lomilomi, ho`oponopono, and la`au lapa`au. Strong community2799partnerships further enhance services, offering behavioral health2800training, medicinal plant access, and Native Hawaiian birth and2801parenting education.2802 6. HMONO (Hawai`i Island) provides comprehensive, culturally2803grounded health services on Hawai`i Island, including primary care,2804behavioral health, nutrition counseling, and chronic disease education.2805Services are offered at the Hilo-based Family Medicine Clinic, via2806telehealth, and through home visits--especially supporting kupuna.2807HMONO emphasizes community wellness through traditional healing2808programs such as la`au lapa`au gardening and taro cultivation, health2809education including yoga, nutrition, and chronic disease management,2810and support groups for diabetes and cancer. HMONO also operates a2811transportation program with wheelchair-accessible vehicles to ensure2812access to medical appointments across the island. Community engagement2813is further supported through major events like the Malama Na Keiki2814Festival and Ladies' Night Out.2815E. Essential Public Health and Social Services: During the Height of2816 COVID-19 via HRSA2817 1. Overview. The establishment of POL, the NHHB, as a non-profit2818organization allowed eligibility to pursue federal, State, county, and2819private sources of funding. Since the first shutdown in the State of2820Hawai`i in March 2020, POL (both alone and in partnership with2821community organizations) successfully applied for or acted as fiscal2822agent for over $2 million dollars throughout various grants. These2823grant funds are in addition to the roughly $3.5 million of ARPA funds2824that POL distributed to community based organizations (CBOs). POL is2825committed to pursuing its mandates and mission through multiple funding2826mechanisms to expand opportunities for Native Hawaiian health. POL2827engaged its Congressional duties by providing the administration for2828the Hawai`i COVID-19 Native Hawaiian & Pacific Islander Response,2829Recovery, and Resilience (NHPI 3R) Team, a coalition of over 602830partners engaged on behalf of communities throughout the State of2831Hawai`i, from June 2020 to present.2832 2. ARPA, Na Makawai. Na Makawai is the name of the initiative that2833encompassed the work of the five NHHCS, POL, and fifteen Native2834Hawaiian serving health entities (20 organizations in total) that2835received ARPA funding to provide COVID-19 response and recovery2836services and resources throughout the State of Hawai`i. ARPA funding2837was administered by HRSA. Notably, ARPA language allowed for funds to2838be applied towards health workforce, infrastructure, and community2839outreach and education--critical components of the Native Hawaiian2840Health Network (NHHN). Given the annual appropriations for federal2841fiscal years 2021 and 2022 ($20.5 and $22 million, respectively), a $202842million increase in funding across a two-year span increases the total2843funding to the NHHCIA by approximately half. The thoughtful flexibility2844and inclusivity of ARPA language and approved activities through HRSA2845allowed POL to partner with local organizations across a wide range of2846programs and services throughout the State of Hawai`i, which included:28472848 Direct clinical COVID-19 services (vaccination and testing,2849 mobile care, and mobile events);28502851 Indirect COVID-19 services (outreach, education, and2852 surveillance; statewide referral hotline for various2853 resources); and28542855 Increasing or maintaining resources needed to expand COVID-2856 19 response (workforce, including community health workers;2857 telehealth capacity and electronic medical records).28582859 In addition, the Na Makawai partners' COVID-19 relief needs2860overlapped with preexisting needs in the Native Hawaiian community.2861These included: sustaining comprehensive primary health care; mental/2862behavioral health; serving rural youth; food insecurity and access2863programs; and maternal/childcare. POL connected with health factors2864that impact clinical needs, so Na Makawai partnerships have also2865supported a broadband infrastructure mapping project so that future2866telehealth projects and programs that rely on broadband accessibility2867can be informed by and based on high quality, locally collected data.2868 3. NHPI 3R. The Native Hawaiian & Pacific Islander Response,2869Recovery & Resilience Team (NHPI 3R) was established in May 2020 to2870collectively address the impact of COVID-19 and recommend and implement2871solutions. Established in May 2020, in alignment with the national2872response team, to improve the collection and reporting of accurate2873data, identify and lend support to initiatives across the Hawaiian2874Islands working to address COVID-19 among Native Hawaiians and Pacific2875Islanders, and unify to establish a presence in the decisionmaking2876processes and policies that impact our communities. More than 602877agencies, organizations, and departments comprise the NHPI 3R Team.2878 As the response to COVID-19 transitions, the NHPI 3R is pivoting2879toward priority issues impacting Native Hawaiian and Pacific Islander2880communities in Hawai'i. Capitalizing on the influence and impact such a2881collective can have, these working committees continue to meet2882regularly: Data & Research, Policy, Communication & Outreach, Health &2883Wellness Priorities and the Community Health Worker Collaborative.2884F. Essential Public Health and Social Services: For Communities2885 Impacted by the Lahaina, Maui Wildfires via SAMHSA2886 1. SERG. SAMHSA Emergency Response Grant (SERG) program is a2887SAMHSA-wide grant opportunity, inclusive of mental health and substance2888use prevention, response, and recovery services, that authorizes SAMHSA2889to act immediately under emergency circumstances that create a2890behavioral health crisis, where the crisis overwhelms the behavioral2891health system or creates behavioral health service needs that do not2892fit existing behavioral health resources. SERG funds are ``funds of2893last'' resort and cannot supplant existing resources. SERG funding2894enables public entities to address emergency behavioral health crises2895when existing resources are overwhelmed or unavailable. \11\2896---------------------------------------------------------------------------2897 \11\ https://www.samhsa.gov/mental-health/disaster-preparedness/2898serg, retrieved May 10, 20252899---------------------------------------------------------------------------2900 2. Lahaina Wildfires & On the Ground Community Impacts. In2901collaboration with SAMHSA grantee, the State of Hawai`i, Department of2902Health, the SERG collaborator network grew initially from 20 to over 302903providers, contractors, programs, serving the emotional, social and2904mental health needs of survivors of the August 2023 Maui2905 Wildfires. Maui SERG accomplishments, from the initial, on the2906ground delivery period February to September 2024: Community Served--29077,298 families and 20,413 individuals; Clinical Care--8,152 urgent2908trauma and mental health clinical appointments; Community Outreach--4522909events and 2,133 non-clinical appointments; Workforce Development--942910training sessions attended by 2,229 local professionals and;2911Collaborative Engagement--Strong partnerships with 14 local2912organizations ensured tailored and effective services, especially for2913under-served populations. \12\ Year 2 of SERG grants began November29142024 and continue to be monitored.2915---------------------------------------------------------------------------2916 \12\ https://kawaiola.news/columns/i-ola-lkahi/collaborating-to-2917support-mental-wellbeing-on-maui/, retrieved May 12, 20252918---------------------------------------------------------------------------2919 3. Programming. Examples of urgent, on the ground, community2920customized programming include:29212922 a. Family Resiliency toolkits rooted in the cultural values and2923 wisdom of Aloha and focus on the 5 Protective Factors that2924 support and strengthen families: Parental Resilience, Social2925 Support, Concrete Support, Understanding of Child Development,2926 and Social Emotional Competence of Children.29272928 b. Via Radio, Newspaper, TV, Social Media--Developed culturally2929 and linguistically appropriate materials and activities (e.g.,2930 family fair, youth empowerment/resiliency building activities);2931 Provide bilingual community navigators to assist in seeking and2932 applying for assistance; Conduct media campaigns (placing2933 educational PSA and events announcements on the radio, social2934 media, and Filipino community newspapers).29352936 Disseminated information and resources through ethnic media and2937 also strengthen promotion of services and resources offered by2938 government and community organizations in Ilokano and Filipino/2939 Tagalog. Develop culturally and linguistically appropriate2940 materials and activities to promote health, wellness, and2941 resiliency (e.g., family fair, youth empowerment, resiliency2942 building activities, job fair). Conduct media campaigns2943 (placing educational PSA and events announcements on the ethnic2944 radio and TV, Facebook, Instagram, Filipino community2945 newspapers and publications).29462947 c. Workshops for Maui First Responders & Families (and2948 partnered with 17 external partners).29492950 d. Disaster Behavioral Health Curriculum & Training (and2951 partnered with 15 SERG orgs and 33 external partners)29522953 e. Cultural Healing & Recovery: Maui Wildfire Disaster (and2954 partnered with 3 SERG orgs and 7external partners)29552956G. Essential Public Health and Social Services: For Child Welfare,2957 Domestic Violence, and Family Needs2958 Often overlooked, but vital to NH and Hawai`i's health status2959include areas addressed by the State of Hawaii's Department of Human2960Services (DHS) in which HHS Divisions' funding flows, particularly2961Medicaid, covering a range of programming and funding for the most2962vulnerable of populations--children, pregnant women, parents of2963eligible children, low income adults, former foster care children,2964aged, blind and disabled individuals. \13\29652966 \13\ What is Medicaid, retrieved May 12, 202529672968---------------------------------------------------------------------------2969 1. Benefit, Employment & Support Services29702971 a. Temporary Assistance for Needy Families (TANF)2972 b. Temporary Assistance for Other Needy Families (TAONF)2973 c. Employment & Training2974 d. Child Care Subsidy Program (Child Care Subsidy or Preschool2975 Open Doors)2976 e. Child Care Regulation (also known as Child Care Licensing)2977 f. Homeless Programs2978 g. Aid to the Aged, Blind and Disabled2979 h. Supplemental Nutrition Assistance program (SNAP, formerly2980 the food stamps program)2981 i. Hawaii Home Energy Assistance Program (HI-HEAP formerly2982 LIHEAP)29832984 2. Social Services Division--Adult Protective and Community2985Services29862987 a. Adult Services and Programs: case management for elderly2988 victims of crime program; chore services; adult foster care;2989 senior companion; respite companion; foster grandparent2990 program; transportation assistance; courtesy services.29912992 b. Licensing and Certification: nurse aide training and re-2993 certification.29942995 3. Social Services Division--Child Welfare Services29962997 Missing children website; mandated reporters; family connections;2998family court; foster and adoptive care; youth resources.29993000 4. Med-QUEST \14\ Division3001---------------------------------------------------------------------------3002 \14\ QUEST stands for: Quality care; Universal access, Efficient3003utilization, Stabilizing costs; and Transforming the way health care is3004provided.30053006 The division is responsible for implementing the DHS3007responsibilities as the single state agency designated to administer3008the Hawaii Medicaid program under Title XIX of the Social Security Act.3009POL understands \15\ the following about Native Hawaiian and part-3010Hawaiian members served by the Hawaii Medicaid Program: Total Hawaiian3011population currently receiving Medicaid equals almost 77,000 which3012represents 19 percent of all Med-QUEST members; almost 26,000 (343013percent), children including over 1,400 current and former foster care3014children; over 400 pregnant women; over 14,000 (18 percent) parents or3015caretakers; about 26,500 (34 percent) adults; about 8,800 (11 percent)3016aged, blind or disabled adults; and over 1,100 other individuals.3017---------------------------------------------------------------------------3018 \15\ State of Hawaii, Department of Human Services3019---------------------------------------------------------------------------3020H. Essential Public Health and Social Services: Via POL and Trusted3021 Community Partners3022 1. Overview. Through presentations, demonstrations, workshops,3023kukakuka sessions and working closely with kupuna (elders), POL seeks3024to improve awareness of and sensitivity to Hawaiian cultural processes3025and the philosophies of spiritual healing, thus assuring that they are3026included within the larger health and wellness arena. Whenever3027possible, POL collaborates and partners with NH community-based3028organizations.3029 2. Cancer Prevention. POL via `Imi Hale, its research department is3030a part of the Native Hawaiian Cancer Network launched in 2000, `Imi3031Hale collaborates with key local, state, national and international3032partners to reduce cancer incidence and mortality among Native3033Hawaiians through the establishment of a core organizational3034infrastructure that: Goal 1: Increase knowledge of, access to, and use3035of beneficial biomedical procedures in cancer prevention and control3036and co-morbid conditions of cancer patients. Goal 2: Develop and3037conduct evidence-based intervention research to increase use of3038beneficial biomedical procedures to control cancer and co-morbid3039conditions. Goal 3: Train and develop a critical mass of competitive3040researchers using community-based participatory research (CBPR) methods3041to reduce health disparities. `Imi Hale is currently one of 233042Community Networks Program Center (CNPC) sites funded by the National3043Cancer Institute's Center to Reduce Cancer Health Disparities.3044 3. Chronic Conditions. Healthy lifestyles, disease prevention and3045health promotion are critical to reducing the impact of chronic disease3046and other conditions such as heart disease, hypertension, stroke,3047diabetes, kidney diseases, cancer and obesity. In many Hawaiian `ohana3048(family), at least one family member is living with a chronic condition3049such as diabetes, heart disease, or stroke. Since Western contact,3050illnesses and the loss of resources have deeply affected the once-3051thriving lahui of Kanaka Maoli, reshaping their way of life. Many3052Native Hawaiians in Hawai`i experience a higher prevalence of chronic3053disease due to a combination of genetic, environmental, and systemic3054factors. While lifestyle choices can influence health, access to3055resources, such as `aina for growing food, can be a significant barrier3056to making healthier choices.3057 There are many ways to support overall well-being and reduce the3058risk of chronic conditions. Engaging in physical activity, eating3059nourishing foods, breastfeeding, and avoiding tobacco are all3060beneficial steps. Fortunately, there are numerous resources and3061community support systems available to help individuals and families on3062their health journey.3063 POL coordinates, facilitates, contracts and sometimes direct3064delivers disease prevention and health promotion programming re:3065breastfeeding, nutrition, physical activity, tobacco use, kidney3066disease, heart disease, cancer, diabetes.3067 4. Harm Reduction. POL and the Hawai`i Health & Harm Reduction3068Center (H3RC) released a harm reduction toolkit for Native Hawaiians.3069This approach to harm reduction focuses on developing a community3070understanding of harm reduction, reducing the harms caused by3071colonization in Hawai`i, and introducing a cultural approach to3072reducing harm and promoting healing.3073 5. Kupuna Brain Health. Aligned with POL's commitment to improve3074the health and well-being of Native Hawaiians and our families, inquiry3075into the brain health of kupuna--elders, grandparents, adults 65 and3076older--and Alzheimer's Disease and Related Dementias (ADRD) has yielded3077insightful observations, a rich body of knowledge, and targeted3078recommendations to agencies that address the interests of elders in3079Hawai`i. The welfare of our kupuna impacts the well-being and3080resiliency of the entire family.3081 6. LGBTQIA+. The Hawaiian `ohana as well as our lahui had roles for3082each person. Whether kane, wahine, or mahu, each person had a kuleana3083in the Hawaiian `ohana. Mahu have long held an important traditional3084role as caretakers-of other `ohana members, of cultural and historical3085knowledge, and as respected contributors to the lahui. However, since3086Western-Colonial contact, we've seen a decrease in health outcomes for3087our mahu (aka LGBTQ) community.3088 Papa Ola Lokahi includes our mahu `ohana in our commitment to the3089health and well-being of Native Hawaiians and all our families. We are3090identifying the health disparities and through programs, public policy3091and partnerships, we are developing strategies to address: Increased3092risk for depression, anxiety and mental health challenges; Increased3093risk for substance use/misuse.; Increased societal stigma around care3094(e.g. HIV, MPOX, etc.); Limited, and sometimes prohibited access to3095gender-affirming care.3096 In 2023 alone, roughly 500 anti-LGBTQ bills were introduced within3097state legislatures across the United States, including six bills3098introduced in Hawai`i that would limit and criminalize vital gender-3099affirming care that our trans and mahu `ohana members need.3100 7. Nutrition and Food Systems. Promoting nutrition education,3101research, and policy related to food access, food sovereignty, and food3102systems. POL efforts build on the foundation established in E Ola Mau,3103Native Hawaiian Health Master Plan, emphasizing food sovereignty,3104community-based education, and sustainable nutrition practices to3105promote lifelong well-being. The 2023 E Ola Mau Update reaffirmed the3106commitment to these principles, incorporating contemporary research and3107community-driven solutions to further address nutritional health,3108chronic disease prevention, and overall wellness.3109 8. `Ohana (Family) Well Being. From keiki (children) to kupuna,3110this strand focuses on adverse childhood experiences, dental health,3111sexual and reproductive health.3112 9. Substance Use, Recovery, and Behavioral Health. This strand3113focuses on substance use, recovery, addictions, and related mental3114health and wellness. Disproportionate numbers of our Native Hawaiian3115population have been consistently over-represented among those who are3116seeking or thrust into Western treatment for substance use disorders3117and mental health issues. Existing systems of care continue to assign3118treatment within the same western frameworks that have led to this3119consistent over-representation, and do not account for the unique needs3120of the Native Hawaiian Community, and are not anchored in Hawaiian ways3121of knowing and being.3122 Research shows that this inequitable health status results from3123several complex and interconnected social determinants of health,3124including historical trauma, discrimination, and lifestyle changes.3125Research also indicates that re-envisioning treatment for the Native3126population, utilizing cultural re-connection and methodologies that3127speak to Native perspectives, is more influential in creating positive3128health outcomes for Native peoples3129 10. Tobacco and Vaping Control and Prevention. Taking action to3130lower tobacco and vaping rates among Native Hawaiians. Big Tobacco, or3131commercial tobacco, has historically ravaged Native Hawaiian3132communities, wreaking havoc and harm to our people from keiki to3133kupuna. Seen as one of the top markets for menthol tobacco products3134since the 1960s, remnants still linger throughout our islands. In3135addition to combustible commercial tobacco, young people (minors and3136young adults) are being targeted by e-cigarette companies.3137 Although makahala (Native Hawaiian tobacco) has been used in la`au3138lapa`au, commercial tobacco as well as its subsequent nicotine-related3139products such as e-cigarettes (also known as ESD, ENDS), have been3140imported into Native Hawaiian communities since Western-Colonial3141contact. Since its import, tobacco, and more recently e-cigs, have3142infiltrated and ravaged through our kaiaulu (communities). The 20213143Youth Risk Behavioral Survey shows that Native Hawaiian youth are3144particularly vulnerable to the Tobacco Industry's targeted marketing.31453146 I. Essential Public Health and Social Services: Via Cultural3147Healing Model31483149 The Ahupua`a model emphasizes relationship among people and the3150environment, identifying protective and risk factors, and promoting3151collective healing. Recognizing Native Hawaiians' holistic worldview,3152which includes strong connections and reciprocal relationships between3153the land, community, and spirituality, is key to developing effective3154healing methods The ahupua`a model provides a framework for3155implementing these interventions or methods and fostering a thriving3156Native Hawaiian Community.3157 By embracing a culturally grounded approach, we can empower and3158uplift our lahui to reclaim and celebrate the unique cultural strengths3159that have kept our people healthy and thriving for generations, leading3160to more impactful and meaningful interventions for healing and growth.3161J. Essential Public Health and Social Services: Via Traditional Healers3162 & Practitioners3163 1. Overview. POL supports the efforts of kupuna (elder) healing,3164and the organizing support of cultural masters and traditionalists3165toward the understanding, support and perpetuation of the Native3166Hawaiian healing knowledge, attitudes, values, beliefs and practices.3167POL advocates for the preservation of such traditions to ensure that3168the rights and cultural integrity of these practices are respected and3169appropriately protected.3170 2. Approach. Through community-based presentations, demonstrations,3171workshops, kukakuka (discussion) sessions and working closely with3172kupuna (elder) of the geographic area, POL seeks to improve awareness3173of and sensitivity to Hawaiian cultural processes and the philosophies3174of spiritual healing, thus assuring that they are included within the3175larger health and wellness arena. Whenever possible, POL networks and3176partners with organizations in the medical communities. The traditional3177healing program keeps apprised of both Hawai`i legislative and3178congressional actions impacting and affecting these practices, responds3179to requests and inquiries, and provides technical assistance to the3180Systems as well as other community-based organizations as requested.3181 POL welcomes kupuna wisdom to provide the support for its cultural,3182spiritual and historical foundation. This foundation seeks the3183knowledge of the source of illness which lies within our ancestral past3184and environment. The wisdom of this knowledge understands that healing3185and wellness embraces the principles and protocols of our Native3186Hawaiian cultural and healing practices and compels respect for our3187kupuna.3188 3. Declaration of Practice, June 2024, Lihu`e, Kaua`i. More than 703189practitioners and advocates of Native Hawaiian healing traditions3190gathered on Kaua`i to maintain the integrity of Hawaiian healing3191knowledge. The chairs of five elder councils of Hawaiian healing3192practitioners signed Ke Kuahaua Mauli Ola, a Declaration of Practice to3193preserve, protect and perpetuate the cultural integrity and ancestral3194traditions passed down through generations of healers. The declaration3195is a response to the growing appropriation of Hawaiian healing3196knowledge and practices by usurpers who don't genuinely understand the3197protocols, the genealogy, the community recognition, the continued3198lineage of healers, and most importantly, that healing is a spiritual3199practice.3200K. Essential Public Health and Social Services: Via Native Healthcare3201 Professionals3202 1. Native Hawaiian Health Scholarship Program32033204 a. Overview. Established within the Native Hawaiian Health Care3205 Act, the NHHSP provides awards to Native Hawaiian students3206 seeking degrees in the health care professions. The purpose is3207 to increase the number of Native Hawaiians in health and allied3208 health professions, thereby increasing access to health care3209 delivery for those who seek it. The program recruits and3210 nurtures professionals in-training for primary health care3211 disciplines and specialties most needed to deliver quality,3212 culturally competent health services to Native Hawaiians3213 throughout the State of Hawai`i. The merit-based program awards3214 scholarships dedicated to providing primary health services to3215 Native Hawaiians and communities in Hawai`i.32163217 b. Impact by the Numbers. Over the past almost three decades,3218 318 scholars via 347 scholarships awarded resulted in 2443219 program alumni in the fields of clinical psychology, dentistry,3220 dental hygiene, dietetics/nutrition, nursing, medicine,3221 physician assistant and social work. Fifty-one (51) scholars3222 are supported by NHHSP staff, thru three primary phases of3223 their journey to serving communities---education, in-service3224 and in community placement.32253226 c. Impact via Native Voices. Hear the voices of in-education,3227 in-service and alumni scholars below:32283229 (i) Scholar A, In-Education, Physician's Assistant (PA),3230 Community Area: TBD: ``The Native Hawaiian Health Scholarship3231 equips me with the financial stability necessary to excel as a3232 physician's assistant and effectively serve the rural3233 communities of Hawai'i. The scholarship alleviates my financial3234 concerns, ensuring that I can pursue my studies without the3235 burden of part-time employment after attending classes Monday3236 to Friday, 8 a.m. to 4 p.m., to cover my living expenses. While3237 the financial support is substantial, the most valuable aspect3238 of this program is the opportunity to connect and learn from3239 esteemed and future leaders in Hawaiian healthcare. The I Ola3240 Lahui lecture series provided me with invaluable insights into3241 the path to leadership as a Native Hawaiian in healthcare. This3242 scholarship not only benefits me personally but also3243 contributes to the greater well-being of the lahui by enabling3244 me to serve the community as a physician's assistant upon3245 completion of my studies.''32463247 (ii) Scholar B, In-Service, Registered Nurse (RN), Community3248 Area: Maui ``The NHHSP helped me obtain my nursing license to3249 serve my rural community of Hana, Maui. The financial,3250 emotional, and mental support allowed me to focus on my3251 education and complete my program successfully. It also lifted3252 the financial burden, allowing me to focus on my family.''32533254 (iii) Scholar C, Alumni, Family Nurse Practitioner (FNP),3255 Community Area: Kaua`i ``The Native Hawaiian Health Scholarship3256 Program has been invaluable to me and my family. Without this3257 scholarship I would not have pursued my Master's degree and3258 would never have become a nurse practitioner serving as a3259 primary care provider and hospice/palliative care provider for3260 my community. Had I not received this scholarship I would have3261 had to decline my acceptance to the Master's program because it3262 was going to be near impossible to afford my tuition as I would3263 have had to quit my full time job and become a full time3264 student. I was also making a choice between purchasing a home3265 (remaining an RN) and pursuing my education (becoming an APRN).3266 When I received the notification of my acceptance for the3267 Scholarship program my family and I were overjoyed as we felt3268 that the decision was made for us and my education was what I3269 was meant to pursue. The scholarship program afforded me the3270 ability to become a full-time student and still be able to help3271 care for my then 3 year old son. The primary challenge I had3272 with the scholarship program was related to taxes the years3273 following my award. However, through the help of an accountant3274 I was able to file correctly and was able to afford the taxes3275 in the end. This was such a small bump in the road compared to3276 the hurdles I faced going to school and being able to afford to3277 provide for my family as well as afford my tuition. I am3278 grateful for this program and feel blessed to continue to be3279 able to be a part of the community it helped me to find.''32803281 (iv) Scholar D, Alumni, Masters in Nursing (MSN), Community3282 Area: Moloka`i ``The NHHSP assisted my Masters In Nursing3283 Program from 2011-2013. Because of the assistance of this3284 program, I was able to obtain a management position as a Branch3285 Coordinator of the only Home Care Agency on the island of3286 Molokai serving a majority of the Hawaiian Population. I am3287 fortunate to serve the people on a rural island and community3288 who lack the medical resources other islands are privileged to.3289 Because of this scholarship, I have been able to make a3290 difference in my community.''32913292 (v) Scholar E, Alumni, Bachelor of Science in Nursing (BSN),3293 Community Area: Maui, Moloka`i: ``I was a registered nurse3294 working at Hui No Ke Ola Pono, Inc. The NHHSP allowed me to3295 pursue my BSN degree while continuing to work full time. I3296 continued to work for Hui No Ke Ola Pono, Inc. serving the3297 Native Hawaiian community. The BSN degree allowed me to move3298 back home to Moloka` and serve the community that helped to3299 raise me. I had the privilege and honor to work with Dr.Aluli,3300 the person who had been instrumental in obtaining the Native3301 Hawaiian Health funding and testified in Washington DC to3302 advocate for the health of our lahui. In my current position, I3303 am able to advocate for our island and help to find solutions3304 for our island's health needs. All this was possible first to3305 Ke Akua for opening the doors and providing the open door to3306 the NHHSP.33073308 2. Department of Native Hawaiian Health, John A. Burns School of3309Medicine, University of Hawaii--Manoa \16\3310---------------------------------------------------------------------------3311 \16\ Presentation to the Board of Trustees of the Office of3312Hawaiian Affairs by DNNH, JABSOM, May 1, 202533133314 a. Overview. For the past five decades, Ho`ona`auao, the3315 medical education division, has been dedicated to developing3316 physicians who are committed to improving the health of Hawai`i3317 through the `Imi Ho`ola Post-Baccalaureate Program and the3318 Native Hawaiian Center of Excellence. Over 350 physicians (383319 percent NH) who serve communities across Hawaii, the Pacific,3320 and the continental U.S., were produced by the program and in3321 the current year, 52 medical students currently enrolled, 473322 pre-medical students preparing to apply to medical schools and3323 2,300 K-12 students engaged through recruitment and outreach3324 events.3325 b. Executive Order Impacts. The following information was3326 shared with the Board of Trustees at the Office of Hawaiian3327 Affairs:3328 Already Lost33293330 Stop order on 20yr+ NIH longitudinal grant on diabetes ($208K/3331 year)3332 Discontinuation of biomedical sciences mentorship pathway3333 program ($2SOK/year)3334 Minority Health Training Grant for students in health sciences3335 (New--$270K/year)3336 Loss of data infrastructure and specialized research staff33373338 At Risk33393340 Current Funding: $5.4M3341 Pending Funding: $6.6M3342 Disruption/halt of health research for Native Hawaiians3343 Reduced support for NH students pursuing medicine, behavioral3344 health, and health science careers3345 Disruption of partnerships with NH communities33463347 Future Outlook3348 Declining rates of NH student recruitment into health fields3349 Reduction of community-based clinical and health science3350 outreach3351 NH will experience widening health inequities without a voice3352 in academic medicine3353 Loss of informed health policy regarding Native Hawaiians33543355L. Essential Public Health and Social Services: Via Education3356 Collaborations3357 POL collaborates with other sectors, including education, resulting3358in the United States Department of Education, Native Hawaiian Education3359Program, \17\ award in 2001, a grant to POL, totaling $1.879 million3360for the Resilient Communities, Families and Schools project. Also known3361as the `Ohana (Family) Resilience Program, approximately 20 community-3362based vendors were contracted, serving sites included in communities3363near community health centers on the islands of Hawai`i (in the3364communities of Mountain View, Honaunau, West Hawaii, East Hawaii) and3365O`ahu (in the communities of Waianae, Waimanalo) to ensure equitable3366access to disadvantaged communities by strengthening community3367partnerships, promoting trauma sensitive practice and enhancing3368coordination of wrap-around prevention/intervention services for3369children and families.3370---------------------------------------------------------------------------3371 \17\ To address and support the educational needs of Native3372Hawaiians, as demonstrated through the 1983 Native Hawaiian Educational3373Assessment Report, Congress enacted the Native Hawaiian Education Act3374(NHEA)3375---------------------------------------------------------------------------3376 POL, Native Hawaiian Health Care System, Hawai`i Department of3377Education, University of Hawai`i Hilo Center for Place-Based3378Socioemotional Development, Hawai`i Afterschool Alliance, Ceeds of3379Peace, and HawaiiKidsCAN committed to support five (5) Title I3380elementary schools located in rural and remote communities where3381poverty, substance abuse and unemployment are pervasive with limited3382access to health and further education. On average, 69 percent of3383students identify as Native Hawaiian or Pacific Island ancestry and 903384percent of students are eligible for free and reduced lunch.3385 Accelerating the unique challenges of rural and remote places,3386COVID-19 exacerbated existing stressors on youth, family and3387communities. In response to the impacts of COVID-19, the purpose of the3388resiliency hubs for communities, families and schools, was to promote3389equitable access to education by empowering schools in disadvantaged3390and/or rural communities to strengthen community partnerships, promote3391trauma sensitive practice and enhance coordination of wraparound3392prevention/intervention services for children and families.3393III--Continuing Needs, Implementing Master Plan Recommendations and the3394 Native Hawaiian Health Network3395A. Continuing Needs3396 Despite Congress' declaration that it is the policy of the United3397States in fulfillment of its special trust responsibilities and legal3398obligations to the indigenous people of Hawaii, health disparities3399persist and programming needs in the following areas are at risk:34001. SAMHSA Emergency Response Grants (HHS>SAMHSA)3401 Currently in Year 2 of the implementation of SERG grants (beginning3402November 2024), and the six-month period reporting in progress,3403emerging data includes (pending final review and confirmation): over34045,400 families served in the community, associated with almost 14,4003405individuals; about 4,400 urgent trauma and mental health clinical3406appointments; almost 475 events, over 3000 non-clinical appointments;3407over 90 training sessions attended by almost 1,700 local professionals;3408and over 140 unduplicated organizations.34092. Rural Health Disparities in Hawai`i'--Native Hawaiian Health Systems3410 (HHS, HRSA>BPHC, Federal Office of Rural Health Policy)3411 The following plain language summary is provided by the Economic3412Research Organization at the University of Hawai`i report ``Rural3413Health Disparities in Hawai`i'', \18\ published in August 2024:3414---------------------------------------------------------------------------3415 \18\ Rural Health Disparities in Hawai`i--UHERO, retrieved May 12,3416202534173418 ``Health can be different in rural and city areas for many reasons.3419For example, rural places might not have as many healthcare services.3420This makes it harder for people to get good care. But rural areas are3421closer to nature and often have close communities. This can be good for3422health. Studies on how rural living affects health in the US have shown3423mixed results. There have not been any studies for Hawai`i before. This3424report looks at health differences between rural and city areas in3425Hawai`i. We used data from a health survey done in June 2023: the UHERO3426Rapid Survey. We looked at things like age, gender, race/ethnicity,3427income, education, and disability to see how they relate to health and3428rural living. We found some big differences in health between rural and3429city residents in Hawai`i. Living in a rural area was strongly linked3430to overall health. The effect was bigger for physical health than3431mental health. People with disabilities and people with low incomes in3432rural areas faced the biggest health differences. Our findings suggest3433that health policies should aim to reduce differences between rural and3434city areas. It is especially important to help groups like people with3435disabilities and people with low incomes in rural areas. These groups3436---------------------------------------------------------------------------3437need additional support.''34383439 Continuing supports via NHHN organizations (POL, Systems, FQHCs,3440CHCs, CBOs, NHOs, universities, State of Hawaii) can collectively3441address rural health disparities.34423.Disproportionate Representation in Programs that Address the Health,3443 Safety and Self-Sufficiency of Native Hawaiian Families \19\3444 (HHS>CMS)3445---------------------------------------------------------------------------3446 \19\ Audit, Quality Control & Research Office Research Staff.3447(2024). Databook. State of Hawaii Department of Human Services. https:/3448/humanservices.hawaii.gov/wp-content/uploads/2025/04/DHS-Databook-3449FY2024.pdf3450---------------------------------------------------------------------------3451 a. 33 percent of Temporary Assistance for Needy Families (TANF)3452clients in June 2024 were Native Hawaiian. This is higher than3453Hawaiians' proportion of the total state population of 21 percent.34543455 b.In State Fiscal Year (SFY) 2024, 39.7 percent of confirmed3456victims of child abuse or neglect were Hawaiian.34573458 c.In the same year, 41.6 percent of children in foster care are3459Native Hawaiian.34603461 d.42.8 percent of incarcerated youth were Hawaiian.34623463 e.Total Hawaiian population currently receiving Medicaid equals3464almost 77,000 which represents 19 percent of all Med-QUEST members;3465almost 26,000 (34 percent), children including over 1,400 current and3466former foster care children; over 400 pregnant women; over 14,000 (183467percent) parents or caretakers; about 26,500 (34 percent) adults; about34688,800 (11 percent) aged, blind or disabled adults; and over 1,100 other3469individuals.34704.Missing and Murdered Native Hawaiian Women and Girls \20\ (HHS>HRSA)3471---------------------------------------------------------------------------3472 \20\ Cristobal, N. (2022). Holoi a nalo Wahine `Oiwi: Missing and3473Murdered Native Hawaiian Women and Girls Task Force Report (Part 1).3474Office of Hawaiian Affairs; Hawai`i State Commission on the Status of3475Women: Honolulu, HI.3476---------------------------------------------------------------------------3477 Pursuant to H.C.R. 11, the Hawai`i State Commission on the Status3478of Women (CSW) convened a Task Force to study Missing and Murdered3479Native Hawaiian Women and Girls (MMNHWG). The Missing and Murdered3480Native Hawaiian Women and Girls Task Force (MMNHWG TF) was administered3481through the Hawai`i State CSW and the Office of Hawaiian Affairs and3482was comprised of individuals representing over 22 governmental and non-3483governmental organizations across Hawai`i that provide services to3484those who are impacted by violence against Kanaka Maoli.3485 The MMNHWG TF had the responsibility of understanding the drivers3486that lead to Kanaka Maoli women and girls to be missing and murdered,3487to propose solutions, and to raise public awareness about violence3488against Kanaka Maoli.3489 The findings and recommendations in the report were provided to3490members of the MMN-HWG TF for review and their insights were included.3491Any disparate agreement with the findings and recommendations will be3492noted.34933494 a. 21 percent of Hawai`i's total population (N= 1,441,553)3495 identifies as Native Hawaiian (U.S. Census Bureau, 2021).34963497 b. 10.2 percent of the total population of Hawai`i identifies3498 as a Native Hawaiian female, with 47.6 percent of this3499 population identified as females under the age of 18 (U.S.3500 Census Bureau, 2021).35013502 c. More than a quarter (1/4) of missing girls in Hawai`i are3503 Native Hawaiian (JJIS, 2001 2021).35043505 d. Hawai`i has the eighth highest rate of missing persons per3506 capita in the nation at 7.5 missing people per 100,0003507 residents (Kynston, 2019).35083509 e. The average profile of a missing child: 15 year old, female,3510 Native Hawaiian, missing from O`ahu (MCCH, 2022).35113512 f. The majority (43 percent) of sex trafficking cases are3513 Kanaka Maoli girls trafficked in Waikiki, O`ahu (Amina, 2022).35143515 g. 38 percent (N= 74) of those arrested for soliciting sex from3516 a thirteen-year-old online through Operation Keiki Shield are3517 active-duty military personnel (Hawai`i Inter net Crimes3518 Against Children Task Force, 2022).35193520 h. In 2021, the Missing Child Center Hawai`i (MCCH) assisted3521 law enforcement with 376 recoveries of missing children. These3522 cases are only 19 percent of the estimated 2,000 cases of3523 missing children in Hawai`i each year (MCCH, 2021).35243525 i. On Hawai`i Island, Kanaka Maoli children ages 15-17,3526 represent the highest number of missing children's cases, with3527 the most children reported missing in area code 96720, Hilo3528 (Hawai`i Island Police Department, 2022).35293530 j. From 2018-2021, there were 182 cases of missing Kanaka Maoli3531 girls on Hawai`i Island, higher than any other racial group (N=3532 1,175) (Hawai`i Island Police Depart-ment, 2022).35333534 k. 57 percent of participants served through the Mana`olana3535 Program at Child & Family Services are Native Hawaiian females3536 who have experienced human trafficking (Ma na`olana, CFS, 2021-3537 2022).35383539 Continued collective, systemic and community-based efforts are3540needed to address MMINHWG issues.3541B. Implementing Recommendations of E Ola Mau--Native Hawaiian Health3542 Master Plan (HHS, HRSA)3543 1. E Ola Mau 2023 Recommendations Overview. \21\ The E Ola Mau3544(EOM) report (NHH Master Plan) provides comprehensive recommendations3545aimed to address and improve the overall well-being of the Native3546Hawaiian community. It is generated through the efforts and commitment3547of a multidisciplinary collective of practitioners across the pae3548`aina. The structure of the 2023 report followed the key areas of3549health and well-being covered in the earlier report, including the new3550addition of recommendations made in the racism, data governance, and3551workforce development chapters. The recommendations emphasize the3552importance of integrating Native Hawaiian culture with modern3553healthcare systems to create a holistic approach to well-being. This3554includes increasing the availability of culturally appropriate services3555and resources, and supporting community-based efforts.3556---------------------------------------------------------------------------3557 \21\ https://www.papaolalokahi.org/wp-content/uploads/E-Ola-Mau-35582023-Recommendations-all-workgroups.pdf, retrieved May 12, 20253559---------------------------------------------------------------------------3560 Additionally, the report advocates for a strengths-based approach3561to wellness, increased monitoring and evaluation of the3562recommendations, and interdisciplinary collaboration. The overarching3563goal of these recommendations is to reduce health disparities and3564promote a healthier, more vibrant future for Native Hawaiians.3565 2. Racism & Well-Being. EOM teams reviewed the literature3566connecting racism with each chapter (e.g., oral health, behavioral3567health, historical and cultural context) that existed in previous EOM3568reports and identified specific recommendations for each section. While3569this chapter is new to the 2023 report, racism has been implicit in the3570previous reports. Recommendations from 1985 called for culturally3571sensitive approaches to health programs and interventions and the need3572to address Native Hawaiian concerns relating to land, urbanization, the3573justice system, self-determination, economic self-sufficiency,3574environmental protection, education, housing, transportation, energy,3575historical and archaeological sites, lawai`a `ana (fishing), mahi`ai3576`ana (farming), and language and culture. The 2019 report called for3577disaggregated data, Kanaka workforce development, and more culturally3578grounded ways of supporting Native Hawaiian health There are3579recommendations for: Racism: Historical & Culture Perspectives; Mental3580and Behavioral Well-Being; Medicine; Nutrition, Oral Health, Data3581Governance, Workforce Development, Resilience; and Mental & Behavioral3582Wellbeing; Nutrition, Policy & Advocacy; and Community Education.3583C. Native Hawaiian Health Network (HHS>HRSA, SAMHSA, CMS)3584 Continuing the work of the collective, the Native Hawaiian Health3585Network (NHHN), is vital for raising the health status of Native3586Hawaiians and Hawai`i, and POL, the NHHB, acknowledges the following3587organizations and the long standing commitment to Hawai`i's3588communities:35893590 1. The Native Hawaiian Health Care Systems35913592 a. Ho`ola Lahui Hawai`i--Kaua`i Community Health Center, also a3593 federally qualified health center.3594 b. Ke Ola Mamo, island of O`ahu;3595 c. Hui No Ke Ola Pono, island of Maui;3596 d. Na Pu`uwai, islands of Molokai and Lana`i; and3597 e. Hui Malama Ola Na `Oiwi, Hawai`i Island.35983599 2. Federally Qualified Health Centers (island), alphabetically and3600with multiple sites and modes within their communities \22\3601---------------------------------------------------------------------------3602 \22\ https://npidb.org/organizations/ambulatory_health_care/3603federally-qualified-health-center-fqhc_261qf0400x/hi/, retrieved May360412, 202536053606 a. Community Clinic of Maui (Maui)3607 b. Hamakua-Kohala Health (Hawai`i Island)3608 c. Hana Health (Maui)3609 d. Kalihi Palama Health Center (O`ahu)3610 e. Ko`olauloa Health Center (O`ahu) f. Kokua Kalihi Valley3611 Comprehensive Family Services (O`ahu)3612 g. Lanai Community Health Center (Lana`i)3613 h. Molokai Ohana Health Care (Molokai)3614 i. Wahiawa Center for Community Health (O`ahu)3615 j. Waianae Coast Comprehensive Health Center (O`ahu)3616 k. Waikiki Health Center (O`ahu)3617 l. Waimanalo Health Center (O`ahu)3618 m. West Hawaii Community Health Center Inc. (Hawai`i Island)3619 n. WHCHC Hawaii Island Community Health Center (Hawai`i Island)36203621 3. Community Health Centers3622 CHCs are the cornerstone of the health care system in Hawai`i,3623providing essential services to the most vulnerable populations. CHCs3624are non-profit organizations, and exist in federally-recognized areas,3625where residents have barriers to getting health care. They also3626actively reinvest in the development of the communities they operate3627in. A comprehensive array of services including: primary medical care,3628behavioral/mental health care, dental services, diagnostic services,3629prescription drugs, case management, language assistance, culturally-3630competent and sensitive care, health education, including nutrition3631counseling, and assistance with program applications, including housing3632and cash assistance. \23\3633---------------------------------------------------------------------------3634 \23\ https://www.hawaiipca.net/what-is-a-chc, retrieved May 12,363520253636---------------------------------------------------------------------------3637 4. State of Hawaii, Department of Health and Department of Human3638Services3639 Both department are integral to working with each other and the3640community at large to accomplish public health goals and objectives.3641 5. Native Hawaiian Organizations3642 POL, the NHHB, recognizes the almost 200 NHOs currently on the U.S.3643Department of the Interior, Office of Native Hawaiian Relations'3644Notification List \24\ which are vital, community and cultural3645connections to the Native Hawaiian community.3646---------------------------------------------------------------------------3647 \24\ https://www.doi.gov/sites/default/files/documents/2025-04/3648nhol-complete-list-final-web.pdf, retrieved May 12, 20253649---------------------------------------------------------------------------3650 6. Community Based Organizations3651 Too numerous to name organizationally, the network of CBOs3652intersect with all of the above named and includes community3653collaborators in education, health, housing, social services, land and3654ocean at all governance levels--community, county, state, federal,3655international.3656 POL, the NHHB, acknowledges all who have been and/or are a part of3657the NHHN, individually and organizationally, and welcome all and3658commits to strengthen the health status of NHs and Hawai`i.36593660 The Chairman. Thank you very much, all of you. We3661appreciate your testimony and what you bring to the3662conversation here today.3663 I want to start with tribal consultation, because it has3664been mentioned by Chairwoman Alkire and Loni Greninger as well.3665I think all of you reference it, and again, we are seeing3666changes that are going on. I believe it was you, Chairwoman,3667that indicated that a letter had been sent urging tribal3668consultation in light of the reductions in staffing and the3669cuts.3670 I am assuming that if there has been response to that, that3671initial consultations have yet not been made. Can you clarify3672for me where we are on that?3673 Ms. Alkire. Yes. I just want to say thank you to the ladies3674here also. We come here to make these statements, and thank3675you, Committee, for hearing what we have to say.3676 But we know really what we have to say has to come from our3677heart. Our people have always struggled with the fact of3678consultation. And I think all our organizations, we send these3679letters but we haven't heard anything yet. And I think that is3680the issue. And that is the issue I think all of America is3681dealing with, with all these issues that we have these are3682saving lives.3683 The consultation for tribal leaders and those involved with3684these grants that are receiving these grants and implementing3685these programs out in the rural communities, that is the voices3686that need to be told how important these programs are that save3687the lives for our people.3688 The Chairman. And that is why we are having this3689conversation with you, representing the many voices within,3690from your tribes, tribal communities, your regions. As I3691mentioned, Secretary Kennedy was before the Health Committee3692today and it is very important for him to be there to be3693presenting the budget as we know it at this point in time.3694 But this feedback is so necessary. We have talked about, we3695are seeing what is happening with the proposals for3696consolidation, the Administration for a Healthy America will3697consolidate the Office of Assistant Secretary for Health, HRSA,3698SAMHSA, ATSDR, NIOSH, and so many of these agencies that are3699really very critical to the services that are provided to our3700tribal communities.3701 So what I am hearing is they are acting first, you are3702responding, saying we need to know what is going on, and true3703consultation is not a responsive action. It is being there at3704the beginning so that some of this input, the imperative of3705Tribal Head Start, the imperative of FVPSA, the imperative of3706LIHEAP, that that is factored in before the decisions are being3707made.3708 So I want to make sure that for the record, what we are3709hearing from you as leaders in your respective areas is that3710that outreach is yet to be had. Is that probably correct? I see3711everybody nodding their heads.3712 Vice Chair Greninger, I want to ask, because you have great3713detailed insight into the ACF Tribal Advisory Committee, given3714your role there. Given the reduction of tribal engagement staff3715that we are seeing there at ACF, going from five to now just3716two, and then the loss of the regional tribal program leads,3717what is this meaning on the ground for you? You mentioned the3718consolidation within the regions, so Alaska, Washington, and3719some of the other impacted areas are now reporting into Denver.3720 Just quickly, what is the impact of all of this? What do3721you think is needed to restore effective tribal advisory3722functions during this reorganization? Because we have a3723reorganization going on. It is just pretty public here. Tribal3724advisory role is pretty key.3725 How do we make this more effective?3726 Ms. Greninger. Those are great questions. So the effect of3727what we are seeing now with the RIFs, those particularly five3728advisory staff that you are talking about come from the ACYF3729within ACF. So they were the ones who were actually helping ACF3730leadership-wide be able to understand tribal nuances, what does3731it take for us to participate in grants.3732 It was also helpful in the consultation setting where we3733could help form agendas together, make it a collaborative3734process rather than just it is a one-sided Federal process.3735Consultation is both of us coming together, right?3736 So with the RIFs of those particular staff, what is walking3737out the door is tribal nuance knowledge, institutional3738knowledge and then intimacy with the tribes. All of that, all3739of the advisory is walking out the door, unfortunately. So we3740are left behind with staff who maybe have minimal knowledge or3741no knowledge, and they are learning it as they go. And it takes3742a long time to understand tribes.3743 So that is one of the areas that I have a huge concern3744about.3745 But what can it take in the meantime? Gosh, if we could get3746those staff back. I don't know what process that would take.3747But if we can get those particular staff back, that would be3748wonderful.3749 And having the consultation process may be ACF specifically3750with tribes, HHS broadly with tribes, each branch of HHS with3751tribes, so we can dig into those particular programs and those3752nuances, that is going to be most helpful, because we have lost3753those advisory staff.3754 The Chairman. I know I am over my time, but I think this is3755a question that my colleagues would agree is worth drilling3756down on. Because the Secretary has said to individuals within3757HHS that have been RIFd, terminated, that if they so desire,3758they can move over within the IHS sphere. Does that make sense?3759Or are you talking about levels of expertise where a body just3760isn't a body?3761 Ms. Greninger. That is a great question. I would be3762concerned that IHS becomes all things Indian for HHS because3763IHS is strictly about health. When HHS programs in tribes, it3764is all HHS offices. So I need expertise in each branch of HHS.3765 The Chairman. Very good. Thank you.3766 Vice Chair?3767 Senator Schatz. Thank you, Chair Murkowski. It occurs to3768me, obviously you are the Chair and you can tell us how to work3769together on a bipartisan basis, but it seems to me this hearing3770is calling for some follow-up and using the convening authority3771of the Senate Committee on Indian Affairs. Because nobody is3772talking to anybody.3773 We could suppose how things might work better and we might3774have some pretty good ideas, but it starts with you knowing who3775to call and that person having any authority or knowledge at3776all. So I am not a believer of, just get everybody into a room3777and it is going to work out, but I do think that is probably a3778necessary condition for success, that we start to have a3779dialogue and know who our points of contact are and kind of3780what the path forward is.3781 I commit to you, Chair, I do my fair share of partisan3782fighting, this is not the place for that. I will try to make3783sure that we keep it on the substance of the matters. Thank you3784for your leadership here.3785 Dr. Daniels, welcome. Papa Ola Lokahi is authorized to3786coordinate health care programs and services for Native3787Hawaiians, subcontracting with Native Hawaiian and community3788health organizations. Are there any other entities authorized3789to do this work under the statute?3790 Dr. Daniels. There are no other entities.3791 Senator Schatz. So as the only entity coordinating care for3792Native Hawaiians across the State, what is your service3793population and what happens if HRSA's funding gets cut?3794 Dr. Daniels. Our service population is targeting Native3795Hawaiians, although because we get Federal dollars, we cannot3796limit access. So it is community.3797 Just in our five Native Hawaiian health care systems, we3798are serving over 70,000 individuals at touch points. That is3799clinical, non-clinical, that is outreach. We know in our3800communities face to face going out to where they are, that is3801what we know we have to do. Traditional practices, all of those3802things roll up into those numbers.3803 That does not include our network partners. So it is not3804just the five systems. Papa Ola Lokahi actually reaches out and3805we contract with other FQHCs. So we recognize we can't be the3806do-all and be-all, that our community doesn't only see one type3807of provider. So reaching out to the FQHCs, our community health3808centers, our hospital and institutions, we are creating3809bridges, we are partnering with them. But also our community3810based organizations across the State.3811 So adding those numbers in, those touch points grow. And we3812know that that is how our community gets help, and accesses3813care. And to adjust that to already be fearful about cuts in3814funding, people are scared and nervous.3815 And having those reach-outs allow us to one, keep a pulse3816on what is happening with our community, so that we can report3817back. But also then we can get the stories, which we did3818provide in our written testimony, from communities in all3819different areas.3820 Senator Schatz. Thank you.3821 Everyone is tracking that there is a House bill that will3822cut Medicaid by about $700 billion. There are carve-outs for3823Alaska Native and Indian tribes. There are no carve-outs for3824Papa Ola Lokahi or for Native Hawaiian health. I am wondering3825if you could speak to the impact of Medicaid cuts for Native3826Hawaiians.3827 Dr. Daniels. Good question, Senator. I want to say this,3828because I think that one comment was, we speak from our heart.3829The fact that there is an exclusion of Native Hawaiians is3830unacceptable. That should stir something in all of us, that we3831talk about being Native communities, yet we exclude. And that3832is not acceptable.3833 So just at the offshoot, the exclusion of Native Hawaiians3834in that House carve-out, it perpetuates the belief that within3835departments and agencies that we do not exist. And I am sure3836some of our other tribal communities might feel that way, these3837moments of not existing. And we cannot perpetuate that.3838 But I think the biggest pieces is in passing these,3839imposing these new hurdles, that is what I am going to call3840them. It is just that, they are hurdles. They impact3841eligibility, they slow access to identification of needs, they3842slow access to services. We don't need any more slowdowns.3843 And specifically, if you talk about the work requirements,3844employment is one of the social determinants of health. And if3845we are talking these things, we are saying these things, all of3846this adds to our community and the people we work with.3847 Already, Native employment rates are among the lowest in3848our State. And you couple that with the highest health3849disparities. Doesn't look good, it doesn't fit. And so3850basically health plus employment are seen as separate issues,3851and they are not. They are tied in together. Employment equals3852health and health equals employment.3853 Senato Schatz. Thank you. There are a lot of very valid3854complaints about the health care system. I have never met a3855single soul who has asked for more paperwork, and that is a lot3856of what the House bill does.3857 The Chairman. So, Senator Lujan was actually here first,3858but he just kind of walked in. If you want to catch your breath3859and let Senator Smith go.38603861 STATEMENT OF HON. TINA SMITH,3862 U.S. SENATOR FROM MINNESOTA38633864 Senator Smith. Thank you, Chair Murkowski, and Vice Chair3865Schatz, for this hearing today. And thank you so much to all of3866you for being here and for providing your testimony.3867 I think that now is a very good time to be talking about3868HHS programs and how they should be benefiting Naive people as3869part of our trust and treaty responsibilities, and to3870acknowledge that what the Trump administration is doing, what3871Secretary Kennedy is doing, and gutting and reorganizing, the3872department is directly hurting communities, Native communities3873in this process.3874 I think it is so ironic, because during his confirmation3875process, Secretary Kennedy talked a lot about being a champion3876for Native people. He talked about his own father; he worked3877hard to build his reputation for being a leader who was going3878to keep Native people in his mind. But yet in his role so far3879the reality has been very different.3880 I am really struck by the stunning lack of consultation3881that you all have described in your testimony. And again, we3882all know here that that tribal consultation is not an optional3883thing to do because it is nice to do, it is part of our legal3884trust and treaty responsibilities, recognizing your sovereign3885nation status to do that.3886 So whether it comes to suicide prevention or HIV prevention3887or ICWA or elder programs, all of these are vital to the health3888and well-being of Native communities. God knows, IHS needs3889reform and improvement and more funding. But to be clear, that3890is not all that we are talking about here.3891 So I am grateful for this hearing and the opportunity to3892talk about this. Because I think in many cases, I know from the3893nations that I represent in Minnesota that these are issues of3894life or death and have such direct consequences on what happens3895to people and their lives.3896 So I want to follow up, I appreciated very much the3897question that Chair Murkowski sneaked in at the end of her3898time, I want to just follow up on that. There has been this3899information about how senior career officials who are tobacco3900regulators, research scientists and others at NIH, as those3901jobs are being eliminated, have been offered jobs in far-flung3902locations in IHS. As I was reading this, I found this offensive3903to the individuals who don't have, and these are clinical jobs3904for the most part, I think. And that these clinical jobs would3905be offered to be filled where we already have such a great3906shortage of staff and people with folks that don't have3907clinical experience.3908 So I want to just ask any witness if you could comment on3909this, what impact do you see this has? And how do you view this3910from your perspective? I will just open that up to anybody.3911Chair Alkire, would you like to take this?3912 Ms. Alkire. Yes. In preparation for coming here, all of us3913ladies here, we all have an area. One of the things in my3914regard was to talk to our CEO at our IHS facility, and talk3915about the impact that it has had in regard to staffing and the3916loss of providers. I am glad that Secretary Kennedy is going3917ahead and letting up a little bit on the hiring freeze, but it3918needs to be across the board, especially for those types of3919providers that we need, to provide that health care.3920 The staffing is so important for these facilities. It is3921even like, if we can't even hire a maintenance janitor, that3922means the hospital is not safe. These kinds of basic things.3923 Senator Smith. Of course.3924 Ms. Alkire. So yes, I think all the ladies could agree on3925that. There is a huge need.3926 Senator Smith. And sending a research scientist who3927specializes in tobacco cessation research to an IHS facility3928when what is needed is not research but clinical care doesn't3929really solve any problem, does it?3930 Ms. Greninger. May I?3931 Senator Smith. Yes, please.3932 Ms. Greninger. I think one thing we also need to remember3933is when we are eliminating researchers, tribal researchers in3934particular, now we are talking about another historical issue3935of concern.3936 Senator Smith. Yes.3937 Ms. Greninger. Research has been used against tribes and in3938unethical ways, it has been implemented in our communities. So3939if we are going to be eliminating positions of research that3940have that tribal nuance and that knowledge --3941 Senator Smith. That is right, it is kind of a double3942whammy.3943 Ms. Greninger. Absolutely. And the nexus for programs and3944ACF, I have actually, in this last budget consultation last3945month with HHS, I was wondering, how can I make a better3946connection between NIH and ACF programs? Because data is huge.3947That is a huge issue for us. Child welfare data, especially3948when we have children in the State systems.3949 Senator Smith. Right.3950 Ms. Greninger. And in our own systems. So to hear that3951those particular positions were also being eliminated, just3952because I am not in NIH intimately doesn't mean I am not3953concerned and I don't see the connection to other programs3954across HHS and my tribal community.3955 Senator Smith. Thank you very much. Thank you very much,3956Chair Murkowski.3957 The Chairman. Thank you. Senator Cortez Masto?39583959 STATEMENT OF HON. CATHERINE CORTEZ MASTO,3960 U.S. SENATOR FROM NEVADA39613962 Senator Cortez Masto. Thank you, Madam Chairwoman.3963 Can I jump back, Dr. Daniels, I want to touch on something3964that you were, a conversation you were engaging with Senator3965Schatz. FQHCs. Medicaid funding to FQHCs is in jeopardy. If3966they don't get their funding, they could close their doors.3967Most people don't realize, in Nevada we have 28 federally3968recognized tribal communities. Not every one of my tribal3969communities has a health center. They just can't afford it.3970They just can't do it.3971 So they rely on FQHCs. And sometimes those FQHCs are a two-3972hour drive for them.3973 So we are not just, a carve-out, which we talked about, is3974not enough. It is really important that we provide a system of3975health care for our tribal communities, indigenous communities,3976that the can not only access, that is reliable, that is3977affordable.3978 So can you talk a little bit about these Medicaid cuts? It3979is not just the impact to tribal communities themselves, but3980surrounding communities where there is a system of health care3981that could be devasted, particularly in our rural communities.3982If you would touch on that?3983 MS. Daniels. Absolutely. I think you brough up a very good3984point, that it is just not the Medicaid. Because if FQHCs or3985others are impacted, it also includes the retention and3986recruitment of staff. But then they can't, we have several3987FQHCs that are in high rural areas that they supplement housing3988for those providers.3989 We have one island that access to it is on little nine-3990seater planes. And providers are coming in. Those things are3991all going to be impacted.3992 So then, where does our community go? Off-island? We3993already have health deserts. Not the same way as I think South3994Dakota, but similar. We have water between the islands, but3995when pregnant women can't give birth on the islands, how does3996that--so we already now are eliminating another access point.3997 Senator Cortez Masto. That is right.3998 Dr. Daniels. That is a challenge.3999 The one thing that we recognize is the network. So I think4000oftentimes FQHCs and other health entitles are siloed. We do4001what we do in our community and that is it. And we have4002recognized that we no longer can do that. That if resources go4003down, we are going to need each other, and to support and pool4004our resources so we can continue to serve our community.4005 But when those keep getting like pinned off, it is really4006hard to keep doing that. Then our communities grow. And our4007providers don't grow. There is still only a handful. But the4008number that is coming grows.4009 So I think it is all of these domino effects, when we start4010picking up, and it might seem very minimal that we are going to4011adjust or take off on Medicaid on things, but then we might not4012see it today or tomorrow, but we are going to see it as people4013start having to close, not even close doors, but close4014services. Maybe they are not doing the five types of services,4015maybe it is only two. And that becomes a problem.4016 For us, then we start looking at if that service isn't4017provided on their island, where do they go? And do they have4018access to pay for a $200 ticket to fly to the next island?4019 Senator Cortez Masto. Right. And it is the same, listen, it4020is the same in rural communities as well. In Nevada, sometimes4021you have to drive four hours just to get access to health care.4022That is if you have a car, and you can get off work to be able4023to access it.4024 So it is a system that will shut down that is essential for4025providing health care that quite honestly, you have worked so4026hard to put together because of a lack of resources and a lack4027of providers and a lack of geography that brings everybody4028together like you have in an urban area.4029 I appreciate this. I want to touch on--my time is running4030out--mental health. Mental health. I cannot stress this enough.4031I am so concerned about the cuts to mental health services that4032we fought for in our communities.4033 There is a program called Native Connections. I know about4034it because in my State, I have talked with so many of my Native4035community members, there is a nine-year old girl in Nevada,4036Urban Indians, who is struggling with mental health. She did4037not, could not get the care from the school or a pediatrician.4038But it was the Native Connections program that, according to4039her father, got his daughter back. It is a Native Connections4040program.4041 So I don't know if any of you are familiar with it or if4042you could talk about it. But please stress the importance of4043why funding for programs, particularly on this mental health4044and Native Connections, is so important.4045 Ms. Alkire. Thank you. I am so glad you brought that up.4046So, it is clear to me that programs like Native Connections4047save lives. Thank you for that. From my tribal community, two4048last week, two suicide ideations happened with a fifth and4049sixth grader. These programs are so important right now to save4050lives.4051 So suicide rates for Native youth are four times higher4052than any other racial or ethnic group. Native Connections4053allows awardees to tailor culturally appropriate programming to4054reduce suicide, substance use, and impact of trauma in tribal4055communities. Native Connections empowers Native youth by4056strengthening community ties and providing, as I said,4057culturally responsive support.4058 Through this program, youth engage in models that promote,4059through protective factors, like personal wellness and positive4060self-image, and a strong sense of cultural identity. Without4061this funding, intervention and support services for Native4062youth will become even more limited.4063 This puts Native youth, many of whom experience4064discrimination, trauma, and loss of loved ones, at greater risk4065for resources available for them to heal. So I think it is so4066important, life-saving. So thank you for that question.4067 Senator Cortez Masto. Thank you. Thank you, Madam Chair.4068 The Chairman. Senator Lujan?40694070 STATEMENT OF HON. BEN RAY LUJAN,4071 U.S. SENATOR FROM NEW MEXICO40724073 Senator Lujan. Thank you, Madam Chair. And thank you and4074Vice Chair Schatz for this important hearing.4075 To each of our honorable and distinguished witnesses, thank4076you for taking time to be here away from other4077responsibilities, and especially from home. I know that this is4078not easy.4079 Madam Chair, before I begin, being more aware that4080Secretary Kennedy would have liked to have been here and that4081his staff may be here, or may be watching, I want to point out4082what a disappointment I believe this administration has been to4083the Indian Health Services. Recently, when Secretary Kennedy4084was in Winter Rock, Arizona and in Gallup, New Mexico, he was4085just minutes away from one of the oldest IHS centers in Gallup,4086New Mexico.4087 If he would have gone there, he would have seen this. What4088it says is, do not drink the water. Do not use the water for4089consumption. Failure to follow this advisory could result in4090illness. Do not use the ice, and then ``made from tap water''4091for drinking and patient care. Don't use it for baby formula,4092for brushing teeth, for making ice, care, until further notice.4093 The way that I was raised is you make time for what is4094important. And he didn't make time.4095 The other thing I would share with Secretary Kennedy is, it4096has been over 60 days that members of the United States Senate4097sent you a letter about the measles outbreak in America where4098many of our constituents are not just sick but some have died.4099 Respond to the letter. Keep your word. When you were asked4100in Committee if you would respond to letters sent by members of4101the United States Senate, you took an oath and said yes. Keep4102your word. I am just very disappointed there.4103 Ms. Charlie, as an alum of Head Start, I am one of only two4104in the United States Senate that went to Head Start. I often4105joke I thought everybody went to Head Start. I didn't know you4106got to be poor enough to go.4107 I believe in early childhood education. I believe the4108United States Senate, this is a place that Head Start can get4109you, in addition to other responsibilities we have around the4110world. Research has demonstrated that high quality early4111childhood education programs increase child educational4112achievement later in life and significantly reduce the4113likelihood of adult poverty.4114 Right now, there are conversations taking place about going4115after one program or another. There are statements on social4116media that are later redacted and things of that nature. What4117can you share with us about the importance of early childhood4118education and programs like Head Start to the livelihoods of4119kids and others that you are honored to represent and speak4120for?4121 Ms. Charlie. Head Start is critical for the kids that we4122serve. At FNA we serve 224 kids. We provide interventions, we4123work with the school district, with the special education4124department. We do the 45-90 days dental health screenings. We4125provide referrals with health care and other specialists4126needed.4127 So we provide early intervention for the kids so when they4128get into school, they are not delayed. The school doesn't have4129the capacity to do what we do. They don't even screen for IEPs4130until third grade.4131 They don't have the capacity to provide the services that4132we do at Head Start. So it is critical, it provides structure4133for them, it develops routines for them. So they are ready when4134they get into school.4135 Not only that, it supports the whole family. Our program4136supports grandparents coming in and volunteering, we are4137culturally based, we do a lot of cultural activities. We4138created a book with Denaka [phonetically] lesson plans. We were4139working on a digital app to give access to that, to anybody who4140wanted it.4141 So it is important. And the school just doesn't have the4142capacity or resources to do what we do.4143 Senator Lujan. I appreciate that strong testimony.4144 I would argue, all of us on this dais, including those that4145are not present right now, we all care greatly for Native4146American mothers and for babies, which is why I am outraged by4147the fact that 92 percent of Native American women that die from4148pregnancy related deaths are considered preventable. Just let4149that sit for a second.4150 And that the CDC has seen a 20 percent reduction in4151staffing, leaving more vulnerabilities out there, this could4152all be preventable.4153 Ms. Alkire, can you speak to how the reduction in force at4154IHS and the reorganization in programs like the Pregnancy Risk4155Assessment Monitoring System will have on people going forward,4156namely moms and babies?4157 Ms. Alkire. [Remarks off microphone.]4158 Senator Lujan. In the area of maternal health, with moms4159and especially with babies, with looking at 92 percent of those4160that we lose, it is all preventable.4161 Ms. Alkire. Right.4162 Senator Lujan. And there are more conversations around4163programs like the Pregnancy Risk Assessment Monitoring System4164getting financial support or not, some of the layoffs at HHS.4165Do you have any thoughts of taking those programs away or4166making it harder, what kind of impact would that have on moms4167and babies?4168 Ms. Alkire. Yes, actually there are several, and we provide4169a lot of this in the testimony, because this is such an4170important issue for us.4171 The investments from HRSA, this is one of the conversations4172I had with the CEO in regard to young moms, where I come from.4173She said the issue is that a lot of them, these programs fill4174the gaps, because IHS does provide services. But these programs4175that HHS provides, they fill the gaps for a lot of our tribes4176with these grants.4177 And one of them is to help young moms get some prenatal4178care, get some education. Because the issue, I think, in having4179such scary statistics that we have is that a lot of these are4180young moms, and they don't come to the hospital until they are4181going to have the baby.4182 So a lot of them need this education. They need these4183programs, these grants that are out there, to provide that4184connection for them to learn what is coming, even to see the4185baby's growth. And that way it provides more of a connection4186for the mom to see how important it is to take care of4187themselves and take care of the baby. That is what these grants4188provide.4189 So HRSA is an investment in Healthy Start that saves lives.4190By supporting tribally tailored programs, it helps reduce4191infant mortality and address adverse perinatal conditions in4192American Indian and Alaska Native populations. Healthy Start is4193a vital lifeline for rural and remote communities. It provides4194essential services like health screenings, nurse visits and4195support through tribal home visiting programs, which I think is4196so important right there, to ensure new and expecting mothers4197receive the care they need.4198 Programs like this help bring knowledgeable staff into our4199communities, so expecting mothers and new moms do not have to4200drive, as we said, three or four hours away to get support for4201pre- and post-natal care. Without HRSA funding, the tribal4202maternal and health safety net is at risk.4203 Losing these dedicated resources would weaken critical4204support for Native families at a time when these services are4205essential, more than ever. Many young mothers, as I said, don't4206show up until they are ready to have their baby. So perinatal4207care is often not even sought.4208 This program puts babies on the radar, so home visits can4209be conducted. As I said, it helps connect them. These programs4210are successful of collaboration and also culturally appropriate4211programs, because I think it just helps with identity issues4212for the mother and the baby and just the family. Super4213important.4214 Senator Lujan. Thank you.4215 Madam Chair, just in closing, thank you for your4216leadership, for putting a face on the people across the Country4217that we are so honored to represent and for fighting for them.4218More of that is what we need. I want to say thank you to you4219and to Vice Chair Schatz for that. Thank you.4220 The Chairman. Thank you, Senator Lujan.4221 Significant issues that we are talking about, maternal4222mortality, how we are able to ensure that the programs that are4223so important for, again, so many that are so vulnerable.4224 We talked about mental health. I want to talk about4225domestic violence for just a moment. This is a matter that I4226raised with the Secretary at the hearing at 1:30. I mentioned4227FVPSA. This is the primary Federal funding source for our4228domestic violence shelters and our support services and our4229tribal communities. Obviously, essential for emergency shelter,4230crisis intervention. We understand all too well up north why4231these are priorities.4232 I received a letter back, it was dated April 2nd from the4233Alaska Native Women's Resource Center, about the impacts of the4234layoffs at the FVPSA office the concerns about what it means to4235have the director of that placed on administrative leave.4236 I am going to enter this into the record, as well as an4237attached letter that was directed to Secretary Kennedy about4238the same subject.4239 When I mentioned this to the Secretary, he indicated his4240clear support for making sure that when it comes to domestic4241violence, shelters for women and the most vulnerable, that it4242is not his intention to be cutting programs. And I don't recall4243his words specifically, but it was something along the lines of4244he didn't think that they had cut programs.4245 But I also recognize that in budgets that are proposed,4246that is one thing. But sometimes you can effectively eliminate4247the effectiveness of a program if you don't have people there,4248right? If there is nobody there to process the grant4249application, if there is nobody there to answer the phone or to4250respond to your email about what the status of your grant is.4251 So let me direct this one to you, Ms. Simpson. Can you4252describe how the Office of Family Violence and Prevention has4253been key in implementing FVPSA in our tribal communities and4254then what happens when you don't have, okay, let's just say the4255program is still there, but you don't have the folks to4256implement it? What happens to those you are trying to serve?4257 Ms. Simpson. Thank you for the question. The Office on4258Family Violence Prevention and Services, we call it OFVPS, the4259OFVPS office under former director Dawson's leadership has been4260instrumental in recognizing the need for culturally grounded4261and Native led programs for survivors of violence. The OFVPS4262office ensures that over 230 tribes and tribal domestic4263violence programs receive FVPSA formula grants that allow them4264to provide emergency shelter and crisis intervention services.4265 OFVPS also partners with Native led organizations like4266NIWRC to provide training and technical assistance and4267resources to tribal grantees and advocates that can build the4268capacity of tribal organizations so that our communities have4269access to long-term and specialized care that meets their4270unique needs. In this way, OFVPS helps to carry out the Federal4271trust obligation.4272 When Director Dawson was abruptly placed on administrative4273leave, not only did that impact the office's ability to move4274forward, but that was felt all the way down to the individual4275tribal grantees. There was a significant gap of communication,4276silence between program officers and the tribal programs in4277terms of what the new, what this was going to mean for ongoing4278funding.4279 There was a lot of uncertainty from grantees, because none4280of the new solicitations have gone out. The continuation4281applications that normally are released in March haven't been4282released yet, so programs are unsure what the funding is going4283to be. So it is good to hear that Secretary Kennedy has assured4284that those programs will maintain funding. But that hasn't been4285expressed to any of the programs yet.4286 There are a lot of questions about what is now allowable4287and what is not allowable. That information that we haven't4288gotten guidance; tribal programs haven't gotten guidance yet.4289So it has caused many programs to kind of feel the need to halt4290services, because they are worried that they might do something4291wrong and then lose their funding and get their grants4292terminated the way things have happened at the Department of4293Justice.4294 So it creates a lot of uncertainty and stress and fear4295within these tribal programs. The substantial reductions in4296force will, if there are more, it will surely interrupt the4297essential functions of these prevention efforts across Indian4298Country. These RIFs threaten decades of improvements in the4299public health response.4300 Tribal programs rely on OFVPS staff who have cultivated4301trusted relationships with the tribal nations. This can take4302years to build. The institutional knowledge is immense.4303 This long-term relationship building has also led to many4304OFVPS staff developing cultural competence, significant4305cultural competence, trauma-informed expertise and a deep4306understanding of the complex realities that face our Native4307communities. So when we lose those staff, when we lose the4308communication with those staff, then we are resulting in gaps4309of silence and tribes unable to be able to move forward with4310their domestic violence programming.4311 So it is pretty significant. Also, I think that the loss of4312leadership, a direct result of that is the funding delays that4313tribes have experienced. It resulted in many programs where the4314possibility of being forced to shut down or lay off staff, and4315we do know that there have been programs that have had to lay4316off staff, because of the long gap in receiving their funding4317through drawdowns as well as the uncertainty of being able to4318maintain funding into the future.4319 The Chairman. We have heard some of that, where the4320uncertainty with the funding coming, let's just say it has been4321put on a pause, or a freeze, or just the uncertainty, and in so4322many of these, with so many of these programs, if you have a4323shelter that you are trying to run, usually you don't have a4324lot of cushion. You are able to pay your staff salaries that4325month and maybe the following month. You are able to get the4326food, the supplies for maybe that month, maybe the following.4327 But there is not, again, a cushion in the event that these4328funds don't come through. And if you can't provide the4329services, you can't open the doors and you can't provide the4330safety that is sought.4331 Ms. Charlie, I know that there at FNA you utilize the FVPSA4332funding to help those that you serve in doing everything from4333temporary housing and safety for survivors. So I am going to4334ask you a question that kind of ties into FVPSA but goes just a4335little bit more. Because I mentioned the issue of LIHEAP, the4336Low Income Heating and Energy Assistance. This is a program4337that has been zeroed out, and for us in Alaska, it makes a4338difference. You need to stay warm in the winter. I would4339imagine that in some of the areas that you represent, it is4340about air conditioning in the summer, in order for your elders4341to be safe in their own homes.4342 One of the things that we have heard is that the assumption4343with this proposed budget was that the greater focus on energy4344production, it would lower the cost of energy to people's homes4345and so thus the LIHEAP assistance would not be necessary.4346 That may be true in the future. I don't know that we have4347an easy button on this to reduce energy costs around the4348Country, much less in a place that is as expensive as Alaska or4349Hawaii. But Melissa, if you can just share for the Committee4350record the expense that a family basically faces in staying4351warm in a place like Fairbanks, Alaska, and what it would mean4352if you weren't able to access this LIHEAP funding.4353 Ms. Charlie. Like you said, the cost of living in Fairbanks4354and Alaska is extremely high. There are places in Alaska that4355one gallon of heating fuel can run from $5 to anywhere over $104356a gallon. And that is for heating fuel.4357 We do have an elders program; we do a lot of case4358management. We do deal with a lot of elders who not only have4359food insecurity but can't pay their energy bill. They can't pay4360their rent. So this is the case management that we provide. We4361also do it with the FVPSA funds for emergency shelter, because4362as women leave a domestic violence situation with just the4363clothes on their back, they can't afford temporary housing, not4364in Fairbanks and especially in Remo, Alaska. So it is really4365critical.4366 For the energy assistance, it is a huge impact on all of4367the families we serve, not just the elders, but the families in4368Head Start. The cost of living in Fairbanks is extremely high,4369and the surrounding areas is much higher. So it would be4370devastating to everybody we serve, across all of our programs.4371 The Chairman. Thank you.4372 Senator Lujan, do you have follow-on questions?4373 Senator Lujan. No, thank you, Chair Murkowski.4374 The Chairman. Okay. I am just going to keep going here for4375just a few more minutes, because I think one of the things that4376we share as members of this Committee when we think about the4377many challenges that we see across Indian Country, and the4378barriers to things like economic opportunities and strong4379education, is the issue of mental health, behavioral health,4380and the lack of services that are then made available.4381 We have had a little bit of conversation about some of the4382statistics related to suicide, and I agree with you, Vice Chair4383Greninger, we are tired of being number one in so many of these4384really awful, awful statistics.4385 So, SAMHSA's Center for Mental Health Services has faced4386pretty significant RIFs, and now with this proposed elimination4387of SAMHSA overall, I would like to hear from you about the4388impacts on the delivery of culturally responsive programs to4389tribal communities.4390 Ms. Greninger. Thank you for the question. SAMHSA is4391important in particular because when you look at SAMHSA mental4392health programs compared to IHS programs, IHS does have mental4393health dollars but it is focused on adult mental health. And4394SAMHSA has children and family mental health.4395 So that is where it is super critical for us tribes to have4396those dollars so that we can specifically tailor our mental4397health to our children and our young families.4398 So I would highlight Circles of Care as one of those4399particular programs.4400 The other great thing about SAMHSA mental health programs4401is tribes don't have to compete for them. In other programs, we4402have to, which is really sad for us. We hate competing against4403our brother and sister nations.4404 So those are the two biggest things, to be able to focus on4405youth and the non-competitiveness of SAMHSA. So the ability for4406us to even have culturally relevant services, that kind of4407flexibility within SAMHSA grants is what allows us to get to4408that spirituality piece that I was talking about in my4409comments, where we can bring in the songs and the language and4410are filling in that emotional and spiritual piece of the holes4411in our hearts that frankly, medical care from the western4412perspective cannot touch.4413 That is why we are always going after those dollars,4414bringing in drum-making kits, bringing in regalia-making kits,4415teaching our kids language, bringing in the language teachers.4416That is all part of mental health, as well as doing, I am going4417to say, more traditional forms of treatment, such as counseling4418and things like that. That is all essential too.4419 But bringing in those spiritual healers as well to teach us4420the songs and to help heal our hearts and spirits in that way,4421those SAMHSA dollars can help us in those ways as well.4422 The Chairman. Important point about not having to compete,4423which is significant.4424 Dr. Daniels, you looked like you were wanting to say4425something.4426 Dr. Daniels. You mentioned the Center of Excellence. I4427think we all have part of that. So at Papa Ola Lokahi, we4428actually are a pass-through with the State for the center of4429excellence, and ours is called the Ohana Center of Excellence,4430which is an AANHPI Center of Excellence.4431 What has been happening is with the RIFs and the changes,4432that program has been asked to scrub the information that they4433have put on for communities to access. So things around4434webinars or culturally appropriate programming that goes onto4435those websites are at risk.4436 So our communities cannot access it. And it is not just4437communities; it is the professionals that are working within4438those communities that it is a TA type of opportunity for them.4439So that center of excellence is at risk.4440 Then also, SAMHSA also funds Emergency The Surge, which is4441the Lahaina Wildfire Disaster monies, same thing, that those4442kinds of opportunities to get creative and really focus in on4443communities are being kind of shifted off. So I agree with the4444SAMHSA kind of understanding and how they support communities.4445 The Chairman. I think part of what we were hoping to4446accomplish today was again to remind not only those in the4447administration but just to remind all of us of the many, many4448programs that are available that are critically important to4449Native people, whether you are in Hawaii, Alaska or elsewhere4450around the Country, that are outside of the IHS system. We have4451talked about SAMHSA, we talked about young people, early Head4452Start.4453 We really haven't had that much of a discussion about4454elders. Clearly, the Older Americans Act, while it doesn't say4455anything about Natives in the title, but clearly, those4456services, whether it is the congregant meal services, the4457caregiver support, these are vitally important. I don't know, I4458know Melissa, probably FNA does a fair amount with the Title4459VI, the tribal program there within the Older Americans Act. Do4460you want to speak to how important these programs are for our4461elders?4462 Ms. Charlie. Yes. At FNA, we do have an elders program at4463community service. We do receive Title VI funding. We provide4464800 meals a month, Monday through Friday. And we also assist4465with food boxes. They have a garden for food insecurity.4466 And we serve over 300 elders in our program. We do a lot of4467case management, if they can't pay their rent, if they can't4468pay their fuel bill.4469 But what I really love about our elders program is they are4470really integrated into everything that we do at FNA. They are4471at the school tanning moose hide, they are at our Head Start4472program teaching them how to make fire bread and cut berries.4473They are at certain schools that they are the grandparents for4474certain classrooms. They are teaching them how to jig; they are4475doing songs and dance.4476 They are just really involved in everything that we do at4477FNA. I really love that program, because it is important that4478we take care of our elders. We are all going to be elders one4479day.4480 And so it is a really amazing program. They love the4481program; they love to come together and congregate and eat and4482just be together. Otherwise, they would be home alone.4483 Every time we invite them to talk at our annual meeting,4484they are there, they are speaking. And they own their program.4485They develop their agendas and meeting and topics that they4486want to do. It is a really amazing program. It really builds4487and makes them happy to be able to come together.4488 The Chairman. I love the fact that they are there with the4489kids as well.4490 I want to ask a question about efficiency. Because we are4491operating in an administration that has taken a very keen eye4492toward efficiency and we all know that we can and should do4493more when it comes to more efficient operations.4494 So I think we have something to advertise when we are4495talking about the 477 program. I look at that as a model for4496tribal self-governance. It really demonstrates how tribes can4497exercise their sovereign authority. It is the integration of4498employment, of training, of human services into one just4499efficient, streamlined plan.4500 So I think this is probably directed to you, Vice Chair4501Greninger, about how, I guess the progress that we have made4502over the years in expanding HHS program participation in tribal4503477 plans. And how important you think it could be in this4504administration, again, one that is really keenly focused on how4505we can do a better job in reducing inefficiencies and4506eliminating kind of the overlap and the overlay. If we have4507multiple programs here, consolidation is good, let's make sure4508we are consulting on it all, let's make sure it makes sense.4509 But talk a little bit for the Committee here about the4510value of the tribal 477 program.4511 Ms. Greninger. Absolutely, thank you for the question.4512 I think I am going to steal the words from my chairman, Ron4513Allen. He said if there is anyone who understands how to run4514things efficiently, it is the tribes, because we are all4515wearing multiple hats, smaller governments and trying to4516stretch the dollar as far and wide as possible.4517 So 477 is really critical to tribes because it allows us4518the flexibility to self-govern, we can take these funds from4519the Federal Government and we can issue them into our community4520the ways that we see fit.4521 The other important part of that is we are talking about4522efficiency, is the reporting structures. Data and reporting is4523much more streamlined. It is a reduced burden for us,4524especially the smaller tribes, such as Jamestown. We aren't 4774525per se, but we will advocate for it. I am more of a 638 tribe.4526 But when we talk about HHS programs in particular, we have4527been working with ACF specifically to increase those particular4528programs. What we would love to see is if all of HHS programs4529and ACF programs could be in 477 because of that streamline4530factor, and it gives us that self-governance benefit.4531 ACF has worked with us, and I think we are up to about4532five, five programs in 477. I would like to highlight for this4533Committee that there are going to have to be conversations to4534talk about the barriers, probably, with some of the regulations4535and maybe part of the statutory pieces of this.4536 With Head Start, we have had some concerns about that. Head4537Start was able to be put into 477. But there was discussion on,4538are we meeting statutory requirements when we put Head Start4539under 477 when we are really seeing some of these data burdens,4540reporting burdens, statutory burdens, health and safety4541burdens, things like that.4542 But I think that those are conversations that tribes want4543to have, and if there is statutory requirements we need to look4544at and evaluate those, I think those conversations should be4545happening.4546 So we are hoping that HHS will remain open to adding more4547programs into 477.4548 The Chairman. So let me ask on that, do you think, or maybe4549it is too early to know whether there is somebody within HHS4550that is dedicated, I guess, to be able to support tribes in4551integrating HHS programs into their 477 plans?4552 Ms. Greninger. I think I will need to follow up with you on4553that. I want to say that ACF has like maybe two or three staff4554that are dedicated to 477 right now. But I can follow up with4555you on that.4556 The Chairman. The reason I ask, and I think the Vice Chair4557noted it at the beginning of his questions, or maybe it was the4558end of them, that this input that we are getting from you today4559is really important that it be an iterative process, that it4560not just be this conversation today but that we build on this,4561that as you are bringing information to us, we are able to feed4562that up to let them know it is going to be really important4563that you have somebody within your department that is tasked to4564these things.4565 Then further, that that individual that has been named, you4566all know who is on point there. We can be that intermediary.4567But it shouldn't be for more than just the fact of getting a4568name and then being able to pass that on.4569 So I think it is going to be important again that we are4570working with the folks at HHS, the folks in the Secretary's4571office, in recognizing and acknowledging the many, many, many4572programs within HHS that have implications for our tribal4573citizens and Native people.4574 So how we do this going forward, we are going to kind of4575rely on those of you, the many that you represent. There is4576still much that is going on within this reorganization that we4577are all just learning about.4578 And the fact that we don't have yet a full president's4579budget, we just have a skinny budget, we are operating off of a4580continuing resolution and we are hoping that the departments4581are going to be following their operational plan, and if not,4582that there is reprogramming.4583 There is just so much that is just uncertain. I think the4584message that I would like to leave with all of you is, amidst4585this uncertainty, know that we all have to kind of link arms4586and get through this together, even though the frustration at4587times may be really, really hard to deal with, because you4588can't seemingly get answers.4589 I know we want to try to give benefit of the doubt as4590administrations are getting stood up. We are very, very slow in4591moving these nominations through the Floor. It is a process. It4592could be made easier, but we are where we are.4593 So you may be the Secretary that is accountable, but you4594might not have your full teams in place to do the execution, to4595do the kind of consultation that I think we are talking about4596that you need and demand, and rightly demand.4597 So, not making excuses for the administration, they have to4598answer on their own. But I do know that the Secretary has4599indicated to me that these matters are priorities to him. We4600want to take him at his word for that. And that he will assign4601teams that work with us to better the lives of our Native4602peoples, wherever they may be.4603 So I am really appreciative for what you have brought here4604today. If there are additional matters that the Committee4605needs, I know that questions for the record will continue to4606come in. We would ask you to try to help us out with that.4607 I started off my morning with the Administrator of the EPA4608and we were asking him about various grants that have been4609paused or frozen or are still under review. And I just told him4610that we would like a list. We want to know from your4611perspective where things are.4612 Because if something has been terminated, that is one4613thing. If something is still under review, that is another4614thing. Maybe you can hold on and keep your folks on it, your4615shelter for another month, if you know that there is still a4616likelihood that that funding is going to come through.4617 But if it has been terminated, then decisions are being4618made for you. So if you have specifics that you want to share4619with us that we can then elevate, know that we also can perform4620that role as well.4621 Thank you to each of you for making the trip and thank you4622for the leadership that you provide respectively.4623 With that, the Committee stands adjourned.4624 [Whereupon, at 5:17 p.m., the hearing was adjourned.]46254626 A P P E N D I X46274628Prepared Statement of Donnie Garcia, Chairman, Albuquerque Area Indian4629 Health Board, Inc.4630 Thank you, Chairman Lisa Murkowski, Vice Chairman Brian Schatz and4631respected members of the Committee for the opportunity to provide this4632written testimony on behalf of the member tribes of the Albuquerque4633Area Indian Health Board, Inc. (AAIHB). As Congress knows, Indian4634tribes have a unique political and legal status recognized by the U.S.4635Constitution. Elimination or disruption of federal funding for Indian4636country has a huge impact on the ability of tribes and tribal4637organizations to provide essential services to American Indians and4638Alaska Natives. Indeed, the problems that face communities nationwide4639are far more severe for Indian communities, with tribes having far4640fewer resources to address basic health care needs and larger problems4641like substance abuse, mental health and other issues. AAIHB4642acknowledges and appreciates that there has been broad bi-partisan4643Congressional support for addressing health and wellness issues facing4644Indian country.4645 AAIHB was established in 1980 and is a consortium of several4646federally recognized tribes in New Mexico and Southern Colorado. \1\4647AAIHB provides direct health care services to not only citizens of4648member tribes, but to citizens of other tribes in the surrounding4649Albuquerque area. AAIHB's purpose is to assess and advocate for the4650well-being of 27 tribal communities through the improved development of4651public health services and health education. AAIHB is almost entirely4652funded--about 86 percent--through various programs under the U.S.4653Department of Health and Human Services. Approximately two-thirds of4654that funding falls outside of the Indian Health Service (IHS).4655---------------------------------------------------------------------------4656 \1\ Member tribes include the To'Hajiilee Band of Navajos, the4657Ramah Band of Navajos, the Jicarilla Apache Nation, the Mescalero4658Apache Tribe, the Ute Mountain Ute Tribe and the Southern Ute Indian4659Tribe. For financial purposes the AAIHB is considered a government4660because the AAIHB board of directors is appointed by members of tribal4661governments.4662---------------------------------------------------------------------------4663 For example, our health programs significantly rely on funding4664directly from the National Institutes of Health (NIH), the Substance4665Abuse and Mental Health Services Administration (SAMHSA), and the4666Centers for Disease Control and Prevention (CDC). While we receive a4667small amount of state and private foundation funding, the loss of our4668federal funding would force us to reduce or completely terminate health4669care services and related educational and research programs. A summary4670of these non-IHS programs that AAIHB receives is set forth below.46714672 CDC Healthy Tribes Program:46734674 --Approximately $1.2 million for Good Health and Wellness in Indian4675Country4676 --Approximately $990,000 for Tribal Epidemiology Center Public4677Health Infrastructure46784679 CDC Division of Injury Prevention:46804681 --Approximately $200,000 for alcohol impaired driving4682 prevention4683 --Approximately $671,000 for tribal opioid prevention46844685 CDC Division on HIV Prevention:46864687 --Approximately $1.3 million46884689 SAMSHA Tribal Opioid Response:46904691 --Approximately $1.5 million46924693 NIH Native Collective Research Effort to Enhance Wellness (N4694 Crew):46954696 --Approximately $497,00046974698 NIH Community Partnerships to Advance Science for Society:46994700 --Approximately $989,42947014702 Some of our funding streams noted above provide much needed4703research within Indian country to address addiction, substance abuse4704and pain, including for related factors like mental health and4705wellness. Understanding and addressing these issues is critical to a4706Healthy America for tribal communities. Secretary Kennedy recently4707testified that ``reducing the initiation of drug use, particularly4708among young people, and increasing the number of individuals receiving4709evidence-based treatment, leading to long-term recovery from substance4710abuse disorders, [is] a top priority.'' \2\4711---------------------------------------------------------------------------4712 \2\ Statement of Robert F. Kennedy, Jr. Secretary, U.S. Department4713of Health and Human Services on the President's Fiscal Year 20264714Budget, Committee on Appropriations, Subcommittee on Labor, Health and4715Human Services, Education, and Related Agencies, at 4 (May 14, 2025).4716See https://docs.house.gov/meetings/AP/AP07/20250514/118230/HHRG-119-4717AP07-Wstate-KennedyR-20250514.pdf.4718---------------------------------------------------------------------------4719 Eliminating or reducing those funding streams because they appear4720to be duplicative or too small for national impacts, ignores the4721uniqueness and size of Indian country compared to the country as a4722whole. For example, funding from N Crew for tribes and tribal4723organizations was a direct result of tribal consultation and the need4724for tribally led research as it relates to substance abuse and pain in4725Indian country. AAIHB receives other funding that may seem duplicative,4726but it is not and the funding is needed in Indian country. AAIHB for4727instance also receives federal grants that focus on opioid addition4728from the CDC and SAMSHA, but unlike the N Crew funds used for research,4729the CDC grants focus on surveillance and public health practice while4730the SAMSHA grant is issued directly to tribes to strengthen capacity of4731tribal behavioral health programs, as noted below.4732 We urge Congress to protect all of these funding streams and4733recognize that tribes and tribal organization receive funding from many4734sources and while it may seem duplicative it is not and all of the4735funding is needed to address health issues throughout Indian country.4736Indeed, Congress acknowledges the chronic underfunding of health and4737wellness related programs throughout Indian country. Rather than4738eliminating or reducing funding streams for research within Indian4739country, these funding streams must be protected and could even be4740consolidated--without reduction to tribes and tribal organizations--to4741eliminate the need to seek funding from multiple grant sources.4742 The Community Health Education and Resiliency Program (CHERP) at4743AAIHB provides trauma-informed and strengths based capacity building in4744STI/HIV prevention, opioid and substance use prevention, positive youth4745development, and mental health. Our program tailors to community needs4746to equip tribal public health professionals with the skills, resources,4747and tools to implement effective interventions and services. This4748program is funded mostly through SAMHSA and CDC grants. CHERP hosts a4749Wellness Conference, which is the only conference of its kind devoted4750to addressing HIV prevention, testing, and biomedical treatments, along4751with harm reduction strategies and substance use disorders within4752tribal communities. This allows for education and capacity building4753that is uniquely geared towards Indian country.4754 Within AAIHB is the Albuquerque Area Southwest Tribal Epidemiology4755Center (c), which is 1 of only 12 tribal epidemiology centers4756nationwide. More than half of the funding for AASTEC comes from non-IHS4757programs. For example, AASTEC operates a Good Health and Wellness in4758Indian Country Program with funds provided by the Centers for Disease4759Control and Prevention--Healthy Tribes Program. Through that program4760AASTEC provides leadership, technical assistance, training, and other4761health resources to AAIHB's 27 tribal communities to promote community4762level changes that support health and wellness and prevent and manage4763type 2 diabetes, heart disease, and stroke and their associated risk4764factors, such as commercial tobacco use, physical inactivity, and4765unhealthy diet. More specifically for example, AASTEC provides 104766direct tribal sub-awards for community projects that are critical to4767improving health and wellness in tribal communities. We have4768significant concerns regarding this funding moving forward. All CDC4769staff within this program have been subject to a reduction in force4770(RIF) and the CDC Division of Population and Health, which is the4771division that oversees this program, is being proposed for elimination4772as part of the Administration's reorganization plan.4773 Similarly, as noted above, AASTEC receives important funding from4774the CDC Division of Injury Prevention. This funding assists with (1)4775building important collaboration among and between tribes and external4776partners, (2) building public awareness aimed at educating tribal4777communities on the burdens of motor vehicle accidents and alcohol-4778impaired driving, as well as risk reduction strategies, (3)4779strengthening the capacity ability within the tribal public health4780workforce to implement best practices, and (4) improving data4781collection and access to data. These evidence-based programs are4782essential for our tribal communities because unintentional injuries4783remain the leading cause of mortality for American Indian and Alaska4784Natives nationwide from birth through middle age. We are concerned4785about this funding because all staff within the CDC Division of Injury4786Prevention have been RIF'd. It is also important to note that the4787various RIFs that are occurring are concerning not only with respect to4788the status of funding moving forward, but the RIFs also result in the4789loss of institutional knowledge and result in the diminished capacity4790of federal staff who not only understand Indian country but provide4791important expertise and technical assistance with tribes and tribal4792organizations.4793 Heavy reliance on non-IHS funding streams to serve our tribal4794communities is not unique to AAIHB. Tribes throughout Indian country4795rely on these funding streams as well. Eliminating funding streams that4796tribes and tribal organizations, like AAIHB rely on will only further4797exacerbate the health disparities that American Indian and Alaska4798Natives face. While we understand that programs may be consolidated,4799any such consolidation should not result in less funding for Indian4800country. As Congress considers the FY 2026 Budget we urge you to4801protect all non-IHS funding sources depended on by tribes and tribal4802organizations. Thank you.4803 ______48044805 Prepared Statement of the American Indian Higher Education Consortium4806 The American Indian Higher Education Consortium (AIHEC) is4807comprised of 34 accredited Tribal Colleges and Universities (TCUs) in4808the United States (U.S.). On behalf of the TCUs, the following comments4809are submitted to the U.S. Senate Committee on Indian Affairs in regard4810to their May 14, 2025, oversight hearing on examining Federal programs4811serving Native Americans at the U.S. Department of Health and Human4812Services (Department) programs. AIHEC's mission is to provide4813leadership and influence public policy on American Indian higher4814education issues, including promoting and strengthening Indigenous4815languages, cultures, communities, and Tribal Nations.4816About Federal Trust and Treaty Obligations4817 Rooted in treaties and authorized by the United States4818Constitution, the federal government's unique responsibilities to4819Tribal Nations have been repeatedly reaffirmed by the Supreme Court,4820legislation, executive orders, and regulations. \1\ The trust4821responsibility establishes a clear relationship between Tribal Nations4822and the federal government. \2\4823---------------------------------------------------------------------------4824 \1\ The Court has consistently held that the federal government has4825a trust responsibility to Tribes, which has formed the foundation for4826federal/Tribal relations. See Seminole Nation v. United States, 3164827U.S. 286 (1942), United States v. Mitchell, 463 U.S. 206, 225 (1983),4828and United States v. Navajo Nation, 537 U.S. 488 (2003).4829 \2\ In Worcester v. Georgia, 31 U.S. 515 (1832), the Supreme Court4830explicitly outlined that the relationship between the federal4831government and the Tribes is a relationship between sovereign nations4832and that the states are essentially third-party actors.4833---------------------------------------------------------------------------4834 This legal duty and trust responsibility applies across all4835branches of the federal government. These trust and treaty obligations4836are owed to Tribal Nations and their citizens and do not have an4837expiration date. Health and Education are central components of the4838federal trust and treaty obligations promised to Tribal Nations, Tribal4839citizens, and Tribal communities. The federal government has long4840endeavored to uphold this duty through the appropriations process and4841through the enactment of laws such as the Snyder Act of 1921, the4842Indian Self-Determination and Education Assistance Act of 1975, and the4843Tribally Controlled Colleges and Universities Assistance Act of 1978.4844About Tribal Colleges and Universities4845 In a bold expression of sovereignty, Tribal Nations began4846chartering their own institutions of higher education--Tribal4847Colleges--in the 1960s. The first Tribal College, like all that4848followed, was established for two reasons: the near complete failure of4849the U.S. higher education system to address the needs of--or even4850include--American Indians and Alaska Natives; and the need to preserve4851our culture, our language, our lands, our sovereignty--our past and our4852future. The guiding vision of the Tribal College Movement is an4853education system founded on traditional knowledge and focused on a4854prosperous future through job creation and strengthening our4855communities.4856 Currently, TCUs operate more than 90 campuses and sites in 164857states, which make up over 80 percent of Indian Country. These4858institutions serve students from over 250 federally recognized Tribal4859Nations and embody a vital component of Tribal higher education. All4860TCUs offer certificates and associate degrees; 22 offer bachelor's4861degrees; 9 offer master's degrees; and one offers a doctoral degree.4862Programs range from liberal arts to technical and career programs and4863are created to address the needs of Tribal Nations and rural economies.4864TCUs train professionals in high-demand fields, including early4865childhood education, law enforcement, agriculture, natural resources4866management, information technology, and healthcare. By teaching the job4867skills most in demand in our communities, TCUs are laying a solid4868foundation for Tribal economic growth, with benefits for surrounding4869communities and the nation as a whole. As open enrollment, community-4870based institutions, Tribal Colleges welcome all students and proudly4871became a part of the nation's land-grant university family in 1994.4872 TCUs provide accessible and affordable options for higher education4873for Tribal citizens and other rural students by offering low tuition4874rates and fees; 97 percent of TCU graduates are debtfree. Additionally,4875most TCU students are first-generation and low-income, with 78 percent4876relying on Pell grants-far above the national average. \3\4877---------------------------------------------------------------------------4878 \3\ American Indian Higher Education Consortium (2023). Retrieved4879from: American Indian Measures of Success (AIMS)4880---------------------------------------------------------------------------4881 TCUs also serve other community members through various community-4882based programs and services each year, such as library services, job4883training, High School equivalency program instruction and testing,4884health promotion, Head Start and K-8 immersion programs, financial4885literacy, community gardens, youth and college prep, summer camps, and4886civic programs.4887Key Program Within the U.S. Department of Health and Human Services4888 Administration for Children and Families--Office of Head Start:4889Tribal Colleges and Universities Head Start Partnership Program. The4890TCU-Head Start Partnership program was re-established in FY 2020 at4891$4,000,000 and has been flat-funded at $8,000,000 for FY 2023 and FY48922024 (funding for FY 2025 has yet to be disbursed). The purpose of the4893TCU-Head Start Partnership Program is to increase the number of4894qualified education staff working in American Indian and Alaska Native4895Head Start programs. The program accomplishes this goal by increasing4896access to higher education degrees in early childhood education.4897Through this unique and successful partnership, TCUs lead and are able4898to build a larger network through their subawardees by:48994900 1. Building Early Childhood Education Career Pathways in Tribal4901 communities;49024903 2. Addressing the employment needs of American Indian and4904 Alaska Native Head Start Programs while being responsive to the4905 cultures and languages of Tribal Nations through a ``Growing4906 Our Own'' Approach; and49074908 3. Meeting the unique needs of individual Tribal communities4909 and supporting staff in American Indian and Alaska Native4910 programs to acquire the competencies that ensure children's4911 academic development while also supporting cultural identity.49124913 This program reaffirms the mission of TCUs by increasing self-4914determination and providing services to their respective Tribal4915community. Through this program, TCUs have been able to successfully4916train early childhood educators and Head Start teachers in high-demand4917areas across Indian Country. In 2021, 71.7 percent of Head Start4918teachers nationwide held a bachelor's degree, but only 42 percent met4919this requirement in Indian Country (Head Start Region 11).4920Additionally, only 39 percent of assistant teachers in Region 11 met4921the associate-level requirements, compared to 76 percent nationally.4922TCUs offer a cost-effective solution to this gap. From 2000 to 2007,4923the program provided scholarships and stipends to help Head Start4924teachers enroll in TCU Early Childhood Education programs.4925 Currently, this program is able to fund six TCUs to increase access4926to both entry-level credentials and early childhood education degrees4927for teachers working in American Indian and Alaska Native Head Start4928Programs. As an example, Navajo Technical University (NTU), located in4929Crownpoint, New Mexico, offers a Bachelor of Science degree that4930specializes in early childhood multicultural education. Since the Fall4931of 2020, NTU has been able to confer over 50 degrees or certificates in4932early childhood multicultural education. \4\ Additionally, as of the4933Spring of 2024, the University had over 85 students enrolled in the4934program, which includes both fulltime and part-time students.4935---------------------------------------------------------------------------4936 \4\ Navajo Technical University. Bachelor of Science: Early4937Childhood Multicultural Education. Retrieved from: https://4938www.navajotech.edu/wp-content/uploads/2024/11/Early-Childhood-Mult-Edu-4939BS-Enrollment-Data.pdf4940---------------------------------------------------------------------------4941 Another example, Salish Kootenai College (SKC), located in Pablo,4942Montana, offers a wide range of early childhood education degrees and4943certificates such as Early Childhood (birth to age 8), Early Childhood4944P-3 (preschool-grade 3), Elementary (K-8), Secondary programs (grades49455-12) in Science and in Mathematics, and a Master's program in4946Curriculum and Instruction. These degree programs provide an4947opportunity for candidates to become highly qualified professional4948educators who serve students in diverse school settings. At SKC,4949students are held to high standards, where the goal is excellence--not4950simply completion. Their student cohorts live, study, and work closely4951with each other and form personal and professional relationships that4952last far beyond the college classroom.4953AIHEC's Concerns on the Potential Termination of the Head Start Program4954 for Fiscal Year 20264955 AIHEC and other organizations were alarmed to learn that the budget4956pass back from the Office of Management and Budget to the Department4957contemplates completely doing away with Head Start altogether for FY49582026. This would not only be catastrophic in the immediate term for the4959individual Tribal communities served, but it would have long-lasting4960and cascading effects throughout all of Indian Country for years to4961come.4962 The need for degree or certificate programs is vital to Head Start4963Region 11, which represents Indian Country. As mentioned previously, in49642021, only 42 percent of primary teachers met the requirement of4965holding a bachelor's degree, and only 39 percent of assistant teachers4966held an associate's degree in the region. TCUs are closing this gap as496724 institutions offer certificates, associates, or bachelor's in early4968childhood education, which represents 11 different states. According to4969the National Indian Health Start Association, through the TCU Head4970Start Partnership, it is expected that the program will confer over 7004971graduates with an early childhood education degree by 2028.4972 Students who attend Tribal Colleges are most often non-traditional4973and potentially have families. As TCUs provide a wide range of student4974services, such as childcare services through their Head Start programs,4975students are able to partake in available support services that assist4976with decreasing any financial and economic burdens outside of their4977education. If Head Start programs are shut down, the enrollment numbers4978will significantly decline for these older, nontraditional students. As4979Region 11 of Head Start is comprised of the American Indian and Alaska4980Native programs, which are most often the only daycare or childcare4981facilities located within the region. These programs not only provide4982childcare or early childhood education services, but they also impact4983the community through cultural and language reclamation, economic4984stability, and long-term positive outcomes for Native children and4985families. Therefore, the elimination of Head Start would be detrimental4986to Tribal communities, along with the nation's TCUs, as they provide4987vital degree programs and professional development as it relates to4988early childhood education.4989Conclusion4990 TCUs provide thousands of American Indian and Alaska Native4991students with access to highquality, culturally appropriate4992postsecondary education opportunities, including critical early4993childhood education programs. The modest federal investment in TCUs has4994paid significant dividends in employment, education, and economic4995development. AIHEC appreciates the Committee for hosting this vital4996oversight hearing. AIHEC remains committed to working collaboratively4997with the Committee as a trusted resource to ensure that Tribal Nations4998and Tribal citizens have a say in shaping their education and their4999future.5000 ______50015002 Prepared Statement of Stephanie Knowlton, Program Coordinator, Fort5003 Peck Tribal Court5004AI/AN Head Start Programs5005 Good Morning.5006 I am a community member, a tribal member, and an employee of Fort5007Peck Indian Reservation. It has come to my attention that we may lose5008our Head Start programs in Indian Country. This is very sad that5009political issues are now affecting our ability to educate our native5010children on Fort Peck.5011 This program has been the most successful program for our children5012teaching not only the fundamental foundation but basic life skills that5013are detrimental to our community and their self growth. As you know,5014children are our future, and they need to be nurtured and placed on the5015highest level of care and support. Without our Head Start, this will5016set us back decades and remind us that we are controlled by people who5017have not lived our lives or walked in our trenches.5018 I have worked in the schools. As an advocate. BIA Social Services5019Child Protection worker and now a program coordinator with the Fort5020Peck Tribal Court.5021 I have seen first hand the benefits of our Head Start programs.5022Knowing that this may come to an end is heartbreaking and very5023disappointing for our children and the people who have worked hard in5024their careers to lead by example for successful children.5025 Head Start is important because it provides low-income families5026with high-quality early childhood education , health, and family5027support services, leading to improved school readiness, cognitive and5028social emotional development, and long term success for children and5029families. It also addresses systemic issues that can hinder a child's5030development, such as poverty, limited access to health care, and lack5031of parenting resources.5032 Thank you for taking the time to read my concerns for our children.5033Your attention and time are greatly appreciated and I am hopeful for5034some positive outcome.5035 ______50365037 Prepared Statement of Eileen J. Lujan, Board Member, National Indian5038 Council on Aging5039 Dear Senators. Congressman,5040 My name is Eileen J. Lujan Pueblo Indian from Taos Pueblo ,5041Southwest Region of New Mexico. I serve on the National Indian Council5042on Aging (NICOA) as a board member. On May 22nd-23rd, 2025 NICOA board5043members were present in several of Senators offices. Expressing our5044concerns about very unsettling decisions being made by President Trump5045and his staff. Sorry to say but you have no idea how an Indian Pueblo5046or reservation lives day to day. This does not sit well with me as an5047elderly voting member. It is very alarming to the elderly population5048that certain services will be cut or wiped off. Such as with in the5049Affordable Care Act, Medicaid, Health Insurance. Other services5050Medicare, Social Security, SNAP. Other departments, Indian Health5051Service, Bureau of Indian Affairs, Natural Resources, Education5052Department. Older Americans Act which affects the Title VI nutrition5053services, Senior Community Service Employment Program (SCSEP).5054 We can no longer accept this treatment. Where did the TRUST5055RESPONSIBILITY, and GOVERNMENT to GOVERNMENT RELATIONSHIP GO. United5056States Government you are not upholding your responsibility. We as5057Indian people are not going anywhere we are here to stay. Please take a5058closer look and hear yourself talk when making these decisions. I thank5059you for being able to write this today.5060 ______50615062Prepared Statement of Francys Crevier, Algonquin/CEO, National Council5063 of Urban Indian Health (NCUIH)5064 My name is Francys Crevier, I am Algonquin and the Chief Executive5065Officer of the National Council of Urban Indian Health (NCUIH), a5066national representative for the 41 Urban Indian Organizations (UIOs)5067contracting with the Indian Health Service (IHS) under the Indian5068Health Care Improvement Act (IHCIA) and the American Indians and Alaska5069Native patients they serve. On behalf of NCUIH and these 41 UIOs, I5070would like to thank Chairman Murkowski, Vice Chairman Schatz, and5071Members of the Committee for your leadership in improving health5072outcomes for American Indian and Alaska Native people and for the5073opportunity to provide testimony in response to the Senate committee on5074Indian Affairs May 14 hearing titled, ``Delivering Essential Public5075Health and Social Services to Native Americans--Examining Federal5076Programs Serving Native Americans Across the Operating Divisions at the5077U.S. Department of Health and Human Services''5078Overview of Urban Indian Organizations5079 The term ``urban Indian'' refers to any American Indian or Alaska5080Native person who is living in an urban area, either permanently or5081temporarily. UIOs were created by urban American Indian and Alaska5082Native people with the support of Tribes, starting in the 1950s in5083response to severe problems with health, education, employment, and5084housing. \1\ Congress formally incorporated UIOs into the Indian Health5085System in 1976 with the passage of IHCIA. UIOs are an integral part of5086the Indian health system, comprised of the Indian Health Service,5087Tribes, and UIOs (collectively I/T/U), and provide essential healthcare5088services, including primary care, behavioral health, and social and5089community services, to patients from over 500 Tribes in 38 urban areas5090across the United States.5091---------------------------------------------------------------------------5092 \1\ Relocation, National Council for Urban Indian Health, 2018.50932018_0519_Relocation.pdf(Shared)-Adobe cloud storage5094---------------------------------------------------------------------------5095 UIOs only receive funding from one line item in the IHS budget, the5096Urban Indian Health line item, which accounts for approximately 15097percent of the IHS budget. As such, UIOs rely heavily on funding from5098grants in various Health and Human Services (HHS) agencies to ensure5099they are able to provide their communities with the quality of care5100they require.5101Proposed Health and Human Services Restructuring and Funding Cuts5102 Many UIOs rely on funding and partnerships through key HHS5103divisions such as the Health Resources and Service Administration5104(HRSA), the Substance Abuse and Mental Health Services Administration5105(SAMHSA), the Centers for Medicare and Medicaid Services (CMS), and5106various Division of Tribal Affairs (DTA) offices. These divisions play5107a critical role in supporting programs and services vital to urban5108American Indian and Alaska Native populations. The value of HHS5109programs outside of IHS cannot be overstated, as they are essential for5110UIOs in fulfilling the federal trust and treaty obligation to provide5111health care services to American Indian and Alaska Native people. \2\5112The proposed reorganization and restructuring of HHS, combined with the5113administration's recommended 26.6 percent cut in agency funding, \3\5114will bring significant changes to several operating divisions, with5115potentially serious consequences for UIOs.5116---------------------------------------------------------------------------5117 \2\ 25 U.S.C. 1601(1)5118 \3\ Office of Management and Budget, Fiscal year 2026 Discretionary5119Budget request (May 2025), retrieved from: https://www.whitehouse.gov/5120wp-content/uploads/2025/05/Fiscal-Year-2026-Discretionary-Budget-5121Request.pdf5122---------------------------------------------------------------------------5123 It is particularly concerning that, to date, HHS has not held5124Tribal consultation or urban confer on the HHS restructuring. The lack5125of tribal consultation and urban confer is a failure to fulfill the5126U.S. Government trust and treaty obligations to Tribal Nations and5127programs serving Tribal citizens. Given the scope and potential impact5128of this restructuring, it is imperative that HHS engage in meaningful5129consultation with both Tribes and UIOs to ensure transparency and to5130address serious concerns about the consequences of such a significant5131public health and policy shift.5132Health Resources and Services Administration5133 The Health Resources Services Administration (HRSA) plays a vital5134role in delivering healthcare to geographically isolated, economically5135disadvantaged, and medically underserved populations. Presently, there5136are 11 UIOs that receive HRSA Community Health Program funding through5137the 330 grant program. \4\ The proposed dissolution of HRSA and its5138integration into the new Administration for a Healthy America (AHA)5139raises serious concerns about the future of these essential programs.5140It remains unclear whether the programmatic support provided by HRSA5141will be preserved or diminished during this transition, which poses a5142direct threat to the continuity of care for UIO patients.5143---------------------------------------------------------------------------5144 \4\ Tribal/Urban Indian Health Centers, HEALTH RES. & SERV. ADMIN,5145https://www.hrsa.gov/about/organization/offices/hrsa-iea/tribal-5146affairs/tribal-urban-indian-health-centers (last visited Mar. 11,51472025).5148---------------------------------------------------------------------------5149 Additionally, recipients of the 330 grant program are required to5150provide care to non-American Indian and Alaska Native patients. As5151such, NCUIH, on behalf of UIOs, has requested guidance and5152clarification from HRSA on complying with the recent Executive Orders5153(EOs) on diversity, equity, and inclusion (DEI). \5\ This guidance and5154clarification is especially important in light of the recent Advisory5155Opinion from HHS Office of the Secretary General Counsel (OGC) which5156states that the recent EOs do not apply to HHS' legal obligation to5157provide healthcare for American Indian and Alaska Native people. \6\5158While the Advisory Opinion provides some clarity on how the5159Administration applies the DEI EOs to American Indian and Alaska Native5160health, it is still unclear how agencies within HHS, including HRSA,5161will apply this guidance in practice when enforcing these EOs,5162particularly as it relates to UIOs who receive HRSA Community Health5163Program funding. UIOs require this guidance to ensure their programs5164can operate effectively and without interruption as implementation of5165EOs could impact or affect HRSA funding if the UIO is not in5166compliance. HRSA has yet to respond to the request for guidance and5167clarification.5168---------------------------------------------------------------------------5169 \5\ Exec. Order No. 14151, 90 Fed. Reg. 8,339 (Jan. 29, 2025),5170https://www.govinfo.gov/content/pkg/FR-2025-01-29/pdf/2025-01953.pdf;5171Exec. Order No. 14168, 90 Fed. Reg. 8,615 (Jan. 30, 2025), https://5172www.govinfo.gov/content/pkg/FR-2025-01-30/pdf/2025-02090.pdf; Exec.5173Order No. 14173, 90 Fed. Reg. 8,633 (Jan. 31, 2025), https://5174www.govinfo.gov/content/pkg/FR-2025-01-31/pdf/2025-02097.pdf.5175 \6\ Dep't of Health & Human Serv., Advisory Opinion 25-01,5176Application of DEI Executive Orders to the Department's Legal5177Obligations to Indian Tribes and Their Citizens (2025), https://5178ncuih.org/wp-content/uploads/HHS-Advisory-Opinion-25-01.pdf.5179---------------------------------------------------------------------------5180Substance Abuse and Mental Health Services Administration5181 American Indians and Alaksa Native people experience5182disproportionately high rates of alcohol, substance use and mental5183health disorders, suicide, violence, and behavior-related morbidity and5184mortality compared to the rest of the U.S. population. \7\ In fact,5185American Indian and Alaska Native people experience serious5186psychological distress at a rate 2.5 times more than the general5187population over a month's time. \8\ These poor outcomes impact American5188Indian and Alaska Native people no matter where they live. For example,5189according to a 2020 report from the Centers for Disease Control and5190Prevention, non-Hispanic American Indian and Alaska Native people had5191the highest rates of drug overdose deaths in both urban and rural5192counties compared to other races, at 44.3 per 100,000 and 39.8,5193respectively. \9\5194---------------------------------------------------------------------------5195 \7\ Fact Sheet: Behavioral Health, INDIAN HEALTH SERV. (2023),5196https://www.ihs.gov/sites/newsroom/themes/responsive2017/5197display_objects/documents/factsheets/BehavioralHealth.pdf.5198 \8\ Id.5199 \9\ Merianne Rose Spencer et al., Urban-Rural Differences in Drug5200Overdose Death Rates, 2020, NAT'L CTR. FOR HEALTH STAT. (July 2022),5201https://www.cdc.gov/nchs/data/databriefs/db440.pdf.5202---------------------------------------------------------------------------5203 SAMHSA programs play a critical role in addressing these outcomes,5204saving lives and improving behavioral health outcomes across Indian5205Country. However, both the reorganization and the President's proposed5206budget include substantial cuts to SAMHSA's three major centers: the5207Center for Mental Health Services (CMHS), the Center for Substance5208Abuse Treatment (CSAT), and the Center for Substance Abuse Prevention5209(CSAP).5210 Notably, CMHS funds several Tribal behavioral grant programs,5211including the Native Connections program. The Native Connections5212program is youth-focused behavioral health grant, with 17 UIOs as5213recipients of the grant. The programs have been influential in reducing5214suicides among American Indian and Alaska Native youth. Unfortunately,5215many UIOs have heard from SAMHSA staff that their Native Connections5216grants will not be renewed in the 2026 grant year. This expected loss5217of funding is deeply concerning, as it would undermine efforts to5218address the behavioral health crisis facing our communities.5219Centers for Disease Control and Prevention5220 The recent reorganization efforts and reduction in force at the5221Centers for Disease Control and Prevention (CDC) have had a significant5222negative impact on Tribal and Urban programs, including the Healthy5223Tribes initiative, which provides a culture-first approach to health5224promotion/disease prevention in American Indian and Alaska Native5225communities and funds key grants for UIOs through the Tribal Practices5226for Wellness in Indian Country (TPWIC) and Good Health and Wellness in5227Indian Country (GHWIC) programs.5228 For example, one UIO recipient of both TPWIC and GHWIC has5229indicated that all their Project Officers, Grant Managers and5230Indigenous subject matter experts have been put on administrative5231leave. The UIO has not received any communications or guidance relating5232to these changes, leaving the UIO unclear about the status of their5233current funding, as well as the their ability to plan, implement, or5234forecast for essential public health initiatives.5235 While TPWIC and GHWIC represent only a small fraction of federal5236spending, they provide essential support for chronic disease5237prevention, increased physical activity, and reduction of commercial5238tobacco use in Tribal and urban American Indian and Alaska Native5239communities. The loss or interruption of these culturally responsive5240programs threatens to further exacerbate already poor health outcomes5241for and undermines the federal trust responsibility to American Indian5242and Alaska Native people.5243Office of the Assistant Secretary for Health5244 American Indian and Alaska Native people have the highest rate of5245undiagnosed HIV cases compared to other racial/ethnic groups in the5246U.S., \10\ and according to IHS, as many as 34 percent of the American5247Indian and Alaska Native people living with HIV infection do not know5248it. \11\ UIOs are an important resource for urban American Indian and5249Alaska Native people for HIV/AIDS testing and referral to appropriate5250care.5251---------------------------------------------------------------------------5252 \10\ IHS Awards New Cooperative Agreements for Ending the HIV and5253HCV Epidemics in Indian Country. (2022, September 27). Retrieved5254January 5, 2023, from https://www.ihs.gov/sites/newsroom/themes/5255responsive2017/display_objects/documents/HIV-Funding-5256PressRelease09272022.pdf5257 \11\ Indian Health Service, HIV/AIDS in American Indian and Alaska5258Native Communities. Retrieved August 8, 2023, from: https://5259www.ihs.gov/hivaids/hivaian/#:-5260:text=The%20IHS%20National%20HIV%2FAIDS,Get%20tested%20for%20HIV.5261---------------------------------------------------------------------------5262 The Office of Infectious Disease and HIV/AIDS Policy (OIDP), housed5263within the Office of the Assistant Secretary for Health (OASH),5264administers key programs such as Ending the HIV Epidemic in the U.S.5265and the Minority HIV/AIDS Fund, which are primary sources of support5266for IHS HIV and sexually transmitted infection (STI) response efforts.5267 Alarmingly, OASH is currently slated for elimination under proposed5268restructuring plans. The loss of this office would endanger critical5269programmatic support for UIOs working to combat HIV/AIDS in urban5270American Indian and Alaska Native communities. Continued funding and5271programmatic support are essential to preventing the spread of HIV and5272STIs. Without sustained investment, our communities face a heightened5273risk of worsening health outcomes.5274Indian Health Service5275 Although IHS staff have not been subject to recent Reduction in5276Force actions, the broader pattern of abrupt terminations and staffing5277changes across HHS has created uncertainty and unease. This has5278compounded the long-standing recruitment and retention challenges5279within IHS, particularly for providers and clinical personnel,5280especially since IHS continues to operate under a hiring freeze with5281extremely limited exemptions, making it difficult to fill critical5282vacancies.5283 While IHS was exempted from the Deferred Resignation Program, it5284was not exempt from the Voluntary Early Retirement Authority or the5285Voluntary Separation Incentive Program. As a result, staff have5286departed and cannot be replaced under current restrictions. Many of5287these vacancies are essential to supporting operations. For instance,5288one Area Office has an urban coordinator vacancy that remains unfilled5289due to the freeze, which is now affecting the efficiency and5290effectiveness of health care delivery for urban American Indian and5291Alaska Native people across the region. The ongoing instability5292regarding staffing authority and exemptions pose real risks to IHS's5293ability to maintain and improve service delivery in Indian Country.5294Centers for Medicaid and Medicare Services Office of Minority Health5295 (CMS OMH)5296 As part of the restructuring efforts, CMS OMH has been eliminated.5297The shuttering of this office will impact revolutionary research that's5298been done in support of American Indian and Alaska Native people. For5299example, CMS OMH supported research on Traditional Healing and Medicaid5300\12\ prior to the newly approved Medicaid waivers. \13\ Data on5301American Indian and Alaska Native people is already scarce, and we5302can't afford cuts to critical research.5303---------------------------------------------------------------------------5304 \12\ Nat'l Council of Urban Indian Health, Recent Trends in Third-5305Party Billing at Urban Indian Organizations: Thematic Analysis of5306Traditional Healing Programs at Urban Indian Organizations and Meta-5307Analysis of Health Outcomes (2023), https://ncuih.org/research/third-5308party-billing/#tab-id-11. Urban Indian Organizations (UIOs) rely on5309reimbursement from third-party payers to sustain operations and provide5310necessary health services to American Indians and Alaska Natives (AI/5311ANs) living in. . .5312 \13\ Press Release, Ctrs. for Medicare & Medicaid Serv., Biden-5313Harris Administration Takes Groundbreaking Action to Expand Health Care5314Access by Covering Traditional Health Care Practices (Oct. 16, 2024),5315https://www.cms.gov/newsroom/press-releases/biden-harris-5316administration-takes-groundbreaking-actionexpand-health-care-access-5317covering.5318---------------------------------------------------------------------------5319Conclusion and Request5320 In conclusion, the proposed restructuring and funding cuts across5321HHS operating divisions represent a significant threat to the health5322and well-being of urban American Indian and Alaska Native communities.5323UIOs rely on critical support from HRSA, SAMHSA, CDC, OASH, CMS OMH,5324and other HHS divisions to fulfill the federal trust responsibility and5325provide culturally competent, life-saving care to their patients. The5326lack of Tribal consultation and urban confer surrounding these changes5327is deeply concerning and undermines the government's obligation to5328engage meaningfully with the communities these policies affect. NCUIH5329urges the Committee to hold HHS accountable for its trust and treaty5330obligations to American Indian and Alaska Native people and to ensure5331UIOs are fully included in decisionmaking processes. We respectfully5332request that Congress protect and strengthen funding for UIOs across5333all HHS divisions and ensure HHS provides transparency and5334collaboration before moving forward with any reorganization that would5335jeopardize the health of American Indian and Alaska Native people.5336 ______53375338 Prepared Statement of Andrea Pesina, President, National Indian Head5339 Start Directors Association (NIHSDA)5340 Chairman Murkowski, Vice Chairman Schatz, and Members of the5341Committee:5342 Thank you for the opportunity to submit testimony on behalf of the5343National Indian Head Start Directors Association (NIHSDA) regarding the5344delivery of essential public health and social services to Native5345communities. We deeply appreciate the Committee's attention to the role5346that federal programs administered by the U.S. Department of Health and5347Human Services (HHS) play in supporting the health, development, and5348well-being of American Indian and Alaska Native (AIAN) children and5349families.5350 NIHSDA represents over 150 Tribal Head Start and Early Head Start5351programs across the United States, serving more than 20,000 Native5352children annually. These programs are not only early education5353services--they are comprehensive, community-driven systems of care that5354provide critical health screenings, nutrition support, mental health5355services, and family engagement in a culturally rooted and sovereign5356framework.5357 They are essential public health and social service providers,5358uniquely situated to meet the needs of Native children and families in5359Tribal communities. Core services include:53605361 Comprehensive Health Screenings: Including vision, hearing,5362 developmental, dental, behavioral, and immunization checks,5363 ensuring early detection and follow-up care.53645365 Preventive Health and Nutrition Services: Programs provide5366 healthy meals, growth monitoring, and nutrition education5367 tailored to local and cultural dietary needs.53685369 Mental and Behavioral Health Services: On-site mental health5370 consultation, trauma-informed supports, and social-emotional5371 learning integrated into the classroom environment.53725373 Family Services and Case Management: Programs conduct family5374 needs assessments and provide referrals to housing, food5375 assistance, substance abuse recovery, and domestic violence5376 services.53775378 Parent and Caregiver Support: Services include parenting5379 education, goal setting, and advocacy to promote self-5380 sufficiency and strengthen family well-being.53815382 Emergency and Wraparound Support: Assistance with5383 transportation, clothing, and other urgent needs, especially in5384 crisis situations.53855386 Culturally Responsive and Sovereignty-Driven Approaches:5387 AIAN programs partner with Tribal health departments,5388 incorporate traditional practices and healing, and reflect the5389 values, governance, and priorities of their communities.53905391 These essential services not only support children's immediate5392development but also address long-standing disparities in health5393access, educational outcomes, and economic opportunity. AIAN Head Start5394programs are often one of the few consistent providers of preventive5395health and social services in Tribal communities.5396Head Start is an Essential Health and Social Service5397 Head Start is a cornerstone public health and social service in5398Tribal communities. AIAN programs have long addressed deeply rooted5399disparities in access to healthcare, early intervention, and early5400education. Head Start's two-generational model strengthens families,5401improves long-term outcomes, and helps fulfill federal trust5402obligations to Native peoples.5403 Despite this, Tribal programs often face disproportionate5404challenges, including:54055406 Limited and Constrained Funding: NIHSDA remains deeply5407 concerned about the future of Head Start in light of recent5408 federal actions and the release of the administration's5409 ``skinny'' budget on May 2, 2025. While the budget did not5410 explicitly propose eliminating Head Start, it offered no5411 reassurance about sustained or increased funding--and the full5412 FY 2026 budget, expected later this month, may still include5413 harmful cuts. These omissions are troubling and risk5414 destabilizing nearly 60 years of investment in children,5415 families, and communities. The stakes are especially high for5416 American Indian and Alaska Native (AI/AN) programs, which could5417 face significant consequences.54185419 AI/AN communities already face some of the highest rates of5420poverty, housing insecurity, limited healthcare access, and educational5421disparities in the country. Reductions in Head Start services would5422exacerbate these inequities and risk undoing decades of progress5423achieved through community-driven, culturally grounded programs. These5424services are a lifeline for Native children and families, and any cuts5425would disproportionately affect the most vulnerable populations.5426 Today, 481 AI/AN Head Start centers operate in 26 states, providing5427vital services to children and families and employing thousands--5428teachers, family service workers, bus drivers, cooks, and more. These5429programs serve as economic engines in Tribal communities, enabling 735430percent of participating families to work, attend school, or complete5431job training. Without sustained federal investment, these families risk5432losing both child care and jobs--further weakening Tribal economies.5433This would have devastating consequences, not only for the children and5434families directly impacted but also for the broader community and5435economy.5436 NIHSDA strongly urges Congress to continue funding Head Start at5437robust levels, ensuring that both the base program and the Tribal set-5438aside are maintained and increased. We recommend that the federal5439government include a 3.2 percent Cost of Living Adjustment (COLA) in FY54402026 to help programs retain qualified staff, manage rising operational5441costs, and ensure the delivery of high-quality services. These5442investments in Head Start are critical to improving educational5443outcomes, promoting self-sufficiency, and addressing the deep-seated5444disparities in AI/AN communities.54455446 The Critical Role of the AIAN Regional Office (Region XI):5447 The separate Regional Office for AIAN Head Start programs5448 within the Office of Head Start (Region XI) is vital to5449 ensuring culturally competent, responsive, and respectful5450 oversight. This office supports Tribal sovereignty by working5451 government-to-government with Tribal Nations and is uniquely5452 positioned to navigate the complexities of operating Head Start5453 programs in diverse and sovereign Tribal contexts. NIHSDA5454 strongly supports the continued operation--and strengthening--5455 of this dedicated regional structure.54565457 Dedicated AIAN Training and Technical Assistance (TTA):5458 Tribal Head Start programs benefit from a separate, culturally5459 grounded TTA system that understands the historical, cultural,5460 and logistical context in which these programs operate.5461 Maintaining a dedicated AIAN TTA system is critical to building5462 Tribal capacity, supporting continuous quality improvement, and5463 ensuring that Tribal programs are not expected to conform to5464 models that do not reflect their community values or realities.54655466Recommendations for HHS and Congressional Action5467 We respectfully urge the Committee to champion the following5468actions:54695470 1. Retain and Strengthen the Tribal Head Start Set-Aside54715472 --Maintain the Tribal set-aside and increase the overall Head5473 Start appropriation to ensure that it reflects actual need and5474 cost in Native communities.54755476 2. Protect and Support Region XI and AIAN TTA54775478 --Continue funding and support for the AIAN Regional Office at5479 the Office of Head Start (Region XI), and maintain a dedicated5480 TTA system to serve AIAN grantees with culturally grounded,5481 community-specific expertise.54825483 3. Center Tribal Voices in Policy and Program Design54845485 --Require meaningful and consistent Tribal consultation in the5486 development of federal policies and systems impacting Tribal5487 early childhood programs, and invest in Tribal-led innovation,5488 evaluation, and system-building efforts.54895490Conclusion5491 For 60 years, Tribal Head Start and Early Head Start programs have5492served as foundational systems of care and opportunity for Native5493children and families. These programs honor cultural identity, promote5494educational success, and strengthen Tribal communities. The federal5495government must uphold its trust responsibility by ensuring equitable,5496stable, and culturally grounded support for these services.5497 NIHSDA strongly opposes any proposals to eliminate or reduce5498funding for AI/AN Head Start programs in the FY 2026 budget or future5499fiscal years. Any such cuts would have a catastrophic impact on Native5500communities, dismantling critical services for children and families5501and violating the federal trust responsibility to Tribal Nations.5502 We thank the Committee for its commitment to oversight and for5503recognizing the vital role of Tribal Head Start in delivering essential5504health and social services to Native children and families.5505 ______55065507 Prepared Statement of Robyn Sunday-Allen, CEO, Oklahoma City Indian5508 Clinic (OKCIC)5509 My name is Robyn Sunday-Allen, I am Cherokee and the Chief5510Executive Officer of the Oklahoma City Indian Clinic (OKCIC), the5511largest Urban Indian Organizations (UIO) in the continental US serving5512only American Indian and Alaska Natives. OKCIC contracts with the5513Indian Health Service (IHS) under the Indian Health Care Improvement5514Act (IHCIA) and the American Indians and Alaska Native patients they5515serve. On behalf of OKCIC, I would like to thank Chairman Murkowski,5516Vice Chairman Schatz, and Members of the Committee for your leadership5517in improving health outcomes for American Indian and Alaska Native5518people and for the opportunity to provide testimony in response to the5519Senate committee on Indian Affairs May 14 hearing titled, ``Delivering5520Essential Public Health and Social Services to Native Americans--5521Examining Federal Programs Serving Native Americans Across the5522Operating Divisions at the U.S. Department of Health and Human5523Services''5524Proposed Health and Human Services Restructuring and Funding Cuts5525 The Oklahoma City Indian Clinic relies on funding and partnerships5526through key HHS divisions such as the Substance Abuse and Mental Health5527Services Administration (SAMHSA), the Centers for Medicare and Medicaid5528Services (CMS), the Centers for Disease Control and Prevention (CDC)5529and various Division of Tribal Affairs (DTA) offices. These divisions5530play a critical role in supporting programs and services vital to urban5531American Indian and Alaska Native populations. The value of HHS5532programs outside of IHS cannot be overstated, as they are essential for5533UIOs in fulfilling the federal trust and treaty obligation to provide5534health care services to American Indian and Alaska Native people. \1\5535The proposed reorganization and restructuring of HHS will bring5536significant changes to several operating divisions, with potentially5537serious consequences for UIOs.5538---------------------------------------------------------------------------5539 \1\ 25 U.S.C. 1601(1)5540---------------------------------------------------------------------------5541 It is particularly concerning that, to date, HHS has not held5542Tribal consultation or urban confer on the HHS restructuring. The lack5543of tribal consultation and urban confer is a failure to fulfill the5544U.S. Government trust and treaty obligations to Tribal Nations and5545programs serving Tribal citizens. Given the scope and potential impact5546of this restructuring, it is imperative that HHS engage in meaningful5547consultation with both Tribes and UIOs to ensure transparency and to5548address serious concerns about the consequences of such a significant5549public health and policy shift.5550Substance Abuse and Mental Health Services Administration5551 American Indians and Alaska Native people experience5552disproportionately high rates of alcohol, substance use and mental5553health disorders, suicide, violence, and behavior-related morbidity and5554mortality compared to the rest of the U.S. population. \2\ In fact,5555American Indian and Alaska Native people experience serious5556psychological distress at a rate 2.5 times more than the general5557population over a month's time. \3\ These poor outcomes impact American5558Indian and Alaska Native people no matter where they live. For example,5559according to a 2020 report from the Centers for Disease Control and5560Prevention, non-Hispanic American Indian and Alaska Native people had5561the highest rates of drug overdose deaths in both urban and rural5562counties compared to other races, at 44.3 per 100,000 and 39.8,5563respectively. \4\5564---------------------------------------------------------------------------5565 \2\ Fact Sheet: Behavioral Health, INDIAN HEALTH SERV. (2023),5566https://www.ihs.gov/sites/newsroom/themes/responsive2017/5567display_objects/documents/factsheets/BehavioralHealth.pdf.5568 \3\ Id.5569 \4\ Merianne Rose Spencer et al., Urban-Rural Differences in Drug5570Overdose Death Rates, 2020, NAT'L CTR. FOR HEALTH STAT. (July 2022),5571https://www.cdc.gov/nchs/data/databriefs/db440.pdf.5572---------------------------------------------------------------------------5573 SAMHSA programs play a critical role in addressing these outcomes,5574saving lives and improving behavioral health outcomes across Indian5575Country. However, both the reorganization and the President's proposed5576budget include substantial cuts to SAMHSA's three major centers: the5577Center for Mental Health Services (CMHS), the Center for Substance5578Abuse Treatment (CSAT), and the Center for Substance Abuse Prevention5579(CSAP).5580 Notably, CMHS funds several Tribal behavioral grant programs,5581including the Native Connections program of which the Oklahoma City5582Indian Clinic is an awardee. The Native Connections program is a youth-5583focused behavioral health grant. This program has been influential in5584reducing suicides among American Indian and Alaska Native youth.5585Unfortunately, many UIOs have heard from SAMHSA staff that their Native5586Connections grants will not be renewed in the 2026 grant year. This5587expected loss of funding is deeply concerning, as it would undermine5588efforts to address the behavioral health crisis facing our communities.5589Centers for Disease Control and Prevention5590 The recent reorganization efforts and reduction in force at the5591Centers for Disease Control and Prevention (CDC) have had a significant5592negative impact on Tribal and Urban programs, including the Healthy5593Tribes initiative, which provides a culture-first approach to health5594promotion/disease prevention in American Indian and Alaska Native5595communities and funds key grants for UIOs through the Tribal Practices5596for Wellness in Indian Country (TPWIC) and Good Health and Wellness in5597Indian Country (GHWIC) programs.5598 For example, the Oklahoma City Indian Clinic, which receives both5599TPWIC and GHWIC funding, is currently running these programs without5600the support of Project Officers, Grant Managers, and Grant Evaluators.5601These positions were eliminated due to a Reduction in Force. As a5602result, we have received very little communication or guidance about5603these changes, leaving us uncertain about the status of our current5604funding. This lack of clarity also hinders our ability to plan,5605implement, and forecast essential public health initiatives.5606Additionally, the absence of key staff makes it difficult to report5607project outcomes to Congress in a clear and effective manner, which5608could impact future funding decisions.5609 While TPWIC and GHWIC represent only a small fraction of federal5610spending, they provide essential support for chronic disease5611prevention, increased physical activity, and reduction of commercial5612tobacco use in Tribal and urban American Indian and Alaska Native5613communities. The loss or interruption of these culturally responsive5614programs threatens to further exacerbate already poor health outcomes5615for and undermines the federal trust responsibility to American Indian5616and Alaska Native people.5617Office of the Assistant Secretary for Health5618 American Indian and Alaska Native people have the highest rate of5619undiagnosed HIV cases compared to other racial/ethnic groups in the5620U.S., \5\ and according to IHS, as many as 34 percent of the American5621Indian and Alaska Native people living with HIV infection do not know5622it. \6\ UIOs are an important resource for urban American Indian and5623Alaska Native people for HIV/AIDS testing and referral to appropriate5624care.5625---------------------------------------------------------------------------5626 \5\ IHS Awards New Cooperative Agreements for Ending the HIV and5627HCV Epidemics in Indian Country. (2022, September 27). Retrieved5628January 5, 2023, from https://www.ihs.gov/sites/newsroom/themes/5629responsive2017/display_objects/documents/HIV-Funding-5630PressRelease09272022.pdf5631 \6\ Indian Health Service, HIV/AIDS in American Indian and Alaska5632Native Communities. Retrieved August 8, 2023, from: https://5633www.ihs.gov/hivaids/hivaian/#:-5634:text=The%20IHS%20National%20HIV%2FAIDS,Get%20tested%20for%20HIV.5635---------------------------------------------------------------------------5636 The Office of Infectious Disease and HIV/AIDS Policy (OIDP), housed5637within the Office of the Assistant Secretary for Health (OASH),5638administers key programs such as Ending the HIV Epidemic in the U.S.5639and the Minority HIV/AIDS Fund, which are primary sources of support5640for IHS HIV and sexually transmitted infection (STI) response efforts.5641Located in Oklahoma and serving the American Indian population, both5642identified as a high risk state or population for the EndHIV5643initiative, the Oklahoma City Indian Clinic is particularly concerned5644about the ramifications of budgetary cuts to such an important program.5645 Alarmingly, OASH is currently slated for elimination under proposed5646restructuring plans. The loss of this office would endanger critical5647programmatic support for UIOs working to combat HIV/AIDS in urban5648American Indian and Alaska Native communities. Continued funding and5649programmatic support are essential to preventing the spread of HIV and5650STIs. Without sustained investment, our communities face a heightened5651risk of worsening health outcomes.5652Indian Health Service5653 Although IHS staff have not been subject to recent Reduction in5654Force actions, the broader pattern of abrupt terminations and staffing5655changes across HHS has created uncertainty and unease. This has5656compounded the long-standing recruitment and retention challenges5657within IHS, particularly for providers and clinical personnel,5658especially since IHS continues to operate under a hiring freeze with5659extremely limited exemptions, making it difficult to fill critical5660vacancies.5661 While IHS was exempted from the Deferred Resignation Program, it5662was not exempt from the Voluntary Early Retirement Authority or the5663Voluntary Separation Incentive Program. As a result, staff have5664departed and cannot be replaced under current restrictions. Many of5665these vacancies are essential to supporting operations. For instance,5666one Area Office has an urban coordinator vacancy that remains unfilled5667due to the freeze, which is now affecting the efficiency and5668effectiveness of health care delivery for urban American Indian and5669Alaska Native people across the region. The ongoing instability5670regarding staffing authority and exemptions pose real risks to IHS's5671ability to maintain and improve service delivery in Indian Country.5672Centers for Medicaid and Medicare Services Office of Minority Health5673 (CMS OMH)5674 As part of the restructuring efforts, CMS OMH has been eliminated.5675The shuttering of this office will impact revolutionary research that's5676been done in support of American Indian and Alaska Native people. For5677example, CMS OMH supported research on Traditional Healing and Medicaid5678\7\ prior to the newly approved Medicaid waivers. \8\ Data on American5679Indian and Alaska Native people is already scarce, and we can't afford5680cuts to critical research.5681---------------------------------------------------------------------------5682 \7\ Nat'l Council of Urban Indian Health, Recent Trends in Third-5683Party Billing at Urban Indian Organizations: Thematic Analysis of5684Traditional Healing Programs at Urban Indian Organizations and Meta-5685Analysis of Health Outcomes (2023), https://ncuih.org/research/third-5686party-billing/#tab-id-11. Urban Indian Organizations (UIOs) rely on5687reimbursement from third-party payers to sustain operations and provide5688necessary health services to American Indians and Alaska Natives (AI/5689ANs) living in. . .5690 \8\ Press Release, Ctrs. for Medicare & Medicaid Serv., Biden-5691Harris Administration Takes Groundbreaking Action to Expand Health Care5692Access by Covering Traditional Health Care Practices (Oct. 16, 2024),5693https://www.cms.gov/newsroom/press-releases/biden-harris-5694administration-takes-groundbreaking-actionexpand-health-care-access-5695covering.5696---------------------------------------------------------------------------5697Conclusion and Request5698 In conclusion, the proposed restructuring and funding cuts across5699HHS operating divisions represent a significant threat to the health5700and well-being of urban American Indian and Alaska Native communities.5701The Oklahoma City Indian Clinic relies on critical support from SAMHSA,5702CDC, OASH, CMS OMH, and other HHS divisions to fulfill the federal5703trust responsibility and provide culturally competent, life-saving care5704to their patients. The lack of Tribal consultation and urban confer5705surrounding these changes is deeply concerning and undermines the5706government's obligation to engage meaningfully with the communities5707these policies affect. The Oklahoma City Indian Clinic urges the5708Committee to hold HHS accountable for its trust and treaty obligations5709to American Indian and Alaska Native people and to ensure UIOs are5710fully included in decisionmaking processes. We respectfully request5711that Congress protect and strengthen funding for UIOs across all HHS5712divisions and ensure HHS provides transparency and collaboration before5713moving forward with any reorganization that would jeopardize the health5714of American Indian and Alaska Native people.5715 ______57165717 Prepared Statement of Shawn M. Kana`iaupuni, Ph.D., President/CEO,5718 Partners in Development Foundation (PIDF)5719 Thank you, Chairman Murkowski, Vice Chairman Schatz, and members of5720the Committee for the opportunity to provide testimony on behalf of5721Partners in Development Foundation (PIDF) in support of programs at the5722U.S. Department of Health and Human Services (HHS), that support the5723Native Hawaiian community, including funding for programs that support5724Native Hawaiian children and youth through the Administration for5725Native Americans (ANA), an office within the Administration for5726Children & Families (ACF).5727Background about PIDF5728 Partners in Development Foundation (PIDF) is an IRS Section5729501(c)(3) public charity incorporated in the State of Hawai`i in 19975730to inspire and equip families and communities for success and service5731using timeless Native Hawaiian values and traditions. Since inception,5732PIDF has provided free programs for at-risk communities across our5733state in the areas of multi-generational education (early education5734through adult), strengthening families and communities (full-service5735community school programming, workforce development, and a safehouse5736for adjudicated teens), and island resiliency (natural farming project5737providing training and youth mentoring for opportunity youth).5738 In our years of experience providing our ten programs to keiki,5739young people and families, we see the challenges our community faces in5740trying to address the needs of their families while struggling to find5741positive solutions to the crises in education, housing, and managing5742the high cost of living in this state. Therefore, at PIDF, every5743program we offer is more than an educational service--it is an act of5744aloha, deeply rooted in Hawaiian cultural values such as malama `aina5745(caring for the land), kuleana (responsibility), and `ike kupuna5746(ancestral wisdom). Our journey over the last 28 years, touching more5747than 175,000 lives, has shown us that meaningful, culturally responsive5748education can break the cycle of poverty, trauma, and marginalization.5749One such notable program is Ka Pa`alana in which young infants and5750toddlers experiencing homelessness gain stability and school readiness5751through Ka Pa`alana's accredited early learning program, delivered5752directly on beaches/shelters/transitional housing alongside vital5753caregiver education and support.5754The Importance of USDHHS: Administration for Native Americans5755 For decades, HHS has provided essential funding to organizations5756like PIDF, supporting the advancement and well-being of Native Hawaiian5757children and youth, through ACF's ANA funding programs. Without5758programs like these, communities across Hawaii will lose access to5759federal support for the planning, designing, restoration, and5760implementing of native language curriculum and education projects to5761support Hawaiian language preservation goals; the development of self-5762determining, healthy, culturally and linguistically vibrant, self-5763sufficient communities; community-driven projects designed to5764revitalize the Hawaiian language to ensure its survival and continuing5765vitality for future generations; culturally appropriate strategies to5766meet the social service needs and well-being of Native Hawaiians across5767the state; and the creation of a sustainable local economy to enhance5768the economic independence of Native Hawaiians.5769 Like many organizations in Hawaii predominantly serving Native5770Hawaiian children and youth, PIDF leverages federal grant programs5771administered by ANA, which have included language revitalization and5772immersion programs, as well as social and economic development5773programs. PIDF has received ANA grant funding for years to provide5774services in various areas of need:57755776 language access for the first and original written Hawaiian5777 language resource which has been foundational for Native5778 Hawaiian families but was previously out-of-print (CFDA 93-587,5779 Grant 90NL0248, Baibala Hemolele, 09/30/02-02/28/06),57805781 recruitment, training and preparation of 144 Native Hawaiian5782 foster parents across the state to meet the needs of the large5783 number of Native Hawaiian children in foster care (CFDA 93-612,5784 Grant 90NA7748, Kokua Ohana, 09/30/04-09/30/06),57855786 creation of a culturally-sensitive math and science5787 curriculum delivered through a mobile computer lab serving5788 houseless families in conjunction with the Ka Pa`alana Homeless5789 Family Education Program (CFDA 93-612, Grant 90NA7931, `Ike5790 No`eau, 09/30/07-09/29/10),57915792 development of Native Hawaiian culture-based toddler and5793 preschool curriculum that meets national standards and empowers5794 30 homeless Native Hawaiian fathers through a Native Hawaiian5795 parent education curriculum focused on the role of fathers5796 (CFDA 93-612, Grant 90NA8188, Ka Pa`alana Homeless Family5797 Education Program, 09/30/11-09/29/14),57985799 development of a Native Hawaiian health curriculum called5800 Ola Mau for 0-5 year olds and their caregivers/families in the5801 Ka Pa`alana Program (CFDA 93-612, Grant 90NA8259, Ka Pa`alana5802 Homeless Family Education Program, 09/30/14-09/29/17),58035804 expansion of Ka Pa`alana services in Keaukaha (East Hawaii5805 on Hawaii Island) (CFDA 93-612, Grant 90NA8366, Ka Pa`alana5806 Family Education Program in Keaukaha, 09/30/19-09/29/22), and58075808 delivery of the Ka Pa`alana program including emergency5809 preparedness for East HI Island and Leeward Oahu's Malama5810 Mobile outreach sites (CFDA 93-612, Grant 90NA8474, Makaukau Ka5811 Pa`alana, 09/30/22-09/29/25).58125813Data: Demonstrating Effectiveness of ANA-funded Programs5814 Some data highlights from the most recent of these critical and5815relevant ANA grants have demonstrated positive impact and an increase5816in knowledge and family wellness.58175818 While 67.9 percent agreed or strongly agreed that they did5819 not know very much about the topic before the parent education5820 class, 94.5 percent agreed or strongly agreed that they had a5821 better understanding of the topic after the class. Topics5822 covered Parenting tips, child development, preschool5823 engagement, STEAM curriculum, literacy strategies, mental5824 health support, discl58255826 While 74.7 percent agreed or strongly agreed that they did5827 not know very much about the topic before the adult education5828 classes (including classes on how to take of health for5829 caregivers and their family), 99.3 percent agreed or strongly5830 agreed that they had a better understanding of the topic after5831 class.58325833 The Hawaii State School Readiness Assessment indicates to5834 what extend the child is ready for Kindergarten with primary5835 focus on literacy skills. On a scale from 1 to 4, with 4 being5836 a perfect score, the overall mean score of the 33 participants5837 was 3.76 which indicates most of these children have mastered5838 literacy skills. There were 22 (66.7 percent) participants that5839 scored a 4 for all four measures.58405841 As part of the Emergency Preparedness curriculum, 38 (84.45842 percent) adult participants improved their knowledge of fire5843 safety after attending the class, and 28 (82.4 percent) adult5844 participants improved their knowledge of hurricane preparedness5845 after attending the class.58465847Conclusion5848 It is imperative that programs at HHS that serve Native communities5849continue to provide necessary support for these important activities5850that serve and support the Native Hawaiian families and communities.5851Thank you for the opportunity to provide testimony to the Committee's5852hearing on federal programs across HHS that serve Native Americans. I5853look forward to working with the Committee on this important issue.5854 ______58555856 Prepared Statement of Jennifer Rowland5857We Need Headstart In Native Country5858 Federal budget discussions have raised concerns for Native early5859childhood education. Considerations for a restructuring of HHS have5860proposed the elimination of Head Start, which includes a set-aside for5861Tribal Nations and Tribal organizations.5862 For nearly 60 years, AI/AN Head Start programs have provided early5863learning, family support, and community-driven services to Native5864children from birth to age five. These programs help families access5865health care, support school readiness, and preserve Tribal languages5866and traditions. In Tribal communities, Head Start and Tribal programs5867are frequently the only childcare available.5868 If this program is eliminated:58695870 Nearly 20,000 Native children could lose access to critical5871 early education58725873 More than 6,000 Head Start staff may lose their jobs58745875 Tribal Nations could face setbacks in community-based5876 efforts to support families and preserve culture58775878 ______58795880Prepared Statement of Esther Lucero, MPP, President/CEO, Seattle Indian5881 Health Board5882 Chairman Murkowski, Vice Chairman Schatz, and members of Senate5883Committee on Indian Affairs (SCIA), my name is Esther Lucero, and I am5884of Dine and Latina descent, currently living in an urban Indian5885community in Seattle, Washington. I am the third generation in my5886family living outside our reservation. Since 2015, I have served as the5887President & Chief Executive Officer of the Seattle Indian Health Board5888(SIHB), one of 41 Indian Health Service (IHS) designated urban Indian5889organizations (UIO) nationwide, a network designed to serve the health5890needs of the 76 percent of American Indian and Alaska Native (AI/AN)5891people residing in urban areas. Over the past 16 years, I have5892dedicated my professional career in healthcare to serving AI/AN5893communities.5894 I am also a delegate to the Washington state American Indian Health5895Commission, a member of the King County Board of Health, the City of5896Seattle Indigenous Advisory Council, and the AstraZeneca Health Equity5897Advisory Councill. I am honored to have the opportunity to submit my5898written testimony today for the SCIA Oversight Hearing.5899Seattle Indian Health Board5900 SIHB is a UIO and Federally Qualified Health Center (FQHC) and5901serves over 5,000 people living in the Greater Seattle, Washington area5902with specialized services for AI/AN people. We are part of the IHS/5903Tribal 638/UIO healthcare system (I/T/U) and honor our responsibilities5904to work with our Tribal and federal partners to serve all Tribal5905people, regardless of where they reside. Urban Indian Health Institute5906(UIHI) is the research division of SIHB, a public health authority, and5907one of twelve Tribal Epidemiology Centers (TEC) in the country--the5908only one that serves UIOs nationwide. UIHI conducts research and5909evaluation, collects and analyzes data, and provides disease5910surveillance for Tribes and the 41 UIOs nationwide. As a UIO and TEC,5911our role is to address the community health and public health needs of5912the over 76 percent of AI/AN people who live in urban areas.5913Fully Fund the Indian Health Care System5914 To truly fulfill its trust and treaty obligations, the federal5915government must fully fund the I/T/U system. The National Tribal Budget5916Formulation Workgroup calculates that to meet this goal in FY 2026,5917Congress must appropriate $63.04 billion to the Indian Health Service,5918including $770.53 million for the Urban Indian Health line item and5919$474.47 million for the Hospitals and Health Clinics: TECs line item.5920 However, until full funding for IHS is achieved, Congress must5921continue to invest in the critical programs that supplement the IHS5922budget but are not administered by IHS. For example, Healthy Tribes, a5923Centers for Disease Control and Prevention (CDC) program, supports5924chronic disease prevention in Indian Country. While not administered by5925IHS, its funding is crucial for the health of AI/AN communities.5926Numerous other programs administered by the Substance Abuse and Mental5927Health Services Administration (SAMHSA), the National Institutes of5928Health, the Health Resources and Services Administration, and other5929divisions of the U.S. Department of Health and Human Services (HHS)5930directly benefit AI/AN communities and cutting their funding also has a5931direct negative impact on AI/AN communities. The proposed $33.35932billion, or 26.2 percent, reduction in the HHS budget, including a5933proposed reduction of $139.8 million to SAMHSA programming will5934disproportionately harm Indian Country. I urge Congress to maintain5935funding for HHS and its divisions.5936Advance Appropriations5937 I urge you to once again support advance appropriations for the I/5938T/U system. It is the only federal healthcare system without mandatory5939appropriations, and failure to include advance appropriations5940jeopardizes the health and wellbeing of AI/AN communities relying on5941IHS, Tribal, and UIO facilities for their health care needs.5942Protect Medicaid5943 Congress must protect Medicaid expansion for AI/AN communities.5944Medicaid is a critical component to the fulfillment of the federal5945government's trust and treaty obligations to AI/AN people. In 2023,594631.3 percent of AI/AN people including 48.7 percent of AI/AN children5947aged 0-19 years old were enrolled in Medicaid. \1\ Medicaid funding5948helps bridge chronic shortfalls in funding for IHS. For many Indian5949health facilities, Medicaid funding accounts for 30-60 percent of total5950revenue, underscoring its vital role in supporting health care services5951for AI/AN populations. In 2024, 50 percent of our relatives (patients)5952seen at SIHB were Medicaid beneficiaries, and our facilities' Medicaid5953revenue was $4.9 million, or, 47 percent of our third-party revenue.5954Clinical services paid for by Medicaid accounted for $1.5 million,5955while pharmacy Medicaid payments accounted for $3.4 million. As an FQHC5956we are required to re-invest these revenues back into our health5957service system--and we do that in innovative ways, such as traditional5958medicine, that we know reduce the rates of chronic diseases. Medicaid5959ensures that all eligible members of the AI/AN community receive health5960care services critical to their well-being no matter where they live5961and I urge you to oppose any cuts to this important program.5962---------------------------------------------------------------------------5963 \1\ Davis, W. (2025), AI/AN Medicaid Enrollment & Funding, National5964Indian Health Board (NIHB).5965---------------------------------------------------------------------------5966Missing and Murdered Indigenous Women and People5967 As I am aware of your deep commitment to addressing the crisis of5968Missing and Murdered Indigenous Women and People, I would also like to5969bring attention to the President's proposed reduction of $107 million5970in funding for U.S. Department of the Interior law enforcement5971programming currently supporting Tribal operations. This is counter to5972efforts, including those carried out under Trump's first5973administration, to combat one of the greatest crises affecting Indian5974Country.5975 I thank you for your continued leadership on issues affecting5976Indian Country and remain a committed partner with you in this regard.5977 ______59785979 Prepared Statement of Hon. Melvin J. Baker, Chairman, Southern Ute5980 Indian Tribe5981 Greetings, Chairman Murkowski, Vice Chairman Schatz, and members of5982the Committee. My name is Melvin J. Baker. I am the elected Chairman of5983the Southern Ute Indian Tribe (``Tribe'') on the Southern Ute Indian5984Reservation in southwestern Colorado. Thank you for the opportunity to5985provide written testimony concerning the need to fully fund Health and5986Human Services (HHS) programs serving Indian Country. Given the5987critical impact Tribal health programs have on communities like ours,5988the Tribe strongly urges Congress to protect funding for HHS. Without5989adequate HHS funding, the Tribe's ability to serve its members and5990other Native Americans living within our community is severely5991diminished.5992 The Tribe is one of two federally recognized Tribes in the State of5993Colorado. Our Reservation is home to thousands of Native Americans,5994including Tribal members, first descendants, and those affiliated with5995other federally recognized Tribes, who are eligible to receive health5996services through the Indian Health Service (IHS). The federal5997government has a legal and moral trust obligation to provide health and5998social services to the Ute people and other Natives in our community.5999This obligation is grounded in long-standing treaties, statutes such as6000the Indian Health Care Improvement Act and the Indian Self6001Determination Act, executive orders, and judicial precedent. HHS is the6002principal federal agency responsible for fulfilling this trust. The6003federal trust responsibility to provide healthcare to Tribes must6004extend not only to the IHS but to all HHS agencies that support tribal6005health. As you noted in your May 9 letter to HHS Secretary Kennedy,6006threats to these programs or ``termination of staff responsible for6007managing these programs threatens the health, safety, and well-being of6008Native communities,'' \1\ including the Tribe's. Funding and staffing6009cuts would disrupt care, reverse hard-won public health gains, and6010violate sacred trust obligations to Tribes that the United States is6011required by law to meet.6012---------------------------------------------------------------------------6013 \1\ Letter to HHS on non-HIS RIFs and reorganization, Senators Lisa6014Murkowski and Brian Schatz, May 9, 2025, at 1, available at: Letter to6015HHS on non-IHS RIFs and reorganization6016---------------------------------------------------------------------------6017 Upholding this trust obligation is critical as Native Americans6018already suffer serious disadvantages in the healthcare space. We have6019long experienced significant and unacceptable health disparities when6020compared with other Americans. \2\ These discrepancies remain prevalent6021today, but they find their roots in historical trauma that flows from6022forced relocation and assimilationist policies. Such trauma contributes6023directly to higher rates of poverty, unemployment, and lack of access6024to quality education and healthcare experienced by Native communities6025today. \3\ These socioeconomic inequities in turn lead to higher rates6026of chronic conditions such as heart disease, diabetes, cancer, and6027obesity. \4\ Life expectancy for Native Americans is 10 years lower6028than the United States average. \5\ Not only is life expectancy6029shortened, but these disparities operate to reduce quality of life for6030Native Americans while alive. For example, Native Americans experience6031disproportionately higher rates of mental health and substance abuse6032issues. \6\ Suicide rates are significantly higher among American6033Indian youth than other youth populations. \7\ Many of these health6034disparities were exacerbated by the COVID-19 pandemic and have long6035been made worse by the persistent, chronic underfunding of Indian6036health care--a problem that dates back decades. \8\6037---------------------------------------------------------------------------6038 \2\ Tribal Public Health Week 2025: Health Equity Starts Here--In6039Truth, Action, and Sovereignty, National Indian Health Board, April 9,60402025, available at: Tribal Public Health Week 2025: Health Equity6041Starts Here--In Truth, Action, and Sovereignty--National Indian Health6042Board6043 \3\ National Indian Council on Aging, Inc., American Indian Health6044Disparities, last accessed on May 21, 2025, available at: American6045Indian Health Disparities6046 \4\ Indian Health Service, Disparities, October 2019, available at:6047Disparities/Fact Sheets; U.S. Department of Health and Human Services6048Office of Minority Health, Obesity and American Indians/Alaska Natives,6049last edited Feb. 13, 2025, available at: Obesity and American Indians/6050Alaska Natives/Office of Minority Health6051 \5\ National Vital Statistics Reports, Vol. 74, Number 2, at 50,6052April 8, 2025, available at: https://www.cdc.gov/nchs/data/nvsr/nvsr74/6053nvsr74-02.pdf6054 \6\ American Addiction Centers, Alcohol and Drug Use Among Native6055Americans, updated May 2, 2025, available at: Substance Abuse6056Statistics for Native Americans; A Path Forward to Fully Fund Tribal6057Nations by Embracing the Trust Responsibilities and Promoting the Next6058Era of Self-Determination and Health Care Equity and Equality, Victor6059Joseph and Andrew Joseph, Jr., at 31, April 2024, available at:6060NIHB=FY26-Budget.pdf6061 \7\ Tribal Public Health Week 2025: Health Equity Starts Here--In6062Truth, Action, and Sovereignty, National Indian Health Board, April 9,60632025, available at: Tribal Public Health Week 2025: Health Equity6064Starts Here--In Truth, Action, and Sovereignty--National Indian Health6065Board; NMSU study finds high suicide rates among American Indian,6066Alaska Native children, Carlos Carrillo Lopez, Dec. 9, 2024, available6067at: NMSU study finds high suicide rates among American Indian, Alaska6068Native children6069 \8\ Am. J Public Health June 2014, Donald Warne and Linda Bane6070Frizzell, available at: American Indian Health Policy: Historical6071Trends and Contemporary Issues--PMC6072---------------------------------------------------------------------------6073 Despite the health imbalances that have plagued generations of6074Native Americans, Indian Country has seen significant and real progress6075in closing these gaps and providing Tribal communities with better-6076quality healthcare. Much of this progress is thanks to funding from HHS6077and other federal programs given directly to Tribes so that we may6078direct how we treat the health needs of our communities. Empowering6079Tribes to operate their own health programs through self-governing6080contracts or compacts is a critical tool for achieving better health6081outcomes for our people. As Tribes, we know best how to care for our6082members.6083 By law, the federal government must continue to empower us to6084provide culturally sensitive and quality care for our patients. Federal6085funding opportunities like those provided by HHS honor Tribal6086sovereignty by allowing the Tribe's governments to be an equal partner6087in shaping the public health systems and policies that affect our6088people. The Tribe takes this partnership seriously.6089 As a result, our Tribal Health Department operates a robust health6090program pursuant to a Title I self-determination contract. The Tribe's6091patients are included in the one million Native Americans who rely upon6092coverage by Medicaid and the Children's Health Insurance Program. \9\6093The Tribe's programs depend upon HHS funding and Medicaid reimbursement6094for health services to function and provide basic services to its6095patients. The proposed massive cuts to Medicaid funding would devastate6096Native communities and risk severe reductions in essential health care6097for Tribal members. \10\ Medicaid funding has allowed the Tribe to make6098major strides in adequately addressing disparities in Tribal healthcare6099and to provide Tribal members with culturally competent healthcare that6100is aimed at tackling the unique health challenges faced by the Ute6101people and other Native Americans in our communities.6102---------------------------------------------------------------------------6103 \9\ Medicaid.gov, Indian Health & Medicine, last visited May 21,61042025, available at: Indian Health & Medicaid/Medicaid6105 \10\ Medicaid cuts would decimate Native American programs, tribal6106health leaders say, CBS News, Jazmin Orozco Rodriguez, March 14, 2025,6107available at, Medicaid cuts would decimate Native American programs,6108tribal health leaders say--CBS News.6109---------------------------------------------------------------------------6110 As a result of this funding, the Tribe's Health Department can6111provide all-inclusive, high-quality health care to over 2000 Native6112Americans in our community and the surrounding areas with the goal of6113elevating the health status of all Native people served by the6114Department. In operating a modern, sophisticated health clinic, the6115Tribe offers comprehensive and integrated direct care programs,6116including mental health and substance abuse treatment, referred6117services, and public health initiatives. Through these programs, the6118Tribe provides a multitude of critical health services to its patients,6119including: adult and pediatric primary care; adult and pediatric6120immunizations; dental and optometry care; physical therapy; urgent care6121and nurse triage appointments; 24/7 triage phone lines; lab and x-ray6122services; pharmacy services; women's health and reproductive services;6123referrals and consultations to specialist care; and specialty clinics6124for nephrology, gastroenterology, rheumatology, and audiology.6125Additionally, the Tribal Health Department provides home health care6126nurses and community health workers to eligible patients and provides6127medical care for Tribal inmates at our Detention Center.6128 Without HHS funding, the Tribe would be unable to sustain essential6129programming or meet the unique needs of its patients. For example, the6130Tribe routinely receives grant funding from the Substance Abuse and6131Mental Health Services Administration (SAMHSA), such as Tribal Opioid6132Response and Native Connections grants. SAMHSA grants allow the Tribe6133to fund programs to address the high rates of suicide, substance use,6134and intergenerational trauma that continue to persist in our6135community--efforts that are vital to the Tribe's ability to safeguard6136the health of our people. These funds also allow the Tribe to support6137the continuum of prevention, harm reduction, treatment, and recovery6138support services for opioid use disorder and co-occurring substance6139abuse disorders. These programs are critical as Native Americans6140continue to suffer the highest rate of fatal opioid overdoses in the6141United States. \11\ The Tribe's Behavioral Health Division further6142relies on SAMHSA grants to pay salaries for many of the Tribe's6143behavioral health staff. Without this funding, the Tribe will not have6144the personnel it needs to address critical behavioral health conditions6145prevalent in its patient population. An inability to address these6146conditions would have disastrous consequences for the health of Tribal6147patients because adequate behavioral health treatment is directly6148linked to positive health outcomes overall. When we fail to treat these6149conditions, we fail our patients. Lack of adequate funding must never6150be the cause of such failures.6151---------------------------------------------------------------------------6152 \11\ NCHS Data Brief No. 457, December 2022, Merianne Rose Spencer,6153M.P.H, Arialdi M. Minino, M.P.H., and Margaret Warner, Ph.D, at 3,6154available at: https://www.cdc.gov/nchs/data/databriefs/db457.pdf6155---------------------------------------------------------------------------6156 Additionally, the Tribe works closely with the Albuquerque Area6157Indian Health Board and the Southwest Epidemiology Center. These6158organizations receive federal grants and distribute subawards to the6159Tribe to address substance use issues and to provide technical6160assistance. We also use HHS funding to operate Shining Mountain Health6161and Wellness program--a fully grant funded community and clinic-based6162program that has a primary focus on chronic disease management and6163prevention, including for diabetes, women's health, and maternal-child6164health. Shining Mountain offers dynamic services, including nutrition6165education, cooking classes, foot care education and exams, membership6166at SunUte Community Center--the Tribe's state-of-the art fitness6167facility, and meal planning assistance, all based on the fluctuating6168and unique needs of the Tribal community. The Tribe's ability to6169continue providing these services is conditioned on its ability to6170receive HHS grants. These include the Special Diabetes Program for6171Indians coordinated by the IHS Division of Diabetes, and Center for6172Disease Control (CDC) grants, such as the Good Health and Wellness in6173Indian Country funding which is coordinated through the Healthy Tribes6174program and aimed at delivering holistic, culturally responsive,6175community-driven interventions for preventing, managing, and6176controlling chronic diseases like diabetes. Cuts to the CDC's Healthy6177Tribes program have already reverberated throughout Indian Country and6178have halted culturally tailored public health initiatives that the6179Tribe relies upon to serve its members. Further cuts to similar6180programming through IHS would negatively impact the Tribe's ability to6181maintain its public health capacity and would limit its ability to6182prevent or treat manageable health conditions.6183 The Tribe also needs key agencies that serve Tribal communities,6184including the Health Resource and Services Administration (HRSA), to6185receive adequate funding. HRSA's loan repayment program allows the6186Tribe to compete for providers with nearby communities that are located6187in less remote areas. The Tribe's Reservation is relatively isolated in6188southwestern Colorado. It is hard enough to recruit qualified providers6189to deliver vital healthcare services to the Tribe's patients. As a6190result, the Tribe is already short on providers. Cuts to programs like6191HRSA would make this situation even worse.6192 The Tribe's ability to operate these vital, life-saving programs6193and provide critical healthcare to Tribal patients is dependent on the6194federal government meeting its obligation to fund Indian healthcare.6195Cuts to HHS, Medicaid, or other essential federal programs--including6196any staff cuts that impact the federal government's ability to process6197Tribal funding in a timely manner--comes with real human costs. As a6198matter of human dignity, the Tribe's patients deserve to be treated by6199high-quality professionals operating in robustly funded programs. But6200the reality is, the Tribe, like many Native communities, is forced to6201operate on an extremely thin margin due to decades of federal6202underfunding of Tribal health programs. Cutting already inadequately6203funded HHS programs risks reversing the significant gains the Tribe has6204made in achieving long-lasting healthy outcomes for its patients.6205 As a sovereign government, the Tribe's primary responsibility--and6206one I take seriously as the Chairman--is to ensure the health and6207safety of our people. As a separate sovereign who has a legal6208responsibility to provide health care to Native Americans, the United6209States must coordinate with the Tribe to help us meet this6210responsibility. This means that Congress must preserve and strengthen6211HHS funding for Tribal health programs. These programs are not6212discretionary--they uphold federal legal commitments and are vital for6213public health equity and Tribal sovereignty.6214 As such, we urge HHS to prioritize the protection and sustainment6215of funding and programming to support Tribal health and wellness across6216all HHS agencies and ensure this funding is flexible and responsive to6217Tribal priorities. We further request that HHS reinstate personnel and6218preserve key HHS programs that provide vital support to Tribes and6219Tribally designated organizations. And we urge HHS to protect and6220expand Tribal eligibility for funding through HHS programs and to6221create a funding mechanism that supports long-term sustainability6222rather than short-term projects.6223 The Tribe greatly appreciates its partnership with HHS and our6224joint efforts to protect critical funding, services, and staff that6225allow Tribes to deliver quality healthcare to Tribal patients. We6226remain committed to our shared vision of a healthy America that must6227include a specific focus on Tribes. Tribal patients are often the most6228vulnerable among us and they need continued commitment from the federal6229government to fully fund the programs and staff that serve their unique6230needs. At the very least, that requires meaningful and proactive6231consultation with Tribes when considering HHS program changes, budget6232and workforce cuts, or new initiatives. The federal government's trust6233responsibility permits nothing less.6234 In closing, I strongly urge HHS to support Tribal sovereignty and6235uphold HHS's Tribal Consultation Policy, which necessitates that HHS6236work in partnership with Tribes to ensure they have unfettered access6237to the critical resources needed to address current and future public6238health challenges that will support, strengthen, and sustain the health6239and wellness of our people. We look forward to working with you to meet6240these challenges head on for the betterment of our people.6241 Thank you for the opportunity to submit this written testimony.6242 ______62436244 Prepared Statement of the United South and Eastern Tribes Sovereignty6245 Protection Fund (USET SPF)6246 On behalf of the United South and Eastern Tribes Sovereignty6247Protection Fund (USET SPF), we write to provide the Senate Committee on6248Indian Affairs with testimony for the record of the oversight hearing6249``Delivering Essential Public Health and Social Services to Native6250Americans--Examining Federal Programs serving Native Americans across6251the Operating Divisions at the U.S. Department of Health and Human6252Services'' (HHS) held on May 14, 2025. As the Committee is aware, this6253is a chaotic and confusing time for the Health and Human Services6254System, including the Indian Health System, which together have the6255responsibility of fulling trust and treaty obligations to Indian6256Country. Recent HHS reorganization and reduction in force (RIF)6257efforts, potential threats to funding and programs, and an overall lack6258of Tribal consultation on any of these issues have caused significant6259confusion and greatly impacted the ability of Tribal Nations to provide6260programs and services to our communities. This testimony focuses on the6261urgent need for Congress to exercise its oversight authorities over HHS6262and protect the various funding and resources provided to Indian6263Country.6264 USET SPF is a non-profit, inter-tribal organization advocating on6265behalf of thirty-three (33) federally recognized Tribal Nations from6266the Northeastern Woodlands to the Everglades and across the Gulf of6267Mexico. \1\ USET SPF is dedicated to promoting, protecting, and6268advancing the inherent sovereign rights and authorities of Tribal6269Nations and in assisting its membership in dealing effectively with6270public policy issues.6271---------------------------------------------------------------------------6272 \1\ USET SPF member Tribal Nations include: Alabama-Coushatta Tribe6273of Texas (TX), Aroostook Band of Micmac Indians (ME), Catawba Indian6274Nation (SC), Cayuga Nation (NY), Chickahominy Indian Tribe (VA),6275Chickahominy Indian Tribe-Eastern Division VA), Chitimacha Tribe of6276Louisiana (LA), Coushatta Tribe of Louisiana (LA), Eastern Band of6277Cherokee Indians (NC), Houlton Band of Maliseet Indians (ME), Jena Band6278of Choctaw Indians (LA), Mashantucket Pequot Indian Tribe (CT), Mashpee6279Wampanoag Tribe (MA), Miccosukee Tribe of Indians of Florida (FL),6280Mississippi Band of Choctaw Indians (MS), Mohegan Tribe of Indians of6281Connecticut (CT), Monacan Indian Nation (VA), Nansemond Indian Nation6282(VA), Narragansett Indian Tribe (RI), Oneida Indian Nation (NY),6283Pamunkey Indian Tribe (VA), Passamaquoddy Tribe at Indian Township6284(ME), Passamaquoddy Tribe at Pleasant Point (ME), Penobscot Indian6285Nation (ME), Poarch Band of Creek Indians (AL), Rappahannock Tribe6286(VA), Saint Regis Mohawk Tribe (NY), Seminole Tribe of Florida (FL),6287Seneca Nation of Indians (NY), Shinnecock Indian Nation (NY), Tunica-6288Biloxi Tribe of Louisiana (LA), Upper Mattaponi Indian Tribe (VA) and6289the Wampanoag Tribe of Gay Head (Aquinnah) (MA).6290---------------------------------------------------------------------------6291Introduction6292 USET SPF is deeply concerned by recent Administration actions and6293reorganization efforts at HHS and their collective impacts on Tribal6294Nations. Across the Department, Tribal programs continue to be reduced6295or eliminated unexpectedly and federal employees that provide services6296to Tribal Nations continue to be terminated without Tribal6297consultation. This is despite Secretary Kennedy's commitment during his6298confirmation hearing to ``make sure that all the decisions [at HHS] are6299conscious of their impacts'' on Tribal Nations. Unfortunately, while6300many of these actions and policies are not directed at Indian Country6301specifically, we have been inadvertently harmed because the6302Administration's implementation actions have been so broad and, often,6303have not accounted for the legal obligations of the United States in6304its relationship with Tribal Nations.6305 As a result of the cession of vast land and natural resources by6306Tribal Nations to the United States--oftentimes by force--the United6307States is legally obligated to provide certain benefits and services,6308including healthcare, to Tribal Nations and Native people in6309perpetuity. The delivery of Tribal programs and services, the provision6310of federal funding to Tribal Nations and Tribal organizations serving6311Tribal Nations, and the federal employees necessary for the provision6312of those programs and services are integral to the delivery of federal6313trust and treaty obligations. These resources provided to Indian6314Country are not discretionary--they are legal obligations rooted in the6315trust and treaty relationship, the U.S. Constitution, and long-standing6316federal statutes. Despite this truth, at no point has the United States6317every fully delivered upon this sacred promise and responsibility. The6318actions to the HHS system serves to further exacerbate data supported6319heath disparities experienced across Indian Country.6320 Despite some of the messaging we have heard from the6321Administration, we are not ``all the same,'' nor are we mere6322stakeholders. Rather, as the Committee is well aware, the United States6323has unique obligations to Tribal Nations and Native people that6324necessitates our disparate treatment. As the Administration implements6325its priorities, it is necessary for Congress to fulfill these6326obligations by protecting funding and resources for the Indian Health6327System in the budget and appropriations processes.6328Exercise Oversight Authority to Ensure Proper Tribal Consultation at6329 HHS6330 At the root of many of the issues Tribal Nations are facing from6331HHS reorganization and reform efforts is the overall lack of proper6332Tribal consultation at HHS. Part of the federal trust and treaty6333obligations is a duty to engage in government-to-government6334consultation with Tribal Nations during the development and prior to6335the enactment of any federal actions that may have Tribal implications.6336Despite this legal obligation, HHS has failed to engage in meaningful6337Tribal consultation while proposing and enacting drastic changes to6338agency budgets, programs, and staffing.6339 Tribal Nations support this Administration's efforts to alleviate6340burdensome regulations and other barriers that hinder Tribal self-6341governance and economic development, but these efforts must be6342developed in close consultation with Tribal Nations to ensure there are6343no unintended consequences on us. This is particularly important at6344this juncture as HHS considers its proposed agency reorganization plan6345and other efforts to reform how programs and services are delivered6346through HHS. Tribal Nations are served by programs and staff across6347HHS, not just by the Indian Health Service (IHS); therefore, all6348efforts to reorganize HHS must start with and include robust Tribal6349consultation. Without Tribal consultation on reorganization, it is6350unclear how HHS intends to protect Tribal programs and resources and6351ensure there are no disruptions to service delivery. HHS has stated6352that its activities are not meant to affect its legal obligations to6353Tribal Nations, but it is impossible to know how a reorganization6354effort of this magnitude could affect delivery of those obligations6355without Tribal consultation. USET SPF shares important goals with HHS6356and this Administration such as reducing chronic disease prevalence and6357increasing access to healthy foods, but existing programs and resources6358that support those goals are being threatened by HHS reorganization6359efforts and our focus on shared priorities is being necessarily6360redirected to address these threats.6361 USET SPF and other advocates in Indian Country have repeatedly6362called on HHS to fulfill its Tribal consultation obligations as this6363Administration engages in government reform efforts. During the most6364recent HHS Secretary's Tribal Advisory Committee (STAC) meeting in6365April 2025, a senior advisor to the Secretary committed to holding at6366least one Tribal consultation on the recent HHS reorganization efforts.6367However, in the month since the STAC meeting, HHS has yet to schedule6368or provide any information on this Tribal consultation. We appreciate6369Committee Chair Murkowski and Vice Chair Schatz for their May 9, 2025,6370letter to HHS reiterating that meaningful consultation on any changes6371to HHS that may impact Tribal healthcare is ``crucial to ensure that6372health disparities are not further exacerbated'' and we urge the6373Committee to continue exercising its oversight authorities over HHS to6374hold the Department accountable for its commitments and obligations to6375conduct robust Tribal consultation.6376HHS Reorganization and Reduction in Force Concerns6377 Beyond the lack of Tribal consultation on these actions, USET SPF6378is concerned by the recent efforts at HHS to drastically reduce the6379federal workforce, radically reorganize the Department and its6380divisions, rescind funding, and alter or eliminate federal programs. We6381remind Congress and the Administration that any Tribal program or6382funding delivered to Tribal Nations--including through Tribal6383organizations serving Tribal Nations--is provided in furtherance of the6384United States' trust and treaty obligations. The federal employees6385necessary for the functioning of those Tribal programs and the6386disbursement of those Tribal funds are also part of the trust and6387treaty obligations. The loss of numerous federal employees who6388supported Tribal Nations in HHS Regional offices and across the6389Department has had serious impacts on the delivery of programs and6390services in Indian Country.6391 The closure of HHS Regional offices 1 (Boston) and 2 (New York),6392which collectively served nearly half of USET SPF's member Tribal6393Nations, eliminated critical support for program delivery and technical6394assistance in Tribal communities. Elimination of these employees has6395also created communication gaps between Indian Country and HHS,6396creating uncertainty and confusion around grant and program resources.6397These issues have, in turn, forced some Tribal Nations and6398organizations to pause or cancel programs in our communities to try to6399avoid endangering our funding and resources. The loss of these6400employees also means the loss of years of relationship building and6401knowledge sharing between Tribal Nations and HHS at the regional level.6402With these employees goes vast institutional knowledge and cultural6403competency that will likely take years to rebuild. USET SPF requests6404that the Committee reinforce our concerns with HHS reorganization and6405reduction in force efforts as they relate to the Department's trust and6406treaty obligations to Tribal Nations and the need for a regional HHS6407presence to execute on those obligations.6408Increased Efficiency Through Tribal Self-Governance Expansion6409 We understand that these reorganization and reduction in force6410efforts at HHS are part of the Administration's goals to increase6411government efficiency. The Indian Self-Determination and Education6412Assistance Act (ISDEAA) has been an important tool that puts federal6413funding into Indian Country's hands so that we may run federal programs6414more efficiently and effectively to serve our own communities. However,6415ISDEAA contracting and compacting is currently limited to certain6416federal agencies and programs.6417 Self-governance expansion beyond IHS at HHS has been a long-6418standing priority in Indian Country. Tribal Nations have successfully6419administered complex healthcare programs for decades, but self-6420governance limitations at HHS have prevented us from taking over other6421aspects of our health systems from the federal government. A6422feasibility study conducted in 2013 found that self-governance6423expansion at HHS is possible, but would require Congressional action,6424and efforts to advocate for this change with HHS and Congress have6425stalled over the years.6426 With the Administration's current focus on government efficiency6427and increased local control over programs and services, it is the6428perfect opportunity to renew Tribal self-governance expansion efforts6429at HHS. USET SPF urges the Committee to work with Tribal Nations and6430HHS to extend ISDEAA authorities to all agencies and programs at HHS at6431serve Tribal Nations, Tribal citizens, or Tribal communities.6432Threats to Indian Country in Budget and Appropriations6433 USET SPF remains concerned about FY 2026 appropriations for the6434Indian Health System, given a leaked proposal in the Office of6435Management and Budget (OMB) HHS 2026 Discretionary Budget Passback to6436substantially reduce funding for the IHS and other HHS offices and6437programs that deliver crucial services to Indian Country and the6438subsequent lack of detail on the IHS budget in the President's Skinny6439Budget Request. The HHS System that serves Indian Country is already6440chronically underfunded, understaffed, and under-resourced; therefore,6441any reduction in resources has the potential to create dire6442consequences for the health of Tribal Nations and our communities.6443 In the leaked OMB Passback, for IHS alone, the Administration6444proposed a nearly 30 percent reduction to the IHS base allocation for6445FY 2026--a cut that would dismantle essential services and affect6446service quality and access across Indian Country--and proposed to6447eliminate advance appropriations for the agency. IHS is currently6448underfunded by 90 percent or more according to some estimates, has a6449staff vacancy rate of 30 percent, and operates out of significantly6450older facilities than other U.S. health systems. If the IHS budget were6451to be cut by the proposed $896 million, these issues would only be6452exacerbated. Fortunately, advocacy opposing the IHS budget cuts was6453possibly successful, as the fact sheet for the President's skinny6454budget request stated that ``The budget preserves federal funding for6455the [IHS].'' However, the Skinny Budget Request offers no detail on the6456IHS budget, creating continued uncertainty.6457 The Skinny Budget Request is also silent on whether the6458Administration will propose to maintain advance appropriations for the6459IHS or continue to support its earlier proposal in the Passback to6460eliminate this practice. Advance appropriations have provided critical6461budgetary certainty for the IHS and its enactment in FY 2024 marked a6462historic shift in the nation-to-nation relationship between Tribal6463Nations and the federal government. Prior to FY 2024, IHS was the only6464federal healthcare provider without advance or mandatory6465appropriations, subjecting Tribal citizens to increased risk of harm or6466death from delays in the annual appropriations process. The elimination6467of advance appropriations would be a violation of the federal6468government's obligations to Tribal Nations and a massive step backwards6469in federal Indian policy. USET SPF urges Congress to maintain IHS6470advance appropriations, regardless of whether the proposal is included6471in the forthcoming President's budget request.6472 Beyond IHS, the Administration is proposing to eliminate key HHS6473agencies and programs that provide critical services to the most6474vulnerable populations in Indian Country. Tribal behavioral health6475grants and the Circles of Care Children's Mental Health Program at the6476Administration for Children and Families (ACF) and other resources for6477combatting opioid use disorders at the Substance Abuse and Mental6478Health Services Administration (SAMHSA) are proposed to be cancelled,6479despite the disproportionate prevalence and mortality rates of mental6480health issues, substance use disorders and suicidality in Tribal6481communities. Other programs slated for elimination or reduction like6482Head Start, the Low-Income Home Energy Assistance Program (LIHEAP),6483Community Services Block Grants, and Temporary Assistance for Needy6484Families (TANF) are all lifelines for Tribal Nations. These programs6485are essential to maintaining healthy communities and economies in6486Indian Country, where the rural and remote nature of many of our6487communities often results in a lack of early childhood education and6488employment opportunities.6489 Tribal Nations are already forced to operate with vastly6490insufficient resources due to decades of chronic underfunding,6491especially for the essential services provided through the annual6492appropriations process. By nearly every measure and indicator, Tribal6493Nations, our citizens, and communities face a lower quality of life6494than others in the U.S. The proposed disruption of what little6495resources are flowing will only exacerbate these issues and deepen the6496divide between Indian Country and the rest of the country. Unless6497dedicated Tribal set-asides, Tribal funding, and Tribal Advisory6498Committees are preserved, either through existing agencies, new6499departments, or new mechanisms (such as an expansion of self-governance6500authority), underfunded Tribal programs will face compounding6501reductions that will require large-scale service cuts. History has6502shown those cuts will inevitably increase health disparities and6503negative outcomes in Indian Country. USET SPF calls upon Congress to6504uphold its trust and treaty obligations and, at minimum, protect the6505limited resources already provided for the Indian Health System, which6506includes the IHS budget as well as other programs and services at HHS6507that support Indian Country.6508Protect Resources for Chronic Disease Prevention and Mitigation in6509 Indian Country6510 USET SPF supports this Administration's goals to reduce chronic6511disease prevalence and severity in Indian Country, as AI/AN people6512experience the highest rates of chronic disease prevalence and6513mortality among all U.S. populations, but proposed cuts to chronic6514disease prevention and mitigation programs threaten the success of this6515goal.6516 For example, HHS is currently proposing to eliminate the Center for6517Chronic Disease Prevention and Health Promotion at the Centers for6518Disease Control and Prevention (CDC). If the Center for Chronic Disease6519Prevention is eliminated, so will its Maternal and Infant Health6520branch, Division of Oral Health, Division of Diabetes Translation, the6521Division of Cancer Prevention and Control, and the Office of Smoking6522and Health, all of which play critical roles in reducing chronic6523disease prevalence in Indian Country. Further, HHS has terminated most6524of the staff within the Healthy Tribes Program (HTP) at CDC, which6525includes the Good Health and Wellness in Indian Country (GHWIC)6526program, Tribal Practices for Wellness in Indian Country (TPWIC)6527program, and the Tribal Epidemiology Centers Public Health6528Infrastructure program. Through its various programs, the HTP supports6529holistic, culturally responsive methods for preventing and managing6530chronic diseases like type 2 diabetes and high blood pressure, supports6531food access and nutrition education services, and supports Tribal6532Nations' public health capacity and infrastructure, among others--all6533of which are supposedly priorities for this Administration. The HTP6534provides critical, cost-saving chronic disease prevention and6535mitigation resources each year, but the elimination of program staff6536puts the HTP and its work at risk. If the HTP program is eliminated or6537otherwise limited by staffing constraints, vitally important chronic6538disease prevention programs at hundreds of Tribal Nations could be at6539risk of being eliminated or limited as well, which is of major concern6540for a population that suffers disproportionately from chronic disease.6541 USET SPF also urges Congress to protect and increase support for6542the Special Diabetes Program for Indians (SDPI), one of the most6543successful chronic disease reduction and prevention programs in the6544U.S. In the decades since its creation, SDPI has greatly reduced6545diabetes prevalence, severity and mortality in Tribal communities while6546diabetes prevalence in the general population has only increased. This6547has saved millions of dollars in health care costs for diabetes-related6548complications. However, despite SDPI's proven, evidence-based success,6549the program has only received meager and insufficient funding increases6550over time. Prior to 2024, SDPI had been flat funded at $150 million for6551the last 20 years, and the slight increase to $160 million annually is6552negligible due to inflation and rising costs from the program's6553expansion. USET SPF requests that Congress significantly increase SDPI6554funding and permanently reauthorize this critical and exceedingly6555successful program. Additionally, we urge Congress to implement Tribal6556Nations' authority to receive SDPI funds through self-determination and6557self-governance contracts and compacts. Currently, program dollars are6558delivered through grant mechanisms which fail to honor the federal6559trust obligation by treating Tribal Nations as grantees rather than6560sovereign governments. With the authority to receive SDPI funds6561directly through Indian Self-Determination and Education Assistance Act6562(ISDEAA) contracts and compacts, Tribal Nations will be able to use6563SDPI dollars more efficiently as less staff time will be needed to6564complete grant-related tasks and can be dedicated to program delivery.6565 We urge Congress to not only protect but expand support for and6566access to critical programs like the SDPI and HTP that work to reduce6567chronic disease prevalence in Indian Country. USET SPF is strongly6568supportive of the Administration's goals to reduce chronic disease6569prevalence, but these goals cannot be achieved without the programs and6570resources that are relied on and proven successful in Indian Country.6571Preservation of Medicaid as Fulfillment of Trust and Treaty Obligations6572 Medicaid is one of the major programs through which the federal6573government fulfills its trust and treaty obligation to provide for AI/6574AN healthcare. It serves a third or more of the AI/AN population in the6575United States, and reimbursements from the Medicaid program constitute6576a significant portion of IHS and Tribal health care program budgets.6577While the Indian Health System makes up less than 1 percent of overall6578federal spending on Medicaid, it is also estimated that Medicaid6579billing constitutes from 30 percent up to 60 percent of the operating6580budgets at most IHS and Tribal health facilities. These funds provide a6581critical bridge in funding between the underfunded IHS and other health6582care systems; therefore, any limitations or reductions in Tribal access6583to Medicaid--including work requirements, per capita funding caps and6584block granting--could have dire consequences for the Indian Health6585System. Any effort to reduce federal spending on Medicaid must not6586impact AI/AN eligibility and access or quality of care within the6587Medicaid program for AI/AN people.6588 The federal government has an obligation to protect Tribal access6589to Medicaid resources and provide appropriate exemptions from work6590requirements and per capita funding caps for AI/AN Medicaid6591beneficiaries. USET SPF has urged HHS to ensure that states include6592these exemptions in any state plan amendments to Medicaid and have6593advocated with Congress to include statutory exemptions in any6594legislation intended to reform Medicaid to more concretely preserve AI/6595AN access to the program.6596 USET SPF was pleased to see that the current reconciliation bill6597text contains a clear exemption for AI/AN beneficiaries from Medicaid6598work requirements. The bill also does not impose annual per capita caps6599or block granting on the Medicaid program, which would have created6600significant issues for the Indian Health System. USET SPF is strongly6601supportive of this exemption and these provisions must be maintained in6602any final version of the bill containing work requirements or other6603limitations on Medicaid.6604Conclusion6605 Congress has a responsibility to protect the HHS System from6606harmful rescissions, budget cuts, and program eliminations and to6607ensure increased, sustainable resources for AI/AN healthcare. Our6608people prepaid for our healthcare through the cession of vast lands and6609resources to the United States, which created the federal government's6610trust and treaty obligations that exist in perpetuity. The proposed6611cuts to the IHS and other parts of the HHS budget that support service6612and program delivery in Indian Country are not only inappropriate but6613also a direct violation of the U.S.'s obligations to provide for AI/AN6614healthcare. Congress must exercise its oversight and appropriations6615authorities to ensure that Indian Country is not wrongfully harmed in6616the efforts to reform the federal government and budget. USET SPF6617stands ready to support Congress and the Administration in its6618priorities to reduce disease prevalence and promote healthier6619communities, but these efforts must honor the federal trust and treaty6620obligations to Tribal Nations.6621 ______66226623 Alaska Native Women's Resource Center6624 April 2, 202566256626Dear Senator Murkowski,66276628 I am writing today to express our concerns regarding the recent6629placement of Shawndell Dawson, Director of the Office of Family6630Violence and Prevention Services (OFVPS), on administrative leave as of6631March 31, 2025. We are very worried about this unexpected leadership6632change and its potentially devastating impact on critical services for6633survivors.6634 The Alaska Native Women's Resource Center (AKNWRC) is the OFVPS-6635designated Alaska Tribal Resource Center and works closely with Tribes6636and communities across our state. Through this work, we have witnessed6637firsthand how OFVPS, under Director Dawson's leadership, has been6638instrumental in addressing the disproportionately high rates of6639violence experienced by our people. Director Dawson has demonstrated an6640undeniable commitment to honoring our Tribes and, in particular,6641honoring Tribal sovereignty, while ensuring that federal resources6642reach our most needed and historically underserved communities. Her6643dedication to meaningful engagement and consultation with our Tribes6644has led to programs that are both culturally appropriate and effective.6645 The impact that this leadership change will have on our Tribes and6646Tribal communities is very unsettling. As you know, Alaska Native6647communities face unique challenges in addressing domestic violence and6648sexual assault due to our geographic isolation, limited infrastructure,6649and limited funding opportunities. The OFVPS is crucial in supporting6650our communities through specialized funding, culturally responsive6651training, and technical assistance that acknowledges these unique6652challenges.6653 Additionally, the OFVPS has been instrumental in implementing6654critical provisions of the Family Violence Prevention and Services Act6655to Tribal communities. Through dedicated funding streams for Tribal6656shelters, advocacy services, and culturally specific prevention6657initiatives, the OFVPS has created a network of support that honors our6658traditional healing practices while providing essential resources for6659survivors. Director Dawson's guidance has ensured these programs6660operate with cultural sensitivity and meaningful Tribal engagement and6661consultation. The disruption in leadership threatens to undermine the6662trust and partnership that has been carefully nurtured and developed6663between OFVPS and Tribes across Alaska, and any interruption or change6664in direction could have devastating consequences for survivors, their6665families, and their communities.6666 As a longtime advocate and champion for survivors of domestic6667violence and sexual assault and as a Senator who has consistently6668demonstrated your commitment to Alaska Native issues, you understand6669the critical importance of stable, informed leadership in addressing6670these complex challenges.6671 We respectfully urge you to:66726673 Inquire into the circumstances surrounding Director Dawson's6674 placement on administrative leave and advocate for transparency6675 in this process;66766677 Utilize your position as Chair of the Senate Committee on6678 Indian Affairs and other committees to ensure that the OFVPS6679 maintains its commitment to Tribes and culturally appropriate,6680 trauma-informed approaches;66816682 Work to ensure that funding for Tribal programs remains6683 robust and that implementation proceeds without unnecessary6684 disruption; and66856686 Request information about any transition plan and6687 qualifications of incoming leadership, particularly regarding6688 their experience working with Tribal nations.66896690 Finally, I have included a copy of a letter sent to the Secretary6691of Health and Human Services yesterday, signed by 72 organizations,6692including Tribal coalitions and nonprofit organizations, state6693coalitions, national organizations, and specialized groups focused on6694domestic violence and sexual assault prevention and response, urging6695the Secretary to change course, reinstate Director Dawson, and ensure6696the stability of the work of the OFVPS.6697 The safety and well-being of Alaska Native survivors and families6698experiencing violence must remain a priority. Leadership changes should6699never come at the expense of those who depend on these essential6700services or undermine the progress made in recognizing the sovereign6701right of our Tribes to address violence in ways that align with our6702cultural values.6703 Thank you for your continued dedication to these critical issues6704affecting Alaska Native communities. I welcome the opportunity to6705discuss these concerns with you or your staff in greater detail and6706look forward to hearing your response and learning how you plan to6707address these concerns.67086709 With gratitude,67106711 Tami Truett Jerue, Executive Director6712 ______67136714 April 1, 202567156716The Honorable Robert F. Kennedy, Jr.,6717Secretary, Health and Human Services,6718U.S. Dept. of Health & Human Services,6719Washington, DC.67206721Dear Secretary Kennedy,67226723 We understand that Shawndell Dawson, Director of the Office of6724Family Violence Prevention and Services (OFVPS), was placed on6725administrative leave on March 31. The undersigned organizations are6726calling on you to reinstate Director Dawson and express our grave6727concern about the impacts this will have on the nation's response to6728domestic violence and sexual assault.6729 This goes far beyond a personnel issue or individual position in6730terms of its potential to disrupt an essential leadership function of6731this work but instead threatens decades of a successful public health6732response to domestic violence.6733 The work of the OFVPS office is specialized. OFVPS administers the6734Family Violence and Prevention Act (FVPSA), which is at the heart of6735our nation's response to domestic violence and supports lifesaving6736services, including shelters, hotlines, counseling, and domestic6737violence programs throughout the states and territories. OFVPS has more6738recently administered funds for sexual assault programs that are6739essential to keeping their doors open. The functions of the OFVPS6740office are unique to the field and leadership requires broad expertise6741of both domestic violence and sexual assault. Moreover, Director Dawson6742and the OFVPS office have had a critical role in addressing the6743intersections of domestic violence and sexual assault with other health6744issues.6745 We must ensure the stability of the work and consistent leadership6746is essential to any efforts to pursue efficiency. Losing that6747consistency will hamstring efforts to respond to domestic violence and6748sexual assault. The field, made up of over 2000 local domestic violence6749and sexual assault agencies, will be closing out a billion dollars of6750grants in the next several months and is currently awaiting grant6751awards. OFVPS administers over $250 million a year. These dollars would6752be in jeopardy without experienced leadership. This effort requires6753leadership with a history and understanding of the grantees and6754services.6755 We urge you to change course and prevent the potentially6756devastating impacts on the domestic violence and sexual assault service6757delivery system.67586759 Sincerely,67606761 Alaska Native Women's Resource Center6762 Alaska Network on Domestic Violence and Sexual Assault6763 Alliance of Tribal Coalitions to End Violence6764 American Samoa Alliance Against Domestic and Sexual Violence6765 Arizona Coalition to End Sexual and Domestic Violence6766 Arkansas Coalition Against Sexual Assault6767 Asian Pacific Institute on Gender-Based Violence6768 ASISTA6769 Battered Women's Justice Project6770 California Partnership to End Domestic Violence6771 Caminar Latino6772 Colorado Coalition Against Sexual Assault6773 Delaware Alliance Against Sexual Violence6774 Delaware Coalition Against Domestic Violence6775 End Domestic Abuse Wisconsin6776 Esperanza United6777 First Nations Women's Alliance6778 Florida Council Against Sexual Violence6779 Futures Without Violence6780 Georgia Coalition Against Domestic Violence6781 Georgia Network to End Sexual Assault6782 Hawaii State Coalition Against Domestic Violence6783 Idaho Coalition to End Sexual and Domestic Violence6784 Illinois Coalition Against Domestic Violence6785 Illinois Coalition Against Sexual Assault (ICASA)6786 Indiana Coalition Against Domestic Violence6787 Indiana Coalition to End Sexual Assault6788 Iowa Coalition Against Domestic Violence6789 Iowa Coalition Against Sexual Assault6790 Jane Doe Inc.6791 Jewish Women International6792 Just Solutions6793 Legal Momentum6794 Louisiana Foundation Against Sexual Assault6795 Louisiana Coalition Against Domestic Violence6796 Maine Coalition Against Sexual Assault6797 Maryland Coalition Against Sexual Assault6798 Maryland Network Against Domestic Violence6799 Michigan Coalition to End Domestic and Sexual Violence6800 Minnesota Indian Women's Sexual Assault Coalition6801 Montana Coalition Against Domestic and Sexual Violence6802 National Alliance to End Sexual Violence6803 National Organization of Asians & Pacific Islanders Ending6804 Sexual Violence6805 National Center on Domestic Violence, Trauma, and Mental Health6806 National Congress of American Indians--Violence Against Women6807 Taskforce6808 National Indigenous Women's Resource Center6809 National LGBTQ Institute on IPV6810 National Network to End Domestic Violence6811 National Organization of Sisters of Color Ending Sexual Assault6812 National Resource Center on Domestic Violence6813 Native Women's Society of the Great Plains6814 Nevada Coalition to End Sexual and Domestic Violence6815 New Mexico Coalition of Sexual Assault Programs6816 New Mexico Coalition Against Domestic Violence6817 New Jersey Coalition to End Domestic Violence6818 New York State Coalition Against Domestic Violence6819 North Dakota Domestic and Sexual Violence Coalition6820 Ohio Alliance to End Sexual Violence6821 Ohio Domestic Violence Network6822 Oregon Coalition Against Domestic and Sexual Violence6823 Pennsylvania Coalition Against Domestic Violence6824 Pouhana O Na Wahine6825 Puerto Rico Coalition Against Domestic Violence and Sexual6826 Assault6827 Respect Together6828 Rights4Girls6829 Rhode Island Coalition Against Domestic Violence6830 StrongHearts Native Helpline6831 Tahirih Justice Center6832 Texas Association Against Sexual Assault6833 Ujima, The National Center on Violence Against Women in the6834 Black Community6835 Vermont Network Against Domestic and Sexual Violence6836 Violence Free Colorado6837 Washington State Coalition Against Domestic Violence6838 West Virginia Coalition Against Domestic Violence6839 Wyoming Coalition Against Domestic Violence and Sexual Assault6840 VALOR6841 ZeroV, Kentucky United Against Violence6842 ______68436844 Rural Alaska Community Action Program, Inc., (RurAL CAP)6845 May 12, 202568466847Senator Lisa Murkowski, Chairman of the Senate Committee on Indian6848Affairs:68496850 Since its founding in 1965, Rural Alaska Community Action Program,6851Inc., (RurAL CAP) has been a cornerstone for low-income Alaskans to6852access economic opportunity, both directly providing essential services6853in early education, housing, and health and well-being and partnering6854with statewide leaders on system building opportunities. Our programs6855offer innovative, community-driven solutions that are crucial for the6856sustainable development of Alaska--for us, a vision of Alaskans6857benefiting from Alaskan economic potential and an improved quality of6858life in our state.6859 The grants and technical support provided by Health and Human6860Services (HHS) enable us to provide critical services to Alaskans.6861While we are a private, non-tribal entity, the majority of our service6862recipients are Alaska Native from communities both urban and rural,6863reflecting Alaska's unique composition of more tribes than any other6864state in the US. Today, we would like to focus on our operational6865relationship with HHS using our Head Start programs' 60-year history as6866an example.6867 Since 2020, RurAL CAP Head Start and Early Head Start has provided6868the following to Alaskan families:6869Services to Alaskan Families68706871 1,903 children in RurAL CAP Head Start and Early Head Start6872 received critical cognitive, social, and educational6873 development68746875 --1,570 of those children are Alaska Native (82.5 percent)68766877 1,416 Alaskan families received Head Start and Early Head6878 Start services68796880 76 families experiencing housing insecurity enrolled in Head6881 Start and Early Head Start68826883 1,856 children received age-appropriate developmental6884 screenings68856886 1,713 health screenings were conducted68876888 279,316 meals served68896890Employment and Local Workforce Development68916892 285 Alaskans employed serving in their own communities6893 through Head Start68946895 --These are Alaskan jobs, staffed by Alaskans, often in rural6896 communities where opportunities for employment can be hard to6897 come by68986899 173 Staff members are former Head Start graduates69006901Innovations in Workforce Development69026903 1 Teacher Apprentice at Homer Head Start69046905 6 more apprentices scheduled to begin next year in 6 rural,6906 off-road communities69076908 --Teacher Apprenticeships help address the ongoing childcare6909 crisis in Alaska while creating pathways to long-term, self-6910 sufficiency through on-the-job training in rural communities69116912Impact Story69136914 ``After unexpectedly losing my husband three years ago I was6915 left alone with our two babies. I was unable to work. I was6916 grieving and honestly just trying to survive in any way that I6917 could. Head Start gave us socialization, new friendships. They6918 offered speech services to my daughter Jade who has now6919 surpassed her goal by 13 percent, and she's even started6920 reading before going to kindergarten. I cannot stress enough6921 how vital Head Start has been in helping my tiny broken family6922 find our new normal, and I hope that Head Start is available6923 for families just like mine for many years to come.''69246925 --Turena, Homer Head Start parent69266927 RurAL CAP remains committed to efficiently creating pathways to6928self-sustainability, workforce development, and finding innovative6929solutions to the challenges facing Alaska. Thank you for the6930opportunity to highlight the significance of our Head Start programming6931in improving the lives of working Alaskans.69326933 Best regards,6934 Tiel Smith, CEO6935 ______69366937 Response to Written Questions Submitted by Hon. Lisa Murkowski to6938 Hon. Janet Alkire6939 Question 1. Staffing reductions have affected the ability of Tribal6940Epidemiology Centers (TECs) to maintain vital surveillance tools and6941data sets, such as Pregnancy Risk Assessment Monitoring System. How can6942Congress ensure that TECs maintain their capacity to collect and6943analyze critical public health data that informs tribal health6944decisionmaking particularly during this period of reorganization?6945 Answer. In order to maintain TECs capacities to collect and analyze6946critical public health data, Congress should ensure that TECs are6947recognized and treated as public health authorities, as required by6948HIPAA (25 U.S.C. 1621m(e)). Additionally, HHS must continue to manage6949and respond to TECs requests for any data held or administered by any6950division at HHS, in accordance with this statutory mandate.69516952 Question 2. What are the specific health outcomes CDC Healthy6953Tribes programs were achieving in Tribal communities and what6954alternatives might exist to maintain these critical public health6955initiatives current funding structures are dismantled?6956 Answer. The CDC Healthy Tribes programs are widely successful in6957improving a wide range of health outcomes for Tribes with a program.6958The Healthy Tribes programs enable Tribes to customize each program to6959fit the needs of each individual Tribe. This flexibility allows each6960site to create programming that meets local cultural and traditional6961values. In Oklahoma, the Southern Plains Tribal Health Board has6962utilized funding to invest in a Caring Van that offers preventative6963health care and health education offering immunizations, dental6964screenings, and HIV/AIDS screenings. In one year, the Caring Van6965completed 294 screenings.6966 As part of Culture is Prevention, the Great Lakes Inter-Tribal6967Epidemiology Center is partnering with the Great Lakes Inter-Tribal6968Council to offer resource gathering and development of a 36-bed6969Adolescent Recovery and Wellness Center.6970 Healthy Tribes is irreplaceable. No other federal or state program6971provides the comprehensive community-driven support that Healthy Tribes6972delivers. It is the only federal initiative that invests in the day-to-6973day multi-sector needs of Tribal communities which focuses on disease6974identification and prevention.69756976 Question 3. Public Health Service Commissioned corps officers6977assigned at CDC have historically provided temporary duty assistance in6978Tribal communities during public health emergencies. Given their6979critical role in addressing urgent issues like sexually transmitted6980infection outbreaks in the Great Plains region, what strategies would6981most effectively preserve this rapid response capability while ensuring6982officers receive appropriate cultural competency training for effective6983service in Tribal communities?6984 Answer. This type of surge staffing with Commissioned Corps6985Officers is critical to our communities. Because of the underfunding6986and high vacancy rates, surge staffing is frequently the only process6987to get sufficient response during a public health crisis. Federal6988employees who provide services to Tribal Nations should be exempted6989from the Reduction in Force (RIF) and hiring freezes. Tribal leaders6990continue to make this request known to Secretary Kennedy. These6991employees are critical to delivering legally mandated services to6992American Indian and Alaska Native beneficiaries and are essential6993extensions of the government-to-government relationship. Once assigned6994to Tribal communities, officers receive education on local cultural6995values and traditions, with cultural competency defined by each Tribal6996Nation.69976998 Question 4. Recent staff reductions at the Public Health Service6999Commissioned Corps Headquarters have raised concerns about essential7000support functions including payroll processing, officer assignments,7001and special pay administration. These changes potentially impact not7002only the approximately 1,200 PHS officers serving at Indian Health7003Service and Tribal facilities but also the nearly 6,000 officers7004serving across critical public health programs at HHS and non-HHS7005agencies. How might these administrative disruptions affect the Corps'7006ability to recruit, retain, and deploy qualified healthcare7007professionals to address ongoing health disparities in Tribal7008communities and what measures could be implemented to stabilize this7009critical workforce?7010 Answer. Public Health Service Commissioned Corps Officers are7011critical to providing services at the IHS and Tribal health care7012facilities and assisting the federal government in meeting the Trust7013and Treaty obligations. Instability in the program and in federal7014hiring have caused a lot of chaos, which drives potential new officers7015away. Additionally, the number of Public Health Service Officers has7016decreased in recent years, which has severely limited staff for the7017public health process in Indian Country.7018 ______70197020 Response to Written Questions Submitted by Hon. Brian Schatz to7021 Hon. Janet Alkire7022 Question 1. Secretary Kennedy has taken steps to ``overhaul''7023agencies across HHS--including those that serve Native communities. We7024heard from several witnesses that because many grants have been7025canceled and HHS regional offices abruptly closed, Tribes have been7026left without assistance with implementing critical programs, including7027those that support victims of domestic violence. Did HHS engage in7028consultation with Tribes regarding any of the changes that have been7029implemented, including its RIF or reorganization efforts?7030 Answer. No, the Department of Health and Human Services did not7031engage in consultation with Tribes regarding any of the changes that7032have been implemented, including HHS' reduction in force or7033reorganization efforts.70347035 Question 2: Earlier this month, I sent a letter with Chair7036Murkowski and Senator Merkley to Secretary Kennedy about our concerns7037with the continued hiring freeze and staff reductions at IHS which are7038exacerbating existing staffing issues and the delivery of healthcare7039services. What impacts have you seen at IHS facilities? Please be7040specific.7041 Answer. The hiring freeze and staff reductions have had many7042impacts on the Indian Health Service. First, the IHS has a vacancy rate7043for physicians at 36 percent and 44 percent for behavioral health7044providers. These providers are critical to delivering services and have7045some exemption from the hiring freeze. Furthermore, 43 percent of our7046IHS facilities would need to close their doors if they lose a single7047provider. With that said, the exemption for hiring has been capped by7048DOGE to less than 500 for the agency. This is not enough to meet the7049demand of the IHS. IHS has experienced staff attrition of 4-5x the7050typical rate, which is exacerbating current understaffing within the7051agency and we expect without a change in course on the current hiring7052freeze, facilities will likely need to at least temporarily close in7053the near future.7054 Additionally, other key positions are not exempt from the hiring7055freeze, such as janitorial staff, administrative reception, or coders,7056billers, and Purchased and Referred Care (PRC) staff. These positions7057must be included in a broader exemption for the IHS. These key7058positions not only help IHS facilities meet accreditation requirements,7059but our PRC staff pay medical bills owed by IHS and ensure Tribal7060citizens can get the referred care they need. Without them, our7061citizens face lack of care or worse bill collections for debts owed by7062the federal government.70637064 Question 2a. In your opinion, how will these impacts and/or7065continued staffing uncertainties affect federal agencies' ability to7066provide legally required health care for Native communities?7067 Answer. In addition to the loss of staff at the Indian Health7068Service, many Tribal Offices and Tribal Support Teams have been reduced7069or eliminated impacting Tribal grants and communication with federal7070agencies. These offices and staff serve as a lifeline for Tribal7071citizens and their dismissal will harm public health programs serving7072Native communities. The number of HHS regional offices has been reduced7073from 10 to 5, placing over 400 Tribes under the jurisdiction of a7074single office in the Western United States.7075 Additionally, the termination of staff working with the Great7076Plains Tribal Epidemiology Center has directly halted critical public7077health response efforts. OASH staff who oversaw HIV/AIDS programming7078have also been terminated impacting local efforts to provide lifesaving7079care and prevention efforts for American Indian and Alaska Native7080individuals living with or at risk of HIV/AIDs. Due to uncertainty in7081funding for Head Start, one Tribe reported the loss of three staff7082causing them to close their facility. Finally, dismissal of staff from7083the CDC's Healthy Tribes and SAMHSA's Circles of Care harms local7084behavioral health initiatives that provide prevention, intervention,7085and treatment efforts.70867087 Question 3. During a May 14th House appropriations hearing,7088Secretary Kennedy called distribution of ultra-processed foods in7089Indian Country a ``genocide'' against Native Americans. But this7090rhetoric doesn't match the Trump administration's actions, e.g. gutting7091the Centers for Disease Control and Prevention (CDC)'s Healthy Tribes7092program, which focuses on chronic disease prevention through nutrition,7093its proposed massive funding cuts to HHS, and staffing reductions,7094including at the Administration for Community Living (ACL), which7095administers Title VI funding through the Older Americans Act. How does7096the CDC's Healthy Tribes program support chronic disease prevention?7097Please be specific.7098 Answer. The CDC Healthy Tribes programs are widely successful in7099improving the prevention of chronic diseases. The Healthy Tribes7100programs able to customize each program to fit the needs of each7101individual Tribe. This flexibility allows each site to create7102programming that meets local cultural and traditional values. In7103Oklahoma, the Southern Plains Tribal Health Board has utilized funding7104to invest in a Caring Van that offers preventative health care and7105health education offering immunizations, dental screenings, and HIV/7106AIDS screenings. In one year, the Caring Van completed 294 screenings.7107The Alaska Native Tribal Health Consortium collaborates with regional7108Tribal health organizations to increase colorectal cancer screening.7109This partnership has resulted in an increase of screening from 467110percent in 2020 to 62 percent in 2024 in Alaska Native populations.71117112 Question 3a. How do ACL programs, including Title IV programs7113authorized by Older Americans Act, support nutrition services and7114health promotion across Indian Country?7115 Answer. The Administration for Community Living funds and7116administers a wide range of nutrition services and health promotion7117programs across Indian Country. They provide transportation services,7118home-delivered nutrition services, congregate nutrition services,7119information, referral, and outreach services, in-home services,7120caregiver counseling and support group services, and caregiver respite7121services. These are all essential to ensuring Native Elders can remain7122and thrive in their own communities. The Native Elder programs within7123ACL's OAA Title VI administration are the only federally funded wrap7124around services for Native Elders and are offered in conjunction with7125other Medicaid services that support keeping our Elders in community.71267127 Question 3b. What do the administration's current and proposed7128funding cuts mean for Tribal health, specifically related to chronic7129disease prevention and health promotion?7130 Answer. The Administration's current and proposed funding cuts will7131mean many Tribal chronic disease prevention and health promotion7132programs will shut down. Tribes will be limited in their scope of7133services and may eventually need to ration resources, like limiting7134prevention services to provide more urgent levels of care. Lack of7135funding, staff, and data will make it harder to specifically address7136disease disparity in our communities.71377138 Question 4. Federal agencies were directed to take down critical7139health data to comply with President Trump's DEI Executive Order.7140Although HHS issued an advisory opinion clarifying that the President's7141Executive Orders regarding DEI do not apply to programs serving7142American Indian and Alaska Natives (AI/AN), AI/AN data has been deleted7143from public view, including data on how many Native youth are7144struggling with mental health and thoughts of suicide, where disease7145outbreaks are happening, what's making moms and babies less healthy,7146and how we can combat chronic health issues. How does losing this kind7147of data and information (now and in the future) impact HHS' ability to7148deliver health care services to Native communities?7149 Answer. The Department of Health and Human Services has issued an7150Advisory Opinion which clearly states that Tribes and their citizens7151are not DEIA and that the obligations to Tribes should not be abridged.7152Under this opinion, American Indian and Alaska Native data should not7153be impacted. However, this is not reality and we must work to get data7154back online. Losing access to critical data sources significantly7155hinders Tribal communities' ability to effectively respond to emerging7156health challenges. Without timely and accurate data, Tribes would be7157unable to identify and address rising health issues, let alone7158implement health education and prevention programs. The inability to7159access and analyze data would also undermine Tribe's ability to secure7160resources and funding, as data is essential for justifying requests for7161support and demonstrating a need. Without critical information, it7162weakens Tribal leaders' ability to make informed decisions and our7163ability to protect the health and well-being of our communities.71647165 Question 5. For the first time ever, in FY23, IHS received advance7166appropriations following years of advocacy from Tribes and Tribal7167Organizations. An initial pass back of the President's proposed FY267168Budget (the ``skinny budget'') threatened to end advance appropriations7169while decimating IHS funding by 30 percent compared to FY25. Why is it7170important that the federal government maintain advance appropriations7171for IHS?7172 Answer. IHS Advance Appropriations has been critical to creating7173stability for IHS, Tribes, and urban Indian organizations. The7174predictable funding helps Tribes plan long-term for programs and staff7175and provide a guarantee that health programs will not be subject to7176stops in funding or reductions. Advance appropriations is important7177because it meets the treaty and trust obligations to tribes and secures7178stability for our programs, communities, providers, and our health.71797180 Question 5a. If the President's proposed FY26 Budget is adopted,7181and funding cuts are implemented across HHS, what impacts should Indian7182Country brace for?7183 Answer. Indian Country will need to brace for severe impacts if the7184President's proposed budget for FY26 is adopted. Most urgently, Tribes7185could lose millions of dollars from critical programs at HHS.7186Additionally, the IHS would no longer have funding certainty, which is7187provided by advance appropriations.71887189 Question 5b. Could Tribes meet their communities' needs as proposed7190in the skinny budget?7191 Answer. No, Tribes would not be able to meet their communities'7192needs as proposed in the skinny budget or the President's Budget7193without reduction to programs.7194 ______71957196 Response to Written Questions Submitted by Hon. Ben Ray Lujan to7197 Hon. Janet Alkire7198 Question 1. How will the reduction in workforce and Health and7199Human Services (HHS) reorganization impact Pregnancy Risk Assessment7200Monitoring System (PRAMS) and other key public health programs?7201 Answer. In addition to the Indian Health Service, several other7202departments within the Department of Health and Human Services provide7203critical healthcare services to Tribal communities. A reduction in7204force would result in many key public health programs, including the7205Pregnancy Risk Assessment Monitoring System (PRAMS) to halt efforts.7206The PRAMS data set is one of the few points of information on AI/AN7207pregnancy risk which is critical to identifying and addressing7208pregnancy risks and disparities in our communities. It is critical that7209all programs serving Tribal communities are protected from the7210reduction in force, so that they can continue providing key public7211health services to Indian Country.72127213 Question 2. Implementing reduction in force measures, like7214eliminating the Office of Minority Health and other key Medicare and7215Medicaid services goes against their promise and their federal legal7216responsibilities to Tribes--can you discuss how the Center for Medicare7217and Medicaid Services supports critical Tribal programs?7218 Answer. Since IHS is already severely underfunded, Medicaid serves7219as a critical funding stream for Indian health care providers,7220including Urban Indian Organizations. Medicaid is essential to7221sustaining Tribal health care services. For some clinics, it accounts7222for 30-60 percent of their operating budgets, making it a critical7223source of funding to sustain services for our Tribal citizens. IHS's7224projected Medicaid is only 0.21 percent of total federal Medicaid7225spending. We are encouraged by bipartisan efforts to protect Tribal7226citizens in Medicaid reform, including the House Energy and Commerce7227text exempting Tribal Citizens from work requirements, and we urge the7228Senate to maintain these protections.7229 We also have seen the Administration re-instate offices like the7230CMS Office of Minority Health understanding the statutory requirements7231to keep such offices open within HHS agencies under the Patient7232Protection and Affordable Care Act (P.L. 111-148). We hope this will7233continue in relation to programs supporting our Tribal communities.7234 ______72357236 Response to Written Questions Submitted by Hon. Brian Schatz to7237 Melissa Charlie7238 Question 1. Secretary Kennedy has taken steps to ``overhaul''7239agencies across HHS--including those that serve Native communities. We7240heard from several witnesses that because many grants have been7241canceled and HHS regional offices abruptly closed, Tribes have been7242left without assistance with implementing critical programs, including7243those that support victims of domestic violence. Did HHS engage in7244consultation with Tribes regarding any of the changes that have been7245implemented, including its RIF or reorganization efforts?7246 Answer. I can only speak on behalf of the Fairbanks Native7247Association. No consultation was offered regarding these changes. One7248day, our federal grant administrators were accessible; the next, they7249were no longer available. We have historically maintained strong,7250collaborative relationships with our federal partners, working together7251to deliver meaningful services to our members. The abrupt termination7252of this relationship-without prior notice-was both unsettling and7253counterproductive for everyone involved.72547255 Question 2. Secretary Kennedy frequently touts that HHS exempted7256the Indian Health Service from the hiring freeze in place across the7257federal government. However, not only is the exemption limited to only7258certain clinical positions, it is still in place across other HHS7259agencies that serve Native communities' health care needs. In addition,7260HHS has engaged in a series of staff layoffs, and additional Reductions7261in Force (RIFs) are looming. Your testimony stated that staffing7262uncertainties are crippling programs for children. How do efforts to7263reduce federal staff affect Head Start programs serving Tribes, and how7264will future reductions exacerbate existing challenges?7265 Answer. As grant recipients, particularly for Head Start programs,7266we are required to navigate an increasingly uncertain fiscal landscape,7267often without clear insight into what changes may come from the federal7268level day to day. In good faith, we submitted grant modifications7269designed to enhance services for the children and families we serve7270while maximizing the use of federal funds. These changes were approved7271shortly before the recent reduction in federal staffing.7272 Like many others, we have been addressing workforce shortages since7273the pandemic and are only now beginning to rebuild, with an increase in7274both teachers and associate teachers that will enable us to expand7275enrollment. This recovery strategy was developed collaboratively with7276our Head Start grant management team.7277 Unfortunately, that team is no longer functioning cohesively due to7278hiring freezes and job uncertainty. Reductions in the federal workforce7279risk undermining the trusted relationships built over time and will7280inevitably disrupt service delivery to those most in need-our children7281and their families.72827283 Question 3. During a May 14th House appropriations hearing,7284Secretary Kennedy called distribution of ultra-processed foods in7285Indian Country a ``genocide'' against Native Americans. But this7286rhetoric doesn't match the Trump administrations actions, e.g., gutting7287the Centers for Disease Control and Prevention (CDCYs Healthy Tribes7288program, which focuses on chronic disease prevention through nutrition,7289its proposed massive funding cuts to HHS, and staffing reductions at7290the Administration for Community Living (ACL), which administers Title7291VI funding through the Older Americans Act. What do the7292administration's current and proposed funding cuts mean for Tribal7293health, specifically related to chronic disease prevention, nutrition7294services, and health promotion?7295 Answer. Our Title VI program provides nutritious meals to our7296elders--often the only complete meal they receive each day. These meals7297include fresh fruits and vegetables, which can be difficult to afford7298for those on fixed incomes. This service is a vital preventive health7299measure that supports the overall well-being of our elders and helps7300reduce avoidable medical visits.7301 In addition to promoting physical health, the program offers7302valuable opportunities for social interaction, helping to combat7303isolation and support mental health.7304 Eliminating or reducing this program, or any of its related7305services, would likely result in increased costs in other areas, such7306as healthcare, due to the adverse effects on the physical and emotional7307well-being of our elder community members.7308 This one example is representative of the impacts any funding cuts7309would have on Tribal health services across the board.73107311 Question 4. For the first time ever, in FY23, IRS received advance7312appropriations following years of advocacy from Tribes and Tribal7313organizations. An initial pass back of the President's proposed FY267314Budget (the ``skinny budget'') threatened to end advance appropriations7315while decimating IHS funding by 30 percent compared to FY25. Why is it7316important that the federal government maintain advance appropriations7317for IHS?7318 Answer. Maintaining advance appropriations for the Indian Health7319Service (IHS) is critically important to ensure the continuity and7320stability of health care services for American Indian and Alaska Native7321communities.7322 Historically, IHS funding was subject to delays and disruptions7323caused by the annual federal budget process and government shutdowns.7324These disruptions directly threatened access to essential health7325services, compromised staffing and retention, and undermined long-term7326planning.7327 Advance appropriations, which provide funding one fiscal year ahead7328of time, allow IHS programs and tribal health systems to operate7329without interruption, regardless of delays in the federal budget7330process. This stability is essential for maintaining:73317332 Continuity of care for chronic and acute health conditions7333 Reliable staffing and recruitment of health professionals7334 Timely procurement of medical supplies and services7335 Tribal self-governance and planning under self-determination7336 agreements73377338 Most importantly, advanced appropriations honor the federal7339government's legal and moral obligation to provide health care to7340tribal nations, as established through treaties, statutes, and trust7341responsibilities. They uphold the federal trust responsibility and7342support the delivery of consistent, quality care in Native communities.73437344 Question 4a. If the President's proposed FY26 Budget is adopted,7345and funding cuts are implemented across HHS, what impacts should Indian7346Country brace for?7347 Answer. While I can only speak on behalf of Fairbanks Native7348Association (FNA), it is clear that such drastic funding reductions7349would severely compromise our ability to provide essential services.7350The Indian Health Service (IHS) is already significantly underfunded,7351and any further cuts would force impossible decisions about which7352critical services to eliminate--despite the persistent and growing7353unmet health needs in our communities.7354 It is important to emphasize that IHS funding is not discretionary7355funding. It is a legal and moral obligation of the federal government,7356grounded in treaties, federal statutes, executive orders, and the7357federal trust responsibility to American Indian and Alaska Native7358peoples. This obligation must be honored with consistent and adequate7359funding, not subject to arbitrary reductions.73607361 Question 4b. Could Tribes in Alaska meet their communities' needs7362as proposed in the skinny budget?7363 Answer. This question would be more appropriately addressed if the7364essential needs of our people were already being met. However, defining7365what constitutes an ``essential need'' is complex. Are immunization7366services more critical than diabetes management? Is treating a broken7367bone more urgent than providing behavioral health related services?7368These are not either-or choices, all are vital, and all are currently7369underfunded.7370 Each tribe must determine its own priorities based on the specific7371needs of its community. For the Fairbanks Native Association (FNA), any7372reduction in funding would have a deeply negative and far-reaching7373impact on the health and well-being of those we serve.7374 ______73757376 Response to Written Questions Submitted by Hon. Ben Ray Lujan to7377 Melissa Charlie7378 Question 1. How has federal funding for Indian Head Start programs7379improved school readiness and mental health outcomes for Native7380American children?7381 Answer. Since its inception in 1965 as part of the federal7382government's War on Poverty, the Head Start program has provided7383critical early childhood education and comprehensive support services7384to millions of children and families across the nation, giving them a7385``head start'' in life.7386 At Fairbanks Native Association (FNA), our Head Start program goes7387beyond traditional classroom instruction. We offer a holistic, child-7388centered approach that includes individualized support tailored to each7389child's developmental needs. Our goal is to ensure every child is fully7390prepared to transition into kindergarten with confidence and readiness.7391 In addition to educational programming, we provide essential health7392and wellness services, including referrals to behavioral health7393support, vision and dental screenings, and regular developmental7394assessments. We also actively engage families as partners in their7395child's learning, recognizing that strong family involvement is key to7396long-term success.7397 I will also add that as a Tribal Head Start program, FNA integrates7398a strong cultural component that honors and fosters the cultural7399strengths of the children and families we serve. We incorporate Alaska7400Native languages, teach traditional dances, and celebrate cultural7401heritage in meaningful ways throughout our curriculum and activities.7402 This culturally responsive approach promotes a sense of identity,7403belonging, and pride, which supports the overall well-being of our7404children and their families--socially, emotionally, and spiritually. By7405grounding our program in culture, we empower families and help children7406thrive in all areas of life.7407 Through these coordinated efforts, FNA Head Start helps lay a7408strong foundation for lifelong learning, well-being, and success.7409 ______74107411 Response to Written Questions Submitted by Hon. Brian Schatz to7412 Dr. Sheri-Ann Daniels7413 Question 1. Secretary Kennedy has taken steps to ``overhaul''7414agencies across HHS-including those that serve Native communities. We7415heard from several witnesses that because many grants have been7416canceled and HHS regional offices abruptly closed, Tribes have been7417left with assistance with implementing critical programs, including7418those that support victims of domestic violence. Did HHS engage in7419consultation with POL or the Native Hawaiian Community regarding any of7420the changes that have been implemented, including its RIF or7421reorganization efforts?7422 Answer. HHS did not engage in consultation with POL regarding its7423RIF or reorganization efforts. We have conferred with a number of7424Native Hawaiian Organization partners who receive funding from the7425Administration for Native Americans and Administration for Children and7426Families. These partners also reported that they were not consulted. We7427are not aware of any other organizations or individuals in the Native7428Hawaiian community that were consulted by HHS.74297430 Question 2. House Republicans are proposing devastating Medicaid7431cuts. In Hawai`i, about 1 in 4 Native Hawaiians rely on Medicaid, and7432while the House bill includes a carve out for American Indians and7433Alaska Natives, it does not include any exemptions for Native Hawaiians7434in clear violation of the federal government's trust responsibility.7435How will imposing new hurdles, such as work requirements and additional7436cuts to Medicaid, affect Native Hawaiian health care in Hawai`i?7437 Answer. The work requirements ``hurdle'' indeed will be a7438``hurdle'' impacting Native Hawaiians, without the same carve out as7439American Indians and Alaska Natives. As noted by HHS's Office of7440Disease Prevention and Health Promotion, \1\ social determinants of7441health (``SDOH'') are the conditions in the environments where people7442are born, live, learn, work, play, worship and age, that affect a wide7443range of health functioning, and quality-of-life outcomes and risks.7444The SDOH domain of Economic Stability indicates the following goal: \2\7445Help people earn steady incomes that allow them to meet their health7446needs. The unemployment rate in Hawai`i in 2025 and 2026 is projected7447to be 2.9 percent, declining to 2.8 percent in 2027 and then 2.77448percent in 2028. \3\ Native Hawaiians on Medicaid in Hawai'i are caught7449in a viscous circle of needing employment to enable access to7450healthcare services for management of individual chronic disease7451conditions plus dependents who are overrepresented in special health7452and social services needs (0-3 years old), early childhood (3-5 years7453old), and special education (5 to 22 years old).7454---------------------------------------------------------------------------7455 \1\ Office of Disease Prevention and Health Promotion. ``Social7456Determinants of Health.'' Healthy People 2030, Office of Disease7457Prevention and Health Promotion, odphp.health.gov/healthypeople/7458priority-areas/social-determinants-health. Accessed 1 June 2025.7459 \2\ Healthy People 2030. ``Economic Stability--Healthy People74602030.'' Health.gov, odphp.health.gov/healthypeople/objectives-and-data/7461browse-objectives/economic-stability. Accessed 1 June 20257462 \3\ ``DBEDT Economists Lower Hawaii Economic Growth Projections.''7463State of Hawaii Department of Business, Economic Development & Tourism,74642025, dbedt.hawaii.gov/blog/25-20/. Accessed 1 June 2025.7465---------------------------------------------------------------------------7466 The poverty rate of Native Hawaiians in Hawaii is relatively high,7467even though they are employed at about the same rate as the state's7468total population. \4\ Over 144,000 Native Hawaiians and Pacific7469Islanders are below the 138 percent poverty threshold for Medicaid. \5\7470---------------------------------------------------------------------------7471 \4\ Hofschneider, Anita. ``Poverty Persists among Hawaiians despite7472Low Unemployment.'' Honolulu Civil Beat, 19 Sept. 2018,7473www.civilbeat.org/2018/09/poverty-persists-among-hawaiians-despite-low-7474unemployment/. Accessed 1 June 2025.7475 \5\ Karthick. ``By the Numbers: Economic Hardship--AAPI Data.''7476AAPI Data, 7 Mar. 2025, aapidata.com/featured/by-the-numbers-economic-7477hardship/. Accessed 1 June 2025.7478---------------------------------------------------------------------------7479 POL understands the following about Native Hawaiian and part-7480Hawaiian members served by the Hawai`i Medicaid Program administered by7481the State of Hawaii's Department of Health: More than 70,0007482individuals that identify as Native Hawaiian are enrolled in Med-QUEST,7483which represents approximately 17 percent of total Medicaid enrollees7484(and 20 percent of those who chose to identify their ethnicity); Almost748526,000 (34 percent) children which includes more than 1,400 current and7486former foster care children; more than 400 pregnant people; over 14,0007487(18 percent) parents or caretakers; about 26,500 (34 percent) adults;7488and about 8,800 (11 percent) aged, blind or disabled adults.7489 While these statistics indicate that Native Hawaiians are generally7490represented in Medicaid enrollment at rates comparable to our7491representation in the state's population. Medicaid enrollment is more7492pronounced on the rural islands. \6\ On O`ahu, 26.5 percent of the7493total population is enrolled in Medicaid. In contrast, nearly half--437494percent--of Hawai`i Island and over half--56 percent--of Moloka`i are7495enrolled in Medicaid. \7\ Each of these islands also have the highest7496percentages of Native Hawaiians, with Hawai`i Island's population made7497up of 29.6 percent Native Hawaiian and Moloka`i's population comprised7498of 65.1 percent Native Hawaiians. \8\ Given these numbers, it is clear7499that hurdles, barriers and cuts to Medicaid will have a pronounced7500impact on Native Hawaiian Medicaid enrollees, especially those in rural7501communities.7502---------------------------------------------------------------------------7503 \6\ Audit, Quality Control & Research Office Research Staff. State7504of Hawaii Department of Human Services Databook. Dec. 2024. Percentages7505of island population covered by Medicaid are as follows: 34 percent7506Kauai, 26.5 percent Oahu, 43 percent Hawaii Island, 33.8 percent Maui,750756 percent Molokai, 29 percent Lanai)7508 \7\ Id.7509 \8\ Office of Hawaiian Affairs. ``Native Hawaiian Data Book:7510Population.'' Ohadatabook.com, 2025, www.ohadatabook.com/7511go_chap01.23.html. Accessed 19 June 2025.7512---------------------------------------------------------------------------7513 In addition to the high representation of Native Hawaiians and7514Medicaid enrollees, these islands tend to be considered more rural with7515significant barriers to accessing health care. Hawai`i Island residents7516often face long drives (60 to 100 miles one way) just to access primary7517and urgent care services. Moloka`i has significant healthcare7518professional and facilities shortages with many residents needing to go7519off island to receive the care they need. This is exacerbated by7520commuter air transportation options for disabled and elderly being7521severely limited or non-existent for flights to and from Moloka`i.7522Again, additional hurdles and disruptions to Medicaid coverage will7523only exacerbate the significant health care access issues on each of7524these and other islands.75257526 Question 3. After federal agencies were directed to take down7527critical health data to comply with President Trump's DEI Executive7528Order, data regarding American Indian, Native Hawaiian, and Alaska7529Health Native health was deleted from public view, including data on7530how many Native youth are struggling with mental health and thoughts of7531suicide, where disease outbreaks are happening, what's making mothers7532and babies less healthy and how we can combat chronic health issues.7533How does losing this kind of data and information (now and in the7534future) impact HHS' ability to deliver health care services to Native7535communities?7536 Answer. Losing the data negatively impacted HHS' ability to deliver7537health care services to Native communities because the actions:7538incorrectly conflated Trust responsibilities with DEI policy;7539intentionally created a vacuum of community-based implementation data,7540sharing and learning; and paternalistically prevented Native7541communities from being solution partners and providers.7542A. Trust Responsibilities are based on Political Relationships and not7543 DEI Initiatives7544 1. Federal Trust Responsibility. Similar to American Indians and7545Alaska Natives, Native Hawaiians never relinquished the right to self-7546determination despite the United States' involvement in the illegal7547overthrow of Queen Lili`uokalani in 1893 and the dismantling of our7548Hawaiian government. As such and as established by more than 1507549federal laws, Native Hawaiians are owed the same trust responsibility7550as other Native groups in the United States. The federal trust7551responsibility extends to all Native Hawaiians, a population that grew7552nationwide by 29.1 percent from the 2010 to the 2020 census data. \9\7553To meet this obligation, Congress--through landmark, bipartisan work of7554this Committee and its Members--created policies to promote education,7555health, housing, and a variety of other federal programs intended to7556build, maintain, and better conditions for the Native Hawaiian7557Community.75587559 \9\ US Census Bureau. ``Chuukese and Papua New Guinean Populations7560Fastest Growing Pacific Islander Groups in 2020.'' Census.gov, 21 Sept.75612023, www.census.gov/library/stories/2023/09/2020-census-dhc-a-nhpi-7562population.html. Accessed 7 May 2025.7563---------------------------------------------------------------------------7564 2. Unique Political Status. More than 150 Acts of Congress7565expressly acknowledge or recognize a special political and trust7566relationship to Native Hawaiians based on our status as the Indigenous,7567once-sovereign people of Hawai`i. Among these laws are the Hawaiian7568Homes Commission Act, 1920 (42 Stat. 108) (1921), the Native Hawaiian7569Education Act (20 U.S.C. 7511) (1988), the Native Hawaiian Health7570Care Improvement Act (42 U.S.C. 11701) (1988), and the Hawaiian7571Homelands Homeownership Act codified in the Native American Housing7572Assistance and Self Determination Act, Title VIII (25 U.S.C. 4221)7573(2000).75747575 3. Declaration of Policy. Congress declared that it is the policy7576of the United States in fulfillment of its special trust7577responsibilities and legal obligations to the indigenous people of7578Hawaii resulting from the unique and historical relationship between7579the United States and the Government of the indigenous people of Hawaii7580(1) to raise the health status of Native Hawaiians to the highest7581possible health level; and (2) to provide existing Native Hawaiian7582health care programs with all resources necessary to effectuate this7583policy. \10\75847585 \10\ The Native Hawaiian Health Care Improvement Act (42 U.S.C.758611702) (1988)7587---------------------------------------------------------------------------7588B. Intentionally Created a Vacuum in Community-based Implementation7589 Data, Sharing and Learning7590 Billions of dollars, over the past five decades, have been and7591continue to be invested in Native community health professionals and7592providers, facilities, interventions, strategies, and initiatives.7593Community data, particularly that, which disaggregates Native7594populations, triangulates the researched native community with7595researchers and research organizations and the health care professional7596community, to recognize and understand problems as well as co-7597construct, community-based solutions. The data vacuum hinders HHS'7598ability to deploy resources and programs and meet the Federal Treaty7599and Trust responsibilities, effectively, including consultation7600practices.7601C. Paternalistically Prevented Native Communities from Being Solution7602 Partners and Providers7603 1. E Ola Mau. The Native Hawaiian Health Needs Assessment (1985)7604was a landmark report that provided a comprehensive assessment of7605Native Hawaiian health, offering recommendations related to the health7606needs of Native Hawaiians. It provided the initial roadmap to local,7607state, and federal agencies on how each could contribute to the health7608and well-being of Native Hawaiians, was foundational in the passing of7609the Native Hawaiian Health Care Act of 1988, and the establishment of7610Papa Ola Lokahi. The assessments conducted in the original E Ola Mau7611and subsequent versions of the document since then are not possible7612without current and reliable data. The availability of data has enabled7613Papa Ola Lokahi and other Native Hawaiian-serving agencies to monitor7614the health status of Native Hawaiians, allowing us to identify areas of7615need and growth, as well as strengths and resiliencies. Chapter topics7616in E Ola Mau have expanded over the years to address these needs, now7617including recommendations for workforce development, health education,7618and data governance.7619 E Ola Mau has not only been used to create policy change, but it7620has also had an impact at the community level, and this would not be7621possible without the availability of data. E Ola Mau is heavily7622referenced among community leaders and Native Hawaiian-serving7623organizations as evidence of need in grant funding applications,7624establishment of services, and in academic literature. E Ola Mau has7625been a catalyst for change for Papa Ola Lokahi, as well as other Native7626Hawaiian-serving organizations, communities, and individuals, all of7627which have been made possible by the availability of reliable data.76287629 2. COVID-19. One key example of the ways in which data that focuses7630on native communities helps community and government partners identify7631and address issues that have impacts on the broader population is the7632data collected and used during the COVID-19 pandemic. By May 2020, data7633indicated that Native Hawaiians and Pacific Islanders (NHPIs) had7634higher rates of confirmed COVID-19 cases. \11\ These important data7635points drove a coalition of organizations and government agencies to7636allocate resources and develop tactics to address the high rates of7637infection and mortality. Papa Ola Lokahi is proud to have helped these7638efforts, which became known as NHPI 3R for Response, Recovery and7639Resilience. NHPI 3R mobilized efforts to ensure the State Department of7640Health was collecting and analyzing accurate and relevant data. From7641there, NHPI 3R was able to work with government agencies to identify7642immediate needs of the community and deliver community-based and7643networked assistance, including testing, educational materials and7644social supports.7645---------------------------------------------------------------------------7646 \11\ Kaholokula, Joseph Keawe`aimoku, et al. ``COVID-19 Special7647Column: COVID-19 Hits Native Hawaiian and Pacific Islander Communities7648the Hardest.'' Hawai'i Journal of Health & Social Welfare, vol. 79, no.76495, May 2020, p. 144, pmc.ncbi.nlm.nih.gov/articles/PMC7226312. Accessed765019 June 2025.7651---------------------------------------------------------------------------7652 In March 2021, the CDC identified that NHPIs had the highest death7653rate of any racial or ethnic group in 18 of 20 states that reported7654deaths of our communities. \12\ At the same time, the State of Hawai`i7655Department of Health was not yet regularly reporting vaccination rates7656broken down into racial or ethnic groups. NHPI 3R, along with other7657community members, pushed the Department of Health for relevant data7658reporting. When data was available, our state saw that Native Hawaiians7659and Pacific Islanders had the lowest vaccination rate coupled with the7660highest infection rate. \13\ NHPI 3R worked with the Department of7661Health and other community partners to build messaging and programming7662that would resonate with our communities. Papa Ola Lokahi partnered7663with the Department of Health to help disperse funds to increase7664vaccination rates among NHPIs. Further, these efforts spurred7665organizing and capacity-building of community health workers, which has7666continued to positively impact our communities.7667---------------------------------------------------------------------------7668 \12\ Seto, Brendan K. et al. ``Differences in COVID-197669Hospitalizations by Self-Reported Race and Ethnicity in a Hospital in7670Honolulu, Hawaii.'' Preventing Chronic Disease, vol. 19, 2022,7671www.cdc.gov/pcd/issues/2022/22_0114.htm#:-7672:text=As%20of%20March%202021%2C%20Native, retrieved June 16, 20257673 \13\ Hofschneider, Anita. ``Pacific Islanders, Including Hawaiians,7674Disproportionately Missing out on Vaccines.'' Honolulu Civil Beat, 177675Mar. 2021, www.civilbeat.org/2021/03/pacific-islanders-including-7676hawaiians-disproportionately-missing-out-on-vaccines/. Accessed 19 June76772025.7678---------------------------------------------------------------------------7679 The data at both state and federal levels that focused solely on7680Native Hawaiians and Pacific Islanders was vital for Papa Ola Lokahi7681and our partners, including the NHPI 3R coalition, to understand what7682our communities needed to address COVID-19 in our communities. Further,7683these data also allowed both the State of Hawai`i and the federal7684government to allocate resources in more effective ways. These data7685helped not just to move needed investments into Native Hawaiian7686communities. The targeted allocation of resources helped to reduce7687COVID-19 infections across Hawai`i and in Hawaiian communities across7688the other 49 states.76897690 3. Maternal Mortality. Another prime example of the way in which7691disaggregated data yields powerful insights is the maternal mortality7692rate. For years, Black American birthing people were known to have the7693highest rates of maternal mortality. This allowed for HHS and other7694organizations to tailor programs, resources and services to address the7695disparity. It was not until the last couple of years that Asian7696American, Native Hawaiian and Pacific Islander populations were7697disaggregated that our community was forced to face the harsh truth7698that our communities faced the highest maternal mortality rates in the7699nation from 2017 to 2019--more than 50 percent higher than Black7700Americans. \14\ In years since, Native Hawaiian and Pacific Islander7701populations have not yet been disaggregated, but we have seen multiple7702years where American Indian and Alaska Native communities also have the7703highest rates of maternal mortality. \15\ These data sets are critical7704for our communities as well as the federal government to identify7705problems and address them effectively. For us to develop solutions7706after all, we must first understand the problem and its root causes.7707---------------------------------------------------------------------------7708 \14\ CDC. ``Data from the Pregnancy Mortality Surveillance7709System.'' Maternal Mortality Prevention, 29 Apr. 2025, www.cdc.gov/7710maternal-mortality/php/pregnancy-mortality-surveillance-data/7711index.html?cove-tab=1. Accessed 19 June 2025.7712 \15\ Id.7713---------------------------------------------------------------------------7714 Mahalo hou (thank you again) for providing the opportunity for POL,7715the NHHB, to respond to the three questions for the record from Vice7716Charman Schatz, as a follow up to the above referenced Committee7717Oversight Hearing; and we stand ready and available to provide any7718follow up information.7719 ______77207721 Response to Written Questions Submitted by Hon. Lisa Murkowski to7722 Hon. Loni Greninger7723 Question 1. As of 2022, there are seventy-six approved Tribal7724Temporary Assistance for Needy Families (TANF) programs operating7725across the United States. These programs serve more than 285 Federally7726recognized Tribes and Alaska Native Villages, providing culturally7727tailored services that promote self-sufficiency and community7728wellbeing. What is the critical role of Tribal TANF programs in7729supporting the most vulnerable in your communities and how is the7730flexibility of Tribal TANF key in achieving self-sufficiency?7731 Answer. Tribal TANF programs provide much more than employment and7732training resources in Tribal communities. They often are actively7733engaged with child welfare, health, youth services, education, and7734behavioral health programs. As one of the four main purposes of TANF,7735these programs focus on services and support to ensure needy children7736can be cared for in their homes. A number of Tribal TANF programs have7737regular engagement with these other service providers to identify risk7738factors early on for children and families that can lead to greater7739crisis and involvement in service systems like child welfare. TANF7740often sees at risk families long before other service systems identify7741the families and with proper support can engage multiple systems to7742identify concerns that threaten family stability and ensure that7743services that promote economic self-sufficiency contribute to the7744strengthening of families and community wellness overall. TANF's7745flexibility to respond quickly, utilize culturally based services, and7746engage various systems effectively is key to serving children and7747families in need in Tribal communities. Operating a Tribal TANF program7748empowers us with flexibility and autonomy to design and administer a7749culturally relevant program that better serves the specific needs of7750our Tribal citizens strengthening Tribal sovereignty, Self-7751Determination, and improving overall community well-being.77527753 Question 2. One of the critical functions of ANA is to provide7754language grants. Preserving and revitalizing Native languages is7755critical to sustaining Native history, culture, and philosophy. There7756are significant impacts from the teaching of Native languages on7757academic outcomes, social indicators, and community wellbeing. Alaska7758has three active Ester Martinez Immersion grants currently, spanning7759Southeast, Southcentral, and Western Alaska. Two of these grants7760support language immersion through early childhood education, serving7761children ages 0-5. What is the role of ANA Native Language Grants like7762Ester Martinez Immersion in enhancing child development and building7763strong communities?7764 Answer. Language is crucial to a child's development of their sense7765of self and their relationship to their family, community, and the7766world around them. Our languages are structured to show our7767relationships with those around us, and express concepts unique to our7768communities and cultures. The Federal Indian boarding school era wiped7769out much of our Indigenous language knowledge, and COVID-19 has claimed7770the lives of many of the remaining elders that were fluent speakers of7771our languages. It is impossible to fully describe the impact that7772losing our language and elders has had on our community. The7773generational trauma of Indigenous language loss is well documented, and7774we live and observe this trauma every day in our Tribal communities.7775ANA Native Language grants, such as the Esther Martinez Immersion7776Grant, provide essential funding to Tribal Nations to develop and7777implement language learning models that incorporate family and elders7778into methods-based curricula and assessments to revitalize our language7779in pre-Kindergarten aged children. Indigenous language use and7780revitalization is well understood to improve health disparities in7781Tribal communities, as well as improve mental health outcomes. Tribal7782communities have always known that culture is healing, and ANA Native7783Language grants empower our sovereignty to rebuild the loss of our7784language, culture, and community, starting with our youngest, most7785vulnerable members.7786 The Jamestown S'Klallam Tribe has actively revitalized our Klallam7787language through various initiatives, including documentation,7788education, and community engagement. The Tribe established the Klallam7789Language Program in 1992, recording our elders and transcribing the7790language. This foundational work provided a basis for creating teaching7791materials and curricula. The program has since expanded to include7792language classes in local schools for pre-school to high school aged7793children. These programs are vital to ensure that our younger7794generations learn the language. Adult language classes and online7795resources contribute to language learning beyond high school. Some7796positive impacts of the Klallam Language Program are increased language7797proficiency, improved academic success for Tribal students and7798community empowerment. It has helped create local networks and7799employment opportunities. The Tribe's efforts have influenced education7800of surrounding non-Native communities and others who visit our area7801with the introduction of bilingual street and Tribal campus signs.7802There is a system in place for training and certifying Klallam language7803teachers as qualified instructors that can continue to ensure the7804language's survival and transmission to future generations. This is7805essential because while our Klallam language is undergoing7806revitalization, it is still critically endangered. The Jamestown7807S'Klallam Tribe's commitment to language revitalization demonstrates a7808dedication to preserving our cultural heritage and ensuring our7809language continues to thrive.78107811 Question 3. What is the importance of the CDC's Tribal Practices7812for Wellness in Indian Country funding and how has this funding7813benefitted the Jamestown S'Klallam Community?7814 Answer. The CDC Healthy Tribes program is important to the7815Jamestown S'Klallam Tribe because it provides a framework and resources7816that support the Tribe's goal of enhancing the health, social strength,7817and self-reliance of our citizens and community members. Traditional7818lifestyle and healing practices are essential to the overall well-being7819of our Tribe and our citizens, and these programs provide us with the7820opportunity to re-engage our ancient ways and utilize them in7821contemporary time. The CDC program prioritizes cultural values,7822traditions, and practices as central to health and wellness and this7823aligns with our Tribe's mission to serve the unique needs of our7824community with cultural sensitivity. Our identity as Tribal people is7825healed and strengthened and our bodies and physical health is improved7826with the healthy foods that we harvest, hunt, and cultivate on our7827Tribal homelands and in our ancestral waters. The Healthy Tribes7828Program recognizes the disproportionately high rates of chronic disease7829and shorter life expectancy faced by American Indian/Alaska Native (AI/7830AN) people often linked to historical trauma and lack of resources. By7831promoting community-led, culturally responsive interventions, we can7832address the root causes of these health disparities and improve health7833outcomes. We have been able to lower the incidence of disease and lower7834stress through traditional dancing, traditional foods, and harvesting7835activities.7836 Funding and resources are used in various ways:78377838 Salaries for staff that have the expertise needed to plan7839 both small- and large-scale events, teach classes, and7840 coordinate the First Foods Ceremony and all food harvesting and7841 preparations.78427843 Stipends are provided to Tribal cultural and spiritual7844 leaders, usually our Tribal elders and wisdom keepers who teach7845 classes, lead songs and teach and facilitate sacred traditional7846 ceremonies.78477848 Supplies include seeds and tools needed to help grow and7849 support our community garden and seasonal feasts. We create7850 safe pathways for citizens and community members of all7851 abilities to come to the garden and participate and actively7852 contribute to harvesting activities and the cooking of meals.7853 The garden serves as an intergenerational gathering place for a7854 plethora of activities including physical education,7855 nutritional and medicinal education, a learning space for7856 singing, drumming and dancing, and Ceremony, and a place for7857 cultural education of traditional harvest practices, food7858 preservation methods, and proper harvesting seasons. Garden7859 activities and opportunities for learning are offered on a7860 weekly basis. Food education includes harvesting, preparing,7861 preserving, cooking and storing. We teach our citizens and7862 community members various food preservation methods such as how7863 to freeze dry, dehydrate, smoke and can foods.78647865 Cultural classes have specific themes and are hosted frequently,7866usually on a quarterly basis. For example, every January we focus on7867winter wellness and teach our citizens and community members about the7868healing and nutritional properties of various plants and animals--we7869make natural cough and cold medicines such as cough honey (a natural7870throat coat and cough suppressant), Devils Club Tea (a natural7871expectorant), Cedar steams (natural sinus cleanser) and healthy and7872nutritious soups like duck soup where we gain health benefits from the7873meat, bones and vegetables.7874 The First Food Ceremony is our largest garden event of the year7875with at least seventy participants ranging in age from our youngest7876Tribal citizens to our elders. During the Ceremony, a variety of7877activities take place, and individuals may participate in a variety of7878roles from assisting staff with harvesting, preparing the foods for7879cooking, cooking the meal, singing and drumming, speaking the names of7880our food in our language, and the act of gift giving. During the7881Ceremony we celebrate the beginning of our traditional seasonal7882calendar that includes only three seasons as we combine both fall and7883winter into a single season that begins in November. We provide samples7884of the major food groups and listen to the language speakers teach us7885the Klallam words for deer, duck, berry, water, crab, camas, and fish.7886Then we share the seasonal feast together and celebrate with songs.7887 The Tribe hosts multiple cooking classes, clam digs, seaweed and7888forest plant harvests throughout the year. There are a number of inter-7889Tribal events where we gather with our sister Tribes and learn about7890their ancient harvest and cooking practices like cooking pits for camas7891bulbs and using watertight bentwood boxes with hot stones to cook soup.7892Our staff learn these traditional practices and bring that knowledge7893back to our community to share with our citizens and community members.7894 These grants are essential for cultural preservation and because7895they play a significant role in helping us learn ancient methods and7896knowledge systems that are not known in western cultures. Holistic and7897traditional health and education systems touch our hearts and7898revitalize our soul in a deeper and more meaningful way than western7899systems due to our belief in the interconnectedness of body, mind, and7900spirit.7901 ______79027903 Response to Written Questions Submitted by Hon. Brian Schatz to7904 Hon. Loni Greninger7905 Question 1. Secretary Kennedy has taken steps to ``overhaul''7906agencies across HHS--including those that serve Native communities. We7907heard from several witnesses that because many grants have been7908canceled and HHS regional offices abruptly closed, Tribes have been7909left without assistance in implementing critical programs, including7910those that support victims of domestic violence. Did HHS engage in7911consultation with Tribes regarding any of the changes that have been7912implemented, including its RIF or reorganization efforts?7913 Answer. There was no Tribal consultation on HHS reorganization7914efforts or decisions ahead of implementation. HHS has just scheduled a7915listening session on this topic on July 16-17, 2025, but a listening7916session is not the same as robust, Nation-to-Nation consultation with7917transparent information-sharing and engagement with Tribal leaders.79187919 Question 2. Secretary Kennedy frequently touts that HHS exempted7920the Indian Health Service from the hiring freeze in place across the7921Federal government. However, not only is the exemption limited to only7922certain clinical positions, it is still in place across other HHS7923agencies that serve Native communities' health care needs. In addition,7924HHS has engaged in a series of staff layoffs, and additional Reductions7925in Force (RIFs) are looming. Your testimony stated that staffing7926uncertainties are crippling programs for children. How do efforts to7927reduce Federal staff affect services for Native children and families,7928and how will future reductions exacerbate these challenges?7929 Answer. Tribal Nations take seriously the program requirements and7930expectations that come with Federal programs, but they work to utilize7931available flexibility within Federal programs to create functional and7932responsive programs that work in their communities. In order for Tribal7933Nations to successfully balance the need to meet requirements,7934administrative and programmatic, that come with Federal funds and7935create effective programming, they rely on HHS staff to partner with7936them to discuss, design, and implement programs with Federal funding.7937This is particularly true in child welfare and behavioral health7938services, where many Federal programs have limited recognition of7939Tribal needs or service delivery systems. The relationship between7940Federal agencies and Tribal Nations is an ongoing relationship with7941ongoing needs that require collaboration throughout the year. Tribal7942Nations invest significantly into developing positive and meaningful7943relationships with Federal staff, which in turn become more7944knowledgeable and helpful in helping Tribal Nations meet Federal7945requirements and develop effective programs. Most of this work occurs7946between Federal staff in the regional offices and Tribes in their7947region. Beginning in February with the prohibition of external7948communication in HHS, loss of Tribal staff within the Central Office in7949DC, and the closing of five regional HHS offices, hundreds of Tribes7950have been scrambling for months to complete and submit their Federal7951program reports and applications and make contact with Federal staff7952that can provide meaningful assistance to them. The impacts to Native7953children and families if Tribal Nations cannot submit their materials7954on time to ensure they will receive funding in the future are profound.7955For example, recipients of Title IV-B child and family services funding7956are required to submit certain reports by June 30 of each year, but due7957to the communications freeze, loss of staff, and regional office7958closures, many Tribes that are new to the program have not received7959sufficient technical assistance to complete the required reports. As a7960result, these Tribes are at risk of losing access to these vital child7961and family services funds in FY 2026. In addition, many Tribal Nations7962will have to lay off staff in sensitive program areas, like child7963welfare, and will have to make hard decisions about whether they can7964participate in state child welfare cases involving their member7965children and families. When Tribal Nations have to pull back from their7966work, states will also suffer, because they rely greatly on Tribal7967expertise and services to support Native children and families who are7968in state systems.79697970 Question 3. For the first time ever, in FY23, IHS received advance7971appropriations following years of advocacy from Tribes and Tribal7972Organizations. An initial passback of the President's proposed FY267973Budget (the ``skinny budget'' threatened to end advance appropriations7974while decimating IHS funding by 30 percent compared to FY25.79757976 a. Why is it important that the Federal government maintain advance7977appropriations for IHS?79787979 b. If the President's proposed FY26 Budget is adopted, and funding7980cuts are implemented across HHS, what impacts should Indian Country7981brace for?79827983 c. Could Tribes meet their communities' needs as proposed in the7984skinny budget?79857986 Answer. Advance appropriations have been a truly life-changing7987improvement for our clinic and patients. It has allowed us to provide7988more consistent day-to-day care, as well as plan for a future expansion7989of our healthcare services. Without advance appropriations, we return7990to a time when shutdowns forced us into financial hardship. Across7991Indian Country, clinics would drastically reduce or discontinue7992services indefinitely, while our patients go without healthcare. This7993is inconsistent with the trust and treaty responsibility. It is a7994violation of Tribal sovereignty because we cannot fully exercise our7995Self-Governance if our funding is held back by unrelated political7996disputes in Washington, D.C. Simply put, the cuts proposed in the draft7997``skinny budget'' would be devastating to our clinic and our patients7998who rely on us for consistent, high-quality healthcare. We would be7999forced to roll back essential services, and our patients would not have8000the same access to comprehensive healthcare services. Furthermore, this8001would force us into the impossible situation of determining which8002services must be pared back. In short, we would not be able to meet8003community needs if any cuts were enacted.8004 We were relieved to see that the final FY 2026 President's Budget8005Request did not propose widespread cuts to the IHS, but the proposed8006flat-funding of most accounts is still concerning to us. As you know,8007this is effectively a cut when you take increased patient needs and8008high medical inflation into account. This Indian health system is8009already so chronically underfunded, leading to Tribal communities being8010disproportionately impacted by obesity, diabetes, heart disease,8011cancer, substance use disorder, and other preventable conditions. In8012our communities, the life expectancy is ten years shorter than that of8013the rest of the United States. The trust and treaty obligation demands8014that we receive increases to our budget, not flat-funding or cuts.8015 We understand that this year, Congress is dealing with a tight8016budget environment. However, the trust and treaty obligation exist8017irrespective of the goal to limit Federal spending. In fact, the IHS8018budget remains so small in comparison to the Federal budget that cuts,8019rescissions, sequestrations, and freezes do not result in any8020meaningful savings in the national debt, but they do harm Tribal8021Nations and our citizens.80228023 Response to Written Questions Submitted by Hon. Ben Ray Lujan to8024 Hon. Loni Greninger8025 Question 1. Despite Nationwide efforts to improve access to8026behavioral health services in Indian country, Native Americans still8027have one of the highest suicide rates in the country, can you talk8028about how Federal programs like Substance Use and Mental Health8029Services Administration (SAMHSA) has made an impact in addressing these8030disparities in Tribal communities? How will cuts to SAMHSA harm Tribal8031communities?8032 Answer. Federal funding for behavioral health services,8033particularly for Native children and youth services, has been extremely8034limited for many years. In addition, Tribal Nations have struggled to8035find Federal behavioral health funding that is flexible enough that8036Tribal traditional healing services can be supported. SAMHSA, while not8037having only a few programs that address the behavioral health needs of8038Native children and youth, has created a number of programs that have8039provided some of the first Federal funding for Tribes to plan for and8040implement traditional healing services in connection with more8041mainstream interventions to address historic and intergenerational8042trauma. The Circles of Care grants, Children's Mental Health Services8043grants, and Tribal Behavioral Health Programs (two programs, one8044focused on preventing youth suicide and other on addressing substance8045abuse) have provided Tribal funding that is child and youth specific8046and allows Tribal communities to utilize Tribal traditional healing8047methods. The combination of these grant programs has helped Tribal8048grantees establish greater stability and resources in an area where8049there have historically been few and raise the capacity to address8050mental health and substance abuse risks. These programs have been8051helpful in creating Tribal models in behavioral health that future8052Tribal grantees can draw upon in developing programs for their8053communities. Cuts to these programs and Federal staff that support8054Tribal grantees will extinguish much of the important work that Tribal8055Nations have done to decrease disparities and likely increase risk8056levels for suicide and substance abuse in affected communities.8057 ______80588059 Response to Written Questions Submitted by Hon. Lisa Murkowski to8060 Lucy R. Simpson8061 Question 1. As of 2022, there are 76 approved Tribal Temporary8062Assistance for Needy Families. (TANF) programs operating across the8063United States. These programs serve more than 285 federally recognized8064Tribes and Alaska Native villages, providing culturally tailored8065services that promote self-sufficiency and community wellbeing. What is8066the critical role of Tribal TANF programs in supporting the most8067vulnerable in your communities and how is the flexibility of Tribal8068TANF key in achieving self-sufficiency?8069 Answer. Tribal TANF programs not only address the immediate8070economic needs of low income families, many of which are survivors of8071violence, but also promote long-term self-sufficiency of these8072families. Due to the high rates of violence and lack of safe housing8073and economic opportunity in Indian Country, some families need help8074meeting their basic needs and many are faced with rebuilding their8075lives after escaping abuse. Tribal TANF allows Tribes to design and8076administer their own programs that reflect the unique needs of their8077communities. This flexibility has made TANF highly successful in8078providing services that are culturally relevant, trusted, and8079effective, making it an excellent example of Tribal self-determination8080and the federal government's trust and treaty obligation at work.8081 ______80828083 Response to Written Questions Submitted by Hon. Brian Schatz to8084 Lucy R. Simpson8085 Question 1. Secretary Kennedy has taken steps to ``overhaul''8086agencies across HHS--including those that serve Native communities. We8087heard from several witnesses that because many grants have been8088canceled and HHS regional offices abruptly closed, Tribes have been8089left without assistance with implementing critical programs, including8090those that support victims of domestic violence. Did HHS engage in8091consultation with Tribes regarding any of the changes that have been8092implemented, including its RIF or reorganization efforts?8093 Answer. No, the Department of Health and Human Services has not8094engaged in consultation with Tribes regarding any of the changes that8095have been implemented, including its Reductions in Force and8096reorganization efforts.80978098 Question 2. Secretary Kennedy frequently touts that HHS exempted8099the Indian Health Service from the hiring freeze in place across the8100federal government. However, not only is the exemption limited to only8101certain clinical positions, it is still in place across other HHS8102agencies that serve Native communities' health care needs. In addition,8103HHS has engaged in a series of staff layoffs, and additional Reductions8104in Force (RIFs) are looming. Your testimony stated that staffing8105uncertainties are crippling programs for children. How do efforts to8106reduce federal staff affect Tribal services to support victims of8107domestic violence, and how will future reductions exacerbate these8108challenges?8109 Answer. The reductions in force (RIFs) issued by HHS have8110interrupted essential functions of sexual assault and domestic violence8111prevention efforts, threatened decades of improvements to our public8112health response to these issues, and risked the loss of vital8113institutional knowledge. Tribal programs rely on federal staff who have8114spent years cultivating trusted relationships with Tribal Nations, as8115well as developing their cultural competence, trauma-informed8116expertise, and a deep understanding of the complex realities Native8117communities face. Additional RIFs will cause a monumental loss of8118institutional knowledge concerning Tribes and Native victims and8119destabilize the work that has been done to make Native communities8120safer over the last four decades.8121 Changes to leadership within HHS have also created uncertainty for8122Tribal grantees due to the abrupt nature and lack of consultation and8123communication. Notably, Shawndell Dawson, Director of the Office of8124Family Violence Prevention and Services (OFVPS), was placed on8125administrative leave on March 31.8126 The OFVPS office, under Director Dawson's leadership, has been8127instrumental in recognizing the need for culturally grounded and8128Native-led programs for survivors of violence. Over 230 Tribes and8129Tribal DV programs receive Family Violence Prevention and Services Act8130(FVPSA) formula grants to provide emergency shelter and crisis8131intervention services. OFVPS, which administers FVPSA grants, also8132partners with Native-led organizations like NIWRC to help build the8133capacity of and provide training and technical assistance to Tribal8134grantees and advocates so Native communities can access long-term,8135specialized care. Director Dawson's abrupt placement on administrative8136leave was felt within the OFVPS office and down to individual Tribal8137grantees, causing deep uncertainty as they attempted to move forward in8138their work. The issuance of Non-Competing Continuations--the funding8139continuation for programs with multi-year grants or cooperative8140agreements--and new funding for grants that terminate at the end of8141this fiscal year have been significantly delayed, with little to no8142communication with the programs relying on this funding. Programs8143continue to face concerns about laying off staff or closing entirely if8144this funding is not received, which would have a disastrous impact on8145the number of resources available to victims in Indian Country.