National Indian Health Board Tribal Health Conference

Good morning, everyone.

My friend and advisor, Chief Bill [Smith, National Indian Health Board Chair], it’s good to see you again, and thanks for the kind introduction. Chief, as a Tribal leader representing Indian Country and Indigenous Peoples around the world, VA is stronger, this country is stronger, because of you, because of your service in uniform and continued service in all these years since.

Distinguished members of the National Indian Health Board (NIHB), good morning.

And Stacy [Bohlen, NIHB CEO], VA has no more important partner than you and the NIHB. Thanks for welcoming me to Rapid City—the land of Oceti Sakowin, Seven Council Fires, and home of the Lakota.  

All this country is tribal land. Let me recognize the tribal leaders, tribal elders, and Veterans here this morning. It’s my honor to be here with you. At VA, we respect you. We respect your Tribal governments. And I reaffirm my deep commitment to our common heritage, to your Tribal sovereignty, and the important work we’re doing—together—for Vets, their families, survivors, and caregivers.

President Biden often says our nation’s most sacred obligation is preparing and equipping the troops this country sends into harm’s way, and then caring for them and their families when they return home. The second part of that sacred obligation, that’s our mission at VA. But here’s the thing. It’s our whole country’s obligation, our shared obligation.

Here’s what I’m thinking about. Kathleen Gray—a member of the Creek Nation—is the Oncology Case Manager at the Oklahoma City Indian Clinic, one of those great Urban Indian Organizations. Well, a few years back, Tom—a Navy Vet and member of the Cherokee Nation—came under Kathleen’s care. You see, Tom had been diagnosed with cancer, with acute lymphoblastic leukemia. Tom’s leukemia was aggressive. He had a poor prognosis.

Now, Kathleen, the Oklahoma City Indian Clinic, and IHS (Indian Health Service) were doing all they could to support Tom. IHS prioritizes cancer care and treatment for their oncology patients, and Tom’s routine cancer treatment at the University of Oklahoma Medical Center was covered. But Kathleen was pulling her hair out trying to find ways to help Tom with everything he needed, get him the kind of support her clinic and IHS just couldn’t provide: a stem cell transplant, incredibly expensive oral chemotherapy medication, home oxygen, and durable medical equipment like a hospital bed, a wheelchair, nebulizer, CPAP machine, to name a few.

To Kathleen, it seemed like “a hopeless scenario.” But hope … so often hope is what we’re about. So often hope is the most important thing.

Now, for a few weeks, Kathleen lost touch with Tom, and it had her worried. Then Tom called Kathleen, and he was overjoyed. Tom had enrolled in VA health care. He’d been admitted to the Oklahoma City VA Medical Center—which, incidentally, is affiliated with the University of Oklahoma Medical Center where Tom was getting his care. Tom reported to Kathleen that VA had provided him with everything he needed, including transportation to his appointments and respite care for his caregiver. As far as medications, services, durable medical equipment, Tom didn’t have to worry about any of that anymore.

Sadly, Tom didn’t win his fight with cancer [d. 2023]. He was simply too weak for the stem cell transplant. He loved the people who cared for him at his local Indian clinic, and Kathleen remembers he “was so proud of the care he received at the VA.” To the very end, Kathleen said, knowing that anything he needed would be provided, Tom felt important, hopeful, and cared for.

Here’s my point. It takes all of us to ensure Vets have access to the excellent, culturally competent care they deserve—whether that’s at a UIO, a tribal health facility, with IHS, at VA, or a combination of those. It takes all of us communicating, consulting, and coordinating to ensure there are no gaps in care across those options. In fact, VA leaders joined IHS yesterday for a roundtable with Northern Plains Tribal Veteran Service Officers and Tribal leaders to talk about how we can work together to increase Vets’ access to health care and other local and state resources they need.

When we work together—and do it well—then we change Vets’ lives for the better.

Now, with all that in mind, I want to bring you up-to-date on some of the things we talked about last time we were together, on some important work to bridge gaps and expand Vets’ access to care.

Last year, VA delivered more care and more benefits to more Veterans than ever before. And this year we’re fighting to reach even more Vets, to continue building trust, to meet them where they are rather than asking them to come to us, to expand options and access to care.

That’s what our co-pay exemption for Native Vets is about. You remember—back in November 2022 I made a commitment to you, said we’d have the co-pay exemption in place for American Indian and Alaska Native Vets by year’s end. We missed that mark. But got it done last spring, and it’s making a difference. Over 6,000 Vets have applied for the waiver. More than 5,200 have been approved—that’s just over $3.3 million saved for Native Vets.

But we have more work to do. 68,000 Native Vets are enrolled in VA health care. That leaves about 62,000 who haven’t applied for the exemption. My concern is how many Native Vets just don’t know this benefit’s there for them? So, Dr. Prairie Chicken, her team in the Office of Tribal Health, and Clay Ward in the Office of Tribal Government Relations are reworking our communications strategy. And I want to ask for your help getting word out to the Native Vets you’re serving. It will only help expand Vets’ choices for care.

That’s the same approach we’re taking on reimbursement agreements—expanding the scope of support. Last December and in consultation with tribal leaders, we signed our revised reimbursement agreement with Indian Health Service. That new agreement covers long-term care, home health services, and Purchased Referred Care. Tribal leaders have been asking for that for a long time.

For Tribal Health Programs (THPs) in the Lower 48, you’ll see the same sort of expansion in the new Reimbursement Agreement, additional direct care services like Home Health, Long-Term Care, Purchased Referred Care, Telemedicine, Contracted Travel, and reimbursement for the kinds of durable medical equipment that were so important to Tom in his cancer fight. By mid-June, that agreement will be ready for Tribal Health Programs to review and sign, so keep an eye out.

Alaska’s new agreement is now under revision, and we owe you a finalized agreement early next month. Chief Bill, we had an in-person consultation with Alaska Tribal stakeholders in April, and we’re working to accommodate all the requested changes. The new agreement does include contracted travel and purchased referred care, which we’ll reimburse at the billed rate. We’ve expanded the scope of what we will reimburse at the All-Inclusive Rate—not only inpatient and outpatient services, but also telehealth, home health, community health aides and direct care services that I know are important to your Vets. We’ve also removed the requirement to follow VA’s formulary for reimbursement, removed the agreement end date, extended filing limits to 36 months, and we’re clearer on what applies to Native and non-Native Vets in Alaska.

Now, let me touch on our expanding work with Urban Indian Organizations, and some of that work we have ahead of us. Last time I was here, I told you about my great visit to Hunter Health UIO in Wichita, Kansas. Back then, our relationship with UIOs was limited, and we’ve made progress. We have reimbursement agreements with six UIOs, and we’re working with seven more.

But I’d hoped we’d be further along by now. Even among the six UIOs we have agreements with, we haven’t paid any reimbursement for Vets’ care. So, we had an Urban Confer with UIOs at the National Council of Urban Indian Health’s annual conference. And we got some good feedback as we’re revising our agreement, which will be ready this summer.

We have more work to do, and we’re doing it. We’re expanding the scope of reimbursement for direct care services along the same lines as our THP and IHS agreements. We’re going to reimburse at a higher rate—the Medicare Federally Qualified Health Center rates. I know it’s still lower than Medicaid rates, but it can make a difference for Vets with private insurance, or no insurance at all. We’re increasing Outpatient Pharmacy Dispensing Fee rates. And we need to do better with outreach and education when it comes to the enrollment process and billing. So, we’re going to keep working on it, keep building these relationships with UIOs, Tribal Health Programs, and IHS to bridge any gaps in care for Native Vets.

Bridging gaps, expanding access, that’s why we’re excited about the “Clinic-in-a-Clinic” model that’s starting to take hold. This model is expanding Native Vets’ access to VA health care in highly rural areas across Indian Country. We have VA clinics up and running in IHS facilities on the Navajo Nation’s tribal lands in Chinle and Kayenta, Arizona. We’re in negotiations with the IHS Phoenix Area Hopi Clinic, as well as the Tuba City Tribal Health Program Clinic. We’re discussing possibilities with Pine Ridge just south of here, and Shiprock in New Mexico has expressed interest.

The IHS White River Hospital has agreed to put VA telehealth equipment in place for Mental Health and Specialty Care services for their Vets … we’re drafting that agreement right now. And thanks to the hard work of Cherokee Nation Chief Chuck Hoskin Jr., Vinita Mayor Chuck Hoskin Sr., and Dr. Kim Denning and Greg Norton at the Jack Montgomery VA, next Tuesday we’ll start serving Vets at our new VA clinic in the Cherokee Nation’s Vinita Health Center. These shared spaces mean new access to VA care for thousands of Native and non-Native Vets. Rather than asking Vets to come to us, we’re meeting Vets where they live.

That’s why we’re working with community partners to reach Vets at IHS facilities, Tribal Health Programs, and UIOs, bringing Mobile Medical Units to Native Vets for their Compensation and Pension Exams. Over the last 15 months, we’ve been welcomed to 13 tribal communities like the Confederated Tribes of Grand Ronde in Oregon and the Cheyenne & Arapahoe Tribes in Concho, Oklahoma. Later this year, we’ll be at the IHS facilities in San Diego and San Jacinto, California; in Mt. Pleasant with the Saginaw – Chippewa Indian Tribe of Michigan; the Eastern Band of Cherokee Indians in North Carolina, and in early September up in Kodiak and Kotzebue, Alaska, with the Alaska Native Vets. If you’d like us to come to you, please be in touch with Clay Ward, let us know, and we will get to work on it.

Now, let me ask for your help expanding Vets’ access by getting more Native Vets to apply for benefits related to toxic exposure. The last time we were together, President Biden had just signed legislation so VA could deliver care and benefits to millions of toxic-exposed Vets and their survivors—the PACT Act. Recall, these are new service-connected presumptions for more than 20 health conditions related to toxic exposures like Agent Orange, burn pits, and a lot more.

Since President Biden signed the PACT Act into law, Vets and family members have filed over 4 million [4.12M] claims. Native Vets and their survivors have filed over 14,000, and nearly 8,300 of those claims have been granted—a grant rate of 73%. That’s meant over $51 million in earned benefits for those Vets and their families.

But we’re coming up short. Only 30% of eligible American Indian and Alaska Native Vets have filed. So, again, that question—how many just don’t know? I need your help on that.

And I need your help telling Vets about the three new groups of Vets who are now eligible for VA health care under the PACT Act. Vets who served in Vietnam, the Gulf War, Iraq, or Afghanistan can enroll. Vets who deployed to any combat zone after 9/11 can enroll. Vets deployed in support of the Global War on Terrorism can enroll. And Vets can enroll who never deployed, but who were exposed to toxins or hazards while training or serving on active duty here at home working with chemicals, pesticides, lead, asbestos, certain paints, nuclear weapons, x-rays, and more.

And Vets don’t need to wait to be sick to enroll. They shouldn’t wait. They may not need the health care access the PACT Act affords them today. But they might need it tomorrow, or the next day, or 30 years from now. All they have to do is enroll, and they have access for life. Help us with that. It’s critical Native Vets apply for their benefits and enroll.

In fact, let me say a quick word on enrollments. Last year when I met with the Tribal Advisory Committee (TAC) out in Roseburg, Oregon, I promised we’d do better tracking demographics for Native Vets enrolling in VA health care. And we’ve made some progress on that. We’ve revised the VA health care enrollment form—the 10-10 EZ—to reflect “American Indian – Alaska Native.” Now, Vets can select two or more races.

This is important beyond just counting Vets enrolled. Precise demographic information will help us identify and correct health disparities in delivering care for Native Vets. And demographic data’s critical to effective clinical research, as well, like President and First Lady’s Cancer Moonshot. Chief Bill, I’m grateful to the TAC for holding us accountable on this.

We still have work to do.

Now, I’ll wrap it up by touching on two topics we’re working on hard that are as important as they are inextricably linked—traditional healing and suicide prevention.

When I talk about meeting Vets where they are, I’m not just talking geographically. I’m talking spiritually and mentally, as well. This is what I mean. For about two decades now, Marine Vet Buck Richardson in the Rocky Mountain Network has been devoted to bringing traditional healing practices to Vets who need and want them. He designed a contract that’s being implemented across that network to get Native Vets we’re serving access to Pipe Carriers, to Traditional Healers, and to Native ceremonies like Sweat Lodges, Talking Circles, Smudging, and End of Life ceremonies.

Thanks to Buck, when a Native Vet in hospice asked for end-of-life ceremonies, Chaplain James Patterson at Fort Harrison VA could meet that spiritual need. Chaplain Patterson sent a Pipe Carrier to the Vet, and that brought great peace, comfort, and healing to the Vet. It brought great comfort to his family, as well.

Right up the road from here at VA Black Hills, many Vets have told Chaplain Micah Covington how the sweat lodge ceremonies they offer have helped them reconnect to their spirituality, to their Native community, and their past. And a Vet in one of our residential treatment centers told the staff he needed to smudge, part of his healing and recovery. At first, a few clinicians were reluctant. But Dr. Teresa Boyd, the Network Director, was in full support.

I don’t have to tell you. It made a remarkable difference in that Vet’s recovery. In short order, the Vet—and four or five other Native Vets—were smudging, drumming, and singing traditional songs, re-connecting to their culture, and powerful traditions where they draw strength from.

Now, we already offer traditional medicine at some of our facilities—thanks, especially, to our great chaplains. But we need more formal recognition and integration of it as part of our health care protocols. So, IHS Director Roselyn Tso is fighting with us for formal recognition of Traditional Healing across federal health care. That means standardized codes so we can provide, bill, pay, or reimburse for Traditional Medicine for American Indian, Alaska Native, and Native Hawai’ian Vets.

This fall, the White House Council on Native American Affairs is convening a Traditional Medicine Summit. The Department of Health and Human Services—HHS—will lead the summit. And a key objective of the summit will be to get this standardized. I appreciate HHS’s collaboration with us on traditional healing.

And you all know how important it is. If we’re going to serve our American Indian and Alaska Native Vets as well as they have served all of us, our sacred obligation, then we have to offer traditional healing practices as part of our treatment protocols.

Which brings me to my last point, and our number one clinical priority—preventing Veteran suicide. And for our American Indian and Alaska Native Veterans, preventing suicide means serving them in a more effective way, a more culturally competent way.

We’re crafting an enhanced model of community-based suicide prevention so we can better support our Native Vets. And with Tribes and tribal organizations, we intend to roll out the first version of this new model next year. Based on the Tribal Advisory Committee’s advice, we’re participating in listening sessions to inform that work. On Monday, we participated in a National Tribal Behavioral Health Listening Session with you. 

And here’s a little bit of what we’ve heard from Native Vets already—it’s both instructive and revealing about where we’ve been coming up short. They’ve told us to move beyond ideas and take action—do more than write about it. Point well taken. They told us not to impose help, but to be collaborative—do nothing for Native Vets, without Native Vets. They’ve told us to recognize, understand, and embrace generational trauma, to appreciate how much language matters, to do better understanding and embracing cultural nuances, to meet Native Vets and Tribal leaders where they are.

And then, listen. Just listen. And we are listening. Informed by your wisdom, your insights, and your traditions, we’re working to do so much better to honor Tribal sovereignty, to shape a community informed, community driven approach. We need a model that finally, genuinely, and directly supports Tribes in developing, implementing, and sustaining local action plans that promote suicide prevention. 

So, there’s a good deal of progress. But I’ll be the first to tell you, we still have a lot of work to do. And we have to do it together. We will continue to make every effort to consult with you and tribes before we make decisions that affect Tribal governments and Tribal citizens. And as those Vets advised us, we will not … will not make decisions about you, without you.

Hold us accountable to that. Hold me accountable to that. And if we come up short—anywhere or anytime—I want you knocking down my door. I’m depending on it. I need you. We need you. Most importantly, our Veterans need you.

Again, thank you for letting me join you this morning. And may God bless all our Veterans, their families, caregivers, and survivors.