The House Natural Resources Subcommittee on Indian and Insular Affairs held an oversight hearing on implementation of Public Law 93-638 (the Indian Self-Determination and Education Assistance Act), examining how the Indian Health Service (IHS) can support the growing number of tribes and tribal organizations that now manage a majority of the agency’s budget under title I contracts and title V compacts.

Deputy Director Benjamin Smith of the Indian Health Service told the subcommittee that IHS now works through a network of “more than 600 federal and tribal health facilities, as well as 41 urban Indian organizations across 37 states,” serving roughly “2,800,000 American Indians and Alaska Natives each year.” He said the agency has “12 area offices that oversee 170 service units” and noted that about “62% of the Indian Health Service budget” is transferred to tribes today. Smith identified workforce shortages, aging facilities (an average facility age he said is 41 years), and rising volume of contract work as the primary operational constraints.

Tribal witnesses emphasized that those constraints directly affect patient care. Cherokee Nation Principal Chief Chuck Hoskin Jr. described 638 as “transformational” and told members his nation has invested quickly in a recently assumed facility, saying they “immediately invested $11,000,000 to take that neglected facility from the IHS standard to the Cherokee standard” and plan “a $244,000,000 state of the art health campus in Claremore.” Hoskin urged predictable funding and consultation, recommending continued advanced appropriations or making certain IHS appropriations mandatory so tribal health systems do not lose services during federal budget disruptions.

Several witnesses and members raised persistent complaints about uneven area-office performance and delays in contract amendments, including long waits on section 105(l) leases. Representative Mike McDowell and others asked where routine bottlenecks form; Smith answered that the agency often faces high volumes of work with too few specialized staff—for example, he said the agency manages “over 1,200 leases annually” with “3 staff dedicated to doing that.”

Tribal testimony also focused on electronic health records. Greg Abramson of the Spokane Tribe said when his tribe’s compact took effect “the systems could not reliably communicate,” harming pharmacy operations, third-party billing and referrals during the transition. Abramson urged HHS to either fully fund tribal transitions to commercial EHR systems or fully fund modernization of the legacy RPMS so continuity of care is preserved.

Witnesses raised concerns about the IHS proposal to realign agency structure and centralize some functions. Speakers from the Tribal Self Governance Consortium and several members said tribes were first provided only a high-level executive summary of the realignment on December 5—about a week before consultations began—and argued that short notice and limited detail hampered meaningful review. The consortium representative said the proposed national office to coordinate negotiations risks replacing relationship-based, local negotiation with a more transactional process unless safeguards—such as strike teams and stronger training—are provided.

Members from both parties pressed for concrete performance measures. Several witnesses recommended that IHS publish uniform timelines and a 638 implementation manual similar to the BIA’s self-governance manual, tie performance metrics to communication timelines and expand technical assistance so smaller tribes can more readily assume operations.

The hearing closed with members asking for written follow-ups and the chair holding the record open for 10 business days for additional questions and responses. The subcommittee adjourned without taking any formal votes.