[House Hearing, 106 Congress]
[From the U.S. Government Publishing Office]
THE CONTRACT SUPPORT COSTS WITHIN THE INDIAN HEALTH SERVICE ANNUAL
BUDGET
=======================================================================
HEARING
before the
COMMITTEE ON RESOURCES
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTH CONGRESS
FIRST SESSION
__________
FEBRUARY 24, 1999, WASHINGTON, DC
__________
Serial No. 106-9
__________
Printed for the use of the Committee on Resources
Available via the World Wide Web: http://www.access.gpo.gov/congress/
house
or
Committee address: http://www.house.gov/resources
______
U.S. GOVERNMENT PRINTING OFFICE
55-613 WASHINGTON : 1999
COMMITTEE ON RESOURCES
DON YOUNG, Alaska, Chairman
W.J. (BILLY) TAUZIN, Louisiana GEORGE MILLER, California
JAMES V. HANSEN, Utah NICK J. RAHALL II, West Virginia
JIM SAXTON, New Jersey BRUCE F. VENTO, Minnesota
ELTON GALLEGLY, California DALE E. KILDEE, Michigan
JOHN J. DUNCAN, Jr., Tennessee PETER A. DeFAZIO, Oregon
JOEL HEFLEY, Colorado ENI F.H. FALEOMAVAEGA, American
JOHN T. DOOLITTLE, California Samoa
WAYNE T. GILCHREST, Maryland NEIL ABERCROMBIE, Hawaii
KEN CALVERT, California SOLOMON P. ORTIZ, Texas
RICHARD W. POMBO, California OWEN B. PICKETT, Virginia
BARBARA CUBIN, Wyoming FRANK PALLONE, Jr., New Jersey
HELEN CHENOWETH, Idaho CALVIN M. DOOLEY, California
GEORGE P. RADANOVICH, California CARLOS A. ROMERO-BARCELO, Puerto
WALTER B. JONES, Jr., North Rico
Carolina ROBERT A. UNDERWOOD, Guam
WILLIAM M. (MAC) THORNBERRY, Texas PATRICK J. KENNEDY, Rhode Island
CHRIS CANNON, Utah ADAM SMITH, Washington
KEVIN BRADY, Texas WILLIAM D. DELAHUNT, Massachusetts
JOHN PETERSON, Pennsylvania CHRIS JOHN, Louisiana
RICK HILL, Montana DONNA CHRISTIAN-CHRISTENSEN,
BOB SCHAFFER, Colorado Virgin Islands
JIM GIBBONS, Nevada RON KIND, Wisconsin
MARK E. SOUDER, Indiana JAY INSLEE, Washington
GREG WALDEN, Oregon GRACE F. NAPOLITANO, California
DON SHERWOOD, Pennsylvania TOM UDALL, New Mexico
ROBIN HAYES, North Carolina MARK UDALL, Colorado
MIKE SIMPSON, Idaho JOSEPH CROWLEY, New York
THOMAS G. TANCREDO, Colorado
Lloyd A. Jones, Chief of Staff
Elizabeth Megginson, Chief Counsel
Christine Kennedy, Chief Clerk/Administrator
John Lawrence, Democratic Staff Director
C O N T E N T S
----------
Page
Hearing held February 24, 1999................................... 1
Statement of Members:
Hayworth, Hon. J.D., a Representative in Congress from the
State of Arizona, prepared statement of.................... 10
Inslee, Hon. Jay, a Representative in Congress from the State
of Washington, prepared statement of....................... 28
Kildee, Hon. Dale E., a Representative in Congress from the
State of Michigan.......................................... 1
Prepared statement of.................................... 1
Miller, Hon. George, a Representative in Congress from the
State of Caliornia, prepared statement of.................. 2
Young, Hon. Don, a Representative in Congress from the State
of Alaska.................................................. 3
Prepared statement of.................................... 3
Statement of Witnesses:
Allen, Mr. W. Ron, President, National Congress of American
Indians.................................................... 16
Prepared statement of.................................... 34
National Congress of American Indians, National Policy
Workgroup on Contract Support Cost, First Interim
Report................................................. 38
National Congress of American Indians, National Policy
Workgroup on Contract Support Cost, Second Interim
Report................................................. 49
Antone, Lt. Governor Cecil, Gila River Indian Community,
Sacaton, Arizona........................................... 22
Prepared statement of.................................... 85
Gover, Kevin, Assistant Secretary, Indian Affairs, U.S.
Department of the Interior................................. 6
Prepared statement of.................................... 92
Lincoln, Michel E., Deputy Director, Indian Health Service,
Rockville, Maryland........................................ 4
Prepared statement of.................................... 32
Williams, Mr. Orie, Executive Vice President, Yukon Kuskokwim
Health Corporation, Bethel, Alaska......................... 18
Prepared statement of.................................... 60
Yukon-Kuskokwim Health Corporation....................... 66
Additional material supplied:
Council Annette Islands Reserve, Metlakatla Indian Community,
prepared statement of...................................... 100
Miller, Lloyd B., Sonosky, Chambers, Sachse & Endreson....... 104
Spratt, Hon. John M., Jr., a Representative in Congress from
the State of South Carolina, prepared statement of......... 32
HEARING ON THE CONTRACT SUPPORT COSTS WITHIN THE INDIAN HEALTH SERVICE
ANNUAL BUDGET
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WEDNESDAY, FEBRUARY 24, 1999
House of Representatives
Committee on Resources
Washington, D.C.
The Committee met, pursuant to call, at 11 a.m., in Room
1324, Longworth House Office Building, Honorable Don Young,
Chairman of the Committee, presiding.
Members present: Representatives Gallegly, Hayworth,
Kildee, Faleomavaega, Ortiz, Smith, Christensen, and Inslee.
Mr. Young. The Committee for Resources will come to order.
The Committee is meeting here today to hear testimony on
contract support costs within the Indian Health Service, the
Bureau of Indian Affairs, annual budget.
Under Rule 4 [g] of the Committee rules any oral opening
statements at hearings are limited to the Chairman or the
Ranking Minority Member. This will allow us to hear from our
witness sooner and help members keep up their schedules.
Therefore, if any members have any statements, they can include
them in the hearing record under this unanimous consent.
Now I recognize Mr. Kildee, for any statement he may have.
STATEMENT OF HON. DALE E. KILDEE, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF MICHIGAN
Mr. Kildee. Thank you, Mr. Chairman, and thank you for
having this very, very important hearing on support costs. In
1975 we passed the Indian Self-Determination Education
Assistance Act. We have not always done right by providing the
dollars that are needed to administer these programs in self
determination, and I think it is important that we address this
as the authorizing committee. And I would like to submit my
statement and also the statement of the Ranking Member, Mr.
Miller, for the record.
[The prepared statement of Mr. Kildee follows:]
Statement of Hon. Dale E. Kildee, a Representative in Congress from the
State of Michigan
Mr. Chairman, today's hearing marks a fine moment in the
106th Congress that allows us to take this opportunity to
highlight the successes of native Americans and Alaska natives
across the nation since the enactment of the Indian Self-
Determination and Education Assistance Act of 1975.
This hearing will also provide us an opportunity to learn
of the impediments that have emerged from the implementation of
the Federal policy promoting Indian self-determination, and to
see what we can do to remove those impediments for the ultimate
benefit of the tribes and the people they serve.
Using the tools of self-determination contracting and self-
governance compacting, tribes today in financial terms operate
$840 million in Indian Health Service Programs, more than 40
percent of the agency's entire budget. The results, as I am
sure the Committee will hear today, have been staggering in
terms of improved local autonomy and flexibility, streamlined
services, expanded programs, better accessing of alternate
resources, and improved education, employment, health status
and welfare of the Indian communities served.
None of this would have been possible without a true
partnership between Congress and the tribes. That partnership
is reflected not only in the many improvements we have made to
the Self-Determination Act and self-governance laws over the
years, but in the financial commitment we have shown, too, in
the form of contract support costs, without contract support
costs, we would be penalizing tribes, first by turning over
underfunded programs to tribal administration, and then telling
tribes they must further reduce those programs in order to
cover the administrative costs of operating them.
Mr. Chairman, Congress's commitment to pay contract support
costs in the Indian Self-Determination Act is not only morally
and legally correct, but it is necessary to fulfill the policy
of self-determination. The Self-Determination Program is in
crisis. Though some may say tribes are victims of their own
courage and success, tribes are at this moment operating
hundreds of millions of dollars in programs with inadequate
contract support costs. We know the problem is not the contract
support cost system, because the system has been exhaustively
studied and scrutinized time, and time again. The problem is
one of funding. While I support the President's FY 2000 budget
proposal calling for a $35 million increase in funding for
contract support costs in the Indian Health Service, I will
request additional funding for contract support costs and
funding for the Indian Self-Determination Fund.
We, Members of Congress, made a commitment nearly a quarter
century ago to support tribal self-sufficiency. Tribes have
done their part in taking over responsibility for essential
Federal programs serving their people. Now we must do our part
to support them. Mr. Chairman, we must restore confidence in
the self-determination system.
I look forward to hearing today's testimony, and to working
with the Committee and the House Interior Subcommittee to close
the contract support gap that is threatening the future of the
nation's Indian Self-Determination Policy.
[The prepared statement of Mr. Miller follows:]
Statement of Hon. George Miller, a Representative in Congress from the
State of California
Mr. Chairman. We were both here in 1975 and helped pass
Public Law 93-638, the Indian Self-Determination and Education
Assistance Act allowing tribes to enter into contracts with the
Bureau of Indian Affairs to run Federal programs previously
provided by the BIA. The concept was simple--through government
to government negotiations, Indian Tribes could take over
specific programs and supply services directly to tribal
members thereby replacing the total Federal involvement. Our
belief was that as more and more tribes gained the expertise to
administer Federal programs, tribal governments would assume
greater control over Federal services authorized for Indian
Tribes. We were correct, the desire and ability to enter into
what became known as ``638 contracts'' grew and evolved to
include Indian Health Service programs and further to include
the ability to negotiate one ``self governance contract'' to
administer most programs within the BIA or IHS.
The problem, however has been inadequate funding of
contract support costs which are necessary costs borne by an
Indian Tribe to cover expenses which, when the program is
provided by the Federal Government, are funded through other
means. These costs can include personnel support, accounting,
legal assistance and utilities. Congress and the courts agree
that these funds are required, however inadequate funding has
brought us to an almost crisis situation.
Several factors have contributed to this problem including
quick expansion of the number of 638 and self governance
contracts negotiated, wide variations in the calculations of
contract support costs, and appropriation levels too low to
address the need. We must get a handle on how to fund these
costs as failure to do so will greatly affect direct programs
to American Indians.
I don't think there are many in this room who would doubt
the appropriateness and success of Indian Tribes running
Federal programs, but the very success of this program could
result in fewer contracts or severe caps placed on funding in
the future. Legislation which I introduced last Congress to
make permanent the self governance program within the IHS, was
blocked in the Senate because of the issue of contract support
costs. I think that was a mistake and I will reintroduce the
legislation again. However, the Appropriators have made it
clear over the last couple of years that if a solution isn't
found soon, they will step in and attempt to curtail spending
as they see fit.
This morning we will hear from the Administration and
Indian Tribes which are running successful health service
programs. In addition the National Congress of American Indians
will testify as to the working group they have assembled to
come up with recommendations to address the problem. I look
forward to all the testimony. We should not go back to the days
where every American Indian had to come to the Federal
Government to receive a service. I believe answers to this
quandary should come from Indian country and not imposed upon
tribes and I will work with all interested parties to come up
with and implement viable solutions.
STATEMENT OF HON. DON YOUNG, A REPRESENTATIVE IN CONGRESS FROM
THE STATE OF ALASKA
Mr. Young. I thank the gentleman. I also have an opening
statement--I would just especially like to welcome my Alaskans
that are here today--and I'll submit it for the record also. We
have Mr. J.D. Hayworth who has joined us today also. And so
we'll continue with the witness list.
[The prepared statement of Mr. Young. follows:]
Statement of Hon. Don Young, a Representative in Congress from the
State of Alaska
I would like to welcome everyone, especially my Alaskans,
to this important hearing on contract support costs.
Last year, the House and Senate Appropriations committees'
were very concerned with the proposed $168 million dollars
appropriated by the Administration for contract support costs
for the Indian Health Service (INS) for fiscal year 1999. The
proposed figure would have covered approximately 58 percent of
contract support costs (across the board). This was
unacceptable to me, the Committee on Resources and the House
and Senate Interior Appropriations Committees. The
Administration and Congress must remember that tribes are
operating Federal programs and are carrying out Federal
responsibilities when they operate self-determination
contracts.
I am pleased to see that the IHS has opted to retain the
$35 million dollars that Chairman Regula added to contract
support costs for FY 1999 in their FY 2000 budget. This
increase coupled with the one year moratorium set on new
contracts, will bring the percentage of coverage on contract
support costs to 70 percent across the board.
The Committee will also hear from the Bureau of Indian
Affairs with regard to their system for contract support costs.
The BIA pro-rates their indirect costs, however, funding for
contract support costs does not include direct costs to tribes.
Tribes believe that the direct costs paid by the IHS are in
fact legitimate and should also be paid by the BIA as well. It
is also my belief that the BIA and IHS should remain consistent
and utilize similar, if not, identical systems to pay contract
support costs.
I want to remind everyone that under the Balanced Budget
Act of 1977, we have strict caps on discretionary spending. In
FY 2000, these caps will be lower than in FY 1999. Unless these
caps are raised, that means that the Appropriations committee
will have to cut back on programs rather than increasing or
even level-funding them.
Senator Stevens in the Senate has told me that while he
strongly supports Indian Self-Determination, he and many of his
colleagues have always believed that as more and more Native
organizations began to run their own programs, that Congress
would see concurrent downsizing in both the IHS and BIA. To
some extent, we have seen that in BIA, but we have not seen
that downsizing in IHS. So, this brings us to the hearing
today.
I will now recognize my Ranking Minority Member for his
opening remarks.
Mr. Young. The first panel is Mr. Michel E. Lincoln, deputy
director of the Indian Health Service, Rockville, Maryland. Mr.
Kevin Gover, assistant secretary of Indian Affairs, U.S.
Department of Interior, Washington DC.
Mr. Lincoln, you are up first.
STATEMENT OF MICHEL E. LINCOLN, DEPUTY DIRECTOR, INDIAN HEALTH
SERVICE, ROCKVILLE, MARYLAND
Mr. Lincoln. Thank you, Mr. Chairman. We appreciate the
opportunity to be in front of the Committee today to talk about
contract support costs. As a part of the President's Fiscal
Year 2000 budget, we're very pleased to report to the Committee
that the President has requested an additional increase for
contract support costs of $35 million.
On January 26th, the Committee, and through its chairman,
has written Dr. Trujillo relative to a number of issues the
Committee would like to entertain today and would like us to be
responsive to. I would like to just briefly make comment on
those issues and to let the Chairman know that we are prepared,
though, to talk in detail about the various issues that are of
concern to the Committee.
The first issue dealt with contract support cost data. And
I'd like the Committee to know that we've been working with the
National Congress of American Indians. We've been working with
what we call our Contract Support Cost Work Group in order to
assist the agency and in order to share the information that
has been developed, and in a very real way validate the data
that has been developed relative to contract support costs. We
believe we have the best data we've ever had and we'd be
willing to share that with the Committee and submit that for
the record.
Mr. Chairman, the second issue that was raised discussed
the Congressional intent that as more contracting was occurring
that there would be, if not a one to one, there would be a
similar reduction occur within the administration of the Indian
Health Service. I'm here to let you know that since 1993 the
Indian Health Service from an administration standpoint has had
significant reductions.
These reductions are associated with increased tribal
contracting, but also are associated with various reductions in
administrative dollars that have occurred as a result of
appropriations Acts five and six years ago, and reductions
associated, as we absorbed inflationary cost increases that
aren't fully funded through the appropriations process.
I would let you know that at our headquarters, as an
example, there has been a 500 FTE reduction since 1993. At that
time there was approximately 934 FTEs at the Indian Health
Service headquarters operations throughout the country, and we
are now at below 434.
A similar kind of reduction has occurred at the Area
Offices which is another administrative unit.
And I have very detailed data in that regard. The actual
increases in FTE for the Indian Health Service have occurred at
the service level, those hospitals and those ambulatory care
centers. And so on one hand we're seeing service FTEs increase
and administrative FTEs go down.
The third issue has to do with the various barriers dealing
with downsizing. And to be quite frank with you, I think we've
been able to overcome most of the barriers that have been
placed in our pathway. And we would be prepared to work with
the Committee and with the tribes as we talk about how better
to right size the Indian Health Service from an administrative
standpoint.
Dr. Trujillo did convene a redesign committee a number of
years and we continue to follow that redesign as the Indian
Health Service changes its organizational structure.
For a cost of administration programs, this is the most
difficult set of questions that the Committee has raised to us.
And I'm here today to let you know that we do not fully have
the information available today that the Committee has
requested. However, we do have information associated with the
Indian Health Service program and what it costs us to
administer these various health care programs.
One of the themes, Mr. Chairman and Committee members, that
you should be hearing from the Indian Health Service is that we
believe any and all of these activities associated with the
operation of the health care program should involve tribal
governments, should involve Indian organizations, Indian
people. As we move forward and plan for our health care system
we will need to work with the Committee, we will need to work
with the tribes in more completely addressing the fourth
question raised by the Committee.
In achieving the highest level of health care, we very much
welcome this particular item. Basically we would like to talk
about with the Committee, either at this hearing or at a later
time when we can meet with your staff and provide a little more
detail, as we have a number of ideas. We have a half a dozen
ideas about the kind of changes that could be made in accessing
third party funding streams and other revenue enhancements.
And we, again, have some details to be shared with you,
some access associated with Medicaid and Medicare
reimbursements, and some barriers associated with the newly
approved Children's Health Insurance Program, and some Title 19
issues associated with Federal Medical Assistance payments to
various organizations.
Mr. Chairman, in terms of the number 6 of the issues
surrounding non-contracting tribes, I would like the Committee
to know that there have been a number of innovative first steps
taken by tribes, and in many instances by the Indian Health
Service in partnership with those tribes, that we would also be
prepared to talk about in more detail.
Noteworthy among these are activities, in Tucson, Arizona,
of the Pascal Yaqui tribe, as it works with the State and with
an HMO. And the successes associated with that HMO in
guaranteeing a benefit package at a reasonable rate and, quite
frankly, the challenges associated with continuing that
particular benefits package through an HMO mechanism when the
population is increasing so rapidly and costs are basically
stagnant.
There are also examples where tribal governments step
forward directly. There are some health insurance demonstration
projects that are occurring in the country, up in the Northwest
specifically. President Allen will be testifying on the next
panel, but his tribe, in particular, has taken quite an
innovative approach associated with providing health care
services to its members.
Needless to say, the Indian Health Service project does not
have authority to purchase a health insurance, if you will, as
you and I would purchase, on behalf of the Indian people. We'd
be looking for some statutory assistance to allow that option
to be available to us. There are a number of other activities
in Oklahoma with the Pawnee benefits package and with a couple
of other examples that we would like to share.
The seventh question dealt with funding needs. And
especially, given the expected limitations for funding for
contract support costs, we certainly appreciate the limitations
and the constraints that the Congress and, quite frankly, the
Administration, and tribal programs, and Indian health care
programs find themselves in relative to funding. Generally,
Indian health care programs are underfunded when we are
compared to non-Indian programs.
What we have done as we've looked at contract support costs
in developing this study, and working hand-in-hand with tribes
and national Indian organizations, is that I think it's through
that partnership through that working together in the budget
process and on contract support costs, in particular, that the
Administration has come forward with its $35 million request.
We believe the need in FY 1999, as our written testimony
states, is approximately $52 million. That need will rise to
approximately $100 million in round numbers as we move into
Fiscal Year 2000. We're certainly looking forward to working
with the Committee, working with the Congress, especially in
terms of also our appropriations committees. And equally as
important, working in partnership with tribes in the national
Indian organizations as we pursue the very important serious
issues surrounding contract support costs.
Mr. Chairman, I would like to acknowledge that Mr. Doug
Black, who is our director of our Office of Tribal Programs is
with me at the table. But also Ms. Paula Williams, who is our
director of the Office of Tribal Self Governance, is seated
behind me. And if you would allow me, they are the experts in
this area and I would like to depend on them for the very
detailed answers to the questions that you may ask of us. I
thank you for the time and I appreciate being here.
[The prepared statement of Mr. Lincoln may be found at the
end of the hearing.]
Mr. Hayworth. [presiding] Mr. Lincoln we thank you for the
testimony. And there is my good friend from American Samoa, Mr.
Faleomavaega. Welcome to all those who serve on this Committee,
including my good friend from Michigan and my friend from New
Jersey. I want to thank you for bringing your associates this
morning, and we will have questions later. Now it's my honor to
introduce the assistant secretary for Indian Affairs, for the
U.S. Department of the Interior, Mr. Kevin Gover. Mr. Gover,
you are recognized.
STATEMENT OF KEVIN GOVER, ASSISTANT SECRETARY, INDIAN AFFAIRS,
U.S. DEPARTMENT OF THE INTERIOR
Mr. Gover. Thank you Mr. Chairman. I have with me the
deputy commissioner of the Bureau of Indian Affairs, Hilda
Manual, and to my right, Deborah Maddox, who is the director of
the Office of Tribal Services. And they will be responding if
the Committee has any difficult questions.
We prepared a series of charts in response to the inquiries
made by the Chairman. And the first of which is on the stand
right now. [Chart]
What that shows right now is that since 1981 the Bureau has
gone from nearly 17,000 employees to less than 10,000. Much of
that is the result of tribal contracting. Some of the decrease
is attributable to various budget cuts and the transfer of the
Office of Trust Fund Management out of the Bureau. But most of
it in fact is due to the increase in tribal contracting over
the years.
You will also note, at the end of that chart, a slight
climb in our FTEs for the year 2000. The reason for that is two
fold. One, we will be adding a number of additional police
officers over the next year in accordance with the President's
law enforcement initiative. The other reason is that right now
we are subject to a moratorium on further expanded self-
determination contracting and self-governance compacting.
So the bottom line is, to those who wish to see the Bureau
of Indian Affairs shrink, we must be authorized to go back to
making those contracts and compacts with the tribes.
The second chart, Mr. Chairman, shows what we project our
reductions will be. Now, there are certain assumptions behind
that. We think we would lose a little less than 400 employees
over the next few years, based on what has been happening over
the past few years in terms of contracting.
That assumes a couple of things. One is that basically
we'll be dealing with a flat budget. One of the things that we
know is that in the years where our funding increases, tribal
contracting increases. And that is only to be expected as the
programs become more attractive. So, again, one of the ironies
about the Bureau of Indian Affairs, the more money you give us,
the smaller our agency becomes due to the tribal contracting.
The next graph, Mr. Chairman, reflects total BIA funding,
the total amount contracted by the tribes, and the total amount
compacted through self-governance compacts. What that shows,
therefore, is that fully well more than half of our funds
actually go to the tribes in the form of contracts, compacts,
and grants to operate BIA schools. Again, we would like to see
those first and second bars go up further so that the tribes
are running even more of our program. And contract support and
funding are primary impediments to increased compacting and
contracting.
And this is the chart that shows why it has become
difficult for us to expand the amount of contracting and
compacting we're doing. As you can see, between 1995 and 1997,
we lost a lot of ground in terms of contract support payments
to the tribes, going from funding around 92 percent of what the
statute says we owe to the tribes to only 77 percent in FY '97.
Now, we have slowly been able to increase those amounts.
And were our budget request for the year 2000 to be granted,
that would only bring us back to around 84 percent. So we're
still far short of the mark of 100 percent.
Let me add that we too have been working with the National
Congress of American Indians on trying to come up with a
solution to this problem. You may also know, Mr. Chairman, that
we were subject to litigation in which a Federal court
determined that we were liable to the tribes for the short fall
in contract support funding, notwithstanding the fact that
we've spent every dollar that the Congress had given us on
contract support funding. The Court found that we were still
legally responsible for the rest.
Let me mention some of the ideas that we have been talking
with the tribes about and considering internally to deal with
this issue. For one thing, we have now been held liable by a
court for contract support to support contracts that have been
let by other agencies. Now that seems to us to be questionable
interpretation of the statute. Nevertheless, it's one that the
courts have made. But it seems much more appropriate, given the
need in Indian Country and given the continuing shrinking
purchasing power of both BIA and IHS dollars, that issue be
revisited and that other agencies who contract with the tribes
be asked to contribute to contract support.
Second, we would propose to continue distributing contract
support on a pro-rata basis. In other words, if we're only able
to fund only 84 percent, say, of the contract support needs
nationally, that we give 84 percent to each tribe, as opposed
to all to some and less to others.
Third, we are considering the tribes' position that we
should be paying certain direct costs that are associated with
contracting that we do not currently pay. I think the tribes
have made a persuasive case that those are appropriate costs of
contracting, and we will continue to work with them to decide
whether or not we'll be able to do that.
And, finally, we would like to improve our system for
anticipating what our contract support costs are going to be in
the future. Right now we have sort of an informal system where
we ask the tribes to guess in advance whether or not they are
going to be contracting with us so that we can anticipate those
costs and ask for the appropriate amount.
However, under the statute, they only have to give us 90
days notice. So if a tribe decides that it wants to exercise
its right, we have no way to anticipate that in a way that
allows us to make it a part of our budget request. And that too
is contributing to our failure to ask regularly for a
sufficient amount of contract support funding.
Mr. Chairman, my time is up and we'd be happy to entertain
any questions that the Committee may have.
Mr. Hayworth. Mr. Gover, we thank you very much for that
and thank the panel for its testimony. And also, Mr. Gover, I'd
say thank you for bringing your associates for any difficult
questions that we might have.
[The prepared statement of Mr. Gover may be found at the
end of the hearing.]
Mr. Hayworth. And using the prerogative as acting chairman,
I just want to welcome my good friend back to the Congress from
Washington state, Mr. Inslee, who is here. Good to see you. And
in the prerogative of the Chair right now, I won't ask a
difficult question here, but just simply for both Messieurs
Lincoln and Gover. First Mr. Lincoln.
If you could offer to us what you believe to be the most
essential aspect to dealing with this challenge of contract
support funding and, in a perfect world, the solution you would
like to see fashioned. A chance really to amplify your
statement. Let me give that to you right now.
What do you believe, in fairly short order, we in the
Congress need to do to deal with this challenge? The very most
important challenge we face and the solution that would be
yours, if we were freed from some of these strictures we find
ourselves under?
Mr. Lincoln. Mr. Chairman, I'm going to say something that
sounds very simple, that has two pieces to it, that is
incredibly complex, but I think both are necessary. First of
all, any solution that is crafted dealing with contract support
costs, dealing with Indian health care issues, dealing with
tribal solvency, and the broad set of issues that we deal with,
both the Congress and the Administration, in this case the
Indian Health Service, just absolutely requires working hand-
in-hand at the beginning with tribal Governments. And that can
be accomplished. That is something, though, that is a mandatory
requirement in our mind, in the perfect world, that would be
part of the response.
As that relates specifically to contract support costs. I
believe that issue confronting us today really is one of
funding, but it's one of funding that is as a result of the
statutes and our interpretation of those statutes, if you will,
the law of the land.
In the Indian Self-Determination Education Assistance Act
there are requirements that the Congress has described, we
think, in clear terms, regarding what the responsibility of the
Federal Government is to tribal governments when they take over
their health care programs, in our instance. And we believe one
of those requirements, one of those essential pieces is the
acknowledgement of the need and the legitimacy of contract
support costs.
Furthermore, from our perspective, it is our belief that
the contract support costs, as we have reviewed them, and as we
have worked with tribal organizations, our own Contract Support
Costs Work Group, the NCAI, and others who will work with us,
those costs are not unreasonable as we look at them and as we
compare them to administrative cost rates that exist elsewhere
in this country with universities or with other organizations.
The answer that we need more resources is a very simple
answer, and it's incredibly complex and difficult to do for all
of us.
Mr. Hayworth. And of course it's something that it's
important to get into the record because from your perspective
and ours, it cannot be overstated. Mr. Gover, in preparation
for your associates and the quote, unquote, ``difficult
questions,'' let me simply mention to both you gentlemen on the
panel that the more difficult questions we will offer to you,
we have a list prepared by the Committee staffs.
And if you could get back to us in writing within 10 days
of this hearing date, we'd very much appreciate it, so that it
will give you a chance to go back and ponder some of the more
difficult answers.
But, Mr. Assistant Secretary, again, I'd be interested in
your notion of the compelling need and the best remedy at this
juncture.
Mr. Gover. I think there are three things that really need
to be done. First of all, we need to develop with the tribes a
system for knowing as far in advance as we possibly can what
programs they intend to contract so that we can do proper
calculations and make appropriate requests for contract support
funding.
Second, each agency needs to pay its own contract support
costs. The Bureau budget simply can't bear the strain of all
tribal contracting with all other agencies in the government.
And, third, we need 100 percent funding. We need to ramp up
toward 100 percent funding of the contract support costs
obligation that we've made to the tribes.
Mr. Hayworth. Mr. Assistant Secretary, I thank you very
much and thank the panel. It may be somewhat unorthodox to my
friend the Ranking Member and my co-chair of the Native
American Caucus, but in closing I have my opening statement
that I will submit for the record, and without objection, make
that a part of the record.
[The prepared statement of Mr. Hayworth follows:]
Statement of Hon. J.D. Hayworth, a Representative in Congress from the
State of Arizona
Chairman Young, I appreciate the opportunity to participate
in this important hearing on Contract Support Cost (CSC)
funding. It is indeed a great honor to sit on the dais of this
Committee, on which I formerly served. I would be remiss if I
didn't personally thank you for your outstanding work on
Contract Support Cost funding in the 105th Congress. During the
waning days of the last Congress, I was pleased to work with
you and others to convince our leadership to cede to our
position on this issue. As part of that agreement, you
expressed your intent to hold hearings on Contract Support Cost
funding. I am pleased to see that you are taking this important
first step.
Mr. Chairman, if you would allow me to indulge for one
moment, I would also like to personally thank you for inviting
to testify Lieutenant Governor Cecil Antone of the Gila River
Indian Community, one of the eight tribes that I represent in
Congress. I believe you will find Lieutenant Governor Antone's
testimony especially compelling because although the tribe
supported the eventual compromise language that was included in
the Omnibus Appropriations bill, it actually lost money because
of the compromise. However, its support for the compromise
language was based on belief that the entire system must be
fixed.
Let me take a moment to explain Gila River's predicament.
In fiscal year 1999, Gila River was slated to receive their $4
million Contract Support Cost request because they had
patiently waited for more than four years and were at the front
of the Indian Self-Determination, or ISD, queue. As you know,
Mr. Chairman, the Administration did not include any new
funding for the ISD queue. Thankfully, Congress provided an
additional $35 million for the queue and Gila River could have
received their $4 million contract. However, the tribe was
willing to lose $1.2 million in 1999 to fix the process and
ensure that all tribes are receiving at least 70 percent of
their fiscal year 1999 request. This is a far cry from the 100
percent promised to the tribe, but Gila River came to the
conclusion that other tribes that are more economically-
challenged should not be penalized by a system that has gone
awry.
Sovereign Indian nations face unique health care challenges
that make it imperative that they receive the necessary amount
of funding. Native Americans suffer from diabetes at a higher
rate than any other segment of our population. Some of the
cumulative effects of diabetes include gum disease and
amputation. Even with these added health care challenges,
Native Americans receive far less than the average American in
health care dollars. We need to end this, and fully-funding
Contract Support Costs is an important first step.
Mr. Chairman, I have one final point to make. There is a
serious dispute between the various government agencies and
Congress about how much funding is actually needed for Contract
Support Costs. The Indian Health Service has one set of
numbers, Office of Management and Budget has another, and
Congress and other groups have still other numbers. I believe
that Congress needs to conduct an audit in order to get
accurate data for Contract Support Cost funding. I found this
to be one of the most frustrating aspects of the entire process
last year. We must have accurate data in order to fully and
properly fund tribes for Contract Support Costs.
Mr. Chairman, you and I represent large Native Alaskan and
Native American populations. We must work now to solve the
problems of Contract Support Cost funding before more tribes
lose crucial funding. I look forward to working with you and
all the members of this Committee to solve this problem. I also
look forward to working with Congressman Kildee, my fellow
cochair of the Native American Caucus, and other members of the
caucus, in rectifying the problems associated with Contract
Support Cost funding.
Mr. Chainnan, thanks again for the opportunity to be here
today.
Mr. Hayworth. And now let me turn to my good friend and
colleague from Michigan, Mr. Kildee.
Mr. Kildee. Thank you Chairman J.D. It's always a pleasure
working with you on Indian matters. J.D. and I don't agree on a
lot of other issues, but we do agree on Indian matters and our
Native American Caucus, I think, has been effective. I enjoy
working together on that.
Mr. Lincoln, I notice that the President's FY 2000 budget
request for IHS did not propose any funding for the ISD Fund.
Did IHS recommend the Administration funding for ISD?
Mr. Lincoln. Mr. Chairman, as the budget was being
formulated, and working with tribes, the tribes in the Indian
Health Service did agree upon an initial request for contract
support costs. That initial request was approximately $150
million. As we were working with the tribes 9, 12 months ago,
as the budget progressed through the process, the Secretary
indeed supported that budget request.
And I think, legitimately, because of constrained
resources, we had to pare back the request both at the
Department level and at our level. Our last request that went
forward, supported by the Secretary, by Dr. Shalala, was a
request of approximately $100 million for contract support
costs that did include both short fall and ISD funding.
Mr. Kildee. And what happened to that $100 million request?
Mr. Lincoln. I believe because of limited resources that
that $100 million amount was reduced to the $35 million that
now appears in the President's budget. That reduction was made
at the Office of Management and Budget level. We had many
discussions with them. We believe there were sufficient
constraints in the available resources that that was one of the
casualties of that negotiation.
Mr. Kildee. At $35 million, what percent of the tribes'
needs or requests would be funded?
Mr. Lincoln. Of the tribes that are basically on what we
call our ``queue,'' our list of pending requests, as we
distribute the $35 million that we received for this fiscal
year, for FY 1999, that will essentially fund all tribes no
less than 70 percent of their contract support costs needs. The
lowest will be 70 percent, the average will be somewhere right
around 80 percent.
With this additional $35 million, I need Mr. Black,
actually, to respond to that. There will be additional costs
associated with contract support costs in the year 2000 and I
do not know that off the top of my head.
Mr. Black. Actually, with regard to the $35 million, what
we would do, I believe, if that was appropriated, is use part
of that money to fund any new contracts or compacts, assuming
the moratorium on 638 would be lifted. The remainder we would
use to raise that 80 percent level up and it would probably be
somewhere between 80 and 90 percent level of need funded for
the tribes in the system.
Mr. Kildee. You know, Mr. Lincoln and Mr. Gover both, you
are both very good people. I know you individually and your
hearts are really set on doing what's just. But I can recall
back in 1981 when President Reagan became President, and he
appointed Cap Weinberger as Secretary of Defense, and Dave
Stockman as his Director of OMB. Now, Dave Stockman went down
to all the other agencies and slapped them around and told them
to reduce the amount of their request, and Dave Stockman
usually won.
But when he went to Cap Weinberger, Cap Weinberger told him
to go to heck. He really became an advocate, a strong
successful advocate of the Department of Defense. And you two,
I know you are good advocates, but I just encourage you to
become just get a little meaner in there when the OMB comes to
you.
Dave Stockman ran the government back in 1981. Except he
couldn't run Cap Weinberger because Weinberger would slap him
in the face and say, ``Go back to your office, kid, we're going
to get this amount of money for defense.''
And I think that with all my high regard, and I do have it
for both of you, I think you really have to look back and take
a page out of Cap Weinberger's book and say, ``We're going to
tell OMB to go the heck and we're going to demand more,'' and
become a strong, successful advocate for these programs.
And I know you have in your heart to do that. I just give
you that advise, not as criticism, because I know you really
believe that. But read Cap Weinberger's biography. He was good
at pushing Stockman around. Thank you. And thank you, Mr.
Chairman.
Mr. Young. Thank you, Mr. Kildee. Let's turn now to my good
friend from American Samoa.
Mr. Faleomavaega. Thank you, Mr. Chairman. It's always a
personal welcome to see the assistant secretary of Indian
Affairs here with us in the Committee. Secretary Gover and our
good friends also from the Indian Health Service, I do have a
couple of questions and maybe one basic observation that is
somewhat at a loss.
Basically, this year the Administration has requested only
$168 million for Indian Health Service contract support costs
and yet we need about $250 million to really do the job in a
better way. Am I correct on this?
Mr. Black. The Administration has actually requested a $35
million increase to a $203 million base in 1999. So the request
is actually $238 million for contract support costs in 1999--
2000, excuse me.
Mr. Faleomavaega. Okay. Do we need an authorization to
increase the level of what you need as far as what the
authorizing committee is concerned?
Mr. Black. No. No, we don't believe an authorization is
needed. In fact the 638 law speaks to the necessity of funding
these types of costs at 100 percent. It's just a matter of
having sufficient appropriations to do so.
Mr. Faleomavaega. Now, do you get the sense that this is
also the reaction from the appropriations committees, that
we're on the right level of funding? Because the information I
have here is the appropriations committees do not agree with
your assessment. You are only asking for $168 million, and yet
for the unmet needs we need to come up with about $250 million.
Is the information I'm reading wrong as far as you are
concerned?
Mr. Lincoln. Yes, Congressman. The amount of funding that
we actually have available this year is $203 million, as Mr.
Black said. And we're requesting an additional $35 million to
bring it to $238 million. We believe the Appropriations
Committee, in our discussions with the committee, is concerned
with a number of issues associated with contract support costs.
One of their concerns that has been expressed to us in
various ways is the increase in the need for additional
contract support costs based upon, though, an analysis that has
been performed working with tribes. But also an independent
analysis that we've done, we believe the increased need for
contract support costs is primarily based upon the increased
contracting that is occurring out there. And so more and more
of the program is coming under contract, and therefore the need
for contract support costs is increasing.
Mr. Faleomavaega. So in your opinion, you don't need any
help from this Committee as far as authorization in concerned?
Mr. Lincoln. To the extent that this Committee can make
known the issues associated with contract support costs,
including the requirement and estimated need for resources,
that would be very helpful.
Mr. Faleomavaega. You are losing me, Mr. Lincoln. Tell me
the bottom line, how much to you need?
Mr. Lincoln. In year 2000, we estimate that the Indian
Health Service would need an additional $100 million to the
$238 million, in round numbers.
Mr. Faleomavaega. Now, do you need an authorization?
Mr. Lincoln. No, we do not. We believe we have the current
statutory authorization. We need the appropriation.
Mr. Faleomavaega. Well, I'm glad to hear that because I'm
just a little upset about the whole process, Mr. Chairman. And
not taking anything from the sincerity of our friends here from
the Indian Health Service, but it's so easy for us to find $18
billion to bail out the financial crisis in Indonesia with a
corrupt dictatorship and fraud and nepotism and corruption,
billions to help Korea, billions of dollars to bail out Bosnia,
and yet we always seem to be trying to look for crumbs to help
the indigenous Native Americans in their needs. To me that's an
insult.
But I sincerely hope, gentlemen, that the piece of paper I
have before me is wrong in its assessment, that we're not short
in funding the IHS contract support costs. I'm very happy to
hear this.
Mr. Gover, you mentioned that over 50 percent of the BIA
funding goes to the tribes?
Mr. Gover. That's correct.
Mr. Faleomavaega. So how much of the administrative cost of
the total budget goes to the administration then?
Mr. Gover. Of BIA's total?
Mr. Faleomavaega. Yes.
Mr. Gover. We believe it's less than 10 percent. I would
have to go back and do some work to get you a number.
Mr. Faleomavaega. Does this mean the decrease of the
employees now, the BIA, from 17,000 to 10,000, it also means a
decrease of everything else the BIA needs?
Mr. Gover. There has been a sharp decrease in the BIA in
almost every program. Both the tribes' contract as well as our
administrative function. We too were subject to a dramatic riff
in FY 1996.
Mr. Faleomavaega. Now, you mentioned that there should be
an increase on contracting for self governance, that's your
recommendation?
Mr. Gover. Absolutely.
Mr. Faleomavaega. How much do you think we need to have on
that?
Mr. Gover. To get the tribes to contract all these
programs?
Mr. Faleomavaega. Yes.
Mr. Gover. The first step is definitely 100 percent funding
of contract support. After that, we actually have to begin
doing some real needs assessments in the communities. What is
it the tribe really needs, and what would it take to get them
to assume the responsibilities that we now have? A lot of
tribes look at our programs and say, ``Look we don't want that
responsibility because this program isn't funded enough.''
Mr. Faleomavaega. The problem we're having is--sorry, Mr.
Chairman.
Mr. Hayworth. That's okay. The gentleman's time has
expired, but he has identified some real areas of concern. And
given the fact that there is a vote on the floor now, we would
ask the indulgence of the panel and other members of the
Committee. We will take a short recess and resume following the
vote so members should return as quickly as possible.
And we thank the panel's indulgence, and I thank my friend
the delegate from American Samoa. The Committee is in recess
pending completion of the vote, and will return here to the
Committee chambers.
[Recess.]
Mr. Hayworth. Mr. Inslee, you have the floor to ask
questions of this panel. And thanks for coming back as rapidly
as you did.
Mr. Inslee. Thank you, Mr. Chairman. Somebody has got to
hold the fort, so to speak.
Mr. Hayworth. That's right.
Mr. Inslee. Thanks for coming and it's good to see you. You
are in a difficult position because many of us would like to
see us move forward on self determination and are very
concerned that these budget numbers are effectively stymieing
that policy. And I think that you know that's a pretty strongly
held position, that we do need to move ahead on self
determination.
And we hate to see anything stand in our way in that
regard. And you are in a difficult position because you are not
the ultimate decisionmakers but you are the ones that are here
today. And I guess the question is, is it a fair statement to
say that these numbers that we are looking at, that this
effectively stymies the intent of the self determination that
Congress has, I think, repeatedly evinced as our public policy?
Mr. Gover. Mr. Chairman, I think it's fair to say that the
primary impediment to the full implementation of the self-
determination and self-governance policies is appropriations to
the Bureau.
Mr. Inslee. Right.
Mr. Gover. That if we could get these programs up to a
point where they are really beginning to achieve some of the
things that they are desiring to achieve, then the tribes will
be much more interested in taking on even more responsibilities
than they have.
I don't think they are particularly interested, nor should
we be in seeing them take over these responsibilities, only to
fail. So, yes, if we got the kind of funding that actually
addressed the extent of the need out there, our agency would
become really quite small and tribal governments would take
over these responsibilities.
Mr. Inslee. During the appropriations discussions, during
the process, have you heard rationales for not fully funding
this clear policy of the U.S. Government? I mean what rationale
is there other than--I'd like to hear it. I've so far not heard
it articulated.
Mr. Gover. There are competing priorities. I should say,
first of all, that this is the first year, that I'm aware of
that this Administration has proposed substantial increases for
both BIA and IHS. Our request is about 9 percent above FY 1999.
I think it's about the same for IHS. So both agencies fared
reasonably well in the process this year.
What's so frustrating is a big increase, what appears to be
a big increase, especially of a time of what's supposed to be a
flat budget environment, still doesn't begin to address the
need that we know exists in Indian Country. And so even numbers
that seem large are small when compared to the need in Indian
Country.
Mr. Inslee. I guess what's really bothersome is there are a
lot of needs in our country, they are infinite in describing
needs, but this is one that has been determined to be a policy
of the United States government. And it's very painful to see
the United States government not fulfilling that policy
commitment.
And I guess, for whatever good or help it does to you, I
hope that you will let everyone who knows, and I recently
worked with HHS and had a good experience there, that's there a
high temperature here, at least among quite a number of members
that this is a very, very important thing to us and we put a
high level of interest in it. And we're going to work with you
through this budget process to try to fulfill this commitment.
Thank you.
Mr. Young. Mr. Lincoln? Do you want to be recognized to
give me an accurate number that you misquoted? I didn't even
know it. You got away with it as far as I'm concerned. Go
ahead.
Mr. Lincoln. Mr. Chairman, I very much appreciate the
opportunity. I was asked what the 2000 need was for the
contract support costs in the Indian Health Service. The number
I gave was approximately $338 million. The correct number is
$309 million. And we know the Committee has asked for
projections of need, and we'll make available the detail to
back up those numbers, sir.
Mr. Young. A member had a question, and where is he? We'll
just wait for a minute here. Where is his staff? Would you get
hold of him? Or I'll ask his question, one or the other. I'll
fill in some time and ask some questions. How is the weather
outside?
Assistant Secretary Gover, the Indian Health Service has
provided the Committee with detailed tables setting forth each
tribal contractor's program funding level, contract support
cost needs, by category of contract support, and FY 1999
contract support payment being made against that need.
Could the Bureau please provide the Committee the same
detailed data we have received from the Indian Health Service
on individual tribal contract support needs, with each need
area and its anticipated FY 1999 payments? Long question.
Mr. Gover. Mr. Chairman, we will do so. We have sent you FY
1998. FY 1999 is being prepared even as we speak.
Mr. Young. Okay. The Indian Health Service recognizes
tribal needs for direct contract support, primarily to cover
personal associated expenses not available to the agency for
transfer to a tribe. Why has the Bureau never before recognized
tribal needs for direct contract support costs in addition to
indirect costs as the Indian Health Service has done so?
Mr. Gover. I don't know why it hasn't in the past but as we
addressed in my statement, in my oral testimony, we are
considering that. Basically, through the process with NCAI and
with IHS over the past year, we've become persuaded that this
is quite likely an appropriate cost for us to pay.
Mr. Young. I have been asked to submit a question by the
gentleman from Hawaii. And I so in writing and you can answer
directly to him. With that, if there is no more questions of
this panel, I'll dismiss the panel. And, thank you, for your
directness and I hope we can go forth and solve these problems.
Thank you very much.
The next panel is Mr. Ron Allen, president of the National
Congress of American Indians; Mr. Orie Williams, executive vice
president, Yukon Kuskokwim Health Corporation, Bethel, Alaska;
and Lt. Governor Cecil Antone, Gila River Indian Community,
Sacaton, Arizona.
And I am going to allow Mr. J.D. Hayworth to chair the
meeting. And Mr. Williams and I discussed his testimony and I'm
quite pleased and enamored with it. And we'll solve these
problems, but I have another meeting I've got to go to, so Mr.
J.D. will take over. I appreciate it.
Mr. Hayworth. [presiding] And as we get the appropriate
labels attached to the appropriate guests, and guests on the
Committee dais as well, we will begin. Mr. Allen, we'd be happy
to have your opening statement, if you please, sir.
STATEMENT OF MR. W. RON ALLEN, PRESIDENT, NATIONAL CONGRESS OF
AMERICAN INDIANS
Mr. Allen. Are you calling upon me, Mr. Chairman?
Mr. Hayworth. Yes, sir. We'd be happy to have your
statement.
Mr. Allen. Mr. Chairman, on behalf of the National Congress
of American Indians, it's a pleasure to be here and testify and
share some observations along with my colleagues with regard to
the contract support issue. You have our testimony for the
record and accompanying it is a couple of reports on the
progress that we've made with regard to this topic.
We want to begin this discussion by saying that the Self-
Determination Act passed in 1975 essentially made a commitment
to empowering tribal governments. And we have made substantial
progress. And today, in 1999, the issue here is a topic that
causes us a great deal of frustration with regard to contract
support. You know, we have spent a great deal of time
eliminating the paternalism and forced dependencies and the
patronizing bureaucratic ways of dealing with Indian affairs
that we have witnessed for decades. And we have now seen tribal
governments begin the process of becoming fully empowered and
capable governments to manage their own affairs as we move
forward today.
In terms of taking over Federal programs, we eventually
started to grow in our capacity and started to ask the
fundamental question, how much of the Federal system should we
be taking over and how much should be left in order to
administer what we would call ``inherent Federal functions.''
We firmly believe that we are moving forward with greater
autonomy and with responsibility and accountability for these
resources.
The contract support component of this issue is one that
causes us a great deal of frustration because it is a policy, a
Federal policy that is inconsistent. We believe that if you
look in every corridor in which the Federal Government
administers contracts with different entities out there,
whether it's educational institutions, or even within the
agencies and departments in the Federal Government itself, you
will see that they fully pay these consistent and similar costs
for those entities.
You would never underfund the educational institutions out
there, you would never underfund the administrative costs for
defense contractors, you never underfund yourselves when you
transfer funds back and forth between agencies and departments.
And I would footnote, the rate that you share these costs back
and forth when one agency does something for another agency
averages around 48 percent.
The average rate for contract support expenses and indirect
cost rates for Indian Country is around 25, 26 percent. So we
aren't even at the same level of the rate of recovery of cost
as you see elsewhere throughout the Federal system. The issue
for us is how are you going to administer these costs with
regard to the programs and activities that we're taking care
of?
So as we take over more Bureau programs, as we take over
more IHS programs, these costs, the indirect costs, the direct
contract support costs, the start up costs for taking over
these functions are all legitimate costs. They are all
straightforward costs, they are established by rules that the
Federal Government establishes, negotiated by the Federal
Government, so there is nothing wrong with these costs.
The thing that's frustrating for us is that when you
underfund and you've been underfunding for two decades, for two
decades you have been underfunding us, it means that when we
take over these Federal programs, we are subsidizing with our
limited dollars Federal Government programs, the programs that
you are responsible for in serving our people.
And we find it very frustrating, the notion that the
Congress or the Administration says we've got to make
priorities in terms of what we can pay for means we can only
pay for so much of this and so much of that. But when you take
over these programs, these are costs that come with it. And in
1994, as the previous panel noted, it recognized that you will
not underfund us. That you will not continue to underfund the
tribes with regard to the contract support. Can you resolve the
underfunding of tribes with regard to Federal agencies outside
of the BIA and IHS which are the two primary funding agencies?
So the frustration for us is that is absolutely outrageous. The
number is outrageous. If you got around $4 billion between
these two agencies alone, it's a little over $4 billion, the
issue to us is that you are telling us that another $150
million is too high a price to pay for the empowerment of
tribal governments.
And our point is if we're going to advance devolution+--
``devolution'' means that we are empowering the local
governments to take care of the community needs--if it works
for the states and local governments, why doesn't it work for
the tribes? The tribes, you know, can take care of their people
and manage their resources.
So the issue with contract support is that if you take away
from these hard costs it means that you are eliminating direct
services. That's what you are doing. Whether it's health care
services, enforcement services, natural resource management
services, travel costs, and so forth, and programs that advance
the welfare reform legislation, then you are cutting away from
those programs to address those needs in our communities. They
are paying for these hard costs for facilities and basic
accounting responsibilities, et cetera.
So we're pointing out that we're working with the
Administration and we want OMB to own up to this responsibility
and quit rationalizing. It is a dry topic, we acknowledge that.
But it's a topic that we can understand. It's a topic that we
can show you in layman's terms how it works and why it's
legitimate. And Congress needs to own up to that responsibility
so we are asking you to work with us.
NCAI has a task force. We will present you a report in
April and that report will show what we believe is constructive
solutions for resolving this issue. Thank you.
Mr. Hayworth. Mr. Allen, we thank you for your testimony.
We look forward to the report, and we thank you for your candid
comments which many of us here share and are happy to hear.
[The prepared statement of Mr. Allen may be found at the
end of the hearing.]
Mr. Hayworth. Let me call upon the gentleman to whom our
Chairman alluded, before he had to exit, his good friend from
Bethel, Alaska, Mr. Williams for his testimony.
STATEMENT OF MR. ORIE WILLIAMS, EXECUTIVE VICE PRESIDENT, YUKON
KUSKOKWIM HEALTH CORPORATION, BETHEL, ALASKA
Mr. Williams. Thank you, Mr. Chairman. I'd like to
introduce Mr. Lloyd Miller, Esquire, who is a renowned tribal
attorney who has helped our tribe and others across the Nation
deal with this issue and many, many others. I'd also recognize
Ken Brewer, in the audience, a chief executive officer from
SEARCH, who has worked on contract support for years, on the
technical and accounting parts.
Good morning, Mr. Chairman, and honorable Committee
members. My name is Orie Williams, and I am the executive vice
president of the Yukon Kuskokwim Health Corporation, based in
Bethel, Alaska. Thank you for the opportunity to testify this
morning on what Congress 10 years ago called the single most
serious problem with implementation of the Indian health
information policy. Namely, the failure to fully fund contract
support costs.
YKHC serves as a consolidated health care provider for 58
federally recognized Alaskan native tribal governments, spread
across a roadless area the size of South Dakota. Poverty and
poor health have led some to compare conditions in many of our
villages to those faced in Third World countries.
Indeed, over 50 percent of all our tribal members are
Medicaid eligible. In many of our villages the unemployment
rate exceeds 80 percent. And most of our village homes use six
gallon plastic buckets for toilets. You may have heard them
referred to as ``honey buckets.''
Prenatal mortality is more than double the average of the
U.S. rate. Death by suicide is four times the national rate.
Fetal alcohol syndrome and fetal alcohol effect are rampant.
And the lack of adequate sewer and water systems has left our
communities victim to every known infectious disease and higher
rates of tuberculosis, even as we enter the 21st century.
Our tribal governments, working together to maximize the
opportunities available under self-determination and self-
governance, are meeting the many challenges we face through the
direct administration of 47 village clinics, one mid-level sub-
regional clinic, with two others under construction, a 51-bed
hospital, and over 1,000 employees operating with approximately
$40 million in Indian Health Service funding.
We have done much to improve the delivery of health care
services since the days of Indian Health Service
administration. But the contract support shortfall we face of
over $2.3 million consistently cripples our ability to do more.
As my written testimony details, the shortfall has meant
deficiencies in our accounting department, our billing and
admissions department, our technology support, and our hospital
and facility maintenance.
In addition, the short fall has required us to transfer
funds from key programs, and has not allowed us the flexibility
to enhance our substance abuse and mental health services, home
health care for the elderly, village clinic operations, and to
promote disease prevention and health education. To those who
are unfamiliar with health care conditions in rural Alaska, our
deficit is just a number. For us it is having a real impact on
the quality of health care in general.
Having contracted the operation of health care programs in
the Yukon Kuskokwim Delta since the mid-1960s, we have the
following recommendations to offer the Committee as it examines
the contract support costs system. First, the system itself is
not broken. So, please do not give in to the temptation to
replace it with something new. It is a system that works well
for determining each tribe's necessary requirements to transfer
and carry out Indian Health Service's health care programs. In
1988, the Committee closely scrutinized the entire contract
support system and came up with only one recommendation for
fundamental change. The system must be fully funded. In 10
years that has not changed.
Second, the Committee would reject persistent calls for
change in the underfunded Indian Health Service contract
support system by a flat pro rata approach. That proposal,
considered and properly rejected last year, would have only
made our own situation worse, causing massive layoffs and
instability. Yes, it is true that the underfunding across
Indian Country, is for a variety of reasons, uneven, but the
answer is not to reallocate the misery among the Nation's
tribes, the answer is to meet the Country's obligation to all
the Nation's tribes.
Third, we agree with the Committee's concern that despite
vast improvements in recent years, the Indian Health Service
must still do more to downsize and transfer to tribes both
headquarters resources and many of the resources in the area
offices.
Not everybody in the Indian Health Service system fully
embraces the self-governance process, and the bureaucracy
therefore often misuses such concepts such as ``residual'',
``inherently Federal,'' ``transitional,'' and ``business
payment plan.'' More often than not, these are simply phrases
and devices used to protect the Federal bureaucracy from being
transferred to a tribal operation.
Fourth, we ask the Committee to remember that the Indian
Self-Determination Policy was initially designed and announced
by President Nixon, not as a means of saving the Federal
Government money but as a way to end Federal paternalism and
promote tribal accountability and responsibility. Congress and
Indian Health Service and the tribes will fall short of that
goal if our focus becomes preoccupied strictly with a cost
accounting of how much the system costs to operate and why
there are differences in those costs.
Fifth, to make the self-determination policy as efficient
as possible, Congress should promptly enact the permanent self-
governance legislation that passed the full House last year as
H.R. 1833. In addition, IHS should expand to all tribes the so-
called ``base budget'' multi-year funding approach, so the
tribal savings and administrative overhead remain available for
program delivery.
Sixth, let us build on the success that we have already
achieved by opening the door to permit tribes to contract over
non-Indian Health Service health care programs currently
operated by the Department of Health and Human Services.
Enacting Title 6, the Indian Self-Determination Act again, as
proposed last year, in H.R. 1833, will help us lay the ground
work for achieving greater economic efficiencies in health
care, as tribes bring more and more programs together.
Similarly, extending the Medicare and Medicaid
demonstration program, as proposed in S. 406, will allow us to
more efficiently bring in third party resources so that the
level of care being funded across Indian Country can be
enhanced.
We are thankful to the Committee for once again focusing
Congress' attention on contract support costs. At long last the
system must stop punishing tribal health care providers that
take up the self-determination and self-governance challenges
to operate Indian Health Service programs.
I say ``punish'' because if a tribe or tribal organization
wants to operate an Indian Health Service program, if it wants
to take on the responsibility for the health of its people, if
it wants to break the cycle of paternalism and dependency,
there is a price; The tribe must finance the government's
underfunding of contract support directly out of program funds.
Congress does not ask this of the Department of Defense
contractors, and Congress certainly should not ask it of tribal
health care providers.
We believe the Indian Health Service's new estimates for
fully funding the contract support system are conservative and
achievable in this fiscal year. We also believe that restoring
the Indian Self-Determination Fund to between $10 million and
$15 million a year may be sufficient to meet the average rate
of growth the Indian Health Service anticipates in the years
ahead.
Self determination and self governance work and other
tribes should be encouraged by Congress to move forward as we
have in Alaska. Tribes and tribal organizations should not be
told we must wait one, two, or more years either to operate a
program or to receive contract support for a program. And we
should not be told we can only operate a program if we agree to
perpetual underfunding in our contract support costs.
Thank you Mr. Chairman, for the opportunity to testify
today. YKC looks forward to working with the Committee, the
National Congress of American Indians, and the Indian Health
Service to improve the Indian Self-Determination and Self-
Governance Acts.
Finally, we extend an invitation to the Committee, the
Committee members, their spouses, and staff to visit us in
Alaska in the Yukon Kuskokwim Delta region. We would like to
share with you the sights of our great state and the
hospitality of our people, and have you witness first hand our
villages and our efforts to improve the health of our people. I
pray for you and your families, the best of good health.
Mr. Hayworth. Mr. Williams, we thank you for your testimony
and for your invitation. As my friends from Arizona will
attest, especially in the summertime, round about August, it
gets pretty hot on the desert floor and we think the climate
would be a marked contrast in the great state of Alaska. So
thank you for that kind and generous invitation, as well as
your testimony.
[The prepared statement of Mr. Williams may be found at the
end of the hearing.]
Mr. Hayworth. Again using the prerogative of the Chair,
last but not least, I'm pleased to call on one of my
constituents. And by way of introduction of this particular
gentleman, let me simply point out something that has already
been included in the record but I need to articulate.
As my colleague from Michigan and my friend from American
Samoa will attest, the whole issue of contract support costs
was something that we worked very closely together on a
bipartisan, indeed, a non-partisan basis to make some profound
changes in the closing days of the 105th Congress.
My friends from the Gila River Indian community in dealing
with this matter, as an additional $35 million was provided for
the queue, Gila River could have received its $4 million
contract. But I think this was significant. The tribe was
willing to lose $1.2 million in 1999 to fix the process and
ensure that all tribes are receiving at least 70 percent of
their FY 1999 request. That's a far cry from the 100 percent
promise to the tribe.
But Gila River came to the conclusion that other tribes
that are more economically challenged should not be penalized
by a system that has gone awry. It is that type of
responsibility and response to challenges that typifies the
Gila River Indian community and my good friend Lt. Governor
Cecil Antone, from Sacaton, Arizona, who will offer his
testimony now.
Mr. Lt. Governor, we welcome you and we thank you, and we
look forward to hearing your testimony right now, sir.
STATEMENT OF LT. GOVERNOR CECIL ANTONE, GILA RIVER INDIAN
COMMUNITY, SACATON, ARIZONA
Mr. Antone. Good morning, Mr. Chairman, members of the
Committee. My name is Cecil Antone. I am the Lt. Governor of
the Gila River Indian Community. In the audience today is Mr.
Pete Jackson, who is the chairman of the Gila River Care
Corporation, along with one of our council members that came
yesterday and is here for the hearing, Councilman Earl Lara.
I'd like to recognize them.
Our community is located on 772,000 acres in south central
Arizona. Our community is comprised of 19,000 tribal members,
13,000 of whom live within the boundaries of the Reservation.
We have a young and rapidly growing population that presents us
with a variety of current and future health care challenges.
Our community is fortunate enough to have a hospital on the
Reservation. Its program's services in and of themselves are
not enough to serve the entire community. Our Public Health
Department provides health care services to our tribal members.
Our community's experience with contract support cost funding
exposes some of the weaknesses of past funding practices. It
also illustrates, however, that significant rewards can result
when Indian tribal governments embrace the self-determination
policy articulated in the Indian Self-Determination Act by
taking over our operation of health care programs.
Our community has expanded and improved services since
assuming local operation and management of health care services
throughout our Department of Public Health and the Gila River
Health Care Corporation which operates our hospital. We
restored services that IHS was forced to eliminate due to
inadequate funding in the early 1990s. We have changed aspects
of our health care delivery system which has resulted in
increased outpatient visits and redirection of services to
target our community's most serious health needs.
We have made these improvements despite operating our
hospital for more than three years with no contract support
cost funding whatsoever. We are also beginning to convert the
Department of Public Health from an underfunded and overworked
tribal health care agency to a public agency we believe can
rival the best of local and state programs. These tremendous
strides in health care service improvements by our community
have been made at the same time a significant cost savings have
been achieved through the assumption of local operation of
administrative functions.
Despite these improvements, our total funding of the
hospital only provides approximately $1,400 per patient, well
below the national average of $3,000 per patient. Underfunding
contract support costs is a significant factor in keeping our
funding per patient so low.
Every contract support dollar that we have been short
changed is one less dollar that we can spend on health care
services over the past three years that we have been operating
our hospital. The hospital has had to absorb over $10 million
in unfunded contract support costs. As you can see, these
dollars would have made a significant impact in bringing per
patient funding closer to the national average.
We need a firm commitment from Congress and the
Administration that they will maintain 100 percent funding for
contract support services for the future. This is the central
theme of my testimony today.
Now I would like to briefly address certain of the issues
that have been raised in the Committee's letter to Dr.
Trujillo. First, we support Federal legislation that would
provide a reduction in IHS administrative costs, consistent
with the goals of Indian self determination, so long as the
diverse and unique needs of all Indian tribal governments are
considered.
Second, we strongly support legislation to make self
determination permanent within IHS. We appreciate the
Chairman's leadership in inducing and securing passage in the
House of H.R. 1833, in the 105th Congress. And we look forward
to supporting similar efforts in this Congress. Clearly, it is
vital to the policy of self determination that Indian tribal
governments have the continued right to enter into self-
determination contracts. We strongly support lifting the 638
contract moratorium applied by Congress this past year on any
new and expanded 638 contracts. The moratorium is a direct
affront to the right of self governance and self determination
provided to Indian tribal governments under Federal law.
Fourth, we encourage Congress to remain committed to
increasing contract support costs not only within the IHS
budget, but also within the Bureau of Indian Affairs budget. In
addition, any proposed Congressional solution to contract
support costs must address contract support costs within IHS
and the BIA in a consistent manner.
In conclusion, what our story demonstrates is that the
self-governance framework can build tribal administrative
capacity, reduce bureaucracy, save money, and most importantly
improve the quality of health care services to tribal members.
And with that, I would like to ask unanimous consent that
my full statement be entered into the record. I would now be
pleased to answer any questions the Committee may have.
But in addition to that, Mr. Chairman, I'd like to
recognize yourself for all the hard work that you have done
throughout the years in representing the Gila River Indian
Community in Congress, as well as other tribal nations
throughout this country.
Mr. Hayworth. Mr. Lt. Governor, I thank you for those kind
words. Without objection, the remainder of your statement will
be included in the record, and that goes for everyone who has
joined us here today, for their written statements. But, again,
I thank you very much for those kind words.
Let me begin Lt. Governor Antone, with a question for you.
It may interest all those who joined us today to understand the
extent to which diabetes is a serious problem within your
tribal population. And I'd like you to first of all to talk
about the nature of the problem. And, also, if you could
address the question, how does contract support cost funding
relate to that issue of the incidence of diabetes among your
community's population?
Mr. Antone. You are absolutely right, Mr. Chairman. Our
community has the highest incidence of diabetes in the world,
and it is a significant health care problem in our community
including among our children. I know you have been a champion
for fighting juvenile diabetes because we have worked with you
on issues in the past and we will continue to work with you on
the same issue in the future.
Taking over health care programs has allowed us to focus on
our community's most serious health problems such as diabetes.
We have been able, for example, to reduce the rate of foot
amputations relating to diabetes significantly by placing two
podiatrists at our hospital on our staff. The decrease in foot
amputations is just one example of how funding to run our
health care programs is improving the outlook of diabetes
patients in our community. Even with this progress however, we
are still so far behind that it remains our top health care
issue. Every contract support dollar that we don't get reduces
the money that we can spend on the diabetes care. Conversely,
every dollar we do get goes into improving the health of our
community members.
Mr. Hayworth. Lt. Governor, thank you for your testimony. I
was privileged to have two members of Congress from both sides
of the aisle join me on a tour, as you know, of your community
in the past weeks, and visiting your health care facilities.
But as you pointed out, as we have seen, your community has
found ways to improve health care services while absorbing
millions of dollars in additional costs each year due to
inadequate or absent contract support costs funding.
In your mind and through your experience, how was your
community able to achieve those improvements?
Mr. Antone. Mr. Chairman, as a result of contracting with
IHS under the Indian Self-Determination Act, we have found that
once we were not burdened by bureaucracy we were able to make
much more efficient use of program dollars that were formerly
under IHS control. We found not only could we stretch these
dollars further and gain significant cost savings, but we also
could create a better quality health care service by tailoring
our programs to the unique health care concerns of our tribal
population, and most importantly, the disease of diabetes.
Mr. Hayworth. Mr. Lt. Governor, in your opinion, is the
queue system of allocating contract support costs funds
preferable, if it means getting 100 percent funding later
rather than 70 percent funding earlier?
Mr. Antone. Mr. Chairman, although we would have received
100 percent last year if the funding procedures related to the
queue had remained the same, the queue system is very
problematic for tribes. There is no predictability with respect
to how much funding will be available each year, how long
tribes will have to wait for new funding, and how long it will
take to get to 100 percent funding.
The fact is, however, Indian tribal governments should not
have to make the choice at all between some funding early or
more funding later. Ongoing and recurring contract support cost
funding is Federal policy.
The real issue is getting Congress to realize that those
funds promised to tribes must be appropriated in full and
recurring amounts. Anything less than full and recurring
appropriations for all contract support cost funding needs is
an abdication of Congressional responsibility toward Indian
tribal governments.
Mr. Hayworth. Mr. Lt. Governor, as I pointed out in
introducing you, the Gila River Indian Community was willing to
really step forward and make a sacrifice. Let me ask you again,
to follow up on that, would your community be willing to
sacrifice 100 percent contract support costs funding so that
all tribes could have funding levels raised to, for example,
about 80 percent?
Mr. Antone. Last year our community was fully expecting to
receive 100 percent of its contract support costs needs because
we had waited patiently for four years to rise to the top of
the ISD queue. In light of FTEs $35 million in new funds made
available for the ISD queue last year, however, we agreed to a
proposed allocation of those funds that would strive to give
all tribes on the ISD queue 70 percent funding.
Mr. Hayworth. Mr. Lt. Governor, we thank you for your
comments and for the efforts of your community.
[The prepared statement of Mr. Antone may be found at the
end of the hearing.]
Mr. Hayworth. Let me turn now to my good friend from
Michigan for any questions that he may have for the panel.
Mr. Kildee. Thank you, Mr. Chairman. First of all I'd like
to thank Ron Allen and Lloyd Miller for participating recently
in the caucus briefing we had on support costs. That was very
helpful. We had about 40 staff members there, including a
member from the Subcommittee on Appropriations, so it was very
helpful.
As a matter of fact our Native American Caucus has grown
from 55 members last year to 74 members this year from both
parties, so we are going to become more proactive. And your
participation in that briefing was very, very helpful and will
lay the groundwork for that. Also, Lt. Governor Antone, please
give my greetings to Governor Murray Thomas. I've enjoyed
visiting your Nation out there. Having grown up wanting to be a
fireman, I was captivated by your fire department out there. I
spent more time in the firehall talking to the fire fighters,
but it was very interesting.
And whether we have a queue system or pro rata the whole
thing will be solved if the United States Government obeys the
law passed in 1975. We have broken treaties and we've broken
the law. And we don't really need an authorization for that
because that was in the 1975 law, the appropriations and the
budget process, to call for that money.
And I certainly will begin to increase my pressure on the
Executive Branch of Government. We have now a surplus in the
budget, no longer a deficit. We're saving most of that surplus
for Social Security and Medicare. But certainly we can find the
dollars for our commitments to the Native American Nations in
this Country. And I will increase my advocacy for that. And we
need your help in doing that, and you've already helped. I just
appreciate all your testimony here today and look forward to
working with you. Thank you.
Mr. Antone. Congressman Kildee, Mr. Chairman, I appreciate
your kind words and I'll relay the information to Governor
Thomas.
Mr. Hayworth. Thank you Mr. Kildee. The gentleman from
American Samoa.
Mr. Faleomavaega. Thank you, Mr. Chairman. I'm sorry that I
wasn't able to follow up with a couple of questions I had with
a previous witness but I certainly welcome our panel members.
Mr. Hayworth. If the gentleman will yield? If my friend
from American Samoa would like to submit those questions in
writing?
Mr. Faleomavaega. I definitely will.
Mr. Hayworth. Without objection, it is so ordered.
Mr. Faleomavaega. And my good friend Ron Allen, there are
some 500 tribes currently in United States, Mr. Allen. How many
do participate in this contracting program of self governance?
Do you have any idea?
Mr. Allen. Well, it's probably in the neighborhood of 325
to 350 that are contracting or compacting.
Mr. Faleomavaega. And in your opinion this has gone very
well since it's been implemented?
Mr. Allen. Well the contracting movement, in terms of
taking over the programs has been very constructive because the
tribes have wanted to take over these programs and services and
manage them for themselves according to their own governmental
priorities, and so that has been moving forward. And the
contract support issue and the notion that it's out of control
has become a new kind of political impediment.
Mr. Faleomavaega. Do you agree with the Administration's
assessment in terms of the proposed budget? I had outlined that
the Administration had actually requested only $160 million and
they disagreed. And they are actually requesting almost $250
million for this contract services program. Is that in line
with your underfunding of the budget proposal for FY 1999?
Mr. Allen. Well, I guess it's about, somewhere around $240
million, just under I think, for next year, FY 2000. And they
had revealed that there is a need for an additional $100
million and we concur with that. One good thing about IHS is on
their side of the aisle they have done a good job in getting
more accurate data.
Their data is pretty accurate now in terms of how many
contracts are out there and what that level of shortfall is
both from those that are new programs by tribes, or new tribes
that are taking on programs, as well as the shortfall for
existing contracts and shortfalls in start up monies as well.
One other factor that was weighed into that number they
gave you is that it's an inflationary adjustment. And you know
the Federal Government gives COLA adjustments, inflationary
adjustments all the time. Unfortunately, we never get them. And
they'll come up with a rationalization of why they shouldn't do
that.
So we're urging IHS and BIA, as they make their
projections, to insert that inflationary adjustment because the
cost of securing those services is increasing.
Mr. Faleomavaega. So in your best assessment, whenever we
talk about Indian funding, there has never been any indexing
done as far as adjusting for inflation?
Mr. Allen. No, it's not adjusted. Basically, all they are
doing is taking the raw numbers and transferring them over to
the next year, and then adding whatever they can justify for
additional increase in CSC numbers in conjunction with the ISD
Fund. It was pointed out earlier that the ISD Fund, which is
for new contracts, needs to be reinstated in IHS. It is on the
BIA, and it does need to be reinstated on IHS to accommodate
those new contracts.
Mr. Faleomavaega. I know we do it for the Department of
Defense and for other Federal agencies but not for the Indian
Services. I'm very surprised. Mr. Williams, I enjoyed listening
to your testimony about the problems affecting Native Alaskans.
Do I understand that of the program under the Indian Health
Service, do the Native Alaskans have a separate Indian Health
Service program, or are you all grouped in it together with the
continental Native Americans?
Mr. Williams. We're all under the same system. We're part
of the United States, as I'm sure you are well aware, but are
all under the same system. The Alaskan area has their own area
office which, as of January, is all contracted. In YKHC's case,
we've contracted everything available to us. In the State;
under the demonstration, the 226 tribes have come together
under one compact with Congress, with the United States, under
the same system and criteria as other tribes in the continental
United States.
Mr. Faleomavaega. So your program is little different
structurally because of the way the----
Mr. Williams. It's 58 individually recognized Federal
Governments that have come together because of their size and
ability to generate the funds and work together to get the best
efficiency out of the funding that we do have. These are very
small tribes; we have 58, the largest one is about 3,000
members and the smallest one might be 48 members. So for
economy of scale they have joined together under one agreement.
And they tribally elect their board members. The tribes
elect the people that make the priorities on the health care
delivery system. Then prioritize them every year. We bring
tribal members in, they prioritize the health care delivery
system. You've given us the flexibility to work within the
funding level that we have to make that system delivery
possible for them.
Mr. Faleomavaega. And the funding level has not been at all
sufficient to meet those needs?
Mr. Williams. No. I call it a ``crisis care delivery
system.'' When somebody can't afford to go to see a provider
until they are so sick that they have to go to the hospital,
and they can't go for prenatal visits, that's a crisis care
system. We want to transfer that to a prevention system.
Mr. Faleomavaega. Thank you, Mr. Chairman.
Mr. Hayworth. Thank you, Mr. Faleomavaega. The gentleman
from Washington State.
Mr. Inslee. I'd ask consent to place a statement, if I may?
Mr. Hayworth. Without objection, it's so ordered.
[The prepared statement of Mr. Inslee follows.]
Statement of Hon. Jay Inslee, a Representative in Congress from the
State of Washington
Mr. Chairman, I am glad that we have the opportunity to
learn more about the critical and sometimes complicated issues
surrounding contract support costs for Indian programs. I look
forward to hearing from and working with my colleagues on the
Committee and today's witnesses, especially NCAI Chairman Ron
Allen, who is chairman of the Jamestown S'Klallam Tribe in
Washington. For those of my colleagues who may not know this, I
am privileged to have the Jamestown S'Klallams located in my
Congressional District.
The Indian Self-Determination and Education Assistance Act
gives tribal governments the rights to assume local control
over Federal Indian programs, such as health care, law
enforcement, education, and natural resources management. A
major principle of the Federal Government's policy under Self-
Determination is that tribal governments should not be
penalized financially for exercising their right under the law
to operate their own programs.
Yet, that is the situation we find ourselves in today.
Because Congress has failed to fully fund the costs associated
with contracting, tribal governments are increasingly forced to
spend their program funds to offset their contract support
costs, pay these costs from tribal funds, or cut critical
administrative activities below the level needed for contract
compliance. I am concerned that the effect of this shortfall is
that we are taking funds from one needed program in order to
pay the administrative costs of another.
In addition, I am concerned that the current moratorium on
new and expanded contracts contained in the FY 1999 Omnibus
Appropriations Act is a not-so-subtle backdoor approach to
eliminating the rights of tribes to operate their own local
programs under the Self-Determination Act. We should not let
appropriations riders take away Indian self-determination or
undermine tribal sovereignty.
I would like to commend the Chairman for holding this
hearing today. I look forward to working with tribal
governments, the Administration and my colleagues to find a
solution to this issue so that tribal governments will be able
to fully exercise their self-determination rights under Federal
law.
Mr. Inslee. I do have a couple of questions, if I may?
Mr. Hayworth. Certainly.
Mr. Inslee. First, I want to thank you all for coming,
particularly Mr. Chair for journeying from the serene bay where
you hang your hat all the way to try to horsewhip Congress into
doing the right thing. That takes a lot of energy and we
appreciate that.
But I'd like to ask you why do you perceive, and this is an
issue that folks who believe in devolution, folks who believe
in having local governments handle affairs, folks who believe
we ought to devolve power to the governments who are closest to
the people, also at times some of those folks seem to be the
ones most opposed to fully funding self determination.
Why is that? I mean, what possible reason do you think we
are up against in trying to convince them to fulfill this
obligation to the Native American Nations?
Mr. Allen. Congressman, it's a complicated question you
ask. And I guess one of my simple answers is that I believe
that there is a subliminal philosophy that permeates throughout
our society with regard to Indian affairs, who the Indian
people are, what our governments are all about. And I believe
that as you move the Federal policy of empowering tribal
government forward there is not really a belief that tribal
governments were going to be really fully empowered, tribal
governments.
And over the course of the last 25 years tribes have proven
that they can be very effective in every aspect of governmental
operation. And all of the sudden you end up with a new level of
clashes over jurisdiction and control, over controlling affairs
over our communities whether it's in rural settings or it's in
urban settings. And, unfortunately, there is this notion that
there is no obligation to the Indian people into perpetuity for
the relinquishing of the lands and the resources that our
peoples gave up. That is simply a premise that is unacceptable.
It isn't honoring the commitment of the United States to these
peoples and our governments.
Now, as tribal governments continue to grow there is a
notion, and it hides behind different theories, about how to be
accountable for the Federal resources designated to serve our
communities. It is increasing but it is not increasing
proportionately.
But we're going to show you and the rest of the
Congressional leadership, in our education campaign, that when
you look across every Indian program, we are categorically not
maintaining the same pace as the other programs serving
mainstream America. And even though there is increases,
proportionately we are not increasing and keeping pace with
mainstream America.
How are we expected to be self sufficient, how are we
expected to become independent governments within the Federal
system, and how are we going to serve our people? We cannot, if
we're not provided the same respect as other governments.
Mr. Inslee. Well, I appreciate your passion. You know,
sometimes I encourage witnesses to be dispassionate, but in
this case I welcome it. And I'm glad you are here showing it
because I think it's appropriate. Let me ask, and anyone on the
panel can help me. Is there a current litigation? One of the
previous panelists made reference to a court case of some sort
involving the BIA. If anybody could tell me the status of that,
I'd appreciate it.
Mr. Miller. Yes, Congressman, there are presently about a
half dozen cases wending their way through different parts of
the court system. Some of them are in the Interior Board of
Contract Appeals, some of them are at the Appellate level of
the Federal System, some are in the Federal District Courts.
Assistant Secretary Gover alluded to a judgment awarded
against the Bureau of Indian Affairs on behalf of all tribes in
the United States, a deal with the Bureau of Indian Affairs.
The matter was concluded on liability, as settled, on damages
at $76 million. That sum is now being approved by the Federal
District Court, and we understand a final approval is imminent
any day this week.
Mr. Inslee. And what is the basis? I mean how is that
number adjudicated? Does that go to a certain time period or--
--
Mr. Miller. Yes, it was a certain time period. Prior to
1994, between 1988 and FY 1993, for those fiscal years, the
Bureau of Indian Affairs employed a method for determining
contract support costs that actually diluted its
responsibility. It counted in the calculation of contract
support small programs from other Federal agencies that don't
contribute contract support but also don't contribute
materially to the work load of the tribe.
But counting those programs, the Bureau of Indian Affairs
was able to shave in a small way its own responsibility, where
shaving it in a small way for 500 tribes for five years became
quite a large sum. And the $76 million represents a settlement
on that amount.
The case is actually into a second phase now, being handled
by a Mr. Michael Gross, out of Albuquerque, New Mexico, where
they will be looking at the BIA policies from 1994 to the
present.
Mr. Inslee. Does the shortage which we've been addressing
here, is that potentially subject to further litigation? Can
the judicial system solve this problem potentially, if Congress
does not?
Mr. Miller. Well, I think the judicial system has been
called upon by individual tribes and even on a larger basis to
do exactly that, Mr. Congressman. It would be unfortunate,
however, I think for the policy of the United States, if it was
the judiciary that had to call the United States Congress and--
--
Mr. Inslee. I'm not suggesting that.
Mr. Miller. [continuing] into account for such an important
responsibility. But I think if Congress is unable, working with
the agencies, with the Indian tribes, to find some common
ground in this area, the courts are going to continue issuing
rulings against both agencies that will be extremely costly.
Mr. Inslee. Thank you.
Mr. Allen. Mr. Chairman, might I add just a little bit to
that?
Mr. Hayworth. Certainly.
Mr. Allen. In our report to you and the Senate, we're going
to address this issue and its complications. And we're going to
throw out some suggestions about how to address this very
complicated issue that was raised in the court. It causes a lot
of people a lot of concern. And we believe there is a very
constructive solution that can be proposed to the Congress in
terms of how to address it.
Mr. Hayworth. Thank you. The gentleman's time has expired.
The Chair would reiterate that if any member of the Committee
has questions for either the first or the second panel, if they
would submit questions in writing to the Committee staff. Mr.
Faleomavaega made the point earlier and we're very happy to
follow up with those inquiries.
I would also state for the record that questions in writing
will be submitted from the Pascal Yaqui Tribe of Arizona, some
of my friends in my home state who also have some concerns. Is
there any further business?
Mr. Kildee. No. I just want to thank the Chairman and
yourself for chairing this meeting today. I think it was very,
very helpful. I think this is an area that is not just a legal
area, it's a moral area. We have a legal and moral obligation
to carry out those responsibilities and I think you presented
the case very, very well. We have to pursue this until you
secure full justice.
Mr. Hayworth. The gentleman from American Samoa?
Mr. Faleomavaega. Mr. Chairman, the 11 years that I have
been a member of this Committee, I, too, would like to echo the
sentiments that have been expressed earlier in terms of your
leadership and the dynamic services that you have provided for
the Indian Country. And I really would like to commend you for
your dedication to this.
Because so often and so many times whenever Indian issues
are brought before this Committee and the Congress--it's not
because I question the sincerity or the insincerity of those
members--that affect the needs of our Native American
community, somehow things just don't get done.
And Mr. Chairman, I want to thank you for your personal
attention given to this real serious problem that we have in
our Nation. And I do want to say that for the record. Thank
you.
Mr. Hayworth.I thank you Mr. Faleomavaega. It's good to
have my friend from American Samoa, who during the course of
the 104th Congress, on a very aforementioned August day,
foreswore his tropical paradise to come to the desert----
Mr. Faleomavaega. Mr. Chairman, as long as you'll continue
this leadership, I promise I will export more football players
to the University of Arizona and Arizona State.
Mr. Hayworth. And let me state for the record, even though
Arizona is my home, at North Carolina State University, I
enjoyed the services of Ricky Logo, from Samoa for many years,
and we appreciated that. And he had to return home to become
King, so he was certainly well prepared with his education at
North Carolina State.
Mr. Faleomavaega. If the Chairman will yield. Most of my
cousins have played for Arizona State and the University of
Arizona, and they continue to do so. And I'm going to tell them
to do so as long as my friend J.D. helps my Native American
brothers and sisters. Thank you.
Mr. Hayworth. I thank you, Mr. Faleomavaega. And again I
thank you not only for your kind comments but all the witnesses
for their valuable testimony. And if there is no further
business, again we thank the members and the members of our
panel. And the Committee stands adjourned.
[Whereupon, at 12:45 p.m., the Committe was adjourned.]
Statement of Hon. John M. Spratt, Jr., a Representative in Congress
from the State of South Carolina
Dear Chairman Young,
Thank you for allowing me the opportunity to submit
testimony regarding the difficulties encountered by the Catawba
Indian Tribe of South Carolina in obtaining adequate Indian
Health Services and contract support funding. The Catawbas'
relationship with the Federal Government was terminated in the
early 1960's and was not re-established until Congress passed
legislation to do so in the mid-1990's. Prior to recognition,
the tribe did not keep an up-to-date, accurate, or complete
record of its members. The tribal roll the Catawbas relied upon
when originally filing for IHS funding understated its tribal
membership by over one-half.
The Catawbas first sought IHS funding in fiscal year 1994
directly following their land settlement and Federal
recognition. At that time the Catawbas had no paid staff. A
loose roll of 1,200 members was kept as a courtesy by an
elderly member, now deceased. Although this roll did not
reflect an accurate accounting of members' deaths, births, and
marriages, it was used by the Catawbas because it was the only
list of members available when the tribe filed for IHS funding.
The tribe has since found that they have a health service
population of 2,700, over twice as many as originally reported.
The Catawbas are currently funded at $1.5 million, or $779
per person, which is well below the average Indian Health
Services funding of $1,430 per member. The tribe spends $2.5
million a year on health care, or $1 million more than IHS
funds. As a result, they must scrape together this additional
money from other programs in an already tight budget.
Other Native American tribes with similar populations are
funded at twice the level of the Catawbas. The Yuma Indians,
for example, receive $4.1 million a year for a near identical
service population. The Catawbas deserve the same level of
funding received by other similarly situated tribes, and should
at least get funding commensurate with the current
determination of their membership.
In addition, the Catawbas have consistently been denied
proper payment for IHS contract support costs. Since their
Federal recognition in 1993, the tribe has been underfunded by
$1.8 million in contract support costs on their contract. In
FY97, for example, the Catawbas' contract support rate was set
at 51.1 percent or $414,368, of which they received only
$57,000. Without the proper funding, the tribe has both
downsized their health-related services and taken steps to cede
the administration of their health program back to Indian
Health Services. The Catawbas simply cannot afford to maintain
it without the proper funding.
Thank you for holding a hearing on this important matter. I
would very much appreciate having this letter entered in the
record of the hearing.
------
Statement of Michael E. Lincoln, Deputy Director, Office of the
Director, Indian Health Service
Good morning. I am Michel Lincoln, Deputy Director of the
Indian Health Service (IHS). Today, I am accompanied by Mr.
Douglas Black, Director, Office of Tribal Programs; and Ms.
Paula Williams, Director, Office of Tribal Self-Governance. We
welcome the opportunity to testify on the issue of contract
support costs in the Indian Health Service. Contract support
cost funding is critical to the provision of quality health
care by Indian tribal governments and other tribal
organizations contracting and compacting under the Indian Self-
Determination and Education Assistance Act ((ISDEA), Public Law
(P.L.) 93-638).
The IHS has been contracting with Tribes and Tribal
organizations under the Act since its enactment in 1975. We
believe the IHS has implemented the Act in a manner consistent
with Congressional intent when it passed this cornerstone
authority that re-affirms and upholds the government-to-
government relationship between Indian tribes and the United
States.
At present, the share of the IHS budget allocated to
tribally operated programs is in excess of 40 percent. Over $1
billion annually is now being transferred through self-
determination agreements to tribes and tribal organizations.
Contract support cost funding represents less than 20 percent
of this amount. The assumption of programs by tribes has been
accompanied by significant downsizing at the IHS headquarters
and Area Offices and the transfer of these resources to tribes.
Contract support costs are defined under the Act as an
amount for the reasonable costs for those activities that must
be conducted by a tribal contractor to ensure compliance with
the terms of the contract and prudent management. They include
costs that either the Secretary never incurred in her direct
operation of the program or are normally provided by the
Secretary in support of the program from resources other than
those under contract. Itis important to understand that, by
definition, funding for contract support costs is not already
included in the program amounts contracted by tribes. The Act
directs that funding for contract support costs be added to the
contracted program to provide for administrative and related
functions necessary to support the operation of the health
program under contract.
The requirement for contract support costs has grown
significantly since 1995 due to the increasing assumption of
IHS programs. In the fiscal years 1996 and 1997 appropriations
committee reports, the IHS was directed to report on Contract
Support Cost Funding in Indian Self-Determination Contracts and
Compacts. In the development of this report, IHS consulted with
tribal governments, the Bureau of Indian Affairs (BIA) and the
Office of Inspector General within the Department of the
Interior. The report detailed the accelerated assumption of IHS
programs by tribes beginning in 1995 as a result of the 1994
amendments to the ISDEA and authorization of the Self-
Governance Demonstration Project for the IHS. The report showed
that despite the significant growth in self-determination
contracting and compacting, contract support cost
appropriations have remained relatively flat. This has resulted
in under-funding of contract support costs. The report also
highlights that the rates for tribal indirect costs, which are
the major component of contract support costs, have averaged
around 23 percent of direct program costs over this same period
of time.
In addition, pursuant to the statutory requirements of the
ISDEA, the IHS gathers contract support cost data annually as a
part of its annual ``Contract Support Cost Shortfall Report To
Congress.'' This report details, among other things, the total
contract support cost requirement of tribes contracting and
compacting under the ISDEA and how these funds are allocated
among the tribes.
As a result of the increase in contract support cost
appropriations in FY 1999, the IHS will be able to fund, on
average, approximately 80 percent of the total contract support
cost need associated with IHS contracts and compacts. No tribe
will be funded at less than 70 percent of their overall
contract support cost need. Although the IHS projects future
need for contract support costs on an annual basis, there are
many variables associated with these projections that are
outside the control of the IHS. These variables include: the
fact that self-determination is voluntary and solely at the
initiative of tribes and that indirect cost rates can
fluctuate. The contract support costs shortfall at the
beginning of fiscal year 1999 was approximately $52 million.
The IHS adopted a contract support cost policy in 1992 in
an attempt to address many of the issues surrounding the
determination of tribal contract support cost needs authorized
under the Act and the allocation of contract support cost
appropriations from the Congress. This policy was subsequently
revised in response to the 1994 amendments to the Indian Self-
Determination Act. In response to concerns expressed by the
Congress, the IHS is currently working on a third version of
the policy. We will work with Congress, the tribes, and BIA to
develop contract support costs solutions that are more in line
with the budget cycle, in order to better predict future CSC
needs. In concert with Departmental and IHS tribal consultation
policies, the IHS is working closely with tribal
representatives in the development of this revised policy.
Before any agency policy on contract support costs is
adopted, tribal leadership is consulted and the significant
procedures under consideration are discussed in great detail.
While we do not always arrive at the same conclusion as tribal
leadership, the process is mutually beneficial and has always
resulted in a more harmonious relationship. We first engaged
tribes with the need to modify the IHS contract support cost
policy last fall.
Since then, we have met with tribal technicians and
administrators on three occasions. We are continuing the
process and will be meeting again in early March. We anticipate
having a final draft of the policy available for tribal leaders
to review and comment on in late spring. The policy should be
finalized by mid-summer for implementation in advance of FY
2000.
In addition to the specific IHS contract support cost
policy work, the IHS and the Bureau of Indian Affairs have also
collaborated with the National Congress of American Indians
(NCAI) on the contract support cost study they have undertaken.
It is my understanding that the NCAI will forward an interim
report on contract support costs to the Congress in the near
future. In addition to the NCAI study, the IHS is presently
providing data and information to the General Accounting Office
(GAO) to assist that organization in its ongoing review of
contract support costs. As you know, the Congress has directed
the GAO to undertake a comprehensive study of contract support
costs in the IHS and BIA. We look forward to the results and
findings of that study, which will be delivered to the Congress
in June.
Thank you for this opportunity to discuss contract support
costs in the IHS. We look forward to working with the Congress
in addressing this important issue. We are pleased to answer
any questions that you may have.
------
Statement of W. Ron Allen, President, National Congress of American
Indians
I. INTRODUCTION
Good morning Mr. Chairman. My name is W. Ron Allen and I am
the President of the National Congress of American Indians
(NCAI) and the Chairman of the Jamestown S'Klallam Tribe of
Washington State. NCAI is the largest and oldest membership
organization of Indian tribes in the United States, and
advocates on behalf of all the Nation's 558 federally
recognized Tribes. I am honored by the Committee's invitation
to appear and testify on the Indian Self-Determination Act and
the role that contract support costs has played under that Act.
II. INDIAN SELF-DETERMINATION ACT OF 1975
The Indian Self-Determination Act of 1975 has proven to be
the cornerstone of the Nation's modern policy toward empowering
tribal governments. The Act rejected all of the Nation's past
failed policies toward our tribes, including paternalism,
forced dependency, assimilation and outright termination of our
unique status as governments. In their place, it established
the basic framework for tribal self-determination, tribal
economic recovery, transfer of Federal resources and services
to tribal operations and true government-to-government
relations between tribes and the United States.
The Act has directly led to every major American Indian and
Alaska Native initiative to come before this Congress in the
last quarter century, and the self-determination goal has
become a reality for hundreds of tribal communities seeking
greater autonomy, responsibility, accountability and control
over their daily affairs and their destiny. Thanks in major
part to this Committee's continuing and unbroken vigilance to
protect against any erosion of the Act, either administratively
or through legislation, the Self-Determination Act has proven a
resounding success in lifting up our tribal communities,
elevating the health status of Native American peoples by
improving the quality and expanding the delivery of our health
care services, promoting local innovation, relieving
unemployment, improving educational opportunities, improving
tribal justice systems and law enforcement, and removing the
distant Federal Government bureaucrats from our daily affairs.
Even with these improvements, however, the continuation of
serious problems still exist. As a 1987 Senate report stated,
in the course of strengthening the Act, ``perhaps the single
most serious problem with implementation of the Indian self-
determination policy has been the failure of the Bureau of
Indian Affairs and the Indian Health Service to provide funding
for the indirect costs associated with self-determination
contracts.''
III. CONTRACT SUPPORT COST UNDERFUNDING
The Senate Indian Affairs Committee, and this Committee,
noted that the failure to fully fund indirect costs had
resulted in severe difficulties for tribes who incur enormous
costs not borne by IHS and the BIA, and who must also carry out
functions similar to those carried out by a variety of other
Federal agencies that support the BIA and IHS, but which are
beyond the reach of the Act. For many tribes, the IHS and BIA
practice of underfunding contract support costs meant either
compromising on these essential functions, reducing already
underfunded program services to help cover these requirements,
or both.
In 1988 and in 1994, this Committee helped enact
legislative amendments, among other purposes, intended to
``prohibit'' the underfunding practice, thus overcoming the
funding problems and disturbing consequences. In some respects,
the amendments worked and some of the contract support problems
improved. But while tribes went on administering hundreds of
Federal Indian programs, the agencies continued to defy the
statutory and contractual mandates to fully fund contract
support costs.
With respect to both the BIA and the IHS, the
administration refused to use all available funds to meet their
obligations and failed to ask for sufficient additional funding
from Congress to get around their self-imposed limitations.
Unfortunately, the Administration eventually supported
statutory funding ``caps'' designed to protect the agencies
from ever fully paying the tribes the amounts determined to be
necessary by the agencies.
On the BIA side, an additional BIA policy (known as the pro
rata policy) has long meant that today tribes never know until
a fiscal year is almost over, and their programs are almost
fully carried out, how much they will receive in contract
support costs that year. From year to year, the payment jumps
up and down anywhere from the mid 70 percent to the low 90
percent range. Unfortunately, over the last 6 years, the
payment schedule has averaged in the low 80 percent range. This
continuing practice seriously undermines the ability of tribes
to achieve real financial stability and predictability even in
one year, no less over the longer term.
To make matters worse, the BIA system fails to provide
tribes with the same personnel benefits that the BIA's own
employees receive when they carry out the same programs, making
it that much harder to maintain service levels in tribal
communities. From IHS's experience, we estimate that this
failure actually pushes the BIA payments down in real terms
another 20 percent below real need.
On the IHS side, IHS policies have until very recently led
to a situation where years go by during which some (and
occasionally all) of a tribe's health care programs receive no
contract support costs at all. Although the IHS policy does
offer tribes better predictability from year to year, most are
nonetheless forced to operate with substantial contract support
deficits.
IV. NCAI NATIONAL POLICY WORK GROUP ON CONTRACT SUPPORT COSTS
Faced with a growing crisis, last year (1998) NCAI
established a National Policy Work Group on Contract Support
Costs. Among the many goals of this initiative were: (1) to
work aggressively with the agencies to improve the contract
support situation; (2) to begin a serious educational campaign
here in Congress on the need for contract support costs and on
the impact of the current crisis on tribal service delivery;
(3) to work more closely with the two Departments and the
Office of Management and Budget to increase awareness of this
critical issue; and, (4) to thoroughly explore all aspects of
the contract support system and develop options and
recommendations where improvements can be made for the benefit
of all concerned.
Our intense work on this initiative has already contributed
to achieving real progress on many fronts:
First, and thanks in major part to the bipartisan
leadership and sensitivity of Appropriations Subcommittee
Chairman Regula, Chairman Young and Congressman Miller, Co-
Chairs Hayworth and Kildee of the House Native American Caucus,
the House Leadership, as well as the support of Senator Ted
Stevens, this year's appropriation included a 21 percent
increase in contract support cost funding. Although IHS reports
that funding will still be some $90 million short in FY 2000,
this year's increase has permitted very real correct
corrections--and changes--to be made to a system in crisis.
Second, both the BIA and the IHS are now working closely
with NCAl and others to reexamine their contract support cost
policies. As a direct result of these efforts, in 1999, IHS
expects to move all tribes closer to the 100 percent necessary
funding level that some tribes--but far too few--already enjoy,
and in doing so to correct the most severe funding inequities
that have plagued the IHS system. For IHS, this represents a
major change from past contract support policies.
Third, IHS in particular has made enormous strides in
improving the accuracy of its data, thanks to truly tremendous
and concentrated efforts by the agency, and thanks also to a
solid commitment to consult and work more closely with tribes.
Fourth, NCAI has issued two interim reports summarizing our
work and much needed data on all aspects of the contract
support cost system. The first report was distributed to all
members of Congress, all relevant agencies, and all Indian
tribes; and, the second report is just now under distribution.
Copies of both reports have been attached to my written
testimony today, and I think Members will find the information
invaluable to a thorough understanding of the system. We
anticipate having our final report out this spring.
Fifth and last, the Administration has now requested an
additional 17 percent increase in contract support
appropriations to IHS for FY 2000. This is the first time any
Administration's budget request has ever acknowledged to such a
degree the serious need in this area, and we hope the House and
Senate will substantially build upon that request in the coming
months. Although the President's budget reflects an increase to
remedy the near-equally serious BIA shortfall, here too we hope
to work closely with Congress and OMB to better address the
need for FY 2000. Unfortunately, the BIA is projecting
increased levels which will only fund 86 percent of need in FY
2000.
Our reports have also revealed important little known facts
regarding the contract support system. For instance,
Our research has clearly dispelled the notion that CSC
costs are ``out of control.'' Individual tribal requirements
for contract support costs have remained level over several
years. In fact, they have not increased and are consistent with
other Federal agencies contract support cost-type
reimbursements--even though the average rate of these inter-
agency rates are almost double that of the average tribal
indirect cost rates.
The increased demand for contract support costs over
the mid-1990s was directly caused by more tribes taking
advantage of the Self-Determination Act's opportunity to
operate the IHS and BIA programs.
On average, contract support costs account for about
one-quarter of a tribe's total IHS funding (when fully funded),
and a smaller proportion of a tribe's total BIA funding. The
difference partly reflects the fact that a number of BIA
programs involve pass-through payments (such as general
assistance and scholarships), and partly reflects the fact that
the BIA still fails to recognize tribal direct contract support
cost requirements.
In every year since 1980 both the Federal agencies and
Congress have known the extent to which contract support costs
requirements have gone unfunded. And yet, and until this year,
the amounts made available by Congress, the agencies or both
have not come close to meeting the need, driving the IHS
backlog higher and higher, and leaving the BIA system
essentially stagnant.
Over one-half of the IHS programs are operated by
tribes, and a larger portion of the BIA programs operated by
tribes, involve programs smaller than $500,000, while only 7
percent exceed $5 million.
Tribal contract support cost requirements have varied
due to diverse local circumstances. No ``one size fits all''
approach can be sensitive to this highly variable situation.
The rate of growth in tribal contracting and
compacting activities with IHS and BIA has slowed markedly,
with each agency now projecting new contract support demands
per year at approximately $12.5 million and $5 million,
respectively.
In a recent three-year period, IHS staffing-reduced by
6 percent, with substantial additional IHS staff currently
detailed to tribal programs. In the last 17 years, BIA staffing
has reduced by over one-third. (Relative to IHS, there are very
few BIA staff currently detailed to tribal programs.)
V. CONCLUSION
Mr. Chairman, a large proportion of the Nation's tribes has taken
advantage of the Self-Determination Act's opportunity to administer IHS
and BIA programs. The result has been highly accredited and acclaimed
health care programs, increased governmental and program service
delivery through reductions in red-tape and bureaucracy, innovative
partnerships with state agencies, multi-fold increases in third-party
revenues from Medicare, Medicaid and private insurance, a broader array
of program choice for tribal members, more relevant and locally-
prioritized health and social service programs, and significant and
measurable improvements in the communities' quality of life.
We have much to applaud in what tribes have done for themselves in
the past 25 years, even with legislative and policy restrictions
including inadequate funding to fully implement tribal self-
determination and self-governance goals. The Congress and the
Administration have been advancing the ``devolution'' process to
empower state and local governments. This movement is based on a simple
theory that the communities in our country will be better served when
the Federal Government provides greater control and flexibility over
Federal resources to address these community needs. This goal should be
applied equally and consistently with the 558 tribal governments
throughout the United States.
One important consideration that must be recognized by the Federal
Government is that the tribes do not have the same revenue-generating
base as state and local governmental tax authority system. In
conjunction with this fact, the Congress must remember it has a
historical, legal and moral obligation to the tribal governments in
lieu of the vast lands and resources relinquished to the United States
by the tribes.
We therefore respectfully caution the Committee to reject
recommendations that would revamp the Self-Determination Act in
significant ways, such as by deferring new contract starts, deferring
tribal entitlements to receive contract support, or otherwise weakening
the Act's contract support cost provisions. These options would
severely undermine the tribes' governmental capacity to provide
effective and responsible programs and services to their communities.
We do believe, however, that improvements can certainly be made in
how the Act has been carried out. For instance, IHS and BIA can report
to Congress on a more timely basis the contract support cost needs
anticipated both for the current year and the upcoming new year.
Further, we believe the agencies can do a better job of refining and
standardizing the process for determining contract support cost needs.
The contract support crisis is solvable--with refinement in the
agencies' policies, the renewed commitment from Congress and the
Administration shown this year, and the willingness of tribes to join
in the search for innovations that will help further close the gap.
Through the collaborative work of the NCAI Workgroup on Contract
Support Costs, we are developing recommendations which support similar
CSC approaches and policies within the BIA and IHS. While the Workgroup
is exploring options regarding consistent standards and criteria in the
calculation of all aspects of contract support costs (including start-
up costs, direct contract support cost and indirect costs), these
options recognize areas of commonality among tribes but are also
sensitive to the unique differences among us.
NCAI stands ready to assist the Congress and Indian country to
reach this goal, and we are hard at work as I speak doing our part to
make it happen. Mr. Chairman, thank you once again for the opportunity
to share these thoughts with the Committee.
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Statement of Orie Williams, Executive Vice-President, The Yukon-
Kuskokwim Health Corporation
Mr. Chairman, thank you for the opportunity to testify
before your Committee on what Congress ten years ago called
``the single most serious problem with implementation of the
Indian self-determination policy,'' namely the failure to fully
fund contract support costs.
To begin, my name is Orie Williams, and I am the Executive
Vice-President of the Yukon-Kuskokwim Health Corporation. Our
health care organization is authorized by and represents 58
federally recognized Alaska Native Tribal Governments, their
members and their village communities, and we are the second
largest tribally-operated IHS program in America. We also
believe we are the most successful tribal operation in the
country, whether measured in terms of improved patient care,
improved health status or increased tribal control over the
health care delivery system.
Having said that, I must state that I truly believe it will
take the next 10 to 20 years of sustained resources to build
healthy families and communities in our service area and to
totally transfer service from an IHS crisis care model to a
health prevention model. This must--and can only--be
accomplished under tribal management with the flexibility
Congress has allowed in the amendments to the Indian Self-
Determination and Education Assistance Act demonstration model.
We applaud Congress' vision and the tribal vision that made
this Act a reality.
We face daunting conditions. The 58 villages and 23,000
people we serve are spread across an enormous, roadless area
the size of South Dakota. Only snowmachine and subsistence
trails, rivers and air transport systems connect our
communities. Transportation during the long harsh winters is
unpredictable. The majority of our people live below the
poverty line. We estimate at least 54 percent are eligible for
Medicaid insurance coverage; overall, 44 percent are
unemployed, although in many villages the unemployment rate
exceeds 80 percent. Most of our village homes have 6 gallon
plastic buckets for toilets. Post-neonatal mortality is more
than double the U.S. rate. Death by suicide is four times the
national rate. Fetal alcohol syndrome and fetal alcohol effect
are extraordinarily high, as are all other alcohol-related
diseases, accidents and deaths. Hepatitis, tuberculosis,
infections caused by lack of adequate sewer and water systems,
and sexually transmitted diseases all plague our young and
growing population.
Attached to my testimony is a detailed profile of our
health care organization and our region. As the profile
reflects, we have succeeded in improving the health care
delivery system since the days of IHS operation. But part of
the reason we cannot do more today is that IHS has required us
to neglect some programs and to divert resources to cover the
fixed administrative overhead that necessarily comes along with
operating a $40,200,476 system comprising 1,003 employees, 47
village community health aid clinics, one mid-level subregional
clinic, and a 51-bed hospital (including two new sub-regional
mid-level clinics under construction).
Our contract support cost requirement--what we need
according to IHS policy, the DHHS Division of Cost Allocation
and our certified annual audits--is $14,925,949. This is what
we need to run our financial management systems, to operate our
personnel, human resource and payroll systems, to support our
facilities, to cover insurance, legal and audit costs, to
operate our procurement system for drugs, equipment and
supplies, to sustain our third-party billing operation, to
support needed technology, to advance employee training, and to
respond to new regulatory and legislative initiatives.
But for several years we have operated with a multi-million
dollar deficit in contract support costs, a deficit this year
of $2,304,663--or fifteen percent (15%) below what we need (per
Alaska Area CSC shortfall report 1/8/99). Keep in mind that
this ``need'' has been determined by IHS and its sister agency
the Division of Cost Allocation, not by us. Frankly, in our
opinion it is artificially low. For instance, it understates
greatly the need to at least match IHS's fringe benefit package
when a tribal organization takes over the IHS system,
especially for Commissioned Corps employees and Civil Service
employees.
The continual backlog in unpaid contract support costs has
had serious consequences. Our accounting department is $212,050
short, including three unfilled positions. Our billing and
admissions departments are $321,375 short, including six
unfilled positions. Technology support is short $236,700,
representing three positions that support the remote
telecommunications system that is the central nervous system of
our health care operation. Hospital maintenance and
housekeeping staff and equipment are down $477,430 to name just
some of the areas where the shortage is causing reduced
performance. We are unable to use IHS ``tribal share'' program
funds for their intended purpose because much of the funds have
been diverted to help close the contract support gap, funds
which should be going to regional substance abuse services,
mental health services, home health care and village clinic
operations, and inhalant treatment, to name a few. In short,
Mr. Chairman, the contract support cost shortfall for YKHC is
very real, and it is causing very real damage to our ability to
further improve the health status of our people.
With this overview, we would like to make these additional
points directed at the issues raised in the Chairman's letter:
how to improve upon the system itself within the framework of
the Indian Self-Determination policy.
1. First, I cannot let this opportunity go without
commenting on last year's proposal to reallocate all contract
support costs on a simple flat pro rata basis.
The flat pro-rata approach would have been a disaster for
many tribes, and tribal organizations, across the country that
have worked hard over the years to justify and secure the
contract support funding they have. For us, our existing
shortfall would have only gotten worse, causing massive layoffs
in a region of Alaska already plagued by a fisheries disaster
and low employment. Other tribal organizations that depend on
the stability of a known contract support cost amount each year
would have been hurt even more.
If there is one thing I would hope to convey today, it is
that last year Congress wisely rejected the proposal to
redistribute all contract support on a flat pro rata basis. It
is an approach that would have made Indian country shoulder the
Federal Government's burden. It is an approach that was wrong
despite its best intentions, and I hope the Chairman, and this
distinguished Committee can assure all of us that it is an
approach that will not be revisited.
It is true that this system seems to work reasonably well
for the BIA. But that is only how it appears. The fact is, the
BIA system is peculiar indeed. Under that system, the BIA
supposedly pays a tribe its full indirect costs the first year,
along with its full start-up costs. But in the second year the
tribe's payment can drop to 80 percent, 70 percent, or some
other level no one knows until the BIA actually calculates it
the following summer, just before the fiscal year is about to
end. The BIA payment goes up and down with no predictability,
causing considerable uncertainty for the tribes. In fact, I
understand that this is a large part of the reason why the
Interior Board of Contract Appeals threw out the BIA system. It
ruled that if a tribe's contract calls for contract support
costs, and the tribe is dutifully performing, and most of the
year is over, the tribe must be fully paid. There is only one
thing I can say for the BIA system: It is administratively
convenient.
The BIA system may help the BIA. But it does not help
tribes. In contrast, the IHS system, although flawed by erratic
appropriations, represents a genuine effort to maintain tribal
stability by continuing to pay each tribal organization at
least the same amount it received in the preceding year, again
beginning with an effort to fully pay the tribe in the first
year.
Yes, the IHS system can be improved upon, especially with
better coordination between Congress and the Tribes; but it is
clearly a better systemz--assuming the goal is the stability of
health programs serving needy Native Americans, and not
administrative convenience.
2. Second, we believe the Committee's concern regarding
accurate data from IHS has been largely addressed in the past
year. We are extremely impressed with IHS's commitment and
progress in this area over a few short months, thanks to a
needed centralization of much of this work, improved training
of IHS Area personnel, and greater oversight from the IHS
Office of Tribal Affairs and the Division of Financial
Management. Candidly, we were one of many who said that IHS
would never be able to bring accuracy back into its system and
to negotiate all the contract support requests it had before
it. But our skepticism was misplaced, and we give credit for
this especially to OTA Director Doug Black and Deputy Director
Ron Demeray, as well as Carl Fitzpatrick, Dan Cesari and Dan
Modrano of the IHS Division of Financial Management.
We do want to emphasize two points regarding the data
issue. First, during last year's debate IHS furnished
undistributed data to the Appropriations Committee staff. It
was never publicized. Neither IRS nor anyone else shared that
data with Indian country. It was finally provided to us by
diligent Congressional staff during the heated debate; and,
once it was received, we were able to show how terribly flawed
the data was, and fortunately decisions based upon that poor
data were abandoned. In the meantime, however, statements were
made on the floor of the House and elsewhere that were plainly
in error based on this false and misleading information.
The point is this: the IHS and the Congress need to trust
us. They need to share such vital information with us in
advance, and at their own initiative, not ours. If the data
withstands the harsh scrutiny of daylight, it can be the basis
for informed decisions. Otherwise, Congress should step back
and hesitate to act on an uncertain record that has not been
tested.
Indeed, even with all the good work IHS has done over the
past few months, we continue to probe, to ask questions, to
find flaws, to point out inaccuracies, and to prompt IHS to
improve its data further. Tribal health care providers are now
in partnership with IHS in this endeavor, and I have no doubt
that IHS will readily acknowledge the value of our
contribution. After all, we have a vested interest: if the data
is called into question, the whole system may be called into
question. And none of us can afford that outcome, least of all
the thousands of Alaska Native people in the 58 villages we
serve.
3. Third, we share the Committee's interest in learning
more about the issue of agency downsizing. While we at YKHC are
not in a position to assess IHS's downsizing nationally, we do
know that it has happened in the Alaska Area and in our own Y-K
Delta Service Unit in Bethel.
At the service unit level, there is no longer any IHS
presence. Everything that was part of IHS has long been taken
over by YKHC through our Compact with Congress. Of course, that
does not mean IHS does not exist, for the hospital facility we
operate is owned by IHS, and many of the professional staff we
use are IHS employees detailed to us under the
Intergovernmental Personnel Act and other applicable law. We do
this because for many positions we simply cannot match the
compensation benefit packages available to IHS for attracting
qualified medical personnel, especially when it comes to
Commissioned Corps personnel. So we leave those positions with
IRS and we enter into agreements detailing those positions to
YKHC. To that extent, then, IHS still has a vital local
presence in the Yukon-Kuskokwim Delta.
At the Area level, in 1994 we helped set into place a three
year process for transitioning most of the Area Office
operations to the Area's several tribal organizations and
individual tribes. The process has worked well, and has been
coordinated with the Alaska Native Tribal Health Consortium's
and the SouthCentral Foundation's take over this year of the
Alaska Native Medical Center. As a result of all these
carefully planned efforts, the Area and ANMC staff working
under the direction of IHS has shrunk from over 1,350 in 1994
to about 40 today. We believe this example--the first
experiment of its kind in the Nation under the Self-
Determination Demonstration Act, involving the tribal
administration of an entire Area and all its constituent
service units--certainly demonstrates that IHS operations
shrink as Congress permits tribes to step into IHS's shoes.
On a national basis, the reduction of the IHS bureaucracy
may be more difficult to see. For one thing, tribes have not
been as consistently aggressive in the other IHS Service Areas
in exercising their rights under the Indian Self-Determination
Act in part due to the fact that they are not willing (or
perhaps, more accurately, able) to take on services without
adequate contract support appropriations, including start-up
funds. Moreover, even where Self-Determination transfers have
occurred, the reductions in the IHS system have often been
balanced out by expansions in the overall system, thanks to
desperately needed congressional attention to the terrible
shortfalls in health care funding facing Indian country. For
instance, in assessing IHS's reductions, it must be noted that
Congress has increased the IHS service budget from $226 million
in FY 1975, to over $1.84 billion in FY 1999. So, although 40
percent of IHS may now be under tribal operation, the remaining
60 percent is many times larger today than was the entire
agency in 1975. In short, it may well be that far more analysis
is needed to determine whether IHS is in fact a much smaller
agency than it would otherwise be in the absence of the Indian
Self-Determination Act.
Nonetheless, one thing remains clear. In 1988 this
Committee and the Senate Indian Affairs Committee observed that
the IHS service bureaucracy had been gradually replaced with an
oppressive contract monitoring bureaucracy. Since then,
especially with the advent of the 1994 amendments, we have seen
a real reduction at our Area level, and a corresponding
transfer of functions to the tribal providers. But we still
believe more can be done at the Headquarters level in this
regard, and that Headquarters can and must also do a better job
of freeing up all available Headquarters resources that support
the system, including assessments paid to other agencies.
As for other Area Offices outside our own, it is clear to
us that IHS is indeed holding on to its empire in some
quarters, and that it is often reluctant to turn over its
operations to tribal control. This has been particularly
evident in the Phoenix, California and Oklahoma Areas, and it
is fair to say that IHS Headquarters has failed to bring
necessary leadership and consistency to the various Area and
Headquarters determinations regarding appropriate levels of
noncontractible, so-called ``residual,'' ``inherently Federal''
functions. Adding to this particular problem, IHS continues in
some Areas to also withhold from tribal operation so-called
``transitional'' operations (this is so in the Portland and
Oklahoma Areas, among others), despite the ruling of at least
one Federal court that such actions are indefensible and
contrary to the Self-Determination Act. This type of
paternalistic approach has helped foster an ``us versus them''
attitude and an attempt by some to divide Indian country and
pit one region of the United States against another.
In sum, we recognize that IHS has substantially downsized
in response to the Self-Determination Policy, but agree that
more along these lines can and must be done.
4. Fourth, the Committee is correct that more can be done
to accelerate the transfer of additional functions from IHS to
the tribes. Under an IHS plan adopted two years ago, IHS now
takes up to three years to transfer functions from Federal
operation to tribal operation. This never used to be the case,
and functions were always transferred within a matter of
months. That's the way it was with the transfer of our Y-K
Delta Regional Hospital. But this new plan, adopted at IHS
insistence over the objection of many tribes, represents a
serious retrenchment clearly intended to protect the Area and
Headquarters offices. It is also directly contrary to the Act,
which mandates that all IHS functions be paid to a contracting
tribe as soon as the contract goes into effect.
5. Fifth, we share the Committee's interest in learning
more about how much the Federal Government really spends to
support an IHS-operated clinic and hospital. However, we are
skeptical this information can be reliably developed in the
short term. After all, innumerable Federal agencies confer some
benefit on IHS in one way or another, be it the Department of
Justice (in prosecuting collection litigation, defending cases
and other matters), the General Service Administration, the
Office of Personnel Management, the Department of Treasury, the
Veterans Administration (as in negotiating pharmaceutical
contracts), the Equal Employment Opportunity Commission, the
Federal Labor Relations Board, the Government Ethics Office,
the Merit Systems Protection Board, the Government Printing
Office--the list goes on and on.
We assume the goal of such an ambitious study, perhaps
better undertaken by the General Accounting Office than IHS,
would be to provide some meaningful comparison between the true
Federal costs of IHS administered care, and the total costs of
tribally administered care, including contract support costs.
Although the results of such a study would be enlightening,
we respectfully suggest that such a study may ultimately be of
limited use, particularly given its likely cost. For one thing,
the Act and other Federal laws impose upon tribes financial
obligations which do not burden IHS or any other branch of the
Federal Government.
For example, tribes undertake detailed annual audit reports
on all their operations. IHS does not. Tribes carry costly
property and vehicle insurance, casualty insurance, errors and
omissions insurance and other insurance outside the scope of
strict Federal tort claims. IHS does not. Tribes bring in
outside risk managers to help secure and maintain accreditation
and to administer sound programs. IHS does not. Tribes bear the
costs of their governing bodies which develop tribal health
care policy in the same way that Congress controls policy for
IHS. IHS does not. Tribes renegotiate their compacts and
contracts every year. IHS does not. A study of the true cost of
Federal administration will miss these tribal-unique costs.
But even more importantly, the Indian Self-Determination
Policy was never designed as a way to save the Federal
Government money. It was built with the goal of promoting
tribal responsibility and accountability. The Act directed that
Federal paternalism and oppression must end, and that
Washington must stop dictating what is best for Indian country
and what is best for the health care needs of Indian people.
And to that extent the policy and its execution have been a
resounding success. Having come so far from where we began, we
must not now let ourselves be diverted from that success by a
preoccupation with whose system costs less, especially given so
many variables in program delivery and facility types.
Nonetheless, we concur in the Committee's interest in
exploring how tribes and IHS can be encouraged to maximize
their efficiency in all operations. One way to do this is to
guarantee to a tribe a stable flow of funding for a period of
years. After all, maximizing efficiency first requires
predictability and stability. If a tribe had a multi-year
budget that was, in fact, actually funded, a tribe would be
free to trim further its administrative overhead as much as
prudently indicated, for the reward would be for the tribe to
retain any savings, to be plowed back into expanded health
care. IHS is already experimenting with this approach, known as
the ``base budget'' approach, with several tribes, and the
proposed permanent Self-Governance legislation would clarify
IHS's authority to do so within the Self-Governance program.
The Committee may wish to encourage IHS to explore the same
avenue for ordinary contracting tribes.
6. Sixth, the Committee has asked for comments on how
tribes could further improve the availability of health care
services within their existing budget limitations, and has
particularly asked whether new authority or flexibility is
needed to achieve this goal.
At YKHC we have experimented with a number of recent
innovations, and we would be pleased to share these innovations
in greater detail with the Committee and other tribes. For
instance, we have invested in staff housing so that we can
attract and maintain professional staff and reduce the turnover
that plagues most health care operations in Indian country. We
have changed the way we do business for the extensive travel
required as part of our health care delivery system, to further
reduce costs and conserve our resources. We have created our
own emergency air medivac system, in lieu of expensive private
carriers. We have worked with city governments and commercial
lending institutions to finance long term facility
infrastructure using municipal bonds, saving millions in
financing and interest. We are working cooperatively with the
State of Alaska Department of Health and Social Services to
maximize program delivery of early child intervention and
developmental health programs as well as State funded substance
abuse and mental health services. The Self-Determination and
Education Assistance Act has proven beyond a doubt that when
adequately funded, Tribes are the best health care providers
not only for their own Native people, but for all members of
our communities.
These and other local innovations have helped us stretch
our limited dollars far beyond IHS's ability. Our Tribes are
proud and able to take the responsibility afforded them under
our Compact with this Congress. All we ask is that Congress
allow us the same resources you would want in providing health
care to your own families.
Substantial additional innovations will come with the
enactment of the pending permanent Self-Governance legislation
that I understand either has been or will be introduced this
week. While the legislation is detailed, such detail is
necessary if we are to overcome the barriers in Federal law and
policy that make doing business much more expensive for tribal
health care providers than it needs to be. Given the
extraordinary scrutiny this legislation was given last year in
the form of H.R. 1833, we respectfully hope the Committee will
be able to move the new legislation rapidly to a mark-up early
in the Session.
Along similar lines, Title VI of the same proposed new
Self-Governance legislation should eventually open the door to
important new programs currently administered by the Department
of Health and Human Services outside the authority of IHS.
Title VI puts into place a study which hopefully will lead to
additional legislation in the years ahead. While we would have
preferred moving directly into a demonstration program with the
Department, as originally proposed in H.R. 1833 as introduced
last year, the Department has insisted that any demonstration
program be preceded by careful study. Again, we hope this
Committee will move swiftly on this important new bill.
Finally, we are confident that tribes can bring
considerably more resources into their systems, and can do so
more efficiently, once the Medicaid demonstration program
established in the Indian Health Care Improvement Act is
expanded to all tribal health care providers, as now proposed
in S. 406.
7. We would like to close by commenting on the last topic
identified by the Chairman, how to fund contract support costs
today and in the coming years.
This Committee helped give birth to the Indian Self-
Determination Policy a quarter of a century ago. What we need
today as tribal health care providers, first and foremost, is a
resounding and unequivocal recommitment of the Nation to that
policy. In the area of contract support costs, we respectfully
believe that that commitment means fully funding existing
contract support cost needs.
It is important that the Committee understand fully the
current situation. As things now stand, tribal health care
providers are actually punished for operating IHS programs. If
they want to operate an IHS program, if they want to take on
responsibility for the program, if they want to realize
improvements in the local health care delivery system, if they
want to break the cycle of paternalism and dependency, there is
a price: the tribes must finance their contract support cost
shortfalls out of the program itself.
This would not be acceptable even under ordinary
circumstances, and circumstances here are far from ordinary.
Already IHS programs are funded at between 40 percent and 60
percent of need. Already, Indian health care is funded at less
than half the national per capita expenditure on health care
for other Americans. It is remarkable, to say the least, that
under these circumstances tribes in our part of the country
living in ``third-world conditions'' should be required to
further reduce their programs in order to realize the benefits
of improved health care and local autonomy that come with the
Indian Self-Determination Act. IHS has provided the Committee
with an estimate of the increase needed to fully fund contract
support through FY 2000 (including inflation adjustments for FY
1999 and FY 2000), and we respectfully urge the Committee to
support a full increase in that amount in its communications
with the Budget Committee and the Appropriations Committee.
For the future, there is every indication that the rate of
increase in contracting activities has now come down
substantially, and will likely carry a contract support cost of
between $10 million and $15 million for the Indian Self-
Determination Fund funding each year. Proportionately, this is
consistent with the size of the ISD Fund in the mid-1990s, and
we therefore believe it is reasonable for Congress to commit to
continue funding new contracts at that level for many years to
come.
Most importantly, we have been unable to identify any
systemic problem either in the general Self-Determination
process or in the specific contract support cost process. We
therefore respectfully caution the Committee to reject
recommendations that would revamp the Self-Determination Act in
significant ways, such as by deferring new contract starts,
deferring tribal entitlements to receive contract support, or
otherwise weakening the Act's contract support cost provisions.
Improvements, however, can certainly be made in how the Act
has been carried out. For instance, IHS and BIA can report to
Congress on a more timely basis the contract support cost needs
anticipated both for the current year and the upcoming new
year, so that Congress can more easily make corresponding
adjustments in the supplemental and ordinary appropriations
processes. While there is no indication that the contract
support shortfall has been caused by a lack of information
regarding its extent--a shortfall that has been regularly
reported to Congress, the Secretary and OMB, and that has long
been well-known--certainly more accurate, detailed and earlier
reporting will lead to correspondingly better decisions here.
Given the progress IHS has made in its data collection this
year, working with the National Congress of American Indians
and Tribal technicians, consultants, and Tribal attorneys, this
is not an ambitious request.
We also believe the agencies can do a better job of
refining and standardizing the process for detennining contract
support cost needs. The National Congress of American Indians
is already looking into this area, and we look forward to
NCAI's recommendations later this year. YKHC certainly supports
standardization that is sensitive to areas of commonality among
tribes, as well as being sensitive to the unique differences
among us. After all, no one would quarrel with the fact that
our contract support cost needs are necessarily higher given
where we are located than an identically-sized program within a
casual drive outside Phoenix, Minneapolis or Seattle.
Finally, Mr. Chairman, we would ask that you and this
Committee do everything possible to elevate the position of
Director of Indian Health to the Assistant Secretary level--a
tribal request that is long overdue.
Mr. Chairman, we thank the Committee for the opportunity
and honor of testifying today on an issue that is directly
affecting the health and welfare of thousands of Alaska Native
and non-native people back home, and of millions of Native
American people across the country. We look forward to working
closely with the Committee as it continues its examination into
the Self-Determination contracting and compacting processes,
and to exploring all avenues for continually strengthening both
the Nation's Self-Determination policy and the ultimate
delivery of the highest quality health care services possible
to our people at home.
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Statement of Lieutenant Governor Cecil Antone, Gila River Indian
Community
INTRODUCTION
Good morning, Mr. Chairman and Members of the Committee. My
name is Cecil Antone and I am the Lieutenant Governor of the
Gila River Indian Community. I have had the privilege of
serving as Lieutenant Governor since I was first elected in
1993. I am honored to have the opportunity today to represent
the Gila River Indian Community before the Committee to discuss
Federal funding for contract support costs associated with
health care programs in Indian Country (``Contract Support
Costs''). This is an issue of vital importance to the health
and welfare of our Community members, as well as members of the
Nation's other Indian tribes.
The Gila River Indian Community (the ``Community'') is
located on 372,000 acres in south central Arizona. Our
Community is composed of approximately 19,000 tribal members,
13,000 of whom live within the boundaries of the Reservation.
We have a young and rapidly growing population that presents us
with a variety of health care challenges, now and in the
future.
It is appropriate that the Committee has asked the
Community to testify at today's hearing. Although our
Community's experience with Contract Support Cost funding
exposes some of the weaknesses of past funding practices, it
also illustrates the significant rewards that can result when
Indian tribal governments embrace the self-determination policy
articulated in the Indian Self-Determination and Educational
Assistance Act (``ISDEA'') by taking over operation of health
care programs. We believe our story has both lessons to teach
and hope to give in reaching a lasting solution to the Contract
Support Cost funding issue.
We have attempted in this testimony to provide the
Committee with our views with respect to the questions it has
posed to the Indian Health Service (``IHS'') about Contract
Support Costs. We have tried to answer those questions in the
context of the story we have to tell about our experience with
Contract Support Cost funding.
THE CONTRACT SUPPORT COST ISSUE
I would like to take the opportunity to briefly present
some background on the role of Contract Support Cost funding in
the successful implementation of self-determination policy. Our
Community believes strongly that anything less than full and
recurring funding of Contract Support Costs compromises the
fundamental purposes underlying the Federal policy of tribal
self-determination. We believe that Congress and the
Administration understand this, as well. More than a decade
ago, the United States Inspector General concluded that the
Federal Government's payment of Indian tribal governments'
Contract Support Costs enables Indian tribal governments to
improve their administrative capacity and comply with Federal
requirements applicable to the operation of their health care
programs.\1\ The Committee Report that accompanied the 1988
amendments to ISDEA went on to state as follows:
---------------------------------------------------------------------------
\1\ S. Rep. 100-274 at 11.
The use of indirect costs is widely accepted by state, county
and local governments, and by universities, hospitals and
nonprofit organizations. The most relevant issue is the need to
fully fund indirect costs associated with self-determination
contracts. The [Administration] should request the full amount
of funds from the Congress that are adequate to fully fund
tribal indirect costs. Furthermore, the Bureau of Indian
Affairs and the Indian Health Service must cease the practice
of requiring tribal contractors to take indirect costs from the
direct program costs, which results in decreased amounts of
funds for services.\2\
---------------------------------------------------------------------------
\2\ Id. at 11-12.
---------------------------------------------------------------------------
Contract Support Cost funding is absolutely crucial to the ability
of Indian tribal governments to operate health care programs
transferred to them by IHS because those funds cover the ``overhead''
and other administrative costs that Indian tribal governments incur in
operating contracted Federal programs. Examples of such costs include
personnel, audit, financial and property management services.
In some cases, full funding for these functions cannot be
transferred from the IHS to Indian tribal governments because the
function is provided by a Federal agency outside the IHS. For example,
the Department of Justice and the Department of Health and Human
Services Office of General Counsel provide IHS with legal services, the
Office of Personnel Management provides IHS with personnel support and
training, and the Office of Management and Budget provides IHS with
budget and program policy formulation and analysis.
In other cases, IHS cannot transfer full funding for such functions
because the costs are not incurred by IHS at all, but Indian tribal
governments must incur the cost to operate the program. Examples of
such costs include liability insurance and audit costs. When the IHS
cannot directly transfer necessary resources to Indian tribal
governments to support a function required by contracts with IHS, IHS
is required by ISDEA to provide the Indian tribal government with
Contract Support Cost funds to cover these costs.
As the Committee is aware, there is a long history of inadequate
funding of Indian tribal governments' Contract Support Costs. Congress
made specific amendments to ISDEA in 1988 and 1994 to remedy this
problem by requiring the IHS to add to the amount available for direct
program costs the full amount of Indian tribal governments' Contract
Support Cost need. Nonetheless, inadequate appropriations have remained
a significant obstacle to realizing the self-determination mandate. The
sad result is that every un-funded dollar of Contract Support Costs
must be compensated for by Indian tribal governments by reducing their
level of effort to maintain administrative systems or by reallocating
funds for patient services to pay administrative costs--a result ISDEA
and its amendments specifically sought to avoid. In the present
environment of inadequate funding for Indian Health Services, funding
for tribal health services cannot be further diverted without having a
severe impact on health care status.
The $35 million that was appropriated for Contract Support Costs in
Fiscal Year 1999 was a significant accomplishment, but we must continue
our work to find a reasonable, lasting solution that recognizes the
validity and necessity of full and recurring Contract Support Cost
funding to the realization of the goals of tribal self-determination.
Any such solution must acknowledge that increases in Contract Support
Cost funding are imperative and unavoidable if the true promise of the
self-determination policy is to be realized.
THE SUCCESS OF TRIBAL HEALTH CARE PROGRAMS AND SERVICES
I would like to turn now to the success of the policy of Indian
self-determination. Tribal leaders have testified consistently
throughout the years to the importance of the self-determination policy
in building local programs and administrative infrastructure. In
oversight hearings conducted in the Spring of 1987, for example, tribal
leaders testified that through self-determination, Indian tribal
governments experienced greater utilization of services, increased
stability in tribal government and communities, and a greater focus on
tribal economic development. Our Community's experience has been the
same.
Since the Community assumed local operation and management of
health care services through our Department of Public Health and the
Gila River Health Care Corporation (``the Corporation''), our Community
has expanded and improved services in many ways. For example, we have
restored services that IHS was forced to eliminate due to inadequate
funding in the early 90's and we have changed aspects of health care
delivery to be more responsive to Community members.
These changes have resulted in increased outpatient visits and a
redirection of services to target our Community's most serious health
needs. We have made these improvements despite operating the largest
component of our health care system--the Corporation--for three (3)
years with no Contract Support Cost funding and our Department of
Public Health at less than full funding. The Corporation alone has
absorbed between $2 and $3 million in un-funded costs in each of the
last three years.
The program funding we ``lost'' as a result of having to absorb
Contract Support Costs was requested and appropriated by Congress to be
used to provide health care services to our Community. Moreover, it is
important to remember that the IHS program funding that is made
available to Indian tribal governments is 2/3 less than the average
U.S. per capita expenditure for health care services for the rest of
the Nation. Indian tribal governments are forced to stretch already
limited health program dollars even farther when Contract Support Costs
are not covered by adequate appropriations.
Our Community, fortunately, has been able to keep the level of
health care service constant due to the increased control its exercises
over program dollars. This control was formerly in the hands of the IRS
bureaucracy. We have also increased our third party collections and
received some funds from other Community sources to support increased
health care services to our members. However, even after re-investing
these additional resources into our program, our total funding provides
approximately $1,400 per patient--well below the national average of
$3,046 per patient. Thus, although our Community has achieved far
greater efficiencies than the IHS in utilizing scarce Federal
resources, the fact remains that under-funding Contract Support Costs
requires our Community to use funds appropriated for services for
administrative costs that are not only legitimate and reasonable, but
legally required by our contracts with IHS.
Despite operating under less than ideal conditions, we believe we
have made impressive strides in improving health care services, which
indicates to us the promise inherent in the policy of self-
determination. For example, our Community, like many other tribal
communities, is facing the challenge of a serious diabetes epidemic.
The social cost of diabetes in our Community is staggering The
incidence of type 2 diabetes exceeds 50 percent in our adult
population, with an additional 10 percent of our members having
impaired glucose tolerance. Our children are not immune from this
epidemicz--over 70 children under age 18 have full-blown type 2
diabetes, which, prior to 1998, was rarely reported in the medical
literature in children of this age group.
Among the many serious complications of diabetes is gangrene of the
limbs, which often results in amputations. In 1988, with no podiatrist
on the staff of the IHS hospital, there were twenty (20) lower
extremity amputations in our Community. In the last few years, with two
full-time podiatrists and a residency program in podiatry we have
reduced the number of amputations to between three and five per year.
While this is a significant improvement, our podiatrists need improved
and immediate access to surgical facilities to further reduce and
hopefully eliminate lower extremity amputations in our population.
Gum disease is another diabetes-related condition, which if left
untreated can result in complete tooth loss. Our Community's dental
program now provides enhanced periodontal care for patients with
diabetes. Our diabetes patients are given immediate access to
appointments for examination and diagnosis and are treated utilizing a
specialized protocol developed at our facility. Treating patients with
this protocol has produced improvements in diabetes management as
measured by glycosolates hemoglobin levels.
With over 3,000 individuals in our diabetes registry, the cost of
providing care continues to increase. Almost 150 of our patients are on
dialysis, awaiting renal transplantation. Pharmacy costs also continue
to increase at a rate that exceeds 18 percent per year as newer agents
(such as troglitazone) are necessary to improve the management of
diabetes and forestall the progression of microvascular disease and its
effect on the kidney, heart, eye, and peripheral vascular systems.
In an effort to combat the severe diabetes epidemic within our
population, the Community is currently pursuing a multi-disciplinary
Center for Excellence for culturally appropriate approaches to the
prevention of diabetes. Our Community would support special assistance
by Congress to Indian tribal governments contemplating such initiatives
to target the most severe health care problems plaguing Indian
populations as an incentive for further health care improvements within
tribal health care programs.
In addition, the limited Contract Support Cost dollars that our
Department of Public Health has been receiving through its separate
contracts with IHS have helped to build our health care delivery
infrastructure. These Contract Support Cost funds, although funded at
much less than 100 percent of need, have helped us create an additional
executive position to further improve the management of the numerous
health care programs within the Department. In addition, our Alcohol
and Drug Abuse Program has been able to hire additional counselors.
Other public health programs within the Community have also been able
to increase services for the benefit of the Community, such as through
hiring additional staff.
We are beginning to convert the Department of Public Health from an
underfunded and overworked tribal health care agency into a public
health agency that we believe can rival the best local and state
programs. So far, we have measured the improvements in Department of
Health programs in small steps, and there remains a long way to go. In
October 1998, we began to examine the infrastructure that was needed by
our Community to develop and maintain the necessary databases to
monitor the public health status of Community members. This type of
tribal-specific health information is not kept by national databases
and is essential to monitoring long-term health statistics of our
Community members. We are also developing an Intergovernmental
Agreement between the Community and the State of Arizona dealing with
areas of mutual concern and cooperation on areas of health. In this
respect, the Department of Public Health, through its self-
determination efforts, has already greatly exceeded the prior efforts
of IHS.
Perhaps most importantly, since taking over operation of certain
health care programs, the Department of Public Health has been able to
locate essential services, such as Well Child Clinics, a Wellness
Center, Alcohol and Drug Abuse Program Counseling, Public Health
Nurses, Community Health Representatives, and emergency medical
vehicles, at accessible locations throughout our Community. These
Community-based services were not even contemplated by the IHS.
These tremendous strides in health care service improvements by our
Community have been made at the same time that significant cost savings
have been achieved through the assumption of local operation of
administrative functions. Examples include the ability to enter into
contracts directly with outside service providers, typically at reduced
rates based on our ability to pay invoices on time, and to hire needed
personnel directly rather than going through the MS Area Office Federal
personnel system, under which we had to wait an excessively long time
and often accept less than ideal candidates.
THE COMMUNITY'S EXPERIENCE WITH CONTRACT SUPPORT COST FUNDING
I would now like to discuss in more detail the Community's
experience with the under-funding of Contract Support Costs during the
last three (3) years to highlight some of the problems we have
encountered. In June of 1995, as the Community was preparing to
contract with IHS to assume operation and management of the Community's
Hospital, our Community submitted a Contract Support Cost request of $4
million.
Because of the IHS practice of utilizing a ``queue,'' or waiting
list, for un-funded self-determination Contract Support Cost requests,
our request was placed on the Indian Self-Determination queue (``ISD
queue'') and we waited for funding. Each year we did not receive
funding and but continued to track and refine our Contract Support Cost
request. Eventually, our requests made it close to the ``top'' of the
ISD queue and we would have been funded at 100 percent in Fiscal Year
1999 if the ISD queue system had continued as it was operated in the
past.
However, despite a backlog estimated at over $60 million in un-
funded Contract Support Cost requests, the Administration requested no
new funds for the ISD queue in Fiscal Year 1999. After a massive effort
by Indian tribal governments and tribal supporters in Congress, $35
million in new funding was included in the Fiscal Year 1999 IHS
appropriation. We understand that this will allow both our Department
of Public Health and Health Care Corporation to receive approximately
70 percent of our Fiscal Year 1999 request.
Although we will not receive our anticipated 100 percent Contract
Support Cost funding in Fiscal Year 1999, we support the proposed
method of allocating the $35 million in new funding because we believe
it goes along way toward bringing all Indian tribal governments closer
to meeting their Contract Support Cost need. However, under the
proposed allocation methodology, another $1.2 million of our IHS-
approved Contract Support Costs will not be funded in Fiscal Year 1999.
This brings our total un-funded Contract Support Costs over the last
four (4) years to between $8 and $11 million.
While Section 314 of the Fiscal Year 1999 IHS appropriations bill
expresses the view that Indian tribal governments should not be able to
collect these past due amounts, we believe this view simply invites
needless litigation and would be better addressed jointly by Congress,
the Administration, and Indian tribal governments discussing this issue
to reach some consensus on how to address this past liability. In this
regard, we need a firm commitment from Congress and the Administration
that they will continue to strive to address our past un-funded costs
and to reach and maintain 100 percent funding for the future.
THE NEED FOR ACCURATE CONTRACT SUPPORT COST DATA
If Congress is to commit to reaching and maintaining 100 percent
Contract Support Cost funding, they obviously need more accurate
Contract Support Cost estimates for appropriations purposes. With
respect to that issue, I would now like to discuss the Committee's
concern about the lack of accurate and complete data relating to
current and projected future Contract Support Costs during the last
appropriations period.
As Committee Members are aware, during the Fiscal Year 1999
appropriations period, there was much discussion about how the $35
million in new funding would be allocated among the Indian tribal
governments. That complex debate was made significantly more difficult
due to the lack of firm Contract Support Cost numbers from IHS.
We believe the past practice of maintaining a queue and expecting
that only the top $7.5 million in requests would be funded each year
very likely contributed to the lack of accurate information concerning
the real Contract Support Cost need for all Indian tribal governments
contracting with IHS. IHS apparently did not feel compelled to
scrutinize and finalize queue requests until an Indian tribal
government was nearing the top of the queue. The Contract Support Cost
debate during the Fiscal Year 1999 appropriations cycle required
accurate numbers for all Indian tribal governments on the queue and
highlighted the importance of accurate and thorough information.
IHS, and particularly the Office of Tribal Programs and Finance
staff, should be commended for their efforts in the past six (6) months
toward getting a handle on current Contract Support Cost needs and
projecting the additional funds needed to remedy the remaining
shortfalls. Now that a significant portion of the hard work has been
done, it is critical that IHS Headquarters work with the Area Office
staff to keep the information updated and accurate and to work more
closely with Indian tribal governments to get their future Contract
Support Cost needs sufficiently in advance.
REDUCTIONS IN IHS
With respect to the Committee's inquiries concerning the
feasibility of further reductions in IHS bureaucracy, we do not believe
it is necessarily possible for IHS to make parallel reductions in the
IHS with each self-determination contract it enters. We would, however,
like to see a dynamic change in the function, direction, and
organization of the agency as more Indian tribal governments provide
their own health care services. For example, in the Phoenix Area, many
Indian tribal governments, unlike our Community, operate their public
health programs and IHS provides the direct care.
Under the present system, these Indian tribal governments continue
to need the support of an Area Office focused on the provision of
direct care. At the same time, our Community no longer needs or
utilizes these IHS program support functions, and where we do need such
support, we generally hire appropriate personnel or contract with
consultants who have the required private-sector expertise.
To support our programs, we need the IHS to work with us in a true
government-to-government partnership to timely and cooperatively
provide us with information pertinent to our Federal funding for which
it is the conduit. There should be some corresponding reduction of
effort within the IHS resulting from the change in services and
functions that are provided by an Indian tribal government under a
self-determination contract. We support Federal legislation that would
provide a reduction in IHS administration, consistent with the goals of
ISDEA policies, so long as the diverse and unique needs of all Indian
tribal governments are considered in any such plan.
We also acknowledge that significant barriers to downsizing IHS
exist. For example, any legislation mandating reductions will have to
take into account Federal employment laws and how they affect the
agency taking reductions commensurate with the functions that have been
contracted.
As a related matter, we strongly support legislation to make self-
determination permanent within the IHS, given the demonstrated success
of the self-determination policy. Such legislation would be similar to
H.R. 1833, co-sponsored by Chairman Young and passed by the House in
the 105th Congress, which would have permanently established and
implemented tribal self-governance within the Department of Health and
Human Services.
ACHIEVING THE HIGHEST LEVEL OF HEALTH CARE
Aside from reducing or reorganizing IHS, we have other suggestions
as to how to achieve the highest level of tribal health care possible.
For example, we believe that higher levels of health care would result
from more consistent and reasonable application by IHS of the rules
governing what is included in the indirect cost pool for determining
indirect cost rates for Indian tribal governments. Currently, an
unintended penalty is imposed on certain Indian tribal governments by
the large differences in indirect cost rates negotiated by the
Inspector General.
Indian tribal governments like ours with lower indirect cost rates,
often due to economies of scale, receive proportionately less of the
available Contract Support Cost dollars as a result. The effect is that
the most efficient Indian tribal governments receive a proportionately
smaller portion of available Contract Support Cost dollars. Our
Community has, comparatively, a very low indirect cost rate of about 13
percent, compared to rates close to 100 percent for other Indian tribal
governments. Therefore, we would support efforts by IHS to apply a more
consistent and reasonable methodology to the determination of costs
included in the indirect cost pool, recognizing of course the diverse
needs of Indian tribal governments.
With respect to the Committee's request for suggestions for the
removal of barriers to efficient health care delivery by Indian tribal
governments in order to achieve the highest level of tribal health
care, our Community would support agency assistance for Indian tribal
governments in accessing other Federal programs that can bring in
additional funds, such as those within the Centers for Disease Control
and Prevention and the Office of Minority Health.
We also have some ideas in response to the Committee's request for
suggestions to increase flexibility in the administration of local
health care programs. Our Community's health care programs would
benefit, for example, from access to the Federal Health Care
Professions Fund, from which the agency currently excludes Indian
tribal governments from participation. Access to the Fund would allow
Indian tribal governments to identify and recruit candidates from the
tribe to send to medical or business school to assume medical or
executive positions within the operation of the local health care
programs. The recruitment of tribal members for long-term employment
within tribal health care operations is a proven way to ensure the
long-term stability of tribal health care programs. In addition,
currently the IHS's Prime Vendor Program requires the Corporation to
purchase drugs through IHS. The Community's ability to purchase drugs
on its own would result in increased cost savings and efficiency.
Although we do not have the opportunity to fully develop these and
other ideas in this testimony, they may be worth exploring further in
another context in an effort to further improve the efficient delivery
of tribal health care services.
HEALTH CARE DELIVERY ALTERNATIVES
With regard to Indian tribal governments that strive for the
highest health care possible but choose not to contract with IHS for
local operation of health care programs, we believe it would be helpful
if non-contracting Indian tribal governments had more authority to tell
IHS what programs they would like to see IHS put in place to meet the
specific health care needs of tribal members. Other mechanisms, such as
meaningful tribal participation on IHS service unit governing boards,
would assist in improving care and meeting the needs of tribal
communities where a tribe does not choose to contract directly.
It is important not to lose sight of the fact, however, that new
approaches to the delivery of health care cannot replace the urgent
need for increases in Contract Support Cost and program funding. What
Indian tribal governments need now before anything else is a firm
commitment from the Administration and Congress new funds will be made
available on a recurring basis to meet existing needs. Even among
Indian tribal governments with dramatic records of health care
improvement, there is much more to be done and much more could have
been done had the Indian tribal governments received the full 100
percent Contract Support Cost funding to which they are entitled. The
first priority, then, should be to add to the IHS budget to give Indian
tribal governments 100 percent of their Contract Support Cost and
program needs so that necessary improvements in services can be made.
MORATORIUM
Finally, in addition to ensuring full and recurring Contract
Support Cost funding for Indian tribal governments that currently have
operating programs, it is vital to the policy of self-determination
that Indian tribal governments have the continued right to enter into
self-determination contracts in order to take over administration of
health care programs and services. That is why we fully support lifting
the 638 contract moratorium applied by Congress this past year on any
new and expanded 638 contracts. The moratorium is a direct affront to
the right of self-governance and self-determination provided to Indian
tribal governments under ISDEA and is not a long-term solution to
Contract Support Cost funding issues.
CONCLUSION
These are just a few of the examples we can offer of the promise
that tribal administration of health programs holds for improving the
health and welfare of Indian people throughout the Nation. In order for
the full promise of ISDEA to be realized, however, Congress must commit
to a plan to increase funding for Contract Support Costs to an extent
that will allow full and recurring funding for Contract Support Costs
in future years.
The Gila River Indian Community believes strongly that the
Administration, Congress, and Indian tribal governments working
together can find a way to improve the mechanism for providing needed
Contract Support Cost funding to Indian tribal governments. The reward
will be increases in health care improvement and efficiencies in the
operation of tribal health care programs throughout the Nation.
The first priority must be increasing the funding available to
Indian tribal governments for Contract Support Costs to reach the goal
of full and recurring Contract Support Cost funding. To that end, we
seek a firm commitment from Congress that it will seek an increase in
the money available to Indian tribal governments to cover Contracts
Support Costs now and in the future.
We appreciate that IHS has made significant progress in addressing
these issues in recent months. We encourage Congress, however, to
remain committed to increasing Contract Support Costs not only within
the IHS budget, but also within the Bureau of Indian Affairs budget. In
addition, any proposed congressional solution to Contract Support Costs
should address in a consistent manner Contract Support Costs within the
IHS and the BIA, as well as any other Federal agency that impacts
Indian programs.
What our story and that of other Indian tribal governments
demonstrates is that tribal contractors will do best when they are
given the funding they need and work in a true government-to-government
relationship to create solutions to their unique health care
challenges. Indian tribal governments have proven that the self-
governance framework can build tribal administrative capacity, reduce
bureaucracy, save money, and, most importantly, improve the quality of
health care services to tribal members. It is now up to all of us to
find a lasting solution to Contract Support Cost funding that honors
the Nation's commitment to Indian tribal governments.
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