[Senate Hearing 107-103]
[From the U.S. Government Publishing Office]
. S. Hrg. 107-103
INDIAN HEALTH CARE IMPROVEMENT ACT
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
FIRST SESSION
ON
THE INDIAN HEALTH CARE IMPROVEMENT ACT FOCUSING ON PERSONNEL ISSUES AND
URBAN INDIAN HEALTH CARE PROGRAMS
__________
JULY 31, 2001
WASHINGTON, DC
U.S. GOVERNMENT PRINTING OFFICE
74-575 WASHINGTON : 2002
____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
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COMMITTEE ON INDIAN AFFAIRS
DANIEL K. INOUYE, Hawaii, Chairman
BEN NIGHTHORSE CAMPBELL, Colorado, Vice Chairman
FRANK MURKOWSKI, Alaska KENT CONRAD, North Dakota
JOHN McCAIN, Arizona, HARRY REID, Nevada
PETE V. DOMENICI, New Mexico DANIEL K. AKAKA, Hawaii
CRAIG THOMAS, Wyoming PAUL WELLSTONE, Minnesota
ORRIN G. HATCH, Utah BYRON L. DORGAN, North Dakota
JAMES M. INHOFE, Oklahoma TIM JOHNSON, South Dakota
MARIA CANTWELL, Washington
Patricia M. Zell, Majority Staff Director/Chief Counsel
Paul Moorehead, Minority Staff Director/Chief Counsel
(ii)
C O N T E N T S
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Page
Statements:
Bird, Michael, president, American Public Health Association,
Albuquerque, NM............................................ 6
Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado,
vice chairman, Committee on Indian Affairs................. 1
Culbertson, Kay, executive director, Denver Indian Health and
Family Services, Inc., Denver, CO.......................... 30
Hall, Robert, president, National Council of Urban Indian
Health, Washington, DC..................................... 19
Hill, Barry T., director, Natural Resources and Environment,
General Accounting Office, Washington, DC.................. 5
Hunter, Anthony, health director, American Indian Community
House, New York, NY........................................ 21
Inouye, Hon. Daniel K., U.S. Senator from Hawaii, chairman,
Committee on Indian Affairs................................ 1
Malcolm, Jeffrey, senior evaluator, Natural Resources and
Environment, General Accounting Office, Washington, DC..... 5
Meyers, Carol, executive director, Missoula Indian Center,
Missoula, MT............................................... 24
Vanderwagen, William C., acting chief medical officer, Office
of the Director, Indian Health Service, United States
Department of Health and Human Services, Rockville, MD..... 2
Waukazoo, Martin, executive director, Native American Health
Center, Oakland, CA........................................ 26
Appendix
Prepared statements:
.............................................................
Bird, Michael (with attachment).............................. 50
Conrad, Hon. Kent, U.S. Senator from North Dakota............ 45
Culbertson, Kay.............................................. 58
Daschle, Hon. Tom, U.S. Senator from South Dakota............ 45
Forquera, Ralph, executive director, Seattle Indian Health
Board (with attachments)................................... 97
Hall, Robert................................................. 75
Hill, Barry T. (with attachments)............................ 65
Hunter, Anthony (with attachments)........................... 87
Meyers, Carol................................................ 53
Taylor, Jr., Wayne, chairman, Hopi Tribe..................... 61
Valadez, Ramona, executive director, Native Direction, Inc.
(with attachments)......................................... 139
Vanderwagen, William C....................................... 48
Waukazoo, Martin............................................. 56
Additional material submitted for the record:
Magedanz, Tom, staff, South Dakota-Tribal Relations
Committee, memorandum (with attachments)................... 152
Perdue, Karen, commissioner, Department of Health and Social
Services, Alaska........................................... 158
INDIAN HEALTH CARE IMPROVEMENT ACT
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TUESDAY, JULY 31, 2001
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The committee met, pursuant to notice, at 10:05 a.m. in
room 485, Russell Senate Building, Hon. Daniel K. Inouye
(chairman of the committee) presiding.
Present: Senators Inouye, Conrad, and Campbell.
STATEMENT OF HON. DANIEL K. INOUYE, U.S. SENATOR FROM HAWAII,
CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS
The Chairman. The committee meets this morning to receive
testimony on the challenges confronting the Indian Health
Service, privately-administered health care programs, and urban
Indian health care programs with regard to recruiting and
retaining health care professionals today and in the years
ahead.
Today's hearing will also address the challenges
confronting the urban Indian health care programs as they
address the health care needs of Indian people residing in
urban areas--a population which now represents 60 percent of
the total population in Indian country.
The committee is pleased to welcome the witnesses. We look
forward to your testimony.
Before we do, I am pleased to call upon our vice chairman.
STATEMENT OF HON. BEN NIGHTHORSE CAMPBELL, U.S. SENATOR FROM
COLORADO, VICE CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS
Senator Campbell. Thank you, Mr. Chairman.
In the 106th Congress the committee held four hearings on
various parts of S. 212, and today we will continue with that
series of hearings. This bill would reauthorize the Indian
Health Care Improvement Act, the core act that authorizes the
majority of Indian health programs.
We have both said many times in the past Mr. Chairman, the
American Indians and Native Alaskans continue to suffer the
worst health status of any group in America. Since 1976 this
act has been a powerful tool in helping tribes and the IHS
change the health status of Native populations for the better.
Since the initial passage of the act, the death rate among the
Native population has decreased in all categories, and the
provision of health services has improved overall. I believe S.
212 will put us on the right path of achieving the goals that
we first set out to accomplish in 1976.
Today we'll discuss an issue of growing concern to me, and
that's the provision of health care for our urban Indian
population. Over one-half of our Indian population lives off-
reservation, most of them in urban areas, and yet funding for
the urban programs in the IHS system is still only 1.14 percent
of the entire IHS budget and has remained stable for the last 3
years, even though the urban Indian population is growing.
Today we'll also look at the personnel programs of IHS. One
of the purposes of the Health Care Improvement Act was to
increase the number of Native people who enter this profession.
I think the act has already helped many individuals enter the
profession, but I also think we need to look more closely to
see if we are doing all we can do to attract more Indian
people, as well as other dedicated health professionals, in the
Indian Health Services.
I look forward to the hearing, Mr. Chairman. Thank you for
calling it.
The Chairman. I thank you very much.
Our first panel consists of the following: The acting chief
medical officer, Office of the Director, Indian Health Service,
Department of Health and Human Services, Dr. William C.
Vanderwagen; the director of the Natural Resources and
Environment, General Accounting Office, Barry T. Hill, and he
will be accompanied by Jeffrey Malcolm, senior evaluator,
Natural Resources and Environment; and the president of the
American Public Health Association, Michael Bird.
I am pleased to call upon Dr. Vanderwagen. Welcome.
STATEMENT OF WILLIAM C. VANDERWAGEN, ACTING CHIEF MEDICAL
OFFICER, OFFICE OF THE DIRECTOR, INDIAN HEALTH SERVICE,
DEPARTMENT OF HEALTH AND HUMAN SERVICES, ROCKVILLE, MD
Mr. Vanderwagen. Thank you, Mr. Chairman, and good morning
to you. It is so good to see you here.
We appreciate greatly the committee taking the time to
review with us the issues of concern to the committee and to
Indian people with regards to Indian health manpower and the
needs of urban Indian people.
I have a prepared statement which I would ask to be entered
into the record.
The Chairman. Without objection, so ordered.
Dr. Vanderwagen. Thank you, sir.
As both you and the vice chairman have noted, sir, the
health status of Indian people still lags well behind that of
the general U.S. population. Diabetes is at least four-fold
what it is in the general population, alcoholism is seven-fold
what it is in the general population, et cetera.
The Congress has given us what I view to be a very sacred
mission, and that is to elevate the health status of American
Indians and Alaska Natives to the highest possible level and
develop the capacity of Indian communities to manage and direct
their own health care systems.
Today, as we talk about manpower, I think the issue of have
we discharged that responsibility with some success around
building local capacity is what we would like to talk with you
about. We believe there are clear indicators of success.
For example, in the ITU setting--that is, in the Indian
Health Service, tribal, and urban programs--and we are a health
system now that encompasses those three facets--Federal,
tribal, urban--75 percent of the staff in those organizations
are Indian people, and it is because of the scholarship
program, it's because of the CHR program.
I like to believe that the woman who 30 years ago became a
CHR supported her daughter through the scholarship program to
become an RN, and now her daughter is attending medical school,
and we've seen that kind of change in the development of
professional skills and capacities in the Indian communities.
We think that is good public health. It strengthens those
communities and their ability to take care of issues.
We've also had a variety of other opportunities provided to
us in terms of how we approach recruitment and retention. Today
we have with us here in this audience a number of folks who are
working with Indian Health Service this summer. They are future
leaders in Indian health. Some of them are wearing uniforms.
They came to the co-step program. We have two medical students
from the Uniformed Services University here. We have students
in the undergraduate area who are here courtesy of the
Washington Internship for Native Students at AU. We have people
who are here because of the externship program that we have
available to us under the Indian health manpower authorities.
These are the future leaders of Indian health. So we believe
there has been success in developing Indian people's capacity
to manage and deliver their own health system.
There are still recruitment issues to be addressed. Using
the loan repayment authority provided, we have been able to
expand the number of individuals, professional individuals that
we are able to bring to Indian country to assist us in meeting
these health challenges of diabetes, of alcohol, and other
issues. This would include podiatrists, pharmacists, nurses,
dentists, physicians. We continue to have vacancy rates that
exceed the general population. Our physician-to-population
ratio still exceeds 1-to-1,000, compared to, say, the District,
where it is 1-to-250. So we still have recruitment challenges
to address.
We have significant retention challenges, as well. The
difficulty in being isolated, cultural transition, and dealing
with a system that is severely rationed does lead to turnover,
and, in fact, those vacancy rates that I mentioned earlier in
some measure are reflective of those issues.
The average tenure of our staff is less than we would like
it to be. Physicians stay on average 8 years. Nurses stay on
average 12 years. We'd like to see them for a whole career.
That is a challenge that we have in front of us yet in manpower
recruitment and retention.
The urban programs are a significant concern to us in the
agency. In the last 5-to-7 years, under the leadership of our
director, Dr. Trujillo, we have taken the approach that I
mentioned earlier--that we are the Federal, the tribal, and the
urban programs that are a health system for delivery of health
services to Indian people.
As Mr. Campbell noted, significant increases in urban
population are confronting us, in part because cities have now
grown to reservation boundaries. Albuquerque can no longer grow
north, west, or south, because they have reached reservation
boundaries. And, in fact, those Indian people who live on those
reservations are now urban Indians in that they live within an
SMSA. On the other hand, the population that was moved in the
1950's and their children and grandchildren has expanded
significantly, as well. So there are real issues to address in
meeting the health needs of urban people.
While we talk about health statistics in Indian
populations, we don't have the data we need to fully understand
the specific issues that affect urban Indian people. We have
only now, in the last 1\1/2\ years, established an epidemiology
center with a focus on health needs of urban Indian people. The
data needs are large for trying to understand where the issues
are and how we can best address them, and that's a task that
we're taking on in consultation with urban people.
Urban Indians have been included fully in the consultation
process around budget allocation. They have been included in
the budget formulation process. We will continue to include
them as active partners in this health system for Indian
people, and we believe that they are active and viable
partners.
I would be remiss if I didn't note that most of those
programs, on average only about one-third of their funding
comes through the Federal sector funded by Indian Health
Service. A significant amount of their funding comes from other
Federal programs and State and county programs, as well. They
have been very successful at surviving and expanding their
programs. I will give you but one example.
In Los Angeles County, a 400-square-mile area, the Indian
population is diffusely scattered throughout that area. The
approach that has been developed is a managed care approach
with case managers, since there's really no focused population
of urban people, and these case managers work with individual
urban people to identify the best care locations for those
people, whether they're in the northeast corner of the county
or they're in the southwest corner of the county, and it has
been a very successful program.
Because of unique needs in behavioral health, the State and
county, and particularly the county of Los Angeles, have now
helped that clinic start an active outpatient behavioral health
program. They just opened it 5 months ago. One-half of the
county commissioners appeared at the opening of this program,
and it is a testimony to the resourcefulness of those Indian
people in L.A. as to the quality of the job that they have been
able to do.
There are real challenges, and we appreciate the
opportunity to be here today, and I'll be happy to answer any
questions you may have as the hearing progresses.
Thank you.
The Chairman. I thank you very much, Doctor.
[Prepared statement of Dr. Vanderwagen appears in
appendix.]
The Chairman. May I now call on Mr. Hill.
STATEMENT OF BARRY T. HILL, DIRECTOR, NATURAL RESOURCES AND
ENVIRONMENT, GENERAL ACCOUNTING OFFICE, WASHINGTON, DC,
ACCOMPANIED BY JEFFERY MALCOLM, SENIOR ANALYST
Mr. Hill. Thank you, Mr. Chairman. It is certainly a
pleasure for Mr. Malcolm and me to appear before this
committee. We're here today to discuss the issue of Federal
tort claims coverage for tribal contractors, and my comments
this morning will focus specifically on the FTCA coverage and
claims history for tribal self-determination contracts at the
Indian Health Service.
If I may, I'd like to briefly summarize my prepared
statement and submit the full text of my statement for the
record.
The Chairman. Without objection, so ordered.
Mr. Hill. Last year we issued a report to this committee on
the combined FTCA claims history for tribal self-determination
contracts at the Indian Health Service [IHS] and the Bureau of
Indian Affairs [BIA]. That report provides more details about
the provisions that extended FTCA coverage to tribal
contractors and four emerging legal issues affecting FTCA
coverage for those contractors.
For my testimony today, we've updated the status of the IHS
claims since our report last year, and the figures I will be
presenting were current as of July 15, 2001.
Let me start my testimony today by briefly describing the
process for implementing FTCA coverage for tribal self-
determination contracts.
We are here today because accidents happen, and when those
accidents are caused by the negligent actions of a tribal
employee, the injured parties may be able to seek compensation
from the Federal Government for their personal injuries. For
example, if a patient receives negligent care at a tribal
health facility or there is an accident involving a tribal
ambulance, the injured party may be able to seek compensation
from the Federal Government. Federal regulations implementing
FTCA prescribe the process that Federal agencies must follow in
resolving claims arising from the negligent or wrongful acts of
Federal employees. With the extension of FTCA coverage to
tribal contractors, tribal employees or volunteers under a
self-determination contract are considered Federal employees
for the purpose of FTCA coverage.
According to the FTCA regulation, claims are subject first
to the administrative review and determination by the Federal
agency whose actions gave rise to the claim. These claims must
be presented in writing to the agency within two years, and
they must contain a request for a specific amount of
compensation.
At the administrative level, claims arising from IHS
programs are filed with the Department of Health and Human
Services Claims Branch in Rockville, MD. The Claims Branch has
been delegated authority to resolve claims of $10,000 or less,
and the Department's Office of General Counsel issues
administrative determinations for claims in excess of $10,000.
Due to medical malpractice considerations, medical-related
claims go through a much more rigorous review process than non-
medical claims.
If the claim is not resolved administratively, a lawsuit
may be filed in Federal court where the Department of Justice
will defend it. Administrative and legal settlements may be
paid from agency funds, the U.S. Treasury, or a tribe's private
liability insurance if duplicate coverage exists.
The Department of Health and Human Services identified 114
claims involving tribal contractors of IHS programs that were
filed during fiscal years 1997-99. The total damages claimed
were $487 million, with patient care activities accounting for
nearly 45 percent of these claims and vehicle accidents
accounting for another 35 percent.
These claims involve tribally-contracted programs for 40
contractors. The Navajo Nation, the largest tribe, had the most
claims, with 14, and 6 other contractors had 5 or more claims
during this 3-year period.
The damages claimed ranged from a low of $75 to a high of
$100 million, with a median claim amount of $1 million. And, as
of July 15, 40 claims had resulted in settlement payments, 18
were ultimately denied, and the final outcome of 56 claims is
still pending either administratively or in litigation. A total
of 58 claims or 51 percent have been brought to closure at a
cost of $680,000 out of the $230 million claimed in those
cases. The small, simple claims for minor incidents, such as a
fender bender, are generally resolved quickly, while the large,
complex claims may take longer to resolve.
The total settlement figure paid to date amounts to
$680,000; however, this figure will likely increase as the
remaining claims are resolved.
Finally, we found that claims involving tribal contractors
are being processed the same way as claims involving Federal
employees, and that the percentage of tribal claims approved
and the amount awarded are comparable with the resolution of
other FTCA claims at the Department of Health and Human
Services.
Mr. Chairman, that concludes my statement. I'd be pleased
to respond to any questions that you or members may have.
The Chairman. Thank you very much.
[Prepared statement of Mr. Hill appears in appendix.]
The Chairman. Now may I call on Mr. Bird.
STATEMENT OF MICHAEL BIRD, PRESIDENT, AMERICAN PUBLIC HEALTH
ASSOCIATION, ALBUQUERQUE, NM
Mr. Bird. Good morning, Mr. Chairman and members of the
committee. You have my written document which has been
submitted to you. I'd like now just to go into a narrative
description on my comments.
I am Michael Bird, Santa Domingo and San Juan Pueblo Indian
from New Mexico. I am president of the American Public Health
Association. I'm the first American Indian president of the
American Public Health Association in 128 years, so if patience
is a virtue Indian people must be very virtuous.
Today I am representing the Friends of Indian Health, the
coalition of over 40 organizations and individuals. We thank
you for the opportunity to testify today and to comment on
health care personnel issues that we think should be addressed
in the reauthorization of the Indian Health Care Improvement
Act.
I'd like to share a quote with you:
The first Americans, the Indians, are the most deprived and
most isolated minority group in our Nation. On virtually every
scale of measurement--employment, income, education, and
health--the conditions of the Indian people ranks at the
bottom.
Mr. Chairman, this quote was made over 30 years ago by then
President Richard M. Nixon. Unfortunately, little has changed
since then, especially in regards to health care for American
Indians and Alaska Natives.
Recently, a member of the Friends of Indian Health sought
care from the Phoenix Indian Medical Center for a 1 o'clock
doctor's appointment. He left his home at 11 a.m., arriving at
noon. He knew that he needed to arrive 1 hour before his
appointment because patients are seen on a first-come, first-
served basis, even those with scheduled appointments. At this
facility, the patient-to-doctor ratio is overwhelming. Not only
does it serve Indian patients within the Phoenix city limits,
but also patients are brought to the Phoenix Indian Medical
Center by vans from adjacent reservations that lack inpatient
services.
Our friend was eventually seen, but also told that his back
condition had worsened and that he would probably need surgery.
Because of a lack of orthopedists at Phoenix Indian Medical
Center, he was unable to schedule consultation until September
27.
The patient's checkup took all afternoon. This experience
is not unique. There is disparity in access to care throughout
the Indian health care system. Or another way to view this
situation is to compare the IHS to the Phoenix Veterans Medical
Center, which is within 1 mile from the Phoenix Indian Medical
Center. The total number of outpatient visits at the VA
facility was over 8,000, compared to more than 14,000 at the
Phoenix Indian Medical Center, a difference of over 6,000. The
VA employs nine psychologists, while the Phoenix Indian Medical
Center employs four. The total number of behavioral staff at
the VA was 75, as compared to 17 at the Phoenix Indian Medical
Center.
The Friends of Indian Health believes that by improving
access to treatment and prevention the IHS will make
significant strides in reducing health disparities and
mortality rates. This was demonstrated by the placement of a
podiatrist with the Winnebago and Omaha Tribes. During his 4-
year tenure, the average annual leg amputations fell from 16 to
0. Not only did this improve the daily living and quality of
life for the patients and their families, but resulted in a
cost savings of over $2 million in surgical expenses.
But the IHS needs to move quickly to better recruit and
retain providers. If the Administration waits too long, the
competition will become more intense. Therefore, the Friends of
Indian Health suggest that Congress take the following steps:
No. 1, make loan repayments tax free. Currently, the IHS
pays providers $20,000 annually, an additional 20 percent of
that sum to the Internal Revenue Service [IRS]. Totally, $3.4
million goes to the IRS from the IHS loan repayment account. If
the loans were tax free, 170 more providers could be available.
No. 2, give IHS health care personnel 3-year student loan
deferments. Volunteers in programs like the armed forces, Peace
Corps, or Domestic Volunteer Service do not have to repay the
principal of or the interest on any student loan for 3 years.
This provision does not apply to those working in IHS or for
tribes. This oversight can cost recent graduates more than
$1,000 a month. Faced with this burden, many health care
professionals cannot afford to join the IHS or work for tribes
or urban programs.
No. 3, conduct exit interviews. As the IHS approaches the
next decade and must compete for health personnel, the Friends
of Indian Health believes that it should require exit
interviews determining whether staff are leaving because of
non-competitive salaries, high debt burden, inadequate housing,
or lack of esprit de corps would be essential to quickly making
corrections to prevent others from leaving.
No. 4, recruit active and retiring health care
professionals interested in providing care on a part-time or
temporary basis. The American Academy of Pediatrics has
received more than 300 requests from active physicians for
information about short-term pediatric opportunities at IHS
sites. Additionally, we believe that many other providers are
not ready to completely retire and would be willing to
volunteer 1 week, 1 day, 1 month, or even 6 months to their
service. Their experience and expertise particularly are in
high demand. The IHS needs to create a program where such
volunteers can be recruited, and assure them that liability
would not be a problem.
Mr. Chairman, the definition of insanity is doing the same
thing over and expecting a different outcome. Therefore, if, in
fact, we desire to make changes to produce different outcomes,
we have to begin today. The Friends of Indian Health believes
our recommendations can move us in that direction.
Mr. Chairman and members of the committee, this concludes
my testimony. I will be happy to answer any questions you might
have.
Thank you.
The Chairman. I thank you very much, Mr. Bird. I find your
testimony most enlightening.
[Prepared statement of Mr. Bird appears in appendix.]
The Chairman. May I begin my questioning with Dr.
Vanderwagen.
I gather that the pay scale of the IHS is tied to DOD; is
that correct?
Mr. Vanderwagen. Yes, sir; that's true.
The Chairman. But does that include bonuses and cost of
living allowances?
Mr. Vanderwagen. For those that are in uniforms, the
bonuses and cost of living allowances are consistent with those
provided to the other uniformed services.
The Chairman. But what happens when there is no comparable
category to tie it in in certain areas?
Mr. Vanderwagen. Well, we have a variety of disciplines,
for instance, where there are no such bonus opportunities or
other inducements that we might provide, and that presents us
with difficulty.
For instance, in nursing there really are no real financial
incentives like that provided through the DOD, so we don't have
much to offer on our side, either, for those that are in
uniform.
The Chairman. For many, many years DOD has been most
reluctant to have joint operations with the VA, and, as a
result, we have had VA hospitals and DOD hospitals. But now,
with the cold war over, many of our military hospitals have
been destined to be closed, and in order to keep them open some
have become joint operations with the VA--for example, in
Hawaii. And the Hawaii operation is a model operation.
Would you consider, where it is feasible, to have DOD have
a joint operation with IHS?
Mr. Vanderwagen. I believe that there are opportunities
like that--for instance, in western Oklahoma. There are other
locations where there may be DOD facilities where, if tribal
and urban people had effective policy involvement in the
development of those relationships, I think we would be very
interested in adding DOD into the partnership.
The Chairman. Mr. Bird, would that be acceptable to Native
Americans?
Mr. Bird. Well, I think it is something that one has to
approach very carefully, because I think there is some concern
in terms of most Indian populations that they're going to end
up losing out when anything like this is explored.
I know in New Mexico, drawing on my 20 years of experience
in the IHS in the Albuquerque area, that there had been initial
discussion back about 10 years ago about negotiating some sort
of an approach with the VA there in Albuquerque, and, as I best
recall, some of the tribes were concerned and actually kind of
put a stop to that because they felt like we would--the tribes,
in fact, would be losing out in some form or fashion.
I don't know if that was based on any real threat to the
services that were provided, but I think that there is that
perception out there in the community that somehow it will
diminish--possibly diminish the Federal Government's role and
responsibility to tribes. But I know that that is a concern.
I think, given the times that we are looking at and the
impact, the adverse impact of lack of services for Indian
people and Indian populations that's occurring today, I think
some tribes might be more open to considering those options.
The Chairman. We will be thinking about that.
Mr. Vanderwagen, is there any partnering or collaboration
between IHS and non-Federal agencies whenever there is a
shortage of specialties?
Mr. Vanderwagen. Yes; I'm glad you asked that, because,
while Michael is here representing the Friends and he was
unable to sort of, in his prepared testimony, speak to some of
the activities with them--for instance, the American College of
OB/GYN routinely assists us in two ways. One is they will go
out with us and do field site visits to assess the quality of
care, needed improvements in patient safety, protections,
medication error management, and that sort of thing, but they
also have a program to provide OB/GYN specialists to assist us
in locations where we have special needs.
The American Dental Association also has done very similar
kinds of site visitation with us and assisted us on a variety
of clinical care needs, as well.
American Academy of Pediatrics--a variety of these
professional organizations that constitute the Friends of
Indian Health have been tremendously helpful, both to the
tribal programs and to the Federal programs. I don't know that
we have been able to link with the urban programs as
effectively as we might with these kind of professional
supports, and that's certainly an area where we could work with
the Friends of Indian Health to expand that relationship.
The Chairman. We have an issue on the Federal Tort Claims
Act.
Mr. Bird. Mr. Chairman?
The Chairman. Yes?
Mr. Bird. Might I share some thoughts?
The Chairman. Sure.
Mr. Bird. I wanted to mention that the American Public
Health Association has, since I became president of the
association, has been much more involved and much more engaged.
There is, in fact, an American Indian and Alaska Native, Native
Hawaiian Caucus, which has a 20-year history of association
with the American Public Health Association. At our annual
meeting this year in Atlanta, which typically draws about
13,000 participants, for the first time in 128 years there will
be a plenary session on dealing with indigenous health. We're
attempting to have four representatives from Native
populations. Actually, there will be a Native Hawaiian
physician who will be part of that program and a Canadian
representative and someone from South America to look at
focusing attention on indigenous health internationally, as
well as within this country.
The Chairman. All right. Thank you.
May I now go to tort claims? Is it true that the Department
of Health and Human Services can only approve settlements of
less than $25,000?
Mr. Hill. Yes; it is.
The Chairman. And yet you have testified that the median
amount is $1 million?
Mr. Hill. That is correct.
The Chairman. Then what should we do? Is something wrong
there?
Mr. Hill. Well, the current process allows them to settle
for those claims that are less than $25,000, but it does allow
the Department of Justice to handle claims in excess of that.
The Chairman. Then what happens?
Mr. Malcolm. I think that's correct. Some agencies have
looked at whether that cap should be increased, kind of
adjusting for inflation type of methodology, given the increase
in the claim amount. Is the $25,000 gap still a reasonable
amount for them to have that authority?
The Chairman. How does it compare with the VA hospitals? Is
there a cap also for veterans going to VA hospitals?
Mr. Malcolm. The restriction of the $25,000 would be for
the entire Federal Government, except where the Department of
Justice has delegated a higher settlement authority. The VA has
been delegated the authority to settle FTCA claims up to
$200,000.
The Chairman. Is that the same with DOD hospitals?
Mr. Malcolm. To my knowledge it is the same, but I'd have
to confirm that.
The Chairman. It is the same?
Mr. Malcolm. To my knowledge it is the same.
The Chairman. Dr. Vanderwagen?
Mr. Vanderwagen. Yes; I agree with him. My understanding is
that that's a Federal-wide cap that independent agencies, short
of litigation going to the Department of Justice, have placed
on them for just settlement.
The Chairman. And what has been the experience with the
Justice Department?
Mr. Vanderwagen. In general, our experience has been mixed.
Without getting too lengthy, we do an extensive quality review
process of any cases brought involving patient care, in
particular, and the Department of Justice has not been actively
involved in that review process with us, and there are times
when we believe that decisions are made despite the review
process that weighs on the merit of the case, and that has been
of some concern to providers, because if Justice proceeds,
despite the fact that the Quality Review Panel does not believe
there's merit against that individual, they end up reported to
the Practitioner Data Bank, whether they were viewed as really
having culpability or not, and that's a problem from the
provider perspective, not speaking about the fiduciary
responsibility of the Government here, but provider concerns.
The Chairman. Is it because of this situation that you are
not able to fully utilize volunteers?
Mr. Vanderwagen. That is part of the situation. The other
circumstance, you may be aware there was a malpractice suit
brought in a tribal court in New Mexico, and while the tribal
council immediately rejected trying that case within tribal
court, it created conflict in the State of New Mexico over
jurisdictional concerns, and the insurance malpractice carriers
for many providers, particularly the pediatricians and
obstetricians, since they were the two specialties involved in
the case, have been real reticent to counsel their members,
their insured providers to practice. In fact, they've
discouraged them from practicing in reservation environments.
The Chairman. And before I call upon the vice chairman, one
final question. Is there any medical school that specializes on
Indian health? For example, you pointed out that there are
problems that you just discovered. Are there any medical
schools that specialize on Indian health?
Mr. Vanderwagen. Sir, I believe there are one-half dozen
institutions nationwide who really have shown tremendous
commitment and involvement in Indian communities through their
participation with tribes, as well as their participation with
providers. Those schools actually have developed a coalition
now to explore ways that they might more effectively support
Indian health issues.
Without getting too extensive about it, it ranges from
Hopkins here in the east to the University of Washington to the
southwest, where Arizona and New Mexico have had real interests
in Indian health, and, of course, the University of Hawaii has
trained a large number of masters in public health and
supported Indian health concerns. So there are a variety of
schools that have been very helpful.
The Chairman. Thank you very much.
Mr. Bird, the staff will be working with you on your
recommendations.
Mr. Bird. Thank you.
The Chairman. Mr. Vice Chairman.
Senator Campbell. Thank you, Mr. Chairman.
While listening to your questions I was just musing to
myself about some of the people that I know who have been sick
who have needed help. I tell you, you take an average elder in
an Indian tribe who is not a very ``sophisticated'' person, a
person that is close to the land and close to their culture,
and you start talking to them when they come in about fiduciary
responsibilities and the legal ramifications and tort reform or
tort problems and punitive damages and all that, I think
they're probably not going to understand. All they know is
they're sick and need help. Somewhere we've got to find a way
to bridge that, you know, and give them more help.
I was interested in the chairman's question about if
there's a DOD program that you work with, and I was thinking of
one that has worked out really well. It's not directly with
DOD, Mr. Chairman, but Fitzsimmons Military Hospital, as you
know, in Denver was a few years ago turned over to the
University of Colorado. They, in turn, with our help and
funding from the Federal Government, are building an American
Indian diabetes center there now for research and treatment,
too, of diabetes among Indian people, so I think there's some
precedent set, maybe not a direct relationship, but through
working with local universities there are, I think, some real
opportunities.
Let me just scatter some of these questions around. You
talked earlier, Dr. Vanderwagen, about the recruitment program.
As I understand from Mr. Hill, there is a problem with
retention, too. What is the reason? Is it low pay? Do they just
go on to better things? Do they get burnout from too many
hours, like people in the medical profession often do?
Mr. Vanderwagen. Well, I think it is a combination of those
factors. I mean, entry level for a pharmacist, let's say, in
Indian health, they have to accept 30 percent lesser pay to
come to work for us than if they went to work for one of the
retail chains in an urban setting, so the pay is an issue.
Second, obviously, if they're working in isolated
environments where spouses don't have the ability to get a job
and so on, those factors play in.
The concern, as I suggested earlier, about the severe
rationing of the system that Mr. Bird referred to and that you
just spoke to about an elder seeking service plays on providers
severely. When you continually have to pull people out of the
river and you do not have the opportunity to figure out how
they got there in the first place because you're just so busy
trying to meet that flow, after a while you do become tired.
There's no question about it.
I was just out in the Dakotas last week, and clearly that
was a message that I heard.
Senator Campbell. Do most of them go to jobs in the private
sector or just quit altogether?
Mr. Vanderwagen. It's a combination of those factors that
you spoke to, and I think it is problematic to try and address
each of those.
Senator Campbell. Let me ask again, the ones that do leave,
do most of them go into the private sector or just burn out and
do something else?
Mr. Vanderwagen. I think the majority of the people who
leave our system will go to another health care environment,
just one that meets their needs individually.
Senator Campbell. When you do recruiting, do you do that on
the reservation?
Mr. Vanderwagen. The scholarship program, if you look at it
that way, yes, we do recruit that way. For certain jobs, skills
that are available in the community, that's clearly where we
would recruit. That's part of the reason why 75 percent of the
staff out there are Indian people. We recruit from Indian
communities for Indian communities.
Senator Campbell. We have tried to increase the IHS budget.
We've put this year, I believe, $78 million more into the
budget than was in last year. It's probably still not enough.
But does some of that get to the salaries of the people that
are in training?
Mr. Vanderwagen. Yes, sir; In fact, the highest priority
that the tribes, the urbans, and the Federal people developing
the budget--the highest priority was let's make sure that the
Pay Act for Federal employees and pay increases for tribal and
urban employees get covered. That has been the highest priority
for expenditure.
Senator Campbell. Let me ask you just a question or two
about the urban Indian community. Mr. Bird, you know, a
person--an Indian person--gets sick in Albuquerque, it's not a
long-distance trip usually to go back to the Pueblos. A lot of
them are pretty close. But our biggest city is Denver, we have
roughly 25,000 Indian people who live in Denver. The nearest
Indian clinic, reservation clinic, is I guess about 250 miles
away, the Southern Ute clinic way down at the end of the State.
They can't just go home when they get sick. They've got to go
downtown.
Do you do any interaction working with local health clinics
for Indian people that need help that can't go home? Or do you
do any kind of an outreach program so that Indian people know
where they can go if they're in the city and need help?
Mr. Bird. Yes; well, without getting too wordy, we do fund
34 urban Indian programs whose primary mission has been
initially to institute an outreach process and provide a way to
coherently assist Indian patients. Some of those now have
expanded into fully-functioning, ambulatory, primary care
facilities. In fact, 14 of them are now federally-qualified
health care facilities under the HCFA guidelines. So that is
exactly what the intent of the act, as we understood it, title
V was, and that's what we've tried to work with the urban
programs to accomplish.
Senator Campbell. I see.
Mr. Hill, what's the average time that claims are settled
now?
Mr. Hill. We don't have a general timeframe. The process is
basically when the claim is filed HHS has 6 months to decide,
and certainly a number of those are spilling over that 6-month
period, but after the 6-month period expires the claimant can
then go and file suit in court to get it settled.
Senator Campbell. What's the longest you would say it takes
to get a claim settled?
Mr. Hill. We found five claims that were filed in fiscal
year 1997 that were still pending. That makes them almost 4
years old.
Senator Campbell. Dr. Vanderwagen, you know, there has been
some discussion. In fact, there is a bill in to elevate the IHS
director to Assistant Secretary in the HHS. Would that be a
priority in the Indian health community?
Dr. Vanderwagen. In consultation with the tribes and the
urban folks, that clearly, from their perspective, is a
priority to elevate the director to an Assistant Secretary
level.
Senator Campbell. Do you have a personal view on it?
Mr. Vanderwagen. I think there are real pluses in terms of
the kind of partnership and access to a wide range of
departmental programs that could be facilitated--for example,
alcohol programs that cross the Department and other kinds of
health programs. There appears to be some merit in the proposal
from that perspective.
Senator Campbell. There are two demonstration programs, Dr.
Vanderwagen, in Oklahoma that are, as I understand, operated a
little differently from the normal programs in the IHS that I
understand are very successful. How are they different and what
makes them so successful?
Mr. Vanderwagen. Well, thank you for asking. Those are
interesting and, I think, unique programs.
In the past, Congress provided authority for those programs
to not only be dealt with under title V as urban programs, but
to be dealt with as service units under the Federal process.
That means that they could access resources not only limited to
the title V budget authority but to all the other budget
authorities within the agency--hospitals and clinics, mental
health, et cetera.
The plus side of that has been that it has allowed them to
expand and become more comprehensive using IHS funds in
addressing the health needs of individual urban Indians in
Tulsa and Oklahoma City, and therefore reduce the requirement
for them to seek funding from other sources, to some degree.
Senator Campbell. There's supposed to be a report made on
those demonstration projects, too, as I understand it. Is that
report finished? I'm told it is.
Mr. Vanderwagen. Yes, sir.
Senator Campbell. And when are we going to get a copy of
that report.
Mr. Vanderwagen. I would have to check on that, but I could
provide you an answer for the record, sir, as to when that
would be available. I'm just ignorant at the moment of that.
Senator Campbell. To your knowledge is there any opposition
to launching more programs along the lines of those
demonstration programs?
Mr. Vanderwagen. It is a complicated issue with regards to
tribal sovereignty and the responsibilities and authorities of
tribal governments vis-a-vis individual Indians who may be in
urban settings and how those programs access resources. This is
a real difficult issue, not just involving Oklahoma and Tulsa,
but I think all of the Indian health system at this point, the
balance between tribal government and the government-to-
government relationship and the needs of individual Indian
people who happen to live in urban settings. It's very
difficult.
Senator Campbell. Well, if they have been successful, there
is a good possibility that we could expand that program, then.
Mr. Bird, tell me a little bit more about this. Which
organization participated in this, as you called it, ``Friends
Organization.''
Mr. Bird. Yes.
Senator Campbell. What's their interest in the Indian
health field?
Mr. Bird. Well, their interest is in seeing that, in fact,
the needs of American Indian and Alaska Native people are
better met, and there is--it's a broad coalition, as was
mentioned before, of the American Dental Association, American
Association of Colleges of Nursing, American Hospital
Association, American----
Senator Campbell. All of them have some health connection?
Mr. Bird. Yes; all involved in the health arena. I will
submit a copy. I do have a list of the members of Friends of
Indian Health.
Senator Campbell. Great. Please submit a copy of that.
We'll try to make that a part of the record.
Did you go out and recruit those people to help, or is that
something they put together themselves and volunteered to do?
Mr. Bird. It's actually something that the American Dental
Association put together, has been active for a number of years
because of their interest and their recognition of the fact
that there's great disparity in American Indian and Alaska
Native communities.
Senator Campbell. I see.
Mr. Bird. And they are to be commended because they are a
very active, viable group, and at their behest I am here today.
Senator Campbell. Okay. Swell.
Thank you, Mr. Chairman.
The Chairman. I thank you very much.
I have a few more questions.
Mr. Vanderwagen, do you have any thoughts on Mr. Bird's
recommendation on having Indian volunteers be on the same par
as Peace Corps workers and others?
Mr. Vanderwagen. Well, that's a refreshing notion and one
that we have not explored, but it certainly seems to have some
merit.
Again, bringing people in, we believe that our mission and
the work that we do is such a blessing in life that if we bring
those people in we're likely to keep them for longer than just
a simple, short-term stint.
The Chairman. Will you have your staff look at Mr. Bird's
recommendations and give us your thoughts on this?
Mr. Vanderwagen. Yes, sir; I will.
The Chairman. Are you aware of other federally-sponsored
loan repayment programs that are tax free?
Mr. Vanderwagen. I believe that there have been programs
funded through the Health Resources and Services Administration
that has had some tax-free loan repayment components, but I may
be wrong about that, but that's what comes to mind.
The Chairman. Then you do not mind if you are on a level
playing field?
Mr. Vanderwagen. If we'd get back onto a level playing
field I'd be real happy.
The Chairman. Well, Mr. Bird, it appears that you have a
few allies here.
Mr. Bird. I'm glad to hear that.
The Chairman. Now may I ask Mr. Hill a few questions. Does
the Tort Claims Act provide malpractice coverage for retired
providers who practice on a part-time basis for a contractor?
These questions are asked because I have had letters from
Indian country.
Mr. Malcolm. Yes, Mr. Chairman; the Federal regulations
that were issued on this--it's 25 CFR, part 900, subpart M
talks about the types of people, both for medical and non-
medical claims, that are covered. It specifically states that
temporary employees, if they are working under a self-
determination contract for a tribe, would have tort claim
coverage.
The Chairman. They are covered?
Mr. Malcolm. Yes; if they are performing a service under a
self-determination contract.
The Chairman. Now, does this act also provide coverage for
medical specialists, as well as primary care providers?
Mr. Malcolm. I believe so. Again, depending on--a lot of
very legal technical terms apply to this area, and that's why
there's a lot of confusion, and the Department of Justice
basically has to make determinations on a case-by-case basis.
If the specialist, again, is working at the tribal
facility, then clearly there would be that coverage. If that
specialist is basically at a hospital in town that's not a
tribal facility, there would be questions about the coverage in
that case.
Again, it's the function that is being performed. If it's
being performed under the tribal contract, there would be
coverage either for full time, part time, or volunteers. When
tribal members are getting care from people outside of that
contract, then there would be questions about the coverage.
The Chairman. Does it make any difference as to the venue
of the care in the tribal hospital or some other hospital?
Mr. Malcolm. Yes; it would. If that person is not directly
working under the contract, there would be--that would be an
issue.
The Chairman. Mr. Hill, you indicated that volunteers
working at a tribal facility will have tort claim coverage?
Mr. Hill. That is correct, as long as they're working under
a contract.
The Chairman. Dr. Vanderwagen suggested that, because of
this tort claim issue, volunteers are reluctant to sign up. How
are these claims examined that involve volunteers?
Mr. Hill. I can't answer that. Of the 114 claims that we
identified, none of them involved volunteers, so I'm not sure
it has been tested yet.
Mr. Vanderwagen. If I may, Senator, it's a climate of
anxiety that is not fully assuaged by Justice approach of
decision on a case-by-case basis, and many providers are
unwilling to accept the sort of verbal assurance that, ``Oh,
yes, you will be covered, but we reserve the right on a case-
by-case to approach these issues,'' and it is that lack of
absolute certainty that is chilling for many people,
particularly in light of their private insurance carrier
counseling them that they are entering into an extremely risky
environment.
So the cases really have not been directly challenged. It
is more a climate of concern and anxiety that we're trying to
attend to on these matters.
The Chairman. Mr. Hill, do you have any response to that?
Mr. Hill. No. That's correct. We would agree with that. We
would note there are some other special coverage provisions
that apply. For example, in California, where you have a lot of
contracting the California Indian Rural Health Board basically
provides services there, and then they have subcontractors. As
a general rule, under FTCA subcontractors would not be covered;
however, Congress has made special provisions for California
that those subcontractors will be covered.
We did find, during the 3 years we looked at, that there
were 10 claims from subcontractors of the California Indian
Rural Health Board that had been provided coverage. So there
are other special mechanisms in there for IHS programs, and we
did find that those are working as they should be.
The Chairman. Then do you feel that the problem expressed
by Dr. Vanderwagen can be resolved or addressed legislatively?
Mr. Malcolm. I don't believe so. Part of the problem is,
again, as Dr. Vanderwagen mentioned, there is a large amount of
confusion and misunderstanding about the coverage, and a lot of
the legal questions about who is covered and who is not
covered, that actually hinges on State law. So, depending on
the location of where the incident occurred, the Justice
Department or HHS, the Office of General Counsel, will look to
the State law as far as the definition of who is an employee
and what functions that person has to be performing to be
considered an employee, so the State law is the controlling
issue there historically, so that's what they look to and
that's why there could be differences from State to State, and
that's a case-by-case basis.
The Chairman. Are volunteers at VA or DOD hospitals treated
the same?
Mr. Malcolm. Our study didn't really include VA and DOD, so
I'll have to--we'd have to look into that further.
The Chairman. My final question on urban Indian programs
has to do with a letter that was received by the staff. Are
urban in health care centers deemed to be ordering agents of
the IHS for the purchase of pharmaceuticals?
Mr. Vanderwagen. In general they have not been direct
participants in the special purchasing arrangements that we
have through the VA, the prime vendor, which gets the absolute
lowest cost. The 638 relationships provide us the authority to
do that, and the majority--obviously, the urban programs are
generally under the buy-Indian provision, and they've not been
included with the VA purchasing arrangements to date.
The Chairman. Is there any reason for that?
Mr. Vanderwagen. Primarily revolving around the authority,
in their view, being Federal, and 638 qualifying tribes as
Federal, as it does in many other environments, but the buy-
Indian contracting not viewed in the same way by the Veterans
folks.
The Chairman. Can this matter be resolved internally?
Mr. Vanderwagen. We are working on it and we think we might
be able to get a solution, but that's certainly something we
can report to you on.
The Chairman. Mr. Bird, are you satisfied?
Mr. Bird. Yes.
The Chairman. Your negotiations are bearing fruit?
Mr. Bird. We need more trees.
The Chairman. Well, we'll try our best, sir.
Mr. Bird. Thank you.
The Chairman. We have a few more questions we'd like to
submit, if we may, and receive your response.
Senator Campbell. May I ask one more?
The Chairman. Yes, please.
Senator Campbell. Let me ask one final question, Mr.
Chairman. Since you had mentioned Peace Corps, originally when
Peace Corps was set up it dealt with helping people in foreign
countries. There was another program called ``Vista'' that was
very similar, but it was more domestic oriented, and Vista
workers at that time some years ago actually were working on
reservations.
I don't know if Vista program is still in effect or if it
has been superseded by Americorps or some of these other groups
such as the National Health Care Service Corps or so on, but do
any of these groups take part in the Indian health profession,
Dr. Vanderwagen? Or do you work with any of those groups at
all?
Mr. Vanderwagen. No; we really have not had formal
relationships with them, and an interesting idea that we have
not explored.
Senator Campbell. Do you have the legislative authority now
to be able to work with them, or do you need something from us
in order to do it?
Mr. Vanderwagen. Well, I'd have to defer to our legislative
people on that, but we could certainly provide an answer back
to you on that question.
Senator Campbell. Would you find out for us, because it
seems to me that there are a lot of good-willed, hard-working
people that want to help out there, and if we could get them
involved with you so you could utilize some of their folks, I
think it would be good for you and maybe good for Indian
country, too. Find out if we need to do something legislatively
or if you can just go ahead and do it. And if you can, I would
encourage you to do it.
Dr. Vanderwagen. We'll do.
Senator Campbell. Thank you.
Thank you, Mr. Chairman.
The Chairman. All right. Thank you very much, gentlemen.
Mr. Vanderwagen. Thank you.
Mr. Hill. Thank you.
Mr. Bird. Thank you.
The Chairman. Before I call upon the next panel, without
objection the opening statement of Senator Kent Conrad will be
made part of the record.
[Prepared statement of Senator Conrad appears in appendix.]
The Chairman. And now may I call upon the second panel: The
president of the National Council of Urban Indian Health,
Robert Hall; the health director of the American Indian
Community House in New York, Anthony Hunter; the executive
director of the Missoula Indian Center of Missoula, MT, Carole
Meyers; the executive director of the Native American Health
Center, Oakland, CA, Martin Waukazoo; and the executive
director of the Denver Indian Health and Family Services,
Incorporated, of Denver, Kay Culbertson.
May I call upon President Hall.
STATEMENT OF ROBERT HALL, PRESIDENT, NATIONAL COUNCIL OF URBAN
INDIAN HEALTH, WASHINGTON, DC
Mr. Hall. Thank you, Mr. Chairman, Mr. Vice chairman, and
also for the Senator of my home State, Senator Conrad, when he
was in here for a while. My name is Robert Hall. I am the
president of the National Council of Urban Indian Health and a
member of the Three Affiliated Tribes from Fort Berthold, ND.
My tribal heritage is Arikara and Hidatsa. The third tribe up
there is Mandan. I also have some prepared remarks I have
submitted for the record. I am also the executive director of
the South Dakota Urban Indian Health Clinics. I wish to thank
you for this opportunity to address the committee on the
reauthorization of the Indian Health Care Improvement Act, S.
212.
I'd like to take a moment to introduce you to our new
executive director for the National Council of Urban Indian
Health, a lady I think you are very familiar with, Beverly
Russell. We're very pleased for the training she received while
she was interning with you.
The Chairman. She's a good lady.
Mr. Hall. Yes.
The CUIH is the only membership organization representing
urban Indian health programs. Our members provide a wide range
of health services and care, ranging from information and
outreach to full clinics. We provide referral services in 34
cities, not counting the new program in Hawaii, to a population
of approximately 332 urban Indians. We are often the main
source of health care and health information for these urban
Indians. According to the 1990 census, 58 percent of American
Indians lived in urban areas. We expect that number to be well
over 60 percent in the 2000 census results.
Like their reservation counterparts, urban Indians
historically suffer from poor health and substandard health
care services.
In 1976, Congress passed the Indian Health Care Improvement
Act. The original purpose of this act, as set forth in a
contemporaneous report, was to,
raise the status of health care for American Indians and
Alaska Natives over a 7-year period to a level equal to that
enjoyed by other American citizens.
It has been 25 years since Congress committed to raising
the status of Indian health care and 18 years since the
deadline has passed for achieving the goal of equality with
other Americans, and yet Indians, whether reservation or urban,
continue to occupy the lowest rung on the American health care
ladder.
Although the road to equal health care still appears to be
a long one for Indians, the CUIH--the National Council of Urban
Indian Health--believes that S. 212 is a step in the right
direction. As a general matter, NCUIH supports S. 212, although
we do recommend certain changes to maintain Congress'
commitment to urban Indians.
The Indian Health Care Improvement Act currently provides
that it is the policy of the United States to achieve the
highest possible health care for both Indians and urban
Indians; however, S. 212 does not contain a reference to urban
Indians in its equivalent paragraphs. Deleting urban Indians
from this policy statement, especially since ``urban Indian''
is a defined term in the legislation, could imply that the
Congress no longer considers the health status of urban Indians
to be a national priority.
NCUIH strongly urges the restoration of ``urban Indian'' to
section 3, paragraphs 1 and 2, of S. 212.
NCUIH is generally satisfied with the definition of ``urban
Indian'' in S. 212, although certain language in the definition
appears to limit its coverage to title V of the legislation.
Urban Indians are referred to in other titles of this
legislation; therefore, this limiting language should be
removed.
NCUIH supports an amendment to S. 212 that would grant
urban Indian health programs the same 100 percent Federal
medical assistance percentage as is currently enjoyed by IHS
facilities and IHS 638 contractors.
Like IHS facilities, urban Indian programs exist because of
the Federal responsibility in the Indian health care area. We
should be treated the same as IHS for the purposes of FMAP, and
we would like to thank the chairman for his support in
introducing FMAP legislation.
NCUIH supports expanded authority in funding for urban
Indian health programs in the area of pharmaceutical services.
Such expanded authority would result in an immediate elevation
of the quality of care for these communities, especially the
elderly.
NCUIH supports the establishment of the National Bipartisan
Indian Health Care Entitlement Commission. The work of this
commission will help provide the basis for a rational and
effective approach to Indian health care well into the 21st
century.
Although addressed in other Senate legislation, we would
like you to know that NCUIH strongly supports the elevation of
the director of the IHS to Assistant Secretary for Indian
health. Too often Native voices are lost in the national clamor
over health care policy and funding. Elevating this position
would greatly strengthen the voice of Indian country, whether
in the halls of Health and Human Services, the corridors of
Congress, or wherever the health care debate occurs.
In fiscal year 2001 urban Indian health programs received
1.14 percent of the total IHS budget, although urban Indians
constituted at least 50 percent of the total American Indian
population.
NCUIH acknowledges that there are some sound reasons why
the lion's share of the IHS budget should go to reservation
Indians; however, the health of Indian people in urban areas
affects the health of Indian people on reservations and vice
versa. Disease knows no boundaries. NCUIH strongly believes
that the health problems associated with the Indian population
can be successfully combated if there is significant funding
directed at the urban Indian population, as well as reservation
population. To address this need, NCUIH has asked for a $5
million increase in the urban Indian health line item in its
2002 budget.
NCUIH also supports the establishment of a 5-percent set-
aside of the IHS diabetes funding to be provided to urban
Indian diabetes programs, and we would like to acknowledge the
vice chairman for his strong letter directing that.
In the chart in front, you will see a history of IHS
funding and urban Indian health funding from 1979. You will
notice in 1979 our funding comprised 1.48 percent of the total
IHS budget, and you can see from the graph we're back down into
a dive in falling behind, not even maintaining. And you also
are very aware that the IHS budget isn't maintaining a level
track with increased cost.
America is nowhere near the lofty goals set by the Congress
in 1976 of achieving equal health care for American Indians.
Whether reservation or urban, NCUIH challenges this committee
to think in terms of that goal as it considers reauthorization
of the Indian Health Care Improvement Act.
NCUIH thanks this committee for this opportunity to provide
testimony on S. 212, and we strongly urge positive action on
the matters we are addressing today.
I would like to take this opportunity to thank both the
majority staff in the committee and the minority staff in the
committee for being very cooperative and helpful in
establishing this hearing and in working with our members.
Thank you.
The Chairman. I thank you very much, Mr. Hall.
[Prepared statement of Mr. Hall appears in appendix.]
The Chairman. May I now call upon Mr. Hunter.
STATEMENT OF ANTHONY HUNTER, HEALTH DIRECTOR, AMERICAN INDIAN
COMMUNITY HOUSE, NEW YORK, NY
Mr. Hunter. Good morning, Mr. Chairman and members of the
committee. We want to thank you for inviting us to testify at
this important hearing on urban Indian health programs. We
would also like to recognize and thank you for your support of
our programs over the years.
With your permission, I will submit my written testimony
and make additional verbal comments.
I'd like to familiarize you with the American Indian
Community House because we have not only health programs but
also cultural enrichment programs. We use an innovative
approach in order to combine these to meet our community's
needs.
The American Indian Community House is a 501(C)(3) not-for-
profit organization serving the health, social service, and
cultural needs of Native Americans residing in New York City.
AICH was founded in 1969 by Native American volunteers as a
community-based organization mandated to improve the status of
Native Americans and to foster inter-cultural understanding.
Since its inception, AICH has grown into a multi-faceted
social support agency, cultural center, and it has a staff of
35.
AICH membership is currently composed of Native Americans
from over 80 different tribes and represents a service
population, according to the 2000 census figures, of 59,000
Native Americans who reside in the greater New York City
metropolitan area.
Native American migration between urban centers and
reservations demonstrates the inter-relatedness of all Native
Americans, and from this reality emerges the recognition that
our issues and concerns are truly shared.
The AICH philosophy is that solutions can be shared, as
well. AICH uses an innovative approach in combining the
objectives of our social service and cultural enrichment
programs to meet that community's multi-faceted needs.
AICH provides programs in job training, placement, health
services referral and advocacy, HIV referral, case management,
and counseling programs for alcoholism, substance abuse, and
mental health. AICH also sponsors programs in cultural
enrichment through a performing arts program and the only
Indian-owned and -operated Native American gallery museum in
New York City. These programs are important to us, because a
large percent of our population comes to New York City
specifically because they are involved in the performing and
visual arts.
A secondary but no less important focus of AICH is to
educate the general public about contemporary as well as
historic American Indian issues and peoples. Some of the
departments that I spoke about--and I'll give you a little more
detail, if I may, on those--our HIV/AIDS project, for example.
In response to the increasing numbers of Native Americans
living with HIV and AIDS, the HIV/AIDS project provides
community prevention, outreach, education, and information,
targeted outreach to individuals at risk, and services to those
infected. The project offers referral to drug and alcohol
programs, sexually transmitted disease clinics, test sites,
general health and mental health care facilities.
They also offer services for gay and lesbian Native people.
At one of our recent community meetings, it was our
understanding that we need to expand our services for gay and
lesbian Native people living in New York, and that it's not
just HIV and AIDS that our agency needs to be concerned about
when serving that population.
Case management services are also offered and provided in
New York City, as well as program offices in Buffalo, Syracuse,
Riverhead, and the Akwesasne Mohawk Reservation.
AICH is actually very unique, I believe, as one of the
urban programs in that we offer services also on the
reservation. We have historically offered also Department of
Labor services on the Shinnecock Reservation in eastern Long
Island.
The employment and training funding by DOL provides
educational services as well as training focused on preparing
an individual for the job market. Interview skills, resume
writing, computer training, referrals to outside job training
facilities, limited tuition and support for higher education,
and job placement assistance are among those services. We are
beginning a process of becoming a training facility registered
with the New York State Education Department.
Our health department is staffed by community health
representatives, or CHRs, and their work includes health
education, medical and dental referrals, community outreach,
and the development of Native American specific health oriented
materials.
The Health Department's alcohol and substance abuse program
services strongly focus on group and individual counseling.
These programs offer a sense of community support as the Native
American people seek to begin and maintain their recovery.
Spiritual and cultural support are integral parts of the
programs, as well as our education and prevention activities,
and other programs within the Health Department include mental
health, the AICH Youth Council and Theater Project, our daily
food and clothing bank, and hot lunches for community members.
According to our recent behavioral risk factor survey
sponsored by IHS and Centers for Disease Control, prevalent in
our population are risk factors associated with heavy cigarette
smoking, sedentary lifestyle, acute alcohol use, and drinking
while driving. Using AICH's innovative approach in combining
health prevention and cultural activities, we will now design
prevention programs specifically addressing these behaviors
using the visual and performing arts.
As part of the Health Department, we have a Women's
Wellness Circle project, and it is specifically for Native
women. Utilizing innovative and cultural-specific strategies
again here in this program, the project works to develop a
network between AICH, health institutions, other front-line
providers, and Native women in the community. The project
provides accessible satellite screening and health information
through mobile units, develops Native educational performance
pieces, holds monthly wellness circles for Native women to
share access concerns and to provide preventive health
education.
The AICH gallery museum is the only Native American owned
and operated gallery in New York City. It exhibits the finest
in contemporary and traditional art in every media by both
emerging and established Native American artists. The gallery
presents a minimum of four exhibitions a year and presents
artists' lectures and forums on contemporary Native arts and
issues.
The artwork on exhibit is often for sale, and we charge
only a small commission on those sales.
Our Performing Arts Department, which is actually part of
our Department of Labor program, they've actually been very
liberal with us in the way we operate and the way we combine
programming, and the Department of Labor, or what is now the
WIA--Workforce Investment Act program--is really the backbone
of our organization over the years, since we first received
Federal funding in 1975.
The Performing Arts Department coordinates various cultural
activities featuring Native American performing arts and
promotes and assists all Native ensembles, such as Spiderwoman
Theatre, Thunderbird American Indian Dancers, Coatlicue
Theatre, and Ulali. The Department provides referrals for
Native storytellers, musicians, and lecturers. It acts as a
non-paid booking agent for Native actors, dancers, and models,
and provides rehearsal space and technical assistance to Native
American artists.
We have a main stage that we have as a moveable space
within our agency that seats up to 150 people during
performances.
We also have a legal service project for Native Americans
in our community, which is actually a joint project between
AICH and the American Indian Law Alliance. The legal services
project is in its fourth year of providing free legal referral
services to Native Americans. The project assists with all
types of legal matters for Native people in an urban
environment, including but not limited to housing, Indian Child
Welfare Act, and Jay treaty issues. The Jay Treaty, as a matter
of fact, has been something that the American Indian Law
Alliance has been looking at very closely, and they're
developing further information on this.
In our population we have a large number of Indians that
come from Canada, and since they are eligible to receive
services in the United States, we advocate for that service for
them by not only attending hearings on their eligibility
requirements, but also doing outreach with departments such as
Social Security Administration to educate them and their
workers about the eligibility of Canadian Indians living and
residing in the United States.
On behalf of the Native American community of the New York
City metropolitan area, I'd like to thank you for your
consideration, and as you go about considering the needs of
urban Indians I'd like to just mention that some of the most
important issues that we have are support of the Jay Treaty and
its rights. We're also having an urban planning meeting coming
up in August that will be attended by representatives of IHS,
the Health Care Financing Administration, our State alcohol
program, and the Bureau of Managed Care Planning to help AICH
decide how it can move forward in its licensing and third-party
billing process.
And, of course, the Indian Health Care Improvement Act
reauthorization is an integral part of AICH's future and its
ability to serve its community.
Thank you.
The Chairman. I thank you very much, Mr. Hunter.
[Prepared statement of Mr. Hunter appears in appendix.]
The Chairman. Ms. Meyers.
STATEMENT OF CAROLE MEYERS, EXECUTIVE DIRECTOR, MISSOULA INDIAN
CENTER, MISSOULA, MT
Ms. Meyers. Thank you. Honorable Chairman, committee
members, my name is Carole Meyers. I'm the executive director
for the Missoula Indian Center, Missoula, MT. I am an enrolled
member of the Blackfeet Tribe and a descendent of the Oneida
and Seneca. I want to thank you for this opportunity to come
before you today.
Missoula Indian Center is a nonprofit organization. It has
been in existence in Missoula, MT, for the past 31 years. The
organization has assisted with health referrals to the 3,100
Native Americans that reside in that area. We have
approximately 65 tribal representation throughout the Nation
that come to our community. It's also the home of the
University of Montana, of which many of our Native American
clients come and attend.
Montana has seven reservations, and of the reservations
there are 11 different Native American tribes represented in
each area.
When Native Americans leave their home reservation and move
to an urban area such as Missoula, they face many obstacles.
One of the most noticeable is their health coverage. Once they
leave the reservation and live in an urban area for more than
180 days, they lose their health coverage through the IHS.
Some of the programs that we provide through our program is
immunization, health promotion and disease prevention, AIDS,
alcohol and mental health, diabetes, and our chemical
dependency programs.
Missoula Indian Center is governed by a 7-member board of
directors, of which 51 percent must be Native American.
Missoula Indian Center is organized under two major programs,
which is our health program and our chemical dependency. We
have 11 full-time staff and one part-time mental health
counselor.
Health issues that surround our Native American clients
range from diabetes to the common cold. With our agency as a
health referral organization, many of our clients see up to
three to five different health providers in the course of a
year. With this inconsistency of health providers, there is not
a medical health history that follows our clients as they go to
their medical provider. This creates more confusion and lack of
medical knowledge of a client's history. Many times, because
lack of funding, clients will be referred to at a point of
emergency in their situation. There is little prevention health
coverage, such as yearly physicals or dental checkups.
Missoula Indian Center's health program provides quarterly
clinics that cover the basic health issues, which in itself is
an excellent program but a significant problem that we are
faced with is if a client comes up with a problem through their
medical checkup, we cannot provide the resources to do the
maintenance or followup, such as when they do a blood
screening. If they come back and there is an issue that they
need to do followup with a medical doctor, we basically have to
tell them they have to go back to the reservation or seek
medical assistance on their own.
It is safe to say that 80 to 90 percent of our clients do
not have health coverage or insurance.
The Missoula Indian Center had 8,865 encounters this past
year. These encounters are community members who accessed the
center for medical issues, drug and alcohol counseling, all the
way up to utilizing the telephone. We are looked upon as a one-
stop agency for many of our needs other than medical.
Other issues besides health issues that our clients face
are housing, employment, school, K-12 and higher education, law
enforcement, and food.
Presently, we contract with the health agencies such as
Partnership Health at a reduced cost for our doctors' visits.
This enables health funds to cover more clients over the course
of 1 year, but this does not address the client's need for
medical followup or maintenance, as I discussed earlier.
When a client needs to have a prescription filled, we are
able to transport them to St. Ignatious, which is located on
the Flathead Indian Reservation. This entails a 90-mile round
trip. Because of the Salish and Kootenai tribal policies,
clients have to physically present themselves at the pharmacy
in order for their prescription to be filled. This creates
hardship with our clients for two reasons: No. 1, they may not
have a vehicle to transport themselves up; and, No. 2, they may
not have gas to put in their vehicle to make the 90-mile round
trip.
Other services that we seek for our clients to try to
utilize on the Flathead Reservation is the dental clinic, but
in order for a client to be seen they have to leave the
Missoula area at 7 in the morning to be there at 8 a.m. to be
seen in an emergency dental situation. Once again, for them to
utilize it, it is an emergency, either a toothache or some type
of infection. There's no or little prevention for our dental.
In our chemical dependency programs we offer intensive
outpatient and standard outpatient groups and some individual
counseling. Our programs are Montana State certified, so we're
able to see non-Native American clients, which we do some
billing with that particular population.
Our programs are spiritually and culturally themed, and
many of the agencies other than our programs that provide
counseling make comment that the uniqueness of the counseling
sessions do help with the holistic approach with recovery of
the addiction, and they have been noted for this in the State
of Montana.
When clients come in to utilize these alcohol programs,
they not only bring their addiction but they bring many, many
health problems, and we are seeing more diabetics in this
course of our target population in this area.
I want to just interject this personal note. My father who
is 82 years old has been a diabetic since the mid 1970's. My
mother is 79 years old and she has been diagnosed with diabetes
for the last 15 years. My father is a World War II veteran, has
been an admirer of yourself, Senator Inouye, and this
Commission for many years and thinks of you as a champion on
issues that pertain to the American Indian. He has made comment
that he would like to leave the reservation, but because of the
lack of health coverage in the urban areas he is unable to
leave the hospital in Browning, Montana, because that is his
life support for he and my mother.
I want to thank you for your time for listening and reading
my testimony. It has been a privilege and an honor to come
before you with my thoughts and ideas. Each and every day
Native Americans are faced with issues and problems of health,
employment, and education. I sincerely hope with my testimony
that our issues have been personalized. Survival on a day-to-
day basis for Native American people is a very real issue.
Thank you.
The Chairman. Thank you very much, Ms. Meyers.
[Prepared statement of Ms. Meyers appears in appendix.]
The Chairman. May I now recognize Mr. Waukazoo.
STATEMENT OF MARTIN WAUKAZOO, EXECUTIVE DIRECTOR, NATIVE
AMERICAN HEALTH CENTER, OAKLAND, CA
Mr. Waukazoo. Thank you, Mr. Chairman and Mr. Vice
Chairman. My name is Marty Waukazoo, and I am an enrolled
member of the Rosebud Sioux Tribe in South Dakota. I was born
and raised in South Dakota. I moved to California in 1973 and
have been the executive director of the Urban Indian Health
Board since 1982. My wife and I have three children and two
grandchildren. My wife, Helen, is the executive director of the
Friendship House Association of American Indians in San
Francisco, which is an alcohol an drug rehabilitation center
partially funded by the IHS.
The American Indian community in the Bay area organized and
incorporated the Urban Indian Health Board in 1972 to open the
first Native American health center in San Francisco. In 1976,
a second clinic was opened in Oakland, CA. Today, the Native
American Health Centers are a full-service clinic with
locations in Oakland and San Francisco, dedicated to making
health services available to the American Indian community of
the five Bay area counties--Marin, Contra Costa, San Mateo,
Alameda, and San Francisco.
The services we offer include medical, dental, mental
health, nutrition, community health education, youth services,
and women, infants and children program, or WIC program.
In 1983, the urban Indian Health Board had an annual
operating budget of $827,000, with 17 employees. Of this
amount, 90 percent was funded through grants and contracts from
IHS. Today our annual operating budget is $7.1 million, with
120 employees. Of that, 14 percent or $960,000 is through
grants and contracts from the IHS. Of the 120 employees we
have, 65 percent are American Indian. For every dollar that the
IHS invests in us, we are able to leverage six additional
dollars.
We are much more than just a medical clinic. We are also
the cultural hub of the Bay area. When an Indian person comes
to the Bay area looking for jobs from the reservations, coming
to the urban area for training, the first question they ask is
where is the clinic, because they know that's where you can
renew friendships, get acquainted, and find someone who can
connect you up with other services.
Within the Bay area Indian community there is a social
service network. When I, as a Lakota or a Sioux and someone
from my State comes to visit us in the area, when they walk up
to me and they find me I'm obligated to help that individual
navigate through the city system or through the local health
care delivery system, so it is really a point of access for our
community that we serve over and beyond that of just a health
clinic.
As I said, the Native American Health Center in the Bay
area is one of the largest, if not the largest, employer of
American Indians in the Bay area. We not only offer employment
opportunities, but we also do dental assistant training,
medical assistant training, clerical training. We do training
within our organization. Many of our employees are former
patients of our clinic. It was very important for us that we
have that balance of having that opportunity and giving
preference, not only Indian preference, but also preference to
those people who are patients of the Native American Health
Center, and we have been very successful over the years.
Just last Saturday we awarded four scholarships--not big
scholarships, $1,000 each, but we made those awards by raising
funds. We raised $7,000 by having the staff talent show, food
sales throughout the previous year. We felt it was important
that we, ourselves, award scholarships. We have two students
going to junior college in the local area. One Indian student
will be going to Harvard this fall. So we're very proud of what
our community has done in the area of not waiting for things to
happen to us, but being on the offense and doing things for our
community.
Last year our medical clinic saw over 4,800 patients, with
over 16,800 visits. Of our patients, 98 percent meet the
Federal poverty level guidelines.
The services we provide reflect our community's expanded
definition of health--that health of an individual depends upon
the health of the community. If we have a healthy community,
we'll have healthy individuals within our community.
I would like to outline some of the critical issues facing
our clinics today--issues that ultimately impact the health of
our community in the Bay area.
Back in 1985 we bought a building in east Oakland, a four-
story, 20,000-square-foot building. We bought that building at
a time when the market was very low. Today, we have filled up
that building--four floors offering comprehensive services.
Again, we also have set up a fitness center, a gym on the first
floor as part of our preventive efforts.
The issues of providing health care has increased
significantly over the years. Pharmacy costs for us have
increased by 34 percent from fiscal year 1999 to fiscal year
2000. According to our medical director, 20 percent of our
medical users are diabetic--20 percent of our medical users are
diabetic. A diabetic with high sugar, high cholesterol, and
high blood pressure, a very common combination, can average
$3,000 per year in drug costs. Just 40 such patients for a
clinic like ours can cost us $120,000 a year, or close to 13
percent of the total IHS funding that we do receive.
Capital needs for our clinic have been and continue to be a
major issue for us. We have been located at 56 Julian Avenue
since 1972. We lost that lease this year. Our lease rent at the
56 Julian site was $6,500 last year [sic]. We moved to a new
location a 1\1/2\blocks down on Cap Street. Our rent has
increased to $20,000 a year--a month. From $6,500 to $20,000 a
month. The market has gone up and exploded in the urban areas.
We are currently at full or near capacity in our medical
clinics and our dental clinics. Poor design, inefficient and
inadequate technology has also been an issue that we have to
struggle with. We've had to obtain additional funding from
within private foundations and corporations in order to buy the
needed computer equipment to at least continue to participate
in the local health care delivery system in Alameda County and
in San Francisco.
Health insurance premiums for employees--we have 120
employees. Our health insurance premiums have increased by 28
percent in the last 3 years.
The California energy crisis is also having a major impact
on us. These costs have increased by 40 percent over previous
years.
Another critical issue that's going to impact our ability
to provide primary care in the next year or two is something
very positive in our community. The Friendship House
Association of American Indians will be building an 80-bed
alcohol and drug treatment center in San Francisco. Through a
partnership with the city of San Francisco, they were able to
obtain funding to buy property in the Mission District to build
this 80-bed facility. That is great. There is a need there.
That 80-bed facility is going to become a regional treatment
center for not only California but for the western United
States.
The Friendship House already has agreements with tribes in
California and throughout the western United States for those
people to come into the urban area to get their treatment for
alcohol and substance abuse. The problem for us is that we have
to provide the health care for them, and, as you know, those
people that are in recovery do need a lot of health care as
they go about turning their life around. How do I know that?
Because 22 years ago I went through the Friendship House. For 1
decade I was homeless on the streets of Oakland and San
Francisco. I entered the Friendship House in 1980, March 12,
1980. This past year I celebrated another year of sobriety.
These urban programs do work.
A financial challenge for us is to find the funding and the
financing to provide care for these people. When I went to the
treatment center in March 1980, I had to go next door to get my
TB test and also to get screened for my physical exam, and also
my dental services. I can always remember that, how they
treated me there. After coming off the streets of Oakland and
San Francisco and coming into the urban area, how they treated
me--they treated me as if I was someone important. I was just
30 days into the program, into the treatment, having gone
through detox and going through the first 30 days. My efforts
today are just an attempt to repay back what they gave me as an
urban program 22 years ago.
The challenge for us in urban country, again, is the
challenge that we have to take on as urban Indian programs, is
to build that relationship with the tribes at the reservations.
There has been miscommunications, misunderstandings. We can get
along individually, but somehow we don't get along as
communities and groups. We need to work on that. We are
uniquely positioned in the State of California, working with
the California Rural Indian Health Board, trying to put
together their statewide HMO plan. It is a unique opportunity
for us in urban country to partner up with the tribes and urban
programs.
Many of our people do return. We are young. When the
relocation programs took place in the 1960's and 1970's, we
were a young community. Those people in the urban areas were
only in their early twenties. Today, we are seeing more
grandparents, more grandfathers, grandmothers. We are seeing an
elderly population starting to emerge. Those of us who are in
our fifties now are grandmas and grandpas. What comes along
with that is increased cost, increased needs in our community.
I'd like to thank you for the opportunity to give you my
testimony and appreciate all that this committee has done for
Indian people throughout the Nation--my relatives--and we look
forward to improving the health care of our people together. We
will work on those things and we will do everything possible in
the local areas to help improve the future for the next
generation.
Thank you.
The Chairman. I thank you very much, Mr. Waukazoo, for your
very inspiring statement.
[Prepared statement of Mr. Waukazoo appears in appendix]
The Chairman. May I now call upon Ms. Culbertson.
STATEMENT OF KAY CULBERTSON, EXECUTIVE DIRECTOR, DENVER INDIAN
HEALTH AND FAMILY SERVICES, INC., DENVER, CO
Ms. Culbertson. Good morning, Chairman Inouye and Vice
Chairman Campbell. I'm very excited to be here, and I feel
honored because I wasn't supposed to be on the presenting
committee, so my testimony was very hurried.
My name is Kay Culbertson. I am an enrolled member of the
Fort Peck Assiniboine/Sioux Tribes from Poplar, MT, and today I
want to talk to you about Denver Indian Health and Family
Services. I think I am going to show you a different
perspective of urban Indian health than Mr. Waukazoo did. I
didn't realize that they had 100-some employees. I knew that
they had a beautiful facility but didn't realize it was so
large. So, as we say in Assiniboine, I'm going to give you the
``oonshaka'' story.
I want to talk about Denver. Like Oakland and San
Francisco, Denver was a relocation center for urban Indians or
for Indians moving off of the reservation. There's also many
Air Force bases and military bases in the area, so a lot of
people that moved to Denver ended up staying there and raising
their families there. Like San Francisco and Oakland, we also
see second- and third-generation urban Indian people, but they
still have their ties with their reservation, and I would like
to talk about that a little bit because my family is still very
close to our people back home, and I'm very anxious to go back
home tomorrow because our family will be coming out of mourning
on Saturday for my uncle that was killed in an accident on the
Northern Cheyenne Reservation and then my grandmother that
passed away last year.
One of the things that brought people to Denver was that
hope for a better future. Like all of the places, you know, we
all thought that--well, my parents moved there when I was 6
years old--that we'd improve our lives, that their children
would grow up free from racism and grow up in a better
environment and have opportunities that they didn't have on the
reservation.
I want to talk a little bit about Denver. We're located
right in the heart of Indian country. I mean, you fly into
Denver, there's conferences there all the time. There's several
national organizations with National Indian Health Board,
Native American Rights Fund, the American Indian College Fund,
but as far as Indian country goes we're pretty isolated.
You talked about us being 250 miles away from the Southern
Ute Reservation. That's true. And we don't see very many people
from Southern Ute. It's too beautiful to leave there, I think,
and to come to Denver. But we primarily see Lakota people,
Sioux people. That's 60 percent of our population, and another
30 percent are the Navajo people.
The closest Indian hospitals, like I said in my testimony,
are in Albuquerque and probably in Rapid City, so that's quite
a long haul for people to go if they need any kind of medical
services that we can't handle.
We were incorporated in 1978. We started out with two
employees, and they were little ladies that worked in the
community and met with hospital people and when Indian people
came to them and needed help they helped them get into medical
appointments or they helped them get to their medical
appointment. They worked with them to find dentists. It was a
very sort of hodgepodge way of providing services in the Denver
area.
We started to grow. Actually, we were part of the Indian
Center, Denver Native Americans United, when we started, and we
moved away from the Indian Center and incorporated in 1978 as
Denver Indian Health Board, now known as Denver Indian Health
and Family Services. We had a full-scale clinic at one point
with 21 employees, not to a point that Marty's program was, but
quite, quite extensive for the Denver area. We had an agreement
with the Denver Health System to provide services, and,
unfortunately, a lot of the people that we see don't have
health insurance. Of the population that we see now, 70 percent
don't have health insurance. I'm sure that it was as high or
higher then, because there weren't the Medicaid programs and
the CHIP programs that they have now. And the people that were
insured, the Indian people that came to our clinic actually put
a burden on our clinic and we ended up having a huge debt with
Denver Health and had to close our clinic operations for the
organization in 1991.
We then entered into a small agreement with a community
health clinic, but all along we'd hear the community people
say, ``This isn't our community. Where is our clinic? We want
our clinic back.'' And so we started to work on that.
In 1998 our board had a planning retreat, and they decided
that, come hell or high water, we were going to have a clinic
back in our community, and so we started out really small. Very
fortunately, we found this young Indian doctor that was just so
excited to be providing services and was fresh out of medical
school and wanted to work for us, and she came and she helped
us get our clinic licensed, so that was a big step for us. She
could only work for us 20 hours a week. Unfortunately, her
husband was also a doctor and--well, fortunate for them,
unfortunate for us--and they ended up moving to Billings, and
we lost a fine doctor, a dedicated person, so we had to
backtrack and start to look at how we could continue to provide
services.
Eventually, we decided that we would go with the least-
expensive method of providing medical services for our
community, and that was through a nurse practitioner. We felt
that a nurse practitioner gave us what we needed--a lot of
health education--but they can do everything a doctor can do as
long as they are supervised by a doctor, except for surgery, of
course, and so that's the mode we are in now. We have a
volunteer physician that oversees our family nurse
practitioner. We do well child checks, acute emergencies,
immunizations, women's health, and abuse physicals--anything
that you don't have to go to the hospital for specialty care
like x rays or casts or anything like that.
Let me talk about our community.
We serve people from Adams, Arapahoe, Boulder, Denver,
Douglas, Jefferson, and Gilpin Counties. That's a pretty large
area, if you look at Denver metropolitan area. But we do see
people that come from the reservations, particularly during
March Pow-wow--you know, the things that are going on in the
community we seem to see a lot of people that come off the
reservation, or if they're visiting their family. I can't tell
you how many times people have come and needed prescriptions
through our offices or need to get something refilled because
they forgot it at home or they ran out, and so they come to us
looking for those services.
Denver's population is fairly young. We have a median age
of 30.2. A lot of older people don't stay in Denver, and I
think it has a lot to do with their health benefits and such
that they move home to the reservation because it is easier for
them to receive services. If they are fortunate to have health
insurance, then they'll stay, but we have a very small elderly
population.
The annual income of a person that comes into our
organization is $7,452, and it is kind of crazy. We wonder why
we have so many people that aren't on Medicaid or the other
programs, but we realize that they come to us thinking that
they have a right to health care--as Indian people, they have a
right to health care, and that they should be able to go to any
place and receive the services that they would on the
reservation.
Beyond our medical clinic, we also offer a community health
program that is sort of our hodgepodge of everything. It helps
with getting people prescriptions. We help pay for people's
prescriptions. They also work very hard to sign up people on
Medicaid and CHIP, because one of the things we try to stress
is that you cannot afford to live in Denver if you do not have
health insurance. One trip to the hospital will wipe you out.
We have a new diabetes program, and we'd like to thank you
for the additional funds. In addition to our management of
glucose and keeping an eye and making sure that our diabetics
are keeping their glucose levels in check, we are going to
start offering new exercise programs and teaming up with
different things in the community so that we have a more active
community.
We also have a behavioral health program, and that's for
mental health and substance abuse counseling. It's a very small
program. We are in need of psychiatric backup for a lot of the
things that we provide.
We have Victims of Crime Act program, where we do case
management, work very closely with the area victims' programs.
Some of the challenges that I'd like to talk to you about
for Denver Indian Health--and I see them as things that can't
be overcome--is that one of the things, unlike Marty's program,
is our board has really struggled with is entertaining becoming
a 330 program or a Federally-qualified health center or a
national health service core provider because we don't want to
lose our identity as an Indian provider. Right now 99 percent
of the people we see are enrolled members of Federally-
recognized tribes, and so we are very proud of that, and we
don't want to lose that. We don't want to lose that complexion
of our community.
We also see that part of it would include additional things
that we don't know we could handle, and that would be signing
up with an HMO and having 24-hour coverage and those type of
things that we haven't been able to do now, so it really limits
our ability in third-party billing and we have a lot of work to
go on there.
As we have said, IHS, as a whole, is funded very low, but
urban programs get the bottom of the barrel. One of the things
that I'd like to mention that is very important to us is dental
care. There's only one urban Indian health program that has
funding for the dental program, and that's in Albuquerque, and
that's just this year that they've received the funding.
We take 10 slots a month for emergency dental people, and
we've got a 3-month waiting list. I mean, I don't know how many
people can plan their emergencies for their dental visits, but
it is very difficult. And alot of the providers in Denver don't
accept Medicaid patients, so we're getting people that have the
insurance but they have nowhere to go, and that has been really
hard.
A little boy was in my clinic the other day and we were
looking for a pedodontist to send him to because he was deathly
afraid of the dentist. We don't usually deal with children. We
usually refer them somewhere else. But they wouldn't accept
him, either, because his family hadn't signed up for Medicaid.
And so we were looking, and I think they found a pedodontist
the other day for him, and hopefully his dental care is taken
care of.
One of the problems we have is hiring and retaining
qualified professionals. Dr. Vanderwagen talked about 30
percent lower pay rates for doctors or people that go into the
tribal centers or into IHS. We can't even begin to match the
salaries that IHS provides or the tribal facilities. I have
calls from people calling about the diabetes positions that I
have open, and they're, like, ``Well, I can't afford to move
there. I'd really like to move there, but you don't pay
enough.'' And it's, like, ``Well, our budget doesn't allow for
us to be able to go much higher than this.'' And,
unfortunately, we're not able to attract them because we don't
have the benefits package that IHS has.
So yes, urban programs are eligible for the scholarship
repayment programs, but it is very limited because they really
have to take a much more decreased salary to come and work for
an urban program than they do with a tribe or with a IHS
facility.
I'll go very quickly now.
Denver Indian Health and Family Services would like to
support the Indian Health Care Improvement Act. We've testified
on that before, of our support.
We'd also like to support the elevation of the director of
IHS to Assistant Secretary for IHS. We think that through his
innovation we'll be able to access other grants through SAMHSA
and different programs other than IHS, and hopefully, with his
speaking with one voice theme for the Indian Health Care
Improvement Act and working with urban programs, that we'll
begin to see urban programs included in some of the funding
mechanisms. Right now a lot of things are just for tribal
programs or for tribal organizations.
Denver Indian Health and Family Services supports section
535 of the amendment to the Social Security Act to clarify that
Indian women with breast and cervical cancer who are eligible
for health services provided under a medical program of the IHS
or a tribal organization are included in the eligibility
category of breast or cervical cancer patients added by the
Breast and Cervical Prevention Treatment Act of 2000. Again,
that's an example that the urban programs will not be included
in that and the urban Indians will be left out.
We'd also like to support the demonstration projects. We've
heard good things. We would like to see the report. But we
think that that is one way for programs that are isolated or
that want to keep their identity as Indian providers to be able
to go on and do that, so we strongly support the funding of
further demonstration projects.
I want to close with a story. And I want to thank you for
the opportunity to provide testimony today. As I was saying, I
was working on my testimony last minute. My son is very active
in the local Native lacrosse program. It's a neat program.
There's about 25 families that participate in this program on a
regular basis.
I was sitting there at the park with my laptop out typing
and working on this, and this mother that I have been friends
with through the year came up to me and said, ``Kay, what are
you working on?'' And I said, ``Well, I'm working on some
testimony.'' And I didn't want to give her a lot of information
because I didn't really want to intimidate her in any way. And
she said, ``Are you an attorney?'' And I said, ``No.'' I said,
``I'm the director of Denver Indian Health,'' and she said,
``You are?'' And I said, ``Yeah.'' And she said, ``What are you
testifying on?'' I said, ``Urban Indian health issues.'' And
she said, ``I have a story for you.''
She's diabetic and she was pregnant with a set of twins and
so she was high-risk with her diabetes and also with a set of
twins. Her family had told her, ``Laura, go home. Go home and
have your babies on the reservation because then you won't have
this huge bill when you go out.'' Well, Laura didn't want to go
home. She wanted to have her children where she lived, and so
she stayed in Denver, without realizing what would happen. She
had the babies. I don't know what hospital she had them at. But
they were in intensive care for quite some time.
At the time they released her and her children, Laura left
the hospital with a $45,000 bill, and she told me, ``You know,
we couldn't afford it. We couldn't do it.'' But she said, ``I
had to have my babies. They needed this care.''
So they ended up filing bankruptcy, and they've never
recovered. They've never recovered from this. And I'm sure that
Laura is not the only person in our community that has had
those problems or had to face that type of situation.
She asked me, she said, ``Will you tell my story?'' And I
said, ``Yes, I will.''
I hope that in the future you will be able to give some
answers to people like Laura and provide us with additional
funding for urban programs.
Thank you.
The Chairman. I thank you very much, Ms. Culbertson. We
will try to help your friend.
[Prepared statement of Ms. Culbertson appears in appendix.]
The Chairman. Mr. Hall, what is your definition of an urban
Indian health center? What services are they required to
provide? Is there any standard?
Mr. Hall. There are basically three levels currently
existing, with the highest being the comprehensive like Marty's
program, where you provide a multitude of services. The second
level would be limited direct, much like Kay's program, where
you provide partial services. And the third level is the
outreach and referral, where when people come to you for advice
and how to find other services that might be available.
The Chairman. How many full-service clinics are there in
urban Indian health centers?
Mr. Hall. I think there's currently 14 that qualify for
FQHC. There are 10 limited direct service programs and ten
outreach and referral.
The Chairman. If I may ask the directors of the centers,
how do you determine your beneficiaries or your clients or your
members? Do they have to be enrolled members of tribes?
Ms. Culbertson. Every program is different. Denver Indian
Health and Family Services, because we don't have a State-
recognized tribe in Colorado, do not serve any State-recognized
members at this time.
When people come into our clinic, we ask them to bring
their documentation either of tribal enrollment, or we will
tell them, because there's so much inter-marriage in the urban
areas, that they are able to collect the CDIBs, and if they can
come up with one-quarter degree of Indian blood from the
federally-recognized tribe we will serve them.
But I know that everybody else has different----
The Chairman. Does one have to have one-quarter blood
quantum?
Ms. Culbertson. Yes; and then we do get the people from
tribes such as the Cherokee where we get in 1/124th or
something like that, but we will serve regardless of blood
quantum for tribal members.
The Chairman. How is it done in Oakland?
Mr. Waukazoo. Self-identified.
The Chairman. What?
Mr. Waukazoo. Self-identified.
Ms. Meyers. In Missoula they are enrolled member of the
recognized tribe or State, and are a descendent of an enrolled
member. If they can prove a descendence through the lineage,
then we will be able to provide services for them.
Mr. Hunter. In New York City, Mr. Chairman, we use the
definition as it is written in the Indian Health Care
Improvement Act in the current legislation, and that applies to
our health services. Our other programs have different
requirements, but for our health services we use that
definition.
We were also able to convince the State, in its managed
care planning process, to accept that definition for exemptions
to mandatory managed care in the State.
The Chairman. Mr. Hall, how many individuals receive
services from these health centers?
Mr. Hall. In any one fiscal year it is approximately
100,000 Native Americans. If you compute that over a 3-year
period, as we do for the IHS user population, it averages about
175,000.
I would like to point out that, of those 14 comprehensive
clinics, we've only got two that are about the size of Marty's.
Most of us are the size of mine, which is just under $1 million
of total program.
The Chairman. From your experience and from statistics that
you have gathered, what is the major health problem?
Alcoholism?
Mr. Hall. They're very much similar with reservation.
Diabetes is a very high concern. In my program we service well
over 500 diabetics in our three urban clinics. Another high
need, of course, is alcohol program, alcohol treatment money.
We have high incidence of obesity and blood pressure problems.
We have high incidence of other related physical structure
problems because of that.
The Chairman. Now, you have been here all morning and you
have listened to the testimony of the IHS. Are you satisfied
with your relationship with IHS?
Mr. Hall. Are you asking anybody in particular or all of us
in general?
Mr. Waukazoo. Could be better. Some of the--no. No, we are
not. In some ways really dissatisfied with the formulas that
they use. Some of the formulas that they use for additional
funding, such as diabetes, was merely division. It doesn't take
into account service population. It doesn't take into account
level of need. Division. Diabetes funding that just came down
was, as I understand it, divided by the number of programs at
two levels. So our center, with two clinics, they treat us like
one clinic. We have the overhead at the San Francisco clinic,
overhead costs in the East Bay, and we're treated as one
clinic. If both of our clinics were stand-alone, they would
probably be within the top ten urban clinics in the Nation
largest. But the funding that comes down comes down based on,
from what I gather over my 20 years, division is the formula
being used.
Mr. Hall. There are a couple of other things, as was
alluded to earlier. There is direct service, IHS-provided
service. There's 638-provided service by tribal groups who
operate under the 638 authority. And the authority that allows
us as urban programs is the buy-Indian authority. There are
inconsistencies throughout IHS in how we are treated through
that buy-Indian authority, and we're trying to work as a
national organization in making more uniform.
We're satisfied with a lot of our relationship with IHS and
being involved in consultation and having input into several of
the policies, but it is still the bottom line. We are a very
tiny portion of the budget process. We're a very tiny voice in
any consultation issue, often one voice among up to 50, 60
representatives. And so in the end, as you can see from the
recommendations, our budgets have been the last to be fully
supported, and so we've got some concerns about those kinds of
things.
They're fixable. We have some concerns.
Mr. Hunter. A lot of that also has to do--and I'll refer
back to Dr. Vanderwagen's testimony, in which he mentioned
several times that authority is not granted. They just don't
have the authority to do some of the things for urban programs
that we need, and so this is why certain parts of the Indian
Health Care Improvement Act are so important, because it will
give the authority that we need in order to partake of some of
the services and available resources that are out there.
Ms. Culbertson. It becomes a tenuous relationship. I don't
think that anybody is saying that they want to lose their
relationship with IHS, but I think that what we'd like is some
of the benefits and the luxuries that tribes and IHS share in,
such as the Federal Tort Claims Act. We're not eligible for
that and so we have to pay for malpractice when we become
direct service providers. I think that's one of the things we
need to look at.
Another thing is that they expect certain things from the
urban Indian health programs, and a lot of times they expect us
to function like IHS facilities or tribal facilities with the
limited funding that we have. My operating budget is only about
$400,000, so trying to provide all the things that IHS
provides, requires is sometimes overwhelming, and so I think
that there needs to be some sort of different look at how the
urban programs can get their funding increased, get some of the
benefits the tribes have, and also provide some support for us.
The Chairman. Montana?
Ms. Meyers. I would like to see a more workable
relationship with IHS. I grew up with IHS, and I would like to
see, as an urban setting--and I put it on a personal note. I've
tried to convince my parents to come live with me in Missoula,
but because of the limited health coverage that they would
receive in Missoula their hands are tied. They would love to
come and spend time with me and live in an area that they
enjoy, but because of the lack of coverage of their medical
needs it is totally impossible.
The Chairman. The first panel spent some time discussing
tort claims, malpractice. Is that a matter of major concern to
the urban Indian health centers?
Mr. Hall. If we fully participated under that protection,
it would save each one of us high malpractice insurance costs.
We all have to maintain high liability once we start providing
direct service for that. Again, its because of the authority.
Because we're not 638, it doesn't apply to a buy-Indian
provider, so technically right now, according to what is
legislated, we wouldn't be able to participate in it. There
would have to be some enabling legislation that would allow us
to be covered by that.
The Chairman. What is the cost of insurance in Denver?
Ms. Culbertson. Well, for us our insurance is running about
$800 a year, but we have a very good relationship with a
nonprofit group that provides the malpractice insurance for us.
And because we have such limited services, our malpractice
insurance isn't as high.
If we opened up our doors to OB, to prenatal care, our
costs would skyrocket and we wouldn't be able to afford those
services.
So the malpractice really determines on what you offer, and
probably the best guess is Marty's malpractice, because they
are a comprehensive center and are probably the closest to what
an IHS facility would be, how much their malpractice insurance
costs.
The Chairman. How is it in Oakland?
Mr. Waukazoo. I don't have that figure in front of me right
now.
The Chairman. Any figures from Montana?
Ms. Meyers. Because we are a health outreach referral, we
considered and looked at when we do become a clinic--and that's
one of our goals, to become a clinic for our area. That is one
issue that has been discussed among staff and our board of
directors is the cost of malpractice insurance, which if we
don't come under this claim, the Tort Claims Act, then we will
be looking at high insurance in that area.
The Chairman. Anything in New York?
Mr. Hunter. Very similar situation in New York, sir. We are
an outreach and referral. We do direct counseling services, and
on occasion some of our counselors in the past have insisted
that there be coverage provided. We don't have it in our
budgets, and so they've had to purchase their own malpractice
insurance.
The Chairman. Mr. Hunter, I would gather that most of your
beneficiaries are from outside New York?
Mr. Hunter. Yes; a large segment of the population is
Mohawk from the two reservations in upstate New York. A large
population is from eastern Long Island from Shinnecock and the
Unkechaug Reservation. Shinnecock is about 90 miles east.
That's where my family is. And Cherokee people are also a large
number. In our Department of Labor statistics, I just noticed
in reviewing those that Navajo is also well represented in New
York City.
The Chairman. And for Montana the population is from that
area?
Ms. Meyers. The biggest population that we serve are the
Blackfeet, and it goes on down to the Flathead, which is Salish
and Kootenai, Asinniboine. All the 11 tribes that live in the
State of Montana do come to the Missoula area, plus nationwide
we have Navajos from the southwest, Apache that do come up to
attend the University of Montana, and we have a variety.
The Chairman. How is it in Oakland?
Mr. Waukazoo. The largest group of tribes that we provide
service for are the California tribes. Individually largest
group is the Navajo, Lakota, Pomo, Cherokee, Apache, Paiute,
Blackfeet, Choctaw, and Chippewa, in that order.
The Chairman. Denver?
Ms. Culbertson. Well, as I said before, 64 percent of the
people we see are from the Sioux tribes, and then 30 percent
are Navajo, and then it is a whole mixture. The one tribe we
rarely, rarely see are the Southern Utes and the people from
our home State.
The Chairman. Well, I thank you.
May I now call upon the vice chairman.
Senator Campbell. Thank you, Mr. Chairman. We have a
conference in another 15 minutes or so, so I'm going to submit
most of my questions in writing, if that's acceptable.
I might just ask Kay, does Rosalie Tall Bull work with you?
Ms. Culbertson. No; Gloria works for me. She's my community
health specialist. But Rosalie works for National Indian Health
Board.
Senator Campbell. Okay. She's my sister. I don't know if
you knew that.
Ms. Culbertson. Yes; I knew.
Senator Campbell. Tell her hello for me. You see her more
than I do.
Ms. Culbertson. I've got alot of friends that know you.
Senator Campbell. Yes; alot of relatives.
Carol, does Henrietta Whiteman still run the Native
American studies program up there at Missoula?
Ms. Meyers. No; unfortunately, Bozeman got her.
Senator Campbell. Bozeman? Oh.
Ms. Meyers. And so she's down in the Bozeman area at MSU.
Senator Campbell. I see. Well, she's not my sister. She's
my cousin.
Ms. Meyers. Okay. That's good.
Senator Campbell. You can tell her hello if you see her,
too. I don't have any relatives in anybody else's area that's
testifying, but they brought up some really interesting
questions, Mr. Chairman. I'm probably not going to get into
them. We just won't have the time.
But Mr. Waukazoo really I thought alluded to something
really important, and that is that when you talk about Indian
healing it's just not a matter of giving them pills and Band-
Aids. It's a form of holistic healing. So much of Indian
healing has to do with their spiritual feeling and their
cultural feeling about being in balance with their surroundings
and so on.
I think that when you talk about all the activities you
have in your center, your health center, and Mr. Hunter's too,
in New York, superficially you might say, ``Well, what do those
have to do with health?'' But they have a lot to do with health
with Indians, and I think they are really worth pursuing and
worth expanding, too, if you can do this.
Obviously there's a question of how to finance all those
things, and that's what I wanted to ask you. You must have a
pretty large staff to do all those different activities you do.
Is that all done with donations and volunteerism?
Mr. Waukazoo. It's done with a lot of dedication and
commitment on the part of the staff. And I agree with you 100
percent about health care--it's much more than just providing
health care externally in the western model.
You know, when I was growing up in South Dakota my parents
used to tell me, ``Get out of the house. Go out and play.''
Today parents are saying, ``Stay in the house.''
Senator Campbell. Yes; you'll get sick.
Mr. Waukazoo. ``Don't go outside.'' So now we have a
generation who is growing up. I coach the Grasshoppers. We have
a tribal athletic program, part of our clinic. The Grasshoppers
are first and second graders, little guys. I coach them. We
haven't won a game in 2 years, but that's not important.
[Laughter.]
Senator Campbell. You're developing character.
Mr. Waukazoo. What's very important is that they're out
there getting active and they're learning that they're at risk
for diabetes. But they can't even run up and down the court
three or four times without getting tired. We get ahead by two
or three points at the end of the first quarter but we loose by
the end of the game because they're all tired.
How do we do it with financing? Well, health care is local.
We spend a lot of time and a lot of energy at the local level.
The local level and the State and the county delivery system
have a responsibility also.
Our greatest concern is we're seeing a larger and larger
group of those uninsured, those individuals that are not
eligible for Medicare, Medicaid, Medical in our State.
Then we also look in that other option in partnering up
with different other organizations. We will be building a youth
development center in the next year which will incorporate a
gymnasium, performing arts studio, fitness center, and it's
really about the next generation because that's our largest
population. If we can get in front of this diabetes and these
other health problems, you know, instead of trying to pull them
out of the stream, go upriver and build or repair that bridge
to keep them from falling into that. That's the initiative that
we've taken.
We're quite proud of the fact that our physicians both have
been with us for over 18 years. Our dentist has been with us
for 25 years. My assistant director has been with me for 16
years.
Senator Campbell. That's a commitment.
Mr. Waukazoo. And, following my father's advice 20 years
ago when I took this job, he said, ``The best place to be when
you don't know anything is in charge.'' [Laughter.]
Senator Campbell. That's why we're here. [Laughter.]
Mr. Chairman, years ago I asked an old man who was a half-
brother to my grandmother, I went over to visit him one time
and he had a really bad cold and I asked him why Indian people
have such health problems now that they didn't have in the
olden days, and he gave me an interesting answer. He said,
``Because look what we're living in.'' I don't remember the
exact words, it has been so many years ago, but he pointed out
in the olden times Indian people lived with nature. In the case
of the Plains people, all of their structures were round. The
sweat lodge, the tepee, and so on, were all round to reflect
the circle of nature, the circle of life. And he said that when
they were moved into square houses it was kind of an affront to
the natural way of living and he thought that their health
problems went up when that lifestyle changed and living in
square things instead of round things.
As I began to reflect on that, almost all Indian housing,
whether it was the Plains tribes or the Southwest tribes in the
desert or no matter where, the northeast, their structures were
round. Maybe he knew something we didn't know. But that's what
his belief was--kind of an old-time belief about why health
problems go up if you're out of tune with nature.
Mr. Hall, I remember we had the infamous tobacco settlement
debate here a few years ago and this committee certainly went
to bat for the Indian tribes being included in that tobacco
settlement. In fact, the current Secretary of the Interior came
back and testified. She was the attorney general for Colorado
then. She testified to help us make sure there were Indian
provisions in that settlement.
The thing fell apart because, typical of the Senate, we
went off in 100 different directions and we couldn't get
anything passed. But States did, as you know, go ahead and sue
tobacco companies and reached some settlements.
Do urban Indian centers have access to any of the
settlement funds that went into States? Do you know?
Mr. Hall. That varies by St. Montana I know gets a little
bit per each urban center. In South Dakota we got zip.
Senator Campbell. You got zip.
Mr. Hall. All of South Dakota's money went to tax relief.
California--I believe you guys participated in that a little
bit. But it varied by State.
Senator Campbell. State by State. There was no negotiated
agreement with the States and tribes.
Another question, Mr. Hall. Some Indian centers access
community health center funding. Denver does not, I understand.
Is the reason because you would have to accept anyone? Oakland
does, I guess. You would have to accept anyone, regardless of
whether they were Indian or not if you accept those funds?
Mr. Hall. A little bit of it is that reason. The other part
of it is that those clinics pretty much operate as a clinic in
a dominant society. Where the access is is from our people
feeling uncomfortable in those kind of environments. For
example, in the State of South Dakota the family planning
office has made three major efforts to reach Native American
women in the past 10 years. This July 1 they finally contracted
with us for a very small contract to reach out to Native
American women, and in the past 10 years they haven't increased
their numbers at all, and we've already submitted 25 names in
less than 1 month. So it's a matter of where Indian people feel
comfortable getting their service.
It's not just a matter of their being resistant. We have to
understand this whole cultural history of being Indian in this
country is like being an outsider in any environment,
especially when you get up in places like South Dakota. So it's
not just that, it's also the recognition that Indian health
care is a Federal responsibility, so many State offices and
stuff are not inviting to Indian people.
Another part of the issue is it is run very much in a time
constrained manner. If you're late with an appointment, just
like with TANF, you end up getting on sanctions, and when you
don't have gas for the car or your babysitter is not there,
boomadee, boomadee, boomadee, you're late. And so people get
very reluctant to do that, just like a lot of our people that
qualify for Medicaid. We have to push and push and push to get
them to jump through the hoops of applying for it because of a
perception and in many instances the reality of being
discriminated against in that application process.
So when you take a full look at how our people have bumped
into walls getting service in various dominant society options,
it really ends up being no option.
Senator Campbell. Sure.
Mr. Hall. In Sioux Falls, for example, I've had several OB/
GYN people tell us that they see a young lady or a young woman
when she finds out she's pregnant and again when she calls in
the emergency room having a baby because of that limited sense
of comfort with the dominant society's provisions.
Senator Campbell. I understand that.
Mr. Hall. Sorry for the long answer, but it was----
Senator Campbell. No; that's all right. I appreciate it.
Mr. Waukazoo, as I understand it, you--what did you say?
The people that come into the clinic self identify? Is that the
word you used?
Mr. Waukazoo. Yes.
Senator Campbell. That means if they come in and they say,
``I'm Indian and I need help,'' you go ahead and help them?
Mr. Waukazoo. Yes.
Senator Campbell. You don't ask them for an enrollment
number or anything?
Mr. Waukazoo. No; they self identify as American Indians.
Senator Campbell. Dealing with health service, then, how do
you handle a mixed family? A guy comes in and says, ``I'm
Indian.'' His wife says, ``I'm not.'' And they've got a couple
of kids with them. Do you say, ``Well, we can help you but not
her?'' How do you deal with that?
Mr. Waukazoo. That's what's in the family.
Senator Campbell. Okay. So if he identifies, his whole
family then is----
Mr. Waukazoo. Yes; the community--you know, in the Bay
area--in urban areas the community is spread out but it is very
highly connected. It's well known. It's just like on the
reservation. You know who is on the reservation.
Senator Campbell. You generally know because you've seen
them at activities----
Mr. Waukazoo. Yes.
Senator Campbell [continuing]. And they participate in the
community.
Mr. Waukazoo. Yes; right.
Senator Campbell. I see.
Mr. Waukazoo. And that decision generally is within the
family as far as where the health care is going to be taken
care of, so we don't get into that part of it.
Senator Campbell. I see.
I think, in the essence of time, Mr. Chairman, I'll submit
the rest of my questions in writing, if I could ask the panel
to respond.
Thank you, Mr. Chairman.
The Chairman. I will also join you in submitting questions,
if I may.
A final question. In the Native Hawaiian Health Improvement
Act, there is a provision for traditional Native healers and
traditional Native Hawaiian healers are officially recognized
by the Government of the United States. They are compensated
for their services.
Are Native American Indians interested in having this act
provide for traditional Native healers? I do not want to tell
you what to do, because I believe in you telling us what to do.
Mr. Hall. I just came from the Aberdeen Area Tribal
Chairman's Health Board meeting, where they spoke of this very
issue. They had a healer from the Navajo Reservation that is
part of the Shiprock, I believe--no, excuse me, Winslow service
unit. Some of the requirements you have to go through to become
billable under Medicaid are so stringent that most of the
healers feel they are stepping outside of their cultural powers
to participate in that, so most of them, as it is now
structured, are not reimbursable.
From the conversation of the Navajo people and from the
Lakota people and others up in the Aberdeen area, if that
provision you're describing could be applied without having to
do all of the hoops, they'd very much appreciate it.
IHS, as a whole, is being very receptive to utilizing
traditional healers, and I think the tribes, but we don't all
speak for the tribes. I can only speak from that experience.
The Chairman. Any objections?
Mr. Waukazoo. I would just say that it would be a decision
that I would prefer to have the tribes make, and if the
decision is yes, then we would be very supportive. But, you
know, sometimes we have to, in urban programs, kind of step
back and follow the tribes.
The Chairman. I think your position is correct. We will
most certainly discuss this matter with tribal leaders.
Before we adjourn, I would like to note the presence of Dr.
Vanderwagen. He has been sitting here all morning, and if you
have been to Senate hearings you will note that Government
witnesses oftentimes testify and leave immediately, but he has
been here and listening to your testimony, and I think all of
us owe him a great debt of gratitude. I commend you, sir, for
doing that.
[Applause.]
The Chairman. He was good enough to sit here to listen to
your concerns, if you had any.
With that, I thank you all for patiently waiting. Your
testimony is very much appreciated. It has been inspiring and
moving.
Thank you.
[Whereupon, at 12:20 p.m., the committee was adjourned, to
reconvene at the call of the Chair.]
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A P P E N D I X
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Additional Material Submitted for the Record
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Prepared Statement of Hon. Kent Conrad, U.S. Senator from North Dakota
Mr. Chairman, thank you for holding today's hearing on the
personnel and urban Indian provisions of the Indian Health Care
Improvement Act.
Senator Dorgan and I chaired a field hearing last August in North
Dakota to consider this legislation. I can attest to the fact that
tribes in my State believe changes need to be made to the way health
care is delivered throughout Indian country.
This bill is one of the most important pieces of legislation being
considered by this committee. Tribes in North Dakota have told me time
and again that health care is their top priority. Without healthy
people, all other endeavors will be less successful.
I am pleased that the committee has worked so closely with tribes
in putting together this important bill. I hope we are nearly to the
point where we can pass this legislation and allow health care
improvements to move forward throughout Indian country.
This is especially important for the growing number of young Native
Americans. We need a greater emphasis on prevention of disease and
injury overall, but especially with respect to young people. Wellness
and nutrition training, teaching young people to stay away from drugs,
tobacco, and alcohol, and greater attention to the mental well-being of
young people are all goals that I believe we should embrace. Greater
access to medical care, both rural and urban, and more health care
personnel throughout the system are vital to reaching those goals.
Mr. Chairman, thank you for holding this hearing today.
______
Prepared Statement of Hon. Tom Daschle, U.S. Senator from South Dakota
Mr. Chairman, thank you for the opportunity to testify on one of
the most important issues before this committee--our commitment to
provide quality health care for American Indians and Alaska Natives. As
you know, the Indian Health Service [IHS] is in far too many cases
unable to provide even basic health services to American Indians and
Alaska Natives. We are failing to uphold a promise we made many years
ago in Federal-tribal treaties as well as Federal statute.
The IHS is tasked with providing full health coverage and care for
American Indians and Alaska Natives, but is so underfunded that
patients are routinely denied care that most of us take for granted
and, in many cases, call essential. The budget for clinical services is
so inadequate that Indian patients are frequently subjected to a ``life
or limb'' test. Unless their condition is life-threatening or they risk
losing a limb, their treatment is deferred for higher priority cases;
by the time they become a priority, there are often no funds left to
pay for the treatment.
As devastating as the problem is for Native American patients and
the tribal governments struggling to address their people's health
needs, the problem does not end there. IHS often contracts with non-IHS
facilities to provide care that cannot be provided at local IHS clinics
and hospitals, due either to the complicated nature of the needed
service or a lack of funds. These non-IHS facilities often receive no
reimbursement for the services they provide and, as a result, face
serious budget shortfalls of their own. In 1999 alone, IHS issued
20,000 contract health service denials, leaving the contract facilities
without any reimbursement.
A compelling example of the impact of this underfunding is the
inability of many tribes to provide emergency medical services [EMS] to
their residents. IHS uses its authority through the Indian Self-
Determination and Education Assistance Act of 1975 to contract EMS to
tribes. Throughout Indian country, however, ambulance service is funded
at only 47 percent of the determined need. On the Rosebud Reservation
in South Dakota, the funding for EMS is depleted by mid-year. The
Rosebud Sioux Tribe's EMS contractors respond to 425 calls per month.
The local IHS facility does not have an obstetrical or surgical unit,
so all high-risk pregnancies and surgeries have to be transferred by
the EMS providers to private hospitals located 180 to 260 miles from
the reservation. When the tribe's funds for EMS are depleted, other
local providers are often called to respond to emergency transport
needs. Consequently, local EMS providers experience serious financial
difficulties because there are no funds left to reimburse them.
Ultimately, this situation can result in discontinuation of ambulance
services in a rural area.
I attempted to address the crisis created by this serious, chronic
underfunding of IHS by offering an amendment to the fiscal year 2002
budget resolution. The amendment called for a $4.2-billion increase for
the fiscal year 2002 clinical services budget of the IHS. This
amendment passed the Senate, but was not included in the bill that
returned from conference. I again attempted to address this situation
in the Interior Appropriations bill, but it appears that we will be
unable to do that at this time due to the inadequate budget allocation
facing the Interior Appropriations Subcommittee.
It seems Congress has grown so accustomed to inadequate IHS funding
that we are failing to recognize the extraordinary tragedy tribal
people are facing. The problem seems so big that we are almost afraid
to tackle it. But we cannot afford to shirk our responsibility.
One reason the problem seems so intractable is that IHS funding--
and, in turn, health care for Native Americans--depends on the
vicissitudes of the appropriations process. The budget for IHS has been
so underfunded for so long, our annual appropriations process may never
allow us to increase it enough to adequately address the health needs
of American Indians and Alaska Natives. The magnitude of the increase I
requested is evidence of this point: For fiscal year 2002, I requested
a $4.2-billion increase to the $1.8 billion budgeted for IHS clinical
services. This 233 percent increase is based on two conservative
estimates of the amount needed to adequately fund the provision of
basic clinical services: The tribal needs budget and the level of need
funding budget, developed by the tribes and IHS respectively.
It is time to change the way we fund our commitment to provide
health services to American Indians and Alaska Natives. This Federal
responsibility was codified by treaties and laws dating from 1787 and
required under the trust responsibility of the United States to the
tribes. It is clear that, in a historic and moral context, American
Indians and Alaska Natives are entitled to receive adequate health
services from the Federal Government. Why then, are they not getting
it?
What some may not know is that health care for Indians is not
delivered as an entitlement. I have come to believe it is time to
consider changing the funding mechanism for IHS from a domestic
discretionary program to an entitlement. Unless we can demonstrate a
renewed commitment to Indian health care in the budget and
appropriations process, granting entitlement status may be the only way
we will live up to our obligation. I understand the political
challenges that this entails. For Indian people, however, this is not
a. question of politics. It is a question of history and obligation. It
is a question of health and life.
If Indian health were moved from a domestic discretionary program
to an entitlement program, it would no longer shoulder the burden of
balancing the Nation's budget, along with other discretionary programs.
We would have to develop a new process to quantify Indian health based
on services and beneficiaries. Funding would be guaranteed.
I wholeheartedly support, therefore, the provision in the Indian
Health Care Improvement Act which establishes a National Bipartisan
Commission on Indian Health Care Entitlement. I look forward to the
Commission's report, and to continuing the discussion of this critical
issue.
I would like to bring to your attention another critical issue
impacting IHS's ability to provide health care services. The IHS
experiences enormous difficulties in recruiting and retaining health
professionals. In 1999, in the Sisseton Indian Health Service unit,
there were 34 different physicians providing medical care in four
funded provider positions. This high turnover rate significantly erodes
the IHS's ability to provide high quality health care services and
continuity of care. We must address this issue because, without health
care professionals, health care services cannot be delivered.
The Sicangu Sioux on the Rosebud Indian Reservation in South Dakota
recently built a beautiful new hospital and health care center. While
in many ways they are equipped to provide state-of-the-art care, they
are unable to retain health care professionals. As a result, their
brand new delivery and surgery rooms stand empty, and individuals
living on the reservation are forced to travel long distances to
receive these vital services.
There are many documented reasons for the difficulty recruiting and
retaining IHS health professionals, including low pay, lack of suitable
housing, isolation, and an overwhelming workload. Some health care
professionals do not want to practice long-term in chronically
underfunded, crowded and outdated facilities that lack essential
equipment. I am pleased that S. 212 includes an array of excellent
programs to improve the ability of the IHS to recruit and retain health
care professionals. There is, however, one issue that is not addressed
in S. 212: Medical license reciprocity for HIS physicians.
IHS physicians, as a condition of employment, must hold a license
in at lease one State. Since they are Federal employees, this license
should guarantee their ability to work as an IHS physician in any
State. This concept is called ``reciprocity''. In South Dakota, IHS
physicians are granted reciprocity and allowed to practice under a
license issued from a different State. Their scope of practice,
however, is limited; they are not allowed to practice outside of an IHS
facility. This limitation is extremely frustrating, since, due to
severe underfunding of the IHS, many areas do not have IHS facilities,
such as hospitals, nursing homes, or specialized clinics. Many
physicians prefer to follow their patients throughout the systems of
care. If an IHS patient is transferred from an IHS facility to a non-
IHS facility for inpatient care, for example, the IHS physician is
currently forced to turn over the care to a non-IHS physician, who may
not even know the patient.
Given the many challenges IHS faces in recruiting physicians, I
firmly believe we should not create another barrier. The inability of
IHS physicians to practice outside the bricks and mortar of an IHS
facility has led to the resignation of too many IHS physicians. I hope
we can find a way to remove this barrier as we move forward with S.
212.
I was pleased to see that S. 212 continues an emphasis on programs
to comprehensively address substance abuse and Fetal Alcohol Syndrome
[FAS]. According to IHS, the 1994-95 age adjusted death rate for
alcoholism in the IHS Service Area was more than six times that of the
general population. Yet, treatment services for Native Americans remain
severely inadequate.
Programs to address FAS are particularly crucial. FAS is the
leading preventable cause of mental retardation in the United States
and the No. 1 cause of preventable birth defects. Although the exact
prevalence of this disorder is unknown, studies have estimated that 3
out of 1,000 Native American children are born with FAS, and many more
with less severe alcohol-related impairments.
These statistics highlight the urgent need for increased access to
residential treatment services for women of childbearing age. In the
Pine Ridge area of South Dakota, there is currently a five-month wait
for IHS residential substance abuse treatment programs. This means that
if an alcoholic woman learns she is pregnant and is motivated enough to
request treatment, she would probably be more than 6 months into her
pregnancy before a bed was available. By this time, her unborn child
could be severely and permanently damaged.
We need to ensure that when a pregnant woman walks in the door to
ask for help with her drinking, help is available. In addition, we need
to do all we can to educate Native American women, as well as
professionals who serve the Native American community [as well as the
non-Native community], about FAS and the dangers of drinking while
pregnant. And we need to ensure that when these approaches have failed
and a child is born with FAS, that child has access to the medical,
educational, and social services he or she needs.
In closing, I would like to thank the chairman, the vice chairman
and the entire committee for their dedication to improving the health
of American Indians and Alaska Natives. S. 212 is a comprehensive
reauthorization of the Indian Health Care Improvement Act, and, when
enacted and if adequately funded, will go a long way toward reducing
the disparities in health outcomes between Native and other Americans.
It saddens me to know that the mortality rate for American Indians and
Alaska Natives is higher than for all races in the United States, and
life expectancy is the lowest. I commend you for your efforts to
eliminate these disparities and live up to our commitment to provide
health services to American Indians and Alaska Natives.
______
Prepared Statement of Dr. William C. Vanderwagen, Acting Chief Medical
Officer, Indian Health Service, Department of Health and Human Services
Good morning, Mr. Chairman and members of the committee. I am Dr.
William C. Vanderwagen, acting chief medical officer, Indian Health
Service [IHS], Department of Health and Human Services.
I am pleased to be here this morning to testify before the Senate
Indian Affairs Committee about two important areas within the IHS
service responsibilities.
The first issue of health manpower, providing and retaining
sufficient health professionals for our health care delivery system, is
one shared by the country overall. The second matter concerns the
operation and challenges facing the urban Indian health programs.
In meeting our goals, the IHS has adhered to its policy of working
with our tribal and urban partners and constituents, on key decisions
and actions. Efforts to improve program delivery of services are
greatly improved by such consultation and cooperation.
The IHS health care delivery system is comprised of 49 hospitals,
219 health centers, 7 school health centers and 293 health stations.
The American Indian and Alaska Native eligible population, in fiscal
year 2000 was approximately 1.51 million. This service population is
increasing at a rate of about 23 percent per year, and this estimate
exclude's the effect of the additions of new tribes. *[Trends 1998-99]
Patient admissions into our IRS, tribal and contract general
hospitals, in fiscal year 1997, were about 85,000. Main causes for
admission were births and pregnancy complications. The 2 ambulatory
statistics in fiscal year 1997 show over 7.3 million medical visits
provided through the IHS-funded operations.
There, are additional data to be found in our IHS 1998-99 Trends
publication, but the main purpose of this review is to provide the
backdrop against which much of our discussions will take place this
morning.
It is to the credit of our personnel, health professionals and
others, that all of our IHS and tribally operated health facilities had
achieved accreditation by the Joint Commission on Accreditation of
Health Care, Organizations [JCAHCO]. This rating was true as of January
20, 1999.
To fulfill our primary goal of ensuring that we achieve the highest
possible health status among American Indians and Alaska Natives, the
health professions activities are critical but could be tested over the
next 5 years. The IHS could lose a substantial number of its staff for
a variety of reasons, including age-eligible retirement and the
fulfillment of service obligations.
As of the end of June 2001, nearly 22 percent of our 13,000 Federal
employees, throughout the whole system, had 20 or more years of
service. Within the health professions, 18 percent of the 8,600 health-
related employees in the 600 personnel series, in which most of the
health professionals are found, are in the 20-plus years category.
Finally, of the three most numerous health professions, nurses,
pharmacists, and dentists, all of these groups have more than 12
percent of their staffs in this group age-eligible retirement category.
Physicians have 8 percent of all of our IHS physicians are in the 20-
plus years category.
Our plans for addressing this pending situation include the
institution of even more vigorous recruitment efforts and a greatly
increased emphasis on retention. Such activities include:
1. Increased advertising in professional journals.
2. Increased Health Educational Institution Recruitment Visits.
3. Increased web-based Advertising.
Retention has been a major factor in reaching our current status.
The average length of service for all IHS employees is just over 12
years. For those in the 600 series, it is just over 11 years.
Of our four most numerous professions, nurses have the longest
average length of service, at nearly 11 years. Physicians, with 8
years, have the shortest, while dentists and pharmacists average just
over 9 years each. The difficulty, however, is that we lose many of our
new recruits before they have served 5 years. Therefore, retention of
new employees must remain a priority.
These difficulties in retention include culture and transition
issues, within rural and often disadvantaged communities. Additionally,
the competition for such qualified individuals is huge. Many of these
professionals are often approached by other health care institutions
with more attractive employee benefits packages and placements. This
situation, of competing health care systems, is only going to grow in
future years as our population, national and in Indian communities
continue to live longer and more productive lives.
Our scholarship and loan repayment programs offer us the
opportunity to attract highly qualified staff. In fiscal year 2000, 37
new scholarships were awarded to participants in two undergraduate
scholarship programs in the Health Professions with 46 extensions.
Forty-five new awards were made in the Preparatory Pregraduate
scholarship program with 61 extensions, and 60 new awards were made to
students in a health professions graduate programs with 287 extensions.
In fiscal year 1996, the average debt load of a new loan repayment
program participant was S32,000. In fiscal year 2000, it was $64,000.
We anticipate that this individual debt load will be even higher this
year.
Such educational financial assistance, in turn, assures the IHS of
a service commitment by the individual who receives such aid. Service
``payback'' commitment can range from 2 to 4 years. Once such
commitment is completed, an individual may have private practice goals
or family obligations that preclude their further employment within the
Indian health care system.
Today 62.3 percent of all American Indians and Alaska Natives
identified in the 1990 Census reside off-reservation. This figure
represents 1.39 million of the 2.24 million American Indian/Alaska
Natives identified in the 1990 Census updated by Indian Health Service.
The updated 1994 Census identifies 1.3 million [58 percent] of the
American Indian/Alaska Natives residing in urban areas. For comparison
purposes the Indian Health Service total service population is 1.4
million with active users at 1.2 million. This figure includes 427,100
eligible urban Indian active users who reside in geographic locations
with access to an Indian Health Service or Tribal facility.
In 1976 Congress passed the Indian Health Care Improvement Act
[IHCIA] [Public Law 94-437]. Title V of the [IHCIA] targeted specific
funding for the development of supporting health programs for American
Indians/Alaska Natives residing in urban areas. Since passage of this
landmark legislation, amendments to title V have strengthened Urban
Indian Health programs [UIHPs] to expand to direct medical services,
alcohol services, mental health services, HIV services, and health
promotion and disease prevention services. [Public Law 100-713, Public
Law 101-630, Public Law 102-573].
The UIHPs consist of 34 nonprofit 501 (C)(3) programs nationwide
funded through grants and contracts from the Indian Health Service,
under title V of IHCIA, Public Law 94-437, as amended. Sixteen [16] of
the 34 programs receive Medicaid reimbursement as Federally Qualified
Health Centers [FQHCs) and others receive fee for service under
Medicaid for allowable services, that is, behavioral services,
transportation, et cetera. The other programs are automatically
eligible by law but may not provide all of the necessary primary care
service requirements mandated by FQHC legislation. Over $10 million are
generated in other revenue sources.
In the Omnibus Budget Reconciliation Act [OBRA] of 1993, title V of
the IHCIA, and tribal 638 self-governance programs were added to the
list of specific programs automatically eligible as FQHCs. The range of
contract and grant funded programs below are provided in facilities
owned or leased by the Urban organizations. Pursuant to title V, the
Indian Health Service is required by law to conduct an annual program
review using various-programs standards of Indian Health Service and to
provide technical assistance to the Urban Indian Health Programs.
The range of Indian Health Service/Urban grant and contract
programs services can include: Information, outreach and referral,
dental services, comprehensive primary care services, limited primary
care services, community health, substance abuse [outpatient and
inpatient services], behavioral health services, immunizations, HIV
activities, Health Promotion and Disease prevention, and other health
programs funded through other State and Federal, and local resources,
for example, WIC, Social Services, Medicaid, Maternal Child Health.
Sixteen [16] of the 34 programs are certified as Federally
Qualified Health Centers. The other programs are automatically eligible
by law but may not provide all of the necessary primary care service
requirements mandated by FQHC legislation.
Today the Indian Health Service provides funding to the 36 [34
title V of the lHCIA and two demonstration programs] urban Indian
health centers and to 10 urban Indian alcohol programs. The urban
Indian health programs, range from comprehensive primary care centers
to referral and information stations. In fiscal year 2001 Congress
appropriated $29,843 million for Urban Indian Health. These centers
continue to receive funding as well, from a variety of other Federal,
state and private sources.
Mr. Chairman, this concludes my prepared statement, I will be happy
to respond to any questions you and other committee members may have.
______
Prepared Statement of Michael E. Bird, President, American Public
Health Association
Mr. Chairman and members of the committee, I am Michael Bird,
president of the American Public Health Association. However, today, I
am representing the Friends of Indian Health, a coalition of over 40
health organizations and individuals. The Friends were formed in 1997
to improve the funding and delivery of health services to American
Indians and Alaska Natives [AVAN].
We thank you for the opportunity to testify today and to comment on
health care personnel issues that we think could be addressed in the
Reauthorization of the Indian Health Care Improvement Act, S. 212.
While the individual members of the Friends have profession specific
concerns we are united on the need to improve the recruitment and
retention of health care providers in the IHS.
A member of the Friends recently sought care from the Phoenix
Indian Medical Center [PIMC]. For a 1 o'clock doctor's appointment, he
left his home at 11 a.m., arriving at the PIMC at noon. Having been
there before, he knew that he needed to arrive an hour before his
appointment because patients are seen on a ``first come, first serve''
basis . . . even though he had a scheduled appointment. At this
facility, the patient to doctor ratio is overwhelming. Not only does it
serve Indian patients from the Phoenix city limits but also patients
from the adjacent reservations that do not have inpatient services are
brought in by vans. The patient was eventually seen but also told that
his back condition had worsened and would probably need surgery for
several herniated discs. However, because of a lack of orthopedists at
the PIMC he was unable to schedule a consultation until September 27.
The patient's check up took all afternoon; he returned home at 5 p.m.
This experience is not unique. There is a disparity in access to
care throughout the Indian health care system. For example:
\\\\\\In fiscal year 1998, there were 74 physicians per
100,000 AI/AN beneficiaries, compared to 242 per 100,000 in the
overall U.S. population;
\\\\\\In fiscal year 1998, there were 232 registered nurses
per 100,000 AI/AN beneficiaries, compared to 876.2 per 100,000
in the overall U.S. population;
\\\\\\In fiscal year 1998, there were 289 public health
nurses in the IHS. This represents a ratio of 19.8 per 100,000
AVAN beneficiaries;
\\\\\\In fiscal year 2000, there were 21 IHS psychiatrists;
\\\\\\In fiscal year 2000, there were 63 IHS psychologists;
\\\\\\In fiscal year 2001, there were 19 podiatrists to
treat the more than 60,000 AI/AN diagnosed with diabetes;
\\\\\\In fiscal year 2001, there are 11 vacancies for
optometrists. Unless these positions are filled, 27,500
patients will not receive care;
\\\\\\In fiscal year 1998, the dentist to AI/AN beneficiary
ratio was 1:2,793 compared to 1:1,743 for the overall U.S.
population; and,
\\\\\\In fiscal year 1999 there were only 20 registered
dietitians per 100,000 AI/AN beneficiaries.
Another way to view this situation is to compare the IHS to the
Veterans Administration. For example, the Carle T. Hayden Veterans
Medical Center and the PIMC are within a mile of each other in central
Phoenix. The total number of outpatient visits at the VA facility was
8,339, compared to 14,400 at the PIMC, a difference of 6,060. The VA
employs 9.5 psychologists, while the PIMC employs 4 psychologists. The
total number of behavioral staff at the VA was 75.5, as compared to the
17 behavioral staff at the PIMC.
While the disparity to access to care is most pronounced in the
IHS, it will not be long before the rest of the country will see
similar problems. Various health professions are already experiencing
or expect to experience shortages in the near future. For example:
\\\\\\According to the American Hospital Association's June
2001 TrendWatch, 126,000 nurses are currently needed to fill
vacancies at our nation's hospitals. Today, fully 75 percent of
all hospital personnel vacancies are for nurses;
\\\\\\According to a study by Dr. Peter Buerhaus and
colleagues published in the Journal of the American Medical
Association [June 14, 2000], the United States will experience
a 20-percent shortage in the number of nurses needed in the
United States health care system by the year 2020. This
translates into a shortage of more than 400,000 RNS nationwide;
\\\\\\In the next 20 years, 85,000 dentists will retire and
only 81,000 will replace them;
\\\\\\The June 2001 TrendWatch also reports that hospitals
have a 21-percent vacancy rate for pharmacists; and
\\\\\\Podiatry has experienced a nearly 50 percent reduction
in its applicant pool since the 1990's. In addition, the number
of graduates is also dropping. This is occurring when most
States have only 1 to 4 podiatrists per every 100,000 citizens.
Federal estimates recommend 6.2 podiatrists per 100,000.
The Friends believes that by improving access to treatment and
preventive services the IRS will be able to make significant strides in
reducing health disparities and morbidity and mortality rates in the
AI/AN population. Evidence of this was demonstrated by the placement of
a full time podiatrist with the Winnebago and Omaha tribes. During his
4-year tenure, the average annual 16 leg amputations fell to zero. Not
only did this improve the daily living and quality of life for tribal
members and their families but there was a considerable cost savings
also. On the average, medical and surgical costs associated with leg
amputations can average $40,000 a piece. This one podiatrist saved the
tribes over $2 million in surgical expenses during his tenure.
But the IHS needs to move quickly to better recruit and retain
health care providers now. If the Administration waits too long then in
the near future when competition for health care providers throughout
the country becomes more intense, the IRS will not be able to compete
for these workers. In order for that to happen, Congress needs to make
it easier for the IHS to recruit health care providers.
Suggested Solutions;
1. Loan Repayment
The most successful recruiting tool that the IHS has is loan
repayment. A few years ago, following recruitment visits to dental
schools, the IHS dental branch received 100 calls from interested
graduating seniors. However, almost every caller asked about the
availability of loan repayment. When they learned that it was minimal,
actual applications fell to just over 30. Loan repayment is an
excellent recruiting tool. Of the 19 podiatrists serving in the IHS, 13
are receiving loan repayment. Most health professionals have incurred
heavy debt loads during their education. The average debt load of the
272 people entering the IHS last year was $64,000. But that figure
understates several individual professions:
\\\\\\The average student debt for physicians is $95,000;
\\\\\\The average student debt for optometrists is over
$100,000;
\\\\\\The average student debt for dentists is $100,000
[this does not include undergraduate debts]; and
\\\\\\The average student debt for podiatrists is $110,000.
As part of the Friends fiscal year 2002 appropriations request, we
requested that the IHS loan repayment budget be raised to $34 million.
This is an increase of $17 million and would allow the IHS to double
its workforce. The IHS could further extend this funding if Congress
were to make these loans tax-free. Under the current system, Congress
not only pays health care providers an annual sum of $20,000 but also
pays an additional 20 percent of that amount for taxes. Therefore, $3.4
million goes to the Internal Revenue Service. If the loans were tax
free, this would allow the IHS to hire 170 more providers. Just
doubling the number of IHS dentists getting loan repayment would mean
that 53,000 more dental visits could be scheduled each year. The
Friends recommends that the committee include a provision in S. 212 to
make the loans tax-free.
2. Loan Deferment
Under the Higher Education Act, volunteers or members of various
health and Federal programs do not have to repay the principal of, or
the interest on, any student loan under the Act for 3 years. This
includes members of the
\\\\\\Armed Forces,
\\\\\\Peace Corps,
\\\\\\Domestic Volunteer Service,
\\\\\\Full time nurse or medical technicians providing
health services, or
\\\\\\Full time employees of a public or private nonprofit
child or family service agency who is providing, or supervising
services to high-risk children from low-income communities.
Health care personnel working in the IHS or for tribes are
noticeably absent from this list. Consequently, recent graduates must
begin immediate repayment of debt upon graduation, when their net
incomes are at their lowest. For some, that monthly payment can be over
$1,000. Faced with this burden, many health care professionals cannot
afford to join the IHS, whether as Commissioned Corps, Tribal hires or
urban hires. For those who do take the risk of joining while waiting to
be accepted for loan repayment, many soon discover that they cannot
make ends meet because of their enormous debt load and leave the IHS to
accept more lucrative opportunities. Therefore, the Friends recommends
that the Committee correct this omission in S. 212 in order to improve
the recruitment and retention of IHS health professionals.
The need for a robust loan repayment and deferment program is
especially critical when one considers that the IHS pay scale lags far
behind the private sector. For example, in 1998, the average net income
among general practice dentists that graduated less than 10 years ago
was $141,690, while the newly graduated dentist in the Commissioned
Corps earned slightly more than $50,000. Similarly, the average annual
income for IHS pediatricians is nearly $40,000 less than for
pediatricians in the private practice. This occurs despite the fact
that one-third of the AI/AN population is under the age of 15.
3. Housing for Health Care Providers
Another important aspect of recruiting health care personnel is
adequate housing. At some sites, health care providers have reported it
is discouraging to have to live in housing that is ``worse than college
dorms.'' The American Dental Association reported to Congress,
following a 1997-site visit, that a dentist was leaving a remote site
because of the unlivable conditions of her mobile home. No suitable
housing could be found to retain her services. In some areas, health
care providers are forced to live miles away, often in other States, in
order to find decent housing for themselves and their families. The
Friends believes that the IHS needs to assess its staff quarters and
develop a consistent approach to replacing or building new staff
quarters. Therefore, the Friends recommends that committee include a
study of staff quarters and a proposal for addressing the situation in
S. 212.
4. Exit Interviews:
As the IHS approaches the next decade and must compete for health
personnel with the rest of the country, the Friends believes that it
would be very helpful to require exit interviews of departing
employees. Determining whether staff are leaving because of non-
competitive salaries, high debt burden, inadequate housing, spousal
needs or a lack of an ``esprit de corps'' would be essential to quickly
making corrections to prevent others from leaving. The Friends has
heard anecdotal stories that because of the Government Performance and
Results Act [GPRA] that midlevel support personnel have been lost and
paperwork burdens have increased. These changes directly impact on
patient care. They decrease the number of patients that can be treated
and reduce prevention education programs which help to keep down the
level of disease. Health care providers feel overburdened which leads
to bum out and retention problems. For example, the financial resources
in the IHS are at 40 percent of that need to provide mental health
services. Most Service Units and Tribal programs are operated with one
or two providers, who provide primarily crisis-related services with
little backup due to the isolated, rural nature of their practice. Not
surprisingly, professional burnout leads to rapid turnover, adversely
affecting the availability of a single backup psychiatrist, let alone
the essentials of an adequate, cost-effective mental health program.
Maintaining strong patient-provider relationships is essential to good
care, but if the provider doesn't stay long enough to form such a bond,
it undermines the care and prognosis of the patient.
Increasing the Use of Students and Volunteers
The IHS employs approximately 500 pharmacists. Many of them joined
the IHS after completing a residency at IHS sites. The pharmacists have
11 IHS sites where students can do their residencies. Interestingly,
new pharmacist hires have a better retention rate than other health
care professionals during the first 5 years of working for the IHS.
While the Friends cannot state for sure that this is due to the
students' early exposure to the IHS we recognize that such a program
offers great opportunities. We would like to see the IHS work with
other professional organizations and education groups to create similar
programs. We believe that this would help to ease the provider shortage
on a short-term basis when the students are at the sites and possibly
in the long run for recruitment efforts.
In addition, the Friends would like to see the IHS explore ways to
recruit active and retiring health care professionals interested in
providing care on a part-time or temporary basis. For example, the
American Academy of Pediatrics has received more than 300 requests from
active physicians for information about its Locum Tenens program, a
national initiative that identifies short-term pediatric opportunities
at IHS sites. Additional, we believe that many other providers are not
ready to completely retire and would be willing to volunteer a week, a
few days a month or even 6 months of their services. Their experience
and expertise, particularly specialists like OB/GYNs, psychiatrists,
oral surgeons, and orthopedic surgeons are in high demand. However, in
order to make use of these professionals the IHS needs to create a
program where such volunteers can be recruited, enter easily without a
lot of paperwork, provide adequate housing and assure the volunteers
that liability would not be problem. The Friends recommends that the
committee include in S. 212 a pilot project to create such a program in
consultation with professional organizations. Individual members of the
Friends would be pleased to work with the IHS on such a project.
Thank you Mr. Chairman and members of the committee for offering
the Friends of Indian Health the opportunity to testify today on the
Indian Health Care Improvement Act. We hope we have provided the
committee with thoughtful suggestions and we will try to answer any
questions you might have.
FRIENDS OF INDIAN HEALTH
AIDS Action
American Academy of Child & Adolescent Psychiatry
American Academy of Family Physicians
American Academy of Ophthalmology
American Academy of Pediatrics
American Academy of Pediatric Dentistry
American Academy of Physicians Assistants
American Association of Colleges of Nursing
American Association of Colleges of Osteopathic Medicine
American Association of Colleges of Pharmacy
American Association of Colleges of Podiatric Medicine
American Association of Dental Schools
American Cancer Society
American College of Obstetricians and Gynecologists
American College of Osteopathic Family Physicians
American College of Physicians
American Dental Association
American Diabetes Association
American Dietetic Association
American Geriatrics Society
American Hospital Association
American Medical Association
American Nurses Association
American Occupational Therapy Association
American Optometric Association
American Osteopathic Association
American Pharmaceutical Association
American Podiatric Medical Association
American Psychiatric Association
American Psychological Association
American Public Health Association
Arizona Academy of Family Physicians
Association of Schools of Public Health
Friends Committee on National Legislation
National Kidney Foundation
National Rural Health Association
National Native American AIDS Prevention Center
George Blue Spruce, D.D.S.
Ward Robinson, M.D.
William Treviranus, D.O.
James Zuckerman, M.D., Harvard Medical School
______
Prepared Statement of Carole Meyers, Executive Director, Missoula
Indian Center, Missoula, MT
Honorable Chairman and committee members, my name is Carole Meyers,
executive director for the Missoula Indian Center, Missoula, MT. I am
an enrolled member of the Blackfeet Tribe and also a descendent of the
Oneida and Seneca Tribes. I would like at this time and thank you for
this opportunity to testify before your committee on the issues of
urban health problems in Missoula, MT.
The Missoula Indian Center is a Non-Profit 301 c. (3) organization
and has been in existence in Missoula, MT since April 1970. This
organization has assisted the Native American community in Missoula for
thirty-one (31) years as a health referral agency. The population of
Native American's in the Missoula Community is approximately 3,100
people with, 65 tribal representations from across the Nation.
Missoula, MT has a population of 74,000, home of the University of
Montana, which many of the Native American people who move to Missoula
attend the University system. Montana has seven (7) reservations and
there are eleven (11) different tribes that live in each area. When
Native American's leave their home reservation and move to an urban
area, such as Missoula, they face many obstacles. One of the most
noticeable is their health coverage. Once they live in an urban area
for 180 days, they loss all of their Indian Health Service coverage.
I want to go on record that I fully support the passage of Indian
Health Care Improvement Act Reauthorization of 2001 S. 212. This
reauthorization of this bill would allow Native American people to
receive the necessary health coverage to enjoy a long and healthy life.
The definition of ``Urban Indian'' means any individual who resides
in an urban center and who-(A) regardless of whether such individual
lives on or near a reservation, is a member of a tribe, band or other
organized group of Indians, including those tribes, bands, or groups
terminated since 1940 and those tribes, bands or groups that are
recognized by the States in which they reside, or who is a descendant,
in the first or second degree, of any such member.
This definition needs to part of the Indian Health Care Improvement
Act. In order for the Urban Indians to receive adequate funding; we
need to be recognized as our own unique group of Indian people. Living
away from the reservation does create different situations.
Below is a listing of the program the Missoula Indian Center
provides:
Indian Health Service
Immunization Health Promotion/Disease
Prevention AIDS
Alcohol
Mental Health
Diabetes
Adolescence Substance Abuse Program
Health
Chemical Dependency Program
Missoula County
Alcohol
State of Montana
Alcohol
Tobacco
The Missoula Indian Center is governed body by a 7-member Board of
Directors, of which, 51 percent, must be Native American. The Missoula
Indian Center is organized under two major programs; the Health
Programs and the Chemical Dependency Programs. There are 11 full-time
staff and one part-time Mental Health Counselor.
The health issues that surround the Native American population
range from diabetes to the common cold.
With our agency as a health referral organization, many of our
clients may see as many as three (3) to five (5) different health
providers in a course of 1 year. With this inconsistency of health
providers, there is not a medical history that follows the clients.
This creates more confusion and lack of medical knowledge of the
client's history. Many times, because of lack of funding, clients will
be referred to at the point of emergency medical attention. There is
very little prevention health care, such as a yearly physical or dental
check-ups.
The Missoula Indian Center's Health program provides quarterly
clinics that cover basic health issues. Which, in itself is an
excellent program activity. But a significant problem the Health
program faces is, if a client has a medical problem we do not have the
resources to provide the medical follow up that is necessary. For
example, at our quarterly, clients are provided with a blood screening,
this is a very through medical screening. If a client's medical report
comes back as an issue, they are basically on his or her own to seek
medical assistance. It is a safe estimate that 80 percent to 90 percent
of our clients do not have medical insurance so they look to us for
their medical needs but we do not have the funding resources to help
them in their crisis. The only thing we can advise them if to go back
to their home reservation to seek medical help but some require a 6-
month waiting period for residency purposes.
The Missoula Indian Center had 8,865 encounters this past year.
These encounters are community members who access the center for
medical issues, drug and alcohol counseling to utilizing the telephone.
We are looked upon as a ``One-Stop'' agency for many needs other than
medical. Other prevalent issues besides the health are: No. 1, housing;
No. 2, employment; No. 3, school (K-12 and Higher Education); No. 4,
law enforcement and; No. 5, food. These are a few that we see on a
daily base if not weekly.
The center staff networks with other agencies within the Missoula
community, such as Office of Public Assistance, Casey Family
Foundation, Youth Court, Adult Parole and Probation, Pre-Release
Center, Missoula County School District, Missoula Food Bank, Public
Health Clinic, Now Care, Missoula Housing Authority, Human Resources,
City Police Department and Missoula County Sheriffs Department, just to
mention a few. Networking within the community is important because
many of our Native American clients utilize those agencies and if there
are issues that clients face, we can advocate for them. The Missoula
Indian Center offers ``In-Service'' training for those agencies that
want a better understanding the type of services we provide.
Presently, we contract with other health agencies, such as
Partnership Health Clinic at a reduced cost for a doctor's visit. This
enables Health funds to cover more clients over the course of a year.
But this does not address a client's need for medical followup or
maintenance.
When a client needs to have a prescription filled, we are able to
transport them to St. Ignatius on certain days, located on the Flathead
Indian Reservation, which is a 90-mile round trip. Because of the
Salish and Kootenia Tribal policies, clients have to physically present
themselves to pick up their medication. This creates some hardship on
our clients due to the fact that they may not have transportation to
drive to St. Ignatius or money to purchase gas for their car. When the
health staff transports, this takes them away from their regular
workday.
The other service clients can utilize is the dental clinic. But in
order for a client to be seen, it has to be an emergency and they have
to be at the dental office by 8 a.m. in order to be seen by a dentist.
This means, the client has to leave Missoula by 7 a.m. in order to have
dental care. And once again, by the time they need emergency dental, it
is a tooth ache or some type of infection and it is in a crisis
setting. Plus, this trip can and is often dangerous drive to St.
Ignatius because of the hazardous weather conditions Montana has during
the winter months.
As you can read in my testimony, there are many factors that play
in to affect when it comes to the health issues of Native Americans
living in an urban area. Native American's leave their home reservation
for many reasons. The most prevalent is education. Trying to achieve a
higher education degree is of the utmost importance from many. This
enables individuals to have a better life style, achieve a goal not too
many Native Americans have been able to accomplish in the past. But in
order for them to achieve this goal, they have to move to an urban area
to attend a 4-year higher education institution. At times, it can be
very difficult in the sense they experience ``culture shock'' when they
move to an urban location. The transition period for adjustment can be
up to 1 year to feel comfortable and cope with many of the difficulties
they encounter. Within the capacity of my job, I have seen many Native
American's try to better themselves and their families but at times
when they are faced with medical problems or other issues and no where
to turn, the only alternative would be for them to move back home and
at times, the cycle poverty or frustration continues.
The Chemical Dependency programs the center offers are Intensive
Outpatient and Standard Outpatient with some group/individual
counseling sessions. Since these programs are Montana State Certified
that enables them to apply for other funding through State and County
programs. Not only the Native American clients utilize these programs,
the non-Native American's attend these sessions. The type of programs
the center offers has a Native American/spirituality theme and many of
the clients who participate have commented that a ``wholelistic''
approach to their addictive issues has benefited them with their
recovery. The Missoula Indian Center is the only program in the
Missoula area that offers this type of services. Other programs in the
Missoula area have recognized the spirituality of these Chemical
Dependency counseling sessions and have commented the uniqueness of
them.
The health programs assist with the Chemical Dependency clients.
They offer HIV testing and counseling, Hepatitis-C testing, and
encourage them to attend the quarterly clinics they offer. Many of them
not only come in with an addiction problem but as well noted stems into
many health issues.
Diabetes is a prevalent health issue that is on the rise with many
of the recovery alcoholic. One incident that comes to mind is a pre-
release client utilizing the Chemical Dependency program complained of
having a blister on his foot. The pre-release staff accompanying him
that day thought it was not a big deal but I told her that a blister on
a diabetic could be fatal. She was not aware of the significant
problems that Native American diabetics face everyday with their
disease. I offered to have the health staff come to the Pre-Release
Center and provide their staff with an ``In-Service'' on the health
issues of diabetic clients.
I want to thank you for your time for listening and reading my
testimony; it has been a privilege and honor to come before you with my
thoughts and ideas. Each and everyday Native American's are faced with
issues and problems of health, employment, and education. I sincerely
hope with my testimony that our issues have been personalized and
``survival'' on day-to-day bases for the Native American people is a
very real issue.
______
Prepared Statement of Martin Waukazoo, Executive Director, Urban Health
Board, Inc., Native American Health Centers San Francisco and Oakland,
CA
Although the majority of Native Americans live in urban settings,
most Federal funding for Native health care and community initiatives
goes to those who continue to live on reservations. The basic medical
and dental needs of urban Indians are unmet in addition to other areas
including mental health, substance abuse, HIV/AIDS prevention and
treatment, diabetes prevention and treatment, and capital needs. Urban
Indian Health Board, Inc. was established in 1972 to address the health
needs of the urban Indian population of the San Francisco Bay Area. In
that year, Indian Health Services [IHS] funding comprised ninety
percent of our operating budget. Today, IHS grants amount to only 14
percent of our total funding. Our success in fundraising and in service
delivery can be attributed to decades of sacrifice and persistence.
However, consistent funding is becoming more difficult to achieve when
costs rise faster than the needs of our service population.
Our service area is the five counties of the San Francisco Bay Area
including Alameda, Contra Costa, Marin, San Francisco, and San Mateo
Counties. Preliminary Census 2000 figures show nearly 80,000 Native
American/Alaska Native and multi-race/Native individuals reside in
these five counties. The Bay Area has one of the largest concentrations
of urban Indians in the country.
Urban Indian Health Board, Inc. is a nonprofit 501(c)(3) community
health care provider operating two licensed clinics, one in San
Francisco, since 1972, and one in Oakland, since 1983. We employ 120
health workers. Our operating budget for the current year is $7.1
million. The Board of Directors is composed entirely of Native
Americans and serves on a volunteer basis.
Ninety-eight percent of Native American patients served meet the
Federal poverty level guidelines. In 2000, the medical clinic saw over
4,800 patients with over 16,800 visits. Many of our patients are
members of tribes from across the United States with the largest number
representing California tribes, Navajo, Lakota, Pomo, Cherokee, Apache,
Paiute, Blackfeet, Choctaw, and Chippewa.
Our services reflect our expanded definition of health: The health
of an individual depends upon the health of a community. Since our
agency is one of the few Native organizations in the Bay Area, we are
in a unique position to directly impact our community's health. Thus,
we function as far more than a medical clinic. As part of our mission
to contribute to the health and growth of our community, we offer adult
and pediatric services in our two clinic settings; women's health care;
prenatal care; a WIC program; comprehensive dental care; mental health
services including substance abuse counseling; fitness and nutrition
counseling; health education and outreach; and a variety of youth
initiatives through our Native American Youth Services program.
We believe health is whole-body and community-based. Urban Indians
feel a sense of isolation and disconnect from the broader community. As
a health service provider, we step in to try to ameliorate that feeling
of isolation among our community members. Our clients are
disproportionately young, poor [nearly every client in 2000 was below
the poverty line, with fully 13 percent at 200 percent or more below
poverty level], and impacted by physical and mental health issues
specific to a people that has suffered cultural and physical
dislocation and decades of poverty. Disparities have arisen in disease
and mortality rates between Native peoples and the general population.
We believe these disparities are due to the consequences of poverty and
cultural dislocation, with urban environments like our own only
exacerbating the lack of family and traditional support systems.
We face several overlapping challenges: Those specific to urban
Native populations, and those specific to the Bay Area. For instance,
the rate of substance abuse is higher for urban Native Americans than
for any other ethnic group, while the rate of HIV/AIDS among Native
Americans is higher in the Bay Area than in any other Native service
area. In the five counties, we estimate that over 75 percent of Native
American families suffer from substance abuse, domestic violence, and
mental illnesses. Additionally, we believe that over 50 percent of
urban Native American children are emotionally disturbed or at high
risk for mental illness, substance abuse, and delinquency. The suicide
rate for Native American teenagers is higher than for any other group.
Another challenge we face is a disproportionate rate of diabetes.
In a local study we conducted last year, we found that two-thirds of
the adults and youth in the study group fell into the nutritionally
poor to very poor category. This correlates with our experience that
the most common physical problems facing our patients are diabetes,
heart disease, obesity and chemical dependency. Poor dietary practices
and lack of exercise contribute directly to heart disease and the
development of diabetes.
Urban Indian Health Board's operates two licensed clinics but we
are treated by Indian Health Services as one entity for funding,
programmatic and evaluative procedures. Although there are 34 urban
Indian clinics in the nation, our clinics are counted as one site.
Funds for urban clinics for some programs are distributed now via a
simple method of division between the 34 urban sites across the country
that serve Native Americans.
We advocate that the formula for distribution be redrawn to
coincide with the number of Native people in the service area and that
area's cost of living. This determination would far more accurately
reflect the costs of providing care to those in need. For instance,
additional money for diabetes care was recently distributed, yet our
clinics received only a tiny portion of that funding despite the fact
that a full twenty percent of our 18,000 patient visits were due to
diabetes.
There is no urban clinic IHS funding available for capital needs.
Our agency is stretched beyond our limits as we struggle to meet the
increasing demand for services. Presently, we are at full capacity and
need immediate capital funds. Existing facility problems such as poor
design, insufficient exam rooms, inadequate information systems and
technology, and limited access for the handicapped result in the
inefficient provision of services. Capital investments in urban Indian
health centers will increase access to primary and preventive health
care.
The cost of providing health has increased significantly over the
years. Pharmacy costs, which accounted for 44 percent of health care
costs nationwide last year, is growing much faster than other
components of health care. Providing this benefit for indigent patients
has become an overwhelming financial drain on our clinics. Our clinics'
pharmacy costs increased by 34 percent from fiscal years 1998-99 to
1999-2000. Pharmacy costs have skyrocketed so significantly that they
directly reduce our ability to provide primary care services, as we
must devote more of the IHS funding to cover the cost of prescription
drugs.
Health insurance premiums for our employees have also increased
dramatically over the past 3 years. The premium rate for our clinic has
increased by 28 percent in the past 3 years. The increase in health
insurance premiums directly reduces the clinics' ability to provide
primary care services. As we spend more money to provide health
insurance for our employees, there are fewer funds available to provide
care.
The California energy crisis is also having a major impact on our
clinics. Our clinics' utility costs have increased by approximately 40
percent this fiscal year. Finally, workforce issues have also had a
tremendous impact on our clinics. Our clinics' ability to provide
quality health care is limited by the number of health care
professionals that we are able to hire and retain. Often, salaries are
not competitive enough to attract various health care professionals. In
addition, vacancies directly limit the resources that we have to serve
our community.
A disproportionate number of Native Americans are ineligible for
any subsidized insurance programs. Our clinic has struggled to respond
to the ever-increasing demand for our services, particularly by
uninsured patients who have no other system of health care to utilize.
Furthermore, as we enroll more children into health insurance programs,
we are seeing changes in the patient mix that reflect an older
population facing more chronic diseases, with the need for acute care
and a greater number of pharmaceuticals. We are now seeing a greater
number of patients with chronic conditions requiring more than one
visit and a greater amount of health care services resulting in
increased costs. Because the number of uninsured patients seeking care
at our health centers continues to increase, urban Indian health
clinics need additional funding to cover the ongoing health costs of
serving more indigent patients and patients that have more expensive
health care needs.
Ninety-eight percent of our clinic patients are low-income and
approximately 60 percent are uninsured. In the past 3 years, we have
seen a 10-percent increase in older uninsured patients. This older
population faces a greater amount of chronic conditions, requiring more
acute care, a greater number of pharmaceuticals and more than one
visit. Our data also shows a 30-percent increase in patient visits per
year in the last 3 years. This data likely reflects an increase in
clinic patients that are needlessly suffering from chronic conditions/
diseases.
In response, our clinics for the past 2 years have been working on
a diabetes management initiative. While physicians play a key role in
diabetes management, other health care professionals including health
educators, community health workers, nurses, case managers, and
nutritionists are crucial to assisting patients in their disease
management by helping individuals learn self-management skills and
assisting patients to make behavioral changes in their lifestyle.
In conclusion, our community clinic is a strong and vibrant
organization committed to providing the highest quality of care for our
community. As an urban Indian clinic we must be creative and
resourceful to weave available funding opportunities to address the
need of our community. We have developed linkages with the system of
health care in the broader community in the San Francisco Bay Area
while at the same time build alliances with other IHS funded urban
programs. For example, we have a working partnership with the
Friendship House of American Indians of San Francisco who is developing
an 80-bed residential treatment facility, the first major development
project in the Indian community of the Bay Area. We are also working
with Friendship House to build a 75,000 square foot Youth Development
Center in Oakland, a project which is in pre-development with
anticipated site control within the next 30 days.
These projects in our community continue to underscore the need for
greater investment in our community. Many times we fall through the
cracks and remain unrecognized within the broader discussions of Indian
issues. Although I.H.S. funding only composes 14 percent of our total
operating budget, for every one dollar invested by IHS we are able to
leverage another $6 from other sources.
We have several recommendations which address the level of need in
our community and will ultimately increase the level of care for our
patients. A funding augmentation is required to provide immediate
``pharmacy relief to allow the our clinics to maintain their capacity
for primary care visits. A special augmentation is also required that
would provide our clinics with relief from health insurance premium
increases. With soaring energy costs already making a tremendous impact
upon our operating costs, we would recommend and allocation to offset
increased energy costs and provide our clinics with additional funds to
address the shortage of health care professionals in our clinics. The
demographics of our patient population is ever-changing along with the
cost of care. We recommend an adjustment in the funding formula that
would take into consideration the higher health care costs to clinics
given the changing patient mix. With an increasingly older patient
population, we require Increased funding to cover costs for patients
participating in chronic disease management initiatives. Although we
strive to provide a high level of care, capital needs in our facilities
is at an all-time high, we strongly recommend allocations of funding to
address greatly needed capital and facility improvement needs. Finally,
we recommend funding for regional and culturally competent approaches
to diabetes prevention and treatment, substance abuse prevention and
care, youth violence prevention and HIV/AIDS prevention and treatment.
We would like to thank the committee for allowing us this
opportunity to share with you our concerns, our successes and our
recommendations. Our ability to provide quality care for our unique
community is directly affected by your work and your commitment. We are
fortunate for the opportunity. Thank you.
______
Prepared Statement of Kay Culbertson, Executive Director, Denver Indian
Health and Family Services
Good morning Chairman Inouye, Vice Chairman Campbell and other
distinguished committee members. My name is Kay Culbertson, I am an
enrolled member of the Fort Peck Assiniboine/Sioux Tribes located in
Poplar, MT. I serve on the board of directors for the National Council
of Urban Indian Health and I am the Executive Director for Denver
Indian Health and Family Services [DIHFS] located in Denver, CO. On
behalf of the Denver Indian Community, I would like to thank you for
the opportunity to provide testimony regarding health issues of Indians
who reside off reservation and the Urban Indian Programs that serve
them. There are currently 34 urban Indian health programs located
throughout the United States, with each program offering a variety of
medical service through many creative and innovative delivery types.
Today, my focus will be on Denver Indian Health and Family Services.
In the past, Denver attracted Indian people for a variety of
reasons. Denver was one of the original sites for relocation of Indian
people from their home reservations. A segment of Denver's Indian
population is a result of Indian men and women who settled here after
serving in the armed forces. Another segment came to Denver because
there was a Bureau of Indian Affairs office located in the area. Many
Indian people moved from the reservation to the Denver area with the
hope of attaining the ``American Dream''. And today, Denver continues
to be a hub for Indian people. Denver's Indian population is estimated
at 25,000 and is comprised of people who have lived in Denver for over
30 years producing second and are third generation Denver natives as
well as those who are transient and move to and from the reservation on
a regular basis. The universal reason for moving continues to be ``Hope
for a better future''.
Although Denver is centrally located within ``Indian country'' and
many national Indian organizations are headquartered in Denver, it is
isolated from tribal health and Indian Health Service services, the
closest Indian health facility in Colorado is located on the Southern
Ute Reservation, an 8-hour, drive. The nearest Indian Health Service
Hospitals are in Rapid City, SD and Albuquerque, NM. Unlike other urban
health programs we do not have the ability to utilize other Indian
health facilities to meet the gaps in services.
Denver Indian Health and Family Services was created as the result
of a needs assessment conducted by the Denver Native Americans United.
Denver Indian Health and Family Services was incorporated in 1978, as a
non-profit Indian organization and received funding from the Indian
Health Service to provide outreach and referral services to the Indian
community. With a staff of two people, the agency gathered and provided
information to Indian people in accessing health care in the Denver
metropolitan area. Eventually, DIHFS began to provide limited health
care through volunteer nurses and doctors and grew into a full scale
clinic entering into an agreement with Denver Health and Human
Services. The number of uninsured and the inability to charge American
Indian patients placed a much larger financial burden on the
organization and clinic services were discontinued in 1991.
Unfortunately, the health care needs of the community exceeded the
funding limits of the agency. In 1996, DIHFS entered into an agreement
with a local community clinic to provide services at a limited cost;
however, the agency could only allow two visits per year and the
patients were responsible for their own laboratory and x ray costs.
This arrangement made it difficult to provide health care to persons
with chronic medical problems such as diabetes. The community voiced
the need for additional health care. Not just any health care but
health care that was culturally sensitive and available through an
Indian organization or provider.
At a 1998 strategic planning retreat the DIHFS board of directors
planted the seeds to begin the process of providing medical services to
the Indian community onsite. The board of directors stressed the
importance of taking slow steps to providing health care. The board of
directors insisted that the services be provided by DIHFS, that
patients would receive more health education, that the delivery of
services be provided in a manner that was comfortable to Indian
patients, that the financial pitfalls of the past be avoided and that
we maintain our identity as an Indian provider and an Indian clinic. In
March 1999, a young Indian physician, Dr. Lori Kobrine, took on the
task of laying the foundation for our clinic. Through her efforts our
clinic met the requirements for state licensure. She worked 20 hours a
week providing limited medical services to the community. Now our
clinic continues to grow. Since May 2000 our clinic has been staffed
with a full time nurse practitioner and a volunteer physician who
provide medical services on a full time basis to the community. The
medical services include immunizations, acute emergencies, well child
physicals, physicals, women's basic health, diabetes management and
screening and other health services that do not require a specialist or
that are not life threatening. DIHFS also provides mental health and
substance abuse counseling, substance abuse prevention, case management
services for victims of crime, energy assistance, diabetes case
management, prescription assistance, emergency dental, and referrals to
meet other community health needs.
The cachement area for DIHFS includes Adams, Arapahoe, Boulder,
Denver, Douglas, Jefferson, and Gilpin counties. However, we also serve
people who travel from as far as Pueblo and Aspen. There is also an
increase in services during peak months of March, June, July, and
August for persons who are visiting during the annual March Pow-wow or
who are staying with relatives over the summer. DIHFS is located in
southwest Denver near the old Fort Logan facility. Although located
outside of central Denver, DIHFS is conveniently located near the
Denver Indian Center and Denver Indian Family Resource Center, making
referrals to other Indian organizations and coordination of case
services much easier for Indian clients.
The Denver Indian community is fairly young population with the
median age of 30.2 as compared to 34.5 for all other races. The
majority of DIHFS clientele are single parent heads of household. The
average income reported by DIHFS patients is $621 per 4 month or $7,452
per year. Seventy-three percent of DIHFS patients do not have health
insurance.
The Medical Clinic provides onsite services through a family nurse
practitioner. Appointments are scheduled for 1 hour at time to allow
for intense patient education regarding their presenting problem. The
most common diseases treated in the clinic are diabetes, hypertension
and dental pain. Wellness screening services include women's health,
family planning, men's health, well child checks and education.
The Community Health Program is the most often utilized program is
the agency. DIHFS assists with prescriptions purchases, energy bills,
adult emergency dental through a contract dentist, referrals for
denture purchases, transportation, tribal enrollment for patients,
optical exams and glasses and many other health related problems.
Education regarding the importance of health insurance [private or
public] is stressed in the Community Health Program. We currently have
a Denver Health Authority navigator stationed at our office to assist
Indian people with access the Denver Health system and walk clients
through the enrollment procedure for the State Child Health Plan and
Medicaid.
Our Diabetes Program is staffed by a Certified Diabetes Educator
and has focused on bringing traditional foods back into our diets. The
focus has been on the Plains Indian diet with additional research on
Southwest Indian traditional diet. Diabetic patients are provided with
free glucometers, and strips to encourage regular checking of glucose
levels. The project also assists diabetic patients with special eye
exams, podiatry checks, shoe inserts, shoes, glasses and medications.
Behavioral Health services include mental health and substance
abuse counseling and youth substance abuse prevention support in area
schools. The program assists with antabuse physicals and medication,
psychological evaluations and court support. The outpatient and women's
counseling program are the only American Indian programs in the Denver
area that are licensed through the Colorado Department of Health,
Alcohol and Drug Abuse Division.
Victims of Crime Act funds a small case management project for
Indian victims of crime. The Bureau of Justice Statistics released a
report in February 1999 detailing the rates of victimization for Indian
people. The study found that American Indians were victims of violence
at twice the rate of the U.S. population, that rates of violence are
higher than any other group in every age group, and that alcohol was
more often involved in crimes against American Indian persons at double
the rate of any other race. These are sobering statistics.
As you can see DIHFS has accomplished a great deal with the limited
amount of funding; that is received and the limitations of our
community. We have learned to build relationships with other programs
and meet some but not all of the gaps in service delivery to American
Indian people living in the Denver area.
In providing services we have encountered barriers that tribes may
not face. If we accept Medicaid, become a National Health Service Corp
provider, federally Qualified Health Center or a 330 Community Health
Center our services must be open to all people. This places a strain on
our identity as an Indian clinic.
Seventy-three percent of the patients seen in our clinic do not
have insurance because they are underemployed, have recently moved to
the area, the employer does not provide health benefits or they do not
qualify for any other health benefits. Often Indian people who come to
an urban area have a misconception that urban Indian health programs
are virtually the same as the Indian Health Service or tribal health
programs on the reservation and may not elect to sign up for health
care benefits. Indian people assume that IHS is everywhere. DIHFS does
not currently have an affiliation with a health maintenance
organization [HMO] because we have neither 24 hour coverage nor
hospital admission privileges. These issues also do not allow us to
generate third party billing from Medicaid because the State of
Colorado contracts with HMO's to provide services to the Medicaid
beneficiaries. The patients who have health insurance do not utilize
their providers due to the expense of co-pay amounts or deductibles,
they enjoy receiving services at the Indian clinic or wait times for
visits are not as long.
Indian Health Service is severely under funded as a whole, but
urban Indian programs receive the least amount of funding. If urban
programs were f1mded at the same amount and provided the core services
of a tribal or IHS facilities, American Indians living off reservation
would have access to comprehensive health care.
Dental services are limited. DIHFS is limited to 10 emergency
dental appointments a month. The dental waiting list is months long.
Affordable dental care is difficult to find, even for persons with
private or public insurance. Very few dentists accept Medicaid
patients. Only one urban program has received funding from the Indian
Health Service for dental services.
Hiring and retaining quality professionals has been difficult.
DIHFS has an operating budget of $430,000. The medical field is highly
competitive in the Denver area and we are not always able to compete
with other health facilities for staff. DIHFS does have the opportunity
to provide IHS scholarship recipients with payback opportunities and
although there has been much interest to work in Denver, we are not
able to provide them with a salary and benefit package that is
commensurate with tribal and IHS staff positions of the same level.
Denver Indian Health and Family Services supports S. 212 a bill to
amend the Indian Health Care Improvement Act. We strongly support
inclusion of urban Indian health programs in title IV, Access to Health
Care.
Denver Indian Health and Family Services also supports S. 214 a
bill to elevate the position of Director of Indian Health Service to
the Assistant Secretary for Indian Health. Through the leadership of
Dr. Michael Trujillo and his concept of ``Speaking with One Voice''
there has been an increase in support from both tribal leaders and
Indian Health Service professionals to address the needs of tribal
members who live off reservation. The elevation of the Director to
Assistant Secretary will benefit both tribes and urban programs in
their ability to access other Department of Health and Human Service
programs as well as to bring to the forefront the severe disparities in
health for Indian people as a whole.
Denver Indian Health and Family Services also supports S. 535 a
bill to amend the Social Security Act to clarify that Indian women with
breast or cervical cancer who are eligible for health services provided
under a medical care program of the Indian Health Services or a tribal
organization are included in the eligibility category of breast or
cervical cancer patients added by the Breast and Cervical Cancer
Prevention and Treatment Act of 2000. We recommend that urban Indian
health programs also be included in the eligibility category. During my
testimony to the Senate Committee on Indian Affairs in March 2000
regarding the Indian Health Care Improvement Act, I relayed a story of
a woman with breast cancer who did not have insurance and had no way of
receiving services. Her only option was to return to the reservation
and hope that Indian Health Service would extend coverage to her. We
may be able to avoid these scenarios if urban Indian health programs
are included in S. 535.
Denver Indian Health and Family Services also strongly recommends
that the feasibility of additional demonstration projects such as those
located in Tulsa and Oklahoma City be funded. We recommend that one
site be funded in an area that is isolated from other IHS or tribal
facilities. It is recommended that the project include provisions for
comprehensive medical, dental, and hospital services.
Once again, thank you for the opportunity to testify on behalf
Denver Indian Health and Family Services. I would like to close my
testimony with the following story:
My son is active with the local Native Lacrosse Program. There are
approximately 25 Indian families who regularly participate in this most
worthwhile sport. The program not only promotes exercise and culture
but also serves as an informal social support system for parents while
the youth practice. I was writing my testimony for today when a young
mother named Laura inquired about my work. I told her that I was
working on addressing urban Indian health issues to the Senate
Committee on Indian Affairs. She became very excited and went into
great length about the need for more comprehensive health care for
Indian people in Denver. She told me of the birth of her twin children
and how her diabetes had caused complications in the pregnancy. The
young family did not have health insurance because of layoffs and they
were not eligible for other services. She was told by her family to go
home to Oklahoma and have her twins at the Indian hospital but she
chose to stay because they could not afford to travel back home. She
gave birth to her children at an area hospital. The twins were kept in
intensive care for an extended amount of time. After the twins were
released from the hospital the family was presented with a $45,000-
hospital bill, a bill that they would never be able to satisfy. The
family had to file for bankruptcy and today continues to suffer from
the effects of that action. Laura asked me why she was not allowed to
have the same medical care as her brothers and sisters who live on the
reservation, why was there not an IHS facility for people in Denver?
She asked that I tell you this story today. I hope that in the near
future I will be able to tell Laura that you heard her questions and
provided the Denver Indian community with additional health care
resources.
______
Prepared Statement of Wayne Taylor, Jr., Chairman, Hopi Tribe
Thank you, Chairman Inouye, Vice Chairman Campbell, and other
distinguished members of the Senate Committee on Indian Affairs for
allowing the Hopi Tribe to provide testimony on S. 212, legislation to
reauthorize the Indian Health Care Improvement Act. We are grateful for
your continued attention to improving health care services for all
Native Americans.
The Hopi Tribe looks to Congress as the ultimate Federal trust
authority. Vested in your authority is the ability to ensure the
provision of quality health services for all Native Americans. We value
your counsel and depend in no small measure on your assistance in
establishing an array of health services of critical importance to all
tribes.
I would like to provide the Hopi Tribe's comments on four
provisions of title II of S. 212 dealing with medical services covered
by the Indian Health Service [IHS]. Each of these four provisions
addresses a service area that is critical for the improvement of the
health status of the Hopi people, and we strongly urge the committee to
enact the strongest possible provisions in these areas during the 107th
Congress.
The Hopi Tribe strongly supports requiring the Secretary of Health
and Human Services, through the IHS or Indian tribes or tribal
organizations, to provide mammography screening for Indian women at an
appropriate frequency under national standards and consistent with
those established for the Medicare program. It is essential to the
improvement of the health and survival of Indian women that the IHS and
tribes be able to significantly increase the availability of early
screening, diagnosis and treatment.
One- and 5-year breast cancer survival rates are significantly
lower among Southwestern American Indian women compared with non-
Hispanic whites, despite the lower rates of breast cancer observed in
the Indian population. One of the major factors contributing to this
poor rate of survival is the later stage at which breast cancer is
diagnosed in the Indian population.
The reduction in breast cancer mortality when screening mammography
is available to American Indian populations is estimated at 27.9
percent. Among populations whose disease is more advanced when it is
first diagnosed, as among Southwestern American Indian women, the
reduction in mortality with screening mammography increases another
estimated 26.4 percent.
The 1993 ``Healthy Hopi Women Survey'' of 559 women on the Hopi
Reservation confirmed the lack of knowledge about breast cancer
screening. Only 55.7 percent of these women had knowledge of a
mammogram procedure, and less than 20 percent knew when women should
begin to have screening exams. Only 61 percent of the women surveyed
reported having annual clinical breast exams as recommended by the
American Cancer Society--less than one-half of the women 40 years and
older had ever had a mammogram and only 26.4 percent had one in the 2
years preceding the survey. The results were similar for women age 50
and older--less than 25 percent of those women had both a mammogram and
a clinical breast exam in the 2 years preceding the survey. The survey
confirmed that the proportion of women receiving screening mammography
and clinical breast examinations is significantly lower than the rate
proposed in the Year 2000 goals.
The Hopi Tribe Breast and Cervical Cancer Early Detection Program
currently provides breast screening services to women 40 years and
older. The program works in collaboration with Indian Health Service to
provide mammography services to women who are seen through the program
or through Indian Health Service. At this time, Indian Health Service
is unable to cover the cost of services for mammography services and
will provide women with mammography service only when it is necessary.
Often times, many women who are covered under Indian Health Service for
mammography services are already at high risk for cancer. The Hopi
Tribal Breast and Cervical Cancer Early Detection Program currently
covers the cost of mammography service for all women who reside on the
Hopi Reservation and who are eligible through the program. Women who
are not eligible through the program are unable to receive a mammogram
unless they pay for the cost or have private insurance to cover the
cost.
To date, 48 percent of enrolled Hopi women ages 40 and over have
been screened through the Hopi Tribal Breast and Cervical grant
program. Although nearly one-half of the women in this age category
have been screened, there is still a need to screen the other 52
percent of the population. While the Breast and Cervical Early
Detection provides breast and cervical screening to all women, services
are limited due to the lack of a full-time women's health provider as
well as the availability of space for services.
With additional funds available to provide screening services, the
Hopi Tribe will be able to screen all women regardless of their
eligibility through the program. The program will also be able to hire
a full-time physician to provide screening services to women on a daily
basis and eliminate the waiting time of 3 months for a women's health
exam. Outreach and awareness in the community is essential, as many
Native American women do not understand the importance of early
detection. The Hopi Tribe needs additional funding to increase our
ability to provide preventative breast and cervical cancer services,
thereby decreasing the cancer rate for native women and improving the
chance of survival for women who suffer breast or cervical cancer.
The Hopi Tribe also strongly supports the ``Native American Breast
and Cervical Cancer Treatment Technical Amendment Act of 2001''
introduced by Senator Jeff Bingaman [D-NM], which would correct an
oversight made by Congress when it enacted the Breast and Cervical
Cancer Prevention and Treatment Act of 2000. Senator Bingaman's bill
[S. 535] would ensure that Indian women with breast and cervical cancer
who are eligible to received health services from the IHS or a tribe or
tribal organization will be included in the optional Medicaid
eligibility category of breast and cervical cancer patients added by
the 2000 legislation. Without this legislation, Indian women who are
diagnosed with breast or cervical cancer through the CDC program may
still find themselves ineligible for coverage of any treatment
services. We strongly urge the committee to support the prompt
enactment of this legislation.
The Hopi Tribe is also strongly supportive of the provisions of S.
212 to require the Secretary, acting through the IHS or tribes or
tribal organizations, to provide funds for appropriate patient travel
costs, including transportation by ambulance, specialized vehicle or
private vehicle, or by air transportation or such other means as may be
available when ground transportation is infeasible.
We have presented testimony to the committee in the past regarding
the difficulty of providing necessary emergency medical transportation
services on geographically remote reservations such as ours.
Insufficient funding for adequate staffing and outdated equipment has
left our existing emergency medical service [EMS] team constantly
struggling to provide services. While they do a wonderful job, our EMS
personnel are stressed for time and lack the equipment necessary to
perform certain lifesaving functions. Our program lacks the resources
to staff the program according to industry standards for the time and
distances involved in rural transport.
The closing of reservation hospitals in Indian country and
replacing them with ambulatory care centers and consolidating medical
services adds to the burden on emergency medical services teams and
magnifies the importance of providing necessary emergency and non-
emergency transport. Patients must now travel longer distances for
necessary inpatient care, requiring highly trained personnel as escorts
and more advanced equipment. Thus, the change health care system itself
is increasing the critical role of emergency transportation and
advanced life support care yet the system has failed to provide the
financial resources necessary to meet the need, resulting in a growing
gap in the continuum of health care.
We applaud the committee's effort to require the Secretary to
provide funds for patient travel costs. However, we remain concerned
that our tribe and others will have difficulty purchasing the high-cost
emergency vehicles and equipment needed to provide these services.
Further, given the historical under-funding of IHS contract health
services, we are very concerned that simply requiring the Secretary to
pay for these added costs from already inadequate funds would
ultimately fail to address the problem. We urge the committee to
address these concerns as it addresses the legislation.
We are very pleased that the committee bill recognizes the need to
address health care related services such as long-term care, home- and
community-based services including homemaker/home health aide services,
and assisted living services. The Hopi Tribe, like many others, faces
serious challenges in providing necessary health care for our aging
population.
Respect and care for our elders is one of the fundamental elements
of Hopi culture and heritage. As a result, the traditional Hopi concept
of family care-giving includes a cohesive community that emphasizes the
desire to keep all members at home--where elders are able to remain
active members of the community and participate in the care of close
and extended family members. Since 1978, IHS and Bureau of Indian
Affairs [BIA] statistics indicate that Hopi has maintained the lowest
nursing home placements of all the 19 Arizona Tribes. In this context,
it is critical for the tribe to establish and maintain services that
are locally available and accessible to our elders.
Currently, about 25 to 30 Hopi members reside in respite care
facilities located in Phoenix, Flagstaff, and Payton. It is difficult
for family members to travel these significant distances to visit their
elders, and the elders themselves feel cutoff from their family and
community. To remedy this situation, the tribe is seeking funding
support from the State of Arizona to establish Senior Centers in 3 of
the 12 Hopi reservation villages. We have also initiated planning for
an on-reservation long-term and respite care facility. However, there
remains a significant need for planning, design, engineering and
construction funding.
The geographical remoteness of our reservation and language
barriers have also made it difficult to access many State services.
Service providers must currently travel 4 hours from their Phoenix
office to provide care for Hopi seniors, and even then they are
available for a limited time. All of our elderly are Hopi-speaking with
limited proficiency in English, and they are often discouraged from
applying for state or Federal services because of the communications
barrier that exists between them and their service providers. We are
investigating the possibility of establishing a local, on reservation
office in partnership the State agencies and recruiting and training
Hopi-speaking providers to reach a broader client population.
Since 1978 the Hopi Tribe has contracted with the IHS to
participate in the Community Health Representative [CHR] program. There
are currently more than 325 Hopi seniors in all 12 reservation villages
receiving services ranging from patient care and monitoring to case
management, education and counseling, and disease prevention. It is
crucial that Congress continue to support and increase funding for this
important support program.
In conclusion, thank you again for allowing the Hopi Tribe to
present this testimony. We look forward to working with you during the
course of your deliberations on legislation reauthorizing and enhancing
the programs provided through Indian Health Care Improvement Act. I
would be pleased to respond fully to any request for additional
information.
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