[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












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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

                              ----------                              
                                                                   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

                              ----------                              


                         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.]
=======================================================================


                            A P P E N D I X

                              ----------                              


              Additional Material Submitted for the Record

=======================================================================


 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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