[Senate Hearing 107-601]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 107-601
 
                  NATIVE AMERICAN ELDER HEALTH ISSUES
=======================================================================

                                HEARING

                               BEFORE THE

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION

                                   ON

 OVERSIGHT HEARING TO EXAMINE THE LONG TERM CARE AND HEALTH CARE NEEDS 
                       OF NATIVE AMERICAN ELDERS

                               __________

                             JULY 10, 2002
                             WASHINGTON, DC













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                      COMMITTEE ON INDIAN AFFAIRS

                   DANIEL K. INOUYE, Hawaii, Chairman

            BEN NIGHTHORSE CAMPBELL, Colorado, Vice Chairman

KENT CONRAD, North Dakota            FRANK MURKOWSKI, Alaska
HARRY REID, Nevada                   JOHN McCAIN, Arizona,
DANIEL K. AKAKA, Hawaii              PETE V. DOMENICI, New Mexico
PAUL WELLSTONE, Minnesota            CRAIG THOMAS, Wyoming
BYRON L. DORGAN, North Dakota        ORRIN G. HATCH, Utah
TIM JOHNSON, South Dakota            JAMES M. INHOFE, Oklahoma
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:
    Allery, Alan, director, National Resource Center on Native 
      American Aging.............................................    12
    Annette, Kathleen, M.D., area director, Bemidji Area, Indian 
      Health Service.............................................     5
    Baker, Frederick, chairman, Mandan, Hidatsa and Arikara 
      Elders Organization, Three Affiliated Tribes, North Dakota.    23
    Baldridge, Dave, executive director, National Indian Council 
      on Aging...................................................    21
    Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado, 
      vice chairman, Committee on Indian Affairs.................     2
    Conrad, Hon. Kent, U.S. Senator from North Dakota............    16
    Finke, Bruce, M.D., elder specialist.........................     5
    Inouye, Hon. Daniel K., U.S. Senator from Hawaii, chairman, 
      Committee on Indian Affairs................................     1
    Jackson, Yvonne, director, Office for American Indian, Alaska 
      Native and Native Hawaiian Programs........................     3
    Ludtke, Richard L., director of research, Center for Rural 
      Health, University of North Dakota.........................    14
    McDonald, Leander ``Russ'', researcher, Center for Rural 
      Health, University of North Dakota, Grand Forks, ND........    12
    Vanderwagen, Craig, M.D., acting chief medical officer, 
      Indian Health Service......................................     5
    Walker, Edwin, director, Centers for Wellness and Community-
      Based Services, Administration on Aging....................     3

                                Appendix

Prepared statements:
    Allery, Alan (with attachments)..............................    46
    Annette, Kathleen............................................    39
    Baker, Frederick.............................................    78
    Baldridge, Dave..............................................    69
    Cantwell, Hon. Maria, U.S. Senator from Washington...........    31
    Ludtke, Richard L. (with attachments)........................    46
    McDonald, Leander ``Russ'' (with attachments)................    46
    Walker, Edwin................................................    32

Note: Other material submitted for the record retained in 
  committee files.


                  NATIVE AMERICAN ELDER HEALTH ISSUES

                              ----------                              


                        WEDNESDAY, JULY 10, 2002


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The committee met, pursuant to other business, at 10:15 
a.m. in room 485, Senate Russell Building, Hon. Daniel K. 
Inouye (chairman of the committee) presiding.
    Present: Senators Inouye, Campbell, and Conrad.

 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 an ongoing study that is being conducted by the 
National Resource Center on Native American Aging within the 
Center for Rural Health at the University of North Dakota 
School of Medicine and Health Sciences. This study examines the 
long term care and health care needs of America's Native 
American elders.
    Despite the fact that the American Indian population is one 
of the fastest growing populations in the United States, the 
status of elderly Native Americans is, to put it simply, poor. 
As the testimony today will indicate, almost three out of five 
elderly Native Americans live well below the poverty level. 
Diseases such as diabetes afflict Indian elders at epidemic 
rates, and the mortality rate from diabetes is five times 
higher than the national average. Deaths associated with kidney 
disease are three times the national average among Native 
American elders.
    These statistics are overwhelming and the need for age 
sensitive health care and for long term care is obvious. 
Unfortunately, the long term care options for most Native 
American elders are minimal at best and often require decisions 
that break families apart. With few long term care facilities 
available on most Indian reservations, elders requiring such 
care may have to be placed hundreds of miles from their homes 
and families. Poor families don't have the means to travel back 
and forth to visit their grandmothers and grandfathers, and 
sadly, we know that many families in Indian country are 
constrained in this way.
    Home health care alternatives are also extremely limited in 
most tribal communities. So while families may ultimately 
decide that it is best to keep their loved ones at home, like 
most families across America, few have the professional 
training to adequately care for their elders. These are the 
tragic circumstances that many Native American elders face as 
they enter into their twilight years.
    Today we hope that the testimony will shed some light not 
only on the conditions in Indian country as they affect the 
elderly, but what can be done to better address their needs. As 
one who qualifies under almost any definition as an elder, I 
take these matters very seriously. And I look forward to the 
constructive solutions that we anticipate will be forthcoming 
from the testimony received today.
    And may I recognize the 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.
    We don't normally make headlines in the New York Times and 
the Washington Post about the activities in this committee, but 
they are extremely important to one segment of the American 
population, and that's the Indian people. The hearing today is 
one of those that involves Native elders, a group revered in 
Indian cultures, but also a group that is often quiet and in 
the background when it comes to public debate. As the 2000 
census makes clear, the Native population, like the U.S. 
population, is growing at a very fast pace.
    I think that when we talk about the future of elders, I 
might mention that during the break I went to Montana, visited 
the Northern Cheyenne, where I happen to be a member. I was 
asking the tribal chairman up there about the growth of that 
tribe. There are about 8,000 enrolled in that tribe. But 75 
percent are under 25 years old, which of course gives us a 
whole host of problems with education and jobs and all that. 
But those youngsters are some day going to be elders, too. And 
we don't seem to be ahead of the curve when we talk about 
what's going to happen in another 20 or 30 or 40 years about 
those young people now who are all going to have these 
problems. These include, as you know, diabetes, which leads to 
poor circulation, gangrene and then amputation of the lower 
extremities, things of that nature.
    I think your comments about the difficulty of families 
visiting is really important. I know that in the case of that 
little community, Lame Deer, MT, one of the places that elders 
are put after the have had their legs amputated, which happens 
too often, is clear in Glendive, MT, about 100 miles away. That 
means if their family, their grandkids, their youngsters want 
to visit them, and they don't have transportation, they just 
don't see them any more, because it's just too far to go to be 
able to visit the elderly that are in the hospitals with their 
extremities cut off. That means they have a mighty lonely 
existence in the last years of their lives, which shouldn't be 
anything that anyone should have to go through. It seems to me 
one of the great things about growing older is your ability to 
be close to your kids and your grandkids. But when they suffer 
these debilitating problems brought on by diabetes, that's not 
the way too many elderly Indian people finally go to their 
Maker.
    Thank you, Mr. Chairman, for convening this hearing.
    The Chairman. I thank you very much. You are so correct, 
your autumn years should be the happy years. But in too many 
cases, such is not the case.
    We have two panels this morning. The first panel, Director 
of the Centers for Wellness and Community-Based Services, 
Administration on Aging, Edwin Walker. He will be accompanied 
by Dr. Yvonne Jackson, Director of the Office of American 
Indian, Alaska Native and Native Hawaiian Programs, 
Administration on Aging. And then we have the Area Director of 
the Bemidji Area Indian Health Service of Bemidji, Minnesota, 
Dr. Kathleen Annette, who will be accompanied by Dr. Craig 
Vanderwagen, Acting Chief Medical Officer, Indian Health 
Service, Rockville, and Dr. Bruce Finke, Elder Specialist.
    Dr. Walker.

 STATEMENT OF EDWIN WALKER, DIRECTOR, CENTERS FOR WELLNESS AND 
COMMUNITY-BASED SERVICES, ADMINISTRATION ON AGING, ACCOMPANIED 
BY YVONNE JACKSON, DIRECTOR, OFFICE FOR AMERICAN INDIAN, ALASKA 
              NATIVE AND NATIVE HAWAIIAN PROGRAMS

    Mr. Walker. Good morning, Mr. Chairman and members of the 
committee. On behalf of the U.S. Administration on Aging, I 
appreciate the opportunity to discuss the health concerns of 
Native elders and to provide some information about our 
programs. I commend this committee's commitment to Native 
Americans and the support you have shown for aging issues in 
Indian country.
    As indicated, I am accompanied by Dr. Yvonne Jackson, the 
Director of our Office of American Indian, Alaska Native and 
Native Hawaiian Programs at the Administration on Aging. 
Josefina Carbonell, our Assistant Secretary for Aging, has 
identified health promotion and disease prevention among her 
priorities for the Administration on Aging. Our focus is on 
encouraging Americans of all ages to live healthier lives. 
Healthy living can prevent diseases and certain disabilities, 
and it can ensure that today's older persons, as well as our 
future generations, not only live longer, but also better.
    Great strides have been made in improving the health status 
of American Indians and Alaska Natives. Yet, cardiovascular 
disease remains the leading cause of death for all populations 
in the United States, and one-half the adults have diabetes. 
Diabetes complications are some of the major causes of 
morbidity and mortality among older Indians. The Administration 
on Aging is working with the Indian Health Service, tribal 
health and social service departments and universities to 
assist in developing programs and services for preventing and 
controlling diabetes.
    The AOA annually awards grants to provide supportive and 
nutrition services for American Indian, Alaska Native and 
Native Hawaiian elders. Our Older Americans Act Title VI 
program has been funding services in Indian communities 
throughout the country for the last 22 years, growing from 
services in 85 tribes in 1980 to over 300 tribes serving nearly 
100,000 Native elders today.
    Our programs provide a wide range of services, including 
congregate and home delivered meals, transportation to meal 
sites and doctor's appointments, wellness programs, home health 
services, adult day care and family caregiver support, just to 
name a few. These services achieve the goal of assisting elders 
to remain in their homes and communities for as long as 
possible. In addition to our programs that directly assist the 
elderly, AOA now assists those who care for the elderly and the 
disabled through our Native American family caregiver support 
program.
    In order to assist the tribes in developing home and 
community based services for their elders, AOA has awarded 
grants to two national resource centers, one at the University 
of Colorado and one at the University of North Dakota. AOA and 
the resource centers collaborated on a study that concluded 
that there is a wide disparity between the need for and the 
availability of home and community based long term care 
services. While emergency and acute primary health care is 
usually met, other services, such as mental health, home 
health, personal care and transportation are only moderately 
met, and services such as adult day care, respite care and 
assisted living are unmet.
    In response to requests for assistance from tribes, we 
asked our resource center at the University of North Dakota to 
develop a needs assessment tool that provides tribes with an 
accurate picture of the health status of their elders. Although 
the resource center will discuss the results of the needs 
assessment in detail, I would like to highlight just some of 
the data noteworthy in developing home and community based 
services.
    Nearly 30 percent of Indian elders live alone. As compared 
to elders in the general population, a greater percentage of 
Indian elders consider their health to be fair or poor. Many 
more Indian elders are overweight, and yet may be less aware of 
their overweight status since they consider their weight to be 
just about right. Most Indian elders indicated they would be 
willing to go to an assisted living facility, while only 18 
percent of the elders indicated they would be willing to use a 
nursing home.
    The feedback that we've received from the tribes who are 
using the needs assessment has been very, very positive. They 
are happy to have the data, but now they are requesting 
additional assistance in interpreting the data and in how to 
use the information in program planning. We are working with 
the staff of the resource center in order to provide this 
additional assistance.
    Mr. Chairman, we are very proud at the Administration on 
Aging that we are able to provide services and assistance to 
American Indian, Alaska Native and Native Hawaiian elders and 
their families. We are committed to working with you and your 
colleagues to improve the quality of life in Indian country in 
the years ahead. Thank you very much, and Dr. Jackson and I 
would be happy to answer any questions that you have.
    [Prepared statement of Mr. Walker appears in appendix.]
    The Chairman. Thank you very much, Mr. Walker. May I now 
recognize Dr. Annette.

  STATEMENT OF KATHLEEN ANNETTE, M.D., AREA DIRECTOR, BEMIDJI 
AREA, INDIAN HEALTH SERVICE, ACCOMPANIED BY CRAIG VANDERWAGEN, 
  M.D., ACTING CHIEF MEDICAL OFFICER, INDIAN HEALTH SERVICE, 
              BRUCE FINKE, M.D., ELDER SPECIALIST

    Ms. Annette. Good morning. My name is Kathleen Annette. 
Accompanying me is Dr. Craig Vanderwagen and Dr. Bruce Finke. 
Dr. Bruce Finke is a geriatric specialist in the Indian Health 
Service, and Dr. Vanderwagen is the chief medical officer.
    I have a prepared statement, which you have, and I would 
like to take the opportunity now to summarize this for you.
    The Chairman. Without objection.
    Ms. Annette. I am an American Indian physician, a family 
doctor who has worked on reservations off and on most of my 
life, and currently am an area director. I also have a mother 
who is currently in dialysis, diabetic and dealing with 
personally many of the issues that we're talking about today.
    Who are these people that we're talking about, these Indian 
elderly? In the tradition of my people, the best way for me 
sometimes to explain this is really to tell you a story. And 
this is a true story. I have, or had, an 84 year old great 
aunt. She called me one 9day and said, as many of our elders 
do, it's your turn to come and take me to the clinic to pick up 
my pills.
    So I picked up Aunt Mary and we headed to Cass Lake Indian 
Hospital, where she had received her care for 84 years of her 
life, and came to the one stop light in town. And the one stop 
light in town stays red and red and red. So we pulled up and 
wouldn't you know it, there was a very young couple that was 
necking at the stop light. I don't know how else to put it. And 
Aunt Mary looked, and I was embarrassed. She kept pushing me 
aside and she kept looking. She said, look at them, they're 
hot. I said, oh, Aunt Mary. She said, well, I used to be. 
[Laughter.]
    This is an 84 year old elder. I took this story about--have 
any of you seen Wind Talkers? A wonderful, wonderful film about 
the Navajo code talkers. I told this story at a national 
meeting that I was attending where the code talkers brought in 
the colors. I was so proud. And they listened, and they came up 
to me afterwards, and I thought, gee, these wonderful elders 
are going to really give me some encouragement. And what they 
told me is they wanted to meet my Aunt Mary. [Laughter.]
    But these are the people we're talking about in terms of 
elders. They're the ordinary Indian people that are at home 
dealing with issues every day, and they are Indian people that 
have had extraordinary experiences and contributions to this 
country.
    What are they dealing with at home? When we ask them, and I 
think the North Dakota study is fantastic, and you'll hear more 
about that, it gives us some baseline data from 88 tribes, that 
is incomplete. It has to be expanded to more, and we'll have a 
much better data base and information to share with tribes.
    The issues they bring to us and that we deal with in Indian 
Health Service is of course long term care. Are we involved in 
long term care? You bet we are. And the reason for that is long 
term care is a spectrum. It's a spectrum. It's a spectrum of 
services that ought to be available. We are responsible for the 
hospital and clinic portions, along in partnership with tribes.
    What is our responsibility? It's ongoing. We really need to 
work with coordination of services. And we find that's a real 
challenge at local, regional and national levels.
    We also really must assure that when our doctors and nurses 
and providers provide geriatric care, the care we provide can't 
be good enough. Our care has to be outstanding. And whatever we 
do to provide that piece, we need to assure that our primary 
care providers have geriatric training as part of what they 
bring to our table when they come to serve our people.
    These are the people we serve, these are people that have 
contributed so much to this Nation. Indian Health Service does 
have a role. We must partner with others. We must continue to 
do much of what we do and do it better. We have to partner with 
tribes and say, ``what is it you really need''. Because I think 
if we're going to have a successful program, we must work with 
the tribes to develop what that program ought to be. And again, 
we'll be talking at length I think with you in terms of the 
services that define long term care and how we can best design 
programs with tribes.
    Thank you.
    [Prepared statement of Ms. Annette appears in appendix.]
    The Chairman. I thank you very much.
    If I may ask, Mr. Walker, what gaps in Federal services 
have you identified in diabetes or nutrition programs that, if 
services were provided to fill these gaps would help alleviate 
the high incidence of diabetes?
    Mr. Walker. What we've noted is that, and as I mentioned, 
we do provide a nutrition program for the elders. What we've 
found is that we need to continue our educational efforts. We 
have some pilot projects, and Dr. Jackson can speak directly 
about those projects that include researchers pairing up with 
elders and tribes to discuss the types of foods that they eat. 
We had one case where they gathered foods, they tested the 
glycemic level in the foods to determine the rate at which 
glucose is generated, I guess, within the food. Then they 
incorporated new practices of preparing foods and which foods 
to use and eat into the Native culture.
    Ms. Jackson. A couple of years ago, we had some funding for 
some pilot breakfast projects. Some of the tribes, notably the 
Rosebud Sioux Tribe, decided they could best serve their 
elders, the diabetic elders, by serving a breakfast. Because 
they would find the elders would come to the site at lunch and 
hadn't had breakfast. And when they had their glucose 
monitored, they would be either really high or really low. So 
they for 1 year with funding from us, they provided breakfast 
for the elders.
    The program was so successful that even when our funding 
ran out, the tribe picked up the funding of it. They have found 
that the elders that participate in the two meal a day program, 
their blood glucose levels are much better controlled.
    So if we could find practices like that, programs like that 
that really made a difference, and then be able to expand those 
into other communities, I think we could see some real benefit 
in the health of the elders.
    The Chairman. What would it cost if we carried out that 
practice on all of the reservations?
    Ms. Jackson. I don't even have a clue. We would have to 
look at that. Because some of our programs now are really 
struggling to provide one meal a day. The number of elders has 
increased so rapidly that the Indian programs differ from the 
non-Indian programs in that we find many of the non-Indian 
programs will cut off the number of people attending the meal 
site. If they're running short on money, then they say nobody 
else can come. The Indian programs, we don't say nobody else 
can come. We'll continue serving people and feeding people, and 
then we have to limit the number of days. So we'll feed 
everybody for 3 days a week, rather than serving fewer people 5 
days a week.
    So we're finding a number of our programs now, due to the 
funding level of the program, are only serving lunches 3 days a 
week, rather than the 5 days a week.
    The Chairman. Mr. Walker, as you can imagine, none of us 
are experts here, so we have to depend upon you and other 
experts to provide us with the necessary statistics and 
information. Based upon that, we can act if moneys are needed.
    When I became a member of this committee about 25 years 
ago, I was told that if an Indian elder reached the age of 50, 
the odds were that he had diabetes, and that the mortality rate 
for those with kidney problems were 3 times the national 
average. And apparently, it is still the same. Will any attempt 
be made by AOA to let us know what it could cost to bring these 
statistics above that of third world countries?
    Mr. Walker. Mr. Chairman, the Administration on Aging, and 
I'm sure the entire Department of Health and Human Services, 
would be very pleased to work with you in reviewing the 
statistics and discussing how we can best achieve better goals 
in addressing the health status of Native Americans.
    The Chairman. Has any comprehensive study ever been made?
    Mr. Walker. Related to the?
    The Chairman. The health of elders.
    Ms. Annette. From an Indian Health Service perspective, I 
think a comprehensive study as you speak of has not. I believe 
we have elements. And a coordinated effort to look at those 
elements will give us a better overall picture. And perhaps the 
gaps can be identified then and we can give you a better feel, 
I think, overall of what the need is. But I think the answer to 
that, to my knowledge, no.
    The Chairman. What would it take for us to have this 
coordinated study to identify the gaps?
    Ms. Annette. I think that to look at this, it may be best 
to have, this is my idea, perhaps have an inter-agency group 
look at this along with tribes and sit down and say, what has 
been done, what needs to be asked. I think we have a beginning 
of that with the North Dakota study. We have some tools to take 
a look at that.
    Again, it may be that from a tribal perspective, they would 
like to have data, to find out where are we today. It's similar 
to what you're asking for, Senator.
    The Chairman. Do we need legislation to bring this about?
    Mr. Vanderwagen. Mr. Chairman, I would think that 
legislation is probably not necessary. I know this Secretary, 
Secretary Thompson and Deputy Secretary Allen are very 
supportive of exploring ways we can eliminate disparities in 
health. This is one of the major initiatives I think that this 
Department is pushing forward at this time. So I believe that 
there is support within the executive branch for this kind of 
interest.
    I don't know at the moment that there's a specific 
requirement necessarily for legislation. But that's something 
that probably needs to be studied a little more 
comprehensively. As we've suggested to you, we don't have a 
comprehensive look at what the impact of many of these issues 
are in aging Indian populations. With study, it may be that 
some legislative corrections may be needed.
    The Chairman. What can we do to bring about this study?
    Ms. Annette. I think we certainly will, you have expressed 
to us such an interest that it's something----
    The Chairman. How much would it cost?
    Ms. Annette. Good question.
    The Chairman. We would try to provide it. But we do not 
know. You will have to tell us.
    Ms. Annette. I'm not prepared today to come up with that 
number. But I certainly will make sure that we coordinate with 
other agencies to get that information to you.
    The Chairman. Will both of you get together and tell us 
what you need?
    Mr. Walker. Absolutely. And in fact, the Secretary operates 
the Department of Health and Human Services as one department. 
As a result, we are working better together, more so than we 
have ever done in the past.
    Ms. Annette. I would like to interject, we also have 
another piece of information that I believe we've provided for 
you, and that's a roundtable that was done really looking at 
long term care needs within Indian country.
    The Chairman. I have the report here.
    Ms. Annette. You have the report.
    The Chairman. Mr. Vice Chairman.
    Senator Campbell. Thank you, Mr. Chairman.
    Before I ask a couple of questions, let me just maybe make 
a few comments. If you were to go into most committees here on 
the Hill, and you asked them what the word commodities brings 
to their mind, they wouldn't have a clue. But many of the 
people that come in this committee, they know what the word 
commodity means. Basically, what it means for anybody in the 
audience that's not here is Government surplus food that is 
given to Indian tribes that is primarily high starch, some of 
it is white cans with no labels, it's just written on the can 
what's inside. Surplus cheese, almost all the commodities have 
a high starch content or a high content of what creates 
cholesterol, as you know.
    So it seems to me that when we do more studies or we talk 
about putting more money into the problem, we need to go back 
and address the underlying problem that got us there. If we 
don't change that, we can pour tons of money into it and it 
still won't correct it. We've got to deal, it seems to me, 
through education and recognize that there is a lifestyle 
problem and maybe in some cases, a difference of heredity too.
    But when I talk to elders about their elders, I don't know 
any that would tell you that their grandparents that lived 
before the turn of the century had a problem with diabetes. 
Maybe after the reservation system was initiated, but certainly 
not when they had plenty to do. They might have died of a lot 
of other things, but it wasn't diabetes. They had a different 
kind of a diet. And I think that has an awful lot to do with 
it.
    I happen to live on the Southern Ute Reservation. They just 
built a very, very nice facility there that is comprised of, 
it's really a gymnasium but it's really a wellness center. 
Because they offer cooking classes and they do a number of 
things to try to teach people that just exercise alone isn't 
going to cut it. You've got to do a lot of other things, too. I 
think that's really important.
    And that makes it all the more difficult, because you can 
educate young people about having a better diet, but if they 
don't have access to money, i.e., a job to buy what they need 
for a better diet, they're still reduced to living on 
commodities. So you have this kind of endless cycle that they 
can't get out of, and so it seems to me the health of Indian 
people is really related to a lot of things just based on the 
circumstances which keep them in that hole where they can't 
seem to get out.
    Let me just ask a couple of questions. One of them is, I 
mentioned that maybe heredity plays a part and so on. The 
Native Alaskans, they still live, I think, to a higher degree, 
on subsistence and gathering, probably more than many in the 
lower 48. I know that having gone up there a number of times 
and eaten muktuk, high fat from a seal and whale and so on, 
which doesn't taste great, by the way, but I'm interested in 
knowing if there is any disparity between the elders in Alaska 
and the elders in the lower 48 on diabetes or diet related 
illnesses.
    Ms. Annette. Yes; there is, there has been. In the past, 
when Alaska Natives lived a life that you describe, their rates 
are much, much lower. What we have found is that as they become 
more acculturated, perhaps, with the western diet as we know 
it, the rates of diabetes are going up. So I guess that goes to 
really support the point that you've made, that it truly is 
lifestyle.
    I'm really intrigued by the fact that you put, and it's so 
true, we have to put an emphasis on prevention. What I've found 
in some of our elders is they seem to think that they're beyond 
prevention at that point when some of these illnesses have hit. 
One of our education challenges is to say to the elders, 
``prevention never stops''. There are ways we can maintain, get 
better, by doing some prevention, interventions throughout a 
person's lifetime. That's a challenge we have and that's a 
message we must get out to our elders. Prevention is always, 
always important, those activities.
    Senator Campbell. Along that line, I might also suggest 
that 50 years of commodities can't be turned around in a matter 
of 1 day or 2 days or 1 year. Some of the damage that's done by 
poor diets over the years, you just don't fix it by taking a 
couple of pills for 1 week. That's something that takes a long 
time.
    Let me mention one other thing I wanted to get your opinion 
on, either you or maybe Mr. Walker. I understand that in the 
case of the Pimas, there are American Pimas and Pimas that live 
in Mexico. The American Pimas, like many of us, they eat more 
processed foods, their kids probably watch more TV and have 
less exercise, like any other kid in America does now, compared 
to years ago when they had to work the land. But the Mexican 
Pimas have a higher corn diet and different lifestyle, probably 
not as many things that we have on this side of the border. Do 
you know of any difference between the Mexican Pimas related to 
diabetes and the American Pimas?
    Mr. Vanderwagen. Yes; there are about 1,500 tribal members 
of the Tohono O'odham Nation that live in Sonora. We have in 
the last few years conducted some health fairs and health 
surveys in that population, because the Tohono O'odham Nation 
of course is, federally recognized and these are tribal 
members. In fact, the rates of diabetes are lower in Sonora 
than they are across the border in Arizona. Unfortunately, 
those folks are dying of accidents much more frequently, so we 
have a different set of issues to cope with there. But at least 
they don't view Spam as a traditional native food.
    Ms. Jackson. The research that's been done on the foods 
that they eat is what prompted us to work with Utah State 
University on doing the nutrient content of foods of the Utes 
in Utah and the northwest. Because down in the Pimas in Mexico, 
they're still eating much more of their traditional food. And 
even though it's corn, a high starch diet, the corn has a lower 
glycemic index than the bread that the Pimas on this side of 
the border are substituting for it.
    So we're using the research that was done down there to 
hopefully incorporate more native foods in the Utes in Utah and 
the northwest tribes to again maintain their culture by eating 
more of the traditional foods, but also substituting some of 
the better foods for the commodity foods and the store-bought 
foods.
    Senator Campbell. Is it less processed, too?
    Dr. Young. Yes; a lot less processed.
    Senator Campbell. A few years ago, some of us on the 
committee tried to initiate a program with the surplus buffalo 
from the Federal herds to go to nutrition programs for Indian 
elders. We weren't very successful with that, but we are still 
trying. I know part of it has to do with low protein, too, in 
diets.
    Let me ask one other thing. Since the University of 
Colorado was brought up, and I am from there, could you 
describe to me the kinds of activities that resource center is 
going to participate in? Mr. Walker?
    Ms. Jackson. The Resource Center in Colorado is developing 
a lot of training materials for health care professionals 
working with tribal members, and especially urban Indian 
elders. We find on the reservations there is much more cultural 
sensitivity. But in the urban areas, there is essentially no 
sensitivity to the needs of elders. They have developed one on 
diabetes, one on cancer, they've just developed one on 
depression and cardiovascular diseases and alcoholism. So their 
focus this next year is going to be on training professionals 
and paraprofessionals for working with Indian elders.
    Senator Campbell. Is that the center that's being developed 
at the old Fitzsimmons site?
    Ms. Jackson. Yes.
    Senator Campbell. Oh. Well, you'll have to come to the 
unveiling. They've named the thing after me. [Laughter.]
    I wondered what the connection was. You'll have to come to 
that. It's a beautiful building, by the way.
    Ms. Jackson. That's what I understand.
    Senator Campbell. Maybe the last thing I mentioned, about 
the elder population and how many youngsters are coming up now, 
the 2000 census reported only 12 percent of the Indian elder 
population is 55 or older. It seems to me that logically, what 
we need to do is cultivate in youngsters lessons about 
exercise, good health habits, that kind of thing. Is that 
outside of the scope of your agencies, Mr. Walker?
    Mr. Walker. No; not really. What we are doing is broadening 
our scope. While we are certainly focused on the needs of the 
elderly, we believe that we need to prepare people to be older 
by giving out broad based messages about prevention, about 
lifestyle changes that need to take place that will impact the 
quality of life you have when you are older.
    Senator Campbell. Good. And perhaps one last question, you 
mentioned that you just awarded caregiver grants to 177 tribes. 
What was the total amount of the grants, and what was the 
average amount given for the grants?
    Mr. Walker. The total amount was $5.5 million, and the 
average award was about $18,000.
    Senator Campbell. Were those grants given on some 
competitive basis, or how do you give the grants?
    Mr. Walker. All federally recognized tribes are eligible to 
apply. And they indicate an interest in the ability to provide 
caregiver services and the statute prescribes five services 
that they choose from in terms of the provision to their elders 
and to family caregivers. So they have to meet those criteria.
    Ms. Jackson. They're non-competitive, and everybody that 
applied received a grant.
    Senator Campbell. Everybody that applied received a grant? 
So that means about 300 and some odd tribes didn't apply, is 
that correct?
    Mr. Walker. That's correct.
    Senator Campbell. Do they know about it? One of the 
problems we have sometimes, we put things in place here, it's 
administered by the Administration, then we're told later by 
tribes that they didn't know, because there is a disconnect, an 
information disconnect about what is available to the tribes. 
Are all tribes aware that they can get these grants?
    Ms. Jackson. Only the tribes that receive the part A 
grants, the nutrition and supportive services, were eligible 
for the caregiver grants. We have 235 that receive the Part A. 
So those were the only ones eligible for the caregivers grants. 
And some didn't apply just because they didn't think they were 
ready to begin a new program at this time.
    Senator Campbell. I see. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. I thank you very much.
    If we may, we would like to submit questions for your 
consideration and response. Thank you very much.
    Our next panel consists of the Director of Research, Center 
for Rural Health, University of North Dakota, Dr. Richard 
Ludtke; Researcher, Center for Rural Health, University of 
North Dakota, Leander ``Russ'' McDonald. He will be accompanied 
by Alan Allery, Director of National Resource Center on Native 
American Aging, University of North Dakota.
    May I call upon Mr. Ludtke.
    Mr. Ludtke. If Dr. McDonald would start, please.

STATEMENT OF LEANDER ``RUSS'' McDONALD, RESEARCHER, CENTER FOR 
  RURAL HEALTH, UNIVERSITY OF NORTH DAKOTA, GRAND FORKS, ND, 
ACCOMPANIED BY ALAN ALLERY, DIRECTOR, NATIONAL RESOURCE CENTER 
                    ON NATIVE AMERICAN AGING

    Mr. McDonald. Mr. Chairman and other members of the 
committee, I'm honored for the opportunity to speak on behalf 
of my elders. My name is Russ McDonald, my mother is an Arikara 
from the Three Affiliated Tribes and my father is a Dakota from 
the Spirit Lake Nation. Both reservations are located in North 
Dakota. I am a research analyst at the National Resource Center 
on Native American Aging. The Resource Center is located in the 
Center of Rural Health at the University of North Dakota School 
of Medicine and Health Sciences. Established in 1993 with 
funding from AOA, the Resource Center has a mission of 
providing research, training and technical assistance to the 
Nation's Native American elders.
    Today we will be presenting new findings about prevalence 
of chronic disease, their effect on functional limitations and 
differences in life expectancy for Native American populations 
from a nationwide elders needs assessment project called 
Conducting Local Assessments: Locating the Needs of Elders. The 
project entails conducting a survey on reservations that 
voluntarily participate in this project and allows for 
comparison of elders on reservations with their national 
counterparts.
    The results from the research not only provide us with new 
information about Native elders, but also gives each tribe data 
they can use to help guide them in developing long term care 
infrastructure for their communities. The data has been used by 
a number of tribal communities in their planning efforts, 
program development and grant application, primarily directed 
at addressing the need for long term care services within our 
community.
    To date, we have 83 tribes with 8,560 Native elders having 
filed out the survey. Two additional tribes are being processed 
this week and will be added to the aggregate file upon 
completion.
    With that background on the study, let me share with you a 
picture of elder health and long term care needs on our 
results. Life expectancy for Native Americans and Alaska 
Natives are low relative to the general population. In addition 
to important differences between Natives and the general 
population, it is also very important to note that there is a 
substantial variation across Native American and Alaska Native 
tribes in life expectancy across the Indian Health Service 
areas. Average life expectancy ranges from a low of 64.3 years 
of age in the Aberdeen area to a high of 76.3 years in the 
California area, a difference of 12 years. Life expectancy for 
the general population is 76.9 years.
    Earlier this year, I attended the high school graduation at 
the Spirit Lake Reservation and watched as grandparents 
congratulated their grandchildren in accomplishing a major 
goal. When I graduated from high school in 1981, I had one 
grandmother still living at age 77. She died 2 years later. My 
other grandmother died during childbirth at age 37, with my two 
grandfathers dying both from heart attacks, one at age 62 and 
the other at age 64. So while the number of Native elders 
living to be old is increasing, old age is still rare on our 
reservations.
    Chronic disease. While quantity of life is an important 
indicator of health for the general population, the health 
status of the aged is also an important focus. As populations, 
including Native Americans, age, there is a likelihood of 
developing chronic illness like arthritis or heart disease, 
which can impact both life span and quality of life. For 
example, the Native elders are 19.5 percent more likely than 
the general population to experience arthritis. Similarly, 
Native American elders are 48.7 percent more likely to 
experience congestive heart failure, 17.7 percent more likely 
to report high blood pressure, 17.5 percent more likely to have 
experienced a stroke, 44.3 percent more likely to report 
asthma, and 173 percent more likely to be afflicted with 
diabetes. Only cataracts are reportedly higher in the general 
population. So what we see here in this data is that the Native 
elder is sicker than their United States general counterparts 
but at least they're able to see a little bit better.
    Our data, as seen in figures 1 through 6, suggests that 
chronic disease rates are higher among Native American elders 
in spite of their shorter life expectancy. These findings 
suggest that the disparate health conditions of the Native 
elder are the result of other factors, such as lifestyle, 
socioeconomic status and access to timely and adequate care. 
Furthermore, these findings, and the prevalence of chronic 
disease, like life expectancy, varies across Native American 
and Alaska Native tribes.
    When the regional chronic disease rates in Native American 
and Alaska Native elders are compared, we see apparent 
differences between areas. Arthritis rates reported in the 
survey tended to be lower in the area of the southwest and high 
elsewhere. The same pattern holds true for congestive heart 
disease. High blood pressure tends to be reported at higher 
levels in the east and south. Asthma rates again appear lowest 
in the southwest. Diabetes, while high generally, produced 
lower rates for Alaska and the highest rates in the Phoenix 
area. Persons reporting having experienced a stroke were lowest 
in the Navajo and Phoenix areas, followed by the north central 
and northwest areas.
    On the last, I'd like you to keep in mind this represents 
people who have been diagnosed with stroke and have survived. 
The areas with the lowest life expectancies tended to also 
report lower rates of stroke victims in their surveyed area. We 
believe these lower and average rates of chronic disease to be 
the result of lower life expectancy, rather than being 
indicative of better health status. Chronically ill elders in 
these regions have shorter life spans, resulting in regional 
chronic disease rates that are lower. In a sense, only the 
strong and healthy survive to be elders, which in turn affects 
the chronic disease rates in the Midwest and Alaska regions.
    My colleague, Dr. Ludtke, will address the issue of 
increasing numbers of Native Americans with functional 
limitations, reflecting a growth in the need for long term care 
services. He will also comment on strategies for decreasing the 
number of individuals with functional limitations.
    I will be pleased to answer any questions now or after Dr. 
Ludtke has completed his remarks. Thank you, Mr. Chairman.
    [Prepared statement of Mr. McDonald appears in appendix.]
    The Chairman. Thank you.
    Dr. Ludtke.

 STATEMENT OF RICHARD L. LUDTKE, DIRECTOR OF RESEARCH, CENTER 
          FOR RURAL HEALTH, UNIVERSITY OF NORTH DAKOTA

    Mr. Ludtke. Mr. Chairman and honored members of the 
committee, I'm also honored and grateful for this opportunity 
to speak.
    Chronic disease varies widely, with some people minimally 
affected, while others have significant levels of disability. 
The level of disability is related to functional limitations in 
the population and used as a criterion for admission to nursing 
homes, assisted living, to community based care, long term care 
programs. Nearly all definitions of functional disability use 
information about activities of daily living and instrumental 
activities of daily living. Examples of the ADLs, activities of 
daily living, include such items as eating and walking. IADLs, 
on the other hand, focus on limitations like with cooking and 
shopping.
    When ADLs and IADLs are combined, people can be classified 
into four levels of need. The associated care requirements can 
be identified as ranging from no long term care services needed 
to home and community based care, to assisted living, and to 
skilled nursing care, as seen in table 1. Using these 
categories, we are able to estimate the numbers of people at 
these different levels of need and determine the needs for 
different levels of long term care services. The prevalence of 
functional limitations increases with age and the severity of 
limitations also increases with age. Figure 1 contains the data 
from our surveys regarding functional limitation for Native 
American elders. It's clear that the rates for all levels, from 
moderate to severe, increase with age and that they do so most 
dramatically in the oldest cohorts.
    As the population ages, there will be an increased need for 
long term care services. The number of people classified as 
elders in the Native American population is about to explode, 
with the arrival of those born during the baby boom as shown in 
figure 2. When one combines the population data with the 
measure of functional limitation, a picture of growth in need 
for long term care is generated.
    The most dramatic growth will occur as a result of the 
large number of the baby boom cohorts in the next decade growth 
will expand the population of young old, and barring any 
change, will increase the need for moderate levels of care 
consistent with home and community based services that are 
greater than the other cohorts.
    Life expectancy for Native elders has been growing rapidly 
and should be expected to grow in the future. Population 
projections using IHS life tables and census data show that as 
of the year 2000, the Nation has approximately 218,000 Native 
American elders with functional limitations of a moderate or 
greater level. As the population ages, the number of elders 
with functional limitations will grow assuming the same rates 
of disability are continued. By the year 2010, as shown in 
Figure 3, we can expect a 51 percent increase, or approximately 
329,000 Native elders, to have functional limitations of 
moderate or more severe levels. The large number of people 
becoming elders and the earlier ages of onset from any chronic 
diseases that produce functional limitations creates a 
conservative estimate in the growth of functional limitations 
to the end of the decade.
    The health and vitality of future elders depends on a 
healthy lifestyle, including good diet, regular exercise, and 
refraining from drinking and smoking. If people take care of 
themselves, they can reduce the need for long term care 
services. Access to preventive and other health services is 
important for delaying the onset of illness, as well as 
effectively treating disease. If we reduce only 10 percent of 
the Native American and Alaska Native limitations, we would see 
a significant decrease in the demand for long term care 
services.
    Figure 4 presents the changes in the numbers of people with 
each level of limitation that would occur if we had a 10-
percent across the board reduction in functional limitation. 
That could occur with improved health promotion and access to 
state of the art health care.
    The recommendations that we derived from these observations 
is that we need an initiative to develop an intervention and 
health promotion models leading to improved outcomes for Native 
Americans and Alaska Natives as they enter their elder years. 
There is a need for the development of long term care, it 
requires solutions that are tailored in terms of both the types 
of care that work best and the means by which local communities 
can realistically produce the type of care required.
    There is a need for increased support for targeted research 
on Native American aging and related educational and capacity 
building programs. These are essential to help fill the gaps in 
information and help tribes anticipate emerging health care 
needs.
    Three points of relevance to the Native American and Alaska 
Native people concerning long term care include the need to 
reduce chronic diseases and functional limitations, to 
eliminate disparities across tribes, between Native American 
elders and the general population, and to increase life 
expectancy. And lastly, to address the shortages and lack of 
long term care options in Indian country.
    I thank you for this opportunity to speak and would 
entertain any questions, along with Mr. McDonald.
    [Prepared statement of Mr. Ludtke appears in appendix.]
    The Chairman. Thank you very much.
    Senator Conrad, do you have any statement you'd like to 
make?

 STATEMENT OF HON. KENT CONRAD, U.S. SENATOR FROM NORTH DAKOTA

    Senator Conrad. Just very briefly, Mr. Chairman.
    First of all, I want to thank you very much for holding 
this hearing. I especially want to welcome Dr. Ludtke and 
appreciate the work that he did on this survey. It is really 
sobering to look at the statistics that are revealed here. When 
compared to the general U.S. population, Native elders are 
almost 20 percent more likely to have experienced a stroke, 50 
percent more likely to have experienced congestive heart 
failure, more than 40 percent more likely to report asthma, and 
perhaps most stunning of all, 170 percent more likely to be 
afflicted by diabetes.
    All of us have known before this survey was done that these 
statistics would probably be alarming. And they are. When it 
comes to life expectancy in the Aberdeen area, which includes 
my home State of North Dakota, we have the lowest life 
expectancy of any area for Native Americans, 64 years compared 
to nearly 77 for the general population.
    Mr. Chairman, these statistics cry out for action. This is 
going to require a dedication of resources and a commitment of 
effort. Unfortunately, we see in the President's budget that 
there is not that commitment. And it is, I think, deplorable. 
But it's not just the President's responsibility. 
Fundamentally, the responsibility lies right here in the 
Congress of the United States. We have the obligation to 
dedicate the resources to make a meaningful difference. And 
there has been a failure to do so.
    Mr. Chairman, I hope this hearing will be the beginning of 
a change in the level of attention and the level of commitment 
by the Congress to address these issues, and once and for all, 
to make a meaningful change.
    I also want to thank Mr. McDonald for his contribution to 
this study. I'm also pleased that Fred Baker, the chairman of 
the Mandan, Hidatsa and Arikara Elders Organization is here to 
share with us some of the experiences of Native elders in North 
Dakota. I'd like also, Mr. Chairman, just briefly, to recognize 
two other people who are here today, Alan Allery, the Director 
of the National Resource Center on Native American Aging, and 
Dr. Mary Wakefield, from the Center for Rural Health in North 
Dakota. Dr. Wakefield is my former chief of staff, and she has 
made a tremendous contribution to these issues, not only in 
North Dakota, but here in Washington. I know of no one with 
greater credibility to speak on these issues than Mary 
Wakefield. I am so pleased that she has gone home to North 
Dakota to make a contribution at our Center for Rural Health 
there.
    Let me say, Mr. Chairman, if I could, that you and the vice 
chairman have been outspoken on the need to make a difference 
on these issues. We appreciate your leadership. I think we've 
got to find some way to convince our colleagues that more of 
the same just isn't going to get the job done. I don't know 
what it's going to take to put a focus on these issues in a way 
that moves our colleagues.
    I was just at one of our reservations over this break. We 
had terrible fires break out on the Standing Rock Sioux 
Reservation, more than 40,000 acres burned. While I was there 
for an emergency meeting, with people who had lost their homes 
as well as with the leaders of the reservation and Federal 
officials who were part of the response team, it really struck 
me once again, as I left that hall, a young woman came up to me 
and said, Senator, something has got to be done. We are having 
suicide on this reservation among young people in numbers we 
have never seen before. She said, there is a sense of 
hopelessness and despair, a sense that there is no future. Now, 
that is a condemnation of what is occurring. And we have an 
obligation to respond.
    I thank the chairman, and I thank the witnesses as well.
    The Chairman. I thank you very much, Senator.
    If I may ask a question of Mr. McDonald, you have 
accumulated much data. Do you share this with the Federal 
Government?
    Mr. McDonald. The descriptive statistics from the study are 
posted on our web site underneath the research icon. So the 
numbers are available to the general public. Those statistics 
are from the aggregate data file.
    The Chairman. Do you know whether the Federal Government is 
making use of that?
    Mr. McDonald. No, sir; I'm not aware.
    Mr. Ludtke. Can I respond to that? These are being shared 
as widely as we can. They are submitted to the Administration 
on Aging. Each publication is submitted to the Administration 
on Aging . They have been shared with the Indian Health 
Service, and Dr. Finke has used them. So we are making every 
effort to get them to the appropriate agencies.
    The Chairman. Senator Conrad said we cannot do the same 
thing for the same problem year after year. But since we are 
not experts in this field, can you tell us what we can do? We 
are awaiting your suggestions.
    Mr. Ludtke. I think there are a number of things that we 
can do. When we work with some of the tribes or State 
organizations and they receive our data, they would like to 
carry it forward, and they look to us for assistance. We're 
frankly equipped to give some of the information and the data, 
but not the counsel on how to develop long term care programs. 
I think we could develop a concerted effort to assist people in 
developing long term care programs on reservations. I think we 
could develop demonstration projects that are unique and 
culturally compatible with reservations. And these could be 
tied to our research and educational efforts. I think these are 
possibilities for responding that would, I think, have a short 
start time and produce great results.
    The Chairman. Have you looked into the possibility of 
submitting such a request to the Government?
    Mr. Ludtke. We have only talked about it. We have 
considered it if we could find the vehicle, we would submit.
    The Chairman. There is your vehicle right there. 
[Laughter.]
    Mr. McDonald, have you looked into the possibility of what 
Dr. Ludtke has stated?
    Mr. McDonald. We've talked about it a little bit within the 
office, but as far as going further with it, we're still in 
that process of thinking of what could be developed first, 
before seeking assistance for that.
    I'd like to maybe have Alan comment on that. He's the 
director of the Resource Center.
    Mr. Allery. Just a brief comment. We are going to be 
meeting with some Federal agencies this afternoon to discuss 
possibilities further. But the Indian Health Service is the 
primary health care provider for American Indians. And 
certainly, additional support for health promotion activities 
would make a huge difference in the health status of elders.
    The Chairman. Well, my concern is that, as a member of this 
committee, we have been giving these impassioned speeches year 
after year about the dismal health conditions in Indian 
country. And it is the same every year. Some day, I hope we can 
give speeches saying that we have done something about it. And 
there isn't much we legislators can do unless we know what to 
do. And no one has suggested to us what we can do, other than 
add 10 percent or add 5 percent. And even at that, we are not 
aware, or we are not certain what it will accomplish.
    But apparently, you people have some scientific data that 
could be put to use. If you come up with a pilot program of 
sorts, I can assure you we'll look at it very seriously and put 
it on the right vehicle, as you say.
    Mr. Allery. We would like the opportunity to translate the 
research into action by working with various groups on model 
projects, including specific tribes, perhaps, in North Dakota 
and other States that would develop some models, some ideas 
that others could replicate.
    The Chairman. Mr. Vice Chairman.
    Senator Campbell. Thank you, Mr. Chairman.
    This by the way, is tremendously informative. Probably also 
predictable. I might say, Senator Conrad mentioned something 
maybe along the line I was talking to, that we've got to really 
get ahead of this curve, this population growth. We're not 
putting enough resources in it, but I don't know if we'll ever 
be able to put enough resources in it, because the underlying 
problem is growing faster than even the resources that are 
available. Before Senator Conrad came in, we talked about the 
population growth and the baby boomers were mentioned and the 
post-baby boomers, the boomers of the baby boomers.
    And I'm not a scientist or a doctor, but I think in mighty 
simple terms. I envision this problem like the shape of a 
pyramid. You have the traditional number of people, and this is 
pretty well, I think, alluded to in your study, traditional 
number of people, X amount at that apex of the pyramid. Then 
you have the adults that are on the reservations now, or Indian 
people, nationally growing at a huge rate. Then you have the 
youngsters. I mentioned before Senator Conrad came in that on 
the Cheyenne Reservation, 75 percent are under 25 years old.
    Well, if we have that kind of a growth rate, and I imagine 
on many reservations it is the same, if you envision that 
pyramid I was talking about, and turn it over, that's where we 
have the problem. The apex is down at the bottom now, and we 
have a number of people that are elders down there that have 
existing problems and that we have got to deal with. But as you 
go higher on that inverted pyramid, the base is getting bigger 
and bigger, and the baby boomer and the post- baby boomers is 
where the real problem is going to be in another 20 or 30 
years.
    I don't know how we get ahead of that, because it's just 
not going to be resolved by more resources from the Federal 
Government. Somehow, we've got to get to the underlying problem 
of unemployment, lack of opportunity, all the things that 
reservations face now that are somewhat similar to the things 
we would see in developing countries. It's something we simply 
have got to not just continue to play catch-up with, but try to 
get ahead and recognize the problem we're going to face in 
another 20 years. It's going to be huge compared to now.
    Senator Conrad mentioned the suicide rate. I don't know if 
that was in the study or not. But I'm told on some reservations 
that almost half the teenage girls try to commit suicide before 
they are out of their teen years, and about a third of the 
boys. I'm not sure if that's a valid number or not, but I know 
having been out to reservations a lot, it's higher than the 
national average. And I'd like to know a little bit about the 
problems that people are facing that are related to suicidal 
tendencies. We're talking primarily with seniors here, so maybe 
somebody could deal with that, if you could. Was there anything 
done in the study that related suicide to bad health in 
seniors, the elders?
    Mr. McDonald. No; we had nothing on the mental health.
    Senator Campbell. Nothing on that.
    Mr. McDonald. No; and I think what you're seeing with the 
elder population is that when we talk about suicides happening 
on the reservation areas, that tends to be with the younger 
population. With the older population, I think at least for my 
people, is that we don't kill ourselves.
    Senator Campbell. Well, we shouldn't, and traditionally 
they didn't. But they are now. A lot of young people are now. I 
know some tribes traditionally, they felt that suicide for men 
was not a way you could go to the next world, you would lose 
your way to the next world if you did that. And it was an 
absolute no-no. They might have died a lot of ways, but they 
didn't kill themselves. But they are now, as you know, 
youngsters are. It's non-traditional, but it's happening.
    So you don't have any, really anything to compare suicide 
rates for Indian elders with the national population?
    Mr. McDonald. No; and from our discussions with the tribe 
that we've been working with over the past few years, this is 
not an issue that has come out of the focus groups that we've 
had or other groups.
    Senator Campbell. Have you found any, in your study, any 
concrete suggestions you could give the committee on improving 
lifestyle habits to reduce some of the statistics you have in 
here?
    Mr. Allery. One of the groups that we worked with in 
Minnesota, the groups of tribes in Minnesota developed a wisdom 
steps program, which encompassed almost all elders in all the 
tribes in Minnesota. And in working with the National Resource 
Center, they were able to parlay their elder needs assessment 
into a $250,000-grant from the Share projects at the University 
of Pennsylvania. Their progress has been substantial. The last 
session that I went to, they had over 400 elders exercising, 
walking at least 2 miles a day. So that was, that's kind of how 
the National Resource Center works with many groups. We depend 
on the tribes to take the initiative. And we work closely with 
them and the data is actually theirs. They can use it for 
planning their own projects and developing programs that meet 
the needs of their elders.
    Mr. Ludtke. Could I followup on that for just one comment?
    Senator Campbell. Yes.
    Mr. Ludtke. In the data we have questions that reflect on 
lifestyle issues. They weren't included as part of the report 
this morning, but it's very interesting to observe that the 
Native elders exercise more than the general population. The 
Native elders drink far less than the general population. But 
in the area of diet, they have greater problems.
    As we looked at the lifestyle comparisons, we were kind of 
stricken with the notion that they seemed to have relatively 
good lifestyles, yet relatively poor outcomes. We're left with 
the conclusion that that had to revert back to diet, and the 
very thing you were talking about earlier.
    Senator Campbell. Well, we've got to try to help, because 
it's the right thing to do. But I also happen to think those 
elders are one of the most valuable resources that tribes have. 
Because those youngsters that are in that population boom, one 
of the problems they're having is relating and finding and 
learning about the old ways. The elders are the key, they're 
the link. If we lose them, I think we've lost something that is 
just simply not replaceable.
    Thank you, Mr. Chairman.
    The Chairman. Your discussion on suicide reminded me of a 
trip that I took to Alaska for the first time 10 years ago. At 
that time, I was advised that the suicide rate among young men 
between the ages of 19 and 23 was 14 times the national norm. I 
think that is unacceptable.
    Senator Conrad.
    Senator Conrad. I'd like to go back to the question of what 
can be done. In your analysis, did you do any separation based 
on economic circumstances for the health of elders? In other 
words, did you look at different income categories and then 
look at how that might relate to health?
    Mr. Ludtke. We haven't. There is a great deal of analysis 
yet to be done. We struggle to find the time to get the 
information back to the tribes to this point, so we haven't 
done extensive analysis.
    One observation on the economic variable is that there's 
not a great deal of variability. My guess is that as we apply 
that, we'll find the absence of variability on that income 
variable, that a large percentage of the population is below 
the poverty line.
    Senator Conrad. The two of you have spent more time with 
this data than anybody else. Are there things that you 
observed, are there things that kind of tickled your fancy, if 
you will, as you looked at this data as to clues that might 
make a difference?
    Mr. McDonald. I think somebody was talking about 
commodities earlier. I was raised on commodities, too, as you 
can tell. But one of the things is that the highest thing, Dr. 
Ludtke mentioned already, is the higher rates of exercise for 
Native elders. So they exercise at higher rates, but they also 
have higher rates of BMI, or they are more likely to fall into 
overweight and obese categories.
    Therefore, the only thing I could think of that would 
otherwise affect their higher BMI would be the nutritionals. So 
I think there would have to be something to provide better 
nutrition and also maybe continue exercising, for those who 
already are, and maybe increase exercise for those people who 
aren't.
    Senator Campbell. Would the Senator yield for a moment?
    Senator Conrad. Yes.
    Senator Campbell. You asked a question about different 
socioeconomic backgrounds for elders. From my own experience, 
you rarely find an elder with much money, because it's not a 
traditional thing to accumulate money. If anything, they give 
it away. They have giveaways, they do things to share it. So 
you don't have much individual wealth among elders anywhere, 
Indian elders. Not that I know of. But that doesn't mean the 
tribes can't accumulate some wealth through different kinds of 
opportunities, and provide some of the programs that the elders 
need.
    Thank you.
    Senator Conrad. In terms of diet, did you make observations 
with respect to dietary differences between the elders and the 
Indian population and elderly people in other populations? Is 
there some clue there as to what they're consuming that is 
different from others in healthier populations?
    Mr. McDonald. Somebody talked about Alaska, and they are 
still eating much of their traditional foods, like fish and 
wild game and that type of thing. And what we're seeing is that 
that region tended to have lower rates in some areas.
    Senator Conrad. Lower rates of?
    Mr. McDonald. Of chronic disease.
    Mr. Ludtke. The information that we gathered on nutrition 
was relatively scant and survey data often tends to be scant, 
we often ask one or two questions. What did happen was that we 
were triggered to look at nutrition as kind of a key variable. 
So if we have an opportunity to do a second generation 
instrument, we plan to expand that significantly.
    We think this is an area that needs attention. We think 
health promotion needs to be directed at nutrition. We think 
nutrition and low incomes are at odds with one another. It's 
very difficult to have a nutritious diet if you don't have an 
adequate income. It's difficult to buy fresh fruits and 
vegetables. And people will end up on processed foods, which 
are less healthy.
    Senator Conrad. Thank you.
    The Chairman. Thank you very much. Like the first panel, 
we'd like to submit question to you for your consideration and 
response. On behalf of the Committee, I thank you very much.
    Our final panel consists of the executive director of the 
National Indian Council on Aging of Albuquerque, Dave 
Baldridge; and the chairman of the Mandan, Hidatsa and Arikara 
Elders Organization of the Three Affiliated Tribes of North 
Dakota, Fred Baker.
    Mr. Baldridge, welcome, sir.

   STATEMENT OF DAVE BALDRIDGE, EXECUTIVE DIRECTOR, NATIONAL 
                    INDIAN COUNCIL ON AGING

    Mr. Baldridge. Thank you, Mr. Chairman. I believe that over 
the time I've been in this business I've heard you make some of 
the most eloquent statements about Indian country since Chief 
Joseph, probably, so it's a great honor to have you listen to 
us this morning.
    I know you need no one to tell you anything about the 
Federal trust responsibility or that nowhere are the 
disparities in minority health care so great, nowhere is the 
mandate to the Federal Government so compelling as with the 
well being of Indian elders. Today we're glad for this chance 
to bring your attention to a few of them.
    First, long term care. The need for long term care services 
in Indian country is great. It continues to grow. And while 
it's recognized that there is no national overall policy 
regarding long term care for the Nation's elderly and disabled, 
it's also true that billions of dollars in Federal and State 
funds are spent on long term care, particularly for nursing 
home and home and community based services under Medicaid. It's 
important to understand that there are virtually no funds 
available to Indian country for long term care.
    States have the ability through Medicaid waivers and CMS 
has the authority to approve requests to establish Indian only 
waivers especially for home and community based long term care 
services. We understand that no further legislative authority 
is necessary, yet States are not seeking these waivers and we 
hope this committee could provide leadership in working with 
tribes and receptive States to put such waivered services in 
place.
    We're also extremely concerned that senior health insurance 
counseling and assistance services, SHIP program, is still not 
available for older Indians. Such funding is provided to all 
States, but inexcusably, there's no counterpart for Indian 
country, no analog. Despite our repeated requests, we're not 
aware that CMS or DHHS has addressed this issue. Perhaps the 
Committee could help us inquire of CMS.
    Of the issues that elders face, those not related directly 
to their health are generally legislated through the Older 
Americans Act. I would like to talk to you about some issues 
that are certainly related to long term care, such as elder 
abuse. Title VII of the Older Americans Act, the vulnerable 
elder rights protection, was created in 1992. It includes 
subtitle B, which authorizes a program to assist Indian country 
to prioritize and carry out elder rights activities. Yet funds 
have never been appropriated, although they have been 
appropriated for States for similar purposes. These programs 
seldom reach Indian elders. Tribe have little or not access to 
the agencies, departments, ombudsmen or other programs that are 
available to States. Further, tribes have no additional source 
of mandated Federal funding for elder protection activities.
    So we request that you not overlook basic protections like 
this that are available to most of the Nation. A demonstration 
grant program for Indian country of a million dollars would 
begin to address this very serious issue.
    I would note on the side that our elders are living longer, 
but they're living longer with the amputations and the 
blindness and the renal failure that go with the diabetes. 
That's putting extraordinary burdens on their family 
caregivers. And we know that 90 percent of care for elders is 
given by adult children in homes and communities. So we think 
that may be a factor in abuse and that long term care is 
certainly related there.
    Title VI, as you've heard this morning, is an especially 
important program in Indian country. The 238 programs funded 
there are a primary source of services provided to reservation 
elders. Since 1980, title VI funding has been so inadequate for 
most of the years that its services have never really been 
``comparable to those provided under title III'' as the OAA 
often indicated. Nevertheless, this program still is the 
cornerstone of Federal Services, including diabetes and health 
education for our elders. Current funding for projects ranges 
from about $71,000 to a top end of $174,000 per program. But we 
need an immediate increase of more than $30 million nationally 
to keep title VI directors able to deal with their great 
responsibilities.
    That's related to title IV of the Act, research and 
demonstration grants. This title has historically provided 
annual training for our title VI program directors. However, 
since 1995, these activities have not been funded. The reality 
is that title VI remains without a national infrastructure, no 
paid staff, without a national training program at any level, 
without the capacity for regional or national meetings, and 
even without the capacity for its estimated programs to 
communicate with each other, its 238 programs.
    We urge you to sponsor a capacity building initiative 
directed by NICOA, hopefully, to engender skill building, 
communication, greater economic self sufficiency for title VI 
programs. We request the sponsorship of $600,000 for training 
title VI directors, so badly needed, and developing their 
capabilities to better serve our elders.
    And I'll conclude, we're very proud of some of our 
partnerships and projects with diabetes, which is front and 
center for all of us. We're connecting some tribes through a 
project with the Administration on Aging with the United States 
Renal Disease System, so they can look at ESRD. For CDC, we're 
conducting a grassroots diabetes education program for Indian 
elders. As the NIH recently published in the New England 
Journal of Medicine its DPPS study, showing that interventions 
really make a difference in diabetes, we are creating an atlas 
of diabetes for CDC, we are in the fifth year of an interactive 
atlas of Indian elder health for the IHS. These data projects 
are being extremely productive.
    So thank you again.
    [Prepared statement of Mr. Baldridge appears in appendix.]
    The Chairman. Thank you very much, Mr. Baldridge.
    Mr. Baker.

  STATEMENT OF FREDERICK BAKER, CHAIRMAN, MANDAN, HIDATSA AND 
  ARIKARA ELDERS ORGANIZATION, THREE AFFILIATED TRIBES, NORTH 
                             DAKOTA

    Mr. Baker. Thank you, Mr. Chairman and honored members of 
the committee. Thank you for allowing me to speak before this 
distinguished group regarding the concerns of the Indian elders 
of North Dakota, and in particular the elders of the Mandan, 
Hidatsa and Arikara Tribes.
    My name is Frederick Baker. I am chairman of the Mandan, 
Hidatsa and Arikara Elders Organization, an organization that 
was officially chartered and sanctioned by the Three Affiliated 
Tribes Business Council to represent the concerns of our elder 
population and provide some direct services. I have been 
appointed to the Governor's Committee on Aging of the State of 
North Dakota.
    The elders of the Fort Berthold Reservation are those folks 
who are 60 years and older. We were born between the years 1905 
and 1942. Our oldest member is 97 years old. There are 
approximately 573 of us that are in this age range; 307 of us 
live on the Fort Berthold Reservation, 74 live outside the 
reservation but in North Dakota, and 192 of us are sharing the 
virtues of North Dakota with other States. [Laughter.]
    Mr. Baker. As an age group, we have endured and survived 
great change. Most of us were born in dire poverty. Most of us 
saw family members die from causes of the frustrations of 
poverty, such as alcohol, despair, poor to non-existent health 
care. Most of us are products of off-reservation boarding 
schools. Many of us were given a one way ticket to urban 
communities, such as Los Angeles, Chicago, Dallas, with 
virtually no preparation of urban survival skills and very 
limited financial resources. Many of us still bear the scars of 
that experience.
    Our age group also went to war in defense of our country. 
Many of us walked the jungles of the South Pacific, landed at 
Normandy, defended the frozen ridges of Korea, and saw the 
monsoons of the Mekong Delta. Many of us returned maimed in 
body and sometimes in spirit. Many of us were returned for 
burial.
    Without question, the most devastating event for us was the 
Garrison Dam. It was almost as devastating as the smallpox 
epidemics of 1781 and 1837. Prior to the Garrison Dam, we were 
settled in communities such as Independence, lucky Mound, 
Nishu, Shell Creek, Elbowoods, Beaver Creek. We were raising 
our own food, just like we had been for centuries. Beef 
replaced the buffalo as our major protein supply, and we proved 
to be excellent cowboys. The River, Missouri, and its 
bottomlands provided us good soil for our gardens and crops, 
shelter for ourselves and our livestock, timber to build our 
homes. But especially, it allowed us to practice our cultural 
traditions. These traditions helped us to be independent and 
develop our own systems of caring for ourselves and one 
another. We didn't need social programs. We took care of our 
children, our elders, our ill. We had our own system of law and 
order.
    The Garrison Dam changed all that. We were forced to move 
from the bottomlands up into the hills, where the quality of 
the land was such that it was very difficult to raise gardens. 
It took many more acres to raise livestock. Our homogeneous 
communities were broken up and replaced by isolation. We did 
not have access to capital, except the meager amounts of credit 
that was offered through the Bureau of Indian Affairs. Most of 
this credit was just enough to get one into serious difficulty.
    Unfortunately, many of our people died in the process of 
relocating from the Garrison Dam. Many of us turned to alcohol, 
and ourselves and our families suffered as a result. Terms like 
unemployment, welfare, foster care, spouse abuse, child abuse, 
elder abuse, alcoholics, alcoholism, juvenile delinquency, low 
rent housing became part of our vocabulary. Our languages are 
in danger of being lost, and we get confused between poverty 
culture and Indian Culture.
    We have never had the mental health resources to deal 
adequately with the problems that were posed to us through the 
Garrison Dam.
    Despite these difficulties, some members of our age group 
were the first in their families to earn a college degree, to 
enter professions such as education, nursing, social work, 
medicine. We face many of the same problems today. Among those 
are inadequate medical care, poor or substandard housing, lack 
of specialized home health care, elder abuse issues, inadequate 
transportation, and our reservation is large, and because of 
the Garrison Dam, we're scattered, large traveling distances, 
inadequate meal service. Our written testimony will more 
clearly document these problems.
    Let me highlight just a few things. The average health care 
expenditure in the United States is approximately $3,500 to 
what at Fort Berthold is $1,300; 75 percent of our elders have 
some type of a depression problem. A lot of it is caused by 
people who as a result of diabetes feel that their quality of 
life is over. All of North Dakota is seeing a return of elders 
who are seriously or terminally ill. Hence, the drain on the 
already limited Medicaid resources is critical.
    Set-aside for Indian reservations for meal sites under 
title VI of the Older Americans Act only is enough to meet a 
part of the needs. At the present time there are six 
communities in Forth Berthold, one is being served through 
title VI, the other five are being served by what resources we 
can muster as a tribe. Housing is badly needed for elders, and 
especially assistance is needed repairing homes. Many elders 
live in very crowded conditions, because their children or 
grandchildren have no housing, and therefore move in with them. 
Our elders will not ask their children or grandchildren to move 
out.
    Elderly abuse is rampant and needs to be addressed. And 
Social Security is something that we are trying to deal with 
and also needs to be addressed. We are receiving a lot less 
than the national average, because of some issues regarding 
reporting and so forth.
    Thank you for your time. I would be glad to answer any 
questions that you may have.
    [Prepared statement of Mr. Baker appears in appendix.]
    The Chairman. I thank you very much, Mr. Baker.
    Mr. Baldridge, can a Native American elder residing in an 
urban area have access to State social services, or does he 
have to rely upon American Indian Alaska Native type programs?
    Mr. Baldridge. We know that probably 50 percent of Indian 
people, including elders, are now urban. We understand from the 
Seattle Urban Indian program that they are seeing third 
generation urban Indians. Yet we know less about this 
population than any Indian population or probably other 
minority population in the country. They tend to not live in 
ethnic neighborhoods. They tend to be transient, they tend 
apparently to have frequently substance abuse or alcohol 
problems.
    So in answer briefly is, I think they fall through the 
cracks very, very frequently. But they do rely on State 
programs and of course, the non-ITU services that are available 
in cities. I don't know that the Indian Health Care Delivery 
System reaches them much at all.
    The Chairman. You indicated that the title VI moneys are 
inadequate. About how much more would you suggest is needed?
    Mr. Baldridge. In 1992, we had $14 million. Currently I 
believe we are at about $27 million. One of the staffers from 
the House side back a few years ago estimated that it would 
take $30 million just to get original title VI programs back to 
their 1980 levels of service; $35 million would, I think, make 
a huge dent in the ability of these programs to serve their 
elders. Many of them still are able to provide only a few 
communal meals a week, and very few home services or 
supplemental services. It's a very pale shadow of the services 
available through area agencies on aging.
    The Chairman. Well, I can assure you I will look into that, 
because I must confess, I have no idea how much the Government 
requested for this program. But I would gather it must be much, 
much lower than $35 million.
    Mr. Baldridge. I believe we're at $27.5 million or so right 
now. And certainly more money is at the top of our list of 
needs.
    The Chairman. Mr. Baker, do you have any suggestions as to 
what we as Members of Congress can do?
    Mr. Baker. Well, I think first of all, some of the things 
that we're trying to do is try to access or have our people 
access those programs that are available that don't come 
through the normal Indian programs, so to speak. Because we are 
citizens of the State of North Dakota and as such, have the 
right to those programs. I think a lot of tribes, a lot of 
people do not think that they're entitled to those programs. So 
we're trying to do that.
    Obviously, there is a need for more funding. One of the 
things, I think there needs to be some type of Congressional 
action, perhaps, regarding elderly abuse in terms of its 
programs to try to deal with elderly abuse. I think it's one of 
those issues that is kind of quietly not mentioned, yet it 
exists in many ways. So I think those are perhaps some issues 
that might be addressed.
    The Chairman. In your presentation, you remarked that many 
in your generation put on the uniform and participated in the 
wars of this Nation. I think we should recall that in the last 
century, on a per capita basis, more native people put on the 
uniform to serve our country in every war of the last century 
than any other ethnic group. That is saying a lot. More Indians 
per capita served than German-Americans or Italian-Americans or 
Chinese-Americans or Japanese-Americans. And I have said many 
times, couple that with the fact that you have given up much of 
your land suggests to me that you have already paid your dues. 
The least we can do is to make certain that you receive what 
you are entitled to.
    Mr. Vice Chairman.
    Senator Campbell. Thank you, Mr. Chairman.
    Let me ask Mr. Baldridge a question or two, but I wanted to 
say to Mr. Baker first, I thought your testimony was poignant. 
Depressing. Absolutely true. It needed to be said. I just wish 
more people here of our colleagues in the Senate could have 
heard your testimony.
    You mentioned elder abuse. I was talking to one of my staff 
here, that I had an elderly gentleman at home, at Northern 
Cheyenne, tell me one time that he doesn't turn his lights on a 
night time because he's afraid somebody will know he's there 
and come and beat him up. That's just a tragic kind of a thing 
to know about. Yet at the same time, that certainly wasn't a 
traditional value of Indian people anywhere. Elders were always 
respected and trusted and learned from and revered. But I 
suppose it's on the rise because of poverty and lack of 
opportunities and so on. So we have this dichotomy, this 
strange relationship between what Indian people believe and 
want to believe from a traditional standpoint and sometimes 
what is actually happening. I just wanted to mention that.
    But I wanted to ask Mr. Baldridge a couple of questions. 
Three out of five, as I understand it, three out of five Indian 
elders are living at or below 200 percent of the poverty level. 
But more tribes are trying to develop their economies, 
certainly some of the gaming tribes have had some success. In 
the Great Lakes region, some of them have had great success, 
too. I have visited them.
    Have you seen any increased resources from those successful 
tribes that have gone toward elder care?
    Mr. Baldridge. Yes, sir; I can. One comes to mind, 
certainly, Sandia Pueblo, which just went into debt enormously 
for a new casino. Yet with their gaming revenues over the last 
decade, they have developed a very fine clinic. They're putting 
all of their tribal members, including elders, through 
secondary education and higher education at no cost. And their 
health care has improved enormously because of that.
    Other Pueblos around Albuquerque, with successful gaming 
operations, have created partnerships with hotel chains to 
create resort golf course, and it's interesting that our 
seemingly more business wise tribes are developing initiatives 
with States and private industry that are benefitting not just 
the elders but all the tribal members. So we're really 
encouraged by those tribes that are gaming.
    Senator Campbell. I have talked to a number of them, and I 
don't know of one single tribe I've talked with that has gaming 
that has not dedicated a portion of their new-found income 
towards senior programs. And I'm gratified that that is 
actually happening.
    Some in fact have even broadened it. I live with the 
Southern Utes in Colorado. They are negotiating with the county 
to build a huge hospital and health care facility that will 
take care of everybody, not just Indian people. So they have 
been, in most cases, I think, very, very generous with some of 
the new money that the successful tribes have made.
    Statistics from the IHS indicate Indian youth are the most 
likely to commit suicide. I may have mentioned, asked this 
earlier about suicide, I did, in fact, I think. But I asked it 
of another panel. Do you have any comparative statistics to 
deal with Indians or non-Indian comparison in suicide?
    Mr. Baldridge. What little data we've seen from IHS seems 
to indicate that once Indian people reach the age of 75, their 
longevity is much greater than that of other races. I believe 
that we see low suicide statistics for elders as well.
    However, I visit from my tribe a medicine man, Crosson 
Smith, and I asked him, what's the greatest problem we face as 
Indian people. He said, we're losing our kids. It's what you 
all have said to us. Indian teens, with 17 to 19 times the 
alcohol and substance average of the Nation, suicide 7 or 8 
times, we're winning some battles with the medicine, but we're 
losing our kids. And it's a challenge for our elders and all of 
us.
    Senator Campbell. All the more reason we need to take care 
of them.
    Several tribal groups have submitted testimony that they 
are being shut out of operating elder care facilities because 
the IHS doesn't fund it. They can't get direct reimbursement 
from Medicare or Medicaid for such facilities. And the states 
won't license a facility for the tribes so they can get 
different reimbursements from the State.
    Do you have any comments on those issues?
    Mr. Baldridge. Yes, sir. I believe South Dakota, we often 
see, is the worst case State, where there is a more than 10 
year moratorium on building nursing homes. The tribes there 
very desperately want and deserve nursing homes on their own 
reservation lands. Yet the State I think says, gee, we're 
sorry, it's a Federal problem, but we have this moratorium, 
even though it's self-imposed. It's very much, I think, a 
critical situation for those tribes, a longstanding one, and 
one that CMS has made some effort to resolve, but it's a very 
difficult, as usual, interface between Federal policy and State 
regulatory authorities.
    Senator Campbell. In that case, even if you found all the 
money you couldn't get a license, because they have a 
moratorium on it.
    Mr. Baldridge. Exactly. It's a very difficult situation.
    Senator Campbell. Thank you for your testimony.
    Mr. Chairman, thank you, I have no further questions.
    The Chairman. Senator Conrad.
    Senator Conrad. Thank you, Mr. Chairman.
    First of all, I'd like to welcome Mr. Baker here. He is a 
very valued and respected member of the Three Affiliated Tribes 
of North Dakota and a very respected member of our State. And I 
thought your testimony was outstanding. I thought you could 
have focused on the disaster that the Garrison Dam has been to 
the Indian people, not only of the Three Affiliated Tribes but 
of the Standing Rock Sioux Nation as well. Because it 
dramatically altered the way of life of the people. And the 
compensation that has been forthcoming, while welcome, has not 
been sufficient to reverse the damage that was done. So I 
think, Mr. Baker, you put the focus right where it belongs.
    Let me ask you, if you could wave a wand, if you could come 
here and say, these are the things that must be done, what 
would be the list that you would give this Committee.
    Mr. Baker. Wow. I guess several things. One is probably 
some type of a way to go back, if we can go back, I look at it 
as probably going forward, to incorporate the traditional 
cultural values that we had with the attempt to become a part 
of the modern day society, through some type of language 
preservation, cultural preservation program of some type. I 
think that's the basis for a lot of our, perhaps the problems 
that have to do with respect for elders, the respect for 
ourselves.
    Somewhere along the line, because of the things that have 
happened, I think we've lost respect, to some extent, for 
ourselves, and probably lost confidence in our ability to deal 
with the issues. I think that's one of the things that I would 
somehow, and I think maybe some of these other things would 
kind of fall into place. Certainly we need some type of an 
increased health care facility, those kinds of issues need to 
be addressed. Certainly employment, although we're trying hard 
to do that, employment issues, trying to find some type of way. 
Also some way to help our people to be able to leave 
successfully and become part of the rest of the community and 
still maintain their Hidatsa, Arikara and Mandan affiliations.
    Senator Conrad. Okay. Mr. Baldridge, if I could ask you the 
same kind of question, if you had the ability to dictate 
outcomes here, what would be the things you would point to? 
What are the things that would leap to your mind as to things 
that need to be done?
    Mr. Baldridge. If this committee, sir, could help us find 
some creative new solutions to home and community based care in 
Indian country that would be at the top of my list, along with 
a single other consideration, that's the empowerment of our 
title VI program. These directors need help so badly and 
training so badly, and it's not available for them. They could 
be a real force in helping us deal with public health issues 
for our elders. We've got to lift them up and really help them 
get on their feet and be more viable.
    Senator Conrad. How much of this is related to resources? 
To put it bluntly, how much is related to money?
    Mr. Baldridge. It seems that poverty is the thread that 
ties everything together in Indian country. Certainly I believe 
that's the case in this. But there's been no training money 
available to them since 1995, I believe, through Title IV of 
the OAA. It's just a stopper right there. That's very resource 
related. Some of the other, the seeking for demonstration 
programs to deal with new ways of community home based care is 
not so directly resource related, but certainly some 
demonstration projects need to be coordinated.
    Senator Conrad. What would your answer to that question be, 
Mr. Baker? The question of money, if you were to try to assess, 
what could be done that would really make a difference, how 
much of it is related to money being provided to have programs?
    Mr. Baker. Well, I think they're probably of somewhat equal 
value. I think there certainly needs to be a lot of thought 
given to innovative ways to deal with the program. Sometimes 
money is a rather simple solution, or probably a quick fix 
attempt. So I think they are kind of equal value. We definitely 
need money to do things. On the other hand, I think it's the 
ideas or the attempts at programs. One of the things we're 
trying to do as an elder organization, is to try to talk to the 
elders, give them a place, have a forum to discuss some of 
these issues and say, now what can we do.
    Senator Conrad. All right, thank you. Thank you both for 
not only excellent testimony here today, but I know in the case 
of Mr. Baker, thank you for a lifetime of involvement in the 
community.
    The Chairman. Before we adjourn, I would like to make an 
observation. I believe I have visited more reservations than 
any other chairman of this. And I have noted one common thread 
in most of my visits. Most tribes for good reasons want to show 
their very best. So they guide me through all the developments, 
the new buildings. I have yet to see one of the dilapidated 
buildings. They show me the new houses, the new apartments. In 
fact, in order to see the worst conditions, I have to ask that 
I see where the asbestos is leaking from the school building 
and such.
    It is the same with wealthy tribes and poor tribes. They 
want to show that they have done something. I would suggest 
that when members of Congress come to reservations to visit, 
show them the real world. I think they will understand the 
situation much better.
    I have had some of the best meals in poor reservations, and 
I do not know why they do that. But they want to extend their 
hospitality and show what friendship is like. But if they are 
poor, show us that they are poor. If there are buildings that 
are dilapidated and school buildings are filled with asbestos, 
we should know about it.
    So with that, I thank all of you for your testimony. This 
hearing is adjourned.
    [Whereupon, at 11:57 a.m., the committee was adjourned, to 
reconvene at the call of the Chair.]
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                            A P P E N D I X

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              Additional Material Submitted for the Record

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Prepared Statement of Hon. Maria Cantwell, U.S. Senator from Washington

    Mr. Chairman, I thank you for the opportunity to speak concerning 
Native American Elder Health Issues.
    I am especially interested in the findings from this hearing 
because I represent 29 federally recognized tribes, with 25,000 tribal 
members.
    The committee is well aware that Native Americans experience 
significant disparities compared to whites for many health indicators, 
and while the mortality rate for American Indians and Alaska Natives is 
higher than for all races in the United States, life expectancy is 
almost 6 years lower.
    While life expectancy is certainly an important indicator of 
population health status--the quality of one's life is also important. 
This morning's testimony tells us that Native American elders are 78.7 
percent more likely to experience congestive heart failure, 17.7 
percent more likely to report high blood pressure, 17.5 percent more 
likely to have experienced a stroke, 44.3 more likely to report asthma, 
and 173 percent more likely to be afflicted with diabetes.
    Diabetes complications, especially end-stage renal disease and 
lower-extremity amputations are major causes of morbidity and mortality 
among older Indians. Diet, sedentary lifestyle and obesity are risk 
factors for the development of diabetes and its complications--factors 
we can prevent or control.
    And we know that heart disease--one condition, at least, which can 
be somewhat mitigated through prevention and treatment--is the No. 1 
cause of death in Native Americans over the age of 45.
    1 think it is no great leap to ask if we actually funded the Indian 
Health Service at more appropriate levels, would the health status of 
our tribal elders not be better?
    While the IHS is tasked with providing full health insurance for 
the American Indian and Alaska Native population, it is so underfunded 
that patients are routinely denied care. The budget for clinical 
services is so inadequate that Indian patients are 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 do become a priority, the treatment 
required is generally more costly and there are often no funds left to 
pay for it.
    Finally, I also want to add that as Congress continues to consider 
Medicare reimbursement issues, we need to make Indian-specific policies 
and procedures to ensure that its billing requirements insure that 
Indian health program receive fair reimbursement for services provided.
    Again, thank you, Mr. Chairman for convening this hearing.
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