[House Hearing, 108 Congress]
[From the U.S. Government Publishing Office]
H.R. 151 AND H.R. 2440
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LEGISLATIVE HEARING
before the
COMMITTEE ON RESOURCES
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
Wednesday, October 1, 2003
__________
Serial No. 108-64
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Printed for the use of the Committee on Resources
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COMMITTEE ON RESOURCES
RICHARD W. POMBO, California, Chairman
NICK J. RAHALL II, West Virginia, Ranking Democrat Member
Don Young, Alaska Dale E. Kildee, Michigan
W.J. ``Billy'' Tauzin, Louisiana Eni F.H. Faleomavaega, American
Jim Saxton, New Jersey Samoa
Elton Gallegly, California Neil Abercrombie, Hawaii
John J. Duncan, Jr., Tennessee Solomon P. Ortiz, Texas
Wayne T. Gilchrest, Maryland Frank Pallone, Jr., New Jersey
Ken Calvert, California Calvin M. Dooley, California
Scott McInnis, Colorado Donna M. Christensen, Virgin
Barbara Cubin, Wyoming Islands
George Radanovich, California Ron Kind, Wisconsin
Walter B. Jones, Jr., North Jay Inslee, Washington
Carolina Grace F. Napolitano, California
Chris Cannon, Utah Tom Udall, New Mexico
John E. Peterson, Pennsylvania Mark Udall, Colorado
Jim Gibbons, Nevada, Anibal Acevedo-Vila, Puerto Rico
Vice Chairman Brad Carson, Oklahoma
Mark E. Souder, Indiana Raul M. Grijalva, Arizona
Greg Walden, Oregon Dennis A. Cardoza, California
Thomas G. Tancredo, Colorado Madeleine Z. Bordallo, Guam
J.D. Hayworth, Arizona George Miller, California
Tom Osborne, Nebraska Edward J. Markey, Massachusetts
Jeff Flake, Arizona Ruben Hinojosa, Texas
Dennis R. Rehberg, Montana Ciro D. Rodriguez, Texas
Rick Renzi, Arizona Joe Baca, California
Tom Cole, Oklahoma Betty McCollum, Minnesota
Stevan Pearce, New Mexico
Rob Bishop, Utah
Devin Nunes, California
Randy Neugebauer, Texas
Steven J. Ding, Chief of Staff
Lisa Pittman, Chief Counsel
James H. Zoia, Democrat Staff Director
Jeffrey P. Petrich, Democrat Chief Counsel
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C O N T E N T S
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Page
Hearing held on Wednesday, October 1, 2003....................... 1
Statement of Members:
Carson, Hon. Brad, a Representative in Congress from the
State of Oklahoma, Prepared statement on H.R. 151 and H.R.
2440....................................................... 5
Kildee, Hon. Dale, a Representative in Congress from the
State of Michigan, Prepared statement on H.R. 151 and H.R.
2440....................................................... 5
Nethercutt, Hon. George R., Jr., a Representative in Congress
from the State of Washington............................... 6
Prepared statement on H.R. 151........................... 7
Pombo, Hon. Richard W., a Representative in Congress from the
State of California........................................ 1
Prepared statement on H.R. 151 and H.R. 2440............. 2
Rahall, Hon. Nick J., II, a Representative in Congress from
the State of West Virginia................................. 3
Prepared statement on H.R. 151 and H.R. 2440............. 4
Udall. Hon. Tom, a Representative in Congress from the State
of New Mexico, Prepared statement on H.R. 2440............. 58
Statement of Witnesses:
Davis-Wheeler, Julia, Co-Chair, National Indian Health Board. 39
Prepared statement on H.R. 151 and H.R. 2440............. 41
Hunter, Anthony, Board President, National Council of Urban
Indian Health.............................................. 31
Prepared statement on H.R. 151 and H.R. 2440............. 33
Lincoln, Michel, Deputy Director, Indian Health Service...... 12
Prepared statement on H.R. 2440.......................... 14
Shirley, Joe, Jr., President, Navajo Nation.................. 25
Prepared statement on H.R. 151 and H.R. 2440............. 27
LEGISLATIVE HEARING ON H.R. 151, TO ELEVATE THE POSITION OF DIRECTOR OF
THE INDIAN HEALTH SERVICE WITHIN THE DEPARTMENT OF HEALTH AND HUMAN
SERVICES TO ASSISTANT SECRETARY FOR INDIAN HEALTH, AND FOR OTHER
PURPOSES; AND H.R. 2440, TO IMPROVE THE IMPLEMENTATION OF THE FEDERAL
RESPONSIBILITY FOR THE CARE AND EDUCATION OF INDIAN PEOPLE BY IMPROVING
THE SERVICES AND FACILITIES OF FEDERAL HEALTH PROGRAMS FOR INDIANS AND
ENCOURAGING MAXIMUM PARTICIPATION OF INDIANS IN SUCH PROGRAMS, AND FOR
OTHER PURPOSES. (INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2003)
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Wednesday, October 1, 2003
U.S. House of Representatives
Committee on Resources
Washington, DC
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The Committee met, pursuant to notice, at 10:20 a.m., in
Room 1324, Longworth House Office Building, Hon. Richard Pombo
[Chairman of the Committee] presiding.
Present: Representatives Pombo [The Chairman] Gibbons,
Hayworth, Renzi, Cole, Pearce, Rahall, Kildee, Pallone,
Christensen, Inslee, Napolitano, Tom Udall, Mark Udall, Carson,
Bordallo and Baca
STATEMENT OF HON. RICHARD W. POMBO, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
The Chairman. The Committee on Resources will come to
order. The Committee is meeting today to hear testimony on two
bills dealing with health care for Native Americans: H.R. 151
and H.R. 2440, sponsored by Mr. Nethercutt and Mr. Young of
Alaska, respectively.
Under Rule 4(g) of the Committee Rules, any oral opening
statements at hearings are limited to the Chairman and Ranking
Minority Member. This will allow us to hear from our witnesses
sooner and help members keep to their schedules. Therefore, if
other members have statements, they can be included in the
hearing record under unanimous consent.
I would like to welcome all of the members and witnesses to
this hearing on H.R. 151 and H.R. 2440. H.R. 151 is a bill to
elevate the position of Director of Indian Health Service
within the Department of Health and Human Services to Assistant
Secretary of Indian Health.
H.R. 2440 is the Indian Health Care Improvement Act
Amendments. This is a huge bill which provides for health care
delivery to over two million American Indians and Alaska
Natives.
H.R. 151 will provide a greater administrative focus on
Native health issues by elevating the Director of the Indian
Health Service within the Department of Health and Human
Services to the Assistant Secretary of Indian Health. By
providing a more visible internal role within the Department,
the head of IHS will be a better advocate of Native health
issues.
While Secretary Tommy Thompson has certainly elevated the
Director of IHS to a top level policy position, and he is to be
applauded for this, previous Administrations have not placed
such a premium on that position. I think that as we work on the
larger Indian Health Care Improvement Act, we should look at
whether elevating the Director to the Assistant Secretary level
is good policy.
The hearing on H.R. 2440 will focus on Title I, Indian
Health Manpower. Title I of the bill strives to increase to the
maximum extent feasible the number of American Indians and
Alaska Natives entering the health professions. It also seeks
to assure an adequate supply of health professionals to the
Service, Indian tribes, tribal organizations, and urban Indian
organizations involved in the delivery of health care to
American Indians and Alaska Natives.
By expanding Title I, tribes can get culturally proficient
health care providers,. thereby increasing health care
professionals. Further, the expansion of Title I will begin to
address the challenges with recruitment and retention of direct
health care providers for the most isolated, rural and remote
American Indian and Alaska Native communities.
I now recognize Mr. Rahall.
[The prepared statement of Mr. Pombo follows:]
Statement of The Honorable Richard Pombo, a Representative in Congress
from the State of California
I would like to welcome all of the Members and witnesses to this
hearing on H.R. 151 and H.R. 2440. H.R. 151 is a bill to elevate the
position of Director of Indian Health Service within the Department of
Health and Human Services to Assistant Secretary of Indian Health.
H.R. 2440 is the Indian Health Care Improvement Act Amendments of
2003. This is a huge bill which provides for health care delivery to
over 2 million American Indians and Alaska Natives.
H.R. 151 will provide a greater administrative focus on Native
health issues by elevating the Director of the Indian Health Service
within the Department of Health and Human Services to the Assistant
Secretary of Indian Health. By providing a more visible internal role
within the Department, the head of the IHS will be a better advocate of
Native health issues.
While Secretary Tommy G. Thompson has certainly elevated the
Director of IHS to a top-level policy position, and he is to be
applauded for this, previous Administrations have not placed such a
premium on that position, and I think that, as we work on the larger
Indian Health Care Improvement Act, we should look at whether elevating
the Director to the Assistant Secretary Level is good policy.
The hearing on H.R. 2440 will focus on Title 1, Indian Health
Manpower. Title I of the bill strives to increase to the maximum extent
feasible, the number of American Indians and Alaska Natives entering
the health professions. It also seeks to assure an adequate supply of
health professionals at the Service, Indian tribes, tribal
organizations, and urban Indian organizations involved in the delivery
of health care to American Indians and Alaska Natives.
By expanding Title I, tribes can get culturally proficient health
care providers, thereby increasing health care professionals. Further,
the expansion of Title I will begin to address the challenges with
recruitment and retention of direct health care providers for the most
isolated, rural and remote American Indian and Alaska Native
communities.
______
STATEMENT OF HON. NICK J. RAHALL, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF WEST VIRGINIA
Mr. Rahall. Thank you, Mr. Chairman.
Mr. Chairman, my home State of West Virginia has the
distinction of being. although relatively small in population,
still the distinction of singlehandedly causing the election of
two United States Presidents. The first was John F. Kennedy
who, by winning over largely Protestant West Virginia,
dispelled the notion in certain quarters that he would be a
Catholic President beholden to the Pope in Rome.
The second, of course, was George W. Bush, because if West
Virginia had voted the way it historically had done, Al Gore
would be in the White House today, regardless of what happened
in Florida.
I raise this in reference to JFK because he was so moved by
the poverty he saw in West Virginia during his campaign that
when he became President he did something about it, by starting
what became known as the Appalachian Regional Commission. A
centerpiece of this initiative aimed at economic rejuvenation
was ensuring that the region was equipped with adequate health
care facilities to serve the public. Indeed, under the ARC,
hospitals, treatment facilities and child care facilities were
constructed as a means to help lift the people from poverty.
We face the same task in Indian Country today. Yet, the
Appalachian Regional Commission went from concept in 1963 to
reality in 1965, in a shorter period of time than it has taken
Congress to reauthorize the Indian Health Care Improvement Act.
I find this situation to be intolerable.
I understand that the issues involved here are complex, but
the landmark National Steering Committee proposal was delivered
to Congress in 1999. The law technically expired in 2001. A
hearing record has been established and I am sure today's
hearing will be beneficial and I thank the witnesses for being
with us.
But the fact remains that people are suffering in Indian
Country. Compared to all races in the United States, Native
Americans suffer a death rate that is 533 percent higher from
tuberculosis, 420 percent higher from diabetes, 770 percent
higher from alcoholism, and 71 percent higher from influenza
and pneumonia.
We must not stand idle any longer. We must move now to
reauthorize the Indian Health Care Improvement Act so that we
can better provide for the delivery of health services for
American Indians and Alaska Natives throughout the Nation.
I thank you, Mr. Chairman, for calling this hearing today,
and thank you for your help on this issue as well.
[The prepared statement of Mr. Rahall follows:]
Statement of The Honorable Nick J. Rahall II, a Representative in
Congress from the State of West Virginia
Mr. Chairman, West Virginia has the distinction of being the State
which, although relatively small in population, singlehandedly caused
the election of two U.S. Presidents. The first was John F. Kennedy,
who, by winning over the largely Protestant West Virginia, dispelled
the notion in certain quarters that he would be a Catholic President,
beholden to the Pope in Rome.
The second, of course, was George W. Bush, because, if West
Virginia had voted the way it historically did, Al Gore would be in the
White House today regardless of what happened in Florida.
I raise this in reference to JFK, because he was so moved by the
poverty he saw in West Virginia during his campaign that, when he
became President, he did something about it by starting what became the
Appalachian Regional Commission.
A centerpiece of this initiative, aimed at economic rejuvenation,
was insuring that the region was equipped with adequate health care
facilities to serve the public. And indeed, under the ARC, hospitals,
treatment centers and child care facilities were constructed as a means
to help lift the people from poverty.
We face the same task in Indian Country today. Yet, the Appalachian
Regional Commission went from concept in 1963 to reality in 1965 in a
shorter period of time than it is taking Congress to reauthorize the
Indian Health Care Improvement Act.
I find this situation to be intolerable.
I understand the issues involved here are complex, but the landmark
National Steering Committee Proposal was delivered to Congress in 1999.
The law technically expired in 2001. A hearing record has been
established. And I am sure that today's hearing will be beneficial.
But the fact remains that people are suffering in Indian Country.
Compared to all races in the United States, Native Americans suffer
a death rate that is 533% higher from tuberculosis, 420% higher from
diabetes, 770% higher from alcoholism, and 71% higher from influenza
and pneumonia.
We must not stand idle any longer. We must move now to reauthorize
the Indian Health Care Improvement Act so that we can better provide
for the delivery of health services for American Indians and Alaska
Natives throughout the Nation.
Thank you.
______
The Chairman. Thank you.
I would now like to introduce our first witness,
Congressman George Nethercutt, who represents the 5th District
of the State of Washington and who is the lead sponsor on H.R.
151.
Let me take this time to remind all of today's witnesses
that under our Committee Rule, oral statements are limited to 5
minutes. Your entire written testimony will appear in the
record.
Mr. Kildee. Mr. Chairman.
The Chairman. Mr. Kildee.
Mr. Kildee. I have another markup on my other committee.
Could I submit comments for the record? I am a cosponsor of
both these bills.
The Chairman. Are they good comments?
Mr. Kildee. They're great comments.
[Laughter.]
The Chairman. Without objection.
Mr. Kildee. Thank you, Mr. Chairman.
[The prepared statement of Mr. Kildee follows:]
Statement of the Honorable Dale E. Kildee, a Representative in Congress
from the State of Michigan
Good morning. Mr. Chairman, I would like to thank you scheduling
this hearing today.
I would like to express my strong support for two very important
bills, H.R. 2440, the reauthorization of the Indian Health Care
Improvement Act, and H.R. 151, the bill to elevate the Director of
Indian Health Service to Assistant Secretary status. I am proud to be
an original cosponsor of both bills.
The Indian Health Care Improvement Act, first enacted in 1976, is
the keystone federal law that made vast improvements in the delivery of
heath care provided to American Indian and Alaska Native people.
Reauthorization of this Act will provide a more comprehensive
approach to the delivery of medical care to Native people.
This bill is based upon the recommendations made by the Indian
Health Community including tribal leaders, tribal health directors,
health care experts, and Native patients themselves.
Its primary objective is to improve access to quality medical care
for the Native American population.
Previous amendments to the Indian Health Care Improvement Act
reflect advancements in health care delivery, respond to the desire of
tribes for greater responsibility over programs, and target high
incidence of certain diseases that have plagued the Native American
segment of the American population.
The proposed changes to the bill will build upon the basic
framework of the Indian Health Care Improvement Act.
Mr. Chairman, by elevating the Director of Indian Health Service to
Assistant Secretary status, Congress will be sending a clear message to
Indian Country that their Indian health needs are a priority for us.
The disparity of health care delivery to American Indians and
Alaska Native communities is disproportionately less than the general
population in the United States.
Native Americans suffer from diabetes, alcoholism, tuberculosis,
and heart disease at far higher rates than non-Indians.
Having an Assistant Secretary that directly reports to the
Secretary of DHHS is a major step toward addressing the health needs in
Indian communities whose health needs exceed $15 billion.
I look forward to hearing from the witnesses. Thank you.
______
Mr. Carson. Mr. Chairman, could I also ask your indulgence
to do the same?
The Chairman. Without objection, Mr. Carson will also
introduce a statement into the record.
[The prepared statement of Mr. Carson follows:]
Statement of The Honorable Brad Carson, a Representative in Congress
from the State of Oklahoma
Chairman Pombo, Ranking Member Rahall, I would like to thank you
both for conducting a hearing on these two critically important pieces
of legislation. I am a cosponsor and strong supporter of both H.R. 151,
legislation to elevate the Indian Health Service (IHS) Director to the
Assistant Secretary for Indian Health, and H.R. 2440, legislation to
reauthorize the Indian Health Care Improvement Act.
Every year, raising the standard of health care for every American
is a high priority for Congress. However, this continuing debate often
ignores the standard of health care in Indian country.
To illustrate my point, I refer to a report published in July 2003,
by the United States Commission on Civil Rights, titled, ``Quiet
Crisis: Federal Funding and Unmet Needs in Indian Country.'' This
report states:
``Native Americans receive less funding per capita than any
other group for which the federal government has health care
responsibilities, including Medicaid/Medicare recipients,
veterans, and prisoners. The legal and moral obligation to
provide health care to Native Americans has not been met, and
unless IHS receives an exponential increase in funding, health
conditions are not likely to improve and will likely worsen.''
Further, the report states that the national per capita health
expenditure for the average American will be $5,775 in 2003. Compare
this to the $1,914 that IHS is projected to spend per capita in 2003.
To put it simply, 3 times more is spent on the health care of average
American citizens than on the Indian people of this nation.
In looking at these statistics, I am puzzled as to why the
principle health care provider and advocate for Indian Health Care is
not an Assistant Secretary position. While the goal of IHS is to raise
the health status of American Indians and Alaska Natives to the highest
level possible, the current administrative structure limits the IHS
Director's authority to set and implement health policy for American
Indians. By elevating the IHS Director to an Assistant Secretary
position, we will greatly strengthen the voice of Indian Country as we
all work together to raise the standard of health care in this country
and to address urgent unmet health care needs.
I also want to say a few words of support regarding H.R. 2440. The
most recent reauthorization of the Indian Health Care Improvement Act
was in 1992. Since that time the Indian population has grown and the
disparity between the health status of Indian people as compared to
other Americans has grown. To address these changing circumstances more
fully and effectively, a reauthorization is desperately needed to
reflect these changes since the last reauthorization 11 years ago. In
recent years, the Indian health care community, namely the National
Steering Committee, has been working hard to draft reauthorization
legislation, and H.R. 2440 is the product of their diligence. It is
time for Congress to do its part and move this legislation forward for
eventual enactment into law.
______
The Chairman. Mr. Nethercutt. Welcome to the Committee.
It's nice to have you here today. You know the rules and you
can begin.
STATEMENT OF HON. GEORGE R. NETHERCUTT, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF WASHINGTON
Mr. Nethercutt. I will, Mr. Chairman. I thank you very
much, to you and the Ranking Minority Member and all the
members of the Committee for holding this hearing on H.R. 151.
I am especially thankful to my friend, Congressman Hayworth,
for cosponsoring, and others for giving this bill so much
consideration, and other cosponsors who are sitting on this
panel.
We have submitted a statement for the record and I would
ask that it be submitted in its entirety, and I will just
summarize my remarks this morning to emphasize the importance
that I think this bill holds for American Indian and Native
American communities across this country. It would elevate the
position of the Director of the Indian Health Service within
the Department of HHS, Health and Human Services, to Assistant
Secretary for Indian Health.
I think it's an appropriate thing to do, given our national
commitment to our Native American and Alaska Native populations
across this country, and also in recognition of the fact that
our American Indian and Alaska Native population suffer
disproportionately certain kinds of diseases, chronic
conditions such as diabetes. I know many of you are part of the
Diabetes Caucus in the House, the largest caucus in the House
that focuses on the chronic disease of diabetes.
Its impact on minority populations, and especially our
American Indian and Alaska Native populations, is profound. Its
impact is disproportionate to the rest of the population.
In addition, I have visited in my own State, and in my own
district, a number of Indian Health Service facilities, Indian
health clinics and other health delivery services that exist on
our tribal lands today. They are struggling, these various
tribal organizations and entities. They are in need of
additional attention on the very critical issue of human health
as it relates to our Native American and Alaska Native
populations.
So this bill is a logical second or third step in our focus
on what is necessary to help meet the health care needs of our
Native American and Alaska Native populations; that is, to give
greater priority within the Department that implements these
programs by elevation of this Director of Indian Health
Services to an Assistant Secretary for Indian Health. By doing
so, this Assistant Secretary will sit at the table with the
Secretary and discuss, on a day to day, week to week, annual
basis the health care needs of the populations that the
Assistant Secretary would serve, and also advocate very
strongly for additional funding, additional programs, or
additional assistance to our Native American populations, who
struggle mightily in the area of chronic disease.
So I would just say to the Committee, and to you, Mr.
Chairman, and all the others, this is a good bill. It's a fair
bill. It is one that I think addresses the critical need of
Indian health care in this United States, and I think it
certainly pays adequate respect to our Native American
populations and their special needs in this country, especially
as it relates to diabetes and other health care conditions.
So I would urge you to favorably consider this legislation,
report it out expeditiously, and hopefully we could pass it in
the House and Senate, and then do justice to those who are in
the greatest need in our country, who are part of this great
heritage of Native Americans and Alaska Natives. I think, in
passing this legislation, we will pay proper respect to them
and their particular health care needs, as well as the
tradition of providing health care assistance to our Native
American populations since this country was formed. So I would
urge your favorable consideration.
I would be happy to answer any questions, and I thank you
so much for taking the time today to hold this hearing and
allow this testimony, not just from me but from the other very
distinguished panels that will follow, who will testify in
support of this measure.
Thank you, Mr. Chairman.
[The prepared statement of Mr. Nethercutt follows:]
Statement of The Honorable George R. Nethercutt, Jr., a Representative
in Congress from the State of Washington
Thank you for the opportunity to appear before you today in support
of H.R. 151. As you know, the Indian Health Service (IHS) is the lead
agency in providing health care to the more than 550 Indian tribes in
the United States. Each year the IHS serves 1.3 million American
Indians and Alaska Natives. The services the IHS oversees range from
facility construction to pediatrics.
As Co-Chair of the Congressional Diabetes Caucus, I have worked
closely with the IHS. The statistics for Native Americans with diabetes
are staggering. Over 15 percent of the Native Americans receiving care
from IHS have diabetes. Prevalence of type 2 diabetes among Native
Americans over 19 years of age is 12.2%. This compares to a 7.3%
prevalence rate for the U.S. population as a whole. One tribe in
Arizona has the highest rate of diabetes in the world. About 50% of
these adults between the ages of 30 and 64 have diabetes. Diabetes has
reached epidemic proportions among Native Americans. Complications from
diabetes are major causes of death and health problems in most Native
American populations. The serious complications of diabetes are
increasing in frequency among Native Americans. Of major concern are
increasing rates of kidney failure, amputations and blindness. I
believe that H.R. 151 will afford IHS a stronger advocacy function
within HHS, and allow for increased representation during the budget
process.
Currently, the ability of the IHS to affect budgetary policy is
limited, in part, by the Director's inability to directly participate
in budget negotiations. As you may know, the IHS director position
currently falls under the authority of the Public Health Service. The
IHS employs approximately 15,000 employees and consists of 594 direct
health care delivery facilities, yet IHS does not have the direction of
an Assistant Secretary.
Each year the IHS provides health care services to 559 Indian
tribes in 35 states. The purchasing power of the IHS budget is steadily
declining and efforts to address Indian health care needs have not
greatly helped. The disparity between Indian and non-Indian communities
in Federal health care expenditures is growing.
Mr. Chairman, the Federal Government is not meeting the needs of
Indian people. The lack of broad-based advocacy for Native American
health needs is partially to blame and I believe this legislation is a
step in the right direction. If H.R. 151 is enacted into law, it would
be much easier for the director of IHS to ensure that HHS funding is
available to meet the health needs of Indian communities. I hope that
this bill will receive favorable consideration by your Committee and
the entire Congress.
______
Mr. Gibbons [presiding]. Thank you very much, Mr.
Nethercutt.
Are there any questions for Mr. Nethercutt? Mr. Pallone.
Mr. Pallone. Thank you, Mr. Chairman.
I don't know if this directly relates, but I do support
your legislation. I think we should try to move the legislation
as quickly as possible.
Two things. One, you know that there is a chronic shortfall
in funding for the Indian Health Service, which all of us
bemoan and in which I think a lot of us would like to see a
significant increase. So I have two questions.
One, do you think this would be beneficial in the sense
that maybe this person at a higher level is better able to
advocate for more funding? That's number one. And the second
thing is--and I don't know the details, but there is this
proposal by the Bush Administration that would transfer a lot
of the people who are in the Indian Health Service over to the
Secretary of Health and Human Services office, which again
people in Indian country seem to think is a bad idea because it
will dilute their--In other words, if they are directly under
the Secretary rather than a part of the Indian Health Service,
there may be a negative impact on the Indian Health Service.
I was wondering how that would relate to this legislation
as well, how you feel about that and whether or not elevating
this position at the same time the Administration is trying to
transfer these people to the Secretary's office, how you feel
about the interaction there. Those are the two questions.
Mr. Nethercutt. Well, Congressman Pallone, I thank you for
the questions.
I serve on the Appropriations Committee, the Interior
Subcommittee, which does the funding for the Indian Health
Service. We are trying our best to increase those Federal funds
that go for Indian health, so we will advocate for that very
strongly.
I think that having this Assistant Secretary position in
place will allow for that greater advocacy. I think the
Director comes to our Subcommittee and testifies in favor of
additional resources. But I think internally, in the Department
of Health and Human Services, there will be a greater
opportunity for advocacy for additional moneys that will also
flow into other subcommittees, so I think the net effect will
be positive on funding and also on advocacy opportunities.
With respect to your second question about the movement of
staff positions, I can testify first hand that Secretary
Thompson is such a strong advocate for the subject of diabetes
and diabetes funding and assistance, and he was a strong
advocate for the extra $750 million over 5 years that goes to
type II Native American disease research. So it may be that the
net impact will be positive rather than negative, if that, in
fact, happens. I don't have a good sense of whether it will or
it won't. But I know Secretary Thompson is such a strong
advocate for those in Indian country who suffer from diabetes
and otherwise and will be a strong voice within the Department
and perhaps this will bolster this argument that we need to
enhance the amount of money that we spend and the time and
attention we spend on Indian health. So that's my hope.
Mr. Pallone. I guess the problem that I have--and again, I
don't have all the details in front of me--is that on the one
hand I agree with what you just said, that the elevation of
this position certainly helps in terms of having a greater
advocate and somebody who can maybe get more funds. But if you
transfer a lot of the positions over to the Secretary's office,
it seems to me that it dilutes the fact that you want to put
all these people under one director, in this case somebody who
is being elevated and becoming more important, and it sort of
undercuts your efforts by having these people transferred to
the Secretary's office.
You know, it is hard to quantify that, but that would be my
impression. But you don't seem to feel that that's true?
Mr. Nethercutt. I guess my sense of it would be this. If we
pass H.R. 151 and report it out and it gets favorable
consideration, maybe then we are in a position to go to the
Secretary or to the Administration and say we have now elevated
the Director to Assistant Secretary and are you sure you want
to make these transfers, is this something that's valid to do.
So maybe this action by this Committee and the House and the
Senate might then lead to the kind of result which I think we
all want, and that is more attention to Indian health and more
advocacy for it and more adequate staffing to make sure the job
gets done.
Mr. Pallone. Thank you. I appreciate that, and I support
the bill.
Thank you, Mr. Chairman.
Mr. Gibbons. Thank you, Mr. Pallone.
Anybody else? Mr. Rahall.
Mr. Rahall. Thank you, Mr. Chairman.
I want to thank the gentleman from Washington for not only
his recognition of the problem but for his leadership,
especially from his position on the Appropriations Committee.
My question relates to the position of the Administration,
the testimony of which is about to be presented to us. I
understand they are going to testify that we do not need to
elevate the Director of Indian Health Services to that of
Assistant Secretary because they have elevated him ``in house''
by giving him direct access to the Secretary. My thinking is
that this does not necessarily give him better budget authority
access and it doesn't provide the next Secretary with the same
direct access.
So my question is, how do you feel about the
Administration's position on this issue?
Mr. Nethercutt. Well, I would just say, Mr. Rahall, that I
support H.R. 151. I think it's the right result and I think
it's the right action to take. I think you make a good point
relative to the next Secretary that might be in the position.
I know this Secretary to be a very honorable man and very
dedicated to the issue of Indian health and also diabetes, so
there is open access. I think that's a good thing.
But institutionally, I prefer to see H.R. 151 passed and
enacted into law, and then we have assurance relatively in
perpetuity that there would be that access and there would be
that advocacy at the table for budget items and other things
that might come to affect Indian health. So I respect the
Administration, as you know, but I also have high regard for
our bill and I think it's the right thing to do.
Mr. Rahall. Thank you.
Thank you, Mr. Chairman.
Mr. Gibbons. Thank you, Mr. Rahall.
Mrs. Christensen.
Mrs. Christensen. Thank you, Mr. Chairman. I want to thank
you for holding this hearing and I want to thank our colleague
for introducing the bill.
I wanted to say that the health task forces of the minority
caucuses have been working together to create and introduce a
bill which was to have actually been introduced today but is
delayed, and within that bill we include your bill, the Indian
Health Care Improvement Act, so we are glad to see it here
before us today and offer our support.
We know how health care disparities have affected our
Native American population, and we intend to continue to
include this bill within the more comprehensive bill that
addresses the health care disparities for all people of color
and we also hope that our colleagues will support the larger
bill as well as we seek to bring equity and accountability into
health care for everyone.
Mr. Nethercutt. Thank you so much.
I would just add, too, that our minority populations in
this country suffer disproportionately certain kinds of chronic
health care conditions, diabetes being a very important one.
Our Hispanic populations, our black populations, our Native
American populations, all of them have a disproportionately
higher incidence of the disease.
So my goal, as Co-Chairman with Diana Degette and others in
the House, is to really focus on chronic disease conditions. As
we put more money in, as we advocate harder and stronger, I
think we will get a better handle for generations to come on
all minority populations, and that's the right thing to do for
our country.
Mrs. Christensen. If I could just add, that bill is also
included in our comprehensive bill.
Mr. Nethercutt. Thank you so much.
Mr. Gibbons. Mrs. Napolitano.
Mrs. Napolitano. Thank you, Mr. Chairman.
I am one of the cosponsors, so you know I support the bill.
Mr. Nethercutt. Good.
Mrs. Napolitano. My question, again dovetailing on some of
the comments my colleagues have made, is that the IHS employs
about 15,000 employees, almost a quarter of all of HHS
personnel. Is this adequate? Is this something where personnel
is not focusing on the issues that affect the Indian Nation?
Why is there not enough support then if there is this number of
employees?
Mr. Nethercutt. Well, I think the critical issues--there
are a lot of issues that affect Native Americans, for example,
and in the Indian Health Service it's a monumental task out
there among I think 559 tribes across this country. I think the
goal is to make sure those 15,000 employees, or however many
there are, dispersed through the Government that focus on
Indian health are going to do good work and have effective
solutions to the problems that face all of our tribal
organizations as well as those who are affected by chronic
disease.
Maybe I'm not answering your question as precisely as you
would like, but as I understand it, I think there is more
advocacy to be gained and there is also more effective advocacy
to be gained within Government agencies today. I'm not so sure
we should look at it just from the number of employees, but we
have to look at what is the advocacy level, what are the issues
that they're stressing prominently, and what are the results.
So I think our goal with this $750 million over 5 years of
mandatory funding, as well as additional money for diabetes,
for example, we have to make sure that money is well spent.
So to the extent those employees can help make sure that
money is well spent and that we have good plans in place for
Indian health, we're all going to be better off and so are
those affected by it are better off.
Mrs. Napolitano. I understand that. Coming from a State
legislature, I have found that sometimes some of those
positions are used for other purposes.
Mr. Nethercutt. Sure.
Mrs. Napolitano. Certainly there needs to be more of a
focus. I know these issues have been identified before, and at
that joint hearing we held with the Senate, all those issues
were brought out.
I would hope that we focus on what we have found, what the
Indian Nation representatives have spoken to, that we do not
let those issues go by the wayside. You talked just about
diabetes. There are other issues that were brought up,
including, of course, alcoholism, asthma, a lot of the issues
that the young children are beginning to show. We should not
let those sit by the wayside while we're arguing over whether
or not we need to get the programs going.
Mr. Nethercutt. I understand. I think maybe the elevation
of this Indian Health Service Director to Assistant Secretary
would give greater authority and greater opportunity to collect
the resources of Government for the right purposes that you're
speaking of.
Mrs. Napolitano. But it's not creating another bureaucracy,
I hope.
Mr. Nethercutt. I don't think so. I think we're really just
giving greater ability and greater authority of that particular
director to manage in an effective way within the agency and
bureaucracy of government. I say that respectfully. I think
this may be a better way to have efficiency, rather than
creating an additional bureaucracy. I think it's just the
opposite. I think it will be greater efficiency and greater
opportunity, greater authority on the part of that person to
lead the charge for Indian health improvement.
Mrs. Napolitano. Thank you.
Mr. Gibbons. Thank you very much.
Are there other members who have questions at this point in
time? If not, Mr. Nethercutt, we thank you for your
presentation and we will excuse you for now and call up our
second panel.
Mr. Nethercutt. Thank you, Mr. Chairman.
Mr. Gibbons. I would now like to call up the second panel
on this issue, Mr. Michel Lincoln, Deputy Director, Indian
Health Service.
Mr. Lincoln, we have a policy in this Committee of swearing
in our witnesses, so if you will rise and take the oath, we
would appreciate it.
[Witness sworn.]
Let the record reflect that the witness answered in the
affirmative. Mr. Lincoln, welcome to the Committee. The floor
is yours. We look forward to your testimony.
STATEMENT OF MICHEL LINCOLN, DEPUTY DIRECTOR,
INDIAN HEALTH SERVICE
Mr. Lincoln. Thank you, Mr. Chairman, and members of the
Committee. I am privileged to be here today in front of the
Committee to testify on behalf of the Indian Health Care
Improvement Act and Title I of the Indian Health Care
Improvement Act.
It is my pleasure to say that, indeed, the Department and
the Secretary support the reauthorization of the Indian Health
Care Improvement Act.
I know it is difficult to talk about Title I in the absence
of talking about other issues that are prominent throughout
Indian country, and many of those have just been discussed
between the dialog with Congressman Nethercutt and members of
this Committee.
I should also add another qualification, Mr. Chairman--and
I will be giving a brief oral statement--in that I have the
distinct privilege, I guess, to have lived as long as I have
and had the privilege in 1976 to be around and working in
health when the original Indian Health Care Improvement Act was
passed by this Congress. I had the privilege, indeed, in follow
up to the passage of that Act, to work in help writing the
specifications that resulted in the regulations implementing
Title I of this Act, primarily the Indian health professions
piece, the scholarships, and the loan repayment piece. So I
have a little bit of history relative to the impact.
I would like to say, though, as this Committee knows, the
Indian Health Service is the primary provider for health care
services on behalf of the Federal Government for approximately
1.6 million American Indians and Alaska Natives throughout our
great Nation. The mission of the agency is indeed to raise the
physical, mental, social and spiritual health of American
Indians and Alaska Natives to the highest level, in partnership
with the population we serve.
This particular piece of legislation, combined with the
Snyder Act, which was passed in 1921, really serves as the
basis, the foundation, if you will, for Indian health
legislation in this Nation--indeed, the policy that is
articulated within those two documents. They are both important
documents, especially when taken together, as you look at
improvements made over the years.
I would like to say that this bill that is before you has
been the result of extensive work between tribal governments,
among tribal governments, among Indian health professionals,
among the Indian Health Service certainly, and with our
colleagues throughout the Department of Health and Human
Services. It is a product of genuine thinking, genuine
collaboration, and genuine disagreement in many instances. We
look forward to working with the Committee as you all consider
this bill and move this piece of legislation forward.
I would like to reiterate a couple of statistics that were
given for the health status throughout Indian country. I don't
believe it is possible to talk about health professions
scholarship or health facilities or health services or any
other piece of the Indian Health Service programs, or health
programs in general, without acknowledging some of the basic
statistics.
One of those statistics, indeed, is that alcoholism
mortality is 770 percent, the data mentioned before, seven
times the U.S. all-races deaths due to alcoholism. Diabetes is
four times, accidents are three times higher, suicides two
times higher, and homicides two times higher.
I think what is important about these statistics, and maybe
the tragedy of what is going on, is that, for the most part,
these chronic diseases that Congressman Nethercutt spoke of,
certainly including diabetes, but the others that I have
mentioned, are all preventable. It seems to me that certainly
our new Director, Dr. Charles Grim, is revitalizing and
reemphasizing preventive health programs throughout this
Nation. There must be a preventive piece in here, not only from
a health care standpoint but from a conscience standpoint. It
just seems like it's the right thing to do.
I do want to describe these health programs also within the
context of great demands and great needs for community
development, for economic development, for education
opportunities, for all the individuals within the community
settings where our families, children and parents live. I
believe it is especially important that we not forget about the
community view of what this piece of legislation brings in
front of us.
I would certainly mention a couple of additional diseases
that need to be reemphasized. Congressman Nethercutt, more than
I could, has been at the forefront of diabetes, preventing
diabetes and treating diabetes. Through the legislation that
Congress passed, we will certainly see improvements in diabetes
mortality, and hopefully we will see over time a reduction in
the incidence of diabetes.
The same needs to be said relative to cardiovascular
disease, though. It is indeed the leading cause of death of
Indian people throughout this country. It is increasing at a
time when cardiovascular disease in most other populations in
this Nation is decreasing. So there is the opposite trend, the
inverse that is occurring relative to cardiovascular disease in
Native American populations.
I would like to move very quickly into a summary and to let
you know about very specific information that is not part of my
testimony on the health professions piece.
These programs of scholarships and loan repayment have made
an impact in Indian country. In 1981, there were only 697
Indian people who were health providers through the Indian
Health Service system. In 2002, there are now in excess of
2,500 American Indian and Native Alaska people who are health
providers within this health delivery system.
Thirty-seven percent of all of our health providers are now
Indian people. In my opinion, that would not have happened in
the absence of a focus, a concentrated effort to increase the
number of Indian people pursuing the health professions and,
quite frankly, providing the opportunities through loan
repayment and other kinds of incentives and encouraging those
individuals to return to their communities to provide services
to their own people.
Mr. Chairman, if I may give you one more set of statistics,
I will then end my testimony. An example of the kinds of
vacancy rates that are currently within Indian country, indeed,
in many ways might mirror the rest of the population for a few
of the professions, but in general are worse in Indian country.
Right now, today, our vacancy rate for nurses, for professional
nurses, is 14 percent. Today, the vacancy rate for physicians
is 10 percent. The vacancy rate for dentists is at 22 percent,
and for some specialties within these professions, like nurse
anesthetists, the vacancy rates are 33 percent. There is a need
for Title I to assist these health programs, both tribal,
Federal and urban programs, in filling these much needed health
providers.
Thank you, Mr. Chairman.
[The prepared statement of Mr. Lincoln follows:]
Statement of Michel Lincoln, Deputy Director, Indian Health Service
Mr. Chairmen and Members of the Committees:
Good morning, I am Michel Lincoln, Deputy Director of the Indian
Health Service (IHS). We are pleased to have this opportunity to
testify on behalf of Secretary Thompson on H.R. 2440, the Indian Health
Care Improvement Act Amendments of 2003, and H.R. 151, the bill to
elevate the position of Director of the Indian Health Service within
the Department of Health and Human Services to Assistant Secretary for
Indian Health. At the Committee's request, I will discuss Title I--
Indian Health, Human Resources, and Development of H.R. 2440; and H.R.
151, the bill to elevate the IHS Director.
The IHS has the responsibility for the delivery of health services
to more than 1.6 million Federally recognized American Indians and
Alaska Natives (AI/ANs) through a system of IHS, tribal, and urban (I/
T/U) operated facilities and programs based on treaties, judicial
determinations, and Acts of Congress. The mission of the agency is to
raise the physical, mental, social and spiritual health of AI/ANs to
the highest level, in partnership with the population we serve. The
agency goal is to assure that comprehensive, culturally acceptable
personal and public health services are available and accessible to the
service population. Our foundation is to promote healthy American
Indian and Alaska Native people, communities and cultures and to honor
and protect the inherent sovereign rights of Tribes.
Two major pieces of legislation are at the core of the Federal
government's responsibility for meeting the health needs of American
Indians/Alaska Natives (AI/ANs): The Snyder Act of 1921, P.L.67-85, and
the Indian Health Care Improvement Act (IHCIA), P.L.94-437. The Snyder
Act authorized regular appropriations for ``the relief of distress and
conservation of health'' of American Indians/Alaska Natives. The IHCIA
was enacted ``to implement the Federal responsibility for the care and
education of the Indian people by improving the services and facilities
of Federal Indian health programs and encouraging maximum participation
of Indians in such programs.'' Like the Snyder Act, the IHCIA provided
the authority for the programs of the Federal government that deliver
health services to Indian people, but the IHCIA also provided
additional guidance in several areas. The IHCIA contained specific
language that addressed the recruitment and retention of a number of
health professionals serving Indian communities.
I am here today to discuss reauthorization of the IHCIA and tribal
recommendations for change to the existing IHCIA in the context of the
many changes that have occurred in our country's health care
environment since the law was first enacted in 1976. H.R. 2440 reflects
the product of an extensive tribal consultation process that took two
full years and resulted in a tribally drafted reauthorization bill. IHS
and other HHS staff provided technical assistance and support to the
Indian Tribes and urban Indian health programs through this lengthy
consultation. However, we recognize that our programs overlap and have
implications for other Department agencies and their programs, and we
are continuing to work with them to develop a comprehensive
Administration position on this legislation.
Health Disparities
While the mortality rates of Indian people have improved
dramatically over the past ten years, Indian people continue to
experience health disparities and death rates that are significantly
higher than the rest of the U.S. general population:
Alcoholism--770% higher
Diabetes--420% higher
Accidents--280% higher
Suicide--190% higher
Homicide--210% higher
Those statistics are startling, yet they are so often repeated that
some view them as insurmountable facts. But every one of them is
influenced by behavior choices and lifestyle. Making significant
reductions in health disparity rates, and even eliminating them, can be
achieved by implementing best practices, using traditional community
values, and building the local capacity to address these health issues
and promote healthy choices.
A primary area of focus that I have identified based on these
statistics is a renewed emphasis on health promotion and disease
prevention. I believe this will be our strongest front in our ongoing
battle to eliminate health disparities plaguing our people for far too
long. Although we have long been an organization that emphasizes
prevention, I am calling on the Agency to undertake a major
revitalization of its public health efforts in health promotion and
disease prevention. Both field and tribal participation in the initial
stages of planning and implementation are critical.
Fortunately, the incidence and prevalence of many infectious
diseases, once the leading cause of death and disability among American
Indians and Alaska Natives, have dramatically decreased due to
increased medical care and public health efforts that included massive
vaccination and sanitation facilities construction programs.
Unfortunately, as the population lives longer and adopts more of a
western diet and sedentary lifestyle, chronic diseases emerge as the
dominant factors in the health and longevity of the Indian population
with the increasing rates of cardiovascular disease, Hepatitis C virus,
and diabetes.
Cardiovascular disease is now the leading cause of mortality among
Indian people, with a rising rate that is significantly higher than
that of the U.S. general population. This is a health disparity rate
that the President, the Secretary of Health and Human Services, and the
IHS are committed to eliminating. The IHS is working with other HHS
programs, including the Centers for Disease Control and Prevention and
the National Institutes of Health's National Heart Lung and Blood
Institute, to develop a Native American Cardiovascular Disease
Prevention Program. Also contributing to the effort is the IHS Diabetes
Program, the IHS Disease Prevention Task Force, and the American Heart
Association. The primary focus is on the development of more effective
prevention programs for AI/AN communities. The IHS has also begun
several programs to encourage employees and our tribal and urban Indian
health program partners to lose weight and exercise, such as ``Walk the
Talk'' and ``Take Charge Challenge'' programs.
Diabetes mortality rates have been increasing at almost epidemic
proportions. American Indians and Alaska Natives have the highest
prevalence of type 2 diabetes in the world. The incidence of type 2
diabetes is rising faster among American Indians and Alaska Native
children and young adults than in any other ethnic population, and is
2.6 times the national average. As diabetes develops at younger ages,
so do related complications, such as blindness, amputations, and end
stage renal disease. Today, however, I want to report to you that we
may be seeing a change in this pattern. In CY 2000 we have observed for
the first time ever a decline in mortality. I must note that this is
preliminary mortality data that needs to be further examined.
What is most distressing however about these statistics is that
type 2 diabetes is largely preventable. Lifestyle changes, such as
changes in diet, exercise patterns, and weight can significantly reduce
the chances of developing type 2 diabetes. Focusing on prevention not
only reduces the disease burden for a suffering population, but also
lessens and sometimes eliminates the need for costly treatment options.
The cost-effectiveness of a preventative approach to diabetes
management is an important consideration, since the cost of caring for
diabetes patients is staggering. Managed care estimates for treating
diabetics range from $5,000-$9,000 per year. Since the Indian health
system currently cares for approximately 100,000 people with diagnosed
diabetes, this comes out to a conservative estimate of $500 million
just to treat this one condition.
Another area of concern is in behavioral health, specifically the
identification and treatment of depression and strategies for
prevention of depression. A recent study from Washington University in
St. Louis has revealed that untreated depression doubles the risk for
chronic diseases like diabetes and cardiovascular disease, not to
mention the risks for alcoholism, suicide and other violent events.
This study also showed that of those individuals with chronic disease,
unrecognized and untreated depression doubles the risk for
complications of the chronic disease (e.g., amputations and renal
disease in diabetics). We must find the best practices that will allow
us to prevent depression primarily, or at the least recognize and treat
it early if we are to reduce the disparities that affect Indian
communities.
A well-trained, caring staff, supported by sufficient funding, is
the best means of successfully addressing these disparities. Programs
authorized in Title I help us to obtain these people. Even better,
three programs help us to ``grow our own,'' in that they support the
development of Indian health professionals.
The most influential of these programs are the scholarship program,
authorized in Sections 103 and 104, and the loan repayment program,
authorized in Section 110. Over the years, the scholarship program has
helped over 7,000 Indian students attend pre-professional and
professional school. Its influence can readily be seen in the fact that
since 1981, the proportion of IHS health professional staff that is
Indian has increased by 131%.
The loan repayment program has served both to attract and retain
health professionals. Since its inception in 1988, more than 3,000
health professionals have participated. Many have stayed well beyond
the time it took to repay their loans, having found that the IHS
practice is what they are seeking.
National shortages in nursing, dentistry, pharmacy and other health
professions are having an impact on Indian health programs. We continue
our efforts to attract the best. These programs, and others authorized
in Title I, help in this effort.
H.R. 151--Elevation of the IHS Director to Assistant Secretary for
Indian Health
H.R. 151 proposes to establish within the Department of Health and
Human Services an Office of the Assistant Secretary for Indian Health.
The IHS is the principal point of contact on behalf of the Department
on health matters related to Tribes. It exists because of the solemn
promises the Federal government has made to Indian people. On matters
of health care, the head of the Indian Health Service acts principally
as the administrator of the vast Indian Health Service system, as well
as an advocate on behalf of the Indian Health needs of the nation's
more than 550 federally recognized Indian Tribes.
Currently, the Director of the IHS enjoys direct access to the
Secretary in the Department on all health services issues that have an
impact on Tribes and Tribal organizations. In addition, the Director
serves as Vice Chair of the Secretary's Intradepartmental Council for
Native American Affairs. The Council serves as an advisory body to the
Secretary and has the responsibility to assure that Native American
policy is implemented across all Divisions in the Department, including
human services programs. The Council also provides the Secretary with
policy guidance and budget formulation recommendations that span all
Divisions of HHS. A profound impact of this Council on the IHS is the
revised premise within HHS that all agencies bear responsibility for
the government's obligation to the Native people of this country.
It is our view that the Director as the Vice Chair of the
Intradepartmental Council for Native American Affairs currently enjoys
an elevated status in the Department. He facilitates advocacy, promotes
consultation, reports directly to the Secretary, collaborates directly
with the Assistant Secretary of Health, advises the heads of all the
Department's divisions and coordinates activities of the Department
concerning matters related to Native American health and human services
issues. This authority is provided in the Native American Programs Act
of 1974. Consistent with the statute, Secretary Thompson has taken
steps to assure that this Council receives the highest levels of
attention within the Department.
Moreover, the Secretary and Deputy Secretary have traveled widely
to Indian Country with their senior staff. These trips have raised the
awareness of tribal issues and have contributed greatly to our capacity
to speak with one voice, as One Department, on behalf of tribes.
Secretary Thompson and Deputy Secretary Allen are daily committed to
working with Tribal leaders on Indian health concerns.
The Director, then, currently is assured the same access to the
highest levels as other agencies in the Department and it is not
necessary to elevate the IHS Director to the level of Assistant
Secretary over other agencies serving American Indians/Alaska Natives
(AI/AN).
Summary
In summary, preventing disease and injury is a worthwhile financial
and resource investment that will result in long-term savings by
reducing the need for providing acute care and expensive treatment
processes. It also yields the even more important humanitarian benefit
of reducing pain and suffering, and prolonging life. This is the path
we must follow if we are to reduce and eliminate the disparities in
health that so clearly affect AI/AN people.
As we continue our thorough review of this far-reaching, complex
legislation on reauthorization, we may have further comments on Title
I. However, we wish to reiterate our strong commitment to
reauthorization and improvement of the Indian health care programs. We
will be happy to work with the Committees, the National Tribal Steering
Committee, and other representatives of the American Indian and Alaska
Native communities to develop a bill fully acceptable to all
stakeholders in these important programs.
Mr. Chairman, this concludes my statement. Thank you for this
opportunity to discuss the reauthorization of the Indian Health Care
Improvement Act and other issues. We will be happy to answer any
questions that you may have.
______
Mr. Gibbons. Thank you very much, Mr. Lincoln.
As we continue our discussion on H.R. 2440, I had a
question for you with regard to Title I. Does Title I authorize
program funding to provide for training in management health
programs, like information technology and business
administration?
Mr. Lincoln. At the current time, this piece of legislation
does not include scholarship support or funding for those
individuals that are in hospital administration or, quite
frankly, as an example, on the business side of the programs
and the need that exists within the Indian health programs,
both tribal, Federal and urban.
Mr. Chairman, given the complexity of Medicare legislation
alone, and the need to be able to fully explain to individuals
in Indian country what their entitlements are when they're
eligible for Medicaid, requires a slightly different kind of
professional working in the community and in these facilities.
We believe your Committee and the Congress should consider
these additional professionals as part of a health delivery
team, not just the providers.
Mr. Gibbons. Well, Mr. Lincoln, section 124 of the bill
makes the benefits of the scholarship program non-taxable. If
this were to happen, would you be able to extend the amounts
appropriated for this activity so you could increase the number
of scholarships awarded and take into consideration some of
these other programs?
Mr. Lincoln. Mr. Chairman, I very much appreciate your
question. As we reviewed this bill, it became fairly apparent
that this section 124 is something that we strongly support. It
is my understanding that a similar provision exists for the
Department of Defense programs and for the National Health
Service Corps. We strongly believe this is an important aspect
of this bill.
Recent estimates have been given to me that it would
increase the number of scholarships of about--I believe the
number is between 75 and 100. That sounds like a small number,
but given our need, it is a very important group where we could
expand access to these programs.
Mr. Gibbons. Considering the fact that Congress did exempt
the National Health Service Corps and the Department of Defense
scholarship benefits from being taxed, doesn't the Indian
Health Service administer similar scholarship programs to that,
like the National Health Service Corps or the Department of
Defense, and are they tax-exempt, and if not, should they be
tax-exempt?
Mr. Lincoln. Mr. Chairman, they are very similar programs.
Obviously, the Indian health professions piece of the Indian
Health Care Improvement Act expands on the one hand efforts to
increase the number of Indian people in the health professions
in hard-to-recruit locations, and we believe our program should
be treated in a similar manner as the National Health Service
Corps. This piece of legislation does that.
Mr. Gibbons. I have just one final question for you, and it
has to do with section 110 of the bill, which authorizes loan
repayment programs, changing the existing law which would
require Indian applications be funded first.
Can you explain how the current authority works and is the
amendment contained in section 110 the appropriate change for
that? I would ask you to explain for the benefit of the
Committee that issue.
Mr. Lincoln. In section 110, which is where the loan
repayment program is described, and the various elements of the
loan repayment program, the way the program currently works is
that the current law requires the Indian Health Service to
identify and prioritize, by profession, the hard-to-fill
locations--actually, all the locations throughout the county.
So we identify for the industry, as an example, all of the
hard-to-fill locations and we rank them, where we are required
by law to rank them. The same would be said of nursing, would
be said of medicine and the other health professions that are
covered by the legislation.
Then we proceed to go forward and use our loan repayment
program and give priority to individuals who are going to
accept positions in those most difficult positions and
locations to be filled.
It is my understanding that this bill continues to require
the Indian Health Service to do what I just described, to
identify the most needy locations and to prioritize them, but
it also requires two other things that are different.
One of the things that it requires is the prioritization of
American Indian and Alaska Native applicants for positions. It
actually describes that, in doing this and providing this
increased priority, it overrides--I think is the language
that's used in this legislation--it overrides the priority
system that we are required to provide.
The second thing that is required from my understanding of
the legislation that is different is that it then establishes a
second priority, a second way to look at the filling and
awarding of these loan repayments. It gives priority to Indian
health programs, tribal health programs and urban programs.
The third priority is then given to other programs, and the
way we are understanding the legislation is that that third
group, if you will, will be those Indian Health Service
employees and locations. So those are the differences between
the current legislation and this current bill.
It is our sense that Title I was created to do a couple of
things. One of them was to fill the hard-to-fill locations.
There are places in this country and Alaska, in the Northern
Plains, the Southwest and other places, that are just extremely
difficult to recruit health professionals to those locations,
and then to keep them and retain them there.
This bill, through its scholarship program, certainly
emphasizes the creation of Indian health professionals, and we
believe we have already seen recipients of the loan repayment
program and others stay longer over time in their jobs than
other individuals, so we believe there is a success story.
We would ask that the Committee work with us in reviewing
these provisions that you have just mentioned. There must be a
way of accomplishing both, of increasing the number of American
Indian and Alaska Native health professionals and at the same
time filling these hard-to-fill locations.
Mr. Gibbons. Thank you very much, Mr. Lincoln.
Does anybody else have questions? Ms. Christensen.
Mrs. Christensen. Thank you, Mr. Chairman. Good morning.
I am looking at some of the testimony from the next panel,
and the representatives of the National Council of Urban Indian
Health, the Navajo Nation, and also the National Indian Health
Board all support 151, the elevation.
A few of us were talking about this just last week. When we
look back at David Satcher, for example, as Surgeon General,
many of us feel that the strengthening of his tenure as Surgeon
General really had a lot to do with the fact that he was
Assistant Secretary as well as Surgeon General.
Is it your sense that raising him to the Assistant
Secretary would in any manner diminish his or her ability to
carry out the responsibilities on behalf of tribal governments?
I'm not sure why the Department does not support 151. Can you
just help me better understand that?
Mr. Lincoln. I believe there is a sincere effort and a
reasoned effort on behalf of the Secretary and the Department
when it says the current Director of the Indian Health Service
has more access to decisionmaking forums and decisionmakers
than any other previous Director of the Indian Health Service.
Again, I have had the privilege of being in Washington,
D.C., originally from Navajo, for the last 10 to 11 years, so I
have had the privilege of working directly as the Deputy
Director for three Directors of the Indian Health Service--for
Dr Everett Rhoades, for Dr. Michael Trujillo, and now for Dr.
Charles Grim. I can unequivocally tell you that Dr. Grim has
more access, enjoys more access and more participation with
decisionmaking groups than either of the two previous
Directors.
I believe the Department and the Secretary sincerely
believe that they are providing him with the kind of access not
only to themselves but to the other agency heads that make
decisions for funding. This Intradepartmental Council for
Native American Affairs, that is mentioned in our testimony, is
becoming a central group where the needs of Indian country are
not only left at the doorstep of the Indian Health Service to
solve and to meet, but now are included with the Administrator
for SAMHSA, the Commissioner for the Food and Drug
Administration and others. I truly believe the Administration,
the Department and our Secretary, believe that in those ways
they have opened up the door to Indian country already.
Mrs. Christensen. The Secretary won't be there forever. The
Council is a creation of the Secretary, and the interaction
that now exists, which sounds exemplary, is not guaranteed.
Wouldn't this be a way to ensure that that same
relationship to the other agencies would continue to exist, but
even beyond that, increase the authority of the Director to
influence what happens in SAMHSA? Because right now, yes, they
are able to talk with them and are able to access them, but
they are not able to influence how those agencies respond to
the needs of the tribal governments and the tribes.
Mr. Lincoln. Two points, Congresswoman. One, the
Intradepartmental Council for Native American Affairs is a
statutorily created council. It is created within the Native
Americans Act, where it identifies this group.
What is unique about this group is that it is now
operational. You're correct, in that the Secretary and the
Deputy Secretary have breathed life into this Council and have
required that these other agency heads, like Mr. Curie of
SAMHSA or Dr. Gerberding of CDC and others, to actually set on
that Intradepartmental Council for Native American Affairs. So
I believe the intradepartmental council will continue because
of the statutory basis.
But how any Secretary uses any council like this is at the
discretion of the Secretary. I think it might be inappropriate
for me to speculate in the future. I think it is more important
for me to say that the access is exemplary now, and I think we
will be able to measure the increased access to non-IHS,
Department of Health and Human Services funds in a very
objective way in the near future.
Mrs. Christensen. It would just seem to me that since you
have established this, the best way to continue it would be to
elevate that position.
Thank you, Mr. Chairman.
Mr. Gibbons. Thank you.
Miss Napolitano.
Mrs. Napolitano. Thank you, Mr. Chair.
I'm going back to services, and under the provision of
Title I, it would establish a Native American psychological
research program at the University of North Dakota, and it
would also provide substance abuse and mental health counseling
and coordinate with tribal colleges and other universities to
expand such services. That is a critical area in my thinking,
in being able to deal with some of the issues that Native
Americans and others face.
Is that the only university that is being considered,
because as you well know, our tribes are dispersed throughout
the United States. How is that going to work with other
universities for that expansion? The provision is not quite
clear on that.
Mr. Lincoln. Thank you for the question.
The Quentin N. Burdick centers--and there are a couple--
that are at the University of North Dakota, certainly one of
them is to increase Indian people into psychology programs.
Another at the University of North Dakota, a long-standing
program, is called the INMED program, which is designed to
increase the number of Indian physicians throughout the Nation,
a very successful program by the way.
There are other programs throughout the Nation that we
believe are necessary, especially in the area of psychology.
The other behavioral health sciences, there is great need in
Indian country.
Mrs. Napolitano. Sir, I know that. I am aware of that. What
I'm asking is how is this going to be dispersed amongst the
Indian tribes to be able to help them. I know they are
established in North Dakota and other universities, but how are
they going to avail themselves or how is that university going
to be able to help all the different issues the tribes have?
Mr. Lincoln. Right now those universities have Indian
students from all over the country, not just from that northern
tier of States. So they have opened their doors.
What I was going to say, Congresswoman, is that we believe
in the Indian Health Service there is greater need for these
kinds of programs in other geographic locations. We would want
to work with the Committee to discuss with you where those
locations would be most logical.
The University of Colorado would be a good example where
programs are being developed. The University of Washington has
a certain number of programs that exist with that institution,
and there are others. The University of New Mexico is another
good example. We need to expand their efforts.
Mrs. Napolitano. I understand. That's why I'm asking the
question. California has a number of tribes. I don't know which
colleges or universities in California are rendering those
services to which we can refer some of our Indian population
that reside in our districts. So I'm wanting to find out how is
this going to be expanded to help all the different tribes in
the areas, because all of them, I would think without
exception, have issues that can be dealt with under some of
these titles.
Mr. Lincoln. We would be glad to explore this, and we would
be glad to bring not only our scholarship people but our--if
we're looking at behavioral health, we will bring our Director
of Behavioral Health and work with you and your staff. I think
we can be a little more detailed at that point.
Mrs. Napolitano. I would appreciate it, Sir. I am the Co-
Chair of the Mental Health Caucus, and that's one of the
reasons I'm asking. Thank you.
Mr. Lincoln. Thank you.
Mr. Gibbons. Thank you.
Mr. Pallone.
Mr. Pallone. Thank you, Mr. Chairman.
Let me start out by saying I appreciate the fact that the
Committee is having this hearing today, because when we had the
joint hearing back with the Senate in the summer, one of the
points that many of us made was that the Resources Committee on
the House side needed to have some hearings on its own on the
issues of the Indian Health Care Improvement Act, because it is
such an important bill to Indian country. I think it needs more
attention by us on the House side.
Keeping that in mind, though, although I appreciate that
we're having the hearing, I wanted to mention, Mr. Chairman,
that it really is a hearing on two bills, both of which are
important, and my understanding is that the hearing today is
only on Title I of the Indian Health Care Improvement Act. I
hope that means we're going to have hearings on the other
titles, and if you could pass that on to the ``powers that
be'', I would appreciate it.
Could I inquire, is that the case, or don't we know yet?
Mr. Gibbons. I would have to ask the Chairman of the
Committee on that question.
Mr. Pallone. All right. If we could pass that along, I
think it is important to have hearings on the other titles. But
I do appreciate that we're doing this today.
What I wanted to ask Mr. Lincoln is by way of background.
First of all, I wanted to say that our Congresswoman
Christensen and Congresswoman Hilda Solis did a great job of
putting together this health disparities legislation that the
Democrats are going to introduce in the next couple of weeks. I
want to commend them again for doing that because I think it
relates directly to Indian country. Although it deals with a
number of other minorities, it does relate directly to Indian
country.
An important part of that bill, one of the principles that
they put forward in this Democratic initiative, is the need to
diversify the health care workforce and to increase the number
of minorities, be they Native American or whoever, that are
involved in delivering health services. The main reason they
say that is because they believe, at least from what they tell
me, that if you have a diversified workforce and you have more
Native Americans involved, then it just means in the long run
not only better quality but also more attention is going to be
devoted to the issue in some fashion. So I think that Title I
is very important in that regard.
There are so many questions that I have about Title I, let
me just ask you these. First of all, do you support Title I and
do you support the larger Indian Health Care Improvement Act,
in general?
Mr. Lincoln. Yes, we do.
Mr. Pallone. OK. That's very important because I think it's
a good bill and I am one of the cosponsors of it. So I
appreciate that.
I believe there is a crisis, not only in Indian health care
in general, the quality of the delivery of services, but also a
crisis in terms of lack of personnel who are Native American,
or even personnel in general. The numbers are unbelievable from
what I have seen.
I guess my question is, I believe that this bill
accomplishes a great deal in terms of moving in the proper
direction, but I wanted to ask you about the specifics in terms
of what we're trying to achieve. Obviously, we need more Native
Americans who are nurses and doctors, but we also need a lot
more people in Indian country at the IHS hospitals and clinics
in addition, whether they're Native American or not, it seems
to me. The problem is not only in terms of recruiting people
and having adequate scholarships, but also making them stay in
some of these rural and remote areas.
So if you could just answer questions about that. In other
words, do you think we have done enough or that we're making
significant strides in terms of getting Native Americans to
become health care professionals, as opposed to non-Native
Americans? Do you think we need to emphasize more on just
recruiting people to these remote areas, where it's difficult
to get people? Third, if you could comment on not only our
ability to get people to enter these health professions, but
also to stay there long term, because a lot of these things
keep them there maybe for a couple of years but are they going
to keep them there for a lifetime.
I know that's a lot.
Mr. Lincoln. Congressman, it's a very, very complex
question, and maybe I can break it down in a way that will
describe support for the entirety of the Indian Health Care
Improvement Act. But I will give you some data that is
preliminary but I think important to address the issue of
retention and how it might relate to Title I.
The breadth of the Indian Health Care Improvement Act is
necessary because if the objective is not just to provide
medical care to individuals, but if the objective is to
actually improve the health status of those individuals and the
communities within which they live, and, if you will, Indian
people in general, that's a very complex task. That requires
more than just a physician's visit with an individual given an
acute episode that's going on. It's incredibly important that
that is dealt with, that visit is dealt with, in a culturally
appropriate manner, and that the clinical outcome is what is
desired.
But the breadth of the Indian Health Care Improvement Act
addresses, as an example, replacing these old, outdated
facilities that exist in many locations throughout Indian
country. I know you have visited Indian country, Congressman,
and I think you may have seen some of the best and some of the
worst at the same time. But this bill moves us forward relative
to the infrastructure that is going to be necessary to provide
health care services in this decade that we are now embroiled
in.
How does just that one example relate to increasing
recruitment and retention? It is more likely that a physician
or a nurse coming out of a medical school, a school of nursing,
a school of dentistry, or a school of pharmacy, it is more
likely they will come to a new facility, one where they can
practice the kind of medicine that they've just been trained to
practice in. So the idea of being able to recruit and retain
somebody, the facilities have a bearing on that.
We know that in our newer constructed facilities the
likelihood of somebody staying there is greater than if you're
isolated and you don't have the proper staff support, and
you're in a building and you don't have the equipment that you
need. It is just a common sense kind of thing.
Second, the Indian Health Care Improvement Act, as we think
about it in the way it focuses resources and the delivery of
health services themselves, the way it prioritizes those
services, I think paints an honest picture of what the health
status of Indian people is throughout this country, and the
kind of interventions that might make sense, both in terms of
the basic health care program, focusing on primary care
services, ambulatory care within that, it's the kind of a
practice that we need to be honest about.
That's what people are going to see. Eight million
outpatient visits this last year, that's what you're going to
see when you deliver health care, and you're going to see an
array of women's health issues, you're going to see an array of
issues of youth. The leading cause of death for Indian people
between 5 and 45, the highly productive years of young people,
are injuries due to automobile collisions. I purposely do not
use the word ``accidents'' because they're rather predictable.
If you go out on Friday night and you drink to excess, and you
drive on a road that is 50 or 60 miles, narrow and unlit--I'm
speaking for our engineers at the moment--it's pretty
predictable that the accidents and death mortality is going to
be high because people are young and driving fast, and they're
driving on roads that aren't well lit, and they may be
intoxicated.
If you look at our data and really use the statistics in
the way they're supposed to be used, and the way the full bill
allows us to analyze, you will come to the conclusion that
these deaths due to automobile collisions are not merely
accidents. They are not acts of God. You can predict them.
Maybe you can't predict the moment, but you can describe that
they're going to occur on Friday and Saturday evenings, late in
the evening, and they're going to occur as a result of somebody
who is tired or somebody who has abused alcohol or some other
drug.
This bill, I believe, provides the needed specificity for
describing how the Federal Government, working in partnership
with tribes, can intervene to improve their health status. I
truly believe that, Congressman Pallone.
I also believe that this bill, with additional work,
working in collaboration with tribes, the Department, our
sister agencies, and the Department of Transportation and the
Department of Housing and Urban Development, et cetera, can
truly make a difference. I believe this bill needs some
additional work and we're prepared to join the Committee, along
with the tribes, in doing that work.
Mr. Pallone. Thank you very much.
Mr. Gibbons. Thank you very much, Mr. Pallone.
Mr. Lincoln, thank you very much for your testimony here
today before the Committee. It's been very enlightening. With
that, we will excuse you and call up our third panel today.
Mr. Lincoln. Thank you, Mr. Chairman.
Mr. Gibbons. The third panel will be President Joe Shirley,
Jr., from the Navajo Nation; Anthony Hunter, President,
National Council of Urban Indian Health; and Julia Davis-
Wheeler, Co-Chair, National Indian Health Board.
Before you all take your seats, let's me once again swear
you in, as is the policy of this Committee.
[Witnesses sworn.]
Let the record reflect that each of the witnesses responded
in the affirmative.
With that, I am going to turn to my colleague from Arizona,
Mr. Renzi, to introduce one of the witnesses. Mr. Renzi.
Mr. Renzi. Thank you, Mr. Chairman.
I have the distinct pleasure today to welcome from the
largest Native American Nation America, the President, Mr. Joe
Shirley, Jr. He is our new President of the Navajo Nation, of a
proud and honorable people, a people who have served this
Nation particularly given the times we're in and in times of
war, a nation of fighting men and women. I am grateful and
honored to have you here today, sir.
His experience is vast, not just in public service but in
the field of social service, helping particularly children in
the Navajo Division of Social Services, where he served as
Executive Director. He helped in Northern Arizona as our Apache
County Supervisor in 1984, where he retired and recently ran
for office and won, overwhelmingly, upon the Navajo Nation. His
leadership and his passion is well-known throughout all of
Northern Arizona, as well as the Southwest.
President Joe Shirley, I am honored to have you here today.
Thank you for coming all the way and making this trip.
Mr. Chairman, thank you for the time.
Mr. Gibbons. Thank you, Mr. Renzi. With that, we will turn
to each of our witnesses here today and thank them for their
appearance. We will begin with Mr. Shirley. Welcome.
STATEMENT OF HON. JOE SHIRLEY, JR., PRESIDENT, THE NAVAJO
NATION, ACCOMPANIED BY ANSIEM ROANHORSE, JR., EXECUTIVE
DIRECTOR, NAVAJO DIVISION OF HEALTH
Mr. Shirley. Thank you, Chairman, Congressman Renzi. It is
an honor to be here before you and other distinguished members
of the Committee on Resources. Thank you for allowing us to be
heard today regarding H.R. 2440, the Indian Health Care
Improvement Act Reauthorization Amendments of 2003.
My name is Joe Shirley, Jr., President of the Navajo
Nation. First, it is in the best interests of the Navajo Nation
and other Native Americans that the 108th Congress reauthorize
the Indian Health Care Improvement Act. The Act serves nearly
300,000 Navajos residing on and off Navajo land. Native
Americans, including the Navajos, have experienced severe
disparities in health care and funding for it for many decades.
This condition is contrary to the Federal Government's trust
responsibility to deliver and fund health care services based
on treaties and legislation.
The Navajo Nation, through a 15-member National Steering
Committee put in place by the Indian Health Service, assisted
with the development of a final agreement between tribes that
was submitted to the Indian Health Service and the appropriate
committees at the U.S. House of Representatives and Senate.
The unmet health care needs of Native Americans are
enormously high compared to the mainstream in the U.S. Heart
disease is the number one killer among Navajo people. Health
care disparities on Navajo land could be reduced by the
improvement of bad dirt roads. Seventy-eight percent of our
roads are dirt. Tribal members, including the elderly, children
and the disabled, often must travel hundreds of miles to
receive specialized care. Improved roads can mean the
difference between life and death. Bad roads, combined with our
inadequate communications network, and insufficient funding and
resources for health care, increase the health care
disparities.
Further, there is a severe Navajo land nursing and dentist
shortage. In Fiscal Year 2003, the Indian Health Service
awarded 130 Indian Health Service scholarship awards. By
expanding Title I, it would help address the challenges with
recruitment and retention of direct health care and specialized
providers for the most isolated, rural and remote Native
American communities.
The Navajo Nation supports a fully funded Indian Health
Service scholarship program for a wider range of health care
disciplines to be implemented through area offices, not through
the Indian Health Service's headquarters office. Working with
our area offices allows for a better understanding of the needs
of our communities. This is especially valuable to Navajo
communities where English is not the only spoken language.
Knowledge of our Navajo language, culture and history is vital
to communication.
Further, the Navajo Nation supports section 216, which
designates the State of Arizona as a contract health service
delivery area for the purpose of providing contract health care
services to members of federally recognized tribes in Arizona.
Considering the high number of Navajos living in urban areas
throughout the State of Arizona, and due to their need for
quality health care, the Navajo Nation recommendations that
section 216 be adequately funded.
Further, Title III would require the Secretary of Health
and Human Services to consult with tribes to determine tribal
preferences during facilities construction. Consultation with
tribes is absolutely necessary. Moneys earmarked for facilities
construction costs need to be spent in ways that are consistent
with tribal needs and preferences. Additional costs are
incurred when corrective actions are undertaken for
inconsistencies.
Further, section 301(c) establishes a health care project
priority system that is based upon need. The methodology
creates a priority listing. The top ten priority inpatient care
facilities, outpatient facilities, and specialized care
facilities will be listed, along with justifications, costs and
methodologies. The Navajo Nation supports this provision
because it provides for a government-to-government consultation
with tribes and establishes a criteria system that addresses
the greatest needs first.
The Navajo Nation requests that those projects currently in
phase three of the existing Indian Health Service health
facilities construction priority system be grandfathered and
integrated into any new proposed facilities priority system.
This is critically important for the Navajo Nation, as it has
five projects currently in phase three.
Further, the Navajo Nation boundaries span across three
States--Arizona, New Mexico and Utah, and three Federal regions
and 13 counties. It is estimated that over 80,000 Native
American beneficiaries in the Navajo area are eligible for
Medicaid, and the majority are members of the Navajo Nation.
Currently, Navajo individuals in three States seeking medical
assistance from State Medicaid programs are subjected to three
different sets of rules. It is for this reason that the Navajo
Nation is planning to establish the Navajo Nation Medicaid
Agency, which would also be more culturally relevant.
Section 414 of Title IV would authorize the Navajo Nation
as a single state agency for purposes of providing medical
assistance to eligible Native Americans residing within the
boundaries of the Navajo Nation. The Navajo Nation Medicaid
Agency intends to streamline the various requirements and
procedures for eligibility, payments, and other functions.
Further, Title V would expand health care assistance for
Native Americans residing in urban areas. The Navajo Nation
supports Navajo people residing off Navajo land. Navajos are
often forced to relocate to urban settings in order to pursue
education or employment, and many end up without proper health
care.
Still further, most Native American communities suffer from
health and social problems related to alcohol and substance
abuse. As a result, the Navajo Nation supports a comprehensive
treatment model for behavioral health which addresses substance
abuse and mental health disorders. Title VII provides a more
effective assessment and treatment of an individual in a
holistic manner and offers comprehensive care in one department
which prevents further referral of a client to several agencies
for services.
Still further, the Navajo Nation supports the establishment
of a 25-member National Bipartisan Commission on Indian Health
Care to study the provision of health care as an entitlement to
Native Americans. Health care as an entitlement would serve as
a mechanism to improve the delivery of health care services to
Native Americans.
Last, regarding H.R. 151, the Navajo Nation supports the
elevation of the Director of the Indian Health Service to an
Assistant Secretary within the Department of Health and Human
Services.
Thank you. I have Mr. Ansiem Roanhorse, Jr. here with me to
help answer questions, if there are any questions. Thank you,
gentlemen.
[The prepared statement of Mr. Shirley follows:]
Statement of Joe Shirley Jr., President, The Navajo Nation
Introduction
Mr. Chairman, Mr. Vice Chairman and distinguished members of the
Committee on Resources, thank you for allowing us to present today:
My name is Joe Shirley Jr., President of the Navajo Nation. On
behalf of the Navajo Nation, we are honored to testify on H.R. 2440,
the Indian Health Care Improvement Act Reauthorization Amendments of
2003 (``Act''). We firmly believe that it is in the best interest of
the Navajo Nation and other American Indians and Alaska Natives that
the 108th Congress reauthorizes the Indian Health Care Improvement Act.
While the Navajo Nation supports the majority of H.R. 2440, we
recommend that minor amendments be made to this Act in order to better
address the needs of the Navajo Nation.
The United States Congress enacted the Indian Health Care
Improvement Act in 1976 to provide a comprehensive and integrated
approach to elevate the health status of American Indians and Alaska
Natives to the highest level. The Act has been reauthorized four times
over the past 27 years with the most recent reauthorization in 1992.
The Act provides authority for appropriation of funding for the
following: 1) health professional development; 2) clinical care; 3)
preventive health services; 4) facility construction and maintenance of
community sanitation improvement; 5) recovery of health care cost from
Medicare and Medicaid; 6) urban Indian health programs; 7) provision of
mental health, alcohol and substance abuse, and domestic violence
programs; and 8) establishment of a 25-member National Bipartisan
Commission to study the provision of health care to American Indians
and Alaska Natives as an entitlement.
Over the past several years, in preparation for the reauthorization
of the Indian Health Care Improvement Act, the Indian Health Service
formed a 15-member ``437'' National Steering Committee and sponsored a
series of Area-wide, Regional, and National Tribal Consultation
meetings to discuss specific health care concerns in Native communities
and to make recommendations regarding the reauthorization of the Act.
The Navajo Nation staff actively participated in the ``437'' National
Steering Committee work and assisted with development of the final
proposed ``consensus bill'' that was submitted to the Indian Health
Service and appropriate committees of the United States House of
Representatives and the United States Senate.
The Act is critical for purposes of providing health care to over
1.6 million federally recognized American Indians and Alaska Natives
through direct Indian Health Service, tribal, and urban Indian health
programs. The Act serves over 295,000 Navajo individuals residing on
and off the Navajo reservation. American Indians and Alaska Natives,
including the Navajo people, have experienced severe disparities in
health care, funding and other resources for many decades. This
condition is contrary to the federal government's trust responsibility
to deliver and fund health care services to the American Indians and
Alaska Natives based on treaties and subsequent legislation.
Although the Indian Health Service is severely underfunded, the
Navajo Area Indian Health Service has made some positive strides
improving the health status of the Navajo people in certain areas.
According to the Navajo Area Indian Health Service data, the health
status of the Navajo people is better than the general U.S. population
in the following areas: 1) cancer deaths particularly breast cancer
deaths; 2) heart disease deaths; and 3) low weight births. However, the
federal funding for Indian health care has not kept pace in the
following factors: 1) medical and overall inflation; 2) rising costs of
health care; 3) increasing costs of pharmaceuticals; and 4) offering of
competitive salaries and benefits to recruit and retain qualified
health care professionals. According to the Indian Health Service Level
of Need Funded Methodology, the Navajo Area Indian Health Service
receives funds to meet only 54 percent of the health needs of the
patient population, and it provides health care services at $1,187 per
person while the national average is about $3,582 per person. The unmet
health care needs of the American Indians and Alaska Natives are
enormously high.
Comments and Recommendations
Title I
The Navajo Nation recognizes, as does the federal government, the
severe nationwide nursing shortage. The Navajo Nation believes that
education is the foundation for a strong, stable and accountable
sovereign tribe. In 2002, the Navajo Nation received over 13,170
applications for tribal scholarship from aspiring Navajo youth who
wanted to pursue post secondary education. The Navajo Nation provided
scholarship support for only 5,920 applicants and had to turn down over
7,200 Navajo students due to limited tribal resources. Additionally,
about 130 Navajo students received Indian Health Service scholarship
awards in Fiscal Year 2003. By expanding Title I, the Navajo Nation can
get culturally proficient health care providers thereby increasing
health care professionals. Further, the expansion of Title I will begin
to address the challenges with recruitment and retention of direct
health care providers for the most isolated, rural and remote American
Indian and Alaska Native communities. Thus, the Navajo Nation continues
to support a fully funded Indian Health Service scholarship
opportunity, through the Area Office, that funds a wider range of
health care disciplines. The Navajo Nation recommends that a greater
degree of flexibility and autonomy be provided to the Indian Health
Service, tribes and urban Indian health programs to implement Title I.
The Navajo Nation appreciates the intent of Title I, which is to
increase opportunities for Indian people so that they may return home
and become health care providers. This is particularly valuable to
American Indian and Alaska Native communities like the Navajo Nation
where English is not the only language spoken. The Navajo population
includes both traditional and non-traditional people, some of whom
speak only Navajo, who need health care providers knowledgeable in
Navajo culture, history and language. The Navajo Nation supports
efforts where Indian people are educated in health care-related fields
and are allowed to return to their communities.
Title II
This Title focuses upon various health initiatives. The Navajo
Nation has special interest in Section 215. This section calls for the
study and monitoring of programs to determine trends that exist in
health hazards posed to Indian miners and Indians on or near
reservations and in Indian communities as a result of environmental
hazards that may result in chronic and or life-threatening diseases.
The Navajo Nation further supports the inclusion of studies with
summaries of findings, reports and plans of action. In addition to the
provision of Section 215, the Navajo Nation supports compilation of
accurate data regarding environmental health issues among Navajos,
along with components for education, prevention and treatment while
requiring entities charged with causing the health problems to take
responsibility and rectify the damages.
Section 216 designates the State of Arizona as a contract health
service delivery area for the purpose of providing contract health care
services to members of federally-recognized Indian tribes of Arizona.
Considering the high number of Navajos living in urban areas throughout
the State of Arizona and due to other need for quality health care, the
Navajo Nation encourages Congress that Section 216 be adequately funded
so that it can be properly implemented.
Title III
This Title focuses on funds spent on construction and/or renovation
of Indian Health Service facilities. According to this Title, the
Secretary of Health and Human Services shall consult with any Indian
tribe that is significantly affected by the facilities expenditure for
the purpose of determining and honoring tribal preferences concerning
that facility. This type of consultation is absolutely necessary.
Without tribal input regarding the undertaking of any construction
and renovation of facilities, there exists a concern regarding self-
determination. Also, there is a concern that monies earmarked for such
construction costs will not be spent in ways that are inconsistent with
tribal needs or preferences and that additional expenses will be
incurred when efforts to correct these issues are undertaken.
Section 301(c) establishes a health care project priority system
that is based upon need. The proposed methodology is to create a
priority list for planning, design, construction and renovation needs.
Thereafter, the top ten priority inpatient care facilities, outpatient
facilities and specialized care facilities will be listed, along with
justifications, costs and methodologies. The Navajo Nation supports
this proposal because it: 1) provides for government-to-government
consultation with tribes; and 2) establishes a criteria system that
addresses the greatest needs first. The Navajo Nation recommends that
those projects currently in Phase III of the existing Indian Health
Service Health Facilities Construction Priority System be
``grandfathered'' and integrated into any new proposed facilities
priority system. This is of particular importance for the Navajo
Nation, as the Navajo Nation has five projects in Phase III, including
one alternative rural hospital in Kayenta, Arizona; three health
centers in Dilkon, Arizona, Pueblo Pintado, New Mexico, and Bodaway/
Gap, Arizona; and a new hospital in Gallup, New Mexico. Technical
assistance from the Indian Health Service is critical to place these
projects on the national funding list.
The Navajo Nation is seriously concerned with Section 302(c)(3)(A).
If this provision were approved, it would gravely widen an already
massive backlog of homes to be served with adequate sanitation
facilities. Although, despite the availability of amenities, such as
running water and electricity, in the majority of homes in the U.S., a
home without proper sanitation facility is an all too common reality,
especially on the Navajo Nation. In fact, 31.9% of homes on the Navajo
Nation lack proper plumbing facilities. The Navajo Nation recommends
that the U.S. Congress provide for proper sanitation facilities in all
new and existing homes on or in American Indian and Alaska Native
communities and homes in order to achieve good public health outcome
and to elevate the health status of American Indians and Alaska Natives
to the highest possible level, without adversely affecting the funding
source of future and existing Indian Health Service programs.
Title IV
The Navajo Nation boundaries span across three states (Arizona, New
Mexico and Utah), three federal regions and 13 counties. It is
estimated that over 80,000 American Indian beneficiaries in the Navajo
Area are eligible for Medicaid and the majority are members of the
Navajo Nation. It is for this reason that the Navajo Nation is planning
to establish the Navajo Nation Medicaid Agency.
Section 414 of Title IV would authorize the Navajo Nation as a
Single State Agency for purposes of providing medical assistance to
eligible American Indians and Alaska Natives residing within the
boundaries of the Navajo Nation. Currently, on the Navajo Nation, there
are three sets of rules with respect to Medicaid services--one from the
State of Arizona, New Mexico and Utah. The Navajo Nation Medicaid
Agency intends to streamline the various requirements and procedures
for eligibility, payments and other functions. The Navajo Nation
anticipates that the medical services will be more culturally relevant
to the Navajo population.
Title V
This Title is to expand health care assistance for American Indians
and Alaska Natives relocated to, and residing in, urban areas. The
Navajo Nation fully supports Indian people residing in off-reservation
locations. These individuals are often forced to relocate to off-
reservation settings in order to pursue education or employment and
many end up without proper health care.
Title VII
The health and social problems related to alcohol and substance
abuse continue to rise and affect the lives of many Navajo youth,
adults and their families. It is estimated that about 25%, or about
44,843, of the total Navajos residing on the Navajo reservation have
alcohol and substance use, abuse and addiction problems. Approximately
35% of the total Navajo population or 35,137 between the ages of 10 and
17 are in the high-risk group, having been exposed to alcohol and
substance abuse problems. It is also estimated that about nine of ten
or about 161,434 Navajo individuals of all ages are affected by
alcohol, substance abuse and other related behavioral health problems.
About 50% or 20,000 individuals that are impacted by alcohol and
substance abuse are not receiving any services. Due to lack of adequate
funds and resources, the Navajo Nation Department of Behavioral Health
Services (``Department'') is unable to provide service to a large
number of high-risk youths and young adults. The Department does
provide treatment and counseling services to about 19,000 patients
every year. Information and education on alcohol and substance abuse is
provided to about 20,000 individuals and families every year and
another 14,000 individuals receive prevention, education, treatment and
after care services through contracts with other providers. The Tribal
Department delivers these services through its 10 outpatient treatment
centers, three residential treatment centers, four mobile and outreach
programs, and five mental health case management offices.
The occurrence of mental health problems and disorders affects 35%
of the total Navajo Nation population between the ages of 15 and 54.
About 13 % of the total children and youth aged 9-17 experience serious
emotional disturbance and one in five children and youth may have a
diagnosable mental, emotional or behavioral problem. Prevalence of
major depression among adults aged 45-64 is 2.3% of the total
population. It is important to note that co-occurrence of mental and
addictive disorders affect the Navajo population. About 37% of the
total population with alcohol abuse are also diagnosed with a mental
disorder and 53% of the other drug abusers have diagnosed mental
disorders as well.
The Navajo Nation staff worked closely with the ``437'' National
Steering Committee and assisted with development of a seamless and
comprehensive treatment model for behavioral health that is inclusive
of substance abuse and mental health disorders. This new model was
incorporated in Title VII and it will provide a more effective way of
assessing and treating an individual in a holistic manner and offering
comprehensive care in one department, which prevents further referral
of a client to several agencies for services.
Title VIII
The Navajo Nation supports the establishment of a 25-member
National Bipartisan Commission on Indian Health Care Entitlement to
study the provision of health care to American Indians and Alaska
Natives as an entitlement. This provision serves as a mechanism to
improve delivery of health services to American Indians and Alaska
Natives and, as such, the Navajo Nation firmly supports it.
Conclusion
On behalf of the Navajo people, I proudly present our concerns and
recommendations to the members of the Committee as a testament to the
continual need and improvement to the health and welfare of the Navajo
people. Your support and consideration in the area of education, health
care reform and self-determination is appreciated. Upon the passage of
H.R. 2440 and S. 556, the Navajo Nation hopes that the Indian Health
Care Improvement Act fulfills its intent to eliminate the health
disparities plaguing Indian Country, thereby enhancing the ability of
the Indian Health Service, tribal governments and urban Indian health
programs to provide efficient health care services. Mr. Chairman, this
concludes my testimony. Thank you for the opportunity to make my
statement about the Indian Health Care Improvement Act Reauthorization
of 2003. We will gladly answer any questions that you may have.
______
Mr. Gibbons. Thank you very much, Mr. Shirley.
We now will turn to Mr. Anthony Hunter, President of the
National Council of Urban Indian Health. Mr. Hunter.
STATEMENT OF ANTHONY HUNTER, PRESIDENT,
NATIONAL COUNCIL OF URBAN INDIAN HEALTH
Mr. Hunter. Good morning, Mr. Chairman. Thank you, members
of the House Resources Committee.
I am also a member of the Shinnecock Nation of Eastern Long
Island, as well as current President of the National Council of
Urban Indian Health, which we affectionately refer to as NCUIH.
On behalf of NCUIH, I would like to express our
appreciation for this opportunity to testify before the
Committee on H.R. 151 and 2440.
Founded in 1998, NCUIH is the only national organization
representing urban Indian health programs. Our programs operate
in 41 cities and are often the main source of health care and
health information for urban Indian communities. According to
the 200 Census, 66 percent of American Indians now live off
reservations, and almost all of those Indians live in urban
areas.
Over the past few years, the urban Indian health programs
have, on average, received slightly more than 1 percent of the
Indian Health Service budget. In 1976, Congress passed the
Indian Health Care Improvement Act, and the original purpose of
this Act was set forth in a contemporaneous House report, which
was to raise the status of health care for American Indians and
Alaska Natives over a period of 7 years, equal to a level equal
to that enjoyed by other American citizens.
It has been 27 years now since that commitment was made,
and 20 years since the deadline for achieving it has passed.
And yet, Indians, whether reservation or urban, continue to
occupy the lowest rung on the health care ladder, with the
poorest access to America's extraordinary health care system.
How can this be changed? First, Indian people need a
stronger voice in the health care debate. Too often, our views
are literally drowned out in the din created by other health
care interests. Elevating the position of Director of Indian
Health Service to Assistant Secretary for Indian Health will
greatly strengthen the voice of Indian country, whether in the
halls of the Department of Health and Human Services, or the
corridors of Congress, or wherever the health care debate
occurs and decisions are made. NCUIH fully supports H.R. 151.
Second, it is important to reauthorize the Indian Health
Care Improvement Act. Overall, NCUIH supports H.R. 2440, but we
have a number of important concerns that need to be addressed
in the legislation before we believe it should be adopted into
law.
We have the following recommendations: Regarding Title I,
the Indian Health Professions and Scholarship Program, we would
like to thank Congress for its support in making the program
available to State-recognized Indians. This will greatly
broaden the base of Indian people going into that system.
Urban programs are able to take advantage of this to the
degree that we are funded to support health professionals. As
you may know, some of our programs are outreach and referral
programs, very small programs, a very limited number of health
professionals available, and very limited funding. Also, the
Federal tort claims, which is provided for in the Indian Health
Care Improvement Act Reauthorization, would help to support
urban programs being able to recruit and retain Indian health
care professionals in their programs.
We recommend that the policy statement be amended to
restore key references to urban Indians. The congressional
policy statement in the existing Indian Health Care Improvement
Act specifically references both Indians and urban Indians,
which are separately defined terms. However, the equivalent
section of H.R. 2440, section 3, paragraphs (1) and (2), do not
include a reference to urban Indians. Removing urban Indians
from this important policy statement would imply that the
Congress no longer considers the health status of urban Indians
to be a national priority. This is a very important issue to us
and we urge you to maintain the current policy of including
both Indians and urban Indians in the policy statement.
Second, to spell out the definition of Indian and Indian
tribe. The definition of Indian has been substantially revised
in H.R. 2440 from current law, principally by separating out
subdefinitions that chiefly apply to urban Indians. NCUIH
accepts the definitions, but recommends that instead of
defining Indian by referring to another statute, the Indian
Self-Determination and Education Assistance Act, that the
definition be spelled out.
We have the same concern for the definition of Indian
tribe. In Title I, section 123, we ask that urban programs be
included in the chronic shortage demonstration projects. In
section 127, we ask that urban programs be included in the
development and technical assistance programs for community
education.
In Title II, we ask that urban programs be included in the
Indian Health Care Improvement Fund and the catastrophic health
emergency fund. Also in Title II, section 212, we ask that
urban programs be rendered the same technical assistance
regarding communicable and infectious diseases available to
other IHS funded programs. In Title II, section 213, we ask
that urban programs be eligible for home- and community-based
services, public health functions, and traditional health care.
Urban programs do not participate in the IHS facility
priority system established in Title III, which concerns
facility construction, maintenance, and enhancement. A good
facility is a key part of a good program and we ask for your
consideration and including urban programs in this title.
Title V is the urban title of H.R. 2440, which we strongly
support. We would like to emphasize particular support for
section 512, which makes the Oklahoma City and Tulsa clinic
demonstration programs permanent. These two projects have been
very successful, and that success is justification for making
them permanent.
In conclusion, the entire Indian population, both
reservation and urban, is deserving, morally and legally, of
support from the Federal Government in achieving the highest
level possible of health care. In my written testimony I have
described at length the Federal trust responsibility as it
applies to all Indians. NCUIH does not believe that this
obligation stops at the reservation boundary. As much as their
reservation counterparts, urban Indians have been affected by
Federal programs and policies, including the BIA's relocation
program of over 160,000 Indians to cities between 1953 and
1962, and the Federal policy of terminating tribes in the 1950s
and 1960s.
America is nowhere near the lofty goal set by Congress in
1976 of achieving equal health care for American Indians. I
challenge this Committee to think in terms of that goal as it
considers H.R. 151 and H.R. 2440. NCUIH thanks the Committee
for this opportunity to provide testimony on those bills.
Thank you.
[The prepared statement of Mr. Hunter follows:]
Statement of Anthony Hunter, President,
National Council of Urban Indian Health
Introduction
Honorable Chairman Pombo and Committee Members, my name is Anthony
Hunter. I am the President of the National Council of Urban Indian
Health (NCUIH) and a member of the Shinnecock Nation of Long Island,
N.Y. I am also the Health Director for the American Indian Community
House in New York City, N.Y. On behalf of NCUIH, I would like to
express our appreciation for this opportunity to address the Committee
on H.R. 151, the elevation of the position of the Director of the
Indian Health Service within the Department of Health and Human
Services to Assistant Secretary, and H.R. 2440, the Indian Health Care
Improvement Act Amendments of 2003, and how they impact American
Indian/Alaska Natives living off reservation.
Founded in 1998, NCUIH is a membership organization representing 34
urban Indian health programs. Our programs provide a wide range of
health care and referral services in 41 cities. Our programs are often
the main source of health care and health information for urban Indian
communities. In this role, they have achieved extraordinary results,
despite the great challenges they face. According to the 2000 census,
66% of American Indians live in urban areas, up from 45% in 1970 and
52% in 1980 and 58% in 1990. We expect that these percentages will
continue to increase over the next ten years. It should be added that
the American Indian population is widely considered the most
undercounted group in the Census. Although the total number of Indians
may actually be low, our experience is that the relative percentage of
urban versus reservation Indians is accurate. Like their reservation
counterparts, urban Indians historically suffer from poor health and
substandard health care services.
Federal Responsibility for Urban Indians
As with Indian tribes, there is a specific Federal obligation to
urban Indians. Congress enshrined its commitment to urban Indians in
the Indian Health Care Improvement Act where it provided:
``That it is the policy of this Nation, in fulfillment of its
special responsibility and legal obligation to the American
Indian people, to meet the national goal of providing the
highest possible health status to Indians and urban Indians and
to provide all resources necessary to effect that policy.''
25 U.S.C. Section 1602(a) (emphasis added). In so doing, Congress
has articulated a policy encompassing a broad spectrum of ``American
Indian people.'' Notably, as originally conceived, the purpose of the
Indian Health Care Improvement Act was to extend IHS services to
Indians who live in urban centers. Very quickly, the proposal evolved
into a general effort to upgrade the IHS. See, A Political History of
the Indian Health Service, Bergman, Grossman, Erdrich, Todd and
Forquera, The Milbank Quarterly, Vol. 77, No. 4, 1999.
Similarly, in the Snyder Act, which for many years was the
principal legislation authorizing health care services for American
Indians, Congress broadly stated its commitment by providing that funds
shall be expended ``for the benefit, care and assistance of the Indians
throughout the United States for the following purposes:...For relief
of distress and conservation of health.'' 25 U.S.C. Section 13
(emphasis added). Congress enunciated its objective with regard to
urban Indians in a 1976 House Report: ``To assist urban Indians both to
gain access to those community health resources available to them as
citizens and to provide primary health care services where those
resources are inadequate or inaccessible.'' H.Rep. No. 9-1026, 94th
Cong., 2d Sess. 18, reprinted in 1976 U.S. Cong. & Admin. News (USCAN)
2652, 2657. As noted above, in Acts of Congress, as well as in both
Senate and House reports, there has been an acknowledgment of a Federal
responsibility for urban Indians.
The Supreme Court and other Federal courts have also acknowledged
that there is a Federal responsibility towards Indians, both on and off
their reservation. ``The overriding duty of our Federal Government to
deal fairly with Indians wherever located has been recognized by this
Court on many occasions.'' Morton v. Ruiz, 415 U.S. 199, 94 S.Ct. 1055,
39 L.Ed.2d 270 (1974) (emphasis added), citing Seminole Nation v.
United States, 316 U.S. 286, 296 (1942); and Board of County
Commissioners v. Seber, 318 U.S. 705 (1943). In areas, such as housing,
the Federal courts have found that the trust responsibility operates in
urban Indian programs. ``Plaintiffs urge that the trust doctrine
requires HUD to affirmatively encourage urban Indian housing rather
than dismantle it where it exists. The Court generally agrees.'' Little
Earth of United Tribes, Inc. v. U.S. Department of Justice, 675 F.
Supp. 497, 535 (D. Minn. 1987). ``The trust relationship extends not
only to Indian tribes as governmental units, but to tribal members
living collectively or individually, on or off the reservation.''
Little Earth of United Tribes, Inc. v. U.S. Department of Justice, 675
F. Supp. 497, 535 (D. Minn. 1987) (emphasis added). ``In light of the
broad scope of the trust doctrine, it is not surprising that it can
extend to Indians individually, as well as collectively, and off the
reservation, as well as on it.'' St. Paul Intertribal Housing Board v.
Reynolds, 564 F. Supp. 1408, 1413 (D. Minn. 1983) (emphasis added).
``As the history of the trust doctrine shows, the doctrine is
not static and sharply delineated, but rather is a flexible
doctrine which has changed and adapted to meet the changing
needs of the Indian community. This is to be expected in the
development of any guardian-ward relationship. The increasing
urbanization of American Indians has created new problems for
Indian tribes and tribal members. One of the most acute is the
need for adequate urban housing. Both Congress and the
Minnesota Legislature have recognized this. The Board's
program, as adopted by the Agency, is an Indian created and
supported approach to Indian housing problems. This court must
conclude that the [urban Indian housing] program falls within
the scope of the trust doctrine....''
Id. at 1414-1415 (emphasis added).
This Federal Government's responsibility to urban Indians is rooted in
basic principles of Federal Indian law.
The United States has entered into hundreds of treaties with tribes
from 1787 to 1871. In almost all of these treaties, the Indians gave up
land in exchange for promises. These promises included a guarantee that
the United States would create a permanent reservation for Indian
tribes and would protect the safety and well-being of tribal members.
The Supreme Court has held that such promises created a trust
relationship between the United States and Indians resembling that of a
ward to a guardian. See Cherokee Nation v. Georgia, 30 U.S. 1 (1831).
As a result, the Federal government owes a duty of loyalty to Indians.
In interpreting treaties and statutes, the U.S. Supreme Court has
established ``canons of construction'' that provide that: (1)
ambiguities must be resolved in favor of the Indians; (2) Indian
treaties and statutes must be interpreted as the Indians would have
understood them; and (3) Indian treaties and statutes must be construed
liberally in favor of the Indians. See Felix S. Cohen's Handbook of
Federal Indian Law, (1982 ed.) p. 221-225. Congress, in applying its
plenary (full and complete) power over Indian affairs, consistent with
the trust responsibility and, as interpreted pursuant to the canons of
construction, has enacted legislation addressing the needs of off-
reservation Indians.
The Federal courts have also found, that the United States can have
an obligation to state-recognized tribes under Federal law. See Joint
Tribal Council of Passamaquoddy v. Morton, 528 F.2d 370 (1st Cir.
1975). Congress has provided, not only in the IHCIA, but also in
NAHASDA, that certain state-recognized tribes or tribal members are
eligible for certain Federal programs. 25 U.S.C. Section 4103(12)(A).
In sum, the Federal government's trust obligation to protect
American Indians does not stop at the reservation boundary.
Federal Policy and the Development of Urban Indian Communities
Urban Indian communities have principally developed as a result of
misguided Federal programs or actions, such as the Bureau of Indian
Affairs relocation program, which relocated 160,000 Indians to cities
between 1953 and 1962. Today, the children, grandchildren and great-
grandchildren of these Indians continue to reside in these cities. They
maintain their tribal identity even if, in some cases, they have been
unable to re-establish ties, including formal membership, with their
tribes. While most, but not all, urban Indians are enrolled in
federally recognized tribes, all are Indian descendants. Their
circumstances are principally the result of Federal Indian policies;
they are deserving, morally and legally, of support from the Federal
government in achieving the highest possible health status.
There are a number of Federal programs and policies which have led
to the formation of the urban Indian population, including:
The BIA relocation program relocated 160,000 Indians to
cities between 1953 and 1962. Today, the children, grandchildren and
great-grandchildren of these Indians are still in these cities;
The failure of Federal economic policies on reservations
has forced many Indians to seek economic refuge in the cities;
The Federal policy of ``terminating'' tribes in the 1950s
and 1960s, many of which have not yet been restored to recognition;
The marginalization of tribal communities such that they
exist but are not federally recognized;
Indian service in the U.S. military brought Indians into
the urban environment;
The General Allotment Act resulted in many Indians losing
there lands and having to move to nearby cities and towns;
Court-sanctioned adoption of Indian children by non-
Indian families; and
Federal boarding schools for Indians.
Some of these federal policies were designed to force assimilation
and to break-down tribal governments; others may have been intended, at
some misguided level, to benefit Indians, but failed miserably. One of
the main effects of this ``course of dealing,'' however, is the same:
the creation of an urban Indian community.
Funding Inequities
Since the first official funding for urban Indian health through
the Indian Health Service in 1979, the urban Indian health program has
received just over 1% of the total Indian Health Service annual
appropriation (although, as noted above, 66% of Indians now live in
urban areas).
During the decade of the 1990s, Congress increased funding for
urban Indian health by 113% from $13,049,000 in 1990 to $27,813,000 in
2000. During this same period, the number of Indian people moving to
American cities was on the increase. Estimates from the 1990 census
found that more than 1.3 million Indian people were living in American
cities out of the 2.4 million people self-identifying at that time. The
2000 census shows that of the 4.1 million people self-identifying as
American Indian or Alaska Native, 2.87 million are urban. Just like the
on-reservation programs, urban Indian programs have experienced a
constant increase in the demand for our services. In fact, the increase
in the urban area is likely greater than the increase on the
reservation.
Throughout its history, the urban Indian health program has never
received a substantial boost to its funding base. Annual increases
offered by the Congress average only about $30,000 per program in new
funding each year. While we are grateful for any and all new dollars
allocated to Indian health, the reality is that urban programs are
finding themselves with increasing numbers of people in need and a
declining supplemental financial base to cover rising costs. As a
result of this lessened funding, urban Indian programs can only service
95,767 of the estimated 605,000 urban Indians eligible to receive
services.
For FY 05, the National Council of Urban Indian Health recommended
a $6 million increase to the Urban Indian Health line item of the IHS
budget. Subsequently, the Senate Committee on Indian Affairs
recommended an increase to the urban Indian health program from its
current proposed 2004 funding level of $32 million to $48 million, a
50% increase. NCUIH believes that an adjustment of $6 million or more
would be an important step in reinforcing urban Indian health efforts
for this nation.
As Urban Indian Health Programs prepared for the FY05 Budget we
have identified 19 program priorities of equal importance. These
priorities are:
1. Diabetes
2. Cancer
3. Alcohol and Substance Abuse
4. Heart Disease
5. Mental Health
6. Maternal and Child Health
7. Dental Health
8. Injuries
9. Elder Health
10. Respiratory / Pulmonary
11. Violence / Abuse
12. Infectious Disease
13. Hearing Disease
14. Eye Disease
15. Health Promo / Disease Prevention
16. Tobacco Cessation
17. Information Technology Support
18. Maintenance and Repair
19. Facilities and Environmental Health Support
With the Urban Indian Health Program occupying only 1% of the total
IHS Budget it is extremely imperative for urban programs to obtain
supplemental funding to remain in operation. Urban Indian Health
Programs access roughly $7 million in federal funds outside of the
Indian Health Service. These funds include Sections 229, 330, 340 of
the Public Health Service Act, Maternal and Children's Health Block
grant, and Title V Public Health Care Service, and Women, Children and
Infant Program, a supplemental of WIC.
NCUIH acknowledges that there are some sound reasons why the lion's
share of the IHS budget should go to reservation Indians. However, we
believe that the disparity is too great. All Indian people are
connected. Disease knows no boundaries. There is substantial movement
back and forth from reservation to urban Indian communities. The health
of Indian people in urban areas affects the health of Indian people on
reservations, and visa versa. We strongly believe that the health
problems associated with the Indian population can be successfully
combated only if there is significant funding directed at both the
urban and reservation populations.
Elevation of the Indian Health Service Director--H.R. 151
NCUIH strongly supports the elevation of the Director of the Indian
Health Service to Assistant Secretary for Indian Health as provided for
in H.R. 151. One reason why the status of Indian health has improved so
slowly since Congress announced its commitment in 1976 is that Indian
people do not have sufficient influence in the health care debate. Too
often, our voices are literally drowned-out by the cacophony of other
health care interests. For example, when we hear that the Director of
IHS cannot attend certain meetings because of his lesser position, it
is time for a change. Protocol should never come at the price of common
sense and the health needs of Americans, Indian or otherwise. Elevating
the position of the Director of Indian Health Service to Assistant
Secretary for Indian Health will greatly strengthen the voice of Indian
country, whether in the halls of the HHS, the corridors of Congress, or
wherever the health care debate occurs and decisions are made.
Indian Health Care Improvement Act
In 1976, Congress passed the Indian Health Care Improvement Act.
The original purpose of this act, as set forth in a contemporaneous
House report, was ``to raise the status of health care for American
Indians and Alaska Natives, over a seven-year period, to a level equal
to that enjoyed by other American citizens.'' House Report No. 94-1026,
Part I, p.13 (emphasis added).
The Senate has recognized that Congress also has an obligation to
provide health care for Indians, that includes providing health care to
those who live away from the reservation.
``The responsibility for the provision of health care, arising
from treaties and laws that recognize this responsibility as an
exchange for the cession of millions of acres of Indian land
does not end at the borders of an Indian reservation. Rather,
government relocation policies, which designated certain urban
areas as relocation centers for Indians, have, in many
instances, forced Indian people who did not [want] to leave
their reservations to relocate in urban areas, and the
responsibility for the provision of health care services
follows them there.''
Senate Report 100-508, Indian Health Care Amendments of 1987, Sept.
14, 1988, p. 25 (emphasis added).
Although the road ahead to equal health care still appears to be a
long one for Indians, including urban Indians, NCUIH believes H.R. 2440
is a step in the right direction. As a general matter, NCUIH supports
H.R. 2440, although we do recommend certain changes to maintain
Congress' commitment to urban Indians in H.R. 2440.
Definitions
The definition of ``Indian'' has been substantially revised in H.R.
2440 from current law, principally by separating out sub-definitions
that chiefly apply to urban Indians. NCUIH has accepted the new
structure, but has recommended that instead of defining ``Indian'' by
referring to another statute (ISDEAA), NCUIH believes that the
definition should be spelled out for clarity's sake. Therefore the
definition should read: ``The term 'Indian' means a person who is a
member of an Indian tribe.'' This also avoids any concern that the
definitional change is intended to incorporate other aspects of the
ISDEAA.
TITLE I
SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE DEMONSTRATION PROGRAMS.
Under this section, urban programs are not eligible to apply for
chronic shortage demonstration projects. Urban programs are not immune
to the same chronic shortages of health professionals that IHS and
Tribal Health Programs face. NCUIH urges amendment of this section to
include the urban programs as possible sites for demonstration
projects.
SEC. 127. MENTAL HEALTH TRAINING AND COMMUNITY EDUCATION PROGRAMS.
This section includes urban Indian programs in the study of mental
health providers that will develop the training criteria for those
providers. However, this section fails to ensure that urban Indian
health providers are included in the development and technical
assistance for community education. This is a concern because urban
programs are often left out of training and technical assistance
programs that are provided for tribal and IHS personnel.
TITLE II
Urban Indian Health Programs are not authorized in the current or
proposed legislation in sections 201 and 202 to benefit from the Indian
Health Care Improvement Fund (IHCF) or the Catastrophic Health
Emergency Fund (CHEF). Lack of authorization for urban ICHF requires
that urban programs divert funding from their current contracts to
address community health needs or seek other funding sources outside of
the Indian Health Service. If urban Indian health programs were
authorized to access IHCF there would be more of a focus on development
and provision of services to Indian patients versus the total patient
population, which includes insured non-Indian patients who are seen in
their clinic. IHCF for urban Indian health programs also would reduce
the need for urban Indian health programs to diversify their funding
sources to the extent that some programs have, e.g. one program has as
many as 60 different funding sources. The administrative savings would
benefit all urban Indian health programs. Currently, tribal members who
reside in the New York metropolitan area, without any type of
insurance, who have a catastrophic illness or are a victim of a
disaster have only three options: 1. Seek care at their home
reservation and wait for up to 6 months until the tribal/IHS contract
health care eligibility guidelines apply; 2. Apply for Medicaid and
other indigent care insurance; or 3. Nothing.
SEC. 212, PREVENTION, CONTROL, AND ELIMINATION OF COMMUNICABLE AND
INFECTIOUS DISEASES
This section includes urban programs in the consultation and
reporting processes but limits project and technical assistance funding
that is available to tribes and tribal organizations. We urge that this
assistance also be extended to urban programs.
SECTION 213
This section eliminates urban Indian health programs from
authorization of funding for certain critical services, primarily home-
and community-based services, public health functions and traditional
health care. These services are highly needed within urban Indian
health centers. Although, the urban population may not be located in an
isolated rural community, a need exists to be able to provide in-home
care to elderly and disabled persons who are not able to navigate the
urban area due to lack of transportation or failing health.
TITLE III
This section is limited to facility construction, maintenance and
enhancement. Unlike tribes and Indian Health Service, both current and
proposed legislation does not permit urban programs to participate in
the facility priority system for funding of health clinics. Several
urban Indian health programs have either purchased or built their own
facilities through commercial loans, capital improvement funds or
utilization of third party revenue received. However, these types of
funding are often difficult to secure and most times are not available
to limited direct service and outreach/referral programs. A good
facility ensures that the community has a stable location. Urban
centers that lease are faced with increasing rental costs and no sense
of ownership by the community. Programs that have had to move have
found it very expensive and time consuming.
TITLE IV
This section speaks to the federal trust responsibility through the
authorization to disregard payments received by tribes, tribal
organizations and urban programs in determining funding appropriations
for health care and services to Indians. In recent years Indian health
programs have not received adequate funding to provide comprehensive
services to Indian people. Although, it appears that appropriations
have increased, these increases have not kept up with medical rate of
inflation, general inflation increases, salary increases or population
growth.
This section also authorizes urban Indian health programs to
recover reasonable charges for services for individuals who have
private or public medical insurance. It is very important for urban
health programs to receive reimbursement from health insurance, Managed
Care Organizations, CHIP, Medicare and Medicaid when the Indian patient
is enrolled with the plan, although urban Indian health organizations
are considered to be an ``out of network provider.''
TITLE V
Title V is the heart and soul of the IHCIA for the urban Indian
health programs. This section creates 36 urban Indian health programs
and 12 urban alcohol a.k.a. ``NIAAA'' programs. This section also
serves as the guidelines for creating other urban Indian health
programs.
Items of note include the ability of current programs to create
satellite clinics to better address the health needs of the Indian
community. This is vital because many programs are located in large
metropolitan cities such as Los Angeles, San Francisco, Chicago or
Denver and have a large concentration of Indian people in their area.
Section 509 authorizes, for the first time, grants to urban
programs for the lease, purchase, renovation, construction or expansion
of these facilities. It also establishes a revolving facilities loan
fund that will be used solely for the purposes of urban facilities. The
proposed fund would be self-sustaining. Facilities funding is a great
need for almost every urban Indian health program. An important note in
this section is that the urban programs do not have access to funds for
maintenance and improvement of their facilities. The program in Boston
currently resides in a very old State institution that utilizes
skeleton keys for some of its offices.
Section 511 deals only with the issue of substance abuse; however
throughout Title VII urban Indian health programs and urban Indians are
included in this behavioral health section. Not to discount the
substance abuse needs of urban Indians, it would better serve the urban
Indians to be carried throughout Title VII because of its comprehensive
look at both mental health and substance abuse issues for Indian
people.
NCUIH recommends that Section 512, the Oklahoma City and Tulsa
Clinics provision, should be made permanent and not subject to the
Indian Self Determination and Education Assistance Act. As you may
know, the Oklahoma City and Tulsa Clinics have been very successful.
That success is the justification for making these projects permanent.
It is not, however, a justification for changing their status as urban
Indian programs. While their success is an incentive for some to urge
such a change, there is a real risk that a change, for no substantive
reason, could unnecessarily jeopardize the success of these programs
and undo all of their accomplishments.
TITLE VIII
The establishment of a National Bipartisan Commission on Indian
Health Care Entitlement is welcome. Healthcare for Indian people must
be viewed as an entitlement versus a discretionary program.
Conclusion
America is nowhere near the lofty goal, set by the Congress in
1976, of achieving equal health care for American Indians, whether
reservation or Urban. It has been twenty-seven years since Congress
committed to raising the status of Indian health care to equal that of
other Americans, and yet, Indians, whether reservation or urban,
continue to occupy the lowest rung on the health care ladder, with the
poorest access to America's vaunted health care system. NCUIH
challenges this Committee to think in terms of that goal as it
considers H.R. 151 and H.R. 2440. We believe that these legislative
measures will result in the betterment of health for all Indian people
regardless of where they live, and reduce health disparities for Indian
people. NCUIH thanks this Committee for this opportunity to provide
testimony. We strongly urge your positive action on the matters we have
addressed today.
______
Mr. Renzi [presiding]. Mr. Hunter, I want to thank you for
your articulation. In speaking with staff, I want you to know
that the silence on the definition as it relates to urban
Indians is no intention to omit. You have our commitment that
we will work with you now to fix it before markup, so that at
markup the language will be included.
I would ask that we please get together. I know there was
representatives from the urban Indian association that were
included in the beginning, and if we need to move forward with
some technical changes, we are willing to do that, OK?
Mr. Hunter. Thank you.
Mr. Renzi. You deserve it, you absolutely deserve it.
We're going to move now to Julia Davis-Wheeler, who is Co-
Chair of the National Indian Health Board. Julia.
STATEMENT OF JULIA DAVIS-WHEELER, CHAIRPERSON,
NATIONAL INDIAN HEALTH BOARD
Ms. Davis-Wheeler. Good morning, distinguished members of
the House Resources Committee. As stated, my name is Julia
Davis-Wheeler, and I am Chairperson of the National Indian
Health Board. I also serve as Co-Chair of the Steering
Committee on the Indian Health Care Improvement Act.
I would like to have the House Resources Committee also
recognize another Board member that is with me, Chairwoman from
the San Carlos tribe, Kathy Kitcheyan. She is sitting behind
me. She is also a member of the National Indian Health Board.
As I stated, the NIHB has served since 1972 all the
federally recognized American Indian and Alaska Native
governments in advocating for the improvement of Indian health
care delivery to American Indians and Alaska Natives.
I would like to speak to you about the elevation of the
Director of the Indian Health Service to the Assistant
Secretary level. I'm just going to say a few words before I do,
though, about Secretary Tommy Thompson.
As a tribal leader, I have publicly stated that I feel very
comfortable in saying that Secretary Thompson has been a most
accessible Cabinet Secretary in this Administration. He has
made every effort possible to visit with tribal leaders. Just
last month, he toured several villages throughout the State of
Alaska and capped off his visit by hosting a listening session
with tribal governments from the States of Alaska, Idaho,
Oregon and Washington.
Tribal leaders have long pushed for the elevation of the
status of the Indian Health Service Director to the Assistant
Secretary level. This has been going on for the past 6 years.
The National Indian Health Board, as well as the National
Congress of American Indians, have passed resolutions at our
General Assembly sessions supporting this elevation.
H.R. 151, elevating the Director, is quite appropriate. As
stated earlier, it reflects the government-to-government
relationship between the United States and the tribal
governments. It is very important to Indian country that we are
extremely hopeful that it finally is signed into law this year.
The National Health Board supports H.R. 151 as it ensures
American Indians and Alaska Natives that their health issues
remain a priority beyond this current Administration.
As we advance this legislation, we would like to take
adequate steps to ensure that we build on the improvements that
have been made within the DHHS over the past few years in
addressing tribal issues, and further, that the Indian Health
Service does not become isolated from other DHHS's. We
recommend that the legislation, indeed, places the IHS Director
at the level of Assistant Secretary, but it do so in a manner
which does not diminish the Secretary's responsibilities to
carry out the Federal Government's trust responsibility.
As I mentioned previously, over the past several years
American Indians and Alaska Natives have slowly crept into the
mindset of nearly all areas of DHHS. The raised awareness is
attributable to several things, including the informed
personnel within the office of the Secretary and the hard work
of the DHHS officials to advance issues internally and, most
importantly, the persistence of tribal governments to ensure
that the purpose and intent of the Executive order mandating
tribal consultation is properly carried out.
One of the more significant examples of the increased
awareness and acknowledgment of the importance of Indian issues
within the Department is the revival of the Secretary's
Intradepartmental Council on Native American Affairs, which the
Indian Health Service Director serves as vice-chair. We, as
tribal leaders, feel that it is appropriate that H.R. 151
incorporate language that places the IHS Director as Chair or
Co-Chair of the Secretary's Intra-departmental Council on
Native American Affairs. The IHS Director currently serves as
Vice-Chair.
Now I would like to speak to you on the Indian Health Care
Improvement Act Reauthorization. I am going to be brief this
morning. I realize that the Committee members are quite of the
need and the purpose of the reauthorization.
In addition to me as Chair of the National Indian Health
Board, I stated earlier that I serve as Co-Chair of the
National Steering Committee, with Rachel Joseph, Chairperson of
the Lone Pine Paiute Shoshone Tribe. The National Ateering
Committee was formed in 1999 to develop and submit
recommendations for changes to the Indian Health Care
Improvement Act.
Over the last several years, the National Steering
Committee has worked closely with American Indian and Alaska
Native tribal leaders, the Administration, Congress and the
Indian Health Service to develop amendments to the Indian
Health Care Improvement Act. We have proceeded with this
process in a spirit of cooperation and negotiation and the
language has gone through numerous changes. The end product is
the language of H.R. 2440.
At this time I would like to discuss Title I, the Indian
Health Human Resource Development. While other titles may
garner more attention due to their potential fiscal impact,
Title I addresses the critical need to increase the number of
American Indian and Alaska Natives entering the health
professions. Health care remains the top priority in Indian
country. It is critical to the existence of our people.
I see that the light is on. I just need to break away from
my summation comments and let the House Committee members know
here today that it is, indeed, a legislation that we feel as a
national steering committee that we would truly and honestly
like to see passed in the 108th Congress.
I just flew in last night from St. Paul. The National
Indian Health Board is having their conference there. Dr. Grim
is at that meeting right now. I informed the assembly before I
left that I was coming to testify. There is so much support
from all of the American Indians and Alaska Native governments
for this legislation. I impose on you to look at this
legislation very carefully and to consider the under-funding
that we, as tribal governments, have gone through for years and
years, and give this legislation its proper passage.
Thank you.
[The prepared statement of Ms. Davis-Wheeler follows:]
Statement of Julia Davis-Wheeler, Chairperson,
National Indian Health Board, Council Member, Nez Perce Tribe
Chairman Pombo, Ranking Member Rahall, and distinguished members of
the House Resources Committee, I am Julia Davis-Wheeler, Chairperson of
the National Indian Health Board. I am an elected official of the Nez
Perce Tribe, serving as Council Member. On behalf of the National
Indian Health Board, it is an honor and pleasure to offer my testimony
this morning on efforts to elevate the Indian Health Service Director
to the position of Assistant Secretary of Health and to reauthorize the
Indian Health Care Improvement Act.
The NIHB serves nearly all Federally Recognized American Indian and
Alaska Native (AI/AN) Tribal governments in advocating for the
improvement of health care delivery to American Indians and Alaska
Natives. We strive to advance the level of health care and the adequacy
of funding for health services that are operated by the Indian Health
Service, programs operated directly by Tribal Governments, and other
programs. Our Board Members represent each of the twelve Areas of IHS
and are elected at-large by the respective Tribal Governmental
Officials within their regional area.
Indian Health Service Director Elevation to Assistant Secretary of
Indian Health
Before I begin discussing H.R. 151 to elevate the Indian Health
Service Director to the position of Assistant Secretary of Indian
Health, I would like to say a few words about the Secretary of Health
and Human Services, Mr. Tommy G. Thompson. As a Tribal leader, I have
publicly stated that I feel very comfortable in saying that Secretary
Thompson has been the most accessible Cabinet Secretary in this
Administration. He and his immediate staff have been available at every
possible opportunity to visit with tribal leaders and to see firsthand
the health needs of our people. Just last month, he toured several
villages throughout the State of Alaska, and capped off his visit by
hosting a listening session with Tribal governments from the States of
Alaska, Idaho, Oregon and Washington.
Also, the National Indian Health Board is very pleased to have Dr.
Charles Grim serving as Director of the Indian Health Service (IHS). We
have supported his nomination from the beginning and, in fact, our Vice
Chair, H. Sally Smith, held the Bible that was used to swear-in Dr.
Grim. We appreciate his willingness to take on such a significant role.
He is actually in Saint Paul, Minnesota, today participating in our
annual conference.
Tribal leaders have long pushed for elevating the status of the IHS
Director as a means to recognize the importance of the federal
government's functions in carrying out its trust responsibility to
American Indian and Alaska Native Tribal governments. The intent of
H.R. 151 is quite appropriate as it does just that in a manner
consistent with the government-to-government relationship between the
United States and Tribal governments. H.R. 151 is very important to
Indian Country and we are extremely hopeful that it is finally signed
into law this year. The National Indian Health Board is very supportive
of H.R. 151 as it ensures American Indian and Alaska Native health
issues remain a priority beyond this current Administration.
As we advance this legislation, we want to take adequate steps to
ensure that we build on the improvements that have been made within the
Department of Health and Human Services (DHHS) over the last few years
in addressing Tribal issues and further, that the Indian Health Service
does not become isolated from other areas of DHHS. We feel that this
can be accomplished with minor revisions to H.R. 151.
We recommend that the legislation indeed places the IHS Director at
the level of Assistant Secretary of Indian Health, but do it in a
manner which does not diminish the Secretary's responsibilities to
carry out the federal government's trust responsibility to Tribal
governments.
As I mentioned previously, over the past several years, American
Indian and Alaska Native issues have slowly crept into the mind-set of
nearly all areas of DHHS. They raised awareness and are attributable to
several things, including the informed personnel within the Office of
the Secretary, the hard work of DHHS officials to advance issues
internally, and, most importantly, the persistence of Tribal
governments to ensure that the purpose and intent of the Executive
Order mandating Tribal consultation is properly carried out.
One of the more significant examples of the increased awareness and
acknowledgment of the importance of Indian issues within the Department
is the revival of the Secretary's Intradepartmental Council on Native
American Affairs, which the Indian Health Service Director serves as
Vice Chair. We feel that it is appropriate that H.R. 151 incorporate
language that places the IHS Director as Chair of the Secretary's
Intradepartmental Council on Native American Affairs.
Because of the many critical issues that need to be addressed
within the Department of Health and Human Services, we feel that any
changes to the structure of the Department must be done in a manner
that does not isolate Indian health issues, but instead makes these
issues a common thread among all Department areas.
Indian Health Care Improvement Act Reauthorization
Given the previous joint House and Senate hearing on the Indian
Health Care Improvement Act, I'm going to be brief this morning. I
realize the Committee members are quite aware of the need and purpose
of the reauthorization; therefore I would like to focus on the efforts
of Tribal leaders to craft H.R. 2440 in a way that addresses previous
concerns raised by the Administration and responds to the current
political realities facing Congress.
National Steering Committee for the Reauthorization of the Indian
Health Care Improvement Act (IHCIA)
In addition to my position as Chair of the National Indian Health
Board, I also serve as the Co-Chair of the National Steering Committee
for the Reauthorization of the Indian Health Care Improvement Act
(IHCIA). Rachel Joseph, Chairperson of the Lone Pine Paiute Shoshone
Tribe, serves as the other Co-Chair. The NSC was formed by the Indian
Health Service in 1999 to develop and submit recommendations for
changes to the Indian Health Care Improvement Act. The NSC is comprised
of elected tribal representatives throughout Indian Country, and also
includes urban health program representation.
Over the last several years, the NSC has worked closely with
American Indian and Alaska Native Tribal leaders, the Administration,
Congress, and the Indian Health Service to develop amendments to the
Indian Health Care Improvement Act. We have proceeded through this
process in a spirit of cooperation and negotiation and the language has
gone through numerous changes. The end product is the language of H.R.
2440.
As the Committee is well aware, funding for the Indian Health
Service lags far behind other segments of the population and has failed
to keep pace with population increases and inflation. Current Indian
Health Service funding is so inadequate that less than 60 percent of
the health care needs of American Indians and Alaska Natives are being
met. In order to address the need for additional health care resources,
Title IV of the Indian Health Care Improvement Act addresses access to
Medicare, Medicaid and other third party reimbursements. It is one of
the most important provisions of the Indian Health Care Improvement Act
as it makes IHS hospitals eligible for Medicare reimbursements, and
also makes IHS facilities eligible for Medicaid reimbursements. Title
IV makes it possible for Medicare- and Medicaid-eligible American
Indians and Alaska Natives to utilize these benefits.
Since the passage of the Indian Health Care Improvement Act in
1976, Medicare and Medicaid payments have become vital sources of
revenue for basic Tribal hospital and clinic operations. In FY 2002
alone, IHS and tribally operated hospitals and clinics collected $460
million for services provided to Indian people enrolled in these
programs. This amount enhances the resources available for the IHS
hospitals and health clinics budget by nearly 30%.
In order to further improve the ability of Indian Country health
providers to access third-party resources, the NSC developed several
changes to Title IV that were included in S. 212 introduced during the
107th Congress. When asked to respond to the language contained in S.
212, several concerns were raised by Health and Human Services
Secretary Tommy G. Thompson regarding the proposed changes to Title IV.
The concerns were primarily related to costs. I would like to note that
S. 556, introduced during this Congress, is identical to S. 212 and
therefore many of the concerns raised in regards to S. 212 remain.
In response to those concerns, the National Steering Committee
revised their recommendations for the reauthorization and those changes
are reflected in H.R. 2440. I think it was quite helpful to hold the
joint House Resources Committee and Senate Committee on Indian Affairs
hearing in July as it illustrates the efforts of both houses to pass a
bill this session. Although the bill was introduced in the House, it
was developed with input and involvement from both House and Senate
members and their staffs.
H.R. 2440 reflects several changes made to the original tribal
proposal prepared in 1999 by the National Steering Committee (NSC). The
legislation includes revisions to the 1999 proposal in response to
Secretary Thompson's concerns. I will now briefly discuss the most
significant changes made in H.R. 2440 that respond to the
Administration's concerns about S. 212.
Qualified Indian Health Program (QIHP). This provision has been
removed. The NSC designed QIHP as a new provider type through which
Indian health programs and urban Indian health programs could more
fully exercise their statutory authority to receive payments under
Medicare, Medicaid and SCHIP. Secretary Thompson expressed concern that
QIHP was complex and would be administratively burdensome. Tribal
leaders acknowledged that the CBO score of this provision--in excess of
$3 billion over ten years--could be a barrier to Congressional
acceptance of QIHP and therefore removed it.
In place of the QIHP proposal, Tribal leaders seek a comprehensive
study by the Department of Health and Human Services (DHHS) of
reimbursement methodologies of Medicare and Medicaid for the Indian
Health Service (IHS), Tribal health programs, and health programs of
urban Indian organizations. The new provision found in H.R. 2440
directs the Secretary to perform such a study and report the findings
to Congress. The Secretary is to examine whether payment amounts under
current methodologies are sufficient to assure access to care and
whether these methodologies should be revised consistent with those
applicable to the ``most favored'' providers under the Social Security
Act. The current ``all-inclusive'' rate system through which IHS and
tribal hospitals and some clinics now receive Medicare and Medicaid
reimbursements would remain in place until the Secretary's
recommendations are reported to Congress and Congress decides whether
to make any changes.
Extension of 100% Federal Medical Assistance Percentage (FMAP).
Tribal leaders also agreed to delete a provision that would have
extended the 100% FMAP to services provided to Medicaid eligible
Indians referred by IHS or tribal programs to outside providers, such
as referrals made through the contract health services program. Under
current interpretation of the Centers for Medicare and Medicaid
Services (CMS), the 100% FMAP is made available to States only for
reimbursements for services provided directly in an IHS or tribal
facility, even though the only reason the patient required care outside
the IHS or tribal facility was that the facility could not directly
provide the service and had to rely on an outside provider.
While State governments are very supportive of the 100% FMAP
expansion, DHHS objected that its cost was too high--more than $2
billion over ten years--and that its financial benefits would flow only
to the States, not to Indian health programs and their Indian
beneficiaries. While the NSC disagrees with the Department's
interpretation of the statute and their conclusions about the effect of
the proposed amendment, we agreed to delete the provision from the
IHCIA.
Waiver of Medicare Late Enrollment Penalty. The 1999 tribal
proposal (and S. 212 and S. 556) sought to waive the premium penalty
for any Medicare-eligible Indian who did not timely enroll in Medicare
Part B because of a number of barriers. The DHHS strongly objected to
this provision as it would treat Indians differently than other
Medicare-eligible persons who do not timely enroll. The DHHS asserts
that the penalty is needed to encourage eligible persons to enroll and
begin paying Part B premiums when they first become eligible, rather
than waiting until they become ill and need to use their Medicare
coverage. Tribal leaders also agreed, reluctantly, to delete this
provision.
Regulations. Secretary Thompson objected to the tribal leaders'
call for all regulations--including Social Security Act regulations
affecting Indian health providers--to be prepared through Negotiated
Rulemaking with tribal representatives. He asserted that the large
number and complexity of Social Security Act regulations makes
negotiated rulemaking unfeasible. In response to this concern, tribal
leaders eliminated Social Security Act changes from the bill's
negotiated rulemaking provision.
We believe the changes to the original tribal proposal submitted in
1999 significantly reduce the bill's federal budget impact. S. 212
(identical to S. 556) was scored in 2001 as having a federal budget
impact of $6.9 billion over ten years. Deletion of the QIHP and the
100% FMAP provisions together reduce the bill's score by about 70
percent. We ask that the Committee submit a request to the
Congressional Budget Office to either score S. 556 without the above-
mentioned provisions, or provide a fiscal budget impact on H.R. 2440.
Centers for Medicare and Medicaid Services Tribal Technical Advisory
Group (TTAG)
At the request of Tribal leaders, the Centers for Medicare and
Medicaid Services (CMS) established the Tribal Technical Advisory Group
(TTAG) to advise CMS on Medicare, Medicaid, and Children's Health
Insurance (CHIP) policy issues related to American Indians and Alaska
Natives. An informal TTAG was formed in 2001 and consists of Tribal
leaders, Area Indian Health Boards, and designated national Tribal
organizations, including the National Indian Health Board. The
activities of the TTAG are coordinated primarily through the
Intergovernmental and Tribal Affairs Office within CMS.
The TTAG has forwarded several recommendations to Congress and CMS
regarding recommended changes to the reimbursement methodologies in
place for the Indian Health Service, Tribal health programs, and Urban
Indian programs. The informal TTAG is adamant in its position that any
reform or changes in the Medicare, Medicaid or CHIP programs must allow
for Tribal allocation or other direct funding mechanisms that authorize
Indian health programs access to Centers for Medicare & Medicaid
Services (CMS) program funding.
The TTAG has worked closely with the National Steering Committee to
develop the changes to Title IV of the Indian Health Care Improvement
Act that are reflected in H.R. 2440, which are the most recent NSC
recommendations.
Conclusion
On behalf of the National Indian Health Board, I would like to
thank the Committee for its consideration of my testimony and for your
diligence in making the health of American Indian and Alaska Native
people a high priority of the 108th Congress. I have been involved with
the National Steering Committee since its inception in 1999 and have
seen the hard work and compromises that Tribal leaders have made.
Tribal leaders have come to the table to work out the more contentious
provisions and we urge the Committee to act swiftly on this important
piece of legislation. In order to reduce the terrible disparities
between the health of American Indians and Alaska Natives compared to
other Americans, we need to provide Tribal governments and the Indian
Health Service with the proper framework to function in the most
effective and efficient manner. Further, we request that the Committee
urge the Administration to raise any concerns regarding this
legislation in a timely manner so that passage of this bill during this
session is not jeopardized.
[An attachment to Ms. Davis-Wheeler's statement follows:]
[GRAPHIC] [TIFF OMITTED] T9608.001
______
Mr. Renzi. Thank you, Julia. I'm grateful.
I want to also thank you for recognizing Chairwoman Kathy
Kitcheyan of the San Carlos Apache tribe, a former teacher and
real strong leader down there in southern Arizona, as well as
nationally, in the health care field. We look forward to her
testimony tomorrow as it relates to some water issues on the
San Carlos reservation. All three of you, thank you so very
much for your testimony.
We're going to move to a 5-minute question and answer
period, if you don't mind. I would like to begin by recognizing
the gentlelady from the Virgin Islands, Ms. Christensen.
Mrs. Christensen. Thank you, Mr. Chairman.
I want to say that on H.R. 2440 you do get two bites at the
apple. As I said earlier, it's in our minority health bill,
which we hope to introduce in the next couple of weeks. I guess
I could presume to say that you have the support of all of the
other minority caucuses in the House. As some of the amendments
are incorporated into H.R. 2440, as you are recommending and as
everyone has pledged to work with you to adopt, those will be
incorporated as well.
Co-Chair Wheeler, you had said in your testimony on H.R.
151 that the elevation to Assistant Secretary of Indian Health
should be done in a manner which does not diminish the
Secretary's responsibilities to carry out the Federal
Government's trust responsibilities to tribal governments. I
just wonder if there is any concern that that elevation could,
in any way, undermine the sovereignty of the tribes, moving
from the Director into the Department as an Assistant
Secretary.
Ms. Davis-Wheeler. There is some concern from tribal
governments. I guess the upside to that is that the Director
would be brought up to the level of Assistant Secretary, but
that is why we put the comment in the testimony, that the
Secretary of DHHS still needs to honor those treaties that were
signed by all the tribal governments.
Mrs. Christensen. Thank you.
President Hunter, having had some summer fellows who were
from urban tribes, I know that within all of the disparities in
health care and the disparities in all services that the tribes
face, the urban tribes perhaps are more adversely impacted.
Just speaking to Title I, are you satisfied that there will
be improvement in Title I? Is there enough outreach in that to
ensure that urban tribal members get the outreach and get the
scholarships to get into the health professions, or do we need
to do something more there?
Mr. Hunter. Congresswoman, you used a very interesting
word--and that word is ``outreach''--regarding the program. I
would have to say no, there has not been enough outreach
regarding that program's availability to urban Indians and
urban populations.
For example, just recently I found out that, as part of the
package, urban programs are eligible to provide for tuition
reimbursement, and we knew that for a while. We have known that
we are eligible as sites for the placement of scholarships, but
we didn't know that there would be additional tuition
reimbursement. So I have been trying to get that word out. But
that probably has been in place for some time and we were not
aware of it. So I do see the need for additional outreach and
information coming out of the IHS to urban programs regarding
Title I and its benefits.
Mrs. Christensen. Thank you.
I also have a question for President Shirley. In your
comments on Title I, you say that the Navajo Nation recommends
that a greater degree of flexibility and autonomy be provided
to the Indian Health Service tribes and urban Indian health
programs to implement Title I. I wonder if you could elaborate
on what you mean by the flexibility. What kind of flexibility
are you recommending be allowed under the Act?
Mr. Shirley. What I am alluding to there is more
consultation with tribes and more input, meaningful input from
tribes into the legislation and services that are being
provided out there in Indian country.
Mrs. Christensen. And even the types of health providers
perhaps, that the tribe be able to look at what their specific
needs are and make sure that, within whatever is included in
Title I, that you have some flexibility to decide what kinds of
health providers you need and so forth; I would imagine that's
what you're also referring to.
Mr. Shirley. That's exactly right, Congresswoman.
Mrs. Christensen. Thank you.
Thank you, Mr. Chairman.
Mr. Renzi. I thank the gentlelady.
I would like to recognize the gentlelady from the great
State of California, Ms. Napolitano.
Mrs. Napolitano. Thank you, Mr. Chairman.
In my questions and comments to Mr. Michel Lincoln, the
Deputy Director, do you have any comments on what I was
alluding to--mental health assistance, in being able to provide
other universities access so that the jurisdiction of tribes in
those areas could be helped?
Ms. Davis-Wheeler. Acting Chairman Renzi, could I respond
to that?
Mr. Renzi. Yes, Ma'am.
Ms. Davis-Wheeler. Some of the factors include the lack of
opportunity for American Indians and Alaska Natives to receive
quality medical education, disproportionate pay for health
professions, inferior equipment, outdated facilities, and the
geographic remoteness of most of our tribal health facilities.
Indian country has to compete with health providers with
governmental facilities that are funded at a much higher level,
as well as the private sector. It is nearly impossible to offer
a competitive employment package to potential health
professionals without proper incentives. Title I of the Indian
Health Care Improvement Act provides Indian country with the
proper tools to employ qualified health professionals.
One of the other things that I would like to state is that
I would recommend to this Committee that you work diligently to
ensure that the Indian Health Service is properly funded to
offer competitive pay for health professionals and top rate
equipment and facilities, and for them to serve American
Indians and Alaska Natives.
Thank you.
Mrs. Napolitano. Mr. Chair, one of the things she is saying
is quite true. I also know that a lot of the women and young
people need education in math and sciences in order to be able
to access getting into many of the professions, including the
health professions.
Now, that being said, I don't know whether that is a focus
in your schools, or in the schools that are in Native American
tribes, and whether or not some of the people who are
unemployed could be helped by giving them additional
instructions on math and science so as to be able to apply for
entry-level health professions, such as certified nurse
assistant, which is right now in dire need throughout the
United States, which leads into the professions of RN, LPN,
medical assistant, whatever you want.
Now, is there any of that being addressed through your
services or through any of the tribal offices, or the health
board, or anybody, because we have a dire need of individuals
to be brought up to a par that they can participate in entry-
level jobs for the medical services. Without that, you can try
to make available training, but if they don't qualify, you're
going to have to have remedial classes for them, whether at the
college level or OP or any other institution.
Ms. Davis-Wheeler. Chairman Renzi, I would like to respond
to that.
Mr. Renzi. Yes, Ma'am.
Ms. Davis-Wheeler. Congresswoman Napolitano, the National
Indian Health Board has been working with the National Congress
of American Indians through a health information systems task
force, which is addressing exactly what you're talking about,
working with the tribal colleges, getting some computers set up
at the colleges and at the tribal headquarters, and within the
tribal structure, to enhance those people that we have now and
bring their skills up.
Also, the National Indian Health Board has been working
with the American Indian Physicians Association. We had a
couple of Indian physicians at our conference yesterday that
spoke to us about the need to collaborate more with them, to
get those health sciences, math and everything, out to those
professions that we need.
Mrs. Napolitano. Thank you, Miss Davis-Wheeler. Not that
you're missing the point, but this instruction has got to be
begun even in the grammar schools.
Ms. Davis-Wheeler. Yes.
Mrs. Napolitano. By the time you're in high school, the
youngsters are no longer able to get enough instruction to be
qualified to enter these professions. I would hope that this
would be one of the things you would look at as you look at the
whole ramification of not only this bill, but also how to
address the issue with every tribe, because I'm sure everybody
has the same problem. It isn't just one tribe or one State. It
is generic. Everybody has the same problem.
So how do we address that by beginning to help, to either
fund it or address it in the education system, to address it
into the medical system.
Thank you, Mr. Chair.
Ms. Davis-Wheeler. A point well taken, and we will as a
Board look at that very closely. Thank you.
Mr. Renzi. The gentleman from New Mexico.
Mr. Tom Udall. Thank you, Chairman Renzi.
Let me say to Chairman Renzi, he and I share the Navajo
Nation in our two Congressional Districts, and we work very
closely together on these issues. We look forward to doing so
in the future.
It is wonderful, President Shirley, to have you here today
representing the wonderful Navajo Nation. I think you have made
a very strong statement. In particular, I'm looking at the
Navajo area health service and the successes you have had. It
is really a wonderful thing to see when the Navajo people are
doing better than the general U.S. population in cancer deaths,
particularly breast cancer, heart disease deaths, low weight
births. I mean, those are some real successes and you should be
very proud of those.
One of the things that you do highlight is what we spend on
health care services. The treaty that the U.S. Government
entered into with the Navajo Nation talked about providing
good, high-quality health care. When you have numbers where the
Indian Health Service is spending a little over a thousand
dollars a person, and the average is close to $3,500 a person,
clearly there are problems there.
Could you tell us the position of the Navajo Nation in
terms of how you think it would change if we had the health
care dollars up to the amount that the average is, and what
difference that would make in terms of health care on the
Navajo Nation?
Mr. Shirley. Congressman Udall, I think what it would mean
is more health care professionals being there on Navajo land
delivering health care services to Navajo people, and not only
to Navajo people but all Native Americans that are within the
Navajo Nation boundaries. In terms of giving dollars to Native
Americans, there would be facilities not as far off. I earlier
alluded to bad dirt roads as being one of our problems. If
there could be more dollars, there would be more facilities out
there with health care professionals to where they are more
locally accessible. I think that's what it means. If we can
have sufficient funding, adequate funding, we will have better
health care delivery services on Navajo land.
Mr. Tom Udall. Thank you.
One of the parts of this--and you mentioned it, and you
just alluded to it now--is Title I, which has the purpose of
really trying to get young Native Americans educated in health
care fields and being able to return to the reservation, return
to the Navajo Nation and work with their community and up the
level of health care. We haven't seen the successes that we
should in that particular area.
I like the idea that you put in here of saying we need to
do more, we do more of an increase in that area. So anything
that you can tell us that would move us along in terms of
getting more young Native Americans into health care education
fields, we would be happy to hear it on this Committee.
Now, you mentioned Title II. You and I have worked, and I
know Chairman Renzi knows about this, with the Navajo uranium
miners. The mining on the reservation has just been devastating
to the Navajo people. We have created a program in order to
compensate Navajo miners who have died of lung cancer and many
other kinds of cancer. But there is still a lot of suspicion
out there that this is more widely dispersed than just people
that went into the mines, that the families may have been
impacted.
What you have called for here under Title II is a section
for studying and monitoring programs to monitor the trends. One
of the areas is the families. As you well know, these Navajo
families that had a miner and the miner came home and had the
mining dust and uranium on their clothes, and brought rocks in,
not knowing that they were dangerous and had uranium in them,
they need to be monitored.
I think that's what you're talking about in a general way,
isn't it, that there are a lot of suspicions in terms of all of
the mining, and we just need to be able to assure people that
we are monitoring their health and following this situation?
Mr. Shirley. Exactly, Congressman. I would point out, too,
the points awarded to the different afflictions that are caused
by uranium radiation I think needs to be re-looked at. Before
compensation can be had, the Federal Government says you have
to have a certain amount of points before that can happen. But
there are members of my people out there and families where
they were also afflicted by the uranium and radiation but are
being told they are not eligible. I think that needs to be
relooked at.
That's where I bring out the point that a lot of what's
going on in Native country in trying to get compensation to
those miners who were afflicted and the families who were
afflicted needs to be revisited.
Mr. Tom Udall. Thank you, President Shirley. I see my time
is up.
I just want to tell you, please let Congressman Renzi and
myself know, as we move along with this legislation, if there
are other changes that you see and if there are things that pop
up that you didn't realize now are going to be detrimental to
the Navajo Nation, we want to help with them.
I have another commitment and I won't be able to stay for
the full hearing, but I thank you very much for your
leadership, and your presence here is really setting a very
high standard in the early months of that presidency.
Thank you, Chairman Renzi.
Mr. Shirley. Thank you, Congressman.
Mr. Renzi. I want to thank Congressman Udall. He speaks the
truth when he talks about a partnership and the friendship that
exists between the two of us to work together. I'm thankful for
his leadership and some of his mentorship that he has shown me
in being a new Congressman. I appreciate that, sir.
Many may not expect it--I know Mr. Hunter probably knows
the next gentleman--but one of the best fighters for Native
American rights and issues comes from the State of New Jersey,
of all places. The gentleman from New Jersey.
Mr. Pallone. Thank you. Is that comment partially based on
the fact that you are from Long Branch, NJ too?
[Laughter.]
I shouldn't say that.
Mr. Renzi. I was born there. But I'm an Arizonan, remember?
Mr. Pallone. I know. I know. I appreciate what the
gentleman said, though. Thank you.
I wanted to ask Miss Davis-Wheeler. You know, I agree with
you 100 percent, that the main goal here in the Committee and
in the House in general is to try to get this bill passed and
moved as soon as possible, because it has been a number of
years now since the National Steering Committee put this
together, and I know there have been some changes. But given
that we do have a crisis, or I think we do have a crisis with
regard to the Indian Health Service and Indian health care, it
is important to move the bill, and we all share that.
You mention in your written testimony that you had tried to
address some of the concerns that had been raised in the past
about the legislation. I think it was primarily the cost,
because I know in the last session, when we were going around
and trying to get a hearing here, many of the members said this
is very costly. I know that the bill that has been introduced
now is somewhat different.
Could you maybe summarize that in a way, because I think
it's important in terms of our ability to get it moved, to talk
a bit about the changes that have been made to address the
cost, overall cost.
Ms. Davis-Wheeler. Yes, thank you, Congressman Pallone.
Well, since the passage of the Indian Health Care
Improvement Act in 1976, Medicare and Medicaid payments have
become vital sources of revenue for basic tribal hospital and
clinic operations. In Fiscal Year 2002 alone, IHS and tribally
operated hospitals and clinics collected $460 million for
services provided to Indian people enrolled in these programs.
This amount enhances the resources available for the IHS
hospitals and clinics budget by nearly 30 percent.
In order to further improve the ability of the Indian
health providers to access third party resources, the National
Steering Committee developed several changes to the Title IV
that were included in S. 212 during the 107th Congress.
When asked to respond to the language contained in S. 212,
several concerns were raised by the Health and Human Services
Secretary, Tommy Thompson, regarding the proposed changes in
Title IV. The concerns were primarily related to costs.
I would like to note that S. 556, introduced during this
Congress, is identical to S. 212 and, therefore, many of the
concerns raised in regards to S. 212 still remain.
In response to the National Steering Committee revising
their recommendations for the reauthorization, I think it was
quite helpful to hold the joint House Resources Committee and
Senate Committee on Indian Affairs hearing that was held in
July. This was developed with input and the involvement of both
House and Senate members and their staff.
I don't know if that adequately answers your question
regarding the costs, but I know Title I has been looked at very
closely by our National Steering Committee members.
Mr. Pallone. Thank you.
I know a part of this has already been asked, and it's kind
of a broad question, but to President Shirley, in terms of
Title I, the problem in terms of not having enough health
professionals, Native American or not, just addressing Indian
country, particularly in the more remote areas--I will look at
it from a threefold question. I asked this before.
Is the problem that a lot of people have difficulty in
gaining entrance to nursing schools or medical schools, or is
it that they can't afford it and we need more scholarships? Or
is the problem the third thing, maybe they take advantage of
these scholarship programs and they serve in Indian country for
a few years, but then don't stay and move on to another area?
I know that the numbers have not really increased much in
the last few years, so obviously in Title I we're trying to
address that. But if you could just talk about maybe those
various stages.
Mr. Shirley. Thank you, Congressman.
Well, I think one of the problems on the upper Navajo land
is that the Navajo Nation, as a government, has never made
education its priority. It has always been down to the number
eight, nine, ten, in there somewhere. But this time around,
through my administration, the Navajo Nation as a whole nation
and as a government has never had education as its number one
priority. So why we aren't having enough people going into the
health professions is one of the things we are looking at.
The biggest problem we have in getting people into the
health professions, as well as the other professions, is the
lack of scholarships. If the Committee here, and the Congress
and the Senate can adequate fund the scholarship program within
the Indian Health Service bill, that would go a long ways
toward helping us to move with our people toward getting them
into the health professions.
A lot of our students aren't having problems getting into
the universities or colleges. That's not a problem. They get
themselves eligible and they get admitted, but then they go
looking for scholarships and it's not there. The Navajo Nation
at this point in time is doing what it can to fund as many of
its members as it can to try to encourage them to go to higher
learning.
The other thing, too, is that we like to graduate more
doctors, nurses, dentists, but there needs to be a guarantee
put into where, when they graduate and get their doctor's
degree or a medical degree, they need to return to Navajo land
and to Indian country to give service to the people. There
needs to be a mechanism put in to where that will happen. Of
course, like I said, for the Navajo Nation, education is our
number one priority. We are looking at mechanisms just like
that, Congressman.
Thank you.
Mr. Pallone. Thank you.
Thank you, Mr. Chairman.
Mr. Renzi. I thank the gentleman.
Last week we passed a land exchange that helped the Eastern
Band of Cherokee, and this next gentleman was absolutely key in
making sure we got it through. He worked across both aisles,
Democrats and Republicans coming together.
I'll tell you, personally, I have had a chance to work with
him and develop a friendship. If I was going into battle, I
would want him on my side. So I want to thank the gentleman
from California, Mr. Baca, for being here today. I will shift
to him for his questions.
Mr. Baca. Thank you very much, Mr. Chairman, and thanks for
your concern for Native Americans as well. And I'm not from New
Jersey. As he stated, I'm from California and not from Arizona.
One of my questions would be that we're all very much
concerned with improving the quality of life, especially in the
health professions. I do agree with Ms. Davis-Wheeler, that we
really need to put in a lot more funding. If we really want
parity, and if we look at sovereign countries as well, we must
have that same opportunity that others have. There seems to be
a lack of funding when it comes to sovereignty and sovereign
countries.
One of the things we have to do is make sure that in order
for health services to be provided, funding has got to be
equal, because you can't provide the health services where a
lot of our reservations are also growing and our needs are also
growing in the health field, especially if you look at
diabetes. Diabetes and type II diabetes in the area is very
important, so we need to develop not only the educational
programs, but are the educational programs there right now, and
if not, what kind of educational programs do we need to develop
and what additional funding do we need to provide, especially
as diabetes affects many of our Native Americans compared to
others. I know that Hispanics are very high in type II.
What can be done in these areas?
Ms. Davis-Wheeler. Congressman Baca, I am very glad that
you asked that question. I'm just returning from Hawaii. I
attended a meeting over there a week before last and met with
the Native Hawaiians. The Native Hawaiians have a high rate of
diabetes, just as much as Native Americans.
I met with a man who was a teacher of the Hawaiian
language, and he was an amputee. He spoke about the lack of
funding that we, as indigenous people, have to address the
diseases that we have. I couldn't help but look at him, and I
tried to avert my eyes to not stare, but you could tell that he
was suffering from this disease.
One of the things that the National Indian Health Board and
the National Congress of American Indians is looking at is
maximizing that money, the diabetes money that has been
appropriated by Congress, through I would like to say the
leadership of Congressman Nethercutt--and he was here earlier
and spoke to the bill that would elevate the Director. I went
outside in the hallway to speak to him because I really wanted
him to know, as a tribal leader, that we appreciate his efforts
in what he's doing.
My recommendation to this Committee would be the
continuation of the appropriation for diabetes to the Native
American governments, whether it be through the Indian Health
Service or to the Indian governments themselves. I have seen an
increase of awareness, the prevention education programs that
have been developed by the different tribes across the United
States, and I think we should get the appropriations increased.
There was a question earlier about how much more do we
need. I think that $2.4 billion is not very much to ask for to
increase the Indian Health Service budget to enhance the health
professions and the other areas that we need to look at.
Thank you.
Mr. Baca. I agree with you. I don't think it's enough,
because when you look at the prevention programs and others
that actually improve the quality of life, in order for the
quality of life to improve you have to be able to provide the
services that are there. It is difficult, even from the point
of recruitment, if you're looking at scholarships--we have many
of our students going on--but you also want to make it
competitive in terms of salary. So if you're trying to draw
them back into the reservations, you have to have the
competitive salaries. Otherwise, they're going to go somewhere
else. They get educated and they're working in some other
health field.
I also agree that we've got to do a better job in making
sure that we're competitive in terms of salaries to attract our
Native Americans who are going on to school to come back; isn't
that correct?
Ms. Davis-Wheeler. That's correct.
Chairman Renzi, if I may also add, the Indian Health
Service is not tax-exempt for its scholarship benefits. That is
one thing that I think needs to be looked at. The scholarship
program that the Indian Health Service has really needs a boost
to get those students to come, and that tax-exempt benefit
would assist a lot.
Mr. Baca. One final question, Mr. Chair, if I can. I know
my time has run out.
Do you believe the changes in the duties of the Director of
the Indian Health Service to the new Assistant Secretary for
Indian Health, is that a way to improve the trust
responsibility or not? Do you think this new change is positive
based on H.R. 151?
Ms. Davis-Wheeler. Congressman Baca, I think that it would
enhance us, as tribal governments, to be accessible to other
agencies within the DHHS. It would also give that recognition
to us as Native American tribes to those other areas across the
United States that are receiving funding and that we are not
receiving funding for. So I think elevating the Director up to
the Assistant Secretary level would be excellent in terms of
getting that information out to the other Federal agencies.
Mr. Shirley. Congressman Renzi, if I can answer the last
question?
Mr. Renzi. Go ahead, Mr. President.
Mr. Shirley. I think the elevation of the Director to
Assistant Secretary position, what it would do for Native
Americans and the Navajo Nation is that we like to work with
people who have the authority to make decisions. Right now,
we're having to go through the bureaucracy and the red tape of
trying to get answers. I think if we can have inside access to
an Assistant Secretary position, who has the authority to make
decisions, it will make the services of the delivery system
much better.
And then if you can allow the Native nations to work with
an Assistant Secretary position, along with the Secretary
position, you're honoring the tribes and Native Americans,
also.
Mr. Baca. Right. And you would have accountability as well.
That's part of it, too, right?
Mr. Shirley. Exactly.
Ms. Davis-Wheeler. Right.
Mr. Baca. Thank you very much.
Mr. Renzi. I thank the gentleman from California.
I just have a few questions and then we'll wrap up. Julia,
I really am grateful for the teachings that you share here
today. You went to the issue of the tax-exempt status. Congress
has set aside legislation, or has created legislation, that
exempts the National Health Service Corporation, as well as the
Department of Defense, on their scholarship benefits.
If we were able to provide a tax-exempt status for IHS
scholarships, what kind of figures do you think we're looking
at? How big is the program right now? I guess we could start
there.
Ms. Davis-Wheeler. Wow. How big is the program?
Mr. Renzi. On the scholarship side. It's OK. I didn't mean
to stump you. What I'm looking for is, we really need to
provide that same kind of equality--is Joe Shirley helping?
Ms. Davis-Wheeler. Yes. We have a chart here, the Indian
Health Service Scholarship Program. The total IHS scholarship
awards are 8,716 this year.
Mr. Renzi. Different scholarships? That many students,
President Shirley?
Ms. Davis-Wheeler. Yes.
Mr. Renzi. So if we can achieve that kind of a tax status,
it's a major benefit that will help close to 10,000 students
and families. It's time, I think. We will look forward to
pushing ahead on that.
Ms. Davis-Wheeler. If I may add, we will get information
from the National Indian Health Board and we will send that in
to you, too.
Mr. Renzi. That would be great. Thank you.
Mr. Hunter, I want to thank you for your testimony. It was
interesting how you articulated and pointed out the definitions
and how it affects all the way through on the different titles.
I appreciate that research and depth of effort you provided to
us.
I really didn't get a chance to get a depth of feeling on
the national programs, and you spoke about the underfunding for
some of the national programs. Could you give me maybe the top
three national programs that you would like to see fully
funded, or where those national programs would go if we had the
proper funding behind it?
Mr. Hunter. That is a difficult question to answer. We did
in our preparations for consultation on the Fiscal Year 2005
budget come up with 19 priority areas that were considered,
that covered both health care areas and facilities and
construction.
It's difficult to say. Even though the priorities were not
prioritized, I think amongst the top ones would be diabetes,
alcoholism and behavioral health. I would say the third, again
not to exclude other health care priorities, would be
facilities. We have to get more money into facilities at urban
programs. We don't have access to those benefits right now.
Mr. Renzi. You do a good job of outlining, and then your
vision of where we need to go with the priorities. I'm
grateful.
Mr. Hunter. Thank you.
Mr. Renzi. President Shirley, thank you for coming all this
way. It's good to have a friend and brother here. I'm grateful
for your testimony.
You compassionately spoke about the dirt roads and the
contribution that makes to respiratory and poor health. You
spoke of the lack of communication and the inability to respond
properly. I thought you were very articulate when it came to
the nursing and dental shortages, not only in your testimony
but in answering the questions. I need you to teach me now as a
friend.
On section 216 you talked about Arizona as a contract area.
Can you tell me a little more about that?
Mr. Shirley. I believe that's a provision in the
legislation that allows the whole State of Arizona as a
contract health services delivery system, but that has never
been adequately funded. If that could be fully funded, I think
it would deliver more services to Navajos out there and in the
urban areas. We find Navajos, you know, in all the counties.
Mr. Renzi. True.
Mr. Shirley. And not only Navajos, but also Native
Americans, the federally recognized tribes living in the State
of Arizona. Many of them are not living on their own Native
land, so when they go off the land, they need to have a plug
into the health services facilities in the urban metropolitan
areas. If the contract services provision for the whole State
of Arizona is fully funded, Navajos living off Navajo land
would then have access to quality health care services
throughout the State.
Mr. Renzi. Thank you, Mr. President.
Is there anything else any of the witnesses would like to
share? Is there anything in your hearts that didn't come out
today during the testimony?
Mr. Shirley.
Mr. Shirley. Congressman Renzi, I would like to give input
or respond to the question you posed to Miss Wheeler regarding
what are our priorities.
On the whole, I would say manpower training. That's why
these scholarships should be given an adequate amount of money
for health professions is very important. Again, like you said,
we need built-in mechanisms where the return to Native country
is guaranteed. I think one Congressman said we need comparable
salaries. That is very important.
The second one would be the prevention aspects of health
care delivery systems in Native country. In our case, the
diabetes program is really working and we appreciate the
Congress and U.S. Government for funding prevention programs
for diabetes. That certainly should continue, to put money into
prevention.
The third one that we would zero in on is behavior health
services. Of course, we have substance abuse, much of it
alcohol, that is very pervasive throughout Navajo land. We're
trying to do the best we can to arrest the problem. If more
moneys could be had for our behavior health services program to
address substance abuse, that would go a long ways toward
helping us alleviate the alcoholism culprit.
Thank you, Congressman.
Mr. Renzi. Well said.
Mr. Hunter.
Mr. Hunter. If I may, thank you.
I think one of the things that is most important is that
when we come to Congress every year and we're looking at the
budget, we're identifying that additional funding is needed.
Very often I think to myself, well, where are we going to get
that money? Well, in the past I proposed that taxes be
increased but that doesn't go over very well.
I think one of the solutions that could be proposed,
particularly within our social services programs, would be
something called ``social entrepreneurship.'' We at NCUIH fully
support and recognize tribal sovereignty. We completely support
the recognition of the Federal Government's trust
responsibility for Native Americans, and we also recognize that
we must also help ourselves. So if within our social programs
we are able to generate funds that can be devoted and turned
back into those programs so that we are more self-sufficient at
expanding health care services, I think it will be a great step
in the right direction.
Mr. Renzi. So social entrepreneurship is profit centers
within the health arena?
Mr. Hunter. I'm sorry?
Mr. Renzi. Social entrepreneurship is essentially a profit
center, making a profit within the health arena, profitable
clinics or whatever?
Mr. Hunter. Right. For example, one project that we're
interested in working on at AICH in New York is when we sponsor
conferences and workshops, particularly since we are
responsible to outreach to non-Native providers of health care
and educate them to developing our education program so that we
can offer education units that are recognized by nursing and
other professions, so that we can develop or charge the people
for taking those education programs and support our programs.
Mr. Renzi. That's creative. Thank you, Mr. Hunter.
Mr. Hunter. Thank you.
Mr. Renzi. Julia, you get to finish.
Ms. Davis-Wheeler. Thank you.
First of all, I would like to tell you that, as a policy
person for my tribe, it is an honor to sit here and testify in
front of the Committee. I appreciate the time that you have
made.
I really would like to say that honoring the treaties that
all of us have signed as American Indians, Alaska Natives, is
the utmost in my mind. Having just come in last night from the
conference and listening to the comments and remarks made at
the conference, health is just one component of the treaty. We
have education, land, water, et cetera.
But the vision I would like to see, and speaking here today
for the National Indian Health Board, is to see that our people
have adequate health care for our people at home. The ones who
are there that can't speak, we are here for them. The ones that
can't walk, we're here for them. It really means a lot to me,
and I know my colleagues here on the panel feel the same way.
The appropriate funding for us as American Indians and
Alaska Natives has to come up to the level of the general
population. So giving us this time to come in and speak was
excellent. I would like to encourage the Committee to have more
hearings, and if there is any way that we can help as the
National Indian Health Board, we will put that effort forward.
Thank you.
Mr. Renzi. The words are nice, but we have got to deliver.
I think that's your message.
I want to thank all the witnesses for your valuable
testimony, particularly to the members for their questions. The
members of this Committee may have additional questions for the
witnesses, and we will ask that you respond to these in
writing. The hearing record will remain open for these
responses.
If there is no further business, we again thank our
valuable witnesses and the Committee stands adjourned.
[Whereupon, at 12:30 p.m., the Committee was adjourned.]
[The prepared statement of Mr. Tom Udall follows:]
Statement of The Honorable Tom Udall, a Representative in Congress from
the State of New Mexico, on H.R. 2440
Mr. Chairman, thank you for holding this hearing today to discuss
the reauthorization of the Indian Health Care Improvement Act (IHCIA).
Created in the spirit of the United States' trust duties, the IHCIA
has become an essential element of the health and welfare of American
Indian communities. It is the primary federal statute that establishes
the structure for operation of health programs for American Indians and
Alaska Natives by the Indian Health Service (IHS).
The chronic under-funding of the IHS has severe ramifications on
the Indian population. Tuberculosis, cardiovascular disease,
alcoholism, SIDS, fetal alcohol syndrome, and, increasingly, AIDS,
plague America's Native communities at incidence rates far greater than
for other Americans. Diabetes is especially prevalent in these
communities.
I am acutely aware of the diabetes problem, both in New Mexico, the
state I represent, and across the nation. According to a recent 2002
health audit from the Navajo Area Indian Health Service, there are
15,805 patients on its diabetes registry, out of a total 180,462
population.
Similarly, the Pueblo of Santo Domingo in New Mexico reports that
since 1997, there was a 105% increase in diabetes patients, and an
increase of 1038% in patients categorized as needing assistance with
chronic diseases.
In addressing the diabetes epidemic, I believe we should strongly
emphasis prevention and education. It is far better to tackle this
disease up front with prevention and education rather than at the tail
end, during end-stage renal disease and dialysis treatments, where
enormous expense is involved and quality of life and health of the
individual cannot be ensured.
Although Congress and the President recently acknowledged the
severity of diabetes among Native Americans by providing historic
funding for prevention and treatment programs, I believe we must
increase our commitment in order to take advantage of the unprecedented
scientific opportunities we have for advances leading to better
treatments, a means of prevention and, ultimately, a cure for this
devastating disease.
As such, I strongly support the reauthorization of the Indian
Health Care Improvement Act so that we may continue to address the
healthcare needs of Indian communities.
Thank you.