[House Hearing, 108 Congress]
[From the U.S. Government Publishing Office]




 
                         H.R. 151 AND H.R. 2440

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

                          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

                               __________

           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
                                 ------                                

                            C O N T E N T S

                              ----------                              
                                                                   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)

                              ----------                              


                       Wednesday, October 1, 2003

                     U.S. House of Representatives

                         Committee on Resources

                             Washington, DC

                              ----------                              

    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.

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