[Senate Hearing 108-795]
[From the U.S. Government Publishing Office]
DEPARTMENT OF THE INTERIOR AND RELATED AGENCIES APPROPRIATIONS FOR
FISCAL YEAR 2005
----------
THURSDAY, APRIL 1, 2004
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 9:36 a.m., in room SD-124, Dirksen
Senate Office Building, Hon. Conrad Burns (chairman) presiding.
Present: Senators Burns, Stevens, Domenici, and Dorgan.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indian Health Service
STATEMENT OF CHARLES W. GRIM, D.D.S., M.H.S.A.,
ASSISTANT SURGEON GENERAL, DIRECTOR
ACCOMPANIED BY:
EUGENIA TYNER-DAWSON, ACTING DEPUTY DIRECTOR
GARY J. HARTZ, ASSISTANT SURGEON GENERAL, ACTING DIRECTOR,
OFFICE OF PUBLIC HEALTH
ROBERT G. MC SWAIN, M.P.A., DIRECTOR, OFFICE OF MANAGEMENT
SUPPORT
WILLIAM C. VANDERWAGEN, M.D., ACTING CHIEF MEDICAL OFFICER
OPENING STATEMENT OF SENATOR CONRAD BURNS
Senator Burns. It's a long drive from Regent; probably had
traffic in Fargo on the way in this morning. We'll call this
subcommittee hearing to order. Thank you very much for coming
and good morning.
We have Dr. Chuck Grim, Director of the Indian Health
Service, and some of his colleagues here this morning to review
the Indian Health Service budget for fiscal year 2005.
Indian health services are delivered to more than 1.6
million American Indians and Alaskan Natives through a system
that employs over 15,000 people and operates close to 600
health facilities, including 49 hospitals, 236 health centers,
and more than 300 health stations. Proposed funding for the
Agency in fiscal year 2005 is $2.97 billion, an overall
increase of $46 million above the current year enacted level.
I'd just like to go over a few highlights of the budget
request: an additional $18 million for Contract Health
Services, and we'll be talking more about that this morning
because every time I go home this is what I hear; $23 million
to meet staffing requirements at newly-constructed facilities;
an additional $10 million for sanitation facilities
construction; and $2 million for a disease prevention
initiative. There are also a few gaps in this proposal, chief
among them the proposed $53 million reduction to the health
facilities construction account. That recommendation probably
will not be very popular with most of our subcommittee members
who, for the most part, have supported doing more and not less
to replace some of the facilities that we have that are getting
into the senior age status.
In the next few days, Congress is expected to conference
and pass a budget resolution. Shortly after that the
subcommittee will receive its allocation and the real work will
begin. It is doubtful that we will have much in the way of
additional resources to distribute to the agencies funded
through this bill given the realities of defense and homeland
security spending. Let me assure you, however, we will work
closely with you, Dr. Grim, and your staff in an effort to
address the highest priorities of your Agency and, of course,
the health care needs of our Native Americans.
PREPARED STATEMENT
Dr. Grim, thank you for being with us today. We look
forward to your testimony. This is the first time you've been
up before this committee and we appreciate the service that
you've chosen in your line of work. I know that sometimes it
has great challenges but nonetheless you appear to be a man
that's up to those challenges.
[The statement follows:]
Prepared Statement of Senator Conrad Burns
Good morning. Today we have Dr. Chuck Grim, Director of the Indian
Health Service, and some of his colleagues here with us to review the
Indian Health Service budget for fiscal year 2005.
Indian health services are delivered to more than 1.6 million
American Indians and Alaska Natives through a system that employs over
15,000 people at close to 600 health facilities, including 49
hospitals, 236 health centers, and more than 300 health stations.
Proposed funding for the agency in fiscal year 2005 totals $2.97
billion, an overall increase of $46 million above the current year
enacted level.
Program highlights include:
--an additional $18 million for Contract Health Services;
--$23 million to meet staffing requirements at newly constructed
facilities;
--an additional $10 million for sanitation facilities construction;
and
--$2 million for a Disease Prevention initiative.
There are also a few gaps in this budget proposal, chief among them
a proposed $53 million reduction to the facilities construction
account. That probably won't be too popular with our subcommittee
members, who for the most part are supportive of doing more not less to
replace health facilities that can be as much as 100 years old.
In the next few days, Congress is expected to conference and pass a
budget resolution. Shortly after that, this subcommittee will receive
its allocation and the real work will begin. It is doubtful that we
will have much in the way of additional resources to distribute to the
agencies funded through this bill, given the realities of defense and
homeland security spending. Let me assure you, however, we will work
closely with you in an effort to address the highest priorities for
your agency and Native Americans.
Dr. Grim, thank you for being with us today. We look forward to
your testimony and appreciate the opportunity to discuss the budget
proposal with you.
Senator Burns. I'm pleased this morning to be joined by my
friend from North Dakota, Senator Dorgan, the ranking minority
member of this subcommittee.
OPENING STATEMENT OF SENATOR BYRON L. DORGAN
Senator Dorgan. Mr. Chairman, thank you for that. You have
a warped sense of direction, however, if you think that you
drive through Fargo coming from Regent. But, Montanans have
never had an acute sense of direction. You have good judgement
in other areas so we will overlook that this morning.
Senator Burns. You don't go east to get to here? You don't
go through Fargo?
Senator Dorgan. No, you go through Aberdeen.
Senator Burns. That's worse yet because you probably go
through Shelby.
Senator Dorgan. Mr. Chairman and Dr. Grim, first of all let
me say something about the Indian Health Service staff out
around the country. I don't know much about you three, though
Mr. Hartz was well educated, I know, at the University of North
Dakota. But I must say the Indian Health Service staff that I
have met around the country are extraordinary men and women.
They're not paid a lot, they don't do this because they're
maximizing income, they do that because they want to provide
health care and assistance to people who desperately need it.
And I walk away every time I visit one of those clinics and
those areas where I see Indian Health Service employees and I
think what a remarkable thing and how blessed we are that
they've decided to commit their lives to this thing. So I just
want you to know that, number one.
Number two, the Indian Health Service is dramatically
underfunded and we are pretending, every year as we deal with
these issues, we pretend that we're providing good health care
and we're not. And it has nothing to do with you or your staff;
you don't have the money. We're spending about 50 percent less
on health care for American Indians than we are--per person--
than we are for Federal prisoners and we're responsible for
both. When we incarcerate someone we're responsible for their
health and we commit money to provide for their health. And we
are also responsible, under our trust responsibility, for
Indian health. And yet we underfund that by about 50 percent
relative to that which we spend for Federal prisoners. And one
has a good reason, it seems to me, to ask why. And I won't go
through the list.
I'm going to ask a series of questions today, and they are
not questions meant to, in any way, describe malfeasance on the
part of your Agency but they are meant to describe the sense of
warped priorities we have. You know, I remember just recently--
and colleagues are tired and probably my colleague from Montana
is tired of hearing me say this--but just recently, with
precious little debate, we shipped off nearly $20 billion to
reconstruct Iraq, build children's hospitals, buy garbage
trucks, and God knows what else we're doing with $20 billion.
To try to soak just a little bit of extra money out of the
Federal budget to build the Indian Health Service budget to
where it ought to be is almost impossible because we just want
to pretend that we're doing the right thing. And we're not,
we're just not. It is not the priority it should be.
You're a dentist, Dr. Grim, I believe.
Dr. Grim. Yes sir.
Senator Dorgan. And you know, I visited the dental
facilities at Standing Rock and you see a dentist in a trailer
house serving 5,000 people and that's not--and incidentally,
when you see so many American Indians with teeth missing it's
for a good reason, because they can't get a tooth replaced when
it's pulled, as you know, so that has health consequences. So
there's so much going on.
I just got off the phone a few minutes ago with some family
members of a 14-year-old girl who hung herself on Tuesday on
the Spirit Lake Nation Reservation and the Indian Health
Service people and others there told me that that's not
unusual. I mean, this little 14-year-old girl's sister hung
herself as well, 2 years ago, committed suicide. We have a
full-scale crisis in health care and the fact is the budget
that you are here to represent, and you must represent it
because you're part of the administration, will actually cause
us to lose ground because you don't have a budget request that
meets the population increase; you don't have a budget request
that meets just the continuing needs. And so I'm going to ask a
series of questions about that today. And again, I started
deliberately because I wanted to thank the people who work in
the IHS but we should stop pretending; we are not doing right
by American Indians with respect to the health care budget that
we have proposed. Not just this year but every year. Not just
under this administration but under previous administrations as
well. And we ought to decide, finally, it's our responsibility
to begin doing the right thing.
So Mr. Chairman, thank you very much.
Senator Burns. Thank you, Senator Dorgan. Dr. Grim, we look
forward to your statement.
SUMMARY STATEMENT OF DR. CHARLES W. GRIM
Dr. Grim. Thank you sir. I want to thank both of you, too,
for your opening comments and for your understanding and for
the support that you've given the Indian Health Service and our
programs over the years. Your committee has a great
understanding of our program.
My name is Dr. Charles W. Grim, the Indian Health Service
Director, and I'm here accompanied by two people at the table,
Dr. Craig Vanderwagen, our Acting Chief Medical Officer and Mr.
Gary Hartz, our Acting Director for the Office of Public
Health. I also have a number of staff with me here in the
audience so that we can try to get answers to your questions
should you pose some that we're not able to answer. I'll be the
only one making an opening statement and then we'll take any
questions you'd be pleased to ask.
I'm very pleased today to have this opportunity to testify
on the President's fiscal year 2005 budget request for IHS.
I'll make just some brief remarks and ask that my written
statement be entered into the record.
Senator Burns. Without objection, it will be.
Dr. Grim. I'm here to provide information on behalf of the
President, the Secretary, and the IHS for the programs that are
critical to achieving our shared goals of health promotion,
disease prevention and the elimination of health disparities
among all Americans. The budget request contains an $82 million
increase for our health services programs. That will allow us
to add up to four new epidemiology centers and increase support
for the existing seven centers that we already have. It would
allow us to add 30 new community health aides or practitioners
to provide service in Alaska native communities, raising the
number of aides and practitioners to 516. It also has funds to
cover some of the mandatory Federal pay costs and provide
tribally run health programs with funds for comparable pay
raises for their staffs. We've also asked for an additional $18
million for Contract Health Services, which was mentioned in
your opening comments, and an additional $2 million is
requested to expand our existing health promotion and disease
prevention initiatives at the local community level.
FACILITIES
Our request on the facilities side includes an additional
$23 million to add staffing for five out-patient facilities
that are scheduled to open during fiscal year 2005. Those are
the Pinon and West Side Health Centers in Arizona, the Dulce
Health Center in New Mexico, the Idabel facility in Oklahoma
and the Annette Island Health Center in Alaska. When fully
operational, these facilities will double the number of primary
care provider visits and bring new services to these sites.
SANITATION CONSTRUCTION
We've also requested $103 million for sanitation
construction--that's an increase of $10 million or 11 percent
over our fiscal year 2004 level--to be able to provide safe
water and waste disposal systems to Indian communities.
Specifically, the President's budget request supports the
provision of safe water and waste disposal to an estimated
22,000 additional homes.
HEALTH CARE FACILITIES CONSTRUCTION
There's also a $42 million request to fund the completion
of out-patient facilities construction at Red Mesa, Arizona,
and Sisseton, South Dakota, and to provide necessary staff
housing for the health facilities at Zuni, New Mexico, and
Wagner, South Dakota. When completed, these out-patient
facilities will provide an additional 36,000 primary care
provider visits, replace the 68-year-old Sisseton Hospital, and
bring 24-hour emergency care services to the Red Mesa area for
the first time ever. The IHS is also going to be able to add 13
units of staff quarters and replace 16 house trailers that were
built over 40 to 50 years ago. Having this new decent local
housing will make it easier for us to recruit and retain health
care professionals at these sites.
In addition to the increased request for sanitation
facilities, there's also an increased request for facilities
and environmental health support. In addition to providing
funds for the provision of health care services to Indian
people on or near reservations, our 2005 budget request also
includes $32 million to help support 34 urban Indian health
organizations that provide services in cities with large
numbers of Indian people.
NATIONAL BUDGET PRIORITIES/CONSTRAINTS
The budget request for the IHS continues to reflect the
commitment of the President and the Secretary to meeting the
health needs of Indian people within the scope of national
priorities. The President's overall request provides
substantial increases to improve our Nation's security and win
the war on terror. It also increases funding for key priorities
such as economic growth and job creation, education, and
affordable health care, which are all key factors in
influencing the health status of our people. To fund these
priorities, the President's national budget request restrains
overall increases in spending in other areas of the government
and in discretionary programs to less than 1 percent. In
support of the President's key priorities, his proposal for the
Department of Health and Human Services discretionary budget
authority is a 1.2 percent increase over fiscal year 2004 and
the IHS request for 2005 exceeds the 1 percent national
discretionary average and the 1.2 percent average for HHS. The
IHS budget request is an increase of 1.6 percent, or $46
million over the fiscal year 2004 enacted level. The total
proposed budget authority for us in 2005 then is at $3 billion
and, if you add in funds from health insurance collections
estimated at $593 million, the designated diabetes
appropriations of $150 million and $6 million for staff
quarters rental collections, it increases our proposed budget
from $3 billion to $3.7 billion in program-level spending. This
increase will allow the continuation of quality health care
services to Indian people and this increase above the national
and HHS discretionary averages reflects the Department's tribal
budget consultations and a continuing Federal Government
commitment to provide for the health of members of federally-
recognized tribes.
OVERALL DEPARTMENTAL BUDGET
The President's budget request for IHS must also be
considered in the context of the proposed increases for the
Department overall. Fortunately, we no longer exist in an era
where the IHS is viewed by the Department as the sole source
and agent for improving the health of Indian people. That
responsibility has expanded to include all programs of the
Department. An example of an increase elsewhere that will
benefit Indian people and also the IHS is the Medicare
Prescription Drug Improvement and Modernization Act of 2003.
Items in this Act that are particularly important to the IHS,
tribal, and urban Indian health programs include: a provision
to increase the reimbursement rates for rural ambulance
services, which will benefit numerous isolated tribal ambulance
programs throughout Indian country; a provision that authorizes
reimbursement to IHS and tribal health facilities for emergency
services provided to undocumented aliens, which is particularly
important for IHS and tribal facilities in remote border
locations of the United States; and a provision that requires
Medicare participating hospitals to accept Medicare rates as
payment in full when providing in-patient hospital services to
IHS beneficiaries who are referred for care, which is going to
allow us to save more money in our Contract Health Services
budget. There's also a 5-year authorization of reimbursement
for increased Medicare B services, which will allow us to
increase our billings in that arena. And there are changes in
critical access hospital reimbursements that are going to
benefit many of our rural IHS and tribal hospitals. They've
also increased the disproportionate share of low-income and
uninsured patient rate from 5.25 to 12 percent and nearly all
of our hospitals will benefit from that.
There are also provisions in that bill to support health
promotion and disease efforts and, beginning this year, all
newly enrolled Medicare beneficiaries will be covered for an
initial physical exam, electrocardiogram and cardiovascular
screening, blood tests, and those at risk will be covered for a
diabetes screening test. Before this legislation was enacted,
the IHS and tribes were providing these services but now we
will be able to seek reimbursement for them, which will extend
our health dollars even further.
Overall, the combination of budget increases and additional
purchasing power provided by that Medicare Modernization Act
will allow for the purchase of an estimated 35,000 additional
out-patient visits or 3,000 additional in-patient days of care.
PREPARED STATEMENT
I want to thank you for the opportunity to discuss the
fiscal year 2005 President's budget request for the IHS and
again I'd like to thank this subcommittee for their support
over the years to ensure that the IHS can continue to help
American Indian and Alaska Native people across the Nation. I
would be pleased, Mr. Chairman, to answer any questions that
you have today.
[The statement follows:]
Prepared Statement of Dr. Charles W. Grim
Mr. Chairman and Members of the Subcommittee: Good morning. I am
Dr. Charles W. Grim, Director of the Indian Health Service. Today I am
accompanied by Ms. Eugenia Tyner-Dawson, Acting Deputy Director, Dr.
William Craig Vanderwagen, Acting Chief Medical Officer, Mr. Gary J.
Hartz, Acting Director, Office of Public Health, and Mr. Robert G.
McSwain, Director, Office of Management Support. We are pleased to have
this opportunity to testify on the President's fiscal year 2005 budget
request for the Indian Health Service.
The IHS has the responsibility for the delivery of health services
to more than 1.6 million members of Federally-recognized American
Indian (AI) tribes and Alaska Native (AN) organizations. The locations
of these programs range from the most remote and inaccessible regions
in the United States to the heavily populated and sometimes inner city
areas of the country's largest urban areas. For all of the AI/ANs
served by these programs, the IHS is committed to its mission to raise
their physical, mental, social, and spiritual health to the highest
level, in partnership with them.
Secretary Thompson, too, is personally committed to improving the
health of AI/ANs. To better understand the conditions in Indian
country, the Secretary or Deputy Secretary has visited Tribal leaders
and Indian reservations in all twelve IHS areas, accompanied by senior
HHS staff. The Administration takes seriously its commitment to honor
its obligations to AI/ANs under statutes and treaties to provide
effective health care services.
Through the government's longstanding support of Indian health
care, the IHS, Tribal, and Urban (I/T/U) Indian health programs have
demonstrated the ability to effectively utilize available resources to
improve the health status of AI/ANs. For example, there have been
dramatic improvements in reducing mortality rates for certain causes
from the three year periods of 1972-1974 to 1999-2001, such as maternal
deaths decreased 58 percent, infant mortality decreased 64 percent, and
unintentional injuries mortality decreased 56 percent. More recently,
the funding for the Special Diabetes Program for Indians has
significantly enhanced diabetes care and education in AI/AN
communities, as well as building the necessary infrastructure for
diabetes programs. Intermediate outcomes that have been achieved since
implementation of the Special Diabetes Program for Indians include
improvements in the control of blood glucose, blood pressure, total
cholesterol, LDL cholesterol, and triglycerides. In addition, treatment
of risk factors for cardiovascular disease has improved as well as
screening for diabetic kidney disease and diabetic eye disease.
Although we are very pleased with the advancements that have been
made in the health status of AI/ANs, we recognize there is still
progress to be made. As the Centers for Disease Control and Prevention
recently reported, the AI/AN rates for chronic diseases, infant
mortality, sexually transmitted diseases, and injuries continue to
surpass those of the white population as well as those of other
minority groups. The 2002 data show that the prevalence of diabetes is
more than twice that for all adults in the US, and the mortality rate
from chronic liver disease is more than twice as high. The sudden
infant death syndrome (SIDS) rate is the highest of any population
group and more than double that of the white population in 1999. The
AI/AN death rates for unintentional injuries and motor vehicle crashes
are 1.7 to 2.0 times higher than the rates for all racial/ethnic
populations, while suicide rates for AI/AN youth are 3 times greater
than rates for white youth of similar age. Maternal deaths among AI/ANs
are nearly twice as high as those among white women.
The type of health problems confronting AI/AN communities today are
of a more chronic nature. The IHS public health functions that were
effective in eliminating certain infectious diseases, improving
maternal and child health, and increasing access to clean water and
sanitation, are not as effective in addressing health problems that are
behavioral in nature, which are the primary factors in the mortality
rates noted previously. Other factors affecting further progress in
improving AI/AN health status are the increases in population and the
rising costs of providing health care. The IHS service population is
increasing by nearly 2 percent annually and has increased 24 percent
since 1994.
This budget request for the IHS will assure the provision of
essential primary care and public health services for AI/ANs. For the
seventh year now, development of the health and budget priorities
supporting the IHS budget request originated at the health services
delivery level. As partners with the IHS in delivering needed health
care to AI/ANs, Tribal and Urban Indian health programs participate in
formulating the budget request and annual performance plan. The I/T/U
Indian health program health providers, administrators, technicians,
and elected Tribal officials, as well as the public health
professionals at the IHS Area and Headquarters offices, combine their
expertise and work collaboratively to identify the most critical health
care funding needs for AI/AN people.
The President's budget request for the IHS will assist I/T/U Indian
health programs to maintain access to health care by providing $36
million to fund pay raises for Federal employees as well as funds for
Tribal and Urban programs to provide comparable pay increases to their
staff. Staffing for five newly constructed health care facilities is
also included in the amount of $23 million. When fully operational,
these facilities will double the number of primary provider care visits
that can be provided at these sites and also provide new services. The
budget also helps maintain access to health care through increases of
$18 million for contract health care and $2 million for the Community
Health Aide/Practitioner program in Alaska. The increase for CHS,
combined with the additional purchasing power provided in Section 506
of the recently enacted Medicare Prescription Drug, Improvement, and
Modernization Act, will allow the purchase of an estimated 35,000
additional outpatient visits or 3,000 additional days of inpatient
care.
As mentioned previously, the health disparities for AI/ANs cannot
be addressed solely through the provision of health care services.
Changing behavior and lifestyle and promoting good health and
environment is critical in preventing disease and improving the health
of AI/ANs. This budget supports these activities through requested
increases of $15 million for community-based health promotion and
disease prevention projects, expanding the capacity of Tribal
epidemiology centers, and providing an estimated 22,000 homes with safe
water and sewage disposal. An additional $4.5 million is requested for
the Unified Financial Management System. This system will consolidate
the Department's financial management systems into one, providing the
Department and individual operating division management staff with more
timely and coordinated financial management information. The requested
increase will fully cover the IHS' share of costs for the system in
fiscal year 2005 without reducing other information technology
activities.
The budget request also supports the replacement of outdated health
clinics and the construction of staff quarters for health facilities,
which are essential components of supporting access to services and
improving health status. In the long run, this assures there are
functional facilities, medical equipment, and staff for the effective
and efficient provision of health services. The average age of IHS
facilities is 32 years. The fiscal year 2005 budget includes $42
million to complete construction of the health centers at Red Mesa,
Arizona and Sisseton, South Dakota; and complete the design and
construction of staff quarters at Zuni, New Mexico and Wagner, South
Dakota. When completed, the health centers will provide an additional
36,000 primary care provider visits, replace the Sisseton hospital,
which was built in 1936, and bring 24 hour emergency care to the Red
Mesa area for the first time.
The IHS continues its commitment to the President's Management
Agenda through efforts to improve the effectiveness of its programs.
The agency has completed a Headquarters restructuring plan to address
Strategic Management of Human Capital. To Improve Financial Performance
and Expand E-Government, the IHS participates in Departmental-wide
activities to implement a Unified Financial Management System and
implement e-Gov initiatives, such as e-grants, and Human Resources
automated systems. This budget request reflects Budget and Performance
Integration at funding levels and proposed increases based on
recommendations of the Program Assessment Rating Tool (PART)
evaluations. The IHS scores have been some of the highest in the
Federal Government.
The budget request that I have just described provides a continued
investment in the maintenance and support of the I/T/U Indian public
health system to provide access to high quality medical and preventive
services as a means of improving health status. In addition, this
request reflects the continued Federal commitment to support the I/T/U
Indian health system that serves AI/ANs.
Thank you for this opportunity to discuss the fiscal year 2005
President's budget request for the IHS. We are pleased to answer any
questions that you may have.
Biographical Sketch of Dr. Charles W. Grim
Charles W. Grim, D.D.S., is a native of Oklahoma and a member of
the Cherokee Nation of Oklahoma. As the Director of the Indian Health
Service (IHS), he is an Assistant Surgeon General and holds the rank of
Rear Admiral in the Commissioned Corps of the Public Health Service. He
was appointed by President George W. Bush as the Interim Director in
August 2002, received unanimous Senate confirmation on July 16, 2003,
and was sworn in by Tommy G. Thompson, Secretary of Health and Human
Services, on August 6, 2003 in Anchorage, Alaska.
As the IHS Director, he administers a nationwide multi-billion
dollar health care delivery program composed of 12 administrative Area
(regional) Offices, which oversee local hospitals and clinics. The IHS
is responsible for providing preventive, curative, and community health
care to approximately 1.6 million of the Nation's 2.6 million American
Indians and Alaska Natives. The IHS is the principal federal health
care provider and health advocate for Indian people.
Dr. Grim graduated from the University of Oklahoma College of
Dentistry in 1983 and began his career in the IHS with a 2-year
clinical assignment in Okmulgee, OK, at the Claremore Service Unit. Dr.
Grim was then selected to serve as Assistant Area Dental Officer in the
Oklahoma City Area Office. As a result of his successful leadership and
management of the complex public health dental program, he was
appointed as the Area Dental Officer in 1989 on an acting basis.
In 1992, Dr. Grim was assigned as Director of the Division of Oral
Health for the Albuquerque Area of the IHS. He later served as Acting
Service Unit Director for the Albuquerque Service Unit, where he was
responsible for the administration of a 30-bed hospital with extensive
ambulatory care programs and seven outpatient health care facilities.
Dr. Grim was later appointed as the permanent Director for the Division
of Clinical Services and Behavioral Health for the Albuquerque Area and
had the responsibility for working with all health related programs at
the Area level. Dr. Grim was then appointed Acting Executive Officer
for the Albuquerque Area, one of three top management officials for the
two-state region, and was responsible for the fiscal and administrative
leadership of the Area.
In April 1998, Dr. Grim transferred to the Phoenix Area IHS as the
Associate Director for the Office of Health Programs. In that role, he
focused on strengthening the Phoenix Area's capacity to deal with
managed care issues in the areas of Medicaid and the Children's Health
Insurance Program of Arizona. He also led an initiative within the Area
to consult with Tribes about their views on the content to be included
in the reauthorization of the Indian Health Care Improvement Act,
Public Law 94-437.
In 1999, Dr. Grim was appointed as the Acting Director of the
Oklahoma City Area Office, and in March 2000 he was selected as the
Area Director. As Area Director, Dr. Grim managed a comprehensive
program that provides health services to the largest IHS user
population, more than 280,000 American Indians comprising 37 Tribes.
The geographic area of responsibility covers the states of Oklahoma,
Kansas, and portions of Texas. Health care is provided through direct
care, contract care, or tribally operated facilities. He was also a
member of the Indian Health Leadership Council, composed of IHS,
tribal, and urban Indian health program representatives. The Council is
a decision making body of the agency that examines health care policy
issues.
In addition to his dentistry degree, Dr. Grim also has a master's
degree in health services administration from the University of
Michigan. Among Dr. Grim's honors and awards are the U.S. Public Health
Service Commendation Medal (awarded twice), Achievement Medal (awarded
twice), Citation, Unit Citation (awarded twice), and Outstanding Unit
Citation. He has also been awarded Outstanding Management and Superior
Service awards by the Directors of three different IHS Areas. He also
received the Jack D. Robertson Award, which is given to a senior dental
officer in the United States Public Health Service (USPHS) who
demonstrates outstanding leadership and commitment to the organization.
Dr. Grim is a member of the Commissioned Officers Association, the
American Board of Dental Public Health, the American Dental
Association, the American Association of Public Health Dentistry, and
the Society of American Indian Dentists. Dr. Grim was appointed to the
commissioned corps of the U.S. Public Health Service in July 1983.
Senator Burns. Dr. Grim, thank you very much. I'm going to
have about three questions and then I think we'll get a pretty
good dialogue off of these three. I want to thank you for
mentioning all of your wellness programs because we don't talk
much about efforts to promote wellness on our reservations--one
example is the screening programs that they'll be reimbursed
for now to find out where our problems are and solve them early
on. I'm also glad you mentioned the sanitation construction
program. It seems like so many reservations we go to have real
sanitation problems. I have two major water projects in
Montana, ongoing now, that are high priority in my office; we
want to complete those because I happen to believe that unclean
water is probably the cause of a lot of our health problems.
You can't believe what water, pure water, does for our
wellness.
Also in the area of diabetes, as you know it is more
prevalent on our reservations than in the rest of the country.
I'll want to know how you're doing there because we funnel more
money into the diabetes fund and I want to know if we're making
any headway, are we seeing any visible results, what is the
impact of that money.
CONTRACT HEALTH SERVICES
Contract Health Service dollars are critical because in
Montana, and I think in other areas, too, where we're a long
way from major IHS medical facilities, those services are met
by hospitals and health care providers off the reservation.
This becomes very expensive but it is also a very vital part of
how we provide health services for our Native Americans. The
IHS budget proposes to increase this program by about $18
million for 2005.
Give me your assessment of that proposal. Even though I
know that it sounds like $18 million is a lot of money, if a
shortfall exists in contract health care overall, can you give
me an estimate of where we should be to provide adequate acute
care through contract services? How many of the highest
priority medical cases must be rejected annually because tribes
just run out of money, and how far will this $18 million
increase go to alleviate some of these problems? That's a
pretty broad field.
Dr. Grim. Yes sir, that's a lot of questions.
Senator Burns. It's a lot of questions all in one, isn't
it?
Dr. Grim. I'll see if we can start addressing those and if
we don't capture all of the ones that you asked please feel
free to ask again.
$18 MILLION REQUEST
As you can see in our budget, that $18 million request for
increases other than our pay act inflationary increases is the
largest increase that we asked for. That's one of the highest
priority items in Indian country, that's the monies that we use
to pay for care in the private sector that we cannot provide in
our facilities. That $18 million in large part goes to help
offset the inflation that will incur in that particular budget
this year. Earlier I mentioned the Medicare Modernization Act.
We've not been able to fully estimate the impact of that Act
because its regulations have yet to be written, but we're
working very closely with the Centers for Medicare/Medicaid
Services. We've estimated that just the one that allows us to
have Medicare-like rates in hospitals where we've not been able
to get those before and had to pay full bill charges is going
to allow us to extend our CHS budget another $8 to $9 million
in specific locations across the IHS Areas.
We're also working very, very hard to enhance our business
practices all across the Indian Health Service. Prior to
becoming Director of the Indian Health Service, I was the
chairman of a business plan committee for the Agency that
worked with all of our stakeholders to develop a business plan.
One of the things that we're trying to do, as you know, our
Contract Health Services budget is the payer of last resort and
so we're doing everything we can in all of our facilities to
exhaust other third-party resources that patients might have,
like Medicare, Medicaid or private insurance. So we're trying
to cover the front in all those arenas. We've asked for one of
the largest increases in CHS; we're also looking at how
Medicare modernization is going to affect our budget and then
we're trying to enhance our business practices as well.
It's very hard to answer your question about some of the
highest priority claims, how many will be denied. We don't
capture them by priority level but we do know that there are
priority one claims, which are considered an immediate threat
to life or limb that are denied throughout the course of the
year. That particular budget is discretionary, not an
entitlement-type program like Medicare and Medicaid, and so we
are required to stay within our appropriation for that budget.
I can give you, for the record, some overall numbers about
denials and deferred services and things like that but we don't
collect by priority one, two and three the way we medically
categorize care, we don't capture it in that fashion to be able
to tell you how many of the most urgent care needs are denied
on an annual basis.
Senator Burns. Well, I think maybe those are some numbers
that this subcommittee should have and Congress should know
about. And what I would do after this year's budget, I think I
would probably have somebody go over that and see how much more
money we would need to take care of what we should, even using
good business practices and even going and trying to save money
where we can.
Tell me about the CHEF Program. That's along the same
lines, I think.
CHEF PROGRAM
Dr. Grim. Yes sir.
Senator Burns. It's meant to cover catastrophic illness.
Tell me about that program; we're hearing a little bit of
feedback from our reservations on that.
Dr. Grim. Yes sir. That's a--you took the words right out
of my mouth. That was the next statement I was going to make to
you. The CHEF Program right now is funded at $18 million. Our
overall CHS budget is approaching $500 million--I believe it's
going to be about, if we get our request this year, in the $480
plus range--and of that amount $18 million is taken off and set
aside to handle catastrophic health emergency cases.
Regulations set out the threshold that would have to be met by
local contract health programs, and I believe for fiscal year
2004 that amount is around $23,800. Whenever a facility spends
more than that on a particular case, they apply to that fund
and then they are reimbursed so that the catastrophic cases do
not cause them to run out of funds early in the year. Congress
raised CHEF from $15 million a few years ago up to $18 million,
we have that authority, but that particular budget has been
running out in about the third quarter of each year. And so in
the fourth quarter of the fiscal year if any programs have
catastrophic cases then they end up having to fund those
themselves. We have estimates in our congressional
justification that would indicate that probably $30 million
would be needed in that fund to capture known cases but it's
very hard to predict from year to year because of the expense
of medical care and the unknown types of cases we might
encounter.
Senator Burns. I've got a couple of other questions
before----
Senator Dorgan. Why don't you finish up and I'll just----
Senator Burns. Well I'm afraid you're going to wear your
thumb out.
Senator Dorgan. No.
Senator Burns. Okay. In your epidemiology--auctioneers
handle that pretty well, don't they?--your epicenters. Tell me
about those. I understand that you have established some and I
think you're short of what you want nationally but you're
getting there.
EPI CENTERS
Dr. Grim. Yes sir. We currently have seven epidemiology
centers and they're funded at approximately $300,000 each. And
those seven centers really only cover about 50 percent of the
American Indian and Alaska Native population. We have several
large Areas of Indian population--Albuquerque, Navajo,
Oklahoma, Billings, and California--that are not currently
covered by epidemiology centers. So the money that we're
requesting in this year's budget will allow us to add,
hopefully, four new centers and to upgrade the existing centers
by $100,000 each. As I said, we're funding them currently at
$300,000; we estimate for them to be fully functional that they
would need around $750,000. But those epidemiology centers take
the money that we put in and they go after other grants,
through States or through other programs, and are able to
essentially use a lot of our money as seed money. Those centers
have been very effective at working with tribes in those Areas
to help them analyze the large amounts of health data that are
gathered through our system. And we also work with CDC, NIH,
and State health departments to try and bring in additional
funding for those epicenters. So the funding that we're asking
for this year would allow us to go out with another request for
funding proposals and hopefully capture four more centers.
Senator Burns. Senator Dorgan.
FUNDING DISPARITIES
Senator Dorgan. Mr. Chairman, thank you very much. Dr.
Grim, I mentioned in the opening statement the contrast between
our responsibility as a Federal Government to provide for the
health of Federal prisoners and the health of the American
Indians. Could you and your staff at some point provide for me
an estimate of what we would spend on the Indian Health Service
if we provided funding for the health of American Indians at
the same level that we provide for the health for Federal
prisoners?
Dr. Grim. Yes sir, we can provide that for you. I don't
have those numbers before me.
Senator Dorgan. I understand. But my cursory glance is that
we spend, on a per capita basis about 50 percent more for
Federal prisoners' health care than we do for American Indians.
You know, you have a responsibility to come here on behalf
of this budget and support the budget. I understand that, I'm
not critical of that because that's your role. But you know and
I know that you've described to us kind of like someone selling
a car. You've said this is a great tail light and we've got a
good door handle over here and I want you to see the shiny hood
and we all directed our attention to what you wanted us to look
at. But you know we're far short. Let me ask a couple
questions.
CONTRACT HEALTH SERVICES
Indian people have had their credit ruined, as you know,
because they were able to access Contract Health Services that
were approved and then the payments weren't made. These are
health services they couldn't get on the reservation so they go
to a hospital some place, get the health care and then the
payment isn't made and they come back to the Indian for payment
and he doesn't have the payment so their credit is ruined. So
we're far short of what's needed for Contract Health Services,
and my understanding is that if you need a hip replacement,
just continue working; you can't get a hip replacement because
of the rationing of care at the present time. Is that correct?
Dr. Grim. Yes sir. Many places are unable to provide that
level of service.
Senator Dorgan. How about arthritis treatment?
Dr. Grim. Again, it depends on the location. We have
disparities of funding within the Service itself; some places
are able to provide care for arthritis patients and others are
not.
Senator Dorgan. My understanding is that allergy testing,
stress tests for diabetics who do not have signs of heart
disease, these are things, for example, that would not be
covered under Contract Health Services. And I simply describe
that to point out that we're just so far short of where we need
to be. Because you're a dentist, Dr. Grim, you know that
dentists, I think, throughout the IHS, do not perform crown or
bridge work. So if you go to a dentist on the reservation to
have your tooth pulled you're going to walk around with an
empty space because there's no crown or bridge work available.
Is that correct?
Dr. Grim. There are some places that are able to provide
crown and bridge work but you are correct that as a whole we
have very, very limited services that are provided in that
realm.
Senator Dorgan. And, with Federal prisoners, do we do crown
or bridge work, I wonder?
Dr. Grim. I'm not sure.
Senator Dorgan. You wouldn't know that but I'm sure we do.
Senator Burns. He's never been in prison.
Senator Dorgan. Yeah. Let me ask a question. I mentioned to
you about the young girl that committed suicide on Tuesday on
the reservation and I think her name was Avis Littlewind; her
aunt told us of this and then I called to find out what had
happened there. You know, this is a reservation like virtually
all of them; one social worker, one psychologist. They tell me
that man, they just struggle to keep up. I had a hearing on
this subject some long while ago and the young woman who was
supposed to be in charge of the office dealing with these kids,
and this was dealing with mental trauma and sexual abuse, child
abuse, in the middle of the hearing she was testifying about
what she's trying to do, she's been there about 6 months, in
the middle of the hearing she just broke down and began sobbing
and couldn't continue. She said you know, I just have to beg to
get a car to take a kid to a clinic; I don't even have wheels
to take a kid to a clinic. And then she just quit; 30 days
later she quit. And you know, this is on the same reservation,
incidentally. So I called these folks this morning. They're
just woefully, dramatically understaffed relative to the load
they have. Is there anything in this budget that's going to
give them hope? As I read this budget, it looks like we're
underfunding the Indian Health Service once again. We're not
going to even meet inflation needs. Would you not agree?
MENTAL HEALTH/SUICIDE PREVENTION
Dr. Grim. We have provided some funding increases for the
mental health program in this budget along with the criteria
that we were to lay out. And one of the things that we've done
on top of that, since I've been in as the Director and
realizing the huge tragedy that suicide causes in Indian
country, I've started an initiative. When I initially became
Director we had just the year before that received a $30
million increase to our budget, one of the largest increases
we'd received in a number of years. And so we worked with
Indian country to determine how we would distribute those funds
and one of the things that we've done recently is we've started
a suicide initiative; we have increased the data collection
methods that we use, we're able to now spot areas where there
might be potential suicide clusters beginning. We've tested
that software and we think averted a crisis in one particular
Area because of the way the data's gathered at a national level
now. I've also begun a suicide task force that's made up from
representatives from all of our regions. They're scheduled to
have their first meeting this summer in June and we're going to
be working with them on various programs across the country.
Any time that we have had suicide clusters and emergencies,
we've dug into emergency funds to try to help those particular
areas, to bring in experts.
PATIENT CONTACTS
Senator Dorgan. But Dr. Grim, whether it's dental health,
alcohol and substance abuse or mental health, in every case we
have fewer patient contacts. More money but fewer patient
contacts. Is that not the case?
Dr. Grim. I would have to check the patient contact----
Senator Dorgan. Well, let me give it to you from your
evidence; 7,700 fewer patient contacts in the mental health
despite the fact there's a $2.5 million increase; in dental
health, 12,000 fewer patients; alcohol substance abuse 29,000
fewer in-patient treatments, 13,000 fewer in-patient
treatments. My point is, add a little money but actually don't
keep pace with inflation and have less money actually for
patient visits in all of these cases. Is that not the case?
RECRUITMENT
Dr. Grim. That is part of the problem, sir. Another part of
the problem is recruitment efforts. We have, especially in
dental, we have some very high vacancy rates right now, also in
pharmacy and physicians and nursing we have some very high
vacancy rates and we're doing as much as we can around
recruitment and retention efforts. I have a huge new initiative
that we've instituted within the Agency. The Secretary and the
President have also agreed to strengthen the Commission Corps
by 1,000 new officers; they've dedicated 275 of that new 1,000
to the Indian Health Service in some of our most difficult-to-
fill sites. So a portion of what you're saying about the
inflationary issue is accurate and the other part of the story
is the recruitment issue and the vacancies that we have.
Senator Dorgan. Well, my time has expired. Our colleagues
are here. I'm going to submit a list of questions to you. Let
me again say that we're spending 50 percent less per person on
Indian health than we are on health for the Federal prisoners
in Federal prisons. And I think we're pretending. We have a
health care crisis and we're pretending that we're sort of
meeting it but we're really not and we need somehow to do much,
much better. So I'll submit a series of questions.
Let me again say thanks to the men and women of the Indian
Health Service who are out there doing remarkable work in a
dramatically underfunded area.
Dr. Grim. I really appreciate that and I will make sure
everywhere I go that I let them know this subcommittee had
thanks for them.
Senator Burns. Along the same lines of mental health, Art
McDonald down on the Cheyenne, headed a program many years ago;
we earmarked some money, $250,000, for the psychology program
in Montana and there are just a few other schools that
participate--University of North Dakota is one of those that
gets an earmark for such programs. We've long been an advocate
for this program and we just kind of struggled along but it's a
model that I think that Art has made work down on the Cheyenne.
So, he's a valuable resource and I'm pretty sure he'd make
himself available if you would call on him.
We've been joined by Senator Domenici of New Mexico and the
chairman of the full committee. I don't know how full he is but
he has joined us. Senator Domenici.
STATEMENT OF SENATOR PETE V. DOMENICI
Senator Domenici. Thank you so much. I wanted to say to the
Senator, it's good for me to find Senators that are willing to
work on these issues. You know, I've been here for a long time
and there weren't a lot of them. You take some of the issues,
he takes some, I take some, and I think we're doing a much
better job. There's no question, we must do better. But I thank
you for what you do and I think you know there's been an
enormous success, not relevant to this, but I just had an
inventory done of how many new schools were built because we
started 3 years ago with a notion of how it should be done.
Compared to 10 years ago it's incredible what's being built for
the kids in terms of new schools.
DIABETES
Dr. Grim, let me say there's many, many things we could
talk about but I think when you see something that's just stark
in your face you can't ignore it. Diabetes is it. I mean, we
have some Indian tribes, as you know, that may have 50 percent
diabetes. We also have showing up babies, kids, I don't mean
babies but kids and most of them are Indian, with diabetes. So
from my standpoint I'm deeply interested in your programs. You
get some extra money.
Dr. Grim. Yes sir.
Senator Domenici. Because we, fortunately, put $150 million
for America and $150 million for Indians. So that was a pretty
big amount. In my State we have a number of centers. How many
Indian tribes are working with those programs, do you know?
Dr. Grim. Almost all tribes across the Nation are
benefiting from that money. And I want to thank you, each and
every one of you, that had a part in that $150 million; it's
been put to great use by tribes across the Nation. We have over
300 grantees that are being funded by that now and we have some
great results that are starting to show up. As you know, in
fiscal year 2004 we received the additional $50 million; prior
to that the first 6 years had gotten up to $100 million. We
also have a report that I think Congress would be very
delighted to see that's going to be available very, very soon
that's going to have a lot of information and a lot of
statistics about the good things that money has helped us
accomplish. Just to give you an example of some of the things
that we've done, in 2002, 71 percent of our diabetes grant
programs reported availability of community-based physical
activity programs for children, youth and families. Prior to us
having those funds available, only 10 percent of our programs
had such activities. In 2002, 53 percent of our grant programs
reported availability of school-based physical activity
programs; prior to that only 22 percent of our school programs
had things like that. Around nutrition education, prior to
those funds being available only 20 percent of the programs out
there had established nutrition activities for parents and
families of school-age children; now we have 60 percent of our
programs that have those sort of activities. This report that
we'll be providing the Congress is just full of----
Senator Domenici. When will that be ready?
Mr. Hartz. Senator, that was the report that was requested
prior to the reauthorization so we have that at the printers
right now. So it'll be forthcoming.
Senator Domenici. One of my questions was going to be,
could you give us such a report?
Mr. Hartz. Yes.
Senator Domenici. You had previously said you would but we
didn't seen it. So it'd be important that we look at it because
diabetes is costing a lot of money and we understand dialysis
requirements in Indian country are just skyrocketing and that's
not very cheap in terms of the program but you've got to do
them.
Dr. Grim. Besides those programmatic sorts of indicators
that we'll be able to show you, Senator, we'll also have
clinical indicators, like Hemiglobin A1c that are markers, and
we can show where we're seeing a strong downward trend in that,
better control in our diabetics and I think you'll be very,
very pleased to see how the money has been put to use and the
type of impact it's had on the health of our Indian people.
Senator Domenici. Well, I want to say, the chairman of the
full committee truly helped us with that. The chairman of the
subcommittee worked--and that actually happened sort of as a
fluke when we did the balanced budget. Newt Gingrich and I
right at the end said oh, we've done everything and we've got
$60 million sitting here. Nobody understands how we could have
it but we did. We decided to spend it since he was worried
about diabetes and I had you all, I said well, why don't we
split it? And he said between whom? I said Indians get half and
diabetics get half; now we've gone on keeping that ratio.
Dr. Grim. We certainly appreciate it. And I think you will
see in this report that it's been money well spent.
Senator Domenici. Okay. I want to switch for a minute. It's
my understanding that the BIA's considering moving or
establishing a children's hospital near Gallup, New Mexico.
Would you please comment on the progress of that project.
Dr. Grim. I'm not aware of that, Senator. We'll have to
submit that for the record for you.
Senator Domenici. Will you please?
Dr. Grim. Yes sir.
[The information follows:]
The IHS is not aware of nor have we been involved in this project
with the BIA.
GALLUP INDIAN MEDICAL CENTER
Senator Domenici. Now we also understand that the regional
hospital in Gallup, New Mexico, which I assume you've seen.
Dr. Grim. Yes sir.
Senator Domenici. Is very, very old and I understand that
it is in need of replacement. What's happening on that front?
Dr. Grim. In the 2000 Appropriations Committee report, the
Indian Health Service was asked to take a look at all the
facilities needs across Indian country. We're in the process
right now of going through tribal consultation; we've had a
committee that's put together recommendations; we've asked all
of our regions to begin doing a health services master planning
effort, and we'll be going out some time this summer with
requests for consultation across the country on a new priority
methodology to look at health care needs. We're hoping that
will be a much broader and much more comprehensive look at the
facilities health care needs than in our current system because
over time Congress has given us some additional avenues other
than our normal facilities appropriations like joint ventures
and small ambulatory programs. Right now we still have four
hospitals that are on our current priority list and five out-
patient health facilities. Once those are completed that new
list, the one that we're looking at now will be going into
effect. Gallup's currently not on it but what Gallup has been
doing with a lot of the monies that they raise through third
party revenues and also with the maintenance and improvement
funds that come through the Indian Health Service is to
maintain and upgrade the facility as needed until we're going
to be able to replace it.
Senator Domenici. Well, I just want to say, anybody that
would go there, especially since it's regional and right in the
middle of the main effort with reference to diabetes, anybody
that would look at that would, in my opinion, have to conclude
that we can't continue to use it very much longer. It is truly
a decrepit hospital compared to what we have in this country.
And I'm not trying to usurp any committee or commission but I
think we can't go so slow, we've got to get on with it. So I
urge that that occur.
Dr. Grim. Actually sir, they are in the process, I was just
told, of completing a program justification document which is a
necessity prior to getting on the list and we're in the process
right now of a $10 to 12 million maintenance and improvement
project with them to upgrade the facility until such time as it
can be replaced.
Senator Domenici. To upgrade the----
Dr. Grim. Existing facility, yes.
Senator Domenici. Yes. So what would I be able to tell
these people that keep asking me? Can you put that in the human
language instead of technical language? What about the
hospital, Doctor? I'm telling the people in Gallup, so could
you answer that?
Mr. Hartz. Yes sir. I was out there within the last year or
thereabouts and there's actually construction going on to the
back of the hospital, between the hospital and the quarters to
the south so that we can, as Dr. Grim was pointing out, address
some of those facility needs because of the tremendous workload
that comes into GIMC. And that's that $10 to $12 million that
actually is underway.
Senator Domenici. All right. Senator, I have some questions
to submit. I'll just submit them, and I thank you very much,
Mr. Chairman. They have to do with sanitation facilities, a
terribly difficult problem; I'd like your views and in
particular would like to know how we might put more emphasis on
it.
Dr. Grim. Yes sir.
Senator Domenici. And professional staff shortages, I had
some questions about it but if you've been asked, fine. I'm
going to submit mine in the event there are not overlaps and
ask you to answer.
Dr. Grim. Be glad to respond to those, Senator.
Senator Domenici. Thank you.
Senator Burns. Thank you, Senator. Senator Stevens.
STATEMENT OF SENATOR TED STEVENS
Senator Stevens. Well, thank you very much Mr. Chairman.
I've just come by really to say hello to Dr. Grim and his
colleagues and to thank Dr. Grim for coming to Alaska. Some of
you may not know that Dr. Grim was sworn in in Anchorage, the
first of the Indian Health Service directors that has been
sworn in in Alaska; we consider that a great honor. And it's
important to us because I think we have the highest percentage
of Native people of any State in the union. It's approaching
one-fifth of our population now, double the percentage of any
other State. Of course, we have a small population base so that
makes them even more important. I think that it's the only
place where the Indian Health Service, working with the Native
people, allows them the greatest role in management, which has
led to our people having even higher regard for the system
because they're directly involved in it.
I think that when you look at it we've got to work to
improve the situation with regard to funding. I agree with
that. The budget caps are very tight right now but we believe
we get more for the dollar up there because of our telehealth
program that you have helped pioneer and people from all over
are now coming to study it, I understand. So I hope we can work
together with the chairman and this subcommittee to make sure
we get the resources for a lasting Community Health Aide
Program.
I was visited, Doctor, by the American Dental Association;
they're seeking to partner with you and our regional
corporations through their non-profit subsidiaries that deal
with health problems to see if we can't use the facilities of
the Community Health Aides for dental services which they will
see if they can't actually raise the money to pay for traveling
dental assistants to come right to the villages and we may have
to put some facilities in those community health--well, there
are community health facilities there but we have to put dental
facilities in them if we're going to work with the dental
people. So I would encourage you to do that.
We have inadequate Native hospitals in Nome and Barrow that
we're going to have to replace; I don't know where they are on
the list yet but----
Dr. Grim. They're close.
Senator Stevens. They're close? I understand that we've
waited our turn before. But clearly the one concept we don't
have adequate control over is substance abuse, particularly
among the village children. So, Mr. Chairman, we have lots to
do. Maybe when you come up you might take a trip out to a few
Native villages this year.
Senator Burns. Yes. I tell you what I'd like to see up
there because we're trying to design the same kind of
telemedicine program on our reservations up in Montana. In
fact, we've made great strides in that respect as you have made
up there. You know they say necessity is the mother of
invention and imagination is necessary when you've got
distances to cover like both of our States. Ours is not the
magnitude of yours but nonetheless we still have a tremendous
distance to cover whenever we start providing health care
services.
We looked, in the State of Montana, when you get in the
rural areas where you have an aging population. I mean, we're
going to have to deliver health care services in a different
way. And of course, I don't think there's been anybody that's
been as much on the cutting edge as Senator Stevens has and
both of us have worked on wireless technologies in rural areas,
where we can use that tremendous technology and do broadband
and move lots of information and take care of lots of things.
And I appreciate your interest in that because it's been an
interest of mine ever since we started talking about
telecommunications and revamping that whole area over the last
10 to 12 years now, and the 1996 Act.
I also have some more questions but----
Senator Stevens. Senator, if I could point out to you, I've
just come back from Iraq and Afghanistan. Those two nations
would fit into my State and leave room for your State.
Senator Burns. We might move it up there. We're getting a
little----
Senator Stevens. Well, we're spending a lot of money in
those two nations and I'm not opposed to it but I do think when
we get through this current phase of trying to help some people
overseas that we ought to start bringing back some of that
money and putting it to work in States like yours and mine.
Senator Burns. Yes.
Senator Stevens. But the distances in ours are just mind
boggling when it comes to delivering health care and that's all
there is to it. And I pointed that out to the dental people
when they came in and I hope that they visit with you and you
bring some reality to their minds about how to deliver dental
care along with the health care that you have pioneered so much
in our State.
Senator Burns. We look forward to coming up.
Senator Stevens. I think you should visit a couple
villages.
Senator Burns. Well, you know, I sent my number one agent
up there and she spent 30 days with your health service.
Senator Stevens. He's talking about his daughter.
Dr. Grim. I was trying to recruit her this morning, too.
Senator Burns. Oh, were you up there when she did that 30-
days?
Dr. Grim. I wasn't there.
Senator Burns. Well she came back and she said if you think
we've got problems in Montana, you want to come up here, Pop.
Senator Stevens. I think she went to where there's more men
available; women outnumber us in Alaska now, did you know that?
Senator Burns. Women outnumber you guys?
Senator Stevens. Yes.
Senator Burns. That's the way it was at the University of
Missouri. When I was at school there we had Stevens and
Christian Colleges; wasn't a bad place to go to school, you
know.
Senator Stevens. Thank you very much, Doctor.
Dr. Grim. Thank you, thank you Senator Stevens.
Senator Stevens. We're drifting aside here.
Senator Burns. We've got some other things that we'll talk
about in the weeks ahead and we really can't say yay or nay to
anything this morning, Dr. Grim, as you well know. The budget
resolution, we hope, gets done this week, and our allocations
come out. And then we'll start the real work of trying to cover
those bases that we understand. But we've got mutual problems
and I understand the problems you have and we all have in this
area. But a lot of people don't realize that we also have other
means of providing services to our reservations other than the
Indian Health Service so when you look at that money when it
comes in it's not as bad as it sounds but it could be better.
And we're going to continue to try to increase those facilities
and everything else in the way we deliver our services.
Thank you for your service, all three of you, and all the
men and women of the Indian Health Service. We appreciate that
and we see its evidence every day in my State of Montana.
ADDITIONAL COMMITTEE QUESTIONS
We're going to hold the record open for a couple of weeks.
If there are any questions coming from other subcommittee or
full committee members we ask that you respond to them and to
this committee and thank you for your appearance this morning.
Dr. Grim. Thank you, Mr. Chairman.
[The following questions were not asked at the hearing, but
were submitted to the Department for response subsequent to the
hearing:]
Questions Submitted by Senator Conrad Burns
ASSESSMENTS/REIMBURSEMENTS
Question. It is estimated that IHS will reimburse the Department of
Health and Human Services for over $40 million worth of services in
fiscal year 2005. In addition, assessments to the IHS operating budget
for participation in Department-wide initiatives and government-wide
administrative functions is estimated to be another $440,000.
What types of reimbursable services does the Department provide to
IHS?
Answer. The Department provides the following types of services:
--Human Resource Services: automated personnel and payroll systems
and payroll processing.
--Commissioned Personnel Services: active duty payroll, personnel
management systems and support, and recruitment for active-duty
Public Health Service Commissioned Officers.
--Financial Management Services: accounting systems and services;
payment management systems; preparation of financial
statements; and audit liaison services.
--Inclusion in new HHS-wide information systems: Unified Financial
Management System; Enterprise Infrastructure (overall systems
integration and security).
--Participation in safety, health and environmental management for
the quality of worklife of the HHS employees.
--Participation in Government-wide activities: principally the Chief
Financial Officers Council; Chief Information Officers Council;
President's Council on Bioethics; and GSA First-Gov.
Question. What benefits does the IHS-tribal partnership derive from
its participation in government-wide and department-wide initiatives?
Please describe what sorts of initiatives IHS will be required to help
fund.
Answer. The government-wide and department-wide initiatives provide
greater access for the IHS-tribal partnership, i.e., personnel systems
that support the 15,500 IHS personnel including approximately 2,000
Federal personnel working for Tribes (IPAs and MOAs), and payment
management systems that make timely payments for Tribal contracts,
grants, and funding agreements. The department-wide initiatives also
provide for economies of scale and common administrative systems,
thereby resulting in more resources available for mission services.
Initiatives to which IHS will contribute in fiscal year 2005
include:
--Human Resources Services
--EEO Complaints Processing
--Commissioned Personnel Services
--Financial Management Services
--Federal Occupational Health Services (Employee Assistance Programs)
--UFMS
--HHS Enterprise Infrastructure
--Employees Quality of Worklife
--IT Access for the Disabled
--Media Outreach
--National Rural Development Partnership
--Government-wide Councils (CFO, CIO, Bioethics)
EPIDEMIOLOGY CENTERS
Question. IHS is working with organizations such as tribal health
boards to create regional Epi Centers. To date, 7 have been
established. The budget includes an increase of $2.5 million, part of
which will be used to establish 3 or 4 more.
Billings is one of 5 IHS Areas that does not have an Epi Center.
Has the tribal health board there expressed an interest in
participating in this program? What criteria would an Area like
Billings have to meet in order to be selected? Is this a competitive
program?
Answer. The Montana/Wyoming Tribal Chairman's Health Board has
expressed an interest in developing an epidemiology center. However,
they did not submit an application in fiscal year 1996 and thus we have
had no method of funding an Epi Center in the Billings Area. We are in
the process of finalizing a Request For Proposals (RFP) at this time to
allow not only the Billings Area tribes the opportunity to apply but
also other American Indian Health Boards representing other IHS Areas
that do not have Epi Centers.
We have cooperative agreements with the 7 currently funded tribal
Epi Centers that had to meet the following criteria:
--Must represent or serve a population of at least 60,000 American
Indians or Alaska Natives.
--Provide letters of support from all tribes in the catchment area.
--Provide tribal resolutions supportive of the Epi Center from the
Indian tribe(s) served by the project.
--Must be a non-profit American Indian or Alaska Native organization.
--Submit an application in accordance with Office of Grants
Management and Policy (OGMP) guidelines responding to the RFP
that will be out by mid-summer for awards in September 2004.
It is a competitive program. The RFP will be for cooperative
agreements with successful applicants.
Question. Please provide examples of the benefits that Epi Centers
offer to their tribes. What are the annual operating costs of an Epi
Center? To what extent are these funds used to leverage dollars from
other sources?
Answer. Operating from within tribal organizations such as regional
health boards, the Epi Centers are uniquely positioned to be effective
in disease surveillance and control programs, and also in assessing the
effectiveness of public health programs. In addition, they can fill
gaps in data needed for the Government Performance and Results Act
(GPRA) and Healthy People 2010. Some of the existing Epi Centers have
already developed innovative strategies to monitor the health status of
tribes, including development of tribal health registries, and use of
sophisticated record linkage computer software to correct existing
state data sets for racial misclassification. These data may then be
collected by the National Coordinating Center at the IHS Epidemiology
Program to provide a more accurate national picture of Indian health.
There are currently seven Epi centers funded at $300,000 each.
These funds are used to support basic operations; all of the centers
write other grants and attract funds from a variety of sources to
accomplish their mission. The Epi Centers utilize the award from IHS to
attract funds from States, non-profit organizations, and other Federal
funding sources. If the additional $2.5 million requested in 2005 is
provided, we plan to fund 4 additional centers at $400,000 each, and
increase the budget of each existing center by $100,000. Remaining
funds would be used by the National Epidemiology Program to hire
project officers for the expanded program and to serve Areas that do
not have a center.
TELEMEDICINE
Question. The IHS budget justification does not seem to focus on
telemedicine as a means to deliver more and better health care to
tribes, particularly those in remote areas. Wouldn't an investment in
this technology offer significant benefits to tribes in large, land-
based states like Montana.
Has IHS looked at ways to better integrate telemedicine into its
services? How much of the IHS annual budget is dedicated to expanding
or operating this kind of network? How much more would the agency have
to invest to provide significantly greater access to this technology
than currently exists? Have tribes expressed interest in developing
this kind of infrastructure? Does the Service have a plan for
developing a national network?
Answer. The IHS is now evaluating several areas for adoption of
telemedicine including diabetic retinopathy screening, teleradiology,
telepyschology, and telepediatric care (in child abuse cases). As
studies confirm the improvement in clinical outcomes and cost
effectiveness of these newer solutions to reaching rural tribes,
replication of the successful programs is occurring. Currently, several
projects have been initiated, particularly in the Southwest, and
partnerships have been established, notably with the Arizona
Telemedicine Program, to serve as a demonstration of this care
modality.
The IHS spends $500,000 to $1,000,000 annually for telemedicine
activities. We estimate that $10 million annually would support entry-
level telemedicine capability at all sites. Resources needed to provide
an entry-level system include national coordination and clinical
education, increased telecommunications infrastructure to handle the
large volumes of files and live video feeds, resources for replacement
of existing incompatible equipment to digitally based medical
equipment, resources to incorporate the digital imagery into our
electronic health record software, and resources to address long term
archival storage on a regional basis.
Tribes are interested in developing this kind of infrastructure.
Telemedicine is emerging as one of the central themes in the
formulation of Area strategic plans. Tribes are seeing this as a way to
provide high quality medical care close to home at a greatly reduced
cost. We believe that this modality will also reduce stress on the
patient's family, as many procedures and follow-ups may be done locally
as opposed to traveling great distances.
Planning has begun on a regional basis, notably with the Southwest
Telehealth Consortium, leveraging existing programs with private and
university-based partners to produce a regional t-health program to
have capacity to evolve as needed to serve larger agency needs.
Additional opportunities are being explored with the VA and other
federal health partners. Our desire is to expand this to a nationally
coordinated effort and take advantage of economies of scale and best
practices.
This Subcommittee also appropriated funds for a mobile women's
health unit in fiscal year 2004 that will be dedicated later this year.
We will be able to do ``realtime'' reads of digital mammography imagery
and eliminate call backs of our patients, in addition to offering a
full range of services in this women's health unit. Many Areas/tribes
are interested in how successful this demonstration will be in the
Aberdeen Area. Operational and staffing aspects of this demonstration
are proving to be quite challenging.
CHANGE IN HEALTH PROBLEMS
Question. The budget justification points out that the kinds of
diseases affecting Native Americans today are changing. Obesity,
injuries from domestic violence, and alcohol and drug abuse, for
example, are beginning to replace the acute illnesses IHS has
traditionally treated. As a result, chronic illnesses like heart
disease, diabetes, liver disease, cancer and injuries that require
costly long term treatment are on the rise.
How is IHS changing its delivery of health care to meet these new
challenges? What adjustments will be necessary to address this growing
set of health problems? What programs will need to be expanded? What
costs are we looking at down the road?
Answer. The IHS system has been a public health and prevention-
oriented program since its inception. The major effort in these areas
has been (and still must be maintained) in maternal and child health
where a variety of public health and disease prevention efforts have
had great impact. Expanded emphasis on prevention and public health
primary care activities must be focused on children of school age,
adolescents, and young adults to promote primary prevention of these
chronic diseases. This will require expanded efforts at the community
and ambulatory level. There is also a need for greater emphasis on
clinical prevention such as better management of diabetes to prevent or
delay the secondary effects of this (and other) disease. Because of
enhanced clinic and community care programs, the number of patients
hospitalized has declined significantly, allowing the agency to reduce
its construction and use of hospital beds.
Tribal leadership in addressing these issues has been so very
helpful. Greater tribal emphasis and control of community prevention
programs is critical to changing the behavior and expectations of
community members. In addition, tribal leaders can bring together all
the non-health entities that can influence health outcomes in ways that
are more effective than the federal government. This would include the
justice, education, labor, and economic development entities that are
needed to improve the quality of life in Indian communities. We can and
must be active partners in supporting such community-wide efforts to
expand opportunities at the Indian community level. Without this
coherent approach, the many factors that influence health outcomes will
not be changed.
Community-based and ambulatory programs will need expansion. The
emerging successes of the diabetes programs in Indian country are
showing the ways and means to achieve healthier communities. Utilizing
the approaches now showing effect in diabetes to address cardio
vascular disease, cancers and behavioral disorders is the roadmap for
the future.
ALCOHOLISM
Question. The incidence of alcoholism is reported to be more than
600 percent greater among Indians than the general population. Drug and
alcohol abuse accounts for 25 percent of deaths among Indian women.
These are devastating statistics.
What will it take to turn these statistics around? What additional
resources do tribes need to reduce these numbers? This disease takes a
particular toll on families. Fetal alcohol syndrome, child neglect and
domestic violence are just a few of the problems that can result. Are
there treatment programs targeted at women and children that have
demonstrated some effectiveness in reducing these problems?
Answer. Alcohol and substance abuse has and continues to be one
among the most pervasive health and public health concerns in Indian
Country. Their effects are widespread, pervasive, debilitating, and
highly resistant to intervention. They are not only personal and public
health issues, but social issues of far reaching effect. Every family
is touched in one form or another by their widespread and devastating
effects. Like problems discussed in other behavioral health areas,
these problems are complex, highly resistant to change, and require
coordinated efforts from family to federal leadership. They are also
among the most intransigent and difficult to treat. Unlike many other
diseases with direct and, by behavioral health standards, fairly
uncomplicated causes and treatments, alcohol and substance abuse
problems represent extraordinary arrays of interconnections between
biology; psychology; history; the individual; families; communities;
economics; politics; spirituality; and the interplay between hope and
possibility versus hopelessness and commensurate helplessness. Simple
and quick answers will not be found here. But answers are there and
effective interventions from individual to community levels can be
found. They are not necessarily simple, easy, nor quick, but they are
there. The key, as usual, is having the appropriate approaches and
resources to implement and sustain them.
A significant change in the past 10-15 years has been the increase
in tribes taking over their own services and interventions for alcohol
and substance abuse. Now, a full 97 percent of the alcohol and
substance abuse budget goes directly to tribally operated programs.
Tribes are now responsible for formulating and delivering their own
services to their people. Subsequently, IHS is shifting its focus from
direct service provision in alcohol and substance abuse, to one of
supporting tribal programs in their service delivery.
There are many programs and service delivery models which represent
tribal and urban approaches to alcohol and substance abuse. The more
effective Native American programs have five major components that are
in place to support not only a person's recovery process, but also the
family's recovery as well.
a. Firm support for and use of Tribal Traditions in the healing
process. It is not a separate process, but integral to the healing
process.
b. Holistic approach to recovery including full array of behavioral
health specialties and services; job/vocational support; education
about and support for household financial planning and decision making;
parenting skills training/support; educational evaluation and support
for school-aged children.
c. Family involvement and, for mothers, care for dependent
children, preferably on site.
d. Accredited programs utilizing defined outcomes measures and
database programmatic decision-making in creating and managing
treatment programs.
e. Continued support and treatment for recovery after residential
treatment is completed because program completion is not the end of
treatment, but rather the beginning of long-term recovery.
Representative programs with these components for mothers include
Native American Rehabilitation Association of the Northwest, Inc., in
Portland, OR; Friendship House of American Indians, in San Francisco,
CA; Rainbow Center on the White Mountain Apache Reservation (known
federally as the Fort Apache Indian Reservation) in Whiteriver, AZ; and
Native American Connections, Inc., in Phoenix, AZ.
There are 11Youth Regional Treatment Centers across the country
that fully embrace these major components and continue to serve tribal
youth with the most fully integrated treatment services in Indian
Country.
DIABETES FUND
Question. The Balanced Budget Act of 1997 established the Special
Diabetes Program for Indians initiative. Through this program, more
than $600 million has been funneled to the tribes for diabetes
prevention and treatment work. These funds are in addition to the
appropriated dollars provided by this Subcommittee for diabetes.
Please give examples of the kinds of work that is supported with
this funding. Are there trends IHS can point to that offer some
encouragement that this initiative is having a positive impact in
Native American communities?
Answer. The SDPI grant programs are providing a variety of diabetes
prevention and treatment services in their respective communities,
based on local community needs and priorities. Listed below are some
examples and outcomes on how the SDPI funds are being used in tribal
communities.
--86 percent of the programs reported that general screening for
diabetes and pre-diabetes screening was available compared to
14 percent.
--83 percent reported screening children and youth for obesity and
overweight to provide an opportunity for early intervention and
60 percent reported the development of weight management
programs for children and youth.
--91 percent reported screening adults (ages 26-54) for overweight
and obesity and 91 percent of the programs reported that they
developed programs to promote healthy lifestyles.
--IHS has been able to demonstrate significant improvements in blood
glucose control over time, greater than 1 percent point drop
for each age group, as measured by A1c.
--As a result of the SDPI grant funds, programs have both enhanced
existing diabetes activities and developed new activities.
Specific program activities are proven to improve diabetes care
outcomes. SDPI grant programs integrated these program
activities into their programs as follows:
--83 percent of programs now track their diabetic patients through
diabetes registries;
--81 percent have diabetes teams in place to provide better care;
--66 percent of programs report that basic diabetes care is now
available for people with diabetes in their communities;
--87 percent of programs now have diabetes education services
available;
--86 percent of the SDPI programs report that screening for pre-
diabetes and diabetes is available; and
--73 percent of the programs conducted community needs assessments.
Question. Is IHS collaborating with other agencies through this
program, and if so, please describe the types of activities that are
being supported.
Answer. The IHS National Diabetes Program developed and built upon
collaborations and partnerships with federal and private organizations
as a result of the Special Diabetes Program for Indians. These include:
--Department of Health and Human Services Agencies (Centers for
Medicare and Medicaid Services, National Institutes of Health,
Centers for Disease Control and Prevention Division of Diabetes
Translation, Head Start Bureau).
--AI/AN Organizations (American Indian Higher Education Consortium,
National Indian Council on Aging, Association of American
Indian Physicians, National Indian Health Board, American
Indian Epidemiology Centers, Urban Indian Nurses Association).
--Diabetes Expert Organizations (American Diabetes Association,
Joslin Diabetes Center, American Association of Diabetes
Educators, National Diabetes Education Program, American
Academy of Pediatrics, Juvenile Diabetes Research Foundation,
Diabetes Research and Training Centers, International Diabetes
Center, MacColl Institute of Group Health Cooperative of Puget
Sound).
--Academic Institutions (University of New Mexico, University of
Arizona, University of Southern California, University of
Colorado, University of Montana).
--Other Organizations and Agencies (U.S. Department of Agriculture,
Boys and Girls Clubs of America).
--Six pilot Boys and Girls Clubs of America have implemented a
diabetes prevention initiative for 9-12 year olds. The
initiative is in partnership with the National Congress of
American Indians and Nike Corporation.
CONTRACT HEALTH SERVICES (CHS)
Question. Contract Health Service dollars are a critical component
of the IHS program. It is key for some of the tribes in my state of
Montana, who depend on these funds to purchase health care from the
private sector. The IHS budget proposes to increase this program by $18
million in fiscal year 2005.
How much of a shortfall currently exists in contract health care
funding overall? How many of the highest priority medical cases must be
rejected annually because tribes run out of money? What impact would
the proposed increase for fiscal year 2005 have in alleviating this
problem?
Answer. The Indian Health Service (IHS) Contract Health Services
(CHS) programs operate within budget and must not obligate the Agency
beyond their appropriations and cannot operate programs at deficits.
The IHS medical priority system was established to ensure that the most
needed medical services are provided within available funding levels.
The fiscal year 2005 President's Budget includes an increase of $18
million for Contract Health Services, (+4 percent) over the fiscal year
2004 enacted level. This funding increase, combined with the additional
purchasing power provided by the recently enacted Medicare
Modernization Act, will allow IHS to purchase an estimated +35,000
additional outpatient visits or +3,000 additional days of inpatient
care. Section 506 of the Act will increase IHS' buying power by
allowing IHS to purchase inpatient care at rates determined by the
Secretary. The IHS CHS program does not track payment or denials by
priority levels.
Question. The Subcommittee has heard complaints from tribes that
the CHEF set-aside, which is meant to cover the medical costs of
catastrophic illness, does not meet the full need in Indian country.
Tribes are forced to use their CHS dollars for these most expensive
cases, eroding the amounts that are available for more routine care and
illness. How much would be required to shore up the CHEF fund? About
how many cases are eligible annually for CHEF payments but aren't being
taken care of because the fund has run out of money?
Answer. Once the Catastrophic Health Emergency Fund (CHEF) fund is
depleted by the 3rd quarter, Areas, Service Units, and Tribal programs
cease reporting high cost cases that could be designated as CHEF cases.
In the past year an additional 800 cases amounting to over $12 million
for a total of $30 million would have been needed to fund all cases
submitted or CHEF funding. It is possible that there is underreporting
of some high cost cases.
INDIANS INTO PSYCHOLOGY PROGRAM--MONTANA
Question. I've been a longtime supporter of the Indians into
Psychology program at the University of Montana. Has this program been
successful in its goal of bringing greater numbers of Native Americans
into mental health professions?
Answer. The Indians into Psychology program at the University of
Montana was initially funded in fiscal year 1999. According to the
American Psychological Association, statistics indicate students take
an average of 7\1/2\ years to complete a doctoral program. The students
at the University of Montana will be completing their studies in 6\1/2\
years which speaks highly of the quality of the program as well as the
quality of the students.
Currently, there are 8 American Indian students in the clinical
psychology program and 2 will graduate in fiscal year 2006 which is
well within the time frame for their program.
All students are given the opportunity to work within their
practicums at locations that serve American Indians.
Question. Are there other programs--my colleague's support for the
nursing recruitment program at the University of North Dakota comes to
mind--where relatively small amounts of money are having a significant
impact in training young Native Americans for careers in the health
care profession?
Answer. Yes, the following are examples of these types of programs:
--Indians into Psychology program at the University of North Dakota;
--Indians into Psychology program at Oklahoma State University;
--RAIN (Recruitment of American Indians into Nursing) program at the
University of North Dakota;
--Indians into Medicine (INMED) programs at the universities of North
Dakota and Arizona;
--Nursing Residency Program--IHS employees who are LPN's, LVN's,
Associate Degree Nurses, or Diploma Graduate Nurses, can return
to school on a work-study program to obtain their RN degrees,
either Associate or Bachelor's;
--Indian Health Service Scholarship Program--supports Native American
students in their efforts to become health professionals.
--Preparatory scholarships assist students in studies such as
prenursing, prephysical therapy, and prepsychology for up
to 2 years.
--Pre-professional scholarships assist students in premedical and
predental studies for up to 4 years.
--No service obligation is associated with either of these
scholarships.
--Professional scholarships assist students in professional
schools, such as medical school, nursing school, pharmacy
school, etc., for up to 4 years in return for their
agreement to serve at an Indian health facility for from 2
to 4 years, depending on the length of their support.
--Indian Health Service Extern Program: Supports IHS professional
scholarship recipients to gain experience in their field of
study during non-academic periods.
Question. Does IHS collaborate with tribal colleges to provide
additional opportunities in health care education for Indian students?
Answer. Many IHS scholarship recipients attend tribal colleges for
their preparatory classes. Many also attend the Salish-Kootenai College
in Montana and the Oglala Lakota College in South Dakota for their
nursing training. We worked closely with the United Tribes Technical
College as they developed their Associate Degree in Injury Prevention
Program. They are now seeking to expand it to a four-year program. They
also have the program on an Internet-based curriculum.
INJURY PREVENTION PROGRAM
Question. The injury prevention program is one of the best examples
of IHS and tribes working to make a real difference in Indian
communities. Within a relatively small annual operating budget, it has
achieved a 53 percent reduction in injury-related deaths between 1972
and 1996.
Is there data to indicate that this downward trend in continuing?
What activities funded through this program have proven most effective
in preventing deaths and eliminating injuries?
Answer. The IHS injury trends indicate the downward trend is
continuing. The most recent data shows between 1996 and 2001 there was
4.2 percent decrease in unintentional injuries. The IHS Injury
Prevention Program advocates the development of a public health
oriented, community based strategy that relies on determining the
trends and patterns of injury in specific Indian communities; forming
community coalitions to address local injury problems; providing injury
prevention training to community-based practitioners; and developing
community-based strategies to identify and implement best practices to
address local problems. This is a summary of some of the categories of
successful initiatives and projects.
Road hazard identification and reduction.--Numerous epidemiologic
studies of motor vehicle crashes and pedestrian fatalities in Indian
communities have resulted in roadway improvement projects that have
provided roadway lighting, pedestrian walkways, traffic channeling
through communities; speed zone and signage; and guard rails and
barriers along roadways.
Occupant Protection.--Multiple efforts have taken place to increase
seat belt usage through the passage and enforcement of seat belt codes
across reservations. A variety of child passenger protection
initiatives are underway, including child passenger safety training and
certification, seat distribution, development of the (Safe Native
American Passengers (SNAP) training program; RideSafe, a Head Start
Center based occupant protection program.
Fire/Burn.--Through a partnership with the U.S. Fire
Administration, IHS has developed SleepSafe: a competitively awarded,
Head Start Center based program to increase the utilization of smoke
alarms in Indian homes. Community-based smoke alarm distribution
programs are also in place in many Indian communities.
Drowning.--Drowning is a large public health problem facing Alaska
Natives where the rivers are the roadways. Alaska Area has made
significant commitment and impact on the drowning problem through the
implementation of community-based float coat sales programs and ``Kids-
Don't Float'' programs. Float coats are winter jackets with Coast Guard
approved liner material that is a flotation device. ``Kids-Don't
Float'' is a PFD loaner box located at marinas and boat launches.
Families that don't have PFD's can borrow one for their kids for their
boat trip and return it when they return. These programs are widely
available and supported by rural Alaska communities.
Fire Arm Safes.--A promising new strategy piloted in Alaska, the
provision of gun safes in homes in rural Alaska villages. Eighty-six
percent of households that were provided a safe had their firearms
properly locked in the safe a year after distribution. Rural Alaska
experiences suicide rates up to 13 times the national rate. Firearm
related suicides in homes are a leading method of suicide. Firearm
safes are a strategy to address this problem; community members are
demonstrating their acceptance of this strategy for injury
intervention.
Question. What is the current funding level for this program? Are
there preventive measures that IHS is unable to implement within
current funding levels? What would be the optimal annual budget for
this program?
Answer. IHS currently has $1.779 million dedicated to Injury
Prevention. These funds support the HQE administered Tribal Injury
Prevention Cooperative Agreement Program and national program
initiatives. The Cooperative Agreement program provides approximately
$1.5 million annually to competitively award tribal injury prevention
infrastructure development projects and direct intervention projects.
Additional IHS funds support 25 full and part-time Injury Prevention
Specialists throughout the 12 IHS Area's; and an Injury Prevention
Practitioners and Fellowship training program.
IHS is able to provide a basic level of support to injury
prevention initiatives with the funding available. Additional funds are
received from 5 Federal agency partners to support specific injury
prevention initiatives; the agency partners are National Highway and
Traffic Administration, U.S. Fire Administration, Consumer Product
Safety Commission, Centers for Disease Control and Prevention, and
Health Resource Services Administration.
FACILITIES CONSTRUCTION PRIORITY LIST
Question. The Subcommittee understands that IHS is in the process
of developing a new priority list for the construction of replacement
hospitals and clinics.
When does IHS expect the new list to be in place? What input has
the agency received from the tribes regarding possible improvements to
the current system?
Answer. Congress directed the IHS to review and revise the
facilities priority system in fiscal year 2000 conference report
language. A Tribal workgroup developed recommendations for a process to
identify need and suggested revisions to the existing priority system.
This revised system and an implementation strategy will be presented to
all Tribes for consultation before finalization. The revised system is
expected to be in place no later than the fiscal year 2008 budget
cycle.
Question. The budget indicates that the Department of Health and
Human Services has instituted a Capital Investment Review Board to
review all IHS health care facilities construction projects. Can you
give us additional information on this Board, why it was created and
how it will function?
Answer. The Board was instituted to help ensure that a coordinated
and consistent approach to facilities construction exists within the
Department. The Board consists of the Assistant Secretaries for
Administration and Management; Budget, Technology, and Finance; and
other members including land-holding Operating Divisions. The purpose
is to implement a non-IT capital facilities investment review process,
with projects that cost more than $10 million reviewed and approved by
this Board.
Question. Given that tribes are already frustrated by the lengthy
process of project approval, why won't they see this Board as an
additional bureaucratic hurdle?
Answer. The IHS is working closely with the Department to minimize
the time that may be involved under the Board's review and approval
process.
JOINT VENTURE CONSTRUCTION PROGRAM
Question. Dr. Grim, a few years ago this Subcommittee provided the
first funding for a new program called Joint Venture. Under this
competitive program, the costs of facilities construction are met by
the tribes and IHS provides the funds to equip, supply, operate and
maintain the health centers.
No funds are requested to continue the program this year. Why
doesn't there seem to be support here? Doesn't this program help the
tribes and IHS get quality care out to Indians at a fast pace than
would be possible through the traditional construction program alone?
Are tribes not interested in participating in the program?
Answer. Funding for the Joint Venture Program was provided to
initiate four projects in fiscal year 2001 and fiscal year 2002. The
fiscal year 2001 funding was utilized to enter into two Joint Venture
agreements from proposed projects on the IHS Health Care Facilities
Outpatient Priority List. These agreements were with the Tohono O'odam
Nation and the Jicarilla Apache Nation. The fiscal year 2002 funding
was utilized to fund two Joint Venture Agreements that were not from
priority lists but were competitively awarded from 15 applications
submitted for this program; they were with the Choctaw Nation, and the
Muscogee Creek Nation. In fiscal year 2003 and fiscal year 2004 funds
to support additional Joint Ventures were neither requested by the
Administration nor provided by Congress. The fiscal year 2005 budget
request completes the four highest priority projects on the
construction priority lists but does not initiate any new projects. The
fiscal year 2005 budget request does support the Joint Venture Program
by requesting an increase of $17 million for the staffing and
operational costs for 3 of the 4 projects which are anticipated to be
open in fiscal year 2005.
HOMELAND SECURITY/BIOTERRORISM
Question. The budget request briefly mentions a Department of
Health and Human Services initiative related to homeland security, and
more specifically, bioterrorism.
Please provide more about this initiative, its impact on IHS, the
cost of implementation and how these costs will be met.
Answer. The funding available to the Department of Health and Human
Services, approximately $1.4 billion, is appropriated by Congress to be
used by States, and a few large metropolitan areas, to improve State,
Local and Hospital preparedness for bioterrorism and other public
health emergencies. Tribal nations are not eligible as direct awardees,
however HHS explicitly requires all jurisdictions to include Indian
tribes in the development, implementation and evaluation of their
bioterrorism work plans. Awardees are also asked to provide
documentation of Indian tribal governments' participation in state and
local emergency preparedness planning. The funds flow through the
Health Resources and Services Administration and the Centers for
Disease Control and Prevention as grants for hospital preparedness and
public health infrastructure development (respectively). Our experience
has been that some States have been very inclusive in providing Tribes
the opportunity to participate in policy development, training, and
funds distribution (Arizona, Alaska, Maine, New Mexico, to name a few).
The Indian Health Service participates in disaster planning and
exercises as part of its ongoing medical emergency response and quality
assurance programs with excellent support coming from some States. No
additional resources have been devoted to this effort.
MEDICAL EQUIPMENT
Question. The budget for the purchase of medical equipment is
currently funded at $17 million. Increases over the past several years
have been minimal and no increase is proposed in fiscal year 2005.
As more sophisticated and expensive technologies become available
for the diagnosis and treatment of disease, how has the Service's
purchasing power been reduced? What amount would be needed to provide
more and better medical equipment to IHS and tribally operated
facilities?
Answer. The average life expectancy for today's medical devices is
approximately 6 years, depending on the intensity of use, maintenance,
and technical advances. Given a medical equipment inventory of $320
million, an annual replacement amount of $53 million would allow
replacement of one-sixth of the inventory each year. The current
funding level for replacement medical equipment is $11 million. The
Medical Equipment request also includes $5 million for equipment for
newly constructed tribal facilities and $1 million for equipment
purchased through TRANSAM (DOD excess equipment) and ambulances.
HEALTH FACILITIES CONSTRUCTION DECREASE
Question. In fiscal year 2005, the budget request for construction
of replacement health care facilities is $42 million, a proposed
reduction of more than $50 million from the fiscal year 2004 funding
level.
Given that the average age of IHS facilities is 32 years, and some
as old as 100, what is the rationale for cutting this program in half?
Answer. The fiscal year 2005 request allows IHS to complete
construction of the 4 highest ranked health facilities and staff
quarters construction projects--Red Mesa, AZ outpatient facility,
Sisseton, SD facility, Zuni, NM staff quarters and Wagner, SD staff
quarters. No new facility construction projects would be initiated.
Question. What amount do you estimate would be required annually in
base funding to operate this program most effectively?
Answer. Funding for health facilities construction is determined on
a project-by-project basis. In developing plans for new facilities
construction, IHS must take into account not only construction costs
but also the cost of operations for new and existing facilities. The
fiscal year 2005 request allows IHS to focus on its priorities while
taking both construction and operations costs into consideration.
______
Questions Submitted by Senator Pete V. Domenici
SANITATION FACILITIES CONSTRUCTION
Question. Sanitation construction and refurbishment is direly
needed in many areas of Indian Country. Wastewater facility
construction is among the most discussed issues by the tribes in New
Mexico. A number of New Mexico tribes have systems over thirty years
old. The IHS states its mission is to ``raise the health status of the
American Indian and Alaska Native people to the highest possible level
by providing comprehensive health care and preventive health
services.'' The foundation for any health system must certainly be
partially based upon adequate sanitation facilities.
The modernization of these facilities is also of concern for a
state in the midst of a devastating drought. Increasing the efficiency
of wastewater facilities and improving the recoverability of wastewater
is an essential step in addressing life in drought. This is especially
true when competition for water is on the rise due to numerous factors
including drought and protecting endangered species.
Question. Comment on the resources that IHS can bring to address
this problem.
Answer. The current total need for waste water disposal facilities
for American Indians and Alaska Natives (AI/AN) is $508 million and of
that total need, $255 million is considered to be economically and
technically feasible. Through the IHS regular funding for existing
homes and Environmental Protection Agency (EPA) Clean Water Act Indian
Set-Aside (CWAISA) funding plus other contributors funding, this
feasible need has been reduced by $21 million since 2002. The waste
water disposal needs have been decreasing over the last several years,
in part due to the recent increase in the EPA CWAISA. While we have
made significant headway in addressing the waste water needs, the water
supply requirements have been very slight and generally the trend in
water supply deficiency have been increasing due to inflation,
population growth and new environmental laws including changes to the
Safe Drinking Water Act. In addition to the EPA funding, IHS continues
to work with Tribes, other federal agencies, and States to find
additional funding for sanitation facilities. In fiscal year 2003, the
IHS received $42 million in outside contributions through the IHS
finance system.
Question. Would it make sense to placing areas suffering from
drought on a higher priority for water and sewer assistance so as to
get more and cleaner water to those with the most immediate need?
Answer. The Sanitation Deficiency system used by IHS to inventory
the sanitation needs for AI/AN, is a priority system and not a waiting
list and since this inventory is updated annually, emerging needs such
as drought, can be addressed as they arise. Health impacts and tribal
priorities can raise the score of a project and the funding priority.
DIABETES PROGRAM
Question. Almost 105,000 Native Americans and Alaska Natives, or
15.1 percent of the population, receiving care from Indian Health
Services (IHS) have diabetes. As you know, the consequences of diabetes
are debilitating, including heart disease and stroke, which strike
people with diabetes more than twice as often as they do others. Other
complications include blindness, kidney disease, and amputations.
Diabetes is the fifth-deadliest disease in the United States.
According to the American Diabetes Association, the total annual
economic cost of diabetes in 2002 was approximately $132 billion, or 1
out of every 10 health care dollars spent in the United States.
Given that diabetes affects such a large percentage of Native
Americans, I am deeply interested in IHS progress and programs.
New Mexico is home to a number of diabetes centers and programs.
How many tribes in New Mexico and the Nation have programs working
directly with them?
Answer. All 27 tribes in New Mexico have a Special Diabetes Program
for Indians (SDPI) grant program. There are a total of 34 SDPI grant
programs in New Mexico. The majority of the NM SDPI programs, 85-90
percent, provide primary prevention activities.
Nationally, the IHS awarded Special Diabetes Program for Indians
grants to 318 programs under 286 administrative organizations within
the 12 IHS Areas in 35 states. The SDPI grant programs work with their
local service unit programs, Area Diabetes Programs, 19 Model Diabetes
Programs and the National Diabetes Program. The NM SDPI grantee
programs work directly with the Albuquerque Area Diabetes Program,
their local service unit diabetes programs, and the two NM Model
Diabetes Programs located at Zuni Pueblo and Albuquerque Service Unit.
Question. Diabetes programs now receive $150 million annually as
reflected in the President's fiscal year 2005 budget request. Could you
please discuss how this money is being spent on diabetes prevention and
treatment and help the committee understand any inroads into the
diabetes epidemic this funding has made possible? Could you also
comment on the Gallup Indian Medical Center and its contributions?
Answer. The SDPI grant programs have made tremendous inroads in
addressing diabetes prevention and treatment. The IHS has shown through
its public health evaluation activities that the SDPI programs have
been very successful in improving diabetes care and outcomes, as well
as the start of primary prevention efforts, on reservations and in
urban clinics. The CDC's Framework for Public Health Evaluation, using
a mixed methods approach (both qualitative and quantitative methods),
has been implemented and an analysis completed. A number of positive
short term and intermediate term outcomes have been identified. In
addition, the IHS NDP has improved the accuracy of baseline long-term
measures (prevalence and mortality) and established a Diabetes Data
Warehouse and ``Data Mart'' using RPMS data to measure accurately the
long-term complications of diabetes.
Prior to the SDPI, AI/AN communities had few resources to devote to
primary prevention of diabetes. In 2002, an overwhelming number of
diabetes grant programs (96 percent) reported that they now use funds
to support diabetes primary prevention activities in their communities.
The implementation of secondary prevention efforts--the prevention of
complications such as kidney failure, amputations, heart disease and
blindness--and tertiary prevention efforts to reduce morbidity and
disability in those who already have complications from diabetes has
also been a focus of SDPI activities. Improvement in the treatment for
risk factors of cardiovascular disease, the prevention of and delay of
progression of diabetic kidney disease, and the detection and treatment
of diabetic eye disease have also been achieved since the
implementation of SDPI.
The Gallup Indian Medical Center serves the Navajo Nation and
focuses on providing lifestyle education for their patients.
Accomplishments include providing a comprehensive school health program
for youth, physical exercise programs, Standards of Care for Diabetes
and clinical interventions.
Question. What is the typical program doing in the prevention and
treatment areas and at what levels of funding?
Answer. The SDPI grant programs are providing a variety of diabetes
prevention and treatment services in their respective communities,
based on local community need. For example:
--83 percent reported screening children and youth for obesity and
overweight to provide an opportunity for early intervention and
60 percent reported the development of weight management
programs for children and youth.
--91 percent reported screening adults (ages 26-54) for overweight
and obesity and 91 percent of the programs reported that they
developed programs to promote healthy lifestyles.
--IHS has been able to demonstrate significant improvements in blood
glucose control over time, greater than 1 percent point drop
for each age group, as measured by A1c (a long term measure of
glycemic control).
Question. Can we expect a report detailing the programs and their
successes and needs?
Answer. Yes. Although Congress moved the actual due date for a
final report on the SDPI to 2007, IHS is in the process of finalizing
in fiscal year 2004 an interim progress report on the SDPI.
PROFESSIONAL STAFF SHORTAGES
Question. About 20 percent of the U.S. population resides in
primary medical care Health Professional Shortage Areas as designated
by Bureau of Health Professionals. This problem is magnified in Indian
Country where health facilities are often few and far between. Staffing
at many Indian health facilities are at critically low levels--not only
are facilities to attract and keep health care workers lacking in many
New Mexico Indian health centers, I have heard of instances where
salaries were delayed or nearly went unpaid.
Please describe what steps IHS is taking to address these staffing
and facility shortfalls.
Answer. IHS efforts to address staffing shortfalls include, but are
not limited to, the following:
--Establishing and maintaining a World Wide Web site that contains
information regarding health professional needs at IHS, tribal,
and urban Indian health facilities;
--Utilizing special pay and bonus authorities as much as possible;
--Visiting health profession training programs to discuss
opportunities in Indian health;
--Attending national, state, and local health profession association
meetings to inform attendees about opportunities in Indian
health;
--Accepting health professions students and residents in training
positions at IHS facilities;
--Establishing internship arrangements between IHS facilities and
health profession training programs;
--Advertising in professional journals and in the Military Transition
Times, a publication that is distributed to all United States
and foreign military facilities bases and installations in an
effort to attract health professionals who are leaving the
military;
--Attending health fairs at colleges;
--Attending high school career days;
--Adding funds to the IHS Loan Repayment Program;
--Establishing special salary rates under the Title 38 authority;
--Sending direct mailings to practicing and student health
professionals;
--Establishing 7 Dental Clinical and Support Centers, whose
activities include addressing the issues of recruitment and
retention;
--Establishing workgroups of professionals to address the issues of
recruitment and retention;
--Surveying current employees to see what attracted them to Indian
health and what has made them stay on or may incline them
toward leaving;
--Working with the National Health Service Corps to make Indian
health facilities eligible to employ NHSC scholarship
recipients;
--Encouraging high school and college students to enter the health
professions;
--IHS Scholarship Programs;
--Tribal Matching Grants;
--Health Professions Recruitment and Retention Grants;
--Nursing Scholarship Program;
--Nursing Residency Program;
--Advanced General Practice Residency Program for dentists;
--Extensive use of the Junior and Senior Commissioned Officer Student
Training and Externship Program (COSTEP) of the U.S. Public
Health Service commissioned corps to help develop health
professionals who are interested in working in the IHS; and
--Use of the commissioned corps Commissioned Corps Readiness Force,
Ready Reserve, and Inactive Reserve to help fill needs for
health professionals on a temporary basis.
In addition to the above, the Division of Nursing has launched an
on-line continuing education (CE) program available to all Indian
Health Service, Tribal and Urban Nurses at no cost. The program offers
over 126 continuing education units, including mandatory updates
regarding Joint Commission on Accreditation of Healthcare Organizations
requirements.
Facility shortfalls are being addressed as follows: The IHS fiscal
year 2005 request includes funds for 244 staff at 5 newly completed
health care facilities and construction funds to complete 2 additional
outpatient facilities in Red Mesa, AZ and Wagner, SD and 2 staff
quarters projects in Wagner, SD and Zuni, NM.
Question. What resources does IHS have at its disposal in this
regard?
Answer. For addressing staffing shortfalls, IHS resources include:
--Specifically identified recruiters in several professions;
--Staff professionals who work in conjunction with the recruiters to
speak at professional schools, colleges, high schools, and
elementary schools to talk about opportunities in Indian health
programs and the requirements to become a health professional;
--A scholarship program that helps to train Indian students in the
health professions;
--Programs that help to identify students with the potential to
become health professionals, assist them to obtain the academic
prerequisites for entry into health professional training, and
provide cultural and academic assistance during the training;
--A loan repayment program that helps professionals work in Indian
health programs and pay off the loans they had to incur in
order to attend health professional schools; and
--Staff members who are very concerned about both the quality and
quantity of health services provided to Indian people and are
willing to commit time and resources to address them.
Question. What tools would enhance the ability of IHS to better
meet its obligations for adequate staffing?
Answer. The following tools would enhance IHS' ability to improve
recruitment and retention:
--The Junior Commissioned Officer Student Training and Extern Program
(JsCOSTEP) to allow summer experience at IHS and Tribal
facilities for a minimum of 30 days and maximum of 120 days for
students, who have not completed their degree program.
--The Senior Commissioned Officer Student Training and Extern Program
(SrCOSTEP) to assist students financially during their final
academic year in health profession programs in return for
agreements to work for IHS after graduation for twice the time
sponsored (i.e., 18-month employment commitment for 9 months of
financial support).
--The utilization of medical students through the Uniformed Services
University of the Health Sciences (USUHS) in return for a 10-
year service obligation time upon graduation from USUHS and
completion of their residency programs.
--Under Public Law 94-437, Indian Health Care Improvement Act, the
IHS is authorized to maintain scholarship and loan repayment
programs. The scholarship program is a valuable tool to prepare
students and train students for critical health professions.
This program also provides opportunities for students to gain
practical clinical experience in their chosen health
disciplines during non-academic timeframes prior to graduation.
The loan repayment program provides the authority to repay
loans in return for service in critical service locations. Both
of these programs are very effective and the continued and
expanded utilization will improve our recruitment and retention
efforts.
______
Questions Submitted by Senator Byron L. Dorgan
BASE FUNDING
Question. The fiscal year 2005 budget justification notes a
decrease in services in several service areas, including dental health
and mental health. How much additional funding beyond the budget
request is needed in pay, increased population growth, and inflation to
maintain a ``current'' level of services?
Answer. The budget addresses salary costs by including an increase
of $36.2 million for Federal and Tribal pay costs. Within this amount,
IHS will also have to manage within grade increases for Federal
employees. The budget request also includes an increase of nearly $18
million for contract health care, which will offset inflation
experienced in purchasing health care from the private sector. Using
estimates of medical inflation costs of 3.3 percent ($49 million) and
population growth of 1.8 percent ($39 million), the estimated cost of
fully addressing these items is $88 million.
CONTRACT HEALTH SERVICES
Question. If your need for service was the same in fiscal year 2005
as in fiscal year 2004 for contract health services, how much would you
need to cover all current services, given inflation?
Answer. In order to provide services at the current level the
Contract Health Services Program is requesting $18 million to address
issues of inequity and disparities of healthcare and off set medical
inflation. This funding increase, combined with the additional
purchasing power provided by the recently enacted Medicare
Modernization Act, will allow IHS to purchase an estimated +35,000
additional outpatient visits or +3,000 additional days of inpatient
care. Section 506 of the Act will increase IHS' buying power by
allowing IHS to purchase inpatient care at rates determined by the
Secretary.
Question. How much additional funding is needed to cover medical
care beyond priority I? Please provide this information by priority
level.
Answer. The IHS does not have a fixed CHS funding standard and is
not able to determine the level of funding needed beyond priority I. In
addition, the IHS CHS program does not have an accurate account of all
CHS denials or deferred services and does not track and collect data by
priority levels.
Question. Will the fiscal year 2005 budget request be sufficient to
cover all priority I medical costs in each region?
Answer. The fiscal year 2005 President's Budget includes an
increase of +$18 million for Contract Health Services, (+4 percent)
over the fiscal year 2004 enacted level. As mentioned above, this
funding increase, combined with the additional purchasing power
provided by the Medicare Modernization Act, will allow IHS to purchase
an estimated +35,000 additional outpatient visits or +3,000 additional
days of inpatient care. IHS does not track or collect data by priority
level.
SUDDEN INFANT DEATH SYNDROME
Question. Please provide an update on IHS efforts to combat SIDS in
Indian country. Specifically, what types of SIDS risk reduction
training is provided to Indian Country through IHS?
Answer. Direct care programs provide standard of care per the
American Academy of Pediatrics (AAP), American Academy of Family
Practice (AAFP), American College of Obstetricians and Gynecologists
(ACOG) guidelines--including messages on evidence-based practices of
``Back to Sleep''; tobacco and alcohol perinatal exposure; early and
timely prenatal care and follow-up; and well child visits. Other
efforts to prevent SIDS include:
--Prenatal Home visits through Public Health Nurses (PHN) are a
priority 1 task.
--Tobacco.--Perinatal tobacco exposure and tobacco control measure in
the form of abstinence and cessation include--patches, the
American College of Obstetricians and Gynecologists 5 A's
``Ask, Advise, Assess, Assist, Arrange--6th Assure,'' provider
survey to assess training needs is underway with National
Partnership to Help Pregnant Smokers Quit, a Robert Wood
Johnson (RWJ) funded program.
--Breastfeeding and lactation consultant promotion.
--Biennial Pediatric Conference and Update.
--Biennial OB-GYN Conference and Update.
--Maternal and Child Health (MCH) IHS National conference calls on
emerging issues and SIDS update.
--Working with numerous foundations and HHS agencies:
--CJ SIDS Foundation.--SIDS Reduction Resource Kit Dissemination
--American Academy of Pediatrics (AAP).--Committee on Native
American Child Health--advocacy, site visits, child health
and newborn outcomes, teen health and teen pregnancy are
addressed.
--First Candle and SIDS Alliance.--Child Care Provider Training.
--SIDS Impact.--Active list serve on leading edge forensic and case
investigation, diagnostic shift since 1998, differential
diagnosis and need for standardized training and
investigation.
--HRSA funded Healthy Start programs in the Aberdeen Area.
--CDC.--Coroners and Death Scene Investigation.
--National Partnership to Help Pregnant Smokers Quit.--Poster and
provider questionnaire on perinatal tobacco control,
patient interaction.
--Phoenix Area.--National Diabetes Program reprint of ``Easy Guide
to Breastfeeding that includes section on back to sleep and
safe sleep environment with CPSC endorsement.
--Consumer Product Safety Commission--IAA.--Back to sleep
information and bedding information included in ``Easy
Guide to Breastfeeding'' booklet to be reprinted 50,000
copies.
--National Native American Emergency Medical Services.--
Dissemination of SIDS Resource Kit.
--Child Fatality and Child Death Review.--State and national leads.
MCH coordinator to present at August 2004 National on IHS
linkages to states.
--CDC--Division of Reproductive Health.--MCH Research Agenda
setting Planning meeting May 10. Perinatal issues are
preeminent.
--NICHD.--Serial meetings planned for teen parent focus group study
to address media and health literacy needs for infant
wellbeing and SIDS reduction in northern tier Tribes and
Alaska.
Question. What is current IHS spending dedicated to SIDS risk
reduction? What is needed?
Answer. Funds are appropriated in very broad line-item accounts and
provided from other sources within the Department and private
foundations. Our cost accounting system is not currently set up to
accumulate this level of specificity. Most care in this area would be
covered in the following line item budgets--all of which provide direct
services to the prenatal and early infancy population:
1. Hospital and Clinics.--Direct Health Care Provision
2. Public Health Nursing
3. Community Health Representative
4. Health Education/Health Promotion and Disease Prevention
Question. Are you partnering with any organizations on the SIDS
issue?
Answer. The Indian Health Service, Tribal, and Urban programs
partner with the following organizations:
--CJ SIDS Foundation.--SIDS Reduction Resource Kit Dissemination
--American Academy of Pediatrics (AAP).--Committee on Native American
Child Health--advocacy, site visits, child health and newborn
outcomes, teen health and teen pregnancy are addressed.
--First Candle and SIDS Alliance.--Child Care Provider Training
--SIDS Impact.--Active list serve on leading edge forensic and case
investigation, diagnostic shift since 1998, differential
diagnosis and need for standardized training and investigation.
--HRSA funded Healthy Start programs in the Aberdeen Area
--CDC.--Coroners and Death Scene Investigation
--National Partnership to Help Pregnant Smokers Quit.--Poster and
provider questionnaire on perinatal tobacco control, patient
interaction.
--Phoenix Area.--National Diabetes Program reprint of ``Easy Guide to
Breastfeeding'' that includes section on back to sleep and safe
sleep environment with CPSC endorsement.
--Consumer Product Safety Commission--IAA.--Back to sleep information
and bedding information included in ``Easy Guide to
Breastfeeding'' booklet to be reprinted 50,000 copies.
--National Native American Emergency Medical Services.--Dissemination
of SIDS Resource Kit.
--Child Fatality and Child Death Review.--State and national leads.
MCH coordinator to present at August 2004 National on IHS
linkages to states.
--CDC--Division of Reproductive Health--MCH Research Agenda setting
Planning meeting May 10. Perinatal issues are preeminent.
--NICHD.--Serial meetings planned for teen parent focus group study
to address media and health literacy needs for infant wellbeing
and SIDS reduction in northern tier Tribes and Alaska.
INDIAN HEALTH CARE IMPROVEMENT FUND (IHCIF)
Question. Did tribes recommend funding for the IHCIF during your
consultation process on the fiscal year 2005 budget? If so, how much?
Answer. The Tribes recommended a minimum increase of $24.3 million
for the Indian Health Care Improvement fund in fiscal year 2005.
CONCLUSION OF HEARINGS
Senator Burns. Thank you all very much. The subcommittee
will stand in recess subject to the call of the Chair.
[Whereupon at 10:30 a.m., Thursday, April 1, the hearings
were concluded, and the subcommittee was recessed, to reconvene
subject to the call of the Chair.]