[Senate Hearing 108-]
[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.]
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