    [Senate Hearing 108-62]
    [From the U.S. Government Publishing Office]

                                                             S. Hrg. 108-62

                               INDIAN HEALTH CARE

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

                                    HEARING

                                   BEFORE THE

                          COMMITTEE ON INDIAN AFFAIRS
                              UNITED STATES SENATE

                          ONE HUNDRED EIGHTH CONGRESS

                                 FIRST SESSION

                                       ON

                                     S. 556

     TO AMEND THE INDIAN HEALTH CARE IMPROVEMENT ACT TO REVISE AND EXTEND
                                    THAT ACT

                                   __________

                                 APRIL 2, 2003
                                 WASHINGTON, DC

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                                WASHINGTON : 2003
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                          COMMITTEE ON INDIAN AFFAIRS

                  BEN NIGHTHORSE CAMPBELL, Colorado, Chairman

                    DANIEL K. INOUYE, Hawaii, Vice Chairman

    JOHN McCAIN, Arizona,                KENT CONRAD, North Dakota
    PETE V. DOMENICI, New Mexico         HARRY REID, Nevada
    CRAIG THOMAS, Wyoming                DANIEL K. AKAKA, Hawaii
    ORRIN G. HATCH, Utah                 BYRON L. DORGAN, North Dakota
    JAMES M. INHOFE, Oklahoma            TIM JOHNSON, South Dakota
    GORDON SMITH, Oregon                 MARIA CANTWELL, Washington
    LISA MURKOWSKI, Alaska

             Paul Moorehead, Majority Staff Director/Chief Counsel

            Patricia M. Zell, Minority Staff Director/Chief Counsel

                                      (ii)

                                C O N T E N T S

                                  ----------
                                                                       Page
    S. 556, text of..................................................     2
    Statements:
        Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado,
          chairman, Committee on Indian Affairs......................     1
        Davis-Wheeler, Julia, chairperson, National Indian Health
          Board......................................................   351
        Grim, M.D., Charles, interim director, Indian Health Service,
          Department of Health and Human Services....................   345
        Kashevaroff, Don, representative, Tribal Self-Governance
          Advisory Committee, president and chairman of the Alaska
          Native Tribal Health Consortium............................   354
        Murkowski, Hon. Lisa, U.S. Senator from Alaska...............   357

                                    Appendix

    Prepared statements:
        Benjamin, Melanie, chief executive, Mille Lacs Band of Ojibwe   361
        Davis-Wheeler, Julia.........................................   362
        3Grim, M.D., Charles (with attachments)......................   365
        Kashevaroff, Don.............................................   392
        National Kidney Foundation, Inc., New York, NY...............   400

           INDIAN HEALTH CARE IMPROVEMENT ACT REAUTHORIZATION OF 2003

                                  ----------

                            WEDNESDAY, APRIL 2, 2003

                                           U.S. Senate,
                                   Committee on Indian Affairs,
                                                        Washington, DC.
        The committee met, pursuant to notice, at 10 a.m. in room
    485, Senate Russell Building, Hon. Ben Nighthorse Campbell
    (chairman of the committee) presiding.
        Present: Senators Campbell, Inouye, and Murkowski.

     STATEMENT OF HON. BEN NIGHTHORSE CAMPBELL, U.S. SENATOR FROM
            COLORADO, CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

        The Chairman. The committee will be in session.
        Good morning and welcome to the Committee on Indian Affairs
    hearing on Secretary Thompson's proposed reorganization of the
    Department of Health and Human Services. This proposal, known
    as the One-HHS Initiative, is being vigorously debated on
    Capitol Hill, in Indian Country and elsewhere. Today, we will
    hear how the One-HHS Initiative will impact health delivery to
    Native people.
        We are focusing on this One-HHS Initiative today, but in a
    sense this hearing is the first in a series this committee will
    be holding on legislation to reauthorize and extend the Indian
    Health Care Improvement Act that I introduced, along with my
    friends and colleagues Senator Inouye and Senator McCain.
    Effort to consolidate Federal programs are not new and at times
    have proven very successful, such as the employment and
    training program known as the 477 Program. We are trying to
    achieve the same success with alcohol, drug and mental health
    programs, and will hold a hearing on that bill next week.
    Nevertheless, the Tribes have expressed concerns with the One-
    HHS proposal, and today we will hear about some of those
    concerns.
        [Text of S. 556 follows:]

        The Chairman. Senator Inouye will not be able to be here
    today. He is in a defense appropriations hearing. As you might
    know, that is extremely important now, so we will just go ahead
    with the testimony.
        We will start with the first panel, Charles Grim, interim
    director of the Indian Health Service. He will be accompanied
    by Mr. Lincoln, Craig Vanderwagen, and Gary Hartz.
        Dr. Grim, before I start, I also wanted to congratulate
    you. I understand 2 days ago we received official papers from
    the White House nominating you to be the permanent director of
    the IHS, and we will schedule a hearing on your nomination
    right after the Easter break, and we look forward to your
    service in that capacity. Congratulations.
        Mr. Grim. Thank you, Chairman Campbell.
        The Chairman. Go ahead and proceed.

       STATEMENT OF CHARLES GRIM, M.D., INTERIM DIRECTOR, INDIAN
        HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES

        Mr. Grim. It is a pleasure to be here before you and the
    committee, Mr. Chairman. I would like to request that my
    written statement that has been submitted be entered to the
    record.
        The Chairman. Your complete statement will be in the
    record.
        Mr. Grim. Thank you.
        I am Dr. Charles W. Grim, interim director of the Indian
    Health Service. I am accompanied today by several of my staff,
    Michel Lincoln, deputy director for the Indian Health Service;
    Craig Vanderwagen, acting chief medical officer for the Indian
    Health Service; Gary Hartz, acting director for the Office of
    Public Health; and Bob McSwain, director for the Office of
    Management Support.
        Today we are here to speak about the reauthorization of the
    Indian Health Care Improvement Act. There is no single piece of
    legislation that will affect the future health status of the
    American Indians and the Alaska Natives more than the Indian
    Health Care Improvement Act Reauthorization of 2003, S. 556. In
    the intervening 28 years since it was first authorized,
    achievements in tribal self-determination, decisions by this
    committee and other authorizing and appropriations committees
    of Congress, and the Indian Health Service Programs have
    improved the health status of Indian people.
        To continue the momentum of improvement and to achieve the
    goals shared by Indian country, this committee and the
    Administration, to eliminate health disparities between all
    Americans, it is critical that the Indian Health Care
    Improvement Act reflect the health and world realities of
    today, and not those of 28 years ago.
        From the beginning of the tribal-Federal relationship, the
    provision of health care services to Indians has been a key
    component of the Federal Government's trust responsibility. Two
    major pieces of legislation are at the core of the Federal
    Government's responsibilities for meeting the health needs of
    American Indians and Alaska Natives--the Snyder Act of 1921,
    Public Law 67-85 and the Indian Health Care Improvement Act,
    Public Law 94-437. The Snyder Act authorized regular
    appropriations for relief of distress and conservation of
    health of American Indians and Alaska Natives. It remains the
    basic authority for appropriations for major Indian programs.
        The Indian Health Care Improvement Act was originally
    authorized in 1976, and was enacted to implement the Federal
    responsibility for the care and education of the Indian people
    by improving the services and facilities of the Federal Indian
    health programs, and encouraging maximum participation of
    tribes in such programs.
        Like the Snyder Act, the Indian Health Care Improvement Act
    provided the authority for the programs of the Federal
    Government to deliver health services to Indian people, but it
    also provided additional guidance in several areas. The Indian
    Health Care Improvement Act contained specific language that
    addressed the recruitment and retention of a number of health
    professionals serving Indian communities. It focused on health
    services for urban Indian people and addressed the
    construction, replacement and repair of health care facilities.
        S. 556 is the product of extensive consultation that the
    Indian Health Service undertook during 1999 with Indian
    country. In anticipation of the reauthorization of the act and
    the changes in the health care environment of the country, IHS
    wanted to consult with Indian country to ascertain how these
    changes have impacted on the ability of tribes and urban Indian
    health programs to deliver high quality and much-needed
    services.
        During consultation with Indian country, we learned that
    tribes were anxious to discuss the impact of managed care and
    other changes in the health care field that affected their
    ability to administer quality health programs and services.
    Based on this consultation, the tribes and urban Indian health
    programs determined that they would draft a legislative
    proposal reflecting their concerns and issues.
        S. 556 contains a variety of new, expanded and strengthened
    provisions, activities and services. The Department supports
    the reauthorization of this cornerstone legislative authority,
    and Secretary Thompson has made Indian health care a priority
    of the Department. In the Department's review of the proposed
    language, to ascertain its relationship to its policies and
    budget priorities during this time in our Nation's history,
    there are certain provisions in S. 556 that generate some
    concern.
        Key provisions in S. 556 are inconsistent with current
    Medicare and Medicaid provider payment practices and could
    inappropriately increase costs. As an example, the bill
    proposes a new provider type called Qualified Indian Health
    Provider for IHS, tribal and urban Indian providers
    participating in Medicare and Medicaid programs. The most
    problematic aspects of the QIHP are the structure and operation
    of the payment provisions, which are not only burdensome, but
    more importantly would not be feasible to administer. In
    addition to the burden and feasibility issues, on a more
    fundamental level, the full cost, plus other costs of the QIHP
    payment approach would be contrary to the way that Medicare
    generally pays providers.
        The bill also expands the current 100 percent Federal
    matching rates to States for Medicare and SCHIP services
    provided through IHS facilities to include services provided to
    American Indians and Alaska Natives by non-Indian health care
    providers. This proposed change would substantially increase
    the Federal program and administrative costs, with no guarantee
    and little likelihood of increasing access to services for
    Indian beneficiaries or better payments to Indian providers.
        We are also concerned that S. 556 would appear to broadly
    mandate the use of negotiated rulemaking to develop all
    regulations to implement the act. Negotiated rulemaking is very
    resource-intensive for both Federal and non-Federal
    participants. While it can be effective and appropriate in
    certain circumstances, it may not be the most effective way to
    obtain the necessary Indian input in the development of the
    Indian Health Care Improvement Act rules and regulations in
    every given case.
        In addition to our expressed concerns with S. 556, I would
    like to present a little bit of an explanation of the
    Secretary's One-Department Initiative and its benefits to the
    Indian Health Service. The Secretary's One-Department
    Initiative has been of great benefit to the IHS, as well as the
    Native American constituents of the Department. The fundamental
    premise of the initiative is that the Department of Health and
    Human Services must speak with one consistent voice. Nothing is
    more important to our success as a Department.
        With regard to our tribal constituents, the Secretary
    observed on his first trip to Indian country that tribal
    programs were often stovepiped and that their existed within
    HHS an assumption that the Indian Health Service has sole
    responsibility for the health issues facing tribes.
        In the 2 short years since the Secretary launched this
    initiative, he has reestablished the Intradepartmental Council
    for Native American Affairs. The membership on this council is
    comprised of the heads of all HHS operating and staff
    divisions, with the IHS director serving as the vice-chair.
    This council serves as an advisory body to the Secretary and
    has the responsibility to assure that Indian policy is
    implemented across all divisions. The council provides the
    Secretary with policy guidance and budget formulation
    recommendations that span all divisions of HHS. The profound
    impact of this council on the IHS is the revised premise within
    HHS that all agencies bear responsibility for the government's
    responsibility and obligation to the Native people of this
    country.
        I want to assure you and the committee that we are
    committed to working with you to ensure that this key
    legislative authority can be reauthorized. We will be happy to
    answer any questions that you may have regarding the
    Department's view on S. 556.
        Thank you.
        [Prepared statement of Mr. Grim appears in appendix.]
        The Chairman. Thank you, Dr. Grim.
        I was listening very carefully to your explanation about
    the One-HHS, and we are getting quite a bit of uncomfortable
    feelings back from the tribes. Is it still on track? Has it
    been revised to reflect the comments and recommendations from
    the review group or from tribes themselves?
        Mr. Grim. The Indian Health Service at the current time is
    also going through a reorganization of its own, as part of the
    President's management agenda. This is an initiative that we
    started prior to the President's management agenda, which asked
    agencies to de-layer their bureaucracies and try to become more
    effective and efficient. As part of the IHS HQ reorganizatiobn
    process, we have been taking input for the Department relative
    to some of the One-HHS initiatives.
        We received numerous comments from tribes, as well as
    resolutions. Primarily the comments have been around the
    consolidation efforts of the Human Resources Department. We
    have made those informations known at all departmental meetings
    on such consolidations.
        The Indian Health service has had a seat at the table. We
    have been involved in all of the planning sessions that the
    Department is holding relative to the HR consolidations. We are
    making all of our unique considerations known in those
    meetings.
        The Chairman. I see. Well, as I understand it, the
    initiative is going to involve the transfer of $838,000 from
    the IHS to the HHS. Clearly, that is one of the tribal
    concerns, that they are going to lose their tribal shares. I
    think you can understand their worry. How do you propose to
    preserve the tribal shares?
        Mr. Grim. One of the initial issues that you brought up,
    Senator, on the $838,000 transfer of funds from Indian Health
    Service into the Department was actually dealt with by the
    Congress. That was restored to the Indian Health Service
    budget. One of the things that we are trying to do to ensure
    that Indian country and Indian Health Service needs are dealt
    with is that our staff, both in legislative and public affairs
    and in HR, have been in attendance at all of the meetings that
    the Department has called relative to having public affairs,
    legislative affairs and other departments try to speak with one
    voice.
        The Chairman. I understand that sometimes when they speak
    with one voice, though, it is a majority voice that leaves a
    lot of people out in the cold. If that money was transferred,
    can the functions that they are now used for under IHS and the
    dollars that are going to be associated with it, are they still
    be contractable once they are consolidated with the HHS?
        Mr. Grim. One of the things we have been making the
    Department aware of are the special needs relative to our
    budget around tribal shares. A large portion of our
    headquarters and regional office budgets, as well as 100
    percent of our service unit budgets, are contractable and
    compactable for tribal shares. One of the things that the
    Department is looking at right now in these consolidation
    efforts are just those issues. Many of these things are still
    in the planning phases, and as I said, we do attend those
    meetings. One of the things the Department is aware of, though,
    is that the Indian Health Service HR budget, parts of the
    legislative and public affairs budget, are eligible for tribal
    shares. Should a tribe who is not currently taking those shares
    come in and ask for said shares, then we would--make those
    moneys available. So those issues have been made known to the
    Department.
        The Chairman. And I further understand that you believe the
    IHS will realize a cost of $21.3 million from the reduction of
    195 FTEs and $9.3 million from information technology. Your
    testimony says that every effort will be made to minimize the
    impact at the service delivery level of the organization. I can
    tell you, Indian people from the health standpoint, they do not
    have an awful lot of slack. A lot of them are right on the
    edge, and I would be interested in knowing the specific impacts
    that, if you foresee any now, that it is going to have on
    service delivery because of the reduction of those FTEs.
        Mr. Grim. One of the things that we have always tried to
    do, Senator, in the past when the agency has been asked to take
    any sort of budget reductions or FTE reductions, a primary
    policy of the agency has been to take those in the
    administrative realm, to try to reduce the impact on the care
    delivery level. The 195 FTE reduction that is being proposed in
    the Indian Health Service budget is because of savings that are
    being requested in that amount for the Indian Health Service.
    The way that the Indian Health Service plans on dealing with
    those is that we will be looking at any sorts of economies and
    efficiencies that we can achieve in the way of administrative
    operations of the agency, as well as consolidating and
    streamlining certain functions like IT and the HR
    consolidations that are occurring within the Health and Human
    Services Department.
        We do not have specific information yet because it is a
    fiscal year 2004 budget proposal on exactly where those 195
    FTEs might come from. What we will be looking at, however, will
    be administrative vacancies that currently exist. We are at
    both the headquarters and regional levels being very careful
    now about the administrative vacancies that we are filling.
    Also the Department is going forward with some early-out and
    buyout authority requests that were granted in the Homeland
    Security Act. We will make wise and judicious use of buyout and
    early-out authorities targeted at areas where we may have
    overages in certain areas. And then, as a last resort, we would
    touch the service unit or the health care delivery level, if
    necessary.
        The agency will look very, very closely, though, at our
    administrative ranks to ensure that what is left will be able
    to fulfill our fiduciary and accountability standards that are
    expected of us.
        The Chairman. Well, I appreciate your answering, but they
    are somewhat broad terms for me. Do you foresee the elimination
    of any existing programs or disease prevention or health
    promotion activities that now tribes avail themselves to?
        Mr. Grim. No, sir; we do not.
        The Chairman. I did not ask all the way. I should have.
    Would any of the other people that are accompanying you--were
    they going to make statements, too?
        Mr. Grim. They do not have any initial statements, no sir.
        The Chairman. Okay. Tell me about the consultation that has
    taken place, if any, with tribes on this proposal.
        Mr. Grim. On the One-HHS?
        The Chairman. Yes.
        Mr. Grim. As I said, the Indian Health Service, as part of
    our own internal reorganization, had a restructuring initiative
    work group that was put together well over 1 year ago--about 1
    year ago January. They had a series of meetings, and in those
    meetings--and that was a group composed of primarily tribal
    leaders from all regions of Indian Health Service--with four
    Federal representatives. In that process, they dealt
    extensively in discussions about the One-HHS Initiative. They
    provided both an interim and a final report to the director of
    Indian Health Service. As part of the restructuring initiatives
    that we are doing at headquarters of Indian Health Service, we
    put together then a final team that developed essentially the
    organizational charts, functional statements and things like
    that, that took into account all of the comments that came in
    from the restructuring initiative work group.
        Further, we sent comments after that out to Indian country
    to each of our regions and asked that they hold meetings with
    their tribes in whatever format they used to do tribal
    consultation. They would then take a look at the restructuring
    of Indian Health Service headquarters as currently proposed in
    draft. We have also been making the Department aware, as we and
    other of the operating divisions have meetings on the HR
    consolidation, of the issues that the tribes have brought
    forward relative to their concerns about HR consolidation.
        The Chairman. How long has this been going on--the
    consultation process?
        Mr. Grim. The consultation process started, I believe it
    was in January 2002 for the restructuring of Indian Health
    Service.
        The Chairman. Well, my own personal view is that I would
    want to know a lot more about any specific impacts,
    particularly if they are going to adversely affect tribes,
    before the 2004 money is going to be triggered. I would think
    that Senator Inouye would be equally interested in that.
        Over the years, the success of tribes with 638 contracts
    and self-governance compacts has resulted in the reduction of
    the IHS headquarters and area staff offices. Are there
    administrative functions that are essentially Federal in nature
    that they cannot be contracted-out to tribes now?
        Mr. Grim. Yes, sir.
        The Chairman. What are a couple of those?
        Mr. Grim. We take a lot of these from an OMB circular that
    talks about inherently Federal functions. One, for example, is
    doing a Federal budget, proposing a Federal budget; dealing
    with Federal contracting; supervising Federal employees--things
    like that. If you would like, I could submit to the record a
    further list.
        The Chairman. Would you please submit that for the record?
        Now that the RIW final report is completed, what is your
    next step in meeting the goals of this One-HHS program?
        Mr. Grim. The agency is almost ready to make some final
    decisions on an organizational structure for the Indian Health
    Service.
        The Chairman. Will there be any further consultation with
    tribes before that report is issued?
        Mr. Grim. What we had indicated to tribes was that at the
    same time we submitted our reorganization plan to the
    Department, we would be submitting it out to Indian country for
    a final look at the plan. At that point, there is still time
    for very minor adjustments in the plan, but the majority of the
    comments received back from Indian country relative to the
    headquarters reorganization itself were relatively minor sorts
    of changes that were requested. We think we have got most of
    those incorporated into the final changes. So we will send it
    out at the same time.
        I think the Department would be willing to allow us to make
    minor adjustments as it is going through its approval process
    there.
        The Chairman. In Alaska for a number of years, the health
    care has been delivered under one compact. In a sense, they
    have already consolidated for literally a unified health
    system. Have you looked at that consolidation process in Alaska
    to see if there is anything you can apply to this One-HHS
    program?
        Mr. Grim. I think we always try to learn from some of the
    things that the tribes are doing. Many times they have
    flexibilities, as you are aware, that we do not, when they take
    over their programs under that act. It frees them from some of
    the constraints that we have as a Federal program.
        The Alaska region and some of those tribes have been making
    us aware of some of the efficiencies they have realized. As an
    example, regarding their human resources that are being managed
    up there, they have a more efficient HR employee to total
    employees ratio now than we are trying to achieve as a
    Department. So I think we do have some things that we can learn
    from looking at the way things are done by some of our compact
    tribes.
        The Chairman. Okay. Well, I have no further questions, Dr.
    Grim, but I may submit some and request an answer in writing.
    Senator Inouye may also, or other members of the committee.
        With that, I appreciate your appearing today and thank you
    very much.
        We will now move to the second panel, which will be Julia
    Davis-Wheeler, the Chairperson for the National Indian Health
    Board, from Denver; and Don Kashevaroff, who is the
    Representative of the Tribal Self-Governance Advisory Committee
    from Anchorage, AK.
        We will go ahead and start with you, Julia, if you would.
    And just as the former panel, you are welcome to submit your
    complete written testimony. That will be included in the record
    if you would like to just summarize.

    STATEMENT OF JULIA DAVIS-WHEELER, CHAIRPERSON, NATIONAL INDIAN
                              HEALTH BOARD

        Ms. Davis-Wheeler. Yes; thank you, Senator Campbell. It is
    good to see you this morning.
        Good morning, everyone. It is a pleasure to be here to
    testify on behalf of the National Indian Health Board. I would
    like to state that I have two Board members with me in the
    audience. I would request Buford Rolin from Nashville and
    Everett Vigil from Albuquerque, stand please with our NIHB
    staff. Thank you.
        I also represent the Northwest Portland Area Indian Health
    Board. I serve as chair for that. I am also the secretary for
    the Nez Perce Tribal Council.
        So it is a pleasure to appear before you today to make
    comments on the Indian Health Care Improvement Act, which is
    important authorizing legislation for the care of all of our
    American Indians and Alaska Natives.
        In June 1999, the director of the Indian Health Service at
    that time, Dr. Michael Trujillo, convened a National Steering
    Committee composed of representatives from tribes and national
    Indian organizations to provide assistance and advice regarding
    the reauthorization of the Indian Health Care Improvement Act.
    Over the course of 5 months, the National Steering Committee
    drafted proposed legislation. In October 1999, the National
    Steering Committee forwarded their final proposed bill to the
    Director of the Indian Health Service and to each authorizing
    committee in the House and Senate. I have testified on the
    Indian Health Care Improvement Act before and I once again want
    to express my appreciation to you.
        Last year, the Northwest Portland Area Indian Health Board,
    with the Billings tribes, California tribes, and the Nashville
    tribes, hosted a meeting at Portland, OR on May 28 to 30, to
    talk about the recommendations on the changes for the current
    legislation, S. 212. The purpose of the meeting was to address
    concerns expressed in the September 27, 2001 letter that
    Senator Inouye received from the Secretary of the Department of
    Health and Human Services Tommy Thompson. These concerns
    focused on the large cost of the bill, and it raised legitimate
    questions about what we were trying to achieve in the bill. The
    participants at the Portland meeting also discussed concerns
    raised about high-cost elements from the score on S. 212,
    prepared by the Congressional Budget Office, CBO, in March
    2001.
        I am very glad you have chosen to introduce S. 556 this
    year. The bill has very few apparent changes to S. 212, so we
    look forward to bringing you up to date on some of the changes
    recommended by the National Steering Committee.
        The National Steering Committee is also working this year
    on a House bill that is expected to be introduced soon that
    will reflect the 2002 Portland meeting changes, and the changes
    discussed in subsequent meetings with House legislative
    counsel, and other legislative staff meetings at the March 20
    and 21, 2002 National Steering Committee meeting at Portland. A
    lot of good things are possible if we pass the bill with our
    recommended changes. The titles have exciting new authorities.
        I want to briefly review the titles contained in the Indian
    Health Care Improvement Act. Time only permits mentioning
    highlights in each title, but I am ready to answer your
    questions of any of the titles to the best of my ability.
    Although I have worked on the bill these past 4 years, there
    are only three or four experts who know everything in the bill
    and I may have to look to them for assistance in answering some
    of your questions.
        The preamble section of the Act has been revised, including
    sections on findings, declaration of Nation policy, and
    definitions. Emphasis has been placed on the trust
    responsibility of the Federal Government to provide health
    services and the entitlement of Indian tribes to these
    services.
        Title I, covering the Indian health human resources and
    development has been substantially rewritten, primarily to
    shift priority setting and decisionmaking to the local area
    levels where appropriate. The importance of education is
    highlighted by changes proposed in this Act.
        Title II, the health services, represents a collection of
    diverse sections addressing issues related to the delivery of
    health services to American Indians and Alaska Native
    populations. Diabetes programs and epidemiology centers are
    just two of the many health programs authorized by this title.
    Title II also offers us the opportunity to improve the long-
    term care needed for Indian elders. As you know, there has
    never been specific authority for long-term care in the Indian
    Health Care Improvement Act. Nursing homes are only a small
    part of the long-term care needs of what we want to accomplish
    with home and community-based health care for our elders.
        Title III, facilities, proposes that tribal consultation be
    required for any and all facility issues, not just facility
    closures. It protects and projects on the current priority
    list, while moving toward a new method of selecting facility
    projects. This title gives permanent authority to small
    ambulatory facility construction.
        Title IV, access to health services, seeks to maximize
    recovery from all third-party coverage, including Medicaid,
    Medicare and State children's health insurance programs, and
    any new federally funded health care programs. It also will
    contain protection against estate recovery proceedings, to make
    heirs pay the Medicaid bills of deceased American Indians and
    Alaska Natives. This was the title that resulted in the largest
    dollar total in the CBO score, but the National Steering
    Committee has agreed to some modifications to the provisions in
    the first tribal bill, and this has resulted in billions less
    in costs to the Federal Government.
        Title V, the health services for urban Indians, addresses
    facility construction authority and coverage by the Federal
    Tort Claims Act for the 35 urban programs. Urban
    representatives were very active members of the leadership
    group on the National Steering Committee, and they feel that
    the changes in Title V will result in millions of dollars in
    new funding for urban programs.
        Title VI, the organizational improvements, includes very
    few changes, including the elevation of the Indian Health
    Service Director to Assistant Secretary in the Department of
    Health and Human Services. Although tribes are generally very
    satisfied with the relationship that Interim Director Dr.
    Charles Grim has with top policymakers in the Department of
    Health and Human Services, we want to institutionalize this
    access with this change.
        Title VII, the newly titled behavioral health title, with
    major revisions, specifically to integrate alcohol and
    substance abuse provisions, with mental health and social
    services authorities. I know the committee is having a hearing
    next week on consolidation of alcohol and substance abuse
    programs, and I think this title can be complementary to the
    goals of that legislation.
        Title VIII, miscellaneous, was largely rewritten. It now
    includes a proposal to establish an Entitlement Commission to
    study and make recommendations on making Indian health an
    entitlement in the same manner as Medicaid and Medicare. Ten
    sections were moved out of Title VIII to more appropriate
    sections in the Indian Health Care Improvement Act. All the CHS
    provisions were moved to Title II, a majority of the free-
    standing and severability provisions from other titles were
    incorporated into Title VIII.
        I pray that this Act will pass this year, with Congress
    hearing from tribes that it is a priority for us in 2003. The
    National Indian Health Board and tribes nationwide are renewing
    their efforts to make this happen. The National Steering
    Committee, working with the National Congress of American
    Indians, the tribal leaders Self-Governance Advisory Committee,
    and the National Council on Urban Indian Health, stand ready to
    work with this committee to make necessary changes and
    improvements to craft a bill that will assist us in our goal of
    raising the health status of American Indians and Alaska
    Natives.
        I hope this hearing can be the final kick-off of the
    renewed effort to reauthorize the Indian Health Care
    Improvement Act. The Indian Health Service is no longer able to
    assist the National Steering Committee as it did in 1999, with
    support for travel and staff expenses. So it is a challenge to
    the tribes and the national Indian organizations, including the
    National Indian Health Board, to move this effort forward. We
    will meet this challenge and the continued support of this
    committee is a critical element of our efforts to pass this
    bill in this session of this Congress.
        Just a note, I would like to support the confirmation of
    Dr. Grim. I was pleased to hear the announcement by Senator
    Campbell regarding his confirmation. I would also like to
    comment, as a tribal leader, that the One-DHHS Initiative that
    my counterpart here is going to comment on, needs to be
    reviewed thoroughly by tribal governments. Speaking as a tribal
    leader, having the head offices in Baltimore is a concern that
    we have as tribal leaders. The other concern is keeping the
    government-to-government relationship intact that we have with
    the Federal Government.
        Thank you for this time and I would be happy to answer any
    questions that you have.
        [Prepared statement of Ms. Davis-Wheeler appears in
    appendix.]
        The Chairman. Thank you, Julia.
        We will now move to Chairman Kashevaroff.

       STATEMENT OF DON KASHEVAROFF, REPRESENTATIVE, TRIBAL SELF-
     GOVERNANCE ADVISORY COMMITTEE; PRESIDENT AND CHAIRMAN OF THE
                 ALASKA NATIVE TRIBAL HEALTH CONSORTIUM

        Mr. Kashevaroff. Thank you, Mr. Chairman.
        I would also request that my written testimony be put in
    the record.
        The Chairman. Yes; it will be included in the record.
        Mr. Kashevaroff. Thank you. And I would like to thank you
    for the opportunity to testify here on the reauthorization of
    the Indian Health Care Improvement Act and on the One-HHS
    proposal that is going through. Since Ms. Davis-Wheeler touched
    a lot on the Indian Health Care Improvement Act, I would just
    like to add a few things from my viewpoint.
        First, I also represent the Tribal Self-Governance Advisory
    Committee. This committee is of tribal leaders, convened by the
    Indian Health Service, to address the health care needs of all
    eligible American Indian and Alaska Natives, especially those
    served by tribal health programs operated through self-
    governance compacts. Even though we have somewhat compacted and
    separated and started to do our own direct operations apart
    from the IHS, we are still very concerned and take both the
    Indian Health Care Improvement Act Reauthorization and the One-
    HHS proposals--we take them both seriously.
        The Indian Health Care Improvement Act, as stated before,
    was worked out in 1999, 4 years ago, and a lot has happened
    since then. We have been going through and making
    modifications. We have been making compromises to some of the
    requests that came down. I think even though we have some
    compromises, we have a much better bill that the House side
    again is working up, and we would ask that that bill when it
    becomes available in the next couple of weeks be substituted
    for the current bill on the Senate side.
        There were a couple of criticisms that we heard back on the
    1999 bill that took immediate offense. There was discussion
    about the high score of the bill, and looking at the Medicaid-
    Medicare provisions and the amount of costs that they will
    require. My viewpoint is that the Indian Health Service and the
    U.S. Government should fully fund the tribes in this country.
    We do not get fully funded. We are basically forced to go out
    and find the funding on our own.
        As compacted tribes, we have taken that on as our own
    responsibility and have been trying to run our hospitals, our
    clinics, like a private organization. Private organizations, go
    out and bill for everything they can bill. They bill private
    insurance. They bill Medicaid. They bill Medicare. We have been
    doing that also. It would be nice if we did not have to. It
    would be nice if we were 100 percent fully funded, but knowing
    that is not the case, I do not think it should be an issue that
    we are doing the same thing the rest of the country does in
    health care. I think we should be allowed to do that. There are
    also some demonstration projects that were underway that we
    think should be made available to all tribes, and I think
    contributed somewhat to the high score also.
        So when the substitute bill comes, we hope, or when the
    House bill comes, we hope that that can be substituted and we
    look forward to working with this committee and taking on any
    extra questions or extra concerns, and working with this
    committee to make sure that we have a good bill for you.
        [Prepared statement of Mr. Kashevaroff appears in
    appendix.]
        The Chairman. Okay. Thank you, Mr. Kashevaroff.
        You have a major job, Alaska being so big, and I am
    delighted to see Senator Murkowski has just arrived. I am sure
    you know that your new Senator is doing a great job, just like
    her Dad did when he was here.
        I note with interest that neither one of you talked very
    much, or in fact almost not at all, about the One-HHS proposal.
    Would either one of you like to comment on that? If you don't,
    I would like to ask you to give us some feedback, some written
    explanation or evaluation of the proposal, if you could.
        Mr. Kashevaroff. Thank you, Mr. Chairman. I will comment on
    that. In my written testimony, we have a couple of pages on it.
    Basically, I understand that HHS is a very large Department,
    and in a large Department there should be efficiencies that can
    be obtained. Change is not bad. Change is usually good. I would
    have no problem, actually. I applaud Secretary Thompson for
    trying to make change, trying to create efficiencies, and
    trying to do a better service.
        What I think is missing is the understanding that IHS is a
    unique agency. IHS provides direct health service, and by
    providing direct health service, that brings a whole host of
    other parts that you need. You need a better HR system. You
    need an HR system that looks at the nursing shortage in
    America, and says, how can we compete for the same nurses that
    the private sector is competing for? Now, that is somebody you
    need there at the hospital, getting those nurses to come to
    your hospital, not somebody back in Baltimore who is out of the
    loop, away from the local level, not knowing what is going on.
        Similarly, on the information technology--on IT, we need
    data systems of patients that have clinical data; we need
    information systems. We need those type of systems. The rest of
    HHS does not really need those type of systems. We also have
    what we call the RPMS, or Resource Patient Management System,
    that collects data from all of IHS and the tribes, combines it
    together to provide data to the Congress. That is unique among
    HHS also, and that is something that takes a lot of work to
    keep going.
        It was an antiquated system. We have proposals on the IHS
    side, the tribes have been putting forth proposals, IHS has put
    forth proposals--around $36 million for a better centralized
    system that looks at a business perspective of what a hospital
    needs to be efficient and be successful. So we are looking for
    a $36-million increase.
        At the same time, HHS has come out and said that we need to
    reduce the $54 million IT budget by $9 million. At the same
    time, the IHS hospitals and clinics are very far behind the
    private sector, we cannot be reducing the budget. We need to be
    increasing that.
        As I said again, I do not mind HHS combining a lot of
    things. I am sure they can combine like agencies that just do a
    lot of granting, but when you turn over to the IHS and see the
    unique status of it, it needs to stand out by itself and be
    recognized for that.
        If they want One-HHS, they should have One-HHS. They should
    look at the disparities in health for the American Indians and
    Alaska Natives, and see that we have the worst statistics
    across the country. One-HHS should come together and say, we
    are going to handle the Indian population, we are going to
    bring them up to the rest of the population, that would be our
    One-HHS mission, and that is what we are going to do first.
        When they do that, then we can talk about all being equal
    again, and then putting everybody back together.
        The Chairman. Julia?
        Ms. Davis-Wheeler. Yes; thank you, Senator Campbell.
        As a tribal leader and participating in the One-HHS
    restructuring initiative with Indian Health Service, one of the
    concerns that came forward many times and was a very hot issue
    at the very beginning of our meetings with certain tribal
    leaders was the down-sizing of the Indian Health Service again.
    I can truly say that in a couple of those meetings, we had some
    tribal leaders just almost walk out on the whole process,
    because they felt that down-sizing the Indian Health Service
    any more was just a catastrophe for us to take care of our
    people.
        The one other big concern that came forward, and I
    appreciate Dr. Grim's response to you on the question of
    consultation, was that the timeframe for proper consultation on
    the One-DHHS Initiative was very short. We had basically seven
    months to try to consult with all the tribes across the United
    States. We did the best that we could under the circumstances,
    but I think in all reality it really needs to be like hearings
    or field hearings or that type of issue. I know that the
    Department of Health and Human Services was really putting a
    lot of pressure on the Indian Health Service agency to do this.
    So as a tribal leader, we worked very hard to help the Indian
    Health Service meet that deadline. It does need some more
    reviewing.
        Thank you.
        The Chairman. Okay. Well, since Dr. Grim is still here, I
    might say in his presence that if you think that some of the
    tribes have not had an adequate voice in that, we probably
    ought to ask him to extend that consultation process at least a
    few more months, Dr. Grim.
        Senator Murkowski, did you have an opening statement or any
    questions of our witnesses?

       STATEMENT OF HON. LISA MURKOWSKI, U.S. SENATOR FROM ALASKA

        Senator Murkowski. Thank you, Mr. Chairman. With your
    permission I would like to submit my opening remarks for the
    record.
        I did have some questions, just general questions, that I
    will also submit for the record.
        I would like to take the opportunity to welcome my
    constituent, Mr. Kashevaroff. We had a little bit of a chance
    yesterday to speak, but I am pleased to have you here this
    morning and you have you answer the questions from this
    committee.
        You did address briefly in your comments here the issue of
    the merger and how that might affect, for instance, the IT end
    of things within the Indian Health Services. A more general and
    broad question for you this morning would be how tribal self-
    governance, with the Alaska Natives, has affected the Indian
    Health Service Program and the delivery of the health services.
    I am not looking for specifics, but if you can just briefly
    describe how is this all working with the tribal self-
    governance.
        Mr. Kashevaroff. Thank you, Senator Murkowski. Alaska looks
    forward to another long tenure of a Senator Murkowski, and keep
    adding the years to the same name. So that will be good.
        I appreciate your question. Alaska, as mentioned earlier by
    Dr. Grim, has pretty much, or is 100 percent contracted-
    compacted. The tribes all operate their own organizations
    themselves, and IHS has a residual there. The residual does
    have 10 HR people that will come over to the tribal side as the
    number of Federal employees dropped. So there are still some
    residual, plus some transition.
        But we think from Alaska, and think this because we have
    been told from around the country, and we have many people from
    around the country coming up to Alaska to see what was
    accomplished in our compacting. I think the shining example,
    the first thing that comes to our mind when we talk about what
    we accomplished, is we took 229 tribes and we built a consensus
    and built a working relationship amongst each other. We have
    been able to expand this relationship now to Federal partners,
    to do projects such as the telemedicine project.
        The idea of working together, cooperating is not unique
    among Indian Nations, but in Alaska, with so many tribes, it
    was amazing that we could come together, and we pretty much try
    to speak with one voice now. I think the power we gain by that
    can be shared across the Nation, not only among Indian tribes,
    but other groups, to say that if you can come together and work
    together, there is a lot that can be accomplished.
        What we have done for the Indian Health Service is we took
    over a system back in 1998, 1999--actually it was 1997--that
    was not meeting the needs of our customers, our owners. We call
    them customer-owners now because every one of the 115,000
    Natives in Alaska own the health system now because we are
    compacted. We took over a system, and we have been steadily
    improving it. The reason we improve it now is that control has
    been passed from Rockville to the local villages, to Anchorage.
    I sit as Chair of that, the Tribal Health Consortium, but I am
    also President of my tribe. I am elected by 400-and-some tribal
    members. When those folks come to our hospital, I want to make
    sure that they get the best care possible. They are treated
    with the highest respect possible, because I know that my
    election depends on it.
        Every one of our tribal leaders now that are overseeing
    health care know that, and we have taken this to heart, that
    our people come first. Now that we have local control, we can
    see the needs at a local level and adjust to it. We are very
    agile now. We can make changes when needed. We can also go out
    and get more resources. We have been getting new grant funding
    we are bringing in to supplement what we have. Again, I know
    that you do not want specifics, but a quick example--my small
    tribe, IHS just refused to give us a clinic. They gave us
    contract health money. Unfortunately, with contract money, they
    would give us 2 or 3 percent a year. Our costs from the private
    doctor we went to were 14 to 15 percent increase every year. We
    are going in the red every year. By taking over our own
    services and doing it ourselves, we then have to go out and get
    grant money, and now we lease a clinic, and hopefully we are
    going to build a clinic here, too, pretty quick; but we are
    leasing a clinic; we are doing it ourselves; we are controlling
    our costs--something that IHS just would never have been in a
    position to do.
        So there are a lot of examples. I guess one last thing that
    I want to say about how IHS can work with the compactors, is
    they can take and look at the success the compactors have had
    all across the country, not just in Alaska. And they can pick
    out the items that we have been successful in and try to
    duplicate those, called best practices, looking at what one
    organization does best and taking that and spreading it across
    the rest of IHS.
        I think if IHS takes that mentality, and I know Dr. Grim,
    who I have had some work with the last year, I know he has come
    to the IHS with a business mind, wanting to do that. I do
    support his nomination. I think he is a great choice to take a
    government agency and try to mold it into a very efficient and
    top-rated health system. I think working with the tribes, he
    can probably accomplish that.
        Senator Murkowski. That is great. It is nice to hear that
    Alaska can be used as a model throughout the rest of the
    country. I am pleased to hear that.
        Mr. Kashevaroff. Thank you.
        The Chairman. Julia?
        Ms. Davis-Wheeler. Yes, Chairman Campbell, I would like to
    respond to Senator Murkowski's question on self-governance. The
    Nez Perce Tribe in Idaho, we just recently in 1999, 2000 went
    to compact. One of the things that we have done with the
    compacting process that we went through is we were able to
    build two clinics--one a small satellite clinic for our up-
    river people that live 70 or 80 miles away from the main
    headquarters, because they were in a community building. So we
    have one building for them. It is not a big one, but a small
    building where all the health programs are together. We did
    that with some of our compact money reserves that we had, and
    then other grants.
        Now, recently, we are working on the main tribal health
    clinic for the Nez Perce Tribe where the headquarters sits. So
    if we did not do the self-governance compact, we would not have
    been able to do that. So that shows that if tribes have the
    initiative or know how to do this, that they can get some
    things done. Whereas if we would have gone through the
    facilities priority selection process, we would have never
    gotten a new facility. So I just wanted to comment on that.
        Thank you.
        Senator Murkowski. Thank you.
        Mr. Chairman, I would just like to take the opportunity to
    thank you. With your assistance last week, we were able to bump
    up the number for the funding for IHS. I know it is not as much
    as some would have liked, but I think we agreed it was an
    attempt to address the need and we will work toward additional
    funding. I thank you for your initiative.
        The Chairman. It was a 10-percent increase, was it not?
        Senator Murkowski. 10 percent over the President's number.
    So every little bit, I think we all would agree, helps.
        Thank you for your assistance when we worked on that.
        The Chairman. Thank you.
        I appreciate your testimony and your support of S. 556. I
    have to tell you, I am really concerned about this One-HHS
    proposal. I understand that we need to streamline and
    consolidate and not duplicate efforts and make better, more
    efficient use of tax money and so on, but I have seen too many
    times in the past when Indian programs get folded into bigger
    programs, money that had formerly been designated for Indian
    programs somehow gets transferred or moved or something. The
    Indian people have never had a real strong voice in the
    Administrations, any Administration or here either,
    unfortunately. I am really concerned about that.
        When one out of every two Pimas on this earth, for
    instance, suffer from diabetes, and there are people who three
    out of their whole 7-day week and sometimes four is spent on a
    road somewhere just so they get dialysis, I sometimes worry
    that folding things into making things look more efficient
    sometimes is going to leave Indian people out.
        I would appreciate your looking at this One-HHS proposal in
    depth and giving the committee back some written guidance. We
    will look forward to that, too, and hopefully you can do that
    in the next few weeks if you could, Julia. I think Senator
    Inouye would be equally concerned about it.
        With that, I have no further questions, but we may have
    some that will be submitted in writing. Thank you for
    appearing.
        The committee is adjourned.
        [Whereupon, at 10:54 a.m., the committee was adjourned, to
    reconvene at the call of the Chair.]

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

                                A P P E N D I X

                                  ----------

                  Additional Material Submitted for the Record

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

      Prepared Statement of Melanie Benjamin, Chief Executive, Mille Lacs
                                 Band of Ojibwe

        Mr. Chairman and members of the committee, this testimony is
    offered in support of Reauthorization of the Indian Health Care
    Improvement Act. The Mille Lacs Band of Qjibwe is a federally-
    recognized tribe with 3,570 enrolled members. Located in east central
    Minnesota, we operate three separate clinics offering services to more
    than 2,000 Mille Lacs Band members, as well as other non-members,
    through 20 different programs.
        When Congress first enacted the Indian Health Care Improvement Act
    (IHCIA) in 1976, one of the major policy reasons for doing so was to
    address the health disparities in Indian Country by raising the health
    status of the Indian population to a level consistent with that of the
    general population of the United States. Unfortunately, the overall
    health status of Indian people has improved very little, and those same
    disparities continue to exist in alarming numbers. Reauthorization of
    the IHCIA would greatly assist efforts to rectify the continuing health
    disparities in Indian country.
        One of the primary purposes of the IHCIA is to authorize
    appropriations for tribal health programs so that they may better
    satisfy their health care goals. Even so, federal funding levels have
    not kept pace with inflation or with the increasing needs that directly
    impact the costs of health care delivery. In fact, today's medical
    dollar is worth less than the funding received, making it very
    difficult to provide comprehensive health care.
        As is true for most tribal communities, the Mille Lacs Band is
    confronting an increased health care burden due to growing incidents of
    conditions such as diabetes, heart disease, and cardiovascular disease.
    These health conditions, which are approaching epidemic proportions,
    are impacting not only our adult population, but also our youth. This
    weighs heavy on our hearts as our children are our future.
        Factors such as poor diet and lack of exercise contribute greatly
    to the increase of these chronic health conditions. The Mille Lacs Band
    would like to develop preventative programs addressing these
    significant health deficiencies. Soaring treatment costs for chronic
    health conditions quickly drain program dollars, and the reality is
    that preventative programs are, in the long run, far more cost-
    effective.
        Our health care burden is impacted further by our ever-growing user
    population, which has increased by more than 30 percent in recent
    years. As a result, we have outgrown our current facilities. Inadequate
    space does not permit us to effectively address the existing needs of
    our members, much less those that continue to emerge each year.
        Presently, we are limited as to the services we are able to
    provide. While we currently employ one full-time dentist, two full-time
    physicians, and a handful of certified nurse practitioners, we are not
    capable of providing the comprehensive health care that our people rely
    upon, and frankly, deserve. Examples are programs targeted at substance
    abuse, mental health, and other behavioral health programs that
    contribute toward wellness beyond basic medical and dental care. We
    greatly need to expand our facilities and construct additional space to
    meet those growing demands for health services.
        Present funding levels are not sufficient to keep up with
    increasing health care needs and the associated costs. Level of need
    funding is designed to bring tribal health care programs to the
    equivalent of mainstream funding agencies throughout the United States.
    Our level of need funding is currently at 30 percent, an amount far
    below comparable non-tribal agencies. As a consequence, the Mille Lacs
    Band consistently faces a challenge in meeting the health care needs of
    our members and other tribal members who utilize our clinic services.
        The Mille Lacs Band makes every effort to access outside funding
    services to complement Federal funding. Third party billings are
    submitted to insurance providers and payments are sought from Medicare
    and Medicaid reimbursements. Regardless, these efforts are not
    sufficient to keep up with increased costs of health care delivery and
    frequently, the Mille Lacs Band must provide the difference. The
    problem with this is that it means other tribal programs and services
    are affected when dollars must be shifted.
        The impacts of non-reauthorization to the Mille Lacs Band of Ojibwe
    and other Tribes are numerous. Educational programs and campaigns may
    be eliminated, which will reduce health awareness. There will be an
    inability to provide comprehensive health care services to our clinic
    users, especially if clinic staff numbers are not increased. There will
    also be reduced access to the latest technology, a problem we already
    face with outdated technology that does not keep up with the latest
    medical advances. These are just some of the problems tribes will face
    without reauthorization of the IHCIA.
        Reauthorization of the Indian Health Care Improvement Act is
    beneficial to the Mille Lacs Band of Ojibwe and to all tribes who
    depend upon federal funding to provide comprehensive health care for
    our communities. Reauthorization will allow the Mille Lacs Band of
    Ojibwe to pursue our health care objectives and goals intended to
    rectify the significant health disparities that the United States
    acknowledges exist on our reservation and reservations across the
    United States.
        Underlying the Indian Health Care Improvement Act Reauthorization
    is the Federal trust responsibility of the United States. The Federal
    trust responsibility extends to all the federally-recognized tribes of
    the United States who have a government-to-government relationship with
    the United States. This trust obligation arises out of the government-
    to-government relationship that is articulated in article 1, section 8,
    clause 3, of the U.S. Constitution, the governing instrument of the
    United States. The trust responsibility also arises out of the numerous
    treaties, executive orders, court decisions and Federal laws of the
    United States, and frequently is acknowledged in the same.
    Reauthorization of the IHCIA is the means by which the United States
    can continue to fulfill its trust obligation to tribal nations.
        Encompassed within the government-to-government relationship is the
    United States' recognition of tribes' right to self-governance. The
    Mille Lacs Band of Ojibwe is a self-governance tribe under the Tribal
    Self-Governance Act of 1994. We were one of the first tribes to enter
    into a self-governance compact, and not long after, entered into an
    Annual Funding Agreement, an arrangement which allows the Mille Lacs
    Band to design its health care programs and services in a manner that
    best addresses goals and objectives we have identified in our
    community. The Mille Lacs Band has been able to prioritize its health
    care needs and attempts to meet those needs as best we can through
    sound policy decisions. However, our self-governance status does not
    interfere with the federal trust responsibility of the United States.
        Indian health care must be improved. Reauthorization of the Indian
    Health Care Improvement Act is essential to improving the lives of
    Indian people and the health care that they receive. Mii Gwetch.
                                     ______

    Prepared Statement of Julia Davis-Wheeler, Chairperson, National Indian
                                  Health Board

        Chairman Campbell, Vice Chairman Inouye, and distinguished members
    of the Senate Indian Affairs Committee, I am Julia Davis-Wheeler,
    chairperson of the National Indian Health Board (NIHB). I am an elected
    official of the Nez Perce Tribe, serving as Secretary, and also Chair
    the Northwest Portland Area Indian Health Board. On behalf of the
    National Indian Health Board, it is an honor and pleasure to offer my
    testimony this morning on S. 556 to reauthorize the Indian Health Care
    Improvement Act, which is the most important authorizing legislation
    for American Indian and Alaska Native health delivery. As you recall, I
    stated in my recent testimony on the FY 2004 Budget that I looked
    forward to coming back and testifying on the Indian Health Care
    Improvement Act. I am pleased that this day has come and it
    demonstrates your commitment to American Indian and Alaska Natives as
    we work toward eliminating the unique health problems facing Indian
    Country.
        As you are well aware, the NIHB serves nearly all Federally
    Recognized American Indian and Alaska Native (AI/AN) Tribal governments
    in advocating for the improvement of health care delivery to American
    Indians and Alaska Natives. It is our mission to advance the level of
    health care in Indian Country and the adequacy of funding for health
    services that are operated by the Indian Health Service, programs
    operated directly by Tribal Governments, and other programs. Our Board
    Members represent each of the twelve Areas of IHS and are elected at-
    large by the respective Tribal Governmental Officials within their
    regional area.
        I have been associated with the reauthorization effort since May
    1999 when I first met with other tribal leaders and the Indian Health
    Service to explore how we, along with Congress and the Administration,
    could work together to pass this vital legislation.
        In June 1999, the director of the IHS, Dr. Michael Trujillo
    convened a National Steering Committee (NSC) composed of
    representatives from tribal governments and national Indian
    organizations to provide assistance and advice regarding the
    reauthorization of the IHCIA. Over the course of 5 months, the National
    Steering Committee drafted proposed legislation, which was based upon
    the consensus recommendations developed at four (4) regional
    consultation meetings held earlier in that year. The consensus
    recommendations formed the foundation upon which the National Steering
    Committee began to draft proposed legislation to reauthorize the IHCIA.
    In October 1999, the National Steering Committee forwarded their final
    proposed bill to the IHS Director and to each authorizing committee in
    the House and Senate and the President. Previously, the House and
    Senate introduced legislation based on the tribal bill, but neither
    passed.
        Last year the Northwest Portland Area Indian Health Board and other
    Area Health Boards hosted a May 28-30, 2003 Indian Health Care
    Improvement Act meeting. The purpose of the meeting was to consider
    changes and provide recommendations on the proposed legislation in
    response to concerns raised in a September 27, 2001 letter and
    memorandum from Health and Human Services Secretary Tommy G. Thompson
    to Senator Daniel Inouye. The primary issues raised in Secretary
    Thompson's correspondence focused on the high costs associated with
    some of the bill provisions, questions about what outcomes were sought
    in regards to certain sections of the bill, and it also included
    opposition to certain elements in the bill. The participants at the
    Portland meeting took a hard look at the high Congressional Budget
    Office (CBO) score on S. 212 and the other concerns and forwarded
    recommendations to the House and Senate in July 2002.
        I am very pleased you have introduced S. 556 early this year and
    have held prompt hearings. The Bill appears to be identical to S. 212
    introduced during the 107th Congress, so we look forward to bringing
    you up-to-date on some changes recommended by the National Steering
    Committee. The National Steering Committee is currently working with
    House members and committee staff on a House bill that is expected to
    be introduced very soon that incorporates the recommendations developed
    at the 2002 NSC meeting in Portland, further changes discussed in
    subsequent meetings with House Legislative Counsel, other legislative
    staff meetings, and at the March 20 and 21, 2003 NSC meeting hosted by
    the Northwest Portland Area Indian Health Board just a couple of weeks
    ago.
        I should tell you that in December 2002 the NSC met in Rockville,
    MD and selected Lone Pine Paiute Shoshone Tribal Chairperson Rachel
    Joseph and me to cochair this year's effort. In addition, Don
    Kashevaroff representing the Tribal Self-Governance Advisory Committee,
    former Navajo Nation Vice President Taylor McKenzie, and Kay Culbertson
    of the National Council of Urban Indian Health make up this years NSC
    leadership group. The balance of members represent each of the 12 areas
    of the Indian Health Service and several national Indian organizations
    that I mention below. A lot of good things are possible if we pass the
    bill with our recommended changes. The titles have exciting new
    authorities.
        I want to briefly review the titles contained in the Indian Health
    Care Improvement Act. Time only permits mentioning highlights in each
    title, but I am ready to answer your questions on any of the titles to
    the best of my ability. Although I have worked extensively on the bill
    over the past 4 years, I may have to call upon one of the technical
    advisers who possess a detailed knowledge of the legislation to assist
    with my answers to your questions.
        The Preamble section of the act has been revised, including
    sections on Findings, Declaration of Nation Policy and Definitions.
    Emphasis has been placed on the trust responsibility of the Federal
    Government to provide health services and the entitlement of Indian
    tribes to these services
        Title I--Indian Health, Human Resources and Development, has been
    substantially rewritten primarily to shift priority setting and
    decisionmaking to the local Area levels, where appropriate. The
    importance of education is highlighted by changes proposed to the act.
        Title II--Health Services represents a collection of diverse
    sections addressing issues related to the delivery of health services
    to American Indian and Alaska Native populations. Diabetes programs and
    epidemiology centers are just two of the many health programs
    authorized by this title.
        Title III--Facilities, proposes that tribal consultation be
    required for any and all facility issues, not just facility closures.
    It shelters projects on the current priority list while moving toward a
    new method for selecting facilities projects. This title gives
    permanent authority to small ambulatory facilities construction.
        Title IV--Access to Health Services, seeks to maximize recovery
    from all third-party coverage, including Medicaid, Medicare, and the
    State Children's Health Insurance Program (S-CHIP) and any new
    federally funded health care programs. It also will contain new
    authority for long-term care and protection against estate recovery.
    This was a title that resulted in the largest dollar total in the CBO
    score, but the NSC has agreed to some modifications to the provisions
    in the first tribal bill and this has resulted in billions less in
    costs to the Federal Government. The main change is that States will
    not receive huge increases in reimbursements.
        Title V--Health Services for Urban Indians, adds facility
    construction authority and coverage by the Federal Tort Claims Act for
    the 35 urban programs. Urban representatives were very active members
    of the leadership group on the NSC and they feel that the changes in
    title V will result in million of dollars in new funding for urban
    programs.
        Title VI--Organizational Improvements, includes changes including
    the elevation of the Indian Health Service Director to Assistant
    Secretary in the Department of Health and Human Services. Although
    tribes are generally very satisfied with the relationship Interim
    Director Dr. Charles Grim has with top policymakers in the Department
    of Health and Human Services, we want to institutionalize this access
    with this role change.
        Title VII--Contains the newly named Behavioral Health title with
    major revisions, specifically to integrate Alcohol and Substance Abuse
    provisions with Mental Health and Social Service authorities. I know
    the committee is having a hearing next week on consolidation of alcohol
    and substance abuse programs and I think this title can be
    complementary to the goals of that legislation.
        Title VIII--Miscellaneous was largely rewritten. It now includes a
    proposal to establish an entitlement commission to study and make
    recommendations on making Indian Health an ``Entitlement,'' in the same
    manner as Medicaid and Medicare. Ten sections were moved out of title
    VIII to more appropriate sections in the IHCIA. All CHS provisions were
    moved to title II. A majority of the ``free-standing and severability''
    provisions from other titles were incorporated into title VIII.
        Conclusion
        On behalf of the National Indian Health Board, I would like to
    thank the committee for its consideration of our testimony and for your
    interest in the improvement of the health of American Indian and Alaska
    Native people. I know that this act will not pass this year unless
    Congress hears from tribes that it is indeed a priority in 2003. The
    National Indian Health Board and tribes nationwide are renewing their
    efforts to make this happen. The National Steering Committee, working
    with the National Congress of American Indians, the Tribal Leaders
    Self-Governance Advisory Committee and the National Council of Urban
    Indian Health stand ready to work with this committee to make necessary
    changes and improvements to craft a bill that will assist us in our
    goal of raising the health status of American Indian and Alaska
    Natives.

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