[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

86-420              U.S. GOVERNMENT PRINTING OFFICE
                            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.]


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                            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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