    [Senate Hearing 108-66]
    [From the U.S. Government Publishing Office]

                                                             S. Hrg. 108-66

                              S. 285 S. 555 S. 558

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

                                    HEARING

                                   BEFORE THE

                          COMMITTEE ON INDIAN AFFAIRS
                              UNITED STATES SENATE

                          ONE HUNDRED EIGHTH CONGRESS

                                 FIRST SESSION

                                       ON

                                     S. 288

         TO ENCOURAGE CONTRACTING BY INDIANS AND INDIAN TRIBES FOR THE
                           MANAGEMENT OF FEDERAL LAND

                                     S. 555

        TO ESTABLISH THE NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION

                                     S. 558

    TO ELEVATE THE POSITION OF DIRECTOR OF THE INDIAN HEALTH SERVICE WITHIN
    THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO ASSISTANT SECRETARY FOR
                                 INDIAN HEALTH

                                   __________

                                 APRIL 9, 2003
                                 WASHINGTON, DC

    86-532              U.S. GOVERNMENT PRINTING OFFICE
                                WASHINGTON : 2003
    ____________________________________________________________________________
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    Internet: bookstore.gpr.gov  Phone: toll free (866) 512-1800; (202) 512�091800
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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. 285, S. 555, S. 558 text of...................................     2
    Statements:
        Benally, Jr., Hoskie, chief executive officer, Our Youth, Our
          Future.....................................................    47
        Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado,
          chairman, Committee on Indian Affairs......................     1
        Davis-Wheeler, Julia, chairperson, National Indian Health
          Board......................................................    44
        Kopanda, Richard, executive director, Substance Abuse and
          Mental Health Services Administration, Rockville, MD.......    40
        Lincoln, Michel, deputy director, Indian Health Service......    40
        Raub, William, acting assistant secretary for Planning and
          Evaluation, Department of Health and Human Services........    40

                                    Appendix

    Prepared statements:
        Benally, Jr., Hoskie.........................................    53
        Davis-Wheeler, Julia.........................................    70
        Naneng, Myron P., president, Association of Village Council
          Presidents (with attachments)..............................    75
        Raub, William (with attachments).............................    55
        Zacharof, Mike, chairman, Alaska Native health board.........    80

                              S. 285 S. 558 S. 555

                                  ----------

                            WEDNESDAY, APRIL 9, 2003

                                           U.S. Senate,
                                   Committee on Indian Affairs,
                                                        Washington, DC.
        The committee met, pursuant to notice, at 10:03 a.m. in
    room 485 Senate Russell Building, Hon. Ben Nighthorse Campbell
    (chairman of the committee) presiding.
        Present: Senator Campbell.

     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 Indian Affairs hearing on three
    modest bills that I believe will positively impact the health
    and status of the Native people if they are enacted. Senator
    Inouye is running late and may be here in a little while, but
    we will go ahead and get started.
        Two of the bills that we will be dealing with this morning
    will benefit Indian health by attracting resources and
    attention to Native health issues, albeit in two different
    ways. S. 555 will establish the Native Health and Wellness
    Foundation to serve as the legal entity that can receive
    tribal, private sector and charitable donations for the
    purposes of Indian health care. S. 558 will enhance the
    presence and effectiveness of the Indian Health Service inside
    the Department of Health and Human Services by transforming the
    Director into an Assistant Secretary for Indian Health. This is
    Senator McCain's bill. And S. 285 is a bill that I have
    introduced for three Congresses in a row now to integrate
    existing alcohol, drug and mental health programs. Efforts to
    consolidate disparate Federal grant programs have been embraced
    by the tribes in the past, and have proven successful, such as
    the employment and training program known as the 477 program.
    With S. 285, we are trying to achieve the same kind of success
    with alcohol, drug and mental health programs.
        [Text of S. 285, S. 555, and S. 558 Follow:]

        The Chairman. I am somewhat disappointed with the past
    opposition from the Department of Health and Human Services to
    this type of legislation. I hope that we will be able to work
    out our differences. The Department has expended a good deal of
    energy promoting its One-HHS proposal, which would restructure
    and consolidate functions within the Department of Health and
    Human Services to be more citizen-centered and results-
    oriented. That is the very concept that I think is the
    foundation of S. 285, yet the Department of Health and Human
    Services has neither supported past versions of the bill or has
    offered helpful suggestions as to how we could improve it so
    that they could support it.
        Senator Inouye and I and other members have worked very
    hard to increase the resources for Indian health, and it is
    simply unacceptable to me that the inconvenience of the DHHS
    has not given them the impetus they need to support it or help
    us move this bill forward.
        We will start with our first panel, which is only Dr.
    William Raub, the acting assistant secretary for Planning and
    Evaluation for the Department of Health and Human Services. He
    will be accompanied by Michel Lincoln and Rich Kopanda.
        If you would just go ahead and set up there, Dr. Raub, we
    will start with you. Your complete testimony will be included
    in the record. If you would like to abbreviate, please feel
    free to do so. Thank you for appearing.

       STATEMENT OF WILLIAM RAUB, ACTING ASSISTANT SECRETARY FOR
        PLANNING AND EVALUATION, DEPARTMENT OF HEALTH AND HUMAN
       SERVICES, ACCOMPANIED BY MICHEL LINCOLN, DEPUTY DIRECTOR,
      INDIAN HEALTH SERVICE; RICHARD KOPANDA, EXECUTIVE DIRECTOR,
      SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION,
                             ROCKVILLE, MD

        Mr. Raub. Thank you, Mr. Chairman. I appreciate the
    opportunity to appear before you this morning. Mr. Kopanda is
    with me. We have learned that Mr. Lincoln is en route, caught
    in one of Washington's infamous traffic jams. With your
    permission, I will have him join us as he arrives.
        The Chairman. Absolutely. Sure.
        Mr. Raub. I will submit my full statement for the record
    and just make some brief comments now, as you have suggested,
    Mr. Chairman.
        The Chairman. That will be fine.
        Mr. Raub. First, with respect to S. 285, S. 285 would
    permit an Indian tribe to carryout a demonstration project
    according to a plan approved by the Secretary to consolidate
    grants for substance abuse and mental health programs into a
    single comprehensive program for purposes of providing improved
    services, facilitating implementation of an automated clinical
    information system, encouraging technology-based quality
    assurance activities, and facilitating evaluation of these
    programs. The Department supports the principle that Indian
    tribes know best how to meet the needs of their members. We
    have no objection to allowing tribes to consolidate programs
    addressing substance abuse and mental health problems where
    appropriate, consistent with the purposes of the underlying
    programs and in order to achieve administrative efficiencies.
        However, the Department has concerns with several
    provisions of S. 285 and thus cannot support it as currently
    drafted. I will summarize these concerns now. My prepared
    statement contains more extensive comments.
        No. 1, the bill does not delineate clearly the programs
    that would be subject to consolidation under the proposed
    authority. Nor does the bill delineate the permissible uses of
    the consolidated funds.
        No. 2, the bill is ambiguous with respect to how the grant
    consolidation authority applies to competitive grant programs.
        No. 3, the bill does not require that its authorized
    waivers of statutory or regulatory provisions be consistent
    with the statutory objectives of the grants proposed for
    consolidation. Prudent stewardship demands that such
    consistency be considered when assessing the appropriateness of
    a waiver.
        No. 4, the 90-day timetable for review of proposed grant
    consolidations is likely to be insufficient in most cases,
    given that a consolidation plan could involve up to seven
    separate Cabinet-level agencies and multiple components of
    several of them.
        No. 5, responsibility for leading the implementation of
    this Act should be vested in the Secretary of Health and Human
    Services, not the Director of the Indian Health Service.
        No. 6, the bill does not limit the amount of grant funds
    that could be used for administrative overhead and information
    technology.
        No. 7, the bill is not sufficiently specific as to the
    extent to which consolidated funds may be used for an automated
    clinical information system that serves not only the behavioral
    health program, as defined in the bill, but also the entire
    Indian health care delivery system.
        No. 8, the bill creates an unfunded mandate by shifting
    responsibilities for oversight of all consolidated programs to
    the Department, without making provision for transferring the
    corresponding administrative resources from the affected
    agencies.
        Notwithstanding these comments, Mr. Chairman, we endorse
    the concept behind S. 285 and are prepared to work with the
    committee to address our concerns.
        With respect to S. 558, we note that it elevates the
    director of the Indian Health Service to assistant secretary
    for Indian Health. We believe this action is unnecessary. The
    director of the Indian Health Service enjoys direct access to
    the secretary on all health services issues impacting tribes
    and tribal organizations. Moreover, the director serves as vice
    chair of the secretary's Intra-departmental Council for Native
    American Affairs and thus has a leadership role toward ensuring
    that Native American policy is implemented across all agencies
    and offices of the Department including human services
    programs.
        With respect to S. 555, we note that the bill authorizes
    the Secretary of Health and Human Services to establish a
    foundation through which private sector partnerships with the
    Federal Government could work to improve the health status of
    American Indians and Alaska Natives. This legislation is under
    review within the executive branch.
        Thank you for the opportunity to appear today, Mr.
    Chairman. I will be pleased to respond as best I can to your
    questions.
        [Prepared statement of Dr. Raub appears in appendix.]
        The Chairman. Okay. Thank you, Dr. Raub.
        First of all, you listed about eight reasons that you do
    not like the bill. I did not hear one, except a very general
    kind of a concept, about what you do like about it. So what I
    want you to do is not tell the committee so much about what is
    wrong with it. I want you to tell us how to fix it. I want you
    to submit some language that you think the Department can live
    with that we can try and integrate with the existing language.
        Mr. Raub. We would be pleased to do that, sir. As you have
    indicated, there have been successes in a comparable activity
    under the 477 authority. The problem and the opportunity for
    consolidation is often a general issue, not only with the
    Indian tribes, but with many entities of local government. So
    it is a concept of interest to the Department, and one of
    particular interest to the Secretary. So we would be pleased to
    work with the staff in addressing the aspects of the bill that
    cause concern.
        The Chairman. I appreciate that.
        You stated the strong objection to the IHS as the lead
    agency. You object, as I understand it, to the bill to elevate
    the IHS Director in S. 558 on the grounds that the IHS is
    already the principal point within the DHHS for Indian health.
    But at the same time, you object to the IHS as the lead agency
    for the purposes of alcohol and drug integration because, in
    your view, the Secretary and SAMHSA are the main agencies for
    substance abuse. Is there some disparity in your belief between
    those two?
        Mr. Raub. I do not believe so, sir. I think what we are
    saying is the Secretary, as the responsible official for the
    management of the Department, would wish to have vested in him
    the overall authorities. He would use those authorities to
    involve systematically not only the Administrator of SAMHSA but
    also the Director of the Indian Health Service and other agency
    heads as appropriate in addressing issues related to American
    Indians and Alaska Natives.
        The Chairman. I see.
        And also, as I understand your testimony, although I did
    not hear you say it specifically, but as I understand your
    testimony, you ``expect that the States will address'' mental
    health and substance abuse needs for Indians and Native
    Alaskans living within the borders of States. It has been my
    experience that they do not; that an awful lot of Indian people
    simply fall through the cracks. They do not get their needs
    addressed. Do you have some statistics that you can provide for
    the committee that indicates the States are providing this
    service?
        Mr. Raub. We would be glad to follow up on that question,
    Mr. Chairman. The reference in the statement was to the
    statutory provisions on those programs in SAMHSA that focus the
    awards at the State and look to the State to involve the tribes
    in funding and their integration with the State programs, but
    we can followup for the record.
        The Chairman. Well, they should. Sometimes what happens,
    though is that when Indians go to a general health clinic, they
    are told that they need to go to their reservation and get it
    through the Indian Health Service, which is sometimes 1,000
    miles away. That is a little difficult to do. So sometimes they
    just sort of give up and stay sick and do not have their needs
    met.
        So it seems to me that sometimes there might be some kind
    of a disparity with what you are saying and what is actually
    happening out there. So if you could--if there is any
    indication that you have that is solid, black and white
    information that we do not know that they are providing it, I
    would like to have that and I am sure the other committee
    members would, too.
        On the elevation bill, I think Secretary Thompson, who I
    have known ever since he was a Governor, and he is a very, very
    fine man, and doing his very best, but sometimes the intentions
    of one Secretary cannot determine what the intentions of a
    future Secretary are going to be. I worry that we will end up--
    sometime in the future we may see the IHS Director relegated
    back to a second-tier position. I know that Senator McCain is
    concerned about that. That is why he introduced that elevation
    bill. Would you like to give us your profound wisdom on that?
        Mr. Raub. I doubt that I have profound wisdom about either
    the present or the future, Mr. Chairman, but I would say that
    the Secretary, as you indicated, is strongly committed to
    involving all the components of the Department with respect to
    Indian Affairs activities. He believes with his own leadership,
    that of the Deputy Secretary, the creation of the
    Intradepartmental Council, and the leadership involvement of
    the Director of the Indian Health Service in that, that he has
    actually gone beyond that which is implied by a title change
    with respect to the Director of the Indian Health Service.
        On the other hand, I am sure the Secretary will be
    attentive to the strong feelings of the members of the Congress
    with respect to that issue. He is always amenable to
    considering that.
        The Chairman. You may not want to answer this, but have you
    noticed any of what can commonly be described as ``turf
    problems'' with other agencies not wanting it to encroach on
    their areas of substance abuse?
        Mr. Raub. Sir, I have not.
        Richard.
        The Chairman. Yes; identify yourself for the record before
    you speak.
        Mr. Kopanda. Richard Kopanda from SAMHSA, Executive
    Officer.
        We have not noticed that either in SAMHSA.
        The Chairman. Would you like to tell Senator McCain that
    this is probably not a necessary bill? [Laughter.]
        I should not even ask you that. I know Senator McCain
    really well--a very determined man. I thought I would just pass
    that on to you.
        We have some additional questions for you and for IHS, too.
    I think those I will probably submit in writing to you, Dr.
    Raub, if that is all right with you. I am not sure if anyone
    else will be showing up. As you might guess, it is pretty
    hectic around here. Many of us are trying to cover two
    committees at the same time.
        With that, I do appreciate your being here, and when you
    get questions in the record from Senator Inouye or other
    members, if you would answer them in writing, I would certainly
    appreciate it.
        Mr. Raub. Thank you, sir. We will.
        The Chairman. Thank you.
        We will now go to the second panel, which would be Julia
    Davis-Wheeler from the National Indian Health Board; and Hoskie
    Benally, the CEO of Our Youth, Our Future, Incorporated in
    Farmington.
        We will go ahead, Ms. Davis-Wheeler. Nice to see you here
    again. What--twice now in 2 weeks or 3 weeks?
        Ms. Davis-Wheeler. Yes; 2 weeks.
        The Chairman. Very happy to see you here. Go ahead.

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

        Ms. Davis-Wheeler. Good morning everyone. It is a pleasure
    to be here. As stated for the record, my name is Julia Davis-
    Wheeler and I am chairperson of the National Indian Health
    Board. I also serve as Secretary for the Nez Perce Tribe
    Council in Idaho. On behalf of the National Indian Health
    Board, it is a great pleasure to be here to offer testimony
    regarding this health-related legislation. At NIHB, we serve
    all the Federal-recognized American Indians and Alaska Natives
    tribal governments in advocating for health care delivery to
    all of our people at home. We strive to advance the level of
    health care and the adequacy of funding for health services
    that are operated by Indian Health Service programs, operated
    directly by tribal governments and other programs.
        We have Board members that represent the 12 areas of IHS
    and are elected at-large by their respective tribal government
    officials within their region. We continue to work diligently
    to address the health disparities that continue to plague
    Indian country. There are several legislative items that have
    been introduced during the 108th Congress that would help us
    improve the health status of American Indians and Alaska
    Natives.
        The first one I would like to speak about is the Indian
    Health Service Director elevation to Assistant Secretary of
    Indian Health. Before I begin discussing S. 558, I would like
    to say a few words about the Secretary of Health and Human
    Services, Tommy G. Thompson. As a tribal leader, I feel very
    comfortable in saying that Secretary Thompson has been the most
    accessible Cabinet secretary in this Administration. He and his
    immediate staff have been available at every possible
    opportunity to visit with tribal leaders and to see first-hand
    the health needs of our people. It is good to see visits to
    Indian country by the President's Cabinet members. I myself was
    at Tacoma, Washington when Deputy Secretary Claude Allen
    attended a coastal meeting there with Northwest leaders. It was
    very well received.
        Also, the National Indian Health Board is aware that the
    committee will consider the nomination of Dr. Charles Grim as
    Director of the Indian Health Service. As I mentioned in my
    testimony last week, we support this nomination. We support his
    nomination and we appreciate his willingness to take on this
    hard, significant role. Resolutions were passed by Affiliated
    Tribes of Northwest Indians, the National Congress of American
    Indians, the National Indian Health Board, and tribal leaders
    have pushed since 1995-1996 to elevate the status of the Indian
    Health Director as means to recognize the importance of the
    Federal Government's functions in carrying out its trust
    responsibility.
        I would like to give you an example of why tribal leaders
    feel this elevation is important. One example is in 1996 when
    President Clinton had a tribal government meeting at the White
    House, the Director of Indian Health Service at that time was
    not allowed to sit with the Cabinet members at this meeting. It
    proved to be not embarrassing, but a little hard for us as
    tribal leaders to see the Director of Indian Health Service set
    to the side, while all the other Cabinet members were brought
    up forward to meet with tribal leaders and the President.
        We have been asking for another meeting with the President.
    The tribal leaders wish to meet with the President and that has
    not come about. So I just wanted to mention that to you.
        The intent of S. 558 is quite appropriate, as it does just
    that in a manner consistent with the government-to-government
    relationship between the United States and the tribal
    governments that have signed their treaties. As we advance this
    legislation, we want to take adequate steps to ensure that we
    build on the improvements that have been made within the
    Department of HHS over the last few years in addressing tribal
    issues, and further that the Indian Health Service continues to
    be a part of this effort. We feel that this can be accomplished
    with revisions to S. 558, and I have prepared specific
    recommendations on the language for S. 558. I would like to
    submit them for the record.
        Our recommendations would be to place the Indian health
    director at the level of the assistant secretary of Indian
    Health, but do it in a manner which does not diminish the
    secretary's responsibility to carry out the Federal
    Government's trust responsibility.
        As I mentioned previously, over the past several years
    Americans Indians and Alaska Natives have slowly crept into the
    mind set of nearly all areas of DHHS. There are three facts
    that I would like to bring forward: No. 1, informed personnel
    and the elevation of tribal issues with the Office of the
    Secretary. No. 2, the hard work of the Indian Health Service
    officials to advance issues internally. No. 3, and most
    importantly, the persistence of tribal governments to ensure
    that the purpose and intent of the Executive order mandating
    tribal consultation is properly carried out.
        One of the more significant examples of the increased
    awareness and acknowledgement of the importance of Indian
    issues within the Department is the revival of the Secretary's
    Intradepartmental Council on Native American Affairs, which is
    cochaired by the Indian Health Service Director. Because of the
    many critical issues that need to be addressed within the
    Department of HHS, we feel that any changes to the structure of
    the Department must be done in a manner that does not isolate
    Indian health issues, but instead makes those issues a common
    thread among all Department areas.
        The integration and consolidation of alcohol and substance
    abuse--all of the purposes expressed in S. 285, the Native
    American Alcohol and Substance Abuse Program Consolidation Act
    of 2003, serve to improve the delivery of alcohol and substance
    abuse. As a tribal leader, I commend the Senator for
    introducing this bill. American Indians and Alaska Native
    tribal governments are consistently searching for ways to
    develop more effective and efficient programs to better serve
    tribal members, and are extremely interested in providing such
    services, utilizing the best practices available.
        While we are certainly supportive of legislation that seeks
    to coordinate and improve the delivery of alcohol and substance
    abuse throughout Indian Country, tribal leaders have expressed
    their concern with certain provisions of this legislation. Many
    of the concerns are due to the language establishing a lead
    agency. The National Indian Health Board feels the IHS is an
    appropriate and capable agency to administer such duties. Also,
    we feel it is equally important to engage all applicable
    agencies to the greatest extent possible, to ensure that IHS
    carries out the functions of this collaborative effort in an
    appropriate manner.
        As an advocate for the alcohol and substance abuse, we as
    tribal leaders need to do all we can to not allow the younger
    generation to fall to the devastating disease of alcohol and
    substance abuse. Perhaps this could be achieved by utilizing a
    committee consisting of the involved agencies, chaired by the
    Indian Health Service. All activities of the lead agency under
    this proposed Act would be carried out according to the
    decisions made by the committee, with input from tribal
    governments. Further consultation should be included to provide
    for tribal involvement for all measures that would affect the
    provision of alcohol and substance abuse treatment in Indian
    country.
        Establishing the Native American Health and Wellness
    Foundation, the intent and purpose of S. 555, to create this
    Wellness Foundation, is absolutely appropriate, and mirrors
    much of what occurs in the private sector delivery of health
    services. It would serve as a valuable mechanism to maintain a
    single organization to allow for the Indian Health Service to
    receive charitable support. Such an entity has not existed
    previously, which has deterred the donation of such support.
    The National Indian Health Board urges that the Foundation's
    activities do not have a negative impact on the Indian Health
    Service budget, but rather serves to boost the Indian Health
    Service funding.
        I would also like to mention that the National Indian
    Health Board would be a capable umbrella organization under
    which the proposed Foundation could operate. As of March 3 of
    this year, the NIHB fully operates out of the Washington, DC
    area and is governed by Board members from across Indian
    country. Many of the activities that would be provided by the
    Foundation, such as activities furthering the health and
    wellness of American Indians and Alaska Natives, and
    participating with and assisting Federal, State, and tribal
    governments, are already provided by the National Indian Health
    Board. We would be willing and supportive to discussing this
    with the committee. We feel this bill should be a part of the
    consultation process.
        In conclusion, 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 Indians and Alaska Native
    people. We are certainly pleased that this is the third hearing
    to take place so far this year on Indian Health, and we trust
    that our issues will continue to be a priority for the 108th
    Congress.
        Thank you.
        [Prepared statement of Ms. Davis-Wheeler appears in
    appendix.]
        The Chairman. Thank you, Julia.
        Why don't you go ahead, Mr. Benally, and then I will ask a
    couple of questions of each of you.

    STATEMENT OF HOSKIE BENALLY, Jr., CHIEF EXECUTIVE OFFICER, OUR
                        YOUTH, OUR FUTURE, INC.

        Mr. Benally. Thank you.
        I come from more of a direct service perspective with
    regard to this bill, S. 285. I just want to discuss the
    importance of the management information system. We have run a
    treatment program for 13 years for Native American adolescents
    down in New Mexico, and serve not only Navajos, but other
    tribes in that area. One of the things that we found was that a
    sound management information system is very helpful in
    determining the needs of clients, as well as determining the
    needs of staff members.
        Some of the statistics that we got out were very helpful to
    us--such stats as what kind of drugs are we seeing in our
    youth? We specialize in adolescent youth treatment, and it
    would be surprising to see some of the things that we thought
    were still in the cities coming onto the reservation. So in
    identifying those types of drugs, such as methamphetamines;
    ours is a high-traffic for that drug. We were able to again
    gear up our staff and provide training in that area to help
    them deal with this drug. But if we did not have this
    management information system to give us that kind of
    information, we would not have been able to identify those
    treatment needs and the client needs in those areas.
        But I think the one thing is that in Navajo country or
    Indian country as a whole (we also provide consultation
    services to other Indian tribes) is that we really do not have
    a handle on where we are in the battle against drugs and
    alcohol, complicated by the addition of the mental issues that
    go along with that. We know that research shows that a high
    percentage, I think in the general public 64 percent have a
    mental health disorder that is driving the substance abuse. In
    this area, we have been able to train our staff with help from
    a Ph.D-level clinical psychologist and master's level people to
    be able to help the youth in this area.
        The other thing I would like to say is that this management
    information system helped us, we are in New Mexico, to become
    accredited by the Joint Commission on Accreditation of Hospital
    Organizations, which is a national accreditation--very
    stringent accreditation that we sought and we received back in
    1993. But along with that, we were licensed with the Children,
    Youth and Families Department of New Mexico. One thing that we
    are finding out there, in talking to other tribes and also
    providing consultation services, is that because of the lack of
    outcome data being produced by treatment programs, they are
    having a hard time tapping into Medicaid dollars, because
    Medicaid requires that you be able to provide outcome data to
    show the effectiveness and quality of your treatment. So we
    were able to do that, and in addition to receiving other
    Federal dollars, we were able to receive Medicaid dollars to
    supplement the operation of the organization.
        Now, I would just like to say also that I think this bill
    here is something that is long in coming and something that I
    think is very useful, because we are finding out that tribes
    out there are not conducting the assessments that are necessary
    in order to identify some of the mental health issues and some
    of the drug disorders that are out there. We are primarily
    focusing on alcohol abuse. With this bill, that will improve
    that and provide quality and effective services to our Indian
    people, I feel. It is more from a direct service approach that
    we are seeing these things happen. So we are real supportive of
    this bill here.
        I would like to say thank you.
        [Prepared statement of Mr. Benally appears in appendix.]
        The Chairman. Thank you.
        Julia, speaking of S. 285, I might tell you that I briefed
    your written testimony and then tried to listen as well as I
    could to your verbal testimony. It is a little bit different--
    or not maybe different, but it seems to be a little milder than
    the comments in your written testimony.
        I guess this is the third time we have dealt with this bill
    in hearings on it, and to my knowledge at our previous hearing,
    there has been no tribal leader, no Indian health organization
    that has made any objections about it at all. Has something
    changed since then, or has it been the official position of the
    member tribes of the NIHB--they just made the decision recently
    about this bill?
        Ms. Davis-Wheeler. Senator Campbell, on the S. 285, it was
    a big discussion at the National Congress of American Indians
    meeting that we had in San Diego last fall. From the discussion
    in the Health Committee that I chair, through the human
    resources structure of NCAI, there was a lot of discussion at
    that meeting that it needed to be looked at a little bit more.
        The Chairman. Well, was part of that discussion your
    opposition to having the IHS as the lead agency?
        Ms. Davis-Wheeler. I did not hear any opposition to having
    Indian Health Services the lead agency, but I guess in the
    record there might be a few that did have a little concern.
        The Chairman. You spoke some of a committee of agencies. Do
    you believe a committee or several agencies can do a better job
    than having one agency responsible, on whose desk the buck
    stops?
        Ms. Davis-Wheeler. The idea was to have someone from each
    agency on the committee to bring about the awareness of the
    tribal leaders or tribal governments' needs, as stated by Mr.
    Benally. We have a lot of drugs on the reservations that are
    brought in from the cities, and having SAMHSA, the other
    agencies present where they can hear that from the tribal
    leaders personally, I think it would help. If anything, it
    would bring about more awareness to all of the Federal
    agencies.
        The Chairman. You mentioned the work that Secretary
    Thompson is doing, and I also said I think he is doing a
    terrific job. He has been very sensitive, I think, to Indian
    issues. But he is only going to be there about 6 more years.
    That is the way it works around here. If the Administration
    changes, well, maybe less than that, but the max would be 6
    more years. Are you confident that the next person that is
    going to be there is going to be as sensitive as Secretary
    Thompson is, because that is one of the reasons I am pushing
    this bill--to give it some continuity through different
    Administrations that support Indian programs and are less
    supportive of Indian programs.
        Ms. Davis-Wheeler. Senator Campbell, I think you have hit
    the nail on the head with that one because we as the National
    Indian Health Board and other national organizations see this
    Administration as being, I guess, an advocate for us in Indian
    country to push legislation. It would be great to have
    Secretary Thompson leave a legacy, in the event that in 6 years
    he has helped us elevate our health status, but leave a legacy
    with us as tribal leaders to honor that administrative Cabinet
    position, and especially in the area of Indian health, but also
    in the area of elevation of the Indian Health Service Director.
        I heard from the testimony previously that the gentleman
    from the DHHS does not feel that it is necessary. I would
    respectfully disagree that as a tribal leader, we have been
    wanting to see this position elevated for such a long time. It
    would make us, as tribal governments, feel better to see the
    IHS Director position elevated. He could really do something
    for us if he would support that.
        The Chairman. I think so, too, but did I understand your
    testimony, you said that elevation should be in a way that does
    not diminish the Secretary's responsibilities to tribal
    governments. Are you worried about an erosion of trust
    responsibility if that position was elevated?
        Ms. Davis-Wheeler. No; not at all. I think that those two
    positions would go hand in hand. Secretary Thompson has been
    very open and able, when he can, to meet with us. He has shook
    our hands and talked with us. We really appreciate that. He has
    given us more time on his agenda than anyone else.
        The Chairman. Was somebody from his agency, or he, at San
    Diego--at the National Congress of American Indians?
        Ms. Davis-Wheeler. Yes; but because of the schedules, I
    cannot remember the exact dates, but they had to just come in
    for a day or two and then go right back out.
        The Chairman. Mr. Benally, from listening to your
    testimony, it sounds to me that your organization is doing a
    terrific job for Native youngsters who are obviously suffering
    from an increased problem with drugs and alcohol. You talked at
    length about the information technology. We have received some
    complaints about this accounting system that is currently used
    by the IHS called the RPMS--the Registered Patient Management
    System. Does your member organizations and clinics use that
    kind of software?
        Mr. Benally. The program that we originally used--this was
    introduced by IHS--we are one of several regional adolescent
    treatment centers throughout the United States that were
    originally funded by the omnibus drug bill of 1986. We became
    the third one to open, but Orion (ph) Health Care, which is
    also called Accurate Assessments and apparently had a contract
    with IHS back about 1998, I think it was somewhere about that
    time, to look into developing a management information system
    and offer it to the adolescent treatment centers. We took
    advantage of that and brought it into our treatment center and
    found it to be very, very useful.
        The other thing that we added onto that system was a
    cultural assessment part that we developed with Accurate
    Assessments to address at some of the cultural needs of our
    students. But what we are finding out is that the old Cadmus
    system did not work, and we are finding out now that perhaps
    IHS is looking at developing another one. I guess my position
    is why develop another one when you have one that is already
    working and proven to work, and there is other software out
    there that can work? It is just going to put us behind time-
    wise. This management information system that we are using is
    also being used by 130 other Native American programs in the
    United States. I think the States are beginning to look at
    these programs with their tribes that reside within their
    States. So we have been real happy with it.
        The Chairman. That is a system you would advise the IHS to
    use with all tribes?
        Mr. Benally. Pardon?
        The Chairman. Is that a system that you would advise the
    IHS to use for all tribes?
        Mr. Benally. Yes; I would very strongly recommend that
    because we have used it. We have also; in providing
    consultation to other Indian tribes, found that it is something
    that is very--can be used by other tribes; has proven to work
    for us, and we have shared data with them. I think CSAT also--
    we have a CSAT grant, and CSAT has recognized our program as an
    exemplary program in using this software, because it helped to
    provide cost analysis and also helped to provide an evidence-
    based treatment program. In other words, we did research with
    this, and it brought a lot of data forward that says that the
    program that we used, not only with our adolescents but with
    the families, was very effective. CSAT is now using us as their
    consultant out there to train others in what they call the
    Accurate Assessment Addiction Severity Index.
        The Chairman. One of the goals of S. 285 is to try to make
    it easier for a tribe to take part in grants and programs that
    might otherwise have been too complicated to apply for, through
    all the different bureaucratic requirements. Are there any
    grants or programs that your organization might be interested
    in that you have found too difficult, too time consuming, or do
    not have the resources to be able to apply for those grants?
        Mr. Benally. Yes; well, I am lucky. I have a Ph.D clinical
    psychologist who has been trained in grant writing, and a
    master level social worker. But if I did not have those people,
    I would not be able to apply for these grants at the level of
    sophistication the grantors are asking for. Now, if the grants
    come out in accordance to this bill in which that you are
    asking for a management system, then I think a lot of tribes
    out there are going to have a tough time with it because I do
    not think they have that infrastructure at this point in time
    to realistically or with much knowledge respond to a grant
    management information systems. I think some kind of transition
    period of technical assistance needs to be provided in that
    area because I think these grants are going to require that
    component before receiving dollars.
        The Chairman. What did you say your Ph.D was in?
        Mr. Benally. No; I have a clinical psychologist who is a
    Ph.D that is on my staff.
        The Chairman. Oh, I see. Very good. Thank you.
        I have no further questions, but Senator Inouye or other
    members may submit some for writing. As I told the first panel,
    I do not want to hear just what is wrong with everything. What
    I want to hear is how we make it better, how we try and move
    something that is going to benefit Indian people. So any
    suggestions you have for S. 285 or any other bills, the other
    two bills, I would appreciate hearing from you
        Yes, Julia?
        Ms. Davis-Wheeler. Yes; thank you, Senator Campbell.
        My oral comments were very different from the written
    comments that were submitted. For the record, I would like you
    to know as the Chair of this committee that we will send a
    revised set of testimony from NIHB.
        The Chairman. Did you talk to somebody between the time you
    sent in the written testimony and the time you--okay.
        Ms. Davis-Wheeler. Okay. [Laughter.]
        The Chairman. I have no problem with that. We do it, too.
    Great. Alright, thank you for being here. I appreciate that.
        Ms. Davis-Wheeler. Thank you.
        The Chairman. I notice Mr. Lincoln came in. I understand
    you were tied up in traffic. I have got a little time. Would
    you like to make your statement for the record, Mr. Lincoln?
    Oh, you were going to accompany Dr. Raub. I see.
        Mr. Lincoln. I was going to accompany Dr. Raub, and I do
    apologize to the committee. I mean no disrespect ever to this
    committee.
        The Chairman. I understand, yes.
        Mr. Lincoln. These bills are important.
        The Chairman. Yes; particularly around the Capitol here
    with the grounds all torn up and the new sensitivity to post-9-
    11 problems, it is a mess to try to get around.
        But I would like to maybe ask you a question if I could,
    and that deals with the elevation bill. Is it your view that
    the IHS Director as the Vice Chairman of the Intradepartmental
    Council for Native Americans currently enjoys an elevated
    status without actually being elevated?
        Mr. Lincoln. It is my observation, Mr. Chairman, if I may
    reflect just briefly on the 11 years that I have been back here
    at headquarters in the Indian Health Service as the Deputy
    Director, that Dr. Grim, the Interim Director, indeed does
    enjoy more access than I have ever seen with the Secretary.
        The Chairman. You have been there 8 years. How many
    Directors have there been?
        Mr. Lincoln. I came when Dr. Everett Rhodes was the
    Director, also with Dr. Michael Trujillo and now with Dr. Grim.
        The Chairman. And I think if I am not mistaken Senator
    McCain has introduced this bill about 8 years in a row or
    something--about 8 years in a row. It has never really gone
    anywhere yet. Have you--well, I will not ask you that. It would
    be subjective. I will not bother asking you.
        Okay. Thank you. I appreciate your being here. I may submit
    additional questions to Dr. Raub or you, too, on behalf of the
    committee.
        Mr. Lincoln. Thank you, sir.
        The Chairman. I have no further comments or questions. We
    will keep the record open for two weeks for any additional
    comments from the audience in general or from the people who
    testified.
        With that, the hearing is adjourned. Thank you for
    appearing.
        [Whereupon, at 10:45 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 Hoskie Benally, Jr., Member, Navajo Nation,
                                  Shiprock, NM

        My name is Hoskie Benally, Jr. I am a member of the Navajo Nation
    of Shiprock, NM. For the past 14 years, I have been the Chief Executive
    Officer of a private non-profit American Indian owned organization, Our
    Youth, Our Future, Inc. (OYOF). OYOF has operated a residential
    treatment center on the Navajo reservation and a community health
    center in Farmington, NM. A majority of our funding came from the
    Indian Health Services (IHS) and the collection of Medicaid dollars.
        Currently we serve as advocates for American Indian adolescents and
    families in the area of alcohol and other drug treatment along with
    mental health disorders. We conduct outcome base research on our
    programs and disseminate information in order to improve the lives of
    our adolescents in need of treatment. Through these endeavors, OYOF has
    developed the Multi-systemic Cultural Treatment Model for American
    Indian adolescents and their families. This treatment model uses a
    multi-modal assessment strategy to measure symptom changes and pro-
    social functioning at intake, termination, 6, and 12 months following
    termination. This is one of the few if not the only manualized
    treatment model for American Indian adolescents that includes a
    treatment outcome design. In addition, it has a quality assurance
    system developed for American Indian programs. OYOF has responded to
    the call of future substance abuse treatment to be guided by a blend of
    best practice clinical treatment and innovative high-tech computer
    technologies. This approach is to facilitate alcohol and other drug and
    mental health treatment that is high-quality, timesaving, consistent,
    evidence-based and cost-effective. OYOF secured a Center for Substance
    Abuse Treatment (CSAT) 3-year grant to conduct a program evaluation and
    a cost analysis of the residential treatment program. Critical
    information was gleaned from the data that provided pertinent
    information to improve treatment of our adolescents. Without this vital
    information our program may not have achieved the success we have
    experienced.
        It is important to realize that a majority of our success was due
    to the implementation of a user friendly management information system
    (MIS). The following are some of the tasks that the MIS completed:
        Manages clinical service hours (prescribed v. actual received
    services).
        Tracks clinician's billable hours for Medicaid and Managed-Care
    services.
        Tracks client's response to treatment and the need of additional
    services.
        All clinical documentation is automated allowing for close
    supervision of treatment.
        This system generates reporting requirements and supports outcome
    base treatment. The above tasks improve the overall quality assurance
    of the program and allows for a structured and consistent treatment to
    be implemented.
        This system allowed us to meet all of our JCAHO accreditations,
    Children, Youth, and Families Department, State of New Mexico and
    Medicaid regulations. In addition, we had Government Performance
    Regulation Act (GPRA) indicators and also the monthly, quarterly, and
    annual tribal government reports. Many of these reports overlapped and
    when we were collecting this data on a manual basis was almost
    impossible to accomplish. Upon implementing a MIS clinical
    documentation system, our ability to collect and collate the data was
    improved substantially. However, it is important to note that the
    overlap continued and we spent many hours disseminating this
    information for the different governing entities. We created innovative
    ways to meet these standards by developing a computerized report that
    met majority of the data reporting requirements. It is important to
    realize that majority of American Indian treatment programs do not have
    this capability or the skilled staff to meet this level of reporting.
    The initial step of implementing a MIS can be costly if an analysis is
    not conducted to determine the actual need in hardware, software, and
    staffing. There are many for-profit organizations that have developed
    such MIS and are being used in Indian country. Accurate Assessments has
    worked with IHS since 1998 customizing software to meet the specialized
    needs of the treatment programs. They are currently serving over 130
    American Indian treatment programs. This is the MIS that OYOF has used
    since 1998 and was instrumental in collecting data that secured our
    CSAT grant.
        Recently, IHS has made the decision to write and develop their own
    MIS for substance abuse. Even though there are excellent programs that
    exist in the field for possibly half the cost. Therefore, it may not be
    the most cost effective approach for IHS. We have been waiting for more
    than 3 years for IHS to respond to the need of treatment programs to
    have ``real time'' data that they can access simply by sitting at their
    computer. In addition, many treatment programs do not collect their
    GPRA data and the area offices have difficulty meeting their data
    requirements. This lack of quality data collection is a result of the
    lack of communication with the field and IHS. The following are some of
    the reasons why agencies do not receive quality data:
        No. 1. Lacks of compliance due to no initial buy in from the field
    in what to collect and the importance of such data.
        No. 2. Trusting IHS to analyze and interpret the data in a
    culturally appropriate manner.
        No. 3. Providing ``real time'' data reports and/or feedback.
        No. 4. Lacks of a user friendly system that can accommodate the
    many challenges of rural programs.
        No. 5. Lacks of ongoing support and training to make the data have
    practical application to the field.
        No. 6. Finally, many of the programs do not have properly trained
    staff to complete the tasks.
        Finally, how do we decrease the ``redtape'' of securing the funding
    from the government to the tribes and/or treatment programs? This is
    not an easy question to answer. It is very complex and has much to do
    with the lack of standards that are required for tribal treatment
    programs to meet. Many of the programs do not have evidence-based
    treatment that requires a data collection component let alone the
    expertise to collect such data that would be require to write a grant.
    It will be vital that this committee look at the whole system and take
    this opportunity to develop a system that not only wants to fund
    programs, but will demand accountability from any program that secures
    such funding. However, the most important issue is that my people
    receive the best treatment possible and that we begin to make gains in
    keeping our young people from a life of alcohol and drugs, trauma,
    poverty, and the loss of hope.
        I thank you for the valuable opportunity to submit written
    testimony and to provide oral testimony to this committee.
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