[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
____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
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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
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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
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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
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Additional Material Submitted for the Record
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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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