[Senate Hearing 108-199]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 108-199
 
                   INDIAN HEALTH CARE IMPROVEMENT ACT

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

                             JOINT HEARING

                               BEFORE THE

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                                AND THE

                         COMMITTEE ON RESOURCES
                         UNITED STATES HOUSE OF
                            REPRESENTATIVES

                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                                   ON

                                 S. 556

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

                                  AND

                               H.R. 2440

  TO IMPROVE THE IMPLEMENTATION OF THE FEDERAL RESPONSIBILITY FOR THE 
   CARE AND EDUCATION OF INDIAN PEOPLE BY IMPROVING THE SERVICES AND 
   FACILITIES OF FEDERAL HEALTH PROGRAMS FOR INDIANS AND ENCOURAGING 
           MAXIMUM PARTICIPATION OF INDIANS IN SUCH PROGRAMS

                               __________

                             JULY 16, 2003
                             WASHINGTON, DC

                               __________

                           Serial No. 108-41

                               __________





                      U.S. GOVERNMENT PRINTING OFFICE

88-462                       WASHINGTON : 2003
_______________________________________________________________________
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                      COMMITTEE ON INDIAN AFFAIRS

              BEN NIGHTHORSE CAMPBELL, Colorado, Chairman

                DANIEL K. INOUYE, Hawaii, Vice Chairman

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

         Paul Moorehead, Majority Staff Director/Chief Counsel

        Patricia M. Zell, Minority Staff Director/Chief Counsel

                                 ______

                         COMMITTEE ON RESOURCES

                 RICHARD W. POMBO, California, Chairman

       NICK J. RAHALL II, West Virginia, Ranking Democrat Member

DON YOUNG, Alaska                    DALE E. KILDEE, Michigan
W.J. ``BILLY'' TAUZIN, Louisiana     ENI F.H. FALEOMAVAEGA, American 
JIM SAXTON, New Jersey               Samoa
ELTON GALLEGLY, California           NEIL ABERCROMBIE, Hawaii
JOHN J. DUNCAN, Jr., Tennessee       SOLOMON P. ORTIZ, Texas
WAYNE T. GILCHREST, Maryland         FRANK PALLONE, Jr., New Jersey
KEN CALVERT, California              CALVIN M. DOOLEY, California
SCOTT McINNIS, Colorado              DONNA M. CHRISTENSEN, Virgin 
BARBARA CUBIN, Wyoming               Islands
GEORGE RADANOVICH, California        RON KIND, Wisconsin
WALTER B. JONES, Jr., North          JAY INSLEE, Washington
Carolina                             GRACE F. NAPOLITANO, California
CHRIS CANNON, Utah                   TOM UDALL, New Mexico
JOHN E. PETERSON, Pennsylvania       MARK UDALL, Colorado
JIM GIBBONS, Nevada,                 ANIBAL ACEVEDO-VILA, Puerto Rico
  Vice Chairman                      BRAD CARSON, Oklahoma
MARK E. SOUDER, Indiana              RAUL M. GRIJALVA, Arizona
GREG WALDEN, Oregon                  DENNIS A. CARDOZA, California
THOMAS G. TANCREDO, Colorado         MADELEINE Z. BORDALLO, Guam
J.D. HAYWORTH, Arizona               GEORGE MILLER, California
TOM OSBORNE, Nebraska                EDWARD J. MARKEY, Massachusetts
JEFF FLAKE, Arizona                  RUBEN HINOJOSA, Texas
DENNIS R. REHBERG, Montana           CIRO D. RODRIGUEZ, Texas
RICK RENZI, Arizona                  JOE BACA, California
TOM COLE, Oklahoma                   BETTY McCOLLUM, Minnesota
STEVAN PEARCE, New Mexico
ROB BISHOP, Utah
DEVIN NUNES, California
VACANCY

                     Steven J. Ding, Chief of Staff

                      Lisa Pittman, Chief Counsel

                 James H. Zoia, Democrat Staff Director

               Jeffrey P. Petrich, Democrat Chief Counsel

                                  (ii)





                            C O N T E N T S

                              ----------                              
                                                                   Page
S. 556 and H.R. 2440, text of....................................     2
Statements:
    Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado, 
      chairman, Senate Committee on Indian Affairs...............     1
    Carson, Hon. Carson, Hon. Brad, U.S. Representative from 
      Oklahoma...................................................   674
    Christensen, Hon. Donna M., U.S. Delgate from Virgin Islands.   675
    Cole, Hon. Tom, U.S. Representative from Oklahoma............   673
    Culbertson, Kay, president, Denver Indian Health and Family 
      Services...................................................   698
    Faleomavaega, Hon. Eni F.H., U.S. Delegate from American 
      Samoa......................................................   672
    Grijalva, Hon. Raul M., U.S. Representative from Arizona.....   673
    Grim, Charles, director, Indian Health Service, Department of 
      Health and Human Services..................................   676
    Hartz, Gary, acting director, Office of Public Health, Indian 
      Health Service.............................................   676
    Jimmie, Andrew, chief, Minto Traditional Council.............   697
    Joseph, Rachel, cochair, National Steering Committee of the 
      Reauthorization of the Indian Health Care Improvement Act..   694
    Kildee, Hon. Dale E., U.S. Representative from Michigan......   671
    Muneta, Dr. Ben, president, Association of American Indian 
      Physicians.................................................   696
    Murkowski, Hon. Lisa, U.S. Senator from Alaska...............   672
    Nesmith, Steve, assistant secretary for Congressional and 
      Intergovernmental Affairs, Department of Housing and Urban 
      Development................................................   679
    Olson, Richard, acting director, Division of Clinical and 
      Preventive Services, Indian Health Service.................   676
    Pallone, Hon. Frank, Jr., U.S. Representative from New Jersey   674
    Pombo, Hon. Richard W., U.S. Representative from California, 
      chairman, House Committee on Resources.....................   671
    Rhoades, Dr. Everett, Oklahoma City Urban Indian Clinic......   700
    Skeeter, Carmelita Wamego, executive director, Indian Health 
      Care Resource Center of Tulsa..............................   701
    Snyder, Rae, acting director, Urban Health Office, Indian 
      Health Service.............................................   676
    Udall, Hon. Mark, U.S. Representative from Colorado..........   673
    Weaver, Steve, director, Division of Environmental Health and 
      Engineering, Alaska Native Tribal Health Consortium........   697

                                Appendix

Prepared statements:
    Beaver, R. Perry, principal chief, Muscogee (Creek) Nation...   705
    Culbertson, Kay (with attachment)............................   708
    Grim, Charles (with attachment)..............................   725
    Guzman, Victoria, Walker River Paiute Tribe..................   752
    Jimmie, Andrew...............................................   705
    Joseph, Rachel...............................................   760
    Muneta, Dr. Ben (with attachment)............................   778
    Nesmith, Steve...............................................   785
    Rhoades, Dr. Everett (with attachment).......................   789
    Skeeter, Carmelita Wamego (with attachment)..................   802
    Sossamon, Russell, chairman, National American Indian Housing 
      Council....................................................   814
    Weaver, Steve (with attachment)..............................   817
    Zacharof, chairman, Alaska Native Health Board...............   705
Additional material submitted for the record:
Letters:
    Citizens Potawatomi Nation...................................   839
    Edwards, James Lee, Governor, Absentee Shawnee Tribe.........   841
    Ration, Norman, executive director, National Indian Youth 
      Council, Inc. (with attachment)............................   842
    Romberg, Carolyn, Health Director, AST Health Programs, 
      Absentee Shawnee Tribe of Oklahoma.........................   841


                   INDIAN HEALTH CARE IMPROVEMENT ACT

                              ----------                              


                        WEDNESDAY, JULY 16, 2003


        U.S. Senate, Committee on Indian Affairs, Meeting 
            Jointly With the Committee on Resources, U.S. 
            House of Representatives
                                                    Washington, DC.
    The committees met, pursuant to notice, at 10:15 a.m. in 
room 106, Dirksen Senate Office Building, Hon. Ben Nighthorse 
Campbell (chairman of the Senate Committee on Indian Affairs) 
presiding.
    Present from the Senate Committee on Indian Affairs: 
Senators Campbell, Inouye, Reid, Conrad, Dorgan, and Murkowski.
    Present from the House of Representatives Committee on 
Resources: Representatives Pombo, Mark Udall, Faleomavaega, 
Cole, Kildee, Grijalva, Pallone, Brad Carson, Christensen, and 
Napolitano.

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

    The Chairman. We will now move to the joint hearing with 
the House Resources Committee and the Senate Committee on 
Indian Affairs bills to reauthorize the Indian Health Care 
Improvement Act. The two bills before our committee, S. 556 and 
H.R. 2440, reflect literally years of hard work by tribal 
leaders, the National Steering Committee and various Federal 
officials.
    Most members know the shameful state of Indian health. 
Senator Dorgan just reiterated that as did Senator Conrad, so I 
won't go through the litany of statistics this morning but they 
are common knowledge.
    Today is the second in a series of hearings on the 
reauthorization bill. We will receive testimony regarding one, 
health disparities; two, health facilities; and three, urban 
Indian health issues. In the interest of time, I'll place my 
full statement in the record but I will say this to the members 
of both committees. After years of work and countless hours of 
meetings and hearings, the time certainly has come for the 
tribes, Congress and the Administration to roll up our sleeves 
and do what we need to do to move this bill and get the act 
reauthorized this year. To achieve that goal I look forward to 
working with my colleagues on both committees.
    [Prepared statement of Senator Campbell appears in 
appendix.]
    [Text of S. 556 and H.R. 2440 follow:]
      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


      
      

  


    The Chairman. Now I would like to turn to our chairman from 
the House. Chairman Pombo, do you have an opening statement?
    Mr. Pombo. Yes; I do. Thank you, Mr. Chairman.

 STATEMENT OF HON. RICHARD W. POMBO, U.S. REPRESENTATIVE FROM 
       WASHINGTON, CHAIRMAN, HOUSE COMMITTEE ON RESOURCES

    Mr. Pombo. I want to thank Senator Campbell for agreeing to 
make today's hearing a joint hearing with the House Resources 
Committee. Holding a joint hearing should send a signal that we 
can develop a bill to address the health care needs of American 
Indians and Alaska Natives on a bipartisan basis.
    Anyone who has studied the statistical data compiled by the 
Census Bureau and by health care experts understands there is a 
profound lack of and access, to quality health care for 
American Indians and Alaska Natives.
    Living conditions for hundreds of thousands of Native 
Americans lag far behind the rest of the population, whether 
they live in a reservation or an urban area. These conditions 
are unacceptable and there have to be new approaches that 
maximize the huge potential in Indian country to improve health 
care and disease prevention.
    Exploring new ways to raise the quality of health services 
for American Indians and Alaska Natives is not an option for 
Congress. It is a basic obligation.
    One way to address health problems for American Indians and 
Alaska Natives is to improve basic infrastructure needs such as 
safe water, sewer, waste disposal and modern medical 
facilities. Unless the bricks and mortar are in place, then we 
will be reduced only to responding to outbreaks of health 
problems, not preventing them. I am glad today's witnesses will 
especially address these issues.
    I look forward to the testimony on these aspects of H.R. 
2440 and S. 556. I thank the chairman for yielding.
    The Chairman. Thank you, Chairman Pombo.
    I'm delighted to see some of my old friends from the years 
I served in the House. I don't know if you have opening 
statements but why don't we start with Congressman Kildee. If 
you have a statement, go ahead.
    Mr. Kildee. Thank you very much, Mr. Chairman.

  STATEMENT OF HON. DALE E. KILDEE, U.S. REPRESENTATIVE FROM 
                            MICHIGAN

    Mr. Kildee. I am happy you and Mr. Pombo are having these 
hearings as a member of the House Resources Committee and 
cochairman of the House Native American Caucus, I think this is 
very important. If by chance we are called back for votes, I 
will leave Kim TeeHee of my staff who handles all matters of 
the Native American Caucus to hear all the testimony.
    The reauthorization of this act will provide a more 
comprehensive approach to the delivery of medical care to 
Native people. The House bill is based upon the recommendation 
made by the Indian health community including tribal leaders, 
tribal health directors, health care experts and Native 
patients themselves. Its primary objective is to improve access 
to quality medical care for the Native American population.
    I look forward to hearing testimony this morning and would 
ask consent that my entire statement be included in the record.
    The Chairman. It will be included in the record.
    [Prepared statement of Mr. Kildee appears in appendix.]
    The Chairman. Why don't we go back and forth? Senator 
Murkowski, did you have any comments?

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

    Senator Murkowski. Thank you, Mr. Chairman. Good morning 
and thank you for the hearing this morning with our House 
members on a very important issue for us in my State.
    I would like to welcome those Alaskans we will be hearing 
from this morning, Chief Andrew Jimmie from Minto and Steve 
Weaver from Anchorage. I also see some other Alaskans in the 
audience. This is our committee's second hearing on Indian 
health care reauthorization but it's the first one that has 
taken place after the National Steering Committee's bill was 
introduced in the other body.
    There are many good things in this legislation but what I 
particularly like about it is that it is not necessarily an 
Alaskan bill or a Navajo bill or an urban bill, it is a 
national bill which was derived through the very diligent work 
of Native health leaders throughout Indian country. I hope, Mr. 
Chairman, that through the good work of the National Steering 
Committee, we will form the nucleus of this bill that we will 
markup in the Committee on Indian Affairs.
    I am very pleased that we will be hearing from Steve Weaver 
on the second panel. Oftentimes when you think of Indian 
health, we think of the doctors and the nurses. Steve is an 
engineer, specializing in sanitation and environmental health. 
His expertise is in preventing disease by focusing on water 
quality and sanitation. It is so important that we do focus on 
these preventative first step measures, so I am pleased he is 
here today to help us as we talk about healthy families and 
healthy communities.
    Mr. Chairman, thank you.
    The Chairman. Thank you.
    Mr. Faleomavaega.
    Mr. Faleomavaega. Thank you, Mr. Chairman.

    STATEMENT OF HON. ENI F.H. FALEOMAVAEGA, U.S. DELEGATE, 
                         AMERICAN SAMOA

    Mr. Faleomavaega. I would like to echo the sentiments 
expressed earlier by my colleagues to thank you for the 
initiative and your leadership in calling this joint hearing, 
along with our distinguished chairman, Mr. Pombo from 
California. I think this effort certainly demonstrates the 
urgency of this legislation that has been on the shelf now for 
4 years. Our Indian communities have deliberated and have had 
so many consultations for many years now and I sincerely feel 
this joint hearing gives it a sense of urgency that we need to 
pass this legislation as soon as possible. We thank you for 
doing this.
    For those of us on the House side, it's nice to be here 
once in a while to see how glorious and big the chambers are.
    The Chairman. Actually, we're a pretty friendly crowd. You 
didn't have to sit that far away.
    Mr. Faleomavaega. I don't know about that, Mr. Chairman. We 
kind of felt we were being intimidated by the gloriousness of 
this beautiful chamber but as a former colleague and certainly 
as a member of our committee, Mr. Chairman, we are delighted to 
be here and look forward to hearing from our witnesses this 
morning.
    The Chairman. Congressman Cole, did you have a statement?
    Mr. Cole. Just briefly, Mr. Chairman.

 STATEMENT OF HON. TOM COLE, U.S. REPRESENTATIVE FROM OKLAHOMA

    Mr. Cole. I'd like to echo my colleagues' appreciation for 
you and Chairman Pombo having this joint session. It is an 
extraordinarily important problem an one that's been allowed to 
languish far too long. I appreciate your initiative. I hope we 
can develop a bipartisan consensus on this legislation and move 
ahead. I particularly hope during the course of the hearing if 
we have an opportunity to look at not only the depth of the 
problem overall but some of the disparities in funding at the 
tribal level. Representing a State that has many, many Native 
Americans but not much in the way of reservations, we've lagged 
in funding compared to some of the other tribes.
    Certainly we appreciate your initiative and this 
opportunity to look at these problems and move ahead.
    The Chairman. Congressman Udall from the great State of 
Colorado, any comments?
    Mr. Udall. Thank you, Mr. Chairman.

STATEMENT OF HON. MARK UDALL, U.S. REPRESENTATIVE FROM COLORADO

    Mr. Udall. I too want to associate myself with the remarks 
of my Chairman, Mr. Pombo, Mr. Faleomavaega and the rest of the 
panel. I want to underline my commitment to proceeding as 
quickly as possible. We all know this has been long in arriving 
and we need to get this legislation passed and to the 
President's desk.
    I look forward to working with everybody here to see that 
we do that as soon as possible.
    Thank you, Mr. Chairman.
    The Chairman. Congressman Grijalva?
    Mr. Grijalva. Thank you, sir.

 STATEMENT OF HON. RAUL M. GRIJALVA, U.S. REPRESENTATIVE FROM 
                            ARIZONA

    Mr. Grijalva. I also would join with my colleagues in 
extending the appreciation to you, Senator, and to our Chairman 
for having this hearing. I want to associate myself with the 
comments made by my colleagues and look forward to an expedient 
process and some quick movement in assuring that access and a 
health delivery system is available to our Native American 
brothers and sisters.
    Thank you, sir.
    The Chairman. Thank you.
    Congressman Pallone, any comments?
    Mr. Pallone. Thank you, Mr. Chairman.

 STATEMENT OF HON. FRANK PALLON Jr., U.S. REPRESENTATIVE FROM 
                           NEW JERSEY

    I just wanted to say that both of you, Senator Campbell, as 
well as our House Chairman Pombo, have really highlighted and 
shown a tremendous concern over this issue. Senator Campbell 
obviously for a number of years and Congressman Pombo over the 
last couple months, particularly last week, has shown on the 
House Resources side that he is willing to move forward on a 
number of these initiatives because he realizes how important 
they are.
    I just wanted to say briefly I think there is a tremendous 
problem, I would call it a crisis, in terms of health care 
services in Native America primarily because you've had an 
explosion in the Native American population but that the IHS 
has not been able to keep up, primarily because of funding. I 
think lack of funding is a major issue.
    There is also the fact that in Congress, I think we have 
not paid enough attention to the lack of money for facilities, 
for new construction and perhaps the Administration more and 
more, and I don't just mean this Administration but the last 10 
years or so, seems to be relying on the tribes more and more to 
pay for their own services, particularly with regard to new 
facilities and renovation of facilities. I think that is wrong. 
I really see provision of health care services for Native 
Americans as an entitlement, as something we are required 
pursuant to the Constitution and treaties over the years to 
provide. I don't think we should rely more and more on their 
providing their own money. I think we have to increase the 
funding.
    In addition, there are just so many changes that we haven't 
paid attention to over the last 10 or 20 years, the need for 
more preventative services, home health care, nursing homes, 
the changes in the demographics so that more and more Native 
Americans are now in urban areas and that those problems need 
to be addressed. Although there is a crisis, I think that we 
can identify what the needs are. I know that people on this 
committee, including the leadership, are very concerned and 
know what to do.
    What we need to do is educate the rest of Congress and try 
to move the legislation and get our other colleagues motivated 
beyond these two committees to move these measures and realize 
the crisis we face, and that it is going to take a lot more 
money and time to address this.
    I'm very pleased we are having this hearing today. I want 
to thank the two Chairmen in particular for their concerns.
    The Chairman. Thank you.
    Any comments, Congressman Carson.
    Mr. Carson. Thank you very much, Senator Campbell.

    STATEMENT OF HON. BRAD CARSON, U.S. REPRESENTATIVE FROM 
                            OKLAHOMA

    Mr. Carson. I'd like to thank you and Chairman Pombo for 
holding this hearing too. Of course I have a great interest in 
this issue representing the most Native American congressional 
district in the country, being a member of the Cherokee Nation 
myself and the son of a career of Bureau of Indian Affairs 
employee. I know how important this legislation is to the many 
Native Americans both in Oklahoma and across the country.
    I am particularly proud that two Oklahomans will today be 
testifying before this committee, Carmelita Skeeter who runs a 
tremendously successful health care center in Tulsa, Oklahoma 
serving the Native American population, as well as Dr. Charles 
Grimm, the interim director of the IHS. He did a tremendous job 
in the State of Oklahoma and I understand his nomination and 
the hearings on his confirmation are proceeding nicely and we 
look forward to this service to this Administration as the 
Director of IHS.
    Oklahoma has more than 300,000 patients in IHS and there is 
only 1.6 million nationwide. You can imagine when you have 20 
percent of the IHS population, you are very concerned about 
what is going on within the institution.
    We appreciate your holding this hearing today. I am proud 
to be a cosponsor of H.R. 2440, the House version of the Indian 
Health Care Improvement Act reauthorization, and we look 
forward to what the panel has to say on this very important 
matter.
    The Chairman. Thank you.
    Congresswoman Christensen.
    Ms. Christensen. Thank you, Mr. Chairman.

  STATEMENT OF HON. DONNA M. CHRISTENSEN, U.S. DELEGATE FROM 
                         VIRGIN ISLANDS

    Ms. Christensen. I want to join my colleagues in thanking 
both you, Chairman Campbell, and Chairman Pombo for holding 
this very important meeting and also to say it is very timely 
as the Minority caucuses in the House are working with members 
of the Senate to put all of the initiatives that we have been 
advocating over several past Congresses into one comprehensive 
minority health bill. Also, to say as chair of the Health Brain 
Trust of the Congressional Black Caucus and as a physician, it 
is my hope that at the end of this process, we will reauthorize 
the Indian Health Care Improvement Act in such a way that we 
can truly begin to rectify the deficiencies of past efforts and 
pass a bill that will bring the health of Native Americans not 
just on par with what we consider average for Americans, 
because if we include the African American, the Hispanic 
American, the Asian Pacific Islanders what is considered 
American health will be far below what we should be aspiring 
to.
    Rather, we want to develop a vehicle that will develop the 
high level of health attained by those of full and unfettered 
access to health services to a bill that provides equal access 
to culturally sensitive, comprehensive, easily and universally 
accessible health care provided mostly by the increasing cadre 
of Native American health providers that will be trained under 
this bill, with best practices determined by Native American 
and Alaska Native led and specific research provided in 
communities that are environmentally and socio-economically 
supportive of good health and developed and directed by the 
communities and the tribes themselves fully funded and 
supported with technical assistance from the Federal Government 
and the agencies that can provide such technical assistance.
    I want to once again thank you for this hearing and I look 
forward to the testimony of our witnesses.
    The Chairman. Thank you.
    We will now start with the first panel which will be 
Charles Grim, director, Indian Health Service, accompanied by 
Gary Hartz, acting director, Office of Public Health, Indian 
Health Service; Richard Olson, acting director, Division of 
Clinical and Preventive Services; Mrs. Rae Snyder, acting 
director, Urban Health Office; and Steven Nesmith, assistant 
secretary for Congressional Affairs, Department of Housing and 
Urban Development.
    We'll start by telling you that all of your written 
testimony will be included in the record. If you would like to 
abbreviate, that would be fine. We will start with Mr. Grim 
first.

  STATEMENT OF CHARLES GRIM, DIRECTOR, INDIAN HEALTH SERVICE, 
 DEPARTMENT OF HEALTH AND HUMAN SERVICES, ACCOMPANIED BY GARY 
HARTZ, ACTING DIRECTOR, OFFICE OF PUBLIC HEALTH, INDIAN HEALTH 
 SERVICE; RICHARD OLSON, ACTING DIRECTOR, DIVISION OF CLINICAL 
 AND PREVENTIVE SERVICES, INDIAN HEALTH SERVICE; AND MRS. RAE 
  SNYDER, ACTING DIRECTOR, URBAN HEALTH OFFICE, INDIAN HEALTH 
                            SERVICE

    Mr. Grim. Thank you, Chairman Campbell, Chairman Pombo, and 
distinguished members of both committees.
    We are very excited too within the Indian Health Service 
for this joint hearing to be able to talk about the issues 
before both the House and the Senate.
    You have introduced the staff I have here. They won't be 
making any opening statements. I will be making the opening 
statement for the agency but they are here should we have 
questions. They are technical matter experts on a number of 
these issues today.
    We are pleased to have this opportunity to be able to 
testify on behalf of Secretary Thompson on both the House and 
Senate bills to reauthorize the Indian Health Care Improvement 
Act. For the record, I'm submitting my written statement and it 
contains specific information about the agency including the 
legislative and legal history regarding the United States' 
commitment to tribal nations and some of the national 
challenges that we're facing to improve the health of American 
Indians and Alaska Natives. My written statement also contains 
comments on specific aspects of the proposed legislation that I 
won't cover in my oral statement so that we can conserve time.
    As I testified last April, there is no single piece of 
legislation that will affect the future health status of 
American Indians and Alaska Natives more than the Indian Health 
Care Improvement Act Reauthorization of 2003. For the past 28 
years, the Indian Health Care Improvement Act has been the 
basis for extending the life span of Indian people by 7 years 
which is still 6 years below that of the rest of the Nation. It 
has helped us to address the basic health needs of a population 
that was not benefiting from the technological and medical 
advances of an industrialized nation and it has also assisted 
us in identifying current and future health challenges.
    To continue to make progress in raising the health status 
of Indian people to at least the level of the rest of the 
Nation requires us to modify the Indian Health Care Improvement 
Act of 1976 to reflect the health status of the Indian 
population of 2003 as best we can and to have it reflect the 
health status of Indian people as we project it into the future 
until the next reauthorization.
    The legislation under consideration today reflects the 
proposed language developed over a 2-year period by Indian 
tribes across the Nation and adopted by both committees of 
Congress. Our Nation faces many priorities today, many of which 
overshadow but do not diminish the importance of other 
priorities. As requested by the committee, I am going to focus 
my brief remarks on the highlighted areas of health 
disparities, health care facilities and urban Indian health.
    My written statement includes some health statistics and 
the agency can supply members with more information if 
requested. Three simple statements to remember regarding 
American Indian and Alaska Native health disparities are: 
First, Indian people continue to experience disease and illness 
at greater rates than the rest of the Nation; second, Indian 
people continue to prematurely die at rates greater than the 
rest of the Nation; and third, Indian people continue to 
experience reduced access to health services and care compared 
to the rest of the Nation.
    It is well publicized and referenced that Indian people 
continue to experience health disparities and death rates that 
are significantly higher than the rest of the United States 
general population. Many American Indians and Alaska Natives 
who receive a diagnosis of diabetes, high blood pressure and 
high cholesterol levels, cardiovascular disease, alcoholism and 
obesity consider it a fatal diagnosis.
    The proposed language of the Indian Health Care Improvement 
Act can help the Indian health system of the Indian Health 
Service, tribal health programs and urban Indian health to 
develop and implement health promotion and disease prevention 
strategies so that healthy behavior choices and lifestyles will 
begin to significantly reduce the health disparity rates. It 
also yields an even more important humanitarian benefit of 
reducing pain and suffering and prolonging life.
    We were successful in working with Indian nations through 
the Indian Health Service with infectious diseases and 
conquering those and I think we can do it again for chronic 
diseases with the help of Congress.
    The IHS Health Care Facilities Program, including the 
tribal program specifically, are responsible for managing and 
maintaining the largest inventory of real property in the 
Department of Health and Human Services with over 9 million 
square feet of space. In the proposed bill, section 
302(B)(3)(c) specifically proposes that IHS Sanitation 
Facilities Construction funds will not be used to support 
service of sanitation facilities to the Department of Housing 
and Urban Development homes. The bill is not clear that homes 
constructed through HUD should also include the necessary 
infrastructure to make a home complete including safe water and 
sewer and wastewater disposal systems for the home. The IHS and 
HUD have cooperated over many decades on the construction of 
homes and reservation communities with IHS providing the 
expertise and development of supporting the sanitation and 
sewage systems that the HUD homes would then hook into.
    Without clarity in the language, there may come a time when 
interpretation may result in IHS funds being expended on 
sanitation systems of HUD homes which would in turn redirect 
IHS funds from providing services to existing homes without 
water, sewer and solid waste facilities. Newly constructed HUD 
homes should be funded to cover everything including the home 
itself and to the street hookup. We request that you consider 
clarifying this point in the proposed bill.
    Title V of the Indian Health Care Improvement Act provides 
specific authority focused on the provision of health services 
for urban Indian people with funds appropriated to the Indian 
Health Service. The IHS currently contributes funds toward the 
operating expenses of 34 independent urban Indian health 
programs including programs in Oklahoma City and Tulsa that are 
demonstration programs. These programs provide a range of 
services. In 1978, the entire State of Oklahoma was designated 
as a contract health service delivery area which means that the 
Indian beneficiaries could reside anywhere in the State and 
maintain their eligibility for both direct services and 
contract health services.
    The 1992 Congress amended the Health Care Improvement Act 
to establish two demonstration projects with Tulsa and Oklahoma 
City clinics to be treated as service units in the allocation 
of resources and the coordination of care. This new and 
innovative approach to ensuring health services were accessible 
to all eligible populations in Oklahoma has resulted in a 
hybrid system. Each program maintains its status under the 
title V as an urban Indian organization, yet the programs 
function like other IHS service units and report on the 
resources and patient management system of the Indian Health 
Service with data utilized for inclusion in the allocation of 
resources.
    Most service populations and overall utilization of 
services have dramatically increased since these programs 
became demonstration projects and from the fiscal year 1994 
specific congressional line item funding increases. They have 
been able to use the best of both urban and IHS structures to 
build a community controlled, high quality health system in a 
State designated as a contract health service delivery area.
    On the other hand, the hybrid system has raised a few 
concerns with some of the Oklahoma tribes that operate their 
own health programs under the Indian Self Determination and 
Education Assistance Act, Public Law 93-638 as amended. The 
issue in its most basic terms is that the two urban programs 
have some aspects of a service unit but their funding is not 
subject to transfer to the tribes under Public Law 93-638 
contracts or compacts as our non-hybrid service units are.
    With an environment of reduced resources and an increasing 
population with greater health needs, it's expected that the 
issue of tribe shares of urban Indian programs, especially the 
hybrid programs, will receive more attention than they have in 
the past.
    As review of this far-reaching, complex legislation 
continues, we may have further comments. However, we wish to 
reiterate our strong commitment to reauthorization and 
improvement of the Indian Health Care Improvement Act and will 
be happy to work with the committees, the National Tribal 
Steering Committee and other representatives of the American 
Indian and Alaska Native communities to develop a bill that is 
fully acceptable to all stakeholders in this important program.
    Mr. Chairman, that concludes my statement. I want to thank 
you for the opportunity to discuss reauthorization of the 
Indian Health Care Improvement Act. We will be happy to answer 
any questions you may have.
    [Prepared statement of Dr. Grim appears in appendix.]
    The Chairman. Thank you, Dr. Grim.
    I understand Admiral Hartz, Dr. Olson, and Ms. Snyder are 
resource people but do not have statements, is that correct?
    Mr. Grim. That is correct.
    The Chairman. Now we will go to Steven Nesmith.
    I might tell my colleagues that Mr. Nesmith is really 
assistant secretary for Congressional Affairs. I understand 
your background is not in Indian health. Is that correct?
    Mr. Nesmith. That is correct, sir.
    The Chairman. Hopefully we won't put you on the spot too 
much. Go ahead.

     STATEMENT OF STEVEN NESMITH, ASSISTANT SECRETARY FOR 
  CONGRESSIONAL AND INTERGOVERNMENTAL AFFAIRS, DEPARTMENT OF 
                 HOUSING AND URBAN DEVELOPMENT

    Mr. Nesmith. As this is a joint hearing, Chairman Campbell 
and Chairman Pombo, Vice Chairman Inouye, and members of both 
committees, thank you for inviting me here to provide comments 
on S. 556, the Indian Health Care Improvement Act 
Reauthorization of 2003.
    My name is Steven Nesmith and I am the assistant secretary 
for Congressional and Intergovernmental Affairs at HUD.
    As you know, the Public and Indian Housing, PIH, is 
responsible for the management and operation and oversight of 
HUD's Native American programs. These programs are available to 
560 federally-recognized and a limited number of State-
recognized Indian tribes. We serve these tribes directly or 
through tribally designated housing entities by providing 
grants and loan guarantees designated to support affordable 
housing community and economic development activities. Our 
tribal partners are diverse. They are located on Indian 
reservations, in Alaska Native villages and other traditional 
Indian areas.
    In addition to those duties, PIH's jurisdiction encompasses 
the Public Housing Program which aides the Nation's 3,000 plus 
public housing agencies in providing housing and housing 
related assistance to low income families. It is a pleasure to 
appear here before you and I would like to take the opportunity 
to express my appreciation for all of your continuing efforts 
to improve the housing conditions of American Indians and 
Alaska Native peoples.
    Much progress has been made and tribes are taking advantage 
of new opportunities to improve the housing conditions of the 
Native American families residing on Indian reservations, on 
trusts or restricted Indian lands and in Alaska Native 
villages. This momentum needs to be sustained as we continue to 
work together toward creating a better living environment 
throughout Indian country.
    At the outset, let me reaffirm the Department of Housing 
and Urban Development's support for the principle of government 
to government relations with Indian tribes. HUD is committed to 
honoring this fundamental precept in our work with American 
Indians and Alaskan Natives. On behalf of Secretary Martinez, 
thank you for the opportunity to provide this testimony on S. 
556.
    The Department agrees that the Indian Health Service, a 
division of the Department of Health and Human Services, is 
vital to the well being of individual Indian families and the 
Native American community as a whole. Native Americans often 
have no other means to receive the health care assistance and 
related activities provided by IHS.
    HUD's Office of Native American Programs continues its 
ongoing dialogue with IHS representatives to coordinate our 
activities in a manner that supports tribal sovereignty, self 
determination and self governance. The Department also 
participates in a Federal Interagency Task Force on 
Infrastructure with the IHS, the Environmental Protection 
Agency, the Bureau of Indian Affairs and the Department of 
Agriculture. It is within this perspective that the following 
comments are offered on behalf of HUD and this bill.
    As you are aware, in 1996, the Native American Housing 
Assistance and Self Determination Act became law. NAHASDA 
changed the way in which housing and housing related assistance 
is provided to Native American families. Prior to the Act, 
Indian housing authorities and Indian tribes applied for a 
variety of competitive and categorical grant programs usually 
with differing program eligibility and reporting requirements.
    NAHASDA created the Indian Housing Block Grant Program 
which is a non-competitive formula grant made to Indian tribes 
or tribally designated housing entities. Under the Indian 
Housing Block Grant Program, an Indian tribe or the tribal 
designated housing entity submits to HUD a 5-year and a one 
year housing plan. The housing plan contains information about 
how the recipient will use its block grant funds to engage in 
the six affordable housing activities authorized by NAHASDA.
    Once the Indian housing plan is found to be in compliance 
with the statutory and regulatory requirements, the tribe or 
that designated entity executes a grant agreement to receive 
the Indian housing block grant allocation. The Indian housing 
block grant formula is based on housing needs of each of the 
tribes and the tribes designated entity ongoing operation, 
maintenance needs and for the dwelling units previously 
developed under the Indian Housing Program authorized by the 
U.S. Housing Act.
    The Indian housing block grant formula is calculated by 
dividing the total amount appropriated for each fiscal year 
among the number of eligible grant recipients. Formula 
components and variables are weighted to ensure that the 
complexities and differences among tribes are taken into 
consideration. Each tribe's formula allocation reflects these 
factors.
    The NAHASDA regulations as described in the Code of Federal 
Regulations requires that the Indian housing block grant 
formula be reviewed by the calendar year 2003 for possible 
modification or revision. At present, HUD is engaged in 
negotiating rulemaking commonly referred to as NEGREG with a 
26-member committee comprised of a broad cross section of 
tribal stakeholders. The first NEGREG session was held in April 
of this year and additional monthly meetings are ongoing and 
are scheduled through September.
    Let me turn to the specific comments on S. 556, the Indian 
Health Care Improvement Act Reauthorization of 2003. As you 
know the Administration is actively reviewing S. 556 and will 
provide you with specific details of our analysis very shortly. 
The Administration has not taken a position regarding the 
transfer of NAHASDA funds between HUD and HHS. We do, however, 
have concerns about transferring NAHASDA funds between Federal 
agencies when NAHASDA now provides for the direct distribution 
of Indian housing block grant funds to tribes and their housing 
designated entities based on a formula negotiated between the 
tribes and HUD.
    An affordable housing activity under the Indian Housing 
Block Grant Program is development which includes 
infrastructure such as site improvements and the development of 
utilities and utility services for housing. The provision of 
water and sanitation facilities are included within this 
category. Tribes and tribal designated housing entities may 
currently enter into agreements with IHS to provide these 
services or they may choose another service provider.
    We believe that this is in keeping with the policy of self 
determination that is articulated in NAHASDA. Since 1997, 
nearly $228 million has been transferred to IHS through the 
tribal designated housing entities for offsite sanitation 
facilities. Tribes and their designated entities continue to 
make difficult budgetary and management decisions on how to 
prioritize their Indian housing block grant dollars which is 
consistent again with tribal self determination and self 
government.
    Let me assure the committee that we will work with both 
committees and with our Federal partners in HHS and other 
Federal agencies, the tribes and their designees to ensure that 
the housing infrastructure needs in the Native American 
communities are met in the most efficient manner possible.
    We are nevertheless concerned about any provision that 
might erode the self determination which we believe is critical 
in NAHASDA.
    Thank you for the opportunity to express the Department's 
views.
    [Prepared statement of Mr. Nesmith appears in appendix.]
    The Chairman. Thank you.
    Since our colleagues in the House are going to have further 
to walk because there is a vote than we have to in the Senate, 
I am going to yield to them for questions first. We will start 
with Chairman Pombo.
    Mr. Pombo. Thank you very much. I appreciate the 
opportunity.
    The House Interior Appropriations bill specifically 
included committee language which states that IHS sanitation 
funds should not be used to provide sanitation facilities for 
new homes funded by the housing programs of the Department of 
Housing and Urban Development. I know, Dr. Grim, that in your 
opening statement you talked about this issue. Could you expand 
upon that for me as to what your level of support or opposition 
to that particular language is?
    Mr. Grim. Yes, Mr. Chairman; the way that came about was 
our appropriations committees have over the years included that 
language because HUD funded home projects prior to NAHASDA had 
infrastructure funds included for sanitation facilities for 
newly funded HUD homes. Once NAHASDA was put in place, it was 
the tribes choice of what to use those funds for, whether to 
build housing infrastructure and so forth.
    The IHS program separates and, apart from that, looks at 
existing homes without adequate sanitation facilities or newly 
built homes built with other than HUD funds. We currently have 
a backlog of those homes as well, so the two programs are 
separate. So our committees have wanted to ensure that moneys 
coming through the Indian Health Service were used for existing 
homes with that need or with newly built homes other than HUD 
homes.
    Mr. Pombo. So you generally in support of that because you 
want to keep those two programs separate?
    Mr. Grim. As mentioned by Mr. Nesmith, we've worked jointly 
with HUD over the years to try to ensure that the two programs 
work together but they are two separate programs.
    Mr. Pombo. Can you tell me a bit more about what you are 
currently doing to deal with that backlog? I've been told that 
the backlog is substantial at this point. Can you expand upon 
that a bit for me?
    Mr. Grim. The current backlog we have estimated in feasible 
projects, those able to be completed roughly is around $900 
million right now. We keep records on that and those records do 
not sometimes include newly built HUD homes that may or may not 
have adequate facilities. Once they become existing homes, we 
try to get those added to our inventory.
    One of the things we try to do on an annual basis, we have 
currently a $94-million appropriation to deal with new and 
existing homes and we have a priority system where we try to 
prioritize those in most need. We are trying on an annual basis 
to work on those backlogs.
    Mr. Pombo. You said something I have a real question on and 
that is when a newly constructed HUD home becomes an existing 
home, then you can use funding to provide the sanitation 
services. Why would you allow a home to be built without the 
sanitation services?
    Mr. Grim. I may let Admiral Hartz take a crack at this 
after I finish but regarding existing HUD homes, the Indian 
Health Service staff work in concert with HUD on those homes. 
However since the passage of NAHASDA the block grants have now 
been transferred to tribes. There is extreme pressures out 
there due to the backlog and need for housing in Indian country 
and there are more and more pressures on tribes to get existing 
homes in place.
    The IHS does not have direct control over any of the 
NAHASDA housing projects themselves. We come in as technical 
assistants but we do have funds, the $94 million I referenced, 
to help existing homes or those that have been built with funds 
other than HUD such as State programs or tribal funds and 
things like that to try to get adequate water and sanitation 
facilities to them. Many times, in Indian country it's not like 
it is in an urban setting like Washington, DC or Maryland where 
all you have to do is hook up to a water main that is a few 
feet from the house. Sometimes there are many, many miles to 
traverse to get to a water or sewer system. So it is not as 
easy as it sounds sometimes when a home goes up many, many 
miles from a location where there is adequate hookups to 
sanitation and water. Sometimes that occurs.
    The point I would make is the IHS works in tandem with HUD 
and with tribes trying to ensure that safe water and sanitation 
facilities go in but the IHS itself is not the one responsible 
for the building programs. We just assist with sanitation and 
those facilities.
    Mr. Hartz. Mr. Chairman, I can build on that with a couple 
of points.
    I think historically as pointed out, we have had an 
excellent relationship with HUD in making sure that the door 
knob is talking to the toilet seat as we get these new homes 
built. I think that's been shown going back to when Congress 
actually started putting that language in our appropriations 
bill which dates back to the early 1980's. It had to do with 
some arrangements that were worked out at that time with OMB 
and Secretary Pierce I believe in 1981.
    The money started flowing to ensure that the HUD units were 
provided sanitation facilities either through an arrangement 
with HUD directly or through the Indian Housing Authorities 
and/or the Indian tribes depending on how they were set up 
locally. Those resources contributed from the HUD Indian 
Housing Program at that time grew from $5-$6 million to $25 
million. That contribution to the Sanitation Facilities Program 
of IHS was of tribes' choosing. They could do the construction 
themselves, they could provide it to IHS. Many times the reason 
they would provide it to IHS is because you can then do a total 
community concept in development of infrastructure as opposed 
to doing a piecemeal approach where houses get dropped in a 
location and you only have dollars to do just that little piece 
for infrastructure. Infectious diseases don't follow those 
kinds of boundaries when the same children from different 
places show up in the school system.
    It grew in 1994 to almost $25 million, the contribution 
that was coming out of the Indian Housing Program from HUD most 
of the time, 90 plus percent of the time, the money actually 
was a decision made by the tribes exercising self determination 
before that was even passed through the HUD authorizations to 
provide those dollars to IHS to carry it out.
    There were lots of arrangements by which that was done. 
Sometimes the tribes would pool the dollars and the tribes 
actually did the construction as on the Navajo Reservation to 
this day, they do 99 percent of all construction related to 
infrastructure on water, sewer, solid waste, et cetera.
    It was only after the passage of NAHASDA that the numbers 
dramatically dropped. We were down as low as $1.3 million. Last 
year in 2002, it was about $4.4 million that was provided. That 
is totally a tribe decision. We concur with that.
    Getting back to your original question about why that 
language was put in our appropriation, we are so limited in our 
resources to address the sanitation deficiency system that 
Congress asked us to identify in that universe of need being at 
$1.5-$1.6 billion for all of the existing homes, plus address 
anything new coming on, we weren't in a position, at least the 
appropriators thought, to pick up additional responsibility for 
HUD sponsored units because we have $94 million we are 
addressing against the feasible amount of $900 million and of 
that $94 million, we put about half of it to address new units 
every year. In 2002, we had a few hundred units we weren't even 
able to address, about 350 units, where individuals were 
financing and paying for their homes themselves that we 
couldn't get to within the priority systems that exist.
    That's a little more background. I hope I haven't expounded 
to far in some of the detail but I'm prepared to expound 
further as needed.
    Mr. Pombo. Thank you, Mr. Chairman.
    The Chairman. I can look at the clock and see that by the 
time we get done with the next panel, we are going to run out 
of time. I would ask my colleagues to keep their questions down 
to 3 or 4 minutes.
    Congressman Kildee.
    Mr. Kildee. On the question of sanitation, the Senate bill 
apparently prohibits the use of IHS funds for sanitation in HUD 
housing whereas the House bill does not contain that 
prohibition. How does the IHS suggest we clarify the language 
referring to IHS funding for sanitation in HUD constructed 
houses?
    Mr. Grim. As I pointed out earlier, right now the two 
programs are really separate programs. We are serving that 
backlog of existing homes that do not have adequate safe water 
and sanitation facilities as well as newly built homes that are 
built with other than HUD funds. There are a large number of 
those being built annually.
    There are currently two separate programs. The two bills 
that have been introduced with differing language, I suspect in 
conference committee will be dealt with but if our funds were 
to be merged with HUD funds, it appears it would be taking two 
separate programs and merging them into one. We would have a 
difficult time then perhaps addressing the existing home 
backlog.
    Mr. Kildee. Perhaps the House and Senate can get together 
and try to bring our language to more compatibility to see what 
we can do to encourage the IHS. In some very remote parts of 
Michigan where I come from where there are no water lines as 
such and no sewer lines, they do have septic facilities and 
there is groundwater they can use for the operation. I think 
remoteness alone, there might be some areas where you don't 
have the groundwater, would not always preclude the 
possibility. This certainly relates to health, there is no 
question about that.
    The Saginaw Chippewa Tribe, in my State but not my 
district, in 1934 the Federal Government built a number of half 
houses for the Indians. Some of those half houses are still 
there, maybe have been finished off and changed a bit but I 
guess the Indians were grateful to get the half houses but they 
really were half. I think we certainly should have come a long 
way since 1934 and a long way since 1980.
    I'm willing to work with you to see what we can do to help 
the IHS and HUD work more closely together to provide this. I 
also believe we should elevate your position to that of 
assistant secretary.
    Mr. Grim. Thank you, Congressman Kildee. I might point out 
for everyone's information that the language in the Senate bill 
relative to the way we work with sanitation facilities is the 
current practice that is being carried on.
    The Chairman. Congressman Cole, any questions?
    Mr. Cole. No; Mr. Chairman.
    The Chairman. Congressman Faleomavaega.
    Mr. Faleomavaega. Again, I want to thank Dr. Grim for his 
testimony.
    Mr. Grim, I think one of the problems that left this 
proposed legislation for authorization hanging was the question 
of scoring. I notice that some estimates come out to $2 
billion, $3 billion, $6.9 billion for the 10-year period. It 
seems we are squeezing blood out of a turnip. Why is it we are 
having such a difficult in time in trying to arrived the best 
cost estimate when it is so simple to get $70 billion to clean 
up Saddam Hussein's mess, so instantly it seems. We're asking 
for a mere $3 billion.
    From the statement here, I am concerned that alcoholism, is 
770 percent higher than the U.S. population; diabetics, 420 
percent higher; accidents, 280 percent higher; suicide, 190 
percent higher; homicide, 200 percent higher and we can't even 
find a common ground to get the proper money.
    The bottomline, Dr. Grim, is funding. What is the 
Administration's best estimate of the level of authorization 
needed for the 10-year period, because I'm getting all kinds of 
figures. I'm a little confused. Can you give us your best 
estimate of how much authorization is needed to properly fund 
our Indian Health Care Program?
    Mr. Grim. The current bill, both House and Senate, I don't 
currently have available today to be able to tell you. Because 
of the variabilities in the two bills, there are some 
significant variabilities in title IV for example.
    Mr. Faleomavaega. We can clear that up on our side. I'm 
asking the Administration's position. What is your position on 
this? How much should be authorized for of this legislation?
    Mr. Grim. We have a study that's been done internally that 
only looks at the personal health care expenditure needs and 
doesn't look at our public health infrastructure which is also 
a big need. We also have a tribal needs based budget the tribes 
have presented.
    Mr. Faleomavaega. Dr. Grim, you still aren't understanding 
my question. The bottomline, what is the Administration's 
recommendation regarding the level of authorization needed to 
assist our Indian community for the next 10-year period? If you 
can't answer it right now, can you submit that for the record?
    Mr. Grim. Yes, sir; I will submit that for the record. 
Because of the variability in the bills, I can't answer that.
    Mr. Faleomavaega. I really would appreciate that.
    The second question, I believe the total population of 
Alaskans and American Native Indians is over 14 million. Am I 
correct?
    Mr. Grim. The American Indian and Alaska Natives we serve 
in our facilities is about 1.6 million. The most recent census 
places the number of American Indians and Alaska Natives in 
combination with another race at over 4 million.
    Mr. Faleomavaega. $4 million. I thought it was more than 
that. If you could give us exactly what the Administration 
proposes. I made the estimate that we have about 14 million 
American Indians and Native Alaskans in this country. You are 
saying the entire health care system provides services for 
about one point six million American Indians and Alaska Native?
    Mr. Grim. Yes, sir.
    Mr. Faleomavaega. For the rest of our Native American 
community, they are out there on their own, really flat out, 
just in the worse situation than any other ethnic group here in 
our country. Would you agree with me on that?
    Mr. Grim. I would say a portion of that population we are 
not serving has private insurance and is seeking care but 
that's a very small percentage. It is hard for us to place a 
handle on it since they don't access our health care system. 
The remainder of that group that is not that small percentage 
with private insurance or the ones seeking care from us, many 
of them are without health care.
    Mr. Faleomavaega. One quick question to Mr. Nesmith. I know 
HUD is not part of the Indian health care authorization 
legislation. For the last fiscal year, how much monetary 
assistance did HUD provide Native Americans for housing?
    Mr. Nesmith. The last fiscal year?
    Mr. Faleomavaega. Yes.
    Mr. Nesmith. About $650 million.
    Mr. Faleomavaega. How much are you proposing for the coming 
fiscal year? I hope it is an increase.
    Mr. Nesmith. I'm not sure if it's level but I can get back 
to you.
    Mr. Faleomavaega. The $650 million in the last fiscal year 
provides for how many of our Native American community people?
    Mr. Nesmith. We believe that would provide for the numbers 
you just mentioned.
    Mr. Faleomavaega. My point is we are totally underserved, 
even with the amount of funding that HUD is providing, it is 
not even the tip of the iceberg as far as the community housing 
needs of our Native American community throughout the country. 
Would you agree with me on that?
    Mr. Nesmith. Not being able to compare, you said it was $14 
million. I would say there needs to be some improvement.
    Mr. Faleomavaega. Thank you, Mr. Chairman.
    The Chairman. Senator Murkowski, did you have any 
questions?
    Senator Murkowski. No; thank you.
    The Chairman. Congresswoman Napolitano.
    Ms. Napolitano. I'd like to followup on my colleagues' 
questions and the health disparities issues. I'm wondering how 
much of the funding is going into addressing the education or 
training of Native Americans to be able to deal with the 
issues. It is not the first year that I've heard of the high 
percentages of these individual groups.
    How are we dealing with the alcoholism, the diabetes, 
suicide and homicide? Accidents, that is another issue but all 
the others are lumped into an area that has been very prevalent 
in the American Indian community for many decades. It isn't the 
first time. What are you doing? How much money is being put 
into programs that will help these communities be able to deal 
with those issues?
    Mr. Grim. I will need to submit part of the answer to that 
question for the record in writing. What I can say is that our 
current budget is approaching $3 billion.
    Ms. Napolitano. Total budget of what?
    Mr. Grim. Of the Indian Health Service. You initially asked 
about education and we do have a scholarship and loan repayment 
program that we do work with trying to get American Indian and 
Alaska Native Youth into the health professions so they are 
back into their own communities. We also have a large portion 
of that budget that is in the health care delivery area. 
Approximately 50 percent of our budget in rough terms is now 
being administered by tribes themselves through Public Law 93-
638. They are making their own decisions about the delivery of 
health care in their communities.
    The other locations where the Indian Health Service 
operates the programs directly, we work closely with community 
health boards and tribal health boards and programs in the 
communities to determine priorities they want within the 
communities.
    Ms. Napolitano. What has been the result of these health 
delivery organizations? According to what I see here, the 
alcoholism is astounding. Do you have programs to actually help 
deal with the alcoholism problem?
    Mr. Grim. Yes; the majority of the programs that are 
alcohol and substance abuse programs in Indian country are run 
and managed by the tribes themselves. As a rough estimate, I'd 
say in excess probably of 95 percent of the programs and the 
money the Indian Health Service receives, about $130 million is 
what we receive in our line item for alcohol and substance 
abuse, well over 95 percent of that is going directly to the 
tribes themselves to run their programs.
    Ms. Napolitano. Is there an issue that what is happening is 
not actually being effective in taking another look at how else 
to approach it, working with the tribes you have authorized the 
money for?
    Mr. Grim. I think a large part of it is the complex nature 
of alcoholism. We have programs directed at both prevention and 
treatment, although we don't have enough inpatient treatment 
facilities or long term treatment facilities in many of the 
communities that need it. However, it is a complex mix of 
socio-economic factors, isolation issues, lack of adequate 
jobs, housing and things like that that all feed into the mix. 
Many of the diseases we are facing in Indian country today are 
behavioral and chronic as opposed to the infectious diseases we 
saw early on. So it requires a different mix of factors and 
programs that are more than just health programs alone to try 
to address them.
    Ms. Napolitano. Are those being implemented? That is what 
I'm trying to get at, thinking out of the box, doing new, 
effective methods that are going to break that cycle, that are 
going to assist families in being able to be supportive of each 
other, the tribes to be able to get to those in alcoholism. My 
husband died of alcoholism so I understand it very well.
    Thank you.
    Mr. Grim. Yes; I think the programs are ongoing out there, 
I think they are effective, I think the tribes are working 
within the communities to implement a more whole body wellness 
approach, physical, mental. emotional and spiritual. Many of 
them are involving their traditional ways into the programs and 
I think we are seeing progress. The issue is just the 
overwhelming numbers that we face right now.
    Ms. Napolitano. I'd like to hear more. If you have anything 
you can submit to the committee on what is actually being done, 
I think it is a great problem and is very hurtful to Native 
Americans. I think we need to be able to understand it, to be 
able to look at how we as a society can assist in being able to 
address it and help them be able to understand how hurtful it 
is to them and their communities.
    Mr. Grim. We will submit some information to you for the 
record on our programs and the things going on with the tribes. 
You are right, there is a huge disparity and a huge need in 
that arena.
    Ms. Napolitano. Thank you, Mr. Chairman.
    The Chairman. Congressman Grijalva, any questions?
    Mr. Grijalva. Yes; thank you, Mr. Chairman.
    In the tribal working group that worked with the Indian 
Health Service throughout this process and as a result, much of 
what we're deliberating is a product of that work, did this 
working group take a position on the point we spend a lot of 
time talking about as to who is going to have the 
responsibility, HUD or Indian Health Service for sanitation and 
sewer?
    Mr. Grim. The group did take a long look at that. There are 
two versions as you see before you right now, one in the Senate 
and one in the House. I don't think there is a consensus in 
Indian country right now relative to how that issue should be 
handled, whether the money should be lumped into one sum or 
whether these two existing programs which have separate goals 
should be kept separate. I just don't think there is consensus 
out there in Indian country yet either.
    Mr. Grijalva. Along the same lines, in reference to the 
steering committee you worked with, long and hard, as you see 
both bills, the Senate and the House, are there any serious 
omissions in this legislation, issues that those of us here 
should be aware of?
    Mr. Grim. I've submitted in my written testimony a number 
of things, some of the things this committee asked us to focus 
on today. Then there are a couple of overarching issues also in 
my written testimony. In the interest of time, I can submit 
some further issues in writing because it is a complex piece of 
legislation.
    Mr. Grijalva. I would appreciate that, sir.
    Thank you.
    The Chairman. Congressman Pallone.
    Mr. Pallone. Dr. Grim, I like you personally so I don't 
want you to take offense from anything I say but I just don't 
get the sense of crisis from your testimony. When you go out to 
Indian country, you hear stories about people dying because of 
lack of access to health care, you hear about the disparities 
with diabetes and alcoholism and so many other issues, and the 
inability to attend to those problems, and particularly with 
the facilities. Every time you go to a tribe, they talk about 
how they are on a 10- or 15-year waiting list to get a new 
facility or to renovate their facilities. Then you get all this 
stuff about funding. As Mr. Faleomavaega said, we just hear the 
funding is so inadequate and even more so that the notion the 
Federal Government is relying on the tribes to provide funding, 
particularly if they have a little money because they have a 
casino or whatever.
    I'm trying to look at the larger picture and I guess I 
could ask two questions and if you can answer them, fine. If 
not, get back to me. Do you see a real crisis because I do and 
where is that crisis? Is it in the lack of money for 
facilities, is it in the diabetes area, is it an inability to 
provide funding for nursing home services? I hear about all 
these things.
    The second question is, the tribes really feel, a lot of 
them say to me that the Government is not following through on 
its commitment to provide the funding federally and that they 
are now expected to use their own resources to build new 
diabetes clinics or new hospitals and almost built into the IHS 
the notion that the tribes are going to pay for a significant 
part of their health care. That's not the way it's supposed to 
be. Do you see a crisis? Where is it? Do you assume that they 
are going to pay a significant portion of their own services or 
construction?
    Mr. Grim. First, let me say that yes, I see a crisis. The 
percentage of mortality rates that our population exceeds 
relative to the U.S. population is not acceptable to me as the 
director of the Indian Health Service or as an American Indian.
    Is there a funding issue? I think we are starting to see 
potentially higher rates of inflation in health care than we 
have in past years. That impacts our budget significantly. 
Whenever health care inflation exceeds the amount of money we 
receive, we have loss in buying power. We have stayed 
relatively static in buying power over the last decade. We have 
not seen a large increase in buying power in the Indian Health 
Service budget, not withstanding the increases Congress has 
appropriated to us.
    I think the issue is a very complex one as I said earlier. 
We certainly need greater access to health care in Indian 
country. There are certain services that need higher levels of 
access than currently available but the other issue is the 
complex nature of health. It is not just being able to access a 
clinic, it is adequate and safe housing, it is economic 
opportunities on the reservations.
    Mr. Pallone. What about the backlog in facilities?
    Mr. Grim. We have a large estimated backlog in facilities 
needs in Indian country. Right now, the average age of an 
Indian health care facility is about 36 years of age. In the 
private sector, the current age of a facility is about 9 years. 
About 20 percent of our facilities meet that 9 years or younger 
average, so we have a large backlog in facility needs in Indian 
country.
    Regarding the issue of appropriating funds for facilities, 
Congress has been consistent over the years in trying to keep a 
number of Indian health facilities projects ongoing but there 
is a large backlog of need out there.
    Mr. Pallone. Do you assume that a lot of these tribes are 
going to take care of their own needs? That is what they tell 
me. They say, we have to build our own clinic, we have to build 
our own hospital, we have to pay for this ourselves. Is there 
an assumption on the part of the Federal Government that is 
going to happen?
    Mr. Grim. No, sir; Congressman Pallone, I do not assume 
that and I don't think the Administration assumes that. One of 
the things we have seen over time is sometimes when tribes take 
over their own health programs and sometimes when the Federal 
Government still runs them, tribes have donated tribal funds or 
placed tribal funds into programs because of the need in 
particular sectors for their communities.
    I do hear the same things you hear when I'm out there 
visiting Indian country, that they feel we should be doing 
more.
    Mr. Pallone. Thank you.
    The Chairman. Congresswoman Christensen, did you have 
questions?
    Ms. Christensen. Yes; I'll try to make them short.
    I've been fortunate to have Native American interns and one 
of them is with me, Caryle Begay, and another. I want to ask a 
question that comes from some of the discussions we have had.
    Considering there has been a significant increase of Native 
Americans, Alaska Natives into urban areas, away from rural 
reservation areas where the majority of Indian health services 
are provided, what measures are being taken to focus on 
providing health services for this growing urban Indian 
population.
    Natalia Arosco, an Indian on the San Pasqual Reservation, 
lives in a very small urban tribal reservation. They also have 
some unique needs for research data collection, publications 
and guidance for health care providers. What in this 
reauthorization addresses that?
    Mr. Grim. You are right in that we have seen a large 
demographic shift of American Indians and Alaska Natives now in 
urban areas. We still have 34 urban Indian programs that we 
provide grant funding for to operate in some existing 
locations. Those funds were put together through title V when 
Congress adopted title V of the current Indian Health Care 
Improvement Act. Those funds were intended to stimulate some 
health care services. Some are just referral and outreach and 
some provide more comprehensive care for areas where there were 
large urban Indian populations.
    Under the former director, Michael Trujillo, when the 
Indian Health Service started consulting with Indian Health 
Service, tribal and urban programs more, we brought the urban 
partners to the table. They now take part in our work groups 
and policy decisions within the agency and we are trying to 
work more closely with them for their needs.
    Ms. Christensen. You also say under the negotiated 
rulemaking part of the bill that the tribal consultation may 
not be the most effective way to obtain necessary Indian 
provider input. As a physician and member of the Small Business 
Committee and my colleague, Grace Napolitano can attest to 
this, we spend a fair amount of time with CMS and their 
rulemaking as it relates to providers of all backgrounds.
    What would be a more effective way because through the 
Office of Advocacy and through the Regulatory Flexibility Act 
we have been able to improve on their consultation. I think the 
Native American and Alaska Native providers deserve the same 
treatment.
    Mr. Grim. Specifically to the tribal consultation process, 
the Indian Health Service believes very strongly in that and 
works with tribes to that end. One of the comments made in my 
written testimony was that due to the number of regulations 
that come out of CMS, there was concern on behalf of the 
Administration that tribal consultation on all of the 
regulations coming through CMS might place an undue burden on 
the agency, on CMS.
    Ms. Christensen. Maybe they ought to simplify their 
regulation and rulemaking.
    Mr. Grim. I'll take back that information.
    The Chairman. Congressman Udall
    Mr. Udall. First, I want to ask about the reauthorization 
and the bill that is before us. In doing that, I compliment 
Chairman Campbell. He has introduced a piece of legislation, S. 
212, in the 107th Congress; we now have before us in the 108th 
Congress, S. 556. There has been a great deal of consensus 
building done on this bill. Is the Administration at the point 
of supporting the bill before this committee now, weighing in 
and trying to make sure it gets passed?
    Mr. Grim. The Indian Health Care Improvement Act 
Reauthorization bill, S. 212?
    Mr. Udall. S. 556 which Chairman Campbell has worked on 
very hard. It is a bill that has been around a long time and I 
don't believe you have a reauthorization. You're just going 
year by year, aren't you?
    Mr. Grim. Currently, that is correct. The reauthorization I 
don't believe has been extended currently but it had been 
extended in previous Congresses and we are still operating. I 
was very excited to see a joint hearing today between the House 
and the Senate on the various versions of the bill.
    Again, both bills are complex, very long bills and the 
Administration has made some comments relative to their issues 
or concerns on specific parts of the legislation and we are 
still doing side by side comparisons right now, so we don't 
have a full analysis.
    Mr. Udall. How soon do you think you will have that?
    Mr. Grim. I would have to submit that for the record, sir, 
about the length of time. I'd have to check with our assistant 
secretary for Legislation.
    Mr. Udall. Do you think you are going to be in a position 
in the next couple months to be able to support this bill?
    Mr. Grim. We work very closely with both committees so that 
we can try to do that.
    Mr. Udall. I think that is very important because I think 
the approach Chairman Campbell and Don Young have taken in 
introducing this legislation is looking at the long term and 
looking at 10 years. It seems to me the more you're required to 
go year by year, you aren't looking at those big issues that 
many members of the panel have been raising. Would you agree 
with that?
    Mr. Grim. I think we have continued to operate our program 
with a long term focus, notwithstanding the fact this current 
bill has been pending reauthorization for a number of years, 
but we are very, very anxious in the Indian Health Service and 
in the Department of Health and Human Services to see the bill 
reauthorized.
    Mr. Udall. I'm happy that is the case. I want to ask one 
other question on this whole diabetes epidemic. I have a 
congressional district that is 22 percent Native American in 
the State of New Mexico, 9 percent Native American. I had a 
very poignant story told to me by a renal specialist in Santa 
Fe about diabetes in our community surrounding Santa Fe which 
we have a number of Pueblos.
    He told me that 20 to 25 years ago, a gentleman that 
started a practice quite a while ago, they did not see very 
many cases of diabetes in Native American individuals that came 
into the Indian Health Service hospital or that were being seen 
privately. In his lifetime, he said this has dramatically 
changed. We truly have an epidemic.
    I'm not a doctor. It is what he described to me but he says 
a lot of what is going on here has to do with diet, obesity, 
sedentary lifestyle, lack of exercise and it seems if this is 
the key, education and prevention are the way to go. What are 
you proposing as to how to tackle this epidemic and how to move 
us out of this horrible cycle we are going into?
    Mr. Grim. I think you have seen the President and the 
Secretary have an increased emphasis on health promotion and 
disease prevention in the last couple of years. Since I've been 
in the Indian Health Service, I've initiated a health promotion 
disease prevention initiative within this past year involving 
tribal leadership and health expertise from our facilities and 
clinics to try to reemphasize or bring to the forefront again 
health promotion and disease prevention efforts.
    I think the Indian Health Service has always been strong 
over the years in our health promotion efforts. We run a public 
health program in the communities as you have heard today and 
some of the testimony is not only the delivery of health care 
but environmental health and sanitation facility issues as 
well.
    We are trying to focus on those chronic disease issues 
because they are not as easily solved as some of the diseases 
we faced in the past. As a Nation, we are now starting to 
address it.
    Internally, Congress has been good to devote $100 million 
over the last 6 years and an additional $50 million to the huge 
problem of diabetes in Indian country. I cannot report to you 
specific numbers but if you'd like them for the record, we have 
a large number of primary prevention programs going on in 
Indian communities right now. We have a large number of 
secondary and some minor tertiary sorts of initiatives going on 
with that $100 million Congress appropriated. We are seeing 
successes out there. We are looking at five to six overall 
clinical indicators and seeing movement in the right direction. 
We think we are staring to make impacts on the diet issues, the 
obesity issues, and such things that not only lead to diabetes 
but a lot of other chronic diseases like cardiovascular 
disease. Right now, cardiovascular disease is on the rise in 
Indian populations, 25 percent greater than the Nation as a 
whole. A number of years back, we were lower than the rest of 
the Nation. The rest of the Nation is seeing reductions in 
those, we are seeing some increase. So we are working very hard 
on the control of blood pressure and things like that in our 
population.
    I think there is a lot going on out there on issues like 
this, it is going to take years before we see significant 
improvements in the indicators to show success is coming.
    Mr. Udall. With the Chairman's permission, could you submit 
those for the record, what you are doing, what you anticipate 
you need in terms of money to tackle the diabetes epidemic in 
terms of prevention and education.
    As a final followup, wouldn't you agree that it is far 
better to tackle these at the front end with prevention and 
education than dealing at the tail end where you have end stage 
renal disease and dialysis and the enormously expensive options 
that patients have at that point?
    Mr. Grim. I believe that 100 percent because I think that 
not only will it reduce the cost of health care in the long run 
and allow us to do more but I also believe it is better for our 
people, they will lead longer, healthier lives.
    Mr. Udall. Thank you. Let me compliment Chairman Pombo and 
Chairman Campbell for convening this joint hearing. I hope it 
will move this legislation along and we can get a 10-year 
authorization for the Indian Health Service.
    The Chairman. If it moves along as fast as this hearing, it 
may be 10 years before we finish the hearing.
    I'm going to submit my questions in writing. We have a 
series of votes starting at 12:10 p.m. in the Senate and the 
House will be voting right after that. We still have six people 
and I'm dividing the time to make sure they have equal time at 
the microphone.
    We will thank this panel and move to the second panel which 
will be: Rachel Joseph, cochair, National Steering Committee on 
the Reauthorization of Indian Health Care Improvement Act from 
Lone Pine, CA and Dr. Ben Muneta, president, Association of 
American Indian Physicians from Oklahoma City and Steve Weaver, 
director, Division of Environmental Health and Engineering, 
Alaska Native Health Consortium.
    As I told the first panel, your complete written testimony 
will be included in the record, but in order to give everyone 
equal time before we have to close it down unless you want to 
come back later this afternoon which most don't, I'd ask you to 
limit your testimony to about 5 minutes or less.
    Why don't we ask the third panel to be seated too: Kay 
Culbertson, president, Denver Indian Health and Family 
Services; Dr. Everett Rhoades, Oklahoma City Urban Indian 
Health Clinic; and Carmelita Skeeter, executive director, 
Indian Health Care Resources Center of Tulsa.
    Rachel, would you start. Remember we have about 5 minutes 
apiece.

    STATEMENT OF RACHEL JOSEPH, COCHAIR, NATIONAL STEERING 
  COMMITTEE ON THE REAUTHORIZATION OF THE INDIAN HEALTH CARE 
                        IMPROVEMENT ACT

    Ms. Joseph. Good morning. My name is Rachel Joseph, 
chairperson of the Lone Pine Paiute-Shoshone Tribe and cochair 
of the National Steering Committee on the Reauthorization of 
the Indian Health Care Improvement Act. I'm also chairperson of 
the Toiyabe Indian Health Project a consortium of nine tribes 
serving California's Inyo and Mono counties.
    Thank you for holding this joint hearing providing us an 
opportunity to state our strong support for S. 556 and H.R. 
2440, the Reauthorization of the Indian Health Care Improvement 
Act. These bills contain provisions that are necessary to 
improve the ability of tribal and urban programs and the Indian 
Health Service to provide comprehensive, personal and public 
health services.
    In 1976, when Congress found that ``the unmet health needs 
of American Indian people are severe and the health status of 
Indians is far below that of the general population of the 
United States,'' the Indian Health Care Improvement Act was 
enacted. Federal health services to Indians and Alaska Natives 
has resulted in a reduction in prevalence and incidence of some 
illnesses. For example, since we delivered our proposed bill, 
the death rate for pneumonia and influenza decreased from 71 
percent higher than all races in the United States to 52 
percent higher.
    However, the unmet health needs of our people remain 
alarmingly severe and continues to decline. Our health status, 
as already stated, is far below that of the general U.S. 
population. This crisis and disparity to be addressed is 
formidable.
    The oral health of our patients is poor and we experience 
approximately three times the amount of tooth decay and 
periodontal disease than the U.S. general population. As 
already stated, the mortality rate for diabetes, 420 percent 
greater than the rest of the Nation, and Type II diabetes is 
rising faster among our children and young people than any 
other population and is 2.6 times the national average. Our 
suffering due to diabetic end stage renal disease is 6 times 
the rate of the national population and amputations due to 
diabetes is three and four times the rate.
    In my community, diabetes is among the three top chronic 
diseases. We serve our population with three clinics and just 
at the Bishop Clinic, we see an increase of two diabetes 
patients every month.
    Cardiovascular disease is now the leading cause of 
mortality among Indian people with a rate that is almost 2 
times that of the U.S. general population.
    The recent fully analyzed and racially adjusted mortality 
data [fiscal year 1999] from the National Center for Health 
Statistics documents an overall 4.5 percent increase rate for 
American Indian and Alaska Native people, from 698.4 per 
100,000 population for the period 1994-96 to 730.1 per 100,000 
for the period 1997-99.
    In recognition of the conditions just reiterated, tribes 
engaged in the consultation with a goal to develop consensus 
and the NSC membership acknowledged that all of our 
constituents included the ``lesser haves'' the ``least haves'' 
and ``have nots''; thus, we agreed not to ``take from each 
other''. One of our ground rules was that ``provisions will not 
adversely affect or diminish funding which is available to 
other Indian programs or the I/T/U system. . . ''
    Now, I will highlight title III of the bills which now 
provides a broader approach to address the unmet facilities 
needs and provides innovative funding options. Language 
concerning Safe Water and Sanitary Waste Disposal Facilities in 
section 302 of S. 556 reiterates a cooperative relationship 
between HHS and HUD regarding safe water and sanitary disposal. 
After consensus was reached on this issue, reflected in S. 556, 
there has been an effort by some housing advocates to amend the 
language that prohibits the use of I.H.S. funds for newly 
constructed HUD homes. Why do it since the I.H.S. Section 302 
funding is already critically under funded for this ``Safe 
Water and Sanitary Waste Disposal Facilities'' program? 
Approximately 21,500 American Indians and Alaska Native homes 
lack safe water and the current backlog of need for this 
program construction is $900 million. Since 1982 Congress has 
repeatedly expressed its intent that funds appropriated to the 
IHS not be used for sanitation facilities for new HUD homes. 
This system worked fairly well until 1996 when NAHASDA was 
enacted and funding is now distributed by a formula which does 
not account for deficiencies or cost of offsite sanitation 
facilities. One of IHS Government Performance Results Acts 
[GPRA] indicators for fiscal year 2005 is to increase the 
proportion of American Indians and Alaska Natives receiving 
optimally fluoridated water by 0.5 percent over 2004 levels.
    An IHS fiscal year 2002 indicator committed to a 5-percent 
increase of American Indian and Alaska Natives benefiting from 
fluoridated drinking water. While the fiscal year 2002 
indicator was not fully achieved, 15 small systems not 
previously fluoridated became fluoridated adding 20,580 
individuals to those receiving the benefits of fluoridated 
water. Since fluoridation is one of the most cost effective 
public health measures for reducing the prevalence of dental 
decay of all ages, we must do what we can to ensure that these 
limited funds remain available for these purposes.
    If I may share a personal experience. This spring, the 
Indian Health Service replaced a water pump, replaced asbestos 
pipes, fluoridated our community drinking water and pressurized 
our system. Before that, my parents had to utilize water that 
would not allow for the brushing of teeth at the same time you 
washed dishes. My dad did not allow us to wash his dress shirts 
at home because our water was tainted with rust color. Now, the 
228 young people in our community will experience the long term 
benefits of fluoridated water. The middle-aged and us elders 
will experience those benefits as well.
    An IHS indicator, No. 35, for fiscal year 2005 is to 
provide sanitation facilities to 22,300 homes, in 2002, 15,255 
homes were served. I support addressing the need and those 
tribes that are next in line to receive these services and I 
hope the dollars are there.
    A new provision of S. 556, section 310 and section 309 of 
2440 authorize a loan guarantee, a revolving loan fund and a 
grant program for loan repayment. The authorization to 
appropriate funds for an Indian health care facility loan 
program could be tremendous support to those tribes that want 
to build their own facilities.
    The joint venture, section 312 of S. 556 and section 311 of 
H.R. 2440, provides for creative, innovative financing by 
tribes for construction of health facilities. This joint 
venture with the Indian Health Service is a viable option for 
those tribes that can construct their own facility. The IHS 
obligation is for equipment, staffing and to operate it.
    In 2001 and 2002, Congress appropriated dollars for this 
program which resulted in the construction of four facilities 
which included two on the IHS priority list. The small 
ambulatory program, section 306 of 556 and section 305 of 2440, 
another popular program with the tribes, authorized in 1992, 
received its first appropriation in 2001 and 2002 of 
approximately $10 million which provided for the construction 
of 17 tribally owned facilities that the tribes equip, staff 
and operate. Unfortunately, neither S. 1391 or H.R. 2691 
includes 2004 funds for this small ambulatory program. Another 
new provision ``Other Funding'' provides for alternative 
financing options.
    The Chairman. Rachel, I apologize, but we are going to run 
out of time.
    Ms. Joseph. The National Steering Committee appreciates 
this opportunity. We completed the process of consultation and 
collaboration with broad support and we want to urge you 
respectfully to consider any procedural actions necessary to 
move this legislation as quickly as possible.
    Thank you for your time.
    [Prepared statement of Ms. Joseph appears in appendix.]
    The Chairman. Thank you.
    Dr. Muneta.

STATEMENT OF Dr. BEN MUNETA, PRESIDENT, ASSOCIATION OF AMERICAN 
                       INDIAN PHYSICIANS

    Mr. Muneta. Good morning.
    I am president of the Association of American Indian 
Physicians. I would like to add our organization's support for 
the reauthorization of the Indian Health Care Improvement Act. 
I am somewhat reflective of our membership in that I worked in 
urban, tribal and Federal health care facilities and we have 
all come to the consensus that this Act is for the good of 
Indian people.
    The Indian Health Service is a highly efficient 
organization. You can't find anything in government that is 
more efficient in the use of dollars as the IHS. We feel any 
money that is directed that way is money well spent by the 
Government.
    I would add that American Indians are living longer but one 
of the big problems we see is in several cities American 
Indians are going to have the lowest quality of life of any 
minority group in this country. The reason is simple. Chronic 
diseases like diabetes are going to sap the health of Indian 
people. Diabetic patients are 4 times more expensive than a 
non-diabetic patient under usual medical care. This translates 
into people being sicker, not having jobs, and economic loss to 
the communities. It is a ripple effect throughout Indian 
communities, not just in the health care system.
    One of the ways we look at these disparities is by training 
more Indian doctors, more health professionals who go back to 
these communities and provide long term, quality care. This is 
one of the great success stories that we have, the health 
scholarships that IHS operates.
    I think that is all I have to say.
    [Prepared statement of Mr. Muneta appears in appendix.]
    The Chairman. Thank you.
    Mr. Weaver. I might mention Senator Murkowski had to 
preside at 12 p.m. She has already left but she did tell me 
that she particularly wanted to hear your testimony, so I am 
sure she will read it with great interest.

STATEMENT OF STEVE WEAVER, DIRECTOR, DIVISION OF ENVIRONMENTAL 
 HEALTH & ENGINEERING, ALASKA NATIVE TRIBAL HEALTH CONSORTIUM, 
 ACCOMPANIED BY ANDREW JIMMIE, CHIEF, MINTO TRADITIONAL COUNCIL

    Mr. Weaver. Thank you for the opportunity to testify 
regarding S. 556 and H.R. 2440, the Senate and the House bills 
that would reauthorize the Indian Health Care Improvement Act.
    I am appearing today on behalf of the Alaska Native Tribal 
Health Consortium where I serve as Director of the Division of 
Environmental Health & Engineering. I am accompanied by Chief 
Andrew Jimmie of the Minto Traditional Council who appears this 
morning in his capacity as the vice chair of the Alaska Native 
Health Board. Chief Jimmie is also the president of the Tanana 
Chiefs Council Conference of Regional Health Boards and 
recently received the prestigious Alaska Federation of Natives 
Health Award.
    Under the leadership of the National Steering Committee, 
the language in what has been introduced as H.R. 2440 was 
developed in nearly complete consensus by tribal leaders. I am 
pleased to testify this morning that from a sanitation 
facilities operations perspective, I recommend to the Senate 
that it substitute the sanitation and facilities provisions of 
H.R. 2440 in place of S. 556.
    I would particularly like to thank the committee for its 
long term support of the SFP program. Sanitation facilities 
construction is first and foremost about public health. It has 
a documented history of success in raising the health status of 
American Indians and Alaska Natives. While much as been 
accomplished, much remains to be done.
    IHS estimates the current national unmet need both feasible 
and infeasible of Indian sanitation unmet need of $1.6 billion. 
Alaska's component is $640 million. Alaska has a unique and 
demanding living environment. Suvonga, displayed to your left, 
is typical of remote Alaska Native communities, accessible by 
air year round and in the summer by boat but it is not 
connected on land by any road network.
    Cooper Bay is also typical of rural Alaska. For the last 40 
years, they have packed in their drinking water and packed out 
their human waste in honey buckets. They are not atypical. One-
third of Alaska Native homes still lack piped water and sewer 
facilities.
    Other Indian communities throughout the United States face 
similar challenges. Current national funding levels are not 
nearly sufficient to make meaningful progress. The Indian 
Health Service sanitation deficiencies, unmet needs inventory 
is increasing at a rate of $50 million a year in addition to 
the construction activities.
    The National IHS Priority List for new health facilities 
has stood without major addition for some 15 years. Language 
improvements in title III of H.R. 2440 represent an opportunity 
to provide flexibility in how we address this backlog and 
enhance how we do business. It establishes requirements to set 
priorities for limited facilities resources. It provides more 
flexibility of program management for tribes and the potential 
for innovation as tribes develop and diversify alternative 
funding sources. It enhances the ability of IHS and the tribes 
to deliver critically needed services as well as clarifying 
operational authorities.
    It also provides the tribes a real opportunity to aggregate 
funding sources and to utilize those to the best opportunity of 
the community. The impact of public health is not in the 
construction of the facility, it's in the long term operations 
and maintenance of that facility to deliver the lifestyle 
improvement and the health improvements so badly needed.
    In conclusion, I'd like to thank Chairman Campbell and 
Chairman Pombo and the respective committee members for this 
opportunity to give an engineer's perspective as we move 
forward together building healthy and safe American Indian and 
Alaska Native communities.
    [Prepared statement of Mr. Weaver appears in appendix.]
    The Chairman. Thank you.
    Ms. Culbertson.

 STATEMENT OF KAY CULBERTSON, PRESIDENT, DENVER INDIAN HEALTH 
                      AND FAMILY SERVICES

    Ms. Culbertson. Good morning. My name is Kay Culbertson. I 
am an enrolled member of the Ft. Peck Assiniboine/Sioux Tribes 
from Poplar, MT; the executive director of the Denver Indian 
Health and Family Services; and also serve on the board of the 
National Council of Urban Indian Health.
    I am honored today by the presence of my father and I am 
very happy he could be here with me.
    Let me start by saying I'm not a lawyer or a policy 
analyst. My testimony both oral and written are from my heart 
and reflect a combination of my brief experience as a program 
director and my lifelong experience of growing up between the 
reservation and the city. Some of my testimony may sound strong 
but I find I must stress these issues or I would not be true to 
my upbringing and values I hold as an Indian person and as a 
wife and as a mother of three, all of whom are enrolled members 
of federally recognized tribes.
    It is time that urban Indian health issues are seriously 
considered and I believe S. 556 is a good beginning. I would 
like to thank you for the improvements in the bill. The 
designation that a major goal of the United States is to 
provide the quantity and quality of health services which will 
permit the health status of Indians regardless of where they 
live to be raised to the highest level that is no less than 
that of the general population and to provide for the maximum 
participation of Indian tribal organizations and urban Indian 
organizations in the planning, delivery and management of those 
health services.
    I would also like to point out at this point, the urban 
Indian health programs receive not even a full two percent but 
almost two percent of the Indian Health Service budget.
    Some key points have been very positive for urban Indian 
health programs in this legislation, allowing urban programs to 
receive reimbursement from insurance programs when the urban 
Indian health provider is considered to be an out of network 
provider; the disregard of payments received through third 
party revenue and determining funding appropriations for health 
care and services to Indians; the ability of current programs 
to create satellite clinics to better address the health needs 
of the Indian community; the establishment of a self 
sustaining, revolving loan fund that will be solely for urban 
Indian health facilities; and permanency for the Oklahoma City 
and Tulsa demonstration projects.
    The development and construction of two residential 
treatment centers for urban Indian youth in each State where 
need exists and where there is a lack of culturally constant 
residential treatment services for youth, as mental health and 
substance abuse needs continue to grow and State facilities and 
funding are cut, we must address these needs for the city 
youth.
    Increased consultation with urban Indian health programs 
and Federal Tort Claims Act coverage for urban Indian 
organizations who receive funding under this legislation are 
also items of concern to me as an urban program director. Urban 
programs are not eligible to apply for chronic shortage 
demonstration projects. We experience shortages in personnel 
all the time through the urban Indian health clinics.
    The sections that address the mental health training and 
community education programs as well as prevention control and 
elimination of communicable and infectious disease programs 
includes urban Indian programs and studies and consultation 
processes but do not include us in the development, technical 
assistance and funding of these programs.
    Urban Indian health programs are not authorized to benefit 
from the Indian Health Care Improvement Fund or the 
Catastrophic Health Emergency Fund. Lack of funding 
authorization for critical services primarily home and 
community based services, public health functions and 
traditional health care in urban programs, we do use 
traditional health care.
    Title VIII, which has been very hard for me, addresses the 
provision of health services to non-eligible persons. This is 
of great concern to me as a tribal member and all members who 
live off reservation. I believe it takes away services from 
legitimate tribal members regardless of where they live. It 
appears unfair that tribal members who reside off reservation 
are subject to minimal care while non-Indians on the 
reservation may receive comprehensive services and possible 
access to contract health care services.
    On behalf of my community and all tribal members who live 
off reservation, I'd like to thank you for the opportunity to 
provide testimony on S. 556. I would like to close with this 
statement. The United States continues to have a legal 
obligation to fulfill with Indian people. Our ancestors, the 
people that live in the cities, also signed treaties with this 
Government that included provision of health care for their 
descendants in exchange for this great country. Whether an 
Indian lives off or on the reservation should not be an issue. 
These obligations should follow our people regardless of where 
they live.
    If all urban Indian people were to return home today or 
even one-half of us returned home today, being we have over 60-
percent of the population, and exercised our right to those 
health benefits, how would the Federal Government meet the 
trust and treaty responsibilities to Indian people?
    Thank you.
    [Prepared statement of Ms. Culbertson appears in appendix.]
    The Chairman. Thank you, Kay.
    Let the record reflect that not being a lawyer doesn't hurt 
you in the eyes of the committee.
    Ms. Culbertson. Thank you.
    The Chairman. We don't have an objection from Congressman 
Udall.
    Dr. Rhoades.

 STATEMENT OF Dr. EVERETT RHOADES, OKLAHOMA CITY URBAN INDIAN 
                             CLINIC

    Mr. Rhoades. Chairman Campbell, Chairman Pombo, members of 
the joint committees that are considering perhaps the most 
revolutionary health bill related to Indians that has been 
passed, my name is Everett Rhoades. I'm a member of the Kiowa 
Tribe. I was one of the incorporators of the original Urban 
Indian Clinic in Oklahoma City and I also had the privilege of 
being one of the outside witnesses that appeared in the 
deliberations of the original bill in 1975. I appeared as a 
predecessor to the imminent Dr. Muneta on behalf of the 
Association of American Indian Physicians at that time where 
our primary interest was in title I, the Indian manpower 
provisions as well as in the disparities.
    I am here today on behalf of the Oklahoma City Urban Indian 
Clinic. Because of the importance of this hearing, I'm 
accompanied by our board president, Rufus Cox, a member of the 
Muskogee Creek Tribe of Oklahoma; our chief executive officer, 
Terry Hunter, a Kiowa from Oklahoma City; and our chief 
operating officer, Robyn Sunday, a member of the Cherokee Tribe 
in Oklahoma City.
    Let me make two points in the interest of time. First, 
there is a general conception that the basic authorization for 
provision of health services to urban Indians, title V of the 
Indian Health Care Improvement Act, I do not believe that to be 
true and many other individuals do not believe that to be true 
either.
    A reading of the 1921 so-called Snyder Act which really 
provides basic authorization for health services simply says at 
that time the Commissioner of Indian Affairs should expend such 
moneys as Congress should from time to time appropriate for 
various programs, including interesting language that says 
conservation of health and relief of distress and for 
physicians, for Indians throughout the United States and does 
not provide additional guidance.
    It is my understanding that the enactment of title V went 
beyond simply the authorization of services to urban Indians 
but it defined the nature of those services, it defined the 
nature of the receiving entity and part of the consideration 
was to avoid what I would call the intrusion of the Indian 
Health Services' program itself into urban communities 
recognizing that even by the 1970's, a dramatic diaspora of 
Indians into urban communities would really ultimately require 
the entire budget of the Indian Health Service.
    As a result of all that, a new entity was created set out 
in the definition of paragraph (g) or (h) in section IV that 
says these programs are to be located in urban areas, to be run 
by a local urban Indian board which, in my opinion, 
distinguishes them from both Indian Health Service and tribal 
programs.
    In that regard, we would ask that the Congress keep that in 
mind in its deliberations in regard to title V and we very 
strongly support the Senate language contained in section V.
    In 1987, as a result of what I would call the growth and 
evolution of urban programs in this country, the Congress set 
two important demonstration programs into being in Oklahoma 
City and in Tulsa which further defined urban health care in 
these two demonstration projects, basically to determine 
whether or not they would be more apt to succeed if they 
received their funding from the hospitals and clinics account 
of the Indian Health Service rather than the urban account in 
title V but the contracts were still executed under title V, so 
they are hybrid programs with a peculiar special characteristic 
that should treat them in many instances as service units are 
now operating units.
    The second point we feel strongly about in Oklahoma City is 
that we respectfully ask the Congress to direct that funds that 
are received in the Oklahoma area by virtue of the fact the 
entire State of Oklahoma is a contract health service delivery 
area and the populations in both Oklahoma City and Tulsa 
therefore are counted in those allocations, unfortunately with 
the present arrangement of distribution of those funds, both 
Tulsa and Oklahoma City receive a minority of the funds that 
their own populations generate. We believe the Indian Health 
Service would welcome direction from the Congress that the 
allocations of additional funds, particularly under Indian 
Health Care Improvement Act, should be treated as service units 
or operating units within themselves.
    In closing, I would reiterate in regard to section 512, the 
Senate language I think is excellent. It really continues 
language that has been in place since 1992 and I would 
respectfully ask the House members if they would accede to the 
language of the Senate where there may be differences.
    Thank you.
    [Prepared statement of Dr. Rhoades appears in appendix.]
    The Chairman. Thank you. Your institutional memory is of 
great value to the committee.
    Ms. Skeeter.

  STATEMENT OF CARMELITA WAMEGO SKEETER, EXECUTIVE DIRECTOR, 
          INDIAN HEALTH CARE RESOURCE CENTER OF TULSA

    Ms. Skeeter. Good morning and thank you for inviting me to 
make this presentation today. I am very happy to see that it is 
a joint hearing.
    I'm the executive director of Indian Health Care Resource 
Center in Tulsa and I have been with this organization for 27 
years, so it is very dear to my heart. I have I hope a very 
good story to tell you on the demonstration programs.
    I am citizen Potawotami enrolled in my tribe and very 
active. Becoming a demonstration project in 1987, we did that 
with the help of Indian Health Service, the Urban Directors, 
coming together and seeing how we could make sure these two 
programs existed even though urban programs nationally were 
zeroed out of the budget.
    Because of IHS and the tribal people seeing our programs 
were so vital to the State of Oklahoma, they wanted to make sue 
we were able to continue, so we were put into the 01 of the 
budget, line item. Since then, we have been able to double our 
resources and in some areas, triple our resources. It was like 
opening a new door or opening a window to a home that had been 
very stale and unsupported. We were able to then start 
receiving GSA vans to do transportation for our patients, we 
were able to start getting health care providers from IHS, able 
to start purchasing medications from the GSA pharmaceutical 
contract, so it was opening a new door.
    The program in Tulsa has a $2.5 million Indian Health 
Service budget. We have been able to turn that budget into over 
$6.5 million by contracting with other agencies competing with 
other Federal programs on grants and contracts. We have five 
contracts with the State of Oklahoma to provide substance abuse 
and mental health services. We are State certified. We are 
accredited through the Association of Accreditation for 
Ambulatory Health Centers.
    We have a contract with the Cherokee Nation where they 
provide the WIC services in our clinic and have done so since 
1979. We have a contract with seven other tribes in the State 
of Oklahoma, a program called BEACH which is through the State 
health department and CDC working with children on obesity, 
drugs, physical fitness, the prevention of diabetes and we are 
in three Tulsa public schools with gym teachers working with 
these children daily.
    I believe that we are a very good partner with all the 
tribes in Oklahoma. We work very closely with them and our 
board is a community elected board, we have elections once a 
year. Any tribal member in Tulsa can run for our board. We have 
in the past had councilmen from the Creek Nation on our board, 
councilmen from the Cherokee Nation on our board. The tribes 
hold meetings at our facility. Oklahoma City and Tulsa are the 
only two urban programs in the United States that have been 
able to get new facilities in the past 25-30 years.
    The facility in Tulsa is 27,000 square feet, the facility 
in Oklahoma City I believe is about 27,000 square feet. We have 
been able to do that because we have been able to collect 
Medicaid at the OMB rate because we are treated as a service 
unit. This makes us different than the other urban programs. We 
have been able to tap into this resource of Medicaid 
reimbursement. That has allowed us to expand our services.
    Tulsa, we do not receive any IHS funds for dental but we 
are able to provide dental services by having one dentist 
because we are able to collect Medicaid at the OMB rate. We are 
able to have an optometry clinic, full-time optometrist because 
we are able to fund that with the Medicaid OMB rate.
    I feel very proud of what we have been able to do in 
Oklahoma, the services we are able to provide. Our service 
population is 15,000 active patients at our facility. We have 
over 6,000 patient visits a month. I have a staff of 85. I have 
the largest mental health outpatient department in the State of 
Oklahoma for Indian people. We take referrals from all over the 
State. I have four clinical psychologists full time, two 
psychiatrists part time, one for children, one for adults; I 
have a developmental pediatrician part time and I have four 
counselors that work out of our behavioral health department. I 
have a full time pediatrician in medical, family practice 
physician assistant, nurse practitioner, so I have a very large 
operation in Tulsa. We work very closely and are very 
integrated with the entire health system of the city.
    We carry a caseload of 120 to 130 OBs continually. I have a 
contract with an obstetrician that comes in 1 day a week to see 
those OBs and the mothers if they qualify or have third party 
reimbursement, they are able to deliver in the city. If not, we 
provide transportation for the mothers to Claremore Indian 
Hospital which is 30 miles away one way.
    We are very entrenched in the community. We are 27 years 
old. We try to tap into every resource we possibly can. We work 
very closely with the tribes and I do support S. 556. I want to 
thank the Senators for honing the language that would protect 
us from sovereignty. We do not want to get into the sovereignty 
issue.
    We serve over 150 tribes and as an urban program, we want 
to continue to serve that 150 tribes. We want to continue 
operating as a 501(c)(3) under a community elected board and 
have the board set the policies that run the organization.
    As I say, I am very passionate about this program. I've 
been there 27 years. I started out as the resource coordinator, 
clinic administrator and I've been the executive director for 
the last 14 years. I feel very strongly and would be more than 
happy to answer any questions.
    [Prepared statement of Ms. Skeeter appears in appendix.]
    The Chairman. Thank you, Ms. Skeeter.
    We have managed to keep it within the timeframe. I'm going 
to ask our colleagues to submit any questions in writing as I 
will because we have run out of time but would like to yield to 
Chairman Pombo if he has any closing comments.
    Mr. Pombo. I want to thank this panel for your testimony. 
It was extremely informative and very valuable for the 
committee as we move forward with this bill. On behalf of 
myself and my colleagues in the House, I want to thank you for 
taking the time to come here and share your stories with us.
    I do have a number of questions as my colleagues do and we 
will be submitting those to you in writing. If you can respond 
to those in a timely manner in writing so they can be included 
as part of the hearing, we would appreciate it.
    Thank you very much.
    Mr. Pallone. Could I just ask a procedural question? I 
thought it was very valuable to have this joint hearing today. 
I don't want to suggest to our chairman what he should do on 
this issue but I know that the Senate committee is planning to 
have future hearings. Either we have our own or if not, if we 
could possibly continue this joint hearing idea, it is 
certainly a way for the House members to participate and also 
for us all to continue with investigation of the issues.
    The Chairman. I will have our staff work with Chairman 
Pombo's staff and see if we can't do that dealing with health 
care.
    We will submit those questions and if you could get those 
back to in writing at your earliest convenience, that would be 
good.
    I want to thank all the panels and we will keep the record 
open for four weeks on this particular hearing because we will 
be doing another on the same subject. Next week we will 
continue the series on health care.
    This hearing is adjourned.
    [Whereupon, at 12:17 p.m., the committees were adjourned, 
to reconvene at the call of their respective Chairs.]
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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 Mike Zacharof, Chairman and Andrew Jimmie, Vice 
                  Chairman, Alaska Native Health Board

    The Alaska Native Health Board [ANHB], established in 1968, is 
recognized as the statewide voice of Alaska Natives on health issues. 
With contributions from its member tribes and tribal organizations, 
ANHB has been active for 35 years as an advocate on behalf of health 
needs and concerns of all Alaska Natives.
    On behalf of 229 tribes within the State of Alaska, and over 
119,000 Alaska Natives, the Alaska Native Health Board strongly 
encourages Congress to support and enact H.R. 2440, a bill to 
reauthorize the Indian Health Care Improvement Act.
    H.R. 2440 is an update to the 1999 National Steering Committee 
draft of the Indian Health Care Improvement Act. Over the last year, 
under the direction of Representative Young, the 1999 National Steering 
Committee draft reauthorization bill and the first House and Senate 
versions of that draft were examined and updated to respond to concerns 
expressed by the Administration to provisions contained in S. 212--the 
predecessor to S. 556--to resolve differences between the bills before 
the Senate and the House in the last session, and to consider tribal 
concerns that have arisen since 1999. This work is reflected in H.R. 
2440.
    We are pleased that Steven Weaver has been invited to testify 
regarding before this joint hearing of the Senate Committee on Indian 
Affairs and House Resources Committee regarding the provisions of Title 
M of the Indian Health Care Improvement Act. As Director of the 
Division of Environmental Health and Engineering for the Alaska Native 
Tribal Health Consortium, he brings to you a wealth of experience and 
technical knowledge. We strongly endorse the recommendations made in 
his testimony.
    Reauthorization of the Indian Health Care Improvement Act is one of 
the highest priorities of the tribes in Alaska. We urge the earliest 
possible action.
                                 ______
                                 

   Prepared Statement of R. Perry Beaver, Principal Chief, Muscogee 
                             [Creek] Nation

    Chairman Campbell, Vice Chairman Inouye, and members of the 
committee.
    Thank you for this opportunity to share some of my thoughts with 
you about S. 556, the ``Indian Health Care Improvement Act 
Reauthorization of 2003.'' My name is R. Perry Beaver and I have served 
as the Principal Chief of the Muscogee [Creek] Nation for the past 8 
years, and as a National Council representative for several years 
before that. I request that my written testimony be made part of the 
hearing record.
    Due to my years of service to the Muscogee Nation and my residence 
in Tulsa County for many years, I am familiar with the many health 
problems faced by Native Americans in Oklahoma, including Creek 
citizens residing in the Tulsa urban area. I have also been a part of 
the development and implementation of Department of the Interior and 
Health and Human Services tribal 638 contracts and self-governance 
compacts under the Indian Self-Determination and Education Assistance 
Act [``ISDEAA''] amendments during the past decade. These programs have 
provided the Muscogee Nation with a great opportunity to identify the 
specific needs of its citizens and to administer programs for that 
purpose, including health programs. The Muscogee Nation has made 
significant progress in its development as a government and in making 
improvements related to the provision of health care due in part to the 
opportunities presented by the ISDEAA.
    Unfortunately, S. 556 contains a proposed amendment to the Indian 
Health Care Improvement Act that would severely limit the Nation's 
ability to exercise self-governance in the area of health care. Section 
512(a) would amend the IHCIA to permanently remove the Indian Health 
Care Resource Center, Inc. in Tulsa, OK [``Tulsa Clinic''] from the 
umbrella of self-governance and make it a permanent direct care program 
of the Indian Health Service. This would be accomplished by the 
following provisions in section 512 (a) of the bill:
    Notwithstanding any other provision of law, the Tulsa and Oklahoma 
City Clinic demonstration projects shall become permanent programs 
within the Service's direct care program and continue to be treated as 
service units in the allocation of resources and coordination of care, 
and shall continue to meet the requirements and definitions of an urban 
Indian organization in this title, and as such will not be subject to 
the provisions of the Indian Self-Determination and Education 
Assistance Act.
    A large number of the Native American population in Tulsa are 
citizens of the Muscogee Nation and the Cherokee Nation. The northern 
jurisdictional boundary of a portion of the Muscogee Nation and the 
southern boundary of a portion of the Cherokee Nation encompass 
separate areas in what is now Tulsa County. The Nation has strong roots 
in Tulsa, which originated as a Creek Tribal Town in the 1830's. The 
Nation owns trust lands in Tulsa County and also still owns a one-
hundred acre tract of land in Tulsa that has been recognized by Federal 
courts as ``historic reservation lands.'' Our capital complex in 
Okmulgee is only 30 miles from Tulsa. Although the Muscogee Nation has 
not fully exercised its self-governance related to its citizens' health 
needs in the Tulsa urban area in recent years, it maintains a strong 
governmental interest in meeting the health needs of Indians within its 
service area.
    The Tulsa Clinic has been existence for approximately 20 years, 
many years before Congress amended the ISDEAA to include self-
governance programs that would enable Indian nations to exercise 
greater control over Federal funds formerly awarded to them under ``638 
contracts.'' During much of that time, the Tulsa Clinic has been 
providing health services to Native Americans in Tulsa as a 
demonstration project under the IHCIA. The Nation has not made a strong 
attempt to obtain tribal control of the provision of health services in 
Tulsa currently provided by the Tulsa Clinic for various reasons, 
including the Nation's concentration on development of its existing 
health programs and its recent conversion to funding through a self-
governance compact. I believe that the indefinite continuation of the 
Tulsa Clinic as a demonstration project would be in the interests of 
Native Americans in Tulsa. However, the Muscogee Nation is opposed to 
making the Clinic a permanent program and permanently removing it from 
the authority of the ISDEAA. This would eliminate the Nation's ability 
to compact for IHS funding allocated for the needs of Indians in Tulsa. 
This would infringe on the Nation's sovereignty within its 
jurisdictional boundaries in a significant portion of Tulsa County. I 
believe that at some point in the not too distant future, the Muscogee 
Nation will be ready to take an even stronger role in the provision of 
health care in Tulsa. The proposed amendment would prevent the Nation 
from doing so, through what would be, in effect, a Congressional 
delegation of the Nation's governmental authority to the Indian Health 
Services and the Tulsa Clinic as its grant recipient. The Board of the 
Tulsa Clinic would be in a permanent position to make decisions which 
are better left to tribal governments.
    I respectfully ask that this committee refrain from approval of S. 
556 unless and until the offending language in section 512(a) is 
removed or amended. I have reviewed new draft language provided by the 
Cherokee Nation, and have no strong objections to use of that language, 
except to language that would make the Tulsa Clinic a ``permanent 
program'' within the Indian Health Service [``IHS''] direct care 
program. I suggest that the language in section 512(a) be revised to 
read as follows:
    Sec. 512(a). TULSA AND OKLAHOMA CITY CLINIC--Notwithstanding any 
other provision of law, the Tulsa and Oklahoma City Clinic 
demonstration projects shall--(1) remain demonstration programs within 
the Service's direct care program; (2) continue to be treated as 
service units in the allocation of resources and coordination of care; 
and (3) be subject to the provisions of the Indian Self-Determination 
and Education Assistance Act, except that the programs shall not be 
divisible.
    Thank you for this opportunity to provide this testimony to you 
today.
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