[Senate Hearing 108-677]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 108-677

       REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

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

                                HEARING

                               BEFORE THE

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED EIGHTH CONGRESS

                             SECOND SESSION

                                   ON

  OVERSIGHT HEARING ON PENDING LEGISLATION TO REAUTHORIZE THE INDIAN 
                      HEALTH CARE IMPROVEMENT ACT

                               __________

                             JULY 21, 2004
                             WASHINGTON, DC



                    U.S. GOVERNMENT PRINTING OFFICE
95-177                      WASHINGTON : 2004
____________________________________________________________________________
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                      COMMITTEE ON INDIAN AFFAIRS

              BEN NIGHTHORSE CAMPBELL, Colorado, Chairman

                DANIEL K. INOUYE, Hawaii, Vice Chairman

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

         Paul Moorehead, Majority Staff Director/Chief Counsel

        Patricia M. Zell, Minority Staff Director/Chief Counsel

                                  (ii)

  
                            C O N T E N T S

                              ----------                              
                                                                   Page
Statements:
    Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado, 
      chairman, Committee on Indian Affairs......................     1
    Domenici, Hon. Pete V., U.S. Senator from New Mexico.........    18
    Dorgan, Hon. Byron L., U.S. Senator from North Dakota........    15
    Grim, Charles, director, Indian Health Service, Department of 
      Health and Human Services..................................     7
    Hayworth, Hon. J.D., U.S. Representative from Arizona........     3
    Johnson, Hon. Tim, U.S. Senator from South Dakota............     2
    Murkowski, Hon. Lisa, U.S. Senator from Alaska...............     6
    Thompson, Tommy, Secretary of Health and Human Services, 
      Department of Health and Human Services....................     7

                                Appendix

Prepared statements:
    Thompson, Tommy..............................................    23

 
       REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

                              ----------                              


                        WEDNESDAY, JULY 21, 2004


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 2:06 p.m. in room 
216, Hart Senate Building, Hon. Ben Nighthorse Campbell 
(chairman of the committee) presiding.
    Present: Senators Campbell, Domenici, Dorgan, Inouye, 
Johnson, and Murkowski.

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

    The Chairman. The committee will be in order. We will go 
ahead and start. Normally we try and make sure Senator Inouye 
is here, too, as the Ranking Member, but he has gotten kind of 
double-booked so he may drop in a little bit later. Right now, 
he is tied up.
    Welcome to the committee hearing on legislation to 
reauthorize the Indian Health Care Improvement Act. I and some 
of the staff were just recently in my ancestral home of Lame 
Deer, MT, where I am a member of the Northern Cheyenne Tribe. I 
can tell you, after my visit up there, when I always visit 
home, it is one thing to read the statistics about Indian 
health, but it is another one to see the faces of the young 
kids or elders in particular who have health problems. In the 
case of elders, many times people who have had their legs 
amputated because of the complications of diabetes. It is not 
an easy thing to see when you recognize that so many Americans 
have so much better health care than people on reservations do.
    It makes me, among many, to be somewhat angry because 
Indian people generally, they do not care about CBO scores or 
committee jurisdiction or controversial provisions or even the 
bickering that we get involved in here in Washington, the 
cross-party bickering. All they know is that they are sick and 
they are not getting enough help.
    It does not have to be that way. Secretary Thompson is 
here, and I know he is a good man and a good friend of mine for 
many years. I know he is well aware of what is happening out 
there. I am interested in hearing his testimony.
    This act was last reauthorized in 1992 when President 
George H. W. Bush, signed a bill into law. Beginning in the 
mid-1990's, Indian tribal leadership has conducted hundreds of 
meetings and consultation sessions aimed at putting together 
the kind of legislation proposal that is required to update the 
act, and to address the health care problems facing native 
peoples.
    Since the late 1990's, Senator Inouye and I repeatedly 
introduced legislation to reauthorize this key statute. We have 
held untold numbers of hearings and any number of formal 
meetings with our colleagues on other committees. With the 
number of legislative days quickly dropping, I think we only 
have about 23 or 24, something of that nature, of actual 
working days, we are honored to have the Secretary of Health 
and Human Services with us to discuss his views on this pending 
legislation. We certainly hope that we are going to, with your 
help, be able to move this bill.
    Senator Inouye is not here, but I would first, before I go 
to you, J.D., I would like to call on Senator Johnson if he has 
any
comments.

 STATEMENT OF HON. TIM JOHNSON, U.S. SENATOR FROM SOUTH DAKOTA

    Senator Johnson. Just very briefly, Mr. Chairman. I am very 
appreciative of your holding this hearing today. I welcome our 
colleague from the House side, Representative Hayworth here, 
and of course Secretary Thompson and Dr. Grim is welcome as 
well to this hearing. Dr. Grim was kind enough to spend some 
time in Eagle Butte, SD with me, talking to leaders of our 
Cheyenne River Tribe relative to health care needs on that 
particular reservation, one of nine Indian reservations in the 
State of South Dakota, where we have a new IHS facility that is 
being planned and at the early stages. Dr. Grim was very 
cooperative and I appreciated his willingness to join me in 
Eagle Butte.
    I am pleased that the Department of Health and Human 
Services is now prepared to share their views, I hope, with us 
on reauthorization of the Indian Health Care Improvement Act. 
We have been holding off and holding off for a long time to be 
in a position to markup this act. This legislation is 
absolutely critical to the health and welfare of Native 
Americans all across America, certainly in my State of South 
Dakota. Mr. Chairman, I think your hearing today was a further 
assistance in moving things along and getting the comments from 
the administration.
    I am pleased as well that the Department of Health and 
Human Services has conveyed to us that they are committed to 
reauthorization, to improvements in the Indian health care 
programs. It is important to me to note their willingness to 
work not only with our committee and other committees, but with 
the National Tribal Steering Committee and other 
representatives of Indian country to develop a bill that all 
stakeholders can support.
    I am very committed to a consultative role that the Federal 
Government necessarily has with our tribes. Our tribes have a 
very unique government-to-government relationship, of course, 
and it is important that in the course of developing a 
reauthorization that our relationship with the tribes 
recognizes their sovereignty, recognizes the need for a 
consultative role in coming together with legislation that we 
all can support.
    We have treaty and trust responsibilities. I think we also 
have a moral obligation. As you note in your experience, Mr. 
Chairman, all across Indian country, certainly in my State of 
South Dakota, the rates of diabetes, the rates of suicide, the 
rates of injury, the rates of virtually every disease are high. 
They are at third-world levels in some instances. The IHS 
budget historically has run along probably half of what it 
really ought to be if we are to provide a quality of health 
care for every Native American that we have obligations to do.
    So we have a lot of catching up to do. We have a lot of 
work to do. It is my hope that this hearing and the cooperation 
of Health and Human Services and our colleagues on the House 
side can help make some very positive things happen, albeit 
with a very short legislative opportunity here remaining of 
this 108th Congress.
    Thank you again for conducting this hearing. I look forward 
to the testimony of the witnesses today.
    The Chairman. Thank you.
    We will first hear from the Honorable J.D. Hayworth from 
the great State of Arizona. Welcome, J.D., before the 
committee.

   STATEMENT OF HON. J.D. HAYWORTH, U.S. REPRESENTATIVE FROM 
                            ARIZONA

    Mr. Hayworth. Chairman Campbell, thank you very much for 
those words of welcome. Senator Johnson, thank you as well for 
your comments. I thank you for the opportunity to testify here 
today.
    As you both have noted, this is an excellent opportunity to 
really have bicameral, bipartisan cooperation to move forward 
this very important piece of legislation. The Indian Health 
Care Improvement Act Amendments of 2003, or as we refer to it 
in the other body, H.R. 2440, the subject of my remarks today.
    As you know, the original Indian Health Care Improvement 
Act, or the acronym IHCIA, became law in the 94th Congress, 
back on September 30, 1976. The purpose of that act was to 
implement the Federal responsibility for the care and education 
of the Indian people by improving the services and facilities 
of Federal Indian health programs and encouraging the maximum 
participation of Native Americans and Alaska Natives in such 
programs.
    The IHCIA provides for health care delivery to over 2 
million American Indians and Alaska Natives, many of whom live 
in my home State, the great State of Arizona. Appropriations 
for Indian health have continued through the Snyder Act, a 
permanent law authorizing expenditures of funds for a variety 
of Native American programs, including health.
    But year-by-year appropriation is not the optimal way to 
fund Indian health services. The tribes do not like it. Fiscal 
conservatives do not like it. I get the feeling the IHS really 
does not like it. And those of us who sit on authorizing 
committees need to exercise our authority to produce a stable 
plan for Indian health.
    In short, the IHCIA requires reauthorization this year. 
Reauthorizing this legislation will address some of the 
problems you and I have been hearing about back home on the 
respective reservations. Unfortunately, today's health care 
delivery to Native American communities remains 
disproportionately less than what the general population 
receives here in the United States. Native Americans continue 
to suffer from diabetes, alcoholism, tuberculosis and heart 
disease at far higher rates than the rest of our population. 
IHCIA reauthorization addresses these issues.
    This bill is based largely upon the recommendations made by 
the Indian health community, including tribal leaders, tribal 
health directors, health care experts, native patients 
themselves, and the Indian Health Service. The proposed 
legislation builds upon the basic framework of the IHCIA. It 
gives tribes a greater role in health care delivery, 
strengthens behavioral health programs, expands assistance 
available to urban areas, provides innovative options for 
funding Indian health facilities, and increases the number and 
availability of Indian health care professionals.
    I would credit Representative Don Young, Congressman of all 
Alaska, who introduced the House version of the bill, of which 
I am a cosponsor; and also House Resources Committee Chairman 
Richard Pombo of California who is working to move the 
legislation. We have stayed in close contact with the Indian 
health community to help address concerns at every step of what 
has indeed become a long legislative process. Through that 
collaboration, I believe we have produced a sound and important 
bill.
    Now, a few words on just where we stand in the House. As 
with this distinguished body, we are waiting anxiously for 
comments back from the Administration. That is why I join you 
in welcoming my good friend, the Secretary of Health and Human 
Services Tommy Thompson as he addresses the committee today. He 
can shed some light on the progress of the Administration. The 
HHS Secretary was just in my home State this week on the Navajo 
Nation, so I know these issues are important to the Secretary 
and to his Department. He has shown his dedication to improving 
Indian health and he is to be commended.
    My staff and I have met with the very capable people the 
Secretary has put in place at IHS and HRSA. They have great 
ability and serious intent, and I would like to publicly thank 
the Administration for its dedication.
    Accompanying that commendation, I simply ask that the 
Administration give us its views on this legislation just as 
quickly as possible. We have three committees of jurisdiction 
with claim on this bill in the House. I am hopeful we can get 
it moved this year in the days that remain. I sit on two of 
those committees, the Committee on Resources and the Committee 
on Ways and Means. I commit my full energies to moving the 
legislation through those respective committees.
    I think we need to accomplish some significant work at the 
staff level during the August recess if we hope to finish 
anything this year. So we will be listening with more than 
casual interest to the Administration views.
    Secretary Thompson spoke during his time in Arizona of the 
bright future of the Navajo Nation and of his commitment to 
advocating for the tribes' health funding here in Washington. I 
am confident we are on the same page. I look forward to working 
together with the Secretary, with the Administration, with this 
committee, with your distinguished body in reauthorizing this 
important piece of legislation.
    Thank you, Mr. Chairman and thank you, Senator Johnson.
    The Chairman. Thank you, J.D. Just as a background matter, 
I am sure you are aware of it, but for maybe our colleagues or 
visitors who are not, this reauthorization is long overdue. I 
introduced a reauthorization bill in the 106th Congress, in 
fact, along with Senator Inouye and Senator McCain. We got it 
out of committee, but could not get it through the Senate. I 
reintroduced it in the 107th Congress and had Senator Johnson, 
Senators Dorgan, Daschle, Feinstein, Murray, all cosponsoring, 
as well as Senators Inouye and McCain who were prime sponsors 
with me.
    We did not get that one out of committee. In the 108th 
Congress, we did it again. I introduced it along with Senator 
Inouye again and Senator McCain again and Senator Johnson, 
Senator Murray, Senator Daschle, a number of people that 
support this bill. About this time right after that, 
Congressman Young, as you mentioned, did introduce H.R. 2440.
    Well, we did a first hearing in the 108th Congress on April 
2. I do not know if Senator Murkowski is on it or not yet. We 
did a first hearing in the 108th on April 2. We did a second 
hearing in 2003 on July 16 of that year; a third hearing on 
July 23 of that year. So this is another hearing, and we still 
haven't gotten this thing done yet. I think everybody I talk to 
knows it is overdue and Indian people are sick and suffering. 
We need to get the thing done with, and with only 23 days left, 
we are just not going to do it unless we have a lot of help 
from both sides of the Hill and the Administration too.
    Mr. Hayworth. Mr. Chairman, I would concur. While a private 
citizen, I remember the remarks of General Schwarzkopf when he 
compared the legislative bodies here on Capitol Hill to a 
daycare center. I do not think that is the case. I think it is 
more a situation like college where sometimes when we have 
deadlines, we can actually get things done. It seems at times 
we work at cross-purposes. We are, after all, deliberative 
bodies. But given the legislative record you chronicled, the 
hearing here, likewise the hearings and the effort we have made 
in the House, there is no time like the present to move 
forward.
    I remain optimistic, even though the days start to dwindle, 
that certainly this must be a priority and we need to get this 
done before the conclusion of the 108th Congress.
    The Chairman. Interesting you should use an educational 
analogy, because my wife used to teach the fifth grade. She 
said there is a distinct similarity between what we do here and 
her fifth grade class sometimes.
    Thank you for appearing here.
    Mr. Hayworth. Thank you very much.
    The Chairman. Senator Murkowski, did you have any opening 
statement before we go to our next witness?
    Senator Murkowski. Thank you, Mr. Chairman.
    I understand that the Secretary is up next. Is that 
correct?
    The Chairman. That is correct.
    Senator Murkowski. If it is appropriate, I will go ahead 
and include my introduction in advance of his testimony then.
    The Chairman. That will be fine.

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

    Senator Murkowski. I thank you, Mr. Chairman, for the 
hearing this afternoon. I welcome you, Mr. Secretary, to the 
committee and look forward to welcoming you again in Alaska 
when you come up and visit us next week.
    The Alaska Native health care delivery system is one of the 
crown jewels of Alaska, from the village health aids spread 
among clinics in the remote villages, to the rural telemedicine 
system which allows the health aids to work collaboratively 
with physicians in Alaska's hub cities. From the regional 
hospitals to the state-of-the-art Alaska Native Medical Center 
in Anchorage, it is clear that our native people are cared for. 
You, Mr. Secretary, are no stranger to this, having visited our 
native health care delivery system on many occasions.
    You know that the Alaska Native health system does not only 
deliver health care, but it delivers economic opportunity. To 
our young native people, it represents an open door to a 
lifelong career in health care. To Alaskans, native and non-
native alike, it is an employer of choice. And to the large 
number of Alaska businesses that benefit from the millions of 
dollars it invests in the Alaska economy, it is an economic 
engine.
    We are here today to discuss the reauthorization of the 
Indian Health Care Improvement Act. Mr. Secretary, I am going 
to tell you that Alaska needs this reauthorization to occur. I 
am also going to tell you that this viewpoint is held by Indian 
health providers throughout the Nation.
    The bill before us is the product of years and years of 
hard work by a national steering committee. It is not a self-
governance bill, a direct services tribes bill, an urban bill 
or indeed, an Alaska bill. It is all of these things, but what 
is most important is that it is the glue that holds the Indian 
health care delivery system together. It may be, Mr. Chairman, 
the most important piece of legislation that the Indian Affairs 
Committee will take up this year. I hope, Mr. Secretary, that 
you will assist us in its passage.
    Mr. Chairman, I thank you for the opportunity to make a few 
comments.
    The Chairman. Thank you.
    With that, we will now turn to Tommy Thompson, Secretary of 
Health and Human Services, accompanied by Dr. Charles Grim, 
Director of the Indian Health Service.
    Mr. Secretary, thank you for appearing, my friend of so 
many years, and not only from a political standpoint, a 
professional standpoint, but my occasional riding buddy, too. I 
might tell you I saw our friend Max Baucus yesterday on 
crutches around here, and reminded him of that old saying that 
there are two types of bikers, the ones that have gone down and 
the ones that are going to go down. So he has been baptized. 
[Laughter.]
    But hopefully he will recover very shortly and get back out 
and ride with us sometimes.
    Please proceed, and we will have a few questions for you.

  STATEMENT OF TOMMY THOMPSON, SECRETARY OF HEALTH AND HUMAN 
 SERVICES, ACCOMPANIED BY CHARLES GRIM, DIRECTOR OF THE INDIAN 
    HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Mr. Thompson. Thank you very much, Mr. Chairman.
    Let me first congratulate you for holding the hearing and 
thank you, Senator Johnson, for being here. Senator Murkowski, 
I will see you next week in Alaska when I make my annual trip 
to Alaska and spend 1 week among the Alaska Natives. Senator 
Inouye, I am sorry he cannot be here because he, too, is a 
friend of mine. I was hoping he would be here.
    I have gone down several times, Senator, so I have already 
been under the baptism of fire as far as a motorcycle is 
concerned. I thank you and I congratulate you also, Senator 
Campbell, for the new post office that is going to be named 
after you.
    The Chairman. Someone told me that.
    Mr. Thompson. I was very honored and pleased to see that, 
and I also read with a great deal of delight your story in the 
Washington Post, and thought that was a wonderful tribute to a 
great Senator. I think it is a real loss, will be a loss to the 
U.S. Senate when you retire, Senator Campbell. You have been an 
excellent Senator, a great public servant, and a wonderful 
friend of mine. I thank you very much for holding this hearing.
    It is great to have this opportunity to discuss the 
reauthorization of the Indian Health Care Improvement Act with 
you and the other members of this committee. Senator Inouye, it 
is great to see you here as well. Thank you so very much, my 
friend.
    This act forms the backbone of the system through which 
many Federal health programs serve American Indians and Alaska 
Natives. I am please to share with you today the 
Administration's support for the reauthorization of the Indian 
Health Care Improvement Act during this Congress. I think all 
of you have indicated the necessity, and I agree with that 
necessity and want to work with you enthusiastically and 
wholeheartedly to get that accomplished, the result of our 
efforts to improve services provided by the Indian Health 
Service, the tribes, the tribal organizations, Alaska Native 
villages and urban health programs.
    From the day I first arrived at the Department of Health 
and Human Services, I have made the health and well-being of 
American Indians and Alaska Natives a priority of my 
Department. I have traveled widely to Indian country over the 
past several years. I have visited with the Chippewa Indians 
throughout the Midwest, the Sioux Tribe, and can remember going 
to the Oglala Sioux Tribe on Pine Ridge and saw on a Saturday, 
Senators, the devastation of individuals waiting in line in 
regards to kidney dialysis because of sugar diabetes. It is an 
epidemic. I will talk about that later.
    Alaska Native villages, I have been all over Alaska. Every 
year, I spend 1 week in Alaska going to different Alaska Native 
villages, and see the need first hand of what is needed. 
Earlier this week, I spent 2 days with the Navajo Nation, the 
first Secretary of Health that has been on that nation and 2 
wonderful days in which we had the opportunity to meet with the 
tribal leaders. We actually went into elderly homes, as you 
have indicated, Senator Campbell, and met with individuals who 
are suffering from diabetes and other circulatory problems and 
need all the help the Government can give them.
    Next week, as I have indicated to Senator Murkowski, I will 
meet with native leaders in Anchorage and representatives of 
the Southeast Alaska Rural Health Consortium in Juneau. Since 
arriving at HHS, Deputy Secretary Claude Allen and I have 
traveled to all 12 of the Department's IHS service areas. We 
are the only Secretary of Health and Human Services to have 
ever done that, and the first Secretary who has been at the 
Navajo Nation, and I have spent each year a week in Alaska.
    As Secretary of Health and Human Services, it has been my 
goal to improve coordination among the operating and staff 
divisions of my Department, and to encourage collaboration 
between HHS and tribes in all the programs that affect their 
members. I reactivated the Intra-Departmental Council on Native 
American Affairs in order to provide a consistent policy when 
working with more than 560 federally recognized tribes. Since 
2001, we have increased spending on tribes 17 percent or $541 
million. This, of course, is not nearly enough, but it has 
shown the inclination and the increases of the Department when 
we have had to zero out other divisions in the Department.
    The Medicare Modernization Act of 2003 includes two 
provisions which are identified by the Indian health programs 
as high priorities. The major medical assistance allows Indian 
health programs to use Medicare's bargaining power when 
purchasing care for contract carriers from hospitals that 
participate in Medicare for patients not on Medicare. This is a 
wonderful new addition for the tribes. It is going to save them 
lots of money and allow them to expand for further care.
    The MMA, the Medicare Modernization Act, also allows IHS 
and tribal hospitals and clinics to build for additional 
Medicare part B services between 2005 and 2008. The Medicare 
Modernization Act also includes provisions to help ensure that 
pharmacies which are operated by Indian health programs, as 
well as other pharmacies, can participate in the temporary drug 
discount card and the permanent part D drug benefit programs. 
These are provisions in the MMA that are going to be very 
beneficial to the tribes.
    I am also exercising my authority, Mr. Chairman, to provide 
health professionals to IHS-served communities with 
longstanding vacancies. We are currently assigning 275 
commission core officers to serve in IHS facilities. As I said, 
my Department is strongly committed to the reauthorization of 
the IHCIA during this Congress in order to improve the health 
and well-being of American Indians and Alaska Natives. This 
legislation should provide increased flexibility for the 
Department in order to work with tribes to improve the quality, 
availability, and the scope of their health care.
    Accordingly, I commend Congress and especially you, Mr. 
Chairman and Senators Inouye, Johnson, and Murkowski, for 
including in H.R. 2440 various changes that respond to concerns 
previously expressed in the bill. I would like to highlight 
several areas of
interest.
    I am very pleased with the other ways that H.R. 2440 
strengthens other program areas including, number one, 
providing for improved health services to eligible Indians; 
expanding behavioral health programs to provide for prevention 
and treatment for child sexual abuse, family violence, mental 
health and suicide and other serious problems. We all know the 
disproportionate number of tribal members that are afflicted by 
these type of abuses and these type of abuses.
    H.R. 2440 also proposes to allow qualified scholarships to 
be treated as tax exempt. This is going to help in the 
recruitment and the retention of health professionals. As 
Senator Murkowski says, this is a vocation of choice, 
especially with Alaska Natives. We need to get more tribal 
members to get involved in the health fields. There is such a 
shortage and we need to encourage more of it. By allowing for 
these qualified scholarships to be treated as tax exempt, it is 
going to allow us to be give at least 50 more scholarships out 
to Indian country. It will ultimately improve the delivery of 
long-term care and similar services to Indians. I would like to 
encourage you to extend this exemption even further to certain 
qualified loans, as well as the scholarships.
    Mr. Chairman, it is no secret that I am personally 
passionate about reducing the incidence of preventable diseases 
in this country, particularly among our most vulnerable and 
hardest-hit communities. Having access to the health care 
system, to doctors, to screenings, and to necessary medicines 
and treatments is critical to a successful prevention strategy. 
Yesterday in the Navajo Nation, there was almost 20 percent, 
18.9 percent of the 300,000 Navajo Indians that are suffering 
from type II diabetes. This is a huge problem, and we have to 
get back to cultural foods, cultural information in getting 
involved in training tribal members about eating properly and 
exercising, not only on Navajo Nation, but across all of the 
Indian reservations.
    We have to come up with a very successful prevention 
strategy. That is why it is so important to me to support H.R. 
2440's provisions to exempt eligible Native American families 
and individuals from the cost-sharing in the premium 
requirements under Medicaid. We all know, and I was at an 
elderly couple's house yesterday. They could not afford to make 
the cost-sharing of Medicaid, and therefore they went without 
medical assistance. We have to make sure that we extend that to 
allow the tribal members to be able to get this coverage.
    There continues to be a problem in Indian country with 
under-enrollment in Medicaid and SCHIP. This provision is going 
to a long ways toward eliminating a barrier to that particular 
care. In families currently enrolled, but who forego care due 
to the out-of-pocket costs they simply cannot meet, would no 
longer bear that burden if you exempt it.
    While we need to continue to dialogue on the complexities 
of the other entitlement provisions in the bill, which have 
programmatic effects that implicate the states' programs, we 
can all agree that paving the way for access to Medicaid 
services is something we should act to do right now.
    This leads me to the broader issue of improving outreach, 
enrollment and the interaction of the tribes with the 
entitlement programs at HHS. The legislation proposes to 
address this issue by establishing a commission to study how 
entitlement programs impact and serve American Indians. While 
in theory I do not object to having an commission, I firmly 
believe that I can engage in a much more productive and 
certainly more expedited dialog with the tribes to better and 
faster identify workable solutions and eliminate barriers to 
quality care.
    If this committee and this Congress decides that a 
commission is the right way to go, we will support it and work 
with it and do everything we possibly can to make it 
successful. But the commission would take possibly 1 year to 
get up and started and running, and I think it is much faster 
and better to expedite it and get started right now. I think we 
can do that throughout the Department. If this committee so 
directs, we will be more than happy to work with you in any way 
possible.
    I commend you, Mr. Chairman and members of this great 
committee, for your swift effort to enact legislation this 
year. It is time to pass this legislation. It will expand 
access to services and lay the groundwork for an ongoing 
productive dialog on the matters of broader entitlement 
programs. We look forward to working with this committee, the 
National Tribal Steering Committee, and all American Indian and 
Alaska Native communities as we work to reauthorize and improve 
Indian health care programs.
    To that end, I will strongly suggest that our staffs meet 
as soon as possible, Mr. Chairman, so that HHS experts may 
provide the committee with technical comments and assistance in 
all of the provisions of H.R. 2440.
    Thank you for giving me this opportunity. Before I yield 
back to you, I would like to introduce Dr. Charles Grim, who 
does an excellent job running IHS. I am very happy that he is 
with me today in order to help answer any questions that this 
committee may have.
    [Prepared statement of Mr. Thompson appears in appendix.]
    The Chairman. Thank you, Mr. Secretary.
    Dr. Grim has been before the committee several times in 
fact, and we appreciate him being here.
    I certainly appreciate your going out to visit Indian 
country, Secretary Thompson. You mentioned the Navajos have an 
18-percent type II diabetes rate. Let me tell you, in Indian 
country that is probably even low compared to some tribes. The 
Pima, I understand, have over 50 percent, 1 out of every 2 
people, 1 out of every 2 people suffer some degree of diabetes.
    I guess it is one thing to look at diabetes on a chart or a 
wall or a graph or something of that nature, but when you see 
people laying in the hospital with their legs cut off because 
of the advanced stages of diabetes or what diabetes brings on 
in terms of gangrene and so on, I think it really comes home to 
roost.
    Dr. Grim knows I have two or three times questioned him 
about the availability of dialysis machines, dialysis machines 
closer to the source of the problem, because we know many, many 
Indians have to spend 3 days a week out of their 7-day week on 
the road to get to wherever a machine is. They will drive icy 
roads, tough conditions, half-a-day to get somewhere to get 
their treatment for dialysis and then have to drive back. They 
just live to be on the road to get to the machine so they can 
stay alive.
    There is something wrong with that. If we put most 
Americans through that, there would be some kind of a rebellion 
on our hands. I think we can do better.
    One of the other problems in my view is that we know we are 
putting more resources into the Indian Health Service. You 
mentioned that. But the problem seems to be growing faster than 
the resources. For one thing, on Indian reservations there is a 
fast birth rate, as you know. Sooner or later those kids are 
going to grow up, and without proper nutrition or preventive 
methods that you mentioned, they are going to end up with the 
same thing.
    It is one thing to be able to say, well, we need to try to 
make sure they improve their diet and do certain things. That 
is great. But what we have to remember is that on the 
reservations, a lot of the reservation people, they do not have 
a choice. They live on what are called commodities, which means 
government surplus canned goods, beans, rice, starches and so 
on, low protein. If they had a choice, I think some of them 
would improve their diets, but when you have almost no jobs on 
many of those reservations, they just have nowhere to turn.
    So it is either eat the commodities, starchy foods, or not 
stay alive. There is no question what they are going to do. 
They are going to eat what is available there, and then they, 
in turn, risk getting diabetes from the very diet that they are 
forced into consuming.
    So it is a catch-22 in a lot of respects. Somehow we have 
to find a way to break that cycle and improve their health from 
the federal government, which is our responsibility, in my 
view.
    Thank you for agreeing to have your staff meet with our 
majority and minority staff, too. I think it is really 
important. I know for some months we have been trying to get a 
meeting, but for whatever reason we have not been able to do 
that. So I take you at your word that we would do that as soon 
as possible. I will relay that to staff and hopefully we will 
be able to get a meeting very shortly, in the next few days 
perhaps, and try and find some consensus about what we can do 
to improve this bill.
    Let me ask you a couple of questions.
    Mr. Thompson. Senator, they are ready to sit down with you 
next week at any time and go line by line through the bill. OMB 
has finally given us the green light to get things done. So I 
want to expedite this as soon as possible. My staff is 
available to go anytime you want to, Senator.
    The Chairman. You mentioned the scholarship loan program. 
It has been increasing, did you say, the number of people?
    Mr. Thompson. It is increasing, but what happens is that 
under the current law, we have to pay about 30 percent into the 
Department of Treasury for taxes on the fringe benefits. Under 
the Indian Health Improvement Act, that is exempted. That 30 
percent of the money that we put in there, which was----
    Mr. Grim. You mean the number of scholarships?
    Mr. Thompson [continuing]. We have about 150, but we could 
expand it, because 30 percent of that money goes into the 
Treasury again. By exempting it, we can roll that money back 
into expanded scholarships for the health care, the health 
professions.
    The Chairman. Okay, good.
    Let me skip around a little bit. I had a number of 
questions, but there are so many Senators here, I think we will 
maybe do it in rounds.
    Your testimony recommends that we strike all references to 
consultation, yet when you spoke a minute ago I thought I heard 
you say the importance of consultation. As you know, Indian 
tribes, they think very highly of some consultation with the 
Government before we implement things in Washington and sort of 
drop it on them. Did I hear you right?
    Mr. Thompson. No, Senator; we have already started the 
consultation process through budgets and through everything 
else. In fact, in every one of the IHS, we have set up 
voluntary consultation. My concern is the prescriptive language 
that you put in there, you shall do this and that. We feel that 
we are already doing it and we are doing it in a way in which 
the tribes have bought into it and like it, and we do not know 
why you have to statutorily prescribe that we do it in a 
certain way. We feel that we are doing it.
    If you decide to do it, we will do it. We will comply, but 
we are already doing it on a voluntary basis, and that is why 
we do not think it is necessary.
    The Chairman. I may have misread my notes, I might have 
because as I understand your testimony, you believe that the 
consultation with tribes is already provided for through the 
Indian Self-Determination and Education Act.
    Mr. Thompson. And we have already set it up. We have 
expanded that throughout the Department. The tribes now have a 
consultative process in every one of the IHS regions. In fact, 
we are holding on in Billings, MT I believe next week, and we 
just got done in Oklahoma. The tribes go there and it is 
working out.
    We have already set up the framework, and that is why we do 
not think we need statutory language to tell us to do it. That 
is the question.
    The Chairman. I see. And in there, I understand that 
working with the tribes somewhat is a little different because 
of different cultural values. Have you, when you were in 
Oklahoma and your other meetings, had the occasion to discuss 
how you fit traditional healing practices in with the grand 
plan of the Indian health care system?
    Mr. Thompson. Yes; we have.
    The Chairman. I think that is really extremely important, 
particularly to our senior citizens.
    Mr. Thompson. Absolutely.
    The Chairman. We are going to do this in rounds, I think. I 
would like to yield to Senator Inouye for a few questions, and 
then we will take questions in order of who got here first. 
Then we will do a second round. Go ahead, Senator Inouye.
    Senator Inouye. Mr. Secretary, I wish to commend you for 
the service you have rendered as Secretary of the Department of 
Health and Human Services.
    Mr. Thompson. Thank you, Senator.
    Senator Inouye. We here are very pleased with what you have 
done.
    Mr. Chairman, regretfully I have other committees I have to 
attend, so if I may, may I submit questions for your response, 
sir?
    Mr. Thompson. Absolutely.
    Senator Inouye. And once again, thank you. It is always 
good to see you.
    Mr. Thompson. It is always a pleasure. I can remember when 
I met with you in Madison, Wisconsin at the Governor's 
resident.
    Senator Inouye. Can I still call you Governor?
    Mr. Thompson. I would much rather have you call me Tommy, 
Senator. [Laughter.]
    Senator Inouye. Thank you, sir.
    The Chairman. Thank you, Mr. Vice Chairman.
    Senator Murkowski, you were next in order of appearance.
    Senator Murkowski. Thank you, Mr. Chairman.
    I do look forward to our visit next week up in the State. I 
am sure it will be a good one, as they all have been for you.
    I appreciate the comments that you have made about 
prevention, and then the followup that you have made, Mr. 
Chairman, about the diet and nutrition. I was in the small 
village of Norvik just last weekend, on Saturday. Norvik is an 
Eskimo community just beyond Kotisivu, about 700 people. I went 
into the store there, as I always do when I go into the 
villages, to see what their availability is of fruits and 
vegetables and milk.
    There is no milk in the store. There is no powdered milk in 
the store. I asked when the last time was they got milk in the 
store, and if they got it, how much. The clerk could not 
remember the last time they had milk there.
    Dr. Grim, you and I have had numerous opportunities to talk 
about the dental issues that we have with so many of our Alaska 
Natives. Our children's teeth are literally rotting out of 
their head. Well, they do not have access to milk. Many do not 
have access to good sanitary drinking water, so they drink pop. 
When I was asking the clerk, what is your most popular item, 
she pointed me to the freezer section where they keep the hot 
pockets. As a mother of teenage boys, this is the quickie lunch 
thing that you put in a microwave. They are selling two hot 
pocket sandwiches for $4.50.
    This is what the families are eating. They are moving off 
of the good traditional subsistence foods that have provided 
for generations. The junk food aisles in the stores are picked 
clean. We simply have so far to go when it comes to educating 
about the proper nutrition, and then furthermore providing it 
for them. When you do not have the fruits and vegetables, when 
you do not have the milk products, it is really difficult to 
talk about that food pyramid and what you should be eating.
    Mr. Secretary, I know we have talked a little bit in the 
past also about Alaska being on the leading edge of public 
health preparedness programs. Our native hospital there is a 
key player in the program. Several weeks ago, I had heard that 
funding for Alaska's bioterrorism program could be reprogrammed 
somewhere else. I sent you a letter on this and I am wondering 
if you have any update for me, or if you can let me know what 
the status is of that.
    Mr. Thompson. Alaska has received quite a bit of money from 
the Department of Health and Human Services on bio-
preparedness. There is a small portion that is going to be 
reprogrammed into cities. It was because the states had not 
used the money. There was appropriated money going back to 
2001-04. Alaska had not used the money from 2002 and 2003, so 
some money was reallocated into major cities in order to expand 
bio-preparedness, especially for surge capacity. Alaska was one 
of those that had, but Alaska still has money that it has not 
used.
    Senator Murkowski. So with those funds that you intend to 
reprogram, what does that do for the future? Are you suggesting 
that because we have not used it in the past, we will not be 
eligible for those funds?
    Mr. Thompson. No; it does not. This is just a 1-time thing 
to get cities better prepared for bio-preparedness. The 
legislation that was passed, Senator Murkowski, was set up so 
that I had the discretion of putting the money into either the 
cities or in the States. After it passed in 2001, I directed 
the money to go to the States. In 2001-03, the States were to 
use that. Now, I have reprogrammed some of the money because 
the money was not getting down to the cities. I reprogrammed it 
into the major cities because the States had not used all of 
the money that was available to them. In fact, it goes back to 
since the program was started, and Alaska was one of those that 
had not used all of its money.
    Most of the States had not used all their money. When I 
went to the National Governors Conference 1 year ago and again 
this year, I told the States that they had to use this money, 
because if they did not use it, Congress was going to take a 
look at these particular money and re-appropriate it. Since we 
needed money for the cities in this particular time, I took 
some of that money. It was a very small portion of that money, 
to reallocate it into the cities for bio-preparedness, surge 
capacity for hospitals. And that is the reason. That does not 
mean it is a permanent fix. It just means it was reallocated 
this year to take care of a particular problem.
    In regard to the nutrition and diabetes, we have expanded 
that program. If you would like, Dr. Grim would be more than 
happy to explain that as well. But diabetes is a passion of 
mine. I speak about it all over the country, and especially in 
Indian country we have to do a better job. We have to, as 
Senator Campbell says, we have to get more diversity, and as 
you have said, better foods into the grocery. You cannot expect 
them to eat five helpings of fruits and vegetables if there are 
no fruits and vegetables. I am sorry about that. If you would 
like to comment. I do not know if you have the time, Senator 
Murkowski.
    Mr. Grim. I would just add to that, Senator, that we are in 
the process at the Indian Health Service of providing an 
interim report to Congress. It should be available very, very 
soon. It is going to give an update to you of what we have been 
spending and what the tribes have been spending the special 
diabetes program for Indian funds on. I think you will be very 
impressed with the amount of primary prevention services that 
have increased in Indian communities; the amount of nutritional 
education, physical activity.
    We also have in that report some clinical indicators that 
we have been tracking on our patients to show you that the 
clinical indicators are moving in the right direction and that 
we are better controlling the diabetes in our patients from a 
clinical perspective. So that will be full of information for 
you, and as soon as it is available we will get it to you.
    Senator Murkowski. Thank you.
    I have to go preside now, Mr. Chairman. If there are other 
questions, I would like to be able to submit those.
    Mr. Secretary, we will be following up with you. I will 
talk with the folks at the state level about the bio-
preparedness money and how we can make that work. As you know, 
we are a long ways away from the rest of the world and we are 
kind of on our own when it comes to taking care of ourselves. 
We want to make sure that we have the moneys that we need to 
provide for our security.
    Mr. Thompson. And I will be talking to your wonderful 
Governor next week as well.
    Senator Murkowski. Thank you.
    The Chairman. Who would that be? [Laughter.]
    Senator Dorgan, you were next in order of appearance.
    Senator Dorgan. Mr. Chairman, thank you.

   STATEMENT OF HON. BYRON L. DORGAN U.S. SENATOR FROM NORTH 
                             DAKOTA

    Mr. Secretary, thank you very much, and Mr. Surgeon 
General, thank you for being here.
    First of all, I think this is awfully important work. I 
think all of us understand we are talking about authorization 
bills here. The real question is how much funding is available 
for these programs.
    I think the first hearing that I did on diabetes on Indian 
reservations was a hearing at which Congressman Mickey Leland 
and I and Congressman Tim Penny flew to the Three Affiliated 
Tribes in North Dakota and did a hearing. They had a diabetes 
rate that was I believe 12 times the national average. These 
were American Indians who were living on the lowlands of the 
fertile Missouri River bottomlands raising fruits and 
vegetables and eating berries and so on. Then when the Pick-
Sloan project came in and they flooded all that and towns like 
Elbowoods did not exist anymore, they were under a large 
500,000-acre reservoir, they moved the American Indians to the 
top of the bluffs up there where you do not grow fruits and 
vegetables and berries, and their diet changed dramatically.
    So this is a long tortured trail, this issue of dealing 
with Indian health care, especially diabetes. I have worked 
hard on it for a long, long time. There is so much to do. There 
is so much funding that is necessary for that, and for so many 
other issues.
    I would like to just focus on one quick issue. Mr. 
Secretary, there is a young girl who recently took her own life 
on the Spirit Lake Nation. Her name was Avis Little Wind. Avis 
Little Wind was a seventh grader. She liked riding horses and 
she liked playing basketball and listening to music when they 
found her hanging in her closet one morning. She was laying in 
a fetal position in her bed for 90 days, missing school. Her 
sister had taken her own life. Two weeks after they found her, 
her other sister drowned driving under the influence of 
alcohol. Her father had died of a self-inflicted bullet wound.
    I went to that reservation just some weeks ago to meet with 
school administrators, and met with some of the classmates of 
this young girl. What I found there is pretty much what I found 
in other areas as well. It is a profound lack of resources. One 
psychologist, one worker who also works in this area that is 
not professionally trained, a social services worker and a 
psychologist, that is it. They talk about even having to borrow 
a car to take a kid someplace to get them treatment. They have 
to beg and borrow a vehicle.
    This is so typical of the problems. There was a young girl 
named Tamara who some long while ago I got involved in. She was 
3 years old and she was beaten severely, nose broken, hair torn 
out by the roots, arms broken. She was put in a foster home on 
the Standing Rock Reservation by a woman who was handling 150 
cases, 150 cases. She put a 3-year-old girl in a home without 
checking the home out. The result is in a drunken brawl, this 
3-year-old girl was beaten severely. It will have an impact on 
her the rest of her life.
    So these things, when you get to the bottom of what is 
happening, almost always it is a case that the resources are 
not available. Now, in the Standing Rock Reservation, we do not 
have one person handling 150 cases anymore. I fixed that. One 
by one, you try to fix some of these things. But we have in my 
judgment, Mr. Secretary, a bona fide crisis in education, 
housing and health care on the reservations in this country. 
This is an authorization bill. We need to do this and much, 
much, much more.
    My understanding is that we have trust responsibility for 
two groups of people for health care in this country. One are 
prisoners in the Federal prison system and the other a trust 
responsibility for Native Americans. My understanding further 
is that we spend exactly twice as much per person on health 
care for Federal prisoners as we do to make available health 
care for American Indians.
    We just have to stop it, and start over and go in the right 
direction. No one has been a stronger champion for that than 
the chairman, Chairman Campbell. I regret that he is leaving 
the Senate because we are losing a great champion.
    Mr. Thompson. So do I.
    Senator Dorgan. I am not asking a question. I wanted to 
mention that to you that I have been deeply involved in these 
issues of suicide, and there is a rash of them on some of these 
reservations. It comes from I think a kind of desperation and a 
whole series of other issues. We just have to provide the 
funding. It is unforgivable for us not to adequately fund these 
kinds of issues such as psychologists and social service 
representatives and others who can reach out and help these 
kids.
    I will give you a chance to comment on that in just 1 
moment. Mr. Secretary, as long as you are here, you know that I 
would want to ask you about something you are working on, and I 
am waiting for an answer on. That is, the pilot project on 
prescription drugs that I suggest for reimportation of 
prescription drugs from Canada. I think it was March 31 that I 
brought that to you. I want to know what the status is and when 
I might see a decision coming from your agency on that issue.
    Mr. Thompson. First off, you are a very good man and I 
thank you very much for your comments.
    You were not here when I made my presentation. I just came 
back from the Navajo Nation. I spent 2 days out there, the 
first and only Secretary of Health that has ever been there. 
Next week, I go to Alaska. Every year, I go to Alaska and spend 
1 week in Alaska touring Native Alaskan villages and seeing the 
despair; seeing and talking to kids and talking about the 
suicide problems. Your example is replicated in many 
reservations across the country.
    We have to do something about it. On the Navajo Nation 
yesterday, we went to see a clinical psychologist who was the 
first Navajo psychologist in the State of Arizona, and the only 
one. She was there and she had about 15 young girls ages from 9 
to 17. She was just doing a wonderful job. I asked you about 
the rate of recidivism. She said that it is very good. She says 
we have very few young ladies that graduate from the program 
that retrogress back into the program; that they go back into 
school and do so well.
    I talked to a young girl who had dropped out of high school 
and now was doing so well in the program she wanted to finish 
high school and then go on to become an architect. She was a 
very talented young lady and made me feel very good.
    I asked the clinical psychologist if she was a benevolent 
dictator, what would be the first thing she would do. She said, 
I would have a lot more clinical psychologists on the 
reservation talking to the young people; I can only do so much 
and the need is so great that we need more.
    In regard to the question that you are so passionate about, 
and I thank you for your passion and I thank you for coming 
over to the Department and giving me your first-hand persuasive 
arguments on it. I would tell you that we are working on it. I 
would tell you that the Surgeon General has held hearings about 
this, and right now we are working on a report to you and to 
Congress and hopefully I will be able to get it to you soon.
    I have to get some clearance for it, but I want to thank 
you for it, and I will keep you up to date better than I have 
in the past. I am sorry about that, but I will get you an 
answer relatively soon.
    Senator Dorgan. Mr. Secretary, thank you very much.
    The Chairman. Thank you. Before I turn to Senator Domenici, 
thanks for the nice words.
    I know, Mr. Secretary, that this problem is not all your 
own problem. We are dealing with an authorization bill here, 
but clearly it does not do any good to authorize a bill if we 
are not going to pay for the thing later. We have to be able to 
have better support from our colleagues on increasing the 
amount of money that goes into Indian health care, but we also 
need help in the Administration when they send a budget over 
here, regardless of who is in the White House at the time.
    I think around here, we too often very frankly end up 
getting caught up in the blame game. It is the Administration's 
fault or the other party's fault or it is somebody else's 
fault, when in my view it is all of our fault a little bit 
because we do not seem to be working together on trying to 
improve it as much as it needs to be improved.
    But thank you, Senator Dorgan.
    Senator Domenici, did you have a statement?
    Mr. Thompson. Senator Campbell, if I could just say you are 
absolutely correct. There is enough blame to go around. Let's 
stop pointing the fingers. Let's sit down and get a good Indian 
health reauthorization law through. Let's see if we can get it 
done. Let's see if that can be the first step toward a 
bipartisan, bicameral, Administration and Congress, a 
congressional response to the needs in Indian Land. I am 
committed to do that, Senator.
    The Chairman. Thank you, thank you.
    Senator Domenici.

   STATEMENT OF HON. PETE V. DOMENICI, U.S. SENATOR FROM NEW 
                             MEXICO

    Senator Domenici. First of all, I wanted to thank the 
Secretary for coming here and indicate a few other areas of 
appreciation. First of all, we want to thank you from New 
Mexico for assisting us in mediating a recent disagreement 
between the University of New Mexico and the Indian Health 
Service, because you got involved and understood that it was 
only technical and we should not cease to build a major 
hospital because of that technicality. We will soon start to 
build a hospital that will end up taking care of our Indian 
people who qualify and be a tremendous asset for the State.
    Second, I would like to say while Senator Dorgan is here 
that starting a long time ago, we pressed very hard for the 
construction of Indian schools. I want to tell you that 
something marvelous has happened since President Bush took 
office. He met with us, Senator Campbell, in Las Cruces, NM. We 
had the Indian leaders of New Mexico there. There were two 
issues, but one was, why aren't we building schools, since we 
are the only one who can build those schools. They are not 
State responsibility or county. The President made a 
commitment.
    And guess what happened? We have built 15 new schools in 
Indian country, and theretofore, we used to build one a year. 
That truly is outstanding.
    Senator Dorgan. Senator Domenici, would you yield on that 
point?
    Senator Domenici. Yes, sir.
    Senator Dorgan. On Saturday last, we did a groundbreaking 
on the Ojibwa school on the Turtle Mountain Indian Reservation 
that has been 18 years in the offing. It has been needed for a 
long, long, long time. Finally, there was a groundbreaking. So 
I understand your point. We are making some progress.
    Senator Domenici. Mr. Secretary and fellow Senators, I want 
to tell you about the diabetes issue because do you know nobody 
paid any attention to it until the time we were balancing the 
budget, believe it or not. Representative Gingrich and I were 
representing the Congress with Administration people. When we 
finished it all, we had $100 million left over, if you can 
believe it, just floating there in this billions of dollars. He 
said to me, what should we use it on? I said to him, how about 
diabetes? He says, how about it? I said, why don't we split it? 
What do you mean? Let's put $50 million in Indian diabetes and 
$50 million for the rest of the country. He said, it is a deal.
    That was the first money ever put in diabetes. It came from 
that arrangement. A couple of years later, we put $150 million 
in. I do not say that indicating that we have solved that 
problem. I know research is going on. It is hard to get done, 
but genetic research is going on. I think you know that, at a 
very high level, because there is something very important and 
very frightening about how many Indian people get diabetes 
versus others.
    We can explain it away saying there is no milk on the 
reservation. There is coca-cola, but the number if startlingly 
high for it to just be that. So I would like to ask you, do you 
know how much we are actually spending, either you or the 
Doctor, on Indian diabetes in the United States this year? 
Doctor?
    Mr. Grim. We can tell you what we have put in since 2002 
with the moneys that you have helped make available, over $500 
million now. The $150 million that started this year, a 
substantial portion of that is out in Indian country right now. 
The thing that I cannot give you additionally, these are 
targeted grant funds that are going directly to tribes 
throughout the country, over 300 tribes and Indian 
organizations now have successful programs running with those 
grants.
    What I can tell you specifically today is how much we are 
spending in our Indian health care system and our hospitals and 
clinics. We are spending a significant amount of funds just to 
treat the ravages of diabetes in our hospitals and clinics. We 
have greatly appreciated the special funds that Congress made 
available to target prevention in that effort.
    Senator Domenici. Mr. Secretary, while you were on Navajo 
land, did you happen to go to any centers where diabetic people 
were being take care of with the big machines that keep them 
alive?
    Mr. Thompson. We went to several hospitals and several 
clinics. We did not go to any dialysis centers. I did that in 
the Oglala Sioux a year ago, and I did that up in Alaska Native 
settlements, but I did not do that in the Navajo region 
yesterday.
    Senator Domenici. Mr. Chairman, I want to tell you that we 
cannot currently as a Nation build dialysis facilities as fast 
as the cases are showing up.
    Mr. Thompson. That is right.
    Senator Domenici. There are centers all over Navajo country 
where 40 or 50 dialysis people are taken care at one time. It 
is like a school full of diabetic Indians, the most startling 
and pathetic thing you ever saw. It looks like a war had been 
waged.
    Mr. Thompson. Absolutely depressing.
    Senator Domenici. Mr. Secretary, I want to conclude by 
telling you that I am very thrilled that you went to Indian 
country, but I think that we have to get commitments earlier 
out of Administrations to go after these Indian health 
problems. I also tell you, the problems surrounding alcohol, 
gangs, and health are truly beyond what we understand.
    Mr. Thompson. That is true.
    Senator Domenici. They are going to have to get so bad 
before we decide to do something that it is almost shameful. 
Indian people come to us saying, what are we going to do about 
drugs? We wonder, why are there drugs in small Indian villages? 
They come and tell us alcoholism is rampant. The next thing we 
have is there are going to be crimes being committed.
    We are underfunded, too few people enforcing the law on 
Indian reservations. I am sure you, Doctor, know that, that the 
people are getting scared to death about crime.
    So Mr. Secretary, you are doing your share. I want to 
encourage that wherever you can, you urge this Administration, 
and if you are fortunate enough to be around, I hope you will 
start early to see if we cannot address these issues some way.
    Would you care to comment?
    Mr. Thompson. I certainly will. But first let me just thank 
you, Senator Domenici, for all that you have done. You have 
been a friend of mine for a long time. I always am impressed by 
whenever you speak, you come out with such wonderful 
commonsense. It is a tremendous tribute to you that you are 
able to do that.
    In regards to Indian country, there are so many problems. I 
have been there. I have traveled all over this country. Every 
time I go there I get more depressed, but at the same time when 
I am there I also find some very good things that are 
happening. Yesterday in the hospital in Chinle, they had a huge 
program there of information. They had a wellness center set up 
that they went right out into the communities to teach people 
about nutrition and about exercise. They have this whole semi 
full of information and equipment that goes out and test 
people.
    These are the kind of things we have to do. We have to find 
the resources. I told the delegates who were assembled in 
Window Rock, the first Cabinet Secretary that has ever talked 
to all of the delegates. They told me all of the things they 
needed. I said, you have to prioritize. You have to tell me 
what are the four or five things that we need to work on right 
now, and then find the money to do that. I think we are going 
to start that dialogue, and hopefully we will be able to come 
up with it.
    I do not think I will be here in the next Administration, 
Senator. I have already indicated I am leaving. But I certainly 
am going to stay committed in this fight, especially on 
diabetes, not only on Indian reservations, but across this 
country. It is an epidemic that all of us have to face, and we 
have to do something about it.
    Senator Domenici. Thank you very much, Mr. Secretary.
    Mr. Thompson. Thank you. Thank you for your cooperation.
    Senator Domenici. Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Speaking of wellness centers, I happened to live on the 
Southern Ute Reservation, where they got tired of waiting for 
Government help on building a wellness center. They finally 
built it themselves. They not only have the gym and classes on 
diets and healthful living, but they actually give cooking 
classes in the wellness center, too. I think that is really, 
very frankly, on the forefront of what we need to be doing on 
more reservations because I think most of us recognize 
prevention is vital.
    Mr. Thompson. It is interesting, the Navajo Nation, Senator 
Campbell and Senator Domenici, were having their delegate 
meetings this week. They were talking about bonding I think it 
was $375 million to expand economic development on the Navajo 
Nation. They said they are the first ones to do this. It is a 
huge undertaking by them, but they want to become self-
sufficient. They are tired of waiting. They want to be able to 
go out and create economic development and jobs on the 
reservation.
    I applauded them. I thought it was a wonderful thing.
    The Chairman. I do, too.
    Let me ask just another maybe one or two more questions, 
and we will wrap it up.
    According to the Department of Health and Human Services 
information, the data on the State children's health insurance 
program is either not complete or not reliable. Yet the states 
and the Department are required by law to get this data. What 
good is it if it is unreliable? Why are we doing this?
    Dr. Grim.
    Mr. Grim. The information that we have on SCHIP in Indians, 
we just feel like they are not accessing it appropriately. We 
have worked with CMS through the Department, and we are trying 
to increase the outreach efforts for Indian children in SCHIP. 
We have waived the co-pay provisions for them in case that was 
an access barrier. We are doing all we can to increase our data 
on how many children are enrolled and what we can do.
    The Chairman. Could you take a period of time, maybe over 6 
months or so, and get back to the committee? I will not be 
here. Senator McCain will be chairing or Senator Akaka, to give 
them, if you have some results on your outreach, if it has 
helped? Get more people involved in it?
    Mr. Grim. Yes, sir; we will do that.
    The Chairman. The other question for you, Dr. Grim, you 
know, years ago the relocation policy in which Indians were 
pretty much uprooted and moved from all the reservations to 
downtown cities, has created some real problems. We have talked 
about this a couple of times. We created urban Indian health 
clinics because we found that the regular clinics a lot of 
times do not want to deal with Indians. They say, wait a 
minute; you are an Indian from Arizona or New Mexico; go back 
to your reservation and get treated.
    Well, you cannot go 1,000 miles and get treated. You are 
there in the city and you are sick, you have to go wherever you 
can. That is what the Indian health programs were supposed to 
be about. Have those programs improved at all, the health care 
of Indians? Have you noticed any kind of reliable data on that?
    Mr. Grim. Yes, sir; we have data that we could show you 
from the urban Indian programs on the health status. The urban 
Indians face the same problems as far as health disparities as 
the rest of our population do, and sometimes greater because of 
their isolation from their culture. But the programs that we 
have, we have a number of very, very successful programs that 
our grants have funded across the Nation. We have them in 34 
different cities across the Nation. They range from outreach 
efforts to full ambulatory care facilities. They are doing an 
excellent job of providing care to that population.
    The Chairman. Maybe another sidebar, too, on updating the 
progress that you have done with Indian tribes are the National 
Institutes of Health and the Centers of Disease Control. Has 
there been any additional care going toward the uranium miners 
that suffered, the Navajo uranium miners of some years ago?
    Mr. Grim. There is no specific earmarks that have been put 
forth for that in our budget, but we have been treating the 
uranium miners in our facilities and taking care of them and 
their families as the issues arise.
    The Chairman. Okay, thank you.
    As I understand it, the IHS professionals, if they are 
licensed in one state they can practice anywhere. Is that 
correct?
    Mr. Grim. Yes, sir.
    The Chairman. If they can do that, is there a way we can 
apply those same principles to tribal health care professionals 
operating under a 638-contract?
    Mr. Grim. Right now, under current authorities, we have not 
thought that possible, but in the reauthorization in H.R. 2440, 
I believe that that is recommended and the Department will work 
with you on that.
    The Chairman. Okay. So finally, then I conclude, and 
hopefully I am right, that you are in support of H.R. 2440, 
both of you?
    Mr. Thompson. Absolutely.
    The Chairman. Okay. I appreciate it.
    Mr. Thompson. And enthusiastically, Senator.
    The Chairman. With only 23 or 24 working days, I do not 
know how far we can go, but we are going to try and get this 
thing as far as we can before we are out of here. If we cannot, 
hopefully next year whoever replaces you and replaces me, while 
we are out riding together, we will pursue this.
    Mr. Thompson. We are going to get it passed this year, 
Senator. This is going to be our capstone, you and I.
    The Chairman. That is great. I hope so.
    Thank you for appearing. This committee is adjourned.
    [Whereupon, at 3:15 p.m. the committee was adjourned, to 
reconvene at the call of the Chair.]


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                            A P P E N D I X

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              Additional Material Submitted for the Record

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   Prepared Statement of Tommy G. Thompson, Secretary, Department of 
                       Health and Human Services

    Good afternoon, Mr. Chairman, Senator Inouye and members of the 
committee. I am honored to testify before you today on the important 
issue of reauthorization of the Indian Health Care Improvement Act 
[IHCIA]. Accompanying me today is Dr. Charles Grim, Director of the 
Indian Health Service [IHS]. This landmark legislation forms the 
backbone of the system through which numerous Federal health programs 
serve American Indians and Alaska Natives [AI/ANs] and encourages 
participation of eligible AI/ANs in these programs. Legislation pending 
before this committee and over in the House has been given the highest 
degree of consideration by the Department. My staff has worked 
tirelessly to respond to this Committee's and the House Resource 
Committee's request for our views on H.R. 2440. I am pleased to share 
with you today the result of our efforts to improve services provided 
by the Indian Health Service, Tribes, Tribal Organizations, Alaska 
Native Villages, and Urban Health Programs.
    As Secretary of the Department of Health and Human Services [HHS], 
it has been my goal to improve coordination to the maximum extent 
possible among the operating and staff divisions at the Department and 
to encourage collaboration between the Department and Tribes on the 
many programs impacting their members. As you know, upon my arrival at 
HHS, I reactivated the Intradepartmental Council on Native American 
Affairs [ICNAA] to provide a consistent HHS policy when working with 
the more than 560 federally recognized tribes.
    I am also proud of the many achievements over that past 3 years in 
the areas of access, consultation, collaboration, organization, 
education, sanitation facilities construction, and Medicare reform. 
And, I have traveled widely to Indian country over the past 3 years and 
visited with tribes from the Chippewa Indians and Oglala Sioux Tribe, 
to Alaska Native Villages including Point Hope and Kwethluk. I just 
arrived back from a visit with the Navajo Nation and will return again 
to Alaska later this month to meet with Native leaders in Anchorage and 
representatives of Southeast Alaska Rural Health Consortium in Juneau. 
Through my travels, I have recognized the need for improvements in 
facilities that provide the base from which so many health care needs 
are met. In this area, I would like to work closely with Congress to 
continue to address this need.
    The Department has improved tribal access to HHS resources in both 
appropriated funding as well as to non-earmarked funds and increases in 
discretionary set asides. Between fiscal year 2001 and fiscal year 
2003, HHS resources provided to tribes or expended for the benefit of 
tribes increased from $3.9 billion in 2001 to $4.4 billion in 2003. 
This reflects an 11-percent increase in access to HHS funding for 
tribes during just a 2-year period.
    In response to tribal leader comments at the regional tribal 
consultation session, we have honored many requests including:

   \\\\\\Establishing a Center for Medicare and Medicaid 
        Services [CMS]-Technical Tribal Advisory Group [TTAG], which 
        held its first formal meeting at the Department on February 10, 
        2004;
   \\\\\\Revising the existing HHS tribal consultation policy 
        and involving tribal leaders in this process;
   \\\\\\Helping to bridge tribal/State relations for HHS 
        programs administered through States: HHS, the National 
        Congress of American Indians [NCAI] and the American Public 
        Human Services Association [APHSA] have now entered into a 
        Federal/State/Tribal collaborative project to work together on 
        health and human services provided to Indian tribes and native 
        organizations. HHS is forming a workgroup to focus on key areas 
        of priorities identified by tribes [TANF, Child Welfare, 
        Information Systems, et cetera].;
   \\\\\\Improving outcomes of Indian children and families 
        with diabetes by increasing education and physical activity 
        programs; and,
   \\\\\\Recommending that funding be increased for the IHS 
        Sanitation Facilities Construction [SFC]: The President's 
        fiscal year 2005 Budget request for IHS includes an increase of 
        $10 million for SFC.
    Moreover, I am pleased that the Medicare Prescription Drug, 
Improvement, and Modernization Act of 2003 [MMA], passed by Congress 
last year, included two provisions identified by Indian health programs 
as high priorities. First, the MMA allows Indian health programs to use 
Medicare's bargaining power when purchasing care from Medicare 
participating hospitals for their non-Medicare patients, thus 
stretching contract health and Urban Indian health funding further. 
Second, the MMA allows IHS and tribal hospitals and clinics to bill for 
additional Medicare Part B services for the period 2005-08. Finally, we 
are pleased that the MMA includes special provisions designed to help 
assure that pharmacies operated by Indian health programs, as well as 
other pharmacies, can participate in the temporary drug discount card 
and the permanent Part D drug benefit programs.
    The Department is strongly committed to the reauthorization of the 
IHCIA during this Congress in order to improve the health status of 
American Indian people and to increase the availability of health 
services for them. We believe that reauthorizing legislation should 
provide increased flexibility to enable the Department to work with 
tribes to improve the quality of health care for American Indian 
people, to better empower the tribes to provide quality health care, to 
increase the availability of health care, including new approaches to 
delivering care, and to expand the scope of health services available 
to eligible American Indians and Alaska Natives.
    Accordingly, I commend Congress for including in H.R. 2440 various 
changes that respond to concerns raised in our September 27, 2001 bill 
report to the Senate Committee on Indian Affairs on S. 212, a similar 
IHCIA reauthorization bill in the 107th Congress. Moreover, I would 
like to note our particular interest in, and support for, certain 
provisions of H.R. 2440. I am impressed with the strengthening of 
provisions in all program areas including:
    No. 1, improving recruitment and retention of qualified providers, 
which are the foundation upon which all services are provided by the 
IHS, Tribes and Tribal Organizations and Urban Health Programs [ITUs];
    No. 2, providing for improved health services to eligible Indians;
    No. 3, exempting Indians from cost sharing in the Medicaid and 
SCHIP programs, consistent with our current treatment of eligible 
Indian children under SCHIP; and,
    No. 4, expanding behavioral health programs to provide for much 
needed prevention and treatment in the areas of child sexual abuse, 
family violence, mental health, and other problems.
    In addition, we believe that H.R. 2440, by proposing to protect 
eligible Indians from cost-sharing under the Medicaid and SCHIP 
programs, reflects the unique government-to-government relationship of 
the United States to federally recognized Indian tribes. We would 
support such a proposal as consistent with current HHS policy to exempt 
eligible Indian children in SCHIP from premiums and cost-sharing. The 
proposed policy on cost-sharing would go far toward addressing the 
continuing under-enrollment of eligible Indian individuals and families 
in Medicaid.
    In the area of behavioral health, H.R. 2440 provides for the needs 
of Indian women and youth and expands behavioral health services to 
include a much needed child sexual abuse and prevention treatment 
program. The Department supports this effort, but we recommend you 
permit the Secretary the flexibility to provide for these important 
programs in a manner that supports the local control and priorities of 
tribes to address their specific need.
    The Department does have concerns about provisions affecting the 
Medicare statute. Given the magnitude of the changes and new programs 
required by the recently enacted MMA and the challenges in implementing 
these changes by the statutory deadlines, we do not believe it is 
feasible to make additional modifications to Medicare at this time. We 
also have concerns about provisions impacting the Medicare trust funds, 
which, as you know, face significant financial challenges in the 
future. Finally, we have several serious concerns about the impact of 
H.R. 2440 on the Medicaid and SCHIP programs. Specifically, we do not 
believe that requiring access to unused SCHIP allotments is appropriate 
because it would set a precedent within SCHIP of prioritizing a 
population that is already eligible for services under current law, 
within a fixed amount of funds.
    Additionally, the Department is concerned with several provisions 
included in the bill related to consultation requirements. H.R. 2440 
proposes requirements for Federal agencies to consult with federally 
recognized Indian tribes and tribal organizations into statute. As 
exemplified by the successful outcomes of the Department's consultative 
process with the tribes, the Administration remains strongly committed 
to consultation with tribes as provided in Presidential Executive Order 
13175. Furthermore, consultation with tribes is provided for in the 
Indian Self-Determination and Education Assistance Act of 1975 
[ISDEAA]. We, therefore, recommend striking all language regarding 
consultation requirements.
    I reiterate our strong commitment to reauthorization and 
improvement of Indian health care programs, and I hope to work with 
this committee and other committees of the Congress, the National 
Tribal Steering Committee, and other representatives of Indian country 
to develop a bill that all stakeholders in these important programs can 
support. To this end, my staff will be communicating with your staff in 
the near future to share additional comments and suggestions regarding 
reauthorization.

                                 
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