    [Senate Hearing 109-162]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 109-162

                       INDIAN HEALTH CARE IMPROVEMENT ACT

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

                                 JOINT HEARING

                                   BEFORE THE

                          COMMITTEE ON INDIAN AFFAIRS
                              UNITED STATES SENATE

                                    AND THE

               COMMITTEE ON HEALTH, EDUCATION, LABOR AND PENSIONS
                              UNITED STATES SENATE

                           ONE HUNDRED NINTH CONGRESS

                                 FIRST SESSION

                                       ON

                                    S. 1057

             INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2005

                                   __________

                                 JULY 14, 2005

                                 WASHINGTON, DC

                     U.S. GOVERNMENT PRINTING OFFICE

    22-554                 WASHINGTON : 2005
    _________________________________________________________________
    For sale by the Superintendent of Documents, U.S. Government
    Printing  Office Internet: bookstore.gpo.gov  Phone: toll free
    (866) 512-1800; DC area (202) 512-1800 Fax: (202) 512-2250 Mail:
    Stop SSOP, Washington, DC 20402-0001

                          COMMITTEE ON INDIAN AFFAIRS

                         JOHN McCAIN, Arizona, Chairman

                  BYRON L. DORGAN, North Dakota, Vice Chairman

    PETE V. DOMENICI, New Mexico         DANIEL K. INOUYE, Hawaii
    CRAIG THOMAS, Wyoming                KENT CONRAD, North Dakota
    GORDON SMITH, Oregon                 DANIEL K. AKAKA, Hawaii
    LISA MURKOWSKI, Alaska               TIM JOHNSON, South Dakota
    MICHAEL D. CRAPO, Idaho              MARIA CANTWELL, Washington
    RICHARD BURR, North Carolina
    TOM COBURN, M.D., Oklahoma

                     Jeanne Bumpus, Majority Staff Director

                    Sara G. Garland, Minority Staff Director

              COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                       MICHAEL B. ENZI, Wyoming, Chairman

    JUDD GREGG, New Hampshire            EDWARD M. KENNEDY, Massachusetts
    BILL FRIST, Tennessee                CHRISTOPHER J. DODD, Connecticut
    LAMAR ALEXANDER, Tennessee           TOM HARKIN, Iowa
    RICHARD BURR, North Carolina         BARBARA A. MIKULSKI, Maryland
    JOHNNY ISAKSON, Georgia              JAMES M. JEFFORDS (I), Vermont
    MIKE DeWINE, Ohio                    JEFF BINGAMAN, New Mexico
    JOHN ENSIGN, Nevada                  PATTY MURRAY, Washington
    ORRIN G. HATCH, Utah                 JACK REED, Rhode Island
    JEFF SESSIONS, Alabama               HILLARY RODHAM CLINTON, New York
    PAT ROBERTS, Kansas

                   Katherine Brunett McGuire, Staff Director

          J. Michael Myers, Minority Staff Director and Chief Counsel

                                      (ii)

                                C O N T E N T S

                                  ----------
                                                                       Page
    S. 1057, text of.................................................     4
    Statements:
        Brandjord, DDS, Robert, president-elect, American Dental
          Association................................................   363
        Brannan, Richard, chairman, Northern Arapaho Business Council   352
        Dorgan, Hon. Byron L., U.S. Senator from North Dakota, vice
          chairman, Committee on Indian Affairs......................   334
        Enzi, Hon. Michael B., U.S. Senator from Wyoming, chairman,
          Committee on Health, Education, Labor and Pensions.........     1
        Forquera, Ralph, executive director, Seattle Indian health
          Board......................................................   353
        Grim, Dr. Charles, director, Indian Health Service,
          Department of Health and Human Services....................   335
        Hartz, Gary, director, Office of Environment Health and
          Engineering, Indian Health Service, Department of Health
          and Human Services.........................................   335
        Joseph, Rachel A., chairperson, Lone Pine Paiute Shoshone
          Reservation................................................   348
        Kashevaroff, Don, president, Seldovia Village Tribe and
          president Alaska Native Tribal Health Consortium...........   350
        Kennedy, Hon. Edward M., U.S. Senator from Massachusetts.....   334
        McCain, Hon. John, U.S. Senator from Arizona, chairman,
          Committee on Indian Affairs................................   334
        McSwain, Robert G., deputy director, Indian Health Service,
          Department of Health and Human Services....................   335
        Murray, Hon. Patty, U.S. Senator from Washington.............   347
        Vanderwagen, M.D., Craig, acting chief medical officer,
          Indian Health Service, Department of Health and Human
          Services...................................................   335
        Williard, Dr. Mary, Yukon Kuskowim Health Corporation Dental
          Clinic.....................................................   361

                                    Appendix

    Prepared statements:
        Anderson, Trudy, President/CEO, Alaska Native Health Board...   452
        Brandjord, DDS, Robert (with attachment).....................   385
        Brannan, Richard.............................................   440
        Cantwell, Hon. Maria, U.S. Senator from Washington...........   375
        Dorgan, Hon. Byron L., U.S. Senator from North Dakota, vice
          chairman, Committee on Indian Affairs......................   376
        Enzi, Hon. Michael B., U.S. Senator from Wyoming, chairman,
          Committee on Health, Education, Labor and Pensions.........   377
        Forquera, Ralph (with attachment)............................   456
        Friedman, DDS, MPH, Jay W. (with attachment).................   570
        Gottlieb, Katherine, president/CEO, Southern Foundation......   581
        Grim, Dr. Charles............................................   584
        Ignace, Georgiana, president, National Council of Urban
          Indian Health..............................................   598
        Inouye, Hon. Daniel K., U.S. Senator from Hawaii.............   379
        Joseph, Rachel A. (with attachment)..........................   623
        Kardos, B.D.S., M.D.S., Ph.D., FFOP (RCPA), Thomas B.,
          professor of Oral Biology and Oral Pathology, University of
          Otago, Dunedin, New Zealand (with attachment)..............   643
        Kashevaroff, Don.............................................   716
        Kelso, DDS, Mark, Norton Sound dental director, Nome, AK.....   381
        Kennedy, Hon. Edward M., U.S. Senator from Massachusetts.....   379
        Kovaleski, DDS, Tom, director, Southcentral Foundation Dental
          Program....................................................   382
        McCain, Hon. John, U.S. Senator from Arizona, chairman,
          Committee on Indian Affairs................................   380
        Milgrom, DDS, Peter, center director, Professor of Dental
          Public Sciences and Health Services, University of
          Washington, Seattle, WA....................................   750
        Murray, Hon. Patty, U.S. Senator from Washington.............   381
        Nash, D.M.D., M.S., Ed.D., David A., professor of pediatric
          dentistry in the College of Dentistry at the University of
          Kentucky in Lexington, KY (with attachment)................   757
        Willard, William R., professor of dental education; professor
          of pediatric dentistry, University of Kentucky Medical
          Center (with attachment)...................................   757
        Williard, Dr. Mary...........................................   784
    Additional material submitted for the record:
    Letters:
        Clark, Robert J., Bristol Bay Area Health Corporation........   788
        Dawson, RDH, BS, Katie L., president, American Dental
          Hygienists' Association....................................   793
        Evans, Robert D..............................................   798
        Juan-Saunders, Vivian, president, Inter Tribal Council of
          Arizona, chairwoman, Tohono O'odham Nation (position paper)   800
        Kaufmann, ND, Andrew J., San Carlos Apache Tribe.............   804
        Sekiguchi, et al, letter to the Editor, American Journal of
          Public Health, November 2005...............................   806
    Questions:
        From Hon. Orin G. Hatch, U.S. Senator from Utah (no responses
          at time of printing).......................................   383
    Reports:
        Intergrated Dental Health Program for Alaska Native
          Populations, by Howard Bailit, D.M.D; Tryfon Beazoglou,
          Ph.D; Amid Ismail, D.D.S.; and Thomas Kovaleski, D.D.S.....   808

                       INDIAN HEALTH CARE IMPROVEMENT ACT

                                  ----------

                            THURSDAY, JULY 14, 2005

            U.S. Senate, Committee on Indian Affairs, Meeting
                Jointly With the Committee on Health,
                Education, Labor and Pensions
                                                        Washington, DC.
        The committee met, pursuant to notice, at 10:16 a.m. in
    room 106 Dirksen Senate Building, Hon. John McCain (chairman of
    the Committee on Indian Affairs) and Hon. Michael B. Enzi
    (chairman of the Committee on Health, Education, Labor and
    Pensions), presiding.
        Present: Senators McCain, Enzi, Cantwell, Coburn, Dorgan,
    Inouye, Isakson, Kennedy, Murkowski, Murray and Reed.

     STATEMENT OF HON. MICHAEL B. ENZI, U.S. SENATOR FROM WYOMING,
      CHAIRMAN, COMMITTEE ON HEALTH, EDUCATION, LABOR AND PENSIONS

        Senator Enzi. I am going to call to order this historic
    joint meeting of the Committee on Indian Affairs and the
    Committee on Health, Education, Labor and Pensions. Today's
    hearing will focus on the state of Indian health care and
    specifically the Indian Health Care Improvement Act.
        We will be welcoming Senator McCain here shortly, and the
    rest of the members of the Indian Affairs Committee to our HELP
    Committee meeting room. Senator Kennedy and I started a policy
    of punctuality and we are continuing that. We will go ahead and
    make our comments and then they can make theirs when they
    arrive.
        Earlier this year, Senator McCain did approach me about
    holding a joint committee hearing on the state of Indian health
    care. I immediately accepted, as health care is important,
    perhaps the most important issue facing tribes today, in fact,
    facing all people today. Today's hearing will enable us to
    chart our current progress and discuss what we can do to
    increase the services that are available to address the
    physical and emotional problems that continue to plague
    American Indians and Alaska Natives.
        When the Indian Health Care Improvement Act was first
    signed into law in 1976, it was written to address the findings
    of surveys and studies that indicated that the health status of
    American Indians and Alaska Natives was far below that of the
    general population. It continues to be a matter of serious
    concern that, as the health status of most Americans continues
    to rise, the status of American Indians and Alaska Natives has
    not kept pace with the general population.
        Studies show that American Indians and Alaska Natives die
    at a higher rate than other Americans from alcoholism,
    tuberculosis, auto accidents, diabetes, homicide and suicide.
    In addition, a safe and adequate water supply and waste
    disposal facilities, something we all take for granted, is not
    available in 12 percent of American Indian and Alaska Native
    homes, as opposed to 1 percent in the rest of the Nation.
        Several years ago, residents of the Wind River Reservation
    in Central Wyoming faced a drinking water shortage that
    threatened the health and safety of everybody in the area, so
    drinking water was donated to tribal members and local
    residents. The lack of these basic services makes life even
    harsher for these people and contributes to those already-high
    death rates. Coming from Wyoming, I know full well the problems
    we encounter in the effort to provide quality health care to
    all people of my home State.
        As I noted during my visits to the Wind River Reservation,
    their problems are not unique. They have an impact on all those
    who live on reservations from coast to coast. We need to take a
    varied approach to address each of those problems separately.
    Clearly, people of different ages have different problems.
        A multifaceted approach to solving each of the problems
    will require a systematic, as well as financial approach.
    Local, State and national governments and agencies must work
    together with tribal leaders to focus our resources where they
    will do the most good. That kind of approach has the greatest
    chance of being successful.
        I appreciate all the witnesses taking time out of their
    busy schedules to be with us today. In addition, of course, I
    would like to welcome Richard Brannan, the chairman of the
    Northern Arapaho Business Council of Fort Washakie, WY. No one
    knows better than he does the problems faced by those living on
    reservations and by those who rely on the Indian Health Service
    for their health care needs. I am very pleased he was able to
    make the journey and to share his experiences with us today.
        I look forward to his comments and those of the entire list
    of witnesses. Each of you has a perspective and a point of view
    to share that only you can provide. I look forward to hearing a
    summary of your prepared remarks so that we can address the
    underlying issues during our question and answer session.
        To the members of the joint committees, we have a
    longstanding tradition on the HELP Committee that opening
    statements are made by the Chairman and Ranking Member, and due
    to the combined number of members of both committees and the
    fact that we have three panels and the fact that we begin
    voting again at 3 p.m., I would respectfully submit or ask that
    the tradition apply for today's hearing, but all members' full
    statements will be made a part of the record, as will all
    witnesses full statements be made a part of the record.
        In addition, members may use the question and answer period
    to make remarks. I did mention that this is an historic
    situation of having the two committees that have an intense
    interest in Indian health working together to come up with some
    solutions. I really appreciate Chairman McCain suggesting that,
    and following through on it. I think this will be the first
    time that this has actually been done outside of Energy and
    Water. This is probably an appropriate place to do it.
        [Text of S. 1057 follows:]

        Senator Enzi. Chairman McCain, welcome to our home.

       STATEMENT OF HON. JOHN McCAIN, U.S. SENATOR FROM ARIZONA,
                 CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

        Senator McCain. Thank you very much, Mr. Chairman. I will
    make my statement part of the record and ask unanimous consent
    to do so.
        I would just like to comment that this act is long overdue.
    It is important. I think you, in your opening statement,
    articulated the importance of this legislation very well. I am
    very pleased for Senator Dorgan and I to have the opportunity
    to work with you and Senator Kennedy and get this bill done. It
    is long overdue.
        Thank you, Mr. Chairman.
        Senator Enzi. Thank you.
        [Prepared statement of Senator McCain appears in appendix.]
        Senator Dorgan.

      STATEMENT OF HON. BYRON L. DORGAN, U.S. SENATOR FROM NORTH
           DAKOTA, VICE CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

        Senator Dorgan. Mr. Chairman, let me just add my thank you,
    and ask that my statement be made a part of the record. I have
    said often I think we have a bona fide emergency in health care
    on Indian reservations, the first Americans. I hope very much
    that this hearing is one more stimulus towards finally passing
    this legislation. We should have done it in the last session of
    Congress, but we were unable to get there.
        So my hope is, and I believe Senator McCain and I have
    worked very hard and appreciate your cooperation to do this. My
    hope is that we will get a bill to the President for signature
    that advances health care on Indian reservations and with
    Native Americans.
        Thank you very much.
        Senator Enzi. Thank you.
        Senator Kennedy.

        STATEMENT OF HON. EDWARD M. KENNEDY, U.S. SENATOR FROM
                             MASSACHUSETTS

        Senator Kennedy. Mr. Chairman, I want to first of all join
    you in thanking Senator McCain and Senator Dorgan for inviting
    us to participate in this program. As we know, they have the
    primary jurisdiction in terms of where Native Americans are
    living, and the enormous health disparities that exist for
    Native Americans in Indian country.
        We know that also there are a number of Native Americans
    who are in urban areas. We want to try and make sure, to the
    extent that we can, is harmonize whatever we are doing here and
    in your committee so it ties on into the excellent legislation
    which they have introduced.
        I just want to commend them. It has been far too long since
    the Senate addressed this issue. We have many health challenges
    in this Nation, but the disparity issue is such a compelling
    one. We will hear time after time of what is happening out
    there in Indian country this afternoon. And that is absolutely
    intolerable in our country and in our society.
        Once in a while we get disparities in urban areas among
    different kinds of groups, but if we look at the total range of
    health disparities, it does not exist in any place in our
    Nation as it exists with Native Americans. This cries out for
    action. It cries out for response.
        I just want to thank Senator McCain and Senator Dorgan for
    their leadership. This legislation is way, way overdue. I thank
    you for having the hearing and giving the spotlight on this. I
    pledge to work with you and our colleagues to do what we can so
    we have a seamless web in trying to make sure that those whose
    tradition comes from Indian land are going to have the kind of
    health care needs that they are entitled to in our Nation.
        I thank you, and I would like to ask that my full statement
    be put in the record.
        [Prepared statement of Senator Kennedy appears in
    appendix.]
        Senator Enzi. Without objection, all statements will be in
    the record.
        I think you can tell from the opening statements that there
    is a lot of passion behind this, so let's get on to the
    witnesses. Our first witness is Dr. Charles Grim. Dr. Grim is
    the director of Indian Health Service. He is the Assistant
    Surgeon General and holds the rank of Rear Admiral in the
    Commissioned Corps of the Public Health Service. We thank you
    for being here, Dr. Grim.

    STATEMENT OF Dr. CHARLES GRIM, DIRECTOR, INDIAN HEALTH SERVICE,
    DEPARTMENT OF HEALTH AND HUMAN SERVICES, ACCOMPANIED BY ROBERT
     G. McSWAIN, DEPUTY DIRECTOR; GARY HARTZ, DIRECTOR, OFFICE OF
      ENVIRONMENT HEALTH AND ENGINEERING; AND CRAIG VANDERWAGEN,
                   M.D., ACTING CHIEF MEDICAL OFFICER

        Mr. Grim. Thank you, Chairman Enzi.
        Mr. Chairman and members of the committee, we are very
    appreciative of this joint hearing that you agreed to hold and
    we are very honored to be able to testify before you here today
    on the important issue of the reauthorization of the Indian
    Health Care Improvement Act.
        My name is Dr. Charles Grim. I am accompanied today by
    Robert McSwain, my deputy director; Craig Vanderwagen, our
    acting chief medical officer; and Gary Hartz, our director for
    the Office of Environmental Health and Engineering. I will be
    giving the opening comments for the Department, but my
    colleagues are with me today so that we can respond to your
    questions.
        This month, July 2005, marks the 50th anniversary of the
    Transfer Act, Public Law 83-568, which officially transferred
    the Indian health programs from the Bureau of Indian Affairs
    [BIA] to the U.S. Public Health Service, effectively
    establishing the Indian Health Service. The Transfer Act
    provided that all functions, responsibilities, authorities and
    duties relating to the maintenance and operation of hospitals
    and health facilities for Indians and the conservation of
    Indian health shall be administered by the Surgeon General of
    the United States Public Health Service.
        This transfer was significant in that our program was moved
    to an executive branch department, then the Department of
    Health, Education and Welfare, and now the Department of Health
    and Human Service. This transfer was more appropriate to the
    role of the Federal Government in addressing the health care
    needs of American Indians and Alaska Natives. Since the
    Transfer Act, the health status of Indians have improved
    significantly.
        Today, we are here to discuss another significant milestone
    in the evolution of our Federal Government's responsibility for
    the provision of health services to American Indians and Alaska
    Natives, the Indian Health Care Improvement Act which was first
    authorized in 1976. It forms the backbone of the system through
    which the Federal health programs serve American Indians and
    Alaska Natives and encourage their participation in these and
    other programs.
        IHS has the responsibility for the delivery of health
    services to more than 1.8 million federally recognized American
    Indians and Alaska Natives through a system of IHS, tribal and
    urban Indian-operated facilities in programs based on treaties
    and judicial decisions and statutes. The mission of the agency
    is to raise the physical, mental, social, and spiritual health
    of the American Indian and Alaska Natives to the highest level
    in partnership with the population we serve. Our goal is to
    assure that comprehensive, culturally appropriate, acceptable
    personal and public health services are available and
    accessible.
        Our foundation is to uphold the Federal Government's
    responsibility to promote healthy American Indian and Alaska
    Native people, communities and cultures, and to honor and
    protect the inherent sovereign rights of tribes.
        The Indian Health Care Improvement Act builds upon the
    Snyder Act of 1921, which authorized regular appropriations for
    the relief and distress and conservation of health of American
    Indians and Alaska Natives. Like the Snyder Act, the Indian
    Health Care Improvement Act authorizes programs that deliver
    health services to Indian people, as well as providing
    additional directives and guidance.
        For example, the Indian Health Care Improvement Act
    contains specific authorities addressing recruitment and
    retention of health professionals serving Indian communities,
    the provision of health services, the construction, replacement
    and repair of health care facilities, access to health
    services, and the provision of health services to urban Indian
    people.
        We are here today to discuss the reauthorization of the
    Indian Health Care Improvement Act and its impact on programs
    and services provided for in current law. S. 1057 proposes to
    amend current program authority to assure the highest possible
    health status for Indians. Improving access for health care for
    all eligible American Indians and Alaska Natives is critical to
    achieving this goal and a priority for all those involved in
    the administration of this important program.
        S. 1057, however, also provides expansions which may
    negatively impact access by requiring the secretary to consult,
    negotiate, develop reports and establish programs and
    activities beyond the reasonable scope necessary to effectively
    implement the Indian Health Care Improvement Act. In S. 1057,
    between desire to improve access and provisions that
    potentially compromise access, we hope to find a means for
    achieving our common goal.
        Since enactment of the Indian Health Care Act in 1976,
    statutory authority has substantially expanded programs and
    activities to keep pace with advances in health care delivery
    and administration. Federal funding for the Indian Health Care
    Improvement Act has contributed billions of dollars to improve
    the health status of American Indians and Alaska Natives. Much
    progress has been made, particularly in the areas of infant and
    maternal mortality.
        The Department has also reactivated the Intra-departmental
    Council on Native American Affairs to provide a consistent HHS
    policy when working with more than 560 federally recognized
    tribes. This council, which was authorized in the Native
    American Programs Act of 1974, gives the IHS Director a highly
    visible role within the Department on Indian policy. I serve as
    the vice chair of that council.
        The Department has also revised our consultation policy
    recently through a process which involved tribal leaders. The
    policy emphasizes the unique government-to-government
    relationship between Indian tribes and the Federal Government
    and assists in improving services through better
    communications. Consultation is conducted at different levels
    and includes annual budget consultations with tribes to ensure
    their participation in this important process. The annual
    budget meetings provide tribes with an opportunity to meet
    directly with all department agencies and identify their
    priorities for upcoming years.
        In addition, the Centers for Medicare and Medicaid Services
    has established a technical tribal advisory group which was
    established to provide tribes a vehicle to communicate concerns
    and comments to CMS on Medicare, Medicaid and SCHIP policies
    impacting their members. IHS has been vigilant about improving
    outcomes for Indian children and families with diabetes by
    increasing education and physical activity programs aimed at
    preventing and addressing the needs of those susceptible or
    struggling with this potentially disabling disease.
        The Department has not been a passive observer of the
    health needs of eligible American Indians and Alaska Natives,
    yet we recognize the health disparities among this population
    do exist and are among some of the highest in the Nation for
    certain diseases, as you pointed out. We know that improvements
    in access to IHS and other Federal programs and private sector
    programs will result in improved health status for Indian
    people.
        We support the provisions that increase the flexibility of
    the Department to work with tribes and urban Indian programs to
    increase the availability of health care, including new
    approaches to delivering care and to expand the scope of health
    services available to American Indians and Alaska Natives. I
    commend Congress for including in S. 1057 various changes that
    respond to the concerns raised in previous proposals. Some of
    the changes improve the ability of the Secretary to effectively
    manage the program.
        In the area of behavioral health, title VII of S. 1057, it
    provides for the needs of Indian women and youth and expands
    behavioral health service to include a much-needed child sexual
    abuse and prevention treatment program. The Department supports
    this effort, but opposes specific requirements in certain
    sections of this title, specifically 704, 706 and 711.
    Essentially, it is a ``shall'' versus ``may'' issue that
    diminishes the flexibility of the secretary in providing for
    these important programs in a manner that supports the local
    control and priorities of tribes and be able to address their
    specific needs.
        The Department also opposes a new section 104(a)(2) which
    proposes to allocate the Indian Health Profession Scholarship
    Program funding by formula to the 12 IHS areas. If allocation
    by formula is authorized, students will not be given an
    opportunity to apply for a scholarships if their area does not
    receive an adequate allocation and if their desired profession
    is not considered a priority in their area, even though there
    may be great needs nationally for such professions. We would
    recommend that this program remain a national program.
        My written testimony includes other specific areas of
    concern. In addition, the Department continues to carefully
    analyze all provisions contained in S. 1057. The department
    would like to continue to work with your committees to discuss
    our concerns with the bill as drafted.
        Based on the work that has occurred between the Department
    and congressional committees in the 108th Congress on the
    predecessor proposal, S. 556, to this current bill S. 1057, I
    am confident that we can reach a mutual agreement on a bill
    that can be acceptable to our parties, including tribes and
    urban Indians, and raise their health status in the years to
    come.
        I would be pleased to answer any questions that you may
    have, and thank your for having us today.
        [Prepared statement of Dr. Grim appears in appendix.]
        Senator Enzi. Thank you very much for being here. I will
    mention that we are going to have some confusion with votes
    that are starting at 3 p.m. today, but one of the things that
    we do by having people serve on panels, we are hoping that they
    are also open to written questions. A lot of times we have
    written questions anyway that go into much more detail than
    would be possible for us to be able to do in a forum like this.
        So we hope that all witnesses will be open to answering
    written questions, from all committee members. Our purpose is
    to build a record so that we have the capability to write the
    best bill. I appreciate the testimony you have given.
        As you might be aware, I am very interested in expanding
    health information technology to all health care providers. We
    have done some legislation on that. Could you briefly tell me
    what kinds of information technology activities are occurring
    in the Indian Health Service? More importantly, are there any
    barriers to broader implementation of those programs?
        Mr. Grim. The Indian Health Service has had electronic
    health records for many, many years. Just this year, we started
    the implementation of a fully electronic graphical user
    interface health record. It has now been rolled out in 24 of
    our sites. We are in hopes that by the year fiscal year 2008 or
    2009, we will have a fully electronic health record in all of
    our programs. We are making use of the latest technology that
    there is. We have tele-health programs that are excellent that
    are in the State of Alaska that tie all of the community health
    clinics into some of the regional hub hospitals. We are looking
    at the expansion of tele-medicine across our agency in the
    years ahead. We have it in various sites, but not others.
        So I would say, Senator, that we are I think right on the
    cutting edge. We are working with the President's Health
    Information Technology Program. We have representatives that
    are sitting on that. I would be happy to answer anything
    further or more details that you might about that for the
    record.
        Senator Enzi. I will do some followup questions in writing.
        Senator McCain.
        Senator McCain. Thank you very much, Dr. Grim.
        For the record, you might mention who is accompanying you
    at the table.
        Mr. Grim. Okay. I have my deputy director, Robert McSwain;
    Gary Hartz, our director for the Office of Environmental Health
    and Engineering; and Craig Vanderwagen, our chief medical
    officer.
        Senator McCain. Welcome.
        Doctor, we have been around this track a few times before,
    as you know.
        Mr. Grim. Yes, sir.
        Senator McCain. Last year, you raised several objections.
    We tried to accommodate them. A lot of those objections have to
    do with flexibility. You want maximum flexibility for the
    Department to work on meeting the health care needs of Indian
    people. I understand that. Most bureaucracies do. But some of
    the objections you raised last year and this year seem to
    reflect an unwillingness to accord the same flexibility to
    Indian tribes. We find that not proportional. What is your
    response?
        Mr. Grim. I would just say that we would continue to work
    with the committee if there are specific provisions in the bill
    where you think that we are giving up the tribes' flexibility I
    would be more than happy to discuss it.
        As I mentioned earlier, we have a very robust consultation
    policy within both the Department and the Indian Health
    Service, and do not make any major policy or budgeting
    decisions without consulting tribes. So we would be more than
    happy to work with the committees on those specific issues.
        Senator McCain. One specific issue, you raise objection to
    the GAO preparing a comprehensive baseline report on Indian
    health facilities that is presently in the bill.
        Mr. Grim. Yes, sir.
        Senator McCain. Yet your department has never been able to
    provide the tribes or Congress any total information on the
    number, size or status of the Indian health facilities. If the
    GAO does not prepare a comprehensive baseline report, then who
    does?
        Mr. Grim. The reason that we made those comments, Senator
    McCain, is that the agency has been in the process over the
    course of the last 1\1/2\ years in consulting with tribes on a
    new priority system for the agency. It will be a more expansive
    type of priority system than our current one. We are in the
    final process of that. We had a tribally driven work group
    called the Facilities Appropriation Advisory Board, made up of
    tribal members across the Nation that developed a priority
    system recommendation with waiting and criteria.
        We sent that out to tribal leaders all across the Nation.
    We received over 800 comments on that. The group incorporated
    those and they are very close to making a recommendation to me.
    That will be a much more comprehensive listing than we
    currently have. That was the reason we asked that reference to
    GAO doing that report be removed. We feel that we are very,
    very close to implementing that. It has been through tribal
    consultation.
        Senator McCain. How does a GAO baseline report interfere
    with any of the things you just said? Are you concerned about
    needless expenditure of taxpayer dollars? I do not see how a
    GAO report would interfere with any of the good things that you
    just described.
        Mr. Grim. Our concern, I think, is that it would take
    additional time of agency staff. We are almost there. We almost
    have the data. We would have to work with GAO I think rather
    extensively to get the data transferred over to them into a
    report, but if that is the committee's wish.
        Senator McCain. Mr. Chairman, I have several questions I
    would like to submit for the record. I thank you, Mr. Chairman.
        I thank the witnesses.
        Mr. Grim. Certainly, Senator.
        Senator Enzi. Senator Dorgan.
        Senator Dorgan. Mr. Chairman, thank you very much.
        Dr. Grim, you and I have had plenty of opportunity across
    the dais to talk about these issues. I will not ask you again
    the question, what was your recommendation to the Office of
    Management and Budget for funding for the Indian Health
    Service. Was it substantially different than that which was
    expressed in the President's budget to the Congress? I have
    asked you that a couple of times and I think you have felt like
    you have been unable to answer it or unwilling to answer it and
    would probably get in trouble if you answered it. Do you still
    feel that way?
        Mr. Grim. Yes, sir. [Laughter.]
        Senator Dorgan. Why don't we get you in trouble today?
    [Laughter.]
        Let me ask you, at a recent hearing one of the witnesses
    who testified after you and Dr. Carmona spoke mentioned that
    the Indian Health Service is funded at about 40 percent or 45
    percent of the level of need. What is your assessment of that?
    Almost all of us would agree that there are in many cases a
    bona fide emergency with respect to health care on
    reservations, so it is funded at something below the level of
    need. What is your assessment of the statement that it is only
    at 40 percent or 45 percent?
        Mr. Grim. We have some data on that and we can provide that
    for the record, Senator Dorgan.
        Senator Dorgan. But do you think it is 50 percent of the
    level of need or 75 percent of the level of need? Any notion?
        Mr. Grim. We have data that we update annually on that and
    I cannot recall what the exact numbers are right now, but we
    will provide that.
        Senator Dorgan. Do any of your staff know the answer to
    that? It just seems to me like that is a pretty fundamental
    question. What is the need out there and how close are we to
    meeting the need? I have said before in other venues that we
    have a trust responsibility for health care for American
    Indians. We also have responsibility for health care of Federal
    prisoners, and we spend about twice as much per capita for
    Federal prisoners' health care as we do for Native Americans'.
        So it seems to me just by observation we are something
    substantially below the level of need. I am trying to determine
    whether we have any notion of what that is.
        Mr. Grim. We do have a notion of what that is. I do not
    know if it has been updated for the current fiscal year,
    Senator Dorgan, but it is somewhere in the nature of 60
    percent.
        Senator Dorgan. At 60 percent? All right. That would
    suggest we are about 40 percent short of fulfilling the need,
    which is really a serious, serious omission.
        My colleague, Senator McCain, asked the question about the
    health care facilities. I believe this year the recommendation
    is a cut in health care facilities. I think it is around $70
    million, $75 million. I would share his question about why
    would anybody object to a GAO baseline report. I understand
    that you are working on a priorities list. I also understand
    from an inquiry I made yesterday that that is about 6 months or
    9 months away.
        Mr. Grim. We have done the master health services planning
    for that whole process across our regions, but you are probably
    accurate in an about 6-month timeframe before a final report
    would be done. What we still have yet to do is we have told the
    tribes that if the recommendations that all came in resulted in
    a significant change to either the criteria that we were
    suggested or the weighting of the criteria, that we would come
    back to tribal leadership one more time, show them the formula,
    talk to them about the changes that had been made and why those
    had been made based on the recommendations from around the
    Nation. And then if there was not significant disagreement, we
    would implement that new priority system, run all of our health
    services master plans through that, and then come up with a
    comprehensive list.
        Senator Dorgan. Yes; there is an urgency to do that and get
    that done as quickly as possible. I hope you would not object
    to the requirement in the bill with respect to the GAO. If it
    is duplicative, so be it. Although perhaps by the time that
    would be implemented, you would have finished your report.
        I think certainly on behalf of those of us who serve on the
    Committee on Indian Affairs, there is an urgency here to find a
    way for us to move this legislation forward. We are very
    frustrated. We could not do it last year. We should do it now.
    I hope that you and others will play a constructive role in
    letting us, not letting us, in cooperating with us to move this
    legislation sooner rather than later.
        Mr. Grim. Yes, sir; Senator Dorgan.
        Senator Dorgan. Thank you, Mr. Chairman.
        Senator Enzi. Thank you.
        Senator Murkowski.
        Senator Murkowski. Thank you, Mr. Chairman.
        Welcome, Dr. Grim. I always appreciate your being here and
    hearing from you. Your statement this afternoon does not make
    any reference to the Dental Health Aide Therapist Program. We
    are going to be hearing a little bit more on the third panel
    this afternoon. As a dentist and as a public health
    professional, can you give your opinion regarding this program?
        Mr. Grim. I have traveled to Alaska numerous times, as you
    know.
        Senator Murkowski. And we like that.
        Mr. Grim. I am looking forward to coming again sometime
    soon. I have traveled with our former secretary to that region.
    We did have an opportunity to talk with the tribes about that
    particular program the last time we were up there last summer.
    We felt that the program had merit, and since then additional
    views have been coming forward and additional concerns.
        We are continuing to meet with all the parties that are
    concerned. We have met with the Alaska tribes. We have met with
    the American Dental Association. We continue to try to look for
    a solution to the problems of the high levels of unmet dental
    care that occur in the bush in the very rural parts of Alaska.
    We are committed to working with you and with the tribes there
    to try to resolve that issue.
        Senator Murkowski. Some of us feel that one way to resolve
    it is through this Dental Health Aide Therapist Program. Can
    you kind of speak to some of the challenges that IHS has in
    recruiting dentists for rural Alaska and to these villages?
        Mr. Grim. Yes; I can, Senator. We currently have about a 24
    percent vacancy rate for dentists nationally, IHS-wide. The
    last statistics that I had seen from the tribes in Alaska
    showed that in the outer-lying parts of Alaska that number is
    getting close to about 50 percent. We are having trouble
    nationally recruiting dentists into many of our programs.
        So we continue to work with organizations like the American
    Dental Association. We work with the U.S. Association of
    Colleges of Dentistry to try to do what we can to recruit at
    locations like that, but currently we are simply lacking the
    ability to fill those.
        Senator Murkowski. Are you having any success with that
    recruitment then?
        Mr. Grim. We are able to fill our positions to this level,
    but we seem to be at about this level and cannot seem to quite
    get over to filling greater than about 75 percent of our dental
    positions right now. It has been hovering around that for a
    couple of years.
        Senator Murkowski. So as we look into the future, then,
    with meeting the dental health care needs of our Alaska Natives
    in our villages, do you see a way that we are going to be able
    to get enough dentists out there in rural Alaska to meet the
    need?
        Mr. Grim. I think it is going to require a long-term
    concerted effort, but I am always hopeful that we are going to
    be able to do that. We continue to have moneys in our
    scholarship and loan repayment programs that we use to try to
    train new native students, and I think we need to continue to
    try to be very aggressive at recruiting current Alaska Natives
    who want to get into dental school and try to encourage them to
    do that; get them into our scholarship program and hopefully
    have them go back home and serve their obligations in their
    communities, and then continue to stay with their tribal
    programs and serve out their professional career.
        I do think it is going to be a long-term effort. We are
    working with all sorts of individuals, as I said, universities
    and the American Dental Association, among others, to try to
    jointly work on that issue for the Indian Health Service.
        Senator Murkowski. You have kind of ducked the specific
    question of how you feel about the Dental Health Aide Therapist
    Program. What I am hearing you say is you recognize the need.
    We have to do something. We must do something and that you are
    going to be working with us on that.
        Mr. Grim. Yes; Senator Murkowski.
        Senator Murkowski. Thank you, Mr. Chairman.
        Senator Enzi. Thank you.
        Senator Reed.
        Senator Reed. Thank you, Mr. Chairman.
        Thank you, Dr. Grim.
        Let me follow on with Senator Murkowski's question and
    broaden it to recruiting other health care professionals. It is
    not just dentists you have a problem recruiting. Could you lay
    out the shortcomings for recruiting as you see them today?
        Mr. Grim. I can give you some specifics on percentages of
    where we are right now in many of the professions. I can supply
    that for the record. Really, a lot of what we deal with tracks
    with what the Nation as a whole is. There is a nursing
    shortage, and so we are facing difficulty recruiting nurses as
    well. Pharmacy and dentistry continue to be areas where we have
    high vacancy rates, too, and it seems to track with some of the
    needs in the Nation as a whole.
        So not only are we facing the private sector economy trying
    to recruit the same types of people. Many times our locations
    are rural and isolated and so we have the difficulty of that as
    well on top of it. But we do have, as I said, scholarships and
    loan repayment programs. We have very active recruitment
    programs for nursing, medicine, dental, pharmacy, and we are
    doing the best we can.
        I know the professions themselves are looking at those
    issues, too, as they see the numbers of certain types of
    professions, you know, more people retiring than are graduating
    and what it is going to mean for the country.
        Senator Reed. Is there more that we can do to assist you in
    terms of legislation or appropriations? Is this simply a social
    problem that is beyond any additional help from us?
        Mr. Grim. I guess if I knew the answer, we might already be
    here. Yet we would welcome any help that the committee might be
    able to provide us. We are still studying the issues, too, and
    working with the various professional organizations. We have a
    large group of professional organizations we work with on a
    regular basis. They are all very, very supportive of our
    program and try to help us within their own ranks of their
    professions, but we still face those difficulties. Thank you
    for your support.
        Senator Reed. Doctor, Senator Dorgan alluded to the budget
    shortfalls which your rough estimate is about 40 percent gap
    between the need and the resources. In high-cost parts of the
    country like Rhode Island, where we have the Narragansett
    Tribe, not only is this funding insufficient, but the costs are
    significantly higher. Is there any attention to these areas?
    Where there are high costs, housing costs in the area where the
    tribe has their tribal lands growing at 100 percent, I am not
    exaggerating, in the last five years. It is incredible.
        Mr. Grim. I believe you.
        Senator Reed. It is hard to just maintain the staff. They
    have not had a raise in 5 years. Is there any attention to
    these specifically high-cost areas?
        Mr. Grim. Well, there are some pay adjustments that staff
    can get for living in higher cost areas, but one of the things
    that we are trying to do is to recognize it on a formula
    allocation basis. As I said, whenever we get any new additional
    program increases, we consult with tribes on how that is
    distributed across the Nation. As they have joined us in the
    process and the agency not making those decisions alone, our
    formulas for distributing money have become more and more
    complex, but more sensitive to issues like that. We have
    certain formulas now for types of funds that we give out that a
    portion of the funds are given out based on the nearest
    metropolitan area and the costs in that area. So we are trying
    to take some of that into account now as we allocate funds. We
    will divide a formula into three parts and maybe one-third is
    devoted to the costs in an area. So if you live in a higher-
    cost area, you get more funds in that component of the formula.
    So we are trying to do that to try to address it within the
    funds that we have.
        Senator Reed. Thank you very much, Doctor.
        Thank you, Mr. Chairman.
        Senator Enzi. Thank you.
        I would mention that Senator Inouye could just be here
    briefly between committee meetings and the vote. He does have a
    statement to submit and questions that he will want to have
    submitted, too. And that is open to members of both committees,
    as well.
        Senator Coburn.
        Senator Coburn. Thank you, Senator.
        Welcome from one Oklahoman to another. Glad to see you
    again, Dr. Grim.
        Mr. Grim. Thank you, Senator. Good to see you.
        Senator Coburn. Would you like to have an irreversible
    dental procedure done on you by a dental health aide? Would you
    want your family to have an irreversible dental procedure done
    by a dental health aide that has a high school graduation and
    some foreign training?
        Mr. Grim. I think if I was in a situation where I was in
    pain with a lack of adequately trained dentists, I would be
    able to do that.
        Senator Coburn. That is my whole point. We are going to
    give less quality because we are not meeting our need. I just
    came through a campaign and one of the things I was critical
    of, and I am critical of, is health care to Native Americans,
    with six times the rate for dialysis for Native Americans, six
    times the rate, which says we are not doing diabetes right. The
    question is, the ADA opposes this, but why can't you work out a
    deal where they have locum tenens up there? If they really do
    not want this to happen, why won't they volunteer for service
    up there? Let's work a deal. Let's have them do the right
    thing.
        You create an environment where we can have dentists who
    will volunteer their services for Native Alaskans and solve
    this problem while we are in a shortfall. I think you will find
    that they will be agreeable to that. I think that would solve
    the problem. But this idea of not meeting our obligation,
    meeting it by name, but not in quality, I think is one of the
    most critical things we have to do at the Indian Health
    Service. That is by no means a reflection on the people who
    work there. You have a burden and you do not have the resources
    with which to carry out the completion and attack that burden.
        With your electronic medical record, have you instituted
    best practices, especially for diabetes?
        Mr. Grim. Yes, sir; we have.
        Senator Coburn. And that is being followed? Are you
    tracking that to see the better outcomes and lower hemoglobin
    and A(1)(c)s and better compliance?
        Mr. Grim. Yes, sir; we have. We have seen a downward trend
    in the hemoglobin A(1)(c)s. We are seeing better blood pressure
    control; better us of the ACE inhibitors. We have an extensive
    database of almost our entire diabetic patient population,
    tracking both clinical indicators. We also with the special
    diabetes program funds for Indians that Congress made available
    for us, we have just recently released the report to Congress
    that shows a huge increase in the number of both primary and
    secondary prevention programs in Indian Country that were
    present now, prior to the funds were not available to the
    population.
        So we are seeing a very positive trend in the care of
    diabetes. We have been in the diabetes care business for many
    years. In fact, the diabetes grant funds, one of the things we
    did was put together with professional experts in the agency
    and the American Diabetes Association a series of 11 or 12 best
    practices that tribes could use in their grants, depending on
    what were the particular problems in their communities, and
    suggested ways they might assess which of those they wanted to
    do. So I think we have done an outstanding job with the use of
    the funds that Congress given. Tribes deserve a lot of credit
    for that because the vast majority of those funds went directly
    to tribes. They have implemented a lot of great programs.
        Senator Coburn. I would just note that the Congress refused
    to support recently with an amendment that I offered for
    additional funding for diabetes prevention. We are going to buy
    more land, rather than take care of the Native American
    obligation that we have. It was pretty disappointing to me. I
    think we got 17 votes in the Senate to fund prevention
    activities for diabetes, so it might reflect on the Senate
    where our priorities are.
        Do you ongoing tracking on prevention across the board
    within Indian Health Service?
        Mr. Grim. Yes, sir; we do. We have long been an agency and
    a health care system that focuses on prevention, not just in
    the clinic, but also in environmental health arenas as well,
    and safe water and sanitation facilities, to make huge
    improvements.
        Senator Coburn. So can you give me a time at which we are
    going to see the same type of diabetic control in the Indian
    population, Native American population, that we see in the rest
    of the population in this country?
        Mr. Vanderwagen. Dr. Coburn, I would say right now we are
    probably leading the Nation in diabetic treatment, not
    necessarily primary prevention, but in secondary prevention
    through effective treatment with evidence-based best practices.
    I would say we have evidence to support the assertion that we
    are probably leading the country right now.
        Senator Coburn. So we are going to see a decline in
    complications, amputations, dialysis?
        Mr. Vanderwagen. In fact, we have had a 50-percent decline
    over the last 5 years in amputations. We are the only sub-
    population where deaths due to ESRD have declined between 2000
    and 2002. I think the Senate, the Congress invested well in
    putting that money into that diabetes effort. Now, can we
    extend it to heart disease, cancer and other chronic diseases
    is the real challenge that I think we are facing in Indian
    country.
        Senator Coburn. Well, best practices is going to help you
    do that. This is a great example to help us know how we solve
    the rest of the health care problem in this country. It is
    called prevention. It is not treatment after the fact. It is
    prevention. And you all are to be complimented on the
    institution of best practices because it is what it is going to
    take for us to get out of the health care crisis that we are in
    in this country. My hat is off to you. I just want to see the
    results coming forward, and then work on the prevention in
    terms of diet because that is just as important for not only
    the Native American community, but the entire American
    community.
        Mr. Grim. Our three primary focus areas that we have been
    working with tribes around the country on are health promotion,
    disease prevention, behavioral health issues, both alcohol,
    substance abuse and mental health, as well as those behavioral
    issues with the lifestyle diseases like diabetes and chronic
    disease management. We are looking at better models with now
    that we might put in place in many of our programs because we
    do have a huge burden right now of patients that already have
    these diseases, but we are focusing on all three of those
    areas. Again, we are looking at some best practice models in
    chronic disease management that we will start using in some
    other disease areas.
        Senator Coburn. I can ask this later and ask it formally as
    part of the record, do you have tracking on malpractice claims
    within the Indian Health Service as relative to outside of the
    Indian Health Service? Can you give that data to the Committee
    so that we can look at it?
        Mr. Grim. Yes, sir; I believe we can.
        Mr. Vanderwagen. In brief, it is about 100 cases per year
    that come to torts. That rate really is about 50 percent
    compared to the private sector.
        Senator Coburn. Come to trial or that are filed?
        Mr. Vanderwagen. That are filed and deemed worthy and are
    carried forward. That has been a pretty steady state for about
    the last 10 or 15 years, some slight trending up. Most of that
    is associated with our larger, more complex hospitals, but we
    would be happy to give you the full picture.
        Senator Coburn. Thank you very much.
        Let me just thank you again for your service, and I am
    proud you are an Oklahoman.
        Mr. Grim. Thank you.
        Senator Enzi. Senator Murray.

      STATEMENT OF HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON

        Senator Murray. Mr. Chairman, I know that we have a series
    of votes on and another panel to come before us. I will be very
    brief.
        I just want to really thank you and Senator Enzi for having
    this joint hearing. I hope that this allows the members of our
    Health Committee to really begin to understand this legislation
    so we can move it forward. I think we all understand the severe
    crisis facing our tribal communities today and the
    responsibility that we have to make sure that we address some
    of the tremendous disparities that are out there.
        I am very pleased that my friend Ralph Forquera, who is
    from the Seattle Indian Health Board, is part of the second
    panel. I think he is going to provide us with some really
    excellent information concerning Native Americans who live in
    urban areas. I am pleased that he is here. I am sorry that we
    are going to be having votes and I will be missing much of his
    testimony, but it is very important for our committee to hear
    that.
        I think when we hear the statistics about the fact that
    Native Americans are much more likely to die from specific
    diseases, 420 percent more likely to die from diabetes, 52
    percent more for pneumonia and influenza. It goes on and on. I
    think we have a responsibility, really, to address that.
        So Mr. Chairman, I will not ask a question at this time. I
    will submit them for the record. Dr. Grim, if you could respond
    because I do know we have a series of votes. I am really
    pleased that we are having this hearing and allowing our
    Committee to begin to understand this problem and help move it
    forward.
        Thank you very much.
        Mr. Grim. Thank you for your interest.
        Senator McCain. Thank you very much, Dr. Grim. You got off
    easy today. We had a series of vote. [Laughter.]
        Mr. Grim. Thank you for that, Senator McCain.
        Senator McCain. Thank you. We would really like to get down
    to some serious negotiations so we can get this thing done as
    quickly as possible. That is going to require, and I know some
    of this is not totally up to you, but some of it going to
    require some concessions on both sides. We do have another body
    that has to consider it as well, who we have been in constant
    communication with, but this is almost an abrogation of our
    responsibilities when we do not address this much-needed
    legislation.
        So thank you, and thank your colleagues for all you do.
        Our next panel is Rachel Joseph. She is the chairperson of
    the Lone Pine Paiute Shoshone Reservation in Lone Pine, CA. She
    is also the cochair of the National Steering Committee for the
    Reauthorization of the Indian Health Care Improvement Act.
        Mr. Don Kashevaroff is the president of the Seldovia
    Village Tribe in Alaska. He is also the president and chairman
    of the Alaska Native Health Tribal Consortium. We are glad you
    could travel this long distance to be with us today.
        I would also like to send a special welcome to Richard
    Brannan, the chairman of the Northern Arapaho Business Council
    from Fort Washakie, WY. Thank you very much from Fort Washakie,
    WY. I thank you for being here today. I have appreciated all
    the expertise on tribal issues that you have provided to us
    over the years. I know the committee will appreciate your
    testimony.
        I would also like to introduce Ralph Forquera, the
    executive director of the Seattle Indian Health Board in
    Seattle, WA.
        Ms. Joseph, it is nice to see you. Please begin.
        Ms. Joseph. Thank you, Mr. Chairman.
        Senator McCain. By the way, my colleagues are voting and
    they will be coming back and forth. I want to extend my
    apologies for the interference of our parliamentary procedures.
    Welcome, Ms. Joseph.

     STATEMENT OF RACHEL A. JOSEPH, CHAIRPERSON, LONE PINE PAIUTE
                          SHOSHONE RESERVATION

        Ms. Joseph. Thank you, Mr. Chairman.
        I am here today to present testimony on behalf of the
    National Steering Committee for the Reauthorization of the
    Indian Health Care Improvement Act, the National Indian Health
    Board and the National Congress of American Indians. Thank you
    for this joint hearing and providing me the opportunity to
    testify in support of S. 1057.
        The message of Indian nations across the country is please
    reauthorize the Indian Health Care Improvement Act this year.
    This act enacted in 1976 declared this Nation's policy to
    elevate the health status of our population to the highest
    possible level. We believe this should be at parity with the
    general U.S. population. Nearly 30 years later, we are no where
    near achieving this goal. However, S. 1057 would facilitate
    forward movement.
        Health care reality in Indian country compared to the
    general population is our people still die due to accidents 204
    percent greater than rest of the population; 650 percent more
    likely to die from tuberculosis, a preventable disease; 318
    percent more likely to die from diabetes. The epidemiology
    center in the Northern Plains has recently reported that the
    Northern Plains Indians have the highest SIDS rate in the
    world. The Surgeon General reports that Indian youth are dying
    at 3.1 times greater than the general population.
        Our challenges are escalating, and like so many other
    programs in the country we are seeing employee take-backs,
    reduced hours of operation, staff reduction and burnout.
    Resources are limited and our estimates indicate that the
    Indian health budget has lost over $2.46 billion in purchasing
    power over the last 14 years.
        I have testified to this before. Medical inflation has
    increased over 200 percent since 1984. Unfortunately for the
    IHS, the OMB inflation rate ranges from 1.9 percent to 4
    percent a year, when medical costs inflation is between 6.2 and
    18 percent.
        Like the private sector, we face ever-increasing costs for
    pharmaceuticals, equipment and other costs. As raised earlier
    by the Senator, the per capita expenditures for our patients is
    approximately one-half of the per capita expenditures for
    Medicaid beneficiaries, and the expenditures for a prisoner's
    health care is almost double what is spent on a patient in the
    IHS system.
        In 1999, a national steering committee for the
    reauthorization was formed. Consultation was held extensively
    across the country to develop consensus recommendations to
    address our current needs. Included among those recommendations
    was the authorization for a comprehensive behavioral health
    program which reflects tribal values and emphasizes
    collaboration among alcohol and substance abuse social services
    and mental health programs, which was reflected in title VII of
    S. 1057. I was quite taken aback when I heard Dr. Grim express
    objection to section 11(2)(b). In fact, that has been a
    challenge for us in dealing with reauthorization. We have never
    seen a finite list of what the objections are.
        But if I might briefly talk about what our intent was when
    we developed language with 711(2)(b). This is a section dealing
    with fetal alcohol disorders. We feel strongly that we need to
    do everything we can to change the behavior of pregnant women,
    high-risk pregnant women, and women that are pregnant with
    Indian babies, to encourage them not to indulge in alcohol and
    substance abuse. That was our intent. We think this is a
    priority and we think that the program should do this. We are
    surprised that there is an objection to that provision.
        Another recommendation is authorizing the elevation of the
    Assistant Secretary, elevation of the Indian Health Service
    Director to an Assistant Secretary appointed by the President
    with the advice and consent of the Senate.
        The deplorable disparities in our health indicators
    compared to the general population require us to assert that we
    need to approach our responsibilities differently. Status quo
    is not acceptable. We believe that elevation would be
    comparable to the administration of the BIA programs by an
    Assistant Secretary in the Department of the Interior and the
    Assistant Secretary for Public and Indian Housing in the
    Department of Housing and Urban Development.
        We also recommend authorizing the Entitlement Commission to
    study the optimal way that health care should be provided to
    our people. Indian tribes strongly believe that through the
    cession of 400 million acres of land to the United States in
    exchange for promises for health care and other services often
    reflected in treaties, that we secured a de facto contract
    which entitles us to health care in perpetuity, based on the
    moral, legal and historic obligations of the United States. We
    also believe that we need to be able to address the long-term
    health care for the elderly as an option, rather than more
    expensive, costly or clinical care.
        We believe that these recommendations, many of which are
    included in S. 1057, are essential to help us modernize our
    health care delivery.
        In closing, I want you to know that in spite of our
    deplorable health conditions, we remain optimistic because our
    tribal governments and programs are having successes and do so
    much with so little. We hope for reauthorization this year. We
    hope that one day our young people no longer commit suicide
    because they will have hope. We hope that one day we will no
    longer have to deal with meth problems and other substance
    abuse in our communities. We hope that our grandchildren will
    be healthy. We hope that we can provide long-term quality
    health care to elders in the waning years of their lives.
        We hope for all these things because we know that the
    Creator has put us here for a purpose and we need your help.
        Thank you for this time.
        [Prepared statement of Ms. Joseph appears in appendix.]
        Senator Enzi. Thank you.
        Mr. Kashevaroff?

       STATEMENT OF DON KASHEVAROFF, PRESIDENT, SELDOVIA VILLAGE
      TRIBE, AND PRESIDENT, ALASKA NATIVE TRIBAL HEALTH CONSORTIUM

        Mr. Kashevaroff. Thank you, Mr. Chairman.
        My name is Don Kashevaroff. I am appearing here as the
    chair of the Tribal Self-Governance Advisory Committee, which
    has appointed me to the National Steering Committee for the
    Indian Health Care Improvement Act. I am from Alaska. I am the
    president of my very small tribe of 400. I am also the
    president and chair of the Alaska Native Tribal Health
    Consortium, which through Anchorage and the Alaska Native
    Medical Center, we co-manage that and we serve 130,000 Alaska
    Natives through the hospital and water and sewer projects in
    various other programs that we have.
        Both my small tribe and my very large company practice
    self-determination and self-governance by assessing the health
    needs of our people and redesigning and expanding our programs
    to improve the available care.
        I have a couple of issues that I want to address with you
    today. The first one is home health care. I also have submitted
    written testimony. Hopefully, that can be in the record, sir.
    What we found at ANMC, we have 150 beds. About one-quarter of
    the beds we have are taken up by folks that might or should not
    be there. If we were a private sector hospital, they would
    discharge the people. We continue to serve them because we have
    no place to send them. Many of them need step-down units and
    various other care that we do not have in existence.
        Home health care is in S. 1057, and we are very supportive
    of that staying in there. What we found out, as I have stated
    already, Indian Health Service does not have the money we need
    to provide the services to Indians. What we have been doing
    over the past few years is relying more and more on third party
    payers. We bill insurance companies, if the Indian happens to
    have insurance, we bill the insurance company. Those insurance
    companies actually say, well, you only can have a stay in the
    hospital for a couple of days and then we will not pay anymore,
    because they know that there are cheaper ways of providing
    health care to people than staying in a hospital bed. So we are
    kind of stuck with the hospitals and we do not have all the
    home health care provisions that we are looking for. So we are
    very supportive of that in the bill that we can expand those
    services.
        We have also found out that our elders, the best care we
    can give our elders are close to home. When we make our elders
    travel, they come in and they actually encounter a foreign
    language, they encounter English, and they have to be with us.
    They have unknown areas that they have to live in. They lose
    track of their families. They are removed from their family.
    Many of them just refuse to come in for care. So by having a
    home health care-based system where we are able to get out
    there and provide the services to them like the rest of the
    country has realized, will modernize IHS and bring us up into
    where we should be, and be able to provide better health care
    at a lower price. So we are very supportive of the home health
    care provisions in there, Senator.
        I would also like to touch on the Federal Tort Claims Act
    coverage. I noticed in Dr. Grim's written testimony that they
    thought that there might have been an expansion of FTCA
    coverage. To the best of my knowledge looking at the Act, there
    is no change in FTCA services to ineligible non-beneficiaries.
    The language does not increase any change in it.
        What we are faced with with Federal tort claims coverage is
    that we provide a service, and if we do not have Federal tort
    claims coverage, we have to take money out of our contracts
    support costs or a direct-service budget to pay for insurance
    that the government or IHS did not have to pay for before. So
    when our tribes take over programs, we have to have coverage.
    If we do not have coverage, we have to pay an insurance
    provider. The amount is staggering that we have to take out of
    our direct services budget.
        In ANTHC alone, if we had to provide insurance for
    everybody, we would lose about four or five specialty
    providers. We have very many specialty docs, and we would have
    to basically let them go and take the money and buy insurance.
    We do not want to be in a situation where we end up doing that.
    So I am actually puzzled a bit by Dr. Grim's written testimony
    that the Administration has these concerns that we are
    expanding coverage because we just do not see it, and maybe
    they can tell us later on where they see those concerns at.
        Real quick, also negotiated rulemaking is in the S. 1057.
    The Tribal Self-Government Advisory Committee is very
    supportive of negotiated rulemaking. We have found in the past
    that when we implemented title V of the ISDEAA that it worked
    extremely well. They even gave us awards for how well it
    worked, that we were able to get IHS in the room, and the
    tribes in the room. The tribes are delivering the health care
    out there and we are encountering a lot of things that IHS does
    not have to encounter. We have the understanding of how to
    provide health care out in the country. By working together, we
    are both able to understand the rules and put the rules down on
    paper so we can work better in the future. It has helped
    tremendously, us both having the same common understanding.
        I also wanted to mention about the dental health aide
    therapists. I know we are going to have a panel on that pretty
    quick. Alaska Native Medical Center, which is managed by the
    Alaska Native Tribal Health Consortium and by South Central
    Foundation, we strongly support dental health aide therapists.
    Without question, that is our answer to our crisis that we are
    having in Alaska. I grew up in a village that luckily had a
    dentist come every 6 months from Anchorage. And it was the same
    dentist, so he knew me, and I got decent care.
        People are concerned that there will not be good care.
    Well, these dental health aide therapists are sent out to
    school on it, and for 2 years they are down getting trained to
    do what they are going to do. I personally have had times when
    dentists maybe did not do as good a job on me as I wished they
    would have, and I had to go in for follow-up care. So I think
    it really comes down to the individual person whether you are
    going to get a quality dentist or quality care or not. We have
    a huge crisis in bush Alaska. If you go to a village of 100 or
    200 people, you are not going to have a dentist wanting to live
    there. Even if you have a volunteer come in once a year, it is
    not going to provide the services the folks need.
        I personally would love to have a DHAT work on my teeth,
    just as I go to a nurse practitioner and a physicians assistant
    for care. I have no problem doing that.
        Finally, I wanted to mention that the tribes want to have,
    fundamentally we want to look at S. 1057 and make sure that it
    does not regress from anything in current law. There was one
    instance that we found in section 403, which is the current law
    section 206, where Indian health programs may only bill third-
    party payers for reasonable charges as determined by the
    Secretary. This is a change. Our concern is by making the
    Secretary figure out what the reasonable charges are is going
    to increase the bureaucracy extensively, as opposed to current
    practice where we bill under current practice methods.
        So I do want to thank you for holding this hearing, Mr.
    Chairman, and hopefully trying to move this legislation
    forward. I am here to answer any questions.
        Thank you.
        [Prepared statement of Mr. Kashevaroff appears in
    appendix.]
        Senator Enzi. Thank you.
        Chairman Brannan.

       STATEMENT OF RICHARD BRANNAN, CHAIRMAN, NORTHERN ARAPAHO
                            BUSINESS COUNCIL

        Mr. Brannan. Good afternoon, Senator Enzi. Thank you for
    asking me to come and testify.
        I come from the Wind River Reservation, carrying a very
    heavy heart because of the suffering, the pain, that children
    and older people are going through on our reservation. I want
    to thank you personally for asking me to come here, and giving
    us a voice.
        There are many statistics that justify the need for
    improving health care on the Wind River Reservation and Indian
    country in general. I have listed a number of them in my
    written statement and I know you hear them from many others.
    But what I would like to do is spend my time here today to try
    to put a face on the problem that we are faced with every day
    on the reservation.
        My testimony here today is in honor of Francis Brown, a
    respected elder and ceremonial leader of the Northern Arapaho
    Tribe, and Marcella Hope Yellow Bear, a baby, both of whom died
    needlessly because of lack of funding. Both of them suffered
    terribly before their untimely deaths. Francis had four brain
    tumors. He went to IHS for assistance. He was told there was no
    funding to help him to get the care he needed. He went home,
    suffered and died. Marcella Hope Yellow Bear was 18 months old
    when she died. Her entire short life was one of torture and
    pain. According to the newspaper accounts, she had an open hole
    through her chin, numerous broken bones, and burns on her body
    and the bottoms of her feet. She was found hanging from a coat
    hook in a closet. The police found her that way. Physically
    abused and tortured, her whole life was nothing but pain.
        When I did hear, it was like somebody shooting my heart
    with an arrow, and part of my soul died when I heard that. Both
    of these could have been prevented. The system and all of us
    failed them because of lack of adequate funding. For his entire
    life, Francis Brown was one of the cultural and ceremonial
    leaders and elders of our tribe. Among his many contributions,
    he helped preserve the medicine wheel up in the Big Horn
    National Forest and other sacred sites. His early loss robbed
    not only his family, but our tribe of his culture and
    ceremonial knowledge.
        Marcella was a beautiful and innocent little baby, just so
    beautiful I cannot describe how pretty she was. She was also
    the hope of our future. That is our future, our children. In
    our tribe, we believe children are sacred and we hold onto them
    because they are not tainted by the world and they are a
    blessing from God. Yet she was killed by her own parents, both
    members of our tribe, because of their addiction to
    methamphetamine. Those drugs and others, including alcohol, are
    the scourge of our reservation in Indian country.
        As you can see from these two painful examples, we need
    funding for both prevention and treatment. I am here today to
    give my support to S. 1057, but also to remind you of the need
    to fully fund it and to remind you of the trust
    responsibilities of the United States to American Indian
    tribes.
        Also, the Almighty gave me a vision where I saw this
    beautiful, wonderful white house with a bright picket fence,
    immaculately maintained yard, with a swing, a play area full of
    children. I am sure people have experienced children full of
    joy, full of happiness, smiling, seen them dressed in their
    Sunday best on Easter Sunday with their little beautiful socks
    and dresses and healthy and smiling, and just shrilling with
    happiness. That is the vision the Almighty gave me of the
    Northern Arapaho children and our people.
        I do know that this committee has the ability to make that
    vision come true for the Arapaho people, and I ask for your
    help. I thank you for allowing me to testify here today.
        [Prepared statement of Mr. Brannan appears in appendix.]
        Senator Enzi. Thank you.
        Mr. Forquera.

    STATEMENT OF RALPH FORQUERA, EXECUTIVE DIRECTOR, SEATTLE INDIAN
                              HEALTH BOARD

        Mr. Forquera. Thank you, Mr. Chairman.
        My name is Ralph Forquera. I am the executive director for
    the Seattle Indian Health Board. I am also the director for the
    Urban Indian Health Institute, which is a division of the
    Seattle Indian Health Board we created in 2000 to conduct
    research and perform epidemiologic studies on the health of
    urban American Indians.
        I am an enrolled member of the Juaneno Band of California
    Indians, which is a State-recognized tribe from the San Juan
    Capistrano region of Southern California.
        The Seattle Indian Health Board is a private nonprofit
    community health center established in 1970 as a free clinic in
    what was then an old U.S. Public Health Service hospital, so we
    are celebrating our 35th anniversary this year. We are
    currently under a contract and hold several grants from the
    Indian Health Service under title V of the Indian Health Care
    Improvement Act. We are one of 34 such nonprofit Indian-
    controlled corporations located in 41 cities and 19 States
    around the country that contract with the Indian Health Service
    under title V.
        About 20 of the 34 existing programs provide some level of
    direct care. The remaining 14 programs provide health
    education, information, referral assistance and other services
    designed to improve access to health care. In addition, urban
    Indian health organizations play an important cultural role in
    many cities by offering programs and services that are
    culturally appropriate and socially acceptable to the wide
    array of Indian people living in cities. For example in Seattle
    we serve Indian people from over 150 American Indian tribes and
    Alaska Native villages each year.
        The role of providing an identifiable and culturally
    acceptable place in American cities for Indian people is an
    often overlooked effect of these programs that in many ways has
    become an essential part of the healing process for Indian
    people who often feel abandoned and isolated in American
    cities. According to the 2000 census, the majority of Indian
    people are now living in American cities. Over 70 percent of
    Americans who self-identify as American Indian alone or mixed
    race on the census are living in American cities.
        The trend toward urbanization has been steady since the
    1950's when the policy of this Nation was to relocate Indian
    into cities in an ill-fated attempt at assimilation. Over
    160,000 people were directly affected by the relocation and
    termination policies. There remains a sizeable number of urban
    Indians who carry an emotional scar of this experience with
    them. As a result, that experience greatly influences their
    behaviors and their ability to trust government institutions,
    including oftentimes our own.
        Little is known about the overall health status of urban
    Indians across the Nation. While the Urban Indian Health
    Program has been a part of the Indian Health Service for nearly
    30 years, only recently have formal efforts to document the
    health of urban Indians been attempted.
        The lack of available data has made it difficult for us to
    defend the need for help in addressing the growing health
    crisis among urban Indians. However, in March of 2004, the
    Urban Indian Health Institute released a first report
    documenting for the public the severe health disparities among
    urban Indians. Using data from the National Centers for Health
    Statistics and the 1990 and 2000 U.S. census data, that we know
    is woefully inadequate for urban areas, the report still found
    significantly higher rates of illness and identified multiple
    known risk factors that likely contributed to these findings.
        The report brought greater attention to the plight of urban
    Indians and helped us to begin to build interest in looking at
    the health of this population. The report documented for the
    first time our anecdotal assertion that urban Indians were
    experiencing ill-health in disproportionate numbers. Our
    principal partner in this work to date is the Indian Health
    Service, which has now included us as one of the 10 Indian
    Health Service-funded regional tribal epidemiology centers,
    ours being the only one that focuses specifically on urban
    Indians and is on a nationwide basis.
        Title V, the urban Indian health section of the Indian
    Health Care Improvement Act, provides the critical link in
    recognizing that Indian country encompasses both reservation
    and urban communities. The 34 urban Indian health organizations
    reflect the nature of their local communities. They offer not
    only services, but a place of Indian identity that is
    frequently lacking for Indian people in American cities. In the
    broadest sense of healing, finding a place of belonging and
    acceptance can have a powerful and positive effect on the
    health of Indian people.
        Our ability to focus on Indian people and not be encumbered
    by the restrictive nature of limiting services to federally
    recognized tribal members adds to our capacity to heal wounds
    also. Title V is the only authority that specifically defines
    the health care role for the Indian Health Service in
    addressing the needs of urban Indians. For this reason, title V
    is an essential tool in assuring that urban Indians are not
    forgotten as a group of Americans in need of health
    improvement.
        In the request for my participation in the hearing today,
    two specific questions were posed to me. The first deals with
    the extension of Federal tort claims protection for urban
    Indian programs. The second concerns an issue that periodically
    has been brought to our attention by the Department of Justice
    regarding equal protections provisions of the Constitution and
    the fact that urban Indians are not subject to tribal
    governments with self-governance authority.
        With regard to the Federal Tort Claims Act issue, similar
    protections have been extended to community health centers
    through the Public Health Services Act. Those of us who receive
    funding through the Bureau of Primary Health Care are already
    eligible for FTCA protection. It would seem to me that
    extending this protection to urban Indian health programs would
    add minimal risk to the government. Inclusion could save
    considerable expense for those programs who are now purchasing
    private liability insurance for support for their work. The
    resulting savings could be used to provide needed services.
        It should also be noted that the title V program is truly
    crafted using the community health centers as a model. So
    therefore the extension of the privilege of FTCA for another
    group of federally sponsored safety net providers seems a fair
    and equitable action.
        With regard to the Department of Justice's concern about
    equal protection matters, I first need to state that I am not
    an attorney nor am I professionally trained in this area.
    However, it seems to me that the enactment of title V defined a
    special class of health care provider similar to various
    arrangements made through other Federal programs like the
    Federally Qualified Health Center Program under the Bureau of
    Primary Health Care and disproportionate share hospital payment
    structure under CMS and others.
        Clearly, the Federal Government has a rational basis for
    providing funding, tax breaks and other benefits it deems to be
    in the interest of the Government or society in general. That
    rational basis should not allow such distinctions to withstand
    an equal protections challenge.
        In the case of urban Indian health programs, the Congress
    has a clear and rational basis for its decision to provide
    programs, services and funding to urban Indians. After all, it
    was the ill-conceived policies of relocation and termination
    that led to the removal of large numbers of Indian people from
    reservations to cities. Congress dealt with Indians as a
    special class of citizens then, and it clearly can and should
    so do as it tries to rationally address the consequences of
    those policies.
        The structure of the title V program, that of using a
    nonprofit Indian-controlled corporate structure, offers the
    full benefits of the self-determination principles called for
    in President Nixon's special message to Congress in July 1970
    that forms the foundation for today's Federal Indian policy.
    Successful urban Indian health organizations in some respects
    embody the spirit of self-determination. Our use of IHS funds
    to leverage our other public-private resources to extend our
    capacity to serve urban Indians is exactly what I believe the
    authors of title V intended.
        It is clear that the Congress has the authority and the
    will to direct programs to address identified and documented
    health disparities affecting American Indians and Alaska
    Natives. In these times of rapid change in the health care
    system in America, and the sharp escalation in the cost of
    health care, the importance of having organizations devoted to
    assuring access and quality health care for Indian people makes
    good public policy. It is fitting, then, that the Congress
    continue this policy by reauthorizing Title V.
        Thank you for offering me this opportunity to testify. I
    would be happy to answer questions.
        [Prepared statement of Mr. Forquera appears in appendix.]
        Senator McCain. Thank you very much.
        Ms. Joseph, what is your response to the Department's view
    that the Intra-departmental Council consultation and Tribal
    Technical Advisory Groups are sufficient for Indian policy so
    that the elevation of the director to an assistant secretary is
    not necessary?
        Ms. Joseph. Thank you for the question, Mr. Chairman.
        The request or the advocacy for the elevation is not a new
    issue for tribes, for one thing. It has been around long before
    this effort to reauthorize. We feel the deplorable health
    conditions of our people warrant us to carry out our
    responsibilities in a different way, and maybe elevating the
    issues to a higher level would be a better approach. We know
    that status quo is not acceptable.
        We think that it is also consistent with the government-to-
    government relationship in that it is comparable to the
    assistant secretary that has oversight of the BIA programs in
    the Department of the Interior. There is an assistant secretary
    for Public and Indian Housing in the Department of Housing and
    Urban Development.
        We think an agency that has such large responsibilities for
    Indian people should be at a level where they can collaborate
    at a higher level in the Department; be a member at the table
    when priorities and policies are addressed; be a player in the
    decisions that are made when the Department's priorities are
    established; and be at a level that ensures that other agencies
    in the Department are also considering the needs of American
    Indians and Alaska Natives.
        Senator McCain. What is your response to the Department's
    view that we should mandate positions such as the diabetes
    coordinators within IHS?
        Ms. Joseph. Mr. Chairman, I thought that was real
    interesting a request, to require a mandate when earlier in the
    testimony there was an objection to mandates. In particular,
    that is related to mandating diabetes coordinators. For the
    record, I believe all areas have diabetes coordinators. The one
    we have in California, she is wonderful and we like her and she
    is doing a lot to inspire us, to prevent and to educate.
        But the tribal leaders during this discussion weighed this
    and did discuss it. They said, say for instance in five years
    we have a major epidemic in our area, and we might want a
    cardiovascular disease prevention coordinator or a tuberculosis
    prevention coordinator. With limited resources, the tribes
    locally may need to move resources and have another priority in
    five years. That was the wish to have some flexibility for
    local decisions.
        Senator McCain. Thank you.
        Mr. Kashevaroff, how would you respond to the views of the
    American Dental Association that there is a ``false concern''
    that in Alaska that is only a choice between no dental care and
    some dental care, so that dental health aides are necessary?
        Mr. Kashevaroff. I believe that anybody that wants to come
    up to Alaska and go out to the bush, which we call it, will see
    that there is basically no access to dental care out there.
    Village folks that live there, if they have a toothache, they
    have a choice of either waiting six months to a year for a
    dentist from a regional hub to arrive, or to get on an
    expensive plane and fly in. That is what we are faced with.
        We do have some dental care. Dr. Grim mentioned that we
    have a 50 percent vacancy rate out in the bush in Alaska. That
    means we only have one-half the dentists. If Washington, DC
    only had one-half the dentists, you would have a lot of lines
    around here of people wanting dental care.
        So it is compounded in the fact that you live in a village
    and there is no way to access dental care than hop on a plane,
    which you cannot always do because we get snowed in for weeks
    at a time sometimes. And you only have one-half the dentists
    out there in the first place. So we have a very big problem,
    Mr. Chairman.
        Senator McCain. You mention in your statement that
    negotiated rulemaking was used in the self-governance
    regulations. What benefits have you seen in the implementation
    of the regulations? What is your response to the Department's
    concerns that negotiated rulemaking is costly and time-
    consuming? Were your negotiations costly and time-consuming?
        Mr. Kashevaroff. Mr. Chairman, I was not privy to the
    budget of the negotiations. I do not think they are that time-
    consuming because we actually had a deadline imposed. I know S.
    1057 has a longer deadline imposed. But the little bit of time
    put up front saves a lot of time in the end.
        By us coming together and working out the issues with the
    IHS, the tribes and IHS working out the issues, getting on the
    same foothold, understanding the same things, has saved us
    immensely right now years later from having tons of lawsuits
    back and forth because we cannot agree on what we said. When we
    are both in the same room, we negotiated it out and you had
    negotiations go where there is give and take, and everybody is
    satisfied somewhat, and we were able to achieve that.
        As I said earlier, they gave us some kind of awards because
    we were so efficient at doing it. I cannot imagine why the
    Administration is against having negotiated rulemaking after we
    have been so successful in the past.
        Senator McCain. As has self-governance.
        Mr. Kashevaroff. Yes.
        Senator McCain. Chairman Brannan, in your testimony you
    state that addiction to methamphetamine and alcohol are
    epidemic on your reservation. What is currently being done to
    combat the problem and, in your opinion, will the new
    comprehensive care behavioral health programs provided in the
    Act be helpful in any way?
        Mr. Brannan. Yes, Chairman; they would be.
        Senator McCain. It is epidemic on your reservation?
        Mr. Brannan. Yes; it is.
        Senator McCain. Would you give me a few statistics to
    describe that situation?
        Mr. Brannan. I guess throughout Wyoming it is considered
    epidemic, even in the State of Wyoming. I do not have the
    specifics.
        Senator McCain. For example, most of your teenagers?
        Mr. Brannan. What you see is an underlying culture of
    people, and we have a number of tribal members coming up and
    saying, can you please do something for my family member; they
    are going to die, because all they are doing is ingesting
    poison into their system. There is no place for us to send
    them. There is no treatment dollars available for
    methamphetamine whatsoever. Alcohol is a significant problem,
    but methamphetamine is 50 times worse.
        Probably their life expectancy is less than 5 years once
    they take it for the first time. Typically, they are addicted
    for life once they do it, just the first time. There is a
    significant backlog of patients that need alcohol treatment
    alone. In some instances, it takes them 6 months to 9 months
    just to go to treatment. With an alcoholic, if they finally
    identify or I guess understand that they do have a problem,
    they confess it, you need to get them to treatment as soon as
    possible. It is a constant theme. People are dying from
    cirrhosis.
        Senator McCain. You have a lot of dental problems, I would
    think.
        Mr. Brannan. Oh, yes.
        Senator McCain. Because of methamphetamines.
        Mr. Brannan. Yes, yes. Even without the methamphetamines,
    we can only serve 25 percent of our actual need. Our service
    unit is funded at 51 percent of the level of need funding. Our
    denial rate is about three times more than what they approve
    under a contract health service budget. We are sending people
    home that have cancer, saying there is no money for
    chemotherapy, therefore you have to die. That is the reality of
    it.
        Senator McCain. Then you must have a problem with teen
    suicide as well.
        Mr. Brannan. Yes; we did in the 1980's, there were over 20-
    some young people that killed themselves, one right after
    another. It is consistent.
        Senator McCain. Is that associated quite often with the use
    of meth?
        Mr. Brannan. No; it is mainly associated with the lack of
    hope on the reservation, lack of opportunity. What we are doing
    right now is we are trying to develop a boys and girls club to
    give them some type of outlet. But the main thing is prevention
    on the reservation. Right now, the lack of funding within IHS
    is so significant we cannot even do prevention. We have to wait
    until somebody is sick or almost dying because the funding is
    so inadequate. What we need is preventive health dollars. We
    can work with our children. We can get them to exercise. We can
    get them to have a vision for their future, hope. But right
    now, we do not have that resource available.
        Senator McCain. Mr. Forquera, is your clinic the only urban
    clinic doing epidemiologic studies on urban Indians?
        Mr. Forquera. It is currently, Senator. We actually
    established the Urban Indian Health Institute out of
    frustration on my part. Nobody was doing work to directly
    address the issue of urban Indians. Shortly after we
    established the organization, Dr. Trujillo, who was then the
    director of the Indian Health Service, who had had some
    experience working in the urban Indian community, helped to
    find some resources to help us set up the epidemiology side of
    the research element of the program.
        We have been struggling since we have had no directed
    resource in order to be able to track the health of urban
    Indians, and the fact that a lot of our data has to come from
    local municipalities or from other institutions that sometimes
    do and sometimes do not collect information that is Indian-
    specific. We have been having to go and develop those databases
    in order to be able to do the work that we are doing. We are in
    the process of doing that now, and I think are making progress,
    but we are also finding tremendous obstacles because of
    resource and other problems.
        Senator McCain. Many of your patients are in Seattle due to
    the policies of relocation and termination. Do you maintain
    contacts with the tribes in which these individuals may be
    members?
        Mr. Forquera. A large number of our clients are in fact
    enrolled members of their tribes. We also see a number of
    Indian people who are members of terminated tribes. We see a
    few Canadian Indians who come down. And then we are also
    identifying an awful lot of Indians who were adoptees or
    children of adoptees or people that had been displaced from
    their nativeness not only in the 1950's, but prior to that.
        One of the great advantages of the work that we do and one
    of the fun things that we do is helping people re-link
    themselves up to their nativeness. It is amazing the power of
    that experience for the individual and how good that makes us
    as an institution feel that we can help people reconnect with
    their roots and help them. They then become great supporters of
    the organization. They get services from us. They help the
    community by using their skills as part of the community. It is
    a wonderful thing.
        Senator McCain. Chairman Brannan, where is the nearest city
    or metropolitan area to your tribal lands?
        Mr. Brannan. Mr. Chairman, we have two cities. One is
    Lander, WY. That is approximately 24 miles from Fort Washakie.
    The other town is called Riverton, WY.
        Senator McCain. Are there problems with drugs and teen
    suicide in those non-Indian areas?
        Mr. Brannan. It is not as prevalent, but the meth problem
    is throughout the State, especially within Fremont County where
    the reservation is located.
        Senator McCain. Are there meth labs on your reservation?
        Mr. Brannan. Well, a lot of it I believe is foreigners from
    old Mexico. They did have a drug bust, and I think they had 250
    pounds of methamphetamine.
        Senator McCain. That is a lot of doses.
        Mr. Brannan. Yes; it is.
        Senator McCain. Well, it is a national problem, as you
    know, but it also seems to be most concentrated in lower-income
    areas, and naturally that means Indian country. At least we
    would see some benefits from passage of this act, wouldn't you
    think?
        Mr. Brannan. Yes; it would help us significantly.
        Senator McCain. I thank the witnesses. I thank you for your
    patience today. I apologize for this back and forth shuttle as
    we try to finish up our voting on the Department of Homeland
    Security. I can tell you at least we passed on amendment
    yesterday that directs funding directly to the Indian tribes,
    so it does not have to go through the State and local
    authorities. So a small benefit.
        Thank you for all you do. Thank you for your good work. We
    look forward to seeing you again.
        This panel is adjourned.
        Now, our last panel is Mary Williard, DDS, deputy director
    of the Yukon Kuskokwim Health Corporation in Bethel, AK; and
    Robert M. Brandjord, DDS, who is the president-elect of the
    American Dental Association in Washington, DC.
        Dr. Williard, welcome. Maybe out of pure curiosity, where
    is Bethel, AK located, in relation to, say, Anchorage?
        Ms. Williard. We are about 450 air miles west of Anchorage.
        Senator McCain. And the population is?
        Ms. Williard. In Bethel itself, about 6,000 to 7,000,
    depending on the time of year.
        Senator McCain. What is it in January? [Laughter.]
        Ms. Williard. Probably around 6,000.
        Senator McCain. And in August?
        Ms. Williard. More like 7,000.
        Senator McCain. Some come to the great State of Arizona in
    the wintertime, and we are always glad to have them.
        I thank the Chairman.
        Dr. Williard, who is that with you?
        Ms. Williard. This is my daughter. Her name is Suskwok or
    Shauna Williard.
        Senator McCain. You are welcome to be here. Do you have
    written testimony? [Laughter.]
        Thank you. She is welcome here, Dr. Williard.
        Ms. Williard. Thank you.

        STATEMENT OF MARY WILLIARD, DDS, YUKON KUSKOKWIM HEALTH
                       CORPORATION DENTAL CLINIC

        Ms. Williard. Mr. Chairman and members of the committee, as
    you know, my name is Dr. Mary Williard. I have been practicing
    public health dentistry for my entire career. About 9 years of
    that has been in the Public Health Service through the IHS. I
    completed a 2-year dental residency in general practice at a
    hospital in North Carolina. I have practiced both in the Navajo
    area as well as in the Bethel, AK area.
        I have been in Alaska for 7 years working for the Yukon
    Kuskokwim Health Corporation [YKHC]. I have also chaired the
    Academic Review Committee for the Dental Health Aide Program
    since its inception.
        On behalf of the Alaska Native Health Board and YKHC, I
    would like to say it is an honor to be here and have the
    opportunity to testify, and to bring my daughter to see how
    this great country runs.
        I really think this is a very important hearing for the
    future of the people in my area and especially for the
    children. I learned this morning that the ADA has started a
    campaign in our village newspapers that states that we are
    providing substandard care, second-tier of care to our village
    people through the Dental Health Air Program, specifically
    dental therapists; that we are experimenting on the people of
    the villages. I am here to say very strongly and clearly that
    that is not true.
        I personally have a vested interest to make sure that that
    is not happening. I believe that what we are doing is a good
    thing and it has been well thought out. I know that the tribes
    and the people in the area are supportive of us.
        I am a little nervous so I might stutter a little. Anyway,
    one of the things that I have done as part of my role in the
    Dental Health Aide Program is help to develop the dental
    standards that dictate how we work with the dental health aides
    and specifically the dental therapists, and how they become
    certified to provide the care that they are allowed to do. The
    quality assessments that are being one on our dental therapists
    are taken directly from the Indian Health Service for dentists.
    We are not allowing them to provide a second-tier or a
    substandard quality of care. They are expected to provide the
    services that they provide at the same level of quality.
        These candidates have been hand-selected from large numbers
    of applicants. They are very responsible, respectable members
    of the community. I feel like we have gotten some really
    wonderful people into our programs. Part of my job at YKHC is
    to supervise the dental therapists that we have there. We do
    have two dental therapists who have completed the 2-year
    training in New Zealand to receive their diploma of dental
    therapy. These two young people are Alaska Natives and have
    been in our clinic for about 6 years now providing services. I
    have looked at every aspect of their service and their skills.
    I have found them to be quite skilled at what they are doing.
    They learned well during their schooling. They have taught our
    dentist, actually, some new materials and information that they
    learned in school.
        One of the other things that I do during my time in YKHC is
    I have observed the new dentists coming in from dental school.
    I have to work with them and bring them up to par with the
    other dentist on our staff. What I can say is comparing dental
    school graduates with our dental therapists is that I have seen
    that the skills are equal.
        Hearing Dr. Grim say, sort of hesitate whether he would let
    a dental therapist work on his own teeth or his own children, I
    am not surprised. Most dentists are very picky about where they
    go. I do not know that I would Dr. Grim work on my teeth. I
    have never seen what he can do. [Laughter.]
        But I can tell you that my children and I have been treated
    by the therapists, and I have no problem with that because I
    have seen what they can do and I believe that they are very
    well trained. They provide a good service.
        I look forward to allowing them to go out to the villages
    once they are certified and working in a general supervision
    capacity with the dentist in Bethel. One of the things that I
    really think is important about this is that we will have very
    competent dental providers in the villages with the people on a
    daily basis, so that not only will the people out there be able
    to see a dentist maybe once a year, but they will actually be
    able to see one when they need one, a dental provider.
        They will be able to see the therapist at the school, at
    the basketball games, mostly, in the villages, and be able to
    talk to them in the grocery store and say, you know, gee, I
    know you told me I need to brush my teeth all the time, but
    what can I do when I cannot afford a toothbrush? And maybe when
    they are deciding what to purchase at the store, they can, you
    know, what were you saying about the diet soda compared to the
    regular soda?
        Those kind of things are really important when you are
    talking about trying to change a community's habits about oral
    health. Daily presence is a much more effective way of changing
    habits in a population than the itinerant-type approach that
    has been utilized in the past. So I think that is a very strong
    aspect of our program.
        I do not think volunteer programs will work. I am not
    saying that I do not want to see volunteers come. Please come.
    Please do as much volunteer work as you can. I think that would
    be great. I do think that they do not provide the continuity of
    care that will address the issues that we need and to help
    build a strong prevention program.
        The drill-and-fill model is still the old volunteer model
    as well. When you come in and you see patients, you drill and
    fill and you just get back out, and you have not made that
    connection with the patient. It just has not worked.
        One of the things that I have seen as well is that village
    residents have long, 30 years there have been community health
    aides in the villages. And when a doctor comes out to the
    village and talks to the patients and tells them what they
    know, the patients will listen, but when the doctor leaves the
    room, the patient turns around and asks the community health
    aide, you know, is that right? What can you tell me? So the
    trust is there when the people are there in the communities.
        One of the things about the Dental Health Aide Program is
    that the main focus is that we are looking at prevention.
    However, the dental health aide therapists are going to be
    there to help us deal with the problems that are already
    existing. You have already heard there is a very large problem
    with dental decay in our areas, unmet needs. Even if Dr. Grim
    was able to recruit dentists to our area to fill all the
    available positions, that is not going to meet our dental
    needs. A study in 1991 was done in Alaska that showed that even
    if the number of dentists in Alaska was doubled at that time,
    it would still take 10 years to meet the needs.
        So recruiting dentists to fill positions is not the only
    answer. We need all the help we can get. That does not mean we
    are looking for substandard care. That means we are looking for
    good quality care and we have come up with a method to do that.
    The dental health aides or dental therapists have been working
    in a number of countries for years and have a very good track
    record. In Canada, over 30 years of practicing; in
    Saskatchewan, being regulated by the dental profession, there
    has never been any merited claim against a dental therapist,
    and they provide the same level of services and more than we
    will allow under our Dental Health Aide Program.
        So in closing, well, one other thing I would like to say is
    that we do thank Dr. Grim for his letter of support of our
    program, and we will have that in our written testimony. We
    also have e-mails of written support from the South Central
    Foundation in Anchorage that states that they strongly endorse
    the Alaska Dental Health Aide Therapy Program.
        What I would like to ask you all, Mr. Chairman and the
    members of these committees is to please listen to the people
    that live and work in these communities and refuse to take away
    our federally recognized right to manage our own health care.
    Please support S. 1057 of the Indian Health Care Improvement
    Act, and do not limit the scope of practice of the dental
    health aides.
        Thank you. I am open to questions.
        [Prepared statement of Dr. Williard appears in appendix.]
        Senator Enzi. Thank you.
        Dr. Brandjord.

     STATEMENT OF ROBERT BRANDJORD, DDS, PRESIDENT-ELECT, AMERICAN
                           DENTAL ASSOCIATION

        Mr. Brandjord. Thank you, Mr. Chairman and members of the
    committee.
        I am Bob Brandjord. I am president-elect of the American
    Dental Association and a practicing oral surgeon in Minnesota.
    I am here to express the American Dental Association's strong
    support for using dental health aides and other innovations in
    dental care delivery to help reduce the disproportionate burden
    of dental disease that many Alaska Natives suffer from today.
        Equally important, I must state the American Dental
    Association's unequivocal opposition to experimenting on Alaska
    Natives by allowing non-dentists to perform irreversible dental
    surgical procedures. This is second-class care. It is unsafe.
    It is unfair. And most of all, it is unneeded. It is an
    admission that those who have been entrusted with the care of
    these people have essentially given up on them. Instead of
    really focusing on preventing disease, the solution is to
    extract it. Alaska Natives deserve better. They deserve high-
    quality, fully trained, licensed dentists to provide the care.
        They can receive that care if we can break down the
    bureaucratic obstacles that are preventing it. Decades ago,
    Alaska Natives were almost entirely free of dental decay, but
    the trend has reversed. Many Alaska Natives now suffer from
    often severe untreated dental disease. Deterioration is due
    partially to the transition from the traditional subsistence
    diet to processed sugary foods and beverages; partly to the
    lack of oral health education and proper self-care; and partly
    to inadequate access to appropriate dental care.
        Alarmed at the declining oral health of its constituents,
    the Alaska Native Tribal Health Consortium has resorted to the
    desperate measure of deploying dental therapists to extract
    teeth, drill out cavities, and do pulpotomies, which are like a
    root canal. With only 18 to 24 months of post-high school
    training, these well-intended, hard-working people do not know
    what they do not know. They are not prepared to routinely
    perform these procedures safely. Dentists perform thousands of
    procedures every day with such expertise that the public views
    them as routine or simple. But there is no simple surgical
    procedure. I know this. I spend a great deal of every working
    day removing teeth.
        For example, extracting a tooth can lead to serious and in
    some cases life-threatening complications. It can lead to
    chronic and acute infection, injury to adjacent teeth, gums,
    and bone, including fractured or broken jaws, displacement of
    teeth, parts of teeth, or foreign objects into the airway,
    gastrointestinal tract, and sinuses; even severe life-
    threatening breathing or airway problems.
        Proponents of the dental therapist plan argue that there
    are only two choices: Second-class care or no care. This is not
    true. Our written testimony includes an alternative model that
    builds on the current dental delivery system by making it more
    efficient. The authors include the dental director of the
    Alaska Native Medical Center in Anchorage. Central to this plan
    is the creation of the new mid-level aide called a community
    oral health provider. They can be trained in Alaska and not in
    New Zealand. These community-based dental aides could provide
    the patient education and preventive services that ultimately
    are the best and perhaps the only way to end the epidemic of
    dental disease that plagues Alaska Natives.
        Despite our attempts to help, we have continually run into
    a bureaucratic brick wall of opposition by those who, by their
    own admission, are so vested in the therapist position that
    they will not consider any alternative.
        Mr. Chairman, the public health agencies who took
    responsibility for providing care for Alaska Natives have been
    unable to meet their own goals. Dentistry did not create this
    situation, but we are willing to help remedy it. But therapists
    are a big step in the wrong direction. Rather, we need a dental
    health aide to provide education, prevention and appropriate
    services in every village. We need a more efficient system to
    provide the needed care safely and effectively. We need less
    redtape.
        We urge the Senate to adopt the language offered on the
    House side by Chairman Young which supports dental aides, but
    precludes the use of therapists to perform irreversible dental
    surgical procedures.
        I want to thank you for your time and attention, and I
    would be happy to answer any questions.
        [Prepared statement of Dr. Brandjord appears in appendix.]
        Senator Enzi. Thank you.
        I thank both of the people who testified. The one who is
    probably the leading expert among Senators among this would be
    Senator Murkowski from Alaska. I will defer to her for
    questions.
        Senator Murkowski. Thank you, Mr. Chairman. I appreciate
    the opportunity to lead off with the questions. I unfortunately
    will have to be excusing myself after this because I have to
    get over to the energy conference, so I am splitting my time.
        I do not know. I am not the resident Senate expert because
    I spend a lot of time in the dental chair, but I do spend a lot
    of time traveling around my State and do know that in terms of
    health care issues and the area where we are so lacking is in
    dental health care. Dr. Williard, I appreciate your bringing
    your daughter here. As a mom with kids that are spending a lot
    of time in the dental chair nowadays, it is at this age where
    we are able to make a difference with our kids.
        Unfortunately, our Native children out in the villages are
    the ones that are suffering most. They are suffering because of
    the change in diet, as you have indicated Dr. Brandjord, and
    because of other changes as we are evolving as a new State, as
    a society that is moving from a subsistence lifestyle to a cash
    economy. It is hurting out kids' teeth. As a consequence, it is
    hurting us as adult. It is putting a stress and a strain on the
    whole health care system.
        What is the answer? The answers are very, very difficult.
    I, for one, I have a real hardship when people say that we are
    experimenting on Alaska Natives by providing them with
    something. We are not experimenting. We are trying to do
    something to take that first step to give the care that is so
    necessary and is so needed. I appreciate your testimony, Dr.
    Williard. I could tell that it was coming from the heart and
    very unscripted. You are living there. You are talking with the
    people and you know that when you have a doctor come to town
    who just blasts in and blasts out, the information that was
    left with you while you were sitting in that dentist chair goes
    out the window with that dentist.
        I know because I was raised in a tiny community where the
    doctor came to town every other week. It was good news for my
    family that my mother was not pregnant that year because she
    did not have to worry about whether or not she was going to
    deliver the baby by herself or whether the doctor was going to
    be in town. So we know what happens when we do not have that
    continuity of care. There are lapse. There are gaps.
        So we have to do something. We have to do something. The
    program that we are talking about here today is novel. It is
    new and as a consequence it is raising concerns.
        I guess I would like to primarily direct my questions to
    you, Dr. Brandjord. When the first class of dental health aide
    therapists graduated from the University of Otago in New
    Zealand, the Associate Dean Tom Kardos, who himself is a
    dentist, said the following. He said:

        The dental therapist will be able to provide oral health
    care, including undertaking procedures such as fillings and
    extractions, along with educating their communities in good
    oral health care and habits in accordance with the course they
    have taken.

        He has been obviously an advocate for the program. He
    believes that the dental health aide therapists can safely do
    the work for which they have trained.
        So I guess my question to you is, what kind of reach-out or
    conversation or dialogue has the American Dental Association
    had? Have you sent any kind of a delegation to New Zealand to
    meet with Dr. Kardos, with his colleagues, to observe the level
    of training that goes on; to attempt to work out some of the
    differences that you have indicated that we have with this
    program?
        Mr. Brandjord. Thank you, Senator. No, we have not sent
    anybody to New Zealand, but last year we sent six volunteers
    from our government affairs committee up to Alaska to work in
    the villages. They went through their normal credentialing
    process which was somehow expedited thanks to Indian Health
    Service. They worked side by side with Indian Health Service
    dentists. They were extremely productive and they worked with
    Alaska Native dental assistants and dental health aides that
    were there.
        Those dental health aides and dental assistants helped them
    with the cultural sensitivity and with continuity of care
    issues that are brought up. Even in the Indian Health Service,
    there is a problem with continuity of care with the low number
    of dentists and the rapid turnover.
        So the dependence on continuity of care comes exactly from
    the dental health aides and dental assistants in the area.
    Dental health aide therapists doing the procedures are not the
    answer. When we looked at the different things, the level of
    care that had to be provided, it was very extensive care. If we
    could look at the screen up there, you can see one of the
    patients that was treated by one of our volunteers. That is not
    simple work. That is something that is more complex.
        If we are going to take care of these individuals, we need
    fully trained, licensed dentists to provide that level of care.
    So that is what we are talking about. We agree almost
    completely with everything Dr. Williard was talking about in
    regards to prevention. Absolutely, prevention is the foundation
    of all health care. We know that. Dentistry has done a good job
    with prevention. We have to do a good job in Alaska, and that
    is why we believe that there should be dental health aides in
    every Alaskan village to help provide dental preventive
    services, doing services such as providing fluorides, sealants,
    cleanings, and also placing temporary restorations.
        So we really think that is a very valuable resource and we
    agree on all of those things. In fact, when you look at our
    proposal, that is exactly what it is about. Then we add the
    community oral health care provider who coordinates all these
    efforts among a number of villages and a population base so
    that when the dentist comes to that community, villagers will
    have continuity of care through the dental health aide that is
    there, and dentists can be more efficient by providing care
    that is a broad spectrum of care at that time. In fact our
    program, when you look at it, uses the Anchorage Hospital
    model, and with this efficient system to provide the care,
    their productivity increased many-fold. In fact, in the last
    year of implementation, their production increased over 100
    percent, and over a 3-year period of time, over 300 percent.
        So we believe that there are four things that we have to
    do. First of all, we have to fill up our quotas of Indian
    Health Care dentists. The American Dental Association has been
    to Congress and we have supported increasing the loan
    forgiveness payments, which seems to be a big advantage for
    getting students out of dental school going into the Indian
    Health Service. In fact, when we met Dr. Grim and one of his
    assistants, Chris Halliday from Indian Health Service, he said
    he believed if he had loan forgiveness for every slot in the
    Indian Health Service for dental positions, he could fill them.
    So he would need the funding for that. That is one thing that
    we want to do.
        Second is prevention. I talked about that. Prevention is
    the foundation for dental care.
        Third, are the volunteers. We want to get the volunteers
    back up into Alaska.
        Senator Murkowski. How do we get them there? We have the
    greatest State on Earth and we cannot get professionals to come
    out to our villages. We might get them to come out and give us
    1 week or 2 weeks on either side of a fishing trip, but we need
    care and the care is not just when the fish are running. We
    have to figure out a way.
        Mr. Brandjord. It is interesting you say that because our
    volunteers went up there in the dead of winter. They were not
    there during fishing season. They understand they are not going
    up there on a vacation. They are going to work. We are putting
    together, and are now in the process right now of hiring a
    full-time individual at the American Dental Association to work
    with finding volunteers and setting up the coordination of
    getting these volunteers into Indian villages and into Alaskan
    villages. We are trying to get the care where it is needed.
        In fact, when we were putting this together, it is
    interesting that we talked to other different health care
    providers who have volunteer programs. The great State of
    Alaska is a little different than some other States because
    when we talked to the American College of Obstetricians and
    Gynecologists, they have a volunteer program and their members
    sign up to participate in these programs to go out specifically
    through the Indian Health Service. They have given up on going
    to Alaska because of the credentialing problems. They are
    different than anyplace else.
        So one thing that this Committee could do is to bring about
    a central certification process that could be used for
    volunteers to go into these areas to help. Our volunteers that
    went, it has been a year and a half now, those that went then
    have to reapply and get recredentialed now. If they went to one
    village for one week and another village for another week, they
    would have to be recredentialed. That is inappropriate.
        Senator Murkowski. It is.
        Mr. Brandjord. When we talked to the Joint Commission on
    Accreditation, of Healthcare Organizations those people say we
    could work with a much simpler form where there would be
    temporary privileges less paperwork.
        Senator Murkowski. We want to work with you on that
    credentialing.
        Mr. Brandjord. We would love to work with you.
        Senator Murkowski. From what I understand, we have extended
    that offer to kind of work through some of these issues on the
    credentialing. To the best of my knowledge, you have not taken
    us up on the offer, so we would hope that we would be able to.
    That seems like one that we ought to be able to figure through.
        Mr. Brandjord. I would totally agree with you. It is
    interesting that I have a letter here from a dentist in Alaska.
    If I may read it, it is very short. It is dated May 25:

        On or about February 11 of this year, I submitted an
    application to participate in dental project backlog. During
    the first week of April of this year, I was fingerprinted as
    part of the application process. It is now almost June. I
    understand there are building transition issues on your part,
    but what is the status and fate of my efforts to help alleviate
    the access issues in the villages?

        So yes, we have made that effort, but we are not getting a
    response on the other side. I do not know how we do that. But
    if there is some way to aid us, and when we went out there, we
    did not just go out on our own. We went with the Indian Health
    Service dentists and we worked with them. We believe that that
    is not a solution that is going to last forever, but if we can
    get them over this backlog of dental disease, we believe we can
    make a difference.
        Senator Murkowski. How many dentists do you think you are
    going to be able to or would have to recruit to be able to
    assist in this effort, full-time dentists?
        Mr. Brandjord. For full-time dentists, I do not know. That
    would have to be through the Indian Health Service. I am not
    sure. But last year at our House of Delegates, which has 360
    members, on 1 day, we handed out a paper, just asking how many
    would volunteer for a minimum of 2 weeks to go to Alaska. We
    had 140 volunteers.
        Senator Murkowski. Well, I am not meaning to be the
    negative nabob here, but one of our big problems is that most
    of these villages, there is no hotel. There is no bed and
    breakfast. You are there and you might sleep at the home of the
    community health practitioner or maybe in the gym. It makes it
    tough on people. So we have some issues that just make this
    tough. We need to know that we have a realistic timeframe that
    we are dealing with, and that we are dealing with enough
    numbers that we can actually make a difference.
        We need to get through this backlog, but we recognize that
    kids are born every day, and they are going to have the next
    generation of dental problems. So this is not just something
    that we can get on top of the wave now and be clear with.
        Mr. Chairman, I am going to have to submit the rest of my
    questions for the record. I really apologize because this is
    extremely important. I think you can tell that I want to do
    something. I hear that you want to do something. We certainly
    know that from the Alaska perspective, those professionals who
    are giving so much every day want to make something work.
        I do not want to get in a situation where I feel it is the
    Dental Association saying this is our turf and nobody else can
    come onto it. This is not about turf. This should be about the
    health and well-being of Alaska Native people. If we can put
    together a program that provides for continuity of care, that
    is good and safe and works, we have the benefits of
    telemedicine where you can be talking to your real-live doctor
    in Boston and working on a procedure. We have made incredible
    advancements in the State with telemedicine.
        I would like to think that we can work through some of
    these issues so that we do not have dentists saying there is no
    other way except for us to come up, and as Alaskans knowing
    that Shauna here is going to be able to see a dentist two weeks
    out of every year, and hope that her toothache is during that
    2-week time period. So work with us.
        Mr. Brandjord. We will work with you. We realize the
    epidemic of dental disease that is there. We want to do nothing
    more than help to resolve that issue. But to resolve that
    issue, to keep doing fillings and extractions will not resolve
    it. What will resolve it is to have good preventive care. We
    can accomplish that with the dental health aides.
        In regards to your statement about the facilities and the
    bed and breakfasts up there, yes, the bed and breakfast for
    every one of our volunteers up there was bringing their own
    sleeping bag and sleeping on the floor of the clinic. So yes,
    we are familiar with that, but they are still willing to go
    back. They are that dedicated. I think that is something that
    is hard for people to perceive.
        I thank you for your concern.
        Senator Murkowski. It is also hard for them to give more
    than 2 weeks, and that is one of our biggest problems. That
    dedication, that passion is there and they will come up and
    they will give, and it is extremely generous. We do not want to
    denigrate that generosity, but there is a recognition that
    there are 50 other weeks of the year that are without any kind
    of care. So we will work on filling those gaps.
        Mr. Chairman, thank you very much.
        Senator Enzi. Thank you.
        Senator Isakson.
        Senator Isakson. Thank you, Mr. Chairman.
        Yesterday, I had one of those irreversible dental
    procedures known as a root canal, so I am having a tough time
    talking about this subject. [Laughter.]
        Senator Isakson. I am honored to be here and appreciate
    both your testimonies. I am sorry I was late for the other
    panels.
        Dr. Williard, you are a dentist and I take it you oversee a
    regional plan. Do you manage the dental health aides?
        Ms. Williard. Yes; I do.
        Senator Isakson. I do not want to cut you off, but I want
    to get to the end question.
        Ms. Williard. Okay.
        Senator Isakson. And that is a full-time program for the
    Native Alaskans.
        Ms. Williard. Yes.
        Senator Isakson. How many dentists and how many dental
    health aides are in that program?
        Ms. Williard. We have nine dentists in the Bethel area. We
    have two dental therapists, and we have nine primary dental
    health aides.
        Senator Isakson. Okay. Here is my question, and I did not
    get a chance to read. I take it this S. 1057 has a scope of
    practice component to it. What new scope of practice are these
    therapists or aides going to be allowed to do under this bill
    that they cannot do now?
        Dr. Williard. There is no new scope of practice that they
    would be able to do under S. 1057. What the American Dental
    Association would like to see done is to have this bill
    modified so that it takes away the rights that we have to
    practice as we are doing right now.
        Senator Isakson. Okay. Now, Dr. Brandjord just referred to
    the program they had recommended. They have suggested a program
    which I take it drew the line on scope of practice for the
    therapist and the aides. Is that correct?
        Dr. Williard. Yes.
        Senator Isakson. You said you have nine dentists there in
    your program now?
        Ms. Williard. Yes.
        Senator Isakson. Then that is not enough dentists to do the
    irreversible dental procedures?
        Ms. Williard. We have 15 dental positions in our area, so
    we have 6 that are vacant right now. As I have said before,
    filling those vacancies does not actually provide enough
    treatment ability to meet the needs. So even if we were to get
    100 percent filling of those positions, it still would not meet
    the needs that are out there. That would just meet the criteria
    that have been set by what is able to be funded by the IHS and
    by our corporation.
        Senator Isakson. One of the issues that comes up in many
    health professions in scope of practice is a shortage of
    trained people being the justification to allow a scope of
    practice possibly beyond the training of others. Are we in that
    position in Alaska now where we in effect have people who are
    trying to do the best they can, but are not sufficiently
    trained to do, say, root canals, which I think take a lot of
    training after yesterday's experience? I hope so.
        Dr. Williard. You are talking about the dental therapists
    not having the training to do that?
        Senator Isakson. Yes. I am saying, in Alaska are we having
    to resort to asking people, with the best of intention, to do
    procedures they are not trained for?
        Ms. Williard. No; we are not asking them to do procedures
    they are not trained for. The dental therapists that we have
    sent to training and are training further in our own facilities
    have a specific scope of practice which limits what they can do
    in a patient care setting. That limit will keep them in a
    practice setting that utilizes only what their skills are. If a
    patient's care needs get beyond the limits that a dental
    therapist has been trained to provide, then they are trained to
    recognize those limits and refer to a dentist.
        The picture that you saw earlier from the ADA, definitely I
    agree with them. That is beyond the scope of practice of a
    dental therapist. That patient would be referred to the hub
    clinics for treatment. But fortunately, that is not the only
    kind of patient we see. We do have a lot of patients that need
    a little less than that severe care, and can be seen by the
    therapists and the procedures that they are capable and
    competent of performing.
        Senator Isakson. Okay. Dr. Williard, in the proposal that
    the ADA made, what is it that you do not like about their
    proposal?
        Ms. Williard. They have excluded the use of the therapists.
        Senator Isakson. Totally? Or just for these irreversible
    procedures?
        Ms. Williard. The therapists are distinguished by the fact
    that they can do irreversible procedures. What their suggestion
    would do for a therapist is strip them of their ability to
    provide those services. They would become basically a primary
    dental health aide, which is a health aide that we already have
    and who we can train for about a month in Bethel to provide the
    preventive services and the fluoride treatments that they are
    providing already.
        So basically, it would be the equivalent of tying a
    dentist's hand or arm behind their back and asking them to
    treat a patient. That is what their proposal would do. We do
    not say that their proposal is not okay, for lack of a better
    word. I think it is a good proposal in some settings. I think
    it would be fine to do that Community Oral Health Practitioner
    Program in parallel with the Dental Health Aide Program.
    Anything that people are willing to do to try and help provide
    more services to our area is a good thing as long as it is well
    thought out and supported with data.
        What I do not agree with is that the American Dental
    Association is not willing to allow that to happen at the same
    time as our Dental Health Aide Program is running. They want us
    to drop the program and then pick up this other program. That
    will not work. We have seen and looked at all of the studies
    that show that the dental therapist is a safe, quality
    provider. You can look at Gordon Trueblood from Canada who has
    done extensive studies on the quality of care provided by a
    dental therapist.
        In those studies, he has shown that the quality is equal,
    if not better, than a dentist in the procedures that a
    therapist is allowed to perform. A therapist does not do a
    whole scope of dental procedures that a dentist would do. Their
    training is very heavily geared towards teaching them what
    their limits are. This is very different from what you might
    learn in dental school, where you are taught all eight
    different specialties in the dental field. Nobody tells you
    that you cannot do something.
        Senator Isakson. Mr. Chairman, could I have the liberty of
    asking two more questions?
        Senator Enzi. Certainly.
        Senator Isakson. I know I have gone beyond my time.
        I have said this before, and am not taking sides here even
    though it is going to sound like I am. The dental profession,
    of all the health professions, seems to me to have done a
    remarkable job of lessening the volume of work because of what
    they did in preventive health care, fluoridation of the water,
    and good health practices. You, Doctor, and the association are
    to be credited for that.
        It sounds to me like the exacerbation of the problem in
    Alaska over the last 10 years is a whole absence of that, or at
    least a significant one. Otherwise, it may be the change in
    eating habits, you referred to people fluoridating and things
    like that.
        If it has been done once in the continental United States,
    understanding there is a world of difference in Atlanta,
    Georgia and Alaska, and where Native villages might be. I know
    accessibility is a problem and everything else. I guess I ought
    to ask the Doctor a question for a minute, because I have been
    directing everything to you.
        Is your proposal designed with that goal in mind? If it is,
    can the number of trained professionals be available to meet
    the demand that exists today, and even would exist if there
    were some lessening of those problems?
        Mr. Brandjord. Thank you for your question. First of all,
    with the proposal that has been made, using the community oral
    health provider, that particular program, and it has been
    looked at by these three people in education and then one who
    is the director up at the Anchorage dental facility, they
    estimate that using that particular program, 85 percent of the
    individuals within that village could be seen and taken care of
    in any year. Now, that is in the paper that has been submitted
    along with our written testimony.
        One other thing in regard to your comments about the scope
    of practice of individuals, part of the issue is that the
    expanded function dental assistants can help do some of the
    reversible procedures and that is why they become more
    efficient. They will have one dentist per three or four
    auxiliaries in the Anchorage facility working in up to three
    chairs at one time so that they can be more efficient and
    produce more care, and then deliver also more preventive
    services.
        So yes, there is an expanded scope that is there that can
    be done, and yes they can reach more people.
        If I can just add one thing. You mentioned fluoridation.
    There are fluoridation units in the villages, but they are not
    activated right now. Some of it is the CDC's requirements for
    maintenance. From our understanding now, we have some new
    technology that CDC has and that has been implemented in the
    tribal villages in South Dakota where they have remote control
    of the fluoridation of the water system that can work.
        Senator Isakson. Well, I have abused my time. CDC is in my
    home State and if you all have any problem with them, you let
    me know because you need all the help you can get out there.
        Your daughter is beautiful, Dr. Williard.
        Ms. Williard. Thank you.
        Senator Isakson. Thank you for the time, Mr. Chairman.
        Senator Enzi. Thank you.
        Ms. Williard. Could I make one comment about the program,
    the community oral health aide program?
        Senator Enzi. Certainly.
        Ms. Williard. Thank you, sir.
        The program, it was written by a panel of people who did
    include one of the chiefs from the Anchorage area, Tom
    Kovalesky. In teleconferences and meetings with the authors of
    that proposal, and the dental chiefs of Alaska throughout the
    State, Dr. Kovalesky and the other officers did concede that
    this proposal was probably not as effective in the rural areas
    and that it would be more effective in an urban setting.
        The situation that we find in our individual villages,
    having to fly in by airplane and being spread out with such
    small populations in some of these communities, the models that
    are used in that program do not apply. That is something that
    the dental directors outside of Anchorage unanimously agree
    with.
        Senator Enzi. Thank you.
        I want to thank both of you and all of the other people
    that have testified. I apologize for the interruptions. We are
    still doing votes. Senator McCain and I have been shifting off
    and on here so that we would have somebody chairing and could
    continue to gather the information. All of this, of course,
    builds some testimony that will be used in furthering the
    legislation, correcting the legislation, drafting additional
    legislation.
        There will be more statements submitted by other members of
    both committees, and questions that I hope all panelists will
    take time to answer. You will not all receive questions because
    we will be searching for things that are in your area of
    expertise or clarifications on what you said in your statement
    or things that you may have said today.
        Also, members of the panel, if you have some comments in
    regard to other questions that were not asked, or if you want
    to expand on the comments that were made, you are perfectly
    able to do that, too. The record will remain open for another
    10 days to complete that process.
        So I appreciate everyone who has helped out here today and
    the hearing is adjourned.
        [Whereupon, at 4:55 p.m., the committee was adjourned, to
    reconvene at the call of the Chair.]
    =======================================================================

                                A P P E N D I X

                                  ----------

                  Additional Material Submitted for the Record

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

    Prepared Statement of Hon. Maria Cantwell, U.S. Senator from Washington

        Thank you, Mr. Chairman. I appreciate your continued leadership on
    these issues which we have been working on for a number of years.
        I'd also like to thank you for opening this hearing up to our HELP
    Committee colleagues. Their expertise in healthcare delivery, will be
    extremely valuable as we work together to improve the health and well-
    being of Native Americans.
        I believe reauthorizing the Indian Health Care Improvement Act will
    help us begin to close the disturbing health disparity in Indian
    country and allow us to fulfill the United States' obligation for
    Indian health.
        According to the U.S. Commission on Civil Rights, between 1998 and
    2003, industry experts estimate that medical costs grew approximately
    10-12 percent, while the IHS funding increases are less than 5 percent
    annually. When compared to other Federal health expenditures, it's
    clear that IHS is grossly under funded. We have a responsibility to
    take a close look at the healthcare services we're providing to this
    population and make sure that they're equitable and adequate.
        This issue is particularly important to Washington State. Between
    1990-2000, the Indian population grew almost by almost 28 percent--7.5
    percent faster than the rest of our population. The life expectancy for
    Indians living in Washington is approximately 4 years shorter than that
    of the rest of the population, due to factors that we can impact--
    chronic under funding of the Indian Health Service, the lack of
    geographically available health services and the lack of trained
    providers that are available to serve the Indian population. We can
    address these issues for Washington and the rest of Indian country by
    moving forward with the reauthorization of this critical legislation.
        To give you an idea of how badly this legislation needs to be
    updated, I'll use the example of behavioral health services. The
    current law limits behavioral health services to those dealing with
    substance abuse. While substance abuse is a critical health issue,
    mental health disorders are not addressed. This is particularly
    alarming when one looks at the suicide rate of the Indian population--
    91 percent higher than the rest of the United States. Clearly there is
    a need for increased attention to the behavioral health needs of the
    Indian population.
        I'm pleased to see the increased focus on preventative health in
    this bill. While Indian country is still experiencing a shorter life
    expectancy than other American populations, the causes of death have
    shifted. Today the leading causes of death among Indian populations are
    chronic disease rather than infectious disease, communicable diseases.
    The health disparities that exist among the Indian population are
    numerous and unacceptable. They have higher rates of almost every
    disease and adverse health condition:

               Alcoholism--777 percent higher.
               TB--650 percent higher.
               Diabetes--450 percent higher.
               Accidents--208 percent higher.
               Pneumonia/influenza--52 percent higher.
               Suicide rate--91 percent higher.

        Although the health disparities still exist in Washington and
    across the country, we have made progress. I am aware, for example, of
    our success in the Northwest in reducing the rate of Sudden Infant
    Death Syndrome, diabetes, HIV/AIDS, cancer and tobacco use through the
    use of health promotion and disease prevention programs.
    Reauthorization would allow for the expansion of facilities
    construction options, enhance tribal decisionmaking and enhance the
    ability to recruit, train and retain health professionals.
        The last time this bill was reauthorized was in 1992 and it expired
    in 2000. Since then, bills have been proposed every year to no avail.
    This is a very complicated issue, it's a huge bill but the time has
    come to fully address the health needs of the Indian population.
        We have a legal and ethical responsibility to provide healthcare to
    Indians and this is the perfect opportunity to begin to address ways in
    which we can improve the way we do so.
        One area of great concern to me is the impact of the Medicare
    Prescription Drug Benefit implementation on Indian country. The Tribal
    Technical Advisory Group was formed to consult with the Center for
    Medicare & Medicaid Studies (CMS) on reimbursement rates and policies.
    Under the roll-out of the transitional assistance or, the drug discount
    card, under the Medicare Modernization Act earlier this year, we saw
    many problems in the implementation of this program. Beneficiaries were
    often confused about their choices and many didn't know they even had a
    choice to make. Like other low-income elders across the country, low-
    income Indian elders will experience a gap in prescription drug
    coverage when their costs exceed the initial $1,500 coverage limit.
    Most Indians will expect their HIS and Tribal Clinics to pay for their
    pharmaceuticals after they fully utilize their prescription drug
    coverage. However, IHS expenditures will not be counted toward the
    threshold to qualify for the catastrophic coverage under the drug plan.
    IHS will have to absorb all pharmacy costs for Indian elders up to the
    $3,600 annual limit. I am hopeful that in consultation with my
    colleagues on the Senate Finance Committee, we will resolve this
    inequity.
        Another area of grave concern to me is the lack of attention that
    behavioral health services in our healthcare delivery system. According
    to the Indian Health Service, 13 percent of Indian deaths occur in
    those younger than 25 years of age--three times that of other
    populations and the U.S. Commission on Civil Rights points out that
    American Indian youth are twice as likely to commit suicide.
        Reauthorization is especially important as it provides an
    opportunity to address the need for mental health coverage within the
    IHS. Title VII proposes a comprehensive approach for behavioral health
    assessment, treatment and prevention.
        Under current law, behavioral health provisions are largely limited
    to substance abuse treatment and prevention and the issue of mental
    health is largely unaddressed.
        The current Indian health bill is a product of much collaboration
    between tribal leaders, IHS officials and program personnel and it's
    imperative that we look to these experts during this process.
        I'd also like to thank Ralph Forquera, the executive director of
    the Seattle Indian Health Board, for joining us here today. Each year,
    the Seattle Indian Health Board serves over 6,000 individual patients
    and provides approximately 30,000 patient encounters. While the Seattle
    Indian Health Board has become quite skilled at providing high quality
    services with limited funding, they're currently facing a budget
    shortfall of $200,000 for clinic services. We must work to make sure
    that our providers have the resources they need to provide high quality
    health care to the Indian populations all over the country and
    especially here in Washington.
        I'm looking forward to hearing of the Seattle Indian Health Board's
    many accomplishments, especially as they relate to the health needs of
    urban Indians.
        Once again, thank you Mr. Chairman for beginning the
    reauthorization of the Indian Health Care Improvement Act and for
    holding this hearing. The time has come for this bill to finally be
    reauthorized and I look forward to working with my colleagues in the
    Senate to make this a reality year.
                                     ______

      Prepared Statement of Hon. Byron L. Dorgan, U.S. Senator from North
               Dakota, Vice Chairman, Committee on Indian Affairs

        I thank Chairman McCain for his leadership.
        I thank my colleagues on the HELP Committee for joining with us in
    considering today the Indian Health Care Improvement Act Amendments of
    2005. I am particularly pleased to note that two of our colleagues from
    the HELP Committee Senator Kennedy and Senator Bingaman--have asked to
    be added as cosponsors of S. 1057.
        It is my earnest hope that, by working together--together as
    authorizing committees, and together with the Administration and
    representatives of Indian country--the Indian Health Care Improvement
    Act will be reauthorized this year.
        I know our witnesses today will provide additional statistics
    regarding health needs in Indian country. We cannot, in good
    conscience, be satisfied with the status quo like this:

       \\\\\\Native American youth are more than twice as likely to
            commit suicide; in the Great Plains area the likelihood is as
            high as 10times.
       \\\\\\American Indians and Alaska Natives are 517 percent
            more likely to die from alcoholism.
       \\\\\650 percent more likely to die from tuberculosis.
       \\\\\\318 percent more likely to die from diabetes.
       \\\\\\204 percent more likely to suffer accidental death.

        Over the past few months, my colleagues have heard me speak on the
    Senate floor about Indian health care in connection with amendments I
    have offered to the fiscal year 2006 budget resolution and the fiscal
    year 2006 Interior appropriations bill. My amendments proposed to
    provide an additional $1 billion for programs not only in the IHS, but
    also BIA, tribal colleges, water infrastructure.
        I have talked on the Senate floor about people in tribal
    communities who are hurting and in desperate need of services. Many of
    these people I know or have known, or, in the tragic case of Indian
    youth suicide, whose surviving family members I have met with.
        I know this is true, too, for Dr. Grim and the other witnesses who
    will testify today--you all see and hear and experience, every day, the
    very real need for the kinds of services and programs and facilities,
    the kinds of best practices, collaborations and innovations that S.
    1057 would authorize for American Indian and Alaska Native communities.
    I want to thank each of you who has stuck with this reauthorization
    process since 1999 and earlier for your persistence and continuing
    vision.
        I want to say that I am particularly pleased with and supportive of
    the provisions of title VII of the Indian Health Care Improvement Act
    Amendments of 2005. This section of the bill would authorize the
    Secretary of Health and Human Services--through the Indian Health
    Service, the tribal health programs and the urban Indian
    organizations--to develop a comprehensive behavioral health prevention
    and treatment program. Such a program would emphasize collaboration
    among alcohol and substance abuse, social services and mental health
    programs and would benefit all age groups.
        Since the Committee on Indian Affairs' hearing on June 15 on teen
    suicide prevention, several more youth suicides have occurred on the
    Standing Rock Reservation in North and South Dakota. The services and
    programs for Indian youth, in particular, the training of
    paraprofessionals, the education of community leaders, the construction
    and staffing of new facilities and research that would be authorized by
    title VII will make a very real difference in the lives of men and
    women who live at Standing Rock, and all Native Americans.
        I look forward to the comments today of the Indian Health Service,
    the tribes and urban Indian organizations, and others and appreciate
    your help in improving this legislation that will provide creative and
    effective solutions to address the health needs of Indian people.
                                     ______

    Prepared Statement of Hon. Michael B. Enzi, U.S. Senator from Wyoming,
         Chairman, Committee on Health, Education, Labor, and Pensions

        Good afternoon. Thank you for coming to today's joint hearing on
    the Indian Health Care Improvement Act.
        There is no greater challenge before us in the Congress than the
    work we must do to continue to improve the quality of the health care
    that is available to those living on reservations. Unfortunately, it
    seems that no matter how much progress we make, there is always more to
    do. Today's hearing will enable us to chart our current progress and
    discuss what we can do to increase the services that are available to
    address the physical and emotional problems that continue to plague
    American Indians and Alaska Natives.
        When the Indian Health Care Improvement Act was first signed into
    law in 1976, it was written to address the findings of surveys and
    studies that indicated that the health status of American Indians and
    Alaska Natives was far below that of the general population. It
    continues to be a matter of serious concern that, as the health status
    of most Americans continues to rise, the status of American Indians and
    Alaska Natives has not kept pace with the general population.
        Studies show that American Indians and Alaska Natives die at a
    higher rate than other Americans from alcoholism, tuberculosis, auto
    accidents, diabetes, homicide, and suicide.
        In addition, a safe and adequate water supply and waste disposal
    facilities, something we all take for granted, isn't available in 12
    percent of American Indian and Alaska Native homes--as opposed to 1
    percent of the general population. Several years ago, residents on the
    Wind River Reservation in Central Wyoming faced a drinking water
    shortage that threatened the health and safety of everybody in the
    area. Canned drinking water had to be donated to tribal members and
    local residents. The lack of these basic services makes life even more
    harsh for these people and contributes to those already high rates of
    death.
        Coming from Wyoming, I know full well the problems we encounter in
    the effort to provide quality health care to all the people of my home
    State. That is why I have always made it one of my goals to help bring
    that perspective to the hearings and floor debates we have on the
    issues that affect the people of my State.
        When I was first elected to the Senate in 1996 I knew that quality
    of life issues on the reservations in Wyoming and throughout the
    country would continue to be a top priority of mine. I also knew that,
    in order to make life better for those living on the Wind River Indian
    Reservation specifically, and other reservations nationwide, my staff
    and I would need to be intensely committed to taking the issues head-on
    and looking for creative ways to solve complicated problems.
        That is why I put someone on my staff who already had a great deal
    of experience with these issues and shared my commitment to act on
    them. His name is Scotty Ratliff and he served with me in the Wyoming
    legislature. I tasked him with the challenge of helping me to find
    solutions to the problems on our reservations that would be both
    progressive and culturally sensitive.
        Tribal leaders are already committed to making things better on
    their reservations and I congratulate them on their vision and the hard
    work they have put into making it a reality. My only question continues
    to be, ``How can I help?'' In the years since I have been in the Senate
    I have made numerous trips to the Wind River Reservation in Wyoming and
    met and spoke with the residents and tribal leaders. We all want the
    same goal--a better life for those who live there. I am confident that
    working together we will continue to make the kind of progress we must
    make if we are going to find effective and efficient ways to address
    the problems that continue to plague those living on our reservations
    across the country.
        As I noted during my visits to the Wind River Reservation, their
    problems are not unique to them. To have an impact on all those who
    live on reservations from coast to coast, we will need to take a varied
    approach to address each of these problems separately. Clearly, people
    of different ages have different problems. A multi-faceted approach to
    solving each of their problems will require a systemic, as well as a
    financial approach.
        Local, State, and national governments and agencies must work
    together with tribal leaders to focus our resources where they will do
    the most good. That kind of approach has the greatest chance of being
    successful.
        Earlier this year the HELP Committee held hearings on the
    nomination of Michael Leavitt to serve as Secretary of Health and Human
    Services. I believe we are fortunate to have Michael Leavitt at the
    helm of an agency that oversees the health care needs of the people of
    reservations all across the country. I am also pleased Dr. Charles Grim
    is here with us today. Dr. Grim has an important job to do as the
    Director of Indian Health Services and he knows firsthand the level of
    dedication it will take to steadily improve health care for all
    American Indians. Dr. Grim has an unmatched understanding of the needs
    of Native Americans that you can't get from reading reports and memos
    from people out in the field. I have every confidence in his
    willingness and his ability to be an important part of the solution to
    the health care needs of those on our reservations and beyond.
        Again--the good news is--we're making progress. As we do, we
    continue to find so much more that needs to be done. How do we best
    provide the assistance that is needed effectively and efficiently? That
    is the challenge that lies before us.
        As we begin to hear from our witnesses, I would like to acknowledge
    and thank them all for their willingness to share their experiences
    with us so that we might craft a more effective bill to address the
    health care needs of our American Indian and Alaskan Native population.
        I would also like to welcome Richard Brannan, the chairman of the
    Northern Arapaho Business Council of Fort Washakie, WY. No one knows
    better than he does the problems faced by those living on reservations
    and by those who rely on the Indian Health Service for their healthcare
    needs. No one understands better than he does the necessity of making
    progress in addressing the health disparities experienced by American
    Indians. Most important of all, no one is more committed than he is to
    making a difference in the lives of all those who live on the
    reservation.
        I know he has an important message to share with us based on his
    experience and background with all those who live on the Wind River
    Reservation. I look forward to his comments and those of our entire
    list of witnesses. Each of you has a perspective and a point of view to
    share that only you can provide. I look forward to hearing a summary of
    your prepared remarks so we can address the underlying issues during
    our question and answer session.
                                     ______

     Prepared Statement of Hon. Daniel K. Inouye, U.S. Senator from Hawaii

        Thank you Mr. Chairman. I commend the committees for holding this
    hearing today.
        The status of Indian Health Care has significantly improved over
    the years and Indian mortality rates have declined. However when
    compared to the United States general population Indians have a higher
    likelihood of dying from diseases such as alcoholism [770 percent],
    tuberculosis [650 percent], AND DIABETES [420 percent]. Life expectancy
    is also 5 years less than the general population. Preventive health
    services are needed more than ever as is increased funding for those
    programs and services.
        In 1976 the Indian Health Care Improvement Act was enacted into law
    for the specific purpose of increasing the health status of native
    peoples. Since then bills were introduced in the 106th, 107th, 108th,
    and 109th congresses. Although these efforts were disappointing, I
    commend Congress for continuing to work on these crucial issues.
        This bill is critical to Indian country. It authorizes behavioral
    programs, provides alternatives for rural dental care, and authorizes
    the Indian Health Service to provide long-term care, are among the many
    positive changes that I have seen in this bill. I believe it is
    congress' obligation to ensure that Native Americans have full and
    timely access to health care.
        There is some language in the bill that I am concerned about
    because it may be detrimental to tribal sovereignty. However I will
    continue to work closely with my colleagues.
        I commend my colleagues Senators Dorgan and McCain for drafting
    this legislation. Once again, thank you for holding this hearing.
                                     ______

        Prepared Statement of Hon. Edward M. Kennedy, U.S. Senator from
                                 Massachusetts

        I commend Senator McCain, and Senator Enzi for convening this joint
    hearing on the Indian Health Care Improvement Reauthorization Act. The
    Nation has a legal and moral commitment to provide Native Americans--
    the Nation's first Americans--with the best possible health care, and
    I'm pleased to be a cosponsor of this important bill.
        From the earliest days of colonization that brought infectious
    diseases to Native Americans, to the 18th century military conflicts
    that sought to destroy Native peoples, to the 19th century treaties
    that sought to confiscate Native lands, to the 20th century boarding
    schools that sought to undermine, tribal culture and language, the
    history of Native America has often been a shameful part of the history
    of America.
        The Federal Government has long promised better health care to
    Native Americans in exchange for land. Since at least 1926, the
    Government has been looking into the adequacy of such health care, but
    sadly, many of the inadequacies identified in the 1920's still exist
    today.
        Decade after decade, Congress refused to give tribes the resources
    to develop and operate their own communities. Too often, it was said
    that Indian peoples did not have the expertise to invest such resources
    wisely to conduct their own governments, operate their own businesses,
    educate their children, or provide health care to their people. For
    generations, this reactionary national mentality poisoned the
    relationships between tribes and the Federal, State, and local
    governments.
        Native Americans are eager to improve the health status of their
    people. They deserve control of their own destiny, but they require
    Congressional action to make their vision a reality, and it is time for
    us to honor the commitments we made long ago.
        Chronic underfunding of American Indian and Alaska Native health
    care by the Federal Government has weakened the capacity of the Indian
    Health Service, tribal governments, and the urban Indian health
    delivery system to meet the health care needs of the American Indian
    and Alaskan Native population. The Indian Health Service per capita
    expenditures for American Indians and Alaskan Natives are one-half of
    what is spent for Medicaid beneficiaries, one- third of that spent by
    the Veterans Administration, and one-half of what the Federal
    Government spends on Federal prisoners' health care.
        As a result of inadequate funding, American Indians endure health
    conditions most Americans would not tolerate.
        Native Americans are 8 times more likely to die from alcoholism, 7
    times more likely to die from tuberculosis, 5 times more likely to die
    from diabetes, and 50 percent more likely to die from pneumonia or
    influenza than the rest of the United States, including white and
    minority populations.
        Native American infants die at a rate 2\1/2\ times greater than the
    rate for white infants.
        Native Americans are at a higher risk for mental health disorders
    than other racial and ethnic groups in the United States.
        Their cardiovascular disease rate is twice that of the general
    population.
        Their life expectancy is 71 years--nearly 5 years less than the
    rest of the population.
        These statistics represent real people who deserve more from the
    U.S. Government.
        The Indian Health Care Improvement Act has been amended many times,
    but it was only extended through 2001. It is long past time to
    reauthorize this act.
        Congress has been working to do so for the past 5 years. The
    current legislation reflects years of consultation with the Tribal
    National Steering Committee and holds great promise for improving the
    lives of Native Americans through comprehensive public health efforts.
    Despite widespread support, the bill has not been brought to the Senate
    floor for a vote.
        A better future is well within our grasp. We have a unique
    opportunity to make much more rapid progress on the long journey toward
    respect for our First Americans. We must bring the Indian Health Care
    Improvement Reauthorization Act to the floor. We must pass this
    legislation. Until every American Indian and Alaskan Native receives
    first class health care, we will never give up the fight. I look
    forward to this hearing and to the testimony of each of the witnesses.
                                     ______

      Prepared Statement of Hon. John McCain, U.S. Senator from Arizona,
                     Chairman, Committee on Indian Affairs

        Good afternoon. The bill before us today, S. 1057, is the latest
    iteration of the reauthorization of Indian Health Care Improvement Act
    that has lingered in the Senate for many years. And while there was
    much debate about the measure at the end of the last Congress, the need
    to improve the provision of health care services for Native Americans
    is undebatable. I am very heartened that our colleagues from the HELP
    Committee under the leadership of Chairman Enzi and Ranking Member
    Kennedy have so actively engaged in advancing the legislative process.
    I appreciate not only their support, but the expertise and insight that
    the HELP Committee brings to the effort.
        Nearly 30 years ago, Congress enacted the Indian Health Care
    Improvement Act to meet the fundamental trust obligation of the United
    States in providing comprehensive health care to American Indians and
    Alaska Natives. It was last reauthorized in 1992--13 years ago.
        This act is the statutory framework for the Indian health system
    and covers just about every aspect of Indian healthcare. S. 1057 builds
    on that framework by providing significant advancements in health care
    delivery and by promoting local decisionmaking, tribal self-
    determination and cooperation with the Indian Health Service.
        Those critical improvements include increased access to care,
    especially for Indian children and low-income Indians, programs
    designed to recruit and retain healthcare professionals on Indian
    reservations, and alternative financing for healthcare facilities and
    other services.
        Reauthorization of this Act is a high legislative priority. It has
    been 6 years in the making--far too long for the much needed
    improvements. Substantial work was completed last year and we have but
    a few remaining issues that I hope we can resolve quickly so that the
    bill can be enacted soon. I welcome the witnesses and look forward to
    the testimony.
                                     ______

     Prepared Statement of Hon. Patty Murray, U.S. Senator from Washington

        Thank you Mr. Chairman.
        I want to thank Chairman Enzi for holding this joint hearing. I'm
    happy that my colleagues on the HELP committee have this opportunity to
    learn more about the crisis facing tribal communities today and why
    this bill is so critically important.
        Mr. Chairman, I believe improving the quality and access of health
    care in tribal communities is one of the Federal Government's greatest
    treaty obligations. But when it comes to providing that care----

       \\\\\\the Federal Government has fallen short of its moral
            and legal obligation.

        Chairman Enzi, I'd ask for your commitment to continue to work
    together on this important issue so that we can help the Committee
    Indian Affairs move this bill forward.
        I know you have some concerns about the bill and I'd like to work
    with you to address them. As you may know, this legislation has been
    through an exhaustive review by tribal leaders and health
    professionals, the Committee on Indian Affairs and the Administration.
        And in light of two reports by the U.S. Commission on Civil Rights
    documenting the health care disparities facing Native Americans living
    on reservations and in urban areas it is time for the Congress to
    reauthorize this law.
        Finally, I'd like to join with my colleagues in welcoming Ralph
    Forquera to the committee. Ralph is a national leader on issues
    affecting Native Americans living in urban areas and I'm pleased to see
    he's here today representing the Seattle Indian Health Board.
        Thank you.
                                     ______

      Prepared Statement of Mark Kelso, DDS, Norton Sound Dental Director
                                    Nome, AK

        As a dentist with 19 years of direct patient care experience in
    Western Alaska, I believe that I can speak with great credibility
    regarding the dental needs of the indigenous people of the region. I
    have observed the cycle of destructive dental disease repeated from one
    generation to the next. The current method of itinerating dentists to
    rural communities for several weeks annually does little to elevate the
    public's aptitude toward the importance of good oral health. The
    dentists' role is viewed as one of simply alleviating pain and
    infection or repairing decayed teeth. While this service is important,
    it ultimately shifts the burden of one's own responsibility in the
    maintenance of their oral health to that of the provider.
        The dentists being of different ethnicity and cultural upbringing
    are not easily viewed as a role model for children and young adults to
    emulate. The dentists' short duration in the village also hampers their
    ability to bring about long-term patient motivation. Patients respect
    the dentists' advice while they are there, but their enthusiasm to
    better clean their teeth and limit the intake of sugary foods soon
    fades upon the dentists' departure. Established poor dental habits re-
    emerge.
        A dental chart review demonstrates that patients receive the care
    that is warranted. An ongoing trend of preschool children being
    afflicted with rampant dental decay in the baby teeth and subsequent
    restoration of these teeth either by multiple sedation appointments
    locally or by operating room procedures in Anchorage is a frequent
    occurrence. The erupting adult teeth are cleaned, sealed, and
    fluoridated but ultimately succumb to the rigors of poor diet and
    hygiene. The teeth usually receive several fillings of increasing
    complexity. In too many cases, the teeth reach a diseased state in
    which extraction of all of the teeth is the only viable treatment. Full
    dentures are fabricated. An analysis of the cost and effort to provide
    all of these services with the end result of being an edentulous
    teenager or young adult is sobering. Thousands of dollars per patient
    in both dental and hospital services along with associated travel were
    expended.
        A change in public perception regarding the importance of good oral
    health is needed. Native American dental providers are key in this
    process. Dental Therapists, residing and working in villages of a high
    oral disease rate, will be a constant dental presence in those
    communities. They will have the luxury to examine and treat patients
    more than once a year. More time can be spent on improving patients'
    oral hygiene index. Weekly fluoride rinse programs in the school will
    be an important job duty. But to gain the respect of the communities,
    the Dental Therapists must be known as the primary dental health care
    providers. They will obtain this status by alleviating existing need.
    The Dental Therapists must be able to perform routine fillings, treat
    infected nerves in children's teeth, and extract painful, hopeless
    teeth. The dentists will still itinerate through the villages to
    perform more complex treatment, eventually providing higher level
    services such as root canal completions, permanent crowns and bridges,
    denture fabrications, and orthodontic assessments not currently
    available in these remote locations. As the level of dental care
    increased in the hub-clinic in Nome, the dental expectation of the
    community did too. A decrease in basic dental disease followed. Such a
    model could be extended to the villages through the use of Dental
    Therapists.
        Another important aspect is the influence that the Dental
    Therapists will have on the school-age children and young adults. A
    criterion for the selection of all of the Dental Therapists in the
    Norton Sound region was that they all possess nice teeth, value a
    healthy smile, and practice good oral habits in their daily lives. Many
    junior and senior high school girls in the villages, the future mothers
    of the next generation, desire to look their best like most American
    girls. They may wear trendy clothes, style their hair, and apply
    cosmetics, but the deteriorated condition of their teeth negates these
    other measures. The Dental Therapists will frequently reinforce the
    need to alter dietary choices and practice daily oral hygiene to
    improve this segment of the population's oral health. Through the
    Dental Therapists own actions, they can inspire the youth that it is
    important and ``cool'' to have good teeth. It will not be socially
    acceptable any longer to brandish a smile of decay -riddled teeth or
    missing teeth altogether. Usually the children's teeth mirror those of
    the mother, either good or bad. This will be an excellent opportunity
    to stop the generational cycle of rampant tooth decay and premature
    tooth, loss. The Dental Therapists will be an ever-present, walking
    advertisement to the importance of good oral health.
        I urge the Senate Committees on Indian Affairs and Health,
    Education, Labor, and Pensions to support S. 1057 as it is written. The
    ability of the Dental Therapists to perform the procedures of fillings,
    dental pulp treatments, and basic extractions is crucial to their
    success. The Dental Therapists' potential to bring about positive long-
    term change is greater than that of any number of itinerant dentists,
    either compensated or volunteer.
                                     ______

       Prepared Statement of Tom Kovaleski, DDS, Director, Southcentral
                        Foundation, [SCF] Dental Program

        Thank you for the opportunity to submit testimony to the SCIA and
    HELP Committee regarding the practice of DHATs and section 121 of S.
    1057, the Indian Health Care Improvement Act Amendments of 2005. Please
    include my testimony in the record of the July 14, 2005 hearing
    regarding S. 1057.
        I was honored to be one of the four authors of the paper,
    ``Integrated Dental Health Program for Alaska Native Populations.''
    Since the first draft was released, I have been in regular discussion
    with tribal dental health program directors in Alaska. I have stated to
    them repeatedly that in my view the COHP model should be viewed by
    them, by the ADA, and by Congress, not as a substitute for DHATs, but
    rather as a tool for achieving additional efficiencies and
    improvements. In my view, there is a place for implementation of COHP
    and DHATs as part of an integrated dental health program.
        I do not endorse the conclusion of the ADA that COHP can substitute
    for DHATs in resolving the crisis regarding access to dental services
    among Alaska Natives. I would recommend both programs be implemented as
    pilot programs with the results evaluated closely. While I think both
    SCF's efficiency expertise and the full implementation of a COHP model
    may help the crisis, there is still a pressing need for additional
    practitioners that expanded function dental hygienists and DHATs could
    help fill. Throughout the development of the DHAT standards ultimately
    adopted by the Community Health Aide Program Certification Board, I
    actively participated with other dental providers in reviewing the
    Standards and the research base for mid-level dental practice and
    shared my concerns around the training and quality assurance
    components. I believe that DHATs have the potential to be high quality
    providers with proper training and quality assurance.
        As a practicing, licensed dentist responsible for a large program
    serving both an underserved urban and rural populations, I do not
    believe the dental community can afford to reject any responsible
    approach to expanding access to dental services. I believe dental
    assistant training, increased capacity, expanded function hygienists,
    COHP, and DHATs, provide such a responsible options for reducing the
    backlog of dental disease in Alaska.
        I urge Congress to not make changes in the authority of the
    community health aide program pursuant to section 121 of the Indian
    Health Care Improvement Act under which DHATs are certified so that we
    can evaluate their impact along with other strategies.
        If I can offer additional information that will help you in your
    deliberations, please let me know.
                                     ______

          Indian Health Care Improvement Act: Questions for the Record

                                (Senator Hatch)

                                 July 15, 2005

    Panel I
    Questions for Ms. Rachel Joseph
    National Steering Committee
    Chairperson, Lone-Pine Paiute Shoshone Reservation

        No. 1. Title VII would authorize a comprehensive behavioral health
    program, reflecting tribal values and collaboration among various
    substance abuse, social service, and mental health programs. You spoke
    of the need to have a ``systems of care'' approach to mental health in
    addition to this comprehensive package. Can you tell me specifically
    what this ``systems of care'' approach would add to the comprehensive
    program already outlined in title VII?
        No. 2. The National Steering Committee has a long history with this
    legislation. Can you tell us what the major stumbling blocks have been
    to passing this bill in the past, and how this bill has addressed these
    issues?

    Panel II

    Questions for Mr. Don Kashevaroff
    Alaska Native Health Tribal Consortium and Tribal Self-
    Governance Advisory Committee

        No. 1. What, specifically, are the concerns on the part of the
    Administration with negotiated rulemaking and how does this bill
    address those concerns? Why is negotiated rulemaking of particular
    importance to tribes?

    Questions for Mr. Richard Brannan,
    Chairman, Northern Arapaho Tribe

        No. 1. In your testimony, you stated that the Arapaho Tribe has a
    high disproportionate number of diabetics--would you please describe
    the current state of the dialysis program available to the Arapaho
    Tribe?
        No. 2. Regarding the issue of care for the elderly, you mentioned
    that most Arapho elderly, choose to remain in their own homes--do you
    believe that they would still remain in their own homes if better
    facilities were available to them?
        No. 3. I understand that family and domestic violence remains a
    large problem facing the American Indian population, and that expansion
    of related services is vital to combating that problem. What services
    are currently provided on the Wind River Reservation with regard to
    family and domestic violence; and what services do you suggest be added
    to enhance the current program?

    Questions for Mr. Ralph Forquera,
    Executive Director, Seattle Indian Health Board;
    and Director, Urban Indian Health Institute

        No. 1. I am concerned by your statement about the lack of available
    data needed to address the growing health crisis among urban Indians--
    it appears that this crisis may be much larger than we are even capable
    of gauging. What are the main reasons it is so difficult to collect
    data of urban Indians; and, do you have suggestions of what Congress
    can do to improve the data collection process?
        No. 2. Do you consider the trend toward urbanization to be
    increasing?
        No. 3. With regard to the Federal Tort Claim Act, you stated that
    inclusion could save considerable expense for programs that are now
    purchasing private liability insurance to support their work ? can you
    provide a hypothetical estimate of those savings?

    Panel III

    Questions for Dr. Mary Williard, D.D.S.
    Yukon-Kuskokwim Health Corporation, AK

        No. 1. You support the current program which permits Dental Health
    Aide Therapists (DHAT) to perform various procedures on patients in
    remote areas. The American Dental Association has concerns with three
    of these procedures (extracting teeth, drilling cavities, and
    pulpotomies). What programs are currently in operation that are similar
    to the DHAT program? Do participants in these programs perform these
    controversial procedures? Can you provide us information on these
    programs: where they are, how long they have been in operation, what
    studies have been done assessing their safety and effectiveness,
    particularly with regard to these three procedures?
        No. 2. You mention that the dental therapists will work under the
    supervision of a dentist. Who are these dentists and how can they
    supervise dental therapists who are in remote villages? What ``back-
    up'' exists if a procedure runs into unexpected complications?