[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
















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                      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.]
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                            A P P E N D I X

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              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?




                                 
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