    [House Hearing, 110 Congress]
    [From the U.S. Government Publishing Office]

                     THE INDIAN HEALTH CARE IMPROVEMENT ACT
                               AMENDMENTS OF 2007

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

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                           ONE HUNDRED TENTH CONGRESS

                                 FIRST SESSION

                                       ON

                                   H.R. 1328

                                   __________

                                  JUNE 7, 2007

                                   __________

                               Serial No. 110-54

          Printed for the use of the Committee on Energy and Commerce

                            energycommerce.house.gov

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                        COMMITTEE ON ENERGY AND COMMERCE

        JOHN D. DINGELL, Michigan,       JOE BARTON, Texas
                 Chairman                    Ranking Member
    HENRY A. WAXMAN, California          RALPH M. HALL, Texas
    EDWARD J. MARKEY, Massachusetts      J. DENNIS HASTERT, Illinois
    RICK BOUCHER, Virginia               FRED UPTON, Michigan
    EDOLPHUS TOWNS, New York             CLIFF STEARNS, Florida
    FRANK PALLONE, Jr., New Jersey       NATHAN DEAL, Georgia
    BART GORDON, Tennessee               ED WHITFIELD, Kentucky
    BOBBY L. RUSH, Illinois              BARBARA CUBIN, Wyoming
    ANNA G. ESHOO, California            JOHN SHIMKUS, Illinois
    BART STUPAK, Michigan                HEATHER WILSON, New Mexico
    ELIOT L. ENGEL, New York             JOHN B. SHADEGG, Arizona
    ALBERT R. WYNN, Maryland             CHARLES W. ``CHIP'' PICKERING,
    GENE GREEN, Texas                        Mississippi
    DIANA DeGETTE, Colorado              VITO FOSSELLA, New York
        Vice Chairman                    STEVE BUYER, Indiana
    LOIS CAPPS, California               GEORGE RADANOVICH, California
    MIKE DOYLE, Pennsylvania             JOSEPH R. PITTS, Pennsylvania
    JANE HARMAN, California              MARY BONO, California
    TOM ALLEN, Maine                     GREG WALDEN, Oregon
    JAN SCHAKOWSKY, Illinois             LEE TERRY, Nebraska
    HILDA L. SOLIS, California           MIKE FERGUSON, New Jersey
    CHARLES A. GONZALEZ, Texas           MIKE ROGERS, Michigan
    JAY INSLEE, Washington               SUE WILKINS MYRICK, North Carolina
    TAMMY BALDWIN, Wisconsin             JOHN SULLIVAN, Oklahoma
    MIKE ROSS, Arkansas                  TIM MURPHY, Pennsylvania
    DARLENE HOOLEY, Oregon               MICHAEL C. BURGESS, Texas
    ANTHONY D. WEINER, New York          MARSHA BLACKBURN, Tennessee
    JIM MATHESON, Utah
    G.K. BUTTERFIELD, North Carolina
    CHARLIE MELANCON, Louisiana
    JOHN BARROW, Georgia
    BARON P. HILL, Indiana
    _________________________________________________________________

                               Professional Staff

     Dennis B. Fitzgibbons, Chief of
                   Staff
    Gregg A. Rothschild, Chief Counsel
       Sharon E. Davis, Chief Clerk
       Bud Albright, Minority Staff
                 Director

                                      (ii)
                             Subcommittee on Health

                    FRANK PALLONE, Jr., New Jersey, Chairman
    HENRY A. WAXMAN, California          NATHAN DEAL, Georgia,
    EDOLPHUS TOWNS, New York                 Ranking Member
    BART GORDON, Tennessee               RALPH M. HALL, Texas
    ANNA G. ESHOO, California            BARBARA CUBIN, Wyoming
    GENE GREEN, Texas                    HEATHER WILSON, New Mexico
        Vice Chairman                    JOHN B. SHADEGG, Arizona
    DIANA DeGETTE, Colorado              STEVE BUYER, Indiana
    LOIS CAPPS, California               JOSEPH R. PITTS, Pennsylvania
    TOM ALLEN, Maine                     MIKE FERGUSON, New Jersey
    TAMMY BALDWIN, Wisconsin             MIKE ROGERS, Michigan
    ELIOT L. ENGEL, New York             SUE WILKINS MYRICK, North Carolina
    JAN SCHAKOWSKY, Illinois             JOHN SULLIVAN, Oklahoma
    HILDA L. SOLIS, California           TIM MURPHY, Pennsylvania
    MIKE ROSS, Arkansas                  MICHAEL C. BURGESS, Texas
    DARLENE HOOLEY, Oregon               MARSHA BLACKBURN, Tennessee
    ANTHONY D. WEINER, New York          JOE BARTON, Texas (ex officio)
    JIM MATHESON, Utah
    JOHN D. DINGELL, Michigan (ex
        officio)

                                 C O N T E N T S

                                  ----------
                                                                       Page
     Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, opening statement.........................     1
     Hon. Nathan Deal, a Representative in Congress from the State of
      Georgia, opening statement.....................................     3
    Hon. Hilda L. Solis, a Representative in Congress from the State
      of California, opening statement...............................     4
    Hon. Heather Wilson, a Representative in Congress from the State
      of New Mexico, opening statement...............................     4
    Hon. Darlene Hooley, a Representative in Congress from the State
      of Oregon, opening statement...................................     6
    Hon. Jan Schakowsky, a Representative in Congress from the State
      of Illinois, opening statement.................................     7
    Hon. John D. Dingell, a Representative in Congress from the State
      of Michigan, prepared statement................................     8
    Hon. Jim Matheson, a Representative in Congress from the State of
      Utah, prepared statement.......................................     8
    Hon. Michael C. Burgess, a Representative in Congress from the
      State of Texas, prepared statement.............................     8

                                   Witnesses

    Charles W. Grim, D.D.S., Assistant Surgeon General; Director,
      Indian Health Service..........................................     9
        Prepared statement...........................................    11
    James Crouch, executive director, California Rural Indian Health
      Board, Incorporated............................................    25
        Prepared statement...........................................    28
    Ralph Forquera, executive director, Seattle Indian Health Board..    37
        Prepared statement...........................................    40
    Ken B. Lucero, Pueblo of Zia.....................................    47
        Prepared statement...........................................    49
    Rachel A. Joseph, co-chair, National Steering Committee for the
      Reauthorization of the Indian Health Care Improvement Act;
      National Indian Health Board...................................    62
        Prepared statement...........................................    64

                               Submitted Material

    Joe Garcia, chairman, All Indian Pueblo Council, statement.......    81
    Rudy Shije, governor, Pueblo of Zia, statement...................    83
    A Joint Memorial Endorsing the Reauthorization of the Federal
      Indian Health Care Improvement Act.............................    84

      H.R. 1328, THE INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2007

                                  ----------

                             THURSDAY, JUNE 7, 2007

                      House of Representatives,
                                Subcommittee on Health,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 11:12 a.m., in
    room 2322 of the Rayburn House Office Building, Hon. Frank
    Pallone, Jr. (chairman) presiding.
        Members present: Representatives Schakowsky, Solis, Hooley,
    Matheson, Deal, Sullivan, Wilson, and Burgess.
        Staff present: William Garner, Amy Hall, Bobby Clark,
    Nandan Kerkeremeth, Chad Grant, Melissa Sidman, and Ken
    Keremath.

    OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
                IN CONGRESS FROM THE STATE OF NEW JERSEY

        Mr. Pallone. I call the meeting of the subcommittee to
    order, and I want to apologize for being so late.
    Unfortunately, we have so much to do in a short week here, and
    I wanted to make sure that we did in fact have this hearing on
    the Indian Health Care Improvement Act, but we are kind of
    fitting it in between a bunch of other things.
        The hearing today is on H.R. 1328, the Indian Health Care
    Improvement Act amendments of 2007 and I recognize myself
    initially for an opening statement.
        This is a bill that I introduced earlier this year with
    Representatives Nick Rahall and Don Young to reauthorize the
    Indian Health Care Improvement Act. Let me start by saying that
    I think this hearing is long overdue. The Indian Health Care
    Improvement Act expired 7 years ago in 2000. While there have
    been several attempts to reauthorize the legislation in
    previous Congresses, sadly none has been successful. In fact,
    this is the first time since the law expired that a hearing has
    been held in the Energy and Commerce Committee on reauthorizing
    it, and as someone who is very familiar with Native American
    issues, and particularly the health care issues they face, let
    me be the first to say that the failure of Congress to
    reauthorize the Indian Health Care Improvement Act had a very
    real impact, negative impact on Indian communities. I have no
    doubt that lives have actually been lost due to inaction, and
    it is my hope that my colleagues on the subcommittee will walk
    away from today's hearing understanding that Indian Country can
    no longer afford to wait. The unmet health needs of American
    Indians and Alaskan Natives are alarmingly severe and grow
    worse every day that we fail to act.
        The statistics speak for themselves. Native Americans
    suffer disproportionately from almost every condition or
    disease when compared to the general population from obesity to
    diabetes and heart disease to HIV/AIDS. All are epidemics that
    are ravaging American Indian communities, which have too few
    resources to respond. A large part of the problem is that
    American Indians have greater difficulty in accessing quality
    health care services. For far too many years there has been a
    growing divide between the health care services afforded Native
    American communities and other segments of the population. In
    example after example, Native Americans do not receive the
    level of service comparable to other Americans, and I think the
    most shocking example that often comes to my mind is that we
    currently spend nearly twice the amount on health care services
    for Federal prisoners than we do for Native Americans, and I
    think that is unconscionable, especially given our trust
    responsibility to provide Native Americans with health care
    services according to the numerous treaties and agreements we
    have signed with them.
        Native Americans have great difficulty in accessing the
    most simplest of services which many of us take for granted
    such as primary medical care, dental and vision services.
    Lengthy wait times, distant locations and transportation
    challenges act as significant barriers to receiving care.
    According to the GAO, Native Americans could expect to wait
    between 2 and 6 months or have to travel between 60 and 90
    miles to receive certain services, and needless to say,
    specialty services are even harder to come by in Indian
    country. I can't imagine that any of us would tolerate such
    conditions so why should we expect Native Americans to do so.
        This critical piece of legislation will help improve access
    to health care for the nearly 2 million Native Americans in
    this country. Specifically, the bill would improve the supply
    of health professionals in the Indian health system by creating
    new opportunities for American Indians and Alaskan Natives to
    pursue health careers. It would facilitate the construction and
    maintenance of safe water and sewage facilities and of
    hospitals, clinics and other health facilities and provide
    funding for urban Indian health programs as well, and these are
    just a few of the provisions in the bill that will help improve
    the current Indian health care system.
        I mentioned in the beginning of my statement that I think
    today's hearing is long overdue and is a much-needed step
    towards accomplishing our goal of reauthorizing this important
    legislation. Even though it has been 7 years since we have been
    trying to do this, I am still pretty optimistic, but I just
    want to stress that it is going to take a lot of hard work. We
    want the administration's position. In the past, as you know,
    we have waited until the second year or the end of the Congress
    to try to address this and then found out that there were
    objections by the administration or that there was difficulty
    with the other body. So we are trying to start out early. The
    bill already passed out of the Resources Committee and I think
    that we are going to take on the responsibility, and I will ask
    our ranking member that we really want to sit down with the
    administration, sit down on both sides of the aisle and come up
    with a bill that can pass, and I don't mean just pass the
    House, come to conference with the Senate, and be signed by the
    President. But that is not going to be easy to do, but I am
    making that commitment that that is what we are going to do. We
    are not just passing this out of here to some other committee
    or to the floor. We are passing this out of here with a bill
    that we think can be signed by the President. That is our goal.
        There is quote from Lone Man of the Teton Sioux Indians
    that I was reminded of recently. It is, ``I have seen that in
    any great undertaking, it is not enough for a man to depend
    simply on himself,'' and so what I am saying is, we need
    everybody to help us out here. We need the tribes, we need the
    administration, we need the health advocates, but we are going
    to move forward, and I just want to thank our witnesses. I
    think it will be a good hearing but we have got a lot of work
    to do.
         With that, I will yield to our ranking member, Mr. Deal.

      OPENING STATEMENT OF HON. NATHAN DEAL, A REPRESENTATIVE IN
                   CONGRESS FROM THE STATE OF GEORGIA

        Mr. Deal. Thank you, Mr. Chairman. I share your concern and
    interest in this issue and I am thankful that we got a referral
    on this legislation so that our committee can have some input
    into it. I look forward to the witnesses' testimony as we
    examine the proposed legislation, and hopefully, their input
    will allow us to make this legislation workable.
        One aspect of the legislation that is before us though was
    always of concern and importance to my friend and a friend of
    everyone on this committee, the late Congressman Charlie
    Norwood. Charlie always expressed reservations regarding
    certain procedures that were being performed by dental health
    aides and dental health therapists in Alaska, and I recognize
    the unique dental health needs presented by the rural nature of
    Alaska, and I understand that this has led to the use of the
    therapists there. However, Dr. Norwood always raised an
    important concern about the irreversible nature of some of the
    procedures performed by these therapists, and I believe that
    Dr. Grim, who is one of our witnesses, is a dentist and I would
    be interested in hearing his opinion on this particular
    subject.
        I am also especially concerned with how the legislation
    before us addresses the Medicaid and SCHIP programs. Nominal
    cost-sharing or co-payments have a role to play in these
    programs and I am concerned about any legislation that removes
    this flexibility. I understand H.R. 1328 contains other
    provisions which deal with the Medicaid and SCHIP and I hope
    our witnesses could speak to some of the changes that are being
    proposed.
        Again, I look forward to the testimony of the witnesses, I
    welcome them here, and I yield back my time, Mr. Chairman.
        Mr. Pallone. Thank you, Mr. Deal.
        The gentlewoman from California, Ms. Solis. You don't want
    to go next?
        Ms. Solis. No.
        Mr. Pallone. It is order of seniority before the gavel, and
    then after the gavel, it is based on who shows up, and if I
    could compliment the gentlewoman from California because I know
    that she took the lead on this whole issue of health care
    disparities and worked with the Native American Caucus and
    Hispanic Caucus and she has really been a champion on that.
        I yield to the gentlewoman.

     OPENING STATEMENT OF HON. HILDA L. SOLIS, A REPRESENTATIVE IN
                 CONGRESS FROM THE STATE OF CALIFORNIA

        Ms. Solis. Thank you, Mr. Chairman, and I am delighted to
    be here and to hear our witnesses today. It is true that the
    Native American population, in my opinion, has been sorely
    underserved for many, many years. I represent Los Angeles
    County, and we have, I believe, services provided to about
    155,000 Native Americans who come through our one and only
    facility there in L.A. County. If you think about L.A. County,
    you are talking about well over 11 to 12 million people and
    those individuals that do come through are self-identified.
    There are so many more that are not even aware of services so
    this is a very timely piece of legislation, and I want to thank
    our chairman and all the members and people like myself who
    really understand that there is a really urgent need to
    increase services. We should not be in a predicament where the
    President is saying there is no value to these programs, and we
    continue to see chronic illnesses come before us here when we
    hear about them and the cost to society overall. I just think
    that that is an assault on our communities and especially
    communities of color where we are the populations that are
    continuing to grow.
        I just want to say I am very excited to hear the witnesses
    today and know that there is a lot of issues that are at hand,
    one of which I think is having an adverse effect on many of our
    patients right now that receive Medicaid to show verification,
    verification from our tribes that they are eligible for this
    assistance. In many cases we have people that were born there
    on the reservation and may not have the appropriate paperwork
    or processes available to help establish their legitimacy.
        So those are really important issues that we need to
    address, and I applaud those witnesses and the chairman and
    members that are supportive of this legislation. Thank you.
        Mr. Pallone. Thank you.
        The gentlewoman from New Mexico.

     OPENING STATEMENT OF HON. HEATHER WILSON, A REPRESENTATIVE IN
                 CONGRESS FROM THE STATE OF NEW MEXICO

        Mrs. Wilson. Thank you, Mr. Chairman. This is a very
    important day in Indian Country. I look back at when the last
    time was that this committee held a hearing on Indian health
    care and it was actually 1991. At least that is the latest one
    that we can find, so this day is long overdue, from my
    perspective.
        The Indian Health Care Improvement Act was first enacted in
    1976, and as the chairman said, the authorization expired
    almost 7 years ago. This bill of which I am a cosponsor will
    help address the high rates of diabetes by helping tribes
    identify and reduce the incidence of diabetes. It directs the
    IHS to screen all Indians receiving services for diabetes. It
    tries to improve nutrition programs and exercise programs,
    authorizes dialysis programs and creates diabetes control
    officers in each IHS area office. It modernizes the Indian
    health care system, and while I still don't think it is perfect
    and there may be some things we need to change as we move it
    forward, I am very proud to be a cosponsor of legislation that
    establishes scholarships and loan programs to encourage Indians
    to go into the health profession. It authorizes construction
    and renovation of medical facilities, and frankly, our medical
    facilities in Indian Country, there is a $3 billion backlog in
    construction of medical facilities in Indian Country, and at
    the current rate of expenditure, it is going to take 120 years
    to overcome that backlog.
        It improves services for urban Indians, about 48,000 of
    whom live in the greater Albuquerque area, and it creates new
    programs for substance abuse, for youth suicide prevention, for
    mental health care, for comprehensive behavioral health care
    and treatment programs. The truth is that teen suicide rates
    among American Indians is three times higher than the national
    average. The life expectancy among American Indians is 6 years
    less than the general population and diabetes is increasing.
    This legislation will matter tremendously to the 173,000
    Indians who live in New Mexico and the 48,000 who live in the
    greater Albuquerque area.
        It is my pleasure today to have a member of the Pueblo of
    Zia here, and I wanted to particularly welcome him. He will be
    part of the second panel. Ken Lucero is the chair of the All
    Indian Pueblo Council Health Committee and he has become since
    his involvement in public life from the Pueblo of Zia one of
    the State's leaders in health care and health policy with
    respect to Indians, and I wanted to thank him for coming all
    the way from New Mexico today to testify and to represent the
    All Indian Pueblo Council and the 19 pueblos in New Mexico so
    that their voice is heard on this issue.
        I also wanted to welcome Ken's dad, the former governor of
    Zia Pueblo. Gilbert Lucero is here. Sir, I wanted to thank you
    for coming. We are honored by your presence.
        Chairman Pallone, thank you for your leadership in
    introducing this bill. I really would like to see this bill
    brought to a markup before our July 4 recess. I agree with you
    that we need to get this moving and out of the House so that we
    get legislation to the President's desk and get this job done.
    The Resources Committee passed it through their committee on
    April 25. I think it has one more stop to go after it sees us
    but we need to move this legislation forward, get the job done
    and get the signature by the President of the United States. It
    will be a great advancement for Indian health care. There is
    more needed to reduce the disparities in health status and
    address the health concerns of Indian people, and we need to
    work not only on this bill but to make sure that the
    appropriations are there to accomplish the goals set out in
    this piece of legislation.
        I thank you, Mr. Chairman.
        Mr. Pallone. Thank you, but I have a word of caution: we
    are not going to be able to do this by July 4 recess. I wish I
    could but we just have so many things to do with PDUFA and
    SCHIP and everything else that I can't make that commitment. We
    wanted to get the hearing in but I don't think we are going to
    be able to mark it up that quickly.
        We have two votes, 12 minutes left on the first one and
    then the second one is a 5-minute. I would like to get a couple
    of these in but I don't know if we can get all three in, so we
    will start with Ms. Hooley.

     OPENING STATEMENT OF HON. DARLENE HOOLEY, A REPRESENTATIVE IN
                   CONGRESS FROM THE STATE OF OREGON

        Ms. Hooley. Thank you, Mr. Chairman.
        I particularly want to express my appreciation for your
    strong leadership on Native American health issues. You have
    long been recognized as a champion on those issues. With your
    continued leadership on the Indian Health Care Improvement Act,
    I hope that we can finally pass this important piece of
    legislation. Our tribes have been waiting since 1999 while we
    have been considering reauthorization of this act. This bill
    takes an important step to help fulfill our promise and our
    obligation to provide health care for American Indians and
    Alaskan Natives.
        To understand the sense of the need for this legislation,
    we need to look no further than to the disconcerting statistics
    about health care outcomes for Native Americans. A 2004 report
    on the health of American Indians reads that Native Americans
    are 770 percent more likely to die from alcoholism, 650 percent
    more likely to die from TB, 420 percent more likely to die from
    diabetes, 280 percent more likely to die from accidents, and 52
    percent more likely to die from pneumonia or influenza than the
    rest of the population. Those statistics are not acceptable and
    demonstrate a clear need to take proactive measures to improve
    health care for our tribes. The Indian Health Care Improvement
    Act will do just that and help our tribes meet their health
    care needs.
        First, I believe the inclusion of health IT provisions will
    help modernize our Indian health care system. The promotion of
    home and community-based services will also provide American
    Indians with access to the type of services long available
    outside the Indian health care system. Moreover, the elevation
    of the Director of the Indian Health Services to assistant
    secretary should give the Director the enhanced authority
    needed to improve these appalling health care statistics for
    Native Americans that I noted earlier. Those are just a few of
    the provisions I know the Northwest Portland Area Indian Health
    Board and our tribes in Oregon see as particularly important to
    improving health care for Native Americans.
        Finally, I understand that there is a tribal leader meeting
    later this afternoon to work on the facilities construction
    concerns that arose in the Resources Committee markup of the
    bill. I want to commend Chairman Rahall and his staff for
    convening this meeting so that tribes can work together toward
    a positive outcome on this matter. I believe a fair and
    equitable compromise is obtainable to ensure that tribes
    throughout the country have access to construction funds they
    need to enhance their health care infrastructure. This is an
    important issue not only for our tribes in Oregon but for all
    tribes and we look forward to a favorable outcome from today's
    meeting.
        I thank you, Mr. Chairman. I yield back.
        Mr. Pallone. Thank you.
        The gentlewoman from Illinois.

     OPENING STATEMENT OF HON. JAN SCHAKOWSKY, A REPRESENTATIVE IN
                  CONGRESS FROM THE STATE OF ILLINOIS

        Ms. Schakowsky. Thank you, Chairman Pallone, for holding
    this hearing today and I know that you have made it a priority
    to reauthorize the Indian Health Care Improvement Act. I
    appreciate the hard work on your part toward that goal.
        As Kenneth Scott, who is the director of the Indian Health
    Service Center of Chicago, puts it, the Indian Health Care Act
    has meant the difference between life and death for many of the
    4.1 million American Indians and Alaska Natives living in the
    United States and has meant the world to those who are able to
    benefit from of the 34 urban Indian health programs. As the
    director of this program, Mr. Scott knows the importance of
    supporting these Indian health projects which serve
    approximately 330 Indians living in urban areas. I have the
    American Indian Center in my district in uptown Chicago and
    this is a very, very important service organization. The Bush
    administration zero-funded the urban Indian health centers
    because they thought community health centers could accomplish
    what they are doing but we know that that is not true and so
    this bill, H.R. 1328, does authorize funding for urban Indian
    health centers, and the community health centers have stated
    they are unable to cover the needs of urban Indians.
        I look forward to hearing from our witnesses today. I am
    eager to hear your particular insight into the prevailing
    health care needs of Native Americans and Alaskan Native
    populations. Though we have made improvements to the delivery
    of health care for this population, current funding meets just
    half of the existing need. In fact, when compared with the
    general U.S. population, the American Indian and Native Alaskan
    population faces downright dismal health outlooks, and you have
    heard those statistics today, and while the rest of the
    Nation's health care infrastructure continues to evolve and
    modernize, we should take care to bring the American Indian and
    Alaskan Native system up to date including the integration of
    electronic health records. This effort should also include
    reinforcing the workforce available to staff these facilities.
    I am glad to see the initiatives in this bill that focus on
    scholarship programs and loan repayment programs that will help
    increase the number of American Indian and Native Alaskan
    medical professionals able to work on reservations and in urban
    Indian health service programs. Making a commitment to
    improving both the infrastructure and workforce needs of the
    Indian health service is paramount to improving access. I look
    forward to working with all of you toward that goal.
        Thank you. I yield back.
        Mr. Pallone. Thank you.
        The gentleman from Utah.
        Mr. Matheson. Mr. Chairman, in the interest of time, I will
    just submit a written statement for the record.
        Mr. Pallone. Thank you. Any other statements for the record
    will be accepted at this time.
        [The prepared statements follow:]

        Prepared Statement of Hon. John D. Dingell, a Representative in
                      Congress from the State of Michigan

        Thank you, Chairman Pallone. I thank our distinguished
    witnesses for appearing before the subcommittee to discuss the
    reauthorization of the Indian Health Care Improvement Act. I
    also wish to acknowledge the leadership of my friend, Chairman
    Pallone, for expediting this bill's consideration before the
    committee. I look forward to working on this important
    legislation to ensure that Indian Health Services has the
    resources to respond to the complex needs of American Indian
    and Alaskan Native communities.
        For nearly a decade, Congress has considered the
    reauthorization of the Indian Health Care Improvement Act.
    Proposals have been offered in each of the past four
    Congresses, yet a reauthorization bill has never passed.
    Congress simply has not given sufficient priority and attention
    to reauthorizing this Act, even though this legislation would
    ensure that American Indians and Alaskan Natives receive the
    critical health care needed in their communities.
        As this legislation moves forward, we want to meet several
    goals: improving tribal participation in negotiated rule-
    making, providing and strengthening needed health services, and
    addressing ongoing concerns about reimbursement provisions for
    Medicaid and other Federal programs.
        When their lands were originally ceded, the Federal
    Government promised that these Native Americans would receive
    decent healthcare services. Unless we address the serious
    deficiencies in the current Indian Health Service programs,
    especially as they relate to accessing mental health services
    and urban health centers, we have failed to make good on our
    promise to the American Indian and Alaskan Native people.
        Again, thank you Mr. Chairman for holding this hearing. I
    look forward to the testimony of our witnesses.
                                  ----------

     Prepared Statement of Hon. Jim Matheson, a Representative in Congress
                             from the State of Utah

        Thank you, Chairman Pallone and Ranking Member Deal.
        I want to thank you for holding this hearing today on H.R.
    1328, the Indian Health Care Improvement Act of 2007. As a
    Member of Congress representing part of the Navajo Nation, the
    largest geographic Native American tribal land holding in the
    United States, I have had the opportunity to visit health care
    facilities in Utah and in Arizona. Moreover, more than 29,000
    individuals in Utah are members of one of at least 35 different
    Native American tribes, which is why I am so concerned about
    improving access to health care on tribal lands.
        Congress made many promises to Native Americans when it
    passed the Indian Health Care Improvement Act in 1976. Although
    that bill provided critical funding and allowed for improved
    access to health care for Native Americans, anyone who has been
    to the Navajo Nation--or to other tribal lands across this
    country--knows that Native Americans are still waiting for
    Congress to fulfill unkept promises. The current funding level
    for the Indian Health Service system has fallen short of the
    critical need. I commend you, Mr. Chairman, for sponsoring this
    legislation and making it a priority for this committee.
        I am very supportive of Indian health services and
    particularly supportive of the Indian Health Service's Urban
    Indian Health Program (UIHP). As you may know, the UIHP
    provides funding for 34 non-profit, Indian-controlled and
    operated urban health programs across the nation. These centers
    are uniquely qualified to provide culturally appropriate
    primary health care services and outreach to urban Indians.
        I look forward to learning more from our distinguished
    panel and working with the Committee to pass this vital piece
    of legislation.
        Thank you, Mr. Chairman.
                                  ----------

      Prepared Statement of Hon. Michael C. Burgess, a Representative in
                        Congress from the State of Texas

        A major concern I have regarding the Indian Health Care
    Improvement Act is its continuance of the Community Health
    Aide/Practitioner (CHAP) created by the Alaska Dental Health
    Aide Program. Understanding that in frontier and rural areas it
    can be difficult to staff clinics with full-time dentists, I
    don't believe the way to address that gap in care is by using
    dental health aide therapists that have a lower standard of
    training to irreversible procedures. By allowing the CHAP
    dental health aid therapist program to continue, I believe that
    IHCIA misses an opportunity to make an improvement to the
    dental workforce in rural and frontier areas. I hope we can
    work together to come up with a more workable solution that
    places as high a priority on access as it does on quality
    health outcomes.
        This is by far a perfect bill and I have additional
    concerns with H.R. 1328's Medicaid and SCHIP provisions, but I
    look forward to hearing from both panels today. I hope that
    this committee can work together and move the Indian Health
    Service forward and improve health care for hundreds of
    thousands of Americans.
                                  ----------

        Mr. Pallone.We will stand in recess for these two votes. We
    will probably be back maybe 20 minutes or so and then we will
    start with Dr. Grim. Thank you.
        [Recess.]
        Mr. Pallone. The subcommittee will reconvene and we will
    now turn to our witness. Dr. Grim, do you want to come up here?
    I will introduce you. This is Dr. Charles W. Grim, who is
    Assistant Surgeon General and Director of the Indian Health
    Service. I welcome you for being here with us. Do you want to
    tell us who else you have with you?

       STATEMENT OF CHARLES W. GRIM, D.D.S., M.H.S.A., ASSISTANT
            SURGEON GENERAL; DIRECTOR, INDIAN HEALTH SERVICE

        Dr. Grim. First, let me say thank you for holding the
    hearing. It is an honor to be before this committee. As
    Congresswoman Wilson pointed out, it has been a while since we
    have had an opportunity to testify before this subcommittee and
    we were excited to be able to do that. My name is Dr. Charles
    Grim. I am the director of the Indian Health Service and I am
    accompanied today by Mr. Robert McSwain, my deputy director for
    the agency; Dr. Rick Olson, who is our director for the Office
    of Clinical and Preventive Services; and Mr. Ron Ferguson, who
    is our director for the Division of Sanitation Facilities
    Construction. As you know, this is a very large bill with a lot
    of issues and so I have tried to bring a number of our subject
    matter experts, depending on what level of detail you all want
    to get in on discussing the bill.
        As I said before, we are very pleased to appear before this
    committee to discuss the reauthorization of the Indian Health
    Care Improvement Act and I, like many of your colleagues, am
    very appreciative that you called this hearing. This landmark
    legislation forms the very backbone of the system through which
    Federal health programs serve American Indians and Alaskan
    Natives and it encourages participation of eligible American
    Indians and Alaskan Natives in these and other programs.
        Two major statutes are at the core of the Federal
    Government's responsibility for meeting the health needs: the
    Snyder Act of 1921, Public Law 67-85, and the Indian Health
    Care Improvement Act, Public Law 94-437. As you know, this act
    was originally authorized in 1976. It was enacted to implement
    the Federal responsibility for the care and education of the
    Indian people by improving the services and facilities of
    Federal Indian health programs and encouraging maximum
    participation of Indians in such programs. Like the Snyder Act,
    the Indian Health Care Improvement Act provides the authority
    for the programs of the Federal Government to deliver health
    services to Indian people but it also provides additional
    guidance in several areas. It contains specific language that
    addresses the 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 for urban Indian people. Since enactment of the
    Indian Health Care Improvement Act in 1976, Congress has
    substantially expanded the statutory authority for programs and
    activities in order to keep pace with the changes in health
    care services and the administration of those services.
        Federal funding for the Act has contributed billions of
    dollars to improve the health status of American Indians and
    Alaskan Natives and much progress has been made, particularly
    in the areas of infant and maternal mortality. The Department
    under this administration's leadership has reactivated a very
    important council called the Interdepartmental Council on
    Native American Affairs. It allows for consistent HHS policy
    when working with the more than 560 federally recognized tribe,
    and I serve as the council's vice chairman.
        In January 2005, the Department completed work ushering
    through a revised HHS tribal consultation policy involving
    tribal leaders in the process. The policy further emphasizes
    the unique government-to-government relationship between Indian
    tribes and the Federal Government and assists in improving
    services to the Indian community through better communications.
    Consultation takes place at different levels including the
    active participation of tribes in the development of the
    Department's annual budget request. For fiscal year 2008,
    tribes identified population growth and increases in the cost
    to providing health care as their top budget priorities and
    IHS's 2008 budget request included an increase of $88 million
    for those items.
        While many of the HHS agencies are important to and work
    closely with tribes, perhaps one of the most important or most
    significant agency is the Center for Medicare and Medicaid
    Services. CMS has formed a technical tribal advisory group to
    provide tribes a vehicle for communicating concerns and
    comments to CMS on Medicare, Medicaid and SCHIP policies that
    impact their members, and the 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 to or struggling with the potentially disabling
    disease. In addition, there is a tribal leaders diabetes
    committee that continues to meet several times a year at the
    direction of myself to review information on the special
    diabetes program for Indian activities and to provide general
    recommendations to the IHS. While the Department hasn't been a
    passive observer of the health needs, we do recognize that
    health disparities do exist among the population and are among
    some of the highest in the Nation for certain diseases and that
    improvements in access to IHS and other Federal and private
    sector programs will result in improved health status for
    Indian people.
        We are here today to discuss the reauthorization of this
    Act and its impact on programs and services provided for in
    current law. The Department is supportive of the
    reauthorization and supports provisions that maintain or
    increase the Secretary's flexibility to work with tribes and to
    increase the availability of health care. We are anxious to
    work with this committee to make progress in moving a program
    supportive of existing authority while maintaining the
    Secretary's flexibility to effectively manage the IHS program.
    However, in the last bill reported by this committee last year,
    there continued to be provisions which would negatively impact
    our ability to provide needed access to services. Such
    provisions establish program mandates and burdensome
    requirements that could or would divert resources from
    important programs. To the extent that those provisions are
    included in the newly introduced legislation, we hope to work
    with you to continue to address the concerns.
        On behalf of Secretary Leavitt, we commit to work with this
    committee and others toward the passage of the Indian Health
    Care Improvement Act proposal that all stakeholders can
    support. My staff and I will be happy to answer any questions
    you may have regarding our statement.
        [The prepared statement of Dr. Grim follows:]

             STATEMENT OF CHARLES W. GRIM, D.D.S., M.H.S.A.

        Mr. Chairman and members of the committee:
        Good Morning. I am Dr. Charles W. Grim, Director of the
    Indian Health Service. Today I am accompanied by Mr. Robert
    McSwain, Deputy Director of the IHS, Mr. Gary Hartz, Director,
    Environmental Health and Engineering, and Dr. Richard Olson,
    Director, Office of Clinical and Preventive Services. We are
    pleased to have the opportunity to testify on the
    reauthorization of the Indian Health Care Improvement Act.
        This landmark legislation forms the backbone of the system
    through which Federal health programs serve American Indians/
    Alaska Natives and encourages participation of eligible
    American Indians/Alaska Natives in these and other programs.
        The IHS provides health services to more than 1.8 million
    federally-recognized American Indians/Alaska Natives through a
    system of IHS, tribal, and urban (I/T/U) health programs
    governed by judicial decisions and statutes. The mission of the
    agency is to raise the physical, mental, social, and spiritual
    health of American Indian/Alaska Natives to the highest level,
    in partnership with the population we serve. The agency goal is
    to assure that comprehensive, culturally acceptable personal
    and public health services are available and accessible to the
    service population. Our duty is to uphold the Federal
    Government's responsibility to promote healthy American Indian
    and Alaska Native people, communities, and cultures and to
    honor the inherent sovereign rights of Tribes.
        Two major statutes are at the core of the Federal
    Government's responsibility for meeting the health needs of
    American Indians/Alaska Natives: The Snyder Act of 1921,
    P.L.67-85, and the Indian Health Care Improvement Act (IHCIA),
    P.L. 94-437, as amended. The Snyder Act authorized regular
    appropriations for "the relief of distress and conservation of
    health" of American Indians/Alaska Natives. The IHCIA was
    enacted "to implement the Federal responsibility for the care
    and education of the Indian people by improving the services
    and facilities of Federal Indian health programs and
    encouraging maximum participation of Indians in such programs."
    Like the Snyder Act, the IHCIA provides the authority for the
    Federal Government programs that deliver health services to
    Indian people, but it also provides additional guidance in
    several areas. The IHCIA contains specific language addressing
    the 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 for urban Indian people.

                                DHHS Activities

        Federal funding for the IHCIA has contributed billions of
    dollars to improve the health status of American Indians/Alaska
    Natives. And, much progress has been made particularly in the
    areas of infant and maternal mortality.
        The Department under this administration's leadership
    reactivated the Intradepartmental Council on Native American
    Affairs (ICNAA) to provide for a consistent HHS policy when
    working with the more than 560 federally recognized Tribes.
    This Council's vice chairperson is the IHS Director, giving us
    a highly visible role within the Department on Indian policy.
        In January 2005 the Department completed work ushering
    through a revised HHS Tribal consultation policy and involving
    Tribal leaders in the process. This policy further emphasizes
    the unique government-to-government relationship between Indian
    Tribes and the Federal Government and assists in improving
    services to the Indian community through better communications.
    Consultation may take place at many different levels. To ensure
    the active participation of Tribes in the development of the
    Department's budget request, an HHS-wide budget consultation
    session is held annually. This meeting provides Tribes with an
    opportunity to meet directly with leadership from all
    Department agencies and identify their priorities for upcoming
    program requests. For fiscal year 2008, Tribes identified
    population growth and increases in the cost of providing health
    care as their top budget priorities and IHS's fiscal year 2008
    budget request included an increase of $88 million for these
    items.
        Through the Centers for Medicare & Medicaid Services (CMS),
    a Technical Tribal Advisory Group was established which
    provides Tribes with a vehicle for communicating concerns and
    comments to CMS on Medicare, Medicaid and SCHIP policies
    impacting their members. And, the 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 to, or struggling with, this potentially disabling
    disease. In addition, a Tribal Leaders Diabetes Committee
    continues to meet several times a year at the direction of the
    IHS Director to review information on the progress of the
    Special Diabetes Program for Indians activities and to provide
    general recommendations to IHS.
        It is clear the Department has not been a passive observer
    of the health needs of eligible American Indians/Alaska
    Natives. Yet, we recognize that health disparities among this
    population do exist and are among some of the highest in the
    Nation for certain diseases (e.g., alcoholism, cardiovascular
    disease, diabetes, and injuries), and that improvements in
    access to IHS and other Federal and private sector programs
    will result in improved health status for Indian people.
        The IHCIA was enacted to provide primary and preventive
    services in recognition of the Federal Government's unique
    relationship with members of federally recognized Tribes.
    Members of federally recognized Tribes and their descendants
    are also eligible for other Federal health programs (such as
    Medicare, Medicaid and SCHIP) on the same basis as other
    Americans, and many also receive health care through employer-
    sponsored or other healthcare coverage.
        It is within the context of current law and programs that
    we turn our attention to reauthorization of the Indian Health
    Care Improvement Act.

                                Reauthorization

        We are here today to discuss reauthorization of the IHCIA,
    and its impact on programs and services provided for in current
    law. In December 2006, the Department submitted to the Senate
    Indian Affairs Committee comments on proposed legislation under
    consideration by the 109th Congress (S.1057). Those comments
    also reflected concerns in the House bill (H.R.5312) and are
    the basis for our testimony today. Any changes introduced by
    the bill under review in the 110th Congress (H.R.1328) are
    being considered as we fully review the legislation. Improving
    access to healthcare for all eligible American Indians and
    Alaska Natives is a priority for all those involved in the
    administration of the IHS program. We have worked with this
    committee in the past and we have made progress in moving
    toward a program supportive of existing authority while
    maintaining the Secretary's flexibility to effectively manage
    the IHS program. However, in the last bill, H.R. 5312, there
    continued to be provisions which could negatively impact our
    ability to provide needed access to services. Such provisions
    established program mandates and burdensome requirements that
    could, or would, divert resources from important services. To
    the extent that those provisions are included in the new
    legislation, we hope to work with you to continue to address
    these concerns.
        The Department is supportive of reauthorization of the
    IHCIA and supports provisions that maintain or increase the
    Secretary's flexibility to work with Tribes, and to increase
    the availability of health care. Committee leadership
    previously responded to some concerns raised about certain
    provisions and some of the changes went a long way toward
    improving the Secretary's ability to effectively manage the
    program within current budgetary resources.
        I would like to note for you today our particular interest
    in provisions previously reported out of this Committee.

                              Overarching Concerns

        We have a number of general objections to the language,
    including, expanded requirements for negotiated rulemaking and
    consultation; new requirements using ``shall'' instead of
    ``may''; use of the term ``funding'' in place of ``grant'';
    expansion of authorities for Urban Indian Organizations; new
    permissive authorities; provisions governing traditional health
    care practices; new reporting requirements; establishment of
    the Bipartisan Commission on Indian Health Care; and new
    provisions that contemplate the Secretary exercising authority
    through the Service, Tribes and Tribal Organizations which is
    not tied to agreements entered into under the Indian Self-
    Determination and Education Assistance Act (ISDEAA). In
    addition, we have some concerns about modifying current law
    with respect to Medicaid and the State Children's Health
    Insurance Program (SCHIP) and, in some cases, we believe
    maintaining the current structure of Medicaid and the State
    Children's Health Insurance Program (SCHIP) preserves access,
    delivery, efficiency, and quality of services to American
    Indians.
        We also have some more specific comments on proposals we
    have previously reviewed for comment.
        In the area of behavioral health, proposed title VII
    provisions provided for the needs of Indian women and youth and
    expands behavioral health services to include a much needed
    child sexual abuse and prevention treatment program. The
    Department supports this effort, but opposes language in
    sections 121, 201, 205, 208, 213, 704, 706, 711(b) and 712 that
    requires the establishment or expansion of specific additional
    services. The Department should be given the flexibility to
    provide for services in a manner that supports the priorities
    of Tribes and IHS, and to address specific needs within IHS
    overall budgetary levels.

                             Reporting Requirements

        H.R. 1328 contains various new requirements for reporting
    to Congress, including requirements for specific information to
    be included within the President's Budget and new annual
    reports to Congress. The IHS and HHS will work with Congress to
    provide the most complete and relevant information on IHS
    programs, activities, and performance and other Indian health
    matters. However, we recommend striking language that requires
    additional specificity about what should be included in the
    President's Budget request and imposes new requirements for
    annual reports.

                                   Facilities

        Sanitation facilities construction is conducted in 38
    States with federally recognized Tribes who take ownership of
    the facilities to operate and maintain them once completed. IHS
    and Tribes operate 49 hospitals, 247 health centers, 5 school
    health centers, over 2000 units of staff housing, and 309
    health stations, satellite clinics, and Alaska village clinics
    supporting the delivery of health care to Indian people.

                Health Care Facilities Needs Assessment & Report

        One provision in last year's bill, section 301(d) (1),
    required Government Accountability Office (GAO) to complete a
    report, after consultation with Tribes, on the needs for health
    care facilities construction, including renovation and
    expansion needs. However, efforts are currently underway to
    develop a complete description of need similar to what would
    have been required by the bill. The IHS plan is to base our
    future facilities construction priority system methodology
    application on a more complete listing of tribal and Federal
    facilities needs for delivery of health care services funded
    through the IHS. We will continue to explore with the Tribes
    less resource intensive means for acquiring and updating the
    information that would be required in these reports.
        We recommend the deletion of the reference to the
    Government Accountability Office undertaking the report because
    it would be redundant of and a setback for IHS's current
    efforts to develop an improved facilities construction
    methodology.

           Retroactive funding of Joint Venture Construction Projects

        In last year's bill, section 311(a)(1) would permit a tribe
    that has "begun but not completed" the process of acquisition
    or construction of a facility to participate in the Joint
    Venture Program, regardless of government involvement or lack
    thereof in the facility acquisition. A Joint Venture Program
    agreement implies that all parties have participated in the
    development of a plan and have arrived at some kind of
    consensus regarding the actions to be taken. By permitting a
    tribe that has "begun or substantially completed" the process
    of acquisition or construction, the proposed provisions could
    force IHS to commit the government to support already completed
    actions that have not included the government in the review and
    approval process. We are concerned that this language could put
    the government in the position of accepting space that is
    inefficient or ineffective to operate. We, therefore, would
    oppose such a provision.

                  Sanitation Facilities Deficiency Definitions

        Another section 302(h) (4) would provide ambiguous
    definitions of the sanitation deficiencies used to identify and
    prioritize water and sewer projects in Indian country. As
    previously proposed ``deficiency level III'' could be
    interpreted to mean all methods of service delivery (including
    methods where water and sewer service is provided by hauling
    rather than through piping systems directly into the home) are
    adequate to meet the level III requirements and only the
    operating condition, such as frequent service interruptions,
    makes that facility deficient. This description assumes that
    water haul delivery systems and piped systems provide a similar
    level of service. We believe it is important to distinguish
    between the two.
        In addition, the definition for deficiency level V and
    deficiency level IV, though phrased differently, have
    essentially the same meaning. Level IV should refer to an
    individual home or community lacking either water or wastewater
    facilities, whereas, level V should refer to an individual home
    or community lacking both water and wastewater facilities.
        We recommend retaining current law to distinguish the
    various levels of deficiencies which determine the allocation
    of existing resources.

                Threshold Criteria for Small Ambulatory Program

        Yet another section 305(b) (1) would amend current law to
    set two minimum thresholds for the Small Ambulatory Program -
    one for number of patient visits and another for the number of
    eligible Indians. In order to be eligible for the Small
    Ambulatory Program under the previously proposed criteria, a
    facility must provide at least 150 patient visits annually in a
    service area with no fewer than 1500 eligible Indians. Aside
    from the fact that these are both minimum thresholds and so
    somewhat contradictory, the proposed provisions would make
    implementation difficult. First, the IHS cannot validate
    patient visits unless the applicant participates in the
    Resource Patient Management System (RPMS). Since some tribes do
    not participate in the RPMS, it is difficult to ensure a fair
    evaluation of all applicants. Second, the term "eligible
    Indians" refers to the census population figures, which cannot
    be verified, since they are based on the individual's statement
    regarding ethnicity.

            New Negotiated Rulemaking and Consultation Requirements

        In addition, we are concerned about the requirements for
    negotiated rulemaking and increased requirements for
    consultation in the bill because of the high cost and staff
    time associated with this approach. We are committed to our on-
    going consultation with Tribes under current Executive Orders,
    as well as using the authority of Chapter V of title 5, United
    States Code (commonly known as the Administrative Procedures
    Act) to promulgate regulations where necessary to carry out
    IHCIA.
        The comments expressed today in this testimony do not
    represent a comprehensive list of our current concerns. And, we
    will continue reviewing H.R.1328 for any provisions that might
    be addressed.
        I reiterate our commitment to working with you to
    reauthorize the Indian Health Care Improvement Act, and the
    strengthening of Indian health care programs. And we will
    continue to work with the Committee, other Committees of
    Congress, and representatives of Indian country to develop a
    bill that all stakeholders in these important programs can
    support. Again, I appreciate the opportunity to appear before
    you today to discuss reauthorization of the Indian Health Care
    Improvement Act and I will answer any questions that you may
    have at this time. Thank you.
                                  ----------

        Mr. Pallone. Thank you, Doctor. Before I recognize myself
    for questions, I just wanted to say that your statement becomes
    part of the hearing record and you may, if you want, submit
    additional brief and pertinent statements in writing either in
    response to our questions or other things that you might want
    to bring in.
        Dr. Grim. Thank you, Mr. Chairman.
        Mr. Pallone. And I will recognize myself for some questions
    and then we will go to the other members.
        As you heard me say in my opening statement, I am very
    frustrated over the fact that we--I say ``we'' collectively--
    the tribes, myself, many of the members have been working on
    this legislation essentially for more than 7 years and we
    haven't been successful, and I am not trying to point the
    finger because I am sure everybody can take some of the blame
    but it does seem that every time at the end of the 2-year
    session when we are close to getting something done that we get
    the administration coming in with some new objection, and it
    might be from HHS or it might be from the Department of
    Justice. That is certainly what happened last year at the end
    of the last Congress. And of course, what I am trying to do is
    avoid that this year. That is why we got it out of Resources.
    That is why we are here early. And as I said before, I would
    like to report a bill out of even the subcommittee that the
    President could sign. So you have got to give me some help
    here, first of all. I would like to have a commitment from you
    that the administration will work with us in good faith to
    reauthorize the bill this year, meaning 2007, if you would make
    that commitment.
        Dr. Grim. As you couldn't make a commitment by July 4, I am
    not sure about 2007, but I can tell you that we are very, very
    close within the Department to getting the comments on the bill
    to you. They are going through some final stages of clearances
    right now and we have made comments on the prior Senate bill
    that I think gave a lot of guidance and a number of those
    things were changed in the bill that you introduced so we can
    be very, very close to giving you some comments that I think
    you can work on.
        Mr. Pallone. When do you expect to give us those comments?
        Dr. Grim. I will have to get back to you for that on the
    record but they won't come in in the 12th hour at the end of
    the second year.
        Mr. Pallone. How about a month?
        Dr. Grim. It depends how many back-and-forths there are but
    the Department is close to getting them----
        Mr. Pallone. Well, if you could get them to us within the
    next month, frankly I would be happy.
        Dr. Grim. We will try to do everything we can to do that.
        Mr. Pallone. OK. Now, just briefly, because I know we don't
    have a lot of time, but did you want to comment on why we have
    this problem? It does seem like at the end we always get more
    objections. Is there some process thing that we need to address
    here to change so that it doesn't happen again and so that we
    move things quicker? You might not have an answer but I just--
    --
        Dr. Grim. I would just say that we have all learned through
    the process that this it is a complex bill. It has a lot of
    sections and it touches a lot of other departments besides HHS.
    In a hearing that I testified before the Senate recently, who
    also had the Department of Justice. The Department of Justice
    committed as well to getting their comments and we are trying
    to----
        Mr. Pallone. Well, I think you hit on the point. I think
    since so many other departments are involved, maybe one thing I
    could ask you to do is to take it upon yourself to get back to
    us and tell us who within the administration other than HHS
    might have to comment on this because I don't want to see HHS
    comments, then Justice and then we find somebody else has to,
    so maybe that is one way you can help me get back to me with
    whoever you think we need to have see this so that we can get
    everybody's comments.
        Dr. Grim. We are trying to gather all those in for you too.
    We are trying to make it a comprehensive set of concerns that
    will come forward.
        Mr. Pallone. That would address all the administration's
    departments?
        Dr. Grim. As much as can know at this time, yes, sir.
        Mr. Pallone. All right. Now, you mentioned objections to
    various provisions in the bill. Do you want to tell us what you
    support? What provisions in it right now would you support?
        Dr. Grim. There are a huge amount of provisions that we
    support and I don't know that I could go through them all, and
    I am assuming the committee has seen some of our comments on
    the previous bill and a lot of those were on the requirements,
    a lot of new requirements for reports that hadn't been done in
    the past that would draw resources away for a large----
        Mr. Pallone. Well, tell us as much as you can what you can
    support at this time as best you can.
        Dr. Grim. There are a lot of responses that we have made in
    the past that express concerns that have been addressed in
    areas of new requirements like negotiated rulemaking and
    consultation. There were a lot of requirements for negotiated
    rulemaking and consultation and a number of those have removed.
    There were some new and expensive requirements that have also
    been addressed, and we appreciate those responses to allow the
    Secretary to maintain flexibility to the greatest extent
    possible. I noted the reporting requirements that we felt were
    labor and time intensive and we note that there is at least one
    instance where such a requirement was addressed in this bill.
    One provision that restricted the Secretary's authority in the
    development of regulations also appears to have been addressed
    under section 802 in regulations, and we realize that was a
    very important accommodation that you all made. It will ensure
    that our resources are focused and prioritized by those most
    closely involved in program administration. Also, there were
    several provisions in the bill that we had made comments on,
    those comments that went in in December to the Senate that have
    been revised in this version of the bill. And so there have
    been numerous things that have already been addressed and----
        Mr. Pallone. Well, maybe again if you would in writing get
    back to us to tell us what you support, OK? Because I think you
    tell us what you don't like but I would like to know more about
    what you think you support at this time.
        All right. My time has run out. I recognize the gentlewoman
    from New Mexico.
        Mrs. Wilson. Thank you, Mr. Chairman. I neglected to do so
    in my opening statement, but I would like to ask for unanimous
    consent to include in the record a letter of support for this
    legislation from the Pueblo of Zia, from the All Indian Pueblo
    Council, and from the New Mexico State Legislature.
        Mr. Pallone. Without objection, so ordered.
        Mrs. Wilson. Thank you, Mr. Chairman.
        Doctor, the Acoma-Canoncito-Laguna Hospital in New Mexico
    is running a $4.6 million deficit, many believe due to poor
    management by the Indian Health Service. Apparently,
    individuals, IHS officials that are overseeing the hospital
    apparently were allowed to borrow some $2 million from another
    service unit within the Albuquerque area without the knowledge
    of tribal leaders and they owe about $2 million more in other
    contracted services. Our delegation from New Mexico has written
    to you several times on this matter, most recently in January
    of this year, without a response from your Department. What are
    the procedures that IHS uses to periodically review the
    financial situation of each facility, and what do you intend to
    do about the ACL Hospital?
        Dr. Grim. The regional leadership in each area on a regular
    basis, and it varies by region, have what are called governing
    board meetings with each facility, with each service unit
    within the region. That is one of the requirements under the
    Joint Commission on the Accreditation of Health Care
    Organizations and part of the things that they review at that
    time are financial transactions as well as other sorts of
    activities in the hospital. It has been a multiple-year process
    that we have been working on with ACL to try to address the
    issue. I personally have met with the tribal leadership and
    other congressional leadership about the situation going on out
    there. The tribe asked us to do a review of that program and
    asked that we include more members from their tribes. We had
    three Federal representatives on that review team. That report,
    the draft copy of that report has been shared with tribal
    leadership. They have asked for some changes to be made to it.
    We are also considering--and also Congressman Pearce, one of
    his senior staff came out and toured the facility and then went
    back to our regional office and we provided them with
    significant amount of financial information that went back a
    number of years.
        Mrs. Wilson. Have you provided that financial information
    to the tribe? Because as I understand it, the preliminary
    report did not include financial information. The tribe has
    asked for it and we still haven't gotten a response to our
    request for that information that we put in writing to you in
    January.
        Dr. Grim. I guess you would have to ask the tribe that. I
    am assuming that that information has been shared. We sent out
    a large amount of information. But what people wanted it to be
    was better organized over a multiple-year period, and that was
    some of the information that was shared with the Congressman's
    office recently and so we do now have the data in what we
    think----
        Mrs. Wilson. Well, you have not shared that information
    with this Congresswoman's office and I would remind you that
    that hospital does not just serve constituents from one
    congressional district, and if I sign a letter, I generally
    expect a response, and we have not gotten a response from the
    IHS and I would ask you to address that issue. You obviously
    can't address it here today, but we are not getting sufficient
    information and neither is the tribe, and there is obviously a
    problem there and I would ask you to put some attention on it.
        Dr. Grim. I apologize that you haven't gotten a response
    yet, and we will get you one as soon as possible.
        Mrs. Wilson. There is also a problem, as I understand it,
    regarding the ability of dentists and others to volunteer with
    the IHS, and I understand there are some barriers that are in
    place. I understand you have a volunteer dentist program that
    you put in place last year but the participation has been low
    because of the burdensome credentialing requirements and
    process. As I understand it, there is no centralized system at
    IHS for credentialing and that volunteer dentists have to be
    re-credentialed each year. They have to fill out more paperwork
    for each clinic in which the practice. What do you recommend
    here to straighten out this process?
        Dr. Grim. I am going to make some preliminary comments and
    then I am going to let Dr. Olson speak to it a little bit more.
    The credentialing requirements that are placed upon our
    providers are not requirements that the Indian Health Service
    has placed upon them. Those are requirements that we have to
    meet to maintain our accreditation through the Joint Commission
    on the Accreditation of Health Care Organizations. Our
    hospitals and clinics go through that process.
        Mrs. Wilson. It is my understanding that the military has a
    centralized credentialing process. Do they not have to be
    accredited?
        Dr. Grim. I am not sure if the military maintains that
    accreditation or not. Rick, do you want to----
        Dr. Olson. I don't know that I can answer whether the
    military does. I can talk some about the central credentialing
    program if you wish.
        Dr. Grim. Go ahead.
        Dr. Olson. OK. As Dr. Grim said, all Indian Health Service
    facilities are either Joint Commission accredited, certified by
    CMS or accredited by the Accreditation Association for
    Ambulatory Health Care Centers, and to meet those standards,
    which are to meet quality-of-care standards, we credential and
    privilege all providers, primary providers who work in our
    facilities so all physicians, all dentists, psychologists,
    various other ancillary staff who work in our facilities are
    all credentialed and privileged by standard providers in all
    our facilities and that includes all hospitals in the United
    States and large health care organizations that have a
    credentialing system. This has to be done every 2 years so all
    of our providers are re-credentialed every 2 years. I am sure
    they do that in the military. They certainly do that in the VA.
    I just don't know the military's system that well. What the
    centralized credentialing system does for the military and it
    probably makes a lot more sense for the military because their
    providers are deployed frequently. Their providers move form
    base to base every few years or so. In the Indian Health
    Service, we want our providers to stay in a location generally.
    A few folks move but most will stay and that is for continuity
    of care. Our patients want to see their physician, not somebody
    new every time.
        Mrs. Wilson. This isn't an issue of continuity in the
    community. This is how do we credential--we have volunteer
    dentists who want to volunteer, pediatricians who want to
    volunteer, psychologists who want to volunteer, but there is,
    as I understand it, no centralized credentialing system at IHS.
    Do you think that is a problem or are you just going to
    continue on with the same system you have?
        Dr. Olson. Well, I don't think that the centralization
    meets the issue at all. We did talk with the American Dental
    Association, the American College of OB/GYN, American Academy
    of Pediatrics folks last summer when we were aware of the
    report requirement, and one of the big issues that they
    identified which we are in the process of fixing now is to have
    one credentialed application form across our whole system. Now,
    that is at IHS facilities. Tribes run their own programs and so
    if they want to use our form, that is fine, but if a volunteer
    goes to a tribal program like in Alaska, that is not an IHS
    issue at all, but we are simplifying. We are going to make it
    Web-based application form and that can be transported from
    location to location so they don't have to fill out a form. But
    they still have to be re-credentialed and it is the same way in
    the military. What the centralized credentialing system
    basically does is have a repository electronically where
    different locations can go in and get the credentials that have
    been verified but then they still have to review the
    credentials and then review the privileging application.
    Privileges have to do with what we allow in a facility, and it
    is based on two things. One is the expertise and training of
    the provider. The other is the capacity of the facility to
    support that provider, and just to give you a brief anecdote to
    understand----
        Mr. Pallone. You have to be brief because we are like
    almost twice the amount of time here, so----
        Dr. Olson. All right. I am a physician and internist. I did
    a lot of cancer chemotherapy. I had the training and expertise
    to do that at my hospital, a small rural hospital in Oklahoma
    where I was for 11 years, but the facility didn't have the
    capacity to support me and so what we did to develop that
    capacity, we had to send off nurses and pharmacists in order to
    support the chemotherapy program and then I got the privileges
    to do that and ran a program for 8 years like that. So capacity
    of the facility is unique from facility to facility. So at
    every location where a provider goes, whether they are a
    physician, a dentist, a volunteer, we have to credential and
    privilege at each location and then we have to re-credential
    every 2 years for all providers whether they are volunteers or
    not.
        Mrs. Wilson. Thank you, Mr. Chairman.
        Mr. Pallone. Sure. Ms. Solis.
        Ms. Solis. Thank you, Mr. Chairman.
        I want to direct my questions to Dr. Grim, and I will just
    ask you, how many people are actually served by the Urban
    Indian Health Care Program?
        Dr. Grim. I will have to get back to you with that number.
        Ms. Solis. You don't have an estimate?
        Dr. Grim. The last number that I have was 150,000 but that
    was for a hearing a year ago. I just want to double-check and
    make sure that that is still accurate for you, and we will
    submit it for the record.
        Ms. Solis. And can you break that down by State?
        Dr. Grim. We can break it down, yes, by State.
        Ms. Solis. Thank you. One of the questions I have is, what
    would happen if these services were not available any longer,
    especially again in urban settings? And look at the case in Los
    Angeles and if you could just elaborate.
        Dr. Grim. I can elaborate some on that.
        Ms. Solis. Where would the patients go, for example? Who
    would provide them with care?
        Dr. Grim. Well, the Indian Health Service funds about 34
    such programs and our average funding for those programs is
    about 50 percent. It ranges from about 15 percent of their base
    funding to in some programs 100 percent. Some of the programs
    are only outreach and referral programs so they provide no
    direct services whatsoever, and others are full-blown
    ambulatory care clinics and so part of what I am saying is that
    not all the programs would close down without our funding. They
    have a lot of other grants and other resources. Some of them
    would have to close down, those that rely on us 100 percent,
    and the administration's view when it made that recommendation
    in the past is that some of the statistics that were cited by
    Congressman Pallone about the per capita funding in Indian
    Health Service, we redirected the funding from the Urban Indian
    Health Program to all of the hospitals and clinics that are on
    or near reservations that have in many cases there is no other
    place to go except an Indian Health Service location, and we
    would have----
        Ms. Solis. I don't have a lot of time so I am going to
    interrupt. I would like to get information specifically on what
    impacts that would have in Los Angeles County. We only have one
    center there in Los Angeles downtown and we have got a vast
    number of urban Native Americans that I don't even believe are
    fully aware that there is a program that exists, and I would
    like to know how that money is being spent there. And then
    secondly, something I raised earlier was with respect to the
    new requirement to show proof of citizenship or some
    documentation. I know we are going to hear from a witness later
    about restrictions that are currently placed on tribes and I
    believe, and you can correct me, that there are only five
    tribes that have recognized status of showing acceptable proof
    of citizenship, so is that true? Is that correct?
        Dr. Grim. I know it is a very small number of tribes. I
    don't know the exact number. We can get that for the record.
        Ms. Solis. So a vast number of the Native American
    population would not be eligible for assistance because they
    are not designated as one of those----
        Dr. Grim. No, that is not true, and right now CMS is
    currently in the process of reviewing comments. I have gotten
    over 1,400 comments on that particular regulation about----
        Ms. Solis. Is there a need to change that regulation?
        Dr. Grim. Well, they are in the process of writing it right
    now. In fact, I submitted a comment myself about some of the
    concerns that Indian tribes had and the fact that some of their
    especially older membership might not have----
        Ms. Solis. Will you share that with the committee?
        Dr. Grim. Sure. And the regulations are in the process of
    being developed finally right now and the issues that you are
    raising may be dealt with. I am just not sure yet.
        Ms. Solis. With respect to community health aides, I know
    that there is such a program that exists right now providing
    culturally competent care in Alaska. Would it behoove us to
    maybe look at how that can be expanded to serve communities
    like Los Angeles and other, say, mega urban areas where you
    have a very diverse population that might be able to benefit
    from information outreach campaigns and just prevention?
        Dr. Grim. I believe if I am interpreting your question
    right, I believe some of the concerns have been addressed in
    some language that we worked with one of the other committees
    where the program that is going on in Alaska right now would
    operate for a period of years and be evaluated. It is under
    evaluation right now, and at the end of that evaluation period
    we would take another look at it and see about applicability to
    the lower 48.
        Ms. Solis. One of the issues that I am concerned with is
    the fact that there are so many cultural barriers, language
    barriers in accessing health care overall, particularly for
    Native Americans as well as Latinos, and in Los Angeles we have
    those communities intermixing very often and sometimes it is
    hard to identify and separate who is Latin American and who is
    Native American, and one of the things that I would like to see
    is that these kinds of programs are actually extended in urban
    areas, whether it be Chicago, New York or Los Angeles County,
    Arizona, and places such as that.
        One last thing, Mr. Chairman, I want to bring up is, I
    really believe that when we are talking about health care and
    prevention, that we really need to go a step farther because we
    hear so many instances on the reservation where many of our
    Native American families are affected by groundwater
    contamination, different types of contaminants that are there
    that are remnants in their home and in their environment and
    what kind of steps could we take possibly through programs like
    this and others that might be able to help provide more
    information on prevention and what to look for because I can
    see where there is really a lack of information available to
    the people on the reservation. Thank you.
        Mr. Pallone. Thank you.
        Mr. Sullivan of Oklahoma.
        Mr. Sullivan. Thank you, Mr. Chairman, and thank you, Mr.
    Grim, for your being here today at the panel. As an Oklahoma
    native and a member of the Cherokee Nation, I know you
    understand the health challenges facing Native Americans in our
    State and Nation and we appreciate the job you do to serve the
    health care needs of Indian Country. In Oklahoma, we have 37
    federally recognized tribes with each different challenges with
    respect to assessing and delivering quality health care. As a
    vice chairman of the Congressional Native American Caucus, I am
    deeply concerned with the status of Indian health care in
    America and their access to care. We know that nationally
    American Indians and Alaskan Natives have three times the rate
    of diabetes and up to three times the rate of suicide. In
    addition, Native Americans also have among the highest rate of
    cardiovascular disease. IHS recently estimated that more than
    two-thirds of the health care that is needed for American
    Indians is being denied. In your review, what are the barriers
    to access to care that Native Americans are experiencing and
    how would reauthorization of H.R. 1328 improve access to
    tribes? And also along those lines, if you can comment on
    prevention. I think prevention in health care, when you look at
    health care is very important. We seem to deal mainly with
    chronic illnesses and not as much on the front end with
    prevention like I think we should, and especially in the Native
    American populations it is no different really than many
    others. What is being done, like I said, with diabetes
    prevention, drug addiction, alcoholism and also mental illness?
        Dr. Grim. We are focusing very heavily on all those areas
    you mentioned actually. We have major initiatives going on in
    prevention, in behavioral health and chronic care management.
    We have all over the country programs that tribes have run both
    because of the special diabetes program for Indian monies as
    well as appropriated funds through Congress of prevention
    initiatives. One of the things we are trying to do now is to
    integrate those three programs. We are working with an
    institute out of Massachusetts called the Institute for Health
    Care Improvement on a chronic care collaborative to change and
    re-engineer our system in the way we deliver chronic care. You
    talked about barriers to access to care and prevention is one
    component. If we could stop some of the disease from occurring,
    it would allow more people to access the types of care that
    they do need. Everyone I think in the country has realized
    that. We have and certainly tribes have and so as we integrate
    these three initiatives, better management of chronic care
    patients, dealing with the behavioral health issues that there
    are in our population. Suicide was mentioned, high alcoholism
    rates. Methamphetamine is on the rise in our population, and
    really a lot of those things are education and prevention are
    some of the keys to dealing with them, and those are some of
    the key things that we are focusing on right now. So I would
    say that No. 1, the authorities that we have are allowing us to
    do those things, and I am very excited that Congress is
    interested in focusing on prevention in this bill.
        Mr. Sullivan. Well, for Native Americans suffering from the
    disease of alcoholism, can they go to a residential treatment
    facility now?
        Dr. Grim. We have limited residential treatment facilities.
    We have 11 of them right now, and right now those are focused
    on youth or youth residential treatment centers. For adults,
    some tribes have started residential treatment programs for
    adults. Right now the Agency has no residential treatment
    programs for adults, and if we do send them for care, it is
    using our contract health service dollars to refer them out to
    a private facility. So that is a gap in access, if you will,
    for the adult population.
        Mr. Sullivan. Do you think it would be important to get
    some treatment facilities for them?
        Dr. Grim. The adults could use them, as I said, but they
    are not going without care right now. Those that need the care
    if we are able to refer them out, we do it with contract health
    service dollars into the private sector where facilities exist.
    Perhaps one of the bigger complaints we get though from tribes
    is that we do have to send them away. They are sent away to
    some location and then they come back. There is nowhere close.
    In some places we send them to other States.
        Mr. Sullivan. I bet you are not sending them to Betty Ford,
    are you?
        Dr. Grim. I wouldn't swear we are not but I could get that
    information.
        Mr. Sullivan. Well, I think that is important that we get
    some access to that. And also, what about mental illness? What
    are you doing about that?
        Dr. Grim. One of the line items in our budget is mental
    health and so a large majority of our facilities provide mental
    health services. They are often times in the smaller facilities
    triage sort of care only, kind of emergent-type care. We have
    tested some models and some larger facilities of on-demand-type
    care that seem to be working successfully and I guess one of
    the things I would want to point out is that we are constantly
    looking at best practice things that are going on, evidence-
    based best practice things in the medical sector, and as we can
    bring them into our system, we are doing that. There is mental
    health care available out there. Is it available for everyone
    that needs it? No, sir.
        Mr. Sullivan. All right. Thank you, sir.
        Mr. Pallone. Thank you.
        The gentlewoman from Illinois.
        Ms. Schakowsky. Thank you very much, Mr. Chairman. I was
    concerned that you seemed reluctant to say that within a month
    that you could respond to some of the questions. I don't know,
    it seems like a reasonable amount of time. Do you think it is
    likely that you will be able to?
        Dr. Grim. I think it is likely that we can have it within a
    month. I am just not going to promise it on the record today.
        Ms. Schakowsky. Is it your intention to stay for the second
    panel?
        Dr. Grim. I didn't know I was going to be here this late so
    I have an appointment with my boss, but if the Congress
    requests that I stay, I will stay.
        Ms. Schakowsky. Well, I always think it is a good idea that
    the people who are actually dealing with these programs hear
    all the testimony, so if you could, I think it would be a good
    idea.
        Dr. Grim. Ninety percent of the time, I do that, but I am
    just not sure today.
        Ms. Schakowsky. In developing your concerns and your
    testimony, did you do this at all in consultation with any
    representatives of the tribes and the deliverers of the health
    care to the Native American population?
        Dr. Grim. In preparing my----
        Ms. Schakowsky. Your testimony today. Are your concerns
    that you listed reflective of what we may hear from the
    providers of the services?
        Dr. Grim. These are administration's concerns. I think you
    are going to hear some different things from the second panel.
    They would like to see things perhaps left in the bill that the
    administration would like to see removed and again the primary
    concerns are to leave flexibility for the Secretary, to not put
    new requirements and reporting provisions in that would take
    funds away from the delivery of care.
        Ms. Schakowsky. One of the top priorities of the chairman
    of the full committee, Mr. Dingell, and I would say of our
    health subcommittee as well is the SCHIP program, and I notice
    that in your testimony you have some concerns about SCHIP. You
    don't elaborate on those concerns. What is your concern?
        Dr. Grim. Well, one of the concerns of the SCHIP
    reauthorization is that--and I guess let me first say that one
    of the concerns is that there are SCHIP-type issues in the
    Indian Health Care Improvement Act and the administration would
    prefer to deal with SCHIP in the SCHIP reauthorization, so that
    is probably the first and the biggest concern. The other
    concern is the expansion that some States have done with SCHIP
    to go beyond some of the initial intent of it to cover adults
    and we think refocusing the efforts to between 100 and 200
    percent of the poverty level, focusing back on children would
    be an immense help to our population. Much of our population
    falls into that 100 to 200 percent of the Federal poverty level
    and so those are examples of some of the concerns that we are
    dealing with, reauthorization of another bill within our bill
    and then a refocusing of the efforts on what the initial intent
    was.
        Ms. Schakowsky. When you say our population, then are you
    saying that you think you are reflecting what your population,
    that is, the Native American population would agree that it
    should not include adults and it should focus only on 100 to
    200 percent of poverty level?
        Dr. Grim. I was not trying to characterize that my
    population would think that, no, that we serve only that. We
    have a significant amount of population that falls in the 100
    to 200 percent range and to the extent that expansions beyond
    that dilute what is available in the way of either services or
    eligibility to that group, that it would hurt the coverage
    within our population group.
        Ms. Schakowsky. Unless more money were allocated for it.
    And with respect to Medicaid, you say you have concerns and you
    are not only talking about dollars, you say the current
    structure of Medicaid. What is the problem with Medicaid?
        Dr. Grim. I would like to get that to you in writing for
    the record.
        Ms. Schakowsky. As I said, the American Indian Center in
    Chicago is located within my district, and the health center is
    really struggling. It is one of those 34. I would really like
    to arrive at a place where we could work with you to bolster
    those rather than this notion that other health care facilities
    or federally qualified health centers could address that
    population. All of our FQHCs are struggling with being
    overloaded and it would seem to me that this one, which is
    culturally sensitive, which has the capacity to do the kind of
    outreach we need to the Native American community could be
    helped. I am wondering if there are ways that we could work
    together to make sure that this particular facility could
    continue to exist and even flourish.
        Dr. Grim. We are willing to work with you. We have an
    Office of Urban Indian Health. I don't have the specifics on
    the type of funding that the center in Chicago gets but we
    either have that or can get that and we can work with you,
    Congresswoman, on that.
        Ms. Schakowsky. Well, if you would take a look at that
    particular center and get back to me and perhaps we could set
    up a meeting with its director, Ken Scott, and talk about what
    we can do.
        Dr. Grim. Our director for the Office of Urban Indian
    Health happens to be in the room today, so she heard that from
    you and we will make sure we do that.
        Ms. Schakowsky. Great. Thank you.
        I yield back, Mr. Chairman.
        Mr. Pallone. Thank you. Hopefully you won't leave but
    before you step down from the panel, I just want to emphasize
    again that it is obvious that there are a lot of disagreements
    with the administration on this bill and I really would like to
    get those all on the table and try to iron them out and see
    that we can come to a consensus because we want a bill that is
    going to pass, that is going to come to conference with the
    Senate and go to the President. There are going to be
    differences but we would like to work them out but we can't
    work them out unless we have them all on the table, so I
    appreciate the fact that you are going to try to get us all
    these objections as well as what you support within the next
    month, and also that you are going to try to be sort of a
    clearinghouse for other departments or agencies, because that
    is just as important.
        So thank you again. We have a lot of work to do. Thank you.
        Dr. Grim. Thank you, Congressman.
        Mr. Pallone. And I will ask the second panel to come
    forward. Welcome to all of you. Thank you for being here. Let
    me introduce each of you from my left to right. First we have
    James Crouch, who is executive director of the California Rural
    Indian Health Board, and then we have Mr. Ralph Forquera, who
    is executive director of the Seattle Indian Health Board, and
    then Mr. Ken Lucero, who is from the Pueblo of Zia, and then we
    have Rachel Joseph, who is co-chair of the National Steering
    Committee for the Reauthorization of the Indian Health Care
    Improvement Act and also representing the National Indian
    Health Board. Good to see you again as well.
        As I said before, your statements will be part of the
    hearing record and each of you may in the discretion of the
    committee submit additional pertinent comments either in
    response to our questions or on your own, if you like, and I
    will start with Mr. Crouch.

    STATEMENT OF JAMES CROUCH, EXECUTIVE DIRECTOR, CALIFORNIA RURAL
                   INDIAN HEALTH BOARD, INCORPORATED

        Mr. Crouch. Thank you very much. My name is Jim Crouch,
    executive director, California Rural Indian Health Board. I am
    proud to serve in that position for the last 20 years. I am
    presenting on behalf of California Rural Indian Health Board,
    its 12 member tribal health programs providing services to over
    44,000 American Indians. I would like to keep my comments
    essentially focused on the new title II Medicare, Medicaid and
    SCHIP provisions. CRIHB is totally supportive of the entire
    bill. We are very pleased to have it in this committee again.
        The Indian Health Service is a discretionarily funded
    Federal program. It is not an entitlement program. There could
    be no greater flexibility than is already provided in the
    Indian Health Service under the appropriations processes. The
    role of the health bill is to give them guidance to better meet
    the needs of the Indian community, and when this bill first
    passed in 1976, really the most exciting part of it was the
    joint funding that responded from including the right of IHS
    facilities to bill the Social Security-based programs. A lot
    has changed in that time. Today the CMS programs provide about
    a third of the operating budget of the Indian Health Service.
    When you all think about the underfunded nature of the Indian
    Health Service, you are including through the level of need
    funded methodology participation and dollars from the CMS
    provides so when we say IHS is underfunded, typically that
    includes the contribution of the Center for Medicare and
    Medicaid Services programs.
        What does this bill do that is new? It newly enfranchises
    tribal providers and IHS facilities to bill for not only
    programs at CMS but also for furnishing items, and as I stated
    in my written testimony, such critical things as wheelchairs,
    diabetic test equipment and strips would be therefore included
    that are currently problematic at this point. It also addresses
    the issue of outreach. Having access to an entitlement program
    coverage like Medicaid or SCHIP, Medicare, simply isn't real
    until you actually are enrolled, and without increased efforts
    on enrollment and outreach, which this bill provides, we will
    continue to have underutilization of particularly the Medicaid
    program in Indian Country. I can't believe that the Indian
    Health Service in fact would oppose or CMS would oppose any
    kind of increase in that work.
        The real heart of the Medicaid provisions and the SCHIP
    provisions in this bill which are perhaps somewhat
    controversial for some is the issue of providing access to
    health care without premiums and co-pays. I would suggest that
    this is important for making that access real. I would like to
    share with you some material that was not in my written
    testimony about low access to health care. In California a few
    years ago, we did some research that matched by education,
    geography and Medicaid category of eligibility over 22,000
    Indian people and compared them to non-Hispanic white
    population exactly matched by the same geography and age
    categories. What we learned from that is Medicaid coverage
    doesn't mean access. The actual visit counts were very
    different between those two populations. The pattern of
    providers that were seen were different and we were looking at
    both IHS tribal and non-IHS-funded providers because it is a
    payment study. And most importantly, the Indian received only
    85 cents for every dollar expended on their similarly situated
    non-Hispanic white population. Why is that? It is in part
    because the geography is much greater. We couldn't actually
    match point by point for geography. It is also because of
    barriers that relate to accessing Medicaid through a share of
    cost arrangement. I would also point out that we looked at a
    broader study, looking at access to hospital-based services.
    The Indian community when we looked at just the rate of gross
    hospitalizations for all payers, and I would add non-payment of
    debt, if you have a problem in Canoncito with the payment of
    CHS dollars being reduced, that is true generally in Indian
    Country. Looking at bad debt, Medicaid payment and IHS payment,
    which in California was very little, overall hospitalization
    rates differed greatly between the non-Hispanic whites and the
    Indian population. American Indian women were getting to the
    hospital at a 52 percent higher rate than the other community
    and the men a more shocking 72 percent.
        Lastly, I would like to particularly point out the issue of
    access to primary care. That is where we will make real
    progress in health care. This bill allows by expanding coverage
    and participation in Medicare, Medicaid and SCHIP. It will
    allow us to hopefully address some of these bad statistics.
    American Indian women are treated at the hospital level with
    ambulatory care sensitive diagnoses 106 percent of the rate of
    non-Hispanic white women in the same age, same sex and same
    geography in the State of California. It is documented over a
    university-level 3-year study. The ambulatory sensitive
    diagnostic rate for men is a whopping 136 percent of the non-
    Hispanic white rate for the same age and sex category. This
    research documents a lack of access. The Indian Health Care
    Improvement Act, particularly the title II new provisions, will
    improve the utilization of Medicare, Medicaid and SCHIP in
    Indian County. It will facilitate Indian program participation
    as providers and it will facilitate Indian enrollment as
    individuals. I urge that you support this bill and work for its
    speedy passage.
        [The prepared statement of Mr. Crouch follows:]

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        Mr. Pallone. Thank you, Mr. Crouch.
        Mr. Forquera, I know I am mispronouncing it probably.
        Mr. Forquera. It is Forquera. Just think of four carrots
    and----
        Mr. Pallone. I am glad that Ms. Solis left because she
    corrects me on my Spanish pronunciations.
        Mr. Forquera. It is OK. No problem. In my bio, I don't know
    if you noticed, but I try to put it into phonetics so that
    people can remember it.
        Mr. Pallone. OK. Thanks.

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

        Mr. Forquera. Mr. Chairman, thank you for allowing me to be
    here today, and thanks for inviting me and to have a
    representative from the urban Indian health side of the aisle
    here to speak on the issue. My name is Ralph Forquera. I am the
    executive director for the Seattle Indian Health Board. I am an
    enrolled member of the Juaneno Band of California Mission
    Indians. It is a State-recognized Indian tribe from the San
    Juan Capistrano area of southern California, and it is a great
    pleasure for me to be here.
        The Seattle Indian Health Board is one of the 34 urban
    Indian health programs along with the Chicago program and the
    one in Albuquerque as well as 32 other cities around the
    country that have urban Indian programs in them. I have been
    working in the field of urban Indian health for the last 25
    years, first in San Diego where I served as the executive
    director for their program for 8 years and for the last 17
    years I have been at the Seattle program in Seattle,
    Washington. My agency is a fairly comprehensive organization.
    It was one of the first funded by the Indian Health Service
    even prior to the Indian Health Care Improvement Act. We
    received our first Indian health resources in 1972 as part of
    the old OEO equal opportunities program, so we have been
    engaged with the Indian health program for quite a long period
    of time. We provide direct health care services to about 7,000
    individuals a year, about 4,000 of whom are American Indians or
    Alaskan Native. The majority of our non-native people that we
    see tend to be family members of American Indian or Alaskan
    Native families. A lot of the cities Indian people live in
    mixed environments; mixed households, they marry into mixed
    racial backgrounds, and we try to take care of families as
    opposed to individuals through our organization. As we talk
    about health promotion and health prevention, you really need
    to talk about families. Talking about individuals is helpful
    but you really need to address the entire comprehensive nature
    of the environment in which these people live in order to be
    able to affect them, and that is really the kind of work that
    we try to do. Through our outreach and education programs, we
    interact with probably another 4,000 or 5,000 individuals, so
    we think that we see somewhere around 10,000 Indian people a
    year, interacting with them in Seattle. Seattle has a
    population of about 35,000 Indian people so about a third of
    the population.
        Through our Urban Indian Health Institute, which we created
    in 2000, which is a research arm that we created, we have been
    able to finally document for the first time the fact that there
    are significant health disparities among the urban Indian
    population. That information has helped us, I believe, to
    interact with other agencies of the Federal Government
    including the CDC and the NIH and others to try to get them to
    recognize the fact that this is a population of people with
    severe health disparities that have not been engaged in a lot
    of the health disparities initiatives around the country. The
    majority of those resources have gone to larger ethnic
    populations, primarily Hispanic and black populations, which
    have great needs for those kinds of services and there is an
    assumption that the Indian Health Service is taking care of the
    needs of Indian people so therefore Indian people that are not
    directly under the auspices of the Indian Health Service are
    oftentimes left out of that debate and so one of the
    initiatives that we tried to do through the Institute was to
    document this information, get this information in the hands of
    policymakers in hopes that that would translate into resources
    for our population.
        The Urban Indian Health Program has also received a lot of
    resources from sources other than the Indian Health Service
    itself. In fact, we believe that we leverage about two to one
    the amount of resource that we get from the Indian Health
    Service for outside resources, primarily from local, State and
    other Federal programs and some private dollars. My
    organization, for example, the Indian Health Service resource
    that we get represents about 31 percent of our financing. The
    rest of it comes through a variety of different programs. I
    think we are managing somewhere around 35 or 40 different
    grants and contracts in a given year, so as you can tell, that
    takes an awful lot of administrative time and overhead as well
    as somebody was talking earlier about IT. Having a fairly
    comprehensive technological base to the work that you do is
    critically important in our operations in order to be able to
    manage both the numbers as well as the finances of those kinds
    of organizations to be able to report appropriately.
        The urban Indian population is a very diverse population.
    We serve enrolled members of federally recognized tribes, which
    is a significant portion of the people that we see who are
    living in cities. We also see members of State-recognized
    tribes. There are 41 States in the country that recognize
    Indian tribes. I believe there is one in New Jersey. There are
    descendants of early Indian people who were displaced as a
    result of adoption back in the early part of the 1920's and
    1930's. It has been very interesting for me to find a lot of
    Indian people living in Seattle who know that they were Indian
    but didn't grow up in that kind of environment, and one of the
    things that we work with, believe it or not, is the Mormon
    Church, who has a very big genealogical center in Seattle, as
    well as the archives in Seattle, the local archives, to help
    people try to link themselves back to their native culture, and
    it is amazing to me in terms of just this idea of health
    promotion and health improvement how getting people linked back
    to their heritage has such a profound effect on their mental
    health, recognizing the fact that they are native and they
    truly are native and then having that linked somehow to some
    kind of documentation is an amazing thing to witness. There is
    also a growing number of Indian people who we serve who are
    Indians of mixed race or of mixed tribal background who are not
    eligible necessarily for services at their tribal reservation
    sites anymore, and those individuals are native people who also
    deserve and need assistance, and that is something that the
    urban Indian programs can provide.
        Indians in most metropolitan areas are geographically
    dispersed. They don't live in one particular community so doing
    the work that we do is very challenging because we are having
    to do a lot more of the outreach that you were talking about
    earlier, a lot more case finding. We do a lot of cultural
    events in the community as a way of kind of gathering people
    together so we can communicate with them about the needs that
    they might have, and at those events we often do health
    screenings and other kinds of activities in order to be able to
    gauge where the people are at and hopefully focus them on
    services.
        As you know, the Indian Health Service primarily serves
    Indians that live on and near reservations, which we think is
    an appropriate role for them. Title V was intentionally created
    as a way of providing core resources and core assistance to
    local Indian communities so that they could organize themselves
    in order to be able to develop health services, and that is
    exactly what we have done. I think that the contribution that
    the Congress makes of $34 million to the urban Indian programs
    is a very wise investment. I think that we have been able to
    leverage those resources and provide a comprehensive set of
    services in many cities around the country that would not be
    possible without the help of the Indian Health Service being
    that foundation on which to build
        As you know, the Bush administration has been trying to
    zero out the Urban Indian Health Program and I really wanted to
    take the opportunity to recognize the leadership of
    Congresswoman Wilson from New Mexico. She and our Congressman
    from Seattle, Jim McDermott, took a leadership role in
    authoring a letter to get that money reinstated and we are very
    fortunate that it was done for the 2007 year. And Mr. Dicks
    also from Washington State has been very generous in making
    sure that that funding continues for the 2008 year.
        We also really believe that the Urban Indian Health
    Program, as has been stated on several occasions here today,
    really has amassed an understanding and a knowledge of the
    urban Indian community----
        Mr. Pallone. I was so interested in what you were saying
    that I didn't realize you are 3 minutes over so you have to
    wrap up.
        Mr. Forquera. I will wrap up.
        Mr. Pallone. All right.
        Mr. Forquera. Basically I just wanted to say that the urban
    Indian programs have really amassed an awful lot of information
    and knowledge about the urban Indian communities and know how
    to serve those communities better than anybody, and even if
    they weren't, even if the community health centers could step
    forward and provide the services, they really couldn't provide
    the cultural and the connectedness that I think is necessary to
    engage the people in the health care process and I think that
    that is the real key to our work.
        Thanks for the opportunity to be here. I appreciate your
    inviting me.
        [The prepared statement of Mr. Forquera follows:]

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        Mr. Pallone. Mr. Lucero.

               STATEMENT OF KEN B. LUCERO, PUEBLO OF ZIA

        Mr. Lucero. Good morning and thank you, Chairman Pallone,
    Ranking Member Congressman Deal, and members of the
    Subcommittee on Health. My name is Ken Lucero and I am a
    councilman from the Pueblo of Zia. I am here on behalf of the
    men, women and children of Zia Pueblo and the All Indian Pueblo
    Council. I would like to thank Congresswoman Wilson for her
    invitation to address the subcommittee of the Energy and
    Commerce committee. Her recognition of the need for the Pueblo
    Nations in New Mexico to articulate their needs concerning
    health care is greatly appreciated. Thank you on behalf of the
    Pueblo of Zia and the All Indian Pueblo Council.
        My message is simple. The Indian Health Care Improvement
    Act must be amended and reauthorized in order to bring the
    Indian health system into the 21st century. The Act expired in
    fiscal year 2000 and since then American Indian and Alaskan
    Native leaders have petitioned Congress to reauthorize the Act
    so that Indian health care may be modernized and disparities in
    Indian health can be positively addressed. Tribal leader after
    tribal leader has come before you to bare their souls and share
    the tragedies endured by their people and yet the requests have
    not been granted, so today I add my voice to those honorable
    tribal leaders that have come before me in calling for the
    reauthorization of the Indian Health Care Improvement Act.
        In 2003, the U.S. Commission on Civil Rights issued ``A
    Quiet Crisis: Federal Funding and Unmet Needs in Indian
    Country.'' This report highlighted the Federal Government's
    failure to provide adequate funding and meet trust obligations.
    Among the Commission report's findings, Native Americans are
    318 percent more likely to die from diabetes, 630 percent more
    likely to die from alcoholism and 658 percent more likely to
    die from tuberculosis. Members of the committee, these
    statistics are gathered from tribal communities. These are our
    grandparents, our grandchildren, mothers and daughters, fathers
    and sons. These statistics are real.
        I understand that it is difficult for this committee and
    your fellow members of Congress to identify with the stories
    and the data buried in the mountains of testimony provided on
    behalf of this Act. So for just a minute, I would like for you
    to pretend that the House of Representatives is a pueblo in New
    Mexico and that the Senate represents the groups of other
    Americans. Picture your fellow lawmakers as members of your
    community. You are all somehow related and you view each other
    as a large extended community. How would this report affect
    your community? In the case of diabetes, if one Senator died
    from complications of the disease, you could expect 14 of your
    members to also die from diabetes. If one Senator died from
    alcoholism, 27 of you are expected to do the same within your
    membership. And finally, if one member of the Senate dies from
    tuberculosis, 28 of your colleagues will meet the same fate. I
    think this room would look much the same if that were to be the
    case as it does now.
        If this committee can keep this example in mind while
    listening to my testimony and the testimony of the rest of the
    panel today, I hope that Congress can gain a better
    appreciation for the urgency of our message. In New Mexico, the
    State's 205,000 Native Americans have the highest rates of
    death for diabetes, alcoholism, pneumonia and influenza. Our
    children suffer the highest rates of behavioral health risks
    such as substance abuse, smoking, illicit drug use and obesity
    and the five major regions for outpatient care at IHS
    facilities are diabetes, respiratory infections, hypertensive
    disease, well-child care and prenatal health care. With such a
    demand for the important health care services, it is
    disheartening to report that the IHS health care programs are
    being ended completely or being drastically reduced. Santa Fe
    Indian Health Service no longer provides birthing services. The
    Albuquerque Indian Health Services are severely limited due to
    the lack of adequate funding, as the Congresswoman Wilson knows
    very well.
        Now, while full and adequate Federal funding is extremely
    important, it is also important that the United States provide
    the quantity and quality of health services which will permit
    the health status of Indians to be raised to the highest
    possible level and to encourage maximum participation of
    Indians in the planning and management of their health care
    services. H.R. 1328 will pave the way and redefine the existing
    health care delivery system for American Indians and Alaska
    Natives and to bring that health care system into the 21st
    century.
        In conclusion, the Indian Health Service services 1.8
    million federally recognized American Indians and Alaskan
    Natives. The 1.8 million represents less than 1 percent of the
    United States population. Now, with this comparatively small
    service population, the Indian Health Service should be the
    gold standard of health care in the United States. The
    potential is there. Through the combined efforts of tribes,
    Congress and the executive branch, we can provide serious,
    meaningful benefits to Indian Country and to this country as a
    whole.
        Mr. Chairman, members of this committee, I strongly
    encourage you to take this opportunity to raise the standards
    of health care provided by the Indian Health Service and to
    begin the work to ensure that American Indians receive the best
    possible health care. I ask that the committee for unanimous
    support of H.R. 1328 and passage at the earliest possible date.
    Thank you.
        [The prepared statement of Mr. Lucero follows:]

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        Mr. Pallone. Thank you.
        Ms. Joseph, thank you for being here.

      STATEMENT OF RACHEL A. JOSEPH, CO-CHAIR, NATIONAL STEERING
      COMMITTEE FOR THE REAUTHORIZATION OF THE INDIAN HEALTH CARE
             IMPROVEMENT ACT; NATIONAL INDIAN HEALTH BOARD

        Ms. Joseph. Good afternoon, Mr. Chairman, members of the
    subcommittee. I am Rachel Joseph, co-chair of the National
    Steering Committee for the Reauthorization of the Indian Health
    Care Improvement Act. I am also testifying on behalf of the
    National Indian Health Board, a national Indian organization
    that advocates health issues on behalf of all Indian tribes.
    Thank you for this opportunity to testify in support of H.R.
    1328.
        In 1999, the director of the Indian Health Service
    established the National Steering Committee comprised of tribal
    representatives from across the country and the national health
    organizations. Since then the steering committee and the
    National Indian Health Board have led reauthorization efforts,
    have accommodated administration and congressional concerns
    through endless compromises and reached consensus on key policy
    issues. We are guided by the principle of no regression from
    current law and protection of tribal interests. As you are
    aware, we will continue with that effort this afternoon when we
    meet with congressional staff to address facilities issues in
    section 301. As Congresswoman Heather Wilson articulated, we
    have not had the opportunity to update our reauthorization for
    over 14 years. Modernization is essential for our health care
    systems.
        Indian tribes ceded over 400 million acres of land based on
    government promises including promises of health care. The U.S.
    Commission on Civil Rights in its 2003 report ``A Quiet
    Crisis'' found that the Federal Government has not lived up to
    its promise to provide adequate health care. The U.S.
    Commission on Civil Rights in its 2004 report ``Broken
    Promises'' evaluating the Native American health care system,
    found tremendous disparities as already articulated by
    Congresswoman Hooley. The travesty in our health conditions is
    knowing that the majority of illnesses and deaths from disease
    are preventable. Additional funding and contemporary
    programmatic approaches are necessary.
        One of the key provisions in H.R. 1328 is the elevation of
    the Indian Health Service director. We believe an assistant
    secretary is essential to advocate for health care issues and
    certainly budget increases. In 2007 at consultation, tribal
    officials implored HHS officials to be an advocate, and there
    was no response, and so we feel that there was no commitment
    and the plea falls on deaf ears. We feel that an assistant
    secretary would be a point to oversee. For example, the issue
    related to regulations implementing section 506 from the
    Medicare Modernization Act of 2003 languished in the Department
    for years and just this week those regulations were published.
    We believe the regs bounce back and forth between IHS, CMS and
    HSS because of lack of ownership by someone for the regulation.
    We strongly support the behavioral health programs.
        Mr. Chairman, I appreciate your question to the
    administration about when we might see their views. I quickly
    reviewed their testimony this morning and their objection to
    section 712 in the behavioral health just astounds me, and we
    would appreciate any assistance you can give us to get a grip
    on what their objection is. Tribal leadership felt strongly
    because of the substance abuse epidemic in our communities that
    we needed to address fetal alcohol disorders and just one
    excerpt from that is to develop, print and disseminate
    education and prevention materials on fetal alcohol disorders.
    We have a hard time understanding what the objection to this
    authorization is, so your assistance will be greatly
    appreciated.
        The issue related to ``shalls'' and ``mays'' it seems to me
    that the testimony is somewhat outdated. We made a commitment
    to scale back ``shalls'' and ``mays'' and the only new
    ``shalls,'' and I believe there is two is something that
    congressional staff supported and felt needed to be included in
    the bill and we agree with that.
        The issue of funding in place of grants, that was addressed
    a couple of generations ago in updating and addressing
    concerns. So we will do anything we can to work with you, other
    Members of Congress and the administration. We met with Laura
    Ott on April 17. Laura is the Deputy Assistant Secretary for
    Health Legislation and respectfully requested that we see their
    views before the markup in the Senate Indian Affairs Committee
    which has already been done on May 10 and reported unanimously
    or reported out. We think that because of the tremendous
    disparity in health care indicators we need to get this
    reauthorization soon.
        Last year one of our respected and esteemed colleagues, Dr.
    Taylor Mackenzie, former president of the Navajo Nation, who
    served on the steering committee with us from the very
    beginning, in his drive and effort to keep us encouraged,
    leaned over and he said, ``Rachel, do you think this will pass
    in our lifetime?'' and we chuckled. It is not funny anymore. We
    lost Dr. Mackenzie a couple months ago. So to us, the
    challenges of providing health care are always present and
    always constant. Our proposal to provide assisted living long-
    term health care to our elders is essential. Tribal leaders
    feel strongly about having to send our grandparents and our
    aunties and uncles so far away from the reservation to receive
    necessary health care and certainly limited visitation
    opportunities for families. We think this kind of modernization
    and update is essential and certainly what is provided in other
    communities in our country.
        Thank you for your efforts on our behalf, and we stand
    willing and able to do anything we can to move this legislation
    this year. Thank you again for this opportunity.
        [The prepared statement of Ms. Joseph follows:]

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        Mr. Pallone. Thank you so much. I am going to start with
    questions from myself and I have one question for each of you
    and I have 5 minutes, so I am going to try to be brief here.
        I wanted to ask Mr. Crouch, first of all, I know and I
    think everyone knows that pursuant to the trust responsibility,
    theoretically you shouldn't be paying anything. There shouldn't
    be any co-pays, any premiums, any contribution--I guess one
    could argue--from the tribes at all because the obligation of
    the Federal Government from the way I understand it; is that
    the trust responsibility is 100 percent to pay for health care.
    But we know that is not the reality but that should be the
    reality. So I just wanted to ask you, Mr. Crouch, about the co-
    pays. In the bill there are no Medicaid co-pays or anything of
    that nature. What are the consequences of having co-pays or
    expenditures for Medicaid specifically? What are the
    consequences out there right now because that is the case?
        Mr. Crouch. The consequences of the co-pays, it is a
    barrier to care. You already have barriers to care that are
    based on geography, people traveling further. You have barriers
    to care being on the poverty and the cost of providing that
    transportation. When you have premiums and co-pays, you are
    adding another barrier to prevent access to care. What I tried
    to show in my numbers was that we have already documented
    under-access to care, low access to care for a population whose
    health status is well documented as being very poor. It is sort
    of like having--if Indian health was a fire, you would want to
    put the hose right where the fire is. The low health status is
    on flame, creating barriers so the fire truck can't get there.
    The patient can't get to the service. The clinic can't provide
    the service. It doesn't make sense.
        Mr. Pallone. All right. I appreciate that. I am just trying
    to move on.
        Mr. Crouch. Sure.
        Mr. Pallone. Mr. Forquera, you talked about contributions
    from outside the Federal Government. I have been to some of the
    reservations where because they may have a little money, they
    actually have to build the complete facilities from scratch,
    which again I think is not right. Just comment a little bit on
    what the tribes themselves have had to contribute on their own.
    You mentioned State and maybe others but a lot of cases the
    tribes themselves are contributing significant amounts of
    resources to health care. How extensive is that?
        Mr. Forquera. For the urban programs or just----
        Mr. Pallone. No, just in general.
        Mr. Forquera. In general, I don't know off the top of my
    head, but I would venture to say that more and more of the
    tribes are having to pick up more and more of the cost of
    health care because the appropriations dollar just isn't
    maintained, and those tribes that have the luxury of having a
    few resources available to them I think are making those
    contributions. I know some of the tribes in California have
    certainly invested in facilities and other kinds of things. The
    question becomes one of the use of those resources for the
    health care which should be taken care of, and the fact that
    there are other needs on those reservations that should be
    taken care of and where do you prioritize your dollar. Health
    care fortunately for most of us is seen as one of those
    fundamental resources that are necessary and so I think that
    people tend to want to prioritize that, and I know a lot of the
    tribal communities are doing so.
        Mr. Pallone. And they really shouldn't have to.
        I wanted to ask Mr. Lucero, we really haven't had much
    testimony about the negative impact of not reauthorizing. Do
    you just want to comment briefly on the fact that we keep
    waiting to reauthorize this bill? What are the negative impacts
    of the fact that we haven't done the reauthorization for 7
    years? And you only have a minute, but----
        Mr. Lucero. OK. Well, I think the biggest impact is that we
    are not able to move into the 21st century. A lot of the
    programs have been held in shackles--that is the only thing I
    can think of right now--and they are not able to expand or to
    implement innovative ideas. One of the questions you asked
    about facilities is, tribes are being forced to go to the State
    and fortunately in New Mexico we have a good working
    relationship with the State and so we have been appropriated
    funds by the State to assist in building facilities. We are
    interested in participating with IHS, which is section 310, IHS
    tribal joint venture, and that is one of the programs that is
    within the Indian Health Care Improvement Act that the
    reauthorization will also assist with innovative ideas and
    moving into telehealth and new modern means of providing health
    care.
        Mr. Pallone. All right. Thank you.
        And then Ms. Joseph, I know we could talk all afternoon. I
    wanted to ask you about the lack of providers available to
    Native Americans and the need for innovative solutions such as
    the community health aid program. In the Resources Committee, I
    was amazed when the gentleman said that there were only 400 or
    500 Native American doctors in the country. I couldn't believe
    that. Do you just want to comment on what we should be doing to
    address the fact that there aren't enough Native American
    providers, whether it be doctors, nurses and what to do about
    that?
        Ms. Joseph. Thank you, Mr. Chairman, for that question,
    because I wanted to make a comment on Ranking Member Deal's
    question about the community health aid program. I will just
    take you back a little bit. For whatever circumstances, there
    were times in our lives--use me, for example. I had an uncle
    who had an extracted tooth--my mom was sweet and kind and just
    couldn't deal with that--with a pair of pliers and an auntie
    tied another tooth to a string, do the old open the door thing
    and pull that. In Alaska in some communities, a dentist only
    comes once a year. Hopefully it is once a year. And through the
    community health program, and extensive at least 2-year
    training, we provide opportunities for emergency care to be
    provided under the supervision of a dentist. That particular
    language authorizing that or at least clarifying that was
    addressed. The concerns raised by I think Congressman Norwood
    and the American Dental Association was addressed before the
    bill was marked up and reported out of the Resources Committee
    last year and that compromise was facilitated by Congressman
    Don Young. So through the opportunity to provide creative ways
    of providing health care through telemedicine and other ways is
    one way and we certainly look toward some of those innovative
    approaches in the reauthorization.
        Mr. Pallone. OK. Thank you. Mrs. Wilson.
        Mrs. Wilson. Thank you, Mr. Chairman.
        Mr. Lucero, thank you again for being here. You mentioned
    in your testimony that the Santa Fe hospital is no longer
    providing OB/GYN services, and of course, you also mentioned
    cutbacks in the Albuquerque and Santa Fe areas. I wonder if you
    could expand on that and particularly what does that mean for a
    family in Nambay? Where do they get their OB/GYN care, if they
    can't get it at the Santa Fe Indian Hospital?
        Mr. Lucero. As far as where they are getting their OB/GYN,
    I think a lot of what is happening is, they are being referred
    to the St. Vincent's Hospital there in Santa Fe and are relying
    on contract health services, and again, we all know and have
    testified about the lack of funding in contract health services
    and that everybody is on a priority one, and so a lot of those
    dollars have to go or are taken away from other services to
    provide that when in fact they should be provided through the
    hospital clinics in the Santa Fe service unit.
        Mrs. Wilson. Would you like to expand at all on the funding
    issues in Albuquerque and Santa Fe and what you are seeing?
        Mr. Lucero. Yes, please. There was testimony offered by
    Senator Jeff Bingaman before the Senate Finance Committee on
    March 22 and he indicated about how over the years that the
    Medicaid and Medicare funding has continued to increase and per
    capita spending had grown nearly $8,000 through Medicare and
    $4,500 through Medicaid while the IHS national average for
    funding remained almost flat at $2,100. Now, in the Albuquerque
    area, those funding disparities are even greater. It would take
    an additional $48 million to achieve even the IHS national
    average of $2,130, and if Congress were to bring the
    Albuquerque up to the U.S. average per capita for health
    expenditures, which is $6,423, it would require an additional
    $380 million in order to even get us up to that level. So those
    are kind of the numbers that we have available.
        Mrs. Wilson. Ms. Joseph, a question for you on health
    education. Are there things that we can do either in the--as I
    understand it, there is a medical education program and there
    may be some caps on slots for, I think it is referred to as
    GME, in the Medicare or Medicaid programs. Are there changes to
    that program that we can make to increase the number of doctors
    who might be allowed to practice out in Indian Country or is
    the IHS able to tap into that pool of doctors under the GME
    program? Are you aware of that at all?
        Ms. Joseph. I am not sure if they can tap into it or not
    but definitely if we can, we should. We can look into that
    because it seems to me we are always recruiting. There is a
    tremendous shortage of doctors and nurses in particular.
        Mrs. Wilson. Because I have heard that there is some kind
    of a barrier there that makes it more difficult for residents
    to practice out in Indian Country, and if there is and there is
    a way to fix that, then I think we should and I would certainly
    appreciate your input on that. And finally, Mr. Crouch, I did
    have a question for you on telemedicine. I understand that
    there are some projects in California on telehealth and
    telemedicine and I wonder if you would describe those a little
    bit and I wonder if you have any opinion on whether the
    telehealth provisions in this bill might help facilitate an
    improved telemedicine network in the IHS.
        Mr. Crouch. Those provisions would be helpful. If you think
    about California Indian Country, basically it is four times
    larger than Navajo but it has about one-eighth the population
    spread over that geography so it is very thinly distributed
    from the north of the State all the way to the south, so it
    covers the entire State. The Telemedicine Program that started
    initially with some philanthropic funds is often the case in
    California. The Indian Health Service is working with a number
    of tribal health programs where they are doing some I believe
    entry-level work, first starting out with diagnosing
    retinopathy in the eye with cameras, now moving into issues
    around dermatology and psychiatry. All of those are services
    that are easily sort of set up. Telemedicine is much more
    expansive in use in other areas such as Alaska and the Phoenix
    area is actually working on a project that would cover a lot of
    Arizona and Nevada. It does have promise. The fact that those
    services are billable through Medicaid is very critical to
    those services being continued because the Indian Health
    Service is indeed underfunded.
        Mrs. Wilson. Thank you, Mr. Chairman.
        Mr. Pallone. I know a vote has been called so we are going
    to have to end, but I did want to ask a couple things and then
    if the gentlewoman from New Mexico would like to add something,
    she could, and then we are going to have to end because we have
    some votes.
        Mr. Crouch, these Medicaid citizenship documentation
    requirements that were in the Deficit Reduction Act last year
    that says that States are prohibited from receiving Federal
    Medicaid reimbursement for individuals who have not provided
    documentation. Ms. Schakowsky got into it a little bit. Current
    Medicaid practice states that tribal documents from only five
    tribes are acceptable proof of citizenship but now we have this
    provision in the bill that changes that. Would you comment on
    whether you think that is going to address this problem
    sufficiently, what we put in the bill?
        Mr. Crouch. The bill language is superior to what is the
    case as we speak. When the new requirement to document
    citizenship came down, it seems almost oxymoronic that proof of
    tribal membership would suffice for this really low level need
    of documentation. I am a member of the CMS KTAG. We have had
    extensive review of this issue and the reality is that there
    are five tribes that have been granted over through history the
    opportunity to document citizenship. The rules that they follow
    don't exist. In other words, the rules at CMS that expects them
    to standards, I guess, whatever, CMS can't define, cannot find.
    Our language in the bill would make it clear that proof of
    tribal membership would be proof of citizenship, and for those
    tribes that do exist on borders but do have members who are not
    citizens, the Secretary would work with them to develop
    additional criteria so that those portions of their tribes
    would be identifiable to Medicaid and therefore not receive
    services.
        Mr. Pallone. So like use the Tohono Odham, in other words,
    that language isn't going to help the guys that are in Mexico--
    --
        Mr. Crouch. It depends on how the Secretary rules. So I
    guess if you think about this rule coming down at a later date,
    one would only guess how it might change. Currently, the
    citizens of Tohono Odham, who are not citizens of the United
    States because of their residence on the reservation but south
    of the border would be excluded because they would not be able
    to document citizenship.
        Mr. Pallone. They have the option of becoming citizens
    though, right? They have that right?
        Mr. Crouch. Sure.
        Mr. Pallone. But they still because they're not citizens
    would not be eligible?
        Mr. Crouch. The Tohono Odham existed exactly where it is
    before the Gadston purchase. If you look at a map of Arizona
    from about 1880----
        Mr. Pallone. I know the history a little bit but what I am
    saying is, the problem is, even though they have a right to
    citizenship, and they are federally enrolled with the Interior
    Department, because they are not citizens, they are still not
    eligible because of the Act. Is that the way you read it?
        Mr. Crouch. The way I read it right now, they would not be
    eligible, and if the bill passed, it is possible that they
    would be eligible not as--they wouldn't be made citizens but
    they would be eligibilized for Medicaid.
        Mr. Pallone. They would be?
        Mr. Crouch. Yes.
        Mr. Pallone. All right. So the way you read this bill, we
    would be able to correct all these situations that have come up
    as far as we know?
        Mr. Crouch. As I read the bill as a member of KTAG, we
    firmly support this language.
        Mr. Pallone. All right. Thank you very much. I know we are
    always in a rush around here and it was important that we have
    the hearing today because we do want to move to markup and so I
    know it has been expedited somewhat but it is better that we at
    least did it, and I think we got some answers and hopefully we
    will get some more, and we do intend to move to markup as
    quickly as we can. Thank you very much and I appreciate all of
    your being here. If you have additional responses to our
    questions or things you want to put in the record, please do
    so. We will certainly take that letter. And I appreciate you
    all being here, and we will adjourn the hearing. Thank you.
        [Whereupon, at 1:40 p.m., the subcommittee was adjourned.]
        [Material submitted for inclusion in the record follows:]

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