[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
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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
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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.]
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