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


 
                 THE INDIAN HEALTH CARE IMPROVEMENT ACT
                           AMENDMENTS OF 2007

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                                   ON

                               H.R. 1328

                               __________

                              JUNE 7, 2007

                               __________

                           Serial No. 110-54


      Printed for the use of the Committee on Energy and Commerce

                        energycommerce.house.gov


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                    COMMITTEE ON ENERGY AND COMMERCE

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

                           Professional Staff

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

                                  (ii)
                         Subcommittee on Health

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

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

                               Witnesses

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

                           Submitted Material

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


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

                              ----------                              


                         THURSDAY, JUNE 7, 2007

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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


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

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

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

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

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

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

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

                            DHHS Activities

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

                            Reauthorization

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

                          Overarching Concerns

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

                         Reporting Requirements

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

                               Facilities

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

            Health Care Facilities Needs Assessment & Report

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

       Retroactive funding of Joint Venture Construction Projects

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

              Sanitation Facilities Deficiency Definitions

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

            Threshold Criteria for Small Ambulatory Program

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

        New Negotiated Rulemaking and Consultation Requirements

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

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

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

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

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

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

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

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    Mr. Pallone. Mr. Lucero.

           STATEMENT OF KEN B. LUCERO, PUEBLO OF ZIA

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

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

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

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

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

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