[Senate Hearing 110-214]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-214
 
   NOMINATION OF CHARLES W. GRIM TO BE DIRECTOR OF THE INDIAN HEALTH 
                                SERVICE

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

                                HEARING

                               before the

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 26, 2007

                               __________

         Printed for the use of the Committee on Indian Affairs



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                      COMMITTEE ON INDIAN AFFAIRS

                BYRON L. DORGAN, North Dakota, Chairman
                 LISA MURKOWSKI, Alaska, Vice Chairman
DANIEL K. INOUYE, Hawaii             JOHN McCAIN, Arizona
KENT CONRAD, North Dakota            TOM COBURN, M.D., Oklahoma
DANIEL K. AKAKA, Hawaii              JOHN BARRASSO, Wyoming
TIM JOHNSON, South Dakota            PETE V. DOMENICI, New Mexico
MARIA CANTWELL, Washington           GORDON H. SMITH, Oregon
CLAIRE McCASKILL, Missouri           RICHARD BURR, North Carolina
JON TESTER, Montana
                Sara G. Garland, Majority Staff Director
              David A. Mullon Jr. Minority Staff Director


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on July 26, 2007....................................     1
Statement of Senator Barrasso....................................    21
Statement of Senator Coburn......................................     2
Statement of Senator Domenici....................................    26
Statement of Senator Dorgan......................................     1
Statement of Senator Murkowski...................................     4
Statement of Senator Smith.......................................    32
    Prepared statement...........................................    34
Statement of Senator Tester......................................     5

                               Witnesses

Grim, Charles W., D.D.S., M.H.S.A, Assistant Surgeon General; 
  Director, Indian Health Service, U.S. Department of Health and 
  Human Services.................................................     8
    Prepared statement...........................................    12
    Biographical information.....................................    16
Smith, Chad, Principal Chief, Cherokee Nation....................     5

                                Appendix

Letters of support for Dr. Grim's nomination..................... 41-87
Nomination withdrawal letter.....................................   103
Written Questions Submitted to Charles W. Grim.................. 88-102


   NOMINATION OF CHARLES W. GRIM TO BE DIRECTOR OF THE INDIAN HEALTH 
                                SERVICE

                              ----------                              


                        THURSDAY, JULY 26, 2007

                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 9:30 a.m. in room 
485, Senate Russell Office Building, Hon. Byron L. Dorgan, 
Chairman of the Committee, presiding.

          OPENING STATEMENT OF HON. BYRON L. DORGAN, 
                 U.S. SENATOR FROM NORTH DAKOTA

    The Chairman. We will call the hearing to order.
    This is a hearing of the Senate Indian Affairs Committee, a 
hearing on the nomination of Charles Grim to be Director of the 
Indian Health Service.
    The two witnesses today I will introduce: The Honorable 
Chad Smith, Principal Chief, Cherokee Nation of Oklahoma; and 
Dr. Charles Grim, who is the Director of the Indian Health 
Service, U.S. Department of Health and Human Services.
    This hearing, as I said, is about the renomination or the 
nomination for Charles W. Grim to continue to serve as Director 
of the Indian Health Service.
    If I could ask the two witnesses to take their place at the 
table.
    Today, the Committee meets to consider the nomination of 
Dr. Charles Grim to be Director of the Indian Health Service. 
On May 21 of 2007, President Bush sent Dr. Grim's nomination to 
the Senate. This is a reappointment for another term of 4 
years. Previously, Dr. Grim was confirmed by the Senate as 
Director and was sworn into office in the summer of 2003.
    I will ask today that we hear an introduction from the 
Chief of the Cherokee Nation. I will call on my colleague, Dr. 
Coburn, for remarks in a moment. I note that Dr. Grim is no 
stranger to this Committee. I believe you have already appeared 
on three occasions in this year alone to present the 
Department's views on the Fiscal Year 2008 budget request, the 
Special Diabetes Program, and reauthorization of Indian Health 
Care and other matters.
    All of us know that the Indian Health Care Improvement Act 
was last reauthorized in 1992. Legislation to amend and 
reauthorize the Health Care Improvement Act has been considered 
by the 106th, 107th, 108th, 109th and now the 110th Congress.
    At our hearing on the Indian health bill in early March, 
Dr. Grim, you accompanied Dr. John Agwunobi, the Assistant 
Secretary for Health, and both of you pledged to work with this 
Committee toward the enactment of reauthorization of the Indian 
Health Care Improvement Act. I reiterate my goal of 
accomplishing reenactment during this Congress.
    The Committee has received statements of support today from 
a wide number of people and interests for Dr. Grim's 
nomination: The Choctaw Nation of Oklahoma, the Commissioned 
Officers Association of the U.S. Public Health Service, the 
Cherokee Nation, the American College of Obstetricians and 
Gynecologists, the Albuquerque Area Indian Health Board, the 
Chief of Psychology at Massachusetts General Hospital of 
Harvard Medical School, the Seminole Nation of Oklahoma, and 
let me include all the rest of them in the record. Those are 
just a few.
    I ask consent that these and other letters be part of the 
record of today's hearing. *
---------------------------------------------------------------------------
    * The information referred to has been printed in the Appendix.
---------------------------------------------------------------------------
    Before I recognize the Vice Chairman, I want to state what 
the process will be for moving this nomination forward. 
Committee members will ask questions this morning, and more 
will be submitted to you in writing, Dr. Grim. Once the 
Committee has received the responses and Members feel their 
questions have been answered, we anticipate we will seek to 
report out this nomination at the next scheduled business 
meeting, again providing that we have received the responses.
    We appreciate your being here today, and appreciate your 
work on a wide range of issues.
    The Vice Chair of the Committee is not yet here, but she is 
on her way. Let me call on Dr. Coburn.

                 STATEMENT OF HON. TOM COBURN, 
                   U.S. SENATOR FROM OKLAHOMA

    Senator Coburn. Thank you, Mr. Chairman. I am grateful to 
you for this opportunity to introduce somebody we all know and 
respect and a fellow Oklahoman as the President's choice to 
head the Indian Health Service for another 4 year term.
    He really needs no introduction to our Committee. He has 
been a friend to this Committee and all of us who seek a new 
direction for Indian health care for many years. His efforts to 
modernize the delivery of health care in Indian Country have 
often been met by resistance within the bureaucracy and here in 
Congress, but he continues his fight nonetheless with class, 
integrity and a tireless commitment to the people he serves. If 
you can't tell by his accent, Dr. Grim is a proud Oklahoman and 
he is also a proud member of the Cherokee Nation.
    While his distinguished career has taken him all over the 
Country, and now to Rockville, much of it has taken place in 
our home State of Oklahoma. He was born in Tulsa, lived in 
Cushing and grew up in Cushing, graduated from the University 
of Oklahoma. He has served his State as a practicing dentist, 
as well as at the Indian Health Service as Administrator in 
Oklahoma City.
    In his later capacity as Oklahoma City Area Director, Dr. 
Grim was responsible for the delivery of IHS programs for all 
of Oklahoma, Kansas and parts of Texas. If you don't know what 
an awesome task that is, let me kind of describe it. In 
addition to Kansas and Texas operations, the system served over 
three dozen Oklahoma tribes, an estimated 12,000 hospital 
admissions a year, and 1.3 million outpatient visits a year. 
His system hospital region delivered almost 2,700 babies a year 
as well.
    The experience in Oklahoma City gives Dr. Grim a very 
unique and important perspective on the state of Indian health 
care. I would guess the Oklahoma region is probably the most 
diverse within the system. Among our nearly 40 tribes, you see 
everything from cutting edge health care to near Third World 
conditions. You will see tribes operating their own standalone 
health care facilities like the Cherokee Nation and others, and 
then you will see traditional IHS-directed health care. You 
will see innovative prevention-based medicine and you will see 
long Soviet-style lines for treatment of chronic disease.
    Dr. Grim has seen it all, the good, the bad and the ugly. 
More important, he has seen how Federal policies, funding 
priorities, and bureaucracies can rob tribal citizens of even 
the most basic health care options.
    I want to applaud Dr. Grim for his commitment to 
collaborating with other Federal and non-Federal agencies to 
make the most of the scarce resources he has had, and for his 
particular passion for disease prevention, which is the answer 
for our health care problems.
    In a very real sense, the future of Indian health care is 
in the hands of this Committee and Dr. Grim. We can choose to 
fight business as usual and policies that say the current 
system is good enough, or we can take this historic moment to 
revolutionize health care for tribal citizens.
    Do we empower tribal citizens to make their own health care 
decisions? Or do we leave them hostage to a system designed for 
the last century? The choice is ours to make.
    In the months ahead, we must turn our attention to 
reauthorization of the Indian Health Care Improvement Act. The 
experience of Dr. Grim as Director will continue to be an 
invaluable asset as we move forward. We should leave no option 
off the table, and I believe one of those options must be 
health care portability and competition for those in Indian 
Country.
    Tribal citizens have a right to quality health care, not 
the right to a promise of quality health care. If the current 
system isn't serving their needs, the ought to be given the 
right to access that need wherever they can find it. I am 
looking forward to the hard work that lies ahead of us.
    In closing, I want again to express my confidence in you, 
Dr. Grim, in your leadership. The man before us has proven 
that. He is up to the task and capable and committed to the 
mission at hand. Government programs and bureaucracies matter 
little when they fail the very people they are intended to 
serve. Dr. Grim realizes this and that is why I am extremely 
pleased that President Bush has asked for us to confirm him yet 
again.
    And one final note I would note. There is a great personal 
sacrifice for Dr. Grim in fulfilling this mission. His wife and 
kids remain at home in Hobart. He has a 1-year old. The travel 
and time away is extremely stressful on both him, his wife and 
his kids. Your example of sacrifice to serve this Nation does 
not go unnoticed.
    The Chairman. Senator Coburn, thank you very much.
    Vice Chairman Murkowski?

               STATEMENT OF HON. LISA MURKOWSKI, 
                    U.S. SENATOR FROM ALASKA

    Senator Murkowski. Thank you, Mr. Chairman.
    You know, it seems like just yesterday that Chuck Grim was 
sworn in to lead the Indian Health Service. It was August 6 of 
2003. I was there. On August 6, Chuck Grim was sworn in as the 
seventh Director of the Indian Health Service on the campus of 
the Alaska Native Medical Center in Anchorage. Secretary Tommy 
Thompson was there. You took the oath in the company of Aleuts, 
of Eskimo, Indians, and the health care providers that serve 
them. I thank you for honoring Alaska's native people in this 
way. I don't believe that you have let us down in any way.
    Four years later, you are back before this Committee 
seeking confirmation for a second term. I appreciate the 
comments of my colleague here from Oklahoma. There are probably 
a few people that are wondering why you are back for the re-up 
and why do you want this job again. You will certainly have an 
opportunity to answer that question this morning. But we 
recognize that this is not an easy job. You can be assured that 
this Senator understands that. It is not easy coordinating 
health care delivery in some of the most remote corners in the 
Country. It is not easy recruiting health care professionals to 
work in those remote places. It is not easy to recruit people 
to work in facilities that are too old, that are too small, 
that lack decent employee housing, and in some cases lack 
running water and indoor plumbing.
    We know that it is not easy to address the perplexing rates 
of chronic disease in Indian Country. It is not easy to hold 
the responsibility for lowering the rates of diabetes and 
suicide in Indian Country.
    We also know that it is not easy doing your job knowing 
that Administrations, past and present, have chronically under-
funded Indian health care delivery. It is not easy to see other 
elements of your department, like NIH and CDC, get generously 
plussed-up on the Senate floor, while you are lucky to make by 
with single digit increases, not even enough to cover 
inflation.
    And we know that it nos easy facing the Chairman's ever 
more creative questions about how much money you think this 
Nation can spend on Indian health care delivery. And it is not 
easy answering him knowing full well that these decisions are 
in no way within your control.
    It is not easy to do your job knowing that this Nation 
spends more money providing health care to prisoners than it 
does to Indians. And it is not easy to confront slogans like 
``don't get sick after June'' because the contract health money 
has run out.
    So if you were to choose to stand down after six very 
successful years, four as Director and two as Interim Director, 
I would certainly understand. But I am glad that you have 
decided to re-up, if you will, for another term. I am not alone 
in this. The Committee has received letters of endorsement from 
the Friends of Indian Health and from tribes and tribal 
organizations who have written on your behalf. Mr. Chairman, I 
would ask that they be made a part of the record. I have here 
22 different letters of support. *
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    * The information referred to has been printed in the Appendix.
---------------------------------------------------------------------------
    I personally appreciate your unwavering support for the 
Dental Health Aide Therapist Program for Alaska. We know that 
without your support, we might not have been able to work out 
what I believe was truly a win-win situation with the dental 
profession that ended the lawsuits and puts the focus on care 
where it needs to be.
    In the exercise of our responsibilities, the Committee, as 
you know, will probably have some tough questions for you this 
morning, but as you tackle those questions, don't forget for a 
minute that we all appreciate what you have done and what you 
have to work with.
    We don't get to say ``thank you'' often enough, so I want 
to close on those words.
    Thank you, Mr. Chairman.
    The Chairman. Senator Murkowski, thank you very much.
    Let me call on the Honorable Chad Smith, Principal Chief of 
the Cherokee Nation of Oklahoma. Chief Smith, why don't you 
proceed, following which I will call on Dr. Grim.
    Let me ask you to hold for a moment. I see our colleague 
Senator Tester has arrived. I would like, before we take 
testimony, Senator Tester, if you have any opening comments, I 
would be happy to have them at this point.

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Mr. Chairman. Sorry I am late.
    I would just say that there is plenty of work to do in 
Indian Country when it comes to health care and making it 
function. I will be interested to hear your comments. I will 
ask some questions afterwards, but I think that you know as 
well as we the kind of situation that is going on Indian 
Country and how we need to have some real proactive work to get 
it fixed.
    So thank you.
    The Chairman. Senator Tester, thank you very much.
    Chief Smith?

   STATEMENT OF CHAD SMITH, PRINCIPAL CHIEF, CHEROKEE NATION

    Mr. Smith. Thank you very much.
    My name is Chad Smith, Principal Chief of the Cherokee 
Nation. It is my honor to appear in front of you this day to 
express our support and desire that you confirm Charles--we 
usually call him Chuck--as the leader of the Indian Health 
Service. Charles Grim has been a great friend to Indian 
Country. He has great support.
    The thing that we share with him is a vision about 
increasing the health care for Indian Country. One of the great 
initiatives that we have had in partnership with the Indian 
Health Service helped led by Dr. Grim is the Joint Venture 
Program. For example, in Muskogee we are just finishing the 
touches on a $24 million facility, 200,000 square feet, which 
will provide 200 jobs and create several hundred thousand 
patient visits in the next few years. It is that kind of 
collaboration and cooperation that is helping us make a change 
in the quality of health care.
    For example, the Cherokee Nation since 2002, in cooperation 
with Dr. Grim and the Indian Health Service, we have been able 
to deliver 1.2 million patient visits. Eight years ago when I 
took office, the highest complaints we received in the Cherokee 
Nation was health care complaints. Of course, those complaints 
have diminished each year.
    Now, to my great delight, we are receiving compliments, 
compliments from people about the quality of health care, how 
it is increasing, how we are getting funding for cancer 
treatment and the equipment for the diabetes epidemic.
    So we are very thankful for Dr. Grim and his leadership. We 
believe in Indian Country we all share that same kind of 
sentiment. What is unique in the situation is that Dr. Grim is 
well received in not only Indian Country, but in the State of 
Oklahoma.
    I have the opportunity to present to him at this time a 
declaration by the Governor of the State of Oklahoma declaring 
this day Dr. Charles Grim Day in Oklahoma. I will just read a 
very few paragraphs: ``Whereas Charles Grim, the Director of 
the Indian Health Service, Assistant Surgeon General, holds the 
rank of Rear Admiral in the Commissioned Corps of the United 
States Public Health Service, and is a native of Oklahoma and a 
citizen of the Cherokee Nation, whereas on July 16th, 2003 the 
U.S. Senate unanimously confirmed Dr. Charles Grim to serve a 
4-year term as the Indian Health Service Director, now I Brad 
Henry, Governor of the State of Oklahoma, proclaim July 26, 
2007 as Charles W. Grim Day in the State of Oklahoma.''
    The information referred to follows:]

    
    

    That, with the letters that the Committee has received and 
the support of the State of Oklahoma and the Cherokee Nation, 
and everybody that he comes in contact with, I think is great 
evidence that he has done a good job in dealing with a great 
and serious demand of health care.
    Thank you very much.
    The Chairman. Chief Smith, thank you very much. We 
appreciate your being with us and your testimony.
    Dr. Grim, thank you. You have an opening statement, I 
believe. Is that correct?
    Dr. Grim. Yes, sir.
    The Chairman. You may proceed with your opening statement. 
We will then ask a series of questions.

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

    Dr. Grim. Mr. Chairman, Madam Vice Chair--and I have not 
gotten to congratulate you in person, Senator Murkowski, 
congratulations on your new role with this Committee--and other 
distinguished Members of the Senate Committee on Indian 
Affairs.
    The Chairman. Will you pull that microphone closer to you, 
Dr. Grim?
    Dr. Grim. OK. It is a pleasure and an honor for me to have 
been nominated by the President, supported by tribal 
governments across the Nation, endorsed by Secretary Leavitt, 
and for this Committee to consider renewing my term as Director 
of the Indian Health Service.
    I would also like to personally thank Senator Coburn for 
introducing me.
    To be nominated for a second term to lead the Indian Health 
Service and to be in a position to continue my service on 
behalf of so many Indian people is a wonderful and a humbling 
opportunity, as well as a great honor and a challenge. As I sat 
and listened to some of you speak about the challenges that 
there are across Indian Country, we have a lot of work yet 
ahead of us.
    I want to acknowledge members of my family who could not be 
here today, and thank Senator Coburn for recognizing their 
sacrifice. My wife, Dr. Gloria Grim, our sons Steven, Jake, 
Chance and the newest one, Nicholas. I would also like to 
introduce my family members who are here with me this morning. 
They are sitting right back here: my mother, Mrs. Ruth Grim, my 
sister Ms. Denise Grim, and my daughter, Ms. Kristen Grim.
    All of my family have been very supportive of me while I 
have held this role and they have also sacrificed to allow me 
to be in this position.
    I also want to acknowledge my late father, Charles Grim, 
who along with my mother has always been a source of strength 
and pride to me.
    For those on the Committee and for those attending this 
hearing, I will quickly introduce myself. Most of you know me, 
but my name is Charles Grim. I am a member of the Cherokee 
Nation of Oklahoma. I come from the town of Cushing, Oklahoma. 
I am a doctor of dental surgery and I also have a master's in 
health services administration, which focuses on the management 
and administration of health services, dental care and hospital 
and ambulatory care.
    I have been a member of the U.S. Public Health Service for 
24 years, which include 5 years as the Director of the Indian 
Health Service. The IHS is one of the largest operating 
divisions within HHS, with a program-level budget of over $4 
billion in 2007, and more than 15,000 employees. The agency 
responds to the needs of more than 560 federally recognized 
sovereign tribal nations in 35 different States.
    Indian tribes are IHS's partners, as well as our customers 
in providing approximately 60,000 in-patient admissions, 9.4 
million outpatient visits, and almost 1 million dental visits 
annually to approximately 1.8 million American Indians and 
Alaska Natives at more than 500 sites across the Nation. We 
also serve 600,000 more American Indians and Alaska Natives at 
34 urban sites across the Nation.
    The IHS has a proud history of dramatically improving the 
health of Indian people. Since the passage of the Indian Self-
Determination and Education Assistance Act in 1975, the greater 
involvement of Indian tribes and Indian people in the decisions 
affecting their health has produced significant health 
improvements. Indian life expectancy has increased by 8.7 years 
since 1973. While significant disparities still exist, 
mortality rates have decreased for maternal deaths, 
tuberculosis, gastrointestinal disease, infant deaths, 
unintentional injuries and accidents, pneumonia and influenza, 
homicide, alcoholism and suicide.
    Rates of some health disparities are decreasing, but the 
2001 through 2003 rates of most leading causes of death for 
Indian people still remain more than double the rates for the 
rest of America.
    In the early history of the IHS, the greatest achievements 
in reducing these disparities were through increased medical 
care and public health efforts, that included massive 
vaccination programs and bringing safe water and sanitation 
facilities to reservations and communities. I believe future 
reductions in these disparities of any significance will be 
made through health promotion and disease prevention efforts 
and programs, rather than through treatment.
    In fulfilling the Federal Government's commitment to 
American Indian and Alaska Natives to provide high quality 
health service, in the past 4 years I have focused the IHS on 
specific health initiatives to address the goals, needs and the 
current health status trends of our people. I believe the 
future of tribal communities depends on how effectively the IHS 
system addresses chronic diseases, and therefore we initiated a 
chronic care initiative in 2003.
    Preventing and treating chronic diseases requires an 
entirely different approach for care delivery. I am proud to 
inform this Committee that in 2007, there are now 14 sites 
within the Indian health system who are applying new evidence-
based approaches to managing chronic care as a result of this 
initiative. We are receiving assistance from a full partnership 
that has been established with the renowned Institute for 
Health Care Improvement. They have commented that with the 
models that we are implementing, if we are able to carry it out 
throughout our entire system over time, it could be a model for 
the Nation on how to deal with chronic care in the years ahead.
    A second initiative that we have implemented is around 
behavioral health. It has three programmatic parts, and I don't 
think these items will be of any surprise to the Committee and 
why we have prioritized them. It is methamphetamine 
intervention, suicide prevention, and family safety and 
protection.
    This initiative increases the emphasis on both clinical and 
community-based health promotion and disease prevention 
efforts. Our collective ability is focused on implementing 
programs designed to prevent disease, rather than relying 
exclusively on treatment. One half of IHS's areas will be 
integrating behavioral health into local tribal area health 
board plans. They are sharing now best and promising practices 
of how to integrate behavioral health with our other two 
initiatives of chronic care and health promotion disease 
prevention.
    We are also forging numerous collaborations with other 
organizations like the National Boys and Girls Clubs of America 
to increase clubs on reservations; the Nike Corporation, to 
promote healthy lifestyles; CDC, to fund IHS positions 
supporting epidemiology and disease prevention activity; the 
Mayo Clinic, to support efforts to reduce cancer and other 
related health burdens; Harvard and Johns Hopkins Universities 
to improve American Indian health and wellness; and the VA, to 
better coordinate the numerous efforts to enhance the health 
care provided to American Indian and Alaska Native veterans. 
Those are just a sample of the partnerships we have forged over 
the last 4 to 5 years.
    The third initiative is health promotion and disease 
prevention. Our goal is to create healthier American Indian and 
Alaska Native communities by developing and disseminating 
proven strategies through collaboration with key stakeholders. 
Again, a few examples. Together with the Mothers Against Drunk 
Driving, we are addressing underage drinking by training Indian 
youth. We have a partnership with the University of New Mexico 
Prevention Center, who developed the American Indian Across the 
Lifespan Physical Activity Kit, which Indian communities can 
use to promote more active lifestyles.
    Now, all 12 of the IHS area offices have a health promotion 
disease prevention coordinator to support the IHS tribal and 
urban programs in developing, implementing and evaluating 
health promotion and chronic disease prevention activities. We 
focus on use of traditional practices and values to communicate 
effective model programs such as breast feeding, language and 
cultural training in early childhood and elementary settings.
    One of my top business priorities has been to implement a 
market-based business plan that actively promotes innovation. 
The plan enhances the level of patient care through increased 
revenue, reduced cost and improved business processes. In 
Fiscal Year 2006, IHS generated approximately $700 million in 
third-party revenue and saved $352 million through the use of 
negotiated contracts with private providers to get the lowest 
cost possible when purchasing care.
    In an environment of increased Federal accountability, it 
was important for me to institute the restructuring of IHS's 
approach to performance management at the national level. In 
2005, I activated the IHS Performance Achievement Team to guide 
the agency toward a more consistent, efficient and effective 
performance management approach to achieve a results-oriented 
organizational culture. Accountability for performance measures 
are now part of the performance appraisal criteria at all 
organizational levels.
    I attribute the improved agency performance accomplishments 
to our strong focus on accountability. As an example, the IHS 
was recognized in 2006 as a national leader in the use of 
health information technology to electronically provide 
clinical quality measures related to monitoring the Government 
Performance and Results Act performance indicators. The agency 
implemented that program, and with our annual targets in 2002 
when 72 percent of those targets were met. In the agency's 
latest report for 2006, 82 percent of the clinical and 
nonclinical targets were either met or exceeded, a documented 
increase of 10 percentage points since 2002.
    Our tribal stakeholders have also helped support program 
assessment. As a result, 65 percent of tribally operated health 
programs voluntarily provided performance data and other 
information demonstrating their achievement of program goals 
and management standards.
    We have made consistent progress in addressing the 
management areas that are included in the President's 
management agenda, the Government-wide management improvement 
initiative. The Indian Health Service has met standards for 
success in carrying out our action plans and we have earned 
green scores for progress for five management areas and one 
program initiative for 2006.
    We continue to implement improvements in plans for six 
programs that were assessed by the program assessment and 
rating tool, a program evaluation instrument of the OMB. All 
six programs were rated adequate or higher, with the IHS having 
one of the highest overall averages in the Federal Government 
by 2005.
    The IHS is the only Federal program delivering hands-on 
care to Indian people based on the government to government 
treaties. Today we are facing many challenges. Change and 
challenge is nothing new to the history of the Nation or to 
Indian nations. Our history attests to our ability to respond 
to these challenges, to overcome adversities that we sometimes 
face, and to maximize our opportunities.
    I have a great passion about this organization and our 
mission to raise the health of our people to the highest level. 
My actions will always reflect the honor of being entrusted to 
provide health services to American Indian and Alaska Native 
people. I am ready to recommit to the job of the Director of 
the Indian Health Service and to working with this Committee 
and this Administration and tribal governments around the 
Country toward our shared goals and objectives.
    I will be pleased to respond to any questions that you may 
have concerning my nomination.
    Thank you.
    [The prepared statement and biographical information of Dr. 
Grim follow:]

   Prepared Statement of Charles W. Grim, D.D.S., M.H.S.A, Assistant 
 Surgeon General; Director, Indian Health Service, U.S. Department of 
                       Health and Human Services
    Mr. Chairman, Madam Vice-Chair, and other distinguished members of 
the Senate Committee on Indian Affairs:
    It is a pleasure and an honor for me to have been nominated by the 
President, supported by tribal governments across the Nation, endorsed 
by Secretary Leavitt, and for this Committee to consider renewing my 
term as director of the Indian Health Service.
    I'd like to thank and acknowledge my family who could not be here 
today. They have all sacrificed to allow me to serve in this position, 
my wife Dr. Gloria Grim, our sons Steven, Jake, Chance and Nicholas. 
I'd also like to introduce here today my mother, Ms. Ruth Grim, sister 
Ms. Denise Grim and my daughter Ms. Kristen Grim.
    I am proud to renew the pledge I made at my first confirmation 
hearing before this Committee four years ago, to both the Federal and 
tribal governments, to do my best to uphold the Federal Government's 
commitment to raising the health status of American Indians and Alaska 
Natives to the highest level. I remain committed to working with this 
Committee, the Administration, and Tribal Governments toward our shared 
goals and objectives.
    The IHS delivers health services to approximately 1.9 million 
federally-recognized American Indians and Alaska Natives through a 
system of IHS, tribal, and urban operated facilities and programs based 
on treaties, judicial determinations, and Acts of Congress. The mission 
of the agency is to raise the physical, mental, and social health of 
American Indians and Alaska Natives to the highest level, in 
partnership with the population we serve. The agency goal is to ensure 
that comprehensive, culturally acceptable personal and public health 
services are available and accessible to the service population. Our 
foundation is to uphold the Federal Government's commitment to promote 
healthy American Indian and Alaska Native people, communities, and 
cultures.
    For those on the Committee and those attending this hearing, I 
would like to provide some background about myself. I am Charles W. 
Grim, a member of the Cherokee Nation of Oklahoma. I come from the town 
of Cushing, Oklahoma. I am descended from those who walked the Trail of 
Tears. I would like to acknowledge my late father, Charles Grim and my 
mother Ruth Grim, whose confidence in me has always been a source of 
strength and pride. I draw my strong sense of heritage and culture from 
my family. From early in my life I envisioned working for the Indian 
Health Service as an important way to help Indian people. Upon my 
graduation from dental school, my aunt Ms. Dorothy Snake also 
encouraged me to work for the IHS as part of my National Health Service 
Corps educational scholarship pay back requirement.
    My first assignment with the IHS was at the Indian health Center in 
Okmulgee, Oklahoma. Working there was like coming home and fulfilling 
the dream I had as a teenager to help Indian people. I knew then and I 
know now, just as strongly, that working for the Indian Health Service 
is a part of my life. I cannot imagine being as satisfied or having 
such a sense of reward working anywhere else. To be nominated for a 
second term to lead the Indian Health Service, and to be in a position 
to do so much for so many Indian people, is wonderful and humbling 
opportunity, as well as a great honor.
    In addition to my personal connection and desire to lead the 
agency, I am a Doctor of Dental Surgery and I have a Masters degree in 
Health Services Administration with focus on the Management and 
Administration of health services, dental care, and hospital and 
ambulatory care. I have served with the U.S. Public Health Service for 
24 years--through assignments to various offices and programs of the 
Indian Health Service, including five years as the Director of the 
Indian Health Service. I am ready to recommit to the job of Director of 
the Indian Health Service.
    Rates of some health disparities are decreasing, but the 2001-2003 
rates of most leading causes of death for Indian people remain more 
than double the rates for the rest of America--for injuries, the rate 
for Indian people is 154 percent of the rate for the general U.S. 
population; for alcoholism, 551 percent; for diabetes, 196 percent; for 
homicide, 108 percent; and for suicide, 57 percent.
    The rate of diabetes-related kidney failure in American Indians and 
Alaska Natives is 3.5 times higher than the general U.S. population, 
although the incidence of new cases has declined 18.5 percent in our 
population since 1999 (while it is still going up in whites and African 
Americans). Cardiovascular disease (CVD) is the number one killer of 
American Indian and Alaska Native adults. CVD is increasing in American 
Indian and Alaska Native population while it is decreasing in the 
general U.S. population. Diabetes is the strongest risk factor in up to 
70 percent of the CVD seen in our population. Amputations due to 
diabetes still occur at rates 3 to 4 times the rates for the rest of 
the nation.
    And the tragedy of Sudden Infant Death Syndrome (SIDS) occurs at 
two times the rate of the U.S. general population. American Indian and 
Alaska Native (15-24 years) suicide mortality within Indian families 
occurs at three times the rate than for other families.
    In the early history of the Indian Health Service, the greatest 
achievements in reducing health disparities were through increased 
medical care and public health efforts that included massive 
vaccination programs and bringing safe water and sanitation facilities 
to reservation homes and communities. I believe future reductions in 
disparities of any significance will be made through health promotion 
and disease prevention efforts and programs rather than through 
treatment.
    American Indians and Alaska Natives have the highest rate of type 2 
diabetes for all age groups of any ethnic or racial group in the U.S. 
The prevalence of type 2 diabetes in American Indians and Alaska 
Natives is 2.2 times higher than for non-Hispanic whites and the death 
rate from diabetes is 3 times higher than the general U.S. population--
but it has been shown that with moderate changes in diet and exercise, 
such as reducing body weight by 7 percent and walking for 30-minutes a 
day 5-6 days per week--the onset of diabetes can be delayed and, in 
some cases, can be prevented.
    Cardiovascular disease is now the leading cause of mortality among 
Indian people, with a increasing rate that is nearly 1\1/2\ times that 
of the U.S. general population; but by modifying or eliminating health 
risk factors such as obesity, sedentary lifestyles, smoking, high-fat 
diets, and hypertension, that trend may be reversed.
    We need to invest in our communities so that despair does not fill 
the lives of our children. The IHS suicide morality rate among Indian 
youth is three times that of the general population. There are many 
programs, not just those of the Indian Health Service, which can be 
implemented to reduce or eliminate the number of our children who are 
killing themselves.
    I believe the more we focus on promoting good health the less will 
be needed for treating the consequences of poor health. The Indian 
Health Service has a proud history of dramatically improving the health 
of Indian people. Since the passage of the Indian Self-Determination 
and Education Assistance Act in 1975, the greater involvement of Indian 
Tribes and Indian people in the decisions affecting their health has 
produced significant health improvements for Indian people: Indian life 
expectancy has increased by 8.7 years since 1973 and while significant 
disparities still exist, mortality rates have decreased for maternal 
deaths, tuberculosis, gastrointestinal disease, infant deaths, 
unintentional injuries and accidents, pneumonia and influenza, 
homicide, alcoholism, and suicide.
    Tribes are IHS's partners as well as customers in providing 
approximately 60,000 inpatient admissions, 9.4 million outpatient 
visits, and 954,000 dental visits annual to approximately 1.8 million 
American Indians and Alaska Natives at more than 500 sites and 600,000 
more American Indians and Alaska Natives at 34 urban sites. The Agency 
responded to the needs of more than 560 federally recognized sovereign 
Tribal nations in 35 states.
    I will continue to support the decision of Tribes to contract, 
compact, or retain the Indian Health Service as their provider of 
choice. The Indian Self-Determination Act allows Tribes to manage their 
own health programs. In addition, this Administration and the Secretary 
have put their words into action and increased the involvement of 
tribal representatives in advising and participating in the decision-
making processes of the Department.
    We also invest wisely in our communities and in promoting good 
health. Health status is the result of interwoven factors such as 
socioeconomic status, educational status, community and spiritual 
wellness, cultural and family support systems, and employment 
opportunities, to name a few. The connection between poverty and poor 
health cannot be broken just by access to health services or treatment 
alone.
    Based on identified trends in Indian healthcare, I believe we must 
begin to lay the groundwork now for the health environment we want to 
have 5, 10 or 20, years in the future. I believe we must focus on 
emerging infectious and chronic disease patterns, and the related 
increasing cost of pharmaceuticals to treat and prevent disease. These 
issues can best be addressed through health promotion and disease 
prevention activities, so that our people will improve their health, 
which will decrease the demand for health services and pharmaceuticals.
    Preventing disease and injury is a worthwhile financial and 
resource investment that will result in long-term savings by reducing 
the need for providing acute and chronic care and expensive treatment 
processes. It also yields the even more important humanitarian benefit 
of reducing pain and suffering and prolonging life.
    In the past four years, I focused the IHS on specific health 
initiatives to address the goals, needs, and health status trends of 
American Indian and Alaska Native people. I believe the future of 
Tribal communities depends on how effectively the Indian health care 
system addresses chronic diseases, and therefore initiated a Chronic 
Care Initiative in 2003. Preventing and treating chronic disease 
requires an entirely different approach for care delivery.
    I implemented strategies within the Indian health system that 
improve the health status of patients and populations affected by 
chronic conditions and reduce the prevalence and impact of those 
conditions by adapting and implementing a chronic care model. We are 
now committed to developing patient and family-centered care processes 
that apply across multiple chronic conditions (instead of care based on 
managing individual diseases). I am proud to inform the Committee that, 
in 2007, fourteen sites within the Indian health system are piloting 
new approaches to managing chronic care as a result of my Chronic Care 
Initiative with assistance from a full partnership established with the 
renowned Institute for Healthcare Improvement.
    My Behavioral Health Initiative has three programmatic parts--
methamphetamine intervention, suicide prevention, and family safety and 
protection--and increases the emphasis on both clinical and community-
based health promotion and disease prevention (HP/DP) efforts. We are 
focusing on using our collective ability to develop and implement 
programs designed to prevent disease rather than relying exclusively on 
treatment of disease. One half of IHS Areas will be integrating 
behavioral health into local Area Tribal Health Board plans. They share 
best and promising practices of how to integrate behavioral health with 
the other two initiatives.
    We are forging collaborations with other organizations like the 
National Boys and Girls Clubs of America to increase clubs on 
reservations, NIKE Corporation to promote healthy lifestyles, CDC to 
fund IHS FTEs supporting epidemiology and disease prevention 
activities, Mayo Clinic to support efforts to reduce cancer and related 
health burdens, and Harvard University to improve American Indian and 
Alaska Native health and wellness.
    Through these initiatives, we target health outcomes that will have 
a beneficial impact, and attempt to change basic practices and 
procedures as well as unhealthy behaviors. Therefore, my third 
initiative is health promotion/disease prevention. American Indian and 
Alaska Native patients will see increased focus on screening and 
primary prevention in mental health, actions aimed at HP/DP to promote 
healthy lifestyles, and increased primary prevention of chronic 
disease.
    My business emphasis focuses on strengthening the infrastructure of 
the Indian health system. The infrastructure supports a very 
comprehensive public health and clinical services delivery program, 
including such diverse elements as water and sewage facilities, 
diabetes prevention and wellness programs, and emergency medical 
services. The IHS is the largest holder of real property in the 
Department with over 9 million square feet of space. There are 48 
hospitals, 272 health centers, 11 school health centers, 320 health 
stations, satellite clinics, and Alaska village clinics, and 11 youth 
regional treatment centers that support the delivery of health care to 
our people.
    Just as the health challenge has changed since 1955 when the IHS 
was transferred to the Department of Health, Education, and Welfare; so 
too has the infrastructure needed to meet those new health demands. In 
1955, our 2,500 employees and annual appropriation, of approximately 
$18 million ($124 million in today's dollars), provided health services 
for a population of 350,000 with a life expectancy 58 years for men and 
62 years for women. In Fiscal Year 2006, we increased to a staff of 
approximately 15,000 and an appropriation of $3.2 billion, supplemented 
by over half a billion dollars from our third-party collection efforts, 
which provides health services for 1.9 million American Indians and 
Alaska Natives with an average life expectancy of 72.3 years.
    Our collections are critical to the solvency of our programs 
because these funds return to the service unit to pay for additional 
staff, equipment, or other infrastructure elements to address the 
health needs of that community. One of my top priorities has been to 
implement a market-based business plan that actively promotes 
innovation. The plan enhances the level of patient care through 
increased revenue, reduced costs, and improved business processes. In 
Fiscal Year 2006, IHS generated approximately $700 million in third 
party revenue and saved $352 million through the use of negotiated 
contracts with private providers to get the lowest costs possible when 
purchasing care. For Fiscal Year 2007, the agency's overall program 
authority is over $4 billion dollars.
    In an environment of increased federal accountability, it was 
important for me to institute the restructuring of the IHS's approach 
to performance management at the national level. In 2005, I activated 
the IHS Performance Achievement Team to guide the Agency toward a more 
consistent, efficient, and effective performance management approach to 
achieve a results-oriented organizational culture. Accountability for 
performance measures is now part of the performance appraisal criteria 
at all organizational levels.
    I attribute the improved Agency performance accomplishments to our 
strong focus on accountability. For example, the IHS was recognized in 
2006 as a national leader in the use of health information technology 
to electronically provide clinical quality measures related to 
monitoring the Government Performance Results Act (GPRA) performance 
indicators. The Agency implemented reporting on GPRA annual targets in 
2002 when 72 percent of the targets were met. In the agencie's latest 
2006 report, 82 percent of the clinical and non-clinical targets were 
either met or exceeded. I am proud of the continuous improvement shown 
by the percentage that reached 82 percent in 2006, a documented 
increase of 10 percentage points since 2002.
    Tribal stakeholders updated their health priorities in order to 
help support program assessment and as a result 65 percent of the 
Tribally-operated health programs voluntarily provided performance data 
and other information that demonstrated their achievement of program 
goals and management standards.
    The IHS has made consistent progress in addressing management areas 
included in the President's Management Agenda, a government-wide 
management improvement initiative. The IHS met standards for success in 
carrying out action plans. The IHS continued to implement improvement 
plans for six programs assessed by the Program Assessment and Rating 
Tool, a program evaluation instrument. All six programs were rated 
Adequate or higher with IHS having one of the highest overall averages 
in the Federal Government by 2005.
    We have continued to effectively implement results-oriented 
management by achieving a 10 percent relative increase in four areas of 
program performance by 2007. In 2006, IHS made significant increases in 
rates for all four program measures over their 2005 levels: screening 
for alcohol use among female patients of childbearing ages increased 16 
percent, domestic violence screening increased 15 percent, diabetic 
patients assessed for LDL cholesterol increased 9 percent, and 
pneumococcal vaccinations for elders increased 8 percent. The Agency 
has consistently demonstrated ability to impact targeted performance 
measures and successfully leverage performance management to advocate 
for improved health status for American Indian and Alaska Native 
people.
    The IHS is the only federal program delivering hands-on care to 
Indian people based on a government-to-government relationship and 
today we are facing many challenges. Change and challenge is nothing 
new to the history of the nation or to Indian nations. Our history 
attests to our ability to respond to challenges, to overcome 
adversities that we sometimes face, and to maximize our opportunities.
    I have great passion about this organization and our mission to 
raise the health of our people to the highest level possible. My 
actions will always reflect the honor of being entrusted to provide 
health services to American Indian and Alaska Native people. I am ready 
to lead the Indian Health Service, with honor and respect for our 
ancestors, and to work with you and the Administration for the benefit 
of American Indian and Alaska Native people.
    I am pleased to respond to any questions you may have concerning my 
nomination.
    Thank you.
                                 ______
                                 
                        BIOGRAPHICAL INFORMATION



Background Information
    Charles W. Grim, D.D.S., M.H.S.A., Director of the Indian Health 
Service (IHS), is an Assistant Surgeon General, and holds the rank of 
Rear Admiral in the Commissioned Corps of the United States Public 
Health Services (USPHS). He was appointed by President George W. Bush 
as the Interim Director in August 2002, received unanimous Senate 
confirmation on July 16, 2003, and was sworn in by Tommy G. Thompson, 
Secretary of the Department of Health and Human Services (HHS), on 
August 6, 2003, in Anchorage, Alaska. Dr. Grim is a native of Oklahoma 
and a member of the Cherokee Nation of Oklahoma.
    As the IHS Director, Dr. Grim administers a $4 billion nationwide 
health care delivery program composed of 12 administrative Area 
(regional) Offices. As the principal federal health care provider and 
health advocate for Indian people, the IHS is responsible for providing 
preventive, curative, and community health care to approximately 1.9 
million of the Nation's 3.3 million American Indians and Alaska Natives 
in hospitals, clinics, and other settings throughout the United States.
    Dr. Grim serves as the Vice-Chair of the Secretary's 
Intradepartmental Council on Native Americans Affairs (ICNAA). The 
ICNAA was established by the HHS Secretary to develop and promote HHS-
wide policy to provide quality services for American Indians and Alaska 
Natives; promote departmental consultation with tribal governments; 
develop a comprehensive departmental strategy that promotes tribal 
self-sufficiency and self-determination; and promote the tribal/federal 
government-to-government relationship on an HHS-wide basis. Under Dr. 
Grim's leadership, the IHS has received numerous national awards for 
innovation and quality, including the 2005 Nicholas E. Davies Award for 
the IHS Clinical Reporting System.
    In 2004 Dr. Grim established three closely related Agency-wide 
initiatives: Behavioral Health, Chronic Care, and Health Promotion and 
Disease Prevention. Through changing behaviors and lifestyles and 
promoting good health and health environment, critical steps are being 
taken in improving the health of American Indians and Alaska Natives. 
Already these initiatives are transforming the Indian health care 
system and the way Indian communities receive health care. Working with 
Tribes in concert with the principles of self-determination and self-
governance, Dr. Grim's leadership has made a positive impact on the 
health and well-being of American Indian and Alaska Native patients, 
families, and communities. The initiatives also are closely aligned 
with the HHS Priorities such as prevention and health transparency 
established by HHS Secretary Michael O. Leavitt.
    Dr. Grim graduated from the University of Oklahoma College of 
Dentistry in 1983 and began his career in the IHS with a 2-year 
clinical assignment in Okmulgee, OK, at the Claremore Service Unit. Dr. 
Grim was then selected to serve as Assistant Area Dental Officer in the 
Oklahoma City Area Office. He was appointed as the Area Dental Officer 
in 1989 on an acting basis.
    In 1992, Dr. Grim was assigned as Director of the Division of Oral 
Health for the Albuquerque Area of the IHS. He later served as Acting 
Service Unit Director for the Albuquerque Service Unit, where he was 
responsible for the administration of a 30-bed hospital with extensive 
ambulatory care programs and seven outpatient health care facilities. 
Later career appointments included serving in the Albuquerque Area 
Office as the Director for the Division of Clinical Services and 
Behavioral Health, and Acting Executive Officer.
    In April 1998, Dr. Grim transferred to the Phoenix Area IHS as the 
Associate Director for the Office of Health Programs. In that role, he 
focused on strengthening the Phoenix Area's capacity to deal with 
managed care issues in the areas of Medicaid and the Children's Health 
Insurance Program of Arizona. He also led an initiative within the Area 
to consult with Tribes about their views on the content to be included 
in the reauthorization of the Indian Health Care Improvement Act, 
Public Law 94-437.
    In 1999, Dr. Grim was appointed as the Acting Director of the 
Oklahoma City Area Office, and in March 2000 he was selected as the 
Area Director. As Area Director, Dr. Grim managed a comprehensive 
program that provides health services to the largest IHS user 
population, more than 280,000 American Indians comprising 37 Tribes.
    In addition to his dentistry degree, Dr. Grim also has a master's 
degree in health services administration from the University of 
Michigan. Among Dr. Grim's honors and awards are the U.S. Public Health 
Service Commendation Medal (awarded twice), Achievement Medal (awarded 
twice), Citation, Unit Citation (awarded twice), and Outstanding Unit 
Citation. He has also been awarded Outstanding Management and Superior 
Service awards by the Directors of three different IHS Areas. He also 
received the Jack D. Robertson Award, which is given to a senior dental 
officer in the United States Public Health Service (USPHS) who 
demonstrates outstanding leadership and commitment to the organization. 
The Governor of Oklahoma recognized Dr. Grim's achievements by 
proclaiming June 11, 2003 ``Charles W. Grim Day.'' He was further 
honored by the State of Oklahoma by being selected as a Spirit Award 
Honoree during their American Indian Heritage Celebration on November 
17, 2003. Dr. Grim was awarded the Surgeon General Medallion on 
February 26, 2007 at the annual meeting of the National Combined 
Clinical Directors.
    Dr. Grim is a member of the Commissioned Officers Association, the 
American Board of Dental Public Health, the American Dental 
Association, the American Association of Public Health Dentistry, and 
the Society of American Indian Dentists. Dr. Grim was appointed to the 
Commissioned Corps of the USPHS in July 1983.

    The Chairman. Dr. Grim, thank you very much.
    We have been joined by Senator Barrasso. Senator Barrasso, 
welcome.

               STATEMENT OF HON. JOHN BARRASSO, 
                   U.S. SENATOR FROM WYOMING

    Senator Barrasso. Thank you, Mr. Chairman.
    The Chairman. Senator Barrasso, do you have an opening 
statement that you wish to give? Or would you just like to take 
your turn at questioning?
    Senator Barrasso. Mr. Chairman, I don't have a statement at 
this time.
    The Chairman. Thank you very much. Well, let us welcome you 
to this Committee. We are very pleased that you are here and 
that you will once again lend a Wyoming voice to the work that 
has been done previously on this Committee.
    Senator Barrasso. Thank you, Mr. Chairman.
    The Chairman. Dr. Grim, let me make a couple of 
observations. First of all, you are a good guy. I have enjoyed 
working with you. I think you have a very strong background in 
public health. I admire your work and admire your commitment. I 
intend to support your renomination.
    As you know, I have great trouble with what has happened 
with respect to Indian health. In many ways, I think you are 
required to manage a scandal. I regret that because of the 
scandal, at least 40 percent of the health care needs of 
American Indians is unmet. That means there is full-scale 
rationing going on with respect to health care. That normally 
would be front page headline news in this country, but it isn't 
these days. It just goes on all the time. We have to find a way 
to address it.
    Now, in your past appearances before this Committee, you 
have talked about, let me quote, ``the IHS is the Federal 
agency responsible for delivering health services to more than 
1.9 million American Indians and Alaska Natives. Two major 
statutes are at the core of the Federal Government's 
responsibility for meeting the health needs of American Indians 
and Alaska Natives--the Snyder Act and the Indian Health Care 
Improvement Act.''
    That implies to me that you have previously indicated to 
this Committee that you believe there is a trust responsibility 
rooted in law for the health care for Native Americans or 
American Indians. Am I correct about that?
    Dr. Grim. I think the quotes that you gave and the two laws 
that I indicated are the cornerstone authority that lays out 
the government's responsibility to Indian people for health 
care.
    The Chairman. Is there a disagreement on that in the 
Administration? The reason I ask the question is I understand 
the OMB has taken that language out of the testimony you have 
given today, and has a disagreement about that language.
    Dr. Grim. I don't believe there is any misunderstanding 
with the Administration that those two laws lay out clearly the 
government's responsibility to Indian people.
    The Chairman. Why would the Office of Management and Budget 
take that language out of the testimony?
    Dr. Grim. As you are well aware, my testimonies and our 
bill reports and things like that get cleared through numerous 
levels. Sometimes changes are made. It was not communicated to 
me the exact rationale for that, but in past testimonies you 
have heard me make those quotes and these have cleared the 
department and the Office of Management and Budget.
    The Chairman. And you stand by that responsibility that you 
previously described?
    Dr. Grim. Yes, sir.
    The Chairman. Dr. Grim, let me ask a couple of questions 
about the quality of the Indian health care service. Before I 
do that, I indicated that in previous testimony, you have 
admitted, and it has kind of been like pulling teeth, and I 
understand why--you have certain responsibilities at the 
witness table to the Administration--but you have admitted that 
the unmet needs of Indians with respect to their health care is 
somewhere around 40 percent. Am I accurate about that?
    Dr. Grim. Yes, sir. That was an actuarial study.
    The Chairman. So if we have a population for whom we have a 
trust responsibility and my colleague, Senator Murkowski, 
pointed out that we spend about twice as much per person 
providing health care to those that are incarcerated in Federal 
prisons as we do for the health care needs of American Indians, 
and about 40 percent of the need is unmet, that is a very 
serious problem. My guess is that people die as a result of 
those unmet needs.
    The question is the quality of the Indian Health Service. I 
want to ask you about that. I go to places where Indian Health 
Service professionals deliver health care. I walk away very 
often deeply admiring the folks who serve in the Indian Health 
Service and Public Health Service generally.
    But we had testimony before this Committee, and let me read 
just a bit of it, and ask for your observations. This is 
testimony from doctors who are in the private sector who have 
seen American Indians. Let me quote one, ``Quality of care at 
Indian Health Service facilities has been a documented problem. 
I have seen this problem since I have worked with the Indian 
Health Service in 1997 until today. A diabetic patient sees me 
with fluid in her knee joint. She has gone to the Indian Health 
Service for evaluation and was told by the physician to wrap 
her knee in cabbage leaves for several days. I obtained an MRI 
of her knee and found a torn anterior cruciate ligament.''
    Well, he goes on to describe a fellow on an Indian 
reservation who had a bad arm. He was a rancher, a 60 year old 
rancher with a bad arm. He said a one-armed rancher isn't worth 
a whole lot; couldn't earn much to eat, and so on. He finally 
got surgery, but it was one of those life and limb contract 
health issues. And the list goes on about these things. The 
same doctor described a woman that was brought into the 
hospital having a heart attack on the Indian reservation, put 
in an ambulance, brought into the hospital with an 8 by 10 
piece of paper taped to her thigh, and as they unloaded her 
onto the hospital gurney to admit her to the emergency room, 
they looked at the 8 by 10 piece of paper taped to this woman's 
thigh and it said, ``By the way, we are out of contract health 
care money, so if you admit this patient, understand you are 
admitting this patient at your own risk''--a woman having a 
heart attack.
    So we have these stories coming to us. This is not about 
you or your leadership. It is about the dramatic under-funding 
of the Indian health care system. I ask about the quality with 
this question. Tell me about the quality issues, and when we 
hear this kind of testimony, what should we make of it?
    Dr. Grim. Well, first, I would like to remind the Committee 
that we have facilities in over 500 different locations in 35 
States, in some of the most rural and isolated areas of the 
Country. The second thing I would like to remind the Committee 
is that we do hear, you and I, I think all the Senators in 
here, probably get letters either about contract health 
services or about issues that have arisen over time like this. 
But we do provide 9 million outpatient visits, 60,000 in-
patient, over 1 million dental visits. I don't even mention the 
mental health and all the other sorts of services we provide.
    We get a few complaints on issues in that nine million plus 
visits over time. But all of our facilities have a quality 
assurance process in place. All of our hospitals are accredited 
by the Joint Commission on the Accreditation of Health Care 
Organizations. That is an external organization, as you know, 
that accredits private sector organizations. They all passed 
those. Those that aren't accredited by JCAHO undergo AAAHC for 
ambulatory health care. And all these organizations require a 
quality assurance program.
    So we do have those in place, Senator. I want to assure you 
of that, and assure you that the things that you are raising 
are very rare exceptions as opposed to the rule of what is 
going on out there.
    The Chairman. But the services are not near what is 
necessary. You and I have discussed the death of a 14 year old 
girl who didn't have access to mental health treatment after 
lying in bed in a fetal position for 90 days, missing school, 
no mental health capabilities, and not even a car to drive this 
little girl to mental health had somebody thought that maybe 
she ought to go there.
    So there is a dearth of services available in many of these 
circumstances and that is a serious problem a well.
    Senator Coburn raised a question about shouldn't American 
Indians, for whom we have a trust responsibility for their 
health care, simply be able to go to any hospital and get the 
health care? We pay the bill. I would support that. But 
wouldn't that cost a substantial amount of money? And I would 
support that, by the way. But there is not a ghost of a chance 
of getting that through this President's budget or this 
Congress.
    But if we had a system where we say we have a trust 
responsibility, if you have a health care need and it is not 
available to be addressed where you live, go to a hospital and 
we will pay contract health support for it. What would that 
cost?
    Dr. Grim. I am not sure that we have a figure for that. We 
can see if there is a figure that could be placed on that. I am 
not sure that is a study that we have ever done. One of the 
things I can tell you is that whenever we are able to refer a 
patient for contract health services, as you know, the law 
states that that is to be the payer of last resort. So we try 
to make those services go as far as possible, and we try to 
make access for our patients to the services that they need 
through the use of making sure that any of them that are 
eligible for Medicare, Medicaid or private insurance are 
enrolled in that, and then we use the appropriate referral 
mechanisms for that particular type of insurance, and we make 
sure they get the care in the private sector, either with 
third-party revenue, and to the extent that CHS resources last, 
with CHS.
    So in one essence, we are doing that to the extent we can 
within the existing programs that are available, both outside 
the Indian Health Service and within the Indian Health Service.
    The Chairman. Dr. Grim, I am going to ask one more 
question, because we have many colleagues who wish to ask 
questions. I will wait until the end to ask additional 
questions. But contract health funds run out early in the year. 
We have had tribal Chairs tell us that they run out of Contract 
Health Service money in January. Many of them tell us in June. 
And then it is life and limb, which is really rationing of 
health care.
    But one final question, the IHS supports tribal management 
of their health programs through Self-Determination contracts 
and Self-Governance contracts, as you have said. The Supreme 
Court held that in the Cherokee Nation v. Leavitt case, the IHS 
was obligated to pay full contract support costs due to the 
tribes who operated health programs and facilities under the 
Self-Determination Act. Is the IHS still insisting that the new 
Self-Governance compacts contain clauses waiving the tribes' 
rights to contract support costs? I understand that was the 
case. Are we still doing that?
    Dr. Grim. What we are asking them to do is to just indicate 
in the contracts that they are able to operate a program if 
they want to assume it, with the possibility of there not being 
either 100 percent of the contract support costs available to 
them, or potentially any of those contract support costs. That 
is what we are asking them to agree to in the contracts now.
    The Chairman. But that doesn't even make any sense, does 
it? If you want--well, I will leave it at that. That doesn't 
make any sense at all. If we are saying we would like you to 
move toward Self-Determination, and, oh by the way, if you do, 
you have to waive your right to contract support costs. I don't 
understand why the Administration is doing that.
    Well, Dr. Grim, you are a good guy----
    Dr. Grim. I can answer that further if you would like.
    The Chairman. Go right ahead.
    Dr. Grim. I mean, we have an existing line item or sub-
activity for contract support costs. When that is insufficient 
to take care of the demand out there, that has necessitated us 
putting that into place. The Supreme Court decision told us, 
and that was before we had a cap on our appropriations, the 
Appropriations Committee has now put a statutory cap on the 
amount that is able to be spent. But prior to that cap, the 
Supreme Court said that you, the agency, and you, the Federal 
Government, should not be entering into commitment that you 
cannot meet.
    So we are trying to allow the expansion of self-governance 
and self-determination still with the awareness that we don't 
have sometimes in a given year the CSC funds available for the 
number of contracts.
    The Chairman. Dr. Grim, we either have the responsibility, 
the trust responsibility, or we don't. And if we do, we can't 
delegate that somewhere. I think it is a disincentive to the 
Self-Governance compacts that a tribe might wish to enter into 
if you say, oh, by the way if you do this, you are going to 
waive your right to contract support costs. As you said, it is 
a matter of money, but we are so far short of dealing with the 
health needs of these folks.
    You are a good person. I am going to support your 
renomination. I have enjoyed working with you.
    Dr. Grim. Thank you, Senator.
    The Chairman. But as I said, in many ways I think you are 
required to manage a scandal because of the rationing of health 
care, which I deeply regret. But I think you are a nominee that 
has a terrific background for this job. If you had the money, 
coupled with your background, then we would have something. We 
are going to continue to push for that.
    Dr. Grim. I will continue to work with you, Senator.
    The Chairman. Senator Murkowski?
    We have been joined by several of our colleagues, and we 
had made opening statements. I don't know whether, and if some 
of you can't stay and would wish to make a brief opening 
statement.
    Are you able to stay for questions? If not, you could make 
a brief opening statement and then I would ask Senator 
Murkowski to proceed.
    Senator Domenici. I would like to make an opening 
statement."
    The Chairman. Please do, and then I will recognize the Vice 
Chair.

              STATEMENT OF HON. PETE V. DOMENICI, 
                  U.S. SENATOR FROM NEW MEXICO

    Senator Domenici. First, Mr. Chairman, I want to thank you 
for joining me as a co-sponsor of a very important bill with 
reference to the Indian people, and that is the diabetic bill. 
A number of you on this Committee have joined us. We are going 
to pass another major diabetic funding bill, Dr. Grim, and you 
know that we started seven or 8 years ago with a little tiny 
bill and it has grown with the national commitment, and you 
have as a result a rather significant diabetes program for the 
Indians.
    If the Indian people will just continue their 
participation, you may indeed prove that entire reservations 
like the Navajo Nation won't let themselves die because of the 
DNA factor that exists, and they are so heavily laden with 
diabetes. I commend you for insisting that this be run properly 
with the universities and that you get your share.
    Mr. Chairman, I want to comment that we could look at all 
different aspects of the shortage that we have, but I think the 
basic one that we better get to and see if we can find a way, I 
am going to suggest it later in a bill form, but I think the 
infrastructure, that is the buildings, are so decrepit and so 
deficient that they are getting close to what we had 5 years 
ago, 4 years ago, with Indian education, where we could not in 
all good conscience tell people to go see Indian education 
buildings on the United States side. There were better ones in 
Alaska, a little better. But we couldn't invite friends to go 
see most of them because they were so bad.
    What we did is we got a commitment out of the President 
that if he won, he would put up a huge amount every year for 5 
years of his presidency and we just about wiped out the needs 
on education, on the new school buildings. I think we ought to 
consider a similar things for the candidates for President that 
are running in both parties, and get them to commit to us that 
they will have a certain amount in their budgets.
    You know, this year we have $12 million in the budget for 
capital improvements for a deficiency of $3 billion. Now, that 
is almost asking the accountants, to hire some accountants and 
say we agree to pay you, and we hope in the process you will 
provide health care; $12 million is such a small amount 
compared to $3 billion in needs. You can't pay the 
administrative costs.
    We just have to get somebody up there in the White House to 
commit that on a regular basis for a number of years, we will 
get $500 million or $600 million and rebuild some old hospitals 
and do the things that are required.
    This gentleman knows all about that, and he knows how to 
lead it. The problem is you can't lead that with nothing. I 
think he should be confirmed. I think, however, that we should 
ask him as he finally gets confirmed that regardless of his 
being an employee of the Administration, that he speak out on 
some of the more egregious situations.
    I think some of them deserve your comment, even though you 
work for the Administration. There are facilities that deserve 
you saying, as a doctor, these ought to be fixed; they 
shouldn't be serving human beings, much less Indian people.
    Thank you, Mr. Chairman.
    Dr. Grim. Thank you, Senator.
    The Chairman. Senator Domenici, thank you very much.
    Senator Tester is presiding on the floor of the Senate at 
10:30. Let me call on Senator Murkowski, and if we can allow 
Senator Tester just following you, if he has the time, to ask a 
couple of questions. I would like to do that.
    Senator Murkowski. Well, if you really have to be there at 
10:30, I will defer to you, Senator Tester, and then take my 
turn after that.
    Senator Tester. That is very kind of you, Senator. Thank 
you very, very much. I appreciate that.
    Dr. Grim, I, too, want to reflect the statements of the 
Chairman that you are a good fellow, and I would be remiss if I 
didn't once again point out that you have a great haircut.
    [Laughter.]
    Dr. Grim. I like yours, too.
    [Laughter.]
    Senator Tester. The Native Americans, the system is upside 
down, the health care system. One of the issues that I have 
looked at a little bit is Native American people to provide 
health care for the Native Americans. Is there anything that 
Indian Health is doing to encourage more Native Americans to 
get into the health care profession and to come back to the 
reservations?
    Dr. Grim. Yes, sir. We are, actually. We have one program 
in particular, our scholarship program, that has about $12 
million in it per year. We run between 400 and 500 students at 
any given time. The unique thing about our program compared to 
some scholarship programs is that we have a pre-professional 
component to it. We can pay for undergraduate work as well as 
the professional work. Over the course of the years Indian 
Health Service has been around, we have gone from, well just in 
the last 25 years, we have increased by 272 percent the number 
of Indian professionals we have. We have with that program 
provided 1,000 doctors, 2,200 nurses, and 300 dentists.
    They also have an obligation back to our system, and we 
tallied the other day that obligation to date there have been 
over 11,000 service years that have been provided back to 
Indian people because of that program.
    Senator Tester. And those scholarships are available 
throughout every State in the Union?
    Dr. Grim. It is a nationally run program, so they are 
available nationally, yes.
    Senator Tester. Good. The VA has signed a memorandum of 
understanding with the Indian Health Service in five areas. You 
are probably familiar with them. They are all laudable. The VA 
has taken no action in Montana, at least, and I don't know if 
they have taken any action anywhere else.
    What can you do to ensure that those areas of concern that 
are listed in that VA MOU, and I can list them to you, but you 
know what they are.
    Dr. Grim. Yes, sir. I do.
    Senator Tester. Follow through on them.
    Dr. Grim. Since you raised an issue that there is nothing 
there, we will look into it and get back to you. But there are 
a huge amount of things occurring and it varies across the 
Nation, but one of the things I will say that my counterpart at 
the VA and I have worked together closely to bring life to that 
MOU. We have had some historic meetings that had never occurred 
before between our regional directors and the VA VISN 
directors. They were working meetings on how we could bring 
life in all of the regions across the Country to that MOU.
    Senator Tester. That is good.
    Dr. Grim. So I know there are varying levels of achievement 
to date, but we are continuing to work on it.
    Senator Tester. A last question, and very quickly, in your 
written testimony, and you may have said it in your verbal 
testimony too, you talk about injuries 154 percent of norm; 
alcoholism, 551 percent; diabetes, 196 percent; homicide 108 
percent; suicide 57 percent, the list goes on and on and on. I 
mean, it is a travesty and it is something that quite honestly 
anybody that would read this would be very, very concerned 
about.
    As quick as you can, in three or four bullet points, what 
could we do to get this to reasonable figures? I am talking 
about the occurrences of these terrible things, you know, two 
times sudden infant death syndrome. The list goes on and on and 
on. What can we do? What can we do?
    Dr. Grim. I can give you a long answer, but I won't and we 
can provide more for the record. But quickly, we are partnering 
with groups that we have never partnered with before around all 
those things that you mentioned.
    Second, we have recognized it is not just a health system 
issue, it is a societal issue. There needs to be safe housing, 
safe roads, and things like that. And so we are reaching out 
and so are the Indian leaders in those communities to address 
some of those issues, too.
    I think the third thing that I would say is that as we 
looked at the epidemiology of all of those things that you just 
mentioned, that is how we settled with Indian Country on the 
three initiatives that we are working on. If you looked at all 
those things you mentioned--prevention--almost all of them are 
preventable. Many of them, if not all of them, have behavioral 
health components. And then another load on our system is the 
chronic care.
    So we chose those three things to focus on and we are 
starting to build and integrate all those three initiatives.
    Senator Tester. In closing, I just want to say one thing. 
That is, that you are very close to Indian health care as far 
as the delivery system. You are a decisionmaker that can really 
make a difference. I would hope, and I am not making any claims 
that the Administration is doing this, trust me. But I would 
just hope that if the Administration is doing things that you 
don't agree with, that you put your job on the line to make 
sure that they are done right, that the right thing is done.
    I think you are a good person. I do think you are in a 
difficult situation, but there is plenty of opportunity here to 
improve the system, and that is a good sign.
    Thank you very much.
    Thank you, Senator Murkowski, once again, I appreciate it.
    The Chairman. Senator Tester, thank you very much.
    Senator Murkowski?
    Senator Murkowski. Thank you, Mr. Chairman.
    Dr. Grim, I think that you should note that your appearance 
here this morning before the Committee has drawn out more 
Senators than we have seen up here in a while. It could be 
because everybody thinks you are a good guy, but I think 
probably the underlying reason is we all appreciate that when 
it comes to representing our constituents, whether they are 
Alaska Natives or Cherokees or where they are, that when it 
comes to health care and providing for the health and the well 
being of these constituents of ours, that we have an enormous 
responsibility. Our statistics are statistics that we simply 
are not proud of. It is a very challenging place that you are 
in. Again, I will repeat my thanks to you for the efforts that 
you take on this.
    As a Committee, we have certainly agreed that the Indian 
Health Care Reauthorization Act should be our number one 
priority. What can you do at this point in this Congress to 
help us facilitate that? What can we be doing more of? What can 
you be doing at your level to make sure that the President has 
this on his desk this year?
    Dr. Grim. I think you could ask my Legislative Director or 
anyone on my staff that works closely with that bill. There has 
been more interest and involvement from the department and the 
Administration on this bill in the last few years than there 
ever has been. We have been working extensively and tirelessly, 
I might add, to try to get the bill report to the Committee. As 
you know, the bill changes slightly each year and we have to 
compare it to the last Senate and House bills to get comments 
in.
    But we are still working on the bill report, and while I 
can't commit to a timeframe today, it is still going back and 
forth in clearance. It has not sat on anyone's desk since the 
last time I was here. And I will continue to work on it, 
Senator.
    Senator Murkowski. I appreciate your commitment to that, 
but I think, again for those of us that recognize the very, 
very high priority of this, we don't want to be doing this next 
year and checking what we did last year on the bill when it has 
been sitting around for 10 years plus. Now is well past time 
that we again get this to the President for his signature. So I 
appreciate all that you can do to help us facilitate that.
    I want to ask you, the Amnesty International report that 
came out several months back, I know that you have reviewed it. 
It was yet one more devastating report in terms of the 
statistics. But there were really some very damning messages 
that came from that in terms of what we are seeing at many of 
the IHS facilities, lacking the clear protocols for treating 
the victims of sexual violence; 44 percent of the facilities 
lack personnel trained to provide the emergency services; a 
statement that IHS has not prioritized the implementation of 
the nurse examiners, some really very, very troubling 
revelations that came out in this.
    I would like for you, Dr. Grim, to just response to this 
report as it relates to the shortcomings in the IHS response. 
And also to ask you, there have been many that have approached 
me from the sexual and domestic violence community that have 
said that IHS is not devoting sufficient attention to 
addressing the needs of the victims, the survivors, to bring 
the perpetrators to justice. I want to know whether you feel 
that this criticism is valid, in your judgment, so if you can 
address some of the outcomes from that Amnesty International 
report.
    Dr. Grim. I have read the report, Senator Murkowski, as 
soon as it came out. We have had a group looking at it. As you 
know, the report was primarily focused on other issues in 
Indian Health--jurisdictional issues, law enforcement. But we 
did take seriously the recommendations that came forward that 
dealt with our system.
    We have had a group looking at it. I don't personally 
believe that all of the criticisms that were leveled, all the 
recommendations are valid, nor able to be carried out in our 
system. First, let me say that.
    Senator Murkowski. Do you think that IHS has the mandate or 
the authority to address some of the issues that are raised by 
Amnesty International?
    Dr. Grim. I feel we have the authority to do it. The 
problem is the ability, if you will.
    Senator Murkowski. Ability financially or in what way?
    Dr Grim. What they were measuring us against essentially 
was the sexual assault nurse examiner, which is the gold 
standard, if you will, for forensic examinations for sexual 
assault. It is really not just an Indian Health Service issue, 
it is a rural issue, if you will, all around the Country. Even 
some of our hospitals that might be capable of carrying out a 
SANE program or a SART program, defer to another hospital in 
their city that have it.
    Part of it is the training is rather demanding for the 
sexual assault nurse examiners. Many of our nurses are 
community members. A high percentage of our nurses are American 
Indian or Alaska Native. The secondary trauma that they go 
through dealing with the victims make it an extremely difficult 
job to retain people in. Then the length of time that the 
examinations take, especially in our smallest and most rural 
facilities--you know, whenever you have the workload demands, 
sometimes it makes it impractical to do that.
    What I will say, and I want to point out to the Committee, 
is that whenever a person who has been sexually assaulted does 
show up at our facilities, they are treated well. They are 
treated with compassion. We have 500 facilities, as I said, 
across the Nation.
    I cannot assure you today, although I can try to find out, 
that 100 percent of them have protocols on domestic violence, 
but all of our major facilities, the facilities that I 
mentioned that are accredited by JCAHO, AAAHC, protocols for 
dealing with domestic violence and sexual assault patients are 
there. Many, many of our physicians and nurses have the 
required training to do the sexual assault exams. We get the 
rape kits. We do those. Those that aren't trained to actually 
do it can hold evidence until State troops or others, or tribal 
police show up.
    So I guess what I want to leave the Committee with is that, 
number one, we are looking at all those recommendations and we 
are taking them seriously. Second, the people that are coming 
into our facilities are getting the care that is necessary, 
although it is not always a SANE program. Any of our facilities 
that are close enough for the patients to be easily transported 
to a SANE program are then transported. Usually, we refer out 
from our emergency departments when there is one of those close 
enough because we realize that right now it is measured as sort 
of the gold standard of care.
    And the last thing I would say just in closing is that the 
report criticizes us for not having a national policy on this. 
But I told you that all of our facilities that are accredited 
are required to have such things. For many, many practice-
related things, we don't develop national policies. There are 
policies and procedures in place that the medical staff have 
there locally that are just standards of care in the medical 
community.
    So I don't want anyone who has read that report to think 
that people are being neglected. But when you go to the most 
isolated parts of Indian Country, sometimes they have to be 
taken a long ways to get to somebody that can do the forensic 
exam or to hold the evidence.
    Senator Murkowski. Well, we will followup with you on 
certain aspects of this.
    Dr. Grim. I will work with you on that. It is a big 
concern.
    Senator Murkowski. I appreciate that.
    One last question, very quickly so that we can get to the 
rest of my colleagues here. You and I have discussed at great 
length the focus on prevention. I absolutely support your focus 
in this area in a way that we can help to reduce the health 
care costs and deal with so much of what faces so many in 
Indian Country.
    You have been an advocate for healthy nutrition, which we 
know is a key aspect when it comes to prevention, particularly 
in some of the diseases that we are seeing, this escalation in 
numbers like diabetes and the complications.
    What is going on specifically to improve the nutrition 
programs within Indian Country, within the Alaska Native 
communities? You know, in Alaska one of our great challenges is 
how you get fresh vegetables and fruits out to villages. The 
cost is impossible and the condition of the fresh produce is 
such that you are not willing to pay the $3 for the black 
banana. What are we doing to make a difference in this area?
    Dr. Grim. You have perhaps in your State one of the largest 
challenges in that arena, perhaps as anyone except for poverty 
reasons in other locations that just flat-out don't allow 
people to do that.
    One of the things that we are doing, and I think everyone--
tribal programs, Federal programs, and urban--have recognized 
that nutrition is an important part of health care. More and 
more programs are trying to ensure that they have nutritionists 
and dieticians on staff. A lot of the work with the tribes and 
the tribal organizations or with the tribal communities that we 
work in are starting to focus on going back to more traditional 
diets. That is starting to have a lot of resonance and a lot of 
success in communities, as opposed to what a nutritionist in an 
urban area might suggest to someone that they do.
    But we are trying to do what we can to improve. We have a 
list of issues that we could show you that we are doing. A lot 
of them are within our diabetes program. They really led the 
way across the Country on both nutrition, physical activity 
programs, and things like that.
    But you do have some big challenges, as you mentioned, for 
a lot of the rural communities in your State.
    Senator Murkowski. Again, that is another one that we will 
look forward to working with you on. My colleague has suggested 
that the answer is frozen vegetables, and he forgets that in 
the icebox of the north, we don't have refrigerators up there.
    Dr. Grim. Good answer. I wish I would have thought of that.
    Senator Murkowski. Yes.
    [Laughter.]
    Senator Smith. For the record, Mr. Chairman, Madam Vice 
Chair, they are fresher than fresh by the time they get to 
Alaska.
    Senator Murkowski. We just can't afford the cost to plug in 
the refrigerator for the freezer unit.
    The Chairman. Senator Smith?

              STATEMENT OF HON. GORDON H. SMITH, 
                    U.S. SENATOR FROM OREGON

    Senator Smith. Thank you, Mr. Chairman.
    I appreciate very much Dr. Grim being here. I am honored to 
support your renomination and look forward to voting for that.
    I also want to thank our Chair and Vice Chair and their 
staffs for working with me and my staff on an issue that--I am 
glad Senator Domenici is not here to talk about, he will have a 
different opinion on it--but it relates to the Health Care 
Improvement Act Amendments of the 2007 bill we are working on. 
What I am talking about is literally the construction formula, 
the health facilities and area distribution fund.
    As it is now, New Mexico and Arizona benefit 
disproportionately to other tribes. I wish those tribes nothing 
but the best and I am anxious to support a larger budget if 
that is what it takes. I don't want to disadvantage them. But I 
do want to make clear that the current formula just is not fair 
to other tribes throughout the Country.
    So what I want to find out from you is if the Indian Health 
Service has the authority under section 301 of S. 1200 to both 
pursue and implement an area distribution fund methodology.
    Dr. Grim. As I stated earlier, our views, our Senate bill 
report on that is still pending, and we have never implemented. 
We have a demonstration authority similar to that in our 
existing authorization in our current legislation. When our 
legislative and facilities people have looked at that, and we 
feel like it gives us the ability to do that, it has just never 
been done.
    The Congress, we work with them very closely and they are 
fairly directive in the funds that they provide for our 
facilities program. So I guess my answer to you, Senator, would 
be it has never been tried, but we think that the authority 
probably exists in current legislation.
    Senator Smith. So there is no current time line to shift 
from the current list to the new work list? There is nothing 
like that at this point?
    Dr. Grim. The existing list has been there for about 15 
years. We closed it about that many years ago because of the 
size of it. Those that are still in progress on the list, plus 
those that still exist, number about 20. We are right now 
preparing a final report to go through clearances with the 
department and OMB on the new facilities priority system. I 
believe that the multitude of options that that new system is 
going to allow is going to allow me to work with the 
Administration and with Congress to work on all the projects 
that have been initiated, plus look at the ways that we will 
implement the new methodology.
    Senator Smith. I just want to emphasize the importance of 
this because as important as our tribes are in New Mexico and 
Arizona, I do want to state for the record that the current 
distribution is inequitable. The system needs more money, but 
the new formula needs to get done and it needs a time line and 
we need a transition period.
    We have nine federally recognized tribes in Oregon. There 
is hardly a time I go home and meet with them that they don't 
mention the importance of our coming up with an agreement on 
this issue and pass this bill. It is essential to have a decent 
health care facility if you are going to provide decent health 
care, and many of them simply don't have that. They are due 
that.
    So I look forward to working with you, Mr. Chairman, Madam 
Vice Chair, to get this bill passed, get this new formula in 
place. It is long overdue.
    Thank you.
    [The prepared statement of Senator Smith follows:]

              Prepared Statement of Hon. Gordon H. Smith, 
                        U.S. Senator from Oregon




    The Chairman. Senator Smith, thank you very much.
    Senator Barrasso?
    Senator Barrasso. Thank you very much, Mr. Chairman.
    Dr. Grim, congratulations. It is so good to see your family 
here. Mrs. Grim, your son, you have a lot to be proud of. He 
does a remarkable job.
    I am proud of the accomplishments you have had in the last 
4 years. I know what you have done in terms of domestic 
violence; your efforts in vaccination, both for the very young 
and the elderly in terms of the flu; some of the screenings you 
have done for substance abuse.
    In my previous life, I worked quite a bit with patients 
injured, and the concern I had with those that Senator Tester 
talked about earlier--the suicide, the unintended injuries, 
substance abuse, domestic abuse.
    I am concerned also about some of the additional preventive 
things like the diabetic work. I know between the late 1990's 
and 2003, we have been the incidence of diabetes almost 
doubling in this population of folks. But I am seeing it also 
in younger people. I am seeing the teenagers. We used to think 
of as malnutrition back when we were in school is people 
starving, but now malnutrition seems to be on the other side, 
the obesity issue which is contributing to this.
    So first, if I could ask you if you are really focused also 
on the younger folks, and not just for the diabetes. Then the 
second question will have to do with substance abuse, because 
sometimes I am taking care of very young folks who are injured, 
and you talk about when their substance use began, and abuse, 
and it is at a young, young age.
    Dr. Grim. First, let me say that we are concerned about the 
same thing greatly. Our statistics have shown some of the 
greatest increases in those younger populations. One of the 
things I would say about the moneys that Congress made 
available for us in the Special Diabetes Program for Indians, a 
huge amount of those dollars are going toward primary 
prevention, secondary prevention, a focus on childhood obesity. 
We are seeing that, too, as one of the largest problems.
    And so, yes, we are strongly working on that. A lot of the 
work that is being done in those programs is primarily with the 
youth. We are taking care of our existing patients that have 
diabetes. We are watching those closely that have pre-diabetes, 
and working with them both with nutrition and physical activity 
sorts of therapy.
    But a lot of the programs and the dollars are going on 
education to youth, on physical activity programs for those. 
And we have partnered, as I said earlier, with both the Boys 
and Girls Clubs of America to introduce programs into their 
clubs that are dealing with basically educational things for 
the youth about the decisions they make today and how it will 
affect their heath in the future.
    We are partnering with several other agencies on that, too, 
with Boys and Girls Clubs. Nike has joined us in a drive to 
increase physical activity levels in Indian communities. So 
there is a lot going on in primary prevention and a lot of it 
is directed at youth.
    Senator Barrasso. Thank you, Mr. Chairman. Because along 
those lines, Dr. Grim, I see the folks in Wyoming who live in 
the general neighborhood of our Wind River Reservation, and 
know that the average lifespan of a man is in his late 70's, 
and a woman in the early 80's. Yet on the reservation itself, 
it is 49\1/2\. I just think that we still have a much bigger 
job to do and a significant responsibility to those citizens.
    So anything you can do that will help we certainly would be 
grateful for. I certainly plan to look forward to supporting 
your nomination and voting in favor of you.
    Dr. Grim. Thank you, Senator.
    The Chairman. Dr. Grim, the first thing I read this morning 
when I began looking at material after I woke up was from 
National Public Radio report last evening. The title was ``Rape 
Cases on Indian Lands Go Uninvestigated.'' Most of this is 
about law enforcement. The circumstances are almost 
unbelievable, almost as unbelievable as the inability to get 
medical care for some.
    I raise it for one reason. This is a young woman who was 
brutally raped, Leslie Ironroad. Nobody investigated the rape. 
She died about 10 days later. Nobody investigated it, not the 
BIA, not the FBI, nor anybody else. The Justice Department has 
said that one in three Native American women will be raped in 
her lifetime. My colleague from Alaska raised this issue of 
violence against women.
    One of the things that I saw in this report, on this 
reservation, the Standing Rock Reservation, the reservation has 
one women's shelter. The health center and the shelter try to 
reach out and help these women. The health center doesn't have 
rape kits to collect the DNA evidence necessary to prosecute 
attackers. They are inadequately staffed, can't even spare an 
exam room for the hour it takes to complete the rape 
examination.
    Staff physician Jackie Quizno in Bismarck said she sees 
rape cases several times a month. They turn over the 
information on the women to the BIA police and Federal 
prosecutors and nothing happens. That is law enforcement, but 
it is also health in some respects.
    It just broke my heart again this morning to read this. We 
have been through this with respect to teen suicide issues and 
violence against women. We are going to hold a hearing on these 
issues, the violence against women issues.
    I do hope we can begin to make some progress. Let me just 
say what a couple of my colleagues have said to you. You serve 
at the pleasure of the President, but you serve the needs of 
American Indians. I hope that you will, if necessary, when 
necessary, take a risk here and there, and speak out and speak 
aggressively about how far short we are of meeting the needs. 
Because this Administration and previous Administrations have 
really not done what we should do.
    I asked you the question not to embarrass you today about 
the Office of Management and Budget, but you have been pretty 
direct with us when testifying here. You have indicated that 
you believe there is a trust responsibility. You have cited the 
laws for the responsibility. When I learned that OMB had asked 
that it be taken out of today's testimony, I asked why. I know 
you are not able to answer that, but it bothers me because we 
have to do better.
    Senator Murkowski and I and Senator Barrasso, we don't want 
to sit at these hearings every year and just say, you know, we 
regret what is happening out there. We have to fix what is 
happening out there, and you have to help us, and this 
President has to help us, and the Congress, Republicans and 
Democrats, have to come together to say that we have to do 
better.
    So again, I am pleased to support your renomination. I 
think you are an awfully good person and you are very well 
qualified. My dealings with you have been extensive and you 
have always been up front and direct. I appreciate that, Dr. 
Grim.
    As our colleague from Oklahoma said, public service is a 
wonderful opportunity, but in many cases a very significant 
responsibility and burden as well. Your family is elsewhere. 
You are here. I thank you for your commitment to public 
service. Work with us and help us, and let's hope in the future 
when we have a hearing, you and I and this Committee can say, 
you know something, we raised a little hell here and we got a 
lot done, because we demanded that it get done.
    Dr. Grim, we will move your nomination through this 
Committee. I think I speak on behalf of virtually every member 
of this Committee: thank you for your public service.
    This hearing is adjourned.
    Dr. Grim. Thank you, Senator.
    [Whereupon, at 10:50 a.m., the Committee was adjourned.]

                            A P P E N D I X




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            Written Questions Submitted to Charles W. Grim *
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    * Responses to written questions were not available at the time 
this hearing went to press.




                                  
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