[Senate Hearing 110-191]
[From the U.S. Government Publishing Office]
S. Hrg. 110-191
INDIAN HEALTH
=======================================================================
FIELD HEARING
before the
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
AUGUST 15, 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
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Page
Hearing held on August 15, 2007.................................. 1
Statement of Senator Dorgan...................................... 1
Statement of Senator Tester...................................... 3
Witnesses
Clark, H. Westley, M.D., J.D., M.P.H., Director, Center for
Substance Abuse Treatment, Substance Abuse and Mental Health
Service Administration, U.S. Department of Health and Human
Services....................................................... 14
Prepared statement........................................... 17
Eaglefeathers, Melbert ``Moke'', President, National Council of
Urban Indian Health; Director, North American Indian Alliance;
accompanied by Marjorie Bear Don't Walk, Executive Director,
Indian Health Board, Billings, MT.............................. 65
Prepared statement........................................... 67
Joseph, Jr., Andy, Chair, Health and Human Service Committee,
Colville Confederated Tribes................................... 109
Killsback, Jace, Billings Area Representative, National Indian
Health Board, Council Member, Northern Cheyenne Tribe;
accompanied by Stacy Bohlen, Executive Director, National
Indian Health Board and Dr. Joseph Erpelding, Orthopedic
Surgeon, Billings, Montana..................................... 31
Prepared statement........................................... 34
King, Tracy ``Ching'', Council Member, Fort Belknap Indian
Community, Assiniboine Tribe................................... 95
Lankford, Carole, Vice-Chair, Salish Kootenai Tribes; accompanied
by Kevin Howlett, Health Director, Salish Kootenai Tribes...... 94
Little Coyote, Eugene, President Northern Cheyenne Tribe......... 96
Prepared statement........................................... 97
Little Plume, Edwin, Chairman, Health Committee, Blackfeet Tribal
Business Council............................................... 101
Prepared statement........................................... 102
McDonald, Dr. Joseph F., President, Salish Kootenai College...... 49
Prepared statement........................................... 51
North, Charles Q., M.D., M.S., Acting Chief Medical Officer,
Indian Health Service; accompanied by Pete Conway, Director,
Billings Area Office, Indian Health Service.................... 5
Prepared statement........................................... 8
Real Bird, Ken, Representative, Crow Tribe....................... 110
Red Eagle, Darryl, Tribal Executive Board Member, Fort Peck
Assiniboine Sioux Tribe........................................ 82
Prepared statement with attachments.......................... 83
Stewart, Leo, Vice-Chairman, Confederated Tribes of Umatilla
Indian Reservation............................................. 100
Venne, Carl, Chairman, Crow Tribe................................ 111
Walk Above, Ms., Member, Crow Tribe.............................. 109
White, Ada M., Health Service Director, Crow Tribe............... 53
Prepared statement........................................... 57
Wheeler, Julia Davis, Tribal Council Member, Nez Perce Tribe..... 95
Windy Boy, Hon. Jonathan, Council Member, Chippewa Cree Tribe
Business Committee; Montana Representative, House District 32.. 60
Prepared statement........................................... 62
Appendix
Adams, Barry, Browning MT, prepared statement.................... 163
Belcourt, Gordon, Executive Director, Montana-Wyoming Tribal
Leaders Council, prepared statement with attachment............ 129
Brown, Dick, President, MHA--an Association of Montana Health
Care Providers, prepared statement............................. 116
Confederated Salish and Kootenai Tribes of the Flathead Nation,
prepared statement............................................. 113
Clairmont, Gwen, Member of the Confederated Salish and Kootenai
Tribes, prepared statement..................................... 124
Fort Belknap Indian Community Council, prepared statement........ 155
Gavin, Shawna M., Chair, CTUIR Health Commission, letter, dated
August 14, 2007, to Hon. Byron L. Dorgan....................... 172
Johnson, Laurene, Member of the Confederated Salish and Kootenai
Tribes, prepared statement..................................... 118
Juneau, Carol, State Senator, Senate District 8, Montana,
prepared statement............................................. 160
Myers, David B., M.D., Billings MT, prepared statement........... 159
Nez Perce Tribe, prepared statement.............................. 168
Norgaard, Margaret, CEO, Northeast Montana Health Services
(NEMHS), prepared statement.................................... 122
Sinclair, John, President, Little Shell Tribe of Chippewa Indians
of Montana, prepared statement with attachments................ 126
Stone, Lou, Member of the Sngaytskstx Tribe, prepared statement.. 119
Ward, Alex, Associate State Director, AARP Montana, prepared
statement...................................................... 166
INDIAN HEALTH
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WEDNESDAY, AUGUST 15, 2007
U.S. Senate,
Committee on Indian Affairs,
Crow Agency, MT
Pursuant to notice, the Senate Committee on Indian Affairs
Field Hearing was held on August 15, 2007, at the Crow Tribal
Multi-Purpose Building, 4 Cap Hill Road, Crow Agency, Montana.
[Opening prayer offered by Mr. Earl Old Person.]
[Crow Tribe Color Guard and Drum Presentation.]
OPENING STATEMENT OF HON. BYRON L. DORGAN,
U.S. SENATOR FROM NORTH DAKOTA
Senator Dorgan. Ladies and gentlemen, we will call to order
this U.S. Senate Committee Hearing. It's the Committee on
Indian Affairs in the U.S. Senate.
I'm Senator Byron Dorgan, the Chairman of the Committee. I
am joined by Senator Jon Tester, a member of our Committee from
the State of Montana.
We are joined by Sara Garland, who is the Chief of Staff on
the majority side of the Committee, and David Mullon, who is
the Chief of Staff on the minority side of the Indian Affairs
Committee.
I want to thank, first of all, all of you for being in
attendance. I know from just having visited with a number of
you, we have Indian leaders and members of tribal governments
and folks from all around this region, and I very much
appreciate your taking the time to be with us today.
I want to especially say to Chairman Venne, with whom I've
had a chance to have a lengthy conversation today about these
issues, thanks to your leadership, thank you for hosting us.
I'm deeply honored to be here with the Crow Nation.
To Earl Old Person, thank you very much for the blessing
today. Earl and I were able to ride on a subway car underneath
the United States Capitol about three, 4 weeks ago, and I asked
him how long he has been in tribal leadership, and I think Earl
told me that he's been the Tribal Chair since 1964. And if you
want a definition of commitment and leadership, look at a
commitment from 1964 to today. God bless you.
Thank you very much for being here, Earl.
I want to especially say, because I am in the State of
Montana, how appreciative I am of being able to serve with
Senator Max Baucus, with whom I've served for some long while.
Max does a great job for Montana and for our country, and pays
a lot of attention to and works hard on Indian issues.
I want to also say that we have been joined in the U.S.
Senate by someone new, someone who I think brings a real breath
of fresh air to the U.S. Senate and to the Senate Indian
Affairs Committee, and that is Senator Jon Tester.
We are, as you know, pushing very, very hard to get the
Indian Health Care Improvement Act done and to the President
for signature. No one has been more important to that push and
to our success in getting it out of the Indian Affairs
Committee, our success in getting a commitment--Senator Baucus
is going to mark it up on September 12th in the Finance
Committee--our success in getting the majority leader, Senator
Harry Reid, to say that he will give us opportunities on the
floor of the Senate to get this passed.
No one has been more instrumental in that than Senator Jon
Tester. He is a tireless worker on behalf of American Indians;
a tireless worker in search of good, thoughtful, sensible
policies that address health care, housing, education and all
the things that we know need addressing on Indian reservations
in this country.
So, I can't thank you enough for sending a real partner to
Washington, D.C. to work on these issues.
Now, I'm here because I was invited. I've taken over the
reins of the chairmanship of the Committee of the Senate, the
Committee on Indian Affairs. I've held some listening sessions
around the country. We've held some hearings.
I've decided this; I'm just a little tired of waiting for
good things to happen. We have to make good things happen. We
shouldn't have patience. When we have people dying because we
don't have adequate health care on the reservations of the
first Americans, the people who were here first, we ought not
have patience to let that happen.
When we have people living in inadequate housing, I'm out
of patience. We shouldn't say that's okay. When we have
children going to school through classroom doors that we know
are not real class settings, we shouldn't accept that. And so,
I'm just out of patience. I'm a little out of sorts.
I believe that we ought to impose on everyone in the
decision-making capacity in our government to say, keep your
promise. You made the promises, you've broken too many. It's
time that you ought to keep them. And that deals with health
care, education, housing and more. And this Committee is going
to work to see that happen.
I was given the honor of an Indian name in a ceremony with
the Standing Rock Sioux Tribe some long while ago, and the
Indian name given me was Cante un Wiyukcan, which they said
means ``thinks with his heart.''
Well, my heart tells me that we don't have a lot of time.
My heart tells me that there are people living among us who
need us, and need answers. They need good schools; they need
better health care, and they need decent shelter. And that's
the mission of this Committee.
So, I want to thank Senator Tester for inviting me here to
Montana.
Let me just say one additional point. I wish very much I
could stay for about three or 4 days. Chairman Venne gave us a
little ride around the area where there's a lot of camping
going on, a lot of preparation for a very big event in the Crow
Nation. I've not been to this event at the Crow Nation, but
I've heard a lot about it.
I sat next to a person on the airplane coming into Billings
today, who was coming here from Iowa. He said well, I come to
this celebration every year on the Crow Nation.
So I've heard about it and I wish I could stay, but I
can't. But I know that you all are going to have a great, great
few days ahead of you.
So, Senator Tester, we will hear testimony from a wide-
range of witnesses today, but before we do, again, I want to
thank you, thank you for your leadership, thank you for
focusing a laser on these issues.
You and I and other members of the panel of the Indian
Affairs Committee are going to get things done, and we're going
to push until that happens.
So, Senator Tester, let me call on you for some comments,
and again, thank you, very much.
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. Thank you, Mr. Chairman, for taking the
time out of your busy schedule to come to Montana and visit
with us. To the people of the State of Montana here in Indian
Country, it's critically important. It's no small measure, I
know how busy you are, and I appreciate you making the time to
be here.
I also want to welcome all my friends that are here that
have come to listen and testify.
You know, I think Montanans really appreciate, Mr.
Chairman, you holding this hearing in Montana to address what
we all know is a very critical issue.
Health care in Montana's Indian Country is in serious
trouble. American Indian citizens are suffering, and we really
need to address the problem now.
I am truly outraged by the statements, and I heard it again
today by Chairman Venne, and that is you don't get sick in
June, after June in Indian Country. That is absolutely
unacceptable, and I'm sorry you have to wait until your illness
gets to a point where you may lose a limb or your life.
Those are examples of health care in Third World countries.
We don't live in a Third World country. American Indians are
Americans, American citizens who are entitled to deserve
respect in this country. Our Federal Government signed binding
legal treaties many years ago and those treaties are still in
effect today. Those treaties promised that in exchange for
millions of acres of land and vast amounts of natural
resources, our government would use some of those dollars that
emerged from those lands to provide American Indians with
adequate health care, education and housing, economic
development to distinct quality of lives.
Everybody in this room knows over the past several hundred
years the government has failed to tell the truth to the
American Indian, cheated the Indians, and failed to fulfill
promises made many, many years ago.
The government got what it wanted out of the deal, but so
far, Mr. Chairman, the government has failed to hold up its end
of the deal. The result is that several generations later, our
government still has legal obligations to live up to its end of
the bargain.
Since then, the price of health care has literally gone
through the roof and will continue to go up. We need to address
the situation now. We need to fund the system. This cannot wait
to be funded any longer. We need to change the national
priorities and introduce legislation to fix this broken system.
All of us in the room know that merely to explain about the
problem is not enough, we need to act and we need to act now.
For my part, I'm seeking for some of the following actions;
cosponsoring the Indian Health Care Improvement Act that
Senator Dorgan talked about, that hopefully will be out of
Finance by September 12. The last time it was passed was 1999.
That's totally, totally ridiculous, and unacceptable.
Also, I have introduced THE PATH Act that is a result of
some hearings that I had in Browning 3 months ago. This
important legislation will award grants and draft cooperative
agreements with the Department of Health and Human Services and
the tribal colleges and universities, to help Indian Country
meet their staffing needs in health care.
It will establish a coordinating officer to assure seamless
transition and administration; establish community-based health
and wellness affairs, and begin to address illness and injury
before it gets to a life or limb situation.
It will develop and expand public health professional
educational opportunities, establish an endowment for rural
tribal colleges to expand health education, and create health
prevention and disease prevention research, particularly in the
areas of diabetes.
Tribal colleges and universities Faculty Loan Forgiveness
Act, it does what it says, it will help forgive loans to
individuals that want to teach in tribal colleges, to recruit
and train more qualified professors at those tribal colleges or
universities, particularly in the field of nursing or health-
related fields.
Our goal, Mr. Chairman, should be to give equal access to
health care for all Montanans. Make no mistake, Mr. Chairman,
I'm not here today working to provide Indians with superior
quality health and quality of life, I'm simply working to
fulfill the promises our grandfathers made over a hundred years
ago.
Today, we focus on three vital issues in American Indian
health care, immediate health care needs, recruiting and
retaining of health care professionals, and improving the
reimbursement process.
In the end, Mr. Chairman, it is truly my goal on this
committee, to re-prioritize issues affecting Indian Country. If
the President can justify spending $3 billion a week to first
destroy and then rebuild Iraq, the government certainly has the
money to fund an Indian health care system.
This issue is not about money, Mr. Chairman, it is about
priorities, and American Indians deserve to be a higher
priority in this country. For that reason, I want to thank you
very, very much for coming to Montana and making Indian health
care a national priority.
I look forward to working with you, Mr. Chairman, in this
session of Congress, to continue to shift our priorities to
improving Indian health care.
With that, I just want to thank you very, very much for the
opportunity that you've given all the good people here to talk
about an issue that's so critically important.
Mr. Chairman.
Senator Dorgan. Senator Tester, thank you very much.
This is a formal hearing of the U.S. Senate, but I want to
do something just a little bit unusual. As I saw the flags
brought in, I saw some very beautiful people behind the flag-
bearers and one of them caught my eye. And if I could ask to
have that young lady brought forward, I want to tell you
something.
[Kailyn Old Crow brought forward.]
What I wanted to tell you is as I watched her come in
following the flags, it occurred to me that we're talking about
all these issues today, but what we're talking about is not
about us, it's not about me, it's not about you, it's about
Kailyn. That's what this is about. It's about our children.
It's about our future, and I can't think of a more beautiful
symbol of our future than this young lady. God bless you.
Thank you very much.
Dr. Charles North is the Acting Chief Medical Officer of
the Indian Health Service, and Dr. Westley Clark, the Director
of the Center for Substance Abuse Treatment. I'd like both of
them to come forward and take their chairs at the witness
table, please.
Dr. Charles North, the Acting Chief Medical Officer of the
Indian Health Service is accompanied by Mr. Pete Conway, the
Director of the Billings Area Office of the Indian Health
Service, and Dr. Westley Clark, Director of the Center for
Substance Abuse Treatment, Substance Abuse and Mental Health
Services Administration.
We appreciate both of you taking time to be with us today
at our invitation, and we will obviously include your entire
statement as a part of the permanent Committee records.
We would ask that both of you summarize, following which we
would like to ask a series of questions. As you testify, I'd
like to ask that you pull the microphone as close as possible
so that everyone in the audience can hear clearly the testimony
you are giving.
Dr. Charles North, you may proceed.
STATEMENT OF CHARLES Q. NORTH, M.D., M.S., ACTING CHIEF MEDICAL
OFFICER, INDIAN HEALTH SERVICE;
ACCOMPANIED BY PETE CONWAY, DIRECTOR, BILLINGS AREA OFFICE,
INDIAN HEALTH SERVICE
Dr. North. Good morning, I am Dr. Charles Q. North, Acting
Chief Medical Officer of the Indian Health Service.
I am glad to be here this afternoon, and I would like to
thank Chairman Venne also for having us at Crow Agency.
Today I am accompanied by Mr. Pete Conway, the Area
Director for the Billings Area of the Indian Health Service,
and we're both pleased to have the opportunity to testify on
behalf of the Indian Health Service Director, Dr. Charles Grim,
on the status of the Indian Health Service and the health of
Indian people.
The Indian Health Service has the responsibility for the
delivery of health services to more than 1.9 million federally-
recognized American Indians and Alaska Natives through a system
of Indian Health Service, tribal and urban operated facilities
and programs governed by statutes and judicial decision.
The mission of the agency is to raise the physical, mental,
social, and spiritual health of American Indians and Alaska
Natives to the highest level, in partnership with the
populations that we serve.
The agency's goal is to insure that comprehensive,
culturally acceptable personal and public health services are
available and accessible to the service population.
We are here today to discuss Indian health and the IHS
focus on improving the health of Indian people, and eliminating
health disparities through health promotion and disease
prevention, behavioral health and chronic disease management.
We will also address issues related to Indian health
manpower, access to health care, consultation and contract
health care.
I would like to also note that the Health and Human
Services Department summer of 2007 Indian Country bus tour to
promote prevention and healthier living is here today and will
follow the hearing.
As part of the ``Healthier US Starts Here'' initiative, the
U.S. Department of Health and Human Services is joining local
officials and health care partners to raise awareness of the
importance of preventing chronic disease and illness, promoting
Medicare preventive benefits, and providing information about
how individuals can take action to maintain and improve their
health.
This effort supports the Indian Health Service goal to
create healthier American Indian and Alaska Native communities
by developing and implementing effective health promotion and
chronic disease prevention programs.
We want to recognize the Crow Tribe for the outstanding
work it does to promote healthy living in its community.
Chairman Venne has been a great friend to the Department by
hosting our former Deputy Secretary and our Assistant Secretary
for Health, and we are here to thank his staff for all their
efforts to make Indian Country healthier.
While the mortality rates of Indian people have improved
dramatically over the past 10 years, Indian people continue to
experience health disparities and death rates that are
significantly higher than the rest of the U.S. general
population.
Alcoholism rates are 550 percent higher; diabetes rates are
almost 200 percent higher; unintentional injury rates, 154
percent higher; suicide is 57 percent higher, and homicide is
108 percent higher than the general population.
Making significant reductions in health disparity rates can
be achieved by implementing the best practices in medicine,
using traditional community values, and building the local
capacity to address these health issues and promote healthy
choices. Since 1997, the Special Diabetes Program for Indians
funding of $150 million has expanded our diabetes prevention
and treatment efforts. These funds support over 300 IHS tribal
and urban community-based diabetes prevention and treatment
projects, along with a demonstration project focused on primary
prevention of type 2 diabetes in 35 separate American Indian
and Alaska Native communities.
The competitive grant initiatives focus on American Indian
and Alaska Native adults with pre-diabetes to determine if an
intensive life-style intervention can be successfully
implemented in our communities.
One of the models we are using was developed by the
National Institutes of Health that proved that diabetes could
be prevented. This program will cover a four-year period. The
outcomes of the demonstration project will enable us to learn
what may be applicable to other communities throughout Indian
Country.
Indian health manpower is a critical issue, it's a critical
issue here in Crow. IHS tribal and urban Indian health programs
cannot function without adequate health care providers.
Indian Health Manpower programs, which is also authorized
in the Indian Health Care Improvement Act that you mentioned
earlier, consists of the Indian Health Service Scholarship
Program, the IHS Loan Repayment Program; and the IHS Health
Professional Recruitment Program.
The IHS Scholarship Program plays a major role in the
production of health care and professionals of American Indian
and Alaska Native descent. Since its inception in 1977, more
than 7,000 American Indian and Alaska Native students have
participated in the program.
The IHS Scholarship Program has been the starting point for
the careers of a number of health professionals now working in
the Federal, tribal and urban Indian health programs.
Many are also involved in academia continuing to help
identify promising young American Indian and Alaska Native
students and recruiting them to the health professions.
The IHS Loan Repayment Program is very effective in both
the recruitment and retention areas. There are currently 723
health professionals in the Loan Repayment Program.
Access to health care can be promoted by the Environmental
Health and Engineering Program of the Indian Health Service,
which is a comprehensive public health program administered by
Indian Health and tribes.
Indian self-determination and self-governance and
consultation are extremely important to this administration.
The IHS has been contracting with tribes and tribal
organizations under the Indian Self-Determination and Education
Assistance Act, Public Law 93-638, as amended, since its
enactment in 1975.
Indian Tribes now administer 54 percent of our budget with
IHS funds transferred through self-determination contracts and
compacts. IHS adheres strongly to its long-standing tribal
consultation policy.
The Indian Health Service purchases medical and dental
services from providers in the private sector though its
Contract Health Services program, which is a component of the
Indian health care system.
In Fiscal Year 2007, the CHS program is funded at $543
million. Patients are referred to the private sector health
facilities, programs and practitioners for treatment when
needed services are unavailable as direct care through the
Indian health care system.
The CHS program makes payment for speciality services and
inpatient care to private sector facilities and providers in
accordance with established eligibility and medical priority
guidelines.
Mr. Chairman, this concludes my oral statement. Thank you
for the opportunity to report on Indian Health Service programs
serving American Indians and Alaska Natives and their impact on
the health status of our populations.
We will be happy to answer any questions that you may have.
[The prepared statement of Dr. North follows:]
Prepared Statement of Charles Q. North, M.D., M.S., Acting Chief
Medical Officer, Indian Health Service
Mr. Chairman and Members of the Committee:
Good morning, I am Dr. Charles Q. North, Acting Chief Medical
Officer for Indian Health Service (IHS). Today I am accompanied by Mr.
Pete Conway, Area Director, Billings Area IHS. We are pleased to have
this opportunity to testify on behalf of Dr. Charles W. Grim, Director,
IHS on the status of Indian Health.
The IHS has the responsibility for the delivery of health services
to more than 1.9 million Federally-recognized American Indians and
Alaska Natives (AI/ANs) through a system of IHS, tribal, and urban (I/
T/U) operated facilities and programs governed by statutes and judicial
decisions. The mission of the agency is to raise the physical, mental,
social, and spiritual health of AI/ANs to the highest level, in
partnership with the population we serve. The agency goal is to assure
that comprehensive, culturally acceptable personal and public health
services are available and accessible to the service population. Our
duty is to uphold the Federal Government's responsibility to promote
healthy American Indian and Alaska Native people, communities, and
cultures and to honor and protect the inherent sovereign rights of
Tribes.
Two major statutes are at the core of the Federal Government's
responsibility for meeting the health needs of American Indians/Alaska
Natives (AI/ANs): The Snyder Act of 1921, P.L. 67-85, and the Indian
Health Care Improvement Act (IHCIA), P.L. 94-437, as amended. The
Snyder Act authorized regular appropriations for ``the relief of
distress and conservation of health'' of American Indians/Alaska
Natives. The IHCIA was enacted ``to implement the Federal
responsibility for the care and education of the Indian people by
improving the services and facilities of Federal Indian health programs
and encouraging maximum participation of Indians in such programs.''
Like the Snyder Act, the IHCIA provides the authority for the provision
of Federal programs, services and activities to address the health
needs of AI/ANs. The IHCIA also includes authorities for the
recruitment and retention of health professionals serving Indian
communities, health services for urban Indian people and the
construction, replacement, and repair of health care facilities.
We are here today to discuss Indian health and the IHS focus on
improving the health of Indian people and eliminating health
disparities through health promotion and disease prevention, behavioral
health and chronic disease management. We will also address issues
related to Indian health manpower, access to health care, consultation,
contract health services and claims processing, eligibility, medical
priorities and the Catastrophic Health Emergency Fund (CHEF).
HHS Summer 2007 Indian Country Bus Tour to Promote Prevention and
Healthier Living
This summer, as part of the ``A Healthier US Starts Here''
initiative, the U.S. Department of Health and Human Services (HHS) is
joining local officials and health care partners to raise awareness of
the importance of preventing chronic disease and illness, promote
Medicare preventive benefits, and provide information about how
individuals can take action to maintain and improve their health.
By the end of August, the bus tour will have visited each of the 48
continental states to promote preventive services. While the bus tour
is promoting healthier living with the country as a whole, the Indian
Health Service has participated to promote and recognize the health
promotion/disease prevention activities that Indian Country practices
on a daily basis to promote healthier living.
This effort supports the Indian Health Service's goal to create
healthier American Indian and Alaska Native communities by developing
and implementing effective health promotion and chronic disease
prevention programs. This is accomplished in collaboration with our key
stakeholders, the American Indian and Alaska Native people, and by
building on individual, family, and community strengths and assets.
On April 18, 2007, HHS hosted a kickoff event with Tribal Leaders
and National Tribal Organizations in Washington, D.C. at the
Smithsonian's National Museum of the American Indian. Since this event,
HHS has visited over 20 Tribal Communities and we have over 6 tribal
stops remaining and with one occurring right after this hearing here at
the Crow Tribe.
We are here this afternoon with our prevention tour to recognize
the Crow Tribe for the outstanding work it does to promote healthy
living in its community. Chairman Venne has been a great friend to the
Department by hosting our former Deputy Secretary and our Assistant
Secretary for Health and we are to thank his staff for all their
efforts to making Indian Country healthier. We will recognize his
tribal prevention programs; recognition of 50+ fitness challenge
participants; and his Meth activities coordinator.
Health Disparities
While the mortality rates of Indian people have improved
dramatically over the past ten years, Indian people continue to
experience health disparities and death rates (2001-2003) that are
significantly higher than the rest of the U.S. general population
(2002: National Vital Statistics Reports: Vol. 53 No. 5. National
Center for Health Statistics):
Alcoholism--551 percent higher
Diabetes--196 percent higher
Unintentional Injuries--154 percent higher
Suicide--57 percent higher
Homicide--108 percent higher
These statistics are startling, yet they are so often repeated that
some view them as insurmountable facts. But every one of them is
influenced by behavior choices and lifestyle. Making significant
reductions in health disparity rates can be achieved by implementing
best practices, using traditional community values, and building the
local capacity to address these health issues and promote healthy
choices.
Many issues that face the families nationally also affect families
in Indian Country, and these problems are often magnified in the
confines of Indian Country. If it is a problem nationally, it is
magnified when it comes to Indian Country. Indian families are besieged
by the numbing effects of poverty, lack of resources, and limited
economic opportunity. Frustration, anger, and violence are among the
prominent effects of this situation, and, while very understandable,
they are equally unacceptable.
Accordingly, the IHS is focusing on screening and primary
prevention in mental health especially for depression, which manifests
itself in suicide, domestic violence, and addictions. The agency is
also working to more effectively utilize available treatment
modalities; and, to improve documentation of mental health problems. We
now have more effective tools for documentation through the behavioral
health software package. We are also working with Tribal communities to
focus on these mental health needs.
Cardiovascular disease (CVD) is the leading cause of mortality
among Indian people. This is a health disparity rate that the
President, the Secretary of Health and Human Services, and the IHS are
committed to eliminating. The Strong Heart Study, a longitudinal study
of cardiovascular disease in 13 AI/AN communities, has clearly
demonstrated that the vast majority of heart disease in AI/AN occurs in
people with diabetes. In 2002, IHS was directed to address ``the most
compelling complications of diabetes,'' including the most critical
complication of heart disease. The IHS is working with other HHS
programs, including the Centers for Disease Control and Prevention and
the National Institutes of Health's National Heart Lung and Blood
Institute, to develop a Native American Cardiovascular Disease
Prevention Program. Also contributing to the effort are the IHS Disease
Prevention Task Force and the American Heart Association.
Our primary focus is on the development of more effective
prevention programs for AI/AN communities. The IHS has begun several
programs to encourage employees and our tribal and urban Indian health
program partners to lose weight and exercise, such as ``Walk the Talk''
and ``Take Charge Challenge'' programs. Programs like these are cost
effective in that prevention of both diabetes and heart disease, as
well as a myriad of other chronic diseases, are all addressed through
healthy eating and physical activity.
Good oral health is essential to improving individuals' overall
health and well being. The oral health of AI/AN people has improved in
some age groups, but has gotten worse in others. While poor dental
health is a significant problem for AI/ANs of all ages, the magnitude
and long-term effects of the problem are greatest among very young
children. The most recent oral health survey administered by the Indian
Health Service showed that the AI/AN people experience some of the
highest oral disease rates reported in the world. The 1999 IHS survey
of Oral Health Status and Treatment Needs indicate the following:
The majority of very young children experience tooth decay,
with 79 percent of children aged 2-4 years reporting with a
history of dental decay;
Since 1991, there has been a significant increase in tooth
decay among young AI/AN children between 2-5 years of age;
The majority of AI/AN children as a group have tooth decay
and the prevalence of decay increases with age: 87 percent of
the 6-14 year olds and 91 percent of the 15-19 year olds had a
history of decay;
Most adults and elders have lost teeth because of dental
disease or oral trauma. 78 percent of adults 35-44 years and 98
percent of elders 55 years or older had lost at least one tooth
because of dental decay, periodontal (gum) disease or oral
trauma; and,
Periodontal disease is a significant health problem for both
adults and elders. 59 percent of adults 35-44 years and 61
percent of elders have periodontal (gum) disease.
In addition, the vacancy rate for dentists is at the highest level
in our 52 year history, with 27.6 percent of authorized positions are
vacant. In addition to the high vacancy rate, there is great concern
over the oral health disparities experienced by the American Indian and
Alaska Native people.
We need to focus our efforts on these age groups that have shown
declines in oral health status. Tribes have increasingly identified
access to preventive and curative dental care as a major health
priority; and the IHS and tribes will continue to advocate for
additional resources for oral health.
The incidence and prevalence of diabetes has been increasing
dramatically since 1972. American Indians and Alaska Natives have the
highest prevalence of type 2 diabetes in the United States (source:
2003-2004 National Health Interview Survey and 2004 IHS Outpatient
database). The prevalence of type 2 diabetes is rising faster among
American Indian and Alaska Native children and young adults than in any
other ethnic population, increasing 106 percent in just one decade from
1990 to 2001 (source: IHS Division of Program Statistics). As diabetes
develops at younger ages, so do related complications such as
blindness, amputations, and end stage renal disease. Fortunately, the
diabetes mortality rate for the entire AI/AN population did not
increase between 1996-1998 and 1999-2001, so we are hopeful that we may
be seeing a change in the pattern of diabetes mortality. In fact, the
overall mortality rate for American Indians and Alaska Natives
decreased approximately 3 percent between these same time periods
(source: IHS Division of Diabetes Statistics and CDC Center for Health
Statistics). And there is good news in that we have recently measured a
slight, but statistically significant, decline in kidney failure in the
AI/AN diabetic population as well.
What is most distressing however about these statistics is that
type 2 diabetes is largely preventable. Lifestyle changes, such as
changes in diet, exercise patterns, and weight can significantly reduce
the chances of developing type 2 diabetes. Focusing on prevention not
only reduces the disease burden for a suffering population, but also
lessens and sometimes eliminates the need for costly treatment options.
The cost-effectiveness of a preventive approach to diabetes management
is an important consideration, since the cost of caring for diabetes
patients is staggering. The cost of managing care for treating diabetes
ranges from $5,000-$9,000 per year with the annual cost per patient
exceeding $13,000 (source: American Diabetes Association).
In 1997, the Special Diabetes Program for Indians (SDPI) grant
program was enacted and provided $30 million per year for a five year
period to IHS for prevention and treatment services to address the
growing problem of diabetes in AI/ANs. In 2001, Congress appropriated
an additional $70 million for Fiscal Years 2001 and 2002. The program
was funded at $100 million in Fiscal Year 2003. Then in 2002 Congress
extended the SDPI through 2008, and increased the annual funding to
$150 million for FY 2004-2008 with the directive to address ``primary
prevention of type 2 diabetes and the most compelling complication of
diabetes--cardiovascular disease.'' We are proud to announce that in FY
2004 our Division of Diabetes Treatment and Prevention launched a
competitive grant to implement two demonstration projects. One is
focused on primary prevention of type 2 diabetes in people diagnosed
with pre-diabetes to determine if an intensive life-style intervention
can be successfully implemented in AI/AN communities. This effort is
based on the NIH sponsored study called the Diabetes Prevention Program
which provided evidence that type 2 diabetes could be prevention with
lifestyle intervention. The other demonstration project is focused on
cardiovascular risk reduction in people diagnosed with type 2 diabetes.
Thirty-six AI/AN communities were awarded diabetes prevention
demonstration projects and 30 AI/AN communities were awarded
cardiovascular risk reduction demonstration projects in November 2004.
These demonstration projects will cover a four year period. The
outcomes of the demonstration projects will enable us to learn what may
be applicable to other communities throughout Indian country. The last
year of the demonstration projects will be aimed at dissemination of
lessons learned to other tribal communities across the nation.
With 65 percent of the IHS Mental Health budget and 85 percent of
the alcohol and substance abuse budget going directly to tribally
operated programs, tribes and communities are now taking responsibility
for their own healing. They provide effective treatment and prevention
services within their own communities.
A primary area of focus is Dr. Grim's renewed emphasis on health
promotion and disease prevention. This is our strongest front in the
ongoing battle to eliminate health disparities which have plagued our
people for far too long.
Fortunately, the incidence and prevalence of many infectious
diseases, once the leading cause of death and disability among American
Indians and Alaska Natives, have dramatically decreased due to
increased medical care and public health efforts including massive
vaccination and sanitation facilities construction programs. As the
population lives longer and adopts a more a western diet and sedentary
lifestyle, chronic diseases emerge as the dominant factors in the
health and longevity of the Indian population as evidenced by the
increasing rates of cardiovascular disease, diabetes, and oral health
problems. Most chronic diseases are affected by lifestyle choices and
behaviors.
In summary, preventing disease and injury, promoting healthy
behaviors, and managing chronic diseases are a worthwhile financial and
resource investment that will result in long-term savings by reducing
the need for acute care and expensive treatment processes. It also
yields the even more important humanitarian benefit of reducing pain
and suffering, and prolonging life. This is the path we must follow if
we are to reduce and eliminate the disparities in health that so
clearly affect AI/AN people.
Indian Health Manpower
IHS, Tribal and Urban Indian health programs could not function
without adequate health care providers. The Indian Health Manpower
program which is also authorized in the Indian Health Care Improvement
Act (P.L. 94-437, as amended) consists of several components:
The IHS Scholarship Program;
The IHS Loan Repayment Program; and
The IHS Health Professional Recruitment Program
The IHS Scholarship Program plays a major role in the production of
AI/AN health care professionals. Since its inception in 1977, more than
7,000 AI/AN students have participated in the program, with the result
that the number of AI/AN health professionals has been significantly
increased. The program is unique in that it assists students who are
interested in or preparing for entry into professional training. Most
scholarships only provide assistance to those who have been accepted
into a health professional training program.
The IHS Scholarship Program has been the starting point for the
careers of a number of AI/AN health professionals now working in IHS,
tribal, and urban Indian health programs. Many are also involved in
academia, continuing to help identify promising AI/AN students and
recruit them to the health professions, thereby helping to produce a
self-sustaining program. We have had several instances of parents going
through the program, followed later by their children and not a few of
the reverse, with children being followed by their parents. The average
age of our students is 28 years, well above the norm for college
students. It is not uncommon for students to have attended 5 or more
colleges or universities during the course of their academic careers,
not because they failed in the first four, but because they had to move
in order to have the employment they needed to support their families.
The IHS Loan Repayment Program (LRP) is very effective in both the
recruitment and retention areas. There are currently 723 health
professionals in the LRP. The scholarship and loan repayment programs
complement one another. Scholarships help individuals rise above their
economic background to become contributing members of the community and
participate in improving the well-being of the community; while loan
repayments are a way for participants to provide service in return for
assistance in repaying loans that could otherwise be overwhelming.
The recruitment program seeks to maximize the effectiveness of both
programs, as well as to make the IHS more widely known within the
health professional community and to assist interested professionals
with job placement that best fits their professional and personal
interests and needs.
Access to Health Care: The Environmental Health and Engineering Program
The Environmental Health and Engineering program is a comprehensive
public health program administered by IHS and Tribes. Two examples are
the sanitation facilities construction program which provides safe
drinking water, wastewater disposal, and solid waste disposal system;
and the injury prevention program which focuses on unintentional
injuries. As a result of these two successful programs, 88 percent of
AI/AN homes now have safe water and mortality from unintentional
injuries has been reduced by 58 percent between 1972-1974 and 2001-
2003. Unfortunately, 12 percent of Indian homes still lack adequate
sanitation facilities compared to one percent of the rest of the United
States population; and the leading cause of death for AI/ANs between
the ages of 1 and 44 years of age is unintentional injuries.
Improvement in these areas is integral to our mission.
The Environmental Health and Engineering program, provides access
to health care services through the health care facilities program,
which funds federal and tribal construction, renovation, maintenance,
and improvement of health care facilities. There are 48 hospitals, 272
health centers, 11 school health centers, over 2,200 units of staff
housing, 320 health stations, satellite clinics, and Alaska village
clinics, and 11 youth regional treatment centers supporting the
delivery of health care to AI/AN people. The IHS is responsible for
managing and maintaining the largest inventory of real property in the
DHHS, with over 9.6 million square feet (899,000 gross square meters)
of space, and the Tribes own over 6 million square feet (571,000 gross
square meters). This is in part the result of Tribally funded
construction of millions of dollars worth of space to provide health
care services by the Indian Health Service funded programs.
Over the past decade, $600 million in funding has been invested in
the construction of health care facilities which include, 1 Medical
Center, 5 Hospitals, 9 Health Centers, 3 Youth Regional Treatment
Centers, 500 units of Staff Quarters, 27 Dental Units, and 21 Small
Ambulatory Program construction projects. Most of these facilities were
replacements of inadequate health care facilities. We have
substantially improved our health care delivery capability in the newer
health care facilities and continue to improve access to services
through health care facilities construction--health care facilities
construction remains a priority.
In response to a Congressional request to revise the Health Care
Facilities Construction Priority System, we have been working to better
identify the health care delivery needs. This will enable us to
prioritize the need for health care facilities infrastructure. We are
using a master planning process to address the complex nature of health
care delivery for AI/AN communities. Both the Federal Government and
Tribes will be able to use these plans to identify our greatest needs
for services and health care facilities, and to plan carefully on how
to best utilize any available resources. The IHS Health Care Facilities
Construction program is fully prepared to address the needs identified
through this process.
Indian Self Determination/Self-Governance
The IHS has been contracting with Tribes and Tribal Organizations
under the Indian Self Determination and Education Assistance Act, P.L.
93-638, as amended, since its enactment in 1975. We believe the IHS has
implemented the Act in a manner consistent with Congressional intent
when it passed this cornerstone authority that re affirms and upholds
the government to government relationship between Indian tribes and the
United States. The share of the IHS budget allocated to tribally
operated programs has grown steadily over the years to the point where
today over 54 percent of our budget is transferred through self
determination contracts/compacts.
Consultation
A primary goal of the Agency has always been to involve Indian
tribes and people in the activities of the IHS. Last year Dr. Grim
adopted a revised IHS Tribal Consultation Policy that will enhance the
partnership between the IHS and this country's 562 Federally recognized
Tribes for the foreseeable future. The policy is the 3rd consultation
policy adopted by the IHS since 1997. Its adoption fulfills a
commitment Dr. Grim made to Tribal Leaders that the Agency's
consultation policy and practices will continually be subject to review
and improvement.
The policy, which was developed by IHS and Tribal Leaders, contains
an improved definition of consultation and the circumstances under
which it needs to occur. The policy also commits the IHS to assisting
Tribal governments in establishing meaningful dialogue and consultation
with other HHS agencies and State governments. It revises the budget
formulation process within IHS to allow for more meaningful Tribal
participation and it contains requirements that IHS report to Tribes on
IHS consultation, its outcomes and effectiveness.
Overview of CHS program
The IHS purchases medical and dental services from providers in the
private sector through its Contract Health Service program, which is a
component of the Indian health care system. In Fiscal Year 2007 the CHS
program is funded at $543 million. Patients are referred to the private
sector health facilities, programs and practitioners for treatment when
needed services are unavailable as direct care through the Indian
health care system.
The CHS program is administered through 12 IHS Area Offices and
consists of 163 IHS and Tribal Service Units (SU). The CHS funds are
provided to the Area Offices which in turn provide resource
distribution, program monitoring and evaluation activities, and
technical support to Federal and Tribal operating units (local level)
and health care facilities providing care.
The CHS funds are used in situations where:
No IHS or Tribal direct care facility exists;
The direct care element cannot provide the required
emergency or specialty services; and/or,
The direct care facility has an overflow of medical care
workload.
The CHS program makes payment for specialty services and inpatient
care to private sector facilities and providers in accordance with
established eligibility and medical priority guidelines.
The CHS program contracts with Blue Cross/Blue Shield of New Mexico
as its fiscal intermediary (FI) to ensure payments are made in
accordance with the IHS payment policy and quality control
requirements. An important and integral function of the FI is to
provide highly effective management reports relative to the provision
of services to our patient population and provision of services by
health care providers from the private sector.
Eligibility
To be eligible for CHS, an individual must be of Indian descent and
belong to the Indian community served by the Tribal Contract Health
Service Delivery Area (CHSDA). Generally, the Tribal CHSDA encompasses
the Reservation, trust land, and the counties that border the
Reservation. The individual must also either: (1) reside on a
Reservation located within the CHSDA; or (2) if he/she resides within
the CHSDA but not on a Reservation, he/she must also be a member of the
Tribe(s) located on the Reservation or of the Tribe(s) for whom the
Reservation was established, or maintain close economic and social
contact with the Tribe(s). The following individuals remain eligible
for CHS during periods of temporary absence from their CHSDA residence:
Students who are temporarily absent from their CHSDA during
full-time attendance of vocational, technical, and other
academic education. The coverage ceases 180 days after
completing the course of study.
A person who is temporarily absent from his/her CHSDA due to
travel or employment.
Other persons who leave the CHSDA temporarily. Their
eligibility continues for a period not to exceed 180 days from
their departure.
Children placed in foster care outside of the CHSDA by court
order and who were eligible for CHS at the time of the court
order.
Payor of Last Resort Rule
The IHS is the payor of last resort and therefore the CHS program
must ensure that all alternate resources that are available and
accessible, such as Medicare Parts A and B, state Medicaid, state
health program, private insurance, etc. are used before the CHS funds
can be expended. An IHS or Tribal facility is also considered a
resource, and therefore, the CHS funds may not be expended for services
reasonably accessible and available at IHS or Tribal facilities. In
FY06, IHS received $681 million in Medicaid, Medicare and Private
Insurance collections And, the agency continues to strive toward
maximizing these other sources of payment.
Medical Priorities
To ensure funds are available throughout the year, medical
priorities are used to authorize CHS funds. There are five levels of
care within the medical priority system; they range from emergent/
acutely urgent care services to preventive and chronic tertiary care.
Generally, IHS and Tribal funding programs currently reimburse only for
Medical Priority I cases, which are for emergent/acutely urgent care.
Catastrophic Health Emergency Fund (CHEF)
The CHS program also includes a Catastrophic Health Emergency Fund
(CHEF) in the amount of $18 million. This fund pays for high cost cases
and catastrophic costs. The CHEF is used to help offset high cost
contract care cases meeting a threshold of $25,000. In FY 2006, the
CHEF program provided funds for over 671 high cost cases in amounts
ranging from $1,000 to $875,000 over the $25,000 threshold.
Mr. Chairman, this concludes my statement. Thank you for this
opportunity to report on IHS programs serving American Indians and
Alaska Natives and their impact on the health status of AI/ANs. We will
be happy to answer any questions that you may have.
Senator Dorgan. Dr. North, thank you very much.
Next we will hear from Dr. Westley Clark. Dr. Clark is the
Director for Substance Abuse Treatment.
Dr. Clark, you may proceed.
STATEMENT OF H. WESTLEY CLARK, M.D., J.D., M.P.H.,
DIRECTOR, CENTER FOR SUBSTANCE ABUSE TREATMENT, SUBSTANCE ABUSE
AND MENTAL HEALTH SERVICE
ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Dr. Clark. Thank you, Mr. Chairman, and I want to
acknowledge Senator Tester and committee staff.
I'm speaking on behalf of Dr. Terry Cline, who is the
Administrator of the Substance Abuse and Mental Health Service
Administration, commonly called SAMHSA.
I am pleased to have this opportunity to join you and share
with you how SAMHSA is working to create healthier tribal
communities.
I am Dr. H. Westley Clark, the Director of the Center for
Substance Abuse Treatment. It is important for us to
acknowledge the issues of substance abuse and mental health
problems experienced among American Indians and Alaska Natives.
We know that American Indians and Alaska Natives suffer
disproportionately from substance use disorders, and they
interfere with health, interfere with major obligations at
work, school, or home.
According to combined data from the National Survey on Drug
Use and Health, American Indian and Alaska Natives over the age
of 12 were more likely than members of other racial and ethnic
groups to have a past year alcohol use disorders, to have past
year illicit drug use disorders, and specifically, rates of
past year marijuana, cocaine, and hallucinogen use, were higher
among American Indians and Alaska Natives than other groups.
With respect to mental health concerns among American
Indian and Alaska Natives, between 1999 and 2004, suicide was
the second leading cause of death among youths between the ages
of 10 and 24. We also know that trauma and PTSD are significant
critical issues for the American Indian community.
Our work at SAMHSA requires partnership and the passion of
others in order to make the largest impact possible. We work
with the Indian Health Service, the Department of Justice, and
the Bureau of Indian Affairs in ways that are instrumental in
our success in assisting tribal communities in training and
technical assistance.
Our state partners are partnering with tribes and tribal
communities to meet service needs. Tribal leaders across the
country are expanding dialogue with SAMHSA every day. We
acknowledge the importance of self-governance and self-
determination.
One important tool to enhance collaboration are the tribal
training and technical assistance sessions that SAMHSA, the
Department of Justice, the Office of Justice Programs and the
Department of the Interior, Bureau of Indian Affairs have
conducted this year focusing on tribal priorities related to
public safety and public health for families and communities.
Four of these cross-agency sessions have been held this
year, and they were designed so that Federal agency partners
could share information on funding opportunities and agency
initiatives with tribes and tribal organizations.
Also included on the agenda for these sessions were
opportunities for tribal leaders to consult with Federal
officials on public safety, justice, and public health issues.
We also rely on these tribal consultation sessions to gain
insight on tribal priorities and gauge needs on pressing health
and human services issues in tribal communities. Some of the
most pronounced areas of concerns expressed at these sessions
surround methamphetamine use, suicide and access to Federal
grants.
SAMHSA's proposed FY 2008 budget reflects these concerns.
Our mission in Indian Country, and around the country, has been
more focused and more clear with the release of our FY 2008
proposed budget.
SAMHSA Administrator, Dr. Terry Cline, has completed
testimony on the FY 2008 SAMHSA budget and there are a few
highlights I would like to share about the $3.2 billion
proposal.
We continue to invest available resources in priority areas
like screening, brief intervention, referral and treatment,
criminal and juvenile justice and drug courts, access to
recovery, substance abuse prevention, children's mental health
services, suicide and school violence prevention, HIV/AIDS, and
mental health system transformation. This information is
available on our website.
I want you to recognize two priorities, and that is our
screening, brief intervention program and our treatment drug
courts. They have received increases for this budget year and
tribes are eligible to apply for both.
Currently, the Cook Inlet Tribal Council in Anchorage
operates an SBIRT program. In FY 2008, approximately $25
million is proposed for new SBIRT grants to increase screening.
This objective is to wed primary care and substance abuse and
mental health together so that we can identify problems early.
Approximately $32 million is proposed to fund 75 treatment
drug court grants. Again, tribes and tribal organizations are
encouraged to apply for both of these important initiatives.
With respect to suicide prevention, SAMHSA's FY 2008 budget
includes $3 million for youth suicide prevention which will
expand on a long-term commitment to tribal youth through the
Native Aspirations project.
The Native Aspirations initiative is a five-year project
that is operated though a contract with Kauffman and
Associates, a Native American business located in Spokane,
Washington.
SAMHSA consulted with tribes through the contractor, and to
date, 24 tribal communities are participating in the Native
Aspirations project, including the Crow Nation. With continued
input from tribal leaders, we expect to expand this initiative
in future years to include additional tribal sites.
Our Access to Recovery program, or ATR program, permits
states and tribal organizations to provide clinical substance
abuse treatment as well as recovery support services through a
voucher-based system.
The ability to provide recovery support services is key to
this grant, and it allows culturally appropriate and
traditional healing practices to be reimbursed through the
grant. Currently, the California Rural Indian Health Board was
one of our first ATR grantees and it continues to serve as an
example. For our second round of ATR grants, up to $98 million
is available to fund approximately 18 new ATR grants in FY
2007, and we expect that more than one tribe will be awarded a
grant in this new addition.
Since the recognition of a growing methamphetamine problem
nationwide, SAMHSA has continued to put a strong emphasis on
prevention.
In FY 2006, SAMHSA awarded ten methamphetamine prevention
grants of approximately $350,000 each for up to 3 years. The
grant program is to support expansion of methamphetamine
prevention, intervention and/or infrastructure development.
Of the ten grants awarded, two were to tribes, the Cherokee
Nation of Oklahoma and the Native American Rehabilitation
Association of the Northwest. The grant program is designed to
address the growing problem of methamphetamine abuse and
addiction by assisting localities to expand prevention
interventions that are effective and evidence-based, and to
increase capacity through infrastructure development.
In addition, SAMHSA is a part of the HHS Indian Country
Methamphetamine Initiative along with the Office of Minority
Health and the National Institutes of Health.
Through this project, approximately $1.2 million was
awarded to the American Association of Indian Physicians and
its partners, to address the outreach and education of Native
American communities on methamphetamine abuse.
Five tribes are included in this project, the Winnebago
Tribe, which has been funded as a preventionsite, the Navajo
Nation and the Northern Arapaho Tribe, which are intervention
and treatment sites, and the Crow Tribe and Choctaw Nation
which are treatment and recovery sites.
The Montana-Wyoming Tribal Leaders Council has a SAMHSA
suicide prevention grant, and as a grantee, they are
implementing the Planting of Seeds of Hope Project.
In many ways, this Council has led the way in developing
new collaborations between all of the tribes in Montana and
Wyoming, along with the states, in order to share resources,
ideas, and truly work together on suicide prevention
activities.
These new collaborations are building hope across the
tribes and the states to overcome what once seemed an
overwhelming and impossible problem to solve alone. These
partnerships are leading the country in developing new
strategies for saving the lives of our youth, and together they
are spreading the word that suicide is a preventable tragedy.
To continue to address the suicide clusters on Standing
Rock, the tribe applied and was competitively awarded a youth
suicide prevention and early intervention program grant in
October, 2006.
This grant is bringing together community leaders to
implement a comprehensive tribal youth suicide prevention and
early intervention plan at Standing Rock that is identifying
and increasing youth referrals to mental health services and
programs, increasing protective factors, reducing risk factors
for youth suicide, and improving access to intervention
services. Additionally, SAMHSA is establishing a new tribal
advisory committee and is accepting nominations for community
members. Similar to other SAMHSA advisory committees, the
purpose of the Tribal Advisory Committee is to assist SAMHSA in
carrying out its mission in Indian Country.
Key to carrying out our agency mission in Indian Country is
increasing awareness of and access to our grants. In response
to comments at the 2006 HHS Tribal Consultation meetings and
the HHS/ASPE published Barriers to American Indian/Alaska
Native/Native American Access to DHHS Programs report, SAMHSA
convened an internal workgroup to develop strategies to remove
barriers in discretionary grant announcements.
Senator Dorgan. Mr. Clark, I'm going to have to ask you
that you summarize, please.
Dr. Clark. One of the most important things is we want to
make sure that tribes have access to our funding. I think one
of the things that we view in these requests for proposals is
making sure that tribes are not precluded from participating as
states or other organizations have. So I'm pleased to note that
we have done this.
We're also having other strategies like the tribal policy
academy on co-occurring disorders and that tribes are along in
that effort so that we can deal with substance abuse and mental
health problems of the tribes.
So changes are underway, and we are working collectively
with tribal communities and tribal governments so that we can
address mental health and substance abuse problems.
Thank you.
[The prepared statement of Dr. Clark follows:]
Prepared Statement of H. Westley Clark, M.D., J.D., M.P.H., Director,
Center for Substance Abuse Treatment, Substance Abuse and Mental Health
Service Administration, U.S. Department of Health and Human Services
Chairman Dorgan and Members of the Committee, I am Dr. H. Westley
Clark, Director of the Center for Substance Abuse Treatment, Substance
Abuse and Mental Health Services Administration or commonly called
SAMHSA. I bring greetings from Dr. Terry Cline, SAMHSA Administrator. I
am pleased to have this opportunity to join you and share with you how
SAMHSA is working to create healthier tribal communities. However,
before I detail a few of SAMHSA's initiatives, I think it is important
to underscore the extent of substance use and mental health problems
experienced among American Indians and Alaska Natives.
American Indians and Alaska Natives suffer disproportionately from
substance use disorders (defined by symptoms such as withdrawal,
tolerance, use in dangerous situations, trouble with the law, and
interference in major obligations at work, school, or home during the
past year) compared with other racial/ethnic groups in the United
States. According to combined data from the 2002-2005 National Survey
on Drug Use and Health (NSDUH) conducted by SAMHSA, American Indian and
Alaska Natives over the age of 12 were more likely than members of
other racial/ethnic groups to have a past year alcohol use disorder
(10.7 vs 7.6 percent). They were also more likely to have a past year
illicit drug use disorder (5.0 vs 2.9 percent). Specifically, rates of
past year marijuana, cocaine, and hallucinogen use disorders were
higher among American Indians and Alaska Natives than among other
racial/ethnic groups.
One factor that may be driving the disparity in substance use
between American Indian/Alaska Native youth and other youth is a higher
rate of substance use risk factors among American Indian and Alaska
Native youth. For example, data from the 2002 and 2003 National Survey
on Drug Use and Health show that American Indian/Alaska Native youth
are more likely than youth of other racial/ethnic groups to perceive
moderate to no risk of substance use and less likely to perceive strong
parental disapproval of substance use.
With respect to mental health concerns among American Indian and
Alaska Natives, between 1999 and 2004, suicide was the second leading
cause of death among youth between the ages of 10 and 24, compared to
the third leading cause of death among the youth population as a whole.
Spirituality may play a protective role in reducing suicide attempts.
Specifically, a study of American Indian tribal members living on or
near their Northern Plains reservations between 1997 and 1999 showed
that those with a high level of cultural spiritual orientation had a
reduced prevalence of suicide compared with those with a low level of
cultural spiritual orientation.
Our work at SAMHSA does not stand alone--it requires partnership
and the passion of others in order to make the largest positive impact.
For example, our partners at the Indian Health Service, the Department
of Justice (DOJ) and the Bureau of Indian Affairs are instrumental in
our success in assisting tribal communities in training and technical
assistance. Our State partners are partnering with Tribes and Tribal
communities to meet service needs. In addition, our grantees are hard
at work in the field providing services. And, Tribal leaders across the
country are expanding the dialogue with SAMHSA everyday. All are
examples of the type of collaborative efforts that create a wider reach
than any single agency can provide alone.
One important tool to enhance collaboration are the Tribal Training
and Technical Assistance Sessions that SAMHSA, the Department of
Justice, Office of Justice Programs (DOJ/OJP) and the Department of the
Interior (DOI), Bureau of Indian Affairs (BIA) have conducted this past
year focusing on tribal priorities related to public safety and public
health for families and communities. Four sessions were held in FY
2007. It should be noted that the fourth session included a 1-day
Tribal Methamphetamine Summit hosted by the Office of National Drug
Control Policy (ONDCP). These cross-agency sessions are designed so
that Federal agency partners can share information on funding
opportunities and agency initiatives with Tribes in one setting.
Community challenges, best practices and lessons learned have been
embedded into the session agendas to provide Tribes the opportunity to
share their experiences and adapt strategies to their unique
circumstances in their tribal communities. Also included on the agenda
for these sessions are opportunities for Tribal leaders to consult with
Federal officials on public safety, justice and public health issues.
And, of course, we also rely on these Tribal Consultation Sessions to
gain insight on Tribal priorities and gauge needs on pressing health
and human services issues in tribal communities. Some of the most
pronounced areas of concerns expressed at these sessions surround
methamphetamine use, suicide and access to Federal grants.
SAMHSA's proposed FY 2008 Budget reflects those concerns. Our
mission in Indian Country and around the country has become much more
focused and more clear with the release of the FY 2008 proposed budget.
SAMHSA Administrator Dr. Terry Cline has completed testimony on the FY
2008 SAMHSA budget and there are a few highlights I would like to share
about the $3.2 billion proposed for SAMHSA.
We are continuing to invest available resources in program priority
areas such as: Screening, Brief Intervention, Referral and Treatment
(SBIRT); Criminal/Juvenile Justice and Drug Courts; Access to Recovery;
Substance Abuse Prevention; Children's Mental Health Services; Suicide
and School Violence Prevention; HIV/AIDS; and Mental Health System
Transformation.. A comprehensive list of our grants can be found on our
website: www.samhsa.gov/grants/.
I want to draw your attention to a few of these priorities briefly.
Two of these priorities--the SBIRT program and the Treatment Drug
Courts--have received increases this budget year and tribes are
eligible to apply for both. Currently, the Cook Inlet Tribal Council in
Anchorage, Alaska operates an SBIRT grant. For FY 2008, approximately
$25 million is proposed for new SBIRT grants to increase screening,
brief interventions, and referral to treatment in general medical and
community health care settings. Approximately $32 million is proposed
to fund about 75 Treatment Drug Court grants. Tribes and Tribal
Organizations are encouraged to apply for both of these important
initiatives.
With respect to suicide prevention, SAMHSA's FY 2008 Budget
includes $3 million for youth suicide prevention which will expand on a
long-term commitment to tribal youth through the Native Aspirations
project. The Native Aspirations initiative is a 5-year project that is
operated through a contract with Kauffman and Associates, Inc. (KAI)--a
Native American business located in Spokane, Washington. SAMHSA
consulted with Tribes through the contractor and to date 24 tribal
communities are participating in the Native Aspirations project. With
continued input from Tribal leaders, we expect to expand this project
in future years to include additional tribal sites.
I don't want to just talk about proposed grant opportunities, but
also current ones as well. One grant program I want to highlight is
SAMHSA's Targeted Capacity Expansion Grants (TCE) program. In May 2007,
SAMHSA announced $10.2 million in TCE Grants to expand or enhance a
community's ability to provide a comprehensive, integrated, and
community-based response to a targeted, well-documented substance abuse
treatment capacity problem and/or improve the quality and intensity of
services. Applications were accepted under four Categories: (1) Native
American/Alaska Native/Asian American/Pacific Islander Populations; (2)
E-Therapy; (3) Grassroots Partnerships; and (4) Other Populations or
Emerging Substance Abuse Issues. Tribes were eligible to apply under
all four categories and SAMHSA expects to award up to 16 grants in
2007, with an average grant amount of $500,000 per year for up to 3
years.
Another program priority area is SAMHSA's Access to Recovery (ATR)
program. The ATR program permits grantees (i.e., States and Tribal
Organizations) to provide clinical substance abuse treatment as well as
recovery support services through a voucher-based system. The ability
to provide recovery support services is a key issue of this grant
program because it allows clients to pursue and maintain their recovery
through many different and personal pathways, including traditional
healing practices. The California Rural Indian Health Board was one of
the first ATR grantees and it continues to serve as an example of what
can be accomplished through tribal collaborations. For our second round
of ATR grants, up to $98 million is available to fund approximately 18
new ATR grants in FY 2007 of which $25 million is expected to support
treatment for clients using methamphetamine.
Since the recognition of a growing methamphetamine problem
nationwide, SAMHSA has continued to put a strong emphasis on
prevention. In FY 2006 SAMHSA awarded 10 Methamphetamine Prevention
grants of approximately $350,000 each for up to 3 years The grant
program is to support expansion of methamphetamine prevention,
interventions and/or infrastructure development. Of the 10 grant awards
2 were to Tribes, the Cherokee Nation of Oklahoma and the Native
American Rehabilitation Association of NW, Inc., of Portland, Oregon.
The grant program is designed to address the growing problem of
methamphetamine abuse and addiction by assisting localities to expand
prevention interventions that are effective and evidence-based and/or
to increase capacity through infrastructure development.
SAMHSA is a member of the Office of National Drug Control Policy,
Executive Native American Law Enforcement Workgroup along with members
from DOJ, Indian Health Services, DOI, Tribal Police, and the Federal
Bureau of Investigation. This workgroup is designed to coordinate and
address the multidimensional aspect of methamphetamine use in Indian
Country. In addition, SAMHSA is part of the HHS Indian Country
Methamphetamine Initiative (ICMI) along with the Office of Minority
Health and the National Institutes of Health. Through this project,
nearly $1.2 million was awarded to the American Association of Indian
Physicians (AAIP) and its partners to address the outreach and
education needs of Native American communities on methamphetamine
abuse. The partners are developing a culturally appropriate national
information and outreach campaign on methamphetamine use in Indian
Country. They are also developing a methamphetamine abuse education
kit, documenting and evaluating promising practices in education on
methamphetamine use, and creating methamphetamine awareness multi-
disciplinary education teams. Five Tribes are included in this
project--the Winnebago Tribe, which has been funded as a
preventionsite, the Navajo Nation and the Northern Arapaho Tribe, which
are intervention and treatment sites, and the Crow Tribe and Choctaw
Nation which are treatment and recovery sites.
The Montana-Wyoming Tribal Leaders Council has received a SAMHSA
suicide prevention grant and as a grantee they are implementing the
``Planting of Seeds of Hope Project.'' In many ways, this Council has
led the way in developing new collaborations between all of the Tribes
in Montana and Wyoming, along with the States, in order to share
resources, ideas, and truly work together on Suicide Prevention
activities. These new collaborations are building hope across the
Tribes and the States to overcome what once seemed an overwhelming and
impossible problem to solve alone. These partnerships are leading the
country in developing new strategies for saving the lives of our youth
and together they are spreading the word that suicide is a preventable
tragedy.
In the Aberdeen Area, SAMHSA continues to work closely with the
Standing Rock Sioux Tribe to respond to an outbreak of suicide clusters
on their reservation. In 2005, through a SAMHSA Emergency Response
Grant (SERG), SAMHSA staff and the One Sky Center staff began working
with the Tribe to design and implement a suicide prevention program at
Standing Rock. Based on SAMHSA's recommendation, tribal leadership
mandated that the program must be Addiction and Dependency certified by
the State of North Dakota. A Bismarck-based consultant from SAMHSA's
Disaster Technical Assistance Center (DTAC) has assisted the Tribe with
this process. The Tribe has funded two additional behavioral health
staff positions to provide case management services and arrange for
treatment and ancillary services for at-risk clients, which is making a
difference. The strategic suicide prevention plan that was developed
and implemented at Standing Rock is being considered as a model by
other Indian reservations and the Indian Health Service. Although the
SERG grant funding ended in December 2006, the Tribe was competitively
awarded a Youth Suicide Prevention and Early Intervention Program grant
in October 2006. This new grant is bringing together community leaders
to implement a comprehensive tribal youth suicide prevention and early
intervention plan at Standing Rock that is identifying and increasing
youth referrals to mental health services and programs, increasing
protective factors, reducing risk factors for youth suicide, and
improving access to intervention services.
SAMHSA is also working with the Office of National Drug Control
Policy, the Office of Justice Programs/Bureau of Justice Assistance
within the Department of Justice and with the National Alliance for
Model State Drug Laws on regional planning events to identify common
issues and concerns among States that may require interstate
resolutions or a Federal focus to address methamphetamine use. Through
this partnership, three regional planning events were conducted in FY
2007. Attendance included representatives of substance abuse programs,
law enforcement agencies, the criminal justice system, community
coalitions and counties, cities and local municipalities. The goal was
the identification of best practices that will be replicated in other
States.
In response to the inescapable link between addiction, mental
illness, and crime, SAMHSA is coordinating across Federal agencies
through our participation on the Native American Law Enforcement Task
Force. When prevention and treatment services are targeted to adult and
juvenile offenders the benefits are three-fold. First, if we prevent
addiction, drug related crime will decrease. Second, if we intervene
early and get the appropriate treatment services in place, recidivism
rates drop. And third, as SAMHSA increases recovery support services,
reentry success rates climb and public safety is increased. It just
makes sense for SAMHSA to strengthen partnerships with the law
enforcement communities both in Indian Country and around the country.
We have reached out to police organizations, correctional
organizations, as well as the National District Attorneys Association
to open the paths to collaboration. And, we will continue working
closely with DOJ as well.
As you may know, the Department of Health and Human Services (HHS)
revised its Tribal Consultation Policy in March 2005. Members of the
Tribal-Federal Team contributed to developing the necessary
recommendations. In early 2006, SAMHSA used the HHS document as a basis
to create a starting point for revising the SAMHSA policy. We shared
that document with tribes at each of the Regional sessions to solicit
comments. During that process, we asked for volunteers interested in
serving on a workgroup to assist with further review and revision of
the Tribal Consultation Policy. In June of 2006, a Technical Team
workgroup was formed. The first meeting of the workgroup produced a
second draft of the SAMHSA Tribal Consultation Policy which was
reviewed and comments as well as resulting edits were incorporated in
the final Tribal Consultation Policy. SAMHSA's goal was to have a
signed Tribal Consultation Policy by early 2007 and I'm very proud to
say we have accomplished that. Additionally, SAMHSA is establishing a
new Tribal Advisory Committee and is accepting nominations for
committee members. Similar to other SAMHSA advisory committees, the
purpose of the Tribal Advisory Committee is to assist SAMHSA in
carrying out its mission in Indian Country.
Key to carrying out our Agency mission in Indian Country is
increasing awareness of and access to our grants. In response to
comments at the 2006 HHS Tribal Consultation Meetings and the HHS/ASPE
published ``Barriers to American Indian/Alaska Native/Native American
Access to DHHS Programs'' report (April 2006) SAMHSA convened an
internal workgroup to develop strategies to remove barriers in
discretionary grant announcements. As a result, in August 2006 a Tribal
Grants Review Team--with members from four Tribes/tribal
organizations--reviewed nine previously published SAMHSA Requests for
Proposals (RFAs). Their findings and recommendations were provided to
SAMHSA grants and policy officials, some of which have already been
incorporated into FY 2007 SAMHSA RFAs.
In addition to increasing the voice of Tribes and Tribal
Organizations through the various avenues mentioned, SAMHSA is also
committed to increasing technical assistance to our tribal partners on
improving services. For instance, through SAMHSA's Addiction Technology
Transfer Centers (ATTCs), SAMHSA is planning one or more special
projects to provide technical assistance on treatment-related issues
through partnerships with Regional Indian Health Boards. We are very
excited about this new partnership and expect to have it underway in
early FY 2008. Also, SAMHSA's Center for Substance Abuse Prevention
will be awarding a contract for a Native American Technical Assistance
Resource Center that will provide targeted technical assistance to
current Tribal Strategic Prevention Framework State Incentive Grants
grantees and prospective grant applicants.
I also want to mention that recently we participated in the IHS-
SAMHSA 5th Annual National Behavioral Health Conference held June 11-14
in Albuquerque, New Mexico. This annual conference is an important
training and networking opportunity for American Indians and Alaska
Natives working in the behavioral health fields with the Indian Health
Service.
Similarly, I'm pleased to announce that plans are underway at
SAMHSA for a Tribal Policy Academy on Co-Occurring Substance Abuse and
Mental Health Disorders in September 2007. The purpose of this Academy
is to improve and expand access to effective, culturally relevant, and
appropriate prevention and treatment services and supports for
individuals with and at-risk for co-occurring substance use and mental
disorders. The Academy will bring together Tribal Teams of officials
with policymaking influence in conjunction with nationally recognized
faculty and facilitators who will assist the Teams to develop an Action
Plan for expanding access and improving co-occurring treatment and
prevention services in their communities. The Academy will also help to
identify promising practices in Tribal communities that may assist
other Tribes to address co-occurring disorders in new and innovative
ways.
Changes are underway--changes that will result in improved
coordination of SAMHSA services to tribal communities. Ultimately the
result will be healthier tribal communities--communities where lives
are full and where native language, culture and traditions including
native healing approaches can flourish. SAMHSA continues to look
forward in assisting each of you in any way we can. Thank you.
Senator Dorgan. Dr. Clark, thank you very much.
Senator Tester.
Senator Tester. Thank you, Mr. Chairman. I have a few
questions here, first for Dr. North, who is the Chief Medical
Officer of the Indian Health Service.
Early this year, we asked your representative about the
adequacy of the budget for this year for Indian Health. The
response we got was, it's pretty good, we can meet most of the
needs. Yet, when we talk with folks in Indian Country, we get a
very different answer.
Do you think the budget request was sufficient to meet the
needs?
Dr. North. The budget in direct care, in all the
facilities, maintenance, is about $3.2 billion. In addition to
that, we have increased our third-party revenue this year
substantially. It's now about three-quarters of a billion
dollars.
We think with the tribal contract, the 638 health centers
and hospitals, that we may be bringing in a billion dollars in
third-party revenue this year in addition to the appropriated
funds.
Senator Tester. So do you think that it was sufficient to
meet the needs?
Dr. North. There are always needs that can be served in
Indian Country.
Senator Tester. Okay. Well, interestingly enough, I think
this story could be repeated with any of the six other
reservations in this state. As we were driving down from the
airport with Chairman Venne today, I said, Carl, when did
Indian Health services run out? He said I think it was about
the first of June here in Crow. That indicates to me that the
program is underfunded.
What does that indicate to you?
Dr. North. I would like to ask the Area Director to comment
specifically on the contract health services funding in the
local service unit and the area.
Senator Tester. Do you want to defer to Mr. Conway at this
time? Do you understand the question Mr. Conway?
Mr. Conway. I believe so. Senator Tester, my thoughts on
that is that we've heard stories, Carl Venne has told us
stories about contract care. I think that whole issue centered
around contract care is it probably not funded at the adequate
level to provide all health care needs. What does that cost?
Sometimes the cost share dollars may be another source to help
cover those types of costs.
Senator Tester. Are you allowed to make recommendations up
the ladder for additional dollars, whether it's contract health
care or some other item?
Mr. Conway. I'm allowed to make recommendations to Dr.
Grim, who is our boss.
Senator Tester. Okay. How do you feel those recommendations
have been accepted, received, I should say?
Mr. Conway. I think generally the recommendations have been
well received. I think that at meetings of the Area Directors
there are problems in other areas also that are talked about
need, where it goes from there.
Senator Tester. How do you characterize the working
relationship that you maintain with the tribal governments, how
do you characterize that? Is it cooperative, productive,
adversarial, how do you classify that?
Mr. Conway. I think generally for the most part the working
relationship that we maintain with the tribes is cooperative. I
think there's some issues that are always going to come up
which may be adversarial. I think working through the Montana-
Wyoming tribal leaders, and them being in Billings, being able
to just walk up the street and discuss issues, I think it's
been a real bonus.
Senator Tester. So what issues are adversarial? What
avenues do you use for reconciliation? Do you just say this is
the way it is, too bad, or is there a process you go through?
Mr. Conway. The process that I go through actually is to
sit down across the table with tribal leaders and talk it over,
just sit down and discuss the issue.
Senator Tester. Okay. Other than dollars, is there anything
we can do in Congress to make your job easier?
Mr. Conway. I think some of the things you can do is look
at some of the administrative requirements that we have, and
perhaps, some HR things possibly, being able to offer somebody
a job, those types of things.
Senator Tester. The last question, do you take any
administrative things off the top regarding what goes out?
Mr. Conway. No, my understanding is funding for the Area
Office, this has been funding before I got there, the cost of
living and things like that.
Senator Tester. Thank you, Mr. Conway.
Mr. North, when I talk to folks in Indian County, they talk
about the fact they can't get health care at certain times of
the year unless they are life or limb, a loss of limb is
involved.
How do you suggest that we move away from a system that
waits until the injury or the health problem disaster, and
encourages more preventive maintenance or adaptive maintenance?
Dr. North. We have a program in health promotion, disease
prevention that's nationwide. We think it's better to prevent
these conditions and ask for treatment later whether it's
direct or through contract care.
This area has a very high rate of contract health emergency
funding, which is a reinsurance program in contract care,
indicating to me that there are probably many opportunities to
prevent illness in an early stage or altogether.
Senator Tester. Do you work through Mr. Conway or through
the tribe directly to encourage prevention programs in this
case?
Dr. North. Yes, we have a nationwide program. One of our
Director's three initiatives is health promotion and disease
prevention.
We're working closely with CMS on that also, and we have
some favorable rates now, Medicare like rates with hospitals
all over the country which helps save our contract health care
dollars.
Senator Tester. Thank you.
Before I go to Dr. Clark, I just want to make a comment,
when we asked about the adequacy of the budget, Senator Dorgan
was there and the Indian Affairs Committee, and they talked
about that budget being adequate, when, in fact, we know when
we go out in the field, it's not adequate.
I think we're wasting a lot of time, I think the budget is
just flat not adequate because it hasn't been a priority.
Things would change a lot, from my perspective, if you guys
would walk up to your bosses, or to the Secretary, and say, we
need more dollars because we've got people dying out there
unless we get more dollars for health care.
There's a lot of things out there that are really
important, and we can go down the list from housing to water to
roads, but if you're sick, you're not going to care, and if you
have the opportunity to get people to help you if you're that
sick, it's just going to cost more and more money for health
preventatives.
With that, I do have a couple of questions for Dr. Clark.
A couple things, Dr. Clark. In your testimony, when you
talked about early intervention and drug use and suicide, in
particular in Indian Country, are you seeing any impacts of
that early intervention, are you seeing suicide rates becoming
static or going down, and the same thing with drug use?
Dr. Clark. One of the most important things from our point
of view is working with tribes and tribal organizations to
deliver the services. So, as a service delivery organization,
we had opened our portfolio up to tribes and tribal
organizations, and as result of economics, monitored the
performance of the tribe and tribal organizations as we do for
every other provider, and we're seeing that more people are
being provided services to.
So from the economic point of view, it's simply a matter of
saying that I can cure the problem. We believe that working
with tribes and tribal organizations with our resources, we are
having a positive impact. Senator Tester: Okay. That's good.
That's positive. We need to continue along that line.
What can we in Congress do to really attack some of the
root causes of moving toward drug addiction or suicide?
Dr. Clark. Well, of course, making sure that we have an
adequate work force, making sure that there's adequate
collaboration between agencies so that this partnership between
IHS, the Bureau of Indian Health Affairs, and the tribes, can
work together so that we can target our interventions in such a
way to produce satisfactory results.
Senator Tester. Okay. One last question, Dr. North, I do
have one more question for you, and thank you, Dr. Clark.
You talked about a manpower program that 7,000 students
have utilized, is that total or is that in the last year? The
number really doesn't matter as much as the next question I'm
going to ask, and that is, do you monitor the number of the
folks that utilize this manpower program that actually come
back into Indian Country and provide service?
Dr. North. Yes, we do. That's 7,000 students since 1977,
which is the year I joined the Indian Health Service 30 years
ago.
Senator Tester. And how many of them come back to Indian
Country?
Dr. North. We have more information on that, that's a
complex answer. If you'd like, I could provide that for the
record.
Senator Tester. I would like more information on that, and
also try to find out what's going to encourage them to come
back to their homes.
With that, thank you very much, Mr. Chairman.
Senator Dorgan. Senator Tester, thank you very much.
Let me ask a couple of questions of Dr. North and Mr.
Conway.
I want to ask about contract health care because Chairman
Venne indicated this morning, that I believe at this point, on
this reservation in the Crow Nation, they are out of contract
health care dollars.
Chairman Venne, you are out of contract health care dollars
at this point in the fiscal year and probably ran out somewhere
in June or July; is that correct?
Chairman Venne. That's correct.
Senator Dorgan. If that's the case, what that means is that
if you are here in the Crow Nation and have a problem, a
medical problem for which there is not treatment here, perhaps
you need a specialist of some type, they're not going to pay
for that specialist unless there is a life or limb at stake,
you've got to lose a limb or lose your life; is that correct,
Dr. North?
Dr. North. And also special senses, hearing and eyesight
would be included in priority one and child birth.
Senator Dorgan. If that is the case, if we're out of
contract health care here now, the Fiscal Year ends at the end
of September, of course, I've had a tribal chairman say they
were out of contract health care funds in January. Former
Chairman Tex Hall used to say on that reservation everybody
understood don't get sick after June because there's no
contract health care money.
If that's the case, isn't it a fact, then, that we are
rationing health care to Native Americans?
Dr. North. The Indian Health Service is the payer of last
resort when it comes to referrals and notification of emergency
care. All other alternate resources must be used first, like
Medicare, Medicaid, private insurance, workmen's compensation,
Veterans Administration benefits and county indigent programs
and state indigent programs where they exist.
So, we're not the only payor of health care for Native
Americans. There are several other options.
Senator Dorgan. Dr. North, you are absolutely correct about
that, there are other payors in certain circumstances, but you,
the Indian Health Service, represented by this government, is
responsible. I mean, you do have a commitment. Others may or
may not have a commitment, but we do know that the Indian
Health Service does have a commitment.
Senator Tester was asking the question the right way, I
think. We have these hearings in Washington, D.C. or in Montana
or elsewhere, and we ask questions, and what we always get is,
you know what, things are pretty good, we're doing the best we
can. We've made a couple percent improvement here or there, but
it seems to me the following:
Dr. Grim has admitted under my pretty intense questioning a
couple of times, that the amount of health service that is
required for American Indians is being covered to the tune of
about 60 percent. That means 40 percent of the health service
that is needed is not available. That means there's rationing
of health care available.
And I think it ought to be on the front page headlines of
every newspaper, because I think it's scandalous, and what I
don't understand is how we finally get people to speak up on
this.
I'm not trying to badger you, but Senator Tester made a
point and I made a point to Dr. Grim when he was just re-
nominated. We said why don't you risk your job, if necessary,
to speak out. Risk your job, if necessary, to speak out.
The fact is, you've got some awfully good people working in
Indian Health Service, in Public Health Service. I admire them,
some terrific, committed, dedicated people. God bless them for
doing it.
But the fact is, they're doing it without the resources
they need, and we have to find a way to deal with that. And the
only way that we're going to do it is to get the Indian Health
Service to stop saying things are pretty good and to start
telling us exactly what's happening. Now, Dr. North, you or Mr.
Conway can respond, but Mr. Conway, isn't it a fact that here
on the Crow Nation if they're out of contract health care money
at this point, that somebody can be pretty sick but it may not
be life or limb and they're going to be told we're sorry, just
wait, you're going to have to wait?, not we're sorry about the
pain, but the pain is yours, not ours, we don't have the money,
you wait.
Isn't that what happens? Am I wrong about that, or isn't
that what's happening?
Dr. North. We have to live with the reality of medical care
daily. I've done that for 30 years as a physician in the Indian
Health Service with my patients, and I think----
Senator Dorgan. I can't hear you, I'm sorry.
Dr. North. I've been a family doctor for 30 years in the
Indian Health Service, and I understand what you're saying,
sir. We struggle to find the best resources for our patients,
the best referral sources and the best methods to diagnose,
treat and cure, and it takes creativity at times, sir.
Senator Dorgan. Well, are you frustrated?
Dr. North. I find this struggle to be a good struggle and
one worth fighting.
Senator Dorgan. All right. Well, let me ask this additional
question.
I assume that somewhere at the bottom of this structure,
there are dedicated Indian Health Service employees who are
saying we don't have enough resources, we need more. We're the
ones that are seeing the patients that we can't take care of,
so we need the additional resources. We need the additional
equipment. We need the additional facilities, and that goes up
the line someplace.
My understanding is that the tribes are even asked to
comment and to work and to make recommendations.
Is there a circumstance where the tribes are involved in
discussions up the line when, for example, the Indian Health
Service goes to the Secretary and the Secretary goes to the
Office of Management and Budget, or is it a circumstance where
when it leaves at this level, the Indian Health Service, at
that point there's no more consultation, it's just the Office
of Management and Budget and perhaps the Secretary and somebody
else makes the decision with no consultation with tribes at
that level?
Dr. North. We take pride in tribal consultation at every
level of the Indian Health Service. About 70 percent of our
employees are Native American and are community members in many
cases, and are family members of the tribal leaders and often
tribal leaders themselves, so we feel like we work very closely
with the communities and we have good two-way communications
with tribal leaders.
Senator Dorgan. I should have mentioned, it's the Secretary
of Health and Human Services, on other issues it's the
Secretary of the Interior on Indian funding issues.
But Mr. Conway, let me ask you that question about someone
who is ill here on the Crow Nation Reservation, and is probably
not going to die, but is in substantial pain, needs to go to a
specialist somewhere else because the service isn't available
here, tell me what happens in that case.
Mr. Conway. Maybe what would happen in that case, they will
be deferred until the next year when we have some money. I
think our job is probably the issue of asking for us to
appropriate more money.
I think in my area, I think Chairman Venne receives 50
percent of the Health Service funding. I think we know that, at
least in this area, we have service units that are funded at
58, 56 percent are being funded, all the way up to probably 76
or 78 percent.
And I think what we have to conclude from that, if they're
funded at that level, there must be some needs out there that
we need to continue to work on.
Senator Dorgan. And isn't that another way of saying that
health care is being rationed to American Indians, really?
Mr. Conway. Yes, it's a way of saying that we do not have
100 percent of the funding. If we're keeping track of every
service unit in the country, what the level they're being
funded at is, we have other areas probably in the Dakotas that
are probably funded at 40 percent level of needed funds.
Senator Dorgan. All I can tell you is I think most
Americans, most Americans, if they've got a provider, health
insurance, some other type of system, VA, they get sick, they
want to go to a doctor, and if they're in pain they want to get
it fixed, they want to get that pain resolved.
It appears to me, and I say this from having visited many
Indian reservations and talked to a lot of patients, it appears
to me we're in a situation where we don't allocate enough
funding so that, for example, here you're out of contract
health care money, and the person that needs that help is going
to be told you just live with the pain because your need is
going to be deferred.
I'm not saying you don't do all you can do, that's my
point. My point isn't that the three of you don't do all that
you can do. My point is we don't have anybody in the system
that comes to us and pounds on the table and says publicly, in
front of everybody, here's what's happening and we need to fix
it.
What happens is they come to these hearings and they say,
we're doing the best we can. Well, you know what, if it's 40
percent health care that's not available to people that need
it, that's not good enough. The best we can is not good enough.
And so, I really want to work with Chairman Venne and
Senator Tester, with you, with some dedicated people in the
Indian Health Service and regional officials, but we need, we
really need to see some evidence of frustration and anger,
saying this isn't working and it needs to be fixed. That's what
we need from you.
Dr. Clark, I've not asked you a question, but you know that
I have held multiple hearings on the issue of teen suicide and,
you know, where there are young people who feel that it is
hopeless and they are helpless.
I've been to the reservations where it's happened. And the
fact is, mental health services were not available. They just
were not available. And it's true that we're making some
strides, but we're not anywhere near where we need to be. And I
hope that you and others in the administration will begin
speaking out as well.
Methamphetamine addiction is a devastating addiction, and
we can't treat that by putting somebody in a treatment program
for 2 weeks, because that doesn't work. This is long-term and
difficult and expensive, but it's the only way we can solve
these problems.
I'm not going to ask you any questions, except I thank you
for your testimony. I want to get to the other witnesses, the
tribal witnesses.
Senator Tester has another question.
Senator Tester. One point real quick. I would hope that
this panel would stay around for the next panel group.
One of the things I would like to inserted in the record,
Chairman Venne passed along to me.
In this region, it is not only underfunded, it's 48 million
in the red on contract care here right now. That means when
we're talking about Crow, Fort Belknap, Fort Peck, Rocky Boy,
Salish and Northern Cheyenne, they're all in the same boat.
Right now on this reservation 28 positions are not filled
in this hospital, 28. That's just not good, so I just wanted
that put in the record.
Senator Dorgan. And before I let you go, one final point, I
believe, and I believe, Dr. North, in your testimony you
reiterate, I believe there is a trust responsibility that the
Federal Government has for Indian health care. This isn't an
option. This isn't a case where we say, well, on an optional
basis we'll provide health care.
I believe there is a trust responsibility. If that trust
responsibility exists, and I think most all of us believe it
exists by custom and by law, then we are far short of meeting
the needs and keeping our promise, and that's the point of it
all.
Let me release you by saying, you are representatives of a
lot of dedicated health professionals, I understand that. I
don't ever want to diminish some Indian Health Service doctor,
Public Health Service physician or others working in these
kinds of circumstances. I don't ever want to diminish what they
do. God bless them for doing it.
But we as a country, and we as health care professionals,
we in the Congress, starting with the President's budget, have
to own up to our responsibility now, not later.
So, thank you very much for testifying.
Next I'd like to call to the witness table Dr. Joe
McDonald, who is the President of the Salish Kootenai College,
Ms. Ada White, the Health Service Director of the Crow Tribe,
Mr. Jonathan Windy Boy, the Chairman of the Subcommittee on
Health Care, Montana-Wyoming Tribal Leaders Council, if you
will come forward when I call your name. Also, Mr. Moke
Eaglefeathers, who is the President of the National Council of
Urban Indian Health Board, and Director of North American
Indian Alliance.
Just let me mention briefly that Dr. Joe McDonald is
accompanied by Ms. Marjorie Bear Don't Walk, the Director of
the Indian Health Board of Billings.
Others on the panel are accompanying Ms. Stacy Bohlen,
Executive Director of the National Indian Health Board. We have
Jace Killsback, Billings Area Representative of the National
Indian Health Board, Council member of the Northern Cheyenne
Tribe, and Dr. Joseph Erpelding, an orthopedic surgeon from
Billings, Montana.
We have many of you testifying on the second panel. I want
to tell you that your entire testimony will be made a part of
the record. And I wish that you would summarize for us, and at
some point, if you're unable to summarize, you may hear me bang
the gavel, gently for you, of course.
I also want to tell you before we call on this panel, that
we will ask any other testimony from any member of this
audience or anyone listening, any testimony can be submitted by
you or you can do it by fax or you can do it through the
Internet or you can call the Indian Affairs Committee in the
U.S. Senate, Washington, D.C.
We will make your formal testimony a part of the record
even though you have not been called as witnesses, but you will
have the opportunity to make statements and provide statements
to this Committee. And that opportunity will exist for 2 weeks
following today, and it will be open to you to submit such
testimony.
Dr. Erpelding has surgery at 3 o'clock today, I understand,
so because of your surgery schedule, we want to call on you
first.
So, Dr. Erpelding, why don't you proceed? And again, I
would ask all the witnesses to speak directly into the
microphone so that all in this gymnasium will be able to share
in your comments.
Dr. Erpelding. Chairman, Senator and distinguished guests,
thank you for allowing me this opportunity.
About a year ago, I was getting frustrated with the trend
that I've seen practicing here for 11 years, that it's just
gotten to the point where I searched out to try and look for
some solutions outside of the current system, and I think Stacy
is going to talk about that.
But, in essence, the trend has been a gradual decline in
access and an increase in severity and diversity of disease,
and I can share some specific numbers that illustrate that.
What I've been told is that IHS funding is currently at 54
percent of need, and the reason I don't know, but the result is
that I cannot take care of patients that come in and need care,
and it's very frustrating.
Access is limited by deferral of service. Patients wait
anywhere from 2 weeks to a year to be seen in a clinic. I've
had a patient wait 6 years to get a total joint replacement, 6
years.
Senator Dorgan. Six years for what?
Dr. Erpelding. For a total joint replacement.
Orthopedic care is the most common deferred service. There
frequently is no wait list. The surgery list that we had here
at Crow 3 years ago was lost. We had about 60 patients on that
list. The list got lost; those patients have to come back in,
be seen, be evaluated and get back on the list. So, we've got
some areas that we need to work on.
The deferral of service has consequences. I looked at the
total joint and back patients that were waiting for surgery, 60
percent of them were on opiates, 60 percent. That's their way
of coping with pain. If they can't get the surgery, they need
something.
Last year we shut down the OR here for 2 months because we
ran out of money, and I couldn't come down and do surgery here.
I come down here and do surgery. There's also a decrease in
employment and an increase in secondary disease due to lack of
access.
I can give you some numbers; total joint patients the last
5 years, my non-Indian health service patients, the average age
is 63\1/2\. The Indian Health Service patients, the average age
was 54.2.
Why? I would submit some of this reflects a lack of access.
It reflects a lack of health opportunities earlier in the onset
of arthritis, and it's seen many years later. But a nine-year
difference in average age for total joint replacement, that is
sad.
When I looked at 20 patients that had ACL reconstructions,
20 that were non-IHS and 20 that were Indian Country patients,
95 percent of those that were Indian Country patients had a
torn cartilage. That leads to an increase in arthritis. Only 10
percent of those who were non-IHS, had torn cartilage.
Why? The average wait for a non-IHS patient was 2 months.
The average wait for an Indian County patient, 13 months. We
can't keep doing this.
I've brought some solutions to the state. I was the
President of the Orthopedic Society in the state. I've asked us
to focus on health disparity education, medical and nonmedical.
People need to know about this. They need to know that there's
a disparity and how can we help.
We need to improve the cultural competency of those of us
involved. I've got a surgery scheduled this Friday, it's during
Crow Fair for heaven's sake. People wait a year to go to the
Fair, and unfortunately, I tried to change it, could not, but
that's cultural recognition, that I shouldn't be offering
surgery on a week that is very important to this Nation.
Additionally, there's prevention principles that we need to
focus on. But most important, I listened to Michael Porter, who
is a Harvard professor and strategist a couple days ago at a
leadership conference, and he said American people respond and
make things happen. He also said we need to provide value. When
we look for increase in funding, we need to provide value when
we do that.
One of the areas that came up when I chatted with the
Billings Area Office, is they need an infusion in business
minds. It's difficult to do third-party collections if they
don't understand how to do it. The private sector knows how to
do it. This is an area where we can garner additional funds
without a lot of increase in cost.
The others areas that I'm concerned about is we measure
things, but the measurements aren't accurate, so it's garbage
in, garbage out. We need to measure access for diagnosis, not
just well, they're going to see a specialist, but do they get a
diagnosis. And then we need to measure access for treatment
better.
I plead with those of you that have the ability to improve
the funding for health opportunity initiatives in Indian
Country, and I thank you for the opportunity to talk.
Senator Dorgan. Dr. Erpelding, thank you very much. Dr.
Erpelding, as I indicated, has surgery scheduled today and so
we took his testimony first.
Thank you very much, and thank you for submitting testimony
and giving us a different perspective, your perspective as an
orthopedic surgeon on some very important issues. If you need
to leave at this point, we will understand. Let me next call on
Stacy Bohlen, and Stacy Bohlen is the Executive Director of the
National Indian Health Board.
Stacy, you may proceed.
Ms. Bohlen. Thank you.
On behalf of the National Indian Health Board, Mr. Chairman
and Senator Tester, thank you for allowing the National Indian
Health Board to be here today. Dr. Erpelding was here as a
witness for the National Indian Health Board, and as you said,
I am the Executive Director.
I'm a member of the Sioux St. Marie Tribe of Chippewa
Indians in Michigan, and I am actually accompanying Mr. Jace
Killsback, who is a councilman for Northern Cheyenne, and he is
also a Board member of the National Indian Health Board, so I'm
going to turn this over to him, if you don't mind, sir.
Senator Dorgan. All right.
STATEMENT OF JACE KILLSBACK, BILLINGS AREA
REPRESENTATIVE, NATIONAL INDIAN HEALTH BOARD, COUNCIL MEMBER OF
THE NORTHERN CHEYENNE TRIBE; ACCOMPANIED BY STACY BOHLEN,
EXECUTIVE DIRECTOR, NATIONAL INDIAN HEALTH BOARD AND DR. JOSEPH
ERPELDING, ORTHOPEDIC SURGEON, BILLINGS, MONTANA
Mr. Killsback. First of all, greetings Chairman Dorgan,
Senator Tester and esteemed members of the Senate Indian
Affairs Committee.
As Stacy mentioned, my name is Jace Killsback, a member of
the Northern Cheyenne Tribal Council, and also a Board member
representing the Billings Area for the National Indian Health
Board.
Stacy will providing me with some technical assistance.
On behalf of the National Indian Health Board, it is an
honor and a pleasure to offer this testimony on health care
issues in Montana and nationally.
Our testimony today will focus on contract health service
policy and practices and the consequences of poor funding and
poor surveillance impacts on American Indians in Montana.
During our discussion, we will focus on the lack of
orthopedic care in Montana, and how contract health services or
CHS funding implementation have created this crisis in Montana.
We especially acknowledge the leadership of Senator Tester
in organizing and holding this hearing on these critical
issues.
So please allow me to express again my gratitude of the
tribes for the work the committee has done in advancement of
the reauthorization of the Health Care Improvement Act.
And we're especially thankful for the leadership that
Senator Dorgan has provided and his tendency to bring this
legislation to a successful conclusion to be enacted this year.
This bill will not only advance without the vigilance of
the tribes, but also Congressional leaders like Senator Dorgan,
and we hope that you will continue to be a champion of this
effort.
We also would like to acknowledge the work of Senator
Baucus and his assurance from the Senate Finance Committee that
they will mark up the bill September 12. We look forward to
seeing this bill progress of community consideration for the
Senate floor.
A snapshot of the health care status of American Indians
and Alaska Natives, they have a lower life expectancy and
higher disease burden than all other Americans. Roughly 13
percent of American Indians and Alaska Native deaths occur for
those under the age of 25. This is three times the rate of the
U.S. population.
Our youths are more likely to commit suicide at 70 percent
in Indian Country. These are involved with alcohol. We haven't
found the effects of methamphetamine abuse.
American Indians have a life expectancy rate 6 years less
than any other group in the United States, and rates for heart
disease are twice the rate for Americans, and this continues to
increase while the rate among the general public is decreasing.
The Center for Disease Control reported earlier this year
that for the first time in 75 years of cancer disease
surveillance, the rates of cancer in the U.S. are decreasing.
This is true for all groups except for American Indians, for
whom cancer rates are continuing to increase.
Disproportionate quality, poor education, cultural
differences, and the absence of adequate health care and
delivery are why these disparities continue to exist. The true
tragedy is that most of these illnesses which American Indians
suffer from are completely preventable.
It's also because the funding for Indian health care on a
per capita basis is half of what Federal prisoners receive.
For the proud nations of people who fought for their
freedom to protect their way of life and negotiated honestly
for a few considerations like health care and education for
their people in exchange for the land they had given up with
their lives, surely Congress can do better.
You guys are pretty familiar with the statutory provisions
for health care for American Indians, which again, is under the
Snyder Act of 1921 and Health Care Improvement Act.
There are two types of services, direct services that are
provided to IHS at our tribal hospitals and clinics, and our
contract health services which are provided by the private
sector facilities, and providers are based on referrals from
IHS from the tribal CHS program.
CHS services are utilized when a direct care facility is
not available, the direct care facility is not capable of
providing the required emergent or specialty care, or is not
capable of providing the care due to medical care workload.
CHS authorizes, subject to the availability of alternate
resources, such as Medicaid, Medicare and private health
insurance. Due to the limit of CHS funding, CHS regulations
require that services must be preapproved at the local CHS
program and determined to be medically indicated within medical
priorities.
If the services are provided in an emergency situation,
notification must be made to the local CHS program within 72
hours. The majority of CHS services are authorized for priority
medical, emergent or acutely urgent care services.
These services are defined in the CHS manual as services
that are necessary to prevent the immediate death or serious
impairment of the health of an individual.
Other medical priorities include priority two for Indian
health care, and priority three, secondary health care issues.
Priority four, prompt tertiary and extended health care
services such as rehabilitation.
For those services that are within the medical priorities
but are considered elective or not emergent or not authorized
for pain due to lack of CHS funding, are considered deferred
services.
In Fiscal Year 2006, the IHS received over 150,000 requests
for services that were deferred. If they had been approved and
paid, they would represent $176 million from the CHS. The data
on these numbers for deferred services is not consistent among
the IHS areas and is probably under reported.
Because the general deferred services are never authorized
and never paid for, there is little incentive for an Indian
patient to request IHS programs to pay for their services.
As an example, the Northwest Portland Indian Area Health
Board has estimated that due to lack of data on deferred
services, that they have estimated there are probably 300
million of unmet needs for CHS in their area alone.
Senator Dorgan. I'm afraid I'm going to have to ask you to
summarize the remainder of your statement in order that we
might get all of the statements in from others.
Mr. Killsback. Here in Montana, we represent the large
land-based tribes, and we are the most desperate, the most
needy of the neediest. Our communities are rural, and a lot of
times we see economic development being pushed on our tribes,
and the notion is here, we can't have economic development
without healthy communities.
The payor of last resort is something that, again, reflects
a perception in Indian Country of the culture of IHS. We have
patients that go in and are not being treated until there is
appropriate funding, and so what you have is a creation of an
addiction, painkillers.
This has also allowed for some issues in the communities
for black market drug trade of prescription drugs that isn't
being addressed also.
The culture of IHS in the continuing fighting for funding
has the Indians playing the numbers game. Some numbers that are
interesting, consider we have 30-year-olds walking around like
50-year-olds on our reservation.
Because of the deferments also, we are not keeping accurate
records so we don't have the appropriate data even for
diagnosis, and how can we get the proper amount of funding for
treatment if we don't have the proper number for diagnosis or
referrals.
I just want to wrap it up by saying that the reimbursement
issue that was brought up earlier, it's not IHS that's
improving the third-party reimbursements, it's tribes improving
third-party reimbursements, and yet, those reimbursements are
still being utilized against us in the budget process when it
comes to the IHS budget formulation.
Thank you for allowing us to testify.
[The prepared statement of Mr. Killsback and Dr. Erpelding
follows:]
Prepared Statement of Jace Killsback, Billings Area Representative,
National Indian Health Board, Council Member, Northern Cheyenne Tribe
and Dr. Joseph Erpelding, Orthopedic Surgeon, Billings, Montana
Senator Dorgan. Mr. Killsback, thank you very much. I have
read ahead of you in your testimony and you have provided, I
think, some very important data and statistics on these issues.
We appreciate that very much.
I'm sorry to ask you to summarize at the end, but we have
so many witnesses and I want to make sure all of them have an
opportunity, but I want to thank you for putting together about
12 pages of some very useful information about Wyoming,
Montana, about some of the data that we are seeking, so thank
you very much.
And Ms. Bohlen, thank you very much for bringing Mr.
Killsback and Dr. Erpelding with you as well.
Dr. Joe McDonald is with us and we will hear next from Dr.
Joe McDonald, President of the Salish Kootenai College.
Dr. McDonald, thank you very much, and as I indicated to
others, you may summarize and your entire statement will be
made a part of the permanent record.
DR. JOSEPH F. McDONALD, PRESIDENT, SALISH KOOTENAI COLLEGE
Dr. McDonald. Honorable Jon Tester and Mr. Chairman, my
name is Joe McDonald, I'm the President of the Salish Kootenai
College. It's really an honor to appear before you today and
provide this testimony. I thank you very much.
And I extend a special thanks to Chairman Venne and the
Crow Tribe for hosting this field hearing and nice lunch and
the nice facility you have here and the excitement of the
celebration that's about to begin.
I can't say enough about the need for recruitment of
American Indian people into the medical provider professions,
ranging all the way from CNAs to medical doctors.
It's difficult to recruit these people into our rural areas
and get them to stay. And I think if we could recruit members
of tribes and have the tribal colleges provide the training,
that they would come and they would stay, and we would not have
the shortage that we have on our reservations. I think they
would provide consistent service.
At Salish Kootenai College, we have been offering nursing
for about 18 years now, and we've had 400 and some nurses
graduate, 200 and some have been American Indian nurses. Our
passing grade on the Implex has been over 90 percent.
They told us when we started that, you know, Indians
couldn't pass that test. They said, Joe, after all, they have
to take this test. Well, we do take it and we do it well.
The doctors say that our nurses are very good. You go to
the hospitals in our western Montana, they say, Joe, you've
really got some great nurses there. And so the Indian people
can do this, and they can do it well.
We have nurses working here at the Crow Hospital, as we
have at all the IHS facilities, Indian Health Care facilities
in Montana and much throughout Indian Country.
When we started our program in 1989, our research showed
that there was one American Indian in nurses training in
Montana that year. This year, just this year, we'll have 46
American Indian students in our classes in Salish Kootenai this
fall.
So given a chance, the American Indian students, they will
enter the field, they will take on the challenge of becoming a
nurse.
We also have a dental assisting technology program. We
hoped it could grow into a dental hygiene program, but it
hasn't to this stage, but they do take the licensure to be
certified dental assistants and they're working throughout the
southwest. We have some even in Alaska and in dental clinics
around our reservations.
There's a need to have more of these programs, licensure
programs in many medical fields, such as dental hygiene,
occupational therapy, all the different x-ray programs, the
medical records technology, all of them. There's a tremendous
need for that.
We in the tribal colleges could do that well if we just had
the resources. We can do the training, and we can do the
recruiting if we have the resources.
Health care in Montana is one of the fastest growing areas
of employment. It's one of the biggest employers in Ronan, and
provides one other opportunity for Indians to get employment.
In order to do the recruitment, our K-12 students need to
be encouraged to think about these health care programs, and
appropriate classroom instruction is needed and counseling is
needed to build confidence and competence so that the Indian
students at the sixth grade level, seventh grade level decide
that I'm going to be a nurse or I'm going to be a doctor or I'm
going to be a x-ray technician, or whatever it might be,
because they can do that.
We need to build a pipeline, a pipeline in Indian Country
that will go from kindergarten all the way through the chosen
profession.
Once students are recruited in the program, they need help
to overcome a lot of barriers and problems that they encounter.
Finance is certainly a problem, individual finance is a
problem. Many of the students come that need help in basic
skills, college skills. They need to complete prerequisites
before entering the nursing program. A lot of times they burn
up a lot of their Pell grant eligibility getting ready to enter
into the nursing program.
Once they enter the nursing program, the study demands are
enormous and they need confidence building, they need a pat on
the back, they need a push and support.
The graduating nurse must be very skilled and very
confident, and we can't cut any slack with them because they
have to be good and they have to be very good.
The costs of the college for the health care provider
training are much greater than the average other programs that
we offer. At Salish Kootenai College we really struggle to find
the fiscal resources and the instruction staff to maintain the
nursing program.
Every year as we get into the budgeting, part of the
program is on the chopping block. We have not done it; we have
been struggling with being able to meet those needs.
Our salaries are not adequate. It's tough to recruit them
with the salaries we pay. We have an opportunity right now to
recruit an American Indian nurse that's been completing her
doctorate degree. We'd like to have her come back, but I'm not
sure that we could negotiate or get through that.
So, I believe that Indian students can be recruited and
retained if given the opportunity, that retention of the
student depends on adequate funding for the college to provide
the program.
I think the solution is to continue to adequately fund the
Tribal College Act, and I know that you've been a leader in
that, and if we could just get our funding equal to the state
allocation averages for 2 and 4-year mainstream colleges, we
would be doing well.
I'm pleased to hear that the legislation, THE PATH, has
been introduced, because I think that's going to be a big help.
I'm also pleased to hear that the Indian Health Care
Improvement Act, Improvement Reauthorization Act is going to be
marked up.
We have suggested some amendments to it. I understand many
of them have been included. I've included that in my testimony
that we have suggested it, so I really do thank you for that.
So, Mr. Chairman and Senator Tester, we thank you for
inviting us and for considering any of our suggestions in the
amendments.
In closing, I want to extend my sincere thank you for your
commitment and hard work in support of our nation's tribal
colleges and Indian tribes.
I think that both of you are true role models for
lawmakers, and I really appreciate it.
Thank you very much for taking this time.
[The prepared statement of Dr. McDonald follows:]
Prepared Statement of Joseph F. McDonald, President, Salish Kootenai
College
Honorable Senators John Tester and Byron Dorgan,
It is an honor to appear before you and offer this testimony. Thank
you very much. I also extend my thanks to the Crow Tribe for hosting
this field hearing.
There is a need to recruit American Indian students into the
various medical provider professions ranging from LPN's to medical
doctors. It is difficult to recruit skilled medical professionals to
work in our rurally isolated Indian communities. The most efficient way
is to recruit, and train American Indian medical staff. They are more
willing to serve on their reservations and will provide consistent
service to their communities.
At Salish Kootenai College we started a nursing program in 1989.
Thus far we have graduated 432 nurses, 202 are American Indian nurses.
Our passage rate of NCLEX certification examination has averaged over
90 percent. Our American Indian nurses that have graduated from Salish
Kootenai College serve the hospital here at Crow Agency as well as the
hospitals on the Blackfeet Indian Reservation, the Fort Belknap Indian
Reservation, the health service agencies on each reservation, private
hospitals, nursing homes, and home health agencies throughout Montana.
When we started our nursing program in 1989 there was only one
identified American Indian student in nursing programs in Montana. This
fall we will have 46 American Indian students in our nursing education
program. We will also have 41 non-Indian students.
We also have a training program for dental assisting technology.
Graduates of the program are eligible to take the Licensure Examination
and become certified dental assistants. Our graduates work in Indian
dental clinics throughout ``Indian Country'' and Alaska. Some go on to
become dental hygienists.
There is a need to have educational programs that lead to licensure
in other medical fields such as dental hygiene, occupational therapy,
x-ray technicians, laboratory technicians, medical records technology,
and many others.
Health care is one of the fastest growing areas for employment in
Montana. It provides a great opportunity for employment for American
Indian people.
Our K-12 students on our Reservations need to be encouraged to
think of working in the health care field. Appropriate classroom
instruction and counseling is needed to build confidence, competence,
and desire to pursue a career in the health care field.
Once students are recruited into the program, they require help to
overcome the many barriers and problems they encounter. Individual
finance is a problem. In addition to family maintenance, students have
the cost of going from Pablo to Missoula or Kalispell for their
hospital practicum. Tutoring is needed, and counseling services are a
necessity.
Many of the Indian students that come need help in basic college
skills and need to complete prerequisites before entering the nursing
programs. Once they enter the nursing program, the study demands are
enormous. The graduating nurse must be very skilled and competent.
Costs to the college for health care provider training are much
greater than for most training in fields of study.
At Salish Kootenai College we really struggle to find the fiscal
resources and the instructional staff to maintain our nursing education
programs. We are competing poorly for faculty salaries and our turn
over rate of nursing instructors is much higher than for the rest of
our college.
In summary, American Indian students can be recruited and retained
in health care professions such as nursing. Retention depends on
adequate funding for the student and adequate funding for the college
providing the program. Continuing to increase the funding of the Tribal
College Act would be a great help and would get tribal colleges funding
equal to the state allocation averages for 2 and 4 year mainstream
institutions.
The passage of the legislation, S. 1779 entitled THE PATH will help
greatly also. It is an Act that will help prepare an American Indian
health workforce, improve health and wellness of students and their
families, and combat substance abuse. It has been introduced by you two
Senators and I thank you for it. And I speak for all of our colleges in
extending thanks to you.
Passage of the Indian Health Care Improvement Reauthorization Act
of 2007 will provide valuable assistance to our tribal colleges. We
have asked for some amendments in the legislation. The amendments
address: (1) delivery of health training programs; (2) recruitment and
retention of Native American nurses in our associate and bachelor
degree programs; (3) scholarship payback options that would allow
payback to include teaching in a tribal college nursing program; and
(4) addition of a provision that would authorize TCU-based social work
and psychology degree programs.
The specific amendments are as follows:
``SEC. 104(b)(1) INDIAN HEALTH PROFESSIONS SCHOLARSHIPS, ACTIVE
DUTY SERVICE OBLIGATION--OBLIGATION MET''
Add a subsection (D) to read ``In a teaching capacity in a tribal
college nursing (or related health profession) program.''
``SEC. 113. INDIAN RECRUITMENT AND RETENTION PROGRAM.''
Add a subsection (c) to read: ``Tribal college health education
programs shall be accorded priority for funding pursuant to this
section.''
``SEC. 115(d) QUENTIN N. BURDICK AMERICAN INDIANS INTO NURSING
PROGRAM, PREFERENCES FOR GRANT RECIPIENTS''--
Add a subsection (5) to read: ``Programs conducted by tribal
colleges.''
``SEC. 115(f) QUENTIN N. BURDICK AMERICAN INDIANS INTO NURSING
PROGRAM, ACTIVE DUTY SERVICE OBLIGATION''--
Add a subsection (5) to read: ``teaching in a tribal college
nursing program.''
``SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY COLLEGES. (a)
GRANTS TO ESTABLISH PROGRAMS--(1) IN GENERAL--
It is essential to recognize that several tribal colleges,
including Salish Kootenai College, are accredited as 4-year
institutions of higher education by regional accrediting associations,
rather than classified or accredited as ``community colleges.''
Construed to its logical extreme, Salish Kootenai College could
arguably be considered ineligible for a training grant under this
section, notwithstanding that it is a community college in the more
global sense. We do not think this is Congress' intent. We therefore
recommend modifying the first sentence of this subsection to read:
``The Secretary, acting through the Service, shall award grants
to accredited and accessible community colleges or tribal
colleges for the purpose of assisting such colleges in the
establishment of programs which provide education in a health
profession leading to a degree or diploma in a health
profession for individuals who desire to practice such
profession on or near a reservation or in an Indian Health
Program.''
We further recommend that this language change be reflected in
subsection ``118(a)(2) AMOUNT OF GRANTS,''--which should also increase
the minimum annual grant award, as follows:
``The amount of any grant awarded to a community or tribal
college under paragraph (1) for the first year in which such a
grant is provided to the community or tribal college shall not
exceed $250,000.''
The rationale for the increase of the first-year ceiling level from
$100,000 to $250,000 rests with the fact that it is virtually
impossible to adequately or credibly initiate a health career-training
program with $100,000. This low amount is a set-up for failure from the
beginning and accordingly needs to be increased.
Also, the term ``or tribal college'' should be inserted after the
phrase ``accredited and accessible community colleges'' or ``community
college'' in Sections 118(b)(1), (2), and Section 118(c).
Under Section 118(b)(2)(C)(i), strike the word ``advanced'' before
the phrase ``baccalaureate or graduate'', as it is redundant,
confusing, and unnecessary.
As to Section 118(a) and (b), we urge that language be added to the
effect ``Priority for the award of funds under this subsection shall be
accorded to accredited tribal colleges with nursing programs.''
Finally, for purposes of consistency, we recommend that the title
of Section 118 be changed to read: ``HEALTH TRAINING PROGRAMS OF
COMMUNITY OR TRIBAL COLLEGES.''
``SEC. 126. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL CURRICULA
DEMONSTRATION PROGRAMS''
We recommend that tribal college social work and psychology
programs be added to this section. In the case of Salish Kootenai
College, our former substance abuse program has been incorporated in
our new social work program. This appears to be the trend. The same
holds true for psychology programs, which have essentially incorporated
former stand-alone substance abuse curricula under the psychology
rubric.
``SEC. 126 (c) TIME PERIOD OF ASSISTANCE; RENEWAL''
A 1-year period is simply too short of a timeframe to administer or
renew an academic program. Accrediting agencies require a minimum of a
3-year timeframe for approval of any new program. These types of
programs are two or 4-year programs, i.e., multi-year. Program and
student learning outcomes (and academic planning and assessment, and
budgeting) are accordingly based on multi-year timeframes, usually 3-5
years. In short, a 1-year life period is wholly unrealistic from all
relevant perspectives.
Mr. Chairman, we thank you for considering our concerns regarding
these much needed amendments to the Indian Health Care Improvement Act.
We respectfully ask you to include this letter in the record of the
Committee's mark-up of S. 1057.
In closing, please accept my sincere thank you for your
longstanding commitment, hard work, and support of our Nation's tribal
colleges and Indian tribes. You are a true role model for lawmakers,
and we will forever appreciate your service. My kindest regards.
Thank you for taking the time to hear about health care for
American Indians.
Senator Dorgan. Dr. McDonald, thank you very much.
Let me mention, as I prepare to recognize Ada White, that
THE PATH legislation that you referred to is legislation that
Senator Tester and I have jointly introduced in July.
Senator Tester has added a great deal with this idea to the
opportunities in education, and I am proud to be a partner with
him and we intend to push it. And I think it's a testament to
Senator Tester's concern and aggressiveness on these issues. So
thank you very much for mentioning that.
Next we will hear from Ms. Ada White, the Health Service
Director of the Crow Tribe.
Ms. White, if you will pull the microphone very, very
close, and you may summarize and your statement will be part of
the record.
STATEMENT OF ADA M. WHITE, HEALTH SERVICE DIRECTOR, CROW TRIBE
Ms. White. Good afternoon, distinguished members of the
U.S. Senate. I am welcoming you to Crow Country, and I thank
you for this great opportunity to provide testimony on behalf
of the Crow Tribal health concerns.
As stated earlier, my name is Ada White. Like many people
in this room, I have devoted most of my life to working for the
Crow Tribe. I can find a lot of value in the fact that we've
had a lot of development, and I've been with the tribe for over
36, 37 years.
I share this information because I want to illustrate my
passion and commitment to the health and welfare of the Crow
people. Throughout my years of being involved, I have always
worked to strengthen tribal sovereignty, to further tribal
self-determination, and to remain vigilant in helping enforce
other Federal trust responsibilities.
Senator Dorgan and Senator Tester, and other members of the
Indian Affairs Committee, I commend your commitment to Indian
Country. I commend your vigilance in watching what's happening
on Capitol Hill, protecting our interests.
In particular, I am certainly indebted to your work in
working for the reauthorization of the Indian Health Care
Improvement Act, working on a special diabetes initiative, and
also keeping in the forefront that it is the responsibility of
the Federal Government to honor trust agreements, trust
responsibilities as it relates to health care.
Unfortunately, this is a challenge that we must continually
work on, and that is to dispel the myth that scheduled
ordinance provision of Indian health care is optional. And as
we have heard from a speaker alluded to earlier, health care is
a must; money is a must to develop health care.
And as stated by my colleague from the Fort Peck
Reservation, James Melbourne, he and I spoke, he says the issue
of entitlement versus discretionary funding must be addressed
by Congress.
Health care provider for the Federal Government, as stated
earlier, is based on the various acts and treaties, and for the
Crow Tribe, it's the 1868 Treaty at Fort Laramie, the 1904 Crow
Tribe Federal agreement and the 1920 Crow Allotment Act.
Despite all this, today we are facing that fact that Indian
Health Service is appropriating less than half of the necessary
funding to provide basic medical services for the Crow people.
I bring to your attention, and I've attached it to my
testimony, a recent article entitled ``Cardiovascular Risk
Factors in Montana--American Indians With or Without
Diabetes.''
The rationing of health care for American Indians described
in the recent Institute of Medicine report on racial and ethnic
disparities, emphasizes the lack of resources for preventive
care in this population. And certainly we know that we get a
lot of lip service on prevention, but when it comes to
providing money for the actual provision of those activities,
we have no funds.
I am now going to direct my comments to the health care as
it is, as we experience it here on the Crow Reservation. And I
know that in the audience, Crow people are listening to how I
cover this topic.
You have been inundated with statistics. I can see them
coming out of your ears. I know that's all you hear in
Washington, D.C. Today, I am going to present some real
information as to what it means for Crow people to receive
health care.
And before I do, I know that my comments and my
observations may be perceived by some as bashing of Indian
Health Service people, however, I want to take this time to
commend the highly committed, the deeply compassionate and
under appreciated health care professionals who serve our
community.
However, I must be honest about dire conditions that exist
here on Crow Reservation so that we may work together to
address the problems. And as alluded to earlier, these problems
are apparent in all of the reservations within the Billings
Area.
I direct your attention to a meeting held in Billings,
Montana August 2, 2006, wherein Dr. Charles Grim, the Director
of the Indian Health Service, was asked for improved health
services. Dr. Grim responded, quote, ``Indian Health Service,
people are the services.'' So what does that do when you look
at Indian health care, that means we look at people providing
those services within the IHS system.
As has been shared, in June of 2006, the Crow service unit
fiscal deficit was approximately 4.3 million. At a meeting
yesterday, I was told that the deficit is 12.3 for this year. I
asked at that time, have you resolved that 4.3 deficit, and no,
it has not.
That just illustrates the accumulation of the deficits that
have gone on here at the Crow service unit historically.
I remember several years ago, I asked a question to the
acting Service Unit Director about personnel and project costs.
Again, I quote, ``67 percent of the local budget was applied to
personnel salaries.''
I remember a comment that our esteemed chairman asked Dr.
Charles Grim in Billings. He said, ``If there are no funds for
pay raises, why give it?'' Dr. Charles Grim at the time
responded that he got that money from third-party
reimbursements. And we know that third-party reimbursements is
a collection activity that sometimes is realized, most often
not.
Again, at the same meeting in Billings, Montana on August
7, 2006, Billings Area IHS Director Pete Conway stated, quote,
``As the dollar get's tighter, there is a need to find ways to
cut in other areas.'' The implications of this statement are
evidenced in many areas.
For example, one, according to Indian Health Service, there
has been a 46 percent increase in denials from Indian Health
Service for services through the contract health service
program from 2001 to 2006. In an article in the Great Falls
Tribune, IHS stated that it's an effort to budget the funds
available efficiently.
Two, the deferred contract health service list increases
daily. For those waiting in excess of several years and living
in constant pain, there is often prolonged use of pain
medication that cause a host of other medical problems, which
may too go unaddressed due to the lack of funding.
As people like to say, ``if it ain't broke, don't fix it.''
In this case, CHS is beyond repair. We pose a challenge for the
decisionmakers in IHS to explore other options. If the CHS
system is not working, come forth with something else that
will.
Third point, prescriptions originating from contract health
care referrals are not filled locally. Over the counter
medications are not provided locally. Certain drugs have been
eliminated. The result is that financially strapped individuals
are unable to purchase needed medications that have been
prescribed for them.
Many of us in here are working, but there are many Crow
people living out there that have very little money to purchase
over the counter medications. A member of the Crow legislative
body brought to my attention the fact that his wife cannot get
the arthritis medication that she had been receiving for
treatment prior years.
I go on to point four, access to proper health care is
inadequate, and in many cases, is denied. I know every Crow
person in this room listening to this testimony can provide
examples of the deficiency and lack of health care, and I
encourage those persons to share their stories with members of
the Senate Committee.
I will personally at this point share with you two cases
involving members of my family. Additionally, I will be
providing several more copies of letters that have been
provided for me.
Senator Dorgan. Ms. White, I want you to share both of
those cases, and then following that, I need to have you
summarize because we have to have the other testimony.
Ms. White. Thank you. Thank you.
Senator Dorgan. But why don't you share both of those
cases.
Ms. White. First, you have here a very cute little girl in
her native outfit, that was very hard work, good to see, but
difficult. People say there is a thousand words in pictures. I
show this picture of my 5-year-old granddaughter. This was
taken at the Lodge Grass Pow-Wow last July. My granddaughter
left us, she died short of a year ago.
From May, 2006 to August of 2006, numerous visits were made
to the clinic at Crow. During this time, Ta'shon (phonetic) was
treated for depression. During one of her clinic visits,
Ta'shon's grandfather pointed out the bulbous condition on her
fingertips and toes, which is indicative of a lack of oxygen.
In June, 2006, I spoke with Ta'shon's doctor and asked the
doctor to eliminate cancer and leukemia. On August 7, 2006, my
granddaughter was rushed from the Crow clinic to St. Vincent
Hospital in Billings due to a collapsed lung.
She was airlifted to Denver. After being there 5 days, we
were told that she had a tumor that was untreatable and
incurable. She died on September 1st.
The point is, if she had been diagnosed earlier, could some
of that have been prevented? I believe she spent the last 2
years of her life in unmedicated pain. One premature death of a
child who suffered excruciating pain is too much for the
conscience.
Case two, Ta'shon's great-grandmother, Ada Rides the Horse
was brought to the Crow Emergency Room, waited 3 hours, taken
by her daughter to the Hardin Clinic, transferred from the
Hardin Clinic to St. V's, she died in the Emergency Room from a
ruptured aneurism.
The RN who was working at the Crow Emergency Room says
later to Ada's daughter, I'm sorry, if I would have known, I
would have taken your mother right in.
Those are the two stories I'd like to share. There are
other points here. We have received a lot of information. We
compliment you, the support that you have given us.
Pryor people, Lodge Grass people are concerned about the
continual discussions about the possibility of closing those
clinics, and again, the same financial considerations exist.
People do not have the money to come to Crow.
Again, you will get all the information, and I present this
to the Committee.
Thank you very much.
[The prepared statement of Ms. White follows:]
Prepared Statement of Ada M. White, Health Service Director, Crow Tribe
To the august Members of the U.S. Senate, serving on the Senate
Select Committee of Indian Affairs, welcome to Crow Country. On behalf
of the Crow Tribal Members, I thank you for this opportunity to provide
Crow Tribal Health concerns to this esteemed Body.
My name is Ada White, I am a member of the Crow Tribe, and
currently employed by the Crow Tribe as the Director of the Crow tribal
Health Department. Previously, some 17 years ago, I worked in Tribal
Health, as the Director of the Community Health representatives Program
for nineteen years. I briefly worked for Indian Health Service for 18
months, and returned to Crow Tribal Employment in the Administrative
Department (Finance, Social Services and Administrative Officer) for 10
years. I then became employed by the Little Big Horn College as the
Grants and Contracts Officer for 3 years, and have been back with the
Crow Tribe, at the Health Department for an additional 4 years. I share
my employment history for the sole purpose in validating the commitment
and involvement I've had in the various aspects of Tribal Health
development. Throughout these years, the maintenance and protection of
the Federal Trust Responsibility; the strengthening of Tribal
Sovereignty, and the enhancement of Tribal self-determination have been
dominant in my endeavors.
Senator Dorgan, Senator Tester and other members of the Senate
Committee on Indian Affairs, I commend your vigilance, in assuring the
Indian Tribes of this Country that Indian Health Care is a Federal
Trust Responsibility.
However, as Tribal Groups continue to work with the Federal
Government, this Trust Responsibility must be promulgated and enforced.
According to my Colleague (James Melborne) from the Ft. Peck
Reservation, ``the issue of entitlement versus discretionary funding
must be addressed by Congress.''
On July 3, 2007, an article in the Great Falls Tribune stated,
``access to and the availability of health care for the First Americans
of this Nation was a trust contract in the Constitution in 1787.''
Certainly, Members of the Crow Tribe firmly believe health care is
assured in the Ft. Laramie Treaty of 1855.
We are also cognizant of this Great Nation's growing pains in
affording basic human rights to its citizenry: the need for the Civil
Rights Act; the need for the Voting Rights Act (there is a pending case
here in Big Horn County, filed by the Citizens Equal Rights Alliance a
right winged group alleging ``denying non-tribal members an opportunity
to participate effectively in the political process on an equal basis
with other members of the electorate. .''); the list can go on and on.
To those associated with the current Administration in Washington, D.C.
alleging ``race based'' considerations, I strongly urge their perusal
of printed materials and studies which document racism in the delivery
of health care; race based discrepancies in health care and funding
restrictions prohibiting resource parity.
I quote from an article, CARDIOVASCULAR RISK FACTORS IN MONTANA
AMERICAN INDIANS WITH AND WITHOUT DIABETES, ``Yet the rationing of
health care for American Indians described in the recent Institute Of
Medicine Report on Racial and Ethnic Disparities emphasizes the lack of
resources for preventive care in this population.'' A dichotomy is
self-evident wherein a major study indicates a lack of funding for
preventive care, and Indian Health is emphasizing Health Promotion and
Disease Prevention. Or, most likely it's the ``catch up'' syndrome.
Honorable Senators Dorgan and Tester, we know you are monitoring
this race based phenomena very closely, and you have voiced your
displeasure, and for this we are most grateful.
I will now proceed in localizing my observations to the Crow Tribal
Health Care concerns. Let me emphasize, that my observations and
comments are not to be interrupted as ``Indian Health Service
Bashings.'' I know we have many Health Professionals highly committed,
deeply compassionate and under recognized for their services.
HEALTH CARE MEANS ACCESSING HEALTH RESOURCES. HEALTH CARE MEANS THE
PROVISION OF HEALTH SERVICES. BEING HEALTHY MEANS A CONDITION OF
WELLNESS, OR FEELING WELL.
At a meeting in Billings, Montana, August 2, 2006, Dr. Charles
Grimm, the Director of Indian Health Service was asked about the
prospect for improved health services, and his response was, ``Indian
Health Service people are the services.'' So this leads one to focus
attention on ``the people.''
THE CURRENT STATE, RELATIVE TO HEALTH CARE, OF THE CROW INDIAN
HEALTH SERVICE HOSPITAL AND CLINICS HAS EXCEEDED THE CRISIS MODE. What
is being provided by Indian Health Service is woefully inadequate and
can be classified as scandalous, unconscionable.
Approximately 3 years ago, the Acting CEO of the Crow Service Unit
stated that ``67 percent'' of the local budget was applied to personnel
salaries.
June 2006, Indian Health Service indicated the Crow Service Unit
fiscal deficit was approximately 4.3 million.
August 2, 2006 at a meeting in Billings, Montana, Mr. Pete Conway,
the Director of the Billings Area Indian Health Service stated: ``As
the dollar gets tighter, there is a need to finds ways to cut in other
areas.'' What implications does this comment bear locally, Consider:
1. According to Indian Health Service, there has been a 46
percent increase in denials from Indian Health Service for
services through the Contract Health Service Program from 2001
to 2006. It's an effort to budget the funds available, $520.5
million in Fiscal Year 2006 efficiently'' (Great Falls Tribune
Article, July 3, 2007).
2. The deferred Contract Health Service surgical list increases
daily. For those waiting in excess of several years, and
experiencing continual pain, prolonged usage of pain medication
leaves other undesirable results.
3.Prescriptions originating from Contract Health Care referrals
are not filled locally. Over the Counter Medications are not
provided locally.
Financially strapped individuals are unable to purchase needed
medications. Is this a National policy for all Indian Health Service
Facilities?
4. Access to proper health care is inadequate or in some cases
denied. Each Crow Person in this room, listening to this
testimony, can provide examples of unanticipated results of
this concern. I personally share with you the following two
cases.
Case One: My 5 year old granddaughter, Ta'Shon Rain Little
light, died September 1, 2206. From May of 2006 to August 7,
2006, numerous visits were made to the Crow Clinic for
services. During this time, Ta'Shon was being treated for
depression. During one of the Clinic Visits, Ta'Shons
Grandfather pointed out the bulbous condition of her finger
tips and toes. This condition is indicative of a lack of
oxygen. June 2006, I spoke with Ta'shons Doctor and I asked the
Doctor to eliminate cancer and leukemia. August 7, 2006, My
Granddaughter was rushed from the Crow Clinic to St. Vincent
Hospital in Billings, Montana for a collapsed lung. The next
day Ta'Shon was air lifted to the Denver Children's Hospital,
where she was diagnosed with an untreatable, incurable form of
cancer. The question remains, what if this tumor was detected
earlier, would it have made a difference? Our baby lived with
unmedicated pain, the last 3 months of her life. Even one
premature death is too much.
Case Two: June 2003, Ta'Shons Great Grandmother, Ada Rides
Horse visited the Crow Emergency Room for stomach pain. After a
wait of 3 hours, her daughter transported her to the Hardin
Hospital (12 miles NW of Crow) for care. Ada Rides Horse was
admitted, and then transferred to the St. Vincent Hospital in
Billings, where she died in the Emergency Room from a ruptured
aneurysm. The ordeal did not end here. The RN who was working
in the Crow Emergency Room later approached Ada Rides Horse'
daughter and said: ``I'm sorry, if I were clairvoyant, I would
have taken your mother right in.''
5. The excessive waiting time for services (Out Patient Clinic,
ER, Pharmacy) needs to be addressed. Throughout the years, the
local facility has tried to modify some of the national trends
and adapt them for local operations, but rather that producing
a positive result, the bureaucratic stratum increases. Case at
hand is having a walk in clinic; add walk in clinic plus a
speciality clinic; add walk in clinic, speciality clinic, plus
prescheduled appointments with specified providers. Tuesday,
August 8, 2007, I waited 3 hours at the Out Patient Clinic,
then I was called to the ER for care. The waiting continues,
patients become angry, and providers become defensive.
The problem in waiting, and not having enough providers on a given
day could be addressed by having some of the professional health
administrators, including the Commissioned Officers Corp provide some
``hands on'' care. Again, I am reminded of Dr. Grimm's Statement that
Our health care is the ``Indian Health Service People.''
I inquired about the list of Medical Professionals posted on the
wall in the Crow Waiting Room, and the ER Nurse stated that ``\1/2\ of
them have left.'' This may be so, however, three of the current
Physician's are employed part-time (Wilson, L. Byron, Upchurch). This
certainly affects the level of care, and may also affect the
recruitment process, because it ties up 1.5 positions.
Our distinquished Crow Tribal Chairman, Mr. Carl Venne asked Dr.
Charles Grimm, the Director of Indian Health Service, ``if no
additional funding is provided for pay raises, why give it? '' Dr.
Grimm responded, ``We make up for this with third party
reimbursements.'' What impact does the fluctuations in third party
collections have on this reasoning? Futhermore, a pay and time audit
may be necessary to fully understand the issues surrounding employee
pay. What we do know is that the salary and benefits for Commissioned
Officer Corp Members runs much higher than it does for a Civil Service
Employee.
There are several other concerns that impact the level of
resources, which impacts the level of care.
1. It has been reported to the Crow tribal Health Board that
non-beneficiaries receive treatment at the Crow facility. The
concern becomes one in determining whether reimbursements are
received for these services?
2. Vacant positions need to be advertised and filled according
to established procedures and Federal requirements; in lieu of
filling these positions, contracts are awarded for services. Is
there a sizable cost savings in this procedure? Recently there
was controversy in the way the Director of Nursing position was
filled, and then ``unfilled.'' Actions of this sort impact the
morale of the service Unit, which in turn impacts the kind of
service Crow People receive.
Certainly, we applaud the efforts of this Senate Committee on
Indian Affairs and their passionate support in pursing the:
reauthorization of the Indian Health Care Improvement Act; recognizing
the effects of Diabetes and addressing the Special Diabetes initiative.
Yet the need for quality health care, which resonated in the past, and
continues today, is an ever present challenge. How does the
equalization in health care occur? As long as we have a dual health
care system (the haves and the have not's); as long as socioeconomic
disparities are apparent, there is going to be a continual need for
this Committee Senators.
The provision of Dialysis is a health concern, and Indian Health
Service can no longer bury its head in the sand, hoping this issue will
dissipate. We need one funding source for this, available for all
Tribes. Diabetes is the fifth (out of ten) ranked health problem for
the Crow Reservation.
We need to continually fund the Epidemiology Center serving the
Billings Area Tribes. The data collected will be made available to and
will be utilized by the specific Tribes.
Funds need to be identified and made available for HPV
immunizations. A recent article in the Billings Gazette identified the
Crow reservation as having the highest reported cases of HPV
infections. Approximately 50 percent of the Crow Tribal enrollment is
under the age of 30. This is the age group with pronounced sexual
activity.
Long term planning and resource identification needs to be
addressed for the problems associated with aging, especially for the
``baby boomers.'' It is anticipated that Cancer and Diabetes will have
an increased prevalence in this group. Expanded care for this age group
includes: nursing home care; assisted living; independent living
services (including home monitoring and health tracking measures);
ophthalmology; prosthetics; mental health.
Senators, the Crow People have a rich heritage. There is a bit of
ethnocentrism, for Crow Speakers still abound, traditional and cultural
practices are adhered to. It is this identity has been the cohesiveness
quality that has kept the Crow Tribe distinct among other groups.
Again, thank you for this opportunity to share the Health Concerns
of the Crow People.
Senator Dorgan. Ms. White, thank you very much, and thank
you for your powerful statement, and we grieve for your loss of
that beautiful young girl.
Let me also thank you for 17 years of work in Indian health
care. That's great dedication. We appreciate your being here
and we will read very carefully the testimony you have
presented as well.
State Representative Jonathan Windy Boy. Representative
Windy Boy, thank you very much for coming. Let me ask if you
would summarize.
I think following your testimony, we will hear from Mr.
Moke Eaglefeathers as well. So if you would summarize, we would
appreciate it very much.
We thank you for your service and thank you for being here,
Representative.
STATEMENT OF HON. JONATHAN WINDY BOY, COUNCIL
MEMBER, CHIPPEWA CREE TRIBE BUSINESS COMMITTEE; MONTANA
REPRESENTATIVE, HOUSE DISTRICT 32
Mr. Windy Boy. Thank you Chairman Dorgan and Senator Tester
for having this hearing.
For the record, my name is Jonathan Windy Boy. I'm a member
of the Chippewa Cree Tribal Council, and also State Legislator
representing House District 32, Chairman of the Rocky Boy
Health Board, and also been appointed Chairman of the National
Caucus of Native American State Legislators Committee on
Health.
I'm going to kind of zip through my testimony here because
you can probably get a copy of it and highlight it.
The situation today is the under-funding of Indian health
care and American Indian health disparities. Under-funding of
Indian health care for some time now in the United States is
not under the true meaning of health services for American
Indian people.
The medical inflationary rate over the past 10 years sat at
11 percent. The average increase for IHS accounts over the same
period has been only 4 percent so that those numbers are kind
of off a little bit from each other on the true need.
In FY 1984, IHS services account received 777 million; in
FY 1993, the budget totaled 1.5 million. Still 13 years later
in 2006, the budget for health services was 2.7 billion, when
to keep pace with inflation and population growth, this figure
should be more like 7.2 billion.
American Indians die at higher rates than other Americans
from tuberculosis at 600 percent higher; alcoholism, 510
percent higher; motor vehicle crashes, 229 percent higher;
diabetes, 18 percent higher; unintentional injuries, 152
percent higher; homicides, 61 percent higher.
There are many challenges in the existing health care
budget, and one of the things that you have heard earlier from
some of the Federal Government is that Medicaid third-party
reimbursements has been accounted for.
And I think the misnomer with that, I feel is that should
not be included in IHS funding, because that is pretty much a
given for the tribes and the states at 100 percent last year.
So I think that should be excluded from the IHS budget.
You know, Mr. Chairman, Senator, aside from all of these
facts and figures and all of that, I want to go back to a real
life happening at home. I have an aunt that's 77 years old. For
several years now she's been diagnosed as a diabetic. She
travels to Great Falls Monday, Wednesday and Friday for
dialysis. That's 120 miles from Rocky Boy to Great Falls.
I have some of my constituents at home that go to dialysis
three times a week to Billings, and that's 250 miles one way.
So if you take those figures, you're looking at 1500 miles
a week to Billings, approximately 720 miles to Great Falls and
back.
If you can imagine the same situation with Fort Peck having
to come to Billings, which is approximately 300 miles one way,
and if a diabetic has to go through the dialysis that's needed
just to stay alive, the remoteness that we have is one of the
factors that tribes in Montana are up against.
Fort Belknap is in a similar situation. They're about 200
miles from Billings, round-trip 400, multiply that times three,
1200 miles. Great Falls is about 160 miles one way. So the
remoteness is really a factor that hasn't really been placed
into call here.
One of the things when you're talking about contract health
services, right now in the middle of July, we have over 360-
some thousand dollars short in my contract health services
budget, and I still have 3 months to go. And if I'm going to be
only having to provide life or limb for those members, I'm
going to be in a real stickler here very shortly.
One of the things too, you know, about recently with the
contract health dollars, there's something that isn't talked
about. You know, when a person who has an emergency to them
which does not fall under the regulations of IHS regulations,
then that individual will go to the Emergency Room. In my case,
we go to Havre or Great Falls.
If they don't fit under those standards, qualifications to
receive contract health service dollars, then those bills are
going to accrue and accrue and accrue, and finally those
hospitals are going to send them to the credit bureau and
that's a reality. And I'm even on that credit bureau for health
services.
One of the things too, you know, it was kind of ironic to
hear that a dentist from Helena that testified in Senator
Baucus' hearing on CHIP a couple months ago, provided
testimony, and why it was ironic to me is because he said that
there was a child who needed surgery, orthodontic surgery, a
child from Box Elder, and that's, come to find out that's one
of my grandkids. And if they had waited a couple more days,
that child would have died from that.
So, you know, the levels of what the Feds and everybody
else tells you, that everything's fine and dandy, you know,
that's a bunch of hogwash.
Every time as a tribal leader, we go to D.C., we go to HHS,
we go to different departments. The one thing that they tell
us, is okay, you go back to the states, we've funneled more
money into the states that you're eligible for. We have grants
that the tribes are eligible for.
If you know the granting process, there's 560-some tribes
across the country, and if we have to complete, the ones with
the best grant writers are going to get the money. So that's
another thing that we're up against as tribal leaders as well.
And also, too, on Medicaid, we talk about Medicaid and the
barriers that we see. One of the things that we see on my local
level is, I'll give you an example of an elderly couple. Right
away that elderly couple, on any reservation, when they see a
brand-new, spanking new car come driving up the driveway, a
non-native guy looking like Jon Tester--in jest, Jon--but
anyway, right away they're going to be cautious.
They're going to take a couple of steps back because
they're not going to trust. Trust is a real thing that we're up
against as far as one of the barriers. And I think in order to
make the Medicaid eligibility process, we need to train our
home to be in that process.
So again, I want to thank you for having this hearing, and
thank you for letting me be a part of your panel, and I'll be
open for questions.
Thank you.
[The prepared statement of Representative Windy Boy
follows:]
Prepared Statement of Hon. Jonathan Windy Boy, Council Member,
Chippewa Cree Tribe Business Committee; Montana Representative, House
District 32
Good afternoon, Chairman Dorgan and Senator Tester. My name is
Jonathan Windy Boy. I am an enrolled member of the Chippewa Cree Tribe
of Rocky Boy's Reservation and a citizen of the beautiful State of
Montana. I have the honor to serve as a council member for the Chippewa
Cree Tribe Business Committee. I also serve as a Representative in the
Montana State Legislature, House District 32. I serve as the Chairman
of the Rocky Boy Health Board, the governing body for the Chippewa Cree
Health Center. I also serve as the chair of the Montana Wyoming Tribal
Leaders Council--Subcommittee on Health and I was recently appointed
the interim Chairman of the National Caucus of Native American State
Legislators'--Subcommittee on Health. I appreciate this opportunity to
address the healthcare issues of the Montana Tribes. I would like to
thank the Committee for the opportunity to testify at this ``Field
Hearing on Indian Healthcare.''
Before I begin this testimony, I would like to reaffirm the
foundation of the provision of health services in relationship to the
sovereign status of Tribes.
``No right is more sacred to a nation, to a people, than the right
to freely determine its social, economic, political and cultural future
without external interference. The fullest expression of this right
occurs when a nation freely governs itself.''
The Late Joseph B. DeLaCruz, Former President, Quinault Nation,
1972-1993.
The Foundation: Tribal Sovereignty and the Provision of Health Services
The overarching principle of Tribal sovereignty is that Tribes are
and have always been sovereign nations, Tribes pre-existed the Federal
Union and draw our right from our original status as sovereigns before
European arrival.
The provision of health services to Tribes is a direct result of
treaties and executive orders entered into between the United States
and Tribes. This Federal trust responsibility forms the basis of
providing health care to Tribal people. This relationship has been
reaffirmed by numerous court decisions, Presidential proclamations, and
Congressional laws.
The Situation Today: Underfunding of Indian Healthcare and American
Indian/Alaska Native Health Disparities
Underfunding of Indian Healthcare
For some time now, the United States has not funded the true need
of health services for AI/AN people. The medical inflationary rate over
the past 10 years has averaged 11 percent. The average increase for the
Indian Health Service (IHS) health services accounts over this same
period has been only 4 percent. This means that IHS/Tribal/Urban Indian
(I/T/U) health programs are forced to absorb the mandatory costs of
inflation, population growth, and pay cost increases by cutting health
care services. There simply is no other way for the I/T/U to absorb
these costs. The basis for calculating inflation used by government
agencies is not consistent with that used by the private sector. OMB
uses an increase ranging from 2-4 percent each year to compensate for
inflation, when the medical inflationary rates range between 7-13
percent. This discrepancy has seriously diminished the purchasing power
of Tribal health programs because medical salaries, pharmaceuticals,
medical equipment, and facilities maintenance cost Tribes the same as
they do the private sector.
In FY 1984, the IHS health services account received $777 million.
In FY 1993, the budget totaled $1.5 billion. Still, thirteen years
later, in FY 2006 the budget for health services was $2.7 billion,
when, to keep pace with inflation and population growth, this figure
should be more than $7.2 billion. This short fall has compounded year
after year resulting in a chronically under-funded health system that
cannot meet the needs of its people.
As the Federal Government develops models that aim to reduce or
eliminate racial and ethnic disparities (i.e., ``Closing the Gap'') a
balance needs to be made between the Federal deficit model (comparison
to All U.S. Races) and a positive development model. Otherwise health
policy (and the subsequent allocation of funding toward Indian
healthcare) will be determined on the basis of Tribes being a
marginalized minority and not as sovereign nations with distinct treaty
rights, which have been negotiated with the ``full faith and honor of
the United States of America.''
American Indian/Alaska Native Health Disparities
American Indians have long experienced lower health status when
compared with other Americans. Disproportionate poverty, discrimination
in the delivery of health services and cultural differences has
contributed to the lower life expectancy and disproportionate disease
burden suffered by American Indians. American Indians born today have a
life expectancy that s 2.4 years less than the US All Races.
American Indians die at higher rates than other Americans from:
Tuberculosis--600 percent higher
Alcoholism--510 percent higher
Motor Vehicle Crashes--229 percent higher
Diabetes--18 percent higher
Unintentional injuries--152 percent higher
Homicide--61 percent higher
Some of these health disparities are historic. Alcoholism continues
to be a serious challenge to American Indian health. Since its
introduction to Tribal people early in this Nation's history, alcohol
has done more to destroy Indian individuals, families and Tribal
communities than any disease. Today in 2007, Tribal people are dying at
a rate 510 percent HIGHER than other Americans from alcoholism. The
overall impact of these health disparities has made us ``at-risk''
communities, weakened and vulnerable. In fact, as reported in a Denver,
Colorado newspaper, the Wind River Reservation in Wyoming was targeted
by Mexican drug cartels because of their history with alcoholism. The
drug dealers figured that the Tribal community (already inundated in
alcohol addiction) would be easy to infiltrate for drug distribution.
Their business plan included marrying into the Tribe, giving free
samples to get people addicted and then get them to distribute to
support their addiction. This is an approach that is being implemented
throughout Indian Country.
Given the significant health disparities that Tribal people suffer,
funding for Indian healthcare should be given the highest priority
within the Federal Government. Many of the diseases that Tribal people
suffer from are completely preventable and/or treatable with adequate
resources and funding.
The Challenges: Access to Medicaid Services, Medicaid and Medicare
Reimbursements, Recruitment and Retention of Health Providers
Access to Medicaid Services
The IHS budget cannot provide the health services needed thus
Tribes must depend upon alternate health resources, such as, Medicaid
for critically needed healthcare for our people. The Indian health
system is funded at less than 60 percent of need and is heavily
dependent upon Medicaid. Understanding this, accessing Medicaid is an
important health issue.
The barriers to accessing Medicaid have been identified by Tribes
through out the years. Though there has been some positive movement,
many of those identified barriers still remain. The most critical of
those identified is the application and eligibility determination
process. This is the first gate and if a Tribal member cannot get
through the first gate--access to needed healthcare is denied. The
application and eligibility determination barriers are often protocols
developed to ``cost contain'' or manage the National Medicaid budget.
Unfortunately, Tribal people often cannot afford to jump through the
``hoops'' of a budget management protocol and the denial of access to
care can be disastrous for the individual Tribal member and their
family.
In FY 2004, the Chippewa Cree Tribe and the Confederated Salish &
Kootenai Tribes partnered with the State of Montana and CMS/Region VIII
to begin discussion on how to alleviate the barriers to accessing
Medicaid for the Montana Tribes. In May 2007, the Chippewa Cree Tribe
signed an agreement with the Governor of Montana and the State of
Montana to contract Medicaid Eligibility Determination. Having the
ability and authorization to determine Medicaid eligibility onsite at
our Tribal healthcare center will facilitate access to care for
eligible Indian users that are eligible Medicaid users. Getting access
to healthcare through Medicaid to those eligible Montana citizens
(whether Indian or non-Indian) as soon as possible benefits the
recipient and the State of Montana. A healthy state community is one
where its citizens can fully participate in education, employment and
economic development.
Medicaid and Medicare Reimbursement
Thirty-one years ago, in 1976, in response to the health conditions
in Indian Country, Congress provided the IHS and Tribes with the
authority to bill for and receive Medicaid and Medicare reimbursements
for services provided to American Indian beneficiaries. Today, Medicaid
and Medicare reimbursements provide a critical source of supplemental
funding for the underfunded IHS and Tribal healthcare delivery service
programs.
Originally Congress did not intend for Medicaid revenue to
``offset'' the strained Indian Healthcare budget but to supplement it.
Today, the IHS and Tribes are expected to bill and collect for Medicaid
to replace IHS appropriations. In the FY 2008 budget Request
Congressional Justification includes specific amounts of Medicaid and
Medicare collections (total of $625,193,000) as part of its total FY
2008 President's request of $4.1 billion. Members of the Committee, we
need this situation remedied in order to realize an appropriate level
of funding for Indian healthcare.
The Indian health system is funded at less than 60 percent of need
and is heavily dependent upon Medicaid payments. States receive 100
percent FMAP for Medicaid services provided in an IHS or Tribal
facility. These facilities have a limited capability to provide all
needed direct care. Any health care not provided by the facility is
referred to a private or public provider. The state must then provide
the regular state Medicaid match for that eligible Indian user/eligible
Medicaid user. Thus states are given an incentive to limit the benefits
that American Indians referred to outside providers would receive under
the state Medicaid plan.
A current issue relating to both Medicaid and Medicare is the
imposition of increased cost sharing or premiums. States may charge a
co-payment for medical services or drugs. The rationale for charging
co-payments is to achieve a more appropriate utilization of Medicaid
covered services. First of all American Indian participation is very
low and the imposition of a co-pay has a negative effect as many
American Indians cannot afford even a modest co-pay (and why would they
if they can receive services from IHS without a co-pay). This could
prevent them from enrolling in Medicaid or Medicare, which could
deprive the chronically underfunded IHS or Tribal facility critical
Medicaid revenue.
Imposing a co-payment has not changed the utilization of American
Indian Medicaid or Medicare beneficiaries because IHS and Tribes do not
charge co-pays to their beneficiaries. Instead co-pay amounts are cost
shifted to the Indian health programs, causing a further reduction to
services they can provide.
Recruitment and Retention of Health Providers
The recruitment and retention of health providers has been a
barrier to effective healthcare delivery for Montana Tribes. As in most
rural areas of this Nation, Montana Tribes are challenged with
providing a continuity of care, because of a high turnover of
healthcare providers. Montana Tribes are located in geographically
isolated areas (only Alaska has a remoteness designation more severe
than Montana). Montana is considered a ``frontier'' area with a
population of less than 6 people per square mile.
It is a challenge to recruit health providers that will commit to a
long term, interact and invest in the Tribal Community and work to
understand and respect the Tribal culture and traditions. These
attributes for health providers are imperative to the effective
provision of healthcare for our Tribal communities. Ideally, most
Tribes want a Tribal member as their healthcare provider, knowing that
a Tribal member would have the maximum investment for their community.
Chairman Dorgan and Senator Tester, it will take the commitment of
the Administration, the U.S. Congress, the State of Montana, and the
Montana Tribes to insure that the issues I have presented are addressed
and accomplished by reauthorizing the Indian Healthcare Improvement
Act. The provisions of the IHCIA will insure that Montana Tribes will
have access to building the healthy Montana Tribal communities where
healthcare is more than a promise but a reality for every man, women
and child. I thank you for this opportunity to provide testimony.
Senator Dorgan. Representative Windy Boy, thank you very
much. Thanks for your service in the state legislature, and
thank you for coming today to testify.
Our final witness is Mr. Moke Eaglefeathers, President of
the National Council of Urban Indian Health and Director of
North American Indian Alliance.
He is accompanied by Ms. Marjorie Bear Don't Walk, Director
of the Indian Health Board of Billings.
I might mention that we had a meeting in Washington D.C. a
while back and Mr. Eaglefeathers was there as well.
So, let me ask you to proceed for the final bit of
testimony, and let me see if we can get a microphone over to
you.
Mr. Eaglefeathers, why don't you proceed. Once again, if
you would please summarize, your entire statement will be made
a part of the permanent record.
MELBERT ``MOKE'' EAGLEFEATHERS, PRESIDENT, NATIONAL COUNCIL OF
URBAN INDIAN HEALTH; DIRECTOR, NORTH AMERICAN INDIAN ALLIANCE;
ACCOMPANIED BY MARJORIE BEAR DON'T WALK, DIRECTOR, INDIAN
HEALTH BOARD,
BILLINGS, MT
Mr. Eaglefeathers. It is an honor for me to be here on
behalf of the National Council of Urban Indian Health, which is
a 36-member organization, and 120,000 urban Indian patients
that are served annually.
I would like to take this opportunity to thank you, and the
opportunity to provide the testimony and address an assessment
of the Indian Health Care Improvement Act.
My name is Melbert Eaglefeathers. You know me as ``Moke''.
I am the Executive Director of the North American Indian
Alliance here in Montana. I also serve as the President of the
National Council of Urban Indian Health. I am a Northern
Cheyenne enrolled member here in Montana.
I am honored to serve as a representative of the urban
Indian population. Thank you for providing me the opportunity
to testify in support of the reauthorized Indian Health
Improvement Act.
Urban Indian Health program has spent the last year
regrouping and solidifying relationships with local and
national tribal leaders. One thing Salish Kootenai was to work
on tribal relationships, I've spent many hours in tribal
leaders' offices and meetings discussing health concerns. To
understand this issue is to look at our next generation for our
health care issue.
At this time, I would like to turn to my colleague,
Marjorie Bear Don't Walk, to talk about the Montana program.
Thank you.
Senator Dorgan. Thank you very much.
Ms. Bear Don't Walk, why don't you proceed?
Ms. Bear Don't Walk. Good afternoon, Chairman Dorgan,
Senator Tester.
I would like to say that the Urban Indian Health program,
we need more money. At the present time 67 percent of Indian
people live off the reservation and they receive 1 percent of
the Indian Health Service budget. By saying that, I would also
like to say, that we do not receive any funds for contract
care.
So, for all of the people who are having problems getting
contract care money, we have none. So our problem with contract
care is that if you are ill and you need contract care, you can
forget it.
The other problem that we have is we need more dollars,
period. One percent of the budget provides the minimal health
care, which is very insulting to any Indian person, let alone a
hurting Indian person who is not eligible for contract care
anywhere.
In Billings, there are about 10,000 Indians, about half of
them are Crows and they are eligible for contract care. About a
fourth of them are Northern Cheyenne, and they are ineligible
for contract care, even though it is the Crow/Northern Cheyenne
hospital. All of the others, and the largest number are Sioux
and Chippewas, are not eligible for contract care.
I am a member of the Confederated Salish and Kootenai
Tribe. Forty-one years ago, when I was young and foolish, I
married a Crow Indian.
[General laughter.]
Senator Dorgan. All right, you're done testifying.
[General laughter.]
Proceed, I'm sorry.
Ms. Bear Don't Walk. His name is Urban Bear Don't Walk, and
I have worked in urban health in excess of 20 years. So, it is
kind of interesting for the definitions of Indian people, of
reservation and urban Indians, when urban Indian, the name
Urban came from a fifth century pope who urbanized Europe.
So we have been branded with the term ``Urban Indians''.
And I hear very often that urban Indians have more opportunity
for health care. That truly is bull. The Indians who have
opportunities in urban areas are the Indian Health Service
workers who have insurance.
Almost all of the other Indians that I know of, unless they
work for the Federal Government, do not have insurance. So if
you're working two jobs or three jobs and you have children and
you need health care, you've got to make a choice, you can use
Indian Health or someplace else.
I have felt that we need to advocate for all Indian people,
that we are all considered as the people who were here when
Columbus landed.
The Federal Government has done a lot to divide us all, and
I would like to see that stop. And we have continued, as Indian
people, to divide ourselves also, and I think that we need to
stop that also.
We, as Indian people, are here in the area of a large
number and my children, while they are Salish and Crow, are
enrolled as Crow Natives.
So I would like to ask the Senate to give more money to
urban Indians for health care, and I would like to see the
health care of urban Indians to be as valuable as anybody
else's health care.
I would like to see Indians, the money appropriated per
capita for people in the United States, I would like to see
where Indian people are no longer at the bottom of that list.
I thank you very much.
[The prepared statements of Mr. Eaglefeathers and Ms. Bear
Don't Walk follow:]
Prepared Statement of Melbert ``Moke'' Eaglefeathers, President,
National Council of Urban Indian Health; Director, North American
Indian Alliance
______
Prepared Statement of Marjorie Bear Don't Walk, Executive Director,
Indian Health Board, Billings, MT
Senator Dorgan. Thank you very much for your testimony.
Thanks to all of you for your testimony.
I know that you have told on occasion a North Dakota joke.
We've told a Montana joke from time to time over on the North
Dakota side of things, but I must tell you that coming to
Montana today has been really impressive for me.
The number of people who have attended this hearing, your
passion, the statements by the witnesses, that is impressive
and a very powerful, strong statement.
You come here at a time when there is a Crow Fair, which
I'm told, I've not attended it, but I'm told is widely attended
and much anticipated. I hope all of you have a wonderful
opportunity to participate in that.
Chairman Venne has been wonderful today to me and to
Senator Tester, as well.
I'm going to have to leave in a little while, and I hope
you will excuse me. I think you will when I tell you why.
I have to be on an airplane at the Billings airport, and
the reason I have to be off an airplane about midnight tonight,
is tomorrow morning I am taking my daughter to college as a
freshman, and we're driving her to college for her first year
of college. And so you understand, I hope, how important that
is to me to be there and catch that airplane.
So I will take my leave in a few minutes and ask Senator
Tester to continue chairing the remainder of this hearing.
I also want to say this, David Mullon, who I introduced
earlier, is a member of our staff, has been a member of the
staff as a Chief of Staff and now Chief of Staff to the
minority, David is from the Cherokee Tribe in Oklahoma. David
is right here.
Heidi Frechette, sitting over there, Heidi, would you stand
up? Heidi is a counsel, an attorney on our staff in the Indian
Affairs Committee, and she is from the Menominee Tribe in
Wisconsin.
At the end of this hearing, both David and Heidi will also
be here and available to spend time with those who have some
issues you want to discuss personally with our staff. And I'd
like you to feel free to seek them out if you would.
My understanding also is that Senator Tester will,
following questioning of this panel, be taking some brief
statements by other tribal officials who have come today and
who have not been able to testify.
But if you will allow me to take my leave for the purpose I
have described, I want to tomorrow morning be driving my young
daughter to her first year in college, and so I want to catch
that airplane out of Billings.
But again, let me say a heartfelt thanks, and to tell you
this, with Senator Tester, myself, Senator Baucus, and so many
others, we will work very, very hard.
This is not just some other time. This is the time for us
to demand that these things get fixed, and I pledge to you
that's what's going to happen. We're going to work and work and
work, and we're going to get things fixed and make some
progress.
So, let me with that turn it over to Senator Tester to
chair the remainder of the hearing, and I thank you for your
hospitality and your passion, and I say God bless to all of
you.
Senator Tester. Senator Dorgan, I just want to express my
thanks to you, Senator Dorgan, as Chairman of the Indian
Affairs Committee and a true leader in the U.S. Senate for the
work that you have done, really working for, not only the folks
in Indian Country, but everybody in the United States that
needs help.
Thank you very much for your commitment and your public
service to this country.
I do have a few questions, and we'll kind of jump around a
little bit.
I'll start with Joe, if you've got a mike that works, Joe,
in front of you.
First of all, Joe, my compliments to you on really a top
rate organization. You've done a great job educating folks in
Indian Country, and I hope you continue in that venue for many,
many more years.
You talked a little bit about having tribal colleges do the
training for everybody, not everybody, but as many people as
possible that could deal with health care in Indian Country.
And you had talked about in 1989 you had one nurse in the
program and now you've got as many as 46.
Over the last few years, I'll ask you the same question I
asked Dr. Moore, have you been able to track where any of these
students have ended up at? Have you been able to determine
whether these they stayed in Salish Kootenai Country. or have
they gone to some other reservation somewhere else?
Dr. McDonald. Yes, pretty well. I could go to the nurse
director. We have their pictures on the wall, and that way I
could point at the nurse and she would tell me pretty much
where they're at because it's very close, and we did keep track
of them.
Senator Tester. Did most of them stay in Indian Country?
Dr. McDonald. The American Indian nurses stayed, they most
generally stayed. We just lost one to Portland. The Sisters of
Providence made an offer to her she couldn't turn down.
Senator Tester. Okay, good.
You talked about adequate funding for tribal colleges in
order for you to be successful, in order for students being
able to afford to go to your institution.
Just where are you at funding-wise as far funding for trial
colleges if we're going to push this along, are you
underfunded, are you adequately funded, where are you at?
Dr. McDonald. We're really underfunded for nursing. Nursing
costs the college about $10,000 per student.
Senator Tester. Okay.
Dr. McDonald. And our money we get on the Student Tribal
College Act is about $5,000. We try to keep the tuition down
for them, so we get about $7,500 of that $10,000.
Senator Tester. Well, thank you. It's good to know that
nursing is something that's going to require some additional
resources.
Would you pass the mike down to Ada, if you're available
for a few questions. I do have a few for you.
I asked, I think I asked Pete Conway about the working
relationship between Indian Health and the tribes, so I'm going
to ask you the same question.
I want to start with your perspective, and I hope it's the
same, but I'm asking the question to find out. Is your working
relationship that you maintain within your health service,
would you classify it as productive, cooperative, adversarial
overall?
Ms. White. I think it's a work relationship that is
fairly--there's a lot of mutual respect, a mutual coming
together sharing ideas.
There are points that I raise and I make them very aware
that my presence there is most often in an advocacy position. I
may articulate, I may question in a manner that may be a little
confrontational, or whatever, but it's a give and take, I
believe a productive relationship.
Senator Tester. Good, outstanding.
You are put in a very difficult position because you have
to make health care decisions when they have more sick people
than they have money. How do you do that? How do you deal with
that?
Ms. White. You're asking me how I make health care
decisions in view of restrictive funds?
Senator Tester. Correct.
Ms. White. I try to put myself in the shoes of the medical
providers, and I look at the doctors, some of them being
extremely capable and competent, not being able to take care of
what's presented to them.
Now, having explored that, sometimes I marvel, I wonder
what goes through their heads, because on my side of the point,
certainly we have very limited funds to operate on. Certainly
we're not the direct service provider that IHS is, but I am
sensitive to that issue, that there is a profound need for more
funds.
Senator Tester. Okay.
You talked about, and I just want to make sure that I heard
what you said, you said that there is no money for prevention;
did I hear that correctly?
Ms. White. My comments had to be tailored somewhat from my
original draft that I sent you. That's why I resubmitted those
copies of the information I received.
I am a person that believes in the buck stops here. If I'm
in a position to make a decision, I certainly do, and if I have
to defer to higher-ups, I certainly do that.
However, in response to your question, what do we mean by
prevention and promotion? It becomes a semantical game. I
believe that the money is not there for people to do an
adequate job in promoting health information, health concepts
and in providing the opportunities for promotion to exist.
We're at a point where that is a novel idea. I do not see
how we can emphasize promotion and prevention when basic care
is not being provided. You have to be well to listen.
You have to have the information at an early age. You have
to be educated to understand what some of the ideas are, and I
think sometimes we get bogged down with lofty ideals.
Senator Tester. That's a good point.
I'll just tell you that for both promotion and prevention,
to my perspective, is one and the same because it's about
education. But I hear what you're saying. Thank you very much,
Ada.
Jonathan Windy Boy, I've got a question or two for you.
Jonathan, good to see you again. I want to tell you that you
being in the legislature, you understand that oftentimes we're
put in positions where you've got X number of dollars and you
need to spread it around between health care and infrastructure
projects and education.
Sometimes I see this as being in the same boat, where
you're pitting one tribe against another tribe for financial
resources.
My question is, and they may already be doing it, so you'll
have to enlighten me on this, how can Montana Indian Nations
work together to promote and improve health care in Indian
Country and not be in competition with one another?
Mr. Windy Boy. Well, first of all, thank you, Mr. Tester. I
think there is a number of ways that the tribes and the
government can work together.
First of all, one of the things, to use an example of what
we did most recently, in 2003, if you recall, there was the
Medicaid redesign--or 2005, I'm sorry, the Medicaid redesign
that came in effect. And what that allowed us to do is to
demonstrate how to stretch the dollar for health care.
And what that basically did, it allowed the tribes and the
state to do, is to think outside the box, basically. The result
of that was to try to access existing resources that are
available, and in this case, Medicaid, Medicare, was that
vehicle.
Realizing that Federal dollars have been limited to the IHS
accounts, there are other resources outside that, and CMS has
definitely been a part of that.
Demonstrating part of that, Senator Tester, is that we have
partnered with the state of Montana. Governor Schweitzer has
come to the table and we have signed agreements. And I think
that while the atmosphere is friendly, I think it's best that
we take advantage of that to try to think outside the box.
And realizing that, like you mentioned, that the dollars
are limited to make it stretch, but I think by doing that,
we're going to make things better hopefully for everybody.
Senator Tester. Okay, thank you.
I'll just say that the point that you made, and you made
many good points, but one of the points that you made that I
thought was particularly appropriate, especially for Montana,
is the remoteness.
And, you know, people back in Washington, D.C. talk about
rural areas. We're beyond rural, we're frontier. It's a huge
issue when you talk about distance in this state to get quality
health care. And it's something that when we talk to our folks
back east that are administering the programs, the only way you
can ever appreciate it is if you drive between Rocky Boy and
Billings and back in the same day. That's one hell of a drive.
So, you know, that's important.
I want to pass it down to Stacy and Jace, and I'll just ask
a question, either one of you can answer it. Do you have a
working mike?
Just curious how the needs of Montana tribes compare with
other tribes in the Nation.
Mr. Killsback. Well, like I mentioned before, the tribes in
Montana are large land-based tribes with large populations, and
our needs reflect those of the direct service tribes.
Another example is during the budget formulation process
this year, the tribes got together and said the number one
priority, instead of piecemealing prevention, different types
of health care needs, we all came together at the table and
said contract health service is the number one priority. And
that's the message we need to take to D.C. when you do describe
the needs.
Senator Tester. So the major disparity between Montana
tribes and other tribes in the U.S. is in contract health care?
Mr. Killsback. I think it could be seen as a possibility
because we are direct service tribes and we don't have the
access to--well, the money is a big factor and that's why
contract health is the number priority here as well.
So I believe our area and Aberdeen Area, those areas with a
large population of urban areas, these populations are served,
have similar issues concerning funding, have similar relations
concerning health care, access to health care.
Ms. Bohlen. Can I say something about that?
Senator Tester. Yes, Stacy.
Ms. Bohlen. Thank you, Senator Tester.
I think that one of the real challenges that Indian Country
faces is the lack of reliable data on where the disparities
specifically are, who's being treated, who's being turned away,
what the outcome of a person being turned away is, where do
they go from here, do they ever get care.
At the National Indian Health Board, we're trying to come
up with programs, like we're trying to work with the American
Academy of Orthopedic Surgeons to get a volunteer orthopedic
program for the Indians in this state. And it's very difficult
to start because we don't have the data about where everyone
is, what the problems are.
I think that's something that Congress could really help
with.
Senator Tester. And as the good doctor, Joe Erpelding said,
the data is probably not necessarily good data, and so we need
to work on that.
I'm going to take just a few minutes here to have some
other comment by elected officials, and I've got to get out of
here by shortly after 3, so I'm in the same kind of boat.
What I'm going to do is this, if we could get a
representative, if you want, if you can add to it, to talk
about health care. I know there's a lot of other issues, but
health care is it.
Go ahead, state your name for the record and what tribe you
represent. You're going to have 2 minutes, and I've got to hold
you strictly to it, otherwise I can't give everybody a chance
to speak.
Go ahead.
STATEMENT OF DARRYL RED EAGLE, TRIBAL EXECUTIVE BOARD MEMBER,
FORT PECK ASSINIBOINE SIOUX TRIBE
Mr. Darryl Red Eagle. Thank you, Senator Tester. My name is
Darryl Red Eagle. I'm tribal executive Board member for the
Fort Peck Assiniboine Sioux Tribe.
Senator Tester. Sir, what I'll ask you to do is talk into
that mike, summarize your statement, your written testimony.
You will turn it in and it will be a part of the record. So
summarize it very quickly. I'm sorry, but this is not something
we normally do anyway.
Speak into that other mike, please.
Mr. Red Eagle. The Fort Peck Tribes appreciate the
committee having this hearing in Montana, and urge swift
passage of this Act. If you have any questions, we will be glad
to respond.
Thank you.
[The prepared statement of Mr. Red Eagle follows:]
Prepared Statement of Darryl Red Eagle, Tribal Executive Board Member,
Fort Peck Assiniboine Sioux Tribe
______
Testimony of John Morales, Jr., Chairman, Assiniboine and Sioux Tribes,
Fort Peck Reservation
______
Senator Tester. Thank you very much. Next up?
STATEMENT OF CAROLE LANKFORD, VICE-CHAIR, SALISH KOOTENAI
TRIBES; ACCOMPANIED BY KEVIN HOWLETT, HEALTH DIRECTOR, SALISH
KOOTENAI TRIBES
Ms. Lankford. I am Carole Lankford, Vice-Chair of Salish
Kootenai Tribes. I want to thank you for coming out and giving
us this opportunity.
We are submitting written testimony and I would also like
to give my tribal health director a chance to say a few words.
Senator Tester. Thank you.
Mr. Howlett. Senator Tester, my name is Kevin Howlett, I'm
the Health Director for the Salish Kootenai Tribes. I would
just like to thank you for holding this hearing.
I think the issues that have been addressed have been
certainly sincere, and I think that as you look across Indian
Country, it isn't just Crow, it's every reservation that has
these kinds of issues.
Things have got to change. People have got to think about
this differently and we really have to move health care into
the twenty-first century.
We will be submitting testimony, and thank you and Senator
Dorgan for having us at this hearing.
Senator Tester. Thank you, I appreciate it, and the
problems are not exclusive to here, but all Indian Country.
Go ahead.
STATEMENT OF TRACY ``CHING'' KING, COUNCIL MEMBER, FORT BELKNAP
INDIAN COMMUNITY, ASSINIBOINE TRIBE
Mr. King. Good afternoon, Senator Tester, my name is Tracy
``Ching'' King, I'm the Assiniboine representative at large of
Fort Belknap.
I want to personally thank you for looking into the matter
of my daughter who is a combat vet of the Iraq war and the
mistreatment she had with the Veterans Administration in
Helena. I appreciate that.
But I'd also like to say that the Tribal Council believes
they don't have a good relationship with Indian Health Service.
If you look at the disparities of the funding, it's somewhere
in the 60 percent range.
In the corporate world, Wall Street, there's like
incentives built into some of the people in corporate America.
Corporate America executives received $154.9 billion, billion.
for incentives for the past 10 years.
And the top 20 executives in Wall Street, their salary is
260 million and up to $1.5 billion totaling $13 billion that
corporate America gets.
170 years ago, my grandfather fought with Sitting Bull, my
three grandfathers, and I come from a family of leaders and
veterans. My daughter is a combat vet. My nephew is a combat
vet, my brother, and I think we need to listen to our needs.
Thank you.
Senator Tester. Appreciate your comments, appreciate your
service and your family's service.
Next up?
STATEMENT OF JULIA DAVIS WHEELER, TRIBAL COUNCIL MEMBER, NEZ
PERCE TRIBE
Ms. Julia Davis Wheeler. Yes, good afternoon. Good
afternoon everyone, my brothers and sisters that are here. My
name is Julia Davis Wheeler, and I'm a Nez Perce Tribal Council
woman from the Nez Perce Tribe in Idaho.
The Nez Perce Tribe is one of the 42 tribes in the
northwest that count on contract support costs to take care of
the majority of our major health needs. We do not have
hospitals, even though in our treaties it's stated that we
would have hospitals.
Nonetheless, having no hospitals, we need to have inpatient
facilities. Regional centers of excellence would be a great
help in helping those of our people that are suffering.
The Nez Perce Tribe is a self-governance tribe by choice of
the General Council, not the Tribal Council, the General
Council. This has been a good move, but this also comes with
inadequate funding. I just returned from a self-governance
meeting in Bellingham, Washington, and we talked about that
issue.
The tribe has been working tirelessly with the issue of
trying to recoup contract support costs that were formerly
withheld for certain Fiscal Years. We're trying to get that
money from the Indian Health Service.
Claims have been dated back to 2005. Two years later we
received letter after letter stating that the $600,000 claim
that we have put in has not been processed. This is a shame.
This is a shame and an atrocity to the people that are counting
on contract health service.
I wanted to bring this to your attention, but I also wanted
to echo what everyone has stated here.
But I want to end my comments with something that is very
near and dear to me, as well as the descendants of chiefs here
in this room.
Chief Joseph stated 120 years ago; I have heard talk and
talk, but nothing is done. Good words do not last long until
they amount to something. Good words do not give my people good
health and stop them from dying. Good words will not give my
people a home where they can live in peace and take care of
themselves. I'm tired of talk that comes to nothing, it makes
my heart sick. But I remember all the good words and all the
broken promises. Too many misrepresentations have been made.
Too many misunderstandings have come up between the white man
about the Indians. There need be no trouble, treat all men
alike, give them all an even chance to live and grow. All men
were made by the same Great Spirit Chief. They are all brothers
and the Earth is the mother of all people.
I end my speech with this from Chief Joseph. Thank you.
Senator Tester. Thank you.
STATEMENT OF EUGENE LITTLE COYOTE, PRESIDENT NORTHERN CHEYENNE
TRIBE
Mr. Little Coyote. Good afternoon. I'm Eugene Little
Coyote, President, Northern Cheyenne Tribe.
I'll be very brief. Of course, the Northern Cheyenne Tribe
strongly encourages and supports the reauthorization of the
Indian Health Care Improvement Act.
We have three priorities we were going to mention today,
diabetes and dialysis, methamphetamine prevention. We have a
war on meth on the Northern Cheyenne, and I'd like to mention
that Chairman Venne and the Northern Cheyenne Tribe have a
interdepartmental coalition, Safe Trails Task Force. We're
doing very well on that.
Third is contract health care. We need increased funding in
all areas of Indian health care, and the Northern Cheyenne will
submit a detailed written testimony on these.
Thank you.
[The prepared statement of Mr. Eugene Little Coyote
follows:]
Prepared Statement of Eugene Little Coyote, President Northern Cheyenne
Tribe
Senator Tester. Thank you very much, Eugene, appreciate it.
STATEMENT OF LEO STEWART, VICE-CHAIRMAN, CONFEDERATED TRIBES OF
UMATILLA INDIAN RESERVATION
Mr. Stewart. Good afternoon, my name is Leo Stewart. I'm
the Vice-Chairman of the Confederated Tribes of Umatilla Indian
Reservation, which consists of Walla Walla--I almost said Nez
Perce because the Cayuse is part of the Nez Perce and the
Umatillas.
One of the things, we would like to thank you a lot for
reintroducing the Indian health care plan.
Another thing, too, is that we have strong care need, like
Julia Davis said about the Indian health care for hospitals in
our areas. It's really a need.
It shouldn't specifically be put into designated areas, but
into the remote areas that would help our people a lot, and the
reaching out for these kinds of funds to make these things
work.
Another thing, too, is to the support of all our funds that
is important to let the unfairness of facility construction
fund is when it takes over 50 percent of IH budget increases to
phase in staff and to new facilities, and only three to four of
the areas get the participant end of facility construction
plan, so that's what we need.
So I'd just like to thank you and thank you for letting me
have this time.
Senator Tester. Thank you for your comments.
And this applies to everybody, we take written comments, so
please, if there's more that you wanted to say that you
couldn't, write them and send them in.
Go ahead.
STATEMENT OF EDWIN LITTLE PLUME, CHAIRMAN, HEALTH COMMITTEE,
BLACKFEET TRIBAL BUSINESS COUNCIL
Mr. Little Plume. Good afternoon, Mr. Tester, appreciate
you coming back to Montana, as well as Mr. Dorgan, Senator
Dorgan. We appreciate your good words for funding for us back
in D.C.
As a new member of our Tribal Council, I sit on the health
committee and chair that committee. As you know, being a new
guy like yourself in Washington, I experience pretty much the
same on our home reservation, funding for health care.
Our hospital, in the 30 years since the original facility
expansion, many variables have changed. Most noticeably, the
hospital visits have continued to increase steadily over the
time from 60,000 outpatient visits in 1984 to 124,000.
Our hospital has become a regional hospital, which
originally was designed for the Blackfeet people which our
treaty stated.
At this time, our hospital visits takes in patients from
all the urban centers in the state of Montana. We have patients
coming from Illinois, Idaho, Minnesota, Oregon, Washington
State, North and South Dakota, are traveling to the Blackfeet
Community Hospital in Browning for their health care needs.
The Browning hospital, which was designed for the health of
the Blackfeet people has become a regional health facility for
many other tribes. The impact of this has become very
noticeable to our own people as their needs for health care are
not being met.
So, with that, I thank you for listening to today's
testimony.
[The prepared statement of Mr. Little Plume and Ms. Tatsey
follow:]
Prepared Statement of Edwin Little Plume, Chairman, Health Committee,
Blackfeet Tribal Business Council and Jane Tatsey, Health
Administrator, Blackfeet Tribe Health Department
Senator Tester. Thank you.
STATEMENT OF ANDY JOSEPH, JR., CHAIR, HEALTH AND HUMAN SERVICE
COMMITTEE, COLVILLE CONFEDERATED TRIBES
Mr. Joseph. Good afternoon to my friends here in the Crow
Nation and Senator Tester. My name is Andy Joseph, Jr. I'm the
chair of the Health and Human Service Committee for the
Colville Confederated Tribes.
I'm also the Vice-Chair for the Northwest Portland Indian
Health Board of 43 tribes in Washington, Idaho and Oregon.
The testimony that I'd like to give is on the IHS budget.
The Office of Management and Budget requires the staff to work
on rules-based budget.For the last 4 years we've had to work on
a rules-based budget of 2 percent or 4 percent.
This last meeting we requested a 23 percent increase in
current spending. That pays for the pay act, Federal employees
get a raise every year. It covers the inflation and it also
covers the population growth for all of the nations.
By being stuck with a rules-based budget every year, we
have to go back there. Dr. Grim negotiates for us the funding
that has been given and he's not a tribal leader. I want to see
tribal leaders at the table.
I pushed a resolution to have a leader from NCAI, a leader
from the National Health Board, a direct service type
representative to be at that table. Government staff according
to Executive Order should not be talking for us.
As you know, he's a commissioned officer and he doesn't
have the high rank to tell his superiors what we really need,
and he's paid to save money for the government, but it's
costing a lot of our people's lives.
I imagine if you took the numbers down of all the people
we've lost over the years, we'd be right up there with our
soldiers that we're losing in Iraq.
Senator Tester. Please, please put it in written testimony.
I'm literally going to have to walk out of here in 1 minute. So
thank you very much.
Mr. Joseph. We'll send in our written testimony from the
Northwest Portland Area Indian Health Board on our health care
status.
Senator Tester. I appreciate that very much.
The next two very quick comment, I mean very quick comment
because I've got to boogie.
STATEMENT OF MS. WALK ABOVE, MEMBER, CROW TRIBE
Ms. Walk Above. Good afternoon, Jon Tester, I'm (inaudible)
Walk Above. I'm a parent, I'm a member of the Crow Tribe.
My baby has been having health problems, which he's okay
now, but I have these bills and I've written to the hospital
here for them to pay for my bill and have them pay for it, and
they didn't approve it.
So I wrote a letter to the Indian Health Service in
Billings and they denied my letter. So I wrote a letter to
Washington, D.C. I haven't heard from them yet, but I would
really appreciate it if they would help me.
And I'm glad that you're here to hear our testimonies
because we cannot go to Washington, D.C. and to go and see you.
Thank you.
Senator Tester. That's one of the reasons we're here. Thank
you very much.
STATEMENT OF KEN REAL BIRD, REPRESENTATIVE, CROW TRIBE
Mr. Real Bird. Thank you, I'm Ken Real Bird. I'm a victim
of this flawed health----
Senator Tester. Are you an elected official?
Mr. Real Bird. Yes, I represent the legislative branch of
the Crow Tribe. I'm a victim of this outfit right here. And I
think that there needs to be some law so the issue of
malpractice is addressed by IHS doctors.
See, when they do something wrong, it's acceptable because
they're covered by IHS, but the individual who causes the
problems, the doctor needs to be liable for some of the things
that they have done.
Now, there's so many problems with the IHS, especially in
management. And one of the things that I'd like to bring out is
that us Indian people have to wait 5 hours or more to get
health care.
Senator Tester. Could you do me a favor? Could you write it
down and send it in because----
Mr. Real Bird. Yes, I could send it out. I've written two
letters before you were elected. I wrote one to Burns and
Baucus on this issues of my problems that I've dealt with.
Thank you.
Senator Tester. That would be great. If you could do that,
that would be marvelous. Thank you.
At this point in time, I have to hurry and I'd like to
thank you because we're out of time. I want to first of all
thank some staff people here, Mark Jette and Amanda Arnold from
my staff; Anna Sorrell from Governor Schweitzer's staff;
Richard Litsey and Jim Corson from Senator Baucus' staff; and
David Mullon who is from Senator Murkowski's staff, the ranking
minority.
I will tell you this, there was one lady that got up and
spoke from the Nez Pearce that talked about Chief Joseph,
talked and talked and nothing was done.
I can tell you this, and I can speak for Senator Dorgan
when I say that, it takes 60 votes to get things done in the
U.S. Senate so we can't do it alone, we need 58 other people to
help us out.
But we will work and we will work and we will continue to
work to make sure that health care is adequate in Indian
County. We will be diligent on that, make no mistake about it.
And finally I want to thank the folks who provided us with
the facility and the great dinner.
I want to thank Chairman Carl Venne. Carl, I want to thank
you very, very much, not only for your friendship but for your
hospitality and courtesy in doing all the work necessary to
help pull this thing off.
Thank you very much.
Before we go, I want Carl to get the last word in.
STATEMENT OF CARL VENNE, CHAIRMAN, CROW TRIBE
Chairman Venne. Senator, I want to thank you for coming and
the committee. If you look at that map of the United States
over there, it says Council of large land-based tribes. That's
where most of the Indian people live. That's where most of the
land is that Indians own, and we are the poorest of the poorest
in the United States of all ethnic groups.
It's sad to see when you look at the Federal budget, when
you see wild horses out in the Pryors, when we in this region
are in the red for $48 million and they give them horses, which
we don't ride or don't eat, $40 million a year.
Something is wrong in this country. We, as Indian leaders,
need to speak up. We don't beg no more. It's rightfully yours
because of the treaties that we have done with these United
States.
During the time of war, 70 percent of all young men and
women from all of the tribes enlist to go to war. Did you know
that? You're the largest population or ethnic group in these
United States who serve this country, but yet to be treated
like we are today, is not good.
We, as leaders, have to speak up. You should be mad at what
this administration has done to Indian tribes throughout the
country.
They wanted to do something way a long time ago when they
infested army blankets and gave it to us and everybody got
smallpox and died. Is that what is still going on today with
this administration?
No, don't take a backseat to nobody. You're entitled as
Indian people.
The Indian people working for Indian Health Service, don't
be afraid to speak up. You know what is wrong. You know what we
need. How can Dr. Grim sit in his office and say no, we don't
need no more money when he has a committee that says we need a
lot more money.
What is going on in this country? We're not begging the
U.S. Government. They made promises.
I can only speak for my tribe, if you look at the Powder
River Basin, the billions and billions of dollars that this
government has made off of it, and yet we're treated like this
today. It's time for Indian leaders to get up and speak.
And I want to thank Senator Tester and his Committee for
coming to Crow Country, and I appreciate what they're trying to
do for us, but we need to speak up and back them up. We need to
get out the vote also.
Thank you.
[Whereupon, at 3:15 p.m. the hearing was adjourned.]
A P P E N D I X
Prepared Statement of The Confederated Salish and Kootenai Tribes of
the Flathead Nation
______
Prepared Statement of Dick Brown, President, MHA--an Association of
Montana Health Care Providers
______
Prepared Statement of Laurene Johnson, Member of the Confederated
Salish and Kootenai Tribes
______
Prepared Statement of Lou Stone, Member of the Sngaytskstx Tribe
______
Prepared Statement of Margaret Norgaard, CEO, Northeast Montana Health
Services (NEMHS)
______
Prepared Statement of Gwen Clairmont, Member of the Confederated Salish
and Kootenai Tribes
______
Prepared Statement of John Sinclair, President, Little Shell Tribe of
Chippewa Indians of Montana
Attachments
______
Prepared Statement of Gordon Belcourt, Executive Director, Montana-
Wyoming Tribal Leaders Council
Attachment
______
Prepared Statement of the Fort Belknap Indian Community Council
______
Prepared Statement of David B. Myers, M.D., Billings MT
______
Prepared Statement of Carol Juneau, State Senator, Senate District 8,
Montana
______
Prepared Statement of Barry Adams, Browning MT
______
Prepared Statement of Alex Ward, Associate State Director, AARP Montana
______
Prepared Statement of the Nez Perce Tribe
______