[Senate Hearing 110-332]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-332
 
  NOMINATION OF ROBERT G. MCSWAIN TO BE DIRECTOR OF THE INDIAN HEALTH 
                                SERVICE

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

                                HEARING

                               before the

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                            FEBRUARY 7, 2008

                               __________

         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
      Allison C. Binney, Majority Staff Director and Chief Counsel
     David A. Mullon Jr., Minority Staff Director and Chief Counsel


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on February 7, 2008.................................     1
Statement of Senator Dorgan......................................     1
Statement of Senator Murkowski...................................     2
Statement of Senator Smith.......................................     6

                               Witnesses

McSwain, Robert G., Nominee to be Director of the Indian Health 
  Service, U.S. Department of Health and Human Services..........     7
    Prepared statement...........................................     9
    Biographical information.....................................    11
Van Huss, Hon. Jacquie Davis, Chairperson, North Fork Rancheria 
  of Mono Indians of California..................................     4
    Prepared statement...........................................     5

                                Appendix

Barrasso, Hon. John, U.S. Senator from Wyoming, prepared 
  statement......................................................    27
Letters of support:
    California Rural Indian Health Board, Inc....................    29
    National Indian Health Board.................................    28
    Toiyabe Indian Health Project, Inc...........................    30
Response to written questions submitted to Robert G. McSwain by:
    Hon. John Barrasso...........................................    33
    Hon. Maria Cantwell..........................................    33
    Hon. Tom A. Coburn, M.D......................................    31
    Hon. Tim Johnson.............................................    36
    Hon. Gordon H. Smith.........................................    30


  NOMINATION OF ROBERT G. MCSWAIN TO BE DIRECTOR OF THE INDIAN HEALTH 
                                SERVICE

                              ----------                              


                       THURSDAY, FEBRUARY 7, 2008


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

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

    The Chairman. We will call the hearing to order. This is a 
hearing of the Indian Affairs Committee of the United States 
Senate.
    Today, the Committee takes another important and necessary 
step in fulfilling its commitment to try to improve Indian 
health care by considering the nomination of Robert McSwain to 
be the Director of the Indian Health Service.
    We talk a lot in this Committee about the challenges and 
what needs to be done. We talk about the statistics: American 
Indians die at higher rates than other Americans from 
tuberculosis, 600 percent higher; alcoholism, 510 percent 
higher; diabetes, nearly double; suicide, 60 percent higher.
    But as we rattle off these numbers, it is important to 
understand we are talking about individuals, people struggling 
to deal with their health care needs. When we talk about the 
1.9 million Indian Health Service patients, we are referring to 
a group of people in this country who have been afflicted often 
with very chronic health conditions. A group who, in exchange 
for land and other possessions that they once had, secured 
federally-sponsored health care, a trust responsibility and 
beyond that, in many cases, a treaty commitment from the 
Federal Government.
    It is our responsibility, it seems to me, to keep this 
promise and to provide the First Americans with quality health 
care, and to do so with accountability, efficiency and 
compassion. Accountability is a major theme that we are going 
to talk about in regards to the Indian Health Service today. I 
would say that I think there are some wonderful, dedicated 
professional people who have committed their lives to the 
Indian Health Service. I have seen them, I have watched them 
work and I commend them.
    I also believe that the Indian Health Service in some other 
areas is a Federal agency whose arteries are clogged with 
bureaucracy, inefficiency, ineffectiveness, and in some cases 
desperately in need of reform.
    We also face a circumstance where about 40 percent of the 
health care needs of American Indians is unmet. That means we 
have health care rationing, which would be scandalous in most 
areas, but seems to be the norm with respect to delivering 
health care to American Indians.
    We need to do much, much better than that. My hope is that 
Mr. McSwain, as the leader of the Indian Health Service, will 
begin to be able to effect some of these reforms. I am terribly 
disappointed with the President's budget, once again. I don't 
think the President or the Congress has done their obligation 
to meet our responsibility, our trust responsibility for Indian 
health care for many, many, years. My hope is that one day we 
can look back with some pride to say that we did what was 
required of us and what we have previously promised: to provide 
health care to Native Americans.
    Today we will focus on the confirmation of Robert McSwain. 
On December 18th, President Bush sent Mr. McSwain's nomination 
to the full Senate. Mr. McSwain has worked in the Indian Health 
Service for 24 years in various capacities. In the field of 
Indian health itself, he has worked for 36 years. He is a 
member of the North Fork Rancheria of Mono Indians of 
California. The Committee has received statements of support 
for Mr. McSwain's nomination from the California Rural Indian 
Health Board, that is the organization that Mr. McSwain served 
as executive director in the mid-1970s, before being tapped to 
be the IHS California area office director.
    The National Indian Health Board, the non-profit 
organization whose membership is made up of each of the Indian 
Health Service areas, also has issued statements of support. I 
ask consent that these and other letters regarding this 
nomination will be included as a record of today's hearing. 
Without objection, that will be done.
    Also, I understand that Mr. McSwain is a cousin to Ms. 
Rachel Joseph, who is Co-Chair of the National Steering 
Committee to Authorize Indian Health Care. She has provided 
tremendous assistance to this Committee in our attempt to 
reauthorize the Indian Health Care bill. Before I recognize the 
Vice Chair of the Committee, I want to state the process for 
moving forward with this nomination. Today we will have an 
opportunity to hear from Mr. McSwain and to ask some questions. 
Once the Committee has received responses, including responses 
from questions we submit, we will report out the nomination at 
the next scheduled business meeting.
    Senator Murkowski.

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

    Senator Murkowski. Thank you, Mr. Chairman.
    Good morning, and I want to thank you for moving very 
quickly to the confirmation hearing of Mr. McSwain. When we 
learned back in September that Dr. Grim had withdrawn his 
nomination, I was one of those that expressed great regret. We 
had a good experience with Dr. Grim in the State of Alaska. But 
I am very pleased that the President has nominated another very 
dedicated Native American for what I think we all acknowledge 
is a very difficult, very challenging job.
    You have indicated, Mr. Chairman, in your opening remarks, 
some of the statistics that we deal with that we face as a 
committee here in trying to advance in a positive way, not only 
the health care needs, but so many of the issues that face 
Indian Country. We are reminded on the one hand of the very 
negative statistics. But as I have had an opportunity to point 
out on the Floor, as we have worked to advance the Indian 
Health Care reauthorization, we do have some good stories, we 
do have some good progress to report in Indian health.
    I have mentioned before the tele-medicine that we are able 
to bring into some of our bush communities and into the 
reservations, some of the sanitation facilities in the remote 
villages where we are making some progress and helping to 
reduce the mortality rates. But again, as you point out, the 
challenges that face far too many are oftentimes 
insurmountable. We face a time of stringent budgets where the 
directive ``don't get sick after June'' continues to be a very 
chilling reminder that the Indian Health care system has fallen 
far, far short of what its beneficiaries deserve.
    You have mentioned the overwhelming disease rates. These 
are despite the dedicated efforts of Indian health 
professionals. We continue to experience far too many 
unnecessary deaths, amputations, the pain caused by diabetes. 
We remain haunted by the youth suicides, the unsolved murders, 
the rapes of countless Native women. We have said, and you 
certainly, Mr. Chairman, have said that the painful truth is 
that we still have third world conditions existing in many of 
our Nation's Indian and Alaska Native communities.
    So you have to ask the question, to our nominee, why, Mr. 
McSwain, would you want to take on this job, knowing the 
difficulties, knowing what you are facing with the disease 
rates, the funding levels, even knowing that there is obviously 
going to be a change of Administration? I have heard it 
expressed that anyone intelligent enough for this job is 
probably too smart to accept it. But I believe that your 
intelligence and that of many of our past IHS directors is 
unquestionable.
    But your presence before us today I think speaks greatly to 
your dedication to Indian health, to improving the lives of 
Indian and Alaska Native people and to tribal sovereignty and 
to self-governance.
    With that, Mr. Chairman, I would like to speak to the 
specifics of Mr. McSwain and introduce him to the Committee, if 
I may. We had a very good conversation a couple days ago in my 
office about Mr. McSwain's mission, his vision and his pledge 
for Indian health. As you noted from the biography that was 
submitted to the Committee, Mr. McSwain has worked for the IHS 
since 1976. He reminded me that he began work for the IHS at 
the same time that the Indian Health Care Act was authorized. 
You have noted it has been a long time, clearly a long time 
within IHS that Mr. McSwain has given his service.
    During that time, he has received numerous awards, most 
notably the President's Rank Award for meritorious service in 
2004 and the President's Rank Award for distinguished service 
in 2006. It appears that you have held nearly every managerial 
position available in IHS: area director in California, special 
advisor to the IHS director, various positions in the IHS in 
the areas of management, human resources, manpower, deputy 
director of IHS and then now appointed to be acting director.
    In my conversation with Mr. McSwain, I noted that he was 
quite proud of his long and distinguished career with IHS, but 
he was also proud, and I think rightly so, of his time spent 
working for tribal health programs from 1971 to 1974 as the 
director of the Central Valley Indian Health, and then in 1974 
to 1976, he served as the executive director of the California 
Rural Indian Health Board in Sacramento. Mr. McSwain comes from 
Indian Country and it is too Indian Country that he has 
remained dedicated. He comes from the North Fork Rancheria of 
Mono Indians in California, proudly supported by his people and 
his chairperson, Jacquie Davis Van Huss, who is here with us 
today and will provide her remarks for Mr. McSwain. We greatly 
appreciate that.
    Mr. McSwain was raised by his grandparents who instilled in 
him Indian values which gave him the perseverance, the 
character, to carry him through his career. Mr. McSwain has 
convinced me that if confirmed, he will remain committed to 
supporting tribal self-governance and self-determination. As 
many know here in the room today, self-governance is working 
successfully, particularly in Alaska, and I expect that success 
to continue under Mr. McSwain's command.
    Moreover, he is committed to the mission of the Indian 
Health Service, which as we have heard many, many times before, 
is to raise the physical, mental, social and spiritual health 
of American Indians and Alaska Natives to its highest level. 
That mission cannot be accomplished without the help of tribal 
leaders and of this Congress.
    Between his time with the tribal health programs and his 
time with the IHS, Mr. McSwain dedicated about 27 years of his 
life to improving the health of Native people. That, Mr. 
Chairman, and to those here, that is really a lot of on-the-job 
training for this very challenging appointment. I have no doubt 
he will need to draw on those years of experience to carry him 
through the tough times that he will experience as Director if 
confirmed.
    With that, Mr. Chairman, I thank you and I look forward to 
hearing from Mr. McSwain this morning, and hopefully to an 
expeditious process. Thank you.
    The Chairman. Thank you very much.
    We will hear from the Honorable Jacquie Van Huss, 
Chairperson of the North Fork Rancheria, North Fork, 
California. Ms. Van Huss, thank you very much. You may proceed.

           STATEMENT OF HON. JACQUIE DAVIS VAN HUSS, 
           CHAIRPERSON, NORTH FORK RANCHERIA OF MONO 
                     INDIANS OF CALIFORNIA

    Ms. Van Huss. Good morning, Chairman Dorgan, Madam Vice 
Chair Murkowski and the distinguished members of the Senate 
Committee on Indian Affairs. My name is Jacquie Davis Van Huss, 
and I am the Tribal Chairperson for the North Fork Rancheria of 
Mono Indians, which is the largest restored tribe in 
California. Joining me today is our Tribal Council Secretary, 
Katrina Lewis.
    I am delighted to be here for several reasons. I am 
privileged to bring you greetings from each of our 1,680 tribal 
citizens who share their immense pride as I come forward to 
introduce and express support for and confidence in one of our 
enrolled tribal citizens, Robert G. McSwain, or Bob, as we know 
and love him.
    For nearly three years, Bob has proven himself at the 
highest levels of leadership at Indian Health Services, first 
as IHS Deputy Director, then as Acting IHS Director. His 
nomination now to be permanent Director of Indian Health 
Services serves as both tribute and testimony to his 
capabilities and to his commitment to improve the health 
conditions of all American Indians.
    Mr. Mike Leavitt, Secretary of Health and Human Services, 
had the following to say about Bob upon assumption of his 
current role as Acting Director in September of 2007: ``I am 
pleased that Bob has taken on this position. Over this 30-year 
career in the Department, Bob has played a pivotal role, most 
recently sharing responsibility with the IHS Director for 
managing a $4 billion national health care delivery program. 
His leadership has helped ensure that IHS is able to provide 
top quality preventive, curative and community care to 
approximately 1.9 million American Indians and Alaska Natives. 
During his tenure, Bob has received two Presidential Rank 
Awards for distinguished and meritorious service. I am 
confident he will continue to provide strong leadership for the 
IHS in serving as its Acting Director.''
    The North Fork Rancheria takes health management seriously, 
having helped create and manage innovative programs such as a 
multi-tribal Temporary Assistance for Needy Families program, 
and the multi-county Central Valley Indian Health, 
Incorporated, in which Bob first started his health career. 
From this perspective, we too have full confidence in Bob's 
ability to lead, manage and advocate effectively on behalf of 
the Nation's American Indians and Alaska Natives in hospitals, 
clinics and other settings throughout the United States.
    The State of California is home to one-fifth of the 
federally-recognized tribal governments in the United States. 
Mr. Robert G. McSwain brings a unique perspective to this high 
Federal position as both a Native son of California and someone 
who has literally worked his way up to the highest levels of 
Government. We believe this experience and perspective will 
serve Mr. McSwain well as he represents the diversity and 
richness of both American Indian health and tribal sovereignty 
concerns and needs.
    We believe that Mr. Robert G. McSwain, our esteemed tribal 
citizen, will serve the position of Director of Indian Health 
Services with great honor and distinction.
    With this said, I have the honor to introduce my tribal 
citizen, Mr. Robert G. McSwain.
    [The prepared statement of Ms. Van Huss follows:]

 Prepared Statement of Hon. Jacquie Davis Van Huss, Chairperson, North 
              Fork Rancheria of Mono Indians of California
    Good morning Chairman Dorgan, Vice Chairman Murkowski and 
distinguished members of the Senate Committee on Indian Affairs.
    My name is Jacquie Davis Van Huss and I am Chairperson of the North 
Fork Rancheria of Mono Indians of California, which is the largest 
restored tribe in California. Joining me today is our Vice-Chairperson 
Elaine Fink and our Secretary Katrina Lewis. I am delighted and honored 
to be here for several reasons. I am privileged to bring you greetings 
from each of our 1680 tribal citizens who share their immense pride 
today as I come forward to introduce and express support for and 
confidence in one of our enrolled Tribal citizens, Robert G. McSwain, 
or ``Bob'' as we know and love him.
    For nearly three years Bob has proven himself at the highest levels 
of leadership at the Indian Health Services, first as IHS Deputy 
Director then as Acting IHS Director. His nomination now to be 
permanent Director of the Indian Health Services serves as both tribute 
and testimony to his capabilities and to his commitment to improve the 
health conditions of all American Indians.
    Mr. Mike Leavitt, Secretary of Health and Human Services, had the 
following to say about Bob upon the assumption of his current role as 
Acting Director in September, 2007:

        ``I am pleased that Bob has taken on this position . . .. Over 
        his 30-year career in the Department, Bob has played a pivotal 
        role, most recently sharing responsibility with the IHS 
        Director for managing a $4 billion national health care 
        delivery program. His leadership has helped ensure that the IHS 
        is able to provide top quality preventive, curative, and 
        community care to approximately 1.9 million American Indians 
        and Alaska Natives. During his tenure, Bob has received two 
        Presidential Rank Awards for Distinguished and Meritorious 
        service. I am confident he will continue to provide strong 
        leadership for the IHS in serving as its Acting Director.''

    The North Fork Rancheria takes health management seriously, having 
helped create and manage innovative programs such as a multi-tribal 
Temporary Assistance for Needy Families program and the multi-county 
Central Valley Indian Health, Incorporated. From this perspective, we 
too have full confidence in Bob's ability to lead, manage, and advocate 
effectively on behalf of the nation's American Indians and Alaska 
Natives in hospitals, clinics, and other settings throughout the United 
States.
    The State of California is home to one-fifth of the federally 
recognized tribal governments in the United States. Mr. Robert G. 
McSwain brings a unique perspective to this high federal position as 
both a native son of California and someone who has literally worked 
his way up to the highest levels of government. We believe this 
experience and perspective will serve Mr. McSwain well as he represents 
the diversity and richness of both American Indian health and tribal 
sovereignty concerns and needs.
    We believe that Mr. Robert G. McSwain, our esteemed Tribal Citizen, 
will serve the position of Director of Indian Health Services with 
great honor and distinction.
    With this said, I have the honor to introduce, our Tribal Citizen, 
Mr. Robert G. McSwain.

    The Chairman. Madam Chairperson, thank you very much for 
traveling here from California to provide that statement.
    Ms. Van Huss. We are very honored to be here, and we highly 
support Mr. McSwain.
    The Chairman. We got that impression from your testimony.
    [Laughter.]
    The Chairman. We appreciate it very much.
    Ms. Van Huss. Thank you.
    The Chairman. Mr. McSwain, would you please come forward?
    Mr. McSwain, we welcome you to the Committee. I am going to 
call on you for a statement in just a moment, but I wanted to 
recognize Senator Smith, who has arrived,if you have anything 
you wish to say.

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

    Senator Smith. Thank you, Mr. Chairman, Vice Chair 
Murkowski, for providing the Senate Committee on Indian Affairs 
with an opportunity to hold a confirmation hearing for Robert 
McSwain.
    The issue of Indian health care is critical in the State of 
Oregon. Whether at my annual tribal summit or visiting tribal 
lands throughout Oregon, I always hear how important access to 
quality health care is to Indian Country.
    The Indian Health Care Improvement Act brings us closer to 
fulfilling the need, and I thank the Chairman and Vice Chair 
and their staffs for working to advance the bill. I look 
forward to its passage on the Floor, and its swift passage. 
While I recognize this bill as a step in the right direction, I 
am concerned that in its current form,the bill maintains an 
inequity in the distribution of health facility construction 
funds. Currently, this fund favors a few tribes and a few 
States, while the majority of tribes, including those in 
Oregon, have never received agency funds to build a hospital.
    I would like to take this opportunity to hear from Mr. 
McSwain whether the Indian Health Services would have the 
statutory authority under the Indian Health Care Improvement 
Act to implement an area distribution fund that would equally 
distribute a portion of health facility construction funds to 
all IHS regions across the Country. I am not trying to require 
the creation of an area distribution fund. That decision must 
rest with the agency, the tribes and their budget situation.
    I do, however, want to ensure that the agency is not 
legislatively precluded from implementing this fund if it 
determines that it is in the best interest of Indian Country as 
a whole. Beyond that, I want to reemphasize that the services 
in the Act, especially those related to health care delivery, 
are vital to the health and well-being of tribal families and 
communities. They need us to finish our work and get this bill 
signed into law this year.
    I look forward to continuing to work with Mr. McSwain and 
the Chair and Vice Chair and other colleagues to explore ways 
to address everyone's interest and ensure that all Native 
Americans, not just some, receive the health care they need and 
deserve.
    The Chairman. Senator Smith, thank you very much.
    Mr. McSwain, thank you for being with us. We will at this 
point take your testimony and then ask some questions. You may 
proceed.

         STATEMENT OF ROBERT G. MCSWAIN, NOMINEE TO BE 
          DIRECTOR OF THE INDIAN HEALTH SERVICE, U.S. 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Mr. McSwain. Mr. Chairman, Madam Vice Chairman and other 
distinguished members of the Senate Committee on Indian 
Affairs, I am truly humbled and honored to have been nominated 
by President Bush, supported by tribal governments, endorsed by 
Secretary Leavitt, and for this Committee to consider my term 
as Director of Indian Health Service. I am quite surprised at 
the speed at which you have done this, and that speaks to your 
concern about the Indian Health Service's continuity.
    I would like to thank and acknowledge my family, especially 
my wife, June McSwain, who has been my confidant and closest 
friend for over 35 years.
    The Chairman. Mr. McSwain, do you have family members here 
you wish to introduce?
    Mr. McSwain. I have family members I will introduce in a 
moment, Mr. Chairman. My daughter, Kristin Ruud, who is a nurse 
in Houston, and my son, Major Eric Ruud, who is still in the 
forces and serving in places around the world. My daughter 
Elizabeth and my granddaughter Britney Ruud are here today to 
accompany and shore me up.
    On this special occasion, as Senator Murkowski noted, I 
have been doing a lot of reflecting as the nomination has 
occurred. I have reflected back many years, not only to my 
career, but to my roots, so to speak. In this case, I was 
calling upon my grandparents, Dan and Ella, who raised me, as 
the Senator noted, with the Indian values of listening, 
compassion, respect, mutual respect and caring for the 
environment.
    I am proud to pledge before this Committee to both Federal 
and tribal governments that if confirmed, I will do my best to 
uphold the Federal Government's commitment to raising the 
health status of American Indians and Alaska Natives to the 
highest level. I remain committed to working with this 
Committee and the Administration and tribal governments toward 
our shared goals and objectives.
    I have had the privilege of having two distinct careers, 
obviously, as pointed out earlier, the first five years 
essentially in tribal health, health programming in California, 
and the second 30 years in actual engaging and working for the 
Indian Health Service. It is interesting, I want to make two 
points not quite on my statement, but when I decided to come to 
the Federal service, tribal folks told me they wanted me to be 
able to go to the Government and do something back for Indian 
people in California. Now, I find myself at the crossroads of 
another, what more can I do for Indian people.
    I have had the pleasure of working with and for five of the 
seven previous directors of the Indian Health Service. All my 
positions have occurred at stages of change and my nomination 
today reflects another stage of change. If confirmed, I will 
work diligently to support the decision of tribes to contract, 
compact or retain Indian Health Service as their provider of 
choice. The Indian Self-Determination Act allows tribes to 
manage their own health programs, and with some rare 
exceptions, they have done an absolutely outstanding job. Let 
there be no doubt that I support and advocate for the sovereign 
rights of tribes to self-govern.
    I am also committed to continuing the Director's three 
initiatives, and work hopefully with Dr. Grim on these three 
initiatives, as they have a great potential for doing great 
things. These three initiatives are health promotion and 
disease prevention; behavioral health; and chronic care 
management. I firmly believe that the future of tribal 
communities depends on how effectively Indian Health Service 
and the health system addresses chronic diseases.
    The leadership of the IHS has concluded that we cannot 
address the health needs of American Indians and Alaska Natives 
alone. And if I am confirmed, I intend to continue to grow and 
expand the collaborations with other Federal agencies and 
private organizations who share our mission and vision.
    The key to our successes in the past and our future efforts 
is based upon two very, very important groups, both Senator 
Murkowski and Chairman Dorgan have noted, the committed, 
compassionate, competent work force that we have throughout the 
system. Indian health care is a labor-intensive process. I 
would say that our competence goes not only to our Federal but 
also our tribal employees as well.
    The second group is some amazing tribal leaders, we have 
one of them here today in Rachel, who have provided many 
selfless hours to the mission of the Indian Health Service. In 
looking to the future, we must pause and review where we are, 
namely, that over one-half of the Indian Health Service program 
over the last 30 years now rests in the hands of tribes. Tribes 
operate over half of the Indian Health Service program.
    The Indian health care delivery system is comprised of many 
parts. Though outstanding in their individual performance, I 
believe we can be more efficient and effective if all the parts 
are working together. Such an example is our experience with 
IHS tribal and urban Indian communities piloting the chronic 
care management model in their communities. I have observed the 
excitement and commitment to a delivery of higher quality care 
that can only be a plus to American Indians and Alaska Natives 
in the future that we serve.
    I have been reflecting on the seven previous Directors of 
the Indian Health Service, particularly as we recently 
celebrated the past 50 years. I come before you on the 
shoulders of a great legacy of Directors. As my predecessors, I 
have the same passion about this organization and our mission 
to raise the health status of our people to the highest 
possible level. My actions have and will always reflect the 
honor of being entrusted to provide health services to American 
Indian and Alaska Native people.
    If confirmed, I am ready to lead the Indian Health Service 
with honor and respect for our ancestors and to work with you 
and the Administration for the benefit of the American Indian 
and Alaska Native people.
    I would be pleased to respond to any questions you may have 
concerning my nomination, Mr. Chair. Thank you.
    [The prepared statement and biographical information of Mr. 
McSwain follows:]

Prepared Statement of Robert G. McSwain, Nominee to be Director of the 
  Indian Health Service, U.S. Department of Health and Human Services
    Mr. Chairman, Madam Vice-Chair, and other distinguished members of 
the Senate Committee on Indian Affairs:
    I am humbled and honored to have been nominated by the President, 
supported by tribal governments across the nation, endorsed by 
Secretary Leavitt, and for this Committee to consider my nomination as 
director of the Indian Health Service.
    I'd like to thank and acknowledge my family, especially my wife 
June McSwain who has been my confidant and closest friend and daughter 
Kristin Ruud, son Major Eric Ruud, daughter Elizabeth McSwain and my 
granddaughter Britney Ruud. On this special occasion I wish to 
acknowledge my grandparents Dan and Ella McSwain, both passed on, who 
instilled in me the Indian values of mutual respect, compassion, 
listening, and caring for the environment.
    I am proud to pledge before this Committee, to both the Federal and 
tribal governments, to do my best to uphold the Federal Government's 
commitment to raising the health status of American Indians and Alaska 
Natives to the highest level. Should I be confirmed, I will remain 
committed to working with this Committee, the Administration, and 
Tribal Governments toward our shared goals and objectives.
    For those on the Committee and those attending this hearing, I 
would like to provide some background about myself. I am a Tribal 
Citizen of the North Fork Mono Indian Rancheria that is located in the 
Sierra-Nevada mountain range, in North Fork, California. I began my 
health career in 1971 as the Director of Central Valley Indian Health, 
Inc., one of 16 original programs of the California Rural Indian Health 
Board. I then served as the Executive Director of CRIHB, providing 
leadership for a state-wide Tribal health program.
    In 1976 Dr. Emery Johnson, Director, Indian Health Service (IHS), 
selected me as Director of the IHS California Area Office (CAO). The 
CAO is one of 12 Area Offices of the IHS. My term as Director of the 
CAO was marked by significant changes brought about by the enactment of 
the Indian Self-Determination and Education Assistance Act (ISDEAA) 
Public Law (P.L.) 93-638; and, the Indian Health Care Improvement Act 
(IHCIA) P.L. 94-437. In 1986 I transferred to IHS Headquarters where I 
held several positions of increasing responsibility and authority, 
culminating in 2005 when Dr. Charles Grim, Director, IHS, selected me 
to be his Deputy Director. In September 2007, Secretary Leavitt 
designated me as the Acting Director, IHS.
    In the early history of the IHS program, the greatest achievements 
in reducing health disparities were through increased medical care and 
public health efforts that included massive vaccination programs and 
bringing safe water and sanitation facilities to reservation homes and 
communities. I believe future reductions in health disparities will be 
made through health promotion and disease prevention efforts and 
programs.
    If confirmed, I will work diligently to support the decision of 
Tribes to contract, compact, or retain the Indian Health Service as 
their provider of choice. The Indian Self-Determination Act allows 
Tribes to manage their own health programs. In addition, this 
Administration and the Secretary have put their words into action and 
increased tribal consultation with the Department.
    I am also committed to continuing the three Director's Health 
Initiatives: Health Promotion and Disease Prevention; Behavioral 
Health; and, Chronic Care Management. I firmly believe the future of 
Tribal communities depends on how effectively the Indian health care 
system addresses chronic diseases. And, preventing and treating chronic 
disease is critical to addressing the most serious illnesses faced by 
the Indian community.
    Collaborative efforts are one way to bring the message of 
prevention to Indian people. As such, they IHS has collaborated with 
other organizations like the National Boys and Girls Clubs of America 
to increase clubs on reservations, NIKE Corporation to promote healthy 
lifestyles, per an Interagency Agreement CDC to fund IHS FTEs 
supporting epidemiology and disease prevention activities, Mayo Clinic 
to support efforts to reduce cancer and related health burdens, and 
Harvard University to improve American Indian and Alaska Native health 
and wellness.
    Organizational performance is also important to the agency's 
effectiveness in administering its programs; and the IHS has made 
consistent progress in addressing management areas included in the 
President's Management Agenda, a government-wide management improvement 
initiative. In addition, the agency was rated ``Exceptional'' by the 
Department of Health and Human Services for the third year in a row for 
its overall organizational performance.
    The Indian Health Service has had a long history, some 50 plus 
years, of continually changing and reacting to meet the new challenges 
and I am excited to report that we have been looking closer at working 
smarter, more efficiently and effectively. Key to our successes in the 
past and our future efforts is the committed, compassionate, and 
competent workforce we have in our Indian healthcare system.
    In making the case for change and recognizing the forces driving 
the need to change we have concluded: The current healthcare delivery 
structure faces many challenges; such as, increasing needs to meet 
demographic and health condition trends.
    Healthcare is labor intensive and we must focus on filling 
vacancies in both health care professions and support positions to 
ensure timely and quality access to health care services for American 
Indian and Alaska Native people.
    The IHS and its Tribal partners through some amazing Tribal 
Leaders, have been advocates for Indian health: In the past we've 
simply adapted to the current health care environment without 
examination of how to improve the entire IHS system. This is a chance 
to change by design; we need to change in such a way as to maximize our 
capacity to deliver care; to continue to meet our responsibility to 
Indian people, we must develop a delivery system to increase access to 
care, and to achieve consistency in services across the system; and, 
design an integrated Indian health system to serve American Indian and 
Alaska Native people throughout the United States.
    We need a Indian Health Service delivery system that is flexible 
while considering the national needs of Indian country as well as 
regional differences. A system where an Indian from the Great Lakes 
region can walk into a clinic in the Southwest and be seen by a 
provider who, with access to the patient's health information and 
records, is able to care for that patient with a level of service equal 
to that of any other facility or program in the system.
    As every previous Director of the Indian Health Service, I have the 
same great passion about this organization and our mission to raise the 
health of our people to the highest level possible. My actions will 
always reflect the honor of being entrusted to provide health services 
to American Indian and Alaska Native people. Should I be confirmed, I 
will lead the Indian Health Service, with honor and respect for our 
ancestors, and work with you and the Administration for the benefit of 
American Indian and Alaska Native people.
    I am pleased to respond to any questions you may have concerning my 
nomination.
    Thank you.
                                 ______
                                 
                      a. biographical information
    1. Name: Robert Gerald McSwain.
    2. Position to which nominated: Director, Indian Health Service.
    3. Date of nomination: December 19, 2007.
    4. Date and place of birth: August 25, 1945--Clovis, California.
    5. Marital status: Married--June Clydene McSwain.
    6. Name and ages of children: Kristin Denise Ruud--40, Elizabeth 
Ann McSwain--26, Eric Phillip Ruud--38.
    7. Education:

------------------------------------------------------------------------
                                            Degrees          Dates of
     Institution        Dates attended      received         degrees
------------------------------------------------------------------------
Fresno City College    1963-1966        A.S.             6/1966
California State       1966-1969        B.S.             6/1969
 University--Fresno
University of          1984-1986        M.P.A./H.S.A.    6/1986
 Southern  California
------------------------------------------------------------------------

    8. Employment record: List below all positions held since college, 
including the title and description of job, name of employer, location, 
and dates.

        Office Manager--Kaweah Construction, Visalia, CA (1969-1970).

        Director, Central Valley Indian Health Program, Clovis, CA 
        (1971-1974).

        Executive Director, California Rural Indian Health Board, Inc., 
        Sacramento, CA (1974-1976).

        Director, IHS California Area Office, IHS, Sacramento, CA 
        (1976-1984).

        Senior Advisor to Director, IHS, Sacramento, CA (1984-1986).

        Director, Division of Health Manpower and Training, IHS, 
        Rockville, MD (1986-1988).
        Deputy Assoc. Director, Office of Admin. and Mgmt., IHS, 
        Rockville, MD (1988-1990).

        Associate Director, Office of Human Resources, IHS, Rockville, 
        MD (1992-1997).

        Director, Office of Management Support, IHS, Rockville, MD 
        (1997-2004).

        Acting Dep. Director for Management Operations, Rockville, MD 
        (2004-2005).

        Dep. Director, IHS, Rockville, MD (2005-2007)/Acting Director, 
        IHS (2007-2008).

    9. Military service: Enter all military service if not included 
above: service, dates, rank, type of discharge--None.

    10. Honors and awards: List below all scholarships, fellowships, 
honorary degrees, military medals, honorary society memberships, and 
any other special recognitions for outstanding service or achievement.

        President's Rank Award for Meriterious Service (2004).
        President's Rank Award for Distinguished Service (2006).

    11. Memberships: List below all memberships and offices held in 
professional, fraternal, business, scholarly, civic, charitable and 
other organizations.

        Senior Executive Association--1998-2008.
        Calif. State University--Fresno Alumni Assn.--1970-2008.
        Univ. of Southern California Alumni Assn.--1987-2008.
        Federal Executive Alumni Assn.--1984-2008.
        American Public Health Association--2007-2008.
        Sandy Springs Friends School PTA--2004-2008.

    12. Published writings: List the titles, publishers and dates of 
any books, articles, or reports you have written.--None published.
    13. Qualifications: State fully your qualifications to serve in the 
position to which you have been named.

        I have held a number of positions over my career that have 
        brought me to this potential pinnacle of my career. My career, 
        among other things, is marked by change. The highlights of 
        which are the Agency-wide Tribal restructuring workgroups in 
        the 1990's, the Indian Health Design Team (I was one of 6 
        Federal representatives) and the Restructuring Initiatives 
        Workgroup (I was one of 4 federal representatives). I have 
        always focused on balancing change with continuous improvement 
        in both program (patient care) and administrative support 
        systems.
        I began my health career in 1971 as the Director of Central 
        Valley Indian Health, Inc., (CVIH). The CVIH Program was one of 
        16 original programs of the California Rural Indian Health 
        Board (CRIHB) that marked the re-entry of Federal Indian Health 
        Care into the State of California. At CVIH, I led the 
        establishment of medical and dental centers supported by 
        community health aides. Toward the end of my time at CVIH we 
        added an alcohol and alcoholism residential treatment center. I 
        then moved on to serve as the Executive Director of CRIHB, 
        thereby providing leadership for a state-wide Tribal health 
        program. My biggest accomplishment was to guide growth and the 
        institution of direct medical and dental care supported by 
        community health programs.
        In 1976 I was selected by Dr. Emery Johnson, Director, Indian 
        Health Service (IHS), for the position of Director of the IHS 
        California Area Office (CAO). The CAO is 1 of 12 Area Offices 
        of the IHS. My principal role as Director of the IHS CAO was to 
        provide support, advocacy and policy guidance to the California 
        Indian health programs. My term as Director, CAO was marked by 
        significant changes brought about by the enactment of the 
        Indian Self-Determination and Education Assistance Act (ISDEAA) 
        Public Law (P.L.) 93-638; and, the Indian Health Care 
        Improvement Act (IHCIA) P.L. 94-437. ISDEAA enabled Tribes who 
        previously were a part of CRIHB to contract directly with the 
        IHS and IHCIA resulted in more resources coming into the CAO.
        In 1986 I transferred to IHS Headquarters where I held several 
        positions of increasing responsibility and authority, 
        culminating in 2005 when Dr. Charles Grim, Director, IHS, 
        selected me to be his Deputy Director. Under the new structure, 
        not only was I second in command, but I was responsible to 
        supervise, guide and rate the performance of the twelve IHS 
        Area Directors. As the principal Deputy Director I participated 
        in setting overall Agency priorities, policies, and strategic 
        direction. I provided significant input in managing the 
        formulation, presentation, justification, and execution of the 
        Agency budget. In September 2007, Secretary Leavitt designated 
        me as the Acting Director, IHS.
        Finally, as it relates to recognition of my accomplishments, I 
        have received many awards and recognition over the years, but 
        the two that stand out as capstones are the President's Rank 
        Award for Meritorious Service in 2004 and the President's Rank 
        Award for Distinguished Service in 2006.
        It is my firm belief that given this experience, both in type 
        and level of responsibility. I feel fully qualified to be 
        considered for the position of Director, Indian Health Service.

                   b. future employment relationships
    1. Indicate whether you will sever all connections with your 
present employer, business firm, association or organization if you are 
confirmed by the Senate: Not applicable.
    2. As far as can be foreseen, state whether you have any plans 
after completing government serve to resume employment, affiliation or 
practice with your current of any previous employer, business firm, 
association or organization: I fully intend to remain in government 
service.
    3. Has anybody made you a commitment to a job after you leave 
government? No.
    4. If you have been appointed for a fixed term, do you expect to 
serve the full term? Yes.
    4a. If you have been appointed for an indefinite term, do you have 
any known limitations on your willingness or ability to serve for the 
foreseeable future? Not applicable.
                   c. potential conflicts of interest
    1. Describe any financial arrangements or deferred compensation 
agreements or other continuing dealings with business associates, 
clients or customers who will be affected by policies which you will 
influence in the position to which you have been nominated: None.
    2. List any investments, obligations, liabilities, or other 
relationships which might involve potential conflicts of interest with 
the position to which you have been nominated.

        My spouse has Stock interest in Westat, Inc., an employee owned 
        research corporation, that has contracts with the U.S. 
        Government including HHS. The company does not currently have 
        any contracts with the Indian Health Service and it's not 
        expected to cause any conflict with my duties. However, as 
        stated in my ethics agreement, I will not participate 
        personally and substantially in any particular matter which 
        will have a direct and predictable effect on the financial 
        interest of Westat, Inc.

    3. Describe any business relationship, dealing or financial 
transaction (other than taxpaying) which you have had during the last 
10 years with the Federal Government, whether for yourself or 
relatives, on behalf of a client, or acting as an agent, that might in 
any way constitute or result in a possible conflict of interest with 
the position to which you have been nominated: None (except as a 
Federal employee).
    4. List and describe any lobbying activity during the past 10 years 
in which you have engaged for the purpose of directly or indirectly 
influencing the passage, defeat or modification of any legislation at 
the national level of government or for the purpose of affecting the 
administration and execution of national law or public policy: None.
    5. Explain how you will resolve any potential conflict of interest 
that may be disclosed by your responses to the above items.

        Although I do not believe that I am involved in any issues that 
        present a potential conflict of interest, as described in my 
        ethics agreement, I have agreed to recuse myself from any 
        matters that possibly could cause a conflict of interest. If 
        questions arise, I will seek guidance from the Department's 
        ethics officials.

    6. Explain how you will comply with conflict of interest laws and 
regulations applicable to the position for which you have been 
nominated. Attach a statement from the appropriate agency official 
indicating what those laws and regulations are and how you will comply 
with them.

        As described in my ethics agreement, I have agreed to recuse 
        myself from any matters that possibly could cause a conflict of 
        interest. If questions arise, I will seek guidance from the 
        Department's ethics officials.
                                 ______
                                 
                                 
                                 

    The Chairman. Mr. McSwain, thank you very much. We 
appreciate your testimony.
    I personally will be supporting your nomination, and I will 
hope to move the nomination out of this Committee in an 
expeditious way and to the Floor of the Senate.
    Having said that, you and I talked yesterday, by telephone, 
and you know that I feel there are some very serious problems 
at the Indian Health Service. First and foremost, of course, is 
the problem of funding. We have unbelievable funding problems, 
and you inherit a difficult situation. You inherit a system in 
which we are required to provide adequate health care to Native 
Americans, the First Americans, and yet about 40 percent of the 
money that is needed to do that is not available. So we have 
rationing going on.
    Give me your perspective about inheriting a system that is 
so dramatically under-funded.
    Mr. McSwain. Senator, that is an excellent question. I was 
reflecting for a moment on the fact that you used the word 
inherited. I did in fact inherit a budget. But I was also very 
much involved in the preparation of that budget. As you well 
know, the current climate in which we operate is the fact that 
we have a budget deficit. We are in a reduction arena. There 
are a lot of problems that are being gauged about what is 
important to them.
    It is fair to say that we have begun to refocus our efforts 
toward that which is our primary core mission. The primary core 
mission of the Indian Health Service is to provide service to 
the Indian people living on or near reservations. And more 
importantly, to our clinical care that we need to provide, 
which is our primary care to American Indians and Alaska 
Natives. That may mean that other parts of our program will 
either be eliminated or downsized in order to make sure that we 
maintain those particular initiatives and program levels, 
particularly as it pertains to clinical services.
    In fact, as you have seen our budget, the increases we have 
are on the clinical side. And the decreases are on the non-
clinical side.
    The Chairman. That is certainly true, overall, of course, 
there is a decrease in recommended funding with respect to the 
increased costs of living and so on. We are losing ground here 
with this budget. It is also the case that our facilities are 
in tough shape and we are cutting facility funding.
    I want to ask you about this, in July of 2007, Dr. Grim, at 
his confirmation hearing, told the Committee that the IHS 
Office of Environmental Health and Engineering had finalized 
revisions to the Health Care Facility's Construction Priority 
System. That was July of last year, and the final report was 
being prepared to be submitted to the Department of the OMB for 
clearance.
    Any word about that? What is the status of that?
    Mr. McSwain. Senator, what happened was unfortunately, Dr. 
Grim left, and his withdrawal resulted in him departing from 
the directorship rather quickly. He had wanted to really sign 
off on that. But I am pleased to report to you that I have in 
fact signed off on the basic system, the basic priority system 
that was recommended by the Tribal-Federal Appropriation 
Advisory Board that had been working on it for a number of 
years. And it is now moving through the Department and will be 
moving for clearance. They are vetting it at the Department 
level. It will be moving through to certainly OMB and then on 
down to the committee that requested the new system, which is 
the appropriations committee.
    The Chairman. Let me refer you to, without using names, a 
letter that I wrote to the Inspector General of the Indian 
Health Service, Inspector General of HHS, setting out a series 
of concerns about one of the regional offices of the IHS. And 
it dealt with a director of a tribal Indian Health Service 
facility and the complaints that had been made by the tribe, by 
employees, about employee harassment, financial impropriety, 
and other things.
    As I looked into it, it appeared to me, Mr. McSwain, that 
in a particular area office, there was staggering incompetence. 
I don't know any of those people, but it seems to me that when 
you have circumstances of the kinds of complaints that existed, 
you would expect a regional office to move quickly to find out 
what is happening. Yet that was not the case here.
    As I looked into it, I am told that the very person that 
was running the Indian health facility at this particular 
tribe, a tribe, by the way, which passed two resolutions 
banishing that person from their reservation, I am told that 
the person had multiple complaints filed against them. There 
were five EEOC complaints, four of which were determined for 
the plaintiffs and against this employee, and yet this person 
has just been transferred along in the Indian Health Service to 
the next tribe. We here about all of these allegations, and 
nothing happens.
    It appears to me that in that region, and I am not using 
names, but you know what I am talking about, you have 
staggering incompetence with a bureaucracy that is just mired 
in the glue of indifference. I mention this because you know of 
this case. But I also sense it exists elsewhere in the system. 
I think this is a bureaucratic system that desperately needs 
reform. If you find some place where somebody has had four or 
five EEOC complaints filed against them, I hope you will 
determine that the person doesn't get transferred, and that he 
or she gets fired.
    I am hoping that you are going to risk your job to do two 
things. Number one, to say to this Administration privately and 
publicly, if necessary, we need adequate money in this system 
to provide health care for Indians that we promised them. 
Number two, you are going to insist on reform in a system that 
is hard to reform, and you will take the risks to require that 
reform. That is what I am hoping from you.
    But I have asked you a big, long, formless question here. 
Give me your impression.
    Mr. McSwain. Thank you, Senator. There are two parts to 
that question, obviously. The first one was about resources.
    I am of the belief that part of our challenge as the Indian 
Health Service is to make the case better and clearer to the 
people we must report to. And that is something I will work 
more diligently on. There has to be a better way to tell the 
story of why we need certain budgets each year. This year, the 
2009 budget, we made a case for it, and now it is the 
President's budget. We will defend it.
    We will go back and look and see whether or not there are 
parts of our proposals that we are missing on, recognizing that 
it is all about competing, if you will, across the board to 
ensure that the Government in total, I realize that poor OMB 
gets a rap every now and then about this whole thing. But they 
are trying to make a decision across Government, much like the 
Secretary must make decisions about cross all the octaves. And 
then for the Director of the Indian Health Service to make 
decisions about all of Indian health.
    So as it rolls up, it is how we make the case. But I can 
assure you, I will continue to make the case when the time 
comes during the rules process to do that. I will commit to 
that.
    On the second issue of the example of the EEO complaints 
and the like, let me just say that after your phone call, a lot 
of actions took place. I am only sorry that it had to require 
you to call me to make that occur.
    The Chairman. You are talking about the call four or five 
months ago?
    Mr. McSwain. Yes. It should not have happened. And that I 
apologize for. But we are in fact looking across the Country, 
in fact, the concern about, was it systemic, we have looked 
into it. There are parts in the Country that we have found 
other, similar situations. It is not systemic, but there are 
some other examples.
    We are moving to, part of the whole of competency at the 
service unit director level, or the CEO of the service units, 
is that we have not paid a lot of attention to ensuring that we 
are getting the best qualified people to operate our service 
units, particularly in those service units where we actually 
are providing the care. And we have started a succession 
planning program that will in fact hopefully ensure that there 
is a level of professionalism and that they are adequately 
trained.
    As you can imagine, something I have observed over the 
years is that as you are very good at what you do, you are a 
good technician, and you do the job extremely well, the next 
thing someone does is say, well, you ought to run the whole 
thing, without any training on what it takes to manage people. 
That is a huge job, when you start to lead and manage people, 
as opposed to just doing your thing. You can't be the best 
accountant and expect to be the director of finance without 
adequate training.
    So those are the things that I believe that we are working 
on and will continue to work and focus on them, particularly at 
our service units.
    The Chairman. Mr. McSwain, one of the things that I suggest 
that you consider is writing a letter to the tribes. We have 
500 and some recognized tribes in America. Write a letter to 
those tribes and ask them, give me your perspective, from your 
level, what is happening in the health care system in your 
area.
    I walked through a clinic in North Dakota about three or 
four weeks ago with a wonderful IHS doctor--wonderful doctor. 
This is a clinic with poor structure, inefficiencies, and it 
needs to be rehabbed. The doctor said, we desperately need a 
new x-ray machine. I said, well, can you get it? He said, no, 
the requisition for it has been in for two years, but the 
request hasn't gotten through. The regional office hasn't 
assigned it yet, but the money is there. I said, how long has 
it been? Two years--can't get it through the regional office.
    It is just a matter of processing paperwork. But when the 
paperwork doesn't get processed, all those folks that were 
sitting in the waiting room, some of whom would want a good x-
ray, aren't going to get the x-ray they expected, because 
somebody sitting in a regional office hadn't found ways to get 
through their papers. And this poor doctor just shook his head 
and said, you know, it is beyond my understanding of how people 
like that keep their jobs.
    So my hope is that you will be able to reform some of this. 
Let's not protect incompetency. If we have incompetent people, 
let's root them out, get good people in who are dedicated and 
passionate and want to do a good job. Because there are some 
incompetent people in this bureaucratic system of ours. That is 
true of the Indian Health Service. I believe I have documented 
some of that. I am not trying to be a policeman for the Indian 
Health Service. That is not my intention. But I want that 
service to work well, and I think it can work much, much better 
than it has.
    I have a couple of other questions, but I want to yield to 
the Vice Chair, Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman.
    You point out one of the obvious problems. If you have 
incompetency in the system, that in and of itself brings great 
frustration to all involved. But to the practitioner who wants 
to be able to provide a level of care, they give up in 
frustration. So then you don't have that experienced 
professional there. It builds on further and further problems.
    Mr. Chairman, I am notified that Senator Barrasso is going 
to be submitting a statement for the record and has asked that 
that be included as part of this as well.
    The Chairman. Without objection.
    Senator Murkowski. Mr. McSwain, we had a chance a couple of 
days ago to talk at some length about the Indian Health Care 
reauthorization and some of the issues that are still 
outstanding and our hopes, our very strong hopes, that we will 
be able to move this legislation through the Senate in an 
expedient manner, allow the House to act quickly and get it to 
the President for his signature this year. Senator Smith raised 
an issue that is out there. As you know, we have been working 
on some of the few outstanding issues.
    What kind of commitment can you give to this Committee that 
you will actively participate in resolving any of the 
outstanding issues that are out there, or basically how you can 
help us get this bill signed into law?
    Mr. McSwain. Thank you, Senator. As I mentioned the other 
day, this is an important bill for me personally and 
professionally. Certainly as I see the bill, I think I 
reflected with you the fact that the bill 30 years ago was not 
as complex as the bill is today, nor is our environment as 
simple as it was in 1976. It is much more complex. There are so 
many different pieces to it. In fact, I speak with Mr. Mahsetky 
almost daily about what is happening as the various issues are 
addressed in the bill.
    But the bottom line is, yes, we do need to have it 
reauthorized. It provides a framework. It provides a 
relationship between the tribes and the Federal Government 
about health services. That is the paramount. The goals that 
are set forth in the law are as real today as they were 30 
years ago. It is about improving and it is about the 
responsibility the Government has to provide care to Indian 
people.
    Those being the underpinning fundamentals of the bill, 
there are all the pieces obviously that go into it. There are a 
lot of other interests that are expressed about the bill. I can 
assure you that I will work within the Department and within 
the Administration to the extent possible that I can help 
resolve those issues that are pending. I will use my office to 
do that.
    Senator Murkowski. We appreciate that. We want to make sure 
that we have that continued support of the Administration. As 
you know, there was a set that was released a couple of weeks 
ago that raised some issues, that caused some concern. We want 
to be able to work through all of those and know that we have 
the support from the Administration and the President will sign 
this bill when we get it successfully moved through the 
Congress.
    You gave a little bit of a status on the health care 
facilities priority system. You mentioned briefly in our 
meeting the Barrow facility. Will both the Nome and the Barrow 
facility retain the priority status that they currently have 
under the newly-revised system?
    Mr. McSwain. Yes, they will. In fact, all the facilities on 
the current system, some 20 facilities, are set there. As you 
were talking about facilities, I was also looking at the same 
five-year plan and realized that we have built a fair number of 
facilities since 1993. I was counting some rather large 
numbers. I can certainly submit those for the record.
    We have been moving out and building facilities, hospitals 
and health centers and YRTCs and the like for the last 18 years 
rather well. While the process is slow, we will continue to 
move forward with Barrow and Nome as well as the facilities in 
the lower 48.
    Senator Murkowski. You responded a little bit about the 
budget issue. We recognize that these are times of budget 
restraints. We have been urging, certainly my constituents as 
they come to the office in frustration about the IHS budget, we 
have been urging Alaska Natives to get involved in the process 
early on, let the agency know what the concerns are. I do 
appreciate the IHS efforts to conduct these budget consultation 
meetings and trying to work with the tribes on their 
recommendations.
    But what we are hearing back from so many, from the tribes, 
is that their priorities are just clearly not reflected in the 
President's budget. How can we make this consultation process 
more meaningful? It is one thing for me to say, go and make 
sure that your concerns are hear, they do, they participate, 
and then they don't see anything on the other side. If it is 
not going to be meaningful consultation, it is tough for me to 
urge them to be a participant, it is tough for them to feel 
like they should continue to be a participant. How can we make 
this work better?
    Mr. McSwain. That is an excellent question. It is one that 
we have wrestled with for some time. When the budget ultimately 
gets presented and the President rolls out the budget, tribes 
are wondering, raise questions about that.
    The process is fairly transparent until it gets up into the 
decision-making that goes on at the higher levels were the 
budget is embargoed. But up to that point, we have not done a 
very good job of relating back to the tribes that have 
participated in the process that, here are your priorities, 
this is what you priorities are by region, by area, and this is 
what they look like in a composite nationally. It is perhaps as 
simple as Chairman Dorgan says, write a letter back to the 562 
tribes that says, for this year, these are the priorities by 
region, these are the priorities that we have collected for the 
national purposes, and we are going to rest on those priorities 
as we move forward.
    I can assure you that all the decisions that go on in the 
process, what goes on in the embargoed stage, we are mindful, 
ever mindful of the tribal priorities and what those priorities 
are. We will continue to do that. The unfortunate thing is the 
process does move into the embargoed state. We are not at 
liberty to share with them those kinds of decisions that are 
being made. But I can assure you that I and all the directors 
before me do in fact rely on those priorities.
    We just need to get the message back to them, and I think 
there is a better way of doing that. The national consultation 
meeting is going to occur next week out in California, where 
they will be talking about national priorities again. We will 
take another look as to how we best represent the priorities.
    Senator Murkowski. Consultation is a two-way street. If the 
tribes don't feel as if they are being heard or that it is a 
meaningful consultation, again, you are not getting much out of 
that process. So it seems to me that there has to be a way to 
ensure that that is meaningful.
    We all appreciate that there is that black hole at some 
point in the budget process, where it is not open and it s not 
transparent. We wonder what in the world happened to our 
priorities. But until that stage, I think every effort that can 
be made to make sure that there is clear understanding as to 
how we outline these priorities, I think it will be better for 
all.
    I mentioned in my opening statement the comment, don't get 
sick after June. It just speaks to the need to support the 
contract health service program. How are we going to address 
the shortfalls in the contract health services?
    Mr. McSwain. A couple of things have occurred. Certainly in 
the contract health service there is the $9 million increase 
for 2009. And there is also the increases that we have received 
for the catastrophic health benefit, which is the CHEF fund. 
That was the one that for cases over $25,000, they are referred 
to the headquarters office and they are paid out of CHEF.
    We were running out of money in the CHEF fund for those 
high-cost cases as early as April, not June, but April. What 
was happening was that we didn't have enough in the CHEF fund 
to be able to pay for those high-cost cases. Therefore, the 
areas were required to begin using their other CHS funds. So 
all you need is a few high-cost cases like that and your CHS 
budget is sorely affected. We are looking at possibly getting 
the CHEF fund all the way through August now, because of the 
increases in the CHEF fund.
    Senator Murkowski. That is good, but that gets you through 
August.
    Mr. McSwain. Yes, I know, but we are moving the ball.
    Senator Murkowski. Yes, I know. It is just difficult to 
have to explain that to somebody who is ill and the expectation 
is that that care is going to be available. If the calendar 
doesn't jive with when you happen to become ill, again, we 
wouldn't accept this anywhere else. And yet we talk about it as 
though, well, it used to be April, now it is June, but soon it 
will be August and we should celebrate that success. I think we 
celebrate the success when we are able to provide for the level 
of health care services year-round, 365 days.
    Mr. Chairman, I have some more questions, but if you want 
to take a turn?
    The Chairman. Go ahead.
    Senator Murkowski. All right, thank you.
    Third-party reimbursements. As you know, in the Indian 
Health Care reauthorization, this is a big effort here to make 
sure that we do allow for increasing Medicaid, Medicare 
enrollment in Indian Country. I understand that there may be 
some concern about how effective the enrolment efforts have 
been in some areas, and that patient care is delayed until they 
are enrolled. What is the plan of action for increasing 
Medicaid and Medicare enrollment, so that we don't see these 
delays?
    Mr. McSwain. Senator, I believe what you are talking about 
is the enrollment, obviously it is getting our patient 
registration system more robust than what it is. We do know 
that patients do arrive at our facilities, and in some cases, 
are immediately screened for alternate resources, namely 
Medicare-Medicaid, VA, private insurance. I know that some of 
our systems do just an outstanding job. The best practices, if 
you will, from those facilities, are being transported to other 
facilities.
    I know that for us, the collections mean a great deal. 
While they are intended to address deficiencies and 
accreditation issues in facilities, they are also a great 
source of additional resources for purposes of providing 
patient care. We are up close to $800 million in third-party 
collections now. That is a rather significant amount.
    The fact is that we are continually working with CMS on 
opportunities that CMS will provide, and also through the 
Tribal Technical Advisory Group, the TTAG, which is tribally, 
basically a group of advisors to CMS for all kinds of Medicaid-
Medicare issues and reimbursements. We are working diligently. 
We know that some of the statements around the system are, make 
sure that we are capturing every possible Medicaid opportunity, 
Medicare opportunity, because it is such an important part of 
our system.
    I know that tribes have been doing an outstanding job, I 
know Alaska has done just a tremendous job, because they have 
literally tripled the collections since they have taken over 
the program. That tells us a lot. And clearly, this is an area 
that we feel we negotiate the rates each year to ensure that 
they are forward-moving. We will continue to do that. The 
business offices throughout the facilities are becoming, I 
think, better at what they do. The ability to bill and collect 
is another facet of our business infrastructure.
    Senator Murkowski. What about contract support costs? 
Shortfalls are pretty significant. Under the contract support 
cost policy that was issued last April, how long is it, do you 
anticipate, before these shortfalls in contract support costs 
are addressed?
    Mr. McSwain. That is a very difficult question. I would 
have to go back and look. I have some numbers in preparation, I 
know they are pulling some numbers together in preparation for 
the upcoming budget hearing. I don't have the latest numbers. 
In fact, I know that I was trying to find out where the last 
shortfall report was. I am of the understanding that the last 
shortfall report that came to the Congress is probably about 
2000, on 2000 data. We are looking for the latest report that 
should be coming to the Congress. I can report on that at that 
point.
    Senator Murkowski. Is it still the IHS policy to deny the 
newer expanded contracts based on the lack of contract support 
costs? Is that still the policy that is in place, then?
    Mr. McSwain. Excuse me, will you repeat the question?
    Senator Murkowski. Whether or not it is the IHS policy 
still to deny new or expanded contracts if you don't have 
sufficient contract support costs?
    Mr. McSwain. No, Senator, the position of the Indian Health 
Service is to have a conversation with the tribe that wants to 
take over a program service, function or activity under the 
Indian Self-Determination Act. We share with them the fact we 
do not have contract support cost money and allow them to say, 
do they still want to take it over. They can take it over, 
recognizing we don't have the contract support costs. We have 
had a number of tribes in fact move forward, assume the program 
responsibility without the contract support costs. We have not 
denied any because we don't have the money. I don't know of 
anyone, anywhere we have denied them.
    Senator Murkowski. Mr. Chairman, that is all I have at this 
point in time. I appreciate the responses from Mr. McSwain.
    The Chairman. Mr. McSwain, the President, either the 
President or his representatives, have suggested the potential 
of a Presidential veto on the Indian Health Care Improvement 
Act. Are you familiar with that and what the reasons for that 
might be?
    Mr. McSwain. I am familiar with the statement of 
administrative policy.
    The Chairman. Right.
    Mr. McSwain. I have only read about the veto. I am not 
involved in the actual messages from the White House.
    The Chairman. My sense is that we have worked through most 
of the concerns. Based on the Administration's comments, at 
least one of them, I believe, they were confused about what the 
provision actually was. I think that we have worked through 
most of those. My hope would be that you, inside the 
Administration with OMB and the White House, would look at our 
work. Our hope would be to get that through the Senate next 
week. When we do, I hope you will look at that work and see 
that substantial changes have been made, changes that will 
resolve those issues.
    You have a responsibility to support the President's 
actions, I understand that. You have a responsibility to 
support the President's budget, I understand that. It is always 
a source of aggravation that those that come to the witness 
table steadfastly support the President's budget. But then I 
understand that you work for the President, not for this 
Committee.
    I do think we have very serious funding problems, and it is 
very hard to run a system that is so dramatically under-funded. 
The contract health care issue is a very serious problem. I 
know that there is some effort to improve that.
    But in addition to what my colleague, Senator Murkowski, 
described, ``don't get sick after June,'' any of us who go to 
reservations understand that this is happening in contract 
health, and as a result, people's credit ratings are ruined. 
They have to postpone getting deathly ill in September or 
August, because there may not be any contract health money 
available. The nearest health care facility is not on the 
reservation, it is an hour and a half away.
    So they go, and the contract health money is not there to 
provide for their needed care. So the debt collectors come 
after them and destroy their credit. It is an awful thing to 
see. A lot of folks on Indian reservations have credit ratings 
that have been completely destroyed because of the inability to 
provide contract health care.
    You are familiar with that, I assume?
    Mr. McSwain. Yes, I am, Senator. While you were speaking, I 
was thinking of a couple of parts of an answer. One part is 
that we need to fill the vacancies we have. Because if we don't 
fill the vacancies, we don't provide the care, we go buy the 
care. So we have some vacancies we need to fill.
    The interesting thing about that strange dynamic is that we 
wind up contracting out to fill those vacancies to even 
continue the care. So that reduces our ability to collect.
    The other thing that comes to mind also is the fat that we 
haven't seen the full measure of the Medicare-like rights, 
where we are actually contracting with facilities for Medicare-
like rights, and that is another facet of insuring that not as 
much contract health service is going out as billed charges. 
But we are still watching, it was only put in place last year. 
But clearly, this is another area that will at least moderate 
the out-go for contract health care. It is still a major issue. 
I agree with you, I think that the fact that we are moving some 
of our facilities, we are replacing them with health centers 
now. We are trying to, and I think the last couple of 
facilities we actually increased the contract health care for 
those facilities. One was Sisseton and the other was Clinton, 
they went from hospitals to health centers. We recognize that 
that is going to require them to go out and buy.
    So we put in our actual contract health care budget request 
some additional funds for those changes, for those two 
facilities. That is another means that we are doing to make 
sure that the care that we are providing when we are moving in 
that direction is actually available.
    Now, the overall set certainly is, in terms of the contract 
health services still operating at the highest level, we are 
only doing top-level, priority one care. The only good thing 
about it is that we are not denying any priority one care 
across the Country.
    The Chairman. Yes, but what is priority one is sometimes a 
matter of judgment. You are talking about life or limb, right?
    Mr. McSwain. That is correct.
    The Chairman. I was at a clinic where they have had a need 
to secure another pharmacist. They have been waiting for a 
year, because all the hires have to run through the regional 
office. The employees at the clinic and the tribe told me that 
that regional office has been unresponsive. So they have had to 
contract out pharmacy services, which runs up to $100,000 a 
month. It has resulted, in some cases, in over-spending to get 
contract pharmacy services, and four hour waits for getting 
prescriptions filled after somebody sees the doctor, in some 
cases doctors have to fill the prescription themselves instead 
of seeing patients, or some patients go without medicines they 
need.
    That is the thing I hear about with these regional offices 
that just makes me angry. We need the bureaucracy to work, and 
we need this thing to function. I think there is so much to do. 
I think what we will do as a Committee, in addition to trying 
to get this Indian Health Care Improvement Act passed, because 
I think that is a first step, is to look at much greater 
reform. But we have to take a first step in the right direction 
before you can get some momentum.
    I think we also as a Committee will write to all of the 
tribes and say to the tribes, tell us what is happening out 
there, give us your perspective. In some cases, their 
perspective may be just that, a perspective of their vision 
through a certain prism. But I think we will get a lot of good 
information. I would encourage you to do the same thing. Let's 
find out what is really happening out there, where the top 
performers are and where there is dramatic need for change.
    I am going to conclude today with something my colleague 
has seen me do on the Floor. I want to do it because we are 
talking about individuals who are having trouble getting 
adequate health care. Adele Hill Baker, I will show you her 
photograph. This is not on your shoulders, it is the system you 
are inheriting now. This lady was having a heart attack on an 
Indian reservation. She was put in an ambulance, taken off the 
reservation, 80 miles or so, 90 miles, to a hospital. She 
didn't want to go in an ambulance, because she knew that she 
couldn't possibly pay the charge, and she worried that the 
Indian Health Service wouldn't pay for it. So she begged not to 
be put in an ambulance, despite the fact that she was diagnosed 
as having a heart attack.
    They put her in an ambulance anyway, and took her to the 
hospital. When they got to the hospital, she had a piece of 
paper taped to her leg that informed the hospital that there 
was no contract health care money available. If you admit this 
patient, understand it is at your own risk. So a woman comes in 
on a gurney with a piece of paper taped to her leg. It is just 
unbelievable.
    That is the story of Adele Hill Baker, a real person having 
a heart attack, who is put into this position of going into the 
hospital and having a piece of paper with her that says, by the 
way, admit me, you are in trouble.
    The other is a photograph of a young girl from Montana. Her 
grandmother saw me at the Crow Reservation in Montana. This 
young girl died, just a young girl, five years old. Her name 
was Teshon Rain Little Light. Her grandmother came to where 
Senator Tester and I were holding a meeting. She held up this 
big picture of this little girl in her Indian dress and she 
told us her story. This is a little girl. They took her to the 
clinic four or five times and they treated her for depression. 
Her grandparents pointed out that her fingers are bulbous and 
discolored, there is something wrong with the oxygen, something 
going wrong inside.
    And one day, of course, it all collapsed and they sent her 
to Billings, Montana on an emergency basis to the hospital from 
the Crow Reservation Clinic. They sent her immediately to the 
Children's Hospital in Denver and discovered that she had 
terminal cancer. Her grandmother said she lived the last three 
months of her life in unmedicated pain, undiagnosed. Of course, 
she died shortly thereafter.
    It so happened I ran into this young girl's aunt on an 
Indian reservation in North Dakota about two weeks ago. She 
again described the case. This is a five year old girl that 
probably shouldn't have died, probably should have been 
diagnosed much, much earlier. These things are going on all 
across the system. Many of these reservations are remote, very 
remote areas where there is not a good hospital, not a hospital 
that is close. So the delivery of health service by the Indian 
Health Service in many cases is the only delivery that is 
available. I know in many cases it means life or death to have 
the right service at the right time.
    One of the clinics I told you about earlier has a lot of 
problems. But one of the significant problems is it is only 
open from 9:00 until 4:00, five days a week. That reservation 
is very remote. You get sick there, have a serious problem 
there, you are in trouble.
    My point is, we need to do much, much better. I am going to 
move your confirmation, and I believe my colleagues will be 
supportive of it. But I do hope you are willing to risk your 
job and risk your career. By risk, I mean be aggressive, speak 
out, be loud. The only portion of your testimony today that 
caused me any problems at all was when you were complimenting 
the Office of Management and Budget. That almost lost me. But I 
am still with you, Mr. McSwain. The Office of Management and 
Budget knows the cost of everything and the value of nothing. 
That is why we get a recommendation that says, let's cut some 
of these Indian Health programs and recommendations to spend 
money in other areas that are so absurd I shall not even 
describe them today.
    Having said all that, you inherit a pretty big load and a 
big responsibility. This Committee wants you to succeed. We 
don't want you to fail, we want you to succeed. Chairperson Van 
Huss described your background with enormous pride, justifiable 
pride. You come from a background of, I am sure, circumstances 
where you had to overcome the odds, and you have carved out 
quite a significant career.
    So speaking for myself, I am pleased to support your 
nomination. But I really do expect a lot out of you. My guess 
is the Vice Chair does as well.
    So justify that faith, because together, we have to figure 
out a way to make something good out of this health care system 
and make it work.
    Mr. McSwain. Thank you, Mr. Chairman. In fact, as I was 
looking at those pictures and hearing the stories, one of the 
things I want to do is stop the stories. We need to stop those 
stories. We can't have people being moved about the system in 
most disrespectful manner. And clearly, patients not being seen 
in appropriate manners. When I say stop the stories, I hope 
these are the only stories we hear in a long time, that there 
won't be any more.
    The Chairman. Well, this little girl named Teshon Rain 
Little Light, her aunt told me that when she got to Denver, 
finally, after going over and over and over again to the clinic 
and being treated for depression, they discovered she was going 
to die because of a terminal illness. The one thing she wanted 
to do was to go to see Cinderella's Castle. So Make A Wish sent 
her to Orlando, Florida, to Disney World. And the night before 
she was to see Cinderella's castle, she died in her motel room, 
in her mother's arms.
    The point of it all is this. It is such a human tragedy 
that we can't provide first-class medical help that we all are 
proud of. These are the first Americans, and it is our 
responsibility. We have made that commitment, a trust 
responsibility, and treaty commitments. Senator Murkowski and I 
and this Committee are just determined to do everything we can 
to try to effect change here. So when someone new begins to 
head an agency, you have an enormous opportunity to effect 
change. We hope that will be the case with your stewardship of 
the Indian Health Service.
    Senator Murkowski, did you have any final comments?
    Senator Murkowski. Just to thank Mr. McSwain. You have to 
appreciate the courage of a man who, even knowing the obstacles 
that he will face, is willing to take on a challenge. I 
appreciate a great deal your willingness to face these 
obstacles, to stop the stories and to take the challenges and 
to really make a difference within a system that has 
experienced great difficulty. I appreciate your willingness to 
serve and do look forward to the opportunity to work with you 
and other members of the Committee, the Chairman, to really 
make a demonstrable difference in the lives of American Indians 
and Alaska Natives. Thank you.
    Mr. McSwain. Thank you.
    The Chairman. The hearing is adjourned.
    [Whereupon, at 10:43 a.m., the Committee was adjourned.]

                            A P P E N D I X

  Prepared Statement of Hon. John Barrasso, U.S. Senator from Wyoming
    Welcome, Mr. McSwain, and congratulations on your appointment. Your 
family has a right to be proud of your accomplishments.
    As we discussed yesterday during a meeting in my office, I believe 
all of us have a responsibility to plan for a healthy future. As a 
physician, I have worked for over two decades to help the people of 
Wyoming stay healthy and lower their medical costs. In my practice, I 
saw first hand the obstacles families face to obtain medical care.
    Rural and frontier areas have to overcome significant challenges in 
order to deliver high quality care in an environment with limited 
resources. Our unique circumstances require us to work together, share 
resources, and develop networks. I think we can all agree these same 
principles are critical to support and modernize the Indian health care 
delivery system.
    Everyone here knows the serious problems we face to deliver health 
care services in a cost-effective, efficient, and culturally sensitive 
way. Wyoming's Wind River Reservation, located near Riverton, is home 
to 10,415 members of the Eastern Shoshone and Northern Arapaho tribes. 
It is the third largest reservation in the United States--covering more 
than 2.2 million acres. Tribal members in Wyoming have worse than 
average rates of infant mortality, suicide, substance abuse, alcohol 
abuse, unintentional injury, lung cancer, heart disease and diabetes.
    When I last visited the Wind River Reservation, tribal leaders told 
me how difficult it is for them to (1) recruit and retain staff, (2) 
stretch each dollar to deliver essential services, (3) respond to 
cultural barriers, and (4) give families necessary information to make 
better lifestyle choices. Additionally, the Wind River Reservation has 
one of the highest unemployment rates of the twelve IHS areas. The male 
unemployment rate is approximately 30 percent while the female 
unemployment rate is approximately 21 percent. I want to put that 
number into context. The national unemployment rate is hovering around 
5 percent.
    These statistics arc important because they directly affect the 
health of Indian communities. Native American families living below the 
poverty level in areas with high unemployment rates most likely live in 
sub-standard housing, have poor nutrition, and suffer from chronic 
health problems.
    In order to make significant strides in reducing the health 
disparities among Native Americans and Alaska Natives, continued and 
sustained improvements in access to treatment and preventive services 
are needed. That is why I joined my colleague, Senator Smith, and other 
members of the Indian Affairs Committee, to send Office of Management 
and Budget (OMB) Director Jim Nussle a letter requesting increased IHS 
discretionary funds. I want to make sure that people on the Wind River 
Reservation, and all Native People across America, have equal access to 
quality, affordable medical care.
    That said, it is equally as important that the care we provide is 
cost effective and produces results. The IHS is not like other federal 
health care programs. Congress has only limited access to the research 
data that is needed to modernize and improve Indian health care. I know 
this Committee will continue to focus its efforts to improve health 
care services, but we need good data and research to evaluate the 
current delivery system--exposing barriers that prevent collaboration, 
networking, innovation, and sharing of resources.
    Today, neither the government nor private Native American/Alaska 
Native advocacy groups can explain exactly how funds are used to 
coordinate medical services. If we do not know where our resources are 
being spent, the number of programs dedicated to provide services, how 
these programs coordinate health services, or the outcomes achieved, 
then can we be certain we are maximizing our ability to help Native 
Americans and Alaska Natives?
    It is incumbent upon the IHS Director to provide timely, accurate 
answers to this Committee and Congress outlining (1) how much money the 
federal government is spending on discretionary and mandatory Indian 
health care programs and (2) how the IHS works with Medicare, Medicaid, 
SCHIP, states, and the tribes to coordinate programs and services. This 
way, we can target federal funds to programs making the greatest 
impact--then focus on additional areas where Native Americans and 
Alaska Natives need our support.
    Mr. McSwain, thank you for your willingness to serve in public 
office. I look forward to working with you to improve the health and 
welfare of the individuals living in Indian Country.
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  Response to Written Questions Submitted by Hon. Gordon H. Smith to 
                           Robert G. McSwain
Health Facilities Construction and the Area Distribution Fund
    Last July, during Dr. Grim, former IHS Director's nomination 
hearing, Senator Smith asked him to confirm whether IHS had the 
authority to implement an ADF. Dr. Grim did not confirm the Agency's 
authority. One week later Senator Smith sent a follow-up letter which 
also has not been answered. In 1999, Congress was concerned about the 
inequities associated with the allocation of health facilities 
construction resources. In turn, Congress directed the Indian Health 
Service, in conjunction with Tribes, to revise the Health Facilities 
Construction Priority System to make it more flexible and to respond 
and accommodate the wide variances in Tribal needs. Nine years later, 
the new list is finally complete, however it has not been approved by 
the Department of Health and Human Services, nor the Office of 
Management and Budget. Many Tribes in Oregon and throughout the country 
are concerned that finalization of the list has been stalled.
    Question 1. Does the Indian Health Service have the authority to 
implement an Area Distribution Fund under the Indian Health Care 
Improvement Act?
    Answer. Section 301 of the Indian Health Care Improvement Act 
requires the IHS to submit an annual report to Congress setting forth 
the Service's current Health Facilities Construction Priority System 
(HFCPS). The report must identify the highest priority inpatient and 
the highest priority outpatient healthcare facilities construction 
projects, but does not specify how IHS should fund these projects or 
whether their funding should have precedence over other high priority 
Indian Health Service needs. In practice IHS has based its funding 
requests on this listing of projects, and the Congress has appropriated 
funds based on these requests. IHS has the authority to adopt a health 
care priority system that allocates a portion of health facility 
construction funding to all Service Areas.

    Question 1a. What is the Indian Health Service's timeline to begin 
implementation of the revised priority list?
    Answer. The IHS Office of Environmental Health and Engineering has 
been working on the revision to Healthcare Facilities Construction 
Priority System (HFCPS) based on the Tribal comments and Facilities 
Appropriation Advisory Board (FAAB) recommendations. We do not have a 
timeline for implementation, as the revision requires Department, OMB 
and Congressional review prior to implementation.

    Question 1b. How will the new list work with the current list of 
pending projects?
    Answer. We believe the current system has appropriately identified 
the priority order of construction projects IHS will undertake. Our 
goal is to avoid disruption of the current priority list when the new 
HFCPS is implemented.
Special Diabetes Program for Indians Funds
    Question 2. Will you conduct Tribal consultation beyond the Tribal 
Leaders Diabetes Committee in allocating the Special Diabetes Program 
for Indians funds under the one year extension (FY 2009)?
    Answer. As you know, Tribal consultation is an integral part of the 
program planning process used by IHS. For the past 10 years, since the 
Special Diabetes Program for Indians (SDPI) was established, the IHS 
has conducted extensive and comprehensive Tribal consultation on the 
development and implementation of this program. Consultation has made 
SDPI a more innovative and successful program. On February 7-8, 2008, 
the Tribal Leaders Diabetes Committee met in San Diego, CA to review 
and discuss issues related to the reauthorization of the Special 
Diabetes Program for Indians (SDPI) funding for one year (FY09) at the 
same amount of $150 million. I asked the TLDC to make recommendations 
to me regarding the new SDPI funding for FY09. Overwhelmingly, the TLDC 
recommended to me that Area Tribal consultation be held. Thus, I have 
prepared direction to the IHS Area Directors from my office to host 
tribal consultation activities in every IHS Area regarding this topic. 
The IHS Division of Diabetes Treatment and Prevention has developed a 
consultation discussion guide and background documents based on TLDC 
direction as well as from previous consultation activities. This was 
done quickly because Nashville Area was holding their tribal 
consultation on Tuesday, February 12th.
    There is a tight timeline for these Area Tribal consultations to 
occur. The deadline for providing results back to the Division of 
Diabetes is March 10th. On March 28th the TLDC is scheduled to review 
the Area Tribal consultation summaries and to develop recommendations 
to be provided to me in order for a final decision to be made. At this 
time, both Nashville and California Areas have completed consultation 
activities on this topic. IHS will distribute FY 2009 SDPI funds in a 
manner that provides the best diabetes care and prevention services 
possible to American Indians and Alaska Natives and in a manner that is 
consistent with Administration policy.

    Question 3. Given the tremendous administrative challenges that the 
IHS grants management office has with getting awards out in a timely 
fashion, it has been recommend that the IHS not deviate from its grants 
process under the one-year extension. Are there plans to significantly 
alter the grants process for the SDPI?
    Answer. It is not clear at this time how the grant distribution 
process will change under the one-year extension.
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Response to Written Questions Submitted by Hon. Tom A. Coburn, M.D. to 
                           Robert G. McSwain
    Question 1. Please describe how you have, or will have resolved the 
longstanding law enforcement void at the Claremore (OK) Indian 
Hospital? Provide details on how the solution will provide adequate 
protection for patients, employees and area residents?
    Answer. Since the Claremore Indian Hospital is Federal Property, 
the only law enforcement entity with jurisdiction is the Federal Bureau 
of Investigation, which responds in cases of serious breaches of law at 
the facility but does not provide on-site security or law enforcement 
services. As a result, security at the Claremore Indian Hospital 
currently consists of one individual whose authority and responsibility 
is limited because of the jurisdictional situation. The Claremore 
Hospital has contacted the Federal Protective Service, which is willing 
to provide on-site law enforcement services, but at a prohibitive cost. 
Consequently, the Claremore Indian Hospital is working to resolve 
jurisdictional issues so that local law enforcement entities can 
provide protection to patients and staff at the facility. The Hospital 
is also pursuing information on the option of contracting through the 
Department of Health and Human Services Program Support Center, which 
has delegated authority to contract for security services that will be 
available on a 24/7 basis to protect patients and staff on the grounds 
of and in the facility.

    Question 2. Recent disclosures by the Indian Health Service 
indicate that the agency spent $2.8 million on conferences in FY 2006 
and $33.7 million on travel for the same period. Please provide the 
Committee with updated data for FY 2007.
    Answer. The Indian Health Service spent $368,000 on conferences in 
FY 2007 and $38 million on travel for the same period.

    Question 3. Do you support an agency-wide reduction in conference 
and travel spending, so that additional resources can be made available 
for patient care? If so, how do you plan to achieve this goal?
    Answer. Yes, the Indian Health Service significantly reduced 
conference spending by $2.4 million between FY 2006 and FY 2007. 
Departmental and agency policies increased oversight of conferences, 
limited attendance, and promoted the maximum use of technology in place 
of travel. Internal controls and increased interactive Web sessions, 
tele-conferencing, and video-conferencing, will continue to enable us 
to put more of our resources into patient transport and care, health 
professional coverage, recruitment, and facility compliance.

    Question 4. Based on your impressive and extensive experience 
within the IHS system, please identify programs and/or offices that are 
in most need of your attention. In addition, please identify any 
programs that you believe are failing to meet their objective.
    Answer. My immediate priority is the recruitment and retention of 
health care professionals because it is fundamental to the ability of 
our hospitals and clinics to meet the health care needs of the American 
Indian and Alaska Native communities we serve. We are experiencing 
double-digit vacancy rates in physicians, nursing, pharmacy, and 
dental--all critical to the delivery of our core mission that is 
patient care to American Indians and Alaska Natives on or near 
reservations. These vacancies affect quantity and quality of care; 
continuity of care; and, increase our operating costs as a result of 
the higher costs of contracting for temporary replacements.
    It is my firm belief that all programs currently funded within 
annual appropriations are meeting their objectives.

    Question 5. Do you believe the current Indian Health care system 
meets our legal commitments to tribes and their citizens?
    Answer. Yes, I believe that the current Indian health care system 
meets our legal commitments to serve eligible American Indian and 
Alaska Native people. The IHS has focused on those programs that 
positively impact the health status of Indian people. In 2006 we 
celebrated 50 years or accomplishments from the transfer from the 
Department of the Interior to the U.S. Public Health Service, 
Department of Health and Human Services. During these 50 years we have 
experienced the increased involvement of Tribes. The current system of 
care reflects not only our on-going consultation with Tribes on the 
status and direction of the Indian health care system, but Tribes now 
operate more than 50 percent of the system.

    Question 6. If your child was gravely ill and you had a choice 
between sending him/her to the very best physician/clinic (regardless 
of its status as private, tribal or IHS) with federal funds and sending 
them to a traditional IHS facility, what would you do?
    Answer. I would not hesitate to send my child to an IHS facility, 
knowing fully that my child will receive immediate care and will be 
referred out for more specialized care if necessary. All our IHS 
facilities (both IHS managed and Tribal managed) are fully accredited 
and staffed by competent, caring, and committed staff.

    Question 7. Again, based on your experience, if you were asked to 
eliminate one program based on poor performance or its relevance to IHS 
priorities, and shift those funds to higher IHS priorities: what would 
you eliminate and where would you send the reallocated funds?
    Answer. IHS programs are not poor performers. Six major programs of 
the IHS have been subjected to the OMB's Program Assessment Rating Tool 
(PART) evaluation and rated an average score of 80, with none below 
adequate. In addition, the IHS exceeded almost all the performance 
indicators for the Government Performance Results Act (GPRA). However, 
in times of deficit reduction budgets, the IHS chose to prioritize the 
mission critical health services for those American Indian and Alaska 
Native people who reside on or near reservations. This choice has 
resulted in decreasing or eliminating programs that have performed at 
the adequate or effective levels, such as the Urban Indian Health 
Program.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Maria Cantwell to 
                           Robert G. McSwain
    Question 1. Mr. McSwain, please describe your view of the Indian 
Health Service's obligation to provide urban Indians with appropriate 
health care services?
    Answer. Health care services for American Indian and Alaska Native 
people who reside in urban areas are part of our broad Federal mission 
stated in the Snyder Act, ``for the benefit, care, and assistance of 
the Indians throughout the United States'' including the purpose ``For 
relief of distress and conservation of health.'' However, Indians 
living in urban areas are able to access health care services from a 
variety of Federal, State, and local providers, including Health 
Centers operated by HRSA, which are located in every urban area 
currently being served by an Urban Indian Health Program.

    Question 2. You are no doubt aware of the need to revise the 
current health facilities construction priority system and create a 
more equitable means of providing resources for every tribal area.
    I understand that the Facilities Appropriations Advisory Board has 
submitted its recommendations to the Office of the Director. This work 
is the product of years of collaboration with IHS and Tribal 
representatives.
    I am particularly interested in one of these recommendations--the 
establishment of an Area Distribution Fund. For sure, there are many 
elements that need to be considered in order to make this proposal work 
in a way that respects the needs of tribes awaiting facilities funds 
under the current priority system, as well as the tribes that receive 
no resources at all.
    As Director of the Indian Health Service would you plan to further 
examine the concept of an Area Distribution Fund?
    Would you be willing to implement an Area Distribution Fund?
    Answer. As Director of the Indian Health Service, I will continue 
to examine not only the concept of the Area Distribution Fund, but I 
would be willing to implement a funding distribution methodology that 
does not adversely affect the continued funding of ongoing construction 
projects.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. John Barrasso to 
                           Robert G. McSwain
    Question 1. Mr. McSwain, you have one of the most challenging jobs 
in Government. The last time I visited Wyoming's Wind River 
Reservation, the issue I heard about most was health care. There is a 
very long list of needs. I know your department has made progress to 
improve the health and welfare of American Indians and Alaska Natives, 
but I think you would agree we still have much left to accomplish. Have 
you crafted an action plan that will help transform the Indian health 
care system and the way Indian communities receive health care over the 
next 4 years? If not, what are your goals? What do you hope to 
accomplish?
    Answer. I appreciate your comments regarding the challenges we face 
in the Indian health system. This is so important because, as you know, 
the work that we do in the Indian health system is not abstract or 
conceptual in any way. The care we provide affects the lives of 
individuals and the health of families and communities. The dedicated 
individuals in the IHS and Tribal Indian health programs that serve 
these communities know why they go to work every day. And yes, we have 
much left to accomplish.
    During his term as Director of the Indian Health Service, Dr. Grim 
visited a great many of these communities and spoke with and listened 
to Tribal members, Tribal leadership, and health professionals. Out of 
these discussions we developed the three Director's Initiatives in 
Health Promotion and Disease Prevention, Behavioral Health, and Chronic 
Care. These three initiatives, together, provide the framework and 
strategy for improving the health status of American Indian and Alaska 
Native people.
    The Health Promotion and Disease Prevention Initiative is focused 
on creating the capacity in our communities to support healthy 
behaviors and wellness through evidence-based practices. Primary 
prevention is an investment that pays off in improved health for 
American Indians and Alaska Natives, in reduction in suffering in our 
communities, and in cost savings to our health system.
    The Behavioral Health Initiative addresses the total health of the 
individuals, families, and communities we serve. A novel and 
transformative strategy for the Behavioral Health Initiative involves 
bringing the whole person into focus in our health system through the 
integration of behavioral health services into primary care.
    The aim of the Chronic Care Initiative is to improve the health 
status of American Indians and Alaska Natives by reducing the impact 
and prevalence of conditions such as diabetes, depression, asthma, 
heart disease, and cancer. Through this initiative we have developed a 
partnership with the Institute for Healthcare Improvement (IHI) to use 
modern improvement methodologies to transform the system of care for 
prevention and management of chronic conditions.
    The Chronic Care Model (Care Model), developed and extensively 
validated by Dr. Ed Wagner of the McColl Institute for Healthcare 
Innovation and colleagues, captures and defines the essential features 
of a system of care that focuses on the relationship between an 
informed and activated patient, family, and community and their 
prepared and proactive health care team. The Indian health system has 
extensive experience with the Chronic Care Model in diabetes care. In 
fact, we attribute some of the success we have achieved in improved 
diabetes outcomes through the Special Diabetes Program for Indians to 
this model. Over the past year we have been working with the IHI to 
support 14 pilot sites representing a slice of the Indian health system 
in a learning community that is adapting the Chronic Care Model and 
developing strategies for implementation to improve care across 
conditions. These programs (including the Wind River Service Unit) are 
using rigorous and ongoing measurement to guide their improvement 
efforts.
    We have already begun to see remarkable improvement within the 
pilot sites in screening rates for cancer and alcohol misuse, and in 
diabetes care. Just as importantly we are seeing reductions in wait 
time, improved access and continuity of care, and the development of a 
truly functional, proactive and prepared care team.
    In the coming year we will take the lessons learned from these 
pioneering programs and expand the collaborative to approximately 40 
Indian health facilities, further refining the process and the package 
of changes and preparing for the spread of improvement in the 
prevention and management of chronic conditions. Over the next two to 
three years, we will be spreading this improvement work across the 
entire Indian health system.
    This effort requires that we think differently about how we care 
for patients, families, and communities, and about how we support the 
spread of improvement and innovation in our health system. It focuses 
us on the patient and family at the center of care. It forces us to 
think about how to create an Indian health system characterized by 
pervasive and reliable quality; everywhere, every time, for every 
person. We are guided and supported in this work by the expertise of 
the Institute for Healthcare Improvement.
    I am pleased to report that we are beginning to see true 
integration of the work being done by some of our Special Diabetes 
Program for Indians grantees with that of the Chronic Care Initiative 
pilot sites. The Chronic Care Initiative provides the Indian health 
system with the opportunity to learn from our efforts in diabetes care 
and transform the prevention and management of other chronic 
conditions. Our partnership with the IHI offers the Indian health 
system new ways of working, new ways of thinking, and new hope in the 
prevention and management of chronic conditions.
    We have much left to accomplish. Over the next four years we will 
use the Director's Initiatives in Health Promotion and Disease 
Prevention, Behavioral Health, and Chronic Care to build strength and 
wellness in our communities and quality in our system of care.

    Question 2. I want to make sure Native Americans have equal access 
to quality medical care. But it is equally as important the care we 
provide is cost effective and produces results. Today, neither the 
government nor private advocacy groups can explain exactly how federal/
state/tribal funds are used to coordinate medical services. It is 
incumbent upon the IHS Director to provide timely answers to the 
Committee and Congress explaining how much money we are spending on 
programs and how the IHS works with Medicare, Medicaid, SCHIP, and the 
tribes to coordinate that care. What efforts will it take to ensure we 
have the information and tools we need to make effective policy 
decisions?
    Answer. I share your concerns and we do make every effort to 
provide quality care and equal access to care in a cost effective way 
for all American Indians and Alaska Native patients who use our 
facilities. We are a comprehensive health care delivery system and 
provide a broad range of health care services with a focus on primary 
care. IHS and Tribally operated facilities (facilities compacted or 
contracted under P.L 93-638) all receive appropriated funds in specific 
health care categories. Also, both IHS Federal and Tribal facilities 
collect from Medicare, Medicaid, SCHIP and private insurance for health 
care provided to patients who are enrolled in those programs. Public 
and private insurance collected for services provided at each facility 
is returned to that specific facility and used to maintain 
accreditation and support the health care delivery system as required 
by law. IHS works closely with the Centers for Medicare and Medicaid 
Services (CMS) to enhance collections and ensure health care is 
delivered in an efficient way. CMS established a Tribal Technical 
Advisory Group to address Tribal concerns and policy issues and both 
CMS and IHS work closely with this group. Also, IHS facilities work 
closely with CMS regions across the country making the process more 
efficient and effective. Facilities work directly with States and State 
Medicaid Agencies and SCHIP programs and collaborate on a regular basis 
to improve health care delivery and health care funding. IHS facilities 
are accredited and work directly with local Tribes to coordinate the 
health care delivery system. The IHS collects information on health 
services and health status and uses this information in the decision 
making process for program planning and evaluation. The information is 
also used in budget preparation and allocation to assure funds for 
Indian health are used in the most effective manner. The IHS also 
consults with Tribes and Tribal programs to coordinate our efforts in 
improving the health status of American Indians. We want to be sure 
Congress has the necessary information and data to make sound 
decisions. We are committed to working with Congress and to providing 
you with the information that will assist you in your decision-making.

    Question 3. Addiction to methamphetamine and alcohol are very 
serious problems on the Wind River Reservation. Mexican drug 
trafficking has substantially increased the supply of Meth in my state. 
The State of Wyoming is continuing to make strong efforts to address 
this issue. But, what are we doing--in collaboration with the states 
and tribes--in terms of treatment and prevention services? Have the IHS 
efforts been successful?
    Answer. IHS has been successful in collaborating with Tribes and 
States to increase clients' access to substance abuse treatment 
services. Examples of this collaborative effort would be:

   Efforts by Tribes, IHS and States to increase awareness and 
        knowledge of addictions and treatment to AI/AN communities;

   Certified and licensed counselors are employed;

   The tribal programs are gaining CARF (Commission on 
        Accreditation of Rehabilitation Facilities) certification, a 
        nationally recognized status, as well as State certification; 
        many programs have both certifications;

   Increased use of evidenced-based models such as MATRIX 
        motivational interviewing training are utilized in treatment 
        services.

   Prevention and community education services are shared by 
        mental health professionals, substance abuse counselors, health 
        educators, public health nurses and diabetes professionals. All 
        of these types of chronic diseases, including depression and 
        substance abuse overlap.

    Methamphetamine and alcohol dependence are very serious problems on 
the Wind River Reservation. The problems created by these two 
addictions impact a large number of individuals and families. The 
primary agencies and organizations involved in addressing these 
problems are the Indian Health Service, the Eastern Shoshone Tribe and 
the Northern Arapahoe Tribe and the State of Wyoming. Collaborative 
efforts are on the increase. Examples of this effort to work together 
for the common goal of meth reduction would be the Eastern Shoshone 
Tribe, which operates the Eastern Shoshone Recovery Program and the 
Sho-Rap Lodge, an 8 bed facility funded jointly by the State and 
Tribes, and also the Northern Arapahoe Tribe, which operates the White 
Buffalo Recovery Center, funded by IHS and the Tribes. Tribal programs 
are becoming increasingly aware of the value of State certification, 
such as with the Eastern Shoshone/Northern Arapaho substance abuse 
program's certification through the State of Wyoming and stronger 
emphasis by Tribes to certify/license the counselors they employ. These 
efforts, among many, serve to illustrate the need and value of working 
collaboratively.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Tim Johnson to 
                           Robert G. McSwain
    Question 1. When individual tribal members in the Aberdeen Area 
need help navigating the Federal agencies on their specific cases they 
often turn to their congressional delegation. In order to effectively 
serve these constitutions we need prompt and fluid communications with 
the agencies both at the area level and at the federal level, this has 
been a continuous problem with IHS. I can't mention the names of the 
individuals involved in the cases without their permission, but some 
examples include:

   A first letter sent to Aberdeen Area office on July 23, 
        2004, congressional staff was informed the response was delayed 
        at Rockville, after repeated inquiries a response was finally 
        received on July 2, 2007.

   The first letter was sent to Rockville on Dec. 6, 2006, the 
        third notice of ``no response'' was sent on June 4, 2007. As of 
        today, there has still been no response. This is an urgent case 
        on contract health appeal to Rockville that desperately needs a 
        response.

    These are just two examples. If you are confirmed, what will you do 
to ensure Congress will receive prompt responses to casework and other 
inquiries of your office?
    Answer. Congressional inquiries are considered to be of utmost 
importance to the Indian Health Service (IHS), and are treated as a 
high priority. Many of the responses, however, require extensive 
research and coordination with IHS staff located in various Area 
Offices and Service Units throughout Indian country. The IHS 
headquarters has a system in place to track and monitor Congressional 
inquiries, and will continue to make every effort to respond to these 
inquiries in a timely manner.

    Question 2. The Aberdeen Area encompasses 6 of the 10 poorest 
counties in the Nation, all of which are reservation counties in South 
Dakota. The Healthcare needs are enormous and multifaceted, how do you 
plan to help these Tribes address some of the largest health 
disparities in the country?
    Answer. South Dakota is where the majority of Native Americans 
served by the Aberdeen Area IHS reside and where these six (6) poorest 
counties in the Nation are located. We are developing new methods of 
healthcare delivery and prevention by redesigning the IHS delivery 
system. As an example, Aberdeen Area has the only mobile digital 
mammography unit in IHS, which is beginning its third full year of 
operation reaching poor, rural communities with bone screening and 
breast cancer screening delivered in the community. Sioux San Hospital 
in Rapid City is a pilot site for colorectal cancer screening.
    Partnering with tribes, the injury prevention component of the 
chronic care initiative is being piloted at Sisseton and Santee. These 
pilot sites have developed screening tools to identify and to increase 
the use of seatbelts and car seats. They are also working to decrease 
substance abuse by early identification and referral for services to 
address alcohol-related injuries, which are a major contributor to 
years of potential life lost and millions of dollars in Contract Health 
costs.
    In addition, the IHS has implemented a 5 year strategic plan to 
develop a telemedicine hub that will provide telepharmacy, 
telepsychiatry, telepain management, teleradiology and other services 
to increase access to healthcare for these poorer isolated 
reservations. The telepharmacy Program is functioning on the Pine Ridge 
reservation and we are advertising for the telepharmacy program 
Director. We are already deploying ``Good Health'' videos into health 
facility waiting rooms bringing timely, community-specific health care 
and preventive services directly to the Indian communities we serve. 
Materials are being developed that are culturally relevant. The ``Good 
Health'' videos and culturally relevant health materials are already in 
at least four sites and being well received.
    Suicide continues to be a glaring marker of health disparity. The 
strategic plan employs the public health model to bring evidence-based 
best practices of community-oriented primary and secondary prevention 
such as Question, Persuade, and Refer (QPR), Critical Incident Stress 
Management (CISM), and Applied Suicide Intervention Skills Training 
(ASIST). The Area telemedicine strategic plan has telepsychiatry as a 
priority to increase access to care for patients and access to 
specialty consultation for providers starting with those sites with the 
highest suicide rates, such as Rosebud. We are developing partnerships 
with Avera Health, Sioux Falls, South Dakota, Sanford, Sioux Falls, SD, 
the Department of Veterans Affairs, and others to increase access and 
educational opportunities for reservation residents. The Behavioral 
Health Plan includes strategies to address primary, secondary and 
tertiary aspects of suicide prevention. The Chronic Care initiative 
focuses on Depression and Meth specifically. The Area continues to 
develop and use many culturally specific CD, DVD, and written materials 
appropriate to the Northern Plains Tribes which are sought after by 
other IHS areas.
    The Area staff recruitment and retention plan includes efforts to 
work with various State, Veterans Health Administration, and private 
partners to address rural health needs and develop strategies to 
address the changing workforce needs. IHS intends to use telemedicine 
and telehealth to recruit, train, develop, and support the workforce.

    Question 3. Do you have adequate funds to carry out your 
responsibility to provide healthcare for American Indian Tribes? What 
do you believe would be adequate funding level?
    Answer. The IHS maximizes health care services to Indian people 
with funds appropriated by Congress. IHS also supplements appropriated 
funds with collections from Medicare, Medicaid, and the State 
Children's Health Insurance Programs and other third payers, including 
private insurance. With combined funding, the IHS system of tribal, and 
federal health programs annually provide millions of health care 
services to Indian people. The IHS is the major, often only, source of 
health care for hundreds of thousands of Indian people and has 
contributed to remarkable improvement in Indian health status in recent 
decades. In recent years the IHS has recognized the need to partner 
with other Federal agencies and private organizations to address the 
complex health conditions facing Indian people. For example, addressing 
suicides and methamphetamine abuse requires a concerted effort by the 
Indian community and Federal health and law enforcement agencies. Each 
year, when developing a budget request, IHS considers what level of 
funding is adequate for carrying out its responsibility to provide 
health care.

    Question 4. Do you have adequate staff and personnel to carry out 
your responsibility to provide healthcare for American Indian Tribes? 
What do you believe would be an adequate staffing level?
    Answer. The health professionals and support staff of the IHS are 
extremely hard working and dedicated to serving the health care needs 
of Indian people. Our challenge to meeting the health care needs of 
American Indians and Alaska Natives (AI/AN) is to assure adequate 
staffing at our hospitals and clinics. A recent personnel review showed 
that in FY 2008, the IHS anticipates the need to fill almost 1,500 
health care professional vacancies including 181 physicians, 131 
dentists, 612 nurses and 65 pharmacists.
    Recruitment of these health care professionals is challenging due 
to a number of factors including nationwide shortages of health 
professionals such as physicians, dentists, nurses and pharmacists, the 
pay differential between federal salaries and how much the private 
sector pays, and the rural settings for many of the IHS health care 
sites.
    To improve staffing at our facilities, the IHS must fill many, if 
not most of these vacancies. To reach this goal, IHS has initiated an 
extensive recruitment and retention effort. To raise awareness of IHS 
career opportunities among health professionals, the IHS launched the 
``IHS Public Health Professions--Recruitment Campaign'' developing new 
advertisements, recruitment materials and new web sites. These new 
advertisements were placed in professional journals and on recruitment 
websites in late FY 2007 and will continue throughout FY 2008.
    The IHS Public Health Professions web site at http://
www.careers.ihs.gov/ has several new updates planned for FY 2008, 
including an updated physician website which will allow physicians and 
medical residents to request materials and ask questions of recruiters.

    Question 5. The Cheyenne River Sioux Tribe has indicated that the 
Design for the Eagle Butte service unit was done to cost-meaning IHS 
developed a total cost for the facility and the Tribe then asked the 
architects to maximize the center's capabilities subject to the 
permitted cost allocation. As a result, any delay in seeking 
construction funds for this facility risks inflationary cost increases 
that will create a need to scale back and re-approve the project plans 
at additional cost. What steps is IHS taking to ensure that this will 
not happen?
    Answer. The design for the Eagle Butte Health Center has been 
completed and has been submitted by the architect. These plans and 
documents were designed not to exceed the IHS Facilities Budget 
Estimate which is based on the Program of Requirements (POR). The POR 
defined the required space necessary to provide health services at this 
new facility. The total cost of this project amounts to $111,100,000.
    Prior to FY 2008, Eagle Butte received $7,797,000 for design and 
initial construction of the new healthcare facility. The FY 2008 
congressional appropriation to continue construction activities totaled 
$17,212,000. The IHS Facilities Budget Estimate has nearly $7,600,000 
in construction contingencies which can be used to assist in addressing 
acts of God and excessive inflation.

    Question 6. IHS has release a document regarding the reduction of 
hours at the Wagner Service Unit claiming that it will allow IHS ``to 
reprogram approximately $600,000 for other services and program 
support.'' Will those cost savings go to benefit the Wagner Service 
Unit?
    Answer. The Yankton Sioux Tribal Chairman met with I.H.S. 
Headquarters staff on December 11, 2007 in Rockville, Maryland, 
regarding plans to transition 24 hour service at the Wagner I.H.S. 
Ambulatory Health Care Facility to an Urgent Care Clinic with hours of 
service from Monday-Saturday, 7:00 am to 11:00 pm. It was discussed at 
the meeting that I.H.S. can no longer justify 24-hour emergency room 
(ER) services, and will need to proceed with the transition to an 
Urgent Care Clinic at the Wagner I.H.S. facility. Last July, Wagner 
I.H.S. decided that the effective date for this transition would be 
January 1, 2008. The effective date was moved to March 1, 2008 in order 
to complete community education. Wagner I.H.S. staff continues to meet 
with the Yankton Sioux Tribe and Wagner Community Memorial Hospital to 
keep them informed of the transitional phase. Weekly notices were 
placed in the local newspaper beginning January 28, 2008.
    The Wagner Service Unit is hopeful that any cost savings will allow 
for more specialty services to be provided on-site which will enhance 
overall comprehensive care to better meet the needs of the patients.

    Question 7. I have been contacted by several IHS employees from 
South Dakota who have been waiting for sometime to resolve long 
standing back pay claims. I hope that IHS and these employees through 
their Union, the Laborers' International Union of North America, will 
engage in substantive dialogue to resolve these issues. What has IHS 
done recently to resolve this dispute? Is there currently an employee 
of the IHS charged with working on this issue?
    Answer. The Union and the Aberdeen Area Office have agreed to an 
arbitration schedule that will start on March 17, 2008. Out of a total 
of 145 claims listed on the Union's (LUINA) list submitted by Mr. 
Robert Purcell, the Agency has reviewed and denied 84 claims because 
the employees were found to be in an on-call status and were paid 
appropriately and did not meet the requirements in regulations set 
forth for standby duty. Additionally 36 claims were found to be 
incomplete as only tolling letters were submitted with no claims or 
claims submitted without the tolling letter (a tolling letter is 
required to preserve the claim period). The remaining 17 claims are in 
a review status.

    Question 8. The Cheyenne River Eagle Butte Service Unit has faced 
some serious problems with its CMS certification. Are these problems 
being resolved? Why did these problems go unresolved for almost seven 
years?
    Answer. CMS determined in its most recent review that Cheyenne 
River Service Unit (CRSU) was fully in compliance with the Medicare 
Hospital Conditions of Participation. CRSU worked hard to achieve this 
result. However, on January 18, 2008 CRSU was advised by CMS that it 
was out of compliance with several of the Emergency Medical Treatment 
and Active Labor Act (EMTALA) requirements, which are separate from the 
Conditions of Participation and have to do with providing an 
appropriate medical screening examination and stabilizing treatment for 
individuals with emergency medical conditions. CRSU is making progress 
in this area, but further improvements are needed to achieve full 
compliance.
    CRSU is sending the CMS Regional Office weekly updates on its 
progress in achieving compliance. We understand CMS will make another 
unannounced inspection of CRSU sometime in the next couple of months, 
and we expect CRSU to be in full compliance at that time.

    Question 9. We all know how chronically under-funded IHS is, yet I 
understand that the IHS' efforts to collect reimbursement from private 
third-party payers have been minimal-even though such reimbursements 
could be as much as $50-100 million a year (based on IHS' own past 
Budget Justifications). What has been done at the headquarters level to 
improve that effort and increase those collections?
    Answer. In FY 2007 the IHS collected approximately $90 million from 
private insurance payers. This is 12% of the estimated overall 
collections with the remaining 88% of collections coming from Medicare 
and Medicaid, which totaled approximately $677 million. IHS has 
consistently increased collections in private insurance ever since it 
received the authority to bill. At Headquarters, the Office of Resource 
Access and Partnerships (ORAP) provides leadership and support to an 
IHS-wide National Business Office Committee comprised of 12 Area Office 
Business Office Coordinators. A major function of this National 
committee includes making recommendations to improve business 
operations, training requirements, software improvements and other 
major issues that can enhance or correct IHS wide problems that affect 
the collection of third party revenue at the hospital and clinic level.
    We are involved in a number of activities to enhance overall 
collections in the IHS. Third party training is provided on the 
Resource Patient Management System (RPMS) business office software 
applications. These classes are designed to improve skills in Patient 
Registration, Third Party billing, Pharmacy Point of Sale claims and 
Accounts Receivable. These skills include identifying alternate 
resources, provider documentation, procedural coding, billing and aging 
accounts receivable follow up. Another major training effort occurred 
when ORAP worked with CMS representatives to provide Outreach and 
Education Training sessions targeted to Benefit Coordinators and their 
role in assisting with processing Medicare and Medicaid application 
forms. When Medicare Part D became a billable service for IHS, training 
was provided to all of the Areas regarding the changes and issues that 
each Area needed to know. The Medicare Fiscal Intermediary (FI) and 
Medicare Administrative Contractor (MAC) also work closely with the 
National Business Office Committee to provide training both on-site or 
on-line to assist each of the IHS facilities on denials, new billing 
rules and system issues for Medicare. Private insurance activities are 
also addressed in the many training sessions conducted each year.
    The Office of Information Technology (OIT) maintains and improves 
the business office software applications that support electronic 
billing, payment posting and collections. One of the objectives for the 
IHS is to implement the electronic health record at all Federal IHS 
locations. With coding and data capture very important to the revenue 
process, separate Health Information Management/Business Office 
training classes are scheduled once a month through IHS. The ultimate 
objective is to transition IHS clinical providers to coding their 
encounters and not relying on manual data entry efforts. Moving away 
from manual data entry will make us more efficient and enhance our 
ability to bill and collect.
    In FY 2008, IHS is actively working with integrating the RPMS data 
with the Unified Financial Management Systems (UFMS). With this effort, 
ORAP has recognized the need to enhance and standardize the business 
process of posting in the RPMS systems the amounts identified on 
remittance advices issued from the payers. This will also assist 
Managers with current reports which identify unpaid revenue. These 
reports will not only assist the local facility managers but also Area 
and Headquarters staff if there is a major payer who is not reimbursing 
IHS at its appropriate level.
    In FY 2008, the IHS will continue its efforts to capture all 
private payer and third party payer information including Medicare and 
Medicaid and SCHIP for reimbursement purposes. The ORAP recognizes the 
need to work with private insurance payers and to maximize collections 
to the full extent of the law. Also, IHS collaborates with State 
agencies to enhance the systems necessary to enroll patients who may be 
eligible for Medicaid or the State Children's Health Insurance 
Programs. Ongoing national broadcasts are scheduled in partnership with 
CMS to share this information and to further provide more leadership to 
the field staff.

    Question 10. I have been informed that the Business Office Report 
of IHS has many provisions that are not consistent with the statutory 
authority given the agency to make these collections. Why would the 
agency voluntarily handcuff itself from collecting these reimbursements 
that are legally owed?
    Answer. The IHS is not sure what ``Business Office Report'' is 
referenced in the question and we do not believe that we have 
voluntarily ``handcuffed'' the organization from collecting 
reimbursements. The IHS pursues all alternate resources for payment for 
services provided at our hospitals and clinics and provides relevant 
training and support to Areas and Service Unit facilities. To support 
these efforts, the IHS has established Internal Controls and business 
operating manuals to guide, monitor and set standards for third party 
revenue collection. We do recognize that third party collections 
require management support at all levels of the IHS organization, and 
IHS management does realize the importance of maximizing collections. 
Since 1976, the IHS has had authority to collect Medicare Part A and 
Medicaid reimbursements. In the past 8 years this authority has been 
expanded to include billing for certain additional Medicare Part B 
services, SCHIP and Medicare Part D. Currently, third party revenue 
represents up to 50% of some hospitals' and clinics' operating budgets. 
Third party revenue is vital to maintaining the current levels of 
services accessible to AI/ANs at IHS hospitals and clinics. The IHS is 
making an effort to maximize collections to the full extent of the law.

    Question 11. Has the Agency looked at how similar reimbursement 
issues are handled by other agencies, like the Veterans Administration?
    Answer. There continues to be increasing internal collaborative 
efforts on the utilization of automated systems between the Department 
of Veterans Affairs (VA) and IHS in which similar structure and 
functionality is shared. These include the Resource Patient Management 
System, Patient Information Management System and the Electronic Health 
Record. The VistA/Computerized Patient Record System systems are public 
domain and IHS is adopting these government developed systems. These 
systems contain core applications for storing codes and recording 
workload, however to facilitate appropriate coding and billing VA 
augments these systems with commercial software. Since IHS is modeling 
its software design based on the VA automated systems, business rules 
and processes are in progress which include coding systems, vista 
imaging and other solutions that will enhance the IHS third party 
revenue data capturing efforts to assure quality claims and accurate 
payments. Many of our facilities that are located near VA facilities do 
collaborate on systems development and support with the VA. The VA does 
not have authority to bill Medicare or Medicaid and concentrates its 
billing efforts on private insurance patients only. Private insurance 
is approximately 12% of IHS' overall collections.

    Question 12. One of the most alarming circumstances that Indian 
Country is currently facing is the issue of suicide and the lack of 
mental health services that provide prevention, intervention and 
aftercare services. While there are many contributing factors that lead 
to suicide, what steps should IHS take to alleviate the lack of mental 
health services?
    Answer. The IHS has been working with other Health and Human 
Service Federal agencies, in partnership with Indian Tribes and tribal 
organizations, to bring all resources to bear on improving behavioral 
health services for American Indian and Alaska Native (AI/AN) 
individuals and communities. Together, we are focusing on developing 
and expanding access to innovative and effective behavioral health 
interventions and resources that directly enhance our ability to 
address critical health issues such as suicide in Indian country.
    Increasingly, as more tribes contract to manage their own programs, 
the IHS is supporting them in the development and administration of 
suicide prevention and early intervention activities at the community 
level. Approximately, 87% of the IHS Alcohol and Substance Abuse and 
47% of IHS Mental Health funding is distributed directly to tribal 
service programs. In FY 2008, the IHS Alcohol & Substance Abuse program 
received $14 million for a methamphetamine and suicide prevention and 
treatment initiative. Tribal consultation will take place before there 
is a final funding distribution plan put in place. We project that 
approximately $5 million of these funds will be used for suicide 
prevention.
    The IHS has historically had high vacancy rates and critical 
behavioral health personnel shortages in varying locations and 
professional categories. The IHS is taking the following steps to 
increase mental health services.
Telebehavioral Health
    One technology being aggressively explored to improve access is use 
of telehealth-based services. Currently over 50 IHS and Tribal 
facilities in 8 IHS Areas are augmenting on-site behavioral health 
services with telehealth services. Areas, including Aberdeen Area in 
the Northern Plains, are building or have built telehealth 
infrastructure and programming to support this type of service where it 
has not existed before.
Recruitment
    Through recruitment and retention activities, the Scholarship 
Program, and Loan Repayment Program, the IHS increases the number of 
Indians entering the behavioral health professions and works toward 
assuring an adequate supply of behavioral health professions to the 
Tribes, tribal organizations, and urban Indian organizations. The 
scholarship program supported a total of 461 students in 2006.
    The IHS InPsych Program addresses the need for American Indians in 
the Psychology field. There are 3 Indians into Psychology Programs. 
They are located at Oklahoma State University, Stillwater, OK; 
University of North Dakota, Grand Forks, ND; and the University of 
Montana, Missoula, MT. They are funded by Indian Health Service and 
have been in operation for approximately 10 years.
Suicide Prevention Initiative
    The IHS Suicide Prevention Initiative is directly related to the 
Health and Human Services National Strategy for Suicide Prevention. IHS 
collaborates with consumers, and their families, Tribes and tribal 
organizations, Urban Indian programs, Federal (e.g. SAMHSA, NIH, BIA 
and others), State, and local agencies, as well as other public and 
private organizations to formulate long term strategic approaches, to 
develop a comprehensive system of care, and to share resources to 
address the issue of suicide in Indian Country more effectively.
    The IHS Division of Behavioral Health is actively promoting a 
suicide event database to record and track suicide events for IHS, 
Tribal and Urban Indian behavioral health programs across the nation. 
This application contains a suicide surveillance tool to capture data 
related to a specific incident of suicide, such as date and location of 
act, method, contributing factors and other useful epidemiological 
information. The Suicide Reporting Form (SRF) provides aggregate report 
options that can be analyzed and interpreted to inform program planning 
activities in support of Agency and Department suicide prevention and 
behavioral health initiatives. The reports are helpful in understanding 
and better addressing suicide in Indian country.
Direct Care
    The overwhelming majority of direct services are provided in 
outpatient settings, but there are 12 IHS-funded Youth Regional 
Treatment Centers (YRTCs) that provide residential treatment, and many 
tribal and urban programs provide similar residential services across 
the country. IHS provides funding to these 12 Youth Regional Treatment 
Centers for prevention and early intervention of alcohol/substance 
abuse and co-occurring disorders, in youth ages 12-18, as mandated by 
P.L. 99-570 and 100-690. Approximately $14.1 million is dedicated on an 
annual basis to IHS Area Offices for YRTCs.
Partnerships
    IHS has developed formal partnerships in the formation of an IHS 
Director's Behavioral Health Workgroup which includes representatives 
from the 12 IHS Areas and is comprised of Tribal behavioral health 
service providers. The workgroup is tasked with updating the original 
Alcohol/Substance Abuse 5-year strategic plan and integration of mental 
health services into the overall Behavioral Health initiative. In 
addition, the IHS Behavioral Health Program is creating a Tribal 
Advisory Committee to give guidance and direction to our Behavioral 
Health Initiative.
    IHS will continue to move the focus of behavioral health from a 
crisis orientation to ongoing behavioral health promotion by seeking 
new and sustainable resources, maximizing current program effectiveness 
through collaborations and data-driven models, and integrating 
technology and clinically sound behavioral approaches with the 
traditions and healing practices of the communities.

    Question 13. What steps will I.H.S. take to ensure that requests 
for resources are considered when tribes and service units are 
experiencing suicide clusters?
    Answer. The Emergency Medical Services/Preparedness Division (EMS/
P) is benefiting AI/AN Communities by responding with emergency 
personnel (to augment the mental health staff), programming, and 
logistical support to communities experiencing significant suicide 
crises. For example, in 2007, the IHS Emergency Medical Services/
Preparedness Division provided oversight for an Office of Force 
Readiness Deployment (OFRD) to two (2) communities. In 2008, the IHS 
Emergency Services with the support of the IHS Division of Behavioral 
Health conducted a Suicide Response Assessment on one (1) community and 
is a part of an HHS Department-wide response to this tribal community.
    In 2003, the IHS established the Suicide Prevention Committee 
(SPC). It is the responsibility of the SPC to provide policy 
recommendations and guidance to the Indian Health Service Division of 
Behavioral Health (DBH) regarding suicide prevention, intervention and 
responding to suicide clusters in Indian country. The SPC is currently 
working on guidelines for responding to tribal requests for assistance. 
These guidelines will establish procedures for responding to emergent 
and non-emergent requests for assistance from tribal service 
organizations in the area of suicide and suicide prevention/
intervention for the DBH within the Indian Health Service.

                                  
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