    [House Hearing, 111 Congress]
    [From the U.S. Government Publishing Office]

      H.R. 2708, THE INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2009

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

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED ELEVENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                OCTOBER 20, 2009

                                   __________

                               Serial No. 111-74

          Printed for the use of the Committee on Energy and Commerce

                            energycommerce.house.gov

                                    _____

                      U.S. GOVERNMENT PRINTING OFFICE

       74-845                 WASHINGTON : 2012
    -----------------------------------------------------------------------
    For sale by the Superintendent of Documents, U.S. Government Printing
    Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC
    area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC
    20402-0001

                        COMMITTEE ON ENERGY AND COMMERCE

                     HENRY A. WAXMAN, California, Chairman

    JOHN D. DINGELL, Michigan            JOE BARTON, Texas
      Chairman Emeritus                    Ranking Member
    EDWARD J. MARKEY, Massachusetts      RALPH M. HALL, Texas
    RICK BOUCHER, Virginia               FRED UPTON, Michigan
    FRANK PALLONE, Jr., New Jersey       CLIFF STEARNS, Florida
    BART GORDON, Tennessee               NATHAN DEAL, Georgia
    BOBBY L. RUSH, Illinois              ED WHITFIELD, Kentucky
    ANNA G. ESHOO, California            JOHN SHIMKUS, Illinois
    BART STUPAK, Michigan                JOHN B. SHADEGG, Arizona
    ELIOT L. ENGEL, New York             ROY BLUNT, Missouri
    GENE GREEN, Texas                    STEVE BUYER, Indiana
    DIANA DeGETTE, Colorado              GEORGE RADANOVICH, California
      Vice Chairman                      JOSEPH R. PITTS, Pennsylvania
    LOIS CAPPS, California               MARY BONO MACK, California
    MICHAEL F. DOYLE, Pennsylvania       GREG WALDEN, Oregon
    JANE HARMAN, California              LEE TERRY, Nebraska
    TOM ALLEN, Maine                     MIKE ROGERS, Michigan
    JANICE D. SCHAKOWSKY, Illinois       SUE WILKINS MYRICK, North Carolina
    CHARLES A. GONZALEZ, Texas           JOHN SULLIVAN, Oklahoma
    JAY INSLEE, Washington               TIM MURPHY, Pennsylvania
    TAMMY BALDWIN, Wisconsin             MICHAEL C. BURGESS, Texas
    MIKE ROSS, Arkansas                  MARSHA BLACKBURN, Tennessee
    ANTHONY D. WEINER, New York          PHIL GINGREY, Georgia
    JIM MATHESON, Utah                   STEVE SCALISE, Louisiana
    G.K. BUTTERFIELD, North Carolina
    CHARLIE MELANCON, Louisiana
    JOHN BARROW, Georgia
    BARON P. HILL, Indiana
    DORIS O. MATSUI, California
    DONNA M. CHRISTENSEN, Virgin
    Islands
    KATHY CASTOR, Florida
    JOHN P. SARBANES, Maryland
    CHRISTOPHER S. MURPHY, Connecticut
    ZACHARY T. SPACE, Ohio
    JERRY McNERNEY, California
    BETTY SUTTON, Ohio
    BRUCE L. BRALEY, Iowa
    PETER WELCH, Vermont

                                      (ii)
                             Subcommittee on Health

                    FRANK PALLONE, Jr., New Jersey, Chairman
    JOHN D. DINGELL, Michigan            NATHAN DEAL, Georgia,
    BART GORDON, Tennessee                   Ranking Member
    ANNA G. ESHOO, California            RALPH M. HALL, Texas
    ELIOT L. ENGEL, New York             BARBARA CUBIN, Wyoming
    GENE GREEN, Texas                    JOHN B. SHADEGG, Arizona
    DIANA DeGETTE, Colorado              STEVE BUYER, Indiana
    LOIS CAPPS, California               JOSEPH R. PITTS, Pennsylvania
    JAN SCHAKOWSKY, Illinois             MARY BONO MACK, California
    TAMMY BALDWIN, Wisconsin             MIKE FERGUSON, New Jersey
    MIKE ROSS, Arkansas                  MIKE ROGERS, Michigan
    ANTHONY D. WEINER, New York          SUE WILKINS MYRICK, North Carolina
    JIM MATHESON, Utah                   JOHN SULLIVAN, Oklahoma
    JANE HARMAN, California              TIM MURPHY, Pennsylvania
    CHARLES A. GONZALEZ, Texas           MICHAEL C. BURGESS, Texas
    JOHN BARROW, Georgia
    DONNA M. CHRISTENSEN, Virgin
        Islands
    KATHY CASTOR, Florida
    JOHN P. SARBANES, Maryland
    CHRISTOPHER S. MURPHY, Connecticut
    ZACHARY T. SPACE, Ohio
    BETTY SUTTON, Ohio
    BRUCE L. BRALEY, Iowa

                                 C O N T E N T S

                                  ----------
                                                                       Page
    Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, opening statement.........................     1
    Hon. Donna M. Christensen, a Representative in Congress from the
      Virgin Islands, opening statement..............................     4
    Hon. Tammy Baldwin, a Representative in Congress from the State
      of Wisconsin, opening statement................................     5
    Hon. Joe Barton, a Representative in Congress from the State of
      Texas, prepared statement......................................    58

                                   Witnesses

    Yvette Roubideaux, M.D., M.P.H., Director, Indian Health Service.     6
        Prepared statement...........................................     9
    Jefferson Keel, Lieutenant Governor of the Chickasaw Nation And
      President-Elect of the National Congress of American Indians...    19
        Prepared statement...........................................    21
    Rachel Joseph, Co-Chair, National Tribal Steering Committee for
      the Reauthorization of the Indian Health Care Improvement Act..    23
        Prepared statement...........................................    25
    Andrew Joseph, Jr., Chairman, Human Services Committee, Direct
      Services Tribe Advisory Committee..............................    34
        Prepared statement...........................................    36
    Patrick Rock, M.D., Executive Director, Indian Health Board of
      Minneapolis, President-Elect, National Council Urban Indian
      Health.........................................................    41
        Prepared statement...........................................    43

                               Submitted material

    Statement of California Rural Indian Health Board, Inc...........    62
    Statement of Dale E. Kildee, M.C.................................    63
    Table, National Indian Health Board, Details of Grants Received,
      2009...........................................................    64

      H.R. 2708, THE INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2009

                                  ----------

                           TUESDAY, OCTOBER 20, 2009

                      House of Representatives,
                                Subcommittee on Health,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The Subcommittee met, pursuant to call, at 2:10 p.m., in
    Room 2318 of the Rayburn House Office Building, Hon. Frank
    Pallone, Jr. [Chairman of the Subcommittee] presiding.
        Members present: Representatives Pallone, Schakowsky,
    Baldwin, Christensen and Shimkus.
        Staff present: Andy Schneider, Chief Health Counsel; Bobby
    Clark, Policy Advisor; Alli Corr, Special Assistant; Mitchell
    Smiley, Special Assistant; Matt Eisenberg, Staff Assistant;
    Brandon Clark, Minority Professional Staff; Aarti Shah,
    Minority Counsel; and Chad Grant, Minority Legislative Analyst.

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

        Mr. Pallone. The hearing of the Health Subcommittee is
    called to order and today we are having a hearing on H.R. 2708,
    the Indian Health Care Improvement Act Amendments of 2009. And
    I will yield to myself for an opening statement initially and
    then we will get to the other members.
        For over the past 10 months our country has been engaged in
    an important debate about how to reform our nation's healthcare
    system. But what few people realize is that for over the past
    10 years a similar debate has been going on in Indian country
    as well as in Congress about how to reform the healthcare
    system that serves American Indians and Alaska Natives. Since
    1999, legislation has been pending before the Congress to
    reauthorize the Indian Health Care Improvement Act which is the
    cornerstone legal authority for the provision of healthcare to
    American Indians and Alaska Natives. I know for those
    testifying before us today and for many of those in the
    audience, it is well known that the Federal Government has a
    legal, and I would say moral responsibility to provide free and
    quality healthcare to this country's Native peoples.
        This responsibility often referred to as the trust
    responsibility is born from a legal doctrine consisting of
    various treaties, contract and court decisions. Putting all the
    legal aspects aside, I think the trust responsibility can be
    summed up by saying that something is owed to American Indians
    for the lands that they were both voluntarily given--that they
    voluntarily gave to the United States or were forcefully taken
    as well as the atrocities that were committed against their
    peoples. And what is owed to them is a pledge from this
    government to ensure that their wellbeing is taken care of
    after centuries of mistreatment. But the Federal Government has
    consistently failed to live up to this responsibility in almost
    every aspect. They have mismanaged the lands that they hold in
    trust for Native peoples and American Indian students struggle
    to receive a proper education that is on par with their peers
    who are non-Indian, and most important, the quality of
    healthcare services available to American Indians certainly
    falls well-below the rest of the general population which in
    turn has resulted in worse outcomes for Native communities.
        Now, I can't tell you how many times I have recited the
    statistics I am going to now give you and I am sure everyone in
    this room has heard them too many times as well but I do want
    everyone to understand what is at stake. For Native Americans
    ages 15 to 44 years, mortality rates are more than twice those
    of the general population, and American Indians and Alaska
    Natives have substantially higher rates of disease than the
    rest of the U.S. population. Based on recent statistics,
    American Indians and Alaska Natives have seven times the rate
    of tuberculosis, more than six times the rate of alcoholism,
    nearly three times the rate of diabetes and a 62 percent higher
    rate of suicide. The Indian Health Service also estimates that
    more than two-thirds of healthcare that is needed for American
    Indians and Alaska Natives is simply denied.
        Over the course of the health reform debate, some opponents
    have used these statistics and pointed to the Indian Health
    Service as an example of the failures that would occur under a
    government-run healthcare system. I even had this in some of my
    town meetings but these portrayals of the IHS are unfortunate,
    gratuitous and misleading. The IHS has not failed. Rather the
    Federal Government has historically failed to properly fund the
    IHS. A 2004 report on Native American health issued by the U.S.
    Commission on Civil Rights found that inadequate Federal
    funding was the major obstacle to eliminating disparities in
    Native American healthcare. The report stated that annual
    increases in funding for the Indian Health Service did not
    include adjustments for inflation or population growth and were
    significantly less than those allocated to other arms of the
    Department of Health and Human Services. And this is an
    important point, in being less is spent on providing healthcare
    to American Indians per capita than any other subpopulation. In
    fact, we spend more money to provide healthcare to Federal
    inmates than we do for American Indians and I think that is
    probably the most shocking statistic of all.
        We have made some headway in recent months. Provisions
    relating to Indian health were included in legislation enacted
    earlier this year including CHIP or SCHIP as I call it and the
    ARRA, the Recovery Act or the Stimulus Bill. In both bills we
    were able to include provisions that would improve outreach in
    enrollment of American Indians eligible for Medicaid and CHIP.
    In addition, the Recovery Act included a substantial increase
    in funding for the Indian Health Service and in May of this
    year the IHS released 500 million of those funds to be used for
    health facilities construction or maintenance and improvements,
    health information technology, sanitation facilities,
    construction and health equipment that will help improve
    healthcare in Indian country.
        In addition to these funds, President Obama proposed a 13
    percent increase for the IHS in his fiscal year 2010 budget
    proposal, and I am happy to say that both the House and the
    Senate are on track to approve the level of funding requested
    by the President or even exceed it. Simply by adequately
    funding the Indian Health Service we can substantially increase
    the health and well-being of Native communities. But we can't
    simply say we are going to increase funding for the IHS and
    call it a day because it is not just a matter of funding. It is
    a matter of making sure these programs work well and can meet
    the needs that are present in those communities. The bill we
    are looking at today would make important changes to the
    delivery of healthcare services in Indian communities to make
    sure needs are being met. That is why we must make sure this
    bill is passed this Congress. It has languished around here for
    far too long.
        I want to say I think many of you know that this effort to
    try to include as much of the Indian Health Care Improvement
    Act in various legislation as well as in the healthcare reform
    bill that is moving is an ongoing effort, and we are still
    trying to do that as much as possible. But I do think that we
    needed a hearing today because whatever isn't included
    obviously we would like to move as separate legislation if that
    becomes necessary and so having the hearing today is which is a
    legislative hearing as our effort to continue down that path as
    quickly as possible.
        I want to thank our witnesses for testifying. We have some
    new faces including Dr. Yvette Roubideaux, who is the new
    Director of the IHS. We also have some returning witnesses
    including Rachel Joseph, who is the co-chair of the National
    Tribal Steering Committee to reauthorize the Indian Health Care
    Improvement Act, and thank you, Rachel, for all you have done
    on this bill. So I want to welcome our witnesses.
        And I will now--well, I was going to recognize--I will have
    to recognize Mr. Shimkus for an opening statement if he likes.
        Mr. Shimkus. Thank you, Mr. Chairman, and I want to welcome
    our guests here, also. I want to first apologize. This is a day
    when I conduct a monthly tour for Army veterans and their
    families at the Capitol which I am already 15 minutes late for
    so but I wanted to make sure that the hearing got off on time
    with members from the Minority Party here too to welcome you
    and I look forward to your testimony.
        The only point that we will add to this debate and it has
    been a debate in the last reauthorization, and it was addressed
    in the Senate legislation and we have this debate now with the
    overall healthcare reform, is the issue of taxpayer funds that
    would go to abortion and abortion services. There are many of
    us who will not--will want us to maintain the position of the
    Hyde language amendment which has been very important in the
    past legislation. It is under challenge today and so it is
    important for you all to know that they will be many of us in
    the pro-life community and it is really a bipartisan group of
    members, Republicans and Democrats, who will make--want to
    really ensure that taxpayer dollars not go for those specific
    type services.
        So with that, I appreciate the time, Mr. Chairman. I
    apologize for departing but I have dual commitments.
        Mr. Pallone. Thank you. Donna, the gentlewoman from the
    Virgin Islands, Ms. Christensen, who has actually both the two
    both of my colleagues who are here today have had major roles
    in pushing this legislation. So I appreciate both of your being
    here and all that you have done.
        The gentlewoman from the Virgin Islands.

           OPENING STATEMENT OF HON. DONNA M. CHRISTENSEN, A
           REPRESENTATIVE IN CONGRESS FROM THE VIRGIN ISLANDS

        Mrs. Christensen. Thank you. Thank you, Mr. Chairman, and
    thank you for holding this hearing.
        You know, preparing for this hearing today just rekindled
    my indignation over the way indigenous people of this country
    have been treated. I don't think it even rises to the level of
    benign neglect. It really can't when one looks at the tragic
    impact it has had on individuals, families, tribes and Native
    populations over the centuries. But H.R. 2708, the Indian
    Health Care Improvement Act Amendments of 2009 is a good and
    welcome start however it just scratches the surface.
        Disease, illness or in the converse, health and wellbeing
    don't exist in a vacuum. They are the consequences of genetics
    to some degree, and behavior as well, but the most influential
    factor is the environment, for the environment affects behavior
    for sure and can even have some impact on the genetics. Given
    the deterioration of the environment in which Native people are
    now confined to, there are extremely poor health, no life
    expectancy and adverse health behavior resulting in high rates
    of injuries, suicide, alcoholism and other substance abuse
    would be expected outcomes of any population group.
        Having had no change in Indian Health Service provisions
    since 1976 despite the dire health indicators and given the
    many advances of health knowledge and technology is truly a
    shame. The fact that we have not been able to pass a
    reauthorization since 2001 is also unacceptable. So I am glad
    that we are having this hearing today following on the one in
    the Committee on Natural Resources where the chairman and I are
    both also members and I am also pleased that in addition to the
    provisions in CHIP and ARRA that H.R. 3200 includes some eye
    care provisions and I am proud to say that the tri-caucus has
    included eye care provisions in our health equity bill and that
    we have fully included concerns of our American Indian, Alaskan
    and Hawaiian Native brothers and sisters in our efforts and our
    initiatives. But these can only be considered first steps in
    the effort that we owe to these first members of the American
    family.
        So I look forward to working with you, Chairman Pallone and
    Ranking Member Deal, to make sure that the Indian Health Care
    Improvement Act Amendments of 2009 are finally passed in 2009.
    So thank you for holding this hearing. Thank you to the
    witnesses who are here with us today, not only for being here
    but for all of the work that you have done over the years to
    improve upon the bill that we have before us today.
        Thank you. I yield back the balance of my time.
        Mr. Pallone. Thank you.
        The gentlewoman from Wisconsin, Ms. Baldwin.

     OPENING STATEMENT OF HON. TAMMY BALDWIN, A REPRESENTATIVE IN
                  CONGRESS FROM THE STATE OF WISCONSIN

        Ms. Baldwin. Thank you, Mr. Chairman. Thank you for
    convening us and convening this hearing on The Indian Health
    Improvements Act. I know that this is a major priority for you,
    Mr. Chairman, and for this subcommittee and I am eager to lend
    my support and help achieve the goal of reauthorization during
    this Congress.
        One of my primary concerns like the gentlelady from the
    U.S. Virgin Islands, one of my primary concerns is the stark
    disparities experienced by minority populations in the United
    States in the healthcare system and with healthcare outcome and
    access. The American Indian and Alaska Native people have long
    experienced lower health status when compared with other
    Americans, and a recent report from the Agency for Health
    Research and Quality outlined a number of areas in which
    American Indians and Alaska Natives lag behind others and the
    specific areas where these disparities are growing worse. The
    report uses a number of measures to assess access to care
    including prenatal care, rate of preventative screening and
    other basic services that are key to preventing illness and
    disease.
        One of the most alarming and difficult issues to address is
    the rampant spread of diabetes in Indian country. Lack of
    public health initiatives leave families without the
    information they need to get healthy and to stay healthy, and
    diabetes ends up being a persistent chronic disease that costs
    the Indian Health Service an extraordinary amount of money but
    much more importantly too many Native Americans their lives.
        That is why I am especially proud of a facility I want to
    boast about it in the district that I represent run by the Ho-
    Chunk Nation. The House of Wellness is a state-of-the-art
    facility designed to offer a full range of health services with
    the focus on prevention and wellness. It is a fitness and
    aquatic facility featuring a range of programs designed to
    promote exercise, a professionally trained staff, indoor
    walking track and studio lifestyle classes. The House of
    Wellness also offers childcare services for parents who need a
    little bit of time to take care of their own health and it also
    offers a health clinic and pharmacy services to help meet the
    needs of the community, both Native and non-Native. Through
    promotion of exercise and helping people of all ages focus on
    prevention, facilities like this one can change the health
    trajectory of many Native American families.
        The Indian Health Service also provides vital water and
    sanitation assistance to members of the Ho-Chunk Nation. As you
    know, ensuring that housing is safe and provides access to safe
    and clean water is one of the most important steps we can take
    towards improving the health of communities. It is unacceptable
    to me that we have languished so long without reauthorizing
    this incredibly important legislation. I want to thank our
    witnesses here today who will help us understand how much more
    pressing the need becomes with each passing day.
        Again, Mr. Chairman, thank you for convening this hearing
    and I also must apologize. I am going to be skipping between
    two simultaneous hearings this afternoon but I hope to be here
    as long as I can to hear your testimony.
        Mr. Pallone. Thank you.
        And we will now move to our witnesses and on our first
    panel we have the Director of the Indian Health Service, Yvette
    Roubideaux, thank you for being here today. I guess I normally
    say that we have 5 minutes but since you are the only witness,
    I am not going to worry about it too much but thank you and if
    you would like to begin.

    STATEMENT OF YVETTE ROUBIDEAUX, M.D., M.P.H., DIRECTOR, INDIAN
                             HEALTH SERVICE

        Dr. Roubideaux. Thank you, Mr. Chairman and members of the
    committee.
        Good afternoon. My name is Dr. Yvette Roubideaux and I am
    the new Director at the Indian Health Service. I am accompanied
    by Mr. Randy Grinnell, the Deputy Director of the Indian Health
    Service. I am really pleased to have this opportunity to
    testify on H.R. 2708, the Indian Health Care Improvement Act
    Amendments of 2009. I am looking forward to working with you to
    ensure passage of this important authorizing legislation for
    the Indian Health Service.
        As you know, the Indian Health Service plays a unique role
    in the Department of Health and Human Services because it is a
    healthcare system that was established to meet the Federal
    Trust Responsibility to provide healthcare for American Indians
    and Alaska Natives. The mission of the Indian Health Service is
    a partnership with the American Indian and Alaska Native people
    to raise the physical, mental, social and spiritual health to
    the highest level. The Indian Health Service provides high
    quality, comprehensive primary care and public health services
    through a system of IHS, tribal and urban operated facilities
    to nearly 1.5 million American Indian and Alaska Natives
    through hospitals, health centers, clinics located in 35
    States. However, meeting the mission of the Indian Health
    Service has become increasingly challenging over time.
    Population growth, increased demand for services, rising
    medical costs and the growing burden of chronic disease have
    place significant strain on the system.
        In the opening statement of my confirmation hearing before
    the Senate Committee on Indian Affairs, I stated that despite
    these challenges I see evidence of hope and change. I have
    worked on a variety of projects and national initiatives over
    the past 16 years that have shown me the great potential that
    exists to improve access and quality of healthcare. I know that
    thousands of dedicated and committed career staff in the Indian
    Health System work hard everyday to provide healthcare to their
    patients in the face of all these challenges and I have seen
    support from tribes and Congress for change and improvement in
    the Indian Health Service. I believe we are at a unique moment
    in time where we have the opportunity to take great strides
    towards fulfilling the mission of the Indian Health Service and
    improving the health of American Indian and Alaska Natives.
        President Obama's commitment to improve healthcare for
    American Indian and Alaska Native people is reflected by a
    significant funding increase for the Indian Health Services you
    mentioned and the fiscal year 2010 budget. While the President,
    the Secretary and I all understand that money alone is not the
    whole answer, the significant increase in resources for IHS
    recommended in the President's budget is essential for the
    agency to increase services and effectively fulfill its
    mission.
        Now is the time to begin the important work of bringing
    change to the Indian Health Service to improve healthcare
    quality, to modernize and upgrade IHS facilities, to expand
    health promotion and disease prevention, and to ensure that
    American Indians and Alaska Natives are able to get the
    healthcare that they deserve. Passage of the Indian Health Care
    Improvement Act will be an important step towards these goals.
    The Department strongly supports reauthorization of the Indian
    Health Care Improvement Act and supports the effort to ensure
    that IHS is able to meet the healthcare needs of American
    Indians and Alaska Natives and takes into account increased
    tribal administration of health programs. It is within this
    context today that we offer our views on H.R. 2708. We will
    provide a few comments today and we will provide additional
    comments once we have had an opportunity to conduct complete
    review of this important reauthorizing legislation.
        First, we note that the authority for the Catastrophic
    Health Emergency Fund or CHEF fund included in title 2 of the
    existing authority has actually been excluded from this bill.
    We recommend its inclusion because the CHEF program is a key
    component of the contract health program administered by the
    IHS and tribal health programs. CHEF provides funding for high-
    cost cases which cannot be absorbed by local service units
    contract healthcare programs.
        Our next comments are in title 1. IHS offers health
    profession scholarships to American Indian and Alaska Native
    students who agree to sign a legal contract agreeing to a
    service obligation upon completion of their health professional
    training. Unfortunately, a small number of students default on
    their service obligation. We believe the determination of
    whether to discharge or suspend a defaulted obligation should
    remain entrusted as is under current law to a review board
    charged with making impartial case by case decisions based on a
    detailed review of the requests. We recommend that the new
    consultation requirement in this section of title 1 be dropped.
    Defaulting on this obligation is a serious breach of a legal
    contract and a resolution must be decided in an impartial
    manner.
        The IHS also offers a loan repayment program to health
    professionals who agree to work in areas of high vacancy or
    need and a list of priority sites is developed each year. In
    title 1, H.R. 2708 changes current law to require the Secretary
    to approve loan repayment of where it is not withstanding the
    priority ranking of positions for which there is a need or a
    vacancy required under the section. This modification means
    that award and approvals would be based on other priorities
    undermining the development of our annual priority list. So to
    keep the intent of the loan repayment program consistent with
    the goal of improving recruitment and retention of health
    professionals in areas of high vacancy or need, we recommend
    the term notwithstanding be replaced by terms consistent with
    the priority list.
        My next comments are on title 3, the sanitations facility
    deficiency definitions. H.R. 2708 would provide ambiguous
    definitions of sanitation deficiencies used to identify and
    prioritize water and sewer projects in Indian country. Our
    written testimony provides examples of the problems with these
    definitions. We recommend retaining current law to distinguish
    the various levels of deficiencies which determine allocating
    existing resources.
        In addition to the comments I have made today on certain
    provisions of H.R. 2708 there will be additional comments once
    we have had an opportunity to conduct a complete review of this
    important reauthorizing legislation. Mr. Chairman, that
    concludes my testimony. I appreciate the opportunity to appear
    before you to discuss the reauthorization of the Indian Health
    Care Improvement Act of 2009. We are committed to working with
    you to ensure the reauthorization of this key legislative
    authority. I will be happy to answer any questions that you
    have. Thank you.
        [The prepared statement of Dr. Roubideaux follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pallone. Thank you and now we will take questions from
    the panel. I will start with myself.
        First of all let me thank you for actually getting specific
    because unfortunately and I know it sounds partisan but in the
    previous administration we--I don't remember any of the open
    testimony at all being, you know, specific about the bill. And
    I also appreciate the fact that you are going to get back to us
    quickly because as I said I would like to see as much of this
    included in the healthcare reform as possible and so, you know,
    as we move with that whatever comments we can get from the
    administration will be very important, you know, over the next
    few weeks or the next few months.
        I want to try to get in three questions here quickly if I
    can. You know, obviously this legislation has languished for
    many years in Congress so could you tell us why it is so
    important to reauthorized the Act and what are the consequences
    to the IHS and those who rely upon it that we have other than
    if we continued not to reauthorize?
        Dr. Roubideaux. Well, reauthorization of the Indian Health
    Care Improvement Act is extremely important. It is important to
    our patients and our tribes because they view it as their
    version of healthcare reform and what the Act does is
    modernizes and updates the Indian Health Service so that we can
    provide better care for the patients that we serve. The
    consequences of not acting are that again are our patients and
    tribes are waiting for this important legislation to be
    reauthorized so we strongly support its passage.
        Mr. Pallone. OK and then the second question, you know, I
    wanted to thank you and for the President obviously for making,
    you know, the additional funding available that is in the
    budget. Clearly, that is very important but IHS doesn't rely
    solely on its annual appropriations to finance services to
    tribes. It collects reimbursements from Medicare/Medicaid and
    private payer so how important is it to make sure that tribal
    members are enrolled in other public programs like Medicare and
    Medicaid or private insurance when they are eligible for such
    coverage? And what types of barriers do tribal members face in
    enrolling in these other programs? How can we overcome those
    barriers that exist?
        Dr. Roubideaux. Right, well, as I had stated the resources
    that we have available in the Indian Health System make it
    difficult for us to meet our mission and so we rely on the
    ability of serving patients who have other resources in terms
    of insurance or Medicare and Medicaid coverage. Third party
    reimbursements from these sources are extremely important. For
    some of our facilities, over half of their operating budget
    comes from third party reimbursements so they serve an
    extremely important source of care for us. I think some of the
    barriers that we have to having some of our patients enroll in
    these forms of coverage is that the paperwork can be confusing.
    There may be a misunderstanding of why they need to provide the
    information that they do for the applications. And with regard
    to private insurance, I think that for many of our patients
    they just can't afford to pay the premiums or can't afford to
    pay the co-pays. That is why a national health reform provides
    an opportunity to perhaps American Indians and Alaska Natives
    have access to better coverage as well.
        Mr. Pallone. Thank you. And then my third question was
    about the, you know, some of the changes. I know you were able
    to offer us some of the administration's positions on
    organizational structural changes and you said you are going to
    get back to us with more which again, I would appreciate as
    soon as possible. But did you want to talk a little more about
    any of these organizational structural changes, say
    particularly the elevation of the IHS Director to the position
    of assistant secretary because that is the important part of
    this legislation for a long time?
        Dr. Roubideaux. Right, we understand that the proposal to
    elevate the Director of the Indian Health Service to an
    assistant secretary level is extremely important to our tribes
    and it has been a recommendation by them because they would
    like their healthcare needs to be addressed at the highest
    levels in the Department. I am working with the Secretary and
    her staff on exploring this issue and once we receive--once we
    develop a position on it we will let you know but we definitely
    understand that the health needs of American Indians and Alaska
    Natives need to be addressed at the highest levels in the
    Department of Health and Human Services and we are committed to
    that.
        Mr. Pallone. And that is obviously one that if you could
    get back to us as quickly as possible. Thank you.
        The gentlewoman from the Virgin Islands, Ms. Christensen.
        Mrs. Christensen. Thank you, Mr. Chairman, and welcome, Dr.
    Roubideaux. I missed you at the first hearing.
        My first question refers to some of the recommendations
    that Dr. Rock has made that the urban Indians be restored in
    section 1 and 6 of section 3 be included in the women's health
    section and in the section that deals with payments under
    Medicare and Medicaid and SCHIP. Would your office be
    supporting those recommendations again? Are you aware of them?
        Dr. Roubideaux. Well, while I can't comment on the specific
    provisions of the bill I can tell you that we are supportive of
    the needs of urban American Indians and Alaska Natives. We know
    that many of our American Indians and Alaska Native people
    choose to leave the reservation and go to urban areas but
    unfortunately that leaves them in many cases uncovered by the
    Indian Health Service. So fortunately in some communities we do
    have the 34 Urban Indian Health programs that are funded by the
    Indian Health Service and those programs are supported by title
    5 of this particular Act, and certainly other provisions apply
    to them as well. So we recognize these clinics as extremely
    important sources of healthcare for Native people who go to
    urban areas. Especially because it is the only source of
    culturally appropriate care that they can receive in urban
    areas and these places often help them have a sense of
    community and a sense of home while they are away from the
    reservations. And so with regard to the specific provisions
    what we will include that in our review but we are very
    supportive of generally doing what we can to support the urban
    Indian population.
        Mrs. Christensen. Thank you. The bill has provisions to
    help and recruit and retain health professionals and I believe
    that the best providers are those from our community--from the
    community themselves. In the African-American community the
    biggest barrier to achieving that kind of diversity in the
    health workforce is the K through 12. I know this is not
    specifically related to the bill but is there some commensurate
    thing from the initiative happening with K through 12 to ensure
    that this provision to train and recruit them and retrain
    perhaps Native American providers would not be an empty
    promise?
        Dr. Roubideaux. Well, there are a number of programs that
    are already funded by various agencies to deal with the health
    professional shortages in our communities. One program that we
    find is the Indians Into Medicine program that looks at
    recruiting young American Indians and Alaska Native individuals
    into the health professions. We have a site in North Dakota and
    we also have a site in Arizona and those address the K through
    12 population to try to get them interested in science careers.
    One of the most innovative projects that we have been involved
    with is the diabetes and science and education project in
    tribal schools that was developed in partnership with the
    National Institute of Diabetes, Digestive and Kidney Diseases.
    And a curriculum was developed by tribal colleges to be given
    to students in the K through 12 grades to expose them to
    science but using diabetes as the example not only to expose
    them to the science of the disease but also how to be healthy
    and in that process helps them learn about health professional
    careers and we are very excited that curriculum is just now
    available and will be disseminated throughout Indian country.
    So I think there is some opportunities to improve the exposure
    of students to science and to health careers in our communities
    but we clearly need more efforts.
        Mrs. Christensen. Thanks. The bill makes reference to under
    sanitation facilities the inordinately high incidence of
    disease, injury and illness directly attributed to the absence
    or inadequacy of sanitation facilities. And it also says that
    the long term cost is far greater than the short term cost of
    providing those sanitation facilities. Is the bill language
    strong enough to provide the services that would be needed in
    terms of the sanitation to create those savings not only in
    money but in terms of illness and lives?
        Dr. Roubideaux. Well, one of the important functions of the
    Indian Health Service is to provide sanitation facilities. The
    Indian Health Care Improvement Act has provided the foundation
    for that. With this bill we have discussed some problems that
    in the definitions of how they are defining those.
        Mrs. Christensen. Right.
        Dr. Roubideaux. And I think that reauthorization of this
    bill is important in terms of what services we could provide
    for our communities.
        Mrs. Christensen. Thank you.
        Thank you, Mr. Chairman.
        Mr. Pallone. Thank you and thanks so much for your
    testimony. I appreciate it.
        Dr. Roubideaux. Thank you.
        Mr. Pallone. Good luck with everything.
        Dr. Roubideaux. Thank you very much.
        Mr. Pallone. I would ask the second panel to come forward.
        Our second panel has four witnesses and I will introduce
    them starting on my left is the Honorable Jefferson Keel who is
    Lieutenant Governor of the Chickasaw Nation and President-Elect
    of the National Congress of American Indians. And then is
    Rachel Joseph who is Co-Chair of the National Tribal Steering
    Committee for the Reauthorization of the Indian Health Care
    Improvement Act. And then we have another Joseph, Andrew
    Joseph, Jr. who is Chairman of the Human Services Committee,
    Direct Services Tribe Advisory Committee. And finally, Dr.
    Patrick Rock who is Executive Director of Indian Health Board
    of Minneapolis and President-Elect of the National Council of
    Urban Indian Health. Thank you for being here and thank you for
    all that you have done over the years on this legislation.
        As I said, you know, we have 5 minutes but there is not a
    lot going on today so we are not going to stick to that too
    much and we will start with Mr. Keel.

    STATEMENTS OF HONORABLE JEFFERSON KEEL, LIEUTENANT GOVERNOR OF
       THE CHICKASAW NATION AND PRESIDENT-ELECT OF THE NATIONAL
    CONGRESS OF AMERICAN INDIANS; RACHEL JOSEPH, CO-CHAIR, NATIONAL
    TRIBAL STEERING COMMITTEE FOR THE REAUTHORIZATION OF THE INDIAN
      HEALTH CARE IMPROVEMENT ACT; ANDREW JOSEPH, JR., CHAIRMAN,
       HUMAN SERVICES COMMITTEE, DIRECT SERVICES TRIBE ADVISORY
     COMMITTEE; AND PATRICK ROCK, M.D., EXECUTIVE DIRECTOR, INDIAN
    HEALTH BOARD OF MINNEAPOLIS, PRESIDENT-ELECT, NATIONAL COUNCIL
                          URBAN INDIAN HEALTH

                      STATEMENT OF JEFFERSON KEEL

        Mr. Keel. Thank you, Mr. Chairman.
        Good afternoon and first I want to begin by just saying as
    the President of the National Congress of American Indians I am
    honored to be asked to present testimony to our friends at the
    Health Subcommittee of the Energy and Commerce Committee. On
    behalf of the National Congress of American Indians I greatly
    appreciate the opportunity to again provide comments and
    support for a House bill on the Indian Health Care Improvement
    Act.
        I want to begin by thanking you Congressman Pallone for
    your continued efforts to improve the healthcare services
    delivered to American Indians and Alaska Natives. The Indian
    country extends its thanks for your hard work over the last
    several years on the Indian Health Care Improvement Act. We
    appreciate all that you and the committee have done. Now it is
    time to get this bill out of committee and passed by the full
    House of Representatives.
        My colleagues today will be providing you testimony on
    duty, rights and obligations for Indian health. They will also
    provide you with the shocking statistics on health disparities
    in our communities and why the reauthorization is so
    desperately is needed, all of which the committee is very
    familiar with. What I would like to do today is simple. I would
    like to ask the committee to set a schedule and procedure for
    when the bill will be passed and enacted.
        Over the last 10 years, NCAI has worked side-by-side with
    the National Steering Committee for the Reauthorization of the
    Indian Health Care Improvement Act and the National Indian
    Health Board for the same procedures. We work with numerous
    committee staff on drafting language, watch leadership in the
    House change and have seen two Presidents come and go in
    office. With each passing year there seems to be a new must-
    pass priority and the Indian Health Care is relegated to the
    sidelines. The nation is now focused on reforming the health
    insurance industry. As with the rest of the country, this issue
    is of critical importance to tribes and we support the efforts
    of the Obama Administration and Congress. Speaker Pelosi and
    Mr. Pallone have recognized the importance of protecting and
    preserving the Indian healthcare delivery system during this
    reform effort and the National Congress of American Indians
    thanks you for your commitment to Indian country.
        The Indian Health Service as you well know is in need of
    updates and modernization. The current House Bill H.R. 2708 is
    a starting point for reforming the IHS. As with the national
    health reform bills its goal is to provide cost-saving features
    for healthcare delivery by shifting the healthcare delivery
    paradigm in the IHS to preventative health. Indian country has
    been waiting for and asking for these updates for over 10
    years. We do not believe the national health insurance reform
    should be used as an excuse for abandoning the effort to
    reauthorize the Indian Health Care Improvement Act. We now come
    before the committee to ask for an assurance that as the nation
    moves forward with health reform the Indian country will be
    included and our bill the Indian Health Care Improvement Act
    will be passed. What I ask again to the committee is, what is
    your strategy for passing the Indian country's health
    modernization bill? The National Congress of American Indians
    knows what this committee can do when it sets its mind to it.
    We all saw how quickly you came together to write and pass the
    Affordable Health Choices Act. We witnessed the hard work of
    the staff in drafting the Indian protections needed within that
    bill and the dedication of the committee in passing those key
    provisions. We now ask that that same enthusiasm and commitment
    be provided for the Indian Health Care Improvement Act.
        The National Congress of American Indians stands ready as I
    do and I am sure the other members of this panel do to do
    whatever it takes to get this bill passed. Again, thank you for
    this opportunity and I look forward to working with you for
    passage of this important bill. Thank you.
        [The prepared statement of Mr. Keel follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pallone. Thank you, Mr. Keel.
        Ms. Joseph.

                       STATEMENT OF RACHEL JOSEPH

        Ms. Rachel Joseph. Good afternoon, Mr. Chairman, and
    distinguished members of the committee.
        I am Rachel Joseph, Shoshone Paiute of the Lone Pine
    Paiute-Shoshone Tribe of California and Co-Chair of the
    National Steering Committee for the Reauthorization of the
    Indian Health Care Improvement Act, the NSC. I appreciate the
    opportunity to testify today and to state our strong support
    for H.R. 2708. On behalf of the NSC and National Indian Health
    Board, we appreciate your ongoing support for improving
    healthcare for Indians. I also acknowledge the contribution of
    tribal leaders who have served on the NSC over the past 10
    years.
        The foundation of our participation in this reauthorization
    is based on two principles. One, that the legislation allow no
    regression from current law and that the healthcare system be
    modernized and strengthened.
        In the Chairman's opening statement he recited the health
    status and the statistics of our population. No other segment
    of the American population experiences greater health
    disparities than the American Indian and Alaska Native
    populations. The heartbreaking aspect of these statistics is
    the knowledge that a majority of illnesses and deaths are
    preventable if additional funding and modern programmatic
    approaches to healthcare were available. Despite two centuries
    of treaties and promises, American Indians and Alaska Natives
    endure health conditions and a level of healthcare that would
    be unacceptable to most Americans.
        Today I respectfully request Congress to fulfill our
    nation's responsibilities to Indian people by reauthorizing the
    Indian Health Care Improvement Act this year. The Indian Health
    Care Improvement Act also needs to be a permanent law, thus we
    urge the committee to amend H.R. 2708 to remove the sunset
    dates and permanently authorize appropriations for the Act's
    programs. Our request for a permanent authorization is not
    unique. Congress has permanently authorized other Federal
    Indian Laws such as The Snyder Act, The Indian Self-
    Determination and Education Assistance Act and other laws which
    I listed in my written testimony.
        There are many provisions in the bill which embody the
    improvements needed for the Indian healthcare system. I would
    like to highlight just three of them. Section 208 recognizes a
    need for tribal epidemiology centers to be expressly authorized
    to access the data they need to monitor the incidents of
    diseases in Indian communities and to help tribes in urban
    Indian organization design programs to attack those diseases.
    Complete fulfillment of this mission requires epicenters to
    operate like public health authorities and to access Indian
    country data compiled by HHS agencies.
        Secondly, we strongly support the bill's revisions to
    current law authorizing a comprehensive system of behavioral
    health programs. Title 7 authorizes the integration of programs
    for mental health, social services, domestic and child abuse,
    youth suicide and substance abuse. Attacking these chronic
    problems is vital to improve the quality of life in Indian
    country and strengthening Indian families.
        Lastly, section 807 addresses a serious issue in Indian
    country when tribes are compelled to try to fill the funding
    gap by expanding direct services, augmenting contract
    healthcare, paying premiums for Medicare part B and D, and
    developing self-insurance plans for their members.
    Unfortunately, the tax consequence of such efforts are unclear.
    Section 807 will clarify that these benefits are tax-exempt as
    they should be. They were prepaid through the cessation of over
    400 million acres of tribal lands and other resources. American
    Indians and Alaska Native people are entitled to healthcare and
    should not be taxed when their tribes step in to assist them in
    obtaining care.
        While the NSC is extremely supportive of this bill there
    are a few provisions that require revision and additional
    provisions we would like to see inserted into the bill. Our
    proposals are outlined in the section by section revisions
    document which was included with my written testimony submitted
    for the record.
        I would like to conclude by sharing my personal
    observations and experiences with this reauthorization which
    have been the most positive and uplifting experience in my life
    and at the same time the most frustrating experience. During
    the consultation with the tribes that began in 1998 and
    continued through 1999, tribal leaders across the country made
    some strong commitments that we would spend long hard hours--no
    cell phones was one of my ground rules which was pretty
    exciting as the tribes developed consensus on the proposal that
    we submitted to Congress. We believe that consensus was
    necessary so that, you know, we would not be in a divide and
    conquer position but as you balance the diverse and the varied
    needs of our tribes it was a tremendous project and undertaking
    and we did it and we have been able to maintain consensus
    through all these years.
        The disappointment part of course is that our job is not
    done. Mr. Chairman, we appreciate your sponsorship of this bill
    and we particularly appreciate our relationship that we have
    been able to have. Excuse the--no pun intended, frank and
    forthright discussions about the need for reauthorization and
    we are fortunate that we have that kind of communication. I
    also would be remiss if I did not acknowledge the support and
    ongoing efforts of Chairmen Rayhall, Waxman and Rangel and
    former Chairman Don Young and Dingell and of course Chairman
    George Miller who has never wavered in his support since he
    first introduced Indian Health Care Improvement Act when he was
    chairman of the Natural Resources Committee. Together with our
    many sponsors who have consistently stayed with us throughout
    the years, there is no reason in our view that this legislation
    should not be enacted this year.
        I would be happy to respond to any questions that you have
    and look forward to working with you to get this job done.
    Thank you.
        [The prepared statement of Ms. Rachel Joseph follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pallone. Thank you.
        Mr. Andrew Joseph.

                    STATEMENT OF ANDREW JOSEPH, JR.

        Mr. Andrew Joseph. Chairman Pallone and distinguished
    members of the committee.
        My name is Badger in my language. I am Andrew Joseph, Jr. I
    Chair the Health and Human Services Committee of the Colville
    Federated Tribes. I Chair the Portland Area Indian Health Board
    and the Vice-Chair for IHS-DST, Direct Service Tribes.
        Thank you for inviting the Direct Service Tribes to testify
    today. The Direct Service Tribes are tribes that have decided
    to receive their healthcare services directly from the IHS. The
    Direct Service Tribes consider the decision as an exercise of
    self-determination and the fulfillment of the Federal Trust
    Responsibility. Out of 564 federally recognized tribes, IHS
    provides direct healthcare services for over 100 tribes and
    accounts for over 50 percent of the total IHS population
    served. Since 1999 tribes have been seeking reauthorization of
    the Indian Health Care Improvement Act. However for reasons it
    is difficult to understand, passage of the Indian Health Care
    Improvement Act Reauthorization Bill has been obstructed each
    year by concerns of unrelated non-Indian issues. I hope the
    committee will work with us to ensure that this bill is not
    sidetracked this year and the bill is passed as soon as
    possible.
        For the Indian people, Federal responsibility to provide
    health services represents a prepaid right. Tribes hold and
    affirm that the treaties with the Federal Government ensure
    that healthcare will be delivered effectively in our
    communities to exchange for the millions of acres of valuable
    land that are ancestors ceded. Today the Indian Health Care
    Improvement Act continues to be a vital important policy with--
    that honors these treaties and serves as a foundation for
    delivery of healthcare to Indian people.
        I would like to speak on a few provisions of H.R. 2708 that
    would have significant impact for Direct Service Tribes. First,
    section 212 provides express authority for IHS and tribes to
    operate hospice, long term care, assisted living programs to
    supply health services in homes and community-based settings.
    All such delivery methods are common in the rest of the country
    but are rare in Indian country.
        Second, the elevation of the IHS director as an assistant
    secretary level that is in the Department of Health and Human
    Services would be a strong step in creating a direct link to
    address the needs of tribes especially Direct Service Tribes.
    With an assistant secretary position, the collaborative efforts
    of tribes and IHS would be enhanced through true government to
    government dialog.
        Additional recommendations--in my remaining time, I also
    would like to touch on two recommendations for H.R. 2708,
    permanent authorization of the Indian Health Care Improvement
    Act. The process of having the Indian Health Care Improvement
    Act authorized has been long. Tribes have invested into the
    process for over 10 years. As a tribal leader I need to justify
    the resources of my--that my tribe puts into trips to
    Washington, D.C. I know that these vital resources could be put
    towards critical patient care, however I and my tribe also
    understand the importance of ensuring that the Indian Health
    Care Improvement Act is reauthorized. To honor our treaties and
    to ensure the continual authority for our healthcare system,
    the bill should be amended to ensure that the authorization for
    appropriations is permanent.
        Establishing an office of Direct Service Tribes, H.R. 2708
    should also be amended to include the establishment of an
    office of Direct Service Tribes located within the proposed
    office of assistant secretary. The responsibilities of this
    office would honor the relationship with tribes by providing
    technical support to Direct Service Tribes in serving as a
    point of contact for tribal consultation.
        I wish to thank the committee for the opportunity to
    provide these comments and I will be pleased to answer any
    questions the committee may have. Thank you.
        [The prepared statement of Mr. Andrew Joseph follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pallone. Thank you.
        Dr. Rock.

                    STATEMENT OF PATRICK ROCK, M.D.

        Dr. Rock. Thank you. Good afternoon.
        My name is Dr. Patrick Rock, Leech Lake Band enrollee and
    also the President-Elect for the National Council of Urban
    Indian Health, and also the CEO of my organization called the
    Minneapolis Indian Health Board.
        On behalf of the National Council of Urban Indian Health
    and the 9,000 patient visits that my clinic serves annually, I
    would like to thank Representative Pallone for introducing this
    important bill. I would also like to thank the subcommittee for
    holding this hearing.
        The Urban Indian Health Program serves over 150,000
    American Indians and Alaska Natives annually through 36 urban
    Indian programs across the county. It is a comprehensive health
    delivery system that integrates public health, preventative
    health measures, behavioral health and primary care services.
    The urban Indian programs providing health services are at
    various levels of services dependent upon the needs of the
    community and the funding. Our programs are both innovative and
    cost effective. As a whole, the urban Indian health program
    leverages $2 for every dollar of Indian health service
    investment.
        We are also a unique system of care designed to fulfill the
    trust responsibility to Indian people living in urban areas.
    Congress has repeatedly stated that the government's trust
    responsibility extends to American Indians and Alaska Natives
    living away from their tribal homes. From the original Snyder
    Act of 1921 to the Indian Health Care Improvement Act Congress
    has affirmed and reaffirmed its commitment to ensure that trust
    responsibility to Indian people is met regardless of where they
    reside.
        Despite this commitment, the trust responsibility to Indian
    people has not been fully met. The Indian healthcare delivery
    system is innovative and well-situated to address the health
    disparities suffered by Indian people in a comprehensive,
    culturally appropriate manner. However, the Indian health
    delivery system needs full funding and modernization promised
    by this bill in order to meet its mission.
        H.R. 2708 provides a number of new tools and updates for
    the Indian health providers. These programs and modernizations
    will help the Indian health delivery system tackle the serious
    health disparities facing our people.
        I would like to take the opportunity to highlight three
    provisions that I believe will greatly benefit urban Indian
    health providers such as myself. First, in section 515,
    conferring with urban Indians, in order to--in order of the
    trust responsibility to urban Indians are fully met, urban
    Indians need the opportunity promised by this section to
    discuss the health needs of urban Indians with the Federal
    Government.
        Second, section 521, authorization for urban Indian
    organizations, H.R. 2708 creates tools and programs to address
    behavioral health disparities suffered by Indian people,
    especially with regard to Indian youth suicide. This provision
    assures that urban Indian programs will have such programs
    available through them through title 5 of IHCIA.
        Third, section 522, health information technology, health
    information technology is the future of health delivery. Any
    provider that does not develop HIT infrastructures and systems
    now will be behind the advances of medicine to the detriment of
    their patients. This provision assures that title 5 programs
    will have the support and the opportunities they need.
        There are also three revisions that the National Council of
    Urban Indian Health seeks. First, NCUIH strongly supports the
    National Steering Committee's recommendation that IHCIA be made
    permanent Federal law. There are several major laws which
    Congress has permanently authorized. We believe that the time
    has come to give IHCIA the same permanency.
        Second, NCUIH also asks the committee to restore urban
    Indians to section 3, the Declaration of National Indian Health
    Policy. Removing urban Indians from this provision is a
    regression from current law. By not including urban Indians,
    Congress opens the door to inferences that it no longer
    believes that the trust responsibility extends to urban
    Indians. We believe that dropping urban Indians from this
    provision was done in error and ask the committee to restore
    urban Indians.
        Third, NCUIH asks the committee to restore urban Indians to
    section 201 of title 2. These provisions pertain to third-party
    billing, a critical necessity for any health provider.
    Including urban Indians in this section would greatly help
    urban Indian organizations strengthen their third-party billing
    capacity which could be a difference between fiscal stability
    and instability for many programs.
        As President-Elect of the National Council of Urban Indian
    Health and the CEO of Minneapolis Indian Health Board, I would
    like to give Representative Pallone, the committee and the
    sponsor of the H.R. 2708 my deepest and most sincere thanks for
    producing this bill. H.R. 2708 provides the necessary
    modernization for Indian health delivery system and all Indian
    health providers from the Indian health service to urban Indian
    health providers will benefit greatly from this passage. While
    there are few provisions--important provisions for urban
    Indians that NCUIH feels should be reconsidered we believe that
    this bill truly reflects the priorities of tribes and of urban
    Indian health programs.
        Thank you.
        [The prepared statement of Dr. Rock follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pallone. Thank you, Dr. Rock.
        And we will take questions from myself initially and then
    my colleague from the Virgin Islands.
        Let me address some of the things you mentioned. First, Mr.
    Keel talked about schedule and procedure for moving the bill
    and I would just, you know, like to reiterate what I said
    before which is that, you know, I would like to see as much of
    this included in the larger healthcare reform as possible, and
    so it may very well be that until we know where we are going
    with that in the next few weeks that, you know, we would have
    to wait until that is sort of resolved.
        And then I wanted to mention with regard to Ms. Joseph, I
    am very much supportive of what you suggested about not taxing
    health benefits provided by tribes. I mean my view of going
    back to what I said in the opening statement is that, you know,
    since we have a responsibility on the part of the Federal
    Government to provide healthcare completely for Native
    Americans, if and we are not doing it, if the tribes set in to
    make up for that difference it is even more outrageous to
    consider taxing them for it when we are supposed to be
    providing the benefit completely. So I have sent letters to IRS
    and of course, you know, co-sponsored the legislation that
    would change--that would make it clear that they are not
    taxable. Now, that is the Ways and Means issue as you know. It
    doesn't actually come before this committee but it is something
    that we are mindful of as well, you know, as we move forward
    with the healthcare reform.
        I wanted to ask you because several of you mentioned about
    the, you know, making the Act permanent and I was going to ask
    Ms. Joseph initially, I mean there is some precedent for that
    especially with respect to Indian law but tell me in a little
    more detail why you think there is a need for permanent
    authorization. I mean why is that needed as a--I mean normally
    we don't do it so would be your justification?
        Ms. Rachel Joseph. Well, thank you, Mr. Chairman, for the
    question.
        I think after this long 10-year experience of course, you
    know, the expenditure of resources that Chairman Joseph spoke
    to, we certainly, you know, don't want to have to go through
    that exercise. But more importantly, we think if we have a
    permanent authorization and Congress we know can revisit that
    and revise and amend it as necessary, we think that in the
    future we would have an opportunity to focus on one or two or
    three issues that need to be addressed, and have some extensive
    conversations and dialog spent on those issues, and we think
    that we should do more of that.
        Mr. Pallone. OK, I wanted to ask Mr. Joseph a different
    question and that is about long term care services. You raised
    that in your testimony and this is something that I am very
    interested in, you know. There is probably not going to be much
    in the healthcare reform, the larger healthcare reform on that
    because of the expense but I am curious to know more about, you
    know, those long term care supports and services provided in
    Indian country. I mean how are the American Indian elders
    provided long term care now and how would the revised authority
    under this bill change the delivery of care?
        Mr. Andrew Joseph. Honorable Mr. Pallone, right now our
    tribe we have--the Colville tribe has a rest home. We have a
    area agency on aging and we have some of the people that take
    care of our elders at home. Some of our elders, you know,
    because of sanitation reasons need to be cared for 24 hours a
    day, you know, everyday of the year. And, you know, we all
    would like to take our last breath in our own home but for some
    of us, you know, we are not able to do that. Some people are
    really physically impaired and some elders are trying to take
    care of elders. So what we would like to be able to do is
    figure out, you know, put an amendment in the bill that would
    be able to help us, you know, take care of our elders. The
    Makah tribe has elders in rest homes that are over an hour, an
    hour and a half away from their reservation. In order to be
    able to go and visit them it is a long commute. And by having
    this in the bill, we can provide that care for ourselves and it
    would provide jobs and it would be allowed for if we can bill
    through IHS an Indian counter-rate through Medicaid or
    Medicare. To me, our convalescence and our elder rest home is
    culturally run. We have our cultural ceremonies there and our
    elders feel more at home there.
        Mr. Pallone. Well, that is what I was going to ask you. I
    would imagine your biggest concern is that if, you know, elders
    have to be taken to a nursing home or some institution off the
    reservation is that very common now amongst tribes? I imagine
    you try to prevent that but is that--is it very common that
    they have to actually go to a, you know, or what I call a
    mainstream nursing home off the reservation?
        Mr. Andrew Joseph. Because of the lack of sufficient
    funding for IHS, a lot of our elders become into more of a
    critical need by the time they, you know, find that their
    illnesses take them to a rest home facility and because it is
    not in the bill right now tribes aren't able to really, you
    know, help fund, you know, for those services to build their
    own and take care of their own.
        Mr. Pallone. All right, thank you.
        Let me just ask Dr. Rock, you of course talked about the
    urban Indian health program primarily and you mentioned that
    the urban Indian health program and how the last Administration
    tried to eliminate it from the bill. Of course, I never quite
    understood that. Can you talk about how that urban Indian
    program why it is so important that it stays in place and needs
    to be expanded the way this bill proposes? And, you know, we
    hear various things that there are more and more, you know,
    Native Americans that are moving off reservations, living in
    cities but then we also hear that a lot of them are coming
    back. Well, maybe that is less so now with the recession or
    maybe more so, I don't know. I mean I guess it depends upon
    whether there is economic opportunities on the reservation but
    do you want to comment on that in terms of, you know,
    particularly now with the recession or where we are going in
    the next few years?
        Dr. Rock. Certainly, well that makes two of us that we
    didn't understand why we were zeroed out to begin with but we
    play a really important part as far as this healthcare system
    that Indian Health Service provides. We see a number of
    patients that are either in transition that are moving in and
    through the Twin Cities, specifically my program the Twin
    Cities, Minneapolis and Saint Paul. People are looking for
    work. I see a number of patients of mine, I still practice
    medicine, that have lost their jobs that have no insurance and
    they have absolutely nowhere to go. They have no access to
    care. Even though we--our clinic is right smack in the middle
    of several hospitals, we have the university system there. We
    have a couple of private hospital systems there that offer
    clinical services too, but our patients feel like they don't
    have the access there because they don't have the funding to
    pay for healthcare, and we often see folks that come in that
    have really advanced disease. They are diabetes, take for
    example, is to the point to where now they are starting to see
    kidney problems or eye problems and we try our best to get
    people to the care they need but we are often at that level of
    where we are just putting a Band-Aid on something that could be
    addressed more appropriately if the funding sources were there.
        Mr. Pallone. Has the recession resulted in more people
    moving back to the reservation, moving off or both? Is there--I
    mean I know I am asking you anecdotally but?
        Dr. Rock. Yes, that is exactly right. It is just through my
    anecdotal experience of seeing patients one-on-one everyday. We
    do see a number of folks that are just moving to the Twin
    Cities looking for opportunities for work. Again, some
    statistics that we see these days that are 60 percent of Native
    populations live in urban settings and I will be interested to
    see what the new census data will show as we head into the
    census as to what that is now currently but anecdotally, I have
    a number of patients who have lost their jobs. I have had one
    gentleman who worked in the foundry, lost his job, his
    insurance. He was a Native man. He was enrolled in the White
    Earth Band of Ojibwe in Northern Minnesota, and his wife
    recently--was recently diagnosed with cancer so she was--the
    family was struggling, and let alone him losing his job and
    presenting to me with new onset congestive heart failure which
    requires, of course, treatment and therapies that he couldn't
    afford. So that is one person that I see but everyday, everyday
    we are open we see this.
        Mr. Pallone. OK, thank you very much. Thank all of you.
        Before I move to our other panels, let me just ask
    unanimous consent that a statement from Congressman Dale Kildee
    and also from the California Rural Indian Health Board, if
    those would be entered into the record, and without objection,
    so ordered.
        The gentlewoman from the Virgin Islands.
        Mrs. Christensen. Thank you again, Mr. Chairman.
        President Keel, just from the frustration that hint in your
    testimony I would imagine that you support the permanent
    reauthorization of IHCIA?
        Mr. Keel. Absolutely, yes, I do.
        Mrs. Christensen. Thank you. I just wanted to get your--
    that on the record.
        And, Dr. Rock, you talked about HIT and the importance of
    improving healthcare but do you see this technology as being
    really important to linking the urban Indian to the tribes and
    to services? Do you think that it can be assistance because I
    understand that we don't even know how many American Indians
    are living in urban centers and the difficulties that they have
    when they need services?
        Dr. Rock. I think it does have a potential. I know the
    current thought behind health information technology is the key
    word of interoperability of how the system is actually going to
    work together, and we have an invested interest also from an
    urban standpoint of being part of that system. We think that we
    could provide really a real high quality of care to our
    patients with the utilization of a system as well even cutting
    our costs as far as healthcare if we have an interoperable
    system and a system that is workable with their providers.
        Mrs. Christensen. Well, I was on Homeland Security before I
    came to Energy and Commerce and interoperability is something
    that we are still working on over there and that has been what,
    7 years.
        Let me see, I guess let me see who I would ask, Ms. Joseph,
    maybe or anyone can really answer this. I am a strong believer
    and supporter of primary prevention and the high prevalence of
    deaths from injury, from auto accidents, from suicide has
    always been something that I have been concerned about. And I
    notice similar patterns in not only in the American Indian but
    the Alaska Natives and I wonder if--I don't think that just
    treating something to the use of alcoholism is enough because
    there are all kinds of conditions as I said in my opening
    statement but is there anywhere that you can see that we could
    do something within this reauthorization that would address
    maybe some of the social determinants as well. We talked about
    the modernization of approaches of medicine and to me one of
    the more the newer, some of the newer thinking is about the
    social determinants to health. But does anybody have any--to
    what would you attribute the high prevalence of death and
    injury and suicide on the reservation and how could we better
    address that?
        Ms. Rachel Joseph. Well, we always--I hesitate to say, of
    course we need more money and but we need more money for one
    thing. We are opposing a comprehensive approach to behavioral
    health which addresses a number of those issues you raise and
    we think, you know, with a comprehensive approach we are able
    to use our money more efficiently which would be some. I do
    believe that some of the safety funding related to ambulances
    and so forth and so on, that comes through another agency and
    HHS and through the States, and some States, you know, have a
    better working relationship with their tribes and some don't.
    So some of that, you know, accident prevention, you know, auto
    accidents.
        Mrs. Christensen. Services when you have had an accident.
        Ms. Rachel Joseph. Yes, that money needs to flow directly
    to the tribes and not through the States.
        Mrs. Christensen. Is there enough in the bill that supports
    the traditional healers or is there a need for us to
    incorporate the traditional healers more in this legislation?
        Ms. Rachel Joseph. Yes, there--thank you, Councilman, there
    is language in the bill that addresses traditional healers and
    it is, you know, a tribe by tribe situation and patient by
    patient and, you know, as the patients and the doctors view
    that traditional healing as necessary, there is authorization
    to provide for that.
        Mrs. Christensen. So you are satisfied with it with the way
    it is treated in 2708?
        Ms. Rachel Joseph. We are satisfied with it. We do have a
    little definition recommendation that we would like to, you
    know, we would like to include in a revision.
        Mrs. Christensen. OK, I don't have any further questions,
    Mr. Chairman.
        Mr. Pallone. Thank you.
        The gentlewoman from Illinois, Ms. Schakowsky.
        Ms. Schakowsky. Thank you.
        First, let me apologize for coming in at the last minute
    but I didn't want to miss the opportunity to let you all know
    that I am a big supporter of the Indian Health Care Improvement
    Act amendments and I am a partner with you in trying to get
    better healthcare.
        I am from Chicago where in my district there is the
    American Indian Center and in my Chicago office, which isn't
    far from there, I have a star quilt that was given to me by the
    Chicago Indian Health Service, and I work very closely with
    them and, you know, want to make sure that the resources that
    are needed are always available. The organization does operate
    a health clinic, conducts education and outreach in diabetes,
    provides home visits to people with diabetes to ensure they are
    managing the disease correctly. In Illinois, there is about
    73,000 American Indian and Alaska Natives and the really there
    is a big concentration in my district. So I just really wanted
    to congratulate you on your advocacy on the good work that you
    have been doing and to make sure that I didn't miss the
    opportunity to tell you that I am grateful for your advocacy,
    for the care that you provide and for the chance to work with
    you to make it even better.
        Thank you. I yield back.
        Mr. Pallone. Thank you and thank you all. I know this was
    short hearing today but I don't--I want you to know that
    doesn't in any way take away from, you know, our efforts to try
    to move this bill or as I said before, include it in the larger
    healthcare reform. And I know all of you have been playing a
    major role in all of this and will continue to as we move
    forward over the next few weeks.
        Did you have a question? Sure.
        Mr. Andrew Joseph. Chairman Pallone, Dr. Roubideaux talked
    about the CHEF and not being included in this and to me it is
    really important that it be included into the bill. One of the
    reasons why is we are in the CHS dependent area and are--my
    tribe's reservation is in a remote location as some of the
    Alaska Native villages and some of the other Direct Service
    Tribes are in remote locations, and by not having that in the
    bill, I would be afraid that we would be losing a whole lot
    more lives. The distance that our people have to travel to get
    to a hospital facility, if we don't have hospitals in our area,
    you know, we have a real need for these funds. My own grandbaby
    had to be heart flighted out a little over a year ago into to
    Spokane and that cost over $10,000. That is where the CHEF
    funds money comes into play. It is almost like sending our
    troops to war and not paying for the helicopters to bring them
    in, you know, once they get wounded. So it is really important.
        Mr. Pallone. Now, I am glad you brought it up and my
    assistant tells me that that was basically a drafting error and
    we are conscious of it and we are going to try to correct it,
    you know, as we move along because I know how important it is
    so thank you for bringing it to our attention again.
        All right, thanks very much and we do intend to move
    forward. Thank you.
        [Whereupon, at 3:25 p.m., the Subcommittee was adjourned.]
        [Material submitted for inclusion in the record follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]