[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
_____
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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
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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
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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:]
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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:]
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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:]
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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:]
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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:]
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