[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

                              ----------                              
                                                                   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:]


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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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