[Senate Hearing 111-12]
[From the U.S. Government Publishing Office]
S. Hrg. 111-12
ADVANCING INDIAN HEALTH CARE
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HEARING
before the
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
FEBRUARY 5, 2009
__________
Printed for the use of the Committee on Indian Affairs
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COMMITTEE ON INDIAN AFFAIRS
BYRON L. DORGAN, North Dakota, Chairman
JOHN BARRASSO, Wyoming, Vice Chairman
DANIEL K. INOUYE, Hawaii JOHN McCAIN, Arizona
KENT CONRAD, North Dakota LISA MURKOWSKI, Alaska
DANIEL K. AKAKA, Hawaii TOM COBURN, M.D., Oklahoma
TIM JOHNSON, South Dakota MIKE CRAPO, Idaho
MARIA CANTWELL, Washington MIKE JOHANNS, Nebraska
JON TESTER, Montana
TOM UDALL, New Mexico
_____, _____
Allison C. Binney, Majority Staff Director and Chief Counsel
David A. Mullon Jr., Minority Staff Director and Chief Counsel
C O N T E N T S
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Page
Hearing held on February 5, 2009................................. 1
Statement of Senator Barrasso.................................... 5
Prepared statement........................................... 5
Statement of Senator Dorgan...................................... 1
Prepared statement........................................... 2
Prepared statement of Senator Johnson............................ 6
Witnesses
His Horse Is Thunder, Hon. Ron, Chairman, Standing Rock Sioux
Tribe, Great Plains Tribal Chairman's Association (GPTCA),
Aberdeen Area Tribal Chairman's Health Board (AATCHB).......... 11
Prepared statement........................................... 13
Joseph, Jr., Andrew, Chairperson, Northwest Portland Area Indian
Health Board................................................... 37
Prepared statement........................................... 39
Joseph, Rachel A., Co-Chair, National Steering Committee to
Reauthorize the Indian Health Care Improvement Act............. 17
Prepared statement with attachments.......................... 19
Peercy, Mickey, Executive Director, Health Services, Choctaw
Nation of Oklahoma............................................. 44
Prepared statement........................................... 45
Rambeau, David, President, National Council of Urban Indian
Health......................................................... 30
Prepared statement........................................... 31
Smith, H. Sally, Alaska Representative, National Indian Health
Board.......................................................... 7
Prepared statement........................................... 9
Appendix
Direct Service Tribes Advisory Committee, Resolution............. 59
Engelken, Joseph, Executive Director, Tuba City Regional Health
Care Corporation, prepared statement........................... 57
Response to written questions submitted by Hon. Maria Cantwell
to:
Andrew Joseph, Jr............................................ 69
Rachel A. Joseph............................................. 61
David Rambeau................................................ 67
Response to written questions submitted by Hon. Byron L. Dorgan
to:
Andrew Joseph, Jr............................................ 68
Rachel A. Joseph............................................. 60
Mickey Peercy................................................ 65
David Rambeau................................................ 67
H. Sally Smith............................................... 62
Hon. Ron His Horse Is Thunder................................ 66
Treadwell, Mead, Chair, U.S. Arctic Research Commission, prepared
statement...................................................... 55
ADVANCING INDIAN HEALTH CARE
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THURSDAY, FEBRUARY 5, 2009
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 11:10 a.m. in
room 628, Dirksen Senate Office Building, Hon. Byron L. Dorgan,
Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. BYRON L. DORGAN,
U.S. SENATOR FROM NORTH DAKOTA
The Chairman. We will next turn to the hearing, an
oversight hearing, on the subject of Indian health care.
This issue is not a stranger to this Committee, the subject
of Indian health care. I mentioned when I opened this hearing
that we are doing the Economic Recovery Bill on the floor of
the United States Senate. We had, I think, 13 votes last
evening starting at 6:30. We are going through long traunches
of votes on this particular piece of legislation, and they have
now set 11:45 for another traunch of votes. That would mean
that we don't have to be on the floor right at 11:45, but it
means we have to be there probably very close to 12 o'clock.
They give us about a 15 minute period to get to the Floor.
So I am going to try to move this hearing along, because I
don't want to have a hearing that requires you to wait an hour
and a half to two hours to come back. If you will give us your
cooperation, I would appreciate that.
Let me say this, and I believe I speak for my colleagues on
the Committee, this is, one of the most important issues that
we face. We struggled mightily in the last session of the
Congress, as you know. We passed an Indian Health Care
Improvement Act out of this Committee, and passed it through
the United States Senate. But it did not become law, as it did
not get through the House. I am dedicated, I know my Vice
Chairman is as well, to turn once again to Indian health care.
We have a crisis in Indian health care. We need to address
it and fix it. And we are going to begin immediately to write
new legislation. That is why I have invited those of you who
are going to be at the table to give us your perspective. And
we will keep the record open and ask for submissions of
testimony as well.
I do want to mention my colleague from South Dakota who is
also from the northern Great Plains. We have a sort of a
terrific geographical representation right at the moment with
the three of us. But all three of us are dedicated to
addressing these issues. We will do so aggressively.
[The prepared statement of Senator Dorgan follows:]
Prepared Statement of Hon. Byron L. Dorgan, U.S. Senator from North
Dakota
Today, we will hold an oversight hearing on Advancing Indian Health
Care. The purpose of the hearing is to obtain input from
representatives of Indian Country about how to proceed with reforming
the Indian health care system.
I don't need to tell anyone in this room that the current system is
broken. We all know it is. We have a federal health care system for
Indians that is only funded at about half of its need. Clinician
vacancy rates are high; and misdiagnosis is rampant. Only those with
``life or limb'' emergencies seem to get care. More than 1.9 million
American Indians and Alaskan Natives must ration their health care
services.
The impacts of this system on the Native population are clearly
shown in the health disparity statistics. [Chart 1] As you can see in
Chart 1, the health disparities between the general U.S. population and
American Indians are vast:
Native Americans die of tuberculosis at a rate 510 percent
higher than the general population.
Infant mortality rates for Native Americans are 12 per 1,000
persons compared to 7 per 1,000 persons for the general
population.
Suicide rates are nearly double the general population among
Native Americans.
American Indians die from alcoholism at rates 510 percent
higher than the general population.
The rate of diabetes amongst Native Americans is 189 percent
higher than the general population.
These numbers are appalling and represent Third World conditions
right here in the United States.
So what do we do about it? Well, ten years ago, Indian Country
asked Congress to reauthorize and modernize the Indian Health Care
Improvement Act. This is the primary law that governs the current
Indian health care system. Indian Country even presented Congress with
a draft bill to consider in 1999.
Since then, certain Members of Congress have been trying to get an
Indian Health Care bill passed. Every Chairman of this Committee, since
1999, introduced an Indian Health Care bill. When I became Chairman of
this Committee last Congress, I made passage of an Indian Health Care
bill my number one priority.
In February of 2008, the Senate debated an Indian health care bill
on the floor for the first time in 16 years. The result was passage of
the bill by a vote of 83-10. Regrettably, the House of Representatives
was unable to do the same.
Like many of you in this room, I started the year very optimistic
about finally improving the Indian health care system. I was hopeful
that we would be getting a Secretary of Health and Human Services that
would make reforming Indian health care a priority. The withdrawal of
Tom Daschle as the nominee for Secretary was very disappointing. I
believe that he would have been a great advocate for reforming Indian
health care.
Regardless of who becomes the new Secretary of Health and Human
Services, improving Indian health care will remain a top priority for
this Committee. I am encouraged by the fact that our new Vice Chairman
is a doctor (an orthopedic surgeon). Senator Barrasso comes from a
state with lots of Indians and a large reservation--the Wind River
Indian Reservation. I also believe he serves as a rodeo physician for
the Professional Rodeo Cowboy's Association.
So, I remain optimistic that this Committee will continue to work
in a bi-partisan fashion to address the health care needs of our First
Americans.
I want to end my comments with a reminder of why we work so hard on
this issue. [Chart 2--Ta'shon Rain Littlelight] This is a picture of
Ta'shon Rain Littlelight. She was five-years-old when she died. When
the little girl lost her appetite, began sleeping more, and her
attitude changed, her family took her to the tribal clinic.
Unfortunately, the clinic did not have the testing capabilities or
Contract Health dollars to send her to another facility for testing.
Repeatedly, this beautiful little girl was misdiagnosed with
depression. It was not until it was far too late that doctors found
that cancer had taken over her little body. She lived the last three
months of her life in unmedicated pain. She died in September, 2006.
Ta'shon was not given the chance to have a normal life because of a
terrible disease and an inadequate Indian health care system. She never
had a chance to fulfill her potential. Our First Americans deserve
better than this. We must all work to achieve adequate health care for
families like Ta'shon's.
We stand at the beginning of this Congress with an opportunity to
reevaluate our strategy and plan for improving Indian health care.
Today, I am asking Indian Country to provide us input on how to
move forward. Tribal leaders and tribal advocates are on the ground
every day. We are not asking that Indian Country come up with all of
the solutions, but this Committee would like to hear your
recommendations on how best to move forward.
With that, I turn it over to our new Vice Chairman.
Senator Barrasso?
STATEMENT OF HON. JOHN BARRASSO,
U.S. SENATOR FROM WYOMING
Senator Barrasso. Thank you very much, Mr. Chairman. I look
forward to the new role. I want to thank Senator Murkowski for
her years of commitment and her contributions to this
Committee.
I would also like to make a statement, because I am
pleased, Mr. Chairman, that we are beginning this new Congress
with a hearing on Indian health care. As a physician, I have
worked for two decades to help people stay healthy and to
reduce their medical costs. I know it requires a considerable
amount of coordination and collaboration and innovation and
good data, which is a big part of this. As I have mentioned in
previous hearings, those principles are critical to support and
modernize the Indian health system. I am looking forward to
this hearing today, Mr. Chairman.
I would like to submit the rest of my statement, just to
give more time for our folks today to testify and then we can
get to the questioning, if that is all right with you.
[The prepared statement of Senator Barrasso follows:]
Prepared Statement of Hon. John Barrasso, U.S. Senator from Wyoming
Good Morning, and I'm pleased, Mr. Chairman, that we are beginning
this new Congress with a hearing on Indian health care.
As a physician, I have worked for two decades to help people stay
healthy and reduce their medical costs.
I know it requires a considerable amount of coordination,
collaboration, innovation, and good data.
As I have mentioned in previous hearings, those principles are
critical to support and modernize the Indian health system.
After the many health hearings this Committee has held in previous
Congresses, it appears that reform and modernization are truly needed
but slow in coming.
The rates of disease and, even more tragically, mortality have not
shown an appreciable decline, and that should disturb us all.
On the Wind River Indian reservation in Wyoming, which is the home
of the Eastern Shoshone and Northern Arapaho tribes, the average age of
death was 49 years old.
That is younger than most other Indian communities, which in turn
is younger than the rest of the U.S. populations.
The staff at the Wind River Service Unit do their best in the face
of considerable challenges, but that service unit is the lowest funded
in the Billings Area.
Meanwhile, both the service population and the medical inflation
rate have grown substantially.
Moreover, the Service Unit is housed in a building that is well
over 100 years old and is not scheduled to be included on the IHS
health care facility priority list anytime in the near or distant
future.
These examples are just a few facing the tribes in Wyoming, and I
suspect that they are similar to what other tribes face around the
country.
But what these examples tell us is that we must be diligent and
more efficient with the scarce resources available for Indian health.
There never seems to be enough resources to address all the Indian
health care needs, so it's all the more critical that the scarce
resources that we do have available are not wasted.
However, last fall, we held a hearing on the property management
issues at the HIS. The hearing brought to light instances of millions
of dollars in lost or stolen property.
This is completely unacceptable.
Mr. Chairman, I look forward to working with you to determine
whether we are spending appropriately and efficiently to achieve the
best return from taxpayer dollars.
I welcome your continued efforts at reform, Mr. Chairman. I look
forward to working with you on this significant and important
initiative.
But in doing so, we must also look to the front-line providers in
Indian health for their help and their ideas.
I want to thank all of our witnesses for their participation today
and look forward to their testimony.
The Chairman. Thank you so much.
Senator Johnson, do you have an opening statement, or do
you want to put it in the record?
Senator Johnson. I will just put my statement in the
record, Mr. Chairman.
The Chairman. All right. We will include the full statement
in the record.
[The prepared statement of Senator Johnson follows:]
Prepared Statement of Hon. Tim Johnson, U.S. Senator from South Dakota
Thank you Chairman Dorgan for holding this hearing. For the nine
treaty tribes in my state, for whom the government pledged to provide
adequate health care, the current failures of the Indian health system
are of vital concern. I am glad that this is a priority for the
Committee.
There are dire health care conditions facing American Indians and
Alaska Natives of this country. I have witnessed these conditions first
hand on the Indian reservations in South Dakota, where, sadly, six
reservation counties share the unfortunate distinction of having the
lowest life expectancy in the country. Poor quality and lack of access
to healthcare also negatively impact the quality of life for many
American Indians. My office receives hundreds of calls from
constituents needing help with even the most basic needs that ought to
be met by the Indian Health Service. Some of the most common complaints
involve the Contract Health system and I look forward to working with
the Committee to solve this problem.
As you know, I returned from my own health challenges with a better
appreciation of what individuals and families go through when they face
the hardship of catastrophic health issues. Providing better healthcare
will serve not just American Indians but protect the overall public
health network for my state and the rest of the Country. This is not
just a tribal issue, and it is not charity. This is a moral issue, an
ethical issue, and a legal treaty obligation of this country.
Thank you Mr. Chairman for your leadership and persistence on this
vital issue that affects the lives of so many American Indians in South
Dakota and across Indian Country.
The Chairman. Sally Smith, Alaska Area Representative of
the National Indian Health Board. Sally has done a lot of work
on these issues for a long time. Ron His Horse Is Thunder, the
Chairman of the Aberdeen Area Tribal Chairmen's Health Board,
an Indian leader on so many different issues, and especially
health care. Rachel Joseph, too, so much work for so long, and
all of us look forward to being able to achieve success. Thank
you for your work.
David Rambeau, the President of the National Council of
Urban Indian Health. David, thank you for your considerable
work on these issues. Andy Joseph, the Chair of the Northwest
Portland Area Indian Health Board. And Mickey Peercy, the
Executive Director of health services at Choctaw Nation. Both
of you have, I know, spent a lot of time on these issues.
So thanks to the six of you. We apologize in advance for
the brevity that we must confront today, but we deeply
appreciate you being here. We expect the three of us to be
connected to you in significant ways throughout this Congress.
Working together, we are going to get something done.
Ms. Smith, why don't you proceed?
STATEMENT OF H. SALLY SMITH, ALASKA REPRESENTATIVE, NATIONAL
INDIAN HEALTH BOARD
Ms. Smith. Thank you for inviting the National Indian
Health Board to participate in this discussion to advance
Indian health issues in the new Congress and the Obama
Administration. Thank you, Chairman Dorgan, Vice Chairman
Barrasso, and other members of this Committee.
You have asked us for suggestions on how to manage expected
legislative activity that will impact Indian health, namely,
efforts to reauthorize the Indian Health Care Improvement Act,
the comprehensive health care reform that is a high priority
for the Obama Administration, and a possible deep examination
of the Indian health care delivery system.
We believe each of these efforts will likely proceed on
different tracks and on different time tables. All will in some
way impact how health care is delivered to American Indians and
Alaska Natives. But the separate objectives of each should not
be blurred by attempting to accomplish our goals through only
one over-arching effort.
My first recommendation is that this Committee vigorously
continue to proceed and complete our decade-long effort to
reauthorize and to revitalize the Indian Health Care
Improvement Act. Last year, through your yeoman efforts,
Chairman Dorgan, and our Alaska Senator Murkowski, a
reauthorization was finally debated and approved by the Senate.
We were all disappointed that the House did not complete the
job in 2008, but we are not discouraged. In fact, we have great
hope that our long struggle will bear fruit in the 111th
Congress and that a bill will be approved by both houses and
signed into law by President Obama.
Our ten years of work on this legislation has been
productive. While no legislation is ever perfect, the bill this
Committee brought to the Floor last year was heartily supported
by Indian Country and should serve as a starting point as we
sprint toward the finish line this year.
As you requested, Mr. Chairman, we are taking a fresh look
at tribal requests that we have dropped or scaled back over the
last ten years. We recognize that even if the health care
reform effort and the comprehensive examination of the Indian
health system go forward apace, these activities will take many
years or months to complete. In the meantime, we must continue
to provide health care to our people today, tomorrow and for
next year. We desperately need the new authorities offered by
the Indian Health Care Improvement legislation, particularly
those that will authorize modern methods of health care
delivery. The NIHB urgently requests that Congress finish work
on this bill within the next 90 days.
On behalf of Indian Country, the National Indian Health
Board will be actively involved in the health care reform
effort. We face several challenges in health care reform.
First, our health care delivery system is unique. Second,
reform developers must honor the trust responsibility for
Indian health and take into account the multiple roles played
by tribes in health care delivery as providers, as payors, as
employers and as governments. Reform proposals should support
and strengthen our system. Indian-specific provisions will
likely be needed in order to make a good idea work for us.
Any public or private coverage for the uninsured must
provide an opportunity for American Indians and Alaska Natives
to enroll and to obtain their care through Indian health care
system providers. The chronic under-funding of the Indian
health system must be addressed in the reform context.
With regard to the health care reform, our request to you
is two-fold. First, continue your leadership role on behalf of
the Indian health interests, and second, assure the Indian
Country advocates are integrally involved on all levels of the
debate. It has been more than 50 years since the Indian Health
Service was created. Much has changed in health care delivery
over these decades. Although some improvements in the health
status of Indian people have been marked, our people continue
to suffer disproportionately high health deficiencies and
health status disparities stubbornly persist.
Thus, we can understand why you believe it is time to
critically examine the fundamentals of the Indian health
system. The National Indian Health Board agrees with you. But
it will be a big job. We offer some thoughts on how to proceed
with such an undertaking.
First, find out what Indian people themselves think. Supply
resources to tribes, undertake examinations in a comprehensive
manner. This is vital to assure that tribes know you are
serious.
Seek Indian Country input through regional meetings,
hearings, and even survey mechanisms. Obtain critical analyses
and innovative ideas from experts, especially those skilled in
providing care to under-served populations in remote, rural
areas. Identify what health care is needed, which needs are
being met, which are not, and the most effective ways to
deliver those services.
It is critical to avoid solutions which merely redistribute
existing resources. Our system already suffers from serious
under-funding, and imbalances in the distribution of the scarce
resources we do have. Merely creating new winners and losers is
not reform.
To be meaningful, any real reform must be fueled by new
funding for unmet needs, to correct imbalances and to fully
fund the contract support costs of tribal contractors.
Recognize and encourage improvements in Indian health and
in the health care delivery system brought about by Indian
self-determination contracting. Focus on areas we need
attention. Therefore, long-term care delivered in Indian
communities, prevention efforts, facilities construction and
recruitment and retention of qualified providers. There are
promising practices in Indian Country. Preserve and encourage
them.
We appreciate your leadership and your commitment to the
betterment of the Indian health system. We all share a common
goal: enhancement of the quality of life and health of our
Nation's first citizens.
Thank you so very much. I am available to answer any
questions you may have.
[The prepared statement of Ms. Smith follows:]
Prepared Statement of H. Sally Smith, Alaska Representative, National
Indian Health Board
Introduction
Chairman Dorgan, and Vice-Chairman Barrasso and distinguished
members of the Senate Indian Affairs Committee, I am H. Sally Smith and
I appear today as the Alaska Representative to the National Indian
Health Board (NIHB), and the immediate past Chairman of the Board. \1\
I also serve as Chairman of the Bristol Bay Area Health Corporation in
Alaska. Thank you for inviting the NIHB to participate in the
discussion about how to advance on Indian health issues in the new
Congress and with the new Obama Administration.
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\1\ Established in 1972, the NIHB serves Federally Recognized AI/AN
tribal governments by advocating for the improvement of health care
delivery to AI/ANs, as well as upholding the Federal Government's trust
responsibility to AI/ANs. We strive to advance the level and quality of
health care and the adequacy of funding for health services that are
operated by the IHS, programs operated directly by Tribal Governments,
and other programs. Our Board Members represent each of the twelve
Areas of IHS and are elected at-large by the respective Tribal
Governmental Officials within their Area. The NIHB is the only national
organization solely devoted to the improvement of Indian health care on
behalf of the Tribes.
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The NIHB sees a number of tremendous opportunities for the
advancement of Indian health in the 111th Congress. In fact, some are
already well on their way to enactment--for example, the Indian-
specific provisions included in the State Children's Health Insurance
Program (SCHIP) reauthorization bill and in the American Recovery and
Reinvestment Act. We are grateful that these provisions could be
enacted into law very soon. But these accomplishments represent only
the beginning of what we hope will be achieved in this Congress. The
other major undertakings include:
1. Renew efforts to reauthorize the Indian Health Care
Improvement Act;
2. Undertake comprehensive Health Care Reform spearheaded by
the Obama Administration; and
3. Institute a deep examination of the Indian health care
delivery system.
The NIHB and the Indian health community are ready and eager to
roll up its sleeves to work hard to achieve success on all of these
efforts.
Today I offer suggestions, on behalf of NIHB, on how each of these
efforts should be pursued in order to obtain maximum benefit for the
Indian health system; to faithfully discharge the United States' trust
responsibility to provide American Indians and Alaska Natives (AI/ANs)
with access to high quality health care; and to end the deplorable
disparities in the health status of Indian people.
We must recognize that each of these efforts will necessarily be
pursued on different tracks and on different timetables. All will in
some way impact how health care is delivered to AI/ANs, but the
separate objectives of each should not be blurred by attempting to
accomplish our goals through only one overarching effort. The NIHB
extends its commitment, on behalf of all Tribes, to the achievement of
this goal.
1. Reauthorization of the Indian Health Care Improvement Act
The first recommendation is that this Committee vigorously proceed
to complete our decade-long effort to reauthorize--and revitalize--the
Indian Health Care Improvement Act (IHCIA). Last year, through the
yeoman efforts of you, Chairman Dorgan, and Senator Murkowski, a
reauthorization bill was finally debated and approved by the Senate. We
were all disappointed that the House did not complete the job in 2008,
but we are not discouraged. In fact, we have great hope that the long
struggle to amend and extend the IHCIA will bear fruit in the 111th
Congress and that Indian Country will finally see a bill approved by
both Houses and signed into law by President Obama.
Our ten years of work on this legislation has been productive.
While no legislation is ever perfect, the bill this Committee brought
to the floor last year was heartily supported by Indian Country and
should serve as the starting point as we sprint to the finish line this
year. Mindful that many tribal requests were dropped or scaled back
over the last ten years, you, Mr. Chairman, asked us to take a fresh
look at these topics. The National Tribal Steering Committee commenced
that review this week and will soon recommend whether some provisions
should be reinstated or revised. The NIHB stands ready to advocate for
these recommendations throughout the halls of Congress.
We ask all to recognize that even if the Health Care Reform effort
and the comprehensive examination of the Indian health system go
forward apace, those activities will take many months or years to
complete. In the meantime, we must continue to provide health care to
our people--today, tomorrow, next month and next year. That is why we
desperately need the new authorities offered by IHCIA legislation,
particularly those that will bring to the Indian health system modern
methods of health care delivery such as hospice, long-term care,
assisted living and home- and community-based care, and an integrated
system for comprehensively addressing the behavioral health needs of
Indian youth, families, and communities.
Quickly enacting an IHCIA bill is vital to the forward progress of
the Indian health system. The NIHB urgently requests that Congress
finish work on an IHCIA bill within the next 90 days.
2. Health Care Reform
The NIHB, on behalf of Indian Country, will be actively involved in
the Health Care Reform effort. An AI/AN Health Care Reform Workgroup
has been established by the NIHB to evaluate reform proposals and
determine how the aspects of each would impact the Indian health care
system. We hope the members of this Committee will stand with us in
this effort. We will need your help to reach key policymakers in the
Administration and on Congressional committees of jurisdiction. Indian
Country faces several challenges in Health Care Reform:
The Indian health delivery system is unique and operates
very differently from the mainstream health care system. Thus,
we must constantly educate policymakers to assure that reform
ideas do not inadvertently harm our system which provides
culturally competent care to 1.9 million AI/ANs.
We must also assure that reform developers honor the trust
responsibility for Indian health, and take into account the
multiple roles played by tribes in health care delivery--as
providers, payors, employers and as governments.
We must assure that reform proposals support and strengthen
our system. Achieving this will likely require writing Indian-
specific provisions in order to make a good idea work in the
Indian health context.
Any legislation that expands public or private coverage to
reach the uninsured must include a meaningful opportunity for
all AI/ANs to enroll and to obtain their care through the
Indian health system providers.
The chronic underfunding of the Indian health system must be
addressed in the reform context. But in order to do this in a
meaningful way, new permanent mechanisms must be designed that
protect the Indian health system from the ups and downs of
budget development.
The recent development of economic stimulus legislation encourages
us that Indian Country's interests are being taken seriously. Members
of this Committee and other Congressional leaders involved in
development of that legislation actively undertook to assure that our
needs were not overlooked. In fact, in response to advocacy from Indian
Country, the legislation targets significant funding for job creation
and infrastructure development to bolster poor Indian economies.
We are gratified by this attention and want to build on it during
the Health Care Reform debate. We must vigorously work toward achieving
high visibility for Indian health concerns as well. In order to assure
that reform proposals avoid damage to our system and actually
strengthen it, we need a seat at the table where reform ideas are
developed. Indian Country cannot afford to be consulted only after the
decisions have been made.
Thus, with regard to Health Care Reform our request to you is two-
fold: Continue your leadership role on behalf of Indian health
interests and assure that Indian Country advocates are integrally
involved in all levels of the debate.
3. Critical and Thorough Examination of the Indian Health System
It has been more than fifty years since the Indian Health Service
was created, and more than thirty years since the original IHCIA
directed how health care should be delivered to AI/AN beneficiaries.
Much has changed in health care delivery over those decades. Although
some improvements in the health status of Indian people have been
marked, our people continue to suffer disproportionately high health
deficiencies and health status disparities stubbornly persist.
Thus, we can understand why you, Chairman Dorgan, and other
Senators believe it is time to critically examine the fundamentals of
the IHS system, to identify what's working and what's not, and to
design structural reforms. The NIHB agrees with you.
Undertaking such a deep examination is an enormous task, but is
well worth the effort. It will take a willingness to address hard
questions, require contributions of experts from within and outside the
system, demand innovative ideas, and necessitate a commitment to see
the job through to completion.
The NIHB offers some thoughts on how to proceed with such an
undertaking:
Find out what Indian people themselves think--health care
consumers, health care providers, and tribal leaders. Supply
resources to tribes to undertake these examination and analysis
in a comprehensive manner. This is vital to assure that tribes
know you are serious.
Seek Indian Country input through regional meetings,
hearings, even survey mechanisms and other methods.
Obtain critical analyses of our system and innovative ideas
from experts, both inside and outside of Indian Country, in the
field of health care delivery, especially those skilled in
providing efficient and effective care to underserved
populations in rural, remote areas.
Identify what health care is needed, which needs are being
met, which are not, and the most effective ways to deliver
services.
Avoid ``solutions'' which merely redistribute existing
resources. Our system already suffers from serious underfunding
and imbalances in the distribution of the scarce resources we
do have. Merely creating new winners and losers is not
``reform''.
To be meaningful, any real reform must be fueled by new
funding for unmet needs, to correct imbalances and to fully
fund the contract support costs of tribal contractors.
Recognize the improvements in Indian health and in the
health care delivery system brought about by Indian self-
determination contracting. Any changes made to the Indian
health system should encourage and facilitate exercise of self-
determination rights whenever any tribe seeks to use these
rights.
Focus in particular on areas we know need attention: long-
term care services delivered in Indian communities, prevention,
facilities, and recruitment/retention of qualified providers.
Remember that there are promising practices in Indian
Country. With the long list of what is needed to improve the
Indian health system, it can be difficult to remember that
there are tribes, clinics and hospitals providing noteworthy
care and improving the lives of AI/AN across the country. These
need to be showcased and honored in any new system.
Conclusion
The NIHB On behalf of the National Indian Health Board, I thank you
for the opportunity to present testimony on how to advance Indian
health care. The NIHB recommends: renew efforts to reauthorize the
Indian Health Care Improvement Act; undertake comprehensive Health Care
Reform; and institute a deep examination of the Indian health care
delivery system.
We appreciate your leadership and your commitment to the betterment
of the Indian health system. We all share a common goal: enhancement of
the quality of life and health for our Nation's first citizens.
I am available to answer any questions the Committee might have.
The Chairman. Ms. Smith, thank you very much.
We have a tradition of allowing five minutes for witnesses,
and you were five minutes right on the dot. Congratulations.
[Laughter, applause.]
The Chairman. Chairman His Horse Is Thunder.
STATEMENT OF HON. RON HIS HORSE IS THUNDER,
CHAIRMAN, STANDING ROCK SIOUX TRIBE, GREAT PLAINS TRIBAL
CHAIRMAN'S ASSOCIATION (GPTCA), ABERDEEN AREA TRIBAL CHAIRMAN'S
HEALTH BOARD (AATCHB)
Mr. His Horse Is Thunder. Thank you, Mr. Chairman, members
of the Committee.
I have been known to take more than five minutes, but I
will try to make this brief. I want to thank you for inviting
us, and for all your support and effort in trying to take care
of Indian health care in this Country.
The question that was posed to me was this: how do we
proceed forward? I know that S. 1200 went forward relatively
quickly last year in the Senate and of course, got stopped in
the House side. We didn't see any movement. Therefore, we are
here today trying to figure out how best to proceed.
Great Plains Aberdeen Area Tribal Chairman's Health Board,
of which I am the chairman, would ask that that we not, we not,
reintroduce the current bill as it now stands. We think that
there are a number of amendments that need to take place before
it goes forward.
And we would ask that you secure through hearings or other
mean tribal elected leaders' support. We believe that this is a
great framework, S. 1200 was a great framework. It had some
provisions in it which we find objectionable, and I will try to
run through those as fast as possible.
One of the areas that we object to is that we don't believe
it upholds necessary tribal sovereignty, that truly, there
should be a government-to-government, there has been
established a government-to-government relationship, and we
think that needs to be upheld. We think there are a number of
areas that go against the tribal sovereignty, if you will, or
tribes' sovereign status. One of those things is the idea of
enrollment and eligibility issues, that tribes themselves
should be the ones who determine who are members. That is one.
Another area which we have concern with is the proposed
sliding fee scale for services, in other words, charging your
own members for services. We believe that those are services
that were promised to us for giving up many acres of our own
land. So we are opposed to any sliding fee.
We understand that because of the lack of appropriations or
adequately appropriations that some of the tribes are taking a
look at innovative ways in how to improve or deliver more
services to their people. However, that is a funding issue. If
Congress would fully fund Indian health care in this Country,
those types of initiatives which go against what we believe are
treaty obligations wouldn't be necessary. So we are opposed to
anything that talks about a sliding fee scale.
One of the other areas that we have a problem with is
regional distribution, that it pits one region against the
other. So we would like to have that looked at.
There are other areas, and they are in my written
testimony, so I won't go through every one of them. Suffice it
to say that the Great Plains is opposed to having the bill
introduced as it was, and we need to take a look at some
technical amendments to it. We would ask that tribal leaders be
the ones who will respond to the technical amendments.
We understand that there are many health organizations out
there, and they have done a great job at having input into what
should be the content of this bill. However, as tribal leaders,
we need to look at not only just health care issues, but how
health care issues affect all the tribes, especially with the
ideal, again, and I reiterate the point of tribal enrollment,
that we as elected tribal leaders, and I must emphasize that
point, elected tribal leaders must have input into these
issues. Not every health care professional, not every health
care organization out there has to take a look at all the gamut
or ranges of issues that tribal leaders must look at. They look
at specifically health care issues, and they have done a good
job at that.
However, we as tribal leaders, elected tribal leaders, have
some issues with some of the content. Therefore, we would ask
that future amendments to the bill, and the bill again is a
good framework, but future amendments be primarily led by
tribal leaders. Again, we must take a look, we as tribal
leaders have to protect our tribal sovereignty. There are other
issues that we must take a look at as tribal leaders that
health care professionals don't necessarily have to look at.
They do a good job providing health care for us.
With that said, there are two other areas that I think do
need some thought. Besides funding health care, actual
services, we also need to take a look at training for health
care professionals. I think the tribal colleges are a good
start at that. They have the ability to train our people, and
those people they train stay in our communities. Other
programs, such as the Quinton Burdick program that is primarily
at UND is a good way of getting health professionals into the
field, and we think those programs need to be emphasized.
Likewise, because of the lack of funding, many tribes do
not now contract for services. In our Aberdeen area, we only
contract for 25 percent of the services. We probably would
contract for more of the services, but because of the lack of
contract support dollars, we are not allowed to go beyond the
25 percent we are now at. Likewise, it reduces the amount of
services that we can provide for our people, because we have to
dip into the funding to take care of the indirect costs that
are associated with running 638 programs. We would like to ask
for full funding for contract support services.
I see my time is up. Thank you very much, Mr. Chairman.
[The prepared statement of Mr. His Horse Is Thunder
follows:]
Prepared Statement of Hon. Ron His Horse Is Thunder, Chairman, Standing
Rock Sioux Tribe, Great Plains Tribal Chairman's Association (GPTCA),
Aberdeen Area Tribal Chairman's Health Board (AATCHB)
Introduction
Mr. Chairman and other Members of the Committee, we thank you for
your hard work to ensure that the appropriate authority and funding for
healthcare services is available to meet the needs of the 17 Tribal
Nations of the Great Plains. I am Ron His Horse Is Thunder, Chairman of
the Standing Rock Sioux Tribe of South Dakota, and Chairman of the
GPTCA and AATCHB--an Association of seventeen Sovereign Indian Tribes
in the four-state region of SD, ND, NE and IA. The Great Plains Tribal
Chairman's Association is founded on the principles of unity and
cooperation to promote the common interests of the Sovereign Tribes and
Nations and their Members of the Great Plains.
Great Plains Region
The GPTCA stands on the Fort Laramie Treaty of 1868 (15 Stats. 635)
Articles V and IX that guaranteed that the United States will provide
services at the local level to our people and reimburse the Tribes for
any services lost. It was clearly understood by the Indian signers of
that Treaty that necessary assistance would be provided to the
signatory Tribes by a local agent (or Superintendent or Director of
Indian Health in the modern era) and that sufficient resources would be
made available to the agent to allow him to discharge the duties
assigned to him. Indian Healthcare is a Treaty fulfillment which our
Tribal people take very seriously.
The Great Plains Region, aka Aberdeen Area Indian Health Care has
18 IHS and Tribally managed service units. We are the largest Land
based area served of all the Regions with land holdings of Reservation
Trust Land of over 11 Million acres. There are 17 Federally Recognized
Tribes with an estimated enrolled membership of 150,000. To serve the
healthcare needs of the Great Plains there are 7 IHS Hospitals, 9
Health Centers operated by IHS and 5 Tribally operated Health Centers.
There are 7 Health Stations under IHS and 7 Tribal Health Stations.
There is one Residential Treatment Center and 2 Urban Health Clinics.
The Tribes of the Great Plains are greatly underserved by the IHS and
other federal agencies with the IHS Budget decreasing in FY 2008 over
the FY 2007 amount. This is in spite of increased populations and need.
The GPTCA/AATCHB is committed to a strengthening comprehensive public
healthcare and direct healthcare systems for our enrolled members.
Health Data and Overview
As documented in many Reports, the Tribes in the Great Plains
region suffer from among the worst health disparities in the Nation,
including several-fold greater rates of death from numerous causes,
including diabetes, alcoholism, suicide and infant mortality. For
example, the National Infant Mortality Rate is about 6.9 per 1,000 live
births, and it is over 14 per 1,000 live births in the Aberdeen Area of
the Indian Health Service--more than double the National rate. The life
expectancy for our Area is 66.8 years--more than 10 years less than the
National life expectancy, and the lowest in the Indian Health Service
(IHS) population. Leading causes of death in our Area include heart
disease, cancer, unintentional injuries, diabetes and liver disease.
While these numbers are heart-breaking to us, as Tribal leaders, these
causes of death are preventable in most cases. They, therefore,
represent an opportunity to intervene and to improve the health of our
people.
Additional challenges we face, and which add to our health
disparities, include high rates of poverty, lower levels of educational
attainment, and high rates of unemployment. All of these social factors
are embedded within a healthcare system that is severely underfunded.
As you have heard before, per capita expenditures for healthcare under
the Indian Health Service is significantly lower than other federally
funded systems.
In FY 2005, IHS was funded at $2,130 per person per year. This is
compared to per capita expenditures for Medicare beneficiaries at over
$7,600, Veterans Administration at over $5,200, Medicaid at over $5,000
and the Bureau of Prisons at nearly $4,000. Obviously, our system is
severely underfunded. It is important to note that as Tribal members,
we are the only population in the United States that is born with a
legal right to healthcare. This right is based on treaties in which the
Tribal Nations exchanged land and natural resources for several social
services, including housing, education and healthcare. Tribes view the
Indian Health Service as being the largest pre-paid health plan in
history.
Positives
In spite of significant underfunding, we do have some positive news
in terms of successful programs. The Aberdeen Area Tribal Chairmen's
Health Board operates a Healthy Start program that is funded by the
Health Resources and Services Administration (HRSA). Healthy Start is a
Targeted Case Management program whose goal is to reduce infant
mortality. In recent years, the Infant Mortality Rate for participants
in the Healthy Start program has been about 6.5 per 1,000 live births--
this is lower than the National Infant Mortality Rate of 6.9, and it is
in the population of highest risk pregnancies.
In a critical example of how we have tried to utilize various
federal agency resources to a combined effort, we received a grant of
$1.25 million per year from HRSA to operate sixteen Healthy Start sites
in our Area. Sadly, the $1.25 million for sixteen sites is not enough
funding for all of these sites. This circumstance is driven by the vast
and rural nature of many of our reservations, and the time-intensive
nature of case management services. In the past, we received additional
funds from IHS, to join with the HRSA funds, to operate the Healthy
Start program at full capacity.
Regrettably, IHS is no longer able to contribute additional
resources to this effective and essential program. In a frustrating
cascade effect, we have been told by HRSA that we need to secure an
additional $450,000 from other sources by March 1st, or we will need to
start closing down Healthy Start sites in our region. Mr. Chairman,
Committee Members, which communities should lose Healthy Start sites
due to this funding cutback? Healthy Start is successful in our region
in reducing Infant Mortality. But it will become less successful
without adequate resources. These cutback decisions will lead directly
to more infant deaths.
In another vital step forward, the Health Board operates an
Epidemiology Center that is focused on studying disease patterns in our
Area. We will be addressing the impact of behavioral health issues on
chronic diseases like diabetes and on health generally. We consider our
Epi Center a successful program directly due to its numerous
partnerships and programs. It would be much more successful if we had
adequate resources to improve information technology and electronic
health records.
Issues of the Day
National Health Care Reform should be set up as an umbrella not
straight jacket. Many of the current proposals for full insurance
coverage, tax breaks and regional purchasing cooperatives are not an
easy fit in Indian country or rural American. We would like to see that
Tribal Nations have strong input, beyond those from Indian ``health
experts or organizations''. As you are aware, Tribes have multiple
roles, as other sovereigns, to regulate and provide services, and as
employers. These different roles require careful thought on how a
National plan will impact the Great Plains and other Tribes with
strained resources and broad expanse of territory and population to
protect.
Self-Determination should be viewed as multi-faceted. The current
IHS view of Indian Self Determination is that Tribes must assume 100
percent control of their health programs, under a ``638 compact'' to be
able to enact innovative changes. Self Determination, however, also
means that Tribal Nations can choose not to ``compact'', and can make
major decisions affecting course of their program by using other means
than a ``compact''. There are cooperative agreements and other
``mechanisms'' available to permit Tribes, who are choose to rely on
Federal ``direct service'', to have significant input into their health
programs' policy decisions. (i.e. particular staffing needs for
physical therapist or other specialty care, emphasis on home health
care beyond CHR's).
Core Policy Principles
Government-to-Government is intended to recognize Tribal Nations'
sovereign status. This should not be diminished, whether by the
expansion of governmental treatment to more than federally recognized
Tribes, including non-profits, or by those federal departments who
``listen'' but do not act on Tribal suggestions and concerns.
Enrollment and Eligibility Issues are at the heart of Tribal Nation
sovereignty. Federal efforts to enter into this arena, especially with
a one-size-fits-all approach or side-stepping Tribal internal
proceedings, is a dangerous step. For example, the Cherokee Freedman
dispute should not be a matter attached to any Indian health bill. If
one Tribe wishes to restrict health services to only their enrolled
citizens, then Tribal Citizens who are not served in such a restricted
Tribal community need to be accommodated, through appropriate resource
allocation adjustments in another venue (Tribal, CHS).
Self-Determination Scope. We are aware that some Tribes wish to
impose sliding fees upon their members (Susanville Rancheria decision)
for certain health services. We are opposed to using federal
legislation as way to institute the ``billing of Indians'' for their
health care. Under current federal Indian legal principles, and in
accord with our treaty rights, our Tribal Nations and their citizens
are to receive certain benefits for lands transferred to the United
States. This principle ensures, and the current Indian health care
improvement act has enunciated, that there is no individual Indian
financial liability for health services when the IHS or Tribes bill
such individual Indian's third party resources.
Department of Health and Human Services (DHHS) Wide Application of
Self-Determination. Tribal access to other Departmental programs has
improved. Meaningful consultation can be improved. Improved Tribal
access is very useful in our efforts to complement the IHS health care
delivery system. We need to continue this department-wide agency
resource access, and with more direct Tribal funding and less Tribal
Subordination to State block grants. Programs and resources provided by
other agencies in DHHS, such as HRSA, SAMHSA, CDC and others are
essential components of the Indian Health system, and we need continued
facilitated access to these resources. We have been, overall, pleased
with our Tribal input into the Center for Medicare and Medicaid
Services (CMS) Tribal Technical Advisory Group (TTAG) and recommend
this approach with strong Tribal Nation emphasis, as well as
establishing a strong DHHS level Tribal Affairs office.
Key Program, Resource Issues
Sufficient Resources. What would it take to give the Indian Health
Service (IHS) sufficient resources to address our health needs? The
current appropriation for IHS clinical services is about $3.4 billion.
Our estimated funding percentage based on level of need is
approximately 50-60 percent. In order to bring IHS up to a more
appropriate level of funding, an additional $2 billion for clinical
service would be needed and making our annual appropriation closer to
$5.4 billion. This would be a major increase, but a small one relative
to the $700 billion budget for the Department of Health and Human
Services (DHHS).
We applaud the Committee Chairman and others for pushing for
greater funding in the Economic Stimulus bill, in last Congress's
Global AIDs health bill, in budget reconciliation amendments attempts,
and appropriation increases. We hope that this hearing, our testimony
and others, will assist you in your efforts to continue this good
fight.
Other areas that could function more effectively with full funding
and clearer guidance include:
Contract Health Services (CHS) timely approval (and appeals)
for all priorities, prompt private provider payment, and
assistance to IHS Clients who have found out too late their
healthcare wasn't taken care of by IHS with their bills were
turned over to Creditors;
Transportation Coverage for Patients and Families when a
patient needs private provider care, and Emergency Medical
Transportation improvements (maintenance, gas, equipment);
Access to contemporary Prescription Drugs Formulary to
ensure effective drug treatment to complement direct or private
health care;
Administrative Improvements in Management Accountability in
hiring and placement decisions, in particular; and
Establishing a Direct Service Tribes' (DST) Office within
the Indian Health Service, beyond a cosmetic name change.
Facility Funding. The Committee Chairman, and other Members, are
aware of the great need for inpatient and outpatient facility funding.
However, the Great Plains does not support fragmenting the current
facility funding into regional pots, and by the equal area distribution
of facility amounts. This is simply the reallocation of a small amount
into equally smaller amounts. Such move would leave our large land
based and direct service Tribes with insufficient funds to even do
necessary repairs to aging facilities.
Most of our facilities are old, outdated structures unsuited for
current medical technology and are in need of replacement. The
estimated average age of IHS facilities is about 37 years as compared
to about 9 years in the private sector. We are hoping that numerous
facilities will be funded through the economic stimulus package being
developed as we speak. There are two major facilities on the IHS
``Ready List'' for facilities construction in the Aberdeen Area--the
facility in Rapid City and the facility in Eagle Butte. Unfortunately,
the budget for IHS facilities construction has been significantly
decreased over the last eight years, adding to our disparities, and I
urge you to invest in new facilities in addition to our clinical
services budget.
Specialty Clinics. We have a significant need for expansion into
preventive and specialty chronic care facilities. We also have great
need for Long Term Care services for the elder and disabled population.
Long Term Care is not currently provided by IHS, and access to these
services is simply not available on most of our reservations. With
appropriate funding, we could serve our most vulnerable community
members with adequate Long Term Care. Wellness and diabetes clinics are
examples of preventive or intervention style facilities. We need to
identify processes to expand our workforce and identify other resources
to focus on prevention. We also need to surmount State barriers to
establishing reservation-based facilities which rely on Medicare or
Medicaid.
Catastrophic Funding Needs. As in other populations, our Indian
population is seeing the unfortunate increase in cancer and other
serious illnesses or diseases. The IHS's Catastrophic fund is a good
start but is inadequately funded and has a major coverage gap between
when a patient and service unit can tap into this National fund, and
after it has depleted all of its local funding. This arrangement makes
our local IHS service units reluctant to authorize funding for the
initial treatment of serious diseases. The result is that these
illnesses take root and become fatal when they might have been halted
with early treatment. The Catastrophic Fund needs to be reviewed for
ways of improving this system, to overcome reluctance to spend all
local funds on one severe case.
Veterans Needs. HIS cooperation with Veterans Administration is not
occurring to the depth hoped for. S. 1200 proposed some fixes to this
problem, and should be followed through on, including the IHS authority
to make the VA individual co-payment in order to collect reimbursement
for services rendered to an eligible Indian veteran, when such
authorized service is performed in an IHS or Tribal facility.
Violence Against Women. The Congress enacted the Violence Against
Women's Act, and also incorporated Tribal provisions. These provisions
are a large and important step but, in our implementation efforts, we
have learned that we still face hurdles to helping our Indian women
victims. The IHS funding priorities have excluded the provision for
rape kits, to enable their health professionals to properly document
and assist in these crimes. Nor are the IHS health care professionals,
who have treated our women in these traumatic events, often available
immediately after such assaults to document them to any degree.
This delayed or absent documentation, and delayed treatment,
results in health professionals who are unwilling to testify in court
on their ``findings'' when these are so minimal and unable to meet
court evidentiary standards. This becomes a more dangerous situation
when the perpetrator is a non-Indian assaulting an Indian, as non-
tribal courts are even less willing to consider stand-alone victim
testimony, absent such evidence. Our women are, thus, victimized
several times by:
(1) their initial assault and perpetrator,
(2) the lack of timely and effective treatment,
(3) the dismissal of their complaint, should they find the
strength to do so in absence of supporting documentation, and
(4) the likelihood of reprisal or continued sexual assault.
Your help in this particular issue is strongly sought, for
both adequate agency treatment guidance, sexual assault
funding, and tribal court strengthening.
Summary
We have demonstrated that we can operate successful programs in
spite of under-funding. We have shown that we can utilize complementary
resources to the greatest benefit, and to further our direct health
care delivery system goals.
In closing, we have the opportunity in the new Congress and the new
Administration to address many of the root causes of health disparities
in American Indian communities. We seek to attack, not band-aid, the
terrible disparities that make our population's health status
comparable to a third world country. The above are our initial thoughts
and can be refined as other health care reform initiatives are
identified, and as Tribal Nations continue their own work in this
regard. Thank you, again, for this opportunity and your attention to
these vital matters.
The Chairman. Chairman His Horse Is Thunder, thank you very
much.
Rachel Joseph, thank you very much for being here.
STATEMENT OF RACHEL A. JOSEPH, CO-CHAIR, NATIONAL STEERING
COMMITTEE TO REAUTHORIZE THE INDIAN HEALTH CARE IMPROVEMENT ACT
Ms. Rachel Joseph. Good morning, Chairman Dorgan, Vice
Chairman Barrasso and Senator Johnson. I am Rachel Joseph, Co-
Chair of the National Steering Committee for the
Reauthorization of the Indian Health Care Improvement Act. I
appreciate the opportunity to testify before this Committee to
present views to enhance the delivery of health care.
The following recommendations are made to advance and
improve the health care delivery. Foremost, passage of the
Indian Health Care Improvement Act reauthorization is a vital
component of any health care reform, so that the underlying
authorities for the operation of Indian health systems reflects
21st century health care practices. Since the enactment of the
Indian Health Care Improvement Act in 1976, the health care
delivery system in America has evolved and modernized, while
our system authorities for health care have not kept up.
Secondly, the Indian health care delivery system needs to
be fully funded, especially full funding for contract support
costs and contract health services. Renewal or revitalization
or enhancement, whatever the word may be, should not turn into
code for being told to do more with less.
And finally, the Committee should explore extending health
care coverage to IHS beneficiaries through the Federal
Employees Health Benefit Program or other universal health care
coverage established under any health care reform legislation
that might be enacted.
I would like to report to you that yesterday, the Steering
Committee met for nine hours to grind through six pages of
revisions that we think we needed to address that either were
revised or dropped out since the bill was initially introduced
and that we think that will revitalize and enhance the delivery
of health care. I am also pleased to report that Indian Country
still reflects consensus on the two issues that the Chairman
just raised. We also agree that we should not have language in
there addressing the co-pay issue. And we do not have consensus
on the area distribution funds, so that is not a provision that
we discussed.
We are excited that we think we have an opportunity to
revisit a number of those issues, and we will be getting to you
next week a summary of our nine hour deliberations and the
update of our consensus positions. We appreciate the Chairman
that stood with us, our colleague Chairman Joseph was there for
the whole time as we worked these through and worked to develop
consensus on a number of issues that have been a challenge
through the years.
The travesty in the deplorable health conditions of
American Indians and Alaska Native populations is knowing that
a majority of illnesses and deaths from disease could be
prevented if additional funding and contemporary program
approaches to health care were available to provide a basic
level of care enjoyed by most Americans. Despite treaties and
two centuries of promises, American Indians endure health care
conditions and a level of health care finding that would be
unacceptable to most U.S. citizens.
On behalf of the NSC, I would express appreciation to your
leadership in bringing S. 1200 to the Floor last year, and
securing its passage in the 110th Congress. Although we were
not successful in the House in securing passage of the
companion bill, we believe you raised the awareness again of
our health care needs. We believe the progress resulted in
certain important provisions in Title 2 of that bill being
included in CHIP and in the Reauthorization Act pending, and
the American Recovery and Revitalization Act, the economic
stimulus. The amendments to Social Security will result in
increased access to the enrollment of our populations in CHIP
and Medicaid. We appreciate the Senate and House leadership
including Indian-specific provisions in these important bills
and we respectfully request your continuing support to ensure
these provisions stay in the economic stimulus legislation.
At this Committee's oversight hearing on proposals to
create job stimulus and jobs, and address Indian Country
economies, a question was raised regarding infrastructure needs
to address long-term health care for the elderly. While
infrastructure needs for long-term care such as nursing home is
needed in Indian Country, it is important to clarify that long-
term care authorities in Indian Country do not reflect long-
term care practices available to the general population. We
need to be able to provide hospice care, assisted living, long-
term care, home and community-based services. Indian elders
need to receive care in their homes, through home and
community-based health services programs or in tribal
facilities close to family and friends.
As part of our revitalization and update, I will be
submitting a revised testimony, because after lengthy
discussions yesterday we no longer support the creation of a
study commission. When we initially had the legislation
introduced, we were talking about entitlements, how we would be
entitled. We feel that the timeliness is important, that we be
prepared to engage in the broader health reform discussions
now. We think the $4 million that was scored by CBO could
better be spent to help us do necessary studies now. And we
think that we need to be at the table in the broader discussion
of reform. And that is happening.
On behalf of the National Steering Committee, I
respectfully request that as part of this Committee endeavor to
advance Indian health care, that legislation to reauthorize
Indian health care be introduced as early as possible in this
Congress. We do not want to lose the momentum and all the
progress that we have made in the 110th Congress and during
these long ten years.
We are pleased to support again the reauthorization and we
have reviewed the record of those tribes that have come in and
testified to and provided information to the Obama transition
team that there is still strong support for reauthorization. We
stand ready to assist in any way that we can to advance and
address the health care needs of Indian Country.
Thank you for this opportunity, and I will be happy to
respond to any questions that you might have.
[The prepared statement of Ms. Rachel Joseph follows:]
Prepared Statement of Rachel A. Joseph, Co-Chair, National Steering
Committee to Reauthorize the Indian Health Care Improvement Act
Introduction
Chairman Dorgan, and Vice-Chairman Barrasso, and distinguished
members of the Senate Indian Affairs Committee, I am Rachel Joseph, a
member of the Lone Pine Pauite-Shoshone Tribe of California and Co-
Chair of the National Steering Committee (NSC) for the Reauthorization
of the Indian Health Care Improvement Act (IHCIA). I appreciate the
opportunity to testify before this Committee and present views on the
advancement of Indian health care.
I have served as a Chairperson and Vice Chairperson of the Lone
Pine Pauite-Shoshone Tribe and served ten years on the Board of the
Toiyabe Indian Health Project, a consortium of nine Tribes, in Mono and
Inyo Counties in central California. I represent the California Area on
the Indian Health Service (IHS) National Budget Formulation team and
was elected by the East Central California Tribes to the IHS California
Area Tribal Advisory Committee.
The following recommendations are made to advance and improve the
Indian health care delivery system.
First and foremost, passage of the IHCIA reauthorization is a vital
component of any health care reform so that the underlying authorities
for the operation of the Indian health system reflect 21st century
health care practices.
Secondly, the Indian health care delivery system needs to be fully
funded, and specifically, full funding is needed for contract support
costs (CSC) and contract health services (CHS).
And finally, the Committee should explore extending health care
coverage to IHS beneficiaries through the Federal Employees Health
Benefit Program or through universal health care coverage established
under any health care reform legislation that might be enacted.
Reform of Indian Health Care Necessary to Address Health Care
Disparities in Indian Country
No other segment of the American population is more negatively
affected by health disparities than the American Indians and Alaska
Natives (AI/ANs) population; and, our people suffer disproportionately
higher rates of chronic disease and other illnesses. Thirteen percent
of AI/AN deaths occur in those younger than 25 years of age, a rate
three times higher than the average U.S. population. The U.S.
Commission on Civil Rights reported in 2003 that ``American Indian
youths are twice as likely to commit suicide. . .Native Americans are
630 percent more likely to die from alcoholism, 650 percent more likely
to die from tuberculosis, 318 percent more likely to die from diabetes,
and 204 percent more likely to suffer accidental death compared with
other groups.'' These disparities are largely attributable to a serious
lack of funding sufficient to advance the level and quality of health
services for AI/AN.
A travesty in the deplorable health conditions of AI/AN is knowing
that the vast majority of illnesses and deaths from disease could be
prevented if additional funding and contemporary programmatic
approaches to health care was available to provide a basic level of
care enjoyed by most Americans. It is unfortunate that despite two
centuries of treaties and promises, American Indians endure health
conditions and a level of health care funding that would be
unacceptable to most other U.S. citizens. Over the last thirty years,
progress has been made in reducing the occurrence of infectious
diseases and decreasing the overall mortality rates. However, AI/ANs
still have lower life expectancy than the general population.
Reauthorization of the IHCIA Is a Vital Component of Indian Health Care
Reform
On behalf of the NSC and Indian Country, I want to express our
upmost appreciation for your leadership, in bringing S. 1200 to the
Senate Floor and securing its successful passage in the 110th Congress.
Although we were not successful in obtaining passage of the House
companion bill, the work you did raised the awareness of Indian health
care needs. And, we believe the progress made by this Committee and the
Finance Committee in the 110th resulted in certain important provisions
in Title II of the IHCIA being included in the Children's Health
Insurance Program Reauthorization Act of 2009 and the pending American
Recovery and Reinvestment Act of 2009. The amendments to the Social
Security Act (SSA) \1\ will result in increased access to and
enrollment of American Indians and Alaska Natives (AI/AN) in the CHIP
and Medicaid programs. We appreciate Senate and House leadership
including Indian health specific provisions in these major pieces of
legislation. We respectfully request your continuing support to ensure
these provisions stay in the economic stimulus legislation.
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\1\ The SSA amendments include: grants for outreach and enrollment
of Indian children in CHIP, recognition of Tribal enrollment cards as
Tier 1 documentation for Medicaid citizenship purposes, Medicaid cost-
sharing exemptions for Indians, exemption of Indian trust property and
resources from eligibility and estate recovery act purposes, and
provisions to ensure Indian health participation in Medicaid managed
care programs.
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Our work is never done--the NSC strongly believes reauthorization
of the IHCIA is a vital component in advancing and improving the Indian
health care system. The IHS, Tribal, and urban Indian programs need
modern and updated authorities in order to provide the same
opportunities for health care to Indian people that are standard
practice for the rest of our Country. Legislation to reauthorize the
IHCIA should be introduced early in this 111th Congress and should not
be postponed pending further examination on how to advance Indian
health care.
In 1999, the Director of IHS established the NSC, comprised of
representatives from Tribal governments and national Indian
organizations, for consultation and to provide assistance regarding the
reauthorization of the IHCIA, set to expire in 2000. When the NSC began
its work, the NSC had many options: it could have recommended
reauthorization of current law, plus additional amendments to address
specific health care issues, or it could have presented a concept paper
and let Congressional legislative counsel draft the legislation.
However, since 1992, when the IHCIA was last reauthorized, the Indian
health delivery system changed considerably with the enactment of the
Indian Self-Determination Education and Assistance Act Amendments of
1994, providing the Tribes with more flexibility and empowerment to
operate their health programs. It was important for the NSC to
incorporate the emergence of Tribally-operated programs throughout the
bill. Thus, the NSC drafted proposed legislation, which reflected the
tribal consensus recommendations developed at area, regional and a
national meeting.
For the last ten years, the Senate and House have introduced IHCIA
legislation based on the original bill drafted by the NSC. Throughout
the years, the NSC has continued as an effective tribal committee by
providing advice and ``feedback'' to the Administration and
Congressional committees regarding the IHCIA reauthorization bills.
Although there were ``compromises'' to the bill we still remain
committed to our position that there should be no regression from
current law.
The IHCIA reauthorization is a necessary first step to any reform
of Indian health care because any reform must ensure access to modern
systems of health care. Since the enactment of the IHCIA in 1976, the
health care delivery system in America has evolved and modernized while
the AI/AN system of health care has not kept up. For example,
mainstream American health care is moving out of hospitals and into
people's homes; focus on prevention has been recognized as both a
priority and a treatment; and, coordinating mental health, substance
abuse, domestic violence, and child abuse services into comprehensive
behavioral health programs is now standard practice.
Reauthorization of the IHCIA will facilitate the modernization of
the systems of health care relied upon by 1.8 million AI/ANs. The IHCIA
reauthorization bill authorizes methods of health care delivery for AI/
AN in the same manner already considered standard practice by
``mainstream'' America. Although not an exhaustive list, the following
are some of the provisions that were contained in S. 1200 that, if
enacted, would bring about advancements and improvement in Indian
Country.
Expanded Authorities for Mammography and Other Cancer Screening
We need to expand authorities for the IHS and Tribal programs to
provide mammographies and other cancer screenings, consistent with
recommendations of the United States Preventive Services Task Force.
AI/ANs have the poorest cancer survival rates compared to other
U.S. populations due to genetic risk factors, late detection and lack
of timely access to diagnostic and treatment methods. The cancer
mortality rates for AI/ANs are highest in Alaska and the Northern
Plains. The American Cancer Society statistics indicate that detection
of cancer results in higher survival rates. Providing for preventive
cancer screenings, would improve, and save, the lives of AI/ANs.
New Authorities for Long Term Care
At the Committee's Oversight Hearing on Proposals to Create Jobs
and Stimulate Indian Country Economies, a question was asked regarding
infrastructure needs to address long term care for the elderly. While
infrastructure needs for long term care, such as nursing homes, is
needed in Indian Country, it is important to clarify that long term
care authorities in Indian Country do not reflect long term care
practices available to the general population.
Section 213 of S. 1200 would have provided for the authorization of
IHS and Tribally-operated health systems to provide hospice care,
assisted living, long-term care, and home and community based services.
Indian elders need to receive long term care and related services in
their homes, through home and community based service programs, or in
tribal facilities close to friends and family. We need necessary
authorities to provide long term care and related services to our
elders that are currently available to the general U.S. population.
Expansion of Indian Health Care Delivery Demonstration Projects
We need new authorities to establish convenient care demonstration
projects to provide primary health care, such as urgent services, non-
emergent care services, and preventive services outside the regular
hours of operation of a health care facility. This provision would
enhance the health care delivery options; reducing the need for
contract health services (CHS) and emergency visits.
National Bipartisan Commission
We have consistently recommended a National Bipartisan Commission
on Indian Health Care. During the reauthorization process, our
recommendations have been modified several times and now reflect
general authority for a Commission to study the provision of health
services to Indians and to identify needs of Indian Country by holding
hearings and making funds available for feasibility studies. The
Commission would make recommendations regarding the delivery of health
services to Indians, including such items as eligibility, benefits,
range of services, costs, and the optimal manner on how to provide such
services.
A Commission would provide a mechanism for this Committee to
advance Indian health care by requiring a Commission to study the
health care needs in Indian Country and to identify and make
recommendations to improve the Indian health care delivery system.
Behavioral Health Services
The NSC and Indian Country strongly support authorizing
comprehensive behavioral health programs which reflect tribal values
and emphasize collaboration among alcohol and substance abuse programs,
social service programs and mental health programs. We need to address
all age groups and authorize specific programs for Indian youth,
including suicide prevention, substance abuse and family inclusion.
Enhancements in an IHCIA reauthorization bill needs to facilitate
improvements in the Indian health care delivery system. Health services
need to be delivered in a more efficient and pro active manner that in
the long term will reduce medical costs, will improve the quality of
life of AI/ANs, and more importantly, will save lives of AI/ANs.
On behalf of the NSC, I respectfully request that as part of this
Committee's endeavor to advance Indian Health Care, that legislation to
reauthorize the IHCIA be introduced early in the 111th Congress. Indian
Country does not want to lose the momentum and all of the progress we
made in the 110th Congress. After almost ten years, Tribal consensus in
support of the IHCIA reauthorization remains strong. At Tribal Leader
meetings with President Obama's Transition Team, there was a resounding
appeal for the need to reauthorize the IHCIA. The NSC is committed to
working with this Committee in making recommendations and providing
input to advance the IHCIA reauthorization in the 111th Congress.
Full Funding of the Indian Health Services Is Necessary to Advance the
Health of Indian People
I represent the IHS California Area on the I/T/U Budget Formulation
Workgroup. As part of the budget formulation process, the IHS
established a Level of Need Funded workgroup to measure the proportion
of funding provided to the Indian health system, relative to its actual
need, by comparing healthcare costs for IHS beneficiaries in relation
to beneficiaries of the Federal Employee Health Benefits (FEHB) plan.
This method uses actuarial methods that control for age, sex, and
health status. In 2002, per capita healthcare spending totaled $2,130
for AI/ANs, compared to $3,903 in other public sector financing
programs serving the non-elderly population.
It is estimated that the IHS system is funded at less than 60
percent of its total need. To fully fund the clinical and wrap-around
service needs of the Indian healthcare system, the IHS budget would
need an additional $15 billion dollars. This estimate uses standard
economic and actuarial forecasting methods that take into consideration
actual inflation rates to measure growth and inflation. OMB routinely
uses non-medical inflation estimates to calculate budget increases for
the IHS budget which vastly underestimates true healthcare inflation
rates. Applying the Federal Disparities Index (FDI) to estimate the
true health care needs of Indian people corroborates the long-held view
that less than 50 percent of true need is funded by the IHS budget.
In FY08, the IHS appropriations were $3.3 billion--which falls
short of the level of funding that would permit the Indian health
programs to achieve health and health system parity with the majority
of other Americans.
Contract Support Costs Need to be Fully Funded
Contract Support Cost (CSC) funding provides resources to Tribes
and Tribal organizations, that operate health programs under the Indian
Self-Determination and Education Assistance Act, to cover
infrastructure and administrative costs associated with the delivery of
health care services. Approximately 70-80 percent of CSC funding is
used to pay salaries of Tribal health professionals and administrative
staff. Without adequate CSC funding, Tribal health programs are forced
to reduce the levels of health care in order to absorb the
infrastructure and salary costs. In most instances, cutting health care
services is the only alternative to financing these costs. Chronic
under funding has resulted in a substantial shortfall of CSC funding in
the amount of $285 million (FY 2009--$132 million and FY 2010--$153
million).
Contract Health Services Need to be Fully Funded
Contract Health Services (CHS) services are provided at private or
public sector facilities or providers based on referrals from the IHS
or tribal CHS program. Due to the severe underfunding of the CHS
program, the IHS and tribal programs must ration health care. Unless
the individual's medical care is Priority Level 1 request for services
that otherwise meet medical priorities are ``deferred'' until funding
is available. Unfortunately, funding does not always become available
and the services are never received. For example, in FY 2007, the IHS
reported 161,750 cases of deferred services. In that same year, the IHS
denied 35,155 requests for services that were not deemed to be within
medical priorities. Using an average outpatient service rate of $1,107,
the IHS estimates that the total amount needed to fund deferred
services, denied services not within medical priorities, and
Catastrophic Health Emergency Fund (CHEF) cases, is $238,032,283. This
estimate also does not capture deferred or denied services from the
majority of tribally operated CHS programs (nearly one-half of all
tribes).
Explore Alternatives for Extending Health Coverage to IHS Beneficiaries
The chronic under funding of the Indian health programs, annual
appropriations for FY 2008 and FY 2009 are at $3.3 billion and
projected level of need funding is estimated at $9 to $15 billion. This
suggests that alternative funding streams and additional health care
coverage is needed to address health care for AI/ANs. The Federal
Government has not lived up to its trust responsibility to provide
health care to Indians--this is evidenced by Indian people suffering
from higher health care disparities than the rest of the U.S.
population.
The current Indian health care delivery system that provides
culturally competent health care to AI/ANs, who reside in the most
remote, isolated and poorest parts of this Country must be retained and
modernized. What is needed is expanded coverage of AI/ANs through
existing health care coverage, such as the Federal Employees Health
Benefits Program (FEHBP). An earlier draft of the IHCIA contained a
provision that would explicitly authorize the Tribes and Tribal
organizations to purchase health care coverage under the FEHBP. The
Committee should consider re-examine this provision and require the
Federal Government to extend coverage to all AI/ANs under the FEHBP.
The IHS, Tribal and urban Indian health care programs would be
designated participating providers of the FEHBP. This would allow the
Indian health programs to bill and receive reimbursements from the
FEHBP to supplement annual appropriations. For services not available
at an IHS or tribal facility, coverage under FEHBP could serve as an
alternate resource for payment of services under the CHS program.
Reauthorization of IHCIA would put in place new services and
authorities in the Indian health system. With better services and
facilities, Indian Country can then participate in discussions about
national health reform which will focus on the financing of available
services from various health systems.
We look forward to working with this Committee to explore how to
advance and improve the Indian health care system. Health care reform
legislation must include Indian-specific provisions to assure that
reform options can work in a self-determination and self-governance
health delivery system. Health care reform must address the chronic
underfunding of the Indian health system and must include full funding
and/or mechanisms to achieve full funding. Renewal should not turn into
code for continuing to be told to do more with less. The Indian health
system (I/T/U) have already proven themselves experts in that. It is
time to give the Indian health system a chance to prove how well it
could work if fully funded.
In closing, it is exciting to be apart of the federal/tribal
partnership and all of us working together can make it better. Thank
you for this opportunity and I will be happy to respond to any
question.
Attachment A
Attachment B
National Indian Health Board--Annual Consumer Conference--September 22-
25, 2008
``Renewing the Indian Health Care System'' by Robert G. McSwain,
Director, Indian Health Service (September 23, 2008) *
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* The text is the basis of Mr. McSwain's oral remarks at the
National Indian Health Board Consumer Conference on Sept. 23, 2008. It
should be used with the understanding that some material may have been
added or omitted during presentation.
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Greetings and welcome to National Indian Health Board's 25th Annual
Consumer Conference. My remarks today will focus on ideas for improving
and renewing the Indian health system. It is not that our system is
``broken'' but that our system needs to able to adapt readily in
response to serious present and future challenges.
Powerful forces have at been at work over the past few decades that
have shaped and changed the face of health care in this country. I am
sure all of you here today are aware of many if not all of these
forces: escalating medical costs; rapid technology advances; the
emergence of chronic health condition as the pervading health issue of
our times; and increased service populations, to name a few.
We are getting set to transition in a new administration. It is a
time of change for the nation and I think it is a time to consider
change in the Indian health system. We need to start positioning
ourselves now to adapt and improve our system to meet the needs of the
future. We want to focus on changing what is not working as well as it
should, while preserving what does works well.
I want to emphasize that nothing has been decided yet. I will
present some ideas we might want to explore, together with our tribal
partners, in order to be ready for the future of Indian health. We
didn't decide just this month to examine our system. We've been
watching and listening for a long time. We heard about both successes
and failures. Some voices we've heard:
From nurses about the national nursing shortage--especially
in critical care.
From doctors about risk of deferred care, recruitment in
crisis, shortages in family practice.
From pharmacists about accelerating drugs costs,
insufficient time to counsel patients.
From patients about denials and losses to creditors because
CHS could not pay bills.
From communities worried about facility closure or desires
for a new facility
From tribal leaders, some who say our system is floundering
and ask us to try something different.
From CEOs who wonder if some sites will remain sustainable
in 5 years.
From employees who are stressed by mounting work and are
concerned about jobs.
From patients who say they can't get appointments and who
ask: ``Why can't IHS pay for care my doctor says I need? ''
From elders about waiting rooms filled with descendants less
connected to the community.
From community members questioning ``Why isn't more done for
kids to preserve their health?'' or ``Why are scarce CHS
dollars spent for chronic alcohol abusers? ''
From business partners who want to work with us, but can't
if we can't pay for their service.
We've been considering what we saw and heard. We have formed some
initial ideas we want to discuss with you. Some of our ideas are pretty
clear. Other ideas are sketchy. You may be able to help clarify or
offer better ideas. We hope to give a fair picture of the condition of
our system so that you may provide well informed ideas of your own. I
think we need to start by examining what works well and what doesn't in
our present system. And a good place to start is by observing the
encouraging signs.
Total healthcare services provided by the Indian health care system
have gradually expanded over decades. Our system serves more American
Indians and Alaska Natives today than ever before. And like medical
trends nationwide, our services have evolved to include less hospital
care and more comprehensive ambulatory care.
Congress has continued to support IHS programs, although major
budget increases in recent decades have been rare. It is worth noting
that our model has a high reputation both within the U.S. and
internationally.
Our programs are geographically spread out and our facilities are
often on or near reservations. Because our model is the only source for
services in many isolated places, this accessibility factor is an
important feature.
A broad spectrum of programs and services are provided that include
medical services to individuals and also public health and
environmental programs that benefit communities.
Our healthcare model is focused on American Indians and Alaska
Natives--their unique needs, cultures, and circumstances. We place a
high importance on respecting traditional beliefs and integrating
traditional healing practices with recent medical science. This has
resulted in a medical environment that is more comfortable and
welcoming to all Indian people.
Our healthcare system has contributed to spectacular health gains
in health status in many ways, especially in establishing access to
primary care services located in the Indian communities, lowering the
high rates of infectious disease, and improving safe water and
community sanitation facilities.
Our programs are operated with a large degree of local autonomy
while sharing administrative and support functions through Area and
national offices. Even more autonomy is achieved through self-
determination, which has been very successful in the Indian health
system, with about half of the IHS budget currently being administered
by Tribes.
Advances in technology, transportation, and communications are
reducing some of the delivery problems linked with isolation.
Innovations in tele-health, remote sensing, and online linkages among
healthcare sites are improving both cost efficiency and quality of
care.
People are a core asset of our model. To put it simply, we have
great people working for us! Their commitment to Indian people and our
mission has been extraordinary even under stressful and trying
conditions. One important aspect of our workforce is that it is
predominantly Indian--71 percent of our entire workforce is Indian, and
the percentage of American Indians and Alaska Natives in our medical
professions continues to rise.
Turning our attention from encouraging to troubling signs: Many
sites through out our system are experiencing difficulties making
financial ends meet. Financial troubles are, of course, prevalent
throughout healthcare in the U.S. But the immediate consequences to
Indian people are more pressing because many Indian people have few
fall-back options. Couple this with an ever-increasing service
population and drastic inflation in medical costs, and you have a
severely strained system. The results of this can be as drastic as
temporary shut-downs of facilities and cut-backs in services.
Payments are strictly limited by law to available CHS funds, which
results in thousands of patient referrals without any source of
payment. CHS funds regularly run out before year end. This produces
hardships for patients and undermines relationships with hospitals and
other providers.
At many sites in our system, essential services are unavailable. If
available, limited staff, equipment, and facility space often result in
deferring services. These deficiencies contribute to backlogs that
result in more severe health problems over the long run. And the
inequity of services across the system is an issue that needs to be
addressed.
Another troubling sign: clinic space and equipment use in our
facilities are often strained beyond capacity, especially in ambulatory
care. The space for exam and treatment rooms, staffing, equipment,
etc., are especially limited in ambulatory settings. Our overall space
configuration was created in an era when hospital admissions were the
norm, which is a mismatch for the high-volume ambulatory care practices
of today.
Recruitment and retention of a highly skilled medical workforce has
always been challenging due to geographically dispersed and remote
sites. We simply cannot fulfill our mission without them, so we need to
find ways to remove barriers and increase incentives for hiring and
retention of qualified professionals.
Strained relations with partners outside our model are rising. Some
are a legacy of racial and community tensions. But other strains are
directly related to referrals without means of payment.
Although we strive to serve any Indian person who seeks services
without regard to tribal affiliation, the shear volume of demand and
the incapacity to meet it have forced some Tribes to reconsider whom
they can serve.
Other troubling signs are more directly health-related. Rates of
obesity and problems linked to lifestyle are epidemic in America. Too
often such problems are more pronounced among Indian people. These
trends point to grim prospects for declining health and even greater
demands on our already over-extended healthcare system.
Perhaps the most troubling sign is that the overall health status
of Indian people remains below that for most Americans, and in some
places that gap appears posed to widen further. Recent studies have
detected rising rates of diabetes, heart disease, and cancer among
Indian people, which are almost certainly related to changing
lifestyles and environments. For decades, significant advances in
raising health status have been documented in our statistics. Now it is
clear our model is no longer producing the big gains it once did,
largely because of the shift in health problems from infectious disease
and sanitation control patterns to lifestyle-related chronic
conditions.
We have just examined some of the strengths and weaknesses of our
present health care system. We now turn to some ideas for renewing this
system, which I hope we can consider together as we prepare ourselves
and our health care model for a historic transition period. Please
realize that we are not considering a dismantling of the present
system, but a variety of ideas for renewing and strengthening it.
It is important to keep in mind that both tribal and federal sites
experience the conditions and forces that we have discussed, often in
tandem. Equally important, Self-Determination law recognizes that
tribally-operated sites may respond to these conditions differently
than the IHS may respond. We encourage all Tribes to fully consider all
the ideas for renewal. Self-Determination allows tribal sites to choose
to participate or not participate. Participation by tribal partners in
renewing and adapting our system is welcomed but not required.
This partnership effort will also include the active participation
of patients with the entire health system as we renew our common vision
for a patient-centered, compassionate, comprehensive, and culturally
appropriate model of health care. Before we talk about some ideas for
renewal, we need to restate some essential principles and goals that
may guide us in thinking about these ideas. These include:
Securing a healthcare system for Indian people that fulfills
our mission, goal, and foundation;
Strengthening our core model of a community-oriented primary
care;
Transforming but not diminishing services;
Equalizing access to healthcare services;
Seeking consultation on policies that affect Indian people;
and
Honoring tribal choice.
The future of our health system requires continuing evolution and
adaptation to historic and emerging health challenges. Before
discussing new ideas, it is important to acknowledge renewal efforts
that are already underway and making impressive progress.
Many individual sites in our system have launched efforts to more
successfully adapt clinical and administrative operations to local
conditions. I endorse these important, often innovative, efforts. For
instance, pilot projects underway in the ``Chronic Care Initiative''
are producing some exciting results. I will not offer more details on
these locally driven efforts this morning, but much more information is
available upon request.
Rather, I will focus the balance of my talk on ideas for renewal of
our system as a whole, for as we have seen, many of the forces that
stress individual sites go well beyond local boundaries. Even sites
with the most favorable local conditions can not effectively address
all of these issues. That is why it is timely for all of us to have a
national dialogue about the whole Indian health care system.
The patient is at the center of our ideas for renewal. The key idea
is a package of services that surrounds every patient. This concept,
which is based on the Indian health system already in place now,
includes:
Core services--Community oriented primary care is the
central core of the service package. Core services should be
accessible in or near Indian communities to maximize their
effectiveness. We think primary prevention services should have
highest priority because we see them as providing the greatest
contributions to improved health status for the entire Indian
population now and in the future. The core package combines
primary care services that are focused on individuals with
essential public health programs that are focused on the
community.
Intermediate and advanced medical services for individuals
would be delivered through regional/in-network referral
facilities that can provide high quality care efficiently. Most
advanced services would be purchased.
A closely connected idea is an integrated delivery system in which
each type of service is provided in manner that is most efficient and
effective.
Core primary care services should be broadly available and
accessible in or near Indian communities. This includes routine
ambulatory, screening, diagnostic, and treatment services; basic
preventive care; covered prescription medications; some dental
services; and some mental health and substance abuse services. Much of
the success of our model can be linked to these types of services.
These services usually would be delivered in a Monday-Friday clinic in
or near the community.
Intermediate services include 24/7 inpatient professional services,
advanced ambulatory screening, diagnostic and treatment services,
vision, hearing, PT, orthopedic, and both noncomplex ambulatory and
inpatient surgery. Intermediate services would be provided through an
interlocking network of centers that accept and support the core
community sites.
Advanced services such as highly specialized diagnostic, surgical,
and treatment services include transplants and sophisticated surgery.
These would usually be purchased from centers of excellence to the
extent that funding allows, or in some cases maybe obtained from in-
network medical centers.
We have a firm idea of the overall integrated framework, which
builds on and extends successful features of our present system, but
there are many details that require study:
Timing--Even though this integrated concept builds on our
present model, we realize this involves transformation of
frontline sites as well as behind the scenes support systems.
This is not a quick fix. We think it will take a long time to
fully achieve.
Thresholds for facilities--As we try to enhance community
access to core services, we also need to consider costs when
establishing community size thresholds for core sites and we
need to consider realistic and practical groupings for referral
networks.
HFPS--we need to see if the Health Facilities Priority
System is aligned with this framework.
Resource Formula--We may need to align budget and resource
allocation formulas.
Reimbursement--We think that spreading costs of secondary
services through a referral system offers significant gains in
efficiency and quality. But we will need a way to fairly
reimburse the in-network referral centers for costs.
Conversion Costs--We know there will be one-time costs for
converting. We must estimate conversion costs and options.
Infrastructure--These costs may include investments in
infrastructure such as Electronic Health Record, beneficiary
ID, communications and transport capacity, etc.
For the integrated model to function coherently and fairly, CHS
funded services and policies should be aligned to fit. One challenge
involves authorization policies known as CHS medical priorities. CHS
funds could be used to fill some gaps in core services to promote wider
and more consistent availability of primary care services. Currently,
the CHS policy prioritizes urgent medical treatment over primary and
prevention services.
Eligibility rules differ for CHS and direct care. We think
eligibility should be consistent for both. We need to decide if the
uniform eligibility should follow the CHS model, the Direct Services
model, or some other. CHS funds have long been treated as fixed,
immovable, and tied to sites. There is no inherent reason to bind CHS
funds to particular sites, particularly as we move towards a more
integrated, mutually supporting network. We should consider aligning
CHS management, authorization policies, and funds within the integrated
framework. This could involve aligning some CHS funds within core
community sites to plug gaps in primary and preventive services and
align other CHS funds at a regional (or Area) level for intermediate
and advanced services. Some issues that need to be addressed include:
Integrating Services--The implications and impacts of an
integrated service package on the CHS medical priorities must
be considered as well as affects on present CHS users.
Balancing Priorities--While everyone can support the idea of
expanding availability and access to core primary services, if
CHS spending on core services reduces funds for urgent care,
some people may find such a tradeoff disturbing. We will need
to thoroughly consult on this complex ethical issue.
Eligibility--We need more exact numbers for unifying direct
services eligibility rules and CHS eligibility rules. Roughly,
250,000 persons are direct service users in our present system
who are not CHS eligible. Most of these reside in cities and
counties adjacent to reservations but are not members of the
local Tribes.
Budget--We also need to forecast budget implications for the
eligibility unification options. Expanding CHS eligibility
could create addition funding needs.
Management Options--Realigning management of CHS to reflect
an integrated layered delivery system has logical appeal, but
we have not yet explored operational implications. It should be
noted that a previous attempt to apply CHS uniformly for an
entire state (Arizona) could not be fully implemented because
of insufficient funding.
The future of our health system requires continuing evolution and
adaptation to historic and emerging health challenges. Our vision is to
work in partnership with tribal governments; Indian people; and
federal, state, and local governments to respond in every way possible
to preserve and improve our health system for future generations of
Indian people.
The Chairman. Ms. Joseph, thank you very much.
Next we will hear from David Rambeau.
STATEMENT OF DAVID RAMBEAU, PRESIDENT, NATIONAL COUNCIL OF
URBAN INDIAN HEALTH
Mr. Rambeau. Good morning, Mr. Chairman and members of the
Committee.
My name, as stated, is Dave Rambeau. I am a member of the
Paiute Tribe of California. I am also the Executive Director
for United American Indian Involvement, the urban program in
Los Angeles.
As many of you are aware, Los Angeles has the largest
population of off-reservation Indians living in any one
particular county. We have, for those who indicated in the last
Census as single race, American Indian, we have 90,000 Indians
that live in our service area. Those who indicated multiple
race, we have 150,000 Indians that live within the L.A. County
area.
On behalf of the National Council on Urban Indian Health,
our 36 member clinics throughout the United States, urban
clinics, and the 150,000 American Indian and Alaska Native
patients that we serve annually, I would like to thank the
Senate Committee on Indian Affairs for the opportunity to
testify on advancing Indian health care.
As we enter into not only a new Congress but also a new
Administration, it is critically important that reforming and
improving the health care system for American Indians remains a
high priority. I would like to thank Chairman Dorgan and
Senator Murkowski and indeed, the entire Committee for all the
hard work that they have done on behalf of the Indian people
and the Indian health care system.
It is my hope that in the new Congress, that we can move
forward on the critical issues facing the Indian health care
system, and that immediate attention be given to passing the
Indian Health Care Improvement Act as soon as possible, as
stated, within the next 90 days if at all possible. I am
particularly honored and grateful to be able to present
testimony for the nearly one million Indian people living in
urban centers. Congress has repeatedly stated that the trust
responsibility to provide health care extends to American
Indians regardless of where they reside. This is an historical
mandate by Congress over the many years that the Federal
Government has been managing the affairs of Indian people,
starting from right after the Revolutionary War.
Congress has repeatedly stated that the trust
responsibility is to provide health care to American Indians
regardless of where they reside. Indian Health Service
estimates that roughly 930,000 of American Indians and Native
Alaskans are living in the urban locations and are eligible for
services at the Urban Indian Health Programs and clinics.
The people who live in the urban settings historically is a
situation that started, like I said, right after the Civil War,
when they started deciding what to do with the Indian problem.
Those of us who live in urban settings are there because of
many reasons which includes jobs, lack of jobs on our
reservations, education and the need to progress and the need
for survival in many cases. We are people of the reservations.
I am a person that is enrolled in my reservation and I do visit
the reservation quite frequently and I am involved with the
business of my reservation. As people living in urban centers,
we realize that we need to be part of the system that provides
health care and other services to the Indian people. We support
the National Indian Health Board's efforts to provide better
care for all Indians throughout the United States.
My time is running out. I am letting it run out. Thank you.
[Laughter.]
The Chairman. Mr. Rambeau, we don't run anybody out.
[Laughter.]
The Chairman. We appreciate very much your testimony.
Mr. Rambeau. It is like the last football game, the last 20
seconds you have to let run out.
[Laughter.]
The Chairman. It is called the two-minute drill, by the
way.
[The prepared statement of Mr. Rambeau follows:]
Prepared Statement of David Rambeau, President, National Council of
Urban Indian Health
Introduction
Honorable Chairman and Committee Members, my name is David Rambeau.
I am the president of the National Council of Urban Indian Health and
the Executive Director of the United American Indian Involvement in Los
Angeles California. On behalf of the NCUIH, our 36 member clinics, and
the 150,000 American Indian/Alaska Native patients that we serve
annually, I would like to thank the Senate Committee on Indian Affairs
for this opportunity to testify on ``Advancing Indian Health Care.'' As
we enter into not only a new Congress but also a new Administration it
is critically important that reforming and improving the health care
delivery system for Native Americans remains a high priority. I would
like to thank Senator Dorgan, Senator Murkowski, and indeed the entire
Senate Committee on Indian Affairs for all of their hard work on behalf
of Indian health. It is my hope that in this new Congress that we can
move forward on the critical issues facing the I/T/U system.
I am particularly honored and grateful to be able to present
testimony for the nearly one million urban Indians. Congress has
repeatedly stated that the trust responsibility to provide health care
extends to Native Americans regardless of where they reside. The 2000
Census reported that over 60 percent of American Indians and Alaska
Natives reside in urban centers and IHS estimates that roughly 930,000
of those living in those locations are eligible for services at Urban
Indian Health Clinics. Our clinics are often the main, if not sole,
source of health care for those communities. It is a small, but
critical component in Native healthcare.
The UIHP provides an important link between reservations and urban
centers as Native people move between the two. As one Federal court has
noted, the ``patterns of cross or circular migration on and off the
reservations make it misleading to suggest that reservations and urban
Indians are two well-defined groups.'' \1\ Reservation and urban health
services are deeply interconnected as we serve the same people and
desire the best possible health outcomes for all Native peoples. The I/
T/U system is precisely that, and integrated system serving the same
group of patients as those patients move between their reservation
homes and urban centers depending upon the demands of their lives. If
one part of the system is damaged or performing poorly the entire
system suffers, and more importantly the vulnerable patients who are
dependent upon this system suffer.
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\1\ United States v. Raszkiewicz, 169 F.3d 459, 465 (7th Cir.
1999).
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It is critical that the Indian Health Care Improvement Act is
passed this Congress in order to modernize and restore the I/T/U
system; moreover, the entire I/T/U system must be fully funded from
contract health to the Urban Indian Health Program. While NCUIH feels
that Indian health organizations must be included in the larger debate
around health care reform--and indeed Indian health providers have many
sound suggestions for overall system reform--passing the Indian Health
Care Improvement Act must be the priority for the 111th Congress. It
has been over a decade since this important piece of legislation has
been last reauthorized. While the Indian health delivery system
certainly needs critical examination, that examination cannot come at
the expense of passing the Indian Health Care Improvement Act.
Today I would like to offer suggestions and examples on the behalf
of the Urban Indian Health Program, on how we can not only move forward
with the Indian Health Care Improvement Act, but advance Indian health
care in the context of comprehensive health care reform. We believe
that the Indian Health Care Improvement Act is not the final say of
health care reform for Indian people, but the first step in a larger
discussion.
State of the Urban Indian Health Organization
I would like to give the Committee a brief overview of the
incredible work that the clinics and programs of the UIHP have been
doing. Despite the great obstacles facing them, urban Indian health
organizations have had many great successes with both individual
patients and in raising the entire wellness of the community. Many
clinics are leaders in innovative health care delivery and community
based medicine. UIHP clinics and programs are also seeing impressive
health outcomes through the integration of traditional medicine
practices with western medicine.
NCUIH firmly believes that health care reform must involve reform
of the health care delivery system in the United States, not just
reform of the insurance market. NCUIH feels that the Urban Indian
Organizations and, indeed all Indian health programs, can be examples
of how to reform health delivery in order to address health
disparities. Urban Indian health organizations are particularly
sensitive to changes in the general health care system as, due to their
structure, they are far more integrated in state and local level health
care systems. NCUIH, therefore, has been much more closely involved in
state level health care reform initiatives and believes Indian health
organizations have many areas where they could be leaders in changing
how the general population conceives health care delivery.
Innovative Health Care Delivery: Urban Indian Organizations excel
at developing innovative, culturally competent, efficient health care
methods. Providing comprehensive care to Native Americans requires re-
conceptualizing many western medical health delivery models in order to
ensure that effective care is actually being provided. Cultural
barriers for Native American patients, along with fiscal barriers, are
the biggest continuing drivers of health disparities for American
Indians and Alaska Natives living in urban centers. NCUIH strongly
advocates for the aggressive reform of the current general health care
delivery because the current delivery system fails to address soaring
health disparities, chronic disease, and fails to provide preventative
health services. The following examples are areas where the urban
Indian health organizations are leading in innovation, and their lead
should be followed in reforming the general health care delivery
system.
NCUIH is working with the Urban Indian Organizations to develop a
database to collect the best practices and disseminate them to not only
other Urban Indian Organizations, but to any interested Indian health
organizations. Often times Urban Indian health organizations are quiet
leaders in innovative health delivery, but have not been able to
adequately disseminate their successes due to their small size. Many
Indian health organizations have developed best practices that are only
now being identified and employed by the general health delivery
system. If better communication between providers within the I/T/U
system were available, and better communication between the Native
health system and the general health system were also available, many
of these models of care would have been disseminated much earlier.
Medical Home Model of Care: Long before the general health
policy community coalesced behind the medical home mode of care
\2\ the Urban Indian health organizations have been employing
that theory of care. The American Academy of Family Physicians
has called the patient-centered medical home model one of the
single most powerful methods of eliminating racial and ethnic
disparities in health care quality and access while improving
care and management of chronic conditions for all patients. \3\
NARA of the Northwest in Portland Oregon has been following the
medical home model for nearly two decades in both its inpatient
residential treatment center and its medical clinic. More
recently the Seattle Indian Health Board has worked with the
University of Washington to develop a medical home model
specific to the urban Indian health community.
\2\ Somnath Saha, Mary Catherine Beach, Lisa Cooper, Patient
Centeredness, Cultural Competence, and Healthcare Quality, Journal of
the National Medical Association 2/2/2009 (calling for health care
organizations and providers to adopt principles of both patient
centeredness and cultural competence jointly.)
\3\ AAFP, ``Medical Home Model Helps Eliminate Health Care
Disparities.'' 7/11/2007. http://www.aafp.org/online/en/home/
publications/news/news-now/health-of-the-public/
20070711commonwealthstudy.html Last accessed 1/30/2009; see also, The
Commonwealth Fund, ``Closing the Divide,'' http://
www.commonwealthfund.org/publications/
publications_show.htm?doc_id=506814 last accessed 1/30/2008.
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Community Based Health Care: Urban Indian health organizations
also have developed many community based approaches to health
delivery. Working closely with community health workers and
focusing on the wellness of the entire community, the San Jose
and San Francisco programs have developed a number of outreach
programs aimed at encouraging early preventative care that have
resulted in increased diagnosis of pre-diabetic conditions and
early heart disease. By focusing on the entire community and
using the community member to community member model of health
education, the San Jose and San Francisco programs have
drastically reduced the levels of health disparity in diabetes
diagnosis and treatment for their areas. Many urban Indian
health programs have launched effective community based
education and early detection programs that have dropped the
rates of chronic disease in their community. Many programs are
also developing Native American specific health communication
tools so that Native American patients are better equipped to
understand and communicate within our incredibly complex health
care system. Moreover, by giving patients methods for
translating their conception of their health and wellness into
a language that non-Native providers can understand, the Urban
Indian health programs are able to empower their patients to
have better control over their health outcomes.
Traditional Medicine: Almost all urban Indian health programs
involve traditional medicine practitioners in their health care
delivery. By incorporating traditional medicine practitioners,
UIOs are able to not only link patients to their community, but
also help foster a sense of community and safety within the
clinic itself. Integrating traditional medicine into the entire
service delivery has resulted in many urban Indian health
programs making a dramatic medical model shift away from the
typical western model based around treating those in medical
crisis, to a more wellness and preventative based approach. As
stated earlier, the medical crisis model of care is
particularly damaging to Native American patients and results
in poor health outcomes and health disparities. Moreover, the
inclusion of traditional medicine practitioners ensures the
necessary cultural accessibility for Native American patients.
Impact of the Recession: Despite these great accomplishments the
UIHP clinics and programs are feeling the impact of several years of
short funding and the burgeoning recession. The UIHP is a fraction of
the entire Indian health system operating at a little over 1 percent of
the entire IHS budget. The clinics and programs of the UIHP have become
adept at finding outside resources, leveraging every dollar of original
IHS investment with two dollars from other sources. However, prolonged
short funding of the UIHP has stretched UIHP resources to the breaking
point. Programs are even more strained as the recession progresses
which increases patient loads and reduces the availability of outside
grants and resources.
Increased Patient Load: Many clinics are seeing increased
patient visits due to the recession. As people lose their jobs
and their regular health care provider, many are turning to the
urban Indian health programs for health care. The Hunter Clinic
in Wichita Kansas saw an increase of 1,200 new patients in one
month alone. Most clinics are reporting an increase of 25 to
100 new patient visits per month since the economic collapse in
September. These figures are not static, but steadily
increasing as the recession grinds on. Most Urban Indian health
clinics were already working at full capacity and are
struggling to provide services to the influx of new patients.
Those programs in areas dependent upon single-source economies
are particularly hard hit as people remain unemployed and
uninsured for far longer. Clinics and programs are also seeing
increased patient loads for social services such as food banks,
unemployment support, and occupational education and training.
State Budget Crisis: As state budgets are forced to cut back
due to the recession and the 2007 CMS regulation limiting
federal reimbursement for outpatient clinics, many clinics are
not receiving full or any reimbursement from state Medicaid
plans for certain services. The urban Indian health
organizations are particularly sensitive to changes in state
and federal policy as they do not receive the OMB all inclusive
rate for CMS reimbursement, nor do they have 100 percent of
FMAP. Therefore, when state governments are forced to cut back
on their Medicaid plans, Native American patients in urban
centers suffer. If the Indian Health Care Improvement act had
been passed prior to the start of the recession many of the
urban Indian health programs would have been in a much stronger
position and better equipped to deal with these issues.
Need for Expanded Services: Many clinics are also seeing
increased patient demand for expanded services as other
providers are increasingly refusing to serve Medicaid and
Medicare patients due to low reimbursement rates. Patients are
finding it increasingly difficult to access dental, optometric,
and skilled nursing services. Either providers for these
services are leaving the area (Montana and Nebraska) or non-
Native providers are increasingly unwilling to take referrals
from Urban Indian health programs (Kansas, Massachusetts,
Washington) and patients are left without a provider for these
critical services.
Conclusion: The Urban Indian health organizations are making
impressive progress in combating health disparities and barriers to
care for their Native American patients. However, many of these
programs would have been in a better place to deal with the surge of
new patients and patient demands caused by the recession if the Indian
Health Care Improvement Act had been passed. In particular, the
provisions increasing enrollment under Medicaid, Medicare, and SCHIP
would have helped numerous patients access critically needed services.
While a complete review of the I/T/U system within the context of
health care reform is definitely necessary, such a review cannot delay
the passage of the Indian Health Care Improvement Act. The Urban Indian
Health Program is only a small part of the I/T/U system, but even this
small part would have been significantly more stable during this
economically uncertain time had the bill passed.
Urban Indians and the Indian Health Care Improvement Act
Passing the Indian Health Care Improvement Act and making serious
progress on improving the health of all Native Americans is a priority
for the Urban Indian Health Program. Our clinics and programs see
patients from every tribe and every walk of life. Many of our patients
would not seek care elsewhere due to problems of fiscal and cultural
accessibility. As described above, the clinics and programs of the
Urban Indian Health Program deliver innovative, culturally competent
care despite funding shortfalls, the economic downturn, and active
hostility from the previous Administration. However, NCUIH feels that
UIHP would be in a much stronger position to deal with these issues had
Congress successfully passed the Indian Health Care Improvement Act in
the 110th Congress. Indeed, the entire I/T/U system desperately needs
the modernization and increased capacity promised by the Indian Health
Care Improvement Act.
The National Council of Urban Indian Health would like to outline
those provisions which are particularly helpful for Urban Indian
Organizations as well as describe provisions which have been lost in
negotiations to the Bush Administration. NCUIH feels that the
provisions lost in prior negotiations with the previous Administration
could potentially be restored without delaying the passage of the
entire bill. Indeed, NCUIH encourages the Senate Committee on Indian
Affairs to complete all necessary work on the bill and introduce it
within the next 180 days. NCUIH strongly feels that this administration
and the focus on health care reform present a rare opportunity to pass
the Indian Health Care Improvement Act this session.
Positive Provisions: The history of the Urban Indian Organizations
within the Indian Health Care Improvement Act has often been fraught
with peril. The inclusion of Title V--which authorizes the Urban Indian
Health Program--has frequently been attacked and nearly successfully
stripped from the bill entirely. Therefore, the simple inclusion of
Title V without losing any of the authorities which currently exist
under current law is considered a victory by most of the Urban Indian
Organizations. While it is sad that the expectations of Urban Indian
Organizations have been so reduced by years of negotiating away
authorities and programs, it does speak to the tenacity of the
programs, the support of Tribes, and the support of Congress that Title
V yet endures. While the Indian Health Care Improvement Act of 2008
does not provide for many new authorities for the Urban Indian Health
Program it did: (1) reaffirm the trust responsibility to urban
Indians--a relationship that has been under attack for the past three
years; (2) provided better outreach and enrollment in Medicaid,
Medicare, and SCHIP for Native Americans, and; (3) provided increased
competitive grant opportunities for the clinics and programs of the
UIHPs. The provisions regarding Medicaid, Medicare, and SCHIP all would
have helped the urban Indian health programs better deal with the
sudden State budget deficits and resulting cut backs in State Medicaid
reimbursements. Moreover, the Indian Health Care Improvement Act of
2008 would have helped stabilize tribal health programs, which would
have in turn helped the Urban Indian Health Programs. When one of the
pillars of the I/T/U system is damaged, the entire system shakes.
Conferring with Urban Indian Organizations: Although NCUIH and
its member organizations do not have a government-to-government
relationship with the Federal Government, and it would be
appropriate to use the term `consult' which has a special
meaning in this context, the Urban Indian Organizations do
represent Native Americans to whom a Trust responsibility is
owed. Within the confines of that obligation, the Federal
Government must make the effort to confer with those the urban
Indian stakeholders.
Congress has consistently acknowledged the government's trust
responsibility extends to American Indians and Alaska Natives
(AI/AN) living in urban settings. From the original Snyder act
of 1921 \4\ to the Indian Health Care Improvement Act of 1976
and its Amendments, Congress has consistently found that: ``The
responsibility for the provision of health care, arising from
treaties and laws that recognize this responsibility as an
exchange for the cession of millions of acres of Indian land
does not end at the borders of an Indian reservation. Rather,
government relocation policies which designated certain urban
areas as relocation centers for Indians, have in many instance
forced Indian people who did not [want] to leave their
reservations to relocate in urban areas, and the responsibility
for the provision of health care services follows them there.''
\5\ This trust responsibility includes, from the perspective of
NCUIH, the obligation to confer with the Urban Indian community
through their duly authorized representatives regarding how
that trust responsibility is met. Given the soaring health
disparities facing the Urban Indian population \6\ it is
particularly necessary for meaningful discussion to take place
in order for both the Federal Government and the Urban Indian
health providers to ensure that the best possible care is
provided to the vulnerable American Indian and Alaska Native
community.
\4\ Snyder Act, Public Law 67-85, November 2, 1921.
\5\ Senate Report 100-508, Indian Health Care Amendments of 1987,
Sept 14, 1988, p.25. Emphasis added.
\6\ The Health Status of Urban American Indians and Alaska Natives,
Urban Indian Health Institute. 2004; see also, Invisible Tribes: Urban
Indians and Their Health in a Changing Worlds. Urban Indian Health
Commission funded by the Robert Wood Johnson Foundation. 2007.
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Inclusion of UIOs in Title II--Improvement of Indian Health
Care Provided under the Social Security Act: The provisions
contained in this Title would significantly help those programs
currently billing Medicaid and Medicare and would help those
programs who do not currently bill Medicaid and Medicare
develop the capacity to do so. Third party reimbursements
significantly stabilize the Urban Indian health programs that
are capable of doing so. Expanded ability to seek reimbursement
for medical services could mean the difference between
providing certain key services such as dental and primary care
and not being able to provide those services. When Urban Indian
health programs are unable to provide services often times
Native American patients simply will not seek care elsewhere,
even if they are enrolled in Medicaid, Medicare or SCHIP.
Provisions that are particularly important to the Urban Indian
health programs are section 201 which amends section 1911 and
section 1880 of the Social Security Act to include the Indian
Health Service, Indian Tribes, Tribal organizations, and Urban
Indian health programs as eligible entities. Currently Urban
Indian health programs are treated as Federal Qualified Health
Centers (FQHC) which are vulnerable to fluctuating
reimbursement rates, particularly under the Medicaid program.
NCUIH strongly encourages the Senate Committee on Indian
Affairs to maintain Urban Indian Organizations in these
provisions as it means the difference between fiscal stability
and instability for many programs.
Section 509: Facilities: This provision provides for the
Secretary to make grants to contractors for the ``lease,
purchase, renovation, construction or expansion of facilities,
including leased facilities in order to assist such contractors
or grant recipients in complying with applicable licensure or
certification requirements.'' This provision is very important
to Urban Indian health programs as they are not currently
eligible for facilities construction funding, though they
currently have authority for facilities renovation. Many
programs have construction projects that are necessary to
maintain or expand services to their patient base.
Unfortunately these programs do not currently have
appropriations authority for construction projects and the
private market for the large scale loans necessary for such
projects has disappeared with the onset of the recession. NCUIH
strongly encourages the Senate Committee on Indian Affairs to
maintain this provision.
Provisions to be Reformed or Re-included: There are, of course,
provisions that the National Council of Urban Indian Health would like
to see reformed, or added; however, it is imperative that this act be
passed in the 111th Congress. NCUIH urges the Senate Committee on
Indian Affairs to consider re-including the Urban Indian health
programs in the provisions listed below. These provisions deal with
authorities and programs that are go to the core mission of the Urban
Indian Health Program and directly address afflictions that are
especially severe in the urban environment. Urban centers in particular
have large patient populations with the very type of problems these
programs address given the nature of living in an urban center where
there is ready access to alcohol and a wider variety of illicit drugs.
Moreover, Native Americans suffer additional stress in urban
environments as they are separated from their community and surrounded
by, in many respects, a foreign culture.
Many problems on the reservations are imported from urban locations
because there is substantial movement back and forth between the
reservation and Urban Indian communities. Tribal members with drug,
alcohol and infectious diseases--like HIV/AIDs (which would be
addressed under Section 212)--bring those illnesses back with them to
the reservation. But that chain can--and has been--broken when they are
treated at the urban center and always in a far more cost efficient
manner then if the same patient receives significantly delayed care at
an on-reservation IHS facility because they were forced to wait until
they reached medical crisis and then return home. Urban Indian health
programs form a critical link in preserving the health and viability of
the Native American population by confronting many illnesses and
substance abuse at their point of origin. The sad and fundamental truth
is that eventually these patients must be seen and either they can be
seen early, before the most destructive behaviors or illnesses set in,
or they will be seen much later at the Tribal or IHS facility after the
drug or alcohol abuse has destroyed their families or HIV/AIDS has gone
untreated for months if not years and been spread to more individuals.
Section 701 Behavioral Health Prevention and Treatment
Services--This provision provides grant, cooperative agreement,
and contract opportunities for the development of comprehensive
behavioral health prevention and treatment programs. This
section also directs the Secretary to act through the Service,
Tribes, Tribal Organizations, and previously Urban Indian
Organizations, to develop plans to participate in developing
area wide plans for Indian Behavioral Health Services.
Section 707(g) Indian Youth Program: Multidrug Abuse Program--
this subsection directs the Secretary to provide programs and
services to prevent and treat the abuse of multiple forms of
substances through Tribes, Tribal Organizations, and previously
Urban Indian Organizations.
Section 212 Prevention, Control, and Elimination of
Communicable and Infectious Diseases--this provision provides
grant opportunities to develop a variety of projects and
programs to for the prevention, control and elimination of
tuberculosis, hepatitis, HIV, respiratory syncytial virus,
hanta virus, STDs and H. Pylori.
Conclusion: It is the first and foremost recommendation from the
National Council of Urban Indian Health is that the Senate Committee on
Indian Affairs move with all deliberate haste to complete our decade-
long fight to reauthorize the Indian Health Care Improvement Act. The
110th Congress came achingly close to passing this critical act through
the truly herculean efforts of yourself, Senator Dorgan and Senator
Murkowski and the other members of this Committee. As stated before,
this bill is not perfect but is the bill drafted through negotiation
and compromise. The Chairman has requested that we take a fresh look at
those areas where Tribal and urban Indian requests and provisions were
dropped. NCUIH has included those areas that we hope the Committee
continues to protect and those provisions that we hope the Committee
will consider re-including. As members of the National Steering
Committee, we will be working with other Indian advocates to review the
entire bill. We will then work with our Tribal partner, NIHB, to
vigorously advocate for these provisions.
Moving Indian Health Care Forward
As stated above, a quickly enacted IHCIA bill is the first vital
step in moving all of Indian health forward. Once that step has been
taken a full review of the entire Indian health care delivery system
can begin. This would be an arduous, intensive process as it has been
over fifty years since the Indian Health Service was created. It has
been over thirty years since the original IHCIA was enacted creating
not only the Urban Indian Health Program but many other Indian health
programs. Health care delivery has significantly evolved in that time--
and stands to significantly evolve yet again under the health care
reform effort spearheaded by the Obama Administration. We hope that the
critical review of the Indian health system will happen within the
context of this reform effort so that the two efforts may inform each
other. As stated earlier, it is critical that Indian issues are
considered during the larger health care reform process, as many
suggestions and best practices from Indian and Urban Indian health
organizations could be put to good use in the larger context.
The National Council of Urban Indian Health believes that in order
to move Indian health forward in the context of this reform effort we
must be willing to take a cold, hard look at many of our programs and
our conceptualization of health care delivery. We agree with the
National Indian Health Board that it will require contribution of
experts from both within and without the system, demand innovative
ideas, and demand a willingness to challenge the current status quo. It
will also take strength of will from both Congress and Indian leaders
to see serious reform through to the end.
NCUIH offers the following recommendations for such a serious reform:
Consult with all Indian people--tribal and urban. NCUIH
strongly urges this Committee to seek out the opinions and
thoughts of individual health care consumers, service
providers, and tribal and urban leaders. Unless all Indian
people are involved in this reform effort it will not reach all
of the people that desperately need the I/T/U system to be
running as the world-class system it could be.
NCUIH strongly agrees with NIHB that any ``solution'' that
simply redistributes scarce existing resources is not a real
solution. It only divides Native Americans against themselves
and further damages the entire system of care for Native
Americans.
Conduct a needs assessment that includes the urban Indian
health programs. It has been over twenty years since any needs
assessment has taken the needs of urban Indians into account
despite the fact that nearly 60 percent of the Native American
population currently lives in urban centers.
NCUIH also supports the NIHB suggestion that the Committee
seek out Indian input through regional meetings, hearing and
other potential mechanisms. NCUIH further urges the Committee
to not forget Urban Indians in this effort.
Serious reform must be accompanied by full funding of the I/
T/U system to address unmet needs.
Seek out and encourage the dissemination of Native American
best practices. Our programs and clinics have been quiet
leaders in innovative health care delivery for decades, but due
to their small size have been unable to disseminate these best
practices. Moreover, in order for the health disparities facing
Native Americans to be seriously addressed best practices that
actually work for Native people must be employed.
Conclusion
On behalf of the National Council of Urban Indian Health and the
Urban Indian health organizations that we represent, I thank you for
the opportunity to provide testimony and suggestions on how to advance
Indian health care. NCUIH thanks the Committee for its support and
dedication to Indian health. We have a rare moment with this
Administration and this Congress to pass IHCIA and to pass it now
without further delays or negotiations. NCUIH strongly urges the
Committee to seize this moment and undertake comprehensive health care
reform with Indian health in mind; pass the Indian Health Care
Improvement Act; and initiate a comprehensive review of the Indian
health care delivery system.
We are deeply grateful for your leadership and your commitment to
improving Indian health, as we are grateful to all of the leaders who
have come to give testimony today. We all have the same ultimate goal:
ensure the best possible health care for our people.
I am available to answer any questions the Committee might have.
The Chairman. Mr. Joseph.
STATEMENT OF ANDREW JOSEPH, JR., CHAIRPERSON, NORTHWEST
PORTLAND AREA INDIAN HEALTH BOARD
Mr. Andrew Joseph. Good morning, Chairman Dorgan, Vice
Chairman Barrasso. [Greeting in native tongue.]
My name in my dad's language is Badger. I am Andy Joseph,
Jr., from the Colville Confederated Tribal Council and the
Portland Area Indian Health Board Chairman. I also serve as the
Vice Chair for the Direct Service Tribes.
Before I begin, I want to commend you, Senator Dorgan and
Committee, for your hard work in getting S. 1200 passed in the
Senate last year. I have submitted written testimony to the
Committee and respectfully request to enter it into the record
of hearing. Let me summarize my testimony for the record.
I am aware that the members of the Committee understand
that the United States has a Federal trust responsibility to
provide health care services to American Indians and Alaska
Natives. I would be neglecting my duty as an elected tribal
leader not to remind us of this responsibility. We as tribal
leaders and members of Congress should not take this duty
lightly. Our forefathers, yours and mine, entered into
agreements that guaranteed certain rights and privileges, in
exchange for millions of acres of land and precious resources.
One of these is the reason why we are here today, health
care. It is important to underscore the significant health
disparities that Indian people face. While the IHS and tribes
have made great strides to address the health status of Indian
people, we still face the highest health disparities of any
group in the United States. My written testimony documents
these concerns, and reauthorizing the Indian Health Care
Improvement Act will help to address these concerns.
Tribal leaders have been working on the reauthorization for
13 years. I have included a chart with my testimony that lays
out the history of the Indian Health Care Improvement Act. The
chart shows that immediately following the passage of the Act
in 1976, Congress passed a number of amendments to improve the
Act on several occasions. As a tribal leader, I am very
frustrated that we have not been able to get this bill passed
in the last five sessions of Congress.
We have spent an extraordinary amount of time and resources
to get the bill passed. Given the chronic under-funding of IHS,
these resources could be put in patient care and truly make a
difference. As a tribal leader, I have a responsibility to my
tribe to be responsible for the resources I use. I sometimes
have difficulty justifying the resources we have spent over the
last 12 years. Yet I know this bill will make a difference.
Every day I see the difference that the Indian Health Care
Improvement Act would make on the Colville Indian Reservation.
My tribe has more than 9,300 members, one of the largest in the
Portland area. Many of our members live on or near the
reservation. The long distances that our members must travel to
receive health care is a tremendous burden and expense. The
Indian Health Care Improvement Act would allow us to provide
hospice care, assisted living, home and community-based
services. These services could be provided in the immediate
community of our members, so they wouldn't have to travel.
The Indian Health Care Improvement Act will improve access
to health services and the ability of tribes to be reimbursed
for providing care. This will help to reduce chronic under-
funding of the Indian health system. Medicare and Medicaid
reimbursements allow our health programs to provide additional
health services that might not be provided by IHS funding
alone. There are improvements that allow tribes to recruit and
retain qualified Indian health professionals to work on the
reservations.
The Colville Indian tribes have had a serious bout dealing
with youth suicides on our reservation. Last year alone, the
Colville Indian Reservation suicide rate was 20 times higher
than the national average. The Indian Health Care Improvement
Act passed in the 110th Congress has an expanded emphasis on
behavioral health programs that provide for a comprehensive
approach to behavioral health, providing important prevention
and treatment programs for American Indians and Alaska Native
people and coordinating services related to alcohol, substance
abuse, child welfare, suicide prevention and social services.
This is a marked improvement that addresses youth suicide
issues in Indian Country.
Over the last four years, the National Steering Committee
has compromised on a number of provisions that have been
altered or dropped from the bill. Many of these issues were not
supported by the previous Administration. In light of the new
Administration and Congress, I urge the Committee to consider
adding important provisions back into the bill. I also urge the
Committee to take opportunities to improve the Indian health
system during health reform, but also caution that we must
protect the Indian health system during this time. I caution
making sweeping changes in IHS, since the system is only funded
at approximately 60 percent of its need. Any evaluations and
improvements for the Indian health system should consider this
fact.
Thank you for this opportunity to testify, and I welcome
any questions the Committee might have.
[The prepared statement of Mr. Andrew Joseph follows:]
Prepared Statement of Andrew Joseph, Jr., Chairperson, Northwest
Portland Area Indian Health Board
Good morning Chairman Dorgan, Ranking Member Barrasso, and
distinguished members of the Committee. My name is Andy Joseph I serve
as a Tribal Council member for the Confederated Tribes of the Colville
Reservation. I thank you for the opportunity to provide my testimony to
the Senate Committee on Indian Affairs.
In my role as a Tribal leader, I also serve as the Chairperson of
the Northwest Portland Area Indian Health Board (NPAIHB). Established
in 1972, NPAIHB is a P.L. 93-638 tribal organization that represents 43
federally recognized Tribes in the states of Idaho, Oregon, and
Washington on health related matters. NPAIHB is dedicated to improving
the health status and quality of life of Indian people and is
recognized as a national leader on Indian health issues.
I want to commend Senator Dorgan and the Indian Affairs Committee
for their work to get S. 1200, the Indian Health Care Improvement Act
(IHCIA) Amendments of 2008, passed by the Senate last year. As you know
there was a tremendous amount of work that went into getting this bill
passed and we acknowledge your leadership and the commitment of the
Committee and its staff to get this done. Thank you for holding this
hearing and your continued work to support legislation to reauthorize
the IHCIA.
Federal Trust Responsibility for Health Care
The United States government has a legal and moral responsibility
to provide health care services to American Indian and Alaska Native
(AI/AN) people. This responsibility is based upon numerous treaties
signed between the United States and Indian Tribes which ceded millions
of acres of land and resources in exchange for certain reserved rights
and basic provisions guaranteed by the United States--including health
care. The unique relationship between Tribes and the Unites States is
underscored in the U.S. Constitution (Article I, Section 8), numerous
Federal laws and court decisions, and Administrative policies which all
affirm the unique relationship between Indian Tribes and the Federal
Government and its obligation to provide health services to American
Indians and Alaska Natives. This obligation is further compelling when
the limited access to health care and significant health disparities
impacting AI/AN people are considered.
Indian Health Disparities
The IHCIA declares that this Nation's policy is to elevate the
health status of the AI/AN people to a level at parity with the general
U.S. population. Over the last thirty years the IHS and Tribes have
made great strides to improve the health status of Indian people
through the development of preventative, primary-care, and community-
based public health services. Examples are seen in the reductions of
certain health problems between 1972-1974 and 2000-2002:
gastrointestinal disease mortality reduced 91 percent, tuberculosis
mortality reduced 80 percent, cervical cancer reduced 76 percent, and
maternal mortality reduced 64 percent; with the average death rate from
all causes dropping 29 percent.\1\
---------------------------------------------------------------------------
\1\ FY 2000-2001 Regional Differences Report, Indian Health
Service, available: www.ihs.gov.
---------------------------------------------------------------------------
Unfortunately, while Tribes have been successful at reducing the
burden of certain health problems, there is strong evidence that other
types of diseases are on the rise for Indian people. For example,
national data for Indian people compared to the U.S. all races rates
indicate they are 638 percent more likely to die from alcoholism, 400
percent greater to die from tuberculosis, 291 percent greater to die
from diabetes complications, 91 percent greater to die from suicide,
and 67 percent more likely to die from pneumonia and influenza.\2\ In
the Northwest, stagnation in the data indicates a growing gap between
the AI/AN death rate and that for the general population might be
widening in recent years. In 1994, average life expectancy at birth for
AI/ANs born in Washington State was 74.8 years, and is 2.8 years less
than the life expectancy for the general population. For 2000-2002, AI/
AN life expectancy was at 74 years and the disparity gap had risen to 4
years compared to the general population. The infant mortality rate for
AI/AN in the Northwest declined from 20.0 per 1,000 live births per
year in 1985-1988 to 7.7 per 1,000 in 1993-1996, and then showed an
increasing trend, rising to 10.5 per 1,000 in 2001.\3\
---------------------------------------------------------------------------
\2\ Ibid.
\3\ American Indian Health Care Delivery Plan 2005, American Indian
Health Commission of Washington State, available at: www.aihc-wa.org.
---------------------------------------------------------------------------
What is more alarming than these data is the fact that there is
abundant evidence that the data might actually underestimate the true
burden of disease and death among AI/AN because--nationally and in the
Northwest--people who classify themselves as AI/AN are often
misclassified as non-Indian on death certificates. A caution in using
AI/AN data is that, due to small numbers, death rates are more likely
to vary from year to year compared to rates for the general population.
Unfortunately, it is safe to say that the improvements for the period
of 1955 to 1995 have slowed; and that the disparity between AI/AN and
the general population has grown. Factors such as obesity and
increasing rates of diabetes contribute to the failure to reduce
disparities.
Reauthorization of the IHCIA
Today, I want to speak about why it's important to get the Indian
Health Care Improvement Act (IHCIA) reauthorized in this session of
Congress. As the Committee is aware--and with its support--Tribes have
been working since 1998 on the reauthorization of the IHCIA. I want to
bring your attention to a chart that we have included as an appendix to
my testimony. The chart shows that immediately following passage of the
IHCIA in 1976, Congress has taken action on a number of measures to
address and improve health care delivery for AI/ANs by amending the Act
on several occasions. Unfortunately, Tribes have not seen the level of
Congressional experienced in the 1980s and 1990s and our people are
suffering because we have not improved our health system. In 1998,
Congress extended the IHCIA by authorizing appropriations through FY
2001; however the Congress has not passed a bill since this time.
It was in 1998, that the IHCIA's National Steering Committee (NSC)
began to work on legislative objectives for reauthorization. It has
taken a tremendous amount of Tribal resources to work on the
reauthorization effort and has been an extremely frustrating process.
As a Tribal leader, I recognize that these important resources could be
put toward patient care, but I also understand the importance of
getting the IHCIA reauthorized. So from this standpoint it's been very
frustrating to get the IHCIA reauthorized, knowing that past Congresses
have passed legislation on a number of occasions to improve the health
conditions for AI/AN people. Tribal leaders have been working on
reauthorization of the IHCIA for eleven years, and it is critical that
we get this bill passed as soon as possible in this Congress. The
improvements contained in S. 1200 would allow the Indian health system
to modernize the way in which it provides health care so that AI/AN
people enjoy some of the same health benefits as most Americans.
Every day I see the difference that the IHCIA would make on the
Colville Indian Reservation. Our reservation encompasses nearly 2,300
square miles (1.4 million acres) and is in northcentral Washington
State. The Colville Tribe has more than 9,300 enrolled members, making
it one of the largest Indian Tribes in the Pacific Northwest. About
half of our members live on or near the Colville Reservation. The long
distances that our Tribal members must travel to receive health care is
a tremendous burden and expense. Some the provisions in the IHCIA would
allow us to develop our health programs to provide hospice care,
assisted living, and home and community based services. These
provisions would allow the Colville Tribe to make health services
available to those that might not be able to get to health facilities.
As the Committee is aware, a significant issue for Tribes is the
lack of funding to provide health care services. The IHCIA provides
authority for programs to improve access for health services and
addresses mechanisms to allow the Indian Health Service (IHS), Tribes,
and urban Indian organizations authority to be reimbursed for services
they provide. This will assist to reduce the chronic underfunding for
the Indian health system. The Title IV provisions are very important to
the delivery of health care services for the Colville Tribal health
programs. The Medicare, Medicaid, and SCHIP reimbursements allow our
health program to provide additional health services that might not be
provided by IHS funding alone.
Another improvement that the IHCIA would allow is for the IHS and
Tribes to be able to recruit and retain qualified Indian health
professionals. Like many parts of Indian Country, it is often difficult
to recruit and retain qualified health professionals to work on Indian
reservations. The amendments made to the Indian health scholarship
programs will permit greater flexibility for IHS and Tribes to recruit,
train, and retain health professionals. This would allow the IHS and
Tribes to address the high health professional vacancy rates
experienced in the Indian health system.
Lastly, the Colville Indian Tribes have had a serious bout of
dealing with youth suicide on our reservation. It is estimated that the
national Indian suicide rate is four times greater than the national
average; however, last year the Colville Indian Reservation suicide
rate was twenty times higher than the national average. The Senate
passed IHCIA (S. 1200) has an expanded emphasis on behavioral health
for IHS and Tribal health programs. The improvements contained in S.
1200 provide for a comprehensive approach to behavioral health,
providing important prevention and treatment programs for AI/AN people.
The bill also emphasizes the coordination of services related to
alcohol and substance abuse, child welfare, suicide prevention and
social services. The addition of the youth suicide provisions will
greatly assist Tribes to address suicide issues in their communities.
New Opportunities for the IHCIA
Since 1999, the IHCIA National Steering Committee (NSC) has worked
to develop bill language that is representative of the health needs of
Indian Country and has the consensus of over 560 federally-recognized
Tribes. Over the last four years, the NSC has worked to negotiate with
Congressional Committees and the Administration to arrive at the final
bill language that was passed in S. 1200. As the NSC negotiated to get
a bill passed by the Senate, they compromised on a number of provisions
that were changed or dropped from the bill. Many of these issues were
not consistent with the previous Administration's policies concerning
Indian health.
In light of the new Administration and Congress, we would urge the
Committee to work with the NSC to revisit some of the IHCIA provisions
that were significantly altered or dropped from the bill that passed in
the 110th Congress. There were important provisions that would have
exempted AI/AN people from cost sharing in the Medicare program and
waiving late enrollment premiums in the Medicare Part B program, that
would be important to increase access and services for Tribal elders.
Another key provision would have established a Qualified Indian Health
Program (QIHP) as a new provider type through which Indian health
programs and urban Indian health programs could more fully exercise
authority to receive payments under Medicare, Medicaid and SCHIP.
Tribal leaders also agreed to delete a provision that would have
extended the 100 percent FMAP to services provided to Medicaid eligible
Indians referred by IHS or tribal programs to outside providers, such
as referrals made through the Contract Health Services (CHS) program.
This would be a very important provision to addressing the backlog of
CHS denied and deferred services. There were other Social Security Act
provisions that would have been beneficial for Indian programs but were
dropped from the reauthorization bills because the Department of Health
and Human Services objected to negotiated rulemaking requirements.
The Administration has stated that health reform will be a priority
on its agenda. The President's plan to provide affordable and
accessible health care for all Americans, will build on the existing
health care system. Any time the Administration and Congress have
undertaken a change to the nation's health care system it has had an
impact on IHS and Tribal health programs. During this era of health
reform there could be some opportunities to improve the Indian health
system. There could also be threats to destroy the current system that
provides culturally competent health care for AI/AN people. So it will
be important for Congress to work with the NSC to understand these
reform proposals and build in the protections for the Indian health
system, but also allow it to be improved when and where appropriate.
It is important to note that there could be critics of the Indian
health system during this time of reform. I want to stress the fact
that the Indian health system is only funded at approximately 50-60
percent of its level of need. The improvements included in the IHICA,
if adequately funded, would allow the IHS and tribally managed health
programs to make marked improvements in overall health status of AI/AN
people. It is not fair to evaluate the Indian health system under the
current circumstance due to the fact that it is only funded at
approximately 50-60 percent of its level of need. The Indian health
system has done remarkably well with the limited funding that it
receives. Health improvements made since the Agency was established and
recent improvements tracked by GPRA indicators demonstrate this.
Imagine the improvements that could be made if the system was funded at
100 percent of its level of need. The Indian health system should be
given the same opportunity to provide comparable health care along the
lines as that provided by the Veterans Administration. This can be
accomplished by passing the IHCIA and providing adequate funding.
Conclusion
On behalf of the Northwest Portland Area Indian Health Board, I
want to thank the Committee for allowing me to testify on Advancing
Indian Health Care. I encourage the Committee to continue to work with
the IHCIA National Steering Committee to identify key provisions that
have been eliminated from the bill in order to improve health services
provided by IHS and tribally operated health programs. And I urge
Congress to make sure to protect and improve the Indian health system
whenever appropriate as the Administration and Congress undertake
health reform.
The Chairman. Mr. Joseph, thank you.
Finally, we will hear from Mickey Peercy, the Executive
Director of Health Services of the Choctaw Nation in Oklahoma.
STATEMENT OF MICKEY PEERCY, EXECUTIVE DIRECTOR, HEALTH
SERVICES, CHOCTAW NATION OF OKLAHOMA
Mr. Peercy. Good morning. I want to thank the Senators for
allowing the Choctaw Nation to be here. I also want to beg your
indulgence, I am from Oklahoma, so I talk more slowly than
most. I may need seven minutes.
[Laughter.]
Mr. Peercy. Greetings to the Chair and all the members of
the Committee, and thank you for inviting the Choctaw Nation to
provide testimony on Indian health care. We extend to you the
support of the people of the Choctaw Nation to work with you in
addressing priority issues of all Native American people. We
have provided written testimony that will expand on my oral
testimony.
The Choctaw Nation is located in rural southeast Oklahoma.
We are ten and a half counties roughly the size of Vermont. We
have managed our own health care system since 1985 totally. Our
system includes one hospital, eight outpatient clinics, two
substance abuse programs, diabetes wellness and a preventive
health program. We have 831 employees, a $102 million annual
budget, half of that being Federal, the other third party and
tribal dollars. We know how to deliver health care.
We also know that the majority of tribal leaders and tribal
nations are capable of managing their own systems. In 2003, the
Commission on Civil Rights prepared an extensive report on
Federal funding and unmet needs in Indian Country. And again,
in 2004, as a follow-up the Commission reported more
extensively on health care disparities in the report, Broken
Promises: Evaluating the Native American Health Care System. We
applaud those reports. These reports cannot continue to be
ignored.
The Indian Health Service, and this is the first issue, the
Indian Health Service authority should be reviewed to determine
the effectiveness of the service in response to the needs of
Indian beneficiaries, and whether it is in the best interests
of the Indian people to change how the Indian Health Service
provides primary health care. Most of us have been in the
business, I know I have, over 28 years. And many of you have
been in the same position.
It is the sense of the Choctaw Nation that given the
current status of health care in this Country, health care for
tribes should be targeted more at the tribal community levels
for the best return on the investment, using best practices as
a key denominator in the equation for health care service
delivery, management and accountability. We do not need another
redesign of Indian Health Service. Senators, much like the fox
and the henhouse, the fox will never remodel the henhouse and
give the hens control over their own destiny. It is not in
their best interest. There is no incentive for that. The fox
will always eat the hen.
IHS does not redesign, they only replace jargon and fortify
their staffing and control. There must be tribal government and
governance over tribal health care delivery. The gentlemen
sitting here are elected leaders. These folks are elected
leaders. That relationship needs to be driven by these tribal
leaders.
For the past decade, Indian Country has rallied behind and
supported the reauthorization of the Indian Health Care
Improvement Act. The most critical Indian health care
legislation has been rewritten, renegotiated and dissected so
much since 1999 that we are left to question if it is
sufficient to make a dent in the needs of the intended
beneficiaries today. The Indian Health Care Improvement Act
bill can serve as the foundation on which to build a more
comprehensive and responsive plan to address the financial and
service needs of tribal communities.
Choctaw Nation asks that this Committee give every
consideration to reassess the contents of the bill to do what
is necessary to restructure and meet the needs and provide
quality care of benefits for people. To answer a question that
the Chairman mentioned, contract support costs is a big issue.
We need to do something about contract support costs. What we
would recommend is that we fund the shortfall, we take care of
the shortfall, and then we adopt an administrative cost plan.
For large tribes it could be 30, 35 percent. For small tribes,
18 to 20 percent. This is something that tribes could plan on.
It gets the indirect cost proposals out of the equation. It
also gets litigation out of the equation. So we would like to
certainly talk about as we go farther.
Medicare-like rates, and the Medicare Modernization Act, I
know three Medicare-like rates was adopted in 2007. This, I
know Senator, your thing of contract health is a big issue. And
what happens with Medicare-like rates now, folks go to the
hospitals, the hospitals can only require Medicare-like rates
from the health systems. We are asking that Section 506 be
amended to include ambulatory services as well as the inpatient
services. That is in my testimony.
One quick thing, facilities construction. Choctaw Nation is
asking that this Committee convene a body to take a look at
facilities construction within the Indian health system. There
have been two priority systems that have been put in place. And
we don't know where we are with facilities construction. We
would ask that this Committee bring IHS forward, take a look at
it or convene a body to really address what is going on with
facilities construction.
With that, we thank you for the opportunity to give you
comments, and would answer questions.
[The prepared statement of Mr. Peercy follows:]
Prepared Statement of Mickey Peercy, Executive Director, Health
Services, Choctaw Nation of Oklahoma
Good Morning Chairman Dorgan, Vice-Chairman Barrasso and
distinguished Members of this Committee. On behalf of Chief Gregory
Pyle, of the Great Choctaw Nation of Oklahoma, I offer congratulations
on this inaugural hearing to you Mr. Barrasso as the new Vice-Chairman,
and new Members of the Committee Senators Udall, Crapo and Johanns. I
extend to you the support of the people of the Choctaw Nation to work
with you in addressing the priority issues of Native American peoples.
Thank you for inviting Choctaw to provide testimony on advancing Indian
health care.
The Choctaw Nation of Oklahoma is an American Indian Tribe
organized pursuant to the provisions of the Indian Reorganization Act
of June 26, 1936-49. Stat.1967. and is federally recognized by the
United States government through the Secretary of the Interior. The
Choctaw Nation of Oklahoma consists of ten and one-half counties in the
southeastern part of Oklahoma and is bounded on the east by the State
of Arkansas, on the south by the Red River, on the north by the South
Canadian, Canadian and Arkansas Rivers. The western boundary generally
follows a line slightly west of Durant, then due north to the South
Canadian River.
We have been operating under a compact of Self-Governance since
1995 in the Indian Health Service/Department of Health and Human
Services and in the Bureau of Indian Affairs/Department of the Interior
since 1996. The Choctaw Nation of Oklahoma believes that responsibility
for achieving self-sufficiency rests with the governing body of the
Tribe. It is the Tribal Council's responsibility to assist the
community in its ability to implement an economic development strategy
and to plan, organize, and direct Tribal resources in a comprehensive
manner which results in self-sufficiency. The Tribal Council recognizes
the need to strengthen the Nation's economy, with primary efforts being
focused on the creation of additional job opportunities through
promotion and development. By planning and implementing its own
programs and building a strong economic base, the Choctaw Nation
applies its own fiscal, natural, and human resources to develop self-
sufficiency. These efforts can only succeed through strong governance,
sound economic development and positive social development.
In 2003, the Commission on Civil Rights prepared an extensive
report on the Federal Funding and Unmet Needs in Indian Country. Again,
in 2004, as a follow-up, the Commission reported more extensively on
health care disparities in the report, Broken Promises: Evaluating the
Native American Health Care System. We all applauded the attention that
both of these reports received and the level of education they provided
to the novices on the topics of need and disparity that plague Indian
communities in all venues, on all levels, in all areas each and every
day. More importantly, these reports shared what is real and what
continues to deprive Indian people of the basic pleasantries of life
and benefits that most Americans enjoy that is so inaccessible at the
reservation level.
The health care needs that were identified in the sequel Commission
report have consistently increased the level of need in our Tribal
communities because of a plethora of shortfalls and rescissions. In
fiscal year 2008, total funding for the Indian Health Service (IHS) was
$4.3 billion, some 48 percent short of the need identified by the
Tribal/IHS Budget Formulation Committee. The Choctaw Nation has been
aggressive in addressing the need of our people, as well as those who
live in proximity to our reservation. We have become impatient with the
current system of health care service delivery that is the
responsibility of the IHS. It is the directive of the Tribal Council at
the Choctaw Nation to move forward in advancing and addressing the
needs of our communities through outreach, alliance building and
partnerships to accomplish our health care goals.
The Indian Health Service authority should be reviewed to determine
the effectiveness of the Service in response to the needs of Indian
beneficiaries and whether it is in the best interest of Indian people
to change how IHS provides primary health care. It is the sense of the
Choctaw Nation that given the current status of health care in this
country, health care for Tribes should be targeted more at the Tribal/
community levels for the best return on the investment using best
practices as a key denominator in the equation for health care service
delivery, management and accountability.
The Choctaw Nation Health Services is the leader in health care in
southern Oklahoma and continues to expand to meet the ever-changing
needs of our people. The Choctaw Nation and Senior Health Officials
from other Tribes and the Urban Program recently convened a meeting
with the Oklahoma Hospital Association. We feel the need to reach
across the aisle to share best practices, learn about the health needs
of our neighbors and forge partnerships to improve and expand the
health care services that are being provided in Oklahoma. We are not
seeking to just serve the Indian community but rather to identify the
needs of others while offering Tribes access; knowledge and choices
about what other services and types of facilities are available to them
in our state.
The Choctaw Nation currently provides the following health services
to the Choctaw people and surrounding communities:
Choctaw Nation Health Facilities
Community Health Representative
Eyeglasses, Dentures and Hearing Aid Program
Office of Environmental Health
Recovery Center
Women's and Children Residential Treatment Program
Diabetes Wellness Center
Drug and Alcohol Testing
Mail Order Pharmacy
Behavioral Health
Youth Advisory Board
For the past decade, Indian Country has rallied behind and
supported the reauthorization of the Indian Health Care Improvement Act
(IHCIA). Tribes remain vigilant in their quest to make the bill a
product that will bring health care for Indian people into the 21st
Century. Unfortunately the previous Administration and Congress fell
short of getting the job done. The most critical Indian health
legislation has been rewritten, renegotiated and dissected so much
since 1999 that we are left to question if it is sufficient to make a
dent in the needs of the intended beneficiaries today. How have we
allowed something that is so important to the lives of 1.5 million
Indian people to become so bare-boned at a time when the current
economic crisis has nothing better to offer? Now is as good a time as
any to look at overhauling the overall health package; to redesign a
health system that meets the needs of Indian people locally in our
communities. The IHCIA bill can serve as the foundation on which to
build a more comprehensive and responsive plan to address the financial
and service needs of the Tribal communities. The Choctaw Nation asks
that the SCIA gives every consideration to reassess the contents of
this bill and to do what is necessary to restructure it to meet the
needs of and provide the quality of benefits that Indian people are
entitled to receive.
While it is not easy to design and overhaul a health care system,
the greatest need we are confronted with is funding. We are denied full
funding to operate contracts and compacts with the Indian Health
Service and yet we are expected to perform as any and all other vendors
in the delivery of goods and services. Contract support costs (CSC) has
not fully been paid under P.L. 93-638. Therefore, we ask that Congress
work with Tribes and the IHS to design a mechanism that will allow for
an administrative cost rate rather than CSC. For smaller tribes, the
administrative cost rate could be as great as 30 percent, and for
larger Tribes possibly 18-20 percent. While these percentages are
random, such a concept supports the need to consider an alternative to
what does not currently work. This could stabilize the outlay and allow
Tribes to recover cost associated with performing the services under
the contracts and compacts. In addition, an administrative cost rate
would eliminate litigation fees.
Medicare-Like Rates
The Centers for Medicare and Medicaid (CMS) issued Section 506 of
the Medicare Prescription Drug, Improvement and Modernization Act of
2003. This section generally provided authorization for contract health
services and urban Indian programs to pay ``no more than Medicare-like
rates'' for referred services (inpatient) furnished by Medicare-
participating hospitals upon the effective date of enacting
regulations. On June 4th the Department of Health and Human Services
published regulations in the Federal Register effective July 5th to
implement Section 506. The regulations describe the payment
methodologies and other requirements covered providers must adhere to
when processing claims for services authorized for purchase by a
Contract Health Service or urban Indian program. Regulations require
hospitals that participate in the Medicare program to accept Medicare-
like rates as payment in full when providing services to Indian
patients. The rules place a cap on the amount hospitals may charge for
patients referred by the IHS, tribal and urban Indian organization
Contract Health Service (CHS) programs. The new law will provide IHS
and Tribally-operated CHS programs with similar benefits to those
enjoyed by other Federal purchasers of health care.
The Choctaw Nation is requesting that Section 506 be amended to
include ambulatory services.
Facilities Construction
The Health Facilities Construction Priority System (HFCPS) is a
two-tiered priority process that has been the culprit of conflict among
the Tribes and the IHS for years. The IHS Backlog of Essential
Maintenance and Report (BEMAR) survey for October 2007 estimates that
there is a backlog of $371 million in needed repairs to Indian health
facilities. The replacement value of facilities eligible for
Maintenance and Improvement (M&I) is $2.42 billion. The current
priority list was developed in 1991 (nearly two decades ago) and
embargoes Tribes from access to construction dollars unless they are
one of the facilities on the list. The current rate of health
facilities appropriations will keep the health facilities construction
priority system locked for at least another decade.
There is yet another priority list from previous years that
demonstrates the complacency of the IHS in acknowledging the enormous
level of need that exists for replacement and construction of health
facilities. Many Tribes support a moratorium on facilities construction
until IHS, in consultation with Tribes, develops an equitable funding
methodology. The Choctaw Nation is requesting that you make an inquiry
about the status of the funding methodology. Tribes would support a
study on this issue that will update the inventory, the level of need
and provide recommendations on how to address the backlog. However, as
I've stated previously, the facilities improvement and construction
backlog is primarily attributed to the lack of funding.
The Joint Ventures and Small Ambulatory construction programs are
an efficient way to maximize resources of the Federal Government and
the Choctaw Nation supports both. Tribes have been able to build more
health care space than IHS at a 3-1 ratio with the Joint Venture
Program and the Small Ambulatory Program. The Joint Venture program was
an amendment to the IHCIA under Section 818 and authorizes Congress to
appropriate recurring funds for increased staffing, operations and
equipment for new or replacement facilities constructed with non-IHS
funding acquired by Tribes. Self-Governance Tribes have been the
primary applicants for Joint Venture and Small Ambulatory programs but
due to the lack of funds, applications continue to gather dust as the
need for alternative facilities increases on a daily basis.
The Choctaw Nation entered into a Joint Venture Construction
Project and constructed the Idabel Clinic in 2005. The Idabel Health
Care Center provides a wide range of services in the 53,262-square-foot
building. The Choctaw Nation built the $11 million clinic with tribal
funds, and is named in honor of Charley Jones, a former Councilperson.
Services include dental, a diabetes component, general medicine,
optometry and a full lab and pharmacy.
In addition to Idabel, Choctaw has health facilities at the
following locations:
Talihina Hospital
McAlester Clinic
Hugo Clinic
Broken Bow Clinic
Poteau Clinic
Atoka Clinic (Opened in 2008)
Stigler Clinic
Hospitality House in Talihina
Choctaw Nation Diabetes Clinic
Children and Family Services--McAlester
Children and Family Services--Atoka
Recovery Center
Chi Hullo Li
On behalf of the Choctaw Nation we appreciate the opportunity to
offer our views on some of the needs and changes to the health care
service delivery system for Indian people.
Thank you for allowing me to testify this morning.
The Chairman. Thank you very much for your testimony.
I want to ask a couple of questions. First, a number of you
have mentioned contract health. And that is a very important
set of issues that we have to try to resolve. I mean, if we are
saying to people that money is only available for life and
limb, we are consigning a whole lot of folks to a lifetime of
pain and suffering.
We have all heard the stories about it. But in many cases,
our Indian populations live far from established cities. They
live on reservations, many miles from other hospitals. So the
Indian Health Service is where they must go to get health
treatment and health care. And when they go to some other
facility, because that facility has the means, the equipment,
and the ability to treat them, depending on the time of the
year, they may or may not get contract health care coverage. If
the services are not covered it may ruin their credit rating,
and they may continue to suffer from pain and illness and so
on. So we just have to try to address this issue of contract
health care.
But one of the things I wanted to ask about was something
Ron His Horse Is Thunder discussed, and some others did as
well, this issue of blood quantum. I fully understand the
sovereignty issue. I think perhaps more than most, I understand
that. On the other hand, when we write a health bill, the
question of eligibility is obviously important. And if one
tribe defines eligibility and another tribe says, no, no,
eligibility is way over here, those tribes then have an
opportunity to decide by themselves how many people will be
eligible. Some perhaps, Oklahoma is probably a pretty good
example, say that if you have any kind of Indian blood at all,
you are eligible for everything.
So I think those of us who look at this question, how do
you deal with blood quantum? If one Tribe says, if you have
one-500th, that triggers enrollment. And Ron His Horse Is
Thunder is short of Indian health care money because somebody
else has decided we are going to take a lot of that money by
the way we define blood quantum. Is that unfair? How do we deal
with this without some standard? Mr. Chairman?
Mr. His Horse Is Thunder. Thank you for the question, Mr.
Chairman. It is a very complex issue. The only thing that we
ask in the Great Plains is simply that, is allow tribes to
determine for themselves who are tribal members. I guess the
point I was trying to make in terms os the current, the
language of the current bill, was that it allowed for self-
identification, I believe, and/or for States to identify who
were and who weren't tribal members, besides tribes.
That is the portion of it that we object to, is States
determine who are and aren't tribal members. It should be
tribes who determine who are tribal members.
The Chairman. But that doesn't answer the question yet.
Mr. His Horse Is Thunder. That leads to the issue that you
were trying to get a handle on, and all tribes are trying to
get a handle on, and that is, simply, as you pointed out, some
tribes don't require blood quantum at all. It is just a lineal
descendance is all that require.
That is an issue that all tribes have to grapple with. But
I wouldn't, as a tribal leader, want to impose my tribal
eligibility criteria on another tribe. I couldn't do that. Nor
could I ask any other tribe to accept our eligibility standards
as well, too. It is something that all tribes are going to have
to come to grips with, simply because of the fact of the matter
that those who require a quarter blood quantum are going to
breed themselves out of existence. So tribes are changing their
blood quantum requirements. My tribe has just done so this past
year, to include all Sioux blood, where in the past we only
counted just Standing Rock blood.
So a number of our members weren't eligible, even though
they were full-blooded Sioux. So we are finally coming to grips
with that as an individual tribe. But that is our tribe's right
to choose who are members and who are not. And again, I would
not want to impose my standards on somebody else.
The Chairman. We wouldn't pass an Indian health care bill
that describes Indian health care by tribe. We will do it
generally. Then the question of who is eligible is an important
question. You talk about the tribes needing to grapple with
this; I understand that, they understand it. But they have
understood it for a long time and not been able to grapple with
it, because I assume no one wants to cede that decision-making
capability to anyone else.
And yet, if somehow the tribes can't deal with this, we
will never have an adequate definition. A definition that
doesn't, in some way, suck money away from one part of Indian
Country, because someone created a definition that was in their
interest on blood quantum.
I'm very sensitive to this issue of sovereignty, but I also
believe, Mr. Chairman, that somehow the tribes have to come
together to find a way to resolve this. Because I don't think
you just put an Indian health care authorization bill out there
and say, okay, now whatever it is you decide, that is okay,
because it doesn't have an impact on others. It has an impact
on others.
Let me just make one other point, if I might. I think the
advice a couple of you have given us today of not reintroducing
the same bill, is good advice. We have worked hard on trying to
create a framework, an architecture for a bill. But time has
changed. It has really been a couple of years.
So I think it would make sense to me if I and Senator
Barrasso and others members of this Committee, working with all
of you, can try to evaluate what should be the new approach in
this legislation. Obviously, we will continue with much of the
same structure, but use different approaches as well. So your
suggestions and thoughts about that, I think, will be
beneficial to us as we begin in a serious way trying to put all
this together.
We wanted to have the first hearing to be on health care to
signal our understanding that this is the priority. There are a
lot of priorities, but this is the priority. We need to get
this done. This is life or death for some people. So we need to
get it done and get it right.
All of you have given us some good things to think about.
Mr. Peercy, were you seeking recognition a moment ago?
Mr. Peercy. I was just going to address real quickly your
question, as the Chairman did, the blood quantum issue. You
alluded to the Oklahoma tribes. And it is really just the Five
Civilized Tribes in Oklahoma, it is based on history and it is
based on constitution. So that is in the constitution, it is a
sovereign issue.
But with us, we receive about $3 million from the Federal
Government in contract health care dollars. Those are used. But
the tribe also, and we are a gaming tribe, so there are lots of
uniquenesses and differences. Our council and chief put an
additional $7 million into our contract health program. So we
have about $10 million, but we still do not get out of category
one. So it is a major issue.
But the blood quantum issue may at some point come down to
the road where tribes such as us, we have to look at a tiered
sort of approach based on blood quantum. That we have not done,
that we try to stay away from. But as you say, the dollars get
thin and health care costs rise and populations rise. Thank
you, sir.
The Chairman. Senator Barrasso.
Senator Barrasso. Thank you very much, Mr. Chairman. I also
want to congratulate you on calling attention to the issues of
Indian health care and having the first committee meeting of
the year really to set the tone of where we need to go. We have
heard some incredible testimony today. First, we congratulated
Sally for being five minutes on the dot. It wasn't just perfect
timing, but it was very informative. You talked about under-
funding, imbalance of resources, and that is what we heard all
the way across.
We heard, write a new bill, use the old bill as a
framework. You talked about training physicians, recruiting
physicians, protecting tribal sovereignty, the tribal colleges
as a way to make sure that people who are trained in the
communities then stay there. In Wyoming, we are just trying to
get accreditation for our tribal college. It is helping with
economic development, with all the computer training. But to
get from that step to actually training of health care
providers is going to take time. We are not there yet.
As you said, don't tell us just to do more with less. And
then you told us of the incredible commitment of a group of
people who spent nine hours working on six pages. I wish that
the Senate would spend that kind of time just focusing on six
pages. We kind of do the opposite, less time on a lot more
pages. But that shows a level of commitment that is really an
example for all of us to try to learn from.
We talked about what is happening with urban care, where it
is different. We have established a community health center in
Wyoming where we have a third of the Board by the Eastern
Shoshone, a third by the Northern Arapahoe and a third by the
other members of the community at large. So there are different
challenges of going from urban centers to rural centers, very
difficult problems.
And then as we go across, we heard about health
discrepancies, I think was the word you used. You talked a lot
about the youth suicide and you said we were only funded at 60
percent of the needs. So again, talking about the failure to
get the required resources and insufficient resources.
And then, it was so obvious listening to your voice, you
could hear in your voice the frustration with the entire
bureaucracy of the Indian Health Service. It sounded to me, Mr.
Chairman, like we are talking about good people trapped in a
dysfunctional system. No matter what you do right, it still
doesn't solve the problem.
So I know we have to vote, and we have some other
obligations, but I just have a couple of quick questions, Mr.
Chairman. When we take a look, and maybe for Chairman Joseph,
what recommendations do you have for evaluating the Indian
Health Service system and the context you noted for including
any particular areas beside just the contract health service
program? Because we talked about Medicare and Medicaid. Do you
have specific ideas? And you may want to give more information
in writing to our staff.
But are there specific ideas that you have? Because in your
written testimony you included several areas to consider for
reform that pertain to Medicare and Medicaid. But you cautioned
that it wasn't fair to evaluate the entire Indian health system
under the current under-funded circumstances. So are there
additional things we should be doing?
Mr. Andrew Joseph. Well, the under-funding of the system is
really critical. If we were funded at 100 percent of the need,
then evaluating the system would be more fair to the system.
The IHS, the GPRA that we had to go through, IHS scored
probably the highest in the Nation out of all the health
departments with the limited amount of money. If we had the
full amount of money, it would definitely be the best program.
But there are a lot of things that do need to be changed, need
to make it more equal all across the Country so that all tribes
could benefit and all our children would benefit in a good way.
The funding is a real big issue. Our board had a meeting
last year in January, and we got a report from our area
director. Just the frustration that you talked about, I was so
frustrated I made a motion to declare the IHS funding in an
emergency crisis situation. And that resolution passed without
anybody denying it from any tribe. From there it went to the
Affiliated Tribes of Northwest Indians. And it was passed there
unanimously. From there it went to NCAI, this declaring a state
of emergency for Indian Health Service funding. And as a direct
service tribe's vice chair, we passed that same resolution.
If we had the full funding, it would really, I think it
would help. I've seen Chairman Dorgan in his testimony in the
Senate and I was there when he was at the Crow Tribe. And the
grandmother of this young lady that they lost, our tribes have
all kinds of similar situations. And I really respect you,
Chairman Dorgan, for bringing that onto the Floor. I think that
we really need to turn this Indian Health Service corner as
soon as possible. I know that the Steering Committee could put
in all the requests and the language that, it is pretty much
already done, it just needs to be re-entered into the Act.
Senator Barrasso. And Chairman His Horse Is Thunder, if I
could ask you, going through this, the differences. Congress
intended through the Indian Self-Determination and Education
Assistance Act for tribes to gain more control over the
programs, particularly through the annual budget consultation
process. But yet there are certain tribes, in Wyoming, the
Eastern Shoshone, the Northern Arapahoe, those tribes that do
not take over administration of the services like the direct
service tribes.
How much control and input do they have? Is this a system
that is working in determining the level of resources because
we heard about unequal resource distribution. Any thoughts on
that?
Mr. His Horse Is Thunder. There is a rule in IHS right now,
and we object to it. They say if you want to contract for
services that is, you must compact, you must compact for 100
percent of the services. And we object to that. We believe that
you should be able to 638 a portion of the services, up to what
you think you can handle. As tribes grow and progress in terms
of their administrative skills and their policy-making, as well
as being able to handle their own health care services, provide
those services, they should be able to 638 them up to the level
that they are comfortable with. If they want to 638 25 percent,
50 percent, 75 percent, that should be their choice. Right now,
IHS says you compact 100 percent or you don't compact at all.
Senator Barrasso. So one step at a time rather than the
whole thing at once?
Mr. His Horse Is Thunder. That is correct.
Senator Barrasso. Thank you, Mr. Chairman.
The Chairman. Thank you very much. In fact, they have just
delayed the vote briefly, so we are in pretty good shape with
respect to time.
I believe Chairman Joseph, you raised the issue of youth
suicide. We have had a couple of hearings on that subject here.
I know Chairman His Horse Is Thunder has had some suicide
clusters among youth on his reservation. And it breaks your
heart to go visit with some of the young people and some of the
family members of those who have felt that things were so
hopeless that they should take their own life. We need to work,
continue to work on that.
We have done some telemental health work here on this
Committee to try to extend services. I recall a hearing where a
young woman just broke down in tears. She was a young woman on
the Spirit Lake Nation Reservation. She was working on a wide
range of investigations of sexual abuse against children and so
on. She said there was a stack in her office, like that, that
had not even been investigated. Then she began talking about
children, some who had been abused, some who had emotional
difficulties, threatened suicide. She said, I don't even have a
car to get some child to mental health help. And we don't have
enough mental health help in the first place. But even if there
was enough help, there is not even a way to get that young
person to the place where they can get some help. Then finally
she just broke down sobbing and couldn't testify anymore. This
is the person who was working for the tribe in this area. About
three weeks later, she quit her job.
There is such under-funding of the resources needed to
address these range of issues. And elders are dying, children
are dying. We just have to do a better job. And we are
determined to try to do that.
The agenda for our Committee, as Senator Barrasso and I
spoke a couple of days ago, is obviously to pay a lot of
attention to health care and focus to try to write a bill and
work with all of you to get that through the Congress. We are
also going to deal with law enforcement, which I think is very,
very important. We have some tribal recognition bills that we
will have some hearings on and try to respond to. In addition
to health care, there are housing and education issues that we
will pay some attention to. And I mentioned the issue of teen
suicide.
There is a lot to do. I am passionate about it, excited
about it. I know the same is true with Senator Barrasso. I am
enormously pleased that he will now fulfill the role that
Senator Murkowski filled in the last Congress. This Committee
is one that has a lot to do. I don't think there is a
population in this Country that is as affected with
unemployment, poverty, lack of health care, good housing and
education challenges than this population. It happens to be the
First Americans who are often finding themselves getting second
class education, second class housing, second class health
care. We are determined to try to do something about that.
So thanks for traveling to Washington, D.C. to testify. It
is the first step of what will be a journey that we will take
together. I hope at the end of that journey, we all will have
felt we have done something that advances Indian health care in
this Country.
This hearing is adjourned.
[Whereupon, at 12:05 p.m., the Committee was adjourned.]
A P P E N D I X
Prepared Statement of Mead Treadwell, Chair, U.S. Arctic Research
Commission
My name is Mead Treadwell. Since 2002 I have been a member, and
since 2006 I have chaired, the U.S. Arctic Research Commission (USARC).
\1\ As a senior fellow at the Institute of the North, based in
Anchorage, Alaska, \2\ and in the private sector, I have worked for
much of my career on Arctic issues. My testimony represents the view of
the USARC, an advisory body to the Executive Branch and Congress, which
includes as a Commissioner Warren Zapol, MD, the Reginald Jenney
Professor of Anesthesia and Critical Care at Harvard Medical School,
and a Member of the Institute of Medicine. The Commission formulates
its positions in public meetings. The recommendations made by the
Commission do not necessarily represent the views of the
Administration. Nevertheless, I am proud to report that every relevant
office we work with in the White House and every relevant agency we
work with in the Executive Branch, takes conditions in the Arctic, and
recent changes to those conditions, very seriously.
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\1\ Under the Arctic Research and Policy Act of 1984, the seven
Commissioners of the USARC are appointed by the President and report to
the President and the Congress on goals and priorities of the U.S.
Arctic Research Program. That program is coordinated by the Interagency
Arctic Research Policy committee, (IARPC), chaired by National Science
Foundation Director Dr. Arden Bement, who is also an ex-officio member
of the Commission. See www.arctic.gov for Commission publications,
including the Commission's 2007 Goals Report.
\2\ The Institute of the North, www.institutenorth.org, was founded
by former Alaska Governor and U.S. Interior Secretary, Walter J.
Hickel. The Institute's work on Arctic issues supports the work of the
eight-nation Arctic Council and the circumpolar, regional governments
of the Northern Forum.
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As the Committee works to reauthorize the Indian Health Care
Improvement Act and add provisions that directly support health care
research, both in basic science and clinical care delivery, the USARC
wants to further stress the health research needs of Arctic residents.
In the Goals Report for the U.S. Arctic Research Program that the
USARC will shortly present to Congress, USARC will recommend, as it did
two years ago, that federal agencies develop an Arctic Health Research
Plan. The U.S. Government, as a committed provider of health care to
American Indians and Alaska Natives, can only improve its results in
fulfilling this responsibility with research that addresses real health
differences and meets real health needs of Arctic residents. The
Interagency Arctic Research Policy Committee within the Executive
Branch has adopted our recommendation, in principle, and several
agencies in the government responsible for health care delivery, as
well as health research, have made some progress in responding to that
direction. We are unable though, as yet, to point to a plan with
specific funding goals. The Arctic Research and Policy Act of 1984, as
amended, instructs the Commission to inform the Congress when budgets
and funding do not meet specific goals adopted in the U.S. Arctic
Research Plan. At present, we see disparate funding for health research
in the budgets of agencies, but, lacking an overall plan, we cannot
point to a coordinated effort. That fact gives the Commission great
concern.
We want the Committee to be aware of startling facts that have
motivated us, as a Commission, to turn up our efforts to see the U.S.
expand health research in the Arctic region.
Alaska's rural communities are experiencing a suicide epidemic.
Alaska Natives hold first place in national suicide incidence, with the
predominance occurring in 15-25 year olds. Indeed, the most recent
Indian Health Service statistics show that Alaska Natives commit almost
four times as many suicides as the general U.S. population. \3\ An
Alaska suicide follow-back study shows the complexity and depth of the
problem. \4\ Alaska Natives form a disproportionately high number of
Alaska's elevated suicide rate. During the 36-month study period,
Alaska Natives had a significantly higher average rate of suicide than
the non-Native population (51.4/100,000 compared to 16.9/100,000). \5\
The leading mechanism of death was firearms, accounting for 63 percent
of the suicides. \6\ Even more troubling, a recent 2007 Youth Risk
Survey reports that of 253 Alaska Natives in high school, 22.5 percent
``had seriously considered attempting suicide during the past 12
months,'' whereas 13.9 percent of 753 white students answered this
question positively. \7\ Clearly this reflects the unacceptably high
incidence of successful suicides, and is believed to be based on many
underlying problems including depression, darkness and seasonal
affective disorder, culture change, genetic susceptibilities,
alcoholism and gun prevalence.
---------------------------------------------------------------------------
\3\ Regional Differences in Indian Health, 2002-2003 Edition, Part
4, Chart 4.19, p. 58.
\4\ Alaska Suicide Follow-back Study Final Report, Study Period
September 1, 2003 to August 31, 2006, submitted by the Alaska Injury
Prevention Center, Critical Illness and Trauma Foundation, Inc. and
American Association of Suicidology to the Alaska Statewide Suicide
Prevention council, Alaska Department of Health and Social Services,
Alaska Mental Health Trust Authority.
\5\ Id. p. 5.
\6\ Id.
\7\ Alaska (Recoded Race) High School Survey, 2007 Youth Risk
Behavior Survey Results, p. 17
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USARC is taking a number of steps to move its recommendations for
an Alaskan health research plan forward.
USARC is working with the National Institutes of Health (NIH)
Fogarty International Center for Advanced Study in the Health Sciences,
to sponsor a conference in June 2009 that will develop a research plan
focusing on Arctic behavioral health. The conference will explore
Arctic health issues on an international scope, looking particularly to
learn if any Arctic country, such as Greenland or Canada, manages
mental health problems with more success than the U.S. It will focus on
what has worked elsewhere to expand what will be tried here.
Concurrent with its upcoming goals report, USARC is urging this
Congress to fund a study by the Institute of Medicine of the National
Academy of Science and the Polar Research Board to explore Alaska
Native genetic and environmental issues and develop a health research
agenda in both basic science and the clinical delivery of care that
goes beyond existing clinical and social work. Although many of the
mental and behavioral health and health-related social issues of Alaska
Natives are similar to those faced by other Native American populations
in other states, the problems in Alaska occur with greater incidence
and are made worse by the difficult physical environment (including
extreme cold and photoperiodic changes), rapid climate change affecting
subsistence resources and the stability of coastal dwellings, and the
limited availability of and access to health services, compounded by
rapid social changes in the past several decades.
The mental health problem cries out for research. Over the past two
decades, the Indian Health Service and Alaska government have tried a
variety of clinical and social work methods to improve Alaska Native
mental health. They simply are not working. Alaska Native mental health
problems remain far more severe than the general population, and
Natives in the Arctic experience a startling higher incidence, not only
of suicide, but also of depression, alcoholism and mental illness.
Suicide is only the tip of the iceberg. The study we recommend will get
the process started to identify which approaches have worked best and
what other research paths should be explored to address the epidemic of
Alaska Native mental health problems. It will review research and
prioritize what needs to be done, focusing on both basic science and
exploring effective interventions. It will examine new techniques, such
as telemedicine and telepsychiatry that will help us reach Alaska's
remote villages more effectively. \8\
---------------------------------------------------------------------------
\8\ Along these lines, the Institute of Medicine has observed that
scientific knowledge about best care is not applied systematically or
expeditiously to clinical practice. It has recommended that the
Department of Health and Human Services establish a comprehensive
program aimed at making scientific evidence more useful and accessible
to clinicians and patients. Also, it recommends using information
technology, including the Internet, to transform the health care
delivery system. ``Crossing the Quality Chasm: A New Health Care System
for the 21st Century,'' Institute of Medicine, National Academy Press,
March, 2001, pp. 5-6.
---------------------------------------------------------------------------
USARC is urging this Committee, and Congress, as it reauthorizes
the Indian Health Care Improvement Act, to make specific provision and
authorization for long-term, extramural research programs to support
Alaska Natives as a population at high risk. In the 21st Century as we
move to reform health care in our nation to be more effective, patient-
centered, timely, efficient and equitable, we must learn the
techniques, methods and practices that can improve Alaska Native mental
health most effectively. Through health care research, the best
practices can be identified and expanded. We believe health care for
Alaska Natives can be made much more efficient by focusing some money
and resources on research to determine what techniques and
interventions are most effective.
Finally, USARC urges this Committee and Congress to press the
Department of Health and Human Services, NIH and the Centers for
Disease Control to report back soon on their actions taken in
responding to the current Alaska Native health crisis.
Thank you for the opportunity to present this testimony.
______
Prepared Statement of Joseph Engelken, Executive Director, Tuba City
Regional Health Care Corporation
I want to thank Chairman Dorgan, Vice-Chairman Barrasso, and all
the Members of this Committee for allowing us to submit our testimony.
As providers of healthcare in Indian Country, we thank Congress for
passing the American Recovery and Reinvestment Act and for committing
significant resources to begin to address the serious backlog of
facilities construction, deferred maintenance and improvement projects
for Indian people. This is a crucial step towards advancing Indian
Health Care, however Congress can do much more than merely provide
funding, Congress can provide the leadership necessary to streamline
the administration of the Indian Health Service (IHS) so that the
delivery of health care is done efficiently, effectively, and
economically.
The Tuba City Regional Health Care Corporation (TCRHCC), is a
former IHS hospital within the Navajo Area Indian Health Services
system, located in Tuba City, Arizona. In 2002, in coordination with
the IHS, the Navajo Nation authorized a contract according to the
``Indian Self-Determination'' provisions of Public Law 93-638,
designating TCRHCC a Tribal Organization. TCRHCC employs nearly 800
people and is a Regional Medical Center for northern Arizona serving
nearly 28,000 primary care patients and administering over 75,000
regional referrals. Our medical service area serves most of the western
part of the Navajo Nation, and the Hopi Nation, which encompasses the
northern regions of Coconino County and Navajo County, including the
cities of Flagstaff, Page, and Kayenta.
In order to advance Indian healthcare from the perspective of a 638
facility, Congress must follow through and support the philosophy of
the P.L. 93-368 legislation of 1975. That is, to encourage tribal
entities to take responsibility for their own future. To create
economic development opportunities in service delivery, to leverage
funds across sources, and to expand our healthcare missions. To do
this, Congress must ensure that IHS become a pass through agency with
true accountability placed with the on the ground providers and not
with Rockville.
The current IHS structure of bureaucracy effectively cancels out
innovative ideas and makes entrepreneurialism impossible. For 638
contracted entities, this is diametrically opposite of the intention of
being community based, creative stewards who can leverage other sources
of funds to expand our health care services and mission. For example,
IHS's antiquated information system is designed specifically for the
purpose of extracting the minimal information that Rockville needs to
feed Congress the same old data reports it always has. As providers, we
have no way to data mine the IHS system for disease identification or
to share our information with other providers. The duplicative testing,
medical errors, and other problems with the Tuba City hospital's
existing system are currently causing loss of revenues estimated at $10
million per year.
Another example is the regulations of IHS's national construction
list, which require justification documents and duplicative engineering
reports. We have a proposed satellite facility, the Bodaway/Gap health
clinic, which ranks as a priority 3 on the national IHS construction
list, it has been in process for 25 years and has approximately another
5 years to wait before any construction occurs. If 638 facilities were
allowed to operate as any other private sector health entity, we could
build the health clinic at much less than estimated by IHS and complete
the project within 3 years.
The average age of a medical building in the private market is 9
years. TCRHCC operates out of two outdated IHS facilities. The old
hospital was built in 1954 and has outlived it's useful life. The
current medical center was built in early 1970s and was designed
inadequately even for its time. Both buildings are used today to house
hospital operations despite the deteriorated infrastructure and space
constraints because we have no other choice. According to a recent
estimate, expanding the hospital workspace will likely increase a
``return on investment'' in clinical productivity up to $1 million per
year. It is obscene the way IHS' capital projects are handled. Without
a requirement that morbidity and mortality be factored into the 30 year
wait for a community care facility then IHS projects will continue to
exist only on lists.
If Congress wants to advance Indian health care then it must get
away from top down approach that is our historical legacy. The best way
to advance Indian health care is to make it a part of the
Administration's overall healthcare reform policy. As long as Indian
healthcare continues to be marginalized it will continue to be seen as
an Indian problem only. This committee must work in collaboration with
the Administration, the House Energy and Commerce Committee and the
Senate Committee on Health, Education, Labor and Pensions to ensure
that Indian health care is considered as one part of our national
healthcare policy.
A first step towards beginning a meaningful dialogue on these
matters is for the Committee to seriously consider conducting a field
hearing in Indian Country. The purpose would be to gather the
perspectives of those on the ground delivering the services. We have
the experience dealing with IHS to know what works and what can be
improved. Such a hearing can also give your members an opportunity to
see first hand how the current IHS system is impeding the delivery of
healthcare service. Once again, we urge the Committee to also consider
a joint field hearing with the House Committee on Natural Resources,
and any other congressional committees of jurisdiction, to be held in
the near future in Tuba City Arizona on the Navajo Nation. Thank you.
______
______
Response to Written Questions Submitted by Hon. Byron L. Dorgan to
Rachel A. Joseph
Indian Health Care Improvement Act
Question 1. How do you see you and your Co-Chair, Buford Rolin's
role in participating in the efforts to move Indian health forward to
pursue reform efforts?
Question 1a.How do you think we can best build upon the work we did
to pass the Senate bill last year?
Question 1b.Please provide the Committee with a list of provisions
from S. 1200 which are essential and which provisions are not
necessary. Also, please provide the Committee with any other
information you think would be helpful in moving forward.
Answer. The NSC was established in 1999 by the Director of IHS to
provide assistance regarding the reauthorization of the IHCIA, set to
expire in 2000. The IHS asked tribes in each Area to designate a
representative and alternate to work together with IHS to make
recommendations for the reauthorization. The recommendations that
resulted and have largely addressed in the legislation considered by
Congress were intended to modernize the delivery of care by the IHS and
to formally authorize the improvements that tribes were making.
Ten years later the role of the NSC remains limited to the
reauthorization of IHCIA. Co-Chair Buford Rolin and I are deeply
committed to the passage of this critical piece of legislation. The
reauthorization of the IHCIA is an important first step in reform
efforts, however the NSC purpose is limited to that step and it is not
tasked to participate in reform discussions. The National Indian Health
Board (NIHB) is participating in health care reform discussions at the
Congressional and Administration level, informed in part by the tribal
leaders' discussions that have guided the NSC. The NSC is confident in
the NIHB's ability to advocate for Indian Country as the reform efforts
continue.
Many of the provisions added to the reauthorization bill as it was
amended on the Senate floor during the 110th Congress weakened the bill
and its ability to pass through the House. The NSC recommends moving
forward with the bill as drafted by the Senate Committee on Indian
Affairs or the House Natural Resources Committee, with updates. The NSC
over the course of a two day meeting and numerous conference calls has
revisited provisions that have been dropped or scaled back during the
ten year reauthorization efforts. Some of the current NSC
recommendations also reflect changes in view that result from the
passage of time. We have provided the SCIA staff with these
recommendations.
Extensive tribal consultation was held to develop the initial
tribal draft of the IHCIA legislation and it has been the subject of
countless meetings and updates in the intervening 10 years. This draft
developed by the tribes contains the essential provisions for Indian
Country. While numerous provisions regarding Medicare, Medicaid and the
Children's Health Insurance Program from the IHCIA legislation were
enacted into law through CHIPRA and ARRA, essential and necessary
provisions remain to be enacted either through the IHCIA or in the
course of health care reform.
Entitlement Programs
Question 2. Do you see increasing enrollment in entitlement
programs like CHIP, Medicaid and Medicare as a satisfactory way to
increase the access and quality of care in Indian Country?
Answer. Increased enrollment in entitlement programs like CHIP,
Medicaid and Medicare is a pragmatic and critical vehicle for
increasing access and quality of care in Indian Country given the
insufficiency of direct appropriations. It is vital that no one come to
believe that these programs can substitute for the Indian health
system, which includes the health programs operated by the Indian
Health Service, tribes, and urban Indian organizations. Culturally
competent and appropriate health care must remain an integral part of
the system and these entitlement programs do no address this when they
work in isolation from the Indian health system. Thus, we continue to
urge that the entitlement programs be designed to recognize and
accommodate the unique characteristics of the Indian health system and
American Indian and Alaska Native people. Indian specific provisions of
the Children's Health Insurance Program Reauthorization Act of 2009 and
the American Recovery and Reinvestment Act of 2009 provide good
examples of how legislation of general application can be tailored to
better support the Indian health system.
______
Response to Written Questions Submitted by Hon. Maria Cantwell to
Rachel A. Joseph
Health Care Reform
Question 1. Can you provide the Committee with examples of general
principles that should be adhered to when addressing Indian health care
reform?
When addressing Indian health care reform the NSC strongly
recommends no regression from current law as a starting point. As
stated in my response to Senator Dorgan's question on health care
reform, the NIHB has the capacity to participate in the health care
reform debate. The NIHB has outlined guiding principles for the new
Administration and Congress to follow in the development of any health
care reform. I have provided those guiding principles below and the
NIHB stands ready to work shoulder to shoulder with Congress on
ensuring that Indian Country is at the table and included in the health
care reform debate.
Trust Responsibility: Health care reform initiatives must be
consistent with the Federal Government's trust responsibility
to Indian Tribes acknowledged in treaties, statutes, court
decisions and Executive Orders.
Government-to-Government Relationship: Indian Tribes are not
simply another interest group. They are recognized in law as
sovereign entities that have the power to govern their internal
affairs. Based on the government-to-government relationship
with the Federal Government, Tribes need to be at the table in
any discussions on health care reform initiatives that affect
the delivery of health services to AI/AN people.
Special Legal Obligations: It is the policy of the United
States, in fulfillment of its legal obligation to Tribes, to
meet the national goal of achieving the highest possible health
status for AI/ANs to provide the resources necessary for the
existing health services to affect that policy.
Tribal Control and Management: The legal authority of Tribal
governments to determine their own health care delivery
systems, whether through the Indian Health Service (IHS) or
Tribally-operated programs, must be honored.
Distinctive Needs of AI/AN People: A community-based and
culturally appropriate approach to health care is essential to
preserve Indian cultures and eliminate health disparities. The
extremely poor health status of Indian people demands specific
legislative provisions to increased funding to break the cycle
of illness and addiction that began with the destruction of a
balanced Tribal lifestyle.
Access to Care: Indian health care services are not simply
an extension of the mainstream health system in America.
Through the IHS, the Federal Government has developed a unique
system based on a public health model that is designed to serve
Indian people in remote reservation communities. The Indian
health delivery system must be supported and strengthened to
enhance access to health care for AI/ANs.
As discussed above in response to the question from Senator Dorgan
regarding the role of entitlement programs, the vehicles for health
care reform, whether existing programs or new ones, need to be adapted
to support the Indian health system. To fulfill these principles,
Congress must expressly provide for meaningful participation by tribal
governments functioning in each of their capacities: as governments, as
employers of tribal members and non-Indians, as providers of health
care services, and as advocates for their members as users of health
care systems with unique cultural perspectives and needs. This
participation must respect the structures that already exist and
provide access and resources for them to grow and improve.
______
Response to Written Questions Submitted by Hon. Byron L. Dorgan to
H. Sally Smith
Indian Health Care Improvement Act
Question 1. Do you think that S. 1200 should be the framework for
future IHCIA legislative efforts?
Question 1a. Please provide the Committee with a list of provisions
from S. 1200 which are essential and which provisions are not
necessary. Also, please provide the Committee with any other
information you think would be helpful in moving forward.
Answer. S. 1200, as reported by the Committee and as revised by the
Manager's amendment accepted during floor debate, was a very good
product. But a number of objectionable provisions were added during
Senate debate--such as Sen. Vitter's amendment applying a far stricter
anti-abortion policy on the Indian health system and to Indian women
than applies to other federally-funded health programs and women whose
health care is provided by those programs.
H.R. 1328 was not burdened by the objectionable Senate floor
amendments. Thus, with regard to those issues, the House bill would be
the more preferred vehicle. Nonetheless, there are some instances where
the Senate's language is preferable to the companion provision in H.R.
1328.
The National Tribal Steering Committee for IHCIA reauthorization
recently transmitted to House and Senate staff recommendations for
refinements in the IHCIA legislation being developed for 111th Congress
introduction. The Committee stands ready to offer additional
recommendations as you or your staff require.
Input from Indian Country
Question 2. You noted in your testimony that holding listening
sessions would be a good way for the Committee to hear from Indian
Country. How do you see these meetings structured?
Answer. I recognize that you, your Committee colleagues and tribal
leaders all have many demands for their time. Thus, it would seem most
efficient to continue what you have been doing--that is, holding
listening sessions with local tribal officials when your Senate
business requires you to travel to other parts of the country, and
scheduling meetings with tribal leaders when they are in Washington,
such as you did during the NCAI Winter Session in Washington, D.C. The
Committee could also schedule field hearings in various parts of Indian
Country as you see fit. Establishing an agenda for discussion--as the
Committee did for the NCAI meeting--is very helpful as it enables
tribal leaders come prepared to discuss topics of interest to you.
Question 2a. Can you describe a timeline of how NIHB plans to be
helpful with moving forward with the health bill?
Answer. Enactment of an IHCIA reauthorization bill remains NIHB's
top priority. Therefore, our Board members and staff are committed to
providing any assistance requested by Congressional staff, and to being
pro-active in advocating for passage. In February, NIHB helped arrange
the meeting of the National Steering Committee which produced the
recommendations referenced above, and has had follow-up meetings with
House and Senate staff who are working on a bill. We also intend to
advocate with leadership in both parties, with individual members, and
with the Obama Administration officials to keep the IHCIA bill high on
the agenda for action.
Indian Health Service Efforts
Question 3. Do you see NIHB playing a role in the process taking
place at IHS? How so?
Answer. We have heard about IHS's internal self-examination but
have so far not been asked to participate in it nor has the Board been
asked to comment on any findings or recommendations. IHS officials made
a presentation on this at the October 2008, NIHB Consumer Conference,
and we are aware that Area Directors were instructed to make a power-
point presentation to tribes in their Areas. NIHB has not been asked,
however, to comment on any recommendations or proposals flowing from
this examination.
American Recovery and Reinvestment Act
Question 4. What type of impact do you think the provisions in ARRA
will have on Indian Country?
Answer. While we always have a greater need than we have funding,
Indian Country is sincerely grateful to have received such a generous
share of the ARRA funding. We appreciate the tremendous effort exerted
by you and others in Congress and the Administration to bring this
about.
We were extremely disappointed that the Conferees dropped the
additional funding for Contract Health Services which the Senate had
proposed.. We are eager to hear the details of the President's FY10
budget request for IHS, and hope that a good portion of the encouraging
increase in IHS funding will be targeted to CHS.
The funding for health care facilities construction is welcome, but
as you know, it is expected to fund only two construction projects
currently on the priority list. While the Indian people to be served by
those two projects will benefit from new facilities, many projects that
have been on the priority list for many years must continue to wait for
funding. Plus, a myriad of facilities needs exist throughout Indian
Country but do not yet appear on the priority list. A meaningful dent
in the facilities construction backlog will not be achieved unless/
until the Federal Government makes a commitment to supply a healthy
amount for new construction in the area of at least $300 million
annually.
It is too early to tell the extent to which the ARRA funding for
facilities maintenance and improvement and sanitation facilities will
be effective in curing the long-standing shortfalls for these programs.
We must first find out how these funds will be apportioned by IHS.
Question 4a. How does NIHB plan to take an active role in ensuring
these funds are utilized by Indian Country?
Answer. It is not within NIHB's authority to apportion funding or
direct how or on what projects it is spent by the agency or by tribes
who receive it. The ARRA gives IHS broad discretion in deciding how to
expend these new resources. We are hopeful that the agency will be
evenhanded in exercising this discretion, and will assure that projects
and programs operated by both IHS and tribes benefit from the funds. If
the Board receives complaints that the agency is not being evenhanded,
we will do our best to advocate for correction.
Indian Health Care Reform
Question 5. As a part of moving forward with Indian health and
reform you recommended in your testimony a deep examination of the
Indian health system. The goal would be to fully understand the issues
and come up with innovative solutions. How do you see the examination
structured? Please describe.
Answer. Ideally, a deep examination of the Indian health delivery
system would be a multi-year effort and be staffed by a cadre of
experts from inside and outside of Indian Country, particularly persons
experienced in delivering health care to underserved populations. A
special appropriation to fund the effort would likely be needed to do
it properly. Whether Federal resources for such an undertaking would be
available in the current economic environment is Questionable. You
would have greater insight on this than I do.
The next-best option is for the Administration and Congress to
assure that the Indian health system is an integral component of
President Obama's health care reform initiative. Like the mainstream
health care system, ours suffers from insufficient and uneven
distribution of resources, lack of access to care, problems with
recruitment and retention of providers to serve in remote areas, and
large numbers of underserved people. But statistics demonstrate that
our challenges are even greater, as the IHS system is funded at only 50
percent of need (at best), and Indian people suffer health disparities
far out of proportion to the overall American population.
Thus, Indian Country must have a seat at the table as health care
reform ideas are developed. To the extent Federally-funded health care
coverage is expanded, these opportunities must be extended to the IHS/
tribal service population with the costs covered by the Federal
Government as part of its trust responsibility for Indian health. We
agree that our Nation must put a greater emphasis on health education,
disease prevention and healthier lifestyles. The IHS system has long
followed these aspects of the public health model to the extent its
resources allow, but there are insufficient resources to achieve these
goals and to provide needed acute care, too.
I know from personal experience that tribally-operated programs use
their scarce funding as efficiently as possible and direct resources to
the specific needs of their local populations to the extent they can.
But we need help in many areas to achieve greater efficiencies. For
example, the ARRA provides much-needed funding for health information
technology--some of which will be directed to the IHS system--but it
will not close the gap.
I do not mean to suggest that all ills can be cured by more funding
alone. We also need authority to utilize modern methods of health care
delivery such as home- and community-based care which, for many
patients, is far more effective and less costly than facility-based
care. Your bill from the 110th Congress, S. 1200, would authorize such
care for the IHS system, as well as authority to provide assisted
living, long-term care and hospice care--all of which are prevalent in
mainstream America but not in Indian Country. Your bill would also re-
vamp behavioral health programs that are so badly needed to enable
Indian people to lead healthier lives, both physically and mentally.
With authority to use modern care delivery options, we can achieve
great economies and improved health status.
Please assure that Indian health advocates have a meaningful voice
in health care reform.
______
Response to Written Questions Submitted by Hon. Byron L. Dorgan to
Mickey Peercy
______
Written Questions Submitted by Hon. Byron L. Dorgan to
Hon. Ron His Horse Is Thunder *
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* Response was not available at the time this hearing went to
press.
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Written Questions Submitted by Hon. Byron L. Dorgan to
David Rambeau *
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* Response was not available at the time this hearing went to
press.
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Written Questions Submitted by Hon. Maria Cantwell to
David Rambeau *
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Written Questions Submitted by Hon. Byron L. Dorgan to
Andrew Joseph, Jr. *
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* Response was not available at the time this hearing went to
press.
Written Questions Submitted by Hon. Maria Cantwell to
Andrew Joseph, Jr. *