[Senate Hearing 111-12]
[From the U.S. Government Publishing Office]



                                                         S. Hrg. 111-12

                      ADVANCING INDIAN HEALTH CARE

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

                                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


                              ----------                              
                                                                   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

                              ----------                              


                       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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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) *
---------------------------------------------------------------------------

    * 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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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
---------------------------------------------------------------------------
    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\
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    \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.
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    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 *
---------------------------------------------------------------------------
    * Response was not available at the time this hearing went to 
press.


                                 ______
                                 
        Written Questions Submitted by Hon. Byron L. Dorgan to 
                            David Rambeau *
---------------------------------------------------------------------------
    * Response was not available at the time this hearing went to 
press.


                                 ______
                                 
         Written Questions Submitted by Hon. Maria Cantwell to 
                            David Rambeau *


                                 ______
                                 
        Written Questions Submitted by Hon. Byron L. Dorgan to 
                          Andrew Joseph, Jr. *
---------------------------------------------------------------------------
    * Response was not available at the time this hearing went to 
press.


         Written Questions Submitted by Hon. Maria Cantwell to 
                          Andrew Joseph, Jr. *


                                  
