    [Senate Hearing 111-88]
    [From the U.S. Government Publishing Office]

                                                             S. Hrg. 111-88

    NOMINATION OF YVETTE D. ROUBIDEAUX TO BE DIRECTOR OF THE INDIAN HEALTH
                                    SERVICE

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

                                    HEARING

                                   before the

                          COMMITTEE ON INDIAN AFFAIRS
                              UNITED STATES SENATE

                         ONE HUNDRED ELEVENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 APRIL 23, 2009

                                   __________

             Printed for the use of the Committee on Indian Affairs

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    -----------------------------------------------------------------------
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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 April 23, 2009...................................     1
    Statement of Senator Barrasso....................................     3
        Prepared statement...........................................     3
    Statement of Senator Dorgan......................................     1
    Statement of Senator Johanns.....................................    45
    Statement of Senator Johnson.....................................     4
    Statement of Senator McCain......................................     8
    Statement of Senator Tester......................................     4
    Statement of Senator Udall.......................................     5

                                   Witnesses

    Hill, Dr. Gerald, President, Association of American Indian
      Physicians.....................................................     6
        Prepared statement...........................................     7
    Roubideaux, Yvette, M.D., M.P.H., Nominee to be Director of the
      Indian Health Service..........................................     8
        Prepared statement...........................................    11
        Biographical information.....................................    13

                                    Appendix

    Department of Health and Human Services organizational chart.....    54
    Indian Health Service organizational chart.......................    53
    Letters submitted in support of the nomination of Yvette
      Roubideaux, M.D., M.P.H.:
        American Diabetes Association................................   111
        American Indian, Alaska Native, Native Hawaiian Caucus of the
          American Public Health Association.........................   121
        American Public Health Association...........................   124
        Association of American Indian Physicians....................   122
        Association of Native American Medical Students, University
          of Arizona College of Medicine.............................   125
        Bemidji Area Representative, National Indian Health Board....   116
        Bill Anoatubby, Governor, Chickasaw Nation...................   112
        Cherokee Nation..............................................   138
        Choctaw Nation of Oklahoma...................................   132
        Fort Belknap Indian Community................................   113
        Jamestown S'Klallam Tribe....................................   136
        Lower Elwha Klallam Tribe....................................   135
        Lummi Nation.................................................   133
        National Congress of American Indians........................   115
        National Council of Urban Indian Health......................   120
        National Indian Health Board.................................   118
        Native Research Network, Inc.................................   114
        Quinault Indian Nation.......................................   131
        Rosebud Sioux Tribe..........................................   127
        Shoalwater Bay Indian Tribe..................................   137
        Squaxin Island Tribe.........................................   134
        United South and Eastern Tribes, Inc.........................   139
    Response to written questions submitted to Yvette Roubideaux,
      M.D., M.P.H. by:
        Hon. John Barrasso...........................................    66
        Hon. Max Baucus..............................................   101
        Hon. Jeff Bingaman...........................................   107
        Hon. Barbara Boxer...........................................   109
        Hon. Maria Cantwell..........................................    75
        Hon. Tom Coburn..............................................    78
        Hon. Byron L. Dorgan.........................................    57
        Hon. John McCain.............................................    83
        Hon. Lisa Murkowski..........................................    85
        Hon. Jon Tester..............................................    87
        Hon. Tom Udall...............................................    97
    Supplementary information of Yvette Roubideaux, M.D., M.P.H.:
        Ethics agreement.............................................    55
        Nomination papers............................................    51

    NOMINATION OF YVETTE D. ROUBIDEAUX TO BE DIRECTOR OF THE INDIAN HEALTH
                                    SERVICE

                                  ----------

                            THURSDAY, APRIL 23, 2009

                                           U.S. Senate,
                                   Committee on Indian Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 2:15 p.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 call the hearing to order.
        This is a hearing of the Indian Affairs Committee of the
    United States Senate. It is a hearing on the nomination of Dr.
    Yvette Roubideaux for the Director of the Indian Health
    Service. Dr. Roubideaux, welcome, we are pleased you are with
    us.
        Let me state that President Obama sent Dr. Roubideaux's
    nomination to the Senate on March 26th. I am pleased to see a
    physician with on the ground experience and other applicable
    experience that this candidate has had for this position. Also,
    Dr. Roubideaux would be the first woman to lead the Indian
    Health Service, so I know this is also a historic nomination.
        I want to start by saying that I believe Dr. Roubideaux
    will be inheriting an Indian health system that is broken. The
    Indian Health Service is only funded at about one half of its
    need. Clinician shortages are rampant. Significant health
    disparities permeate Indian Country.
        In addition, the Indian Health Service is an agency, I
    believe, with some very serious management problems and very
    little follow-through, even when those problems are apparent.
    As I've said in the past, I think there are a lot of really
    terrific people working for the Indian Health Service. I've
    seen them and met with them. I've been around them all across
    this Country. God bless them for the work they do every day.
        But the fact is, many of them are working in a system that
    is unbelievably bureaucratic, in some cases headed by people
    who are incompetent in managing the system. This is not new.
    We've held hearings about this. We need to fix it. And my
    discussions about it and the requirements to fix it should not
    tarnish a lot of good people who work there. But it certainly
    ought to be a warning to the people who are there who have
    caused very serious management problems.
        The result of all of these issues is that Native Americans
    in our Country suffer health disparities on par with some of
    the Third World nations. Patients seem only to get care when it
    is life and limb emergencies. In Indian Country, we have heard
    from the table where you sit Dr. Roubideaux, don't get sick
    after June because there is no money to provide you with
    Contract Health Services. There is a rationing of health care
    in Indian Country that should be considered, in my judgement, a
    national scandal and should be headline news, but it is not.
        The impact of this broken system is clearly shown in the
    health disparities. A chart that we will ask to be shown, shows
    the health disparities between the general population, which is
    in blue, and American Indians in red. You can see with respect
    to tuberculosis, infant mortality, the rates of suicide,
    pneumonia and influenza, alcohol-induced illness, diabetes, you
    can see the disparity. It is very significant. The mortality
    rate of tuberculosis is 510 percent higher, suicide rates 70
    percent higher, alcoholism 500 percent higher, and diabetes 189
    percent higher.
        This is not just about numbers, but about people, people's
    lives. The next photograph you will see is of Jami Rose Jetty.
    In February, this Committee held a hearing, an oversight
    hearing on Indian youth suicide, teen suicide. At that hearing
    a young woman of 16 named Dana Lee Jetty of Spirit Lake Nation
    in North Dakota testified. She described losing her sister,
    Jami Rose Jetty, who committed suicide at just 14 years of age.
    Jami's mother knew there was something wrong with her daughter.
    She took her to the Indian Health Service over and over again,
    but they did not diagnose her with depression. And even though
    her mother knew better, the doctors would say, she is just a
    typical teenager and they sent the family home.
        November of last year, she took her life. Her sister, Dana
    Lee, found her. And during testimony, Dana said that she felt
    Jami would still be alive had there been trained mental health
    professionals available near the Spirit Lake Reservation to
    diagnose the needs. But Jami didn't receive those services. Her
    death was tragic and unnecessary.
        I have spoken about Avis Little Wind, who was 14, took her
    life on the same reservation. I have spoken about her several
    times on the Floor of the Senate. She laid in her bed in a
    fetal position for 90 days, nobody seemed to miss her. A
    terribly dysfunctional family, and eventually she took her own
    life.
        I spoke at length last year about Ta'shon Rain Little
    Light, this is a photograph that her grandmother used. Senator
    Tester and I were together on the Crow Nation Reservation in
    Montana when her grandmother began walking towards us as we
    held a hearing. She held that photograph above her head and
    that photograph, she said, is of my granddaughter. She said,
    you should know that she spent the last three months of her
    life in unmedicated pain. And she too was taken over and over
    and over again to the Indian Health Service and was told that
    she was depressed and sent home, over and over again.
        Finally, with a referral from the Billings Hospital and a
    plane ride to Denver got a diagnosis that she had terminal
    cancer and was about to die. The fact is, this young woman, was
    diagnosed as just being depressed. She wasn't depressed, she
    had terminal cancer.
        We just have to do so much better. I show you these
    photographs only to say that all of us, myself, Senators
    Barrasso, Johnson, and Tester, we represent real people that
    have real health care problems whose needs in many cases are
    not being met. The kind of health care problems that we would
    expect on a routine basis to be met for us, for our family, for
    the American people. They are not being met and young kids are
    dying and elders are dying. We have to do something about it.
        So we have today before us a new nominee for the position
    of running the Indian Health Service. I am going to support the
    nominee. I am very pleased she offered herself for public
    service. I desperately want her to succeed. We have to improve
    this; we must. People's lives depend on it.
        Before we proceed, let me call on my colleague, Senator
    Barrasso.

                   STATEMENT OF HON. JOHN BARRASSO,
                       U.S. SENATOR FROM WYOMING

        Senator Barrasso. Thank you very much, Mr. Chairman. I
    agree with you and associate myself with your remarks. I have a
    statement that I will include for the record.
        I would like to also join you in saying I do intend to
    support the nominee. I had a wonderful opportunity to visit
    with Dr. Roubideaux yesterday, had a great discussion on
    diabetes, on health care and prevention. We talked at length on
    the issues that you just discussed, that of the issue of
    suicide and what we can do to help, working so much with
    prevention, because in the Wind River Reservation in Wyoming,
    the life expectancy is 49. When you compare that to other men
    and women of our State with life expectancies around the age of
    80, those are tragic numbers and we need to do better.
        Thank you, Mr. Chairman.
        [The prepared statement of Senator Barrasso follows:]

      Prepared Statement of Hon. John Barrasso, U.S. Senator from Wyoming
        Good Morning and thank you Mr. Chairman for holding this hearing on
    Dr. Roubideaux's nomination for Director of the Indian Health Service.
        This position-along with Assistant Secretary for Indian Affairs-is
    one of the most challenging in the government.
        The Indian health care system is complex. It involves an extensive
    list of health services and programs, in a wide variety of geographic
    and demographic settings, provided by IHS, Indian tribes, and urban
    Indian organizations.
        In the past, I have pointed out challenges facing the Indian Health
    Service clinics on the Wind River Indian reservation. Like many other
    parts of Indian Country, funding is a problem for the Wind River
    clinics.
        But the condition of our facilities is particularly noteworthy.
        Built in 1877, the clinic in Fort Washakie is one of the oldest--if
    not the oldest--facility in the Indian health system.
        It's hard to imagine, but we are attempting to deliver modern
    health care services in a 132-year-old clinic. Yet with the current
    funding system, the Wind River clinics probably will not be replaced or
    extensively renovated during our lifetimes.
        Also, inefficiencies in the management systems of the IHS have real
    impacts at the reservation level. It is critical that the taxpayer's
    dollars are used efficiently, wisely, and effectively. This is
    especially true when the goal is the delivery of health care.
        Dr. Roubideaux's extensive research and educational background are
    impressive. Her dedication to improve Indian health is unquestionable.
    There is no doubt that she is an intelligent, thoughtful candidate for
    this position.
        But I am particularly interested in hearing what Dr. Roubideaux
    intends to bring to the IHS as its Director. What does she want to
    achieve? When she looks back on her time as Director, what will she
    point to as her principal accomplishment?
        Mr. Chairman, we are in the midst of the nation's health care
    reform debate. Now, more than ever, the IHS needs an exceptional
    leader.
        Thank you, Mr. Chairman.

        The Chairman. Senator Johnson, I know that you wanted to
    introduce Dr. Roubideaux, if you would be willing to do that.

                    STATEMENT OF HON. TIM JOHNSON,
                     U.S. SENATOR FROM SOUTH DAKOTA

        Senator Johnson. Thank you, Mr. Chairman. It is my honor
    today to introduce Dr. Roubideaux as the Indian Affairs
    Committee considers her nomination to be Director of the Indian
    Health Service. Dr. Roubideaux was born in Pierre and graduated
    high school in Rapid City in my home State of South Dakota. She
    is a member of the Rosebud Sioux Tribe, where I am fortunate to
    have many friends.
        The Chairman might be interested to know, her mother was
    from Standing Rock Reservation, which is straddling both South
    and North Dakota.
        We are very proud to have one of our own be nominated to
    this position. She has a bachelor's degree and a medical degree
    from Harvard. As you know, we have many unique challenges that
    face us in Indian Country, and especially in the Aberdeen Area.
    We would be well served to have Dr. Roubideaux as the IHS
    Director. Her experiences as a patient, a doctor and
    administrator within the IHS system provides her with first-
    hand knowledge that she needs to be an effective director of
    the IHS.
        I look forward to welcoming Dr. Roubideaux back to South
    Dakota soon. I also look forward to working with her as IHS
    Director to ensure that Federal Government does all that they
    can to fulfill its treaty and trust responsibilities to
    American Indians.
        Thank you.
        The Chairman. Senator Johnson, thank you very much.
        Senator Tester.

                     STATEMENT OF HON. JON TESTER,
                       U.S. SENATOR FROM MONTANA

        Senator Tester. Thank you, Mr. Chairman, and I too want to
    thank you for your remarks. I think that they said what a lot
    of us were going to say, and I appreciate that.
        The system is broken. There is no doubt about it. We have
    seen a lot of instances brought before this Committee and we
    have seen first-hand the kinds of challenges that IHS has been
    presented with. And quite frankly, in a lot of those cases,
    they failed to step up to the plate and hit the ball.
        I am impressed with your resume and I think you bring some
    things to the table that will help this agency move forward
    into the 21st century in a way that we have all hoped it would
    have been moving forward for a long time, and it hasn't. So
    success is critically important to all of us.
        There is one issue, and hopefully you can address this in
    your opening statement, and it is management experience. Lack
    of it can be a blessing and it can be a curse. So I think in
    your particular case, with your on the ground experience with
    the medical side of things, I like that. I like that a lot. And
    maybe you could talk about the administrative challenges and
    how you plan to address them.
        But with that, I too look forward to your taking over the
    Indian Health Service. I think as a Native American woman, you
    bring a lot of things to that department that can improve it.
        Thank you.
        The Chairman. Senator Udall?

                     STATEMENT OF HON. TOM UDALL,
                      U.S. SENATOR FROM NEW MEXICO

        Senator Udall. Thank you very much, Chairman Dorgan. Let me
    say that I had a very nice visit with Dr. Roubideaux and I
    think her credentials are excellent.
        I think maybe sometimes, like Senator Tester said, that not
    having the so-called management experience you can move in and
    really shake things up and move them in the right direction.
    You certainly have an inquisitive mind and curiosity about that
    process.
        One of the things that I hope you address, because I see it
    as just an addition to the massive problems that the Chairman
    mentioned, a huge issue is preventive care with our Native
    communities. We in New Mexico have an epidemic in diabetes and
    obesity on the reservation. Those problems have increased over
    time. I remember a nephrologist, a kidney doctor telling me in
    New Mexico that 30 years ago, when he started practice, he
    didn't see any Native American clients. And just in the short
    30 years that he has been in practice, he is now in the middle
    of an epidemic.
        So it shows in what a short period of time that has
    changed. This isn't some long, chronic situation. It is
    something that has occurred rather quickly. I kid my Navajo
    friends that it is the biliganna diet, the white man diet and
    all of them laugh. But I think that is a large part of it. And
    I think if we could put that preventive care in place it would
    really make a difference. I know you have been a real leader on
    that, you have focused on that. You have done epidemiological
    work in the area of diabetes. So we really look forward to
    working with you.
        I think each of the individuals have said, the Senators
    before me, that you are under-funded. I hope we can
    aggressively work on that. To me, the most traumatic comparison
    is that we spend three times as much for Federal prisoners as
    we do for a patient in the Indian Health Service. So that
    really says it all to me.
        With that, Mr. Chairman, thank you very much for this
    hearing.
        The Chairman. Senator Udall, thank you very much.
        Dr. Roubideaux, the Committee members will ask you
    questions today following your presentation. And then
    additional questions may well be submitted to you in writing.
    Once we have received responses to those questions, it is my
    intention that we would seek to report out your nomination at
    our next scheduled business meeting. We will try to move very
    quickly, because I would like this nomination to be approved by
    the entire Senate.
        The witness list today is Dr. Gerald Hill, who is the
    President of the Association of American Indian Physicians in
    Oklahoma City, Oklahoma. We will call on him first.
        But before I do, Dr. Roubideaux, do you have family members
    that you wish to introduce today who are with you?
        Dr. Roubideaux. I would just like to introduce my mother,
    Cecelia Roubideaux, who is back home in Tucson, Arizona, and
    will watch this webcast later.
        The Chairman. All right. We wish her well as well.
        Dr. Hill, why don't you proceed, and then we will recognize
    Dr. Roubideaux.

        STATEMENT OF DR. GERALD HILL, PRESIDENT, ASSOCIATION OF
                       AMERICAN INDIAN PHYSICIANS

        Dr. Hill. Thank you.
        Good afternoon, Chairman Dorgan, Ranking Member Issa, and
    the members of the Committee.
        My name is Dr. Gerald Hill. I'm a member of the Klamath
    Tribe of Oregon and a practicing emergency physician in St.
    Paul, Minnesota. I am also the elected president of the
    Association of American Indian Physicians, a national non-
    profit organization made up exclusively of American Indian and
    Alaska Native physicians.
        It is a great honor to be here today to introduce and
    express our support for Dr. Yvette Roubideaux in her nomination
    as Director of the Indian Health Service. The mission of the
    AAIP is to pursue excellence in Native American health care by
    promoting education in the medical disciplines, honoring
    traditional healing practices and restoring the balance of
    mind, body and spirit.
        Dr. Roubideaux, a Harvard-trained physician, is a member of
    the Association and one of our finest examples. She has earned
    a national reputation for professional excellence in all of her
    professional endeavors.
        Dr. Roubideaux's Native heritage and understanding of the
    community, as well as her development into a respected leader,
    physician, teacher, mentor and colleague, will provider her
    with a strong foundation should she be confirmed as Director of
    the Indian Health Service. Further, Dr. Roubideaux has
    witnessed the challenges of Indian health first-hand. Her work
    as a physician in the Indian Health Service for the San Carlos
    Apache Tribe and in the Gila River Indian community required
    that she not only understand western medicine but also how to
    apply this knowledge in Native communities.
        Dr. Roubideaux is among the most intelligent and dedicated
    people I have ever met. She has worked as a primary care
    physician in Native communities; led Native people in the fight
    against diabetes; mentored Native students; advised tribes and
    Government agencies; and as President of the AAIP, served as a
    leader for Native physicians. I have witnessed Dr. Roubideaux
    in discussion with tribal leaders in several settings. She
    shows the proper respect and interacts with them in familiar
    ways; has the courage to speak frankly and honestly to all and
    always from her heart. It is Dr. Roubideaux's breadth of work
    in all these areas that sets her apart and will lead to an
    outstanding career as Director of the Indian Health Service.
        Dr. Roubideaux's most outstanding work is her leadership
    and passion in the fight against the diabetes epidemic. I know
    this Committee is keenly aware of Dr. Roubideaux's integral
    role in the implementation and multiple reauthorizations of the
    Special Diabetes Program for Indians, which provides funding
    for 399 IHS, tribal and urban diabetes programs across the
    Nation. Such accomplishments are what make Dr. Roubideaux an
    outstanding choice for Director of the Indian Health Service.
        Dr. Roubideaux represents for Native people hope and
    intelligence, compassion and caring, education and achievement
    and more. She represents the best that Indian people have to
    offer to our communities and the Nation.
        I cannot think of another person more suited to lead the
    Indian Health Service. On behalf of the Association of American
    Indian Physicians, we sincerely appreciate this opportunity to
    introduce Dr. Yvette Roubideaux to the Committee and support
    her nomination. The vast scope of her knowledge and experience,
    combined with her passion and commitment to the health and
    well-being of Native communities, uniquely qualify her for the
    position of Director of the Indian Health Service.
        Thank you for the privilege and honor of introducing this
    outstanding Native woman to the Committee.
        [The prepared statement of Dr. Hill follows:]

       Prepared Statement of Dr. Gerald Hill, President, Association of
                           American Indian Physicians

        Good afternoon Chairman Dorgan, Vice Chairman Barrasso, and members
    of the Committee.
        My name is Dr. Gerald Hill. I am a member of the Klamath Tribes of
    Oregon, and a practicing emergency physician in St. Paul, Minnesota. I
    am also the elected President of the Association of American Indian
    Physicians, a national, non-profit organization made up exclusively of
    American Indian and Alaska Native Physicians. It is a great honor to be
    here today to introduce and to express our support for Dr. Yvette
    Roubideaux's nomination for Director of the Indian Health Service.
        The mission of the AAIP is to pursue excellence in Native American
    health care by promoting education in the medical disciplines, honoring
    traditional healing practices and restoring the balance of mind, body
    and spirit. Dr. Roubideaux, a Harvard-trained physician, is a member of
    the Association and one of our finest examples. She has earned a
    national reputation for excellence in all of her professional
    endeavors.
        Dr. Roubideaux's Native heritage and understanding of the
    community, as well as her development into a respected leader,
    physician, teacher, mentor and colleague, will provide her with a
    strong foundation should she be confirmed as Director of the Indian
    Health Service. Further, Dr. Roubideaux has witnessed the challenges of
    Indian health first-hand. Her work as a physician in the Indian Health
    Service for the San Carlos Apache Tribe and in the Gila River Indian
    community required that she not only understand western medicine but
    also how to apply this knowledge in Native communities.
        Dr. Roubideaux is among the most intelligent and dedicated people I
    have ever met. She has worked as a primary care physician in Native
    American communities, led Native people in the fight against diabetes,
    mentored Native students, advised tribes and government agencies, and,
    as president of the AAIP, served as a leader for Native physicians. I
    have witnessed Dr. Roubideaux in discussion with tribal leaders in
    several settings. She shows the proper respect and interacts with them
    in familiar ways, has the courage to speak frankly and honestly to all,
    and always from her heart. It is Dr. Roubideaux's breadth of work in
    all these areas that sets her apart and will ultimately lead to an
    outstanding career as IHS Director.
        Dr. Roubideaux's most outstanding work is her leadership and
    passion in the fight against the diabetes epidemic. I know this
    Committee is keenly aware of Dr. Roubideaux's integral role in the
    implementation and multiple reauthorizations of the Special Diabetes
    Program for Indians, which provides funding for 399 IHS, tribal and
    urban diabetes programs across the nation.
        Such accomplishments are what make Dr. Roubideaux an outstanding
    choice for Director of the Indian Health Service. Dr. Roubideaux
    represents, for Native people, hope and intelligence, compassion and
    caring, education and achievement, and more. She represents the best
    that Indian people have to offer our communities and the Nation.
        I cannot think of another person more suited to lead the Indian
    Health Service. On behalf of the Association of American Indian
    Physicians, we sincerely appreciate this opportunity to introduce Dr.
    Yvette Roubideaux to the Committee and support her nomination. The vast
    scope of her knowledge and experience combined with her passion and
    commitment to the health and well-being of Native communities uniquely
    qualify her for the position of Director of the Indian Health Service.
        Thank you for the privilege and honor of introducing this
    outstanding Native woman to the Committee.

        The Chairman. Dr. Hill, thank you very much for your
    comments.
        We have been joined by the former Chairman of this
    Committee, Senator McCain. Senator McCain, I am about to
    recognize Dr. Roubideaux for an opening statement. Would you
    like to have an opening statement?

                    STATEMENT OF HON. JOHN McCAIN,
                       U.S. SENATOR FROM ARIZONA

        Senator McCain. Could I just mention that obviously we are
    very pleased to have Dr. Roubideaux, but also, I think it is
    worthy of mention, she currently is at the Department of Family
    and Community Medicine at the University of Arizona. We are
    very proud of your work and we are very proud and appreciate
    the many contributions you have made.
        Thank you, Mr. Chairman.
        The Chairman. Senator, everyone is trying to claim her at
    the moment.
        [Laughter.]
        The Chairman. South Dakota, and her mother is a member of
    the Standing Rock Tribe that joins North Dakota. So we have all
    been very complimentary of Dr. Roubideaux.
        Dr. Roubideaux, why don't you proceed with your statement,
    following which you will entertain questions.

      STATEMENT OF YVETTE ROUBIDEAUX, M.D., M.P.H., NOMINEE TO BE
                 DIRECTOR OF THE INDIAN HEAlTH SERVICE

        Dr. Roubideaux. Thank you, Chairman Dorgan, Vice Chairman
    Barrasso, and members of the Senate Committee on Indian
    Affairs.
        My name is Dr. Yvette Roubideaux. It is an honor to appear
    before you today as President Obama's nominee to be the next
    Director of the Indian Health Service.
        I am a member of the Rosebud Sioux Tribe, which is my
    father's tribe, and I am also part Standing Rock Sioux Tribe,
    which is my mother's tribe. I have a long history with the
    Indian Health Service, first as a patient, then as a physician
    and a medical administrator.
        If confirmed, I look forward to working with your Committee
    to do whatever we can to improve health care for American
    Indians and Alaska Natives. Even though we face enormous
    challenges in this time of hope and change, I believe we have a
    unique opportunity to begin the difficult work of restoring
    health and wellness to American Indian and Alaska Native
    communities.
        I am grateful for all that your Committee has done to
    improve the health of American Indians and Alaska Natives. I
    know you understand the significant challenges facing the
    Indian Health Service. It is a health care system that is
    confronted with all of the same challenges facing the U.S.
    health care system today.
        But the Indian Health Service, which is different from all
    other agencies in the Department of Health and Human Services,
    also faces unique challenges. The Indian Health Service was
    established to meet the Federal trust responsibility to provide
    health care to members of federally-recognized tribes. The
    mission of the Indian Health Service is to raise the physical,
    mental, social and spiritual health of American Indians and
    Alaska Natives to the highest levels.
        However, this task has become increasingly difficult over
    time. Rapid population growth, increased demand for services,
    skyrocketing medical costs, difficulty in recruiting health
    care professionals, long waits for referral services and the
    growing burden of chronic diseases, such as diabetes, obesity
    and cardiovascular disease, have created a significant strain
    on a system that is struggling to maintain current levels of
    services and in some areas, faces reductions in services and
    potential closures.
        Despite these challenges, I see evidence of hope and
    change. As I mentioned, I have a long history with the Indian
    Health Service. I have seen up close the challenges of
    providing health care to this population with limited
    resources.
        However, I have also worked on a variety of projects and
    national initiatives over the past 16 years that have shown me
    the great potential that exists in the system to improve access
    to and the quality of health care. I know that thousands of
    committed and dedicated career staff in the Indian health care
    system work hard every day to provide health care to their
    patients under difficult circumstances. And I know that many
    facilities and programs in the Indian Health Service have
    implemented innovative programs and have helped solve some of
    our greatest administrative challenges at the local level. We
    need to do more to learn from those successes and apply those
    lessons to other programs in the system.
        In addition, with the new Administration, strong allies in
    Congress and renewed focus and energy on health reform from
    members of both parties, we have an opportunity to bring change
    to the Indian Health Service. President Obama is committed to
    ensuring that our First Americans have access to high quality
    health care. Even as a Senator, he supported increased Indian
    Health Service funding and passage of the Indian Health Care
    Improvement Act. New leadership in the Department of Health and
    Human Services will provide desperately needed support and
    direction. Congress has already passed legislation, the
    American Recovery and Reinvestment Act, that included critical
    resources for Indian Country. And many members have
    demonstrated a commitment to doing even more.
        In listening sessions held with tribes during the
    Presidential transition, I heard a great call for change and
    for a renewed effort to improve health care for our people.
    With this outpouring of support, I cannot help but feel we are
    at a unique moment in time where we have the potential to make
    great strides towards fulfilling the mission of the Indian
    Health Service and toward improving the health of American
    Indians and Alaska Natives.
        I am ready to serve and work with you to improve health
    care for American Indians and Alaska Natives. If confirmed, I
    plan to focus on four priority areas. First, I plan to renew
    and strengthen the Indian Health Service's partnership with
    tribes. I believe the only way we can restore our communities
    to health is to work in partnership with them. Toward that end,
    I intend to work with tribes to reviewing the existing tribal
    consultation process and to find ways to make that process more
    meaningful, so that we can work more closely together on the
    difficult challenges and decisions that face us in the coming
    years.
        Second, as a part of the effort to reform our national
    health system, I plan to begin discussions with tribes, our
    health care providers and our patients on how we can bring
    reform to the Indian Health Service. We need to undertake a
    comprehensive review of our system to determine how to better
    meet the needs of our patients within the parameters of both
    broader reform effort and the available resources in our
    system. With respect to both quality and delivery of care, I
    hope we can look at what we are doing well and do more of it,
    as well as understand what we are not doing well and come up
    with specific solutions.
        There may be difficult decisions ahead, but I am confident
    that in partnership with our tribes and with Congress, this
    Administration can and will make the right decisions.
        Third, if I am confirmed, I plan to make improving the
    quality and access to care a primary goal of all our work in
    the Indian Health Service. This has been a central goal of my
    work ever since I decided to become a physician. I believe it
    is a primary wish of our patients. In order to restore their
    confidence in our system, we have to demonstrate that we
    provide high quality care they know they deserve. We need to
    implement more strategies to increase access to care in our
    system, to improve the quality of clinical services that we
    provide, and just as important, to provide better customer
    service.
        Finally, we need to ensure that what we do to improve the
    Indian Health Service is transparent and accountable, and that
    we are as fair and inclusive as possible in considering the
    needs of all of our patients, whether they are seen in INS
    direct facilities, tribally-managed programs or urban Indian
    health programs. I know we can make strides to improve care in
    the Indian Health Service. I have seen the best of what we can
    do in my work as co-director of the Coordinating Center of the
    Special Diabetes Program for Indians demonstration projects.
    This $27.4 million annual Congressional appropriation created a
    grant program to translate scientific evidence into real world
    diabetes and cardiovascular disease prevention programs.
        This successful initiative has proven that when the Indian
    Health Service and tribal and urban Indian programs are given
    needed resources and adequate technical assistance and support,
    they can step up to the plate, implement a complex set of
    evidence-based services, evaluate their activities and deliver
    positive outcomes that exceed everyone's expectations. These
    programs demonstrated that the Indian health system has the
    potential to markedly improve the quality of health care it
    provides if given the support it needs to be successful.
        I realize that we face enormous challenges and that this
    work will not be completed in days, weeks, months or even
    years. But if confirmed, I am ready to begin the important work
    of bringing change to the Indian Health Service. I know our
    patients are ready for it, and I know there are many tribal
    leaders, Indian health care staff and providers who have ideas
    for how we can achieve that goal.
        I am confident that we can all work together in this
    effort, and I will rely on the guidance and support of this
    Committee as we move forward.
        Again, thank you for the opportunity to have a conversation
    about American Indian and Alaska Native health care today. I am
    happy to answer any questions.
        [The prepared statement and biographical information of Dr.
    Roubideaux follow:] *
    ---------------------------------------------------------------------------
        * The financial disclosure report of Dr. Roubideaux has been
    retained in Committee files.

     Prepared Statement of Yvette Roubideaux, M.D., M.P.H., Nominee to be
                     Director of the Indian Health Service

        Chairman Dorgan, Vice Chairman Barrasso, and members of the Senate
    Committee on Indian Affairs: My name is Dr. Yvette Roubideaux, and it
    is an honor to appear before you today as President Obama's nominee to
    be the next Director of the Indian Health Service.
        I am a member of the Rosebud Sioux Tribe, my father's tribe, and I
    am also part Standing Rock Sioux, which is my mother's tribe. I have a
    long history with the Indian Health Service--first as a patient, and
    then as a physician and medical administrator.
        If confirmed, I look forward to working with your committee to do
    whatever we can to improve healthcare for American Indians and Alaska
    Natives. Even though we face enormous challenges, in this time of hope
    and change I believe we have a unique opportunity to begin the
    difficult work of restoring health and wellness to American Indian and
    Alaska Native communities.
        I am grateful for all that your Committee has done to improve the
    health of American Indians and Alaska Natives. I know you understand
    the significant challenges facing the Indian Health Service. It is a
    healthcare system that is confronted with all of the same challenges
    facing the U.S. healthcare system today.
        But the Indian Health Service, which is different from any other
    agency in the Department of Health and Human Services, also faces
    unique challenges. The Indian Health Service was established to meet
    the federal trust responsibility to provide healthcare to members of
    federally recognized tribes. The mission of the Indian Health Service
    is to raise the physical, mental, social, and spiritual health of
    American Indians and Alaska Natives to the highest level. However, this
    task has become increasingly difficult over time. Rapid population
    growth, increasing demand for services, skyrocketing medical costs,
    difficulties in recruiting and retaining healthcare professionals, long
    waits for referral services, and the growing burden of chronic diseases
    such as diabetes, obesity, and cardiovascular disease have created a
    significant strain on a system that is struggling to maintain current
    levels of services and, in some areas, faces reductions in services and
    potential closures.
        Despite these challenges, I now see evidence of hope and change. As
    I mentioned, I have a long history with the Indian Health Service. I
    have seen up close the challenges of providing healthcare to this
    population with limited resources. However, I have also worked on a
    variety of projects and national initiatives over the past 16 years
    that have shown me the great potential that exists in the system to
    improve access to and quality of healthcare. I know that thousands of
    committed and dedicated career staff in the Indian healthcare system
    work hard every day to provide healthcare to their patients under
    difficult circumstances. And I know that many facilities and programs
    in the Indian Health Service have implemented innovative programs and
    have helped solve some of our greatest administrative challenges at the
    local level. We need to do more to learn from those successes and apply
    those lessons to other programs in the system.
        In addition, with a new Administration, strong allies in Congress,
    and renewed focus and energy on health reform from members of both
    parties, we have an opportunity to bring change to the Indian Health
    Service. President Obama is committed to ensuring that our First
    Americans have access to high-quality healthcare Even as a senator, he
    supported increased Indian Health Service funding and passage of the
    Indian Health Care Improvement Act. New leadership in the Department of
    Health and Human Services will provide desperately needed support and
    direction. Congress has already passed legislation--the American
    Recovery and Reinvestment Act--that included critical resources for
    Indian country, and many members have demonstrated a commitment to
    doing even more. And in listening sessions held with tribes during the
    Presidential Transition, I heard a great call for change and for a
    renewed effort to improve healthcare for our people. With this
    outpouring of support, I cannot help but feel that we are at a unique
    moment in time, where we have the potential to make great strides
    toward fulfilling the mission of the Indian Health Service, and toward
    improving the health of the American Indian and Alaska Native
    population.
        I am ready to serve and to work with you to improve healthcare for
    American Indian and Alaska Native people. If confirmed, I plan to focus
    on four priority areas.
        First, I plan to renew and strengthen the Indian Health Service's
    partnership with tribes. I believe the only way we can restore our
    communities to health is to work in partnership with them. Toward that
    end, I intend to work with tribes to review the existing tribal
    consultation process and to find ways to make that process more
    meaningful so that we can work more closely together on the difficult
    challenges and decisions that face us in the coming years.
        Second, as part of the effort to reform our national health system,
    I plan to begin discussions with our tribes, our healthcare providers,
    and our patients on how we can bring reform to the Indian Health
    Service. We need to undertake a comprehensive review of our system to
    determine how to better meet the needs of our patients within the
    parameters of both the broader reform effort and the available
    resources in our system. With respect to both the quality and delivery
    of care, I hope we can look at what we are doing well and do more of
    it, as well as understand what we are not doing well and come up with
    specific solutions. There may be difficult decisions ahead, but I am
    confident that, in partnership with our tribes and with Congress, this
    Administration can and will make the right decisions.
        Third, if confirmed, I plan to make improving the quality of and
    access to care a primary goal of all of our work in the Indian Health
    Service. This has been a central goal of my work every since I decided
    to become a physician, and I believe it is a primary wish of our
    patients. In order to restore their confidence in our system, we have
    to demonstrate that we provide the high-quality care they know they
    deserve. We need to implement more strategies to increase access to
    care in our system, to improve the quality of clinical services that we
    provide, and just as importantly, to provide better customer service.
        Finally, we need to ensure that what we do to improve the Indian
    Health Service is transparent and accountable, and that we are as fair
    and inclusive as possible in considering the needs of all our patients,
    whether they are seen in IHS direct service facilities, tribally
    managed programs, or urban Indian health programs.
        I know we can make strides to improve care in the Indian Health
    Service. I have seen the best of what we can do in my work as the Co-
    Director of the Coordinating Center for the Special Diabetes Program
    for Indians Demonstration Projects. This $27.4 million annual
    congressional appropriation created a grant program to translate
    scientific evidence into real world diabetes and cardiovascular disease
    prevention programs. This successful initiative has proven that when
    Indian Health Service and tribal and urban Indian programs are given
    needed resources and adequate technical assistance and support, they
    can step up to the plate, implement a complex set of evidence-based
    services, evaluate their activities, and deliver positive outcomes that
    exceed everyone's expectations. These programs demonstrated that the
    Indian health system has the potential to markedly improve the quality
    of healthcare it provides if given the support it needs to be
    successful.
        I realize that we face enormous challenges and that this work will
    not be completed in a matter of days, weeks, months, or even years.
    But, if confirmed, I am ready to begin the important work of bringing
    change to the Indian Health Service. I know our patients are ready for
    it. And I know there are many tribal leaders, Indian healthcare staff,
    and providers who have ideas for how we can achieve that goal. I am
    confident that we can all work together in this effort, and I will rely
    on the guidance and support of this committee as we move forward.
        Again, thank you for the opportunity to have a conversation about
    American Indian and Alaska Native healthcare today. I am happy to
    answer any questions.
                                     ______

        The Chairman. Dr. Roubideaux, thank you very much.
        I am going to defer my questions until the end of the
    process. I will call on the Vice Chairman, Senator Barrasso.
        Senator Barrasso. Thank you very much. You have had a
    chance to answer most of the questions that I had yesterday.
        Listening to Dr. Hill talking about your intelligence, as
    well as your dedication, and both will serve you very well in
    this job, but it is, I believe, your dedication which is going
    to make the real difference in the success that I see you
    having in the years to come. So I am very grateful for that.
        I did a little research last night. I told you about the
    Indian Health Service building that we have in Wyoming, and I
    said, it must be at least 100 years old. I think somewhere in
    here we had the number, and I have lost it right now, I think
    it is approximately 130 years old. So I am still welcoming you
    to visit us in Wyoming at the Wind River Reservation and see
    what we can do to help things there.
        Yesterday you and I talked a bit about diabetes management
    and treatment. I told you about a number of young men who were
    with us on Sunday in Casper, Wyoming, at a deployment service
    for members of the military. They performed a tribal ceremony,
    a send-off, a blessing. Looking at them, I had great concerns
    for their own health, for the potential for diabetes, for their
    life expectancy. Could you just take a couple of seconds to
    share with us your vision and maybe some ideas you have on how
    we can really come to grips and, even more successfully under
    your leadership, address these problems?
        Dr. Roubideaux. Thank you. Yes, the problems of the health
    status of the American Indian and Alaska Native population are
    great. Chronic diseases such as diabetes and obesity are
    threatening the lives of our people. What is so heartbreaking
    about it is we are seeing young children who are obese, and we
    are seeing young children with diabetes. We know that if they
    have these conditions early in life, they are also going to
    experience the complications early in life as well. And that is
    heartbreaking. We don't want this new generation of American
    Indians to die before their parents. We want them to live long
    and healthy lives.
        So first, we do need to look at the Indian Health Service
    and look what we have done well in terms of treating and
    preventing diabetes. Fortunately, your Committee has supported
    the Special Diabetes Program for Indians. I believe these
    resources have gone to great use in terms of helping us begin
    the process and the fight against diabetes, both prevention and
    treatment of this illness.
        If confirmed, as I look at the Indian health care system, I
    definitely want to improve the quality of care, I want to
    improve access to care and to make sure our patients are
    getting needed health care services.
        Senator Barrasso. I will just go with one other question,
    Mr. Chairman. We are having a major debate here in the Senate
    and in Congress on overall reform of health care in America. We
    passed a bill last year through this Committee and through the
    Senate that had to do with the Indian Health Service and didn't
    make it all the way through the process. Are there thoughts you
    have on ways that we can improve the Indian Health Service from
    a legislative standpoint to make you more successful in your
    job as the new Director?
        Dr. Roubideaux. Well, yes. As you know, the Indian Health
    Care Improvement Act was passed by the Senate but didn't make
    it through Congress last year. Tribes have supported this bill
    for years because they see it as a way to improve and modernize
    the Indian Health Service. Both the President and I support
    passage of this legislation.
        So I am looking forward to working with you to find
    solutions to ensure that we pass this important piece of
    legislation.
        The Chairman. Senator Johnson.
        Senator Johnson. Congratulations, Dr. Roubideaux.
        Is it possible to address the issues of preventive care,
    diabetes, obesity, cancer, suicide and mental health, among
    other things, within your current budget?
        Dr. Roubideaux. Well, you have hit the nail on the head. It
    is clear that the Indian Health Service funding is woefully
    inadequate to meet the needs of this population. It is clear
    that we can do a lot better job if we had more resources.
        Of course, these are difficult budgetary times, and
    everybody is being asked to do more with less. But if you look
    at the Indian Health Service, I am confident that it needs a
    significant increase in additional resources to help address
    some of these problems.
        In addition, the President and I know money is not the only
    solution. So I plan to look at what we are doing in the system,
    what we are doing well and try to spread the lessons learned of
    that around in the system, and make sure that if there are
    things we are not doing well that we correct them. So I think
    there is a lot we can do toward preventing disease and treating
    disease.
        In addition, I am looking forward to talking with our
    tribal leaders. I think that the solutions to restoring our
    communities to health and wellness is to partner with our
    tribes. Now more than ever, we need their help. Because the
    clinic cannot deal with these health problems alone. Many of
    the health problems have their roots in other conditions in the
    community. So I am really looking forward to working with our
    tribes on solutions to these problems.
        Senator Johnson. Where is there such a level of suicide
    among our Native Americans?
        Dr. Roubideaux. The story of suicide in Native Americans,
    especially young teenagers, is heartbreaking. It is
    heartbreaking to see a young life end before they have had a
    chance to make their potential contribution they could to our
    society. I think that problems like suicide have deep roots
    throughout all of the issues we face in Indian Country, and
    that it is important, when we look at the solution for suicide,
    that we work closely with our communities and we work with as
    many partners as we can to try to figure out how to adequately
    identify people at risk, how to treat them and respond to them
    and keep them safe. But we also have to definitely work on
    correcting those factors in our communities that are making our
    children think that they don't have a life that is worth
    living. We want them to live longer and we want them to be
    healthy.
        So I am looking forward, if confirmed, to working with you
    to talk about what some of those solutions might be and also
    working with our tribes.
        Senator Johnson. One last question. It seems to me that the
    level of education and income ought to be addressed along with
    health care. They are intertwined. As long as we lack education
    and income, we will have a problem with obesity among other
    things. Do you agree with that?
        Dr. Roubideaux. Yes. I think that in order for a person to
    be healthy, they need to be living a healthy life. And if they
    don't know how to live a healthy life, then they don't have a
    chance. In our communities, we have a problem with poor
    schools, we have problems with crime, we have problems with
    substance abuse. All of those things are barriers to the
    successful lives of our population.
        I look forward to working with our tribes to see if there
    are ways that we as the Indian Health Service can help provide
    more health education into the community. I think it is
    important that everybody should know how to eat healthy, how to
    make healthy choices, the importance of exercise. And to
    understand how the clinic works and make sure that they can get
    access to good quality care.
        So if confirmed, I look forward to working with you and our
    tribes on this problem as well.
        Senator Johnson. Thank you, I yield back.
        The Chairman. Senator Johnson, thank you very much.
        Senator McCain?
        Senator McCain. Congratulations again, Doctor, and we look
    forward to working with you on issues that you obviously have
    very in-depth knowledge of and are highly qualified to address.
        One of the problems that we have seen throughout my time on
    this Committee is the failure, at least perceived failure, on
    the part of the tribes to be adequately consulted when
    priorities are set by the Department of Health and Human
    Services and the Indian Health Service as well. So I think it
    is important, as you mentioned in one of your answers, that you
    travel to Indian Country as extensively as possible,
    particularly at the beginning of your tenure.
        As you know, most of the tribes that I know feel there is a
    big disconnect between Health and Human Services and the Indian
    Health Service and the tribal priorities. Sometimes I think
    those concerns are real, sometimes maybe not. It is just a lack
    of information flowing all the way to the tribal governments.
        Nearly $500 million in stimulus money goes to the Indian
    Health Service, as you know; $227 million of it will be spent
    on construction of IHS facilities. Will you have an input into
    what those priorities are?
        Dr. Roubideaux. Well, I am aware, and I am grateful for the
    funding in the stimulus package for facilities in the Indian
    health care system. What I can tell you is that upon
    confirmation and when I assume this office, I can look into
    this issue and look at how priorities are made for how this
    funding is going to be distributed.
        Senator McCain. Do you know if those priorities have been
    established yet?
        Dr. Roubideaux. I know that there are existing priority
    lists for facilities and maintenance and construction. I
    imagine that those existing priorities may have been used, but
    I am going to need to look into this more once if confirmed to
    be IHS Director.
        Senator McCain. I don't know whether those decisions have
    been made or not, and maybe some of them are tentative. But let
    me recommend to you, $227 million for construction of IHS
    facilities, an additional $227 million, doesn't come along very
    often. So let me be a little presumptuous and strongly
    recommend you jump right into that process now.
        As you know, there have been alot of projects on the
    priority list that have been on there for years and years and
    years. You also know that the construction projects are
    unfunded by nearly $3.5 billion. As of fiscal year 2008, the
    maintenance backlog is estimated to be $408 million.
        So how this money is spent I think is very important. I
    would be very interested in how our Native American tribal
    leadership sets those priorities. A lot of times they don't
    want to, because they don't want to, as you well know, maybe
    alienate some other tribes by setting the priorities. But I
    think you should ask our tribal organizations what their
    priorities are, so that they are consulted.
        Finally, the issue of diabetes we are very well aware of. I
    think we also know that wellness and fitness plays a big role
    in that. You have seen it, as I have, time after time. So I
    hope you will devote some of your efforts on the issue of
    obesity, because we all know, you know better than I that the
    incidence increases dramatically. And that goes down to
    wellness and fitness.
        So I want to congratulate you. I am sure that your
    nomination will be held up and there will be great controversy
    surrounding it, but we will try and get it done as quickly as
    possible. I am sure the Chairman will agree.
        Thank you very much, Doctor, and thank you for your
    willingness to serve. We are very proud of you.
        Dr. Roubideaux. Thank you.
        The Chairman. Senator McCain, thank you very much.
        Senator Johanns.

                    STATEMENT OF HON. MIKE JOHANNS,
                       U.S. SENATOR FROM NEBRASKA

        Senator Johanns. Thank you very much, Mr. Chairman.
        Doctor, it is good to see you again. I of course had an
    opportunity to visit with you at some length and I appreciated
    that opportunity. And of course, I join with Senator McCain in
    saying congratulations and I wish you the very best. I am very
    anxious to work with you on issues important to Nebraska.
        Let me follow up on the issue of diabetes, which we had a
    conversation about. It is hard for me to imagine that we
    improve Indian health very much if we don't address the issue
    of diabetes in a very meaningful sort of way. I go to a
    reservation in Nebraska, the Omaha reservation, and they have a
    dialysis center there, doing great things, doing exactly what
    you want them to do. Somebody shares with me that 40 to 50
    percent of the adult population there has diabetes. And of
    course, that just brings everything with it, heart problems and
    it is just a bad deal. My father had adult onset diabetes.
        Give me some ideas, if you will, in terms of how do we
    attack that? How do we knock this rate down? What are some of
    the things that science or just good medical practices tell us
    that would make a difference here? If you could be in charge of
    everything for a day, and resources were not an issue, which of
    course they always are, what would you do? What would you
    recommend to the Senate that we do?
        Dr. Roubideaux. If confirmed, I would be pleased to work
    with you on this problem of diabetes in American Indians and
    Alaska Natives. You are correct, it is a huge problem. It is
    causing so much of a burden on our population and a huge part
    of the budget in the Indian Health Service is spent on the
    complications of diabetes.
        I think we can focus efforts in two areas, in both
    prevention and treatment. I think the Special Diabetes Program
    for Indians was a great start, but we clearly need to do more.
    I think we can do more efforts regarding prevention in our
    communities. Maybe we could do more prevention education in our
    schools with our children. Maybe we can do more education with
    our teenagers, more work with our tribes to make sure healthy
    foods are available in the grocery stores, to make sure that
    there is more exercise and safe walking paths so that people
    can be fit and healthy. So there is a lot we can do toward
    prevention.
        This is based on science. We know based on the Diabetes
    Prevention Program that lifestyle changes, including losing up
    to 7 percent of body weight through healthy eating and through
    regular exercise, not running marathons, but 30 minutes five
    days a week, can reduce the risk of diabetes by 58 percent. We
    know that is possible and being a scientist, I really believe
    in using evidence-based strategies to be able to improve the
    health of our population.
        So in the area of prevention, we know what to do, we just
    need to more of it. I think there is a lot of great lessons
    learned in the Special Diabetes Program for Indians. All of the
    great things that have been done there, and I would like us to
    share the lessons learned of that program as well.
        And again, treatment, we know what we need to do for
    diabetes. So if confirmed, I am looking forward to working with
    you all to see what else can we do to address this serious
    epidemic. And let's turn it around as soon as possible.
        Senator Johanns. I appreciate the answer. I know many have
    worked on this issue for a long time. There is some great
    science out there. We do have a lot of answers.
        But I would just wrap up by saying, I really look forward
    to working with you on a whole host of issues. I have met with
    my tribes and they were very excited about you. My hope is that
    we can get you back to Nebraska some time. So I will just
    extend an invitation to you now, and I hope your schedule will
    permit that.
        Dr. Roubideaux. Thank you very much.
        Senator Johanns. Okay, great. Thank you.
        Thank you, Mr. Chairman.
        The Chairman. Senator Johanns, thank you very much.
        Dr. Roubideaux, the diabetes issue is a very important one.
    I began work on that so, so long ago, flying into the Three
    Affiliated Tribes on the Fort Berthold Reservation. I flew in
    on a small airplane one day with the late Mickey Leland, who
    later died in a plane crash in Ethiopia, I believe. I was on
    the Hunger Committee with Mickey when we were both in Congress.
    We began to take a look at this issue of diabetes on Indian
    reservations in this Country, in addition to the hunger issues
    on Indian reservations.
        I am very interested in working with you, as I indicated
    earlier, and with other members of this Committee, on the
    diabetes issue. It is the case where it is not just double,
    triple, quadruple, but in some cases eight and ten times the
    national average. It affects virtually every other aspect of
    health care for American Indians who suffer from diabetes. So
    we have a number of programs, Special Program on Diabetes. The
    issue of detection, treatment and screenings and all of those
    issues are very important. This Committee, and I especially,
    want to spend a lot of time on that with my colleagues.
        A couple of quick points. Number one, our colleague,
    Senator Tester, raised the point, and I raised it with you
    yesterday or the day before, and that is, the Indian Health
    Service is in desperate need of good management. Your
    experience, your background would not be in managing a large
    organization. I think you would be the first to admit that you
    don't come here saying, I have a lot of experience managing
    15,000 people.
        But you come here with a lot of other great qualities,
    which commends me to very aggressively support you. But I think
    the number two spot that you are going to have to fill, will
    take someone with a very significant background in management.
    You and I had a long discussion about some of what I think is
    the incompetence in the bureaucracy, the structural cement
    through which you have to walk in the Indian Health Service to
    get things done.
        I think only with a very strong administrator working with
    you will you be successful to do that. Your response to that?
        Dr. Roubideaux. Yes, I agree with you. I need to have the
    highest quality people working with me, if I am confirmed as
    IHS Director, to help support all of the initiatives that we
    together want to implement. I know it is a large, complex
    organization. And I know that there is a lot to be done and
    there are enormous challenges. So I will definitely, if
    confirmed, I will go back and look at that position and look at
    the responsibilities and look at the possible candidates for
    that position and make a good choice.
        But also in terms of making sure we have great, effective
    managers in our system, I am going to make sure I take a look
    at all of our staff and do what I can to encourage their
    excellence as they work on these difficult, challenging
    problems.
        The Chairman. Well, you and I talked about specifics, not
    specific people, but specific complaints, specific practices
    the other day. So I think I have alerted you to some of the
    concerns. I described to you circumstances where, an employee
    has had multiple, three or four or five EEOC complaints filed
    against them in the Indian Health Service, and on three or four
    occasions, the case is adjudicated against the Indian Health
    Service employee and that employee continues to be employed.
        In my judgment, it would take a nanosecond to decide,
    whatever it takes, we are going to get rid of employees like
    that. And I am hoping that you will go to this job dedicated,
    number one, to promoting Indian health and number two, to
    fixing the problems inside the Indian Health Service management
    structure.
        Are you familiar with the term locum tenens?
        Dr. Roubideaux. Yes, I am.
        The Chairman. And what is that?
        Dr. Roubideaux. It means that you hire people under
    contract to come in for a short period of time to fill a
    vacancy.
        The Chairman. And when you are with the Indian Health
    Service at a facility, and you are trying to find a new doctor
    to come in, and you instead contract for a temporary doctor,
    how much more does that cost the Indian Health Service?
        Dr. Roubideaux. Oh, the cost of contracting for health care
    providers is enormous. It can be two to three times the cost of
    a regular health care provider. It is a huge drain on our
    resources.
        The Chairman. And how prevalent is that practice?
        Dr. Roubideaux. Unfortunately, because of the budget
    shortfalls that we have, some facilities are not able to
    recruit and retain the number of physicians and other health
    care staff that they need. But they still need to provide
    health care to the people in the community.
        So one option is to hire doctors under contract to come in
    for a period of time. I agree with you, the optimal solution
    would be that all of the doctors work in the clinic and are
    there for long periods of time. But unfortunately, the
    resources in the Indian Health Service are woefully inadequate.
    So what happens is we have staffing shortages.
        The Chairman. I understand that. One of the first things
    I'd like you to do when you are confirmed, and I believe you
    will be, would be to report to this Committee the amount of
    money that is spent in these locum tenens, temporary doctors
    program. My understanding is, and I accept the fact that
    sometimes it is hard to find a doctor to come to one of these
    facilities.
        But if the absence of finding a doctor means you go out and
    hire a temporary doctor and pay twice as much money, and my
    understanding is that is not unusual at all. If that is the
    case, if we are short of money for health care, and paying
    twice as much for doctors because we are hiring temporary
    doctors through contracting firms, and in some cases, some of
    them are only doing it through one special, preferred firm, and
    again paying double for the doctor's services, I am wondering
    whether that is a very smart way to handle the taxpayers'
    money.
        Dr. Roubideaux. Well, I am looking forward to working with
    you on finding solutions to our shortages with health care
    providers. I would prefer that we hired health care providers
    that were in the clinics, lived in the community, who were
    there, so that we could provide continuity of care for our
    patients. We would provide better quality care if we could do
    that. But we are short of resources, and I look forward to
    working with your Committee, if confirmed, to finding solutions
    to how we can get more resources for staff that we can hire,
    and incentives, not only to recruit those providers, but also
    to retain them.
        It is very challenging to work in a rural area. You are out
    in the middle of nowhere, there is a lack of resources, you are
    away from major city areas. There are a number of very great,
    wonderful, dedicated health care providers that are working in
    our clinics who need much more recognition, especially the ones
    who have been in for 10, 20, 30 years. Because they have
    demonstrated a commitment to improving health for our people.
        So yes, I am looking forward to, if confirmed, working with
    you on this problem.
        The Chairman. But I might also say, Dr. Roubideaux, that it
    might be hard to recruit doctors to work in poorly managed
    facilities. It might be that a doctor might take a look at a
    facility and say, you know what, that is the last place in the
    world I want to work. It doesn't have anything to do with the
    community, just talk to people who work there.
        I say that because I have visited facilities, I will give
    you a couple of examples. I visited a facility in which the
    doctor that took me around was wonderful. I was deeply
    impressed by the doctor, overworked, waiting room full, not
    good facilities. The doctor said, here is where the new x-ray
    machine is going to go. He showed me the space they had
    prepared for it.
        And I said, when is it coming? He said, I don't know. He
    said, it was approved I think two years ago, and it is all
    ready, but the paper has not been signed by the regional
    office. I said, how long has that been? He said, oh, a long,
    long time. It just sits there and has never been signed. I
    said, Doctor, that is unbelievable. You say it is approved and
    is awaiting a signature at a regional office and it has been
    sitting there? He said, absolutely. He said, it just drives us
    crazy, because this should be here. This should be here to help
    my practice.
        So I mean, I think past the difficulty of recruiting is
    also the bureaucracy that exists in the system. We have a
    hospital that is right now not taking patients into the
    hospital. And that hospital is diverting patients elsewhere
    because it doesn't have proper staffing, it has a serious set
    of management problems.
        But it is not because people don't know about it. I went
    there, sat around the table with all of the people that ran the
    hospital, asked the regional director of health care to come to
    that town and sit around the table with me. That was over a
    year ago. Things have gotten worse, not better. It is very
    frustrating.
        So I told you at the start of this, you face a big
    challenge, and you are going to have to be tough to try to fix
    some of these things. Because the fact is, we can't let these
    things continue. The existing or former head of the Indian
    Health Service pledged that he was going to fix this last
    problem I described. It has not gotten fixed, it has gotten
    worse.
        Somehow, not even the head office seems to be able to
    manage a regional office that is just stuck in the glue of its
    own incompetence. So that is not a question, that is just an
    observation. You can probably understand my frustration just by
    the description of what we have done.
        We are going to need your help to work together to write a
    new Indian Health Care Improvement bill. We are determined to
    do that, we have brought on a new staff person here in the
    Indian Affairs Committee. The minority and majority staff work
    together on this Committee for common purpose. We are going to
    write a bill. We hope to get a bipartisan bill through the
    Senate once again.
        And we are going to do this in a couple of stages. We will
    write a typical improvement bill that is better than the last
    one, because we will now have some ability to do that. Then we
    are going to do something even more than that. We are going to
    try to step up toward a broader reform. If we can offer cards
    for Medicare, and we have signed the line on treaties to say to
    the Indian folks, we have taken your land, we have given you
    reservations, we promised you health care. If we have done
    those things and intend to keep those promises, and we should,
    then there isn't any reason we ought not give them some
    alternatives for health care as well. And that is a card to go
    to a hospital somewhere, or some other facility, whether it be
    Indian Health or some other health care facility to meet their
    health care needs.
        So that represents a second piece of reform. I want to work
    with my colleagues, Senator Johnson, Senator Johanns. Senator
    Johnson, for example, he understands, I think Senator Johanns
    does as well, because they have the same geographical
    circumstance. Indian reservations in our area are not located
    near a big metropolitan area. So Indian Health Service
    represents the preferred and the first and often the only
    circumstance where Native Americans can access health care.
        I didn't mean to give a presentation here, but I am going
    to really lean on your advice and help as we prepare our
    Committee members and our staff work to prepare some
    improvements in Indian health care. We hope very much in this
    session of Congress, finally, at last, at long, long last, we
    will get that done.
        Do you have any concluding comments, Dr. Roubideaux?
        Dr. Roubideaux. I would just like to say thank you,
    Chairman Dorgan, and the rest of the Committee, for having this
    opportunity to talk about American Indian and Alaska Native
    health today. I know there are enormous challenges, I know
    there are problems. But if confirmed, I am really looking
    forward to working with you to find solutions, so that we can
    say that we have all contributed to improving the health of
    American Indian and Alaska Native people.
        The Chairman. Well, let me end on a positive note as well.
    All it not hopeless. I think the fact that someone with great
    qualifications will step forward to say, let me be part of
    fixing things, that gives me great cause for hope. And you do
    inherit thousands of people in that system who today, right
    now, are working, going door to door in their clinic, helping
    people, terrific people. My compliments to them and God bless
    them for doing it.
        So there are a lot of assets and a good foundation to build
    upon. So all is not lost here. If we work together, we can fix
    what's wrong, we can improve it and we can make it right. This
    hearing gives me hope that you are willing to serve and willing
    to help us make a difference.
        Senator Johnson, anything further? Senator Johanns?
        All right. Thank you very much. This hearing is adjourned.
        [Whereupon, at 3:15 p.m., the Committee was adjourned.]

                                A P P E N D I X

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      Response to Written Questions Submitted by Hon. Byron L. Dorgan to
                        Yvette Roubideaux, M.D., M.P.H.

       Response to Written Questions Submitted by Hon. John Barrasso to
                        Yvette Roubideaux, M.D., M.P.H.

       Response to Written Questions Submitted by Hon. Maria Cantwell to
                        Yvette Roubideaux, M.D., M.P.H.

         Response to Written Questions Submitted by Hon. Tom Coburn to
                        Yvette Roubideaux, M.D., M.P.H.

        Response to Written Questions Submitted by Hon. John McCain to
                        Yvette Roubideaux, M.D., M.P.H.

       Response to Written Questions Submitted by Hon. Lisa Murkowski to
                        Yvette Roubideaux, M.D., M.P.H.

         Response to Written Questions Submitted by Hon. Jon Tester to
                        Yvette Roubideaux, M.D., M.P.H.

         Response to Written Questions Submitted by Hon. Tom Udall to
                        Yvette Roubideaux, M.D., M.P.H.

         Response to Written Questions Submitted by Hon. Max Baucus to
                        Yvette Roubideaux, M.D., M.P.H.

       Response to Written Questions Submitted by Hon. Jeff Bingaman to
                        Yvette Roubideaux, M.D., M.P.H.

       Response to Written Questions Submitted by Hon. Barbara Boxer to
                        Yvette Roubideaux, M.D., M.P.H.

                                     ______