[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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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.
______