[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.





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