[Senate Hearing 111-181]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 111-181
 
                REFORMING THE INDIAN HEALTH CARE SYSTEM 

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

                                HEARING

                               before the

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                             JUNE 11, 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 June 11, 2009....................................     1
Statement of Senator Barrasso....................................    58
Statement of Senator Johanns.....................................    59
Statement of Senator Tester......................................     1
Statement of Senator Udall.......................................    55

                               Witnesses

Carlton, Jr., Paul K., M.D., Director, Office of Homeland 
  Security, Health Science Center, Texas A&M University..........    47
    Prepared statement with attachment...........................    49
Davidson, Valerie, Senior Director, Legal and Inter-Governmental 
  Affairs, Alaska Native Tribal Health Consortium................    35
    Prepared statement...........................................    38
Keel, Jefferson, First Vice President, National Congress of 
  American Indians...............................................     2
    Prepared statement...........................................     6
Rolin, Buford, Chairman, Poarch Band of Creek Indians; Vice 
  Chairman, National Indian Health Board.........................    11
    Prepared statement...........................................    13
Roth, Geoffrey, Executive Director, National Council of Urban 
  Indian Health..................................................    19
    Prepared statement with attachment...........................    22

                                Appendix

Chickasaw Nation, health care reform--Indian Country 
  recommendations................................................   101
Cook, Michael, Executive Director, United South and Eastern 
  Tribes, Inc., prepared statement...............................   125
Direct Service Tribes Advisory Committee, resolution.............   115
Engelken, Joseph, CEO, Tuba City Regional Health Care 
  Corporation, prepared statement................................   117
NCAI, health care reform--Indian Country recommendations.........    69
NPAIHB and ATNI, letter with health care reform recommendations..    81
Oklahoma City Area Inter-Tribal Health Board, health care reform 
  recommendations................................................    97
Response to written questions submitted to Paul K. Carlton, Jr., 
  M.D. by:
    Hon. John Barrasso...........................................   157
    Hon. Byron L. Dorgan.........................................   143
    Hon. Tom Udall...............................................   157
Response to written questions submitted to Valerie Davidson by:
    Hon. John Barrasso...........................................   160
    Hon. Byron L. Dorgan.........................................   157
    Hon. Tom Udall...............................................   162
Response to written questions submitted to Geoffrey Roth by:
    Hon. John Barrasso...........................................   136
    Hon. Byron L. Dorgan.........................................   133
    Hon. Tom Udall...............................................   138
Response to written questions submitted to Buford Rolin by:
    Hon. John Barrasso...........................................   130
    Hon. Byron L. Dorgan.........................................   128
    Hon. Tom Udall...............................................   132
Skeeter, Carmelita, CEO, Indian Health Care Resource Center of 
  Tulsa, Inc., prepared statement................................   107
Smith, Chad, Principal Chief, Cherokee Nation, prepared statement   112
Sunday-Allen, Robyn, CEO, Central Oklahoma American Indian Health 
  Council, Inc., prepared statement..............................   120


                REFORMING THE INDIAN HEALTH CARE SYSTEM

                              ----------                              


                        THURSDAY, JUNE 11, 2009


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:20 p.m. in room 
628, Dirksen Senate Office Building, Hon. Jon Tester presiding.

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

    Senator Tester. I call the Committee to order.
    I appreciate the panelists giving testimony today. 
Unfortunately, Chairman Dorgan is unable to be with us here for 
this hearing, and I can tell you I know that he would love to 
be here because this is a big issue in Indian Country, and he 
knows it. It is something he talks about all the time.
    Today's Committee is to discuss ideas for how to reform the 
Indian health care system. Everybody in this room knows that 
the Indian health system is broken. Estimates are that the 
Indian Health Service is funded at about 52 percent of need.
    However, the issues in the Indian health system extend far 
beyond lack of funding. Myself, as well as Chairman Dorgan and 
other Members of this Committee, have expressed serious 
concerns about the IHS. It has been over 10 years since Indian 
Country first asked Congress to reauthorize the Indian Health 
Care Improvement Act.
    Last Congress, this Committee brought the Indian health 
care bill to the floor and it was debated for the first time in 
16 years. The Senate passed the bill overwhelmingly. 
Regrettably, the House did not.
    Health care continues to be a top priority for this 
Committee. We must do something to address the appalling health 
statistics among Native Americans. In my home State of Montana, 
Native American women have a median life expectancy of 64 years 
as compared to 81 for the general population. That is a 
difference of 17 years.
    Native Americans have the highest rate of Type II diabetes 
of any population in the world. Native Americans have 
tuberculosis at a rate of 650 percent higher than the general 
population. Infant mortality rates for Native Americans are 12 
per 1,000 compared to 7 per 1,000 for the general population. 
Suicide rates are nearly double than the general population. 
Among Native Americans, my State of Montana has one of the 
highest rates of suicide for Indian Country. American Indians 
die of alcoholism at the rates of 670 percent higher than the 
general population.
    You get the idea. It is clear that the Federal Government 
is not fulfilling its trust responsibility to provide health 
care for Native Americans in this Country.
    On May 6, the Senate confirmed Indian Health Service 
Director Yvette Roubideaux. Having an IHS Director committed to 
addressing the deficiencies at the agency is an important step 
toward improving Indian health. Dr. Roubideaux has also 
expressed a commitment to reforming the Indian health care 
system, and I look forward to working with her and achieving 
that goal.
    President Obama has tasked Congress with passing national 
health care reform this year. With health care gaining such 
attention, there is a unique opportunity to improve the Indian 
health care system.
    The Committee is working on a draft bipartisan legislation 
that does more than reauthorize the Indian Health Care 
Improvement Act. We want to look for ideas in the Indian health 
care system that are needed and significant reform, which is 
why we are here today. We hope to hear ideas from our witnesses 
today on how Indian Country can move forward with reform. We 
want to address and find solutions to such areas as serious 
health disparities, health provider shortages, rationing of 
health care services.
    Myself, like Chairman Dorgan and the Committee, look 
forward to working with the new Administration, the Indian 
Health Service tribes, and all of you to bring meaningful 
change to truly reform the Indian health care system.
    I want to thank our witnesses for being here, and I would 
remind the witnesses to limit their remarks to five minutes. 
Your entire testimonies will be in the official hearing record.
    The expert witnesses that we have here today are Jefferson 
Keel, Vice President of the National Congress of American 
Indians. Good to have you here, Jefferson.
    Buford Rolin, Vice President and Nashville Area 
Representative of the National Indian Health Board. Good to 
have you here.
    Geoffrey Roth, Executive Director of the National Council 
of Urban Indian Health. Geoffrey.
    Valerie Davidson, Senior Director of Legal and Government 
Affairs for the Alaska Native Tribal Consortium.
    And Dr. Paul Carlton, Jr., Director of Homeland Security of 
Texas A&M Health Science Center.
    A powerful group of witnesses, and we look forward to tour 
testimony. I believe that we will just go from Jefferson and go 
down the line. Is that okay? All right. Yes.
    So how about it, Jefferson? Thank you.

  STATEMENT OF JEFFERSON KEEL, FIRST VICE PRESIDENT, NATIONAL 
                  CONGRESS OF AMERICAN INDIANS

    Mr. Keel. Good afternoon. Thank you, Mr. Chairman, Members 
of the Committee who could not be here, we look forward and 
want to thank you for being here.
    My name is Jefferson Keel. I am Lieutenant Governor of the 
Chickasaw Nation and First Vice President of the National 
Congress of American Indians.
    I want to thank you for the opportunity for testifying 
today. I am honored to be here.
    First and foremost, the provision of health care to 
American Indian and Alaska Native tribes is founded on a 
sovereign government to government relationship between the 
United States and tribes. As such, the provision of health care 
to American Indian and Alaska Native people is based on a 
unique political relationship and is not based on race.
    This provision of health care is formalized as a Federal 
trust responsibility to American Indian and Alaska Native 
people that has been guaranteed as a Federal trust 
responsibility, and been guaranteed through numerous treaties 
and Federal law.
    Health care for American Indian and Alaska Native people 
was permanently authorized in the Snyder Act of 1921. The 
Indian Health Care Improvement Act, as you mentioned, Senator, 
needs to be reauthorized immediately. Perhaps no where in the 
Country is debate on health care more important or will have 
more of an impact than in tribal communities.
    Tribal leaders and tribal health advocates have been 
working diligently to ensure that Indian Country and current 
Indian health delivery systems are being included in a 
meaningful way in the national plan for health care reform. We 
are poised to consider achievable reform opportunities for the 
delivery of health care throughout the Indian health care 
delivery system.
    We have provided for the record a copy of health care 
reform Indian Country recommendations put forth by the National 
Indian Health Board, the National Council on Urban Indian 
Health, and the National Congress of American Indians.
    I might also add that the Chickasaw Nation has provided 
testimony for the record, and those are included in the 
testimony.
    These recommendations have been shared with all committees 
of jurisdiction in the House and Senate working on health care 
reform.
    The National Congress of American Indians respectfully 
offers the following recommendations. I want to quickly address 
eligibility before we get into the recommendations.
    To be clear, there is no problem with eligibility. The 
issue that should be addressed, however, is resource 
allocation. If the Committee wishes to examine the issue of 
resource allocation more closely, tribes and the National 
Congress are happy to assist, and you will also hear later 
about self-governance tribes and how they are innovative in 
this approach.
    It has been proven that self-governing tribes are the most 
efficient and deliver the highest quality of health care to our 
people. Self-governing tribes have developed sophisticated 
collection systems to enable them to enter partnerships with 
other agencies to utilize every dollar effectively. Current law 
authorizes tribes to set priorities for health care delivery, 
therefore avoiding bureaucratic delays and life-threatening 
situations. We urge that those current laws be preserved.
    Tribal consultation. Given the expeditious nature of moving 
health care reform forward, we would like to thank the 
Committee for engaging and including Indian Country. We need to 
continue the consultation process. Realizing the short time 
frame involved, we would suggest partnering with the Department 
of Health and Human Services, who will be conducting a 
consultation session in Denver later in July.
    Contract health services. Reducing the spiraling cost of 
health care is a priority for Indian Country, as you well know. 
Astronomical medical inflation rates, the expense of providing 
services in extremely rural communities, along with an 
increasing Indian population and limited competitive pricing 
have all tremendously hindered tribes' and IHS's ability to 
provide health care to Indian people.
    One of the most impacted areas of the Indian health system 
is the Contract Health Service Program. This program provides 
funding for primary and specialty health services that are not 
available at IHS or tribal health facilities to be purchased 
from the private sector health care providers. This includes 
hospital care, physician services, outpatient care, laboratory, 
dental, radiology, pharmacy and transportation services. It is 
estimated that CHS is currently funded at about 50 percent of 
the need.
    While the Committee has previously heard from Indian 
Country on this issue, we must continue to stress that anything 
less than full funding and recurring funding of CHS compromises 
the health and lives of those in our communities. By supporting 
us in these efforts, you will be ensuring that tribes have the 
ability to deliver the highest quality services to the tribal 
members.
    One way to immediately and dramatically address the 
shortfall in CHS funding is by ensuring that all American 
Indians and Alaska Natives are auto-enrolled in Medicaid. 
Creating an Indian-specific subsection or category of Medicaid 
would facilitate access to the comprehensive health care 
benefits of this program, while easing the already overburdened 
CHS system. This joint proposal submitted by the national 
Indian organizations provides recommendations of fast-tracking 
Indian patients into the Medicaid system. We suggest that 
proper consideration be made to establishing a new category of 
eligibility under Medicaid for Indian patients.
    Tribal health facilities are oftentimes located in remote 
rural geographic locations, making them in some instances the 
only viable option of health care delivery. With the 
anticipated increase in demand for health services, tribes 
recognize that they are likely to be asked to open their doors 
to serve non-Indians. This is a challenging decision that 
requires consideration of capacity and resources, and whether 
adding users will improve the services that can be offered or 
would diminish an already limited capacity.
    Senator Tester. Jefferson?
    Mr. Keel. Yes?
    Senator Tester. Your entire statement will be in the 
record. I would ask you to try to wrap it up. It is a 
critically important issue that literally we all could talk on 
for a long time, but if you could hit your high points so we 
can do it, then we will move on.
    Mr. Keel. Okay. I certainly will.
    Senator Tester. Okay.
    Mr. Keel. Indian health care workforce. Indian Country is 
not alone in its concern on how to address this ever-increasing 
workforce shortage. Mid-level practitioners is one answer.
    Exclusion of health benefits as income. This is an 
important part, and I want to touch this and I will wrap up.
    Tribal governments have been trying to meet the challenge 
of addressing the health care needs in our communities. Some 
tribal governments have met this challenge by providing 
supplemental services above and beyond the limited IHS 
services, while others are providing more comprehensive care 
through self-insured funds or third party plans. This type of 
universal health coverage for tribal citizens is similar to 
Medicare.
    However, some IHS field offices are asserting that this 
type of coverage when provided by a tribal government should be 
treated as a taxable benefit. In order to continue to encourage 
tribal governments to provide such benefits to their members on 
a nondiscretionary basis, NCAI seeks a statutory exclusion to 
clarify that the health care benefits and coverage provided by 
tribal governments to their members are not subject to income 
taxation and excluded from gross income in the same manner as 
Medicare.
    Senator, I thank you for the opportunity to speak here. One 
final note. As a tribal leader, I would simply ask that the 
gains that we have made since 1975 in the Indian Self-
Determination and Education Assistance Act not be compromised, 
and the Indian Health Service has been characterized as broken. 
We believe it is starved because we can't determine how much is 
broken until we fully fund it.
    Thank you.
    [The prepared statement of Mr. Keel follows:]

 Prepared Statement of Jefferson Keel, First Vice President, National 
                      Congress of American Indians

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Senator Tester. Thank you very much.
    You are exactly right, and have great hopes for Yvette when 
she gets fully going that we can get some good recommendations 
out of Indian Health Service.
    We have a vote that has just started, but I think Senator 
Dorgan is on his way. Correct? And so, Buford, if you want to 
start. If in fact he doesn't get here, I don't want to miss 
this vote, so I may have to call you down.
    Better yet, we are going to adjourn for a minute, because 
evidently Senator Dorgan may not. And I will run down and catch 
the vote and I will be right back, or potentially Senator 
Dorgan may be here.
    So we sit in adjournment until one of us returns.
    [Laughter.]
    [Recess.]
    Senator Tester. I call the Indian Affairs Committee hearing 
back to order.
    Welcome, Senator Johanns.
    And Buford Rolin, if you want to continue with your 
statement, we would much appreciate it.
    Mr. Rolin. I will begin.
    Senator Tester. All right.

   STATEMENT OF BUFORD ROLIN, CHAIRMAN, POARCH BAND OF CREEK 
      INDIANS; VICE CHAIRMAN, NATIONAL INDIAN HEALTH BOARD

    Mr. Rolin. Thank you, Mr. Chairman and Members of the 
Committee, I am Buford Rolin, Chairman of the Poarch Band of 
Creek Indians and Vice Chairman of the National Indian Health 
Board, and I co-chair the Tribal Leaders Diabetes Committee, in 
addition to serving on the National Steering Committee for the 
Reauthorization of the Indian Health Care Improvement Act.
    The National Indian Health Board worked together with the 
National Congress of American Indians and the National Council 
of Urban Indians to examine reform proposals from the 
perspective of the Indian health care system. These 
organizations have taken the first step to make recommendations 
on national health care reform and NIHB has submitted a joint 
paper for the record.
    The Indian health care system is not health insurance, but 
it is Indian Country's health care home. Our system was 
designed by the Federal Government to carry out its trust 
responsibility for providing and making health care accessible 
to all Indian people.
    The Indian health care system is a community-based delivery 
system that provides culturally appropriate health care 
services to our people. Thus, we must be assured that reform 
measures do not inadvertently cause harm to our system. We ask 
you and your colleagues to evaluate all components of health 
care reform proposals to guarantee that the proposals do not 
harm the Indian health care system.
    Assure that the legislation supports and protects the 
Indian health care system through Indian health-specific 
provisions where needed. Ensure that the Indian people in the 
Indian health programs have full opportunities to participate 
in and benefit from national health care programs, and respect 
the status of Indian tribes as sovereign nations.
    On behalf of the NSC and NIHB I would like to express our 
appreciation to the Chairman and this Committee for their 
leadership in the Senate's passage of S. 1200. We shared your 
disappointment that the House did not complete their job. 
Reauthorization of the Indian Health Care Improvement Act 
remains a top priority for Indian Country.
    Today, I request Congress to fulfill the Nation's 
responsibility to Indian people by reauthorizing the Indian 
Health Care Improvement Act this year. I also urge Congress to 
make this law permanent, as Congress has done with other major 
Indian laws such as the Snyder Act and the Indian Health and 
Self-Determination Act.
    The joint paper includes a list of the Indian Health Care 
Improvement Act provisions which would bring long-sought 
authority and advancement to the Indian health care system. We 
ask this Committee to advocate for their inclusion in national 
health care reform legislation.
    This joint paper also sets forth recommendations for 
protecting the Indian health care system in the area of 
national health care reform.
    Today, I would like to discuss three of these 
recommendations. First, the joint paper notes that in one 
sense, the IHS system does not constitute credible coverage 
because it is not health insurance, and not all locations are 
able to provide a comprehensive health benefits package. 
However, American Indians and Alaska Natives need the 
protections offered by the concept of credible coverage in 
order to shield individual Indians from any penalty imposed for 
failing to obtain health insurance and for many late enrollment 
penalties.
    It would be a gross violation of the trust responsibility 
for the Federal Government, which is responsible for providing 
health care to Indian people, to then penalize these 
beneficiaries for failing to obtain insurance coverage.
    Second, American Indians and Alaska Natives should be 
expressly exempt from all such cost sharings. This policy is 
consistent with the recent amendments to the Title 19 Medicaid 
of the Social Security Act, which prohibits the assessment of 
any cost-sharing against any American Indian, Alaska Native 
enrolled in Medicaid who is served by the IHS or by a health 
program operated by a tribe, tribal organization or urban 
Indian organization.
    Third, health care reform legislation must assure that 
programs operated by IHS, tribes and urban Indian organizations 
are admitted to provide a network established by insurance 
plans. This is essential to ensure that these providers are not 
excluded from network and denied payment for services to 
insured patients.
    Lastly, I would like to make some observations about the 
Indian health system. We can all agree that the Indian health 
care system is grossly underfunded, with a funding level of 
only 50 percent. I am very hopeful that this unacceptable 
situation will end in a reform environment.
    Some have suggested that the Indian health care system is 
broken, but I would disagree. Even though it is burdened with 
having to do more with less, our system has made many strides 
towards fulfilling its mission of improving the health status 
of our Indian people.
    I am particularly proud of the many innovations and 
improvements made by many of our tribes and tribal 
organizations. For example, the Special Diabetes Program, for 
instance, has led to a dramatic decline in blood sugar levels. 
Just imagine the success we could achieve if our system were 
fully funded.
    Finally, this is not to say, however, that our system is 
perfect or that the only thing needed to make it perfect is 
more funding. There are inequities and inefficiencies in the 
system that require attention. I am aware that the Committee 
would like to make some changes in IHS operations, such as 
facilities construction and contract health service. Indian 
Country looks forward to hearing these ideas and to working in 
partnership with the Committee to advance those ideas that 
truly promise for our Indian health care system.
    Thank you very much.
    [The prepared statement of Mr. Rolin follows:]

  Prepared Statement of Buford Rolin, Chairman, Poarch Band of Creek 
          Indians; Vice Chairman, National Indian Health Board

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Senator Tester. Thank you, Mr. Rolin. I appreciate your 
comments.
    Geoffrey Roth?

   STATEMENT OF GEOFFREY ROTH, EXECUTIVE DIRECTOR, NATIONAL 
                 COUNCIL OF URBAN INDIAN HEALTH

    Mr. Roth. Thank you, Mr. Chairman.
    My name is Geoffrey Roth. I am the Executive Director of 
the National Council of Urban Indian Health and the President 
of the National Native American AIDS Prevention Center in 
Denver, Colorado.
    I am a descendant of the Hunkpapa Band of Lakota Sioux 
Nation, part of the Standing Rock Sioux Tribe.
    On behalf of NCUIH, our 36 member organizations, and the 
150,000 Indians that we serve annually, I would like to thank 
the Senate Committee on Indian Affairs for allowing us to 
testify on Indian Country's recommendations for health care 
reform.
    I would also like to thank the tribal leaders for allowing 
us to be here today and testify.
    NCUIH strongly supports the joint recommendations drafted 
together with the National Indian Health Board and the National 
Congress of American Indians. All of our organizations believe 
that these recommendations are the minimum of what must be 
included in health care reform.
    NCUIH also strongly encourages the Committee to pursue a 
standalone bill to reauthorize the Indian Health Care 
Improvement Act.
    While NCUIH fully endorses all the recommendations in the 
joint document, I would like to highlight a few of the 
recommendations.
    Health care reform must take into account the trust 
responsibilities to Native American people. As the Members of 
this Committee understand, the trust responsibility to provide 
health care follows Indian people regardless of where they 
reside. Congress has clearly and unequivocally stated this 
since 1921 in the Snyder Act.
    While we do not object to an individual mandate for health 
care coverage, we firmly believe that any penalty enforced on 
Indian people for failing to acquire health insurance would 
violate the Federal trust responsibility.
    There are three other areas of recommendations I would like 
to highlight: health information technology, a needs assessment 
for urban Indian health programs, and fast-tracking provisions 
for Medicaid and SCHIP enrollment.
    Health information technology is the future of health 
delivery. Any provider that does not develop HIT infrastructure 
and systems now will be behind in the advance of medicine, to 
the detriment of their patients. Given that Indian health 
providers are already at such a disadvantage and our 
communities suffer high health disparities and disease burden, 
all possible support should be given to Indian health providers 
that are trying to develop HIT infrastructure and technology.
    The Indian Health Service should be encouraged to work with 
Indian providers to develop interoperable HIT systems that link 
together the ITU system.
    A comprehensive needs assessment must be conducted for off-
reservation Native Americans. Such a needs assessment must be 
undertaken in order to determine health status, health 
outcomes, health access and utilization, and the availability 
of health services. The study must be conducted not only in 
areas where current urban Indian health program exist, but also 
in all major urban cities.
    The last comprehensive needs assessment undertaken by the 
Indian Health Service was done in 1981. We have seen 
indications of increased migration and need in the cities that 
do not currently have urban Indian health programs.
    We need to allow urban Indian organizations to expand 
needed health services by alleviating financial and 
bureaucratic strain. A fully developed and actualized urban 
Indian health program could be the center for health services, 
social services, enrollment in all public programs, and the 
cultural center for the urban Indian community.
    Many urban Indian health providers would be able to expand 
their current range of health services if they were able to 
better access third party billing opportunities either through 
inclusion in the all-inclusive rate, better IHS support of 
third party billing software, directly billing Medicaid and 
Medicare, or if they were able to alleviate some of their 
overhead costs with medical liability insurance coverage.
    The Indian Country recommendations also include fast-
tracking provisions for Medicaid and SCHIP enrollment. The 
ability of all urban Indian health providers to undertake fast-
track enrollment and be provided funding for staff to do this 
would help urban Indian health program providers identify 
Indians eligible for enrollment in Medicaid, get them enrolled, 
and then start providing services at the very moment the 
patient presents at the clinic.
    Urban Indian health program providers excel at preventive 
health care and fast-track enrollment would help these programs 
reach patients at earlier stages of illness and even maybe 
prevent illness.
    On behalf of NCUIH and the urban Indian organizations that 
we represent, I want to take this opportunity to thank the 
Committee for allowing us to testify today. We thank the 
Committee also for the dedication on Indian health care reform 
and Indian health. We have a rare moment with this 
Administration and this Congress to seriously reform the health 
delivery system for this Nation and for Indian Country.
    NCUIH strongly urges the Committee to seize this moment and 
undertake comprehensive health care reform with Indian health 
in mind. Pass the Indian Health Care Improvement Act and 
initiate a comprehensive review of the Indian health care 
delivery system.
    Thank you.
    [The prepared statement of Mr. Roth follows:]

   Prepared Statement of Geoffrey Roth, Executive Director, National 
                     Council of Urban Indian Health

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Senator Tester. I want to thank you for your comments. Our 
work is laid out ahead of us. Thank you.
    Valerie Davidson?

   STATEMENT OF VALERIE DAVIDSON, SENIOR DIRECTOR, LEGAL AND 
              INTER-GOVERNMENTAL AFFAIRS, ALASKA 
                NATIVE TRIBAL HEALTH CONSORTIUM

    Ms. Davidson. I thank you for the opportunity to testify 
today. [Greeting in native tongue.]
    My name is Valerie Davidson, and in the interest of time, I 
will skip through some of my qualifications. And I want to 
thank the Committee for the opportunity to testify today on 
behalf of self-governance tribes.
    I think as we are thinking about health reform as it 
applies to Indians, I think we should be mindful that Indian 
families want what every family wants. We want our families to 
be healthy. We want them to be happy, and we want them to live 
in safe communities.
    But because of our history, because of our circumstances 
and some of our unique political status, in order to be able to 
accomplish that, we have to do things a little bit differently 
in our communities. And what works for one tribe may not 
necessarily work for another.
    Some tribes have chosen to have their health care services 
provided directly by the Indian Health Service. Other tribes 
choose to contract or compact services through self-governance 
compacts or contracts.
    The other that is equally important is that opportunities 
for individual tribal members who live in urban centers need to 
continue to have access to urban Indian programs for their 
health care.
    And those three things really work together to make sure 
that the Indian health system really is a public health system 
that works as well as the funding allows. And any diminishment 
of those choices really further limits the already limited 
resources that are available to the collective Indian health 
system.
    Some of my written testimony outlines the fact that self-
governance tribes, we provide more services and more facilities 
than the Indian Health Service does. Because of self-
governance, we are able to actually leverage our IHS funds and 
seek additional grant funds to be able to extend our reach and 
extend our programs in ways that a direct Federal agency is 
unable to, for example, because they are barred from applying 
for other agency grants.
    One of the reasons that many tribes choose self-governance 
isn't because it is an indictment of the Indian health system. 
We actually choose to be able to provide that because we have 
greater control. We have greater flexibility, and we can 
provide services as close to home as possible. One of the 
things that is important to know is that kind of flexibility is 
not necessarily as possible before self-governance.
    Through self-governance, we have been able to do very 
innovative things in our communities. Examples include the 
Community Health Aid Program, the Behavioral Health Aid 
Program, and the Dental Health Aid Program, which allow us to 
be able to extend our provider types in very, very small 
communities.
    The Cherokee Nation also has an incredible PACE Program 
that provides services for elderly patients in their 
communities, and those services are really amazing.
    In the interest of time, I am not going to spend any more 
time. I am just going to go highlighting some of the 
accomplishments. I am just going to go straight to the 
recommendations.
    First, we have incredible opportunities to be able to 
eliminate barriers where they exist, for example, with 
veterans' services. It really makes more sense where veterans' 
services are not available in small rural Indian communities 
for the Veterans Administration to be able to partner with 
tribes and Indian health facilities to be able to extend that 
reach. And there is no reason why the Veterans Administration 
can't provide reimbursement to the already underfunded Indian 
health system to make sure that health services can continue.
    We recommend specifically the creation of a VA clinical 
encounter rate to reimburse IHS facilities for that care, and 
precedent is already there.
    Anytime we talk about health reform, we need to be really 
mindful of the opportunities for the existing funding, as well 
as the opportunities to expand third-party reimbursement. We 
already know that the Indian health system is severely 
underfunded. That point has been made by many folks who have 
spoken here today.
    Specifically, if health reform legislation is really 
inclusive of Indian health providers and creates opportunities 
for expanded coverage for individual American Indians without 
breaking the trust responsibility, it will help to provide 
additional resources to be able to cover that gap in funding.
    Health reform also has to include individual American 
Indians and Alaska Natives without imposing penalties on those 
who choose to use the Indian health system. It also has to 
assure so on the one hand we need to be mindful of the 
opportunities that are available to individuals, but we also 
have to be mindful of the implications that health reform has 
on providers, that providers have to be able to have the full 
opportunity to be participants in the same way that other 
private providers are.
    And finally, we have to extend to Indian health care 
programs all of the resources that are available to any other 
safety net providers. And in health reform, if there are any 
other special considerations that are made to, for example, 
Federally qualified health centers, the 330 clinics, I would 
ask that the Committee take a moment and pause and ask 
yourselves: Is there an opportunity? Does it make sense to 
include Indian health facilities?
    And I would guess that 99 times out of 100, that is 
probably true.
    We endorse the recommendations that were provided by the 
National Indian Health Board, NCAI, NCUIH, as well as the 
Northwest Portland Area Indian Health Board, tribes.
    I do want to clarify one inconsistency with regard to the 
whole issue of creditable coverage. I don't want to get caught 
up in the details, but one thing we all actually agree on is 
that Indian health people shouldn't be barred from qualifying 
for subsidies due to their eligibility for health care from the 
Indian Health Service health care delivery system, whether it 
is the I, whether it is the T or whether it is the U.
    Similarly, though, I think there is universal support among 
the panel for objection to imposing any penalties on an Indian 
individual who fails to obtain mandatory health insurance.
    We strongly support expanding Medicaid coverage or any 
other kind of coverage options as indicated earlier. Funding 
alone is not enough. There is a tremendous opportunity to look 
beyond the Indian Health Service and look at Title VI as an 
opportunity to expand health care delivery. This Committee 
actually made great progress. Unfortunately, we weren't able to 
actually realize that in the prior Administration.
    There is incredible opportunity here, and we believe that 
it is the greatest opportunity to be able to extend health 
care.
    Some folks thought it was kind of odd that we recommended 
Title VI, but the reason is pretty simple, that you can't undo 
the economic status of people with their health status, and 
therefore it really makes sense to the extent that we can, to 
utilize TANF programs, where often it is the first time people 
hear about Medicaid and health programs that might be 
available.
    Finally, we urge passage of the Indian Health Care 
Improvement Act. We have been waiting too long. It is time. I 
served as one of the founding members of the National Steering 
Committee on the Indian Health Care Improvement Act I think 10 
years ago. Many of us are hoping that this year will really be 
the year. My kids ask me every year, is this the year that it 
is passed? And every year, I keep having to say, not quite, but 
maybe next year.
    Finally, I just wanted to emphasize that full funding 
really is critical. It is a critical piece of being able to 
accomplish what we need to. We really need full funding for 
contract support costs. In the event that you are considering 
insurance participation, tribes are employers. We are providers 
of health care as well. Contract support cost is what pays for 
buying health insurance for employees, so we urge that as well.
    Thank you so much for the opportunity, and I appreciate it 
and will be available to answer any questions.
    [The prepared statement of Ms. Davidson follows:]

  Prepared Statement of Valerie Davidson, Senior Director, Legal and 
   Inter-Governmental Affairs, Alaska Native Tribal Health Consortium

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Senator Tester. Thank you very much.
    Paul Carlton?

      STATEMENT OF PAUL K. CARLTON, JR., M.D., DIRECTOR, 
          OFFICE OF HOMELAND SECURITY, HEALTH SCIENCE 
                  CENTER, TEXAS A&M UNIVERSITY

    Dr. Carlton. Mr. Chairman, Members of the Committee, it is 
nice to be here from Texas A&M.
    Senator Tester. Good to have you here.
    Dr. Carlton. Texas A&M focuses on solutions. As you know, 
we regard complaints without solutions as whining, and we live 
in a no-whine zone.
    I am a Professor of Surgery at Texas A&M and a retired Air 
Force Surgeon General. We have the only college of medicine 
dedicated to rural health in the Country, and we have been 
addressing the rural health issues aggressively for the last 
several years.
    As universities are wont to do, we had a semester-long 
project in the fall of 2007 with our College of Architecture 
and the Health Science Center saying: How can we bring this new 
revolution in construction into the health care industry?
    We invited many of the players to come. We got actually 
several of our Iraqi senior officers to come. And out of that 
spun the testimony that I will give you today.
    Specifically, what we learned is the building industry in 
our Country has truly undergone a revolution in efficiency, 
with new methods and new thinking in the last decade. This is 
prefabrication of larger portions of buildings, done in 
climate-controlled facilities. Literally led by the modular 
building industry, they have progressively improved their 
quality, their efficiency and their timeliness. There are 
currently over 100 manufacturers scattered throughout the 
Country.
    As you look at the value equation of cost, quality and 
time, timeliness is what always wins on the modular side. We 
have a perfect example of that in Balad in Iraq. We contracted 
for two major headquarters to be built, same square footage, 
same signing time. One was completed in 18 weeks component. The 
other is four years, site-built, still under construction. Same 
cost. And so in the value equation, time counts.
    Now, literally in the component building industry, what you 
do is you don't build 25 hospitals. You build one hospital 25 
times, each unique on the outside, but common on its inside. So 
you don't pay the engineering, the architectural firm, et 
cetera, 25 different times.
    Now, in that revolution that has been going on, the in-
patient facilities started in Bensalem, Bucks County, 
Pennsylvania in 2007, a combination of factory-built and site-
built. This is a consistently superior quality, literally 24 
hospital beds were laid in two days. The timeliness of this is 
remarkable. It is understandable. It is done in a factory by a 
staff that does things repetitively, increasing their 
individual productivity, as well as avoiding weather delays. It 
is exactly what Henry Ford taught us.
    On the outpatient side, we had a facility languishing at 
Creech Air Force Base north of Las Vegas, where money had been 
allocated and no contractor could come within four times of the 
price. Out of this group that we pulled together in fall 2007 
at Texas A&M, we said we can do this. We brought it in on time, 
on price. After languishing for four years, it was completed in 
four and a half months, a remarkable meets all standards steel 
and concrete building, a beautiful building.
    As we look at our critical access hospitals, I am learning 
an awful lot as those come due to be replaced, and it is much 
the same story as our IHS facilities. We have a perfect example 
in Tehachapi, California which has recently been estimated at 
$67 million. It was turned down in a component proposal at $25 
million. And it is all about change, as the standards, they are 
the same way either way.
    An innovative physician from Nashville has come back and 
said, I can do better than that. Instead of $25 million, I can 
do $14.5 million and put in an electronic medical record.
    So the question is: Can we afford to resist change at that 
difference in price? We are doing exactly the same thing for 
Iraq today, recommending to them that we use the workforce in 
America to rapidly solve many of the pressing issues they face 
in medicine, in housing and in other areas.
    Now, how does this apply to the Indian Health Service? 
Well, using factory-built options literally replacing critical 
access hospitals at half the price, for that $2.4 billion 
construction backlog that I have now see, I believe we could 
more timely and cost-effectively bring that backlog down 
considerably using these two techniques.
    On the outpatient facility, if Creech really is a model for 
the Nation, we could put in new clinics in the Indian Health 
Service at a fraction of the current cost, delivery time 
measured in months, not in years.
    Now, the piece that pulls all of these together I call the 
mobile health care. Obviously, there is no difference in 
quality. These are State-certified, joint commission-certified, 
meet all standards. But what it would do is allow you to turn 
any clinic into a full-up hospital. As a practicing physician, 
that took care of a referral population throughout my 37 years 
in the military. Every time I stuck my hand out and said, I'm 
Dr. Carlton and I am here to help you, if the patient was 
local, it was fine. If they were from far away and had 
traveled, the other side of that was, you rascal. You are 
telling me you are more important than I am because you have 
made me travel instead of you.
    We then started an outreach program that we call Medical 
Center Without Walls. We did it for 25 years. The same thing 
could be done in the Indian Health Service through a concept 
that we call the Thursday Hospital. This literally pays for 
itself by training the Public Health Service, if this equipment 
using mobile facilities was available and it was designated as 
going to the FEMA. Then whatever medical national emergency 
there was, you would have already trained the Public Health 
people there on its use, by using it every day in Indian 
Country.
    Now, linking all of those together, then, with an 
electronic medical record or telemedicine, literally I think we 
could build an integrated delivery system that was first class 
in the world. There would be no isolated nurse practitioners, 
no isolated physicians. They would all be part of a bigger 
piece so that you could have morning rounds. You could have 
weekly rounds. You could have grand rounds, literally 
university-based, but tying all of them together. I believe 
that would solve a tremendous recruitment problem as well, and 
again tell people they are important members of the team.
    So I encourage you to go look at these facilities. They are 
very first-class facilities. Bucks County is just outside 
Philadelphia. Our clinic at Creech, you may see when you have 
other business in Las Vegas. The mobile units are out of St. 
Johnsbury, Vermont. All of these are available to see.
    What we lack right now is the vision to say, I am sorry, 
quite whining. Let's solve the problem at the current dollars. 
We are not asking for money.
    Thank you for this opportunity to share some thoughts.
    [The prepared statement of Dr. Carlton follows:]

 Prepared Statement of Paul K. Carlton, Jr., M.D., Director, Office of 
     Homeland Security, Health Science Center, Texas A&M University
    I am Dr. Paul K. Carlton, Jr., currently a professor of surgery at 
The Texas A&M Health Science Center, TAMHSC, and the retired Air Force 
Surgeon General. As part of the Texas A&M land grant mission, the 
TAMHSC seeks to provide solutions to the many challenges we face in 
healthcare delivery, particularly in rural, frontier, and emerging 
regions. This includes training providers willing to serve these areas, 
promoting the use of innovative technologies to increase access to 
healthcare, and application of the breadth of science across the Texas 
A&M University System to improve the public health. This focus on 
solutions led to a joint conference hosted by the Texas A&M Health 
Science Center and the Texas A&M College of Architecture in the fall of 
2007. This conference presented a pioneer effort on how to use the 
component building method in medical applications. Out of this 
conference came many new and innovated ideas for the reconstruction of 
Iraq, applications for Air Force facilities and applications for the 
Indian Health Services. These medical construction innovations comprise 
the rest of this testimony.
    The building industry in our country has been undergoing a 
revolution in efficiency using new methods and new thinking with pre-
fabrication of larger portions of buildings, done in climate controlled 
factories. The Modular Building Industry has been leading this charge 
by progressively improving their quality, their efficiency, and their 
timeliness. They currently have over 100 manufacturing facilities 
scattered across our country.
    They recently started moving into the healthcare field with both 
in-patient and out-patient facilities. The largest user of out-patient, 
pre-fabricated facilities has been in the dialysis field. By moving 
these facilities closer to their population served, they are able to 
give better service, closer to home. The in-patient pre-fabrication 
world opened with a full up hospital in Bensalem, Bucks County, PA., in 
2007. This was a combination of factory built and site built. The 
factory portion of this building is what allows the efficiencies and 
quality improvement that have been noted. A consistently superior 
quality has been delivered by these factories because of the excellent 
working conditions that are not influenced by weather or availability 
of professional workers. These are done in a factory by a staff that 
does tasks repetitively, increasing their individual productivity as 
well as avoiding the weather delays. The facilities were even certified 
as meeting all standards before leaving the factory by the State of 
Pennsylvania. The transportation issues are worked through by designing 
exactly what the transportation system will allow in terms of moving 
these larger portions of buildings.
    A provider of these types of facilities, U3 Innovations of San 
Antonio, along with Modern Renovators and Aspen Street Architects built 
the Air Force their first truly component, pre-fabricated section 
clinic in the last six months at Creech AFB, Nevada. All of these 
businesses participated in the fall semester project with the College 
of Architecture and Health Science Center at Texas A&M in 2007. This 
clinic was to fulfill a need that had languished for over two years, 
with no bids coming close to the allocated amount of money. Using pre-
fabricated sections, this clinic was built in four and a half months 
and on budget for $1.5M. Our group from the fall project held a grand 
opening for all of our colleagues to see what high quality this 
building represented. It has an all-steel frame, concrete floors, and 
an exterior that blends with its surroundings nicely. It was built in 
six components in Loretto, TN., and transported by truck to the site. 
The beauty of this approach is that it was built to cost and we will 
add a nicer parking lot and nicer roof as money becomes available. 
Pending those, we have a fully functional facility to meet the needs of 
this isolated Air Force Base so vital to the current wartime mission.
    Our critical access hospitals (and many urban hospitals) have now 
reached their life expectancy, having been built about 50 years ago 
under the enlightened funding initiatives of the Hill-Burton act. These 
under 25 bed facilities, vital to the nation's healthcare system in 
rural American, need to be replaced and we cannot afford to do so. A 
critical access hospital construction project in Tehachapi, California, 
was recently estimated at $67M, to be completed in three to four years. 
The similar sized pre-fabricated hospital, using all components, had 
been contractor proposed at $25M. It was cancelled because pre-
fabricated construction was considered unacceptable. Standards are 
standards and both would have met all standards. Unfortunately, the 
change was more than Tehachapi was ready to accept. Change is hard for 
all of us but fiscal reality has to be considered at some point.
    One innovative physician executive from Nashville, Dr. Jerry 
Tannenbaum, has designed such a critical access hospital and is ready 
to write contracts on such facilities for $14.5M. That design includes 
12 beds, two large operating rooms, a post anesthesia recovery unit, a 
complete imaging suite, a full laboratory, a 12 bed patient wing, 
Emergency Department, and administrative section. This would be 33,000 
sq. ft., all pre-fabricated, and up in nine months from contract 
signing with a fixed guaranteed price. Comparing that to the $67M that 
Tehachapi estimated for their hospital and you have to say ``what is 
the difference? '' Can we afford to resist change at that difference in 
price?
    I am currently involved in the rebuilding process of medical 
activities in Iraq. We are proposing all pre-fabricated section type 
construction for them, using the work force in America, to rapidly 
solve many of the pressing issues they face in medicine and in housing. 
We have also proposed using mobile surgical vans, that meet all 
standards of care, to turn any clinic into a full up hospital whenever 
and wherever it is needed. The Iraqis currently have one of these units 
in country and love its flexibility and ease of use.
    How does all of this then apply to the Indian Health Service? I 
believe that what we have learned could easily be applied by providing 
better service to the Indian Nation at a more affordable cost:

        1. In-patient facilities: If we used the critical access model 
        proposed by Dr. Tannenbaum, the physician from Nashville, at 
        $14.5M each, you could provide twice the number of hospitals 
        for the same cost. A similar component model by the Rural 
        Health Consortium in California, comprised of 13 critical 
        access hospitals, has similar numbers. If you used either of 
        these models, tailored it to the exact size needed in any 
        location, using pre-fabricated sections, you could cut down on 
        the $2.4B construction backlog that currently exists for the 
        Indian Health Service. Better service at a lower cost is hard 
        combination to beat.

        2. Out-patient facilities: If we use the Creech AFB model for 
        clinics for the Indian Health Service, we could be building 
        modern state of the art out-patient facilities for fractions of 
        the cost of what we are paying now. The issue of timeliness is 
        also a critical portion here--these are done in a factory, with 
        fixed pricing, and they meet delivery dates because weather is 
        not a factor.

        3. Mobile Medical Care--You could also use the mobile surgical 
        vans, as the Iraqis do. These vans are used in our country for 
        operating room renovations routinely and meet all standards of 
        care including Joint Commission on the Accreditation of 
        Healthcare Organizations (JCAHO), Medicare certification and 
        state licensure. They would allow us to turn any clinic into a 
        full up hospital for the number of days per month that it would 
        be effectively used at our more remote Indian Health Service 
        locations. This would allow each reservation to have surgical 
        or other specialty services offered to them as the need 
        dictated. The real payback for using such a concept is that by 
        providing better service for the Indian Nation, we would be 
        fulfilling a training requirement for the Public Health 
        Service. We call this the ``Thursday Hospital'' concept, moving 
        the surgical vans from place to place as demand exists. These 
        vans, which are totally self-contained, could then be the 
        foundation of a national response system for any medical large 
        scale disaster. Since they meet all standards of care, they can 
        be used daily for non-emergency healthcare. The Indian Health 
        Service, comprised of Public Health Service people, would have 
        been using them daily, so no equipment training would be 
        required to respond to national emergencies. You would use them 
        like you use a portable CT scanner or MRI machine, simply have 
        a docking station built onto the clinic or hospital so the 
        patient never has to move outside. To have the potential of 
        superb mobile facilities, no training tail involved for the 
        professional staff, and used every day is exciting to 
        contemplate! There would then be little fixed cost for 
        preparedness for equipment for our nation in times of a medical 
        emergency. From a national preparedness perspective, this is a 
        very cost effective alternative to consider.

    The Indian Health Service has a great mission, to take care of the 
health needs of our Native Americans. You have a great group of people 
to do this with, the Indian Health Service medical professionals. 
Perhaps these new methods for providing high quality facilities could 
enhance the delivery of healthcare to this deserving group of people--
at an affordable cost. I encourage you to look closely at all I have 
discussed. Go see the facilities I have described in Bucks County, PA; 
at Creech AFB, NV; and in St. Johnsbury, VT. Look closely at how to 
allocate the tax payer dollars involved. I believe that you will find 
this revolution in the building industry applicable to the Indian 
Health Service and other federal building projects.
    Thank you for this opportunity to share these thoughts.
Attachment

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Description: The nearly 66,000 square-foot project could be done by 
        January 2013.
    A new Tehachapi hospital came several steps closer to reality with 
the presentation March 18 of a proposed $67 million, 65,909-square-foot 
master space plan.
    Hospital Project Executive Manager Norm Clendenin told the 
Tehachapi Valley Healthcare District Board of Directors that the $67 
million preliminary project budget amounts to about $720 a square foot 
and includes contingencies.
    ``I'm suggesting that's about as tight as we can get,'' Clendenin 
said.
    He said the target date for license approval and to welcome the 
hospital's first patients is January 2013.
    Stephen Wen, AlA, senior principal in SWA Architects of Pasadena 
and Phoenix, presented the space plan, which is an outline of the 
overall traffic flow and placement of the elements of the hospital.
    ``There is no fat in this program,'' Wen said. ``It is pure muscle, 
pure functional.''
    The healthcare district directors, who junked a previous state-
approved but unsatisfactory hospital design at a loss of $1 million, 
were pleased with SWA's conceptual plan.
    ``It looks great,'' district director Dr. Susan Hall said. ``I love 
how it's expandable. The flow really looks good. It seems to make 
sense.'' The board is accepting bids from architects to refine and 
develop the final design.
Sought staff input
    Wen said that to develop the made-to-order master plan, his team 
spent the last four months working closely with Tehachapi Hospital's 
senior staff. Detailed interviews with all the staff, he said, 
``allowed us to trim this and fine tune that.''
    The hospital components will be comprised of more expensive medical 
sections that must be approved by the Office of Statewide Health 
Planning and Development (OSHPD, pronounced ``OSH pod'') and less 
expensive non-medical sections that include administration, storage and 
reception (``Non-OSHPD'').
    The OSHPD components amount to 54,296 square feet.
    The non-OSHPD components amount to 5,413 square feet in Phase I and 
an additional 6,200 square feet in Phase II. The hospital complex, to 
be built on a 22.36-acre hospital property at Capital Hills north of 
Highway 58 near the Post Office, will fit snugly into a gently sloping 
hillside that will require minimal grading, Wen said.
    ``We would like it to be readily visible but not on the steep 
slope,'' he said, ``So we placed it on the lower end.''
    Wen studied the morning and afternoon sun angles as well as view 
sightlines before selecting the optimum location to build on the 
property.
    The public entrance will be on Magellan Road, with a side entry for 
emergency vehicles, a service road that loops around the structure and 
a heliport on the north side.
    Core elements of the emergency room, lab, radiology, operating 
suite, medical surgical units, imaging, surgery supply and intensive 
care unit were placed ``in close functional relationship'' with each 
other, he said.
    The plan includes ``growth directions'' for core elements that are 
expected to expand, notably the operating room and the emergency room.
    Wen's plan provides for 141 parking spaces, more than double the 
required number.
    Healthcare District CEO Alan Burgess said the new hospital will be 
as green as possible, ``No grass--that saves water for other purposes--
and we will use indigenous plants like Joshua Trees and yucca.''
Squeezed 'em down
    Clendenin said Wen and his team had quite a job on their hands when 
they got the Tehachapi assignment last October.
    ``I made it very difficult for SWA to get this done,'' Clendenin 
said. ``They had to get it down from 88,000 square feet to 54,000 
[OSHPD] square feet. I squeezed 'em down as far as they could go.''
    The new 25-bed hospital is designed to replace the 1954-vintage 
existing hospital on F Street, which will be remodeled as a 
rehabilitation center and outpatient clinic featuring global 
consultation via telemedicine, according to Burgess. The original plan 
to retain the old hospital as a skilled nursing facility is unworkable 
because of state seismic requirements related to overnight bed stays.
    The old structure must abandon its role as an acute care, overnight 
hospital by the last day of December, 2012, Burgess said. The state 
granted the Healthcare District a five-year extension past Jan. 1, 
2008, to meet new seismic requirements, which will be met by the new 
hospital complex at Capital Hills.
    Clendenin said that he has received 40 responses to requests for 
architectural bids on the new hospital and it is a good time to build.
    At the beginning of the board meeting, held at the Golden Hills 
Community Services District boardroom, Clendenin introduced Division 
Chief Gordon Oakley and Regional Compliance Officer Brian Coppock from 
OSHPD. They promised their support to Tehachapi.
    Oakley said the state is happy to approve incremental or phased 
construction ``instead of waiting for the big package.'' He called the 
phased process ``bite-sized, like eating one scoop of ice cream at a 
time.''
Now for the money
    Bringing the space concept and the total cost into focus is the 
first step in formulating an aggressive fundraising plan, according to 
Healthcare District Chief Financial Officer Joe Demont.
    Demont said the financial picture for the Healthcare District is 
positive.
    Cash collections are up and adjustments are down, he said, and the 
district operating budget is on its way to being ``significantly in the 
black.''
    In 2004, voters authorized $15 million in bonds to seed development 
of a new hospital. The district raised $12.7 million under Series A and 
B, he said, and the C series was never raised.
    That $12.7 million has increased in value to $14 million, which is 
sitting safely in the bank.
    Further fundraising could take the form of a new bond issue, 
donations, government grants and other sources.
    Burgess said he will approach local religious congregations and 
other organizations to help fund the ``quiet room,'' which in former 
times was called a chapel. The room will be available for meditation 
and will offer a place for families to meet with spiritual advisors and 
counselors.
    At least $50 million has to be raised or borrowed to build the 
hospital.
    ``We have been holding back until we got the numbers accurate and 
the conceptual site plan,'' Burgess said. ``There's error in to going 
out too early. We have to do a sales job. The whole community has to 
get behind it.''
    Tehachapi cannot afford to lose its hospital and its emergency 
room, Burgess said, and building a new one is the only option.
    Burgess said that $5 million will put the name of the angel donor 
on one of the core elements.

    Senator Tester. I thank you all for your testimony. I 
appreciate it very, very much.
    As long as you are warmed up, Dr. Carlton, we will start 
with you, and I will just go in reverse order.
    What is the disadvantage of the component construction?
    Dr. Carlton. I am sorry?
    Senator Tester. What is the disadvantage? You talked about 
a lot of advantages. Are there disadvantages?
    Dr. Carlton. Oh, yes, sir. Tremendous disadvantages, it is 
different.
    Senator Tester. That is it?
    Dr. Carlton. That is it. It is the same concrete. It is the 
same steel. You do it in a climate-controlled environment. The 
quality is consistently better. It is just different.
    Senator Tester. You have dealt with Federal agencies, 
mainly the military. Is there problems with this kind of 
construction with guidelines that you know of through other 
government agencies?
    Dr. Carlton. Well, sir, I have learned a lot about 
construction, a nice physician has had to learn an awful lot 
about construction. The reality is there are national 
guidelines. There are State guidelines. There are international 
guidelines. Every one of these meets those guidelines, and 
literally the facility in Bucks County was certified by the 
State of Pennsylvania before it left the factory.
    Senator Tester. Okay. I just got a note that said 
Jefferson, you have to leave. So I will jump over to you. And 
then I will turn it over to Senator Udall in case he has any 
questions for you, and then we will kind of hop around here a 
little bit.
    The National Congress of American Indians, the National 
Indian Health Board, the National Council on Urban Indian 
Health all produced a position paper with proposals for health 
reform in Indian Country. Was this vetted with individual 
tribes that you know of?
    Mr. Keel. Yes, sir. The individual tribes around the 
Country, or the National Indian Health Board represents tribes 
around the Country. And all of those tribal leaders from all of 
the different areas and different regions have had an 
opportunity to provide input to that, to review it, to take a 
look at it, provide comments. And then they brought it back and 
put together a comprehensive set of recommendations.
    There are some specific areas around the Country that have 
some innovative ideas. Portland area has some specific ideas. 
The Oklahoma City area Indian health boards, all of those have 
some very innovative folks who look at these plans and provide 
various ideas and input to this comprehensive set. Thank you.
    Senator Tester. Okay. And in your testimony, you spoke 
about mid-level practitioners, actually, and how they are 
underutilized in health care delivery in Indian Country. Do you 
have any barriers that come to mind as to why this is the case?
    Mr. Keel. Well, primarily there are some issues. One, I 
would specifically talk about would be the dental health 
practitioner, the dental health aides that are utilized in 
Alaska. Those are not well utilized around the Country 
primarily because of funding. However, there is an opportunity 
for the self-governing tribes to partner with the local 
universities. For instance, in the Chickasaw Nation, we have an 
opportunity to contract with the University of Oklahoma Health 
Science Center to contract and provide internships with PAs and 
nurse practitioners. The problem is funding for those. I could 
talk a lot about it.
    Senator Tester. I come from frontier America where nurse 
practitioners and physician assistants are the standard. That 
is who is providing the front line care. And if they are not 
being utilized in Indian Country, I would love to know why. If 
it money, that is one thing. If it is something else, then we 
want to go the direction to fix it, is what I am saying.
    Mr. Keel. I think, Senator, that the self-governing tribes, 
you are absolutely right. The nurse practitioners and PAs are 
pretty much the norm for the self-governing tribes. I think the 
problem exists in the direct service tribes and it is a lack of 
funding.
    Senator Tester. Okay. All right.
    Senator Johanns, did you have any questions? The reason I 
do is Jefferson Keel has to leave quicker than the rest. So if 
you have any questions for him in particular? Okay.
    Senator Udall?

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

    Senator Udall. So you are suggesting we get our questions 
out of the way?
    Senator Tester. I don't want to see him leave unscathed.
    Senator Udall. Good, good. Oh, okay, okay.
    [Laughter.]
    Senator Udall. Let's see here.
    Mr. Vice President Keel, you mentioned Medicaid auto-
enrollment and the establishment of an American Indian/Alaska 
Native category of eligibility as an easement on the Contract 
Health Service program. As you know, there are very strict 
criteria for Medicaid eligibility. Do tribal data collection 
systems currently have the capability for supporting auto-
enrollment practices?
    Mr. Keel. Yes, sir, they do. The self-governing tribes are 
perfectly capable of collecting all the data that is required. 
They have sophisticated business systems, business models to 
allow for data collection, auto-enrollment, providing 
partnerships with all of those agencies to enhance the overall 
level and quality of care for those patients.
    So, yes, sir, they do have the capability.
    Senator Udall. And you state there should be a limit on the 
amount of funds that the Indian Health Service can use for 
administrative costs. That way, more money can be used for 
direct health care services. Would you also support a limit 
being placed on the amount of funds a tribe can use for 
administrative costs when it is the tribe that is operating the 
facility?
    Mr. Keel. I really can't answer that directly because there 
is such a wide variance across the board with different tribes. 
Some tribes, for instance, have sophisticated third party 
collection systems that are required in order to meet the 
shortfall in funding that is provided by the Indian Health 
Service. Those collection systems enable us to hire 
practitioners, provide other services that are not normally 
provided by the Indian Health Service in terms of funding.
    So providing a limit on those administrative costs is 
normally offset by those third party collections that the 
tribes enjoy right now.
    Senator Udall. And you also state that Indian tribes must 
retain the authority to make decisions regarding whether to 
provide services to non-IHS eligible beneficiaries. One reason 
that the tribes may choose to provide services to non-IHS 
beneficiaries is so they may become a preferred provider 
organization in a State network.
    If a tribe decides to serve non-IHS beneficiaries at its 
health facility, what protections would need to be in place to 
ensure that the IHS-eligible patients continue to receive the 
care they need?
    Mr. Keel. Thank you, Senator. That is a very good question. 
The only protection that would be needed, the only legislative 
fix would be that the Federal tort claims would be extended to 
cover the liability of the tribe providing those non-
beneficiaries. The tribal leaders will guarantee that their 
citizens are provided the highest quality of care that is 
available.
    Senator Udall. Thank you.
    Thank you, Chairman Tester.
    Senator Tester. Absolutely.
    Senator Udall. Doesn't that sound great?
    Senator Tester. I don't know. We will have to talk to 
Chairman Dorgan about that.
    [Laughter.]
    Senator Tester. Mr. Rolin, you stated that the Indian 
Health Care Improvement Act should be made permanent. This is a 
change. And you mentioned some of the ones that were permanent, 
the Indian Self-Determination Act, Snyder and some others. Can 
you give me some insight into why the change and is this a new 
position of the tribes, too?
    Mr. Rolin. Well, as I said in the testimony, for years now 
we have been trying to get the Indian Health Care Improvement 
Act reauthorized, some 10 years.
    Senator Tester. Yes.
    Mr. Rolin. As you have heard. We just feel like it is time 
now to make this reauthorization a permanent part of health 
care for our Indian people. I gave you some examples that we 
have already. We just believe with tribes that are now going 
into self-governance or contracting or compacting, we have 
found that working with the local health providers in our 
communities and adjoining cities that we can provide and make 
better use of that dollar that is available to us, and as Mr. 
Keel said, provide some additional services here, and that is 
what we are all looking for, is better use of that dollar.
    Senator Tester. Okay.
    Mr. Roth, you demonstrate a need for funding authorities 
for urban Indian data collection. The Committee has 
demonstrated strong support for strong information technology. 
What kind of information technology systems do urban programs 
currently operate, if any?
    Mr. Roth. Good question. Well, it is kind of a patchwork 
system right now. The programs have been highly encouraged by 
IHS as of the last couple of years to move to the RPMS system 
which is difficult for our programs because it doesn't have a 
real strong third party billing application to it. It takes a 
lot of maneuvering and then programming support in order to get 
the system working.
    But other than that, our organizations tend to buy off-the-
shelf software packages, and many times end up having to hire 
individuals to do data input in two different systems in order 
to keep reporting with the RPMS system and the other system 
that actually works for their program.
    So there needs to be some reform and a uniform system 
across the board.
    Senator Tester. Okay. Are there specific areas where data 
collection is particularly difficult?
    Mr. Roth. Are you talking about geographic areas?
    Senator Tester. I mean, it wasn't geographic. I was 
thinking more of just areas where you try to get information 
from the folks and you can't get it, or from the medical 
professionals, too, as far as it goes.
    Mr. Roth. Yes. I would say that data is a really difficult 
issue, especially for us as a system, an urban Indian health 
system, and I believe the entire ITU system. The Indian Health 
Services seems to be a bit fragmented in the way that it is 
administered right now through the areas. And I don't know how 
good the accountability is back to headquarters and the ability 
to bring data together. So that is one area that we have had 
difficulty in getting data from.
    Senator Tester. Okay.
    Ms. Davidson, you stated that the Alaska Native Medical 
Center is a level two trauma center in Alaska. It is tribally 
operated. Does it serve any non-IHS beneficiaries?
    Ms. Davidson. We primarily serve IHS beneficiaries, but we 
do have authorization to serve some non-IHS beneficiaries who 
are Public Health Service employees.
    Senator Tester. Are there protections against malpractice 
claims?
    Ms. Davidson. Yes, there are. Those services are covered 
under Federal Tort Claims Act. One of the things that it is 
really important for the Committee to understand is that over 
the last Administration, sometimes there are protections in the 
law that have been construed very, very narrowly by the 
previous Administration, and that sometimes those terms were 
constrained a little bit too narrowly. For example, with FTCA 
coverage, so long as a service and activity is adequately 
described in your resolution, your tribe's resolution, with 
applicability to non-IHS beneficiaries, FTCA coverage applies.
    The challenge we have is sometimes we have to go to 
incredible steps to get the Department of Justice to overcome 
that determination.
    I do want to revisit one of the questions you asked earlier 
about data.
    Senator Tester. Yes?
    Ms. Davidson. Quite honestly, our capabilities to be able 
to access that data really vary depending on where you go. And 
the simple reason for that is because there are not sufficient 
funds for health information technology enhancements.
    For example, some folks are able to use RPMS, but right now 
with RPMS the only way to be able to get it to work effectively 
is it has to be so customized to each service unit that any 
upgrades that happen, tribes and tribal organizations really 
have to spend a lot of money to be able to make it work, to be 
able to fix those patches.
    The other piece is that, for example, the recent funds that 
came through ARRA for health information technology, zero of 
those funds went through self-governance tribes or urban Indian 
programs. And so to the extent that tribes should have the 
opportunity to get their health information technology funds 
met, we should be clear that that opportunity should be 
available through ONC.
    The other piece is that normally what pays for health 
information technology systems is contract support costs. So 
the simple answer is we have that capability to the extent that 
we are able to use contract support cost dollars to fund that.
    Senator Tester. Okay.
    Mr. Carlton, I especially appreciate your perspective that 
talked about meeting people on their home turf instead of 
making them come to you. Can tribes purchase the mobile units 
at this point in time? Are they available?
    Dr. Carlton. Yes, sir, they are available. The mobile units 
are literally used in the VA system right now for operating 
room renovation. University of Virginia just finished a four 
year contact. So the key is not the equipment. The key is the 
staffing. And the Indian Health Service's chief problem is they 
end up needing a .1 or a .2 full-time equivalent staff. This 
solves that problem by serving multiple areas.
    Senator Tester. Got you.
    I am going to turn it over to Senator Barrasso, the Ranking 
Member, to take the hearing from here.

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

    Senator Barrasso. [Presiding.] Thank you very much, Mr. 
Chairman.
    And I want to thank all of you for being here today. This 
is a very important hearing, as the health care debate 
continues nationwide. It is timely, Mr. Chairman, that we hear 
from Indian Country today.
    Recently, I had a meeting in Riverton, Wyoming on this very 
issue. I also met on the Wind River Reservation with the Joint 
Business Council of the Eastern Shoshone and the Northern 
Arapaho Tribes. The Wind River community was generous to meet 
with me and my staff to share their concerns and their 
priorities for health care reform, prevention, accountability, 
increasing access to care. They really were among the most 
important issues that we raised.
    And Mr. Chairman, I also want to, while you are still here, 
thank Senator Dorgan, as well as the capable staff from the 
majority, Allison and John, who attended the meeting in 
Wyoming. They fully participated in the meeting and their input 
was significant and very much welcome.
    There is significant support, of course, for reauthorizing 
the Indian Health Care Improvement Act. There is also 
recognition that we must do more than simply reauthorize a 
troubled, inefficient system. That is why I was so pleased that 
Senator Dorgan and I have been able to work together and that 
Senator Dorgan has agreed that we begin a path to reform. I 
expect a significant amount of work is going to be done this 
summer. The Committee operates in a very bipartisan manner. We 
roll up our sleeves. We work together. Our work is going to 
require outreach to our tribal friends to help with refining 
health policy.
    We need to act in a quick way, as well as a cooperative way 
so that Indian Country does not get left behind in the 
nationwide health care reform effort.
    And I would like to say that Senator Murkowski has not been 
able to be here today. She has asked me to express her regret 
for not being able to join us. She is wrapping up amendments in 
both the Energy Committee, as well as the Appropriations 
Committee. But Ms. Davidson, she specifically wanted me to 
welcome you with the Alaska Native Tribal Health Consortium, to 
welcome you to the Committee. And I know that she is going to 
be very interested in reading all of your testimony and the 
answers to your questions. So thank you so much for traveling 
such a great distance.
    And with that, I would like to turn it over to Senator 
Johanns, who has some questions. Thank you.

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

    Senator Johanns. Well, let me thank each of you for being 
here today. It is a very important topic.
    Let me, if I could, start with Mr. Roth, a couple of 
questions on IHS-funded urban Indian clinics. I think you 
mentioned in your testimony, or mentioned that 36 member urban 
Indian clinics serve about 150,000 American Indian/Alaska 
Natives. Congress has gone on record, as you know, in support 
of the trust responsibility to Indian people no matter where 
they reside. Of the 36 member clinics, do you know how many 
utilize IHS eligibility regulations to determine who receives 
services?
    Mr. Roth. They all do. It is part of their contract with 
their areas and IHS. So all of the programs adhere to their 
contracts. Now, some of our programs are dual-funded, so they 
are also funded by other sources of funding, so they provide 
services to other non-Indian individuals as well, but all the 
programs adhere to those.
    Senator Johanns. Okay. What other eligibility standards, 
then, would they use in addition or in place of IHS? Are there 
any that you are aware of?
    Mr. Roth. Well, I believe it is seven of the programs are 
dual-funded urban Indian programs and community health center 
programs. So they are funded, 330-funded programs. They would 
use the 330 funding formula for eligibility of non-native 
individuals to provide services to them.
    Senator Johanns. Okay. Something you said in your 
testimony, I must admit, kind of lit up the light bulb, if you 
will. I think you were talking about health care reform and the 
potential that a Federal mandate might have on already existing 
Federal obligations in Indian Country. Can you talk me through 
that a little more extensively, your concerns there?
    Mr. Roth. Was that in relations to the trust 
responsibility?
    Senator Johanns. Yes.
    Mr. Roth. At the beginning? Yes. The trust responsibility, 
we believe and I believe, that it extends to all Native 
Americans in this Country no matter where they live. And there 
is a Federal obligation at that point to provide health care 
services to all Indian people.
    The Federal Government isn't doing that right now. There 
are cities where Indian people live where they cannot access 
services that are provided by Indian Health Services or 
services that are free of charge.
    So that is what I was intending to get across there, and I 
hope that that did.
    Senator Johanns. Okay. Great. That clarifies it.
    Chairman Rolin, if I could ask you a question, and actually 
this was not in your testimony. This was in Jefferson Keel's 
testimony, but I am hoping you will have some thoughts on this.
    He had a section in his testimony relative to service to 
non-Indians out of Indian health care facilities. And he 
basically, at the risk of paraphrasing his position, he said, 
look, we need to continue to reserve the power to decide 
whether we will provide those services or not. Again, the light 
bulb kind of came on. In our State, we have reservations that 
are in parts of the State that aren't very populated. And I can 
think on one reservation that I visited, they had a dialysis 
facility there, very much utilized, providing a very necessary 
service there in Indian Country.
    And then it occurred to me as I was reading that testimony, 
gosh, I wonder where the next dialysis equipment is at. It 
could be 150 miles away.
    Talk me through this whole issue about making that 
available to non-Indians and what concerns you might have about 
that, if you would.
    Mr. Rolin. Well, the issue before us, sir, is in most 
cases, our Indian tribes, there is just not enough resources to 
provide the services that we had hoped to provide to our own 
people. However, in different areas, the situations are quite 
different. And as far as Indian tribes are scattered throughout 
the Nation, in my area, I live in South Alabama, I have access 
to the city of Mobile, Alabama; the city of Pensacola, Florida. 
We are in a general area right on the Alabama line there. 
Working within the community that I live, we utilize, you 
mentioned dialysis, we utilize the system that is within our 
county because that one particular area that you mentioned 
there in Dallas is so expensive. And we have been able to 
provide services for our people by referring them to that 
facility, which is utilized by all of the people that live 
within the area.
    As far as tribes, again, that is a new aspect of whether 
tribes want to move in to providing services to the community. 
It is certainly an opportunity for them to have some additional 
resources and income. But most of the time, the problems that 
we have on our reservations is that we just, the facilities 
that we have we can barely provide care, something like maybe 
50 percent at the most, to our people. And when you start 
providing these services beyond that, it really takes a way 
from the needs of your community.
    Senator Johanns. So it is more of a resource issue and a 
what you have got.
    Mr. Rolin. It is indeed, sir, resources.
    Senator Johanns. Okay. That helps me understand that 
because, again, if we could somehow solve these problems, that 
may be a resource for that area and provides, I am sure, 
necessary revenue for the facility.
    Let me, if I might, turn to Valerie Davidson. I had a 
couple of questions for you, and I hope I am asking the right 
person.
    I come from a State, the State of Nebraska, where we have 
everything from very urban areas, Omaha, Lincoln, Kearney, 
Grand Island, I could name other communities, to very, very 
rural areas. One of the things that we have been working to put 
in place quite successfully is telemedicine. And we have found 
real advantages not only in delivering mental health services 
like counseling, but diagnostic services and that sort of 
thing.
    How much telemedicine is available in Indian Country, or 
maybe even more specifically, in your State? Has that been 
something we have been able to move down the field a little 
bit?
    Ms. Davidson. I think the availability of telemedicine in 
Indian Country is really varied. It is like many of the things 
we have talked about. In Alaska, we are fortunate that we do 
have telemedicine in many of our communities.
    One of the things that telemedicine has been able to allow 
us to do is to be able to extend the reach of the provider. In 
many of our villages, in Alaska we have a four-tier health care 
delivery system, where about half of the patient encounters 
occur in a small village community, average population of about 
350 people. And they get their care from a community health 
aide. That is where I got most of the health care during my 
entire childhood.
    And one of the great things about having a person who is 
from that community, who speaks the language, who knows who you 
are, and quite frankly knows all of the things you are or your 
should or should not be doing as a child, it is amazing how 
much those folks know about you, and can set you in the right 
direction.
    Having that relationship with that person at the community 
level is what we have found, along with interactions with small 
children, really helps to be able to shape health care 
decisions, and also be able to focus on wellness and 
prevention.
    Now, what telemedicine brings to the equation, though, is 
if it is service that is beyond that person's training or 
capability, then for them to be able to be hooked up to a 
telemedicine machine to be able to have that conversation with 
a doctor or a psychiatrist or a dentist or another person in 
another community, that also extends their ability to provide 
care.
    In other parts of the Country, however, telemedicine really 
isn't utilized at all, and there is a tremendous opportunity to 
make those services available.
    The other piece besides just having the equipment 
available, and we have Alaska Federal Health Care Access 
Network has a great telemedicine cart that is available that we 
have developed over time. But in addition to the hardware, the 
other piece that is a really critical piece is having the 
available band width to be able to provide that service.
    And the USAC, the Universal Services Administrative 
Companies, subsidies to be able to provide decent band width to 
rural communities, including tribal communities, is critical 
because tribe simply can't afford a $13,000 a month T1 line, 
whereas USAC comes in, pays the difference, and it will cost 
about $1,000 a month.
    Senator Johanns. Has the stimulus package helped any in 
that area? I know there was some money identified in the 
stimulus package to try to get broadband into more rural areas. 
Is that impacting this at all?
    Ms. Davidson. I believe it has the opportunity to provide 
impact, but I am not sure that the rules are actually out for 
how tribes can actually access that. And I appreciate the 
question today so much because things are moving so quickly 
that sometimes tribes aren't necessarily aware of some of the 
issues and opportunities that are available. So to the extent 
that this Committee can do its part to make sure that as 
services or opportunities are available for any other health 
care provider, for individual, if you can help to make sure 
that tribes are included in that mix, that will help 
tremendously.
    I did mention earlier that we were concerned that the 
Health Information Technology Funds that were made available to 
the Indian Health Service, we were hoping that some of those 
resources would be available to self-governance tribes, as well 
as to urban Indian programs, to be able to meet that unmet 
need. And unfortunately, that did not happen.
    So any opportunity, we should be careful that sometimes 
when we are making funds available to the Indian Health 
Service, it is important to keep in mind not only direct 
service programs, but all three, not only direct service, but 
also self-governance, tribally operated programs, as well as 
the Urban Indian Centers, because it takes all three working 
together to be able to meet the need of individual American 
Indians and Alaska Natives.
    Senator Johanns. Those are really excellent points. 
Sometimes I think that part of our challenge is just getting 
everybody on the same page, and making sure that the funding 
that we are providing really gets to helping people, if you 
know what I am saying. Not to indict anybody, that is not what 
I am suggesting. It is just, gosh, this seems terribly 
complicated to me sometimes.
    Ms. Davidson. On that point, if I may? There has been a lot 
of talk about how the Indian health system is broken, et 
cetera. And there was a point that was made earlier, I think by 
Jefferson, that we are not broken. We are starved. And I don't 
know any other health care delivery system who could continue 
to operate year after year after year with the level of funding 
at about 54 percent.
    And if you are looking at making investments in health care 
reform, and making investments in the right place, I would 
challenge this Committee to look for any other health care 
delivery system in this Country that has shown that it can do 
more with less. Quite frankly, we have been innovative because 
we have been forced to. We live in these communities. We don't 
have that option.
    And this Committee could do so much in health care reform 
by remembering the impact that it has on individual American 
Indians and Alaska Natives. So if there is a health benefit 
that is available, make sure that Indians are expressly 
eligible. If there is an opportunity for health providers to be 
able to get additional reimbursement or additional 
considerations, make sure that the Indian health system, 
whether it is an IHS facility, direct operated; whether it is 
tribally operated; or whether it is an Urban Indian Center, 
also has that express authority.
    And then finally, because tribes are, like many areas, we 
are employers. If there are any opportunities that are 
available for employer health plans, for us to be able to get 
some tax benefits just like any other employer, please also 
remember to expressly include tribes.
    Unfortunately, our experience has shown that unless that 
express authority is there, we encounter resistance after 
resistance after resistance. And often what we hear is, well, 
if Congress intended that to happen, Congress would have 
provided express authority. And so therefore, we are asking the 
Committee that if there is any opportunity to provide that 
express authority, please do so, because otherwise we may just 
be left out of the mix.
    Senator Johanns. Okay.
    Dr. Carlton, I will wrap up my questions with you.
    I was reading your testimony and I have to admit I was just 
amazed by what you were laying out there in terms of the 
capacity to put something up quickly, that gets the job done. 
Let me zero in, if I might, a little more on cost. Give me just 
a rough idea of how what you are suggesting with this kind of 
facility, compares with ground-up sort of construction, that 
sort of thing. What are the cost differentials here? Is there a 
rule of thumb?
    Dr. Carlton. Well, when we talk cost differentials, you 
break it down into housing, commercial buildings, and then the 
highest end is medical, and the most expensive. So standard 
housing construction generally $100 to $150 per square foot; 
commercial buildings, $150 to $250; and unfortunately medical 
has gone skyrocketing. The Air Force planned to reconstruct 
their medical facilities in San Antonio at $400 a square foot. 
By the time the bill was passed, it was $600 a square foot, and 
in many areas of our Country, it is $1,000 a square foot today.
    So what we are talking about is we are talking about 
critical access hospital for $14 million is you have minimized 
the space so that the staff is more effective. And so what used 
to take 50,000 feet and the staff having to walk twice as far, 
now can be done in 33,000 feet, and the staff is more 
effective.
    So it is an efficiency model, but when you come down and 
say, well, how big a hospital do you need? The critical access 
is defined as it can't be bigger than 25 beds, but the reality 
is that most of them are running five and six-bed censuses, 
because their world has changed. We have changed to an 
outpatient environment for surgery.
    So when we have an example, and I included the Tehachapi 
example specifically for you, that was bid in a component 
fashion for $25 million and construction ready to start. An 
outside consultant came in and said, oh, we don't do component 
in the medical world. You need to go to site-built, stick-
built, $67 million.
    Now, at some point, fiscal reality has to come to our 
Nation. And I am not sure it has in the medical world. Now, 
that $14.5 million isn't $14.5 million. It is $14.5 million 
with a full lab, with a full x-ray, fully equipped nurses 
station, beds and an electronic medical record.
    So it is not exactly an apple to an apple. And so we have 
to be careful as we talk about even Tehachapi. Tehachapi at $25 
million was 50,000 square feet, $500 a square foot. And at $67 
million, it is 60,000 square feet because they wanted more 
administrative area.
    Well, if you keep it under the same roof under California 
directives, you have to then built to the highest standard. 
Where if you separate by seven feet, you can build an 
administrative area at a lower standard, which is what the 
component builders had done.
    So it is a complicated issue, but for rural States like 
yours, to be able to replace a rural hospital that then has an 
electronic medical record, and the other piece of this, we are 
talking facilities and I am talking equipment and facilities 
with you, but you have to have people, equipment, facilities, 
training and organization all at the same time.
    What we are trying to do in Texas is tie this on the people 
side into the university. The biggest problem we have in rural 
Texas is getting people to go. So the nurse, the physician 
won't go because they are all by themselves.
    Well, if we tie them to a central location so that if they 
train in our training program, they never leave the boss. They 
can always call back. They can present the cases. It is part of 
the deal.
    And the Congress has made that available. That is a pass-
through under this critical access, but we are not doing it 
because that is not the way we do things. So the potential is 
remarkable.
    Senator Johanns. I agree with you based on what I know. 
Like I said, as I was reading through your testimony, I just 
was amazed by what you were laying out there. The challenge, I 
think, for us today with this hearing is how to interface the 
knowledge you have and the experience, with what we are trying 
to do out there. Because you are absolutely right, with budget 
issues and everything else going on, we have to bring reality 
to this.
    So I would encourage you to continue somehow to interface 
with Committee Members, but then also with your Senate 
delegation back home because oftentimes they will come to a 
meeting where we are all together, and say, hey, I have a good 
idea, and that is another way of keeping you in the loop, 
because I do think there are some things here that we can use.
    I will wrap up there, and I just and I just want to say to 
all the panelists again thank you so very much for being here 
today.
    Senator Barrasso. Thank you, Senator Johanns.
    Just following up on what you were asking Mr. Carlton, I am 
also very interested in what you are doing with these mobile 
clinics and then the way you can do this, because in limited 
health resources and big distances, I think it would be really 
the answer for the future.
    I was going to ask, have you engaged other Federal agencies 
on the use of this kind of activity with mobile units and the 
component construction? What have you found? Has there been any 
difficulty moving forward in a big government bureaucracy?
    Dr. Carlton. Senator, as a physician, we understand change 
is difficult for all of us. In a governmental setting, change 
is difficult for all of us.
    I am the architect of the Iraq War plan, laid it out in 
1983 on the medical side. It took 20 years to implement because 
it wasn't the way we do business.
    Far forward, surgery critical care, the air, and integrated 
delivery system, right now, our centers in San Antonio, we have 
two level one trauma centers are two standard deviations above 
the mean for survival on identically injured patients. And you 
say, why? It is because we have a standardized protocol. We do 
things the same way.
    We may deviate from that and explain it just like a pilot 
in command, but our charter now I believe as military members 
or former military members is to share that with our community 
and bring the standard deviation up on the civilian side. If we 
are running two standard deviations above, it means that we are 
in a 97 percentile. We are doing something right.
    And we need to come talk to the Senate, and we need to say, 
well, here is what we have done in Iraq. We are doing better 
for the severely injured in Iraq across a system of 8,000 miles 
than we are in rural Nebraska. Well, there is something wrong 
with that.
    And so, with the Mayo Clinic and Texas A&M, we have now 
started a program to say, okay, let's integrate the lessons 
learned. Maybe we even need different types of surgeons. Maybe 
a general surgeon, maybe a general orthopedic surgeon shouldn't 
do everything, but we should all teach them salvage surgery, 
how to get a survivor in the first 12 hours, knowing that your 
partner will be behind you six hours later, connected by a 
transportation system. For the Indian Health Service, the same 
thing.
    So the challenge before us now is how do we standardize 
construction in a cost-effective manner, delivery of health 
care in a cost-effective manner, and the lessons learned in 
wartime how can we quickly bring them to the United States of 
America. And I think rural America, you two gentlemen, are the 
perfect examples of how we might be able to show that, and then 
integrate that.
    I mean, I am very excited about it. But it is a 20-year 
program, and so we could be a two-year program into the 
civilian world. We just have to figure out how to properly 
reward it.
    Senator Barrasso. So then specifically with regard to the 
Indian Health Service, obviously there is huge value there. Are 
there bureaucratic barriers? Or how do we get this accomplished 
in a timely manner?
    Dr. Carlton. Our Government has bureaucratic barriers. I 
presented this in 2003. The Surgeon General was a very good 
friend, Rich Carmona. And he said, you have to bring this to 
our architects, this component construction. It was a solid 
turn-down, no, we are not going to do that. No, thank you.
    And that is okay. We had to prove it. Now, we have proven 
on the inpatient side, on the outpatient side, and oh, by the 
way, we can then connect them all with a mobile system and a 
telemedicine system, and an electronic medical system, and do a 
much better job than we are doing today.
    That is not to say we haven't done a good job in the past. 
We can just do better.
    Senator Barrasso. Okay.
    For the other panelists, usually you come to these 
hearings, you testify, and then you say, I just wish I had said 
this one other thing. And I would just go down, Ms. Davidson 
and Mr. Roth and Mr. Rolin, if there are any last things that 
you would like to share with the panel, the Committee, as part 
of the formal record, I would love to hear what you have to say 
now.
    Ms. Davidson. I just want to go back to a statement that we 
made earlier that may have gotten lost in the comments, which 
is that I think time and time again, we have shown that we are 
a good investment, that we do every year more with less. But 
you also need to know that we are at a point right now where 
our resources, we have no more margin. I mean, we don't have 
it.
    And a lot of times when we talk to people about contract 
support cost, people immediately think contracts, lawyers, 
litigation, and they completely turn off. But to us, contract 
support cost is really providing necessary infrastructure. It 
is about jobs and it is about people.
    If we know that we have to use resources to be able to pay 
rent, to buy insurance, to do all of the things that are 
required, but those resources aren't available, then what 
happens is that instead of being able to provide as many direct 
services as we could, what happens is that we necessarily, 
because we have to do all those other things, all the 
infrastructure that it takes to be able to operate, those come 
from the service that we would be able to provide.
    So contract support cost is more than just about 
infrastructure because when we don't fund infrastructure, we 
have to take that money from direct services and from services 
that we otherwise would be able to provide, things like dental 
services, things like long-term care services, things like 
behavioral health services, residential treatment services. 
Those are things that we just don't have the resources to 
provide. And contract support costs lack of funding means that 
there are even fewer resources that are available.
    So thank you.
    Senator Barrasso. Thank you.
    Mr. Roth?
    Mr. Roth. Yes, I realized about 10 minutes after Senator 
Tester asked me my question that I answered it incorrectly.
    Senator Barrasso. Go right ahead.
    Mr. Roth. So I would like to highlight a little bit more 
about data and the need for really doing a comprehensive review 
in this Country on where urban Indian people live and how or if 
they are accessing services. We know that there is a lot of 
migration between reservation and urban communities, and we 
know there is a great deal of need in communities that don't 
have urban Indian health programs now.
    I was recently in Riverton as well, and was able to tour 
the 330 clinic that the tribe has started up in Wyoming. And 
that is a great example of a tribe that has come in and has 
decided that they are going to deal with the urban Indian 
population there by providing services because the access or 
the funding didn't exist within Title 5 of the Indian Health 
Care Improvement Act to do that and to expand services to that. 
So I applaud the tribe there and I applaud Riverton for being 
able to do that.
    What we really need is a needs assessment to get an 
accurate picture of what the population looks like and examine 
systemic issues related to delivery of health care to urban 
Indians, facilities, buildings, issues and workforce 
development issues.
    Thank you.
    Senator Barrasso. Thank you for the clarification. Thank 
you.
    Mr. Rolin?
    Mr. Rolin. Thank you.
    Well, as you have heard from all of us here in our 
comments, there is a need in Indian Country. I want to first 
make that known for the record. We have all done well at some 
point, and we have this and utilize the services and have the 
services that we do. We really utilize those resources to the 
very end. And it is important for us as Indian people to 
provide health care to our tribal members. In certain areas we 
have talked about, certainly providing that service has not 
been the hardship as it has other areas. And that is our 
concern, is to be able to bring health care up to the level.
    Earlier years when Dr. Everett Rhoades was Chair, I mean 
Director of the Indian Health Service, he used an example of 
getting us to a level. At that time, he said if we could get to 
70 percent. Well, we haven't been able to get there, Senator, 
and that is a goal that we are all working on.
    And if we could get to that level and go beyond that level, 
certainly by meeting the needs of our people, certainly that 
would benefit us all, and we would be a much happier community.
    Senator Barrasso. Well, I want to thank all of you for 
coming to testify. We will keep the record open for two weeks 
if there is some additional information you would like to 
supply us. We may supply you with some additional written 
questions.
    But I want to thank everyone who has come here to 
participate and to listen.
    And with that, this hearing is adjourned.
    [Whereupon, at 3:57 p.m., the Committee was adjourned.]














                            A P P E N D I X

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   Prepared Statement of Carmelita Skeeter, CEO, Indian Health Care 
                     Resource Center of Tulsa, Inc.

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   Prepared Statement of Chad Smith, Principal Chief, Cherokee Nation
    On behalf of the Cherokee Nation, please accept this correspondence 
as testimony regarding reform in the Indian Health Care System. The 
Cherokee Nation believes it is vital that the Indian health care system 
join in the broader discussion of national health care reform and have 
the ability to fully participate in any implemented advancements in 
health care policy. Through our engagement in state-level health care 
reform, the Cherokee Nation has identified three key areas where the 
Indian health system can play an active role in national reform: 
Addressing the Uninsured, Increasing Access, and Improving Information 
Technology Capacity.
Addressing the Uninsured
    Although increasing health coverage alone does not necessarily 
equal reform, the lack of health coverage does serve as one of the 
largest barriers to seeking health care. Because the Indian health 
system is able to access 3rd party payment sources, the Indian Health 
Service (IHS) and Tribal Nations have a vested interest in increasing 
the number of American Indians/Alaska Natives (AI/AN) with health 
insurance.
    Community outreach and education efforts must be undertaken to 
ensure existing programs are serving all that are eligible to 
participate. Outreach and education is especially important for the AI/
AN population as many do not participate in Medicare, Medicaid, State 
Children's Health Insurance Program, or private insurance because of 
the misperception that participation is not necessary due to IHS 
eligibility. It is important to note that according to the U.S. Census 
Bureau's Current Population Survey, individuals who report IHS 
eligibility and no other coverage are classified as uninsured. Due to 
inadequate funding and limited access, IHS eligibility does not equal 
health coverage. Therefore, national health reform legislation should 
include language that will allow IHS/Tribally-operated Programs/Urban 
Indian Health Organizations (I/T/U) expenditures to apply toward 
Medicare Part D True Out-of-Pocket-Expenses. Another legislative effort 
that would greatly improve the ability of the Indian health system to 
access private insurance resources is automatically classifying 
services provided within the Indian health system as ``in-network'' for 
purposes of payment.
    The Cherokee Nation is aware of recent proposals to explore 
``privatizing'' Indian Health Services by providing AI/ANs with a 
voucher or credit to seek health care in the private sector. Based on 
the per capita funding level for IHS users in Oklahoma ($976 annually) 
and nationally ($1,914 in 2003), funding is woefully inadequate to 
purchase comparable health services in the private sector. In recent 
reviews of similar efforts at the state and federal level, the Cherokee 
Nation has found that the State of Oklahoma in a 2006 privatization 
pilot project determined that it spent an average of $3,453 per capita 
annually on Medicaid beneficiaries. In FY 2003, the Federal Government 
spent $5,200 per capita annually for patients within the Veterans' 
Health Administration (VHA) system. These findings lead the Cherokee 
Nation to conclude that the level of funding provided by the Federal 
Government for IHS beneficiaries is not adequate to seek coverage 
through the private sector.
    Additionally, the Cherokee Nation urges the Committee to take into 
consideration that in FY 2001 IHS provided health services to only 1.3 
million American Indians and Alaska Natives. Using 2000 Census figures, 
even if every one of the 4.1 million eligible AI/AN accessed the IHS 
system, the federal fiscal impact would still be negligible compared to 
the 37.7 million Medicare enrollees, 29.2 million Medicaid enrollees, 
and the 8.4 million accessing services through the VHA and Department 
of Defense.
    Given the significant disparity in per capita spending for Indian 
health system users relative to other populations, the fact that the 
AI/AN population represents only a small segment of the overall 
population, and the Indian health system's consistently demonstrated 
ability to provide quality care with minuscule resources, the Committee 
should champion an effort to fully implement the framework of the 
Indian health system in order to increase the services for current 
patients and improve access for those unable to utilize the system.
Increasing Access to Healthcare Services (workforce and rural needs)
    In order to address the impending healthcare workforce crisis, 
efforts must be made to both increase the workforce and make the 
current workforce more accessible to the rural population. The Cherokee 
Nation supports appropriate expansions of the quantity and quality of 
health care professionals and workers, and supports practices that 
allow this workforce to operate at ``the top of their licenses.''
    While it may not be practical to construct full-time, dedicated 
clinics in remote areas, efforts can be undertaken to utilize existing 
infrastructure such as schools, places of business and retail 
establishments, to host health provider sites. The flexibility to allow 
the IHS and Tribally-operated health systems to carry out such efforts 
is critical.
    In FY 2008, the Indian Health Service Scholarship program accepted 
only 101 (or 5.3 percent) of the over 1,900 new applications were able 
to be funded. It is apparent that the IHS Scholarship Program is an 
attractive program designed to both meet the needs of the Indian health 
system and enable qualified individuals to pursue health careers. 
Adequate funding will allow this existing program to accomplish its 
designed purpose.
    National health reform should also include specific language to 
ensure Tribal facilities operated by a Tribe or Tribal organization 
authorized by Title I or III of the Indian Self-Determination and 
Education Assistance Act, aka ISDEA (P.L. 93-638, as amended) are 
eligible to participate in the National Health Service Corp (NHSC).
    Further, facilities in Indian Country continue to be desperately 
needed. The IHS Joint Venture (JV) program demonstrates the shared 
commitment of Tribal Nations and the Federal Government in providing 
additional health facilities within the Indian health system and the 
staff necessary to support the facilities. The JV program is a proven 
success in leveraging resources to construct and build critically 
needed health facilities, making federal funds go farther. The JV 
program would greatly benefit from funding on an annual basis, 
including contract-support-costs funds and adequate operational funds.
    Finally, it is a well settled principle that the government-to-
government relationship between the United States and federally 
recognized Tribal Nations provides the foundation for the federal trust 
responsibility to carry out various programs and services for Tribal 
citizens. Eligibility for such programs and services should be based on 
the political status of the individual. By virtue of citizenship in the 
Cherokee Nation, an individual should have equal access to all programs 
and services carried out by the Federal Government as part of the 
federal trust responsibility. For uniformity and objectivity, the 
Cherokee Nation recommends eligibility criteria be based on citizenship 
in a federally recognized Tribal Nation.
Improving Information Technology Capacity
    Tribal Nations still need further assistance in developing 
Universal Enterprise Network Systems to build inter-network 
connectivity and operability. An investment in the technological 
capacity of Indian Country will enable the expedited implementation of 
electronic health records, telemedicine, health information exchange 
and related initiatives in an efficient, secure and user-friendly 
manner.
    The Cherokee Nation fully embraces the principle that, in order for 
health care reform to be effective, preventive health must be 
considered on the same level as health coverage, access, and 
information technology. To create and implement effective preventive 
health programs however, better data collection and dissemination 
procedures are needed. To address the health disparities facing AI/AN, 
improved data collection is particularly needed on topics such as the 
quantification of chronic disease prevalence, chronic disease risk 
factor reduction, hypertension, and stroke prevalence and prevention. 
One of the most beneficial improvements in this area would be the 
establishment of a single, integrated website with data available to 
calculate simple statistics, such as incidence and prevalence rates, as 
well as access to relevant published data.
                                 ______
                                 

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                                 ______
                                 
 Prepared Statement of Joseph Engelken, CEO, Tuba City Regional Health 
                            Care Corporation

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                                 ______
                                 
    Prepared Statement of Robyn Sunday-Allen, CEO, Central Oklahoma 
                  American Indian Health Council, Inc.

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                                 ______
                                 
 Prepared Statement of Michael Cook, Executive Director, United South 
                        and Eastern Tribes, Inc.

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                                 ______
                                 
  Response to Written Questions Submitted by Hon. Byron L. Dorgan to 
                              Buford Rolin
Behavioral Health
    Question 1. In the absence of expressed authority, what types of 
behavioral health services are being provided by tribes?
    Answer. Behavioral health programs in Indian Country address key 
health priorities such as suicide prevention, violence/injury 
prevention, and alcohol/drug use prevention. Services may include 
mental health and alcohol and drug assessments, counseling, 
consultation, and training services. In the delivery of behavioral 
health services, many Tribes emphasize a culturally sensitive method 
that respectfully integrates tribal spirituality and cultural awareness 
into the full range of behavioral health assessment and treatment.
    Examples of these programs include:

   From Legacy to Choice--A suicide prevention program run by 
        the Colville Confederated Tribes.

   Youth Prevention Programs--The Penobscot Nation Health 
        Department supports various youth programs that provide skills 
        in the areas of substance abuse prevention, chronic disease 
        prevention and suicide prevention.

   The Home Grown Project--A healthy eating program developed 
        by the Little Traverse Bay Bands of Odawa Indians to encourage 
        nutritious eating by utilizing a more traditional approach/
        relationship with growing, gathering and cooking food.

   Healthy Lifestyle Programs--The Houlton Band of Maliseet 
        Indians implemented seven behavior health programs to address 
        tobacco prevention, increased physical activity, diabetes self-
        management and nutrition.

    Additionally, the Indian Health Service Health Promotion and 
Disease Prevention Program has compiled a database of the best and 
promising practices and local efforts in Indian Country regarding 
behavioral health. Topic areas include cardiovascular disease, oral 
health, injury/violence, mental health, overweight/obesity, sexual 
behavior, substance abuse, physical activity, and tobacco use. To 
access the comprehensive database of best and promising practices and 
local efforts, please visit: http://www.ihs.gov/hpdp/ or http://
www.ihs.gov/NonMedicalPrograms/HPDP/BPTR/
index.cfm?module=BestPractices&option=BPPPLE.
    However, not all tribes are able to provide such integrated 
services or have limited availability of such services due to chronic 
under-funding. The proposed Title VII in the Indian Health Care 
Improvement Act would provide the authority for all tribes to have 
authority to access comprehensive behavioral health programs to address 
the behavioral needs of their tribal members. In addition, additional 
funding would enable IHS and Tribal governments to provide culturally 
appropriate behavioral health services in a more timely and efficient 
manner.

    Question 2. How are behavioral health services being funded?
    Answer. Tribal behavioral health services may be funded through a 
number of sources such as:

   Office of Minority Health (example: Cooperative Agreement 
        with the Association of American Indian Physicians)

   Office of Juvenile Justice and Delinquency Prevention Tribal 
        Youth Program

   Indian Health Service

   Substance Abuse & Mental Health Services Administration

   Center for Disease Control and Prevention

   Department of Health & Human Services (via various grant 
        opportunities through the agencies and divisions of the DHHS)

   State and local agencies/health departments

   Tribes (through the Public Law 93-638 contract with the 
        Bureau of Indian Affairs and a Self Governance Compact with the 
        Indian Health Service)

   Health organizations (e.g. American Heart Association, 
        American Diabetes Association)

   Private entities/donors

    Question 3. Do you know of any successful tele-mental health 
programs being operated in Indian Country?
    Answer. The Indian Health Service has compiled a database of 
current Telemedicine programs existing in Indian Country broken down by 
the twelve Tribal areas. The IHS reports that there are about forty 
telemedicine programs and partnerships within the IHS that are 
delivering care to smaller, more isolated communities. These programs 
(including mental health programs) are listed on the IHS Telemedicine 
website at http://www.oehe.ihs.gov/telemed/.
Creditable Coverage
    You stated in your testimony that IHS does not qualify as 
creditable coverage in all instances, but that sometimes it does or 
should for ``protections''. This concept is new to the Committee.

    Question 1. In what instances would IHS be considered ``creditable 
coverage'' ?

    Question 2. In what instances would IHS not be considered 
``creditable coverage'' ?

    Question 3. Has Indian Country considered other terminology to 
alleviate the confusion?

    Answer. The implications of the term ``creditable coverage'' can 
only be understood in the context of the program or policy in which the 
term is used. In the Medicare Part D context, for example, a Medicare 
beneficiary who already has prescription drug coverage which meets the 
minimum requirements of Part D would not suffer any adverse 
consequences if he/she retained the existing coverage instead of 
enrolling in a Part D prescription drug program immediately upon 
becoming eligible to do so. By contrast, a Medicare beneficiary without 
``creditable coverage'' who delayed enrolling in a Part D plan as soon 
as he/she became eligible would be subject to a late enrollment penalty 
when he/she did decide to enroll. The amount of the penalty is 
calculated according to the number of months delay in enrollment.
    The prescription drug programs operated by IHS, tribes and urban 
Indian organization (I/T/U) pharmacies were declared to be ``creditable 
coverage'' for purposes of Medicare Part D. Thus, an Indian Medicare 
beneficiary served by an I/T/U pharmacy would not be subject to a late 
enrollment penalty if he/she later decided to enroll in a Part D plan--
which might occur if the Indian moved to a location where an I/T/U 
pharmacy was not available to him/her.
    The term ``creditable coverage'' is not used in any of the draft 
health care reform bills released so far. The Senate HELP draft uses 
the term ``qualifying coverage'', and the House draft employs 
``acceptable coverage''. In essence, both terms are intended to 
describe existing health insurance coverage, which includes certain 
minimum benefits set out in the drafts. If the coverage does not meet 
these minimums, the individual is considered uninsured. Such an 
uninsured individual is required to comply with the individual 
mandate--meaning he/she must acquire ``qualifying'' or ``acceptable'' 
health insurance coverage. Failure to do so would result in assessment 
of a penalty in the form of a tax.
    In most cases, the health services offered by I/T/Us do not meet 
the minimum benefits packages because IHS programs are so badly funded 
they cannot afford to supply the minimum required services. \1\ In that 
case, IHS would not be ``qualifying coverage'' or ``acceptable 
coverage'', and the Indian beneficiary would be subject to the 
individual mandate, and to the tax penalty if the individual does not 
purchase or otherwise obtain such coverage. Assessing a penalty on an 
Indian who was promised adequate health care by the United States but 
does not receive the appropriate level of care, would, in our view, 
constitute a gross violation of the trust responsibility for Indian 
health. That is why Indian Country has asked that individual Indians be 
exempted from the penalty for failing to comply with the individual 
mandate called for in the health care reform proposals.
---------------------------------------------------------------------------
    \1\ The Congressional Budget Office, in its paper titled Key Issues 
in Analyzing Major Health Insurance Proposals (Dec. 2008), observed (at 
page 127): ``Because of staff shortages, limited facilities, and a 
capped budget, the IHS rarely provides benefits comparable with 
complete insurance coverage for the eligible population; as a result, 
estimates of the uninsured population in the United States do not treat 
the IHS as a source of insurance.''
---------------------------------------------------------------------------
    Furthermore, it must be noted that IHS offers direct care services 
to Indian beneficiaries; IHS is not an insurance program. In that 
sense, then, eligibility for IHS services is very different from having 
insurance coverage.
    Health care reform proposals are expected to offer subsidized 
insurance to low/moderate income individuals and families who do not 
have qualifying/acceptable coverage. Indian Country wants to assure 
that eligible Indian individuals can qualify for these subsidies to the 
same extent as all other Americans, and that Indians enrolled in such 
insurance plans can use their benefits at I/T/U providers.
    At the same time, Indian Country wants to assure that Indian people 
who currently receive care from an I/T/U can, at some future date, 
elect to enroll in a subsidized (or even an un-subsidized) health 
insurance plan without suffering any penalty for a delay in 
enrollment--such as a late enrollment penalty or a waiting period for 
eligibility--consequences that might otherwise attach to a delay in 
enrollment.
    You ask whether Indian Country has considered using terminology 
other than ``creditable coverage'' to avoid confusion. Selecting other 
terms is not within Indian Country's authority. We must work with the 
terms used in each legislative proposal and make sure that we know what 
they mean in any given bill. When Indian Country developed its first 
policy paper for the health care reform debate, no draft bills had yet 
been released. Thus, we used the terminology of ``creditable coverage'' 
as that term was already in use in Medicare Part D and other health 
insurance contexts.
Cost Sharing
    Question 1. Has the National Indian Health Board discussed tribally 
imposed cost sharing provisions?
    Answer. The issue of whether a tribally-operated health program 
charges a co-pay to an Indian beneficiary is and should remain a 
decision made by the tribe in the exercise of its self-determination 
rights.

    Question 2. Do you have a sense of what Indian Country's view of 
this issue is?
    Answer. Like other issues affecting Indian Country, there are 
tribes who support and tribes who are against cost sharing levied by 
tribes for tribally delivered health care. Although there is not a 
uniform perspective across Indian Country, this decision, like other 
areas affecting a tribe's administration of its government and 
services, should be left for Tribes to decide.
Working in Partnership
    You stated, with emphasis, the interest of working in partnership 
with the Committee on reforming the IHS facilities construction and 
Contract Health Services programs. This Committee agrees that the best 
solutions will be developed in partnership with the tribes, tribal 
organizations, urban organizations and IHS.

    Question 1. Is there the perception that the Committee has not 
worked in partnership with key stakeholders like the National Indian 
Health Board?
    Answer. Our emphasis on ``working in partnership'' with this 
Committee was by no means intended to convey the notion that such a 
cooperative relationship does not already exist. We believe that it 
does--and are very grateful for it.
    The emphasis was merely intended to recognize that any legislation 
which would make changes in the operation of critical programs such as 
facilities construction and CHS must be supported by both the lawmakers 
who order them and the tribes who will be impacted by them. We 
sincerely doubt that this Committee would ever want to force on the 
Indian health system alterations whose consequences have not been fully 
considered and found to be desirable. We seek the opportunity to 
examine in detail any proposed changes; in fact, we have a 
responsibility--both to the Committee and to our beneficiaries--to do 
just that. If we believe a new idea will strengthen the system's 
ability to provide better/greater care to Indian people, we will 
support it; but if we believe a change would harm the system, we know 
you want us to tell you that, too.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. John Barrasso to 
                              Buford Rolin
Personnel Shortages
    Your written testimony urges some new approaches to address the 
personnel shortages in the Indian health system.
    Among other things, you suggest revising mechanisms for assignment 
of National Health Service Corps personnel.

    Question 1. How would you revise those National Health Service 
Corps mechanisms to be more user-friendly for the Indian health system?
    Answer. The placement of National Health Service Corps personal 
would help address the significant shortage in personal within the 
Indian health care system. However, the competition with other Health 
Professional Shortage Areas (HPSAs) for National Health Service Corps 
personnel decreases the probability for placement. HPSAs are designated 
by Health Resources and Services Administration (HRSA) as having 
shortages of primary medical care, dental or mental health providers 
and may be geographic (a county or service area), demographic (low 
income population) or institutional (comprehensive health center, 
federally qualified health center or other public facility). Although 
an Indian health service site is likely to located in a designated 
HPSA, Tribes and IHS must compete with other designated HPSA areas for 
the limited Corps personal available. The other qualified sites 
typically have a larger population and the ratio for need is likely 
higher.
    Another limitation of placement of National Health Service Corps 
personnel in IHS or Tribal facilities is the requirement that qualified 
sites must accept all patients who can receive care covered by 
Medicare, Medicaid, and The Children's Health Insurance Program. 
Currently, I/T/U may not have the physical capacity or resources to 
provide services to non-Indians who may qualify to receive care under 
these entitlement programs. An example of a solution to this issue is 
in the House bill H.R. 2708. Sec.124 (b) provides that for the service 
of National Health Service Corps member assigned to an I/T/U may be 
limited to the persons eligible for services from the I/T/U.

    Question 2. How could telehealth programs assist in addressing 
personnel shortages in the Indian Health System?
    Answer. Through telehealth programs, patients located in geographic 
isolated areas of Indian Country, may received initial diagnosis and 
services from medical staff located miles away. Application of such 
programs could reduce the need for health care personnel, reduce travel 
for health care professionals and patients and improve diagnosis. 
Various I/T/U sites could all rely on the same specialists for care. 
The health care professional would also gain an experience in 
delivering care to the AI/AN population. Also, telehealth programs 
would reduce the need for such health professionals and patients to 
travel long distances during unsafe weather periods. Only patients who 
require necessary care in person would be required to travel. Likewise, 
only health professionals who had to provide care in person would be 
required to travel to isolated and remote tribal communities. Lastly, 
telehealth programs provide the opportunity for the initial diagnosis 
or review of such diagnosis to be conducted by experience specialists 
located in other parts of the country.
    As noted in a response to Senator Dorgan, there are forty 
telemedicine programs and partnerships within the IHS that are 
delivering care to smaller, more isolated communities. These programs 
are listed on the IHS Telemedicine website at http://www.oehe.ihs.gov/
telemed/.

    Your written testimony also recommends expanding funding to train 
and support alternative provider types who have proven records of 
providing quality care, such as community health representatives, 
community health aides, behavioral health aides, and dental health aid 
therapists. Several of these alternative providers are already 
authorized under the Indian Health Care Improvement Act for the Indian 
health system.

    Question 3. How would those alternative providers which are not 
authorized across the Indian health system such as the dental health 
aide therapists be regulated?

    Question 4. What standards of practice or care would apply to the 
services performed by these alternative providers?
    Answer. Dental health aide therapists are regulated under the 
Indian Health Care Improvement Act now, as they are part of the 
Community Health Aide Program (CHAP) for Alaska authorized by Sec. 119 
of the current law (25 USC Sec. 1616l). That provision requires CHAP 
aides and practitioners to undergo rigorous training programs with 
established curricula, and to quality for certification from the 
Community Health Aide Certification Board. Their work is subject to 
ongoing review and evaluation ``to assure the provision of quality 
health care, health promotion, and disease prevention services.'' 25 
USC Sec. 1616l(b)(6).
    Current law authorizes the CHAP program to operate in Alaska, only. 
Tribal leaders have supported expansion of CHAP authority to tribes in 
the Lower 48 states, and S. 1200, the 110th Congress bill from this 
Committee, contained such a provision. If enacted, new money and 
development of appropriate curricula and certification standards would 
be needed to implement the Lower 48 authorization. Because of issues 
previously raised by the American Dental Association, the 110th 
Congress legislation did not permit expansion of the dental health aide 
therapist component of the CHAP program to Lower 48 tribes. Instead, 
the legislation ordered an evaluation of Alaska's DHAT component. 
Presumably, if that evaluation demonstrates the value and soundness of 
DHAT services, as we expect it will, the Committee would recommend new 
legislation to permit Lower 48 tribes to also offer a DHAT component in 
the CHAP program.
    With regard to standards of practice, the CHAP aides and 
practitioners in Alaska must comply with the standards set by the 
Certification Board for each discipline. This same procedure would be 
followed for regulation of CHAP programs for Lower 48 tribes if program 
authority is extended to them.
Facilities
    The committee received testimony that pre-fabricated health care 
facilities have been constructed in this country and in Iraq which have 
cut construction costs and time delays.

    Question. How would these types of in-patient and out-patient 
facilities fit within the Indian health care system?
    Answer. Such facilities may be tailored to address the unique 
health needs of each tribal community. For example, a tribal community 
with a high rate of diabetes but without local access to a dialysis 
treatment facility may consider having a pre-fabricated facility serve 
as its own dialysis center. Indeed, there are many possibilities to 
incorporate such facilities into the Indian health care system. Still, 
due to the prevalent presence and historic experience with 
prefabricated and mobile homes in tribal communities, Indian people may 
be initially hesitant to using pre-fabricated buildings as their tribal 
health care facilities. Indian Country must be reassured that such 
facilities are safe and cost efficient. In addition, there must be a 
guarantee that such structures satisfy all building safety codes. 
Serious discussions must occur in each tribal community to determine 
that if this tribe would like this type of structure and the structure 
can addressed the health needs of the community.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                              Buford Rolin
    Question 1. How does the tribal experience with stimulus funds 
provide any insights for Indian Health Care Improvement 
reauthorization, or is it too soon to tell?
    Answer. It is probably too soon to fully evaluate the extent of 
stimulus funding provided for construction and maintenance of Indian 
health facilities, although the promise of funding for the two projects 
identified for new construction has brought the hope for better and 
expanded health care to the tribal communities in which they are being 
built--Barrow, AK and Eagle Butte, SD. Both communities have waited a 
long time to qualify for facility construction. While we are grateful 
that these projects can now move forward, there are many projects on 
the IHS facilities construction priority which still await funding, and 
many more tribal communities in need of facilities who have not yet had 
the chance to be added to the priority list.
    It was a big disappointment to Indian Country to learn that none of 
the $85 million appropriated for health information technology will be 
made available to tribes who operate health programs. Rather, the IHS 
Director decided that all funds will be retained and expended at the 
headquarters level. This decision denies tribally operated programs the 
resources needed to upgrade their health IT systems and to realize the 
efficiencies upgrades would provide. The IHS Director's decision also 
means that tribes will not be able to take advantage of the incentives/
rewards federal law offers to health programs, which meet IT goals.

    Question 2. What is available for the tribes to help Indian people 
develop health behavior--such as smoke free and having a healthy 
weight, in order to prevent diabetes and heart disease?
    Answer. Focusing on wellness is good public health practice and 
reflects Tribes' traditional cultural values. Tribes cite a variety of 
effective strategies, including: community-based health education, 
patient case management, screening and early detection campaigns, 
training for healthcare professionals, and incorporating traditional 
healing approaches to improve wellness. As noted in a previous response 
to Senator Dorgan, the IHS's Indian Health Service Health Promotion and 
Disease Prevention Program has compiled a database of the best/
promising practices and local efforts in Indian Country regarding 
behavioral health. Topic areas include cardiovascular disease, oral 
health, injury/violence, mental health, overweight/obesity, sexual 
behavior, substance abuse, physical activity, and tobacco use. To 
access the comprehensive database of best & promising practices and 
local efforts, please visit: http://www.ihs.gov/hpdp/ or http://
www.ihs.gov/NonMedicalPrograms/HPDP/BPTR/
index.cfm?module=BestPractices&option=BPPPLE

    Question 3. With health care reform about to be debated in 
Congress, what changes would tribes recommend to enhance the health 
outcomes of Native Americans?

    Question 3a. What are the major stumbling blocks to improving these 
outcomes? What assets/strengths helped tribes achieve the successes 
that have been reached so far?
    Answer. Since our system suffers from chronic underfunding (we are 
funded at only 54% of need), the most meaningful and beneficial 
``change'' we can recommend is to greatly improve the level of 
resources supplied to the Indian health system. The budget process for 
Indian health must build in automatic increases for medical inflation 
and population growth merely to avoid losing ground, and it should 
routinely request actual program funding increases to enhance the 
quality and quantity of care these programs should be providing. In 
addition, the unmet backlog of facilities needs remains staggering--in 
the billions of dollars.
    Health care reform could pump additional revenue into the Indian 
health system by assuring that Indian providers have full opportunity 
to participate in provider networks serving individuals enrolled in 
insurance products listed on the proposed insurance Exchange/Gateway. 
We heartily support reform proposals which would encourage prevention/
screening services by exempting such services from patient co-pays. 
Also, incentives to enlarge the health workforce must apply to the 
Indian health system which constantly experiences difficulty in 
recruiting and retaining health care professionals in all specialties.
    In terms of identifying assets/strengths which have helped tribes 
achieve successes that have been reached so far, tribal contracting/
compacting of health care programs gets my vote. The Indian Self-
Determination and Education Assistance Act has empowered tribes in all 
areas of Indian Country to become knowledgeable about health care 
delivery; to design programs which respond to local community needs; to 
hire and train community members to operate programs and deliver 
culturally appropriate care; and to be accountable to their 
beneficiaries for program outcomes. Because of chronic resource 
shortages, we are constantly challenged to do more with less and to 
develop more efficient methods of operation. Knowing how much tribally-
operated programs have achieved with inadequate funding makes me dream 
of how we could improve the health status of Indian people if we were 
funded at our real level of need.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Byron L. Dorgan to 
                             Geoffrey Roth
National Needs Assessment
    Question 1. What federal agency would the urban programs propose to 
conduct a needs assessment study?
    Answer. In 1981 the Indian Health Service conducted a comprehensive 
needs assessment not bound to the current locations of the urban Indian 
health programs. This was not only the last study conducted on the 
needs of the urban Indian community, but the most comprehensive needs 
assessment conducted for the urban Indian community by any federal 
agency. This study is the basis upon which NCUIH has developed its own 
recommendations for a new needs assessment.
    Given the good work that the Indian Health Service did with that 
assessment, NCUIH would suggest that IHS be the ideal federal agency to 
oversee the study. We feel strongly that the study should be undertaken 
with the maximum amount of urban Indian participation as possible to 
ensure that such a study is truly reflective and understanding of the 
unique position of urban Indians.
    If the Indian Health Service, for reasons not currently considered, 
is unable or not the ideal federal agency for conducting--or overseeing 
the contract/grant process for this study--then NCUIH would suggest 
either the National Institutes of Health or the Agency for Healthcare 
Research and Quality. Both of these institutions are well equipped to 
conduct such a study in theory. However, in practice neither NIH nor 
AHRQ have undertaken an extensive study involving Native Americans 
involving social determinants of health. The 2008 AHRQ study on health 
disparities indicates that AHRQ would find doing such a study for urban 
Indians to be difficult as they cited difficulties obtaining data on 
American Indians and Alaska Natives as the primary reason for the very 
short section on AI/AN health disparities in their report.
    NCUIH believes that Indian health organizations and epidemiology 
centers are best equipped to do such a study through collaboration with 
either the Indian Health Service or NIH. Any contractor chosen to 
conduct the needs assessment must be thoroughly grounded in and 
accountable to the urban Indian community.

    Question 2. Has your organization considered what methodology and 
criteria would be required of such a study?
    Answer. While NCUIH has not developed a detailed proposal for the 
needs assessment, recommended methodology is included in Appendix A. 
NCUIH does rely heavily upon the 1981 needs assessment conducted by the 
Indian Health Service as a guide for which criteria and methodology 
should be used, with the caveat that new criteria explained below must 
be included. That study was a complete analysis of the health status of 
urban Indians including the social determinants of health. 
Comprehensive demographic data was pulled from various sources to 
understand the various communities across the country. Comprehensive 
demographic data is necessary to determine not only where UIHP 
providers are needed, but also what kinds of services are needful. The 
social determinants of health extend beyond traditional health 
indicators such as health care access to economic and social status. 
\1\ Such details are necessary to better understand the urban Indian 
community and its needs.
---------------------------------------------------------------------------
    \1\ See generally, Unnatural Causes: Is Inequality Making Us Sick? 
PBS Documentary, 2008; see further, ``Health Inequality, Not Health 
Disparities'' lecture by Dennis Raphael at the Center for Health 
Disparities 12/14/2006.
---------------------------------------------------------------------------
    Service access was thoroughly examined in the 1981 report; however, 
service access, utilization, and availability should be more clearly 
delineated. These three concepts are imperative for helping identify 
the health status of American Indians and Alaska Natives and are not 
interchangeable. For example, a patient may have a particular service 
available in their community; however they may not be able to access 
the service. Likewise, a patient may be able to access a service but 
may not utilize the service for a variety of reasons that include 
environmental barriers and cultural barriers. Perhaps most importantly, 
the 1981 report had no focus on health outcomes for American Indians 
and Alaska Natives. Available, accessible, and utilized health care is 
ineffectual if people do not receive positive outcomes. Today, we must 
demand that the available health care people access and use is 
appropriate, needed, and results in improvements in health. Therefore, 
examining availability, access, utilization, and outcomes of health 
care is a necessity in determining the current state of health for 
urban Indian people. These are the criteria that NCUIH would suggest.
    For a full discussion of proposed methodology please see Appendix 
A.
All-Inclusive Rate, Federal Tort Claims Act Coverage and Federal Supply 
        Schedule
    Question 1. Has your organization conducted a review of requirement 
and/or guidelines for all-inclusive rates, Federal Tort Claims Act 
coverage and the federal supply schedule to make certain they can be 
met by the urban Indian programs?
    Answer. Unfortunately NCUIH has not had sufficient resources to 
undertake a comprehensive review of the requirements or guidelines for 
the all inclusive rate, the Federal Tort Claims Act, or the federal 
supply schedule. NCUIH could conduct such a review if it would be 
helpful to the Committee, but has not currently been able to direct 
resources to doing so. However, NCUIH has developed an initial legal 
analysis of the FTCA coverage insofar as it could be extended to urban 
Indian health providers with minimal amendments to current law.
    In developing our ask for FTCA coverage for urban Indian health 
programs, we envisioned the protections largely applying to urban 
Indian health programs in a manner analogous to the Federally Qualified 
Health Clinic (FQHC) FTCA protections, which would mean that only those 
programs providing comprehensive primary care would be eligible for 
FTCA protections. NCUIH does have a great deal of experience with the 
FQHC requirements for FTCA coverage as 8 urban Indian health providers 
are FQHCs. Another 13 are FQHC look-a-likes and 2 are Rural Health 
Clinics (RHC). Under current law neither FQHC look-a-likes nor RHCs 
receive FTCA coverage, meaning the majority of urban Indian health 
programs providing comprehensive primary care services are currently 
ineligible for FTCA coverage despite meeting all other requirements for 
FQHC status except receiving a section 330 grant. Some urban Indian 
health providers have made a principled decision not to pursue 330 
status as it would require serving non-Indians. Some urban Indian 
health providers have decided not to pursue 330 status as they do not 
have the support staff necessary to maintain the necessary accounting 
firewall between their Title V grant funds and funds received through a 
potential 330 grant. These programs have FQHC look-a-like status which 
confers upon them higher Medicaid/Medicare reimbursement, but does not 
include FTCA coverage.
    Full FQHC programs receive FTCA coverage under the theory that as 
330 grant or contract recipients they are contracting with the federal 
government to provide a service and thus deserve protection from 
liability for those services. NCUIH believes that those programs who 
meet the requirements for FQHC look-a-like status and receive a grant/
contract under Title V of the Indian Health Care Improvement Act should 
be treated in an analogous manner as they, like a Community Health 
Clinic (CHC), are providing clinical health services as part of a 
grant/contract with the federal government. The 13 FQHC look-a-likes 
and 2 RHCs already met all necessary requirements for FQHC status 
except for a 330 grant.
    With regard to the all inclusive rate, it is NCUIH's understanding 
that the all inclusive rate is not the result of any statute, 
regulation, or other law--but rather the result of an agreement or 
understanding between the Centers for Medicare and Medicaid and Tribes 
and Tribal organizations, and thus the requirements are a matter of 
agency policy and thus do not require legislative activity. As NCUIH 
currently understands the all inclusive rate, the main requirement is 
being deemed an eligible Indian health provider by CMS. Currently the 
agency employees the definition of Indian health program found in the 
current law text of the Indian Health Care Improvement Act which does 
not include urban Indian organizations. While changes to existing law--
such as 100% FMAP or FTCA coverage--would make negotiations with CMS 
for the inclusion of urban Indian health providers in the all inclusive 
rate easier, there exists no law for Congress to directly amend for the 
inclusion of urban Indians in the all inclusive rate as the all 
inclusive rate exists nowhere in statute. However, urban Indians could 
potentially be included within this agreement between CMS and Tribes/
Tribal organizations if urban Indian organizations were included in the 
definition of Indian health program. NCUIH does strongly encourage the 
Committee to consider writing a letter suggesting that CMS consider 
including urban Indians in the all inclusive rate.

    Question 2. Will the requirements/guidelines require amendments or 
modifications? Please describe.
    Answer. To NCUIH's current understand of FTCA law, and how NCUIH 
envisions it being applied to urban Indian health providers, 
requirements/guidelines for that law would not need any major 
amendments, although not all urban Indian health programs would be able 
to access FTCA coverage.
    NCUIH cannot definitively state at this time whether or not 
inclusion in the federal supply schedule would require amendments or 
modifications any applicable federal law as we have been unable to 
complete a comprehensive legal review of all impacted law. It is, 
however, NCUIH's initial impression that no amendments or modifications 
to existing law should be necessary beyond the proposed amendment that 
urban Indian health programs be given similar status as Tribal health 
organizations, though of course deferment should be granted to Tribes 
and Tribal organizations.
Adequate Data
    Question 1. Lack of adequate data is often cited as problematic 
when addressing and improving Indian health care. Does this problem 
exist strictly within the Center's for Medicare and Medicaid Services 
or does it extend beyond that particular agency?
    Answer. Unfortunately the lack of data on American Indians and 
Alaska Natives is not unique to the Center for Medicare and Medicare 
Services. CMS has particular constraints upon their data collection as 
their methods for collection of current enrollment are woefully 
inadequate and antiquated; \2\ however, federal agencies such as the 
Agency for Healthcare Research and Quality also have reported 
difficulties in obtaining necessary data to conduct a complete health 
disparities analysis for American Indians and Alaska Natives. The 2008 
AHRQ health disparities report only spends a scant 3 pages out of over 
289 on American Indians and Alaska Natives because of the difficulty 
obtaining needed data. \3\
---------------------------------------------------------------------------
    \2\ California Rural Health Board (CRIHB), American Indian and 
Alaska Native Medicaid Program and Policy Data, 2009.
    \3\ Agency for Healthcare Research and Quality (AHRQ). National 
Healthcare Disparities Report 2008
---------------------------------------------------------------------------
    The difficulty with obtaining health data for American Indians and 
Alaska Natives stems from several interconnected causes that are 
difficult for any one agency to overcome. American Indians and Alaska 
Natives are a small portion of the population, generally live in 
isolated communities, have cultural and linguistic difficulties 
communicating with researchers, and are often an afterthought to many 
public and private studies. Other institutions that have reported 
difficulty obtaining data on American Indians and Alaska Natives 
include the Kaiser Family Foundation, \4\ Centers for Disease Control, 
\5\ and Harvard School of Public Health. \6\ In fact Indian and urban 
Indian epidemiology centers have also reported difficulties obtaining 
necessary information. \7\
---------------------------------------------------------------------------
    \4\ Kaiser Family Foundation, American Indian and Alaska Natives: 
Health Coverage Access to Care, 2004.
    \5\ Recent documentation on H1N1 have be unable to quantify impact 
on Indian communities.
    \6\ Sallie Sharp, Symposium Addresses Disparities in Native 
American health care, Harvard Science online. November 10, 2007 @ 
http://www.harvardscience.harvard.edu/medicine-health/articles/
symposium-addresses-disparities-native-american-health-care;
    \7\ See fn 2.
---------------------------------------------------------------------------
                                 ______
                                 
   Response to Written Questions Submitted by Hon. John Barrasso to 
                             Geoffrey Roth
Health Information Technology
    Question 1. Please describe the current capabilities urban Indian 
clinics have for health information technology?
    Answer. It is important to recognize that the urban Indian health 
program within the Indian Health Service consists of a wide array of 
programs and services, not all of which constitute clinical care. The 
vast majority of those offering clinical care have some technology as 
the demands for patient documentation and billing demand technological 
support. Only 2 have an electronic health record. One operates on the 
Indian Health Services, RPMS system. The other uses a private source.
    The capabilities for carrying out operations with Health 
Information Technologies (HITs) in Urban Indian Health Programs (UIHPs) 
as a group are--in general--varied. However, it is critical to note 
that UIHPs present a variety of developmental stages; therefore 
readiness to implement operations through HITs will depend very much on 
the stage of development that each UIHP operates within. The 
introduction and use of Information and Communication Technologies 
(ICTs) for health matters is precisely one of the quickest and most 
efficient manners for clinics and public health programs to leapfrog 
developmental stages and expand services in an optimal fashion. The 
latter explains the recent Obama Administration's extensive focus on 
the use of technologies for all American health facilities . The main 
issues in the introduction of these technologies have been;

        1. They require an initial moderately expensive investment in 
        hardware and personnel training.

        2. The right technology must be used in order for these systems 
        to render the maximum benefits. If the technology used is not 
        the correct one, the implementing agency may find itself 
        thwarting its own path for ongoing development.

    A comprehensive assessment on the HIT capabilities for UIHPs must 
be conducted in order to find the best approach to introduce or improve 
the HIT capacity of our programs. There is, however, \8\ one issue that 
is ongoing and common to many Urban Indian Health Programs: the 
compatibility of the current Indian Health Service strongly preferred 
Resource and Patient Management System (RPMS) \9\ with current 
technologies. There is also a lack of flexibility with RPMS when it 
needs to be improved in a comprehensive fashion. RPMS was a pioneer HIT 
when it was first launched (30 years ago), but its current version does 
not seem to work in a seamless fashion with other systems. \10\
---------------------------------------------------------------------------
    \8\ http://www.ehealthinitiative.org/stimulus/education.mspx
    \9\ http://www.ihs.gov/CIO/EHR/
    \10\ To be ``locked-in'' in a technology that is hard to update, 
upgrade or obsolete is a common problem faced by early technological 
adapters as explained by various technology theorists. For a quick and 
easy explanation about this issue see: Miozzo, Marcela and Grimshaw, 
Damian. Knowledge Intensive Business Services: Organizational Forms and 
National Institutions Edward Elgar Publishing (2006). p. 142
---------------------------------------------------------------------------
    For instance, the information entered and electronically stored 
into RPMS cannot be migrated or used by other software systems for 
Third Party Billing, which, in many cases, forces the UIHPs to 
duplicate efforts in both entering information and in training 
personnel for the use of various systems. As mentioned, a comprehensive 
and in depth assessment for solving this common issue must be conducted 
in order to find the best solution for all UIHPs.
    Aside from the afore-mentioned specific issue, the National Council 
of Urban Indian Health believes that in order to make HITs effective 
for UIHPs the following factors must be addressed: (a) Basic 
Infrastructure--PC's, Server, other hardware; (b) Appropriate Software, 
(c) Correct Training; (d) Updates for the previous three.
    Information in these four factors is very scarce and indeed 
necessary. Having that in mind, NCUIH recently carried out a survey to 
preliminary assess UIHPs in a variety of fields, including the basics 
of e-readiness (the ability of an organization to use electronic 
systems for their operations). The survey was responded to by 20 out of 
37 UIHP members (around 61% of all members). The following results 
shown below must be taken into context as most of the programs 
responding the survey were those on the middle and higher ends of the 
average UIHP development stage. It must be taken into account that some 
of the non-respondents are far from being considered technologically 
ready, infrastructure and personnel-wise.
NCUIH UIHP 2008 Survey results for--basic e-Readiness Components
    Of UIHP's reporting, 72.2% of UIHP's reporting have T1 Internet 
Service (broadband), 16.7% Dial up connection. Approximately 95% of all 
staff has e-mail access.
    UIHPs use the following methods for Internal Operations:

     41.88% using Email/PDF
     2.64% Fax
     11.50%Written
     33.00% Face-to-face
     2.67% intercom
     2.86% memos
     16.40% phone/cell

    UIHPs use the following methods for External operations:

     48.75% Email/PDF
     6.07% Fax
     25.31% Telephone/Cell
     10.93% Written letters
     14.47% face to face
     .46% text

    All UIHPs reporting have their own server, with a specific email 
for work used by staff, and most with an organizational website 
(94.1%). UIHP websites offer General UIHP Information (100%), 
Programmatic Information (100%), Contact Information (87.5%), News/
Events (81.3%), Job Opportunities (31.3%), Community Resources (43.8%), 
Online Services (25%), Community Stats (25%), and Forums (12.5%).
    According to this same survey the top three UIHP priorities for an 
information technology grant are (1) Online RPMS Infrastructure, (2) 
Online RPMS Training and Upgrading computer equipment (tied), and (3) 
Training on Special Software.
    Again, comprehensive assessment on both Information and 
Communication Technologies and on HIT capabilities for UIHPs must be 
conducted in order to find the best approach to introduce or improve 
the capacity and capabilities for our programs. NCUIH would be glad to 
participate in the conducting and coordination of such assessment if 
necessary.
    Please see Appendix B for further information on HIT and urban 
Indian health programs.

    Question 2. Please explain why urban Indian programs are not able 
to currently access this source of supply.
    Answer. Current law does not permit urban Indian health programs as 
urban Indian health programs to access the federal source of supply. 
Some urban Indian organizations may be able to access certain aspects 
of federal sources of supply through their status as Community Health 
Centers. However, that access is extremely limited, temporary, and any 
resources received under the 330 grant must be kept separate from 
resources received through the Indian Health Service in terms of 
accounting. However, only 8 of the 36 urban Indian health providers are 
also CHCs. 13 are FQHC look-a-likes and 2 are Rural Health Clinics, but 
neither FQHC look-a-likes nor the 2 RHCs have access to the federal 
supply schedule under current statute. The type of access given to 
Tribes and Tribal organizations through the Indian Health Care 
Improvement Act's current law provisions are not currently available to 
urban Indian health programs, even those that are full FQHCs.
    In terms of federal Indian law currently only Tribes and Tribal 
organizations have the legal authority to access to the federal supply 
schedule. Urban Indian health programs are not included in those 
provisions and FQHC look-a-likes--13 urban Indian health providers are 
FQHC look-a-likes--are not permitted to access federal sources of 
supply for property. Urban Indian health providers may, in certain 
situations, have access and use of federal facilities, but not of other 
property such as medical equipment.

    Question 3. Please describe how urban Indian programs will ensure 
accountability if such access is authorized, particularly regarding the 
pharmaceutical programs.
    Answer. As Indian Health Service contractors, and since the Indian 
Health Service would be the primary point of contact for accessing the 
federal supply schedule, urban Indian health programs would be bound by 
the new requirements and accountability procedures recently enacted by 
the Indian Health Service to combat waste and misuse of federal supply.
    Moreover, those urban Indian health programs with pharmacy capacity 
would be already bound by federal law and regulation regarding the safe 
and accountable access of those pharmaceuticals. The 23 urban Indian 
health programs with pharmacy capacity (8 full FQHCs, 13 FQHC look-a-
likes, and 2 Rural Health Clinics) already have implemented policies 
and procedures compliant with federal law to ensure the safety and 
accountability of pharmaceuticals and pharmaceutical scripts handled by 
the urban Indian health provider. It is difficult to describe a single 
set of policies or procedures for accountability as the difference 
between FQHC, FQHC look-a-like, and RHC status among the urban Indian 
health programs means that each program, depending upon status, may 
have different sets of standards and requirements to follow.
    Access to federal sources of supply will not elevate those programs 
currently unable to meet the requirements of federal law for class D 
pharmacies, or the regulations surrounding FQHC/RHC pharmacies, to the 
position of maintaining pharmacies. Those programs will still be 
required to meet such requirements as set in place by agency regulation 
or federal law.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                             Geoffrey Roth
    Question 1. What are the two most important changes you would 
recommend to improve the health care system delivery for Native 
Americans?
    Answer. Full funding of the Indian Health Service, including full 
funding of the Urban Indian Health Program--it's well documented that 
the Indian health delivery system is underfunded and that lack of 
funding has a deep, damaging impact upon the ability of Indian health 
providers to provide comprehensive health services. The Indian Health 
Service is funded at roughly 50% of actual need \11\ and the Urban 
Indian Health Service is funded at 22% of estimated need. While Indian 
health providers are among the most innovative and dedicated, there are 
limitations on a providers ability to make up for lack of funds through 
sheer determination and creativity. Funding for Indian health providers 
must be the very first priority in order to deliver serious change to 
the health status of Indian people. Changes to the law and additional 
programs are necessary and helpful, but without the underlying 
sustainable funds to support them those programs can only go so far.
---------------------------------------------------------------------------
    \11\ See National Indian Health Board. Testimony to the 
Subcommittee on Interior Appropriations. 2008.
---------------------------------------------------------------------------
    With full funding Indian health providers--including urban Indian 
health providers--would no longer be force to essentially ration health 
care services. Complete funding would allow Indian health providers to 
develop comprehensive, community based intervention strategies, and 
workforce development programs focused on cultural competence. Indian 
health providers are required to spend an inordinate amount of time 
simply struggling to stay financially stable and maintain the base 
level of services required by their communities. If Indian health 
providers were financially stable these resources--both financial and 
human--could be freed to focus upon developing new best practices.
    Complete funding for the Indian health system--and for the urban 
Indian health programs within IHS--would allow Indian health providers 
to build upon their innovations that have been born from necessity. 
Programs such as the special diabetes program for Indians could be 
expanded beyond diabetes into the co-morbid, chronic diseases suffered 
by many American Indians and Alaska Natives such as hypertension, heart 
disease, and depression.
    Fully integrate the I/T/U system so that each element of the Indian 
health delivery system is fully supported and fully integrated with the 
other providers. We know our patients move between provider types 
within the Indian health delivery system. They may see a direct service 
provider (I) one year and then be living in Los Angeles being seen by 
an urban Indian health provider the next. However, there is very little 
continuity of care or continuity of service level. Indeed many 
providers across the Indian health service exist at wildly different 
capacities. While certain communities may require different services, 
the entire community still requires the highest level of services and 
to be assured that as they move from one provider to another that they 
will receive the services that they require.
    Full integration would mean assured portability of health care 
regardless of where and Indian patient went. Under the proposed changes 
to the health care system under the American Affordable Health Choices 
Act Indian patients need to be able to access Indian health providers 
without fear of penalty. Furthermore, Indian health providers need to 
be included in any and all preferred provider organizations/networks 
for public health programs.
    Protections need to be secured for Indian health providers that 
preserves the choice of Indian people to use Indian health providers, 
protections such as section 50006 and 50007 of the American Recovery 
and Reinvestment Act. Moreover, urban Indian health providers must be 
included in any such protections--such as section 201 of Title II of HR 
2708 the Indian Health Care Improvement Act--because when urban Indian 
health providers are not included in these provisions they are unable 
to maintain financial stability which in term threatens the health of 
Indian patients.

    Question 2. What would you say are the current priorities areas for 
urban Indian health services?
    Answer. Financial stability is the first and foremost priority for 
urban Indian health providers. Unless a program is fully financially 
secure that provider will always be fighting for survival rather than 
building upon existing services.
    Fully developing the urban Indian health providers--this priority 
is less easy to concretely describe or even really give definitive 
dates for conclusion. Ultimately the development of the urban Indian 
health providers will only be completed when all urban Indian health 
providers are able to fully serve all of the needs of the urban Indian 
communities in which it exists--and that all urban Indian communities 
have culturally appropriated health providers.

    Question 3. How would you characterize the options urban Indians 
have for health services if they don't have access to the Indian Health 
Service?
    Answer. NCUIH would have to characterize the health services 
available to urban Indians outside the Indian Health Service in one 
word: poor. Urban Indians are often poor, underemployed, and lack 
health care benefits. Accessing non-Indian health providers is 
difficult for most urban Indians as non-Indian health providers are not 
culturally accessible, often not financially accessible, and in the 
case of some areas are not locationally accessible. \12\
---------------------------------------------------------------------------
    \12\ One of the things noted by the DC health department in a 
lecture given to the Tri-Caucus health brain trust was that in most 
major cities health care providers--particularly primary health care 
providers--have migrated to the suburbs leaving inner city dwellers 
without reliable access to health care.
---------------------------------------------------------------------------
    Financial and cultural accessibility are the largest barriers to 
health care outside the Indian health provider network. Despite the 
high rate of poverty and underemployment in Indian communities, the 
enrollment rates for American Indians and Alaska Natives in public 
health programs such as Medicaid, Medicare, and CHIP remain very low. 
\13\ Enrollment rates in private insurance for the urban Indian 
community are even lower than enrollment in Medicaid, Medicare or CHIP. 
\14\ Without the financial means to pay for health care, many urban 
Indians are forced to delay care until they can return to their tribal 
homes or are forced to seek emergency care when they reach medical 
emergency.
---------------------------------------------------------------------------
    \13\ See fn 2 and fn 4. Neither the Kaiser Family Foundation nor 
the California Indian Health Board are able to determine the exact 
reason for the low rates of eligibility given the lack of necessary 
data on enrollment from CMS; however, both note a low rate of 
enrollment given the statistical calculation of probability of 
eligibility for the population.
    \14\ See Urban Indian Health Commission. Invisible Tribes: Urban 
Indians and Their Health in a Changing World. 2007
---------------------------------------------------------------------------
    Cultural inaccessibility is the companion problem to financial 
inaccessibility as urban Indians, even if they are able to afford non-
Indian health provider care, are often unable to effectively 
communicate with a non-Indian health care provider leading to higher 
rates of misdiagnosis and poor care. \15\ Moreover, most urban Indians 
will simply refuse to seek care at non-Indian health providers as they 
feel shut out and shut down by those providers.
---------------------------------------------------------------------------
    \15\ ibid.
---------------------------------------------------------------------------
    Question 4. What solutions are there for improving this situation?
    Answer. Expand the urban Indian health program to serve all cities 
with significant urban Indian communities and assure the portability of 
health care. Currently the urban Indian health program has 32 programs 
across the country and accounts for only 25 of the major US cities. 
Urban centers such as Atlanta, New Orleans, and Nashville where the 
Census bureau has reported large Indian communities remain without 
urban Indian health programs because the urban Indian health program 
has been struggling to simply survive and has not been able to make the 
necessary steps to expand the program. The best first step to fully 
developing the urban Indian health program would be a comprehensive 
needs assessment to determine not only where urban Indians are 
currently without necessary Indian health providers, but to also 
determine what needs exist in areas with current Indian health 
providers. Plans to build upon the urban Indian health program in a 
comprehensive, sensible manner can begin after this necessary first 
step is taken.
    American Indians and Alaska Natives need the ability to not only 
move between Indian health providers, but also to move between the 
Indian health system and the general health system. American Indians 
and Alaska Natives need the ability to participate in any public health 
program as well as be assured that private insurance plans will accept 
their decision to see Indian health providers. NCUIH strongly 
encourages the Senate Committee on Indian Affairs to endorse and enact 
Indian health care provider protections that assure that American 
Indian and Alaska Native patients can seek care at Indian health 
providers without penalty.
                                 ______
                                 
                        Appendix A: Methodology
    NCUIH suggests that a National Needs Assessment on Urban Indian 
Health should begin with the development of an Urban Indian Health 
Advisory Board to guide the project. The Advisory Board would include 
13 members representing the following: tribal leader, urban Indian 
leader, urban EPI Center representative, a representative from a 
national, membership based urban Indian health organization, a 
representative from a national tribal health organization, federal 
representatives (HHS, IHS, CMS, Census), urban Indian Community member, 
urban Indian elder, community cultural/spiritual leader, and a 
university partner.
    Data collection will include archival data collection and both 
qualitative and quantitative data collection.
    1.) The Archival Data Review would involve a stepwise process. \16\
---------------------------------------------------------------------------
    \16\ ``Stepwise'' refers to the process of building knowledge and 
systems from each step of a proposed methodology so that information 
builds upon previous developments.
---------------------------------------------------------------------------
    The first step will be a review of Census data to determine the 
population of American Indians and Alaska Natives in cities across the 
United States. This review will be reported in both real numbers, as 
well as, percentage of population. Census data will also report 
demographics by city, such as income, educational levels, and other 
household information.
    In collaboration with the advisory board, the entity conducting the 
study will develop criteria for selecting 70 communities based on 
Census data for further assessment of archival data. Once selected, 
archival data will be reviewed for each of the selected cities from:

        CMS
        HHS
        Justice
        Education

    This data should provide insight into the current state of health, 
primarily service access and use, for urban Indians living in the 
respective cities.
    In collaboration with the advisory board, the entity conducting the 
study will develop criteria for selecting 50 communities for original 
data collection. These 50 communities will be selected from the 70 that 
were selected for more in-depth data collection.
    2.) Original Data Collection will involve both qualitative and 
quantitative data from a variety of stakeholders, including:

        Urban Indian Leaders (ED's Board Members)
        Urban Indian Staff (Direct Care Providers, Ancillary and 
        Support Staff)
        Consumers (Elders, Adults, Youth)
        Urban Indian Community Leaders (Spiritual, Cultural)

    3.) Methodology will include random selection of both consumers of 
services, as well as, those who choose not to use area services (or 
have limited and/or emergency use).
    4.) Specific assessment tools will be developed in consultation 
with the advisory board and include the major constructs identified in 
the assessment. The constructs will include service availability, 
access, use and patient outcomes. The broader service system will be 
examined given that many of the cities identified for assessment will 
be those without current Urban Indian Health Programs.
    5.) The entity conducting the study will work with the selected 
communities to identify and train local evaluators to complete the 
assessment at the local level. These evaluators will either comprise or 
work with an independent review board. Training will be provided by 
teleconferences, webinars, and teleconferencing. The entity conducting 
the study will use a community-based participatory research model with 
university partnerships at both national and local levels. Community 
evaluators will be compensated for their work.
Data Protection
    A national Institutional Review Board will provide oversight of the 
project through a university partner. All data will be de-identified at 
the local level and reported to the entity conducting the study for 
data analyses and reporting.
Data Analyses
    All data will be reported in aggregate. Site specific reports will 
be generated for each of the 50 communities selected for original data 
collection. National aggregated reports will be generated for:

        The US Census Archival Data Review

        The 70 sites selected for further archival data review from 
        various federal agency data.

        The 50 sties selected for original data collection

Data Dissemination
    Site specific reports will be shared with local communities (i.e., 
Indian organizations, local FQHCs, community advocacy organizations), 
area tribal communities, other stakeholders (such as Indian Health 
Services Area office), US representative(s) and state legislators.
    National reports will be shared with legislators, Indian Health 
Services, and Indian organizations.
                                 ______
                                 
                Appendix B: Information on HIT for UIHPs
What exactly is Health Information Technology?
    In plain English, it is the use of electronic means to carry out an 
operation related to a health care or to a medical management task. 
\17\ HITs therefore, range from purely administrative operations, to 
task-specific tools for management systems; to highly specialized, 
patient-customized solutions.
---------------------------------------------------------------------------
    \17\ The official language states HIT as an IT system that ``allows 
for comprehensive management of medical information and its secure 
exchange between health care consumers and providers.'' To learn more 
about these systems visit: http://www.hhs.gov/healthit/
---------------------------------------------------------------------------
How does it affect me and my Clinic?
    The most common notion about the use of information technologies 
for health is the use of Electronic Health Record (EHR) systems. These 
systems bring about a great deal of benefits to any implementing clinic 
by making information: quickly available, customizable, shareable and 
searchable in a quick fashion (in addition to greatly lowering the 
costs and making management more efficient). However, there are many 
other e-health-based systems and applications that once implemented can 
help our health programs expand services, improve existing ones and/or 
leapfrog stages of development and catch up with national trends. 
According to international expert, Dr. Per-Gunnar Svennsson, e-Health 
Care Management can be divided according to their type of user: (a) 
Consumers informatics, Clinical Informatics and Biomedics. \18\
---------------------------------------------------------------------------
    \18\ Svennsson, Pre-Gunnar. eHealth Applications in Health Care 
management. E-health International journal.2002. http://
www.pubmedcentral.nih.gov/articlerender.fcgi?artid=135526
---------------------------------------------------------------------------
    A recent report of the Health Information Management Systems 
Society (HIMSS) stresses the potential for HITs to help clinics provide 
better, more customized and efficient care for their patients: ``Today 
much of the driving clinical need centers around efforts at enhancing 
patient safety, patient satisfaction throughout and the demand for 
quick and accurate access to clinical information in order to provide 
not only quality patient care, but also access real time information 
for crucial leadership decision making.'' \19\ In general terms, there 
are three crosscutting themes where HITs can improve health care 
facilities and practitioners' performance: (a) Administrative tasks, 
(b) Clinical Support; and (c) infrastructure efficiency. Some examples 
of specific areas where HITs can positively impact performance are:
---------------------------------------------------------------------------
    \19\ To Learn more about the use and impact of HITs go to: http://
www.himss.org/content/files/ClinicalPerspectives_whitepaper_052907.pdf

   Clinical Decision Making-- generating case-specific advice
   Chronic Care
   Managing clinical competency
   Maintaining cost control
   Monitoring medication orders
   Avoiding duplicate or unnecessary tests
   Support of patient safety
   Clinical research
   Education of future caregivers \20\
---------------------------------------------------------------------------
    \20\ Idem.

    As technologies evolve, it is expected that HITs will be embedded 
in many more specific tasks and supportive areas of health care. The 
more practitioners get used to working with e-health systems, the more 
customized solutions will arise. \21\
---------------------------------------------------------------------------
    \21\ For a list of HITs applications please visit http://
www.medpac.gov/publications/congressional_reports/June04_ch7.pdf
---------------------------------------------------------------------------
Why are Urban Indian programs better suited for HITs; and why is this a 
        great opportunity for us?
    Traditionally, the government has fostered the use of information 
technologies as great alternatives for getting rural and isolated areas 
connected to regional and national systems. Under this general notion, 
urban communities were greatly overlooked, regardless of the fact that 
cities offered the advantage of services agglomeration--that is, the 
series of services that can be found in urban settings-- such as 
technology providers, cheaper broadband access, skilled personnel, 
transportation options, etc.
    The American Recovery and Reinvestment Act takes a two-pronged 
approach to advanced education relating to the use of health 
information technology, providing support both for health informatics 
programs and for clinical education programs that integrate HITs. \22\
---------------------------------------------------------------------------
    \22\ For more information on the stimulus package: http://
www.ehealthinitiative.org/stimulus/education.mspx
---------------------------------------------------------------------------
How HITs are tools for Sustainable development in my organization
    HITs can foster sustainable development in three main ways:

        a.) Freeing up resources: although the initial investment can 
        be expensive funding and training wise, Information 
        technologies have proven to lower fixed costs significantly 
        through significantly faster operations and increased 
        efficiency. \23\ These resources can be used for improving or 
        expanding services.

    \23\ http://esciencenews.com/articles/2009/01/27/
health.information.technologies.associated.with.better.outcomes.lower.co
sts
---------------------------------------------------------------------------
        b.) Knowledge Transfer and Foundation: once the technology has 
        been engrained in the health facility, it creates a 
        technological foundation that can be used by managers to find 
        customized solutions according to the challenges they are 
        facing--which can expand capabilities without much investment.

        c.) Standardized systems: the technology to be provided through 
        this government initiative would be standard for all 
        facilities, which reduces costs as well as it eases both 
        management and IT personnel recruitment, etc.
What if we do not join these efforts?
    The technological and medical gap will increase considerably. As 
health care providers, UIHPs would not only be missing the opportunity 
to take advantage of the funds and efforts this administration is 
putting into creating the basis for a sustainable health care system 
for all (including minorities and the Indian Health Service); but we 
would also be thwarting our own way to get further government funding 
in the future--as federal and local initiatives and grants will most 
likely require the utilization of these systems. Lastly, our population 
would suffer from not getting the improved and expanded health care 
services that could potentially be provided with HIT systems.
Where can I find more information on HITs?
    There is plenty of literature available depending on the specific 
topic you would like to research on. You may also contact your regional 
I.H.S Office for information on the initiatives to be implemented. 
Alternatively you may visit the following informational websites:

    Indian Health Services: http://www.ihs.gov/cio/ihimc/

    e-Health Initiative: http://www.ehealthinitiative.org/

    U.S. Dept. of Health and Human Services: http://www.hhs.gov/
healthit/

    National Alliance for Health Information Technology: http://
www.nahit.org/

    Human Resources Services Administration: http://www.hrsa.gov/
healthit/

    Center for Information Technology Leadership: http://www.citl.org/
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Byron L. Dorgan to 
                       Paul K. Carlton, Jr., M.D.
Mobile Health Units
    Question 1. How much do the mobile medical units cost? What are the 
financial benefits to using mobile units?
    Answer. The units that are certified by Medicare, licensed in nine 
states, and recognized as meeting all standards by the Joint Commission 
are the only ones that I would recommend, to do otherwise would be very 
controversial. They are made in St Johnsbury, Vt., by a company called 
Mobile Medical International. Their basic surgical unit cost about 
$2.5M, dialysis unit cost about $2.1M for four chairs fully equipped, 
dental unit about $2.5M, ICU unit a little more at $2.7M, so the round 
number to use is $2.5M each.
    The financial benefits to using the mobile units are that you can 
make any clinic fully hospital capable simply by pulling one up to the 
door and hooking it up. This would meet the ambulatory surgical needs 
of most reservations very nicely. I will attach a proposal that I gave 
to the Public Health Service about five years ago, outlining exactly 
how these could be used to greatest effectiveness. This was for the 
Aberdeen Area Indian Health Service in the Dakotas. Instead of building 
an Ambulatory Surgical Unit that cost over $10M each and is not used on 
a regular basis, you could pull up one of these mobile surgical units, 
use it for one day or longer, then move on to the next reservation and 
provide the surgical services to that area. This would solve the 
biggest challenge to the Indian Nation on medical care, the requirement 
for care that is only 0.1 or 0.2 Full Time Equivalents medical 
practitioner. The demand is not on the reservation to keep full time 
people assigned, so today they must travel for their medical care. 
Unfortunately, this tells the Indian customer that his time is not as 
important as the medical practitioners--a bad customer relations 
position. This would allow you to deliver the care on site to the 
reservation in any specialty that is ambulatory in nature and then move 
to the next reservation.
    The most complex and harder to measure financial benefit is the use 
of these mobile units in disaster situations. If we have complex 
medical equipment sitting and not being used, it will last as long as 
it would if it were being used every day. Medical technology progresses 
so fast that any medical piece of equipment has a half life of about 3-
4 years max. By using your response equipment everyday for elective 
surgical or conscious sedation care, you are telling the Indian 
customer that they are important and using the medical equipment that 
you might need in a true national medical disaster. You can then, in 
such a national disaster, delay that on reservation convenience care 
and move this same surgical unit down to the site of the disaster, set 
it up in hours, and use it in austere environments while meeting all 
standards of care. The best part is that the Public Health Service 
would be the group that uses this equipment every day, and they are 
also designated to be the disaster response group. So you could avoid 
the expense of training the Public Health service on different 
equipment, just let them use the equipment that they have been using 
every day.
    That is a double return on investment-no training cost and you are 
using disaster equipment everyday while waiting for that disaster to 
occur, instead of letting it sit and outdate.
    Unless you put both of these two functions together, regular care 
on site on the reservation and disaster response, you have not 
optimized your investment! Together, they give you the double return!

    Question 2. Are you aware of any mobile units used in Indian 
Country now?
    Answer. Yes, the Tuba City Reservation has a mobile breast care 
unit that has been in use for several years and been very well 
received. It provides comprehensive screening tests for woman's health 
issues. That mobile breast care unit was also manufactured by the group 
in St Johnsbury, Vt, Mobile Medical International.

    Question 3. Is it possible for the units to rotate between 
Reservations? Do you have recommended schedules? Do you see this being 
a problem during winter months in cold, snowy climates like North 
Dakota?
    Answer. The units should rotate between reservations to optimize 
their usage. It is not a necessity, but to maximize their utility, I 
would certainly plan to rotate them.
    I will attach a schedule that I proposed in 2005 for how such units 
could be used on different Indian Reservations in the Dakotas. You 
could rotate daily if distances are short, or on a weekly basis if 
distances are long. If the weather is really bad, as sometimes occurs 
in our northern areas, then the mother hospital could just keep the 
units and use them themselves. I have included an architect's drawing 
of what such a mother facility would look like. These would allow the 
units to be actually indoors for each location, yet the facility could 
utilize the space for waiting rooms or whatever when the mobile units 
are on the road.

    Question 4. As you know there is very high rate of diabetes in 
Indian Country, could mobile health units be used for dialysis services 
and other specialty care? Do you see a benefit to using these units in 
Indian Country?
    Answer. The dialysis question is a more difficult one because the 
typical dialysis patient requires every other day treatment (Monday, 
Wednesday, Friday or Tuesday, Thursday, Saturday). This limits your 
mobility distances greatly if you use only one mobile unit to take care 
of two different locations. For distances of less than one hundred 
miles, it would be easy to run a morning clinic in one location, fold 
up, drive the next location, set up for an afternoon and next morning 
dialysis run, then come back to the original facility and pick up the 
afternoon dialysis run. This would give you the capability to run two 
locations easily. You could do four if the numbers were small at each 
location, and the distances were short
    My recommendation for this dialysis concern, because of the 
frequency of treatment, would be to go component instead of mobile for 
these. Several hundred of these component dialysis clinics have been 
built around the country at prices less expensive than mobile and 
removes the challenges of moving the dialysis units. These are then 
steel framed structures that the Army Corps of Engineers calls 100 year 
construction. The mobile units are great, but will not last 100 years. 
Such component construction could be on site and fully functional in 3-
4 months easily. Two such component dialysis facilities would cost the 
same as one mobile system.
    Other specialty care is certainly something that could be planned 
for using these types of sophisticated mobile medical units. The Mobile 
Medical group just built a mobile endoscopy unit for a VA hospital in 
West Virginia. Every medical group has different requirements for 
support. Any reasonable outpatient surgery or conscious sedation could 
be accomplished in the mobile unit. Any outpatient oriented medical 
specialty could be set up for full function in such vehicles. The 
Breast Care unit in Tuba City is a perfect example.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Component Model Construction
    Question 1. Could you explain briefly how component construction 
was selected for the federally funded facility at Creech Air Force 
Base?
    Answer. The project was funded in FY 2005 at $1.5M. No one gave a 
bid that came close until the pressure really got high from the SECDEF 
to make our training base at Creech AFB fully mission capable (the 
people assigned to Creech AFB were driving over 60 miles one way for 
routine medical and dental appointments, which hurt mission capability 
a lot). That opened the Corps to entertain other potential construction 
methods. A group called U3I out of San Antonio teamed with an 8A 
company to do this in a component fashion and built it to cost. That 
meant that it was built and fully functional 4.5 months after contract 
signing but other things can be added as needed in the future. A 
planned better parking lot, nicer looking roof, expanded Dental Clinic, 
etc., are all planned for the future. But the fully functional 
component Clinic and Dental facility were delivered on time and on cost 
in 4.5 months.

    Question 2. Have you engaged other federal agencies on the use of 
component construction or mobile units? Has there been difficulty 
moving forward with this type of construction at federal agencies?
    Answer.

    A. Other federal agencies have used the mobile units:

        1. The White River Junction VA Medical Center in White River 
        Junction, Vt., used two Mobile Surgery Units for an operating 
        room renovation in Jan-Feb 2008. This saved them money and 
        preserved the function of the medical center for surgical 
        workload.

        2. The Miami VA is building the docking stations to bring in 
        six surgical units for a two year operating room renovation to 
        begin fall 2009.

        3. The Muskokee VA has started initial procurement to use two 
        Mobile Surgery Units for an operating room renovation in late 
        2009 or early 2010.

        4. The Naval Hospital Pensacola is in process of leasing two 
        surgical vans for an operating room renovation in FY 2010.

        5. The New Orleans VA is beginning the process for a major 
        renovation project for the operating rooms in 2010 and begun 
        negotiations for use of the surgical units.

        6. FEMA used the surgical units to respond to the Hurricane Ike 
        problems in Galveston in Sept 2008. The vans were on site and 
        fully functional three days after being requested to provide 
        surgical support for the damaged University Medical Center.

        7. The countries of Oman, Saudi Arabia, and Iraq have bought 
        these surgical units and use them on a regular basis. Oman 
        modified their Police Hospital in Muskat to house these 
        surgical units, use them on a regular basis, and make them 
        available for disaster response.

    B. Other federal agencies have begun to use the component 
construction method cautiously, mostly in non-medical activities:

        1. Non-Medical Facilities

          a. Fort Bliss has built entire complexes using these 
        component methods. A local Texas group from DeSoto, Warrior 
        Group, has gotten several of these large contracts that include 
        headquarters buildings, training buildings, and dormitories.

          b. Fort Carson, in Colorado, has used this component method 
        of construction and they are very happy with its results. 
        Again, the Warrior Group has gotten several of these contracts, 
        building a 3 story Headquarters building and multiple 2 story 
        barracks.

          c. Fort Hood has also used this method of construction and 
        been very happy with the results.

          d. The Immigration and Customs Enforcement Agency has 
        purchased a number of these component facilities for their 
        outposts in the unpopulated areas of New Mexico and Arizona. A 
        Texas firm from Burleson, Modular Designs have done these 
        outposts.

          e. I just toured the Medical Education and Training Complex, 
        METC, in San Antonio that was begun under BRAC 2005 to 
        consolidate all enlisted medical education and training on one 
        campus on Fort Sam Houston, Tx. It is a hybrid facility, about 
        \1/3\ site built, and \2/3\ factory built. It is a huge project 
        at 1.9M sq. ft. and $500M in total cost, and is on time and on 
        cost right now. It was a very short timeline from contract 
        award to completion, which was greatly facilitated by the use 
        of component construction. I have just built a brief on this 
        method, which I would be happy to share with the group. The Air 
        Force Civil Engineers and the Army Corps of Engineers are 
        monitoring all of these projects very closely and are very 
        impressed with their quality and timeliness. Again, the Warrior 
        Group has been awarded the component portion of this project.

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
        
        2. Medical Facilities

          a. Clinic at Creech AFB, delivered February 2009.

          b. MRI unit, refurbished at 60% of new cost, to Tuba City 
        Reservation 2009.

          c. MRI unit, refurbished at 60% of new cost, to Brook Army 
        Medical Center, August 2008. The above represents one of the 
        greatest savings-you can pull a component out totally, 
        refurbish it to new standards in the factory, and save the 
        customer about 40% off new cost by this recycling. A group out 
        of Loretto, TN, Modern Renovators, has done the MRI units and 
        showed us the utility of recycling these components.

          d. The VA Medical System has built several clinics using 
        component methods and they have been very impressed with their 
        quality, cost effectiveness, and timeliness. The VA considers 
        this permanent construction and has done both offices and 
        clinics.

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
        

    Question 3. What are the disadvantages to component construction?
    Answer. Overcoming the stereo-type of poor quality! This is not the 
mobile home industry, it is factory building in the same manner and 
using the same methods used on site, only doing it in the comfort and 
convenience of a factory. The economies of scale, comfort of a factory 
environment, and repetitive tasks all lead to a higher quality of 
product at a lower cost and in a more timely manner.
    I see no other disadvantage to this method. I have made multiple 
visits to factories around the country, gone to medical component 
building construction sites, non-medical component construction sites, 
and seen how this works in detail. I was a skeptic about this method 
until I did my very thorough investigations and am now its biggest 
supporter!

    Question 4. How long do these types of facilities last?
    Answer. The Army Corps of Engineers calls the wood based frame a 40 
year structure. That is what the ICE group has bought for their 
outposts. They call the steel frame construction a 100 year structure. 
That is what the Air Force bought for our Clinic at Creech AFB, Nv. 
These can be specified to any wind strength, any snow load, or any 
seismic activity load--just as any site built building can be.
Component Construction in Indian Country
    In our Committee's research of component construction, one of the 
concerns we have developed is the fixed structure of units. Health 
facilities in Native American communities tend to be very culturally 
appropriate-with Native art, ample light and circle-shaped rooms.
    Question 1. How flexible are the component units for these types of 
features?
    Answer. As flexible as you would like them to be. This is a method 
of construction, not any different than conventional in its innovations 
or culturally appropriate features. The METC construction site in San 
Antonio is a perfect example of the flexibility of this method. It was 
designed as a hybrid, part site built and part factory built. It has 
innovative traditional features and maximizes the efficiency of factory 
building. Any exterior or interior design can be created using these 
methods.

    Question 2. Are you aware of any Indian Tribes or groups 
approaching people like yourself about using component construction?
    Answer. No Indian Tribe or group has approached me personally 
regarding component construction.
    However, the Past President of the Modular Building Industry, Mike 
Mount, was invited with other representatives of the industry out to 
Albuquerque, NM June 17-18, 2009, to discuss this method with the 
Bureau of Indian Affairs. Since our hearing as on June 11, 2009, that 
makes me believe that the BIA is listening and doing their homework now 
to move into a new and very exciting future!
    U3 Innovations, the group that did our medical facility at Creech 
AFB, met with the Indian Health Services' Facility Planning Consultant 
in Denver this week, July 6-8, 2009. They discussed the applicability 
and advantages of modular construction for IHS clinics and small 
hospitals.
    So, the process seems to have started for the application of 
component construction into Indian new construction of all types.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. John Barrasso to 
                       Paul K. Carlton, Jr., M.D.
    The prefabricated facilities discussed in your testimony have been 
used for both in-patient and out-patient facilities in this country and 
in Iraq.
    Question. Can you elaborate on the potential life-span and 
maintenance costs of these facilities, particularly in harsh climates 
such as in Wyoming or the Dakotas?
    Answer. The Army Corps of Engineers refers to these facilities in 
year expected life span. For the wooden framed component construction 
buildings, they call them 40 year life structures. For the steel framed 
component construction buildings, they call them 100 year life 
structures.
    When the state of California directed that 10% of their classrooms 
be built with high end modular construction 20 years ago they never 
expected these buildings to last so long. When they went in to do 
renovation/modernization to the schools they found that the modular 
buildings were in better shape and required less upgrades than the 
traditional site built structures.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                       Paul K. Carlton, Jr., M.D.
    Question. Ideally we will construct facilities that meet the needs 
of Indian people at a cost that meets the needs of the government. You 
discussed modularity being the most efficient way to lower construction 
costs of Indian health facilities. How do you see IHS implementing this 
proposal?
    Answer. In a perfect world, I would recommend that several pilot 
programs be started to prove the concept in many different areas of the 
Indian Health Service and see if we have missed anything in our 
thinking.
    However, your needs are great and the facilities are old, so I 
would ask your IHS/BIA architectural and engineering staff to go to 
several of the facilities that I have described, see the quality, see 
the innovation, see the timeliness, and recognize that there is nothing 
experimental about any of this. That could be done in a matter of weeks 
and may have even already started with the meetings in Albuquerque and 
Denver. Then I would plan a significant percentage of your building 
program for the next several years to be component in its method of 
construction.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Byron L. Dorgan to 
                            Valerie Davidson
Veterans Affairs
    Question 1. What recommendations do you have regarding the 
Memorandum of Agreement (MOA) between the Indian Health Service (IHS) 
and Veteran's Administration (VA) to address the issue raised in your 
testimony?
    Answer. American Indian and Alaska Native (AI/AN) veterans 
frequently come from very rural and remote locations within the United 
States. There are few, if any, Veterans' Administration facilities in 
these locations. As a result AI/AN veterans must travel long distances 
to use their veteran's health benefits. Because this is impossible for 
many, instead they use the IHS or tribal health program that is nearer 
to them. Under current VA practice, no reimbursement is provided to the 
Indian health program. As I stated in my oral testimony, a VA clinical 
encounter rate needs to be established so that Indian health facilities 
can bill the VA for care provided to VA-eligible individuals. The VA 
should be directed to work with IHS to develop the VA clinical 
encounter rate. We believe there is no legal obstacle to implementing 
the VA-IHS MOA. The primary holdup in implementing the MOA seems to be 
resistance from an entrenched bureaucracy within the VA that is 
resistant to change.

    Question 2. Describe any legislative fixes that may be required to 
serve this unique population?
    Answer. Related to the answer to question one, there would appear 
to flexibility under current law to currently serve this population, 
however unfortunately there has been little action to take advantage of 
that authority. Sections 406, which amends section 816 of current law, 
and 407 of the recently introduced Indian Health Care Improvement Act 
Amendments of 2009 (IHCIA), H.R. 2708, would address this issue by 
granting explicit authority for reimbursement from VA to IHS, and vice-
versa, for services rendered to dual eligible American Indian and 
Alaska Native (AI/AN) veterans. This would allow these individuals to 
be served by Indian health providers when VA providers are not 
available and for the Indian health providers to be reimbursed for 
providing services for which VA is obligated to provide. This would 
lessen the unfair burden on the significantly underfunded Indian health 
system, provide better care to these individuals and allow more care to 
be provided to other AI/AN beneficiaries with additional resources 
provided by VA reimbursement.
Title VI of the Indian Self-Determination and Education Assistance Act
    Question 1. You reference a 2003 HHS report supporting Title VI 
which proposed 11 programs that could be accessed to begin expansion of 
Self-Governance. Is this report still applicable 6 years later?
    Answer. The report is even more applicable today. Self-Governance 
began in 2000, so the data for the 2003 report was collected in the 
early years of Self-Governance. Even then, the data and report showed 
that tribes were overwhelmingly good stewards of federal funds and 
programs and recommended expansion of Self-Governance. Now six years 
later these findings have been proven valid. Self-Governance is one of 
the few federal programs for Indian country that has been an 
unequivocal success. Tribes have countless stories of how Self-
Governance has allowed them to succeed in meeting the unique needs of 
their communities and provide better and more care to their members. 
Expanding Self-Governance to the 11 other HHS agencies and beyond would 
greatly enhance the success of Self-Governance. It would eliminate 
administrative burdens and costs by lessening the number of different 
reporting requirements on tribes and decrease the confusion and 
complexity of tribes having to follow many different rules, policies 
and regulations when utilizing funds from these many separate agencies.
    As I briefly mentioned in my oral testimony, the health of AI/ANs 
is affected by many factors, economics and education being among the 
most significant. Expanding Self-Governance to Temporary Assistance for 
Needy Families and Head Start programs would allow tribes to address 
employment and education issues that affect the health of AI/ANs.

    Question 2. The ISDEAA is already law, in your opinion what can 
Congress do to make sure Title VI is implemented?
    Answer. The genius and challenge of self-determination and self-
governance are that they require the ``bureaucratically unthinkable''; 
they require federal agencies to transfer funding and authority upon 
demand to the Tribes they serve. The tendency toward bureaucratic 
entrenchment is as predictable as it is unfortunate. The legislative 
history of the Indian Self-Determination and Education Assistance Act 
is riddled with legislative ``fixes'' of various administrative 
interpretations that were unworkable and clearly at odds with 
congressional intent and, often, contrary to the plain language of the 
statute. A number of the proposed provisions in the IHCIA and the 
implementation of Title VI follow suit.
    In order for Title VI to be successfully implemented at this point, 
Congress would need to pass legislation granted authority to go forward 
with a demonstration project. We believe that there is ample data to 
support that Congress should indeed authorize the Title VI 
demonstration project. The 2003 HHS report was supportive of the 
ability of tribes to run HHS programs. The Senate Committee on Indian 
Affairs has already drafted the legislation and held hearings on this 
issue and favorably reported out the draft bill to the full Senate in 
2004. That bill, or a similar one, should be revived and reintroduced 
in Congress.

    Question 3. Has Title IV of the ISDEAA been successfully 
implemented within the Department of Interior (DOI)? Please provide 
some examples of why or why not?
    Answer. Although we do not have a contract with DOI for any 
programs under Title IV, I can speak to the issues that other tribes 
have voiced regarding Title IV. At past Congressional hearings tribes 
have voiced concerns that Title IV is outdated and that Title V has 
been vastly superior in allowing tribes greater flexibility in 
operating HHS programs. Many tribes have voiced their desire that DOI 
programs be given analogous authority to Title V.
Level II Trauma Center in Alaska
    Question 1. Does this medical center serve non-IHS beneficiaries?
    Answer. The Alaska Native Medical Center (ANMC) provides services 
to a small proportion of non-IHS beneficiaries under specific 
circumstances. Many of these cases involve individuals who need 
immediate emergency medical services because they have been seriously 
injured. ANMC, as the only level II trauma center in Alaska, is 
sometimes the only facility in Alaska with the capacity to provide the 
care they need. As a Medicare provider, ANMC must comply with the 
Emergency Medical Treatment and Labor Act by providing emergency 
medical screening and stabilization services within its capability and 
capacity to all individuals who come to the emergency room.
    ANMC also provides services to non-IHS beneficiaries in other 
limited circumstances under the auspices of the Alaska Federal Health 
Care Partnership agreement and the authority of several statutes and 
regulations, such as the Public Health Services Act and the Indian 
Health Care Improvement Act. For example, ANMC provides pre-natal care 
and labor and delivery services for non-Indian women who are pregnant 
with the child of an AI/AN. Similarly, ANMC may treat an infectious 
disease of a member of a Native household or community to help 
safeguard the health of beneficiaries.

    Question 2. What protections does the facility have against 
malpractice claims?
    Answer. Several provisions of federal law combine to protect ANMC 
from the financial liability for most malpractice claims (primarily 25 
USC Sec. 450f(d), 25 USC Sec. 1680c, 25 USC Sec. 1638c). Because these 
laws provide a remedy to individuals through the Federal Tort Claims 
Act, these provisions are sometimes referred to as ``FTCA protection'' 
or ``FTCA coverage.''
    These laws protect ANMC from malpractice claims brought against 
ANMC when the activity the led to the claim is related to fulfilling 
ANTHC's and Southcentral Foundation's (SCF) compact and funding 
agreements with HHS/IHS, are described in the resolutions ANTHC and SCF 
have adopted pursuant to section 813 of the Indian Health Care 
Improvement Act (25 USC Sec. 1680c), or when the claim is otherwise 
covered by law. As a practical matter, these claims are ``deemed'' to 
be claims against the federal government. The Department of Justice 
defends the claims. Settlements and judgments are paid by the Treasury. 
Claims are subject to the limitations and protections of the Federal 
Tort Claims Act. Employees of ANTHC and SCF are similarly protected 
when they act within the scope of their employment. (The Federally 
Funded Health Care Assistance Act provides somewhat similar protection 
to ``330 Community Health Clinics,'' which tribes and tribal 
organizations sometimes combine with ISDEAA clinics, resulting in 
potentially overlapping protection and considerable confusion due to 
the differences in protection. Section 314 of P.L. 101-512 provides 
similar protection for other types of claims.)
    Although we think that virtually all ANMC services should be within 
the ambit of the so-called FTCA protection, both ANTHC and SCF purchase 
supplemental malpractice insurance due to concerns about some 
ambiguities in existing law and, more importantly, due to our lack of 
confidence in how the HHS Office of General Counsel and the DOJ will 
interpret the laws in specific cases.
    These laws also create an inadvertent gap in protection for peer 
review activities that almost all other providers have, including 
providers for the Veteran's Administration and the Department of 
Defense. Section 814 of the proposed IHCIA amendments would fill this 
inadvertent gap. However, neither these laws nor section 814 in H.R. 
2708, shield physicians and other providers from being reported to 
licensing authorities or from the National Practitioner Data Bank.
Fee for Service Model
    You state that using a fee-for-service model would undermine the 
IHS/tribal system because it ignores preventive, community, and 
environmental health, etc.
    Question 1. What kinds of billing mechanisms would you recommend 
that support the IHS/tribal system?
    Answer. IHS (and the tribal programs) rely on both appropriated 
funds and revenue from third-party payors, which include Medicaid, 
Medicare, private insurance and other payors. The latter are generated 
only for direct health care services. As I noted in my written 
testimony before the Committee, even with both sources of funding, 
Indian health programs receive less than 60 percent of the funding 
necessary to provide services equivalent to those provided under the 
Federal Employee Health Benefit Program.
    For direct medical services, the current reimbursement model used 
by Medicaid and Medicare that provides for an encounter rate is a very 
efficient reimbursement method. Most Indian health programs still lack 
the health information technology infrastructure and financial 
capability that is necessary to assure that Indian health programs have 
the same financial and billing infrastructure of private facilities. 
Thus, encounter rates are preferred.
    Other critical components of Indian health programs, such as 
preventive, community, and environmental health, are funded only with 
direct appropriations, supplemented somewhat by grants when they are 
available. These program components are essential to improvement in 
health status, but are not addressed in any billing mechanism. My 
testimony regarding the limitations of fee-for-service was intended to 
highlight the fact that the Indian health system is far more expansive 
in its scope than of a typical health provider and that fee-for-service 
reimbursement does not address the wrap-around elements of our 
programs, which are critical to our mission and to achieving the goals 
in the Indian Health Care Improvement Act and the goals trying to be 
achieved under health care reform. No fee-for-service payment of which 
we are aware addresses these critical services. Nor, is fee-for-service 
a viable model for funding such services since they are generally 
community-based services in which frequently the population as a whole 
is benefiting.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. John Barrasso to 
                            Valerie Davidson
Federal Tort Claims Act Coverage
    Under limited circumstances, non-Indian patients may receive health 
care at tribal health facilities. The Committee has received testimony 
suggesting that the current Federal Tort Claims Act coverage for tribal 
programs should be expanded to include tribal services to these non-
Indian patients.

    Question 1. Please elaborate on what tribes currently have to do to 
provide services to non-Indians that would be covered by the Federal 
Tort Claims Act?
    Answer. In general, tribes and tribal organizations could provide 
services to non-Indians that would be theoretically covered by the 
ISDEAA/FTCA protection in one of three ways: (1) negotiate with the IHS 
for the inclusion of those services for that population in their 
funding agreements; (2) provide the services in accordance with other 
legal authority; or (3) adopt a tribal resolution in accordance with 
section 813 of the Indian Health Care Improvement Act (25 USC 
1680c(b)(1)(B)).
    Section 813 includes several significant requirements for the 
governing body's resolution. The governing body must consider the 
extent to which other services are available to the non-IHS 
beneficiaries and whether extending services to them would result in 
the denial or diminution of services to IHS beneficiaries. Although it 
appears to be contrary to the statute, the IHS and one administrative 
tribunal have taken the position that the resolution is not effective 
for the purposes of ISDEAA/FTCA protection unless IHS concurs with 
these findings and agrees to incorporate the resolution into the 
individual funding agreements of each tribe/tribal organization.
    The IHS typically rejects tribal resolutions regarding services to 
non-beneficiaries unless it concludes there are no other providers of 
the particular service anywhere in the area. Some of the circumstances 
in which tribes concluded services to non- beneficiaries should be 
offered and IHS rejected the resolution, include:

   locations in which elders who rely on Medicare or children 
        with Medicaid coverage cannot find a non-Indian provider who 
        will accept new Medicare or Medicaid patients;

   communities in which there are only part-time practitioners 
        who have limited their practices leaving many (particularly 
        those with only Medicare or Medicaid coverage) without access 
        to a primary care or dental provider;

   communities in which some services are available only 
        through the emergency room (for instance, IHS rejected a 
        resolution authorizing services to non-beneficiaries in a 
        community-based health program for homeless individuals that 
        would have served both AI/AN and non-Indian homeless people 
        even though the program was not viable unless both were served 
        and the only access to health care for the non-AI/ANs was in 
        the hospital emergency room and the AI/ANs were much less 
        likely to seek care if it were not offered in this kind of 
        alternative setting.)

    Also, the IHS/HHS and DOJ have taken the position that ISDEAA/FTCA 
protection cannot be determined in advance, but must be decided on a 
case-by-case basis. Their case-by-case determinations (together with 
discussions in other contexts) demonstrate a marked tendency to apply 
the protection as narrowly as possible (and often more narrowly than 
could be justified by any plain language interpretation of the law). In 
a recent (non-malpractice case), we were very disturbed to see what 
appeared to be a form letter automatically denying protection, despite 
language in our funding agreement clearly describing the activity that 
led to the lawsuit and despite signed agreements with the IHS approving 
those very projects. Although the correct determination was eventually 
made, the practice is similar to that of insurance companies that 
automatically deny everything in hopes of discouraging people from 
benefiting from assistance to which they are entitled.
    At the same time, the DOJ tries to take advantage of any insurance 
policy that a tribe/tribal organization may have purchased, even if the 
policy was intended just to fill the gaps and provide a backup plan.
    As a practical matter, there is some ambiguity and vagueness in 
existing law providing ISDEAA/FTCA protection, partially because it 
results from a series of piecemeal enactments. Unfortunately, the DOJ, 
HHS and IHS have expanded considerably the uncertainty associated with 
ISDEAA/FTCA protection through their unreasonably stingy 
interpretations and various practices that undermine the value of that 
protection.

    Question 2. Do tribes obtain medical malpractice coverage and, if 
so, what is the cost of that coverage?
    Answer. There are a wide range of practices with respect to 
purchasing malpractice insurance due to the practical uncertainties 
described above together with the great variety of circumstances among 
self-determination contractors and self-governance compactors. Some 
tribes and tribal organizations rely entirely on the protections 
provided through ISDEAA and the FTCA, while others purchase a full 
spectrum of insurance. Some, like ANTHC, try to purchase policies 
specifically designed to fill the ``gaps'' in ISDEAA/FTCA protection 
rather than paying the full price for policies that provide duplicative 
coverage.
    The price of ``gap'' policies can vary considerably, depending on 
what the limits and deductibles are, how well the insurance brokers and 
carriers understand the ISDEAA/FTCA protection, the negotiating skill 
of the tribe/tribal organization, and whether the insurance is intended 
to cover other things that are clearly not within the ambit of the 
ISDEAA/FTCA protection. For ANTHC, which co-manages the Alaska Native 
Medical Center with the SouthCentral Foundation (SCF), a supplemental 
``gap'' policy for malpractice related to inpatient hospital care, 
outpatient specialty services, emergency care, specialty field visits 
to small Alaskan communities, etc. is about 25-30% of the cost of a 
full policy. (Gap insurance for primary care, behavior health and other 
programs administered by SCF is purchased separately.) While this price 
is much improved over prior years, it is still too much from our 
vantage point. As noted below, this is a cost that is allocated to the 
Secretary by law. Also, ANTHC is paying 25-30% of the cost of a full 
malpractice policy (even though there is little, if any, activity that 
we think should not be covered by the ISDEAA/FTCA protection) rather 
than 100% of a policy for those few things that might genuinely be 
unprotected. Without more decisive answers about what exactly is or is 
not covered, however, actuarial determinations are elusive.
    We understand that some insurers provide little, if any credit for 
the ISDEAA/FTCA protection to other tribes/tribal organizations, which 
pay considerably more for malpractice insurance.
    This is both the cause and effect of a practice of the DOJ that has 
injected another element of uncertainty that artificially elevates the 
price of supplemental coverage as well. It often demands to be treated 
as an implied insured so that the supplemental gap policy essentially 
becomes the primary policy for a wide range of risks that the tribe and 
insurer specifically intended to exclude. Since it is difficult to 
predict when this might happen, the price is adjusted upward to 
compensate the insurer for this risk.
    While we agree with the DOJ and courts that the insurance companies 
should not be permitted to enjoy windfall profits under these 
circumstances, the better policy would be to disgorge the profits in 
favor of the tribes and tribal organizations that have been taken 
advantage or to simply enforce existing law which requires the 
Secretary of Health and Human Services to purchase liability insurance 
for tribes and tribal organizations, taking into account the extent of 
ISDEAA/FTCA protection--that is to fill the gaps. (25 USC 450f(c).) To 
the best of our knowledge, the Secretary has neither purchased such 
insurance nor issued any determination no such insurance is needed 
since there are no real gaps in the protection. The latter would be 
especially helpful, assuming courts would be required to adhere to the 
determination. In any case, the cost of procuring insurance for each 
individual tribal program is likely to be significantly more expensive 
than pooling the cost at a national level.
Title VI Expansion
    Your written testimony recommends expanding the self-governance 
program to other programs within the Department of Health and Human 
Services such as Head Start.

    Question 1. Please explain how expanding self-governance principles 
to these other programs will ensure accountability, particularly that 
the funds will be used in accordance with governing statutes and 
purposes.
    Answer. The 2003 HHS report found that self-governance programs are 
good stewards of federal funds and exhibited high degrees of 
accountability for federal fund and complied with the use of the funds 
for which they were intended. Title VI would merely be an expansion of 
Title V authorities to other HHS programs outside of IHS. The auditing 
standards and reporting requirements would still be the same as Title V 
for any programs compacted for under Title VI and should have the same 
high degree of accountability and effectiveness that tribes have shown 
under Title V IHS programs. Title VI is not about eliminating 
accountability for federal funds provided to tribes, it is about 
eliminating bureaucratic red-tape and administrative burdens that 
tribes are encumbered with by having to deal with a multitude of 
reporting requirements from the different HHS agencies. It is also 
about respecting the tribe's priorities within its own tribal 
community. Title VI would eliminate this problem by only requiring 
tribes to meet one reporting and accountability requirement for all the 
programs--one that has shown to be effective in providing 
accountability through Title V.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                            Valerie Davidson
    Question 1. All of us have habits that promote our health and 
habits that compromise our health. I imagine that you have encountered 
obstacles in your efforts to motivate tribal members to take charge of 
their health and to motivate tribal leaders to provide adequate health 
services. What can we learn from your experience that would help us 
improve Indian health?
    Answer. Indian health programs are unique among providers in their 
focus on prevention and community health. Unfortunately, funding for 
health promotion and disease prevention is inadequate, particularly as 
the health challenges have changed from those that can be addressed 
with immunizations to those that require behavioral changes. Passage of 
H.R. 2708, the Indian Health Care Improvement Act Amendments of 2009, 
is important as it broadens the definitions of health promotion and 
disease prevention to bring them up-to-date. The integration of 
behavioral health in Title VII is also important. Many tribal health 
programs have begun this process, and some have even begun to fully 
integrate behavioral health assessment and treatment into their primary 
health programs. This is important to earlier identification of mental 
health and substance use disorders that trigger or confound other 
health problems.
    As I alluded to in my oral testimony, improving Indian health is a 
complex issue and to successfully address the issue a multitude of 
approaches must be taken. This is why the authorization of the 
demonstration project of Title VI of the Indian Health Care Improvement 
Act is so important. The 2003 HHS report, Tribal Self-Governance 
Demonstration Feasibility Study, concluded that it was feasible and 
desirable to extend tribal self-governance to the Department of Health 
and Human Services (HHS) programs outside of the Indian Health Service. 
The report recommended 11 HHS programs that could be included to begin 
with. The eleven included programs such as Temporary Assistance for 
Needy Families and Head Start that would allow tribes to better address 
economic and education issues in their communities that have been shown 
to have a significant impact on the health of AI/AN communities.

    Question 2. I am aware that one element of improving Indian health 
services is to increase the number of skilled Indian health care 
providers. What specific suggestions could you offer this Committee to 
inspire more American Indians and Alaska Natives (AI/ANs) to succeed in 
school and become doctors, dentists, nurses, and other health care 
providers on reservations or in the urban areas where other Indians 
live?
    Answer. First, more mid-level health providers, such as a community 
and behavioral health aides, are needed to provide services in Indian 
country. Obtaining education and training to be certified as a 
community or behavioral health aide lowers the burden for many Native 
American members of these communities who may want to provide health 
services to their community but do not want to be away from their 
communities for years and years to obtain the training necessary to 
become a physician or psychologist.
    Second, for those AI/ANs that do wish to pursue higher education 
and training outside of their communities, there needs to be proper and 
adequate support. This can be accomplished by expanding the Indian 
health professions program by allowing more scholarships for AI/AN 
students pursuing health professions. Additionally, the waiver of 
taxation on scholarship and loan repayments can be waived as it is for 
the Veteran's Administration. Providing health services to AI/AN people 
is not a lucrative career, health professionals work for the Indian 
health system because they believe in what they are doing and want to 
make a positive contribution to the health of AI/AN and their 
communities. Whatever opportunity there is to allow AI/AN students and 
providers to accomplish this should be pursued.

    Question 3. Providing care for Indian children with disabilities is 
a major need. I know that the IHS has a contract with three 
universities (Utah State, Northern Arizona University and New Mexico 
State University) to serve Indian children with special needs in the 
Southwest region of the country. These universities are looking for 
funding to expand tele-behavioral health to serve rural, geographically 
isolated communities in New Mexico and Arizona. Can you comment on 
successful strategies that provide health promotion and health services 
to rural areas such as in my sate of New Mexico?
    Answer. As I stated at the hearing, Alaska has a long history and 
advanced model for providing health services to rural areas. The model 
that has worked for us in Alaska for providing care in rural 
communities is a combination of having mid-level health providers in 
the rural communities who are able to consult with higher-level health 
providers through a telehealth network.
    By necessity the Community Health Aide (CHA) program was born in 
the 1950s to address the TB outbreak in remote Alaska villages, where 
CHAs were needed to provide vaccinations. Through ingenuity this 
program has been improved and expanded. First by establishing a uniform 
and accepted certification standard for CHAs, and later by expanding 
the program to include Dental Health Aides and Behavioral Health Aides.
    The small rural villages in Alaska do not have the population base 
to support higher level providers, such as physicians or psychiatrists, 
to be in the communities full-time. However, they can support health 
professionals that are mid-level providers. These mid-level providers 
still have training and expertise and are more willing to work in rural 
communities at salaries that smaller communities can support. 
Additionally, while people from these small communities may neither 
have the desire or opportunity to obtain a medical or dental degree and 
study for 10 years outside of their communities, they can obtain 
training and certifications as CHA, DHAT and BHAs without having to 
leave home for too long and with much less financial burden. This 
allows them to return to their communities to provide services and 
allows for a steady and trusted presence in those communities.
    Telehealth is an important support for the modern CHA program 
because it allows higher-level providers located in more populated 
areas to actually see how various symptoms present rather than relying 
exclusively on verbal descriptions from CHAs in difficult cases. This 
helps to extend their expertise out into the rural areas in cases that 
would otherwise require patients to travel to a regional hub or 
Anchorage for care. ANTHC has developed special AFHCAN telehealth carts 
and software that provide CHAs with the tools they need to capture 
photos, images and other data that often allows the higher-level 
providers to evaluate and direct the treatment of patients at great 
distances without the high cost or time involved in travel.

                                  
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