[Senate Hearing 111-888]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-888

  HEALTH CARE WITHOUT AN IHS HOSPITAL: OVERTAXING THE CONTRACT HEALTH 
                            SERVICES PROGRAM

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

                             FIELD HEARING

                               before the

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                            OCTOBER 2, 2010

                               __________

         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
AL FRANKEN, Minnesota
      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 October 2, 2010..................................     1
Statement of Senator Dorgan......................................     1

                               Witnesses

Bell, Hon. Billy A., Chairman, Fort McDermitt Paiute and Shoshone 
  Tribes.........................................................    10
    Prepared statement...........................................    12
Curley, Cindy, Health Director, Pyramid Lake Paiute Tribe........    14
    Prepared statement...........................................    17
Harris, Catherine S., CFO, Reno Heart Physicians.................    18
    Prepared statement...........................................    20
Moyle, Alvin, Chairman, Fallon Paiute Shoshone Tribe; President, 
  Indian Health Board of Nevada..................................     5
    Prepared statement...........................................     9
Sammaripa, Hon. Loren, Chairman, Walker River Paiute Tribe; 
  accompanied by Kenneth Richardson, Health Director.............    22
    Prepared statement...........................................    24

                                Appendix

Campa, Hon. Lucille, Tribal Chairperson, Las Vegas Paiute Tribe, 
  prepared statement.............................................    39
Charts, submitted for the record.................................    56
Joe-Kinale, Rose Mary, Human Services Director, Yerington Paiute 
  Tribe, prepared statement......................................    41
Letters, submitted for the record, by:
    Hon. Elwood L. Emm, Jr.......................................    48
    Alex Conway, Bea McMinn, and James McMinn....................    51
    Tina M. Nino.................................................    54
    Katherine Marie Quartz.......................................    52
Melendez, Hon. Arlan D., Tribal Chairman, Reno-Sparks Indian 
  Colony (RSIC), prepared statement..............................    39
Walker, Hon. Waldo W., Chairman, Washoe Tribe of Nevada and 
  California, prepared statement.................................    45
Wright, Jr., Hon. Mervin, Chairman, Pyramid Lake Paiute Tribe, 
  prepared statement.............................................    43

 
  HEALTH CARE WITHOUT AN IHS HOSPITAL: OVERTAXING THE CONTRACT HEALTH 
                            SERVICES PROGRAM

                              ----------                              


                       SATURDAY, OCTOBER 2, 2010


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                          Reno, NV.
    The Committee met, pursuant to notice, at 1:30 p.m. in the 
Hyatt Place Reno-Tahoe Airport Building, Hon. Byron L. Dorgan, 
Chairman of the Committee, presiding.

          OPENING STATEMENT OF HON. BYRON L. DORGAN, 
                 U.S. SENATOR FROM NORTH DAKOTA

    Senator Dorgan. We're going to begin the hearing today. I'm 
Senator Byron Dorgan. And this is a hearing of the U.S. Senate 
Indian Affairs Committee. I want to thank all of you for being 
here. This is a formal hearing of the Committee. We have held 
many, many hearings this year on the subject of Indian health 
care. And we will be holding at least one more hearing by the 
end of the year, but this is beginning to rap up a series of 
hearings that we've held on health care.
    I wanted to say at the outset that we've made, I think, 
very significant progress this year on a range of issues 
dealing with Indian health care. For the first time in 18 years 
the United States Congress has taken action and the President 
has signed a piece of legislation that reauthorizes permanently 
in federal law the Indian Health Care Improvement Act. I'm 
enormously proud that we were able to do that. We got it passed 
through the Senate in the last Congress, and it died in the 
U.S. House. But this year we got it through the Senate and the 
House and it is now law. In addition to that, we passed the 
Tribal Law and Order Act, and, as you may know, the President 
had a signing ceremony in the East Room of the White House. 
We're enormously proud of that legislation, as well.
    There are other things that we have done in the Indian 
Affairs Committee this year that are very, very important, but 
I wanted to mention those two especially, because I think both 
will have a very significant impact going forward with 
assistance to Native Americans in this country and to tribal 
governments, as well.
    Senator Reid had asked if I would hold a hearing in Nevada 
on the subject of Indian health care. And I said I would. I 
wasn't able to get here until now, but I'm really pleased to be 
here now, and on behalf of Senator Reid, say welcome to all of 
you. Since he's not able to be here on this day. This was the 
day I was able to come and he is somewhere else in the state. 
But I know that he asked me to hold a hearing here on Indian 
health for a couple of reasons.
    I know that there is substantial use of contract health 
funds here in this area of Nevada. I know that the State of 
Nevada does not have a hospital within the Indian health care 
system and that often it's 700 or 800 miles to drive to the 
hospital in Phoenix. I know that in the Indian Health Care 
Improvement Act, there is a provision that requires the 
development of a plan to create an IHS area office here in 
Nevada, which I assume would be the precursor to all of the 
things that would accompany the designation as a region. This 
is the only state, I think, of its size that does not have a 
hospital within the Indian health care system. The State of 
Nevada previously, as I understand it, had two hospitals. Both, 
I believe, have lost certification and are no longer hospitals.
    But it's pretty clear that if you are a Native American, 
one of the First Americans who welcomed everyone who showed up 
later--if you are a Native American living here in this state, 
you rely more heavily on Contract Health Services. It's also 
the case that Contract Health Services is inadequately funded 
by virtue of not having sufficient money in the budget; it 
never has. And it's also the case that the formula by which the 
basic amount of contract health money is distributed around to 
the various tribal governments is a formula that no one in the 
country understands, including those who distribute the funds. 
And that says something. If you ever want to try to get the 
bottom of it to say: Let us understand the base formula that 
goes back some many years? Be prepared to sit and listen until 
your eyes glaze over and still never understand the description 
from someone who's offering the description, because those who 
are offering it don't understand it either.
    Having said all of that, this year we have embarked on 
something, in addition to passing legislation to improve Indian 
health care. We have also begun a very specific investigation 
of one region of the Indian Health Service. I know that many of 
you, perhaps, have read about this and understand it, but the 
specific investigation is of the Aberdeen region. We have 
undertaken the investigation for very important reasons. There 
are very significant allegations, and have been for a long, 
long while, of things that we should not allow to happen. I 
have always said as we begin this process--and I said it again 
the other day when we had a hearing--I think there are a lot of 
very wonderful people working for the Indian Health Service. I 
think every day there are men and women, doctors, nurses, 
health care professionals who go to work and are proud to 
serve, do everything they can possibly do to provide the kind 
of service that all of us are proud of.
    I also know that at the Indian Health Service there's a 
bureaucracy that in some cases is not thinking very clearly, 
they do things they shouldn't do. They transfer people instead 
of fire people when people, in some cases, misappropriate money 
or in other cases, take narcotics, pilfer narcotics, or when 
they harass people. I can't describe to the whole series of 
things, but I'm just saying to you I know plenty of instances 
where problem employees in the Indian Health Service have not 
been to just one or two, but they have been transferred to one 
and two and three and four different places in the Indian 
Health Service when they have failed at each place. That, in my 
judgment is shameful.
    One example is a woman who has had four separate EEOC 
complaints against her, adjudicated against her, and in each 
case she was transferred to another facility, only to fail 
there. We cannot allow that to continue. Even as I'm proud of a 
lot of good work by a lot of people, I'm determined that the 
bureaucracy in the Indian Health Service has to begin making 
the right decisions on behalf of Native Americans in order to 
provide the best kind of health care for American Indians.
    Now, even if we had the best people available in every 
circumstance and I didn't have horror stories to tell you or 
horror stories that required me to investigate one area of the 
Indian Health Service--and, by the way, there will undoubtedly 
be investigations of others--even if that were not the case, 
there are other problems that I think lead all of us to 
understand this system doesn't work very well.
    I have told the story on the Floor of the Senate and used a 
chart that shows a very large photograph of a woman named Ardel 
Hale Baker. She happens to come from a tribe in my state, but 
that's just happenstance. I've also used photographs of others 
from other states. Ardel Hale Baker was having very serious 
chest pains. She went to a clinic on her reservation. She was 
told she was having a heart attack, diagnosed as having a heart 
attack, and she was sent to the nearest hospital, which is 
about 80 to 90 miles away off of the reservation. When they 
took her out of the ambulance--which she didn't want to go in 
because she was worried she would be stuck with paying a bill 
that she couldn't pay and ruin her credit--but, nonetheless, 
she was taken by ambulance, and when they took her out of the 
ambulance and transferred her from the gurney that she was on 
to the hospital gurney, they found a piece of paper taped to 
her thigh. It was an eight-by-ten piece of paper with masking 
tape attached to the thigh of this woman, it was a letter, from 
the Indian Health Service to the hospital, which said something 
like, Understand this: If you admit this woman to your 
hospital, you're doing that at your own risk because we are out 
of contract health care money.
    Now, just think of the consequences of that. You're having 
a heart attack, being transferred to the hospital, and someone 
tapes a piece of paper to your leg to tell the hospital 
provider: ``If you admit this person, understand we're out of 
contract health care money. Do it at your risk.''
    On that reservation, and on many others that have testified 
before our Committee, the mantra very clearly was: Don't get 
sick after June, because by June we're out of contract health 
care money. You get sick after June, tough luck.
    The reason I tell you that story is I know that the 
majority of the reliance on health care in this region, because 
you don't have a hospital, is on contract health care. And the 
funding in contract health care is woefully inadequate. There 
should be front page headlines in newspapers about the 
rationing of health care to American Indians. It is rationing. 
About 60 percent of the need is met; 40 percent is not met. 
That means rationing. That ought to be a scandal. That ought to 
be front page headlines in newspapers, but it's not. And this 
Committee has tried in every way that it knows how to hold a 
mirror to say to the Congress, to the Indian Health Service to 
say to Department of Health and Human Services: We can't allow 
this to continue; this must be fixed.
    So as I indicated to you, Senator Reid asked me if I would 
hold a hearing in Nevada. I had hoped to get here a couple 
months ago, but was not able to do that. But this hearing is 
focusing especially on the difficult circumstance of contract 
health care funding.
    Before I begin with witnesses, and I very much appreciate 
the witnesses for being here--I do want to introduce a couple 
of people who are joining me today. One is the Chief of Staff 
of the Indian Affairs Committee, Allison Binney. Allison is 
from a tribe in California.
    There is also Erin Bailey, right behind me, who did a lot 
of work as a principal staffer on the Indian Affairs Committee 
on the health care bill that is now signed into law. Allison 
and Erin had everything to do with that. Wendy Helgemo is 
Senator Reid's staff person that works on the Indian Affairs 
Committee issues. And Wendy is with us back here.
    As a matter of courtesy, I'm going to introduce all of the 
folks who are going to be witnesses today, but I want to 
especially introduce the tribal chairs. Before I do that, let 
me introduce Dorothy Dupree, who is the acting Director of the 
Phoenix Area Indian Health Service office. Dorothy is right 
back in the back of the room. We appreciate very much your 
being here today.
    Ms. Dupree. Thank you very much.
    Senator Dorgan. We have a number of tribal chairs. I want 
to pay recognition to the tribal chairs, some of whom I'll 
introduce as witnesses. Let me indicate who is here. Chairman 
Waldo Walker from the Washoe Tribe. Right back over there. Mr. 
Chairman, thank you.
    Chairman Mervin Wright, Pyramid Lake Tribe, right here. Mr. 
Chairman, thank you.
    Daryl Crawford from the Inter-Tribal Council of Nevada.
    Mr. Crawford. Right here.
    Senator Dorgan. Daryl is right over here.
    And the Honorable Alvin Moyle, Chairman of the Fallon 
Paiute Shoshone Tribe. Right here. I'll introduce Alvin in a 
moment.
    The Honorable Billy Bell, Chairman of the Fort McDermitt 
Paiute-Shoshone Tribe. Where are you? Right here.
    The Honorable Loren Sammaripa, Chairman of the Walker River 
Paiute Tribe, right over here.
    And Larry Curly is with the Indian Health Board of Nevada. 
He's right back here. Larry, it's good to see you again.
    Let me thank all of you who worked on these issues, and 
especially thank the Chairmen of Tribes who are here. They 
represent the government leadership of the various tribes. As I 
understand it, there are 27 tribes in Nevada. It's a big old 
state. Somebody was telling me if you go from the north part to 
the south part, you're driving about 700 or 800 miles. It's a 
big place. And these tribes, based on the map that I looked at 
earlier, are spread out. I know that it is a challenge, even 
under optimum circumstances, to try to make certain you've got 
the provisions for the delivery of health care in an area that 
size.
    But let me say that those who have agreed to be witnesses 
today and talk to us about what they are facing and the 
challenges that confront them, I very much appreciate you being 
here.
    Alvin Moyle is Chairman of the Fallon Paiute Shoshone Tribe 
of Fallon, Nevada. Mr. Moyle, thank you very much for being 
here. And what we will do is, we will take all of the formal 
statements that you have brought as part of the permanent 
record of the Committee, and we will ask each of you to 
summarize your testimony as best you can. We will have a two-
week period following this hearing, and we will invite anyone 
who wishes to submit any testimony to the Committee to be a 
part of the permanent record, as well. We offer that invitation 
to any interested observer or tribe based on what they've heard 
at this hearing.
    So, Mr. Moyle, welcome. Thank you very much for being here. 
And you may proceed.

        STATEMENT OF HON. ALVIN MOYLE, CHAIRMAN, FALLON 
        PAIUTE SHOSHONE TRIBE; PRESIDENT, INDIAN HEALTH 
                        BOARD OF NEVADA

    Mr. Moyle. Good morning. Thank you very much, Senator 
Dorgan, for taking the time out of your schedule to come out 
here to the State of Nevada. And I'd like you to also pass this 
on to Senator Reid: That we appreciate him asking you to do 
this. We are grateful to him and we are grateful to you. And we 
are grateful to a number of people that are advocates that 
helped pass the Indian Health Care Improvement Act. What I 
would like to do, Senator, on your permission--that we allow a 
blessing before we begin.
    Senator Dorgan. I'd be honored. And who would----
    Mr. Moyle. Billy Bell.
    Senator Dorgan. Chairman Bell, we would be honored if you 
would offer a blessing today.
    Mr. Bell. Thank you for giving me this opportunity to offer 
this short prayer. On behalf of everyone here as well, Senator, 
thank you. If I may use my own language.
    [Prayer/Blessing.]
    Senator Dorgan. Chairman Bell, thank you very much for that 
blessing. I was thinking, as you completed the blessing, that 
among the things I'm very proud about this Committee is the 
passage some while ago of the Esther Martinez Language 
Preservation Act. It was a long time coming, and the passage of 
that was, I think, a very significant event.
    Mr. Moyle, Chairman Moyle, you may proceed.
    Mr. Moyle. Thank you, Senator. Is this also recorded, other 
than the fact that we can turn in our testimony?
    Senator Dorgan. What we have is a court reporter. That's 
the method of recording. We also have amplification as a result 
of the microphones.
    Mr. Moyle. Okay. Senator, I do ask that because of the fact 
that I have testimony prepared, but I would also like to speak 
on and with the subject as I am getting to that area.
    Senator Dorgan. That's fine. Your formal testimony will be 
part of the record, but anything else that you say or add is 
also a part of the record today as a result of the recorder 
that we have with us.
    Mr. Moyle. Thank you for that. I think that you have done 
well with taking a look at the Indian Health Care Improvement 
Act in that it's a needed item in the lives of the Indian 
people. And the order of summarization of that--there's no use 
of me restating something that you've already said, and it was 
part my oral statement. I want to thank you for being a big 
part of that. I'll go that far because I know that you were one 
of the major players in what went through Congress, as you 
stated it already; I'll still go ahead and state it because it 
is going to come from the leadership from the State of Nevada.
    I happen to be, also, the President of the Indian Health 
Board in Nevada, and at the present time, President of the 
Inter-Tribal Counsel of Nevada. I also serve on two committees 
that have been set up by the Indian Health Service Director. 
One has to do with the consultation policy, which we pretty 
much, I think, completed at this point. There are two items 
that we're working on--the Contract Health Service and the 
formula. We had began talks at two meetings already on the 
Contract Health Service, and we have yet to begin on the 
formula. And this is one which, as you spoke on earlier, is a 
major issue. I appreciate the fact that you mention that 
there's going to be some investigations at some of these Indian 
reservations, because that is what we're trying to bring to you 
or Senator Reid, our Senators, is the story that's at our 
reservations. If Congress fails to observe what is actually 
happening and continues to disregard what is actually 
happening, our people will suffer, and continue to suffer. And 
it should not happen. Not in this century that we're living in, 
and it shouldn't have happened in the past. Not for what the 
Indian people gave. I wouldn't say ``gave.'' What was taken. 
I'm talking about the land. They have contributed a lot to the 
United States of America. And to be treated like a third-world 
country is unreal. And I could say it in many different ways, 
but, myself, as a tribal leader, I have a responsibility, for 
one, a huge responsibility. And I am proud to be in a position 
that I'm at to be able to relate to you what some of those 
responsibilities are. And this morning what we're talking about 
today is health. And I don't want to go on and on about it, but 
I just want you to be aware.
    In this case, I'm from Fallon, but there are tribal leaders 
here from some of the other reservations, which I'm grateful 
of, and I appreciate your asking for as many of them to show up 
here. But as being president of the Indian Health Board in 
Nevada, it is also, not only a responsibility for me to look at 
as far as my people in Fallon, but there's also the State of 
Nevada. But I do have other colleagues with me now that are 
going through the same, I guess you would call it an issue that 
is critical to our people, critical to the point of--there will 
be expressions made, and I appreciate the people that are here 
that I see sitting at the table that will explain what we're 
going through. And that is the other question I have that: If 
we provide you with testimony here and it will be going forward 
to another point in time, you did talk about another hearing, 
is that what we have looked at time after time--and I'll go 
back to being a member of NCAI, is that we asked for a follow 
up, and you know, we were a big part of helping them move the 
Health Care Improvement Act with the efforts of all of the 
tribal leaders and NCAI, but the issue is still there, such as 
the one that, even more or less expounded on talking about the 
Aberdeen area. The State of Nevada is similar to that. Very 
similar. In the meetings that we've had the with the director, 
the tribal leaders that have been able to be appointed to that 
Committee, we talked about: Okay, we're doing this, we're 
working on this issue, but how far will it go? How far will 
this go? And we keep asking that.
    Discussing it just a little bit further: At our last 
session that we had in Denver, we talked about that again. And 
we talked about it to the point of bringing it before the next 
assembly in NCAI, the one coming up. I know that you have been 
a person that has been at almost all the NCAI conferences. If 
you're not there in live person, you're there on screen. And 
there's a lot of people that realize that your heart is with 
us. I'd like to mention one of the items before I get into this 
testimony. You brought it out. The system that has been 
developed--and I'll say it's been developed by--in this case, 
the Indian Health Care system, let's call it--it has a 
beginning point of how to get to developing a program. It gets 
to a certain point of being developed and then it starts 
becoming where it gets into this political arena. And what I 
mean by that is that regardless of each year that the tribal 
leaders are asked to develop a budget for your reservation, and 
then we go further and develop the one for the State of Nevada, 
and then we turn that in and it goes to the Phoenix area 
office. And then from Phoenix, they take it further, and the 
budget continue on coming from around the country, and before 
it gets too far up the ladder, before it gets to the Congress 
that would make a decision on appropriation, O.M.B. takes their 
visit with it. And this is where I have, being a tribal leader 
for a number of years, have taken a look at that and listened 
to a lot of people that take a look at where is the--let's call 
it the real concern that those people sitting on the Office of 
Management and Budget, as far as making decisions about let's 
just cut this because we don't feel it's necessary. We feel 
that there is a gap in this, let's call it, the process that 
has been developed by Congress in this case of a need that has 
been asked for and requested for by tribes working day and 
night to develop a budget. And it goes to one point and it goes 
to another point and O.M.B. gets it on their desk and it gets 
cut.
    And then in the meantime, behind the scenes at home, we 
have a lady dying, we have a young child that needs an 
operation that is being denied that because we don't have 
enough money or, like you said, that lady had a message taped 
to her leg that said that if she gets admitted, it's your bill, 
not ours. Now, that is totally wrong, and you brought that out; 
I appreciate that.
    Anyway, my people are going through this of being denied 
services, and I do believe that there's a few more other people 
here that's going to say the same thing. And I don't want to 
take a lot of time and keep elaborating on that, but I do want 
to make that expression; I want you to know that. The testimony 
that I have is a few pages long and I've already said who I am 
and how many tribes are in the state of Nevada. I think that's 
very important. There are a number of people that we have that 
we have a responsibility to help and I'm glad that you 
acknowledge that.
    The Fallon Paiute Shoshone people live 65 miles from Reno, 
I'm pretty sure you're aware, in an area that has been known as 
the Oasis of Nevada, also it's what is called the Great Basin 
Area.
    So getting back to the 27 tribes. And really three tribes 
in the state: the Washoe people, the Paiute people, and 
Shoshone people. But because over the years that bands were 
formed and they're from north to south, east to west in the 
state of Nevada, actually beyond the state, into Idaho, into 
California, California on into Arizona, the Paiute people, 
Shoshone people, and the Washoe people. We're not only in the 
state, but we do have a number of miles to go if we are to 
receive medical care, because of no hospital. And that is a 
detriment to our people. I think what I've done as far as 
expounding on some of the issues, I think I've provided you 
with that. I think you have a chance or opportunity to read my 
testimony and I appreciate Allison being here because, to me, 
she has been a real advocate for Indian people in working with 
those issues that you assign her to.
    One of the areas that I think that is very important for--
other than the fact that I have some of this in my testimony 
that I'm going to refer to, I guess I can start off: I do 
believe that you talked about another hearing happening--and 
I'm not just exactly sure, it might be happening in another 
area which will give that other group of tribes an opportunity 
to be able to testify--the one thing that I do believe is very 
important that happens in the state of Nevada, talking about 
that area office, we're talking about one way to take a look at 
this issue of adequate health--or the access to health care. 
Access to health care, to me, is very important. How does the 
State of Nevada justify to the people, at the area level, at 
the regional levels, and then at the headquarters level, and 
then further on into Congress? And I have to bypass O.M.B., 
because it's immaterial to them.
    Getting back to my point is that access to health care: How 
is that really determined other than the fact that O.M.B.--we 
don't really--you know, that's no concern of ours. Congress 
says this is the amount of money we're going to have and this 
is what it will be. There has to be a, call it, a collection of 
data that can prove for a fact that this is what's happening in 
the state of Nevada; such as the one in I think that you're 
going to take a good look at in the Aberdeen area. There has to 
be a collection of data. And that's why when I look at, okay, 
what is the real benefit of an area office? To me, if you're 
looking at a problem, okay, let's get some people there and 
we'll take a serious look at this, and that's what I would like 
to see. That we take a serious look at this, not just a look at 
some spreadsheet that someone types up and it will tell the 
area of this and then we'll go further and tell headquarters of 
that. When you take a look at it, in some cases what we would 
have, we would have a number of denials that are not going to 
be on that spreadsheet. It flat isn't going to be on that 
spreadsheet. They'll be back at our clinic. And that is wrong.
    In the meantime we have--other than the fact that we have 
that problem, we have a problem of people that would be 
treated, let's call it, with preventative medicine or 
preventative treatment that could prolong the life of that 
person--be it in a youngster or in the oldest person we have--
it could prevent that person from getting worse, and yet we're 
prohibited right now because of the funding from having that 
preventative care. I think it's just to me, I wouldn't want to 
offend you at all. You're probably way past that point. But to 
me, it's almost a replication of genocide. By denying a person 
treatment for cancer--and I'm talking about not a person, I'm 
talking about people, a number of people. And that's happening 
right today in the state of Nevada. To me, I'll put a label on 
it, this is a replication of genocide. It shouldn't happen. It 
should not happen.
    Senator Dorgan. Well, Chairman Moyle, we certainly 
understand and can feel and hear your passion in the testimony. 
And we will hear from the others, as well, and then I'm going 
to ask a series of questions about some of the items that 
you've mentioned as well.
    But I really very much appreciate your testimony and the 
fact that I know it is heartfelt. We appreciate your being 
here.
    Mr. Moyle. Thank you.
    [The prepared statement of Mr. Moyle follows:]

    Prepared Statement of Hon. Alvin Moyle, Chairman, Fallon Paiute 
        Shoshone Tribe; President, Indian Health Board of Nevada
    Senator Dorgan, Members of the U.S. Senate Indian Affairs 
Committee, and Staff. It is a pleasure and honor for me to welcome you 
to Nevada and the opportunity to address the Committee regarding the 
healthcare crisis that we, in Nevada, have endured for the past 24 
years. There will be others who will present their views and comments 
on this crisis.
    My name is Alvin Moyle. I am the Chairman of the Fallon Paiute 
Shoshone Tribe and currently the President of the Indian Health Board 
of Nevada and the Inter-Tribal Council of Nevada. There are twenty-
seven Tribes in the State of Nevada with a total Indian population of 
over 36,000; approximately half of this number reside on the 
reservations and colonies previously mentioned. Twenty-five of the 
tribes are located in the northern half of the State--a State that 
measures over 777 miles from the Duck Valley Shoshone Paiute 
Reservation on the Nevada/Idaho border to Laughlin, Nevada at the 
southernmost tip of Nevada. It is mostly rural with at one County 
having 4/10's of a person per square mile! It is within this 
geographical environment that Nevada tribes exist--a place where they 
have lived for centuries. Approximately 65 miles east of Reno lies 
Lahonton Valley and referred to as the ``Oasis of Nevada:'' an area 
known for its agriculture and ranching environment. It is also an area 
where my ancestors lived, hunted, and gathered. This land was given to 
the United States government in exchange for a guarantee that the 
Federal Government will provide certain services to our tribe and one 
of them was the provision of health care. Unfortunately, it is a 
guarantee that has not been honored for the past few decades. It is 
within this historical background that 13 tribal health clinics were 
either contracted or compacted by tribes. There are no Indian Health 
Service Hospitals anywhere in the State and if specialized medical care 
is required by patients, they are either sent to Phoenix Indian Medical 
Center (PIMC) or to local providers using the Contract Health Service 
(CHS). Either of these options are daunting options: (1.) Traveling to 
PIMC requires enduring ground transportation of over 600 miles from the 
Fallon Paiute Shoshone Tribe to Phoenix or air travel that requires an 
hour and half of flight time--too long when one is sick and in pain; or 
(2.) being CHS-referred to local providers, who for lack of timely 
payment by the Indian Health Service will report the patient to 
collection agencies or worse, being requested to ``pay up front'' for 
their healthcare.
    As the elected leader of my tribe, it is my responsibility to 
ensure the health, safety, and well-being of my tribal constituents. I 
have begun to conclude that access to quality healthcare in Indian 
country has become a struggle between the ``haves and have nots.'' 
Nowhere on the Indian Health Service list of healthcare facilities to 
be built in the foreseeable future is there any mention of a Nevada 
tribe on the list--yet it appears that larger tribes with greater 
resources continue to inhabit the top rungs of that priority list. 
Maybe they continue to be on the list due to their population growth 
and maybe they are growing in population because they are getting 
better healthcare and living longer! In some areas of the country, 
there are 3-4 Indian Health Service hospitals within a 50 mile radius 
of an IHS Medical Center. Yet, we in Nevada have no access to an IHS 
hospital Within a 600 mile radius and thus, our reliance on Contract 
Health Service funding for the provision of specialized medical care 
grows exponentially. When my medical director of our tribal health 
clinic makes a CHS referral, it is due to his knowledge of medicine. 
Yet his practice of medicine is dictated by the availability of CHS 
dollars. When President Obama signed an Executive Order requiring all 
federal departments to develop and implement their respective Tribal 
consultation policies, nowhere in that document was there an exemption 
for any federal department. Yet, the Office of Management and Budget 
(OMB) cuts Contract Health Service funds WITHOUT consulting with 
tribes--funds necessary for my medical doctor to practice medicine and 
provide the best medical care which was promised when we gave away the 
Lahonton Valley. The Federal Trust Responsibility is a federal 
responsibility of which the OMB is a part. Furthermore, it should be 
noted that the guarantee of healthcare to my people and the tribes of 
Nevada was not contingent on the availability of funds or whether it 
fit into the ``Priority One'' category of the CHS Program.
    Senator Dorgan, the combination of these issues have impacted our 
communities, our families, and the future of Nevada tribes. The lack of 
CHS funds, the inequitable funding formulas, the non-existence of an 
IHS Hospital in Nevada, and the arbitrary treatment of tribes by OMB 
contrary to the promises made and the federal trust responsibility that 
are inherent to every federal agency. In the past decade, there have 
been many unnecessary deaths due to patients delaying their medical 
needs ``until there are more funds at the beginning of the fiscal 
year.'' I have gone to far too many funerals in the past year and I am 
tired. Even with these dire circumstances, there have been rays of hope 
which is contained in the passage of the Indian Health Care Improvement 
Act. To you Senator Dorgan and members of the Indian Affairs Committee, 
we are grateful and thank you for your continued support. Specifically, 
contained in the new law is the establishment of the Nevada Area 
Office. We believe this to be a major accomplishment in beginning to 
address the healthcare disparities in Nevada. In order to make this a 
viable office, it will require funding. It is estimated that this 
amount is $8.7 million. Senator Dorgan, keep the promise that was made 
and ensure that it is funded adequately and ensure that CHS funds are 
available so I will not have to write condolences to families who have 
lost their loved ones unnecessarily.
    Senator, thank you for the opportunity to provide our testimony and 
we continue to look to you for your leadership--whether you are in the 
Senate or whether you are at your favorite fishing pond.

    Senator Dorgan. Next we will hear from Chairman Billy Bell, 
who is Chairman of the Fort McDermitt Paiute and Shoshone 
Tribes in Fort McDermitt, Nevada. Mr. Chairman Bell, thank you 
for being here. You may proceed.

   STATEMENT OF HON. BILLY A. BELL, CHAIRMAN, FORT McDERMITT 
                   PAIUTE AND SHOSHONE TRIBES

    Mr. Bell. Thank you, Senator, and good morning and also 
welcome to Nevada. It's a great pleasure to be here this 
morning and represent Fort McDermitt Tribe. I, too, like the 
rest of the leadership here, and I'm sure the rest of the 
leadership throughout the country that you've heard so far, 
would like to discuss some of the impacts that the Contract 
Health Services inadequately provided for a lot of our tribal 
members. And it's created a lot of impacts for a lot of us.
    And as far back as I can remember, it's been over a decade 
or so, where I recall as a tribal employee over at Fort 
McDermitt Tribe and its leaders are working pretty close with 
their neighboring tribes, some of who are represented here 
today, in fact. And I'm trying to make this awareness to the 
IHS leadership out of their service unit, as well as the area 
office, as well. I think at some point we realize that all of 
our people's health care is really beginning to dwindle. In 
fact, you've heard Chairman Moyle's testimony of how some of it 
is really impacted a lot of us. And some people are not here 
today to testify if they were given that opportunity. And, I 
guess, there at Fort McDermitt, if you will, Senator, we're No. 
9 on the map, which is way up on the top left-hand corner, Fort 
McDermitt side of the Nevada/Oregon border. I guess, what we 
looked at there at Fort McDermitt is the geographical location, 
the retention there, that we try to maintain, I suppose, at out 
clinic. We are a direct service tribe from the IHS. That's what 
separates us from the rest of Nevada. The tribe's under the 
Schurz Service Unit, which we're serviced under. And a lot of 
it has to do the inadequacy of our contract health funding and 
lack of oversight, the administrative part from the Schurz 
Service unit.
    So more recently what we became more concerned with is the 
denial for referrals to outpatient treatment and diagnosis. 
And, of course, that has to do with the Contract Health Service 
budget, and also the IHS, which is a tier-1 system, that 
approval rating system that they have created. And, 
historically, Fort McDermitt is a former military reservation. 
It was established in 1865. It was abandoned in the late 1800s, 
and it became an Indian agency. We call ourselves the ``Pah-
na'kwit''; that means people that come from water. It has to do 
with the Great Basin itself. It was Lake Lahontan at the time. 
And, like many other tribes, we're located approximately 75 
miles from any type of goods and services, which is in 
Winnemucca, Nevada, and that's our nearest hospital. And it 
doesn't provide all of the specialized services that we 
require. And for those specialized services, we highly depend 
on the Contract Health Service budget.
    The majority of people, in order to receive that type of 
care, come here to Reno. Round-trip, that's an eight-hour 
drive. The majority of those people are diabetics, elderly, and 
very sick people that are transported in 15-passenger type 
vans. Right now we have an IHS health facility, the very first 
one. It was built somewhere in the early 1970s. And, then, more 
recently we had it replaced. Currently, we have about ten full-
time IHS employees. We also have emergency medical service, 
which at some times is not staffed. And it also has to do with 
the budgetary issues. It also has to do with administrative 
oversight. And, I guess, the government's gone to contracting a 
lot, and not be able to maintain or hire any IHS employees. IHS 
has been contracting a lot of its services to people. And I 
believe that through contracting, in order to fulfill some of 
those quotas, we don't have the quality or qualified personnel 
to fill some of those vacancies.
    And we also do have a diabetes program on my reservation, 
through a wellness center. And the tribe there has given or has 
an agreement with IHS to utilize our tribal health--or our 
tribal gym and our youth center. We've turned it into a 
wellness center for the people. And ever since Fort McDermitt 
realized these problems began, the tribal leaders, their 
efforts was to ensure that we at least somehow receive quality 
health care. And we banded with the other tribes. And, in fact, 
that's how the Indian Health Board became an entity itself 
because of the concerns from our people and the tribal 
leadership.
    But, I guess, more specifically, Senator, we affirm that 
our basic health demands is the trust responsibility to the IHS 
for overseeing our health care delivery system and for ensuring 
that the delivery of that care of services and programs 
provided by IHS. And we continue to insist that our health 
services were mirrored by a lack of administrative oversight. 
An example is the Phoenix area office at one point owed health 
providers over $6.7 million in unpaid health costs, just like 
the Aberdeen office. As of a few days ago, when I spoke to the 
administrator of the Humboldt General Hospital which serves our 
reservation, IHS currently owes them $609,000 for the past two 
years. These are an unpaid debt that's owed to them still. And 
really there, Senator, has created an almost a defensive mode 
and somewhat similar to the story you talked about this lady 
that was brought into the ER. It's almost the same situation. 
It's created an animosity amongst the health care providers in 
our area, especially with our ambulance service when they bring 
in patients; they're ridiculed by some of the staff there 
because of this issue.
    As you are aware, it's not just in Aberdeen, but here, we 
believe the service unit caused the catalyst amongst our 
Northern Nevada health care providers. Some of them has 
discontinued their relationship with us. Not only in the tribal 
clinics, but also through the IHS. Because of the IHS issue, 
our tribal members are denied those services. As you mentioned 
earlier, it does affect personal credit.
    One thing that I would like to point out directly is that 
in Fort McDermitt, we assert that the Federal trust 
responsibility through President Barrack Obama Tribal Nation's 
address for government-to-government stability and 
transparency, and his overall all strategy on health care. We 
believe that it can be delivered to us through a Nevada IHS 
Indian hospital.
    In closing, Senator, and to fulfill America's health care 
needs--which is a big concern and talk around many tables, I'm 
sure, around the country, and also to meet our tribal nations 
unmet health care needs, I urge the Senate Committee to take 
all of our testimonies here today and earnestly go to our 
request and utilize the contents. It shows how we care about 
our people. At the same time we strive to reside among 
ourselves within our own communities and with the other tribes 
and neighbors in our homelands here.
    And I also want to thank you, Senator Dorgan, for this time 
here today, and also the diligence in serving the American 
people and the interests and allowing me to speak on behalf of 
all of my Na-Nuwuhs, relatives, Paiute and Shoshone and the 
Washoe peoples of Nevada. Thank you.
    [The prepared statement of Mr. Bell follows:]

  Prepared Statement of Hon. Billy A. Bell, Chairman, Fort McDermitt 
                       Paiute and Shoshone Tribes
    Good morning. Senator Dorgan, it is my great pleasure to appear 
before the Senate Committee on Indian Affairs this morning to discuss 
the IHS Contract Health Service and the impacts it created along the 
way for my Na-Nuwuh (relatives) of the Fort McDermitt Indian 
Reservation of Nevada and Oregon.
    For over a decade the Fort McDermitt Paiute and Shoshone Tribe and 
its leaders has worked extensively with neighboring tribes to ensure 
that the Health needs of our Tribes were met and made aware to the 
Schurz Service Unit, the Phoenix Area Office and their respective 
directors, especially when health care services on our reservations 
became ever so despairing as our people's health began to rapidly 
decline.
    Fort McDermitt's efforts were based on our geographical location, 
retention of key medical and support staff, the inadequacy of contract 
health funding, lack of oversight from the Schurz Service Unit, and 
more recently, the Indian Health Service's denial of referrals to 
special providers for out-patient diagnosis and treatment due to the 
lack of funding in the Contract Health Service budget and the IHS tier-
1 approval rating system.
    The Fort McDermitt Indian Reservation straddles Nevada and Oregon, 
is a former military reserve built in 1865 and abandoned to become an 
Indian agency. We are known as the Pah-na'kwit (People from water). 
Today, we are located 74 miles from goods and services and our nearest 
hospital in Winnemucca, Nevada. For our specialized health care needs 
we highly depend upon the contract health services and receive this 
type of care our nearest facility is here in Reno, a tiresome eight 
hours round-trip drive.
    Approximately 9 years ago our long-time resident provider retired 
due to his own ailing health, the medical records person is nearing 
retirement, and our substance abuse provider has retired. Currently, we 
have a temporary medical provider, a community health representative, a 
billing clerk, a facilities manager, facility maintenance, and two 
motor-vehicle operators, an Emergency Medical Service (two ambulances 
and several paid volunteers) and on a monthly basis we have a contract 
optometrist, dentist, podiatrist and psychologist. Our pharmaceutical 
and prescription requests are filled from the pharmacy at the Schurz 
Service Unit. We also have a diabetes program, which contracts two 
positions and operates our wellness facility. Our first health clinic 
was built in the early 1970s and was recently replaced in 2009.
    Fort McDermitt is a direct service tribe, our administrative and 
support services to maintain and operate our clinic is managed and 
overseen by the Schurz Service Unit Director in Schurz, Nevada.
    Over the past decade, our efforts to ensure we at least received 
quality health benefits, has fallen on deaf ears, from the unit 
director to the area director. Our remoteness, lack of providers, 
retention and recruitment, and distance from acute and long-term health 
facilities has attributed to the health needs of my People.
    Moreover, we affirm that our basic health demands is the trust-
responsibility of the IHS for overseeing our health care delivery 
system and for ensuring the delivery of that care consists of services 
and programs provided directly by the Indian Health Service. We 
continue to insist our health services were mired by the lack of 
administrative oversight. The Phoenix Area Office owed health providers 
$6.7 million in unpaid health costs and currently IHS owes Humboldt 
General Hospital $609,184.00 for the last two years. HGH serves the 
Fort McDermitt IHS area.
    This oversight has caused a catalyst among some of Northern 
Nevada's health care providers to discontinue their relationship and 
refusal to provide specialized services to our tribal members and the 
unpaid bills turned over to collections affecting personal credit.
    We assert that the Federal trust-responsibility through President 
Barrack Obama's Tribal Nation's address for government-to-government 
stability and transparency, and his overall strategy on health care can 
be delivered to us through a Nevada IHS Indian hospital.
    In closing, to fulfill America's health care needs and to meet the 
Tribal Nation's unmet health care needs, I urge the Senate Committee to 
take our testimonies and earnestly look to our requests and utilize 
their contents to show how we care about our People while we strive to 
reside among ourselves and our neighbors in our homelands. Thank you 
Senator Dorgan, for your time here today and the diligence serving the 
American people's interests and allowing me to speak on behalf of all 
my Na-Nuwuh; the Paiute, the Shoshone and the Washoe Peoples of Nevada.

    Senator Dorgan. Chairman Bell, thank you very much. My 
understanding is that $6.7 million that is owed to providers 
here in this region has grown to nearly $10 million, which I 
assume puts more and more pressure on some of these providers. 
To say, You know, we don't want to continue to offer these 
services is a serious problem. We'll talk about that in a bit.
    Ms. Cindy Curley runs a tribal health clinic. So we're 
talking about the things in the abstract; now we're going to 
hear from a witness who is the Director of the Pyramid Lake 
Tribal Health Clinic. My assumption is your experience is you 
go to work every morning trying to see what this clinic is 
doing and managing the affairs of the clinic, and you 
understand what day-to-day all of this is about. So we're very 
pleased that you're willing to be here with us today to 
testify.
    Ms. Curley, you may proceed.

STATEMENT OF CINDY CURLEY, HEALTH DIRECTOR, PYRAMID LAKE PAIUTE 
                             TRIBE

    Mr. Curly. Thank you. I'd like to start off by saying thank 
you for the opportunity and honor to come up here and share my 
thoughts and views. I also want to thank the Chairman of the 
Pyramid Lake Paiute Tribe and the other counsel members for 
being here today. The Pyramid Lake Paiute Tribe is located in 
Nixon, Nevada, and we're 45 minutes northeast of Reno. You 
should go out there sometime; it's absolutely beautiful.
    More to the point: Due to the depletion of the contract 
health funds, last year we ran into a huge problem. We had over 
100 health care providers that refused or limited the services 
that they would provide to our patients, unless either the 
patient or the clinic paid up front. The situation got so bad 
that when we finally could get an approved referral, we had no 
provider to send our patients out to. We had cases that we 
would even try to send them to PIMC, Phoenix Indian Medical 
Center, to try to get care, and we couldn't even get them into 
Phoenix Indian Medical Center. They were turned away, saying 
that there was no time available to see our patients. This puts 
our patients in a really bad situation. We have had dialysis 
patients, patients we need to refer out for various kinds of 
heart disease, pacemaker implementations, no providers to send 
them to. Nevada is one of the highest health care states in the 
Nation.
    And to further exacerbate this problem is the fact that we 
pay full billed charges for any health care to these contracted 
providers. So what little money we do get for contract health 
care, we pay the highest rate possible. We have asked for years 
that we have somebody that could negotiate with these specialty 
providers for a reduced rate agreement. And to date, this has 
not happened. So the CHS funds deplete rapidly. And in a lot of 
cases, we're out of CHS funds by April or May, and we have 
nowhere to send our patients. This not only puts our patients 
in a really bad situation, but it puts our providers that we 
have at our health care facilities in a very precarious 
situation. It forces our providers to work more and more 
outside of their scope of work. So there's a lot of liability 
issues.
    We have cases, and we still deal with cases today, where we 
cannot get approved referrals to send our patients out that 
need care that we just cannot give in our facilities. If you 
were able to come out and take a look at a lot of our clinics, 
you would see that we don't have the same equipment that other 
clinics, like in Arizona and other places, have. We don't have 
all the equipment that they do. We have limited labs. We don't 
have the resources to provided good prenatal care. Yet we have 
denials, CHS denials for prenatal and delivery services. So 
those aren't getting paid for. We have patients who need their 
pacemakers put in, and that's not paid for. Seizure patients 
that we have to refer out that they don't get paid for. 
Patients who we can send out and they can find out that they 
have cancer, but they won't be approved--the chemotherapy 
treatment that they need to save their lives. We have a patient 
who has a pacemaker and the battery was going dead. We couldn't 
get an approved referral for a new battery for that pacemaker. 
So if his heart stops, there's nothing to get it going again. 
These are just a few cases.
    My contract health clerk put together a spreadsheet. And 
after I get approval, I would like to send it to you guys. 
There is a rather detailed spreadsheet that lists all of the 
referrals we've done in the last year. We did four hundred--and 
I updated the list--we had 486 referrals from November to 
current. Out of those 486 referrals, only 94 of them were 
approved. Ninety-four. That's it. Most times when we try to 
send our patients to Phoenix Indian Medical Center because we 
can't afford to pay the specialty providers out of our own 
clinic funds, we can't get them into Phoenix Indian Medical 
Center. The Schurz Service Unit Hospital wasn't shut down 
because it lost its certification; it was because it was 
condemned. And there was a promise of replacement--or repair by 
replacement, and today that hasn't happened.
    We have a huge need. Almost every day I talk with the 
patients. For one reason or another a patient will come in to 
my office. We have patients that have severe 1 injuries that 
have never had the opportunity to be able to go in and have the 
surgical procedures to correct those injuries. So instead 
they're put on high-powered pain medications that were never 
intended to be taken for long periods of time. The prolonged 
use of these pain medications create other problems with these 
patients. It does liver damage, kidney damage. They become 
addicted. And then they're labled as addicts. Well, the 
patients didn't do this to themselves. They can't get referred 
out for the--and they can't afford the surgeries themselves. So 
by no choice of their own they're put on pain medications; they 
get addicted. And more and more the formularies in our 
pharmacies are being reduced. And we don't have pain management 
specialists. And we don't have access to them.
    I called last week. For example, we had a few cases that we 
need to--some patients that we need to send for pain 
management. And this costs $391 for the first initial visit; 
between $45 and $91 for each follow-up visit thereafter. We 
can't afford that at our clinic. And it's not something that's 
paid for by contract health dollars. So we have a big problem 
on our hands. And we have had accidental overdoses. We have 
been faced with a huge gauntlet of problems. The patient, when 
we have to send them out--and we tell them up front that 
there's no guarantee that their health care bills are going to 
be taken care of. A lot of them, even if we get them a referral 
and it's been approved, they're still afraid to go to the 
doctor because they know they can't afford to pay that bill. 
They get hounded by the bill collectors, even though we send 
letters out telling the bill collectors you cannot send that to 
our patients if they have an approved referral. Therefore, they 
just won't go and seek the medical care they need. And this 
leads to a lot of other health conditions for them, a lot of 
health problems that they have that are totally preventable and 
avoidable.
    And it's frustrating for the patient. It affects them 
mentally, it affects them physically, and emotionally. When 
they can't have their health care needs taken care of and they 
cannot go out and get a full-time job, it affects their quality 
of life. It not only impacts the patient, but it impacts the 
patient's family and relatives, as well. We have a very high 
unemployment rate out there. And we have a lot of patients that 
are in a lot of pain. Some of their medications that they take 
are not part of our formulary, and they are no longer approving 
for our patients to go to outside pharmacies to receive what 
they need. We have a very high diabetic population out there. 
They suffer from a lot of other health conditions and 
comorbidities that are actually preventable.
    We have, as part of our CHS denials, one of our contract 
health patients, one of their denials was that they were a 
dialysis patient. We have a dialysis patient that did not get 
an approved referral. We have patients, not only at the Pyramid 
Lake Tribal Health Clinic, but at other tribes that will make 
the comment: They're just waiting to die. We had 18 mortalities 
this last year. And I can't sit here and say that their lack of 
health care is the only reason for them passing away, but it 
does contribute to a shortened life span for these guys. I 
mean, it is really sad. And the family members that they leave 
behind--and it's extremely frustrating.
    All of us health directors--and there's a couple of us here 
today--work on the frontlines. And we spend a lot of time 
trying to find alternative resources for our patients. The 
problem is staggering. And it's not getting any better. And 
when we have less than one percent of the American Indian 
population here in Nevada that can access Phoenix Indian 
Medical Center, but we can't get a hospital here, this is a 
serious problem. And the providers are upset, the specialty 
providers we send our patients to, they're angry because they 
went for a long time without having their bills paid. They 
don't want to have to deal with this. In a lot of cases our 
patients come back and say they've been treated badly, so they 
don't want to go back again. So, the clinics--we do spend our 
own funds to try to help for medications. We had a dialysis 
patient--she was a kidney transplant patient--she got approved 
for a kidney transplant, but we cannot get an approved referral 
for the medications that she needs to keep her body from 
rejecting the kidney. The medications are not part of our 
formulary. So here's this huge cost for a kidney transplant, 
but if it was left up to the IHS contract health--this patient 
doesn't have the funds to pay for help, so she would die 
without any intervention. So we help pay for her medications to 
keep her going.
    I'm trying to keep it toned down. This is a very 
frustrating issue. We've spent years talked about these 
situations. There was another hospital that was put in Nevada, 
but the tribes weren't consulted as to where that hospital 
should go and where it would be most effective.
    Bottom line is we have patients that are suffering because 
they cannot get the health care they need. We're not equipped 
in our facilities to deal with a lot of the needs of these 
patients.
    Senator Dorgan. Ms. Curley, I have a hunch that you could 
talk about this all day.
    Ms. Curley. Yes, I could.
    Senator Dorgan. And what you're telling me is pretty 
unbelievable in many ways. I expect we'll hear from Catherine 
Harris, as well. I think a lot of policy-makers would be very 
surprised to hear much of the testimony about the day-to-day 
difficulty of people who have very significant health issues. 
The provider knows it; that is, the Indian Health Service. That 
comes to the diagnosis at the clinic and then the question is, 
yes, that's a very serious health problem, but a patient can't 
get from ``A'' to ``B'' to ``C,'' because the system doesn't 
allow that. And so it is--I'm going to ask some questions about 
the testimony that you've given me. But it appears to me when 
you talk about 59 percent that were turned down and I believe 
you indicated 6 percent of those died. That's 14 people that 
died, despite having shown up, tried to get help, and didn't 
get the help they needed. I mean, whoever those 14 people might 
be, no one will ever know because they just dropped through the 
systems.
    Ms. Curley. Yes.
    [The prepared statement of Ms. Curley follows:]

   Prepared Statement of Cindy Curley, Health Director, Pyramid Lake 
                              Paiute Tribe
    Mr. Chairman, members of the Committee and staff, thank you for the 
opportunity and the honor of sharing with you our views and thoughts 
about the healthcare crisis that we in Nevada face with a shortage of 
contract health service dollars.
    My name is Cindy Curley; I am the Health Director for the Pyramid 
Lake Paiute Tribe located in Nixon Nevada which is 45 minutes northeast 
of Reno Nevada. I do not pretend to speak on behalf of the 26 other 
tribes in the State of Nevada. I will however; share with you our 
experiences with the CHS program, lack of access to healthcare and the 
impact of these two issues on our population at Pyramid Lake Paiute 
Tribe.
    And what are these issues?

        1. Due to the depletion of CHS funds, 106 local healthcare 
        providers are either restricting or declining to accept any 
        additional CHS patients who are referred to local health care 
        provider UNLESS they are ``paid up front.''

        2. Further exacerbating this problem is that local healthcare 
        providers are still billing Tribal Health Clinics at ``full 
        charge billing.'' Although regulations were disseminated to 
        clarify that the Tribal clinics are exempt from this practice, 
        healthcare providers have interpreted the revised regulation as 
        pertaining to only ``inpatient care'' and not ``outpatient 
        care.''

        3. As a result, patients who have been referred are being 
        hounded by Collection agencies to collect the cost of the 
        healthcare provided--bills that rightfully IHS should be 
        paying. Patients are impacted by this situation--mentally, 
        physically, and emotionally. Moreover, their credit ratings are 
        being negatively affected.

        4. More significant are the numbers of CHS-referred patients 
        either declining or deferring their healthcare until additional 
        CHS funds are available. As a result, their health status 
        worsens and will eventually cost even more. The number one 
        health issue affecting Nevada Tribal members is Diabetes--
        chronic disease with costly co-morbidities such as heart 
        disease, chronic kidney disease, amputation.

        5. CHS approves renal transplant yet patient unable to obtain 
        required medications to support the transplanted kidney. 
        Medications include: Cell Cept, and rapid acting insulin 
        regimens per the Stanford protocol at high risk for rejection 
        of donor kidney due to formulary restrictions.

        6. Pain management issues are huge in this environment. 
        Individuals with chronic pain are denied orthopedic and 
        neurological consults with escalating narcotic requirements now 
        at risk for sudden death due to extraordinary requirements 
        without pain management availability. Sometimes the cost of the 
        narcotics may be more than the procedure needed to correct the 
        problem or the appropriate pain management which is not 
        available.

        7. In the past year, we have had 413 referrals of which 59 
        percent have been denied due to ``not within priority'' What 
        constitutes priority? The response is: if you can make an 
        appoint to have it done, it does not constitute priority level 
        one. And Mr. Chairman, members of the Committee, of the 59 
        percent that have been denied; 6 percent have died. Yet we are 
        told this problem is the same across the board. This 
        explanation holds no comfort to the families affected by these 
        untimely/preventable deaths.

Proposed solutions
The CHS Funding Formula Needs to be Revised to Reflect:
Distance Traveled
    Members of the Pyramid Lake Paiute Tribe have to travel between 45 
and 90 minutes to see a specialty provider or get to the hospital. 
Other tribes have to travel 2 hours or more each way to receive any 
sort of healthcare. This is extremely difficult and tiresome for 
Dialysis patients who have to make this trek 2 to 3 days per week.
Access to Healthcare
    There is no Indian hospital in the state of Nevada since the Schurz 
hospital was shut down in the 1980s and further exacerbating the 
problem; less than 1 percent of the Nevada Tribal populations have had 
access to Phoenix Indian Medical Center.
Cost of Healthcare
    Since no contracting has been done with specialty providers or 
hospitals, we are forced to pay full bill charges which rapidly deplete 
the CHS dollars.
Need for Preventive Healthcare
    This would in the long run reduce CHS spending and improved the 
health status of Native Americans in Nevada.
    Funding for the creation of the Nevada Area Office; this would give 
Pyramid Lake and other tribes in Nevada a louder voice and provide the 
Nevada tribes and clinics much needed assistance.

    Senator Dorgan. Well, thank you for your testimony, Ms. 
Curley. And we're going to hear from a couple others and I have 
a series of questions I'd like to ask. Ms. Catherine Harris is 
Chief Financial Officer at the Reno Heart Physicians in Reno, 
Nevada. Ms. Harris, thank you for being here and giving us your 
perspective.

  STATEMENT OF CATHERINE S. HARRIS, CFO, RENO HEART PHYSICIANS

    Ms. Harris. Thank you for having me.
    Good afternoon to all the tribal leaders and community 
members and Senator Dorgan. I do want to let you know that in 
my over 30 years of health care experience, it is a privilege 
to be here to be able to potentially have an impact on what is, 
not a minute by any chance, portion of the health care crisis 
that this country is facing right now.
    I am here on behalf of the providers of care who, in their 
way shape or form are advocates for their patients and strive 
every day to make sure that we can accommodate the patients and 
their needs and provide the continuum of care that is so 
lacking.
    My focus is more navigational within the system, and the 
reimbursement and being able to cover costs. I represent a 21 
cardiology practice that provides services here in Reno, 
Sparks, Carson City, as well several rural areas, including 
Minden, Elko, Winnemucca, Fallon. Our providers generally have 
a passion for providing care to their patients, but they also 
have a a business to run. It is very frustrating when they 
insert a pacemaker and can't get the approval to have a 
pacemaker checked and follow ups. Although, I would have to say 
that we've had a few meetings in the past and that situation 
specifically has gotten much, much better.
    Being community-based health care professionals, we provide 
a very valuable service to this community. As far as the Indian 
Health Board goes and the beneficiaries, residents of the 
reservations, we are one community, as far as we are concerned, 
and our responsibilities to providing care for the members of 
this community, including those who are not always able to 
afford it.
    Again, our focus is cardiology. It's been very sad for us, 
as a provider of care, to see how many local area providers, 
health care providers, have turned away and discontinued 
providing services to tribe beneficiaries. Most of those 
decisions have been made because they're not able to cover 
their costs of providing care. Again, very serious issue as our 
population continues to age and as we have longer life spans, 
the strain on health care resources and resource dollars 
continues to be an issue nationwide.
    I do believe, though, it is our position that there are 
some deficiencies within the Indian Health Care system that are 
contributing significantly to these costs of providing care. 
And that what we would like to see is some review and 
refinement of the internal processes of processing claims, 
getting claims paid, getting visits approved. I think a lot of 
the panel here have already touched the topic of the continuity 
of care in a case-by-case basis. I don't believe that this is 
an issue that bubbles up to the budgetary and fiduciary owners 
of this process, in that they don't understand that where, as 
we may see ten patients for a pacemaker insert, there is a 
series of follow-up visits that have to occur after that in 
order to keep this patient well and to keep them healthy. No 
single one of our providers in our practice want to treat a 
patient and lose them because they don't have coverage.
    About six months ago, as I was alluding to, the 
authorizations department of our practice made significant 
milestones and progress in getting these pacemaker checks 
approved so we're not getting as many denials as we were. 
However, we continue to experience frustrations in dealing with 
various individuals, particularly with the communications 
within the IHS clerical staff. We have certain individuals that 
we leave messages for and never hear back from them, so we 
can't get the authorizations or P.O.s we need to continue 
treating patients. We have individuals that we contact that are 
great at the claims processing piece and getting us paid and 
terrible at the initial authorization and approval of the 
visit. So it appears that there is just a lot of the 
inconsistencies in the practices and how the system is 
administering the authorization and approval of visits as well 
as the reimbursement. We have noticed, and I know that it is 
not the technical practice, but we have also noticed that every 
year, they run out of funds, the system runs out of funds. And 
every year, a portion of those current year funds are used for 
old claims. May not be the intention of the fiduciary 
responsibility party; however, it is what happens.
    We currently have over $18,000 in unpaid claims from 2007 
and 2009; that does not include any of the 2010 claims. And I 
do want to say that things have gotten better, but they still 
have a long way to go.
    Again, the inconsistency between case workers is just very, 
very frustrating. Also, the inconsistency between IHS and their 
fiscal intermediary, particularly in New Mexico. Whereas I 
respect the comment that was made earlier about collecting 
data--what appears to be a major problem for us is that there's 
no consistency in the data. For example, we have a patient that 
has Hometown Health coverage as well as Indian Health Services 
coverage. We'll get a response from New Mexico that they 
received the explanation of benefits for this patient that has 
Hometown Health coverage, but they're waiting on information 
from Blue Cross. When we go ahead and investigate that 
particular case, the patient has no Blue Cross coverage; that 
coverage was termed three years ago. So then we have to go 
through the process of calling the Board, having them 
communicate with the fiscal intermediary in New Mexico, having 
to turn around and reprocess.
    There is such a disparity in the system as far as the 
content of the data and consistency as far as it being updated 
on a regular basis. I don't need to tell anybody in this room 
how much that costs us on the back end. We've all heard 
comments about the detriment to the patient and not being able 
to have the access to the care. It's really heartbreaking on 
the back end when we have to spend many hours to get one case 
resolved, that really, if there were a refinement of the 
process and some consistency between the systems, it wouldn't 
be the case.
    I want to assure everyone here that we have no intention of 
denying access to care. We care about our patients. We want to 
see them treated. We want to see them treated well. We want to 
be able to continue to provide excellence in quality in 
cardiology care to all of our patients, including our tribal 
patients. We are very much open to any improvements, 
conversations, communications that we can enter into jointly in 
making sure that we can go forward.
    I feel very strongly that the concept of having negotiated 
rates with providers who have agreed to provide care, much like 
any other health system--the Cignas, the Blue Crosses--is an 
excellent idea, and would provide some budgetary stability. 
However, I think that there's a lack of understanding at the 
budgetary level that needs to be part of the budget process.
    [The prepared statement of Ms. Harris follows:]

 Prepared Statement of Catherine S. Harris, CFO, Reno Heart Physicians
    Thank you for the opportunity to speak to you today. I am here on 
behalf of Reno Heart Physicians, a 21 physician Cardiology practice 
that provides services in Reno, Sparks, Carson City and rural areas 
from Minden to Elko.
    Community based healthcare professionals like Reno Heart Physicians 
provide a very valuable service to those in our community who are in 
need of cardiology services. Not only are our physicians board 
certified in their specialty, but being community based allows them to 
respond in a more timely, efficient manner to the needs of patients 
within our community. This ensures continuity of care and is also 
convenient for patients.
    Indian Health Services beneficiaries are among community members 
who benefit from our quality cardiology care. They are also the 
beneficiaries of discounted rates that are reflective of our practices 
commitment to provide excellence as well as affordability to our 
community.
    Sadly, more and more local providers are not, however, able to 
continue providing care to Indian Health Service patient because they 
are unable to cover their costs of providing care. As our population 
continues to age and live longer, the strain to provide coverage and 
service to our community becomes like an elastic band that is stretched 
so tight that it is about to break.
    The responsibility to continue to provide quality medical care to 
those who need it at an affordable rate is the responsibility of every 
citizen in our community. As providers, we are constantly evaluating 
our expenses and quality outcomes and making adjustments wherever 
necessary. We continuously strive to refine our processes in order to 
more expeditiously serve our population.
    It is our position that there are a number of deficiencies within 
the Indian Health System that significantly contribute to the increase 
cost of care that our community providers are experiencing that have 
not received the same level of review and refinement. It is imperative 
that this take place in order for the safety net to remain in tact as 
the population ages and we are called upon to continue to provide care. 
The systems fiduciary responsibilities to their beneficiaries and 
providers as well as its internal claims processing practices need to 
be refined and improved upon.
    Since the last meeting with IHS about six months ago the 
Authorization Department at Reno Heart Physicians requests for 
pacemaker checks are being approved without any denials with few 
exceptions. However, we are experiencing communication issues with IHS 
clerical staff. We can leave multiple messages and we don't get any 
correspondence back. We would like to see the communication between our 
business office and IHS be more consistent and timely, to make sure the 
care of the patient is not disrupted. Reno Heart Physicians believes 
that there should be a specified timeframe within which all patient 
related requests are responded to and that this should be no more than 
24 hours.
    Distribution of funds has been irresponsible at best. Not only are 
the rates nominal, but the delay in getting paid is unacceptable. Reno 
heart Physicians continues to carry over $18,000 in unpaid claims for 
IHS patients that date as far back as September 12, 2007 through 2009. 
This does not include any unpaid claims in 2010.
    Of specific interest to us is the lack of consistency between case 
workers. It is apparent that once the claim is received by the contract 
health unit, no one can predict what will happen to it next, much less 
when it will be processed and paid. One specific individual case worker 
is responsible for the ``old'' accounts. Another specific case worker 
(who processes claims efficiently) is notorious for not returning 
messages, particularly from our authorizations department. Reno Heart 
Physicians believe that there should be a consistent, measurable, 
monitored process that these case workers are not only held to, but 
evaluated based upon. Giving them a stake in the outcomes, would make 
them more of a partner with providers of care and therefore improve the 
communication and response times.
    There are also inconsistencies between the FI and IHS. Of 
particular interest to Reno Heart Physicians is the FI in New Mexico, 
Blue Cross. As providers, we are supposed to be able to get updates 
from IHS with regards to eligibility and other coverage, however we are 
not able to get that information and when we do it is not current. For 
example, we will get information on a patient who has Hometown Health 
Plan coverage as well as IHS; we will get a response from New Mexico 
that they have received the patients' explanation of benefits from 
Hometown Health Plan and are waiting for an explanation of benefits 
from Blue Cross; we will initiate researching the specific patient with 
Blue Cross we find that their coverage terminated 3 years ago. IHS and 
the FI in New Mexico are either not communicating and/or are working on 
disparate data systems.
    Having to go through this lengthy process of calling the FI, then 
calling Blue Cross then contacting IHS to tell them that they are 
reflecting the same information as the FI cost us hundreds of dollars 
every case. Indian Health Services then has to call the FI in New 
Mexico and request that they update their system so that our claim can 
be processed. These two entities need to communicate consistently and 
have the same information in their systems for every single IHS 
beneficiary.
    The distribution of funds has been unpredictable at best. It 
appears that every year when funding is received, a significant portion 
of those funds are used to ``clean up'' old accounts receivable. This 
creates a situation where the system is constantly in arrears--robbing 
Peter to pay Paul if you would. Perhaps if the data was accurate and 
consistent, then not only would the provider's cash flow be more stable 
and predictable, but IHS would have a better grasp on what their 
funding needed to be from one year to the next.
    Reno Heart Physicians is dedicated to providing quality affordable 
care in our community. We are prepared to do whatever we can to improve 
the communication and or processes of IHS in order to make this 
possible. To do otherwise would be irresponsible. However, we are not 
in this alone. We need your help and commitment to making this process 
more efficient and productive so that our patients can continue to 
receive excellent cardiology care where they live.
    Thanks again for your time today. Reno Heart Physicians is looking 
forward to partnering with you in improving the provision of cardiology 
care to our community at large, and more specifically to IHS 
beneficiaries.
    Thanks again!

    Senator Dorgan. Ms. Harris, thank you very much.
    With respect to the point you made about not being able to 
get returned telephone calls and so on, I hope you will take 
advantage today of the fact Dorothy Dupree is here. I know that 
she's here because she wants to understand what's going on in 
the region. And so that would be very helpful to her, I think. 
I know she's shaking her head back there saying ``Yes.'' You've 
indicated that there's been some improvement, but make sure you 
don't leave without accessing that opportunity. And I 
appreciate Ms. Dupree being here.
    Ms. Harris. Thank you.
    Senator Dorgan. Finally, the Honorable Loren Sammaripa, 
Chairman of the Walker River Paiute Tribe in Schurz, Nevada. 
Chairman Sammaripa, thank you for being here.

         STATEMENT OF HON. LOREN SAMMARIPA, CHAIRMAN, 
 WALKER RIVER PAIUTE TRIBE; ACCOMPANIED BY KENNETH RICHARDSON, 
                        HEALTH DIRECTOR

    Mr. Sammaripa. Thank you, Senator. As you noticed on the 
map, we're No. 22. And I want to thank Mr. Moyle, Mr. Bell, 
Cindy Curley, and Catherine Harris for presenting their side of 
the issue that we all have our concerns with.
    I know what we've talked about in various meetings with our 
health committees, and each and every time, you know, we 
address health issues, lack of service, denials. All this has 
surfaced, and we're still at this point. And as we continue 
through with our meetings and our attendance, no matter where 
it's at, we're going to still talk about it. And I appreciate 
you being here this afternoon to hear our concerns, and also 
your Committee.
    And, again, I just want to say, my name is Loren Sammaripa, 
Chairman of the Walker River Paiute Tribe. I was born and 
raised in a hospital that we all talk about: Schurz Hospital. 
This was in the early 1940s, at which time the hospital was a 
full-staff hospital. We served the whole State of Nevada at one 
point. And the services that were provided there were services 
that we talk about today, and being that they denied, and here 
in the big cities.
    But, again, the opportunity that I have here today and to 
speak regarding our Contract Health Service and our health care 
crisis that we are encountering on our reservations is a main 
concern. Our tribal members, they were currently placed on 
Level 1. These levels that we talk about, they've been 
established throughout our meetings that we meet with our 
health representatives. And Priority 1 is defined as: Emergent 
or acutely urgent care services that are necessary to prevent 
the immediate death or serious impairment of the health of the 
individual, because of the threat to the life or health of the 
individual necessitate the use of the most accessible health 
care available and capable of furnishing such services.
    So, again, we talk about all these diagnosis and treatments 
that we are being denied on the outside service. Schurz being 
centrally located in Nevada, we have to sometimes rely on air 
flights for our most severe cases of patients that needed 
direct attention. Our care flights are costing around $15,500 
per flight. And we have no other alternative but to provide and 
pay for these services because IHS has not made any type of 
cost comparison with any other direct services. So we are 
located primarily 102 miles south of Reno. And which Fallon is 
about 30 miles north of Schurz; they provide the necessary care 
for some of our minor and emergency care, also. But our lab and 
X-rays and our pharmacy costs are well above, and quite 
severely drains our funding.
    We have providers, also, that we have to make contracts 
with. A lot of times our providers are denying seeing our 
patients, because of the payment again. As our panel here has 
talked about, the needs that have been not addressed by CHS, we 
are imposed with all these issues. So, again, the referrals 
that we had for FY 2010 for Walker River was 740. And the 
number of denials for 2010 for Walker River was 586. We have a 
list of referrals that would be available to you in our 
pamphlet, and it will give you each and everyone of them that 
have been mentioned here.
    I have some scenarios that I want to read a few to you on 
that tells of the devastating that we have encountered. We had 
a 63-year-old grandmother in November 2009; she was having 
chest pains. Our doctor requested a referral to have a scan 
done to rule out cardiac or a malignancy. She suffered through 
numerous clinic visits, pain, and weight loss. In December she 
was sent to the ER with left chest pains at Banner Hospital; 
that's in Fallon. And then later tranferred to Renown here in 
Reno with lung mass. This ER visit was approved. Subsequently, 
she was referred for CT scan and bronchoscopy of her lungs for 
her mass with possible malignancy, and the sad course 
continues. And by February 2010 she was severely debilitated, 
wheelchair bound, and wasting away. She had one more visit to 
the ER with prolonged hospitalization toward the end of her 
life. She passed on in March of 2010.
    So as you can see, the concerns that we have and our elders 
that are chosen not to be seen by providers and for creating 
more bills, we are faced with this situation each and every 
day. But the struggle, we continue. And with the services, 
limited service that we have with our facility now, we have no 
other alternatives but to refer out our patients. And to be 
seen and the referrals denied, we have to deal with.
    Numerous cases that we have are listed in the testimonies 
that I have here today. All our representatives here that we 
have sitting before you testified of the health concerns, just 
as I have done. We talk about area offices, our Schurz Service 
Unit has been condemned, but we are still providing services on 
a limited basis.
    And we would also like to seek funds to build a facility 
that would benefit our people, not only for Schurz, but for 
surrounding communities. This would be something that I would 
like to see funded in my lifetime. I'm one of the few elders 
that are left on the reservation, and still have the ability to 
represent our tribe. We have a handful left that are dependent 
on dialysis, health care services, but they, too, have chosen 
not to go out and see a provider. A lot of the testimonies that 
we have presented, the distance that is involved to go to the 
PMS in Phoenix, the health services there, that's the 
alternative. But when you get to the area in Phoenix, a few of 
our patients have also been denied. And they are left down 
there, stranded. Some of them are told that maybe you can 
return back or stay here for a week or so to come back in to be 
seen. But within that time frame, and the expense that occurs 
for them to be on a waiting list to be seen at the Phoenix unit 
is, you know, a burden on the families.
    So, again, I can't stress the importance that we have 
presented to you today with our health issues. And until that 
is addressed, it would be a benefit to all of our tribes here 
in Nevada to hear that we would be refunded to address our 
health concerns.
    And the funding in 2010 on the backlog of unpaid bills for 
five to six years total in the amount of 4.6 to 4.8 million. 
But to the money that was there, a lot our bills weren't paid. 
The money amount didn't reach it.
    So, again, I thank you for being here today to hear the 
concerns of our Nevada people and our health services. We can 
go on with many scenarios of patients that have been denied, 
patients that chose not to be seen. So, again, the bill paying 
is something that we need to address so our people can survive. 
And I want to thank you for the concerns today for listening to 
us, and I'm sure that our Natives that are in attendance at 
this meeting today have more to add. So with that in mind and 
our testimony that we have presented as true facts. So, again, 
for Walker River I want to thank you for listening to our 
concerns and we'll continue on.
    [The prepared statement of Mr. Sammaripa follows:]

  Prepared Statement of Hon. Lorren Sammaripa, Chairman, Walker River 
                              Paiute Tribe
    Good afternoon Senator Dorgan and distinguished members of the 
Indian Affairs Committee. My name is Lorren Sammaripa, Chairman for the 
Walker River Paiute Tribe of Nevada. I would like to thank you for this 
opportunity to speak to the Committee regarding Contract Health 
Services (CHS) and the Health Care Crisis we are encountering on the 
Walker River Paiute Reservation and in the Schurz Service Unit.
    Our Tribal Members are currently placed on Priority Level 1 
services which is defined as Emergent or acutely urgent care services 
(diagnostic or therapeutic) that are necessary to prevent the immediate 
death or serious impairment of the health of the individual. Because of 
the threat to the life or health of the individual necessitate the use 
of the most accessible health care available and capable of furnishing 
such services. Diagnosis and treatment of injuries of medical 
conditions that if left untreated, would result in uncertain but 
potentially grave outcomes.
    Due to years of funding shortfalls in the Schurz Service Unit, the 
Phoenix Area Office has begun the implementation of life or death only 
diagnosis for the patients of the Schurz Service Unit and payment by 
Indian Health Service Contract Health Service funding. As a result, 
services for treatment and follow-up care are no longer allowed. We 
were told by the Medical Director at Phoenix, ``if you can make an 
appointment, then it does not meet the definition of Priority Level 1 
services and any referrals will be denied.
    The Schurz Service Unit is solely dependent on Contract Health 
Services for hospital stays, specialty visits, lab and X-rays and all 
Pharmacy costs paid for with CHS funds. For the past five (5) years, 
Walker River has had to call Care Flight out of Reno for severe cases 
at a cost of $15,500 per flight as IHS has failed to contract with a 
provider to lower these costs. This is the case for many of the 
providers.
    Here are some of the case examples of the Health Care being 
provided or should I say not being provided to our Tribal Members and 
community. Services for all these cases had been DENIED for not being 
Priority Level 1 eligible.

   A 63-year-old grandmother in November 2009 was having chest 
        pain. Our doctor requested a referral to have a scan done to 
        rule out Cardiac or Malignancy. She suffered through numerous 
        clinic visits, pain and weight loss. In December she was sent 
        to the ER with left chest pain at Banner Hospital and then 
        transferred to Renown Medical with a lung mass. This ER visit 
        was approved. Subsequently, she was referred for CT Scan and 
        bronchoscopy of her lungs for her masses with possible 
        malignancy. The sad course continued and by February she was 
        severely debilitated, wheelchair bound and wasting away. She 
        had one more visit to the ER with prolonged hospitalization 
        toward the end of her life. She died on March 19, 2010.

   A 39-year-old mother of five came to the clinic with 
        shortness of breath. She begged the provider to just give her 
        antibiotics or a breathing treatment. She did not want to go to 
        the ER and incur more bills she could not pay. She explained 
        that IHS had not paid for her gall bladder removal or her heart 
        catheterization. The provider informed her that she may have a 
        pulmonary emboli. She still refused to go the ER. She died the 
        next day from a pulmonary emboli.

   A 34-year-old mother of two with central abdominal pain near 
        a hernia repair site was denied to go back to the surgeon. She 
        went on her own and had a CT scan ordered by the surgeon for 
        diagnosis to rule out a second hernia. Payment was denied. The 
        CT scan showed a right ovarian cyst and the provider 
        recommended a Gynecologist. This was denied. The patient's 
        mother is currently being treated with chemo for ovarian cancer 
        with metastasis.

   Two male patients have been diagnosed with brain and liver 
        cancer. All services have been denied by IHS.

   A 63-year-old male with Diabetes since 1995. This disease 
        has affected multiple body systems. He has had a partial foot 
        amputation, his kidneys are beginning to shut down, endocrine 
        referral was denied. Patient has had a heart attack with 
        angioplasty with a 23 percent ejection fraction (normal is 60 
        to 80 percent). In early 2009 his pulmonary consult s were 
        approved but later denied. He has hypoxia, fibrosing 
        alveolitis, and chronic respiratory failure. Pulmonologist is 
        requesting follow-up tests. This complex patient has over 30 
        significant active problems being managed by a family care 
        physician. The Podiatrist, Nephrologist, Endocrinologist, 
        Cardiologist and Pulmonologist have all been denied. Patient 
        was sent to collections by the Endocrinologist for non-payment 
        and he will not see the patient.

   A 11-year-old female patient with full blown Rheumatoid 
        Arthritis was referred to Rheumatoid Arthritis specialist so he 
        could prescribe Embril shots that the Drug Company would pay 
        for at no cost to IHS. This was also denied.

   A 15-year-old female diagnosed with a type of Rheumatoid 
        Arthritis called Raynauds. Parents paid for the diagnosis as 
        all her referrals were denied. She must wear gloves to prevent 
        severe pain, she also has syncopal episodes and altered mental 
        status and palpitations with shortness of breath. Specialty 
        referrals for a Neurologist, Cardiologist and Rheumatoid 
        Arthritis were all denied.

   A 50-year-old male with a family history of Heart Disease 
        came into the clinic with significant chest pain and had an EKG 
        that showed a heart attack at age indeterminate. Cardiology 
        referral was denied even though the standard of care dictates 
        Cardiologist involvement.

   A 70-year-old female who has severe Obstructive Sleep Apnea 
        documented by a sleep study previously approved by IHS in 
        October 2009. Subsequently was denied treatment of this 
        condition by IHS. Untreated Obstructive Sleep Apnea can cause 
        or worsen many medical conditions including Hypertension, 
        Coronary Artery Disease and Diabetes. She is at significant 
        risk for a major medical event at any time. She has also been 
        denied for a re-evaluation by her Cardiologist for chest pain 
        and her nighttime oxygen supplementation in May 2010.

   A 24-year-old female had a gall bladder removal that had the 
        risk of complication causing pancreatitis. She was admitted to 
        the ER with pancreatitis at a small rural hospital then 
        transferred to Carson Tahoe Regional Medical Center.

    We have been told that we should utilize Phoenix Indian Medical 
Center as it was created as a tertiary care facility for the Phoenix 
Area Tribes of Nevada, Utah and Arizona.

   A 25-year-old male that tore his Achilles heel in February, 
        2010 was denied service to an Orthopedic Specialist in Reno and 
        was told he had to go to PIMC for service. It took until the 
        middle of May (3 months) before he got to see a specialist at 
        PIMC.

    There are currently no approvals for Orthopedic Care in the SSU, no 
physical therapy for patients after surgeries, no durable medical 
equipment for anyone including elders and no prenatal care. I am sure 
with what you have heard so far that you now have a better 
understanding of the Health Care Crisis that my people have had to 
endure. These are only a few out of the total 511 cases denied by IHS.
    It is appalling that bonuses are still being paid to all levels of 
personnel at the Phoenix Area Office while our people are dying on a 
daily basis for lack of funding for Healthcare.
    IHS received the largest increase in CHS funding in 2010 which 
didn't even begin to address the healthcare needs of our Nevada Tribes 
and our Indian people especially when there was a backlog of unpaid 
bills for the previous 5-6 years at the Phoenix Area Office in the 
amount of $4.6 to $4.8 million.
    There's also a huge difference in Priority Level 1 care between 
Tribal Health Clinics in Nevada compared to Hospitals in Arizona.

    Senator Dorgan. Chairman Sammaripa, thank you for 
testifying.
    Chairman Bell, you're a friend of Chairman Wright. I know 
that he had to leave very quickly. I have a note as to the 
reason for that. Is it appropriate or not for me to describe 
why? Would you wish to? He had to leave for a family emergency, 
I guess.
    Mr. Bell. I think I'd leave that up to him.
    Senator Dorgan. All right. Let me just say that my thoughts 
are with him. As we appreciate him being here, but understand 
the reason that he had to leave.
    Let me thank all of you for being here today. I also wanted 
to mention that Susan Lisagor is with us. Susan is with Senator 
Harry Reid here in the State. I indicated when I started this, 
I'm here because Senator Reid, some while ago, had asked if I 
could hold a hearing on the subject of contract health because 
there's no state that has more reliance on contract health than 
the State of Nevada. And we know the problems with contract 
health. And when you are subject to having that kind of 
reliance on it, there are destined to be circumstances that are 
really dysfunctional and in some cases fatal.
    Mr. Sammaripa, I read your testimony. And let me read one 
other example. You provided some really interesting and tragic 
examples. Let me read one, because it is at the heart of the 
reason that I'm here and the reason that Harry Reid and I are 
desparately trying to find a way to fix this.
    This from Chairman Sammaripa's tribe, and I'm quoting now: 
A 39-year-old mother of five came to the clinic with shortness 
of breath. She begged the provider to just give her antibiotics 
or a breathing treatment. She did not want to go to the 
emergency room and incur more bills that she could not pay. She 
explained that the IHS had not paid for her gallbladder removal 
surgery or her heart catheterization. The provider informed her 
that she may have a pulmonary embolism. She still refused to go 
the ER. She died the next day from a pulmonary embolism.
    Now, why did this 39-year-old mother of five die? Because 
she had had opportunities to get some amount of health care 
previously for which Indian Health Service and contract health 
did not provide reimbursement. My guess is she was living with 
a circumstance of her credit being destroyed, bills she 
couldn't pay, so she comes to the clinic with a very serious 
problem, and what's on her mind? ``I can't pay for this; I 
can't possibly get health care that's going to cost me money.'' 
Now five children are without a mother. That is such a powerful 
description of the dysfunction that exists. Dysfunction that in 
this case proves fatal. And, you know, if all of us in this 
room knew this young mother, you know, our heart would break. 
It breaks just talking about the story. So we've got to fix 
this. We can't ignore it. We have to find ways to fix it.
    All of you have provided really interesting and troubling 
testimony in many ways. I want to ask a series of questions, if 
I might.
    Let me ask: Miss Curley, tell me about the prevalence of 
diabetes. Would diabetes be one of the significance problems--
and I would ask others, as well--the rate of diabetes multiple 
times the national average? Is diabetes a serious driver of 
health care problems on the reservations in Nevada?
    Ms. Curley. For the Native American population, it is. The 
diabetes rate is higher than the non-Native. It is a big driver 
of a lot of health problems. A lot of diabetics have a lot of 
comorbidities that go along with them. They're hypertensive, 
they're obese, they have issues that lead to unpreventable 
amputations. There's a whole gauntlet of problems. Part of the 
problem is, you know, the kind of medications that we have in 
the formularies, you know as part of our formularies. Health 
conditions that are beyond what we can do for the patient, but 
we can't get the patient referred out to deal with.
    Senator Dorgan. How about dialysis? Do you have people from 
your tribe on dialysis?
    Ms. Curley. Yes.
    Senator Dorgan. Where do they get the dialysis?
    Ms. Curley. Carson City or Reno.
    Senator Dorgan. And how far is that?
    Ms. Curley. So to go to Reno for the dialysis patients, 
it's between 45 minutes and an hour to go to Carson City.
    Senator Dorgan. One way?
    Ms. Curley. One way. And Carson City is----
    Senator Dorgan. How many times a week?
    Ms. Curley. Two to three times a week, depending on the----
    Senator Dorgan. So two to three times a week, a two-hour 
round-trip, plus the time they're on dialysis.
    Ms. Curley. Yes, it's very taxing for them.
    Senator Dorgan. How many people in your area are on 
dialysis?
    Ms. Curley. I think we only have two left on dialysis. The 
others have passed away.
    Senator Dorgan. Mr. Chairman, how about in your area: Is 
diabetes a significant problem? Do you have people on dialysis, 
and, if so, where do they get the dialysis?
    Mr. Moyle. Yes, thank you, Senator. The exact number right 
at this present time, I do know that we have six. We had eight, 
but as Ms. Curley said, some of them get to the point of 
they're gone.
    Senator Dorgan. And where do they get the dialysis?
    Mr. Moyle. They just recently built a dialysis treatment 
facility in the town of Fallon. Prior to that, up until about a 
year and a half ago, they were getting their treatments at 
Reno. And I thank you for asking that, but the funding that 
comes from the Federal Government for diabetes, I will tell you 
that is very helpful. But once again, it gets back to the 
follow-up to that, other than the fact that we can educate our 
people and try to begin a program that would probably help 
relieve that from happening--that could be done. But then, 
again, let's say they get to the point of the dialysis issue 
and the fact that once again, I'll go back to that, decrease in 
funding--we were thankful the hundred million got approved and 
the Schurz Service Unit was able to get some of that, but 
still, basically, what that did was almost like help out with 
inflation. It's helpful, but in a sense, when you get down to 
that many patients that--and I'll refer to our statement--is 
inadequate funding. Okay. So I hope I answered your question. 
Are you going talk with Mr. Bell?
    Senator Dorgan. Yes, I'll ask Mr. Bell to answer the 
question.
    Mr. Moyle. Because his people----
    Senator Dorgan. Yes. Go ahead.
    Mr. Moyle. Did I answer your question?
    Senator Dorgan. Yes. Chairman Bell: Diabetes, dialysis?
    Mr. Bell. Yes. Mr. Senator, I'm not sure of the percentages 
but we have a number of Diabetes Type 2. Most recently, within 
a year, we've learned that some of them are in our youth now. 
And like the rest of the tribes, our specialized services are 
here in Reno. And I've had to--I don't know if I want to call 
them a privelege or pleasure--about 11 years ago I used to ride 
on this transportation van. I used to transport dialysis 
patients. I guess the only reason why I liked riding with them 
is amongst themselves they had a pretty good charisma and they 
liked to joke a lot. But when we'd come back after their 
treatment, they'd be so worn out and tired. By the time we'd 
get going down the road, they'd be nagging on each other, so on 
and so forth. So, yes, we had a high number. A lot of those 
people are now deceased.
    Senator Dorgan. I should mention that in the Economic 
Recovery Act that was passed, there was not Indian funding 
originally proposed. I was able to get $2.5 billion in the 
Economic Recovery Act, with Senator Reid's help, specifically 
for Indian Country. We were able to add $2.5 billion. Of that 
$2.5 billion, $300 million of it went to Indian country for 
health service facilities, especially, and the information 
technology system for the services. Now, that's not a lot of 
money, but it's more than is generally made available. And I 
have not yet seen how the IHS has moved that around the 
country. But there has been several hundred million dollars 
available building facilities in the last year and a half.
    Ms. Harris, as I indicated to you previously, you know, we 
want to have the Indian Health Service have people working who 
return telephone calls and you know, the system doesn't work if 
you can't get answers, can't get responses, can't get 
approvals, and so on. So I hope we'll get that addressed. I 
just think it's very important that we try to find ways to make 
sure that when someone testifies they say, ``You know what? 
This service is great because there are people there we know 
and we work with, and they respond quickly.''
    The thing that was troubling today is the issue of approval 
for a pacemaker, but not for a battery. Or approval for a 
kidney transplant but not for the drugs that will prevent 
rejection of the kidney transplant. I don't understand the 
decision-making process, where the decision-making process 
would break down. Because it's just common sense: Why would you 
approve a kidney transplant if you don't intend to approve the 
lesser cost of the drugs that would prevent rejection? Why 
would you possibly approve a pacemaker if you don't intend to 
provide batteries for the pacemaker? So where does this 
breakdown?
    Ms. Curley. Well, what we're told is, and when our 
providers do a referral and refer a patient out and it gets 
denied, and we specifically ask, what do we have to do to get 
our patients approved for a referral? And the come back is: If 
you have to make an appointment to have it done, it's going to 
be denied. And that's the rational.
    Senator Dorgan. Explain that to us again.
    Ms. Curley. If our patient needs to go, say, into a 
specialty provider to have a new battery put in their 
pacemaker, you make an appointment to go and have that battery 
put in----
    Senator Dorgan. Yes.
    Ms. Curley.--therefore, it will be denied.
    Senator Dorgan. So that means it's not Priority 1, Life or 
Limb?
    Ms. Curley. Right.
    Senator Dorgan. If you have to make an appointment, it 
means that there's not an urgent emergency at the moment if you 
have time to make an appointment, the thought process is to say 
I'm going to need this, therefore they say ``It's not 
covered''?
    Ms. Curley. Right.
    Senator Dorgan. Okay.
    Ms. Curley. But even as far as ER visits--my contract 
health clerk just came back after a CHS meeting the other day--
and she came back to the clinic and told me that some of the 
information she found out through the course of that meeting is 
that they're looking at no longer approving a lot of ER visits. 
So even if you have to have an appointment to have it done, it 
doesn't get approved, but what if you have to race to the ER, 
those aren't going to get approved either?
    Senator Dorgan. Right. Ms. Harris wanted to say something, 
then I'll call on Chairman Sammaripa.
    Ms. Harris. I think the basic problem is a lack of 
understanding. A diagnosis and treatment does not cure a 
disease, it does not cure a spell of illness. There's a lack of 
case management and a case management approach to the provision 
of care, as well as the reimbursement. Again, it doesn't make 
sense to you or me that we would get a diabetic, diagnosed as a 
diabetic--diabetes is horribly debilitating disease if not 
treated; it is fatal--why would you go ahead and say, yes, this 
patient's a diabetic and not provide somewhere budgetarily as 
wells as physically for this patient and their life span? And I 
think that is an essential component that is missing.
    Ms. Dupree and Mr. Curley were very reluctant when we sat 
down and said, ``Listen, when we put a pacemaker in, here's the 
situation, here's the follow up.'' We have had very little 
trouble with those cases since then. But I think what we're 
getting to is a lack of understanding and a lack of a case 
management approach to the funding.
    Senator Dorgan. Well, let me understand that point, though. 
Ms. Curley, you're the one who talked about a pacemaker without 
a battery, right?
    Ms. Curley. Yes.
    Senator Dorgan. Ms. Harris, you don't work in Ms. Curley's 
clinic. So you say that you've got an understanding and you 
feel pretty good about that.
    Do you, Ms. Curley? Do you have that understanding? Or is 
it something that happened in the past that you think won't 
happen again?
    Ms. Curley. No. This is a more recent one, and it's on our 
list of denied referrals that we have. And so this is a case 
that was brought to my attention about three months ago. I 
don't think this patient goes here. But, no, this is a more 
recent case that we had.
    Senator Dorgan. Where would that approval or denial happen?
    Ms. Curley. We do the referral at our facility.
    Senator Dorgan. Right.
    Ms. Curley. Then we send it--it used to be the Service 
Unit. But the referrals are getting approved or denied in 
Phoenix.
    Senator Dorgan. All right. Ms. Harris, the understanding 
you have is working better with Phoenix; is that correct?
    Ms. Harris. Well, locally, too.
    Senator Dorgan. Okay.
    Ms. Harris. And it is working well. I guarantee that's not 
one of our patients. And if it is, you call my office.
    Senator Dorgan. Chairman Sammaripa?
    Mr. Sammaripa. Yes, thank you. If I may, Mr. Richardson 
here that actually works with the referrals and runs our health 
care at Schurz, if I may turn this over to him to--he has some 
more to add to it, so with your permission.
    Senator Dorgan. That would be fine.
    Mr. Sammaripa. Thank you
    Senator Dorgan. Mr. Richardson, welcome. Would you give us 
your full name.
    Mr. Richardson. Kenneth Richardson. I've worked for the 
Walker River Tribe for 23 years as health director. And I 
worked, before that, with the hospital when it was running.
    And the thing that we're seeing right now, Senator, is that 
the heart patient that goes into Renown and is ready to die, 
they'll put a heart monitor in them so they will keep them 
alive. But right after that, then we're getting denied for 
everything. And it became very hard this year for our 
providers; we've lost providers because they couldn't live with 
this either, at our clinics. We have kids that have broken 
wrists, they were swollen up, the doctors couldn't do anything 
until a couple days when the swelling goes down. Well, that's 
been denied now. Because if you can make an appointment, it's 
not within priority.
    Senator Dorgan. Let me understand. I don't understand the 
notion ``If you can make an appointment.'' If a kid has a 
broken wrist that's ``limb,'' right?
    Mr. Richardson. Right.
    Senator Dorgan. I mean, you've got to set a broken wrist so 
it heals properly. And if you can't set it properly when it's 
swollen badly, you have to wait until the swelling goes down. 
And so the kid comes back three days later and two days later 
and gets it set, are you saying because an appointment is made 
for that return visit, it is denied?
    Mr. Richardson. It's denied.
    Senator Dorgan. Now, who denies that? I mean, what's the 
basis--this almost seems to me like it would be impossible for 
someone to make that judgment. I mean, I know what you're 
telling me is what you believe and what you see. I'm just 
telling you what I hear is that has no basis in common sense. 
So someplace this is broken. It's a broken understanding 
somewhere between you and whoever is going to make this 
judgment that the kid with the broken wrist shouldn't get 
coverage because they showed up two days later.
    Mr. Richardson. Well, It goes way back. But like everybody 
said: Just last November, they started paying five years of 
bills for us, because we had all our providers quitting us, we 
had to bring a lawyer in, Senator Reid had to help us, you 
know, to get IHS to pay for five years of bills that were still 
out there on the table just to get services. And at that point, 
with the new fiscal year, FY10, it became a dollar amount, a 
figure that we were being told they had to control. And, 
basically, for the Schurz Service Unit, we get $6.4 million 
dollars for Contract Health Services to take care of 9,000 
people. Out of that, $2 million is spent on pharmacy and labs 
and X-rays, anything like that. So it brings you down to about 
$4.4 million for services. And this is what we've had trouble 
explaining to Congress----
    Senator Dorgan. Well, I understand it's short. I understand 
that. What I don't understand is the criteria by which someone 
says: We're going to allocate this based on a criteria that 
seems artificially ignorant; that is--not artificially--really 
ignorant, by saying that life or limb shall be described as 
whether you make an appointment or not. I can understand the 
rationale of suggesting that is true in many cases, perhaps, 
but never could I understand that that would be true in all 
cases. You've described one that is probably a perfectly good 
description of it: a broken wrist, unable to set it for two 
days, and, therefore, gets denied. Somehow, that suggests to me 
somebody's not thinking in this process.
    Mr. Richardson. And that's exactly how we feel. And that's 
why in our Chairman's testimony, that's the first thing we talk 
about, because it does say: Also for diagnostic and therapeutic 
purposes, a patient can be seen as long as you know, so we 
don't harm the patient.
    And that's how we've felt like third world, we felt like, 
we're not part of the Phoenix area. And when you see, you know, 
our people sitting here dying because they can't get treatment, 
and we're expected to accept that.
    Senator Dorgan. But let me ask you: If I might go to the 
39-year-old mother of five--are you familiar with this case?
    Mr. Richardson. Yes, it came from our clinic.
    Senator Dorgan. It came from your clinic?
    Mr. Richardson. Yes.
    Senator Dorgan. A 39-year-old mother of five came to the 
clinic with a shortness of breath, begged the provider to just 
give her antibiotics or breathing treatment, did not want to go 
to the ER--where would she have gone, if she should not have 
gone to an emergency room?
    Mr. Richardson. We were trying to take her to Fallon. She 
was, actually, a Pyramid Lake patient that just happened to be 
visiting relatives that day.
    Senator Dorgan. I see. Okay.
    Mr. Richardson. And so I also run with the ambulance 
service. I also had to deal with that on the ambulance side. 
You know, and also from the EMS side, it makes it very--you 
know, because do we care-flight that patient, because----
    Senator Dorgan. Right, I understand the ambulance issue, as 
well, because I've been involved in some of that.
    So this woman said that she doesn't want to go to the ER 
because IHS previously had not paid for gallbladder removal and 
her heart catheterization. So was that a case where she came in 
after you were out of funds and had procedures that didn't get 
paid, and I suppose ruined her credit--is that what we're 
talking about here?
    Mr. Richardson. That, and she'd also been denied, I 
believe, at Pyramid Lake----
    Ms. Curley. Yes.
    Mr. Richardson.--for services to go be checked out.
    Senator Dorgan. And why was that--tell me about that denial 
at Pyramid Lake.
    Ms. Curley. It was denied due to ``Not within priority.''
    Senator Dorgan. Not within priority one--you mean----
    Ms. Curley. We did a referral, we had to refer her out to a 
specialty provider, and the referral comes back--because we 
can't make the appointment until we find out if it's going to 
get approved. And it came back, ``Denied, not within 
priority.''
    Senator Dorgan. And that means, like, on Priority 1: 63 
gunshot wounds, severe burns, coma, apendectomy, obstetrical 
emergencies, and if it's not within that, they're told ``Sorry? 
''
    Ms. Curley. Yes.
    Senator Dorgan. I mean, that's what I----
    Ms. Curley. But you don't get deliveries paid for anymore 
either. And we have prenatal deliveries that don't get paid for 
either.
    Senator Dorgan. Well, that's what I talked about at the 
start of this, about health care rationing.
    Ms. Curley. Yes.
    Senator Dorgan. Everybody's always worried about rationing: 
It's going on in this country, every single day to American 
Indians.
    Ms. Curley. Yes.
    Senator Dorgan. It's unbelievable. It ought to be headline 
news. And then, perhaps, the country would say, We've got to 
stop this.
    Ms. Harris. Yes.
    Ms. Curley. Yes.
    Senator Dorgan. Senator Reid and I and others have been 
grappling with this Contract Health Care issue for so long, and 
we have to get it fixed somehow. We just have to get it fixed.
    Mr. Richardson. One other thing.
    Senator Dorgan. Yes.
    Mr. Richardson. Our prenatal care is all being denied. Yet 
we're expecting our mothers to go into ER, have emergency 
surgery that's costing more. I mean, this is what is hard for 
us as tribes to try to visualize is it's costing us more in the 
long run not doing the preventative care.
    Ms. Curley. Yes. And I would like to add to that. We had a 
case study. We had an epidemiologist come and do a case study 
with some of our patients to track their health conditions over 
a prolonged period of time. And so when she was looking at 
them, it took from the time that patient got that injury or 
whatever the health condition was, and then looking for all the 
referrals in their history and watch their health conditions 
decline over time to the point where it gets really severe, now 
your going to pay a much larger amount of money on the back 
end, and a lot of times it's still too late; the damage has 
already been done. Whereas, if you were spending a little more 
money in dealing with the immediate problem when it starts, the 
early intervention and prevention component, you would save a 
lot more money in the long run. But to wait until their health 
conditions deteriorate to the point where it's going to cost an 
astronomical amount doesn't make any sense to any any of us. 
You're spending a lot more money.
    Senator Dorgan. What's it feel like to have to run a system 
like that--because you're at the ground level where all the 
patients show up?
    Ms. Curley. It's extremely frustrating when we're trying to 
figure out how we're going to get the patients out of the 
facility with what they need, or dealing with a system that 
assumes that our facilities can do things that other facilities 
can't. Some of this rationale comes from an assumption that our 
clinics can do a lot more than what they really can. Our 
providers are extremely--we came ``this close'' to losing our 
provider, our doctor. You know, they're very frustrated. And 
they're terminology is ``It should be illegal to make people 
suffer like this.'' They get angry because they know what the 
patient needs. It's a liability for everybody. The patient 
knows that their condition is just going to get worse. The 
doctor is working outside of his or her scope to try to help, 
and we're just equipped to deal with the cases that--we're a 
clinic; we're not--and it's extremely frustrating.
    Our doctors and our nurse practitioners and our nurses, our 
benefits coordinator, contract health clerks, they do 
extraordinary things. Our staff took up a collection at the 
clinic to buy medications for our kidney donor patient, because 
she couldn't afford to buy it on her own. I mean, these are--
Walker River--or, you know, Walker Lake: They do a lot of--but 
there's a lot of extraordinary things that we do within our 
clinic to try to help our patients. Our providers spend a lot 
of time working with the drug companies to try to get free 
medications for our patients. And we do a lot of things. We 
have money that we pull out of our own clinic funds, our third 
party revenue funds, that we spend to help our patients. But 
it's not enough. It's not enough.
    Senator Dorgan. And, you know, the Chairmen of Tribes, I 
visited a lot of reservations, of course, as Chairman of the 
Indian Affairs Committee, and I know how the political system 
and the government system works in tribal government. And my 
guess is that all of the issues that confront the clinic, that 
they just can't deal with, end up, very often, with the tribal 
chairman, saying, ``What are you going to do about this? And 
then what can the tribe--how do I get help? I'm assuming that, 
unless you represent tribes--I don't think you do--that have 
independent wealth and extra revenues, I'm assuming that when 
Contract Health Service runs out, you're all in the same 
dilemma, in the same situation.
    Ms. Curley. Exactly.
    Senator Dorgan. When does your Contract Health Care funding 
run out, on average, Mr. Chairman?
    Mr. Moyle. I've been the Chairman for going on 23 years 
now--it has been for years--you could look at May, we're out. 
And we began to get the, let's call it the, ripples of that 
going to be happening in April. By May, we are out. And going 
back to what they were all saying----
    Senator Dorgan. So that's seven months out of the year, and 
then the next five months there's no money.
    Mr. Moyle. As you stated earlier that you've visited a lot 
of the Chairmen and realize a lot of what you might call 
frustrations--it really amounts to that, because I'm 
responsible for entire tribe. A lot of them are relations, a 
lot of them. They're dying. Not only my own relations, but 
other members of our same tribe, other members--we're related 
because of our closeness to Pyramid Lake, Walker Lake, and also 
Reno and Sparks that there's relations amongst all five of 
those tribes, even Fort McDermitt area. But all of our people 
are going through the same thing. Because of that lack of 
funding that handcuffs our people from being able to walk in 
the door and have a provider see him and then have a person--
well, in this case, because of the insufficient dollar Phoenix 
follows, I'll just make a reference to this--the Bible, about 
Level 1 Priorities and which ones will be approved. You have 
some good examples of how drastic it's got to be before that 
person can be either seen or turned out the door. We're not 
going to authorize it. And that's daily.
    Senator Dorgan. Chairman Bell?
    Mr. Bell. Mr. Senator, Fort McDermitt is a direct service 
tribe. We did compact our 648R Fund, so the Schurz Service Unit 
is responsible for oversight on all of our administrative 
oversight. But as a tribal counsel, we've asked numerous 
occasions for the unit director to come to our reservation. All 
of these exact same concerns were brought to his attention. 
Basically, he's the health director for our clinic. And I could 
tell you that about maybe four or five years ago, basically 
what it boiled down to is this formula that we keep speaking 
of. And from my reservation, out of the youths, for me, and for 
everybody else, it's only for our contract health dollars for 
me to come to a contract health provider, it's only $500 for 
me. So I rarely use that source.
    Senator Dorgan. Chairman Sammaripa, I assume you and Mr. 
Richardson confront these things every single day. When do you 
run out of Contract Health funds on your reservation?
    Mr. Sammaripa. Well, Mr. Richardson can probably address 
that, and he has the facts and figures, so.
    Senator Dorgan. All right.
    Mr. Richardson. Thank you. It's real hard to say, Senator 
Dorgan, because, like we're on a continuing resolution now, 
and, you know, health care is not static; it's continuing. 
Bills are coming in now that are probably piling up as we 
speak. So, basically, we are out of money for this quarter 
already, because those emergencies or whatever, they're coming 
in, and by the time we get the money, there still has to be 
pharmacy taken out of it, all the X-rays, laboratories, we're 
really out of money all the time. And one of the big things, 
like, for us, I can track historical spending of almost $1.8 
million just for Walker River on a yearly basis. Now we're down 
to about 400,000 because we're basically being put on our user 
population. And the user population, in some cases, always 
benefits the bigger tribes. And we have to fight the Phoenix 
Indian Medical Center that has an urban population of 55,000, 
but you know we really fought this year with the big increases 
in CHS, you know, unheard of. And we get $1.1 million. And the 
bigger get bigger, richer, basically. And there's nothing in 
there about needs or any of those type of things, but we're 
always out of money. That's the way we feel. And this year was 
the worst. And it's one of the things that we put in our 
report--is that it's really hard for us to understand how I 
just can give out bonuses, which are monetary rewards, to their 
staff when our people can't even get care. You know, it really 
affects all the tribes.
    Senator Dorgan. Ms. Harris, you may proceed. You wish to 
say something?
    Ms. Harris. I'm sorry. Getting back to the disconnect, as 
far as the Priority 1 and the approval process, I can't speak 
for IHS, but as I alluded to before, I've been around the 
health care block for a while: What you have is you have a 
situation, you call for an approval, the person on the other 
end of the phone is not a clinician, what they hear is there's 
a child who has broken their wrist, and they say, ``Okay. Go 
ahead.'' The child appears, there's too much swelling, the 
wrist can't be set, so they have to come back in two days. When 
you call for that, what the person on the end of the line, a 
nonclinician, is hearing ``follow-up visit.'' A follow-up visit 
doesn't meet the criteria; broken wrist did. And that's part of 
the lack of understanding between the people who are granting 
the permission, if you would, for these visits and access to 
care.
    Senator Dorgan. All right. I believe we've been at this 
about two hours. We've been at this so long that the roof 
starting leaking.
    [Laughter.]
    Senator Dorgan. I want to make a couple of comments to you. 
Number one, I indicated at the start that we passed the Indian 
Health Care Improvement Act. I'm really proud of that. It will 
not by itself, just like that, fix everything in health care; 
we understand that. But in the previous congress, the 110th 
Congress, I asked Senator Reid for time to get to the Floor to 
deal with this Indian Health Care Improvement Act. I told him 
we could be on and off the Floor of the Senate in just a couple 
days. Well, it turned out that wasn't the case. It took longer. 
It was controversial. Nonetheless, we got through it, and we 
passed it, and then it got hung up in the House of 
Representatives, and it didn't become law. This year, again, 
with the Indian Health Care Improvement Act, I went to Senator 
Reid and said, ``We need to move this, get this done. I think 
we can get it through the House this time.'' So we got it added 
to the larger health care bill, and it is now law.
    And we included a couple of things that are important. One 
of them written by Senator Reid, and I supported that, and that 
is there is now a requirement for the Secretary of Health and 
Human Services to develop a plan by which Nevada would become 
its own IHS area. This is a big state. I believe it's the only 
similar geography that doesn't have a hospital. I think it 
would be the first step towards finally getting a hospital. 
But, in any event, having to drive 700 or 800 miles, 600 miles 
to access the hospital in Phoenix is just not an adequate way 
for our country to meet its promise, treaties and other 
responsibilities, trust responsibilities.
    So, number one, there's a requirement, Secretary of HHS 
develop and report to Congress a plan for a regional IHS office 
here. Number two, the Act also requires the Secretary of--
number one, we asked for a Government Accountability Office to 
conduct an investigation into the Contract Health Service 
program and also the formula for the program, and then after 
the study and tribal consultation, which is included in the 
language, required tribal consultation, which I think is 
critical. After the study and the tribal consultation is 
complete, if the Secretary determines that the formula will 
need to be changed, then she will recommend that to the 
Congress and recommend the type of change.
    I think because no one can explain what the formula is or 
how it was developed, this formula must be changed. There are 
three things, it seems to me, that are critical here. One, you 
are the most reliant, of all the states, on Contract Health 
Service programs. Therefore, what happens to Contract Health 
Care Services is much more important--it's important to 
everybody, every tribe in the country, but even more important 
to you. So this process by which we finally at long, long last 
are going to say, ``You've got to investigate this, work 
through it, and come up with a better approach,'' I think is 
going to be very important.
    But most important, at the end of the day, is once we've 
discovered what kind of payments and how they are apportioned 
and so on. Once there is a plan for implementation of an Area 
Office here, then the question is how are we going to make 
certain that the Congress appropriates funds that are 
sufficient to avoid what is rationing for about 60 percent of 
American Indians health care needs? Again, I can't say it often 
enough: This ought to be a national scandal.
    And, I mean, the story you have told today of a 39-year-old 
mother, I've heard that story over and over again in so many 
different ways. And the way that I was able to get the Indian 
Health Care Bill through the Senate was to put a face on the 
these issues. Some of you may have seen me on the Floor of the 
Senate. I guess I did it probably ten times, talking about 
Ardel Hale Baker. I brought a big picture of Ardel Hale Baker 
to the Floor of the Senate to say here's the woman on whose leg 
they masked-taped an eight-by-ten piece of paper as they hauled 
her in the hospital having a heart attack, saying, ``If you let 
her in the hospital, you may not get paid.'' Here's the woman. 
Take a look at her.
    And then I brought the photograph of Ta'Shon Rain 
Littlelight, whose grandmother gave me the photgraph at the 
Crow Reservation when I was there one day. I told the story of 
this six-year-old little girl over and over and over again. And 
I'll tell you the story just briefly because I think it bears 
repeating. Ta'Shon's picture that her grandmother gave me 
showed a little beautiful six-year-old girl with bright eyes in 
a fancy dress, because she loved to dance, and she was 
beautiful. Ta'Shon became ill. She was taken to the Indian 
Health Service clinic and taken again and taken again and taken 
again, and was always sent home with the diagnosis of 
depression, and medicine for depression. This for a six-year-
old girl. Well, finally, her condition became an emergency, and 
she was air-lifted to Denver, and they discovered she had 
terminal cancer. So Ta'Shon was not long to live.
    Make-a-Wish Foundation asked her what Ta'shon wanted to do. 
She wanted to go to Disneyworld in Florida to see Mickey Mouse 
and Donald Duck. So Make-a-Wish Foundation made it possible for 
her and her mother to go to Disneyworld. In the hotel, the 
night before they were to go into the park, she said to her 
mother, ``Mommy, I'm sorry that I'm sick.'' And then she died. 
Never got to Disneyworld World. She died in a hotel in her 
mother's arms. This is a six-year-old girl, believe it or not, 
who shouldn't have died.
    But I asked her grandparents and her mother if I could use 
her photograph on the Floor of the Senate, not to exploit it, 
but, perhaps, to tell people: This is about real people; this 
is kids dying; it's elders dying; it's about real people. And I 
think enough members of the Congress finally said, ``Boy, it's 
hard for me to turn my head to that; it's hard for me to resist 
doing what needs to be done. So we've made some progress.
    It's not all the progress we need, but, you know, when I 
come here to the state that's most reliant on Contract Health 
Services and hear your stories, it reminds me how urgent it is 
that we continue to get the funding, continue to move with the 
two provisions that are in the Indian Health Care Bill dealing 
with these issues. Do what this country promised: Provide for 
Indian health care for the first people who were here who met 
everybody else, provide for the health care needs we promised 
them. And if you don't believe me, go look at the Treaties, see 
how they're written, we signed them. So we've got to do this 
and we've got to continue this fight.
    Your willingness to come to a hearing and provide testimony 
and provide a base of information, especially about Nevada is 
very, very helpful. I know that Senator Reid wished he could 
have been here today, but he's asked me for some months if I 
could come and do this hearing in Nevada because this contract 
health care issue is so important. It turns out the day I was 
able to come, he's not able to be here in Reno. But I'm here 
because he cares about the issue and is with me to pass the 
Indian Health Care Improvement Act and the other things that we 
have done.
    So let me say one more time that we will keep open the 
record of this hearing for two weeks from today. If you want to 
submit testimony from someone else in your tribe or others who 
have witnessed this hearing, you're welcome to submit formal 
testimony and it will become a part of our permanent record.
    And let me, with that, close this hearing and ask if we 
might call on Chairman Bell, once again, to provide a blessing 
as we close this hearing.
    Mr. Moyle. May I ask one more question?
    Senator Dorgan. Yes, you may, Chairman Moyle.
    Mr. Moyle. I want thank you because I know you have high 
standards and your staff.
    The one thing that I feel is important to ask is that, as 
we read it and as we hear about it, the GOP is working daily on 
issues that they feel are wrong that should be passed by the 
present administration. Now, listening to the issue of the 
repeal of the health care reform that had been approved at this 
point: Will the Indian Health Care Improvement Act, because it 
is a part of that, be affected by that decision if there is 
going to be one?
    Senator Dorgan. If there were a repeal of the health care 
bill that was passed by the Congress, the Indian Health Care 
Improvement Act would similarly be repealed, because that's 
where we attached it. But let me just say this: That is not 
going to happen; it will not happen. Let me tell you why: Even 
if those who believe this should be repealed--and I don't; that 
would be a profound mistake to repeal that law--even if they 
had enough votes to repeal it, they would not have enough votes 
to override a presidential veto. There would need to be 67 
senators that would say, yes, we want to repeal this law, and 
we would overturn a president veto. Clearly President Obama 
would veto a bill that would repeal the Health Care Bill, and 
clearly the Senate would be willing to sustain a veto.
    Mr. Moyle. Thank you very much. Thank you very much.
    Senator Dorgan. All right. Chairman Bell, again, you opened 
this hearing with a blessing. Let me ask you, similarly, to 
close it with a blessing.
    Mr. Bell. Thank you. First off, Senator, I want to thank 
you again. Thank you for listening to all of our testimonies 
here, each and every one of us. And I believe you are 
personable in the area that you're working with throughout this 
country in the testimonies that's already been provided to you 
on behalf of Contract Health. So I appreciate that. Appreciate 
the honor to meet your acquaintance. I've met you once before 
in Bizmarck, North Dakota, Tex Hall with the NCAI president, he 
held one of the conferences there when I was attending the 
college. So I appreciate that. I've had an opportunity to go 
back to your state. I enjoyed and look forward to going back; 
I've been invited as a guest speaker at the college. Thank you 
for being here.
    [Prayer/Blessing.]
    Senator Dorgan. This hearing is adjourned.
    [Whereupon, at 3:37 p.m., the hearing was adjourned.]
                            A P P E N D I X

Prepared Statement of Hon. Lucille Campa, Tribal Chairperson, Las Vegas 
                              Paiute Tribe
    As Chairperson of the Las Vegas Paiute Tribe (the Tribe) I would 
like to outline some key concerns regarding coverage for medical and 
dental care through Contract Health Services, utilization patterns, 
billing issues, and how these key issues have impacted the Tribe and 
our service population. We are aware that our fellow Tribes may face 
different issues where reimbursements and CHS budgets are concerned, 
and where certain common concerns exist--there are variations depending 
on the Tribe in question. Our hope is that we will be able to identify 
areas for improvement to avoid budget shortfalls and billing errors 
that have compromised access to much-needed healthcare.
    Our service populations has experienced significant delays in 
obtaining medically services necessary specialty care for our covered 
members due to barriers to access at the nearest Indian Health Service 
facility, Phoenix Indian Medical Center. When possible, we rely on our 
local referral network; however, there are gaps in this system due to 
our inability to negotiate contracts with providers who are unwilling 
to accept Medicare's fee schedule. Due to funding limitations on CHS 
dollars, we have had to deny treatments and supplies that were deemed 
to be beneficial and necessary by our contracted providers. In 
addition, we are unable to meet the dental care needs of our 
orthodonture candidates, as well as our elders in need of dentures and 
bridge work. Some of our infirm elders, as well as some younger 
members, with major medical problems need enhanced medical and social 
service support that unfortunately we are unable to provide.
    Las Vegas Paiute Tribe strongly supports the development of a 
Nevada Area Office of the Indian Health Service that would allow us to 
better channel Federal resources to Nevada Natives. In southern Nevada 
alone, there are an estimated 25,000 Indians who have no IHS services 
readily available. Further, the exclusions by PIMC have caused 
hardships to our patients, which is ironic given that the Tribe is part 
of the Phoenix Area. Extending the Medicare-Like-Rates rule to apply to 
outpatient services would dramatically alleviate the strain on CHS 
dollars and severely impact the services to our primary services 
population.
    Please feel free to contact me or our Acting Clinic Director, 
Andrea Harper, if you have any questions or need further assistance.
                                 ______
                                 
  Prepared Statement of Hon. Arlan D. Melendez, Tribal Chairman, Reno-
                      Sparks Indian Colony (RSIC)
Background
    The Reno-Sparks Indian Colony (RSIC) is uniquely situated in Washoe 
County, right at the borderline of the Cities of Reno and Sparks, 
Nevada. RSIC has also established the Hungry Valley community 19 miles 
away. The urban population is included in the tribe's catchment area.
    Between our own patient count, the urban Indians and the patients 
crossing-over from nearby tribes, one would begin to understand the 
strain placed on the Contract Health Services (CHS) and Hospitals and 
Clinics (H&C) funds realizing that we exist in a Contract Health 
Services Delivery Area (CHSDA) state and adhere to the Indian Health 
Service (IHS') open door policy.
    RSIC views the distribution of CHS funds as inequitable among the 
Service Units within the Phoenix Area. Our Tribe is located within a 
multi-tribal service unit. The Schurz Service Unit (SSU) is one of the 
few Service Units in the Phoenix Area that does not contain a hospital 
directly operated by the IHS, nor are the tribal clinics fully staffed, 
equipped or constructed per IHS standards. The seven (7) clinics within 
SSU rely solely on CHS funds to pay for hospital and certain outpatient 
specialty services. RSIC regards the difference in service availability 
as inequitable. This is especially true when Service Units are placed 
on Level 1 priority for CHS services, where the Service Units without 
direct hospital or in-house ancillary services appear to suffer 
unfairly.
CHS Funding Inequity
    It has come to our attention that the CHS-dependent Area Offices in 
Portland and California fared better in the last CHS funding 
distribution due to their CHS-dependency. Unfortunately, the Nevada 
Tribes fell under the Phoenix Area which is dominated by the Phoenix 
Indian Medical Center (PIMC) and Arizona hospitals operated by the IHS. 
Our CHS-dependent needs were ``masked'' in the formula.
    Several options to address the CHS shortfall in Nevada, and more 
specifically, for the Reno-Sparks Indian Colony include the following:

   RSIC does recognize that a major problem in the Schurz 
        Service Unit is the lack of medical contracts with specialty 
        and Hospital providers which contributes to the high CHS costs. 
        A concerted effort by the IHS needs to be made as soon as 
        possible, to contract with providers using Medicare or better 
        rates;

   The lack of direct inpatient care in Nevada creates an 
        unfair service delivery for IHS beneficiaries in the Schurz 
        Service Unit. The CHS distribution formula for new monies 
        should contain the following factors, by Operating Unit:

           CHS-dependency weight (75%)

           Active CHS User Population (15%)

           Cost Adjustment for Cross-over of patients (5%)

           Cost Adjustment for Inflation and Population Growth 
        (5%)

            These rate adjustments to the formula are proposed; 
        the final rate should be agreed upon after Tribal consultation 
        with the affected tribes;

   Another option that IHS needs to consider is the 
        reallocation of CHS base budgets to address the inequities 
        among the IHS Areas nationwide.

   The limited CHS funds could be more efficiently used by 
        using a portion of the CHS funding to establish a ``Center of 
        Excellence'' within the Reno-Sparks Tribal Health Center to 
        provide services that are currently paid for by CHS funds, 
        namely:

           Regional lab or radiology services;

           Same day surgeries;

           Or other specialty services.

    By moving towards a Center of Excellence concept, the IHS will save 
the CHS program thousands of dollars. The Reno-Sparks Indian Colony is 
willing to plan for these services on a regional basis. Our tribe has 
already constructed a 65,000 square foot health center using private, 
public and tribal funds and we stand ready to expand services for the 
benefit of our beneficiaries. Funding for a Center of Excellence will 
go a long ways addressing health needs in Nevada as well as the CHS 
shortfalls.

   The limited CHS funds in the Schurz Service Unit are used to 
        pay for pharmaceutical supplies for the tribes under this 
        service unit. Should decisions be made to eliminate the 
        financing of these costs, RSIC wants assurance that the IHS 
        will allocate other additional funds to cover the costs, and 
        not transfer the burden to the tribes.

Health Crisis in Nevada
    Indian health care is on the verge of crisis in Nevada. The health 
care funding has been woefully inadequate. Denials of CHS care have 
increased 400-fold in the last 9 months, ranging from life-saving 
treatment of dialysis to emergency room visits involving congestive 
heart failure, motor vehicle accidents, birthing, and other 
emergencies.

   To be more consistent with services provided elsewhere in 
        the IHS, the IHS needs to drop the priority levels used by the 
        Schurz Service Unit in favor of a ``Medically Necessary'' 
        approach to medical care. The medical provider determines that 
        care is needed and the care is arranged;

   The IHS has not addressed the ``crossover'' issue impacting 
        the Reno-Sparks Tribal Health Center. As the regional hub of 
        specialty and hospital services in northern Nevada, patients 
        from surrounding Tribes have migrated to our facility out of 
        convenience. The current funding formulas do not give credit to 
        the crossover workload that is occurring. The term crossover is 
        used to identify those patients whose community of residence 
        lies with Tribal clinics throughout northern Nevada and 
        California. Our tribe is not given credit for the active users 
        from the surrounding areas, since the IHS is defining active 
        users as a patient's community of residence. This policy has 
        added a financial burden to Reno-Sparks and there needs to be a 
        process to compensate for the time and expenses incurred as a 
        result, including but not limited to the providers, medical 
        supplies, support personnel, ancillary services, transportation 
        and any referrals to outside providers that must be prepared 
        for the continuation of the care.
In Closing
    In summary, we are fully aware that more funding is needed for 
Contract Health Service nationwide, but that does not mean that 
substantial increases will reach the most needy and CHS-dependent 
Tribes. The CHS funding formula needs to be changed to address the 
needs of the Tribes who are primarily dependent on CHS due to the lack 
of access to an Indian Hospital within close proximity to where they 
live. If there is a strong correlation between having Indian Health 
Service Hospitals and the need for CHS funding, then more funding 
should go to the primarily dependent Tribes without access to Indian 
Hospitals.
                                 ______
                                 
 Prepared Statement of Rose Mary Joe-Kinale, Human Services Director, 
                         Yerington Paiute Tribe
    This is my personal viewpoint, and the expressions are from my 
experience with IHS matters. I have worked in all the tribes under WNA-
BIA and see virtually the same issues.
    The Schurz Service Unit has been primarily the focal of 
misunderstanding, failed agendas, and always behind on paying the bills 
of the service population of the Native Americans of Nevada. To begin 
with there are several items that are in dire needed of changing in 
order to facilitate better services. These include:

   Budget to the Unit: The questions of who administers the 
        funding, what clinics are involved, is there policy and 
        procedures that govern the budget, do tribes have a say in 
        their funding and though not directly involved in the clinics, 
        as a tribal social worker I have always had to work with the 
        local tribal clinic that I am assigned or work at. These are 
        matters that I don't know about. I do know that we are always 
        at Level 1 and referrals are not honored. As a matter of fact, 
        one of the providers told me ``I feel guilty, and don't know if 
        my personal ethics will allow me to stay.'' I asked him what he 
        meant and he said ``your people come to me for their illness, I 
        assess, evaluate, and diagnosis then make a referral which IHS-
        Schurz Service Unit many times denies.'' He said that he feels 
        guilt because he than has to prescribe a stronger pain 
        medication and there is addiction to pain relief medication and 
        it is a vicious cycle to many native clients.

   Policy and Procedures: There is no policy laid out for the 
        referral system. I was ill in June, and woke up at my Mother's 
        home in Schurz, Nevada and had symptoms of a heart attack. I 
        was taken by ambulance to Yerington, Nevada and the Care 
        Flight--REMSA flew me to St. Mary's Hospital in Reno, NV. I 
        didn't have an attack; however was referred back to my own 
        physician. Than I had major issues about paying the bill 
        although I had private insurance with my employer (Yerington 
        Paiute Tribe) and Medicare--Part A.

   Referrals: After my discharge from St. Mary's several weeks 
        later, I went to see my doctor to set up surgery for the 
        diagnosed health issue. I was very aggressive as I was told at 
        the Pyramid Lake Paiute Tribal Clinic that I need to go to 
        Phoenix but would need to pay my own transportation and IHS 
        would reimburse me. I asked why as I had two insurance plans, 
        and also was concerned as if the procedure didn't go the way it 
        was supposed to, than where I would go for follow-up. I told 
        the referring staff person to schedule me anyway, and I would 
        deal with IHS later. I did have complications.

   Computers and Software for Billing: The computers at the 
        unit are very, very old, and with new computers and software 
        the filling could be taken care of in a short time and we 
        wouldn't always be behind in payments to our providers. In all 
        of the tribal areas that I have worked at this is a major 
        issue. There could be a centralized system with all Western 
        Nevada tribal clinics working the billing system the same.

   Training: This brings up the responsibility of Phoenix Area 
        Office to train and have a training packet so when new tribal 
        clinic personnel began work they have some notice and ways to 
        work. I believe that most tribal clinics are small with the 
        exception of the Reno-Sparks Indian Health clinic and maybe the 
        Washoe clinic.

   Meeting: At a meeting that I went to there was a 
        representative from IHS and St. Mary's Hospital in Reno and the 
        representative offered to have a meeting with clinic directors, 
        IHS personnel and others to set up what clinics should look 
        like and this included a billing process. He stated that 
        hospitals and all that is needed to provide comprehensive 
        services was his business. He offered his CEO to be at the 
        meeting and nothing came of this. This was information that he 
        felt that he needed as now we no longer use the Renown Medical 
        Center and have to go to St. Mary's.

   Substance Program: As a social worker, I see a dire need for 
        this issue as any provider who gets this recommendation will 
        tell you that this issue must be dealt before we see any 
        results in a change of the person and than the family. 
        Substance use and drugs are a major issue and there is a 
        definite need for the program. Our clinic doesn't have funds to 
        send anyone to in-patient treatment. Why are we left out?

    I would like to see these major matters dealt with. For so long our 
Schurz Service Unit has been running like it is now and we are like 30 
years behind in comprehensive services to our people. Something must be 
done with planning, adequate budgets, and programs.
    Thank you for the opportunity to offer testimony.
                                 ______
                                 
 Prepared Statement of Hon. Mervin Wright, Jr., Chairman, Pyramid Lake 
                              Paiute Tribe



                                 ______
                                 
 Prepared Statement of Hon. Waldo W. Walker, Chairman, Washoe Tribe of 
                         Nevada and California


                                 
                                  
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