[Congressional Record Volume 142, Number 130 (Thursday, September 19, 1996)]
[Senate]
[Pages S11051-S11053]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




    INDIAN HEALTH CARE IMPROVEMENT TECHNICAL CORRECTIONS ACT OF 1996

  Mr. STEVENS. Mr. President, I ask unanimous consent the Senate turn 
now to the immediate consideration of Calendar No. 577, H.R. 3378.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       A bill (H.R. 3378) to amend the Indian Health Care 
     Improvement Act to extend the demonstration program for 
     direct billing of Medicare, Medicaid, and other third-party 
     payors.

  The PRESIDING OFFICER. Is there objection to the immediate 
consideration of the bill?
  There being no objection, the Senate proceeded to consider the bill.


                           Amendment No. 5392

                   (Purpose: To provide a substitute)

  Mr. STEVENS. Mr. President, Senator McCain has a substitute amendment 
at the desk. I ask for its immediate consideration.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       The Senator from Alaska [Mr. Stevens], for Mr. McCain, 
     proposes an amendment numbered 5392.

  The amendment is as follows:

       Strike all after the enacting clause and insert the 
     following:

     SECTION 1. SHORT TITLE; REFERENCES.

       (a) Short Title.--This Act may be cited as the ``Indian 
     Health Care Improvement Technical Corrections Act of 1996''.
       (b) References.--Whenever in this Act an amendment or 
     repeal is expressed in terms of an amendment to or repeal of 
     a section or other provision, the reference shall be 
     considered to be made to a section or other provision of the 
     Indian Health Care Improvement Act.

     SEC. 2. TECHNICAL CORRECTIONS IN THE INDIAN HEALTH CARE 
                   IMPROVEMENT ACT.

       (a) Definition of Health Profession.--Section 4(n) (25 
     U.S.C. 1603(n)) is amended--
       (1) by inserting ``allopathic medicine,'' before ``family 
     medicine''; and
       (2) by striking ``and allied health professions'' and 
     inserting ``an allied health profession, or any other health 
     profession''.
       (b) Indian Health Professions Scholarships.--Section 104(b) 
     of the Indian Health Care Improvement Act (25 U.S.C. 
     1613a(b)) is amended--
       (1) in paragraph (3)--
       (A) in subparagraph (A)--
       (i) by striking the matter preceding clause (i) and 
     inserting the following:
       ``(3)(A) The active duty service obligation under a written 
     contract with the Secretary under section 338A of the Public 
     Health Service Act (42 U.S.C. 254l) that an individual has 
     entered into under that section shall, if that individual is 
     a recipient of an Indian Health Scholarship, be met in full-
     time practice, by service--'';
       (ii) by striking ``or'' at the end of clause (iii);
       (iii) by striking the period at the end of clause (iv) and 
     inserting ``; or''; and
       (iv) by adding at the end the following new clause:
       ``(v) in an academic setting (including a program that 
     receives funding under section 102, 112, or 114, or any other 
     academic setting that the Secretary, acting through the 
     Service, determines to be appropriate for the purposes of 
     this clause) in which the major duties and responsibilities 
     of the recipient are the recruitment and training of Indian 
     health professionals in the discipline of that recipient in a 
     manner consistent with the purpose of this title, as 
     specified in section 101.'';
       (B) by redesignating subparagraphs (B) and (C) as 
     subparagraphs (C) and (D), respectively;
       (C) by inserting after subparagraph (A) the following new 
     subparagraph:
       ``(B) At the request of any individual who has entered into 
     a contract referred to in subparagraph (A) and who receives a 
     degree in medicine (including osteopathic or allopathic 
     medicine), dentistry, optometry, podiatry, or pharmacy, the 
     Secretary shall defer the active duty service obligation of 
     that individual under that contract, in order that such 
     individual may complete any internship, residency, or other 
     advanced clinical training that is required for the practice

[[Page S11052]]

     of that health profession, for an appropriate period (in 
     years, as determined by the Secretary), subject to the 
     following conditions:
       ``(i) No period of internship, residency, or other advanced 
     clinical training shall be counted as satisfying any period 
     of obligated service that is required under this section.
       ``(ii) The active duty service obligation of that 
     individual shall commence not later than 90 days after the 
     completion of that advanced clinical training (or by a date 
     specified by the Secretary).
       ``(iii) The active duty service obligation will be served 
     in the health profession of that individual, in a manner 
     consistent with clauses (i) through (v) of subparagraph 
     (A).'';
       (D) in subparagraph (C), as so redesignated, by striking 
     ``prescribed under section 338C of the Public Health Service 
     Act (42 U.S.C. 254m) by service in a program specified in 
     subparagraph (A)'' and inserting ``described in subparagraph 
     (A) by service in a program specified in that subparagraph''; 
     and
       (E) in subparagraph (D), as so redesignated--
       (i) by striking ``Subject to subparagraph (B),'' and 
     inserting ``Subject to subparagraph (C),''; and
       (ii) by striking ``prescribed under section 338C of the 
     Public Health Service Act (42 U.S.C. 254m)'' and inserting 
     ``described in subparagraph (A)'';
       (2) in paragraph (4)--
       (A) in subparagraph (B), by striking the matter preceding 
     clause (i) and inserting the following:
       ``(B) the period of obligated service described in 
     paragraph (3)(A) shall be equal to the greater of--''; and
       (B) in subparagraph (C), by striking ``(42 U.S.C. 
     254m(g)(1)(B))'' and inserting ``(42 U.S.C. 254l(g)(1)(B))''; 
     and
       (3) in paragraph (5), by adding at the end the following 
     new subparagraphs:
       ``(C) Upon the death of an individual who receives an 
     Indian Health Scholarship, any obligation of that individual 
     for service or payment that relates to that scholarship shall 
     be canceled.
       ``(D) The Secretary shall provide for the partial or total 
     waiver or suspension of any obligation of service or payment 
     of a recipient of an Indian Health Scholarship if the 
     Secretary determines that--
       ``(i) it is not possible for the recipient to meet that 
     obligation or make that payment;
       ``(ii) requiring that recipient to meet that obligation or 
     make that payment would result in extreme hardship to the 
     recipient; or
       ``(iii) the enforcement of the requirement to meet the 
     obligation or make the payment would be unconscionable.
       ``(E) Notwithstanding any other provision of law, in any 
     case of extreme hardship or for other good cause shown, the 
     Secretary may waive, in whole or in part, the right of the 
     United States to recover funds made available under this 
     section.
       ``(F) Notwithstanding any other provision of law, with 
     respect to a recipient of an Indian Health Scholarship, no 
     obligation for payment may be released by a discharge in 
     bankruptcy under title 11, United States Code, unless that 
     discharge is granted after the expiration of the 5-year 
     period beginning on the initial date on which that payment is 
     due, and only if the bankruptcy court finds that the 
     nondischarge of the obligation would be unconscionable.''.
       (c) California Contract Health Services Demonstration 
     Program.--Section 211(g) (25 U.S.C. 1621j(g)) is amended by 
     striking ``1993, 1994, 1995, 1996, and 1997'' and inserting 
     ``1996 through 2000''.
       (d) Extension of Certain Demonstration Program.--Section 
     405(c)(2) (25 U.S.C. 1645(c)(2)) is amended by striking 
     ``September 30, 1996'' and inserting ``September 30, 1998''.
       (e) Gallup Alcohol and Substance Abuse Treatment Center.--
     Section 706(d) (25 U.S.C. 1665e(d)) is amended to read as 
     follows:
       ``(d) Authorization of Appropriations.--There are 
     authorized to be appropriated, for each of fiscal years 1996 
     through 2000, such sums as may be necessary to carry out 
     subsection (b).''.
       (f) Substance Abuse Counselor Education Demonstration 
     Program.--Section 711(h) (25 U.S.C. 1665j(h)) is amended by 
     striking ``1993, 1994, 1995, 1996, and 1997'' and inserting 
     ``1996 through 2000''.
       (g) Home and Community-Based Care Demonstration Program.--
     Section 821(i) (25 U.S.C. 1680k(i)) is amended by striking 
     ``1993, 1994, 1995, 1996, and 1997'' and inserting ``1996 
     through 2000''.

  Mr. McCAIN. Mr. President, I rise today in support of H.R. 3378, a 
bill to amend the Indian Health Care Improvement Act to extend the 
authorization of the Indian health demonstration program for direct 
billing of Medicare, Medicaid and other third party payors. I am 
pleased to support the House-passed provisions of H.R. 3378 and to 
offer a substitute amendment that will make additional technical 
corrections to the Indian Health Care Improvement Act and reauthorize 
additional Indian health demonstration programs.
  Mr. President, approximately 20 years ago, the Congress enacted the 
Indian Health Care Improvement Act to meet the fundamental trust 
obligation of the United States to ensure that comprehensive health 
care would be provided to American Indians and Alaska Natives. Despite 
advances achieved through the implementation of the act, the health 
status of Indian people remains far below that of the national 
population.
  The Indian Health Service, as the lead agency responsible for 
administering programs under the act, has identified several areas 
where the act requires modification to fulfill its intended purpose. 
The substitute amendment I have proposed incorporates those amendments 
to the act to allow maximum flexibility in the delivery of health 
services to American Indians and Alaska Natives.
  First, the substitute amendment clarifies certain provisions in order 
to allow greater flexibility to the IHS in administering IHS 
scholarships and programs. The amendment modifies the definition of 
Health Profession in section 4(n) to include ``allopathic medicine'' in 
order to provide more flexibility to the IHS in awarding scholarship 
assistance to individuals enrolled in health degree professions. Prior 
to the 1992 amendments, individuals studying disciplines such as 
allopathic medicine were eligible to receive IHS assistance. Because 
the 1992 amendments omitted this reference, many individuals were 
denied eligibility for scholarship assistance. This amendment restores 
their eligibility for scholarship funds and fulfills the Act's intent.
  Next, the amendment also clarifies certain provisions under section 
104(b), the Indian Health Professions Scholarship, to clarify the 
authority of the Secretary of the Department of Health and Human 
Services to waive or defer service or payment obligations of Indian 
health professionals under specified circumstances. Many requirements 
for a degree in the health professions include an internship, 
residency, or other advanced clinical program. The substitute amendment 
would clarify the authority of the Secretary to defer a scholarship 
recipient's service or repayment obligation until the recipient has 
completed his or her education program.
  The Indian Health Care Improvement Act also authorizes several 
innovative demonstration projects to increase and improve services to 
Indian communities and to serve as models to be replicated on other 
reservations. The substitute amendment includes the extension for the 
Indian Health Medicare/Medicaid Program, as provided for in H.R. 3378, 
and reauthorizes several additional programs through the year 2000. 
Several of these demonstration projects, including the California 
Contract Health Services Demonstration Program, the Gallup Alcohol and 
Substance Abuse Demonstration Program, the Substance Abuse 
Counselor Education Demonstration Program and the Home and Community 
Based Care Demonstration Program, are due to sunset in this fiscal 
year.

  The California Contract Health Services Demonstration Program 
authorizes the California Rural Indian Health Board to act as a 
contract care intermediary to improve the accessibility of health 
services to California Indians. The program has successfully enabled 
tribal programs to provide in-patient services and prevent high-cost 
cases from devastating many small tribal health programs in California. 
It is estimated that 41 percent of the California tribes participate in 
this program.
  The Home and Community Based Care Demonstration Program authorizes 
Indian tribes to enter into contracts to establish demonstration 
projects for the delivery of home and community based services to 
functionally-disabled Indians. The Substance Abuse Counselor Education 
Demonstration Project authorizes the IHS to enter into contracts with, 
or make grants to, colleges, universities and tribally-controlled 
community colleges to develop educational curricula for substance abuse 
counseling.
  The Gallup Alcohol and Substance Abuse Treatment Program has funded 
residential treatment for alcohol and substance abuse at the Navajo 
Adult Rehabilitation Demonstration Project. The grant program has also 
funded a protective custody program for alcohol abuse offenders at the 
Gallup Crisis Center. These programs are unique to the Navajo Nation 
area and provide valuable services as a community-based outpatient 
program.
  Finally, the substitute amendment includes the House-passed language 
to

[[Page S11053]]

extend the authorization for the Medicare/Medicaid Demonstration 
Program. This program allows four tribal health contract operators to 
directly bill and collect Medicare/Medicaid payments rather than 
operate through the current system of channeling payments through the 
IHS. The four participating Indian tribes include Mississippi Band of 
Choctaw Indians, Bristol Bay Area Health Corporation of Alaska, Choctaw 
Tribe of Oklahoma and South East Alaska Regional Health Consortium. The 
Medicare/Medicaid Demonstration Program has been a highly successful 
program for the participating tribes and the IHS, who have reported 
significantly increased collections for Medicare/Medicaid services and 
greater efficiency in the billing/payments process.
  In an interim report on this program, Secretary Shalala of the 
Department of Health and Human Services describes the remarkable 
increase in Medicare and Medicaid collections by tribal health 
providers achieved through this program. For example, through the 
demonstration program, the Mississippi Band of Choctaw Indians has 
doubled its Medicare and Medicaid collections, which has led to further 
improvements to the overall quality of health care provided to its 
members. The Bristol Bay Area Health Corporation of Alaska has been 
able to expand its health care, disease prevention and health education 
services to an additional 32 villages in Alaska. The Southeast Alaska 
Regional Health Corporation reported a 600 percent increase in Medicaid 
collections during the first 2 years of the pilot project. This funding 
increase has allowed the Southeast Alaska Regional Health Corporation 
to upgrade its health care facilities and achieve ``Accreditation with 
Commendation'' from the Joint Commission on Accreditation of Healthcare 
Organizations. Unless this program is reauthorized, these tribal health 
facilities will be forced to return to the IHS-managed collection 
system and forego much of the progress that has been achieved. Based on 
the record of success of this program, I am pleased that my colleagues 
support the extension of this program for 2 years.
  Mr. President, the changes I am proposing in this substitute 
amendment will bring us closer to meeting the goals of the Indian 
Health Care Improvement Act to raise the health status of Indian people 
and to ensure the continuation of several important Indian health care 
programs. The changes I have proposed in the substitute amendment have 
been cleared by the respective Committees of jurisdiction in the House 
of Representatives. I thank my colleagues for their support in passing 
this important legislation.
  Mr. STEVENS. I ask unanimous consent that the amendment be agreed to, 
the bill be deemed read for a third time, passed, the motion to 
reconsider be laid on the table, and any statements relating to the 
bill be placed at the appropriate place in the Record.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment (No. 5392) was agreed to.
  The bill (H.R. 3378), as amended, was agreed to.

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