[Senate Report 105-319]
[From the U.S. Government Publishing Office]



                                                       Calendar No. 560
105th Congress                                                   Report
                                 SENATE

 2d Session                                                     105-319
_______________________________________________________________________


 
TO ELEVATE THE POSITION OF DIRECTOR OF INDIAN HEALTH SERVICE TO 
  ASSISTANT SECRETARY OF HEALTH AND HUMAN SERVICES, TO PROVIDE FOR THE 
  ORGANIZATIONAL INDEPENDENCE OF THE INDIAN HEALTH SERVICE WITHIN THE 
  DEPARTMENT OF HEALTH AND HUMAN SERVICES, AND FOR OTHER PURPOSES

                                _______
                                

               September 9, 1998.--Ordered to be printed

_______________________________________________________________________


   Mr. Campbell, from the Committee on Indian Affairs, submitted the 
                               following

                              R E P O R T

                         [To accompany S.1770]

    The Committee on Indian Affairs, to which was referred the 
bill (S. 1770) to elevate the position of Director of Indian 
Health Service to Assistant Secretary of Health and Human 
Services, to provide for the organizational independence of the 
Indian Health Service within the Department of Health and Human 
Services, and for other purposes, having considered the same, 
reports favorably thereon with an amendment and recommends that 
the bill as amended do pass.

                                Purpose

    The purpose of S. 1770, as amended, is to elevate the 
position of the Director of the Indian Health Service to the 
status of an Assistant Secretary within the Department of 
Health and Human Services. The bill establishes the Office of 
Assistant Secretary for Indian Health in order to further the 
unique government-to-government relationship between Indian 
tribes and the United States, facilitate advocacy for the 
development of Indian health policy, and promote consultation 
on matters related to Indian health.

                               Background

    In exchange for the cession of millions of acres of land to 
which Indian tribes held aboriginal title, the United States 
entered into treaties with the Indian nations. Many of the 
treaties provided that health care services would be provided 
to the citizens of Indian country in perpetuity. Some have 
asserted that these contracts between the United States and the 
Indian governments represent the first pre-paid health care 
plan in America.
    The federal obligation for the provision of health care 
services in Indian country also arises out of the special trust 
relationship between the United States and Indian tribes, which 
reflects the authority found in Article I, Section 8, Clause 3 
of the U.S. Constitution, and which has been given form and 
substance by numerous treaties, laws, Supreme Court decisions, 
and Executive Orders.
    The first federal statue authorizing the appropriation of 
federal funds to carry out the United States' trust and treaty 
responsibilities was the Snyder Act of 1921, 25 U.S.C. 13. In 
1976, the Indian Health Care Improvement Act was enacted into 
law. The Act was the first comprehensive statute specifically 
addressing the provision of health care in Indian country and 
the federal administration of health care.

               a. evolution of the indian health service

    The Bureau of Indian Affairs within the U.S. Department of 
the Interior was initially charged with carrying out the United 
States responsibilities for the provision of health care to 
federally-recognized tribes and tribal members. However, in 
1954, in response to a growing concern by the public health 
community that Indian health care responsibility to the Surgeon 
General. Acting through the Public Health Service (PHS), the 
Surgeon General established the Division of Health (DIH) to 
administer the Indian health program. In 1968, the Division 
became the Indian Health Service (IHS) and operated as a sub-
agency of other agencies within the Public Health Service 
including the Health Resources and Services Administration. In 
1988, the Indian Health Service was established as a separate 
agency within the Public Health Service.
    On October 1, 1995, the Department of Health and Human 
Services (DHHS) reorganized its internal administrative 
structure and the Indian Health Service, along with the other 
agencies of the Public Health Service, became a separate 
operating division of the department. The Director of the 
Indian Health Service is appointed by the President and is 
subject to Senate confirmation pursuant to 25 U.S.C. 1661(a). 
Under current law, the IHS Director reports to the DHHS 
Secretary through the Assistant Secretary for Health.
    After the reorganization of the Department, all agencies, 
operating divisions, and programs within the Department, 
including those previously part of the Public Health Service 
and under the direction of the Assistant Secretary for Health, 
are required to report directly to the Secretary. Under the 
DHHS restructuring, the position of Assistant Secretary for 
Health was combined with the position of Surgeon General and 
the Office of Public Health and Science (OPHS) was established. 
The Assistant Secretary for Health directs the OPHS, serves as 
the Secretary's senior advisor for public health and science, 
and provides leadership and coordination across the Department 
on public health and science issues.
    A key component to the IHS health care system is the Public 
Health Service's Commissioned Corps. The Corps was established 
by the Congress in 1889, as part of the Marine Hospital 
Service, which later became the Public Health Service. The 
original mission of the Corps was to provide medical care to 
sick and disabled navy and merchant seamen. While the Corps' 
duties were expanded during World Wars I and II, its original 
mission now serves as the basis for its continuing status as a 
uniformed service. The Surgeon General is statutorily 
responsible for supervising the activities of the Commissioned 
Corps. The Corps is also charged with providing technical and 
financial assistance to a variety of other federal agencies, 
state, and local public health departments.
    At the request of this Committee, the General Accounting 
Office (GAO) conducted a study of the role of the Corps in the 
Indian Health Service system. Corps officers have been assigned 
to Indian health agencies since 1926 and the Corps continues to 
provide many of the physicians, registered nurses, dentists, 
pharmacists, engineers, and sanitarians in Indian health 
facilities. As of March 1995, the Public Health Service 
employed 6,276 Corps officers of which 2,401, or about 35%, 
were assigned to the Indian Health Service.
    Like its legislative predecessors in previous sessions of 
the Congress, S. 1770 seeks to honor the government-to-
government relationship between the United States and Indian 
tribes, to provide the necessary leadership within the 
Administration on Indian health issues, and to bring focus and 
national attention to the health care status of American 
Indians and Alaska Natives. The bill is intended to enhance the 
federal capacity to respond to the ongoing health crisis in 
Indian country and the continuing frustrations of Indian 
patients that their needs and concerns are not adequately 
addressed under the current administrative policy and budgetary 
processes.

              b. Indian health care and status of the ihs

    The IHS employs approximately 15,000 employees or about 25% 
of all DHHS personnel. The IHS is a comprehensive health care 
delivery system operating nationwide through a variety of 
health care facilities. The IHS provides health care services 
directly and through tribally contracted and operated health 
care programs. Health services are also purchased from more 
than two thousand private providers. As of 1996, the IHS system 
consistedof 533 health care facilities funded through the IHS: 
150 of these were directly operated by the IHS and 383 were operated by 
tribes. These facilities include, among others, 37 hospitals, 65 health 
care centers, 50 health stations, five school centers, and 34 urban 
Indian health projects.
    Each year the IHS provides health care services to 559 
Indian tribes and in 1996 provided services to 1.4 million 
American Indians and Alaska Natives. In FY94, IHS and tribal 
hospitals had about 91,000 admissions and IHS and tribal 
medical facilities had 6.3 million outpatient visits.
    Previous legislative attempts to bring attention to Indian 
health care needs and concerns within the Administration have 
not successfully bridged the gaps or affected the steady 
decline of the IHS budget. The disparity between Indian and 
non-Indian communities in federal health care expenditures 
continues to grow. Current IHS Medicaid statistics reflect a 
$3,261 per capita outlay for non-Indians, compared with a 
$1,382 per capita expenditure for Indians. The Committee 
believes that the institutionalization of a senior policy 
official responsible for Indian health within the DHHS is 
necessary to bring parity to Indian health care needs.
    The Committee has been notified by the tribes of the 
Administration's failure to incorporate tribal concerns in the 
final budget request, despite tribal participation throughout 
the budget process. As an example, prior to the FY99 budget 
request, the tribes met with the Administration to provide 
their input, but the FY99 budget request was $153 million below 
the expected Presidential request.
    The tribes expressed disappointment that the President's 
FY99 budget request for the IHS included only a 0.9% increase 
over the FY98 budget levels. The IHS budget requested by the 
Administration ignored factors such as: rising inflation of 
health care costs, mandatory cost increases for federal 
personnel, limited third party cost collections (such as 
Medicaid, Medicare and private insurance), a 2% annual service 
population increase, and increasing chronic and acute care 
costs because of a lack of screening, diagnosis and early 
treatment.
    At current budget levels, the IHS estimates that it can 
meet only 62% of tribal health care needs, whereas, the tribes 
estimate that the current funding levels meet only 36% of their 
health care needs. These deficits are even more startling in 
light of the fact that almost half the Indian population is now 
under the age of 25 and half of those under age five live in 
poverty. The gap between health care needs and federal funding 
levels has never been more apparent or more critical. The 
growing and alarming disparity between the health status of 
American Indians and Alaska Natives as compared to other 
Americans is well documented. On May 20, 1998, the Assistant 
Secretary for Health reported to the Committee on Indian 
Affairs that Indians have the second highest infant mortality 
rate in the United States, the lowest prenatal care rate and 
lower breast and cervical cancer screening and treatment rates 
because of limited access to screening and treatment. In 
addition, Indian teen pregnancy rates are double that of their 
white counterparts, cardiovascular disease continues to be the 
leading cause of death, diabetes rates are two to three times 
the national average, and as many as 40% of Indians over the 
age of 18 use tobacco.
    S. 1770 is intended to complement and strengthen the two 
Executive Orders issued by the current Administration. The 
Executive Order issued in April 1994 recognized the government-
to-government relationship between the United States and the 
tribes and the recent May 1998 Executive Order directed 
executive agencies to consult with Indian tribes prior to any 
federal action that would affect the tribes.

        C. The Role of the Assistant Secretary for Indian Health

    On August 6, 1998, President Clinton announced that the 
Administration is committed to working with the Congress to 
elevate the position of the Indian Health Service Director to 
the rank of Assistant Secretary for Health and Human Services. 
President Clinton declared that ``(b)y elevating the head of 
the Indian Health Service, we can ensure that the health needs 
of our Native Americans get the full consideration they deserve 
when it comes to setting health policy in our country.''
    The Committee acknowledges the Administration's support for 
the elevation of the IHS Director. The Committee also 
recognizes the role of the Assistant Secretary for Health 
(Surgeon General) in addressing the health needs of all 
citizens of this country, including the American Indian and 
Native Alaska populations. S. 1770 does not alter the important 
role the Assistant Secretary for Health (Surgeon General) 
serves, particularly as principal adviser to the Secretary of 
DHHS for public health matters affecting the general 
population. It is the Committee's hope that a close 
collaboration between the Assistant Secretary for Health and 
the Assistant Secretary for Indian Health will be a model of 
interagency cooperation and partnership that will integrate 
their respective responsibilities and raise the health status 
of American Indian and Alaska Natives.
    S. 1770 elevates the position of the IHS Director, but more 
importantly, this legislation recognizes the unique government-
to-government relationship between federally recognized Indian 
tribes and the United States. The Assistant Secretary for 
Indian Health will provide the necessary leadership and 
consultation to the Secretary, the Assistant Secretary for 
Health, and others, on the important health issues facing 
Indian people. S. 1770 supports the federal policy of tribal 
self determination and ensures that Indian people are heard and 
their concerns are brought to the table when important policy 
and budget decisions are made.
    The establishment of an Assistant Secretary for Indian 
Health will ensure that there is at least one senior official 
in current and future administrations who is knowledgeable 
about the United States' legal and moral obligations to Indian 
people, the mission of the IHS, and who has the status to 
advocate within the DHHS and the Office of Management and 
Budget (OMB) for the funding resources and policies that are 
necessary to effectively and efficiently address the health 
care needs and concerns of the Indian people. S. 1770 places 
this important and special leadership role with the Assistant 
Secretary for Indian Health.
    The Committee substitute amendment makes three changes to 
the original bill, S. 1770, asintroduced. The first change 
clarifies the authority of the Assistant Secretary for Indian Health in 
section 1(e). The second change strikes section 2 from the bill, which 
provides for the organizational independence of the IHS from the Public 
Health Service. The third change makes conforming and technical changes 
to section 601 of the Indian Health Care Improvement Act for creation 
of the position of Assistant Secretary for Indian Health.
    The Committee substitute responds to the concerns raised by 
the Administration to the original proposed bill. While the 
Administration stated its support for the direct elevation of 
the IHS Director to an Assistant Secretary, it did not support 
the reorganization of the IHS as an independent agency. The 
Committee agreed to strike section 2 from this legislation in 
order to focus S. 1770 on the elevation of the IHS Director. 
The Committee intends that the concept of the IHS as an 
independent agency will be further evaluated in the next 
Congress during the overall reauthorization of the Indian 
Health Care Improvement Act. The Committee believes that the 
IHS independence deserves further input, debate, and evaluation 
by Indian country, the IHS, and the Congress.

                          Legislative History

    S. 1770 was introduced on March 17, 1998 by Senator McCain 
for himself, and Senators Campbell, Inouye, and Conrad, and 
referred to the Committee on Indian Affairs. The bill was the 
subject of a joint hearing held by the Senate Indian Affairs 
Committee and the House Resources Committee on June 22, 1998. 
S. 1770 was ordered to be reported to the full Senate on June 
29, 1998.

                      Section by Section Analysis

    Section 1. Office of Assistant Secretary for Indian Health.
    Subsection (a) provides that the Office of Assistant 
Secretary for Indian Health is established within the 
Department of Health and Human Services.
    Subsection (b) provides that the Assistant Secretary for 
Indian Health shall report directly to the Secretary on all 
policy and budget related matters affecting Indian health, 
collaborate with the Assistant Secretary for Health on Indian 
health matters, advise other Assistant Secretaries and others 
within DHHS concerning matters of Indian health, perform the 
functions of the Director of the Indian Health Service, and 
other functions as designated by the Secretary of Health and 
Human Services.
    Subsection (c) provides that any references to the Director 
of the Indian Health Service is deemed to refer to the 
Assistant Secretary for Indian Health.
    Subsection (d)(1) provides a technical change to comply 
with the section. The elevation of the Director of Indian 
Health Service to Assistant Secretary would increase the number 
of assistant secretaries to seven.
    Subsection (d)(2) abolishes the position of the Director of 
Indian Health Service.
    Subsection (e)(1) amends section 601 of the Indian Health 
Care Improvement Act, 25 U.S.C. 1661, and other Acts by 
deleting all provisions referring to ``the Director'' or 
``Director of Indian Health Service'' and inserting in lieu 
thereof ``the Assistant Secretary for Indian Health.''
    Subsection (e)(2) further outlines and clarifies the duties 
of the Assistant Secretary for Indian Health.
    Subsection (f) provides that the individual serving as the 
IHS Director at the time of the enactment of this Act may 
serve, at the pleasure of the President, as the Assistant 
Secretary for Indian Health.
    Subsection (g) provides for conforming amendments to other 
statutes to comply with this Act.
    Amends the title to read: ``A bill to elevate the position 
of Director of the Indian Health Service within the Department 
of Health and Human Services to Assistant Secretary for Indian 
health, and for other purposes''.

            Committee Recommendation and Tabulation of Vote

    On June 29, 1998, the Committee on Indian Affairs, in an 
open business session, considered an amendment to S. 1770 
offered by Senator McCain. The bill, as amended, was ordered 
favorably reported with a recommendation that the bill, as 
amended, do pass.

                    Cost and Budgetary Consideration

    The cost estimate for S. 1770, as amended, as calculated by 
the Congressional Budget Office, is set forth below:

                                     U.S. Congress,
                               Congressional Budget Office,
                                   Washington, DC, August 13, 1998.
Hon. Ben Nighthorse Campbell,
Chairman, Committee on Indian Affairs,
U.S. Senate, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 1770, a bill to 
elevate the position of Director of the Indian Health Service 
to Assistant Secretary for Indian Health.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Dorothy 
Rosenbaum.
            Sincerely,
                                         June E. O'Neill, Director.
    Enclosure.

               congressional budget office cost estimate

S. 1770--A bill to elevate the position of Director of the Indian 
        Health Service to Assistant Secretary for Indian Health, and 
        for other purposes

    CBO estimates that enacting this bill would have no 
significant effect on the federal budget. Because the bill 
would not affect direct spending or receipts, pay-as-you-go 
procedures would not apply. S. 1770 contains no 
intergovernmental or private-sector mandates as defined in the 
Unfunded Mandates Reform Act and would not have a significant 
impact on the budgets of state, or tribal governments.
    S. 1770 would establish the position of Assistant Secretary 
for Indian Health in lieu of the current position of Director 
of the Indian Health Service. The duties and responsibilities 
of the office would not be changed significantly. The rate of 
pay would increase from level V to level IV of the Executive 
Schedule, an increase of about $8,000. This change would not 
affect the salary of the current Director of the Indian Health 
Service. Michael H. Trujillo, whose pay is governed by the pay 
structure of the Public Health Service Commissioned Corps.
    The CBO staff contact for this estimate is Dorothy 
Rosenbaum. This estimate was approved by Robert A. Sunshine, 
Deputy Assistant Director for Budget Analysis.

                      Regulatory Impact Statement

    Paragraph 11(b) of rule XXVI of the Standing Rules of the 
Senate requires that each report accompanying a bill to 
evaluate the regulatory paperwork impact that would be incurred 
in carrying out the bill. The Committee believes that S. 1770 
will have minimal regulatory or paperwork impact.

                        Executive Communications

    Kevin L. Thurm, Deputy Secretary of the Department of 
Health and Human Services, testified on July 22, 1998, that 
while the Administration strongly supports the elevation of the 
Director of the Indian Health Service to the Assistant 
Secretary level, there was a strong belief, within DHHS, that 
the Indian Health Service should remain a part of the Public 
Health Service. Mr. Thurm's statement is included below.

   TESTIMONY OF KEVIN L. THURM, DEPUTY SECRETARY OF HEALTH AND HUMAN 
                                SERVICES

    Good morning, Chairman Campbell, Chairman Young, and 
Members of the Committees on Indian Affairs and Resources. I am 
pleased to appear at today's joint hearing to convey the views 
of the Department on S. 1770, the Assistant Secretary for 
Indian Health Act of 1998, and to discuss our shared concern 
for the health and well-being of the nation's American Indian 
and Alaska Native people.
    The Administration strongly supports the elevation of the 
Director of the Indian Health Service to the Assistant 
Secretary level, and we look forward to continuing to work with 
you on statutory language to achieve our shared goal.
    Mr. Chairman, provision of federal health services to 
American Indian and Alaska Native communities is based upon the 
special government-to-government relationship between Indian 
Tribes and the United States. This relationship has deep 
historical, legal, and moral roots. These deep roots reach back 
not only to the signing of the first treaties between the 
United States government and the Tribal Nations in 1784, but to 
the earliest encounters between European settlers and the 
original inhabitants of the Americas over five centuries ago. 
It is a relationship born of solemn promises. It was forged at 
great cost and sacrifice. The sovereign Tribal Nations gave up 
land, water rights, mineral rights, and forests in exchange for 
guarantees of peace, security, and among other things, health 
care. Over the years, the special relationship between Indian 
Tribes and the United States has been reaffirmed by all three 
branches of the federal government.
    Through several important initiatives, the Administration 
and the Department of Health and Human Services are working to 
fulfill the promises made between the United States and Indian 
Tribes. For example, President Clinton has directed all federal 
agencies to implement policies and procedures for consulting 
with Indian Tribes on matters that affect Indian people. In 
response to the President's directive, an HHS Tribal 
Consultation Working Group developed the Department's plan to 
engage in meaningful consultation with Tribes. The plan was 
approved by Secretary Shalala and announced in October, 1997. 
As an initial step in implementing our plan, I traveled last 
November to Santa Fe, New Mexico, where I attended the annual 
conference of the National Congress of American Indians and had 
opportunities to meet with elected Tribal leaders and delegates 
from throughout the United States. I will again be traveling 
this fall, and will be inviting Tribal representatives to 
listening sessions in regional locations.
    Also at the President's direction, special efforts are 
being made to support Tribal colleges and universities. These 
institutions, chartered by Tribal governments, play a vital 
role in providing higher education opportunities to American 
Indian and Alaska Native students and preparing them for future 
leadership and service to their communities. On February 2, 
1998, the presidents of the Nation's Tribal colleges and 
universities were in Washington and met with HHS officials. I 
chaired the meeting, which was attended by Department 
principals, senior advisors, and staff. We heard the delegation 
of Tribal college presidents share their concerns and 
expectations for this relationship with HHS. Several of our 
Operating Divisions are participating in this year's Washington 
Internship for Native Students (WINS) program in conjunction 
with American University, and the entire Department has been 
enriched by the presence of a group of American Indian students 
interns.
    Also within the Department, the Racial and Ethnic Health 
Disparities Initiative is now underway. The President has 
committed the nation to an ambitious goal by the year 2010: the 
elimination of disparities in six areas of health status 
experienced by racial and ethnic minority populations while 
continuing the progress we have made in improving the overall 
health of the American people. These six areas of health 
status--infant mortality, child and adult immunizations, 
diabetes, cardiovascular diseases, cancer screening and 
management, and HIV/AIDS--include some of the most important 
health issues for American Indian and Alaska Native people.
    In these and other efforts, the Indian Health Service 
fulfills a critical mission. Under the continued leadership of 
Dr. Michael Trujillo, and in partnership with American Indian 
and Alaska Native communities and Tribal governments, the IHS 
provides a comprehensive system of primary health care, 
prevention, and public health services. The IHS also acts as 
the principal federal health advocate for Indian people.
    As both Dr. Trujillo and Assistant Secretary for Health and 
Surgeon General, Dr. David Satcher reported to the Committee on 
Indian Affairs in June, there have been some important gains in 
the health status of Indian people during recent years. Infant 
mortality rates, maternal death rates, deaths due to 
unintentional injuries, and morbidity and mortality from 
infectious diseases have decreased dramatically. The work of 
the Indian Health Service has been a cornerstone in achieving 
these successes.
    But as American Indian and Alaska Native families and 
communities know only too well, there continue to be major 
challenges. Diabetes, heart disease, substance abuse, and 
domestic violence continue at especially troubling rates. 
Poverty, unemployment, and lack of educational opportunities 
complicate intervention efforts.
    In his remarks upon introducing the ``Assistant Secretary 
for Indian Health Act'' on March 17, 1998, Senator McCain 
characterized the health problems facing Indian people as an 
``epidemic crisis.'' The real challenge before us is how best 
to mobilize and allocate resources in response to this 
situation.
    S. 1770 proposes to establish within the Department of 
Health and Human Services an Office of the Assistant Secretary 
for Indian Health. We support the elevation of the IHS Director 
to the Assistant Secretary level, and look forward to 
continuing ongoing discussions with you and your staff on the 
design of this legislation. We share your goals, Mr. Chairman, 
and those of Senators McCain, Inouye, and Conrad, to address 
the health challenges in American Indian and Alaska Native 
communities and to effectively position the Indian Health 
Service for this effort within the changing environment of 
Tribal self-governance. We commend all of you for the depth of 
concern and sincerity of purpose that your legislation 
demonstrates.
    We recognize that the Indian Health Service is not just a 
program serving the interests of one among a number of minority 
constituencies. Rather, the IHS is the organizational 
embodiment of the government-to-government relationship between 
the United States and the Indian Tribes. It exists because of 
the solemn promises this government has made to Indian people. 
On matters of health care, the head of the Indian Health 
Service acts principally as the administrator of the vast 
Indian Health Service system, as well as an advocate on behalf 
of the needs of the nation's more than 550 federally-recognized 
Indian Tribes. The elevation of the IHS Director to the 
position of Assistant Secretary is consistent with the 
government-to-government relationship and unique political 
status of American Indian and Alaska Native people.
    In conveying our support for the proposal to establish an 
Office of the Assistant Secretary for Indian Health, we should 
note, at the same time, that issues of Indian health are the 
concern of the entire Department of Health and Human Services. 
Elevating the IHS Director to the position of Assistant 
Secretary will strengthen the government-to-government 
relationship and facilitate communication and consultation with 
the Tribes on matters of Indian health. But in making this 
change, I think we all want to be sure that we continue to 
utilize the resources and expertise that exist within every 
Operating Division of HHS to address Indian health needs, 
either directly or indirectly. Whether it is the National 
Institutes of Health or the Centers for Disease Control and 
Prevention, each component of the Department has dedicated 
staff who have made Indian health the focus of their 
professional work.
    In this same connection, the Assistant Secretary for Health 
is empowered by the President and the Congress to attend to the 
health needs of all of our citizens, regardless of their racial 
or ethnic background. The people of the United States are 
privileged to be served in this role by Dr. David Satcher, who 
has reaffirmed a commitment to continue the work of his 
predecessor, Dr. Philip Lee, to work closely with Tribal 
leaders on Indian Health concerns.
    As we move to elevate the head of the Indian Health Service 
to the Assistant Secretary level, we look forward to working 
with you and your staff to recognize in statute the important 
ongoing responsibilities of the Office of the Assistant 
Secretary for Health. The work of the ASH is vital to ensuring 
that research, resources, and policies are integrated in ways 
that benefit all the people of the United States.
    Our support for the proposal to elevate the IHS Director to 
the position of Assistant Secretary reflects our commitment to 
consultation with the nation's Indian Tribes. While in Santa Fe 
last fall, I listened closely as Tribal leaders discussed their 
views on the proposal and described their hopes for what the 
change might accomplish. We have reviewed resolutions and 
correspondence from the National Congress of American Indians, 
Tribal governments, and other bodies representing Tribal 
interests. While elevating the IHS Director to the level of 
Assistant Secretary will not have an immediate impact on how 
decisions are made about IHS administration and budget, it will 
raise awareness of Indian health concerns throughout HHS and 
the entire federal government. We do not underestimate the 
importance of increased awareness, because heightened awareness 
is the first step toward meaningful action.
    We have closely reviewed the proposal in S. 1770 to 
separate the IHS from the Public Health Service. As we have 
conveyed to your staff, we believe that the present 
organizational structure of the Public Health Service--
especially its ability to flexibly utilize the resources of the 
Commissioned Corps--benefits the Indian Health Service and the 
individuals, families, and Tribal governments that receive 
services through its programs.
    Through the combined and complementary resources of its 
component agencies, the PHS offers the nation--and under-served 
or remote communities in particular--unsurpassed medical 
treatment, health promotion and disease prevention services, 
public health and biomedical research, and health professions 
education programs.
    The close ties and collaboration between PHS components 
directly benefit American Indian and Alaska Native people. For 
example, during last year's bipartisan discussions about the 
need to allocate more resources to diabetes prevention and 
treatment, scientists of the Centers for Disease Control and 
Prevention worked closely with medical personnel from the 
Indian Health Service to provide information and technical 
assistance. The support of the CDC helped assure that funds 
authorized for diabetes interventions would not only provide 
immediate, short-term assistance to Indian Tribes and 
communities, but also be a long-term investment in identifying 
effective prevention strategies that respect American Indian 
culture. CDC support would assure that future generations of 
American Indian children, not yet born, will benefit from this 
important effort.
    Another example of how existing relationships and 
collaboration between PHS components benefits American Indian 
people is the integrated research on non-surgical intervention 
for refractory periodontal disease being conducted by the IHS 
and the National Institute on Dental Research (NIDR), part of 
the NIH. The IHS and NIDR recently entered into an agreement to 
repeat an important clinical trial on the effectiveness of this 
method for treating a troublesome form of gum disease, in order 
to validate the results of an earlier trial on the same 
protocol. The State University of New York (SUNY) at Buffalo is 
also a partner in this project. The original protocol was 
developed and tested by IHS, NIDR, and SUNY in the Phoenix Area 
between 1995 and 1997. The new testing will be done in the 
Albuquerque Area. Data indicate that this treatment may offer 
clinicians an exciting new non-surgical tool to combat tooth 
loss, especially among those with diabetes. Inter-agency 
collaboration of this kind means that lower-cost, less-invasive 
medical treatments will continue to become more widely 
available.
    While Sen. McCain's bill makes provisions for the IHS to 
use officers or employees of the Public Health Service, the 
assignment of PHS personnel and Commissioned Corps officers to 
the IHS will be complicated by additional administrative 
procedures that must be used when details of these personnel 
are made outside of a PHS agency. Currently, for example, 
Commissioned Corps personnel--personnel that comprise the 
backbone of the health professional cadre in IHS--can be 
assigned to the IHS directly, utilizing administrative 
processes that are common to all PHS agencies using common 
authorities contained in the PHS Act. The IHS can then, in 
turn, assure that Tribes receive health professional personnel 
appropriate to the need. IHS currently uses these shared PHS-
wide processes which help to minimize personnel overhead costs 
and assure optimal efficiency.
    If the IHS is separated from the PHS, Commissioned Corps 
personnel will need to be detailed to the IHS and Tribal 
facilities under multiple, Tribe- or location-specific detail 
agreements, utilizing unique administrative processes which 
will undoubtedly be more expensive and complex to administer. 
Operating through this type of administrative process would 
also complicate personnel supervision, thus impeding the 
ability to respond promptly to personnel concerns and 
performance issues.
    It is also important to note that we can maintain IHS as 
part of the Public Health Service without impeding the direct 
reporting relationship to the Secretary, that we all support. 
All heads of PHS Operating Divisions, including the Director of 
the IHS, currently report directly to Secretary Shalala without 
having to go through any intermediate level of management 
authority. There is no filtering of information between 
operating division heads and the Secretary. Budget requests for 
the IHS are handled in the same way as budget requests for 
every other component of the Department.
    In short, we believe strongly that the IHS should remain 
part of the Public Health Service. In our view, there is 
nothing to gain in administrative relationships or patient care 
by separating the IHS from the PHS, but there is potentially 
much to lose.
    We share the concerns of Members of these Committees that 
the IHS be positioned and structured in the best possible way 
to respond to a future of growing needs, changing expectations, 
and developing operational and management methods. As the 
system of delivering Indian health service evolves, 
organizational independence for the IHS must be balanced 
against the recognized need to collaborate with federal and 
Tribal partners, leveraging maximum benefit from limited 
resources, and being able to bring all appropriate aspects of 
the Department's talents to bear.
    Mr. Chairman, the Department of Health and Human Services 
looks forward to continuing our effort to develop consensus 
legislation to elevate the IHS to the Assistant Secretary 
level. We stand ready to work with Congress and Tribal 
governments as, together, we seek to fulfill the solemn 
promises to which we are committed. We look forward to a vital 
partnership and pledge continued--and thoughtful--
responsiveness to changing health care and public health needs 
in Indian country.
    Thank you, Chairman Campbell, Chairman Young, and Members 
of the joint Committees. I appreciate the opportunity to share 
the Department's views on these matters, and look forward to 
answering any questions you may have.

                        Changes in Existing Law

    In compliance with subsection 12 of rule XXVI of the 
Standing Rules of the Senate, the Committee states that 
enactment of S. 1770 will result in the following changes in 
the following statutes as noted below, with existing language 
which is to be deleted in brackets and the new language which 
is to be added in italic:
Section 1. Office of Assistant Secretary For Indian Health
    (D) Rate of Pay.--(1) Section 5315 of title 5, United 
States Code: ``Level IV of the Executive Schedule applies to 
the following positions, for which the annual rate of basic pay 
shall be the rate determined with respect to such level under 
chapter 11 of title 2, as adjusted by section 5318 of this 
title:
    Assistant Secretaries of Health and Human Services [(6)] 
(7).''
    (2) Section 5316: ``Level V of the Executive Schedule 
applies to the following positions, for which the annual rate 
of basic pay shall be the rate determined with respect to such 
level under chapter 11 of title 2, as adjusted by section 5318 
of this title:
    [Director, Indian Health Service, Department of Health and 
Human Services.]''
    Duties of Assistant Secretary of Indian Health.--(1) 
Section 1661 of title 25 of the United States Code: (a)(1) 
Establishment
    In order to more effectively and efficiently carry out the 
responsibilities, authorities, and functions of the United 
States to provide health care services to Indians and Indian 
tribes, as are or may be hereafter provided by Federal statute 
or treaties, there is established within the Public Health 
Service of the Department of Health and Human Services the 
Indian Health Service. The Indian Health Service shall be 
administered by [a Director] The Assistant Secretary for Indian 
Health, who shall be appointed by the President, by and with 
the advice and consent of the Senate. [The Director of the 
Indian Health Service shall report to the Secretary through the 
Assistant Secretary for Health of the Department of Health and 
Human Services. Effective with respect to an individual 
appointed by the President, by and with the advice and consent 
of the Senate, after January 1, 1993, the term of service of 
the Director shall be 4 years. A Director may serve more than 1 
term.] The Assistant Secretary for Indian Health shall carry 
out the duties specified in paragraph (2).
    (2) The Assistant Secretary for Indian Health shall--
          (A) report directly to the Secretary concerning all 
        policy- and budget-related matters affecting Indian 
        health;
          (B) collaborate with the Assistant Secretary for 
        Health concerning appropriate matters of Indian health 
        that affect the agencies of the Public Health Service;
          (C) advise each Assistant Secretary of the Department 
        of Health and Human Services concerning matters of 
        Indian health with respect to which that Assistant 
        Secretary has authority and responsibility;
          (D) advise the heads of other agencies and programs 
        of the Department of Health and Human Services 
        concerning matters of Indian health with respect to 
        which those heads have authority and responsibility; 
        and
          (E) coordinate the activities of the Department of 
        Health and Human Services concerning matters of Indian 
        health.
    (c) Conforming Amendments.--
    (1)(A) Section 601 of the Indian Health Care Improvement 
Act (25 U.S.C. 1601):
    (i) ``(c) The Secretary shall carry out through the 
[Director of the Indian Health Service] Assistant Secretary for 
Indian Health--
    (1) all functions which were, on the day before November 
23, 1988, carried out by or under the direction of the 
individual serving as [Director of the Indian Health Service] 
Assistant Secretary for Indian Health.''
    (ii) ``(d)(1) The Secretary, acting through the [Director 
of the Indian Health Service] Assistant Secretary for Indian 
Health, shall have the authority--''
    (B) Section 816(c)(1) of the Indian Health Care Improvement 
Act (25 U.S.C. 1680f(c)(1): ``Cross utilization of services (1) 
Not later than December 23, 1988, the [Director of the Indian 
Health Service] Assistant Secretary for Indian Health and the 
Secretary of Veterans Affairs shall implement an agreement 
under which--* * *''
    (2)(A) Section 203(a)(1) of the Rehabilitation Act of 1973 
(29 U.S.C. 761(a)(1)): ``(a) Establishment; membership; 
meetings, (1) In order to promote coordination and cooperation 
among Federal departments and agencies conducting 
rehabilitation research programs, there is established within 
the Federal Government an Interagency Committee on Disability 
Research (hereinafter in this section referred to as the 
``Committee''), chaired by the Director and comprised of such 
members as the President may designate, including the following 
(or their designees): the Director, the Commissioner of the 
Rehabilitation Services Administration, the Assistant Secretary 
for Special Education and Rehabilitative Services, the 
Secretary of Education, the Secretary of Veterans Affairs, the 
Director of the National Institutes of Health, the Director of 
the National Institute of Mental Health, the Administrator of 
the National Aeronautics and Space Administration, the 
Secretary of Transportation, the Assistant Secretary of the 
Interior for Indian Affairs, the [Director of the Indian Health 
Service] Assistant Secretary for Indian Health, and the 
Director of the National Science Foundation.''
    (B) Subsections (B) and (E) of Section 518 of the Federal 
Water Pollution Control Act (33 U.S.C. 1377 (b) and (e)): ``(b) 
Assessment of sewage treatment needs; report: The 
Administrator, in cooperation with the [Director of the Indian 
Health Service] Assistant Secretary for Indian Health, shall 
assess the need for sewage treatment works to serve Indian 
tribes, the degree to which such needs will be met through 
funds allotted to States under section 1285 of this title and 
priority lists under section 1296 of this title, and any 
obstacles which prevent such needs from being met.''
    ``(e) Treatment as States: * * * Such treatment as a State 
may include the direction provision of funds reserved under 
subsection (c) of this section to the governing bodies of 
Indian tribes, and the determination of priorities by Indian 
tribes, where not determined by the Administrator in 
cooperation with the [director of the Indian Health Service] 
Assistant Secretary for Indian Health. The Administrator, in 
cooperation with the [Director of the Indian Health Service] 
Assistant Secretary for Indian Health, is authorized to make 
grants under subchapter II of this chapter in an amount not to 
exceed 100 percent of the cost of a project. * * *''
    (C) Section 803B(d)(1) of the Native American Programs Act 
of 1974 (42 U.S.C. 2991b-2(d)(1)): ``(d) the Intra-Departmental 
Council on Native American Affairs: * * * The [Director of the 
Indian Health Service] Assistant Secretary for Indian Health 
shall serve as vice chairperson of the council.''

                                
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