[Senate Report 108-405]
[From the U.S. Government Publishing Office]



                                                       Calendar No. 796
108th Congress                                                   Report
                                 SENATE
 2d Session                                                     108-405

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



 
AMENDING THE NATIVE HAWAIIAN HEALTH CARE IMPROVEMENT ACT TO REVISE AND 
                            EXTEND THAT ACT

                                _______
                                

               November 10, 2004.--Ordered to be printed

 Filed, under authority of the order of the Senate of October 11, 2004

                                _______
                                

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

                              R E P O R T

                         [To accompany S. 702]

    The Committee on Indian Affairs, to which was referred the 
bill (S. 702), a bill to amend the Native Hawaiian Health Care 
Improvement Act to revise and extend that Act, having 
considered the same, reports favorably thereon without 
amendment and recommends that the bill do pass.

                                Purpose

    The purpose of S. 702, a bill to provide for the 
reauthorization of the Native Hawaiian Health Care Improvement 
Act, is to improve the health status of Native Hawaiians 
through the continuation of a comprehensive health promotion 
and disease prevention effort that involves health education in 
Native Hawaiian communities, and the provision of health 
services using health care providers trained in western 
medicine and traditional Native Hawaiian healers. In areas 
where there is an underutilization of existing health care 
delivery systems that have the capacity to provide culturally-
relevant health care services, S. 702 provides authority for 
the Secretary of the Department of Health and Human Services to 
enter into contracts with Native Hawaiian health care systems 
to provide health care referral services to Native Hawaiian 
patients. S. 702 is intended to assure the continuity of the 
health care programs that are provided to Native Hawaiians 
under the authority of Public Law 100-579.
    As enacted in 1988, the Native Hawaiian Health Care 
Improvement Act is premised upon the findings and 
recommendations of the Native Hawaiian Health Research 
Consortium report to the Secretary of the Department of Health 
and Human Services of December, 1985. That report clearly 
indicates that the underutilization of existing health care 
services by Native Hawaiians can be traced to the absence of 
culturally-relevant services in which traditional Native 
Hawaiian concepts of healing are lacking, as well as to a 
general perception in the Native Hawaiian community that health 
care services, which are fundamentally based on concepts of 
Western medicine, will not effect the healing or cure of 
diseases and illnesses afflicting Native Hawaiian people.

                         Historical Background

    The islands that now compose the State of Hawai`i were 
governed by a monarchy of Native Hawaiians until 1893. The 
Native Hawaiian government was recognized as an independent 
sovereign nation by foreign governments, and treaty 
relationships were established with the United States (Treaty 
of Friendship, Commerce, and Navigation of 1849; Treaty of 
Commercial Reciprocity, January 30, 1875.) Expanded trade with 
the United States resulted in increased western influence in 
the islands, and in 1893, the government of the Kingdom of 
Hawai`i was overthrown in an insurrection engineered by a group 
of western businessmen in an effort to secure the annexation of 
Hawai`i to the United States. The United States minister in 
Hawai`i ordered one company of marines and two companies of 
sailors to be landed, and the minister then recognized a new 
provisional government even before Queen Liliuokalani's lines 
of defense had surrendered. Although the provisional government 
sought immediate annexation by the United States, President 
Grover Cleveland refused to submit a treaty of annexation to 
the Senate, finding that the provisional government lacked the 
popular support of the Native Hawaiian population and that the 
government would not have been established but for the lawless 
and unauthorized military intervention of the United States 
(see Pub. L. No. 103-150). Upon the inauguration of William 
McKinley as the new President of the United States in 1897, 
however, the western businessmen that sought annexation were 
able to change the official U.S. position, and in 1898, Hawai`i 
became a territory of the United States.
    Prior to European contact, it was estimated that there were 
400,000 Native Hawaiians in the Hawaiian Islands. By 1919, the 
Native Hawaiian population had been reduced to 22,600, and many 
were concluding that the native people of Hawai`i were a 
``dying race,'' (see S. Rep. No. 108-85, at 13-14 (2004)) and 
that if they were to be saved from extinction, they must have 
the means of regaining their connection to the land, the 
`aina.' Accordingly, in 1920, the Hawaiian Homes Commission Act 
was enacted into law by the U.S. Congress, establishing a land 
base that could serve as a permanent homeland for Native 
Hawaiians and encouraging agricultural pursuits. The Act placed 
approximately 203,000 acres under the jurisdiction of the 
Hawaiian Homes Commission, a branch of the territorial 
government established for the purpose of ``rehabilitating'' 
persons of at least fifty percent Native Hawaiian ancestry 
through a return to pastoral life. The Act also authorized the 
Commission to undertake ``activities having to do with the 
economic and social welfare of the homesteaders.'' (See 
generally Hawaiian Homes Commission Act, 42 Stat. 108 (July 9, 
1921))
    Hawai`i was admitted into the Union of States in 1959. 
Under the Hawaii Admission Act, the title to the lands set 
aside under the Hawaiian Homes Commission Act was transferred 
from the United States to the State of Hawai`i. The Admissions 
Act requires the State to hold the lands ``as a public trust * 
* * for the betterment of the conditions of Native Hawaiians * 
* * and their use for any other object shall constitute a 
breach of trust for which suit may be brought by the United 
States'' (Hawaii Statehood Admissions Act, Pub. L. No. 86-3, 
Sec. 5(f), 73 Stat. 4 (Mar. 18, 1959)).

                               Background

    Language contained in the 1984 Supplemental Appropriations 
Act, Public Law 98-396, directed the Department of Health and 
Human Services to conduct a comprehensive study of the health 
care needs of Native Hawaiians. The study was conducted under 
the aegis of Region IX of the Department by a consortium of 
health care providers and professionals from the State of 
Hawai`i in a predominantly volunteer effort, organized by Alu 
Like, Inc., a Native Hawaiian organization. An island-wide 
conference was held in November of 1985 in Honolulu to provide 
an opportunity for members of the Native Hawaiian community to 
review the study's findings. Recommended changes were 
incorporated in the final report of the Native Hawaiian Health 
Research Consortium, and the study was formally submitted to 
the Department of Health and Human Services in December of 
1985. The Department submitted the report to the Congress on 
July 21, 1986, and the report was referred to the Select 
Committee on Indian Affairs (S. Rep. No. 108-85 (2004)).
    Because the Consortium report's findings as to the health 
status of Native Hawaiians were compared only to other 
populations within the State of Hawai`i, the Select Committee 
requested that the Office of Technology Assessment (OTA), an 
independent agency of the Congress, undertake an analysis of 
Native Hawaiian health statistics as they compared to national 
data in other United States populations. Using the same 
population projection model that was employed in OTA's April 
1986 report on Indian Health Care (U.S. Congress, Office of 
Technology Assessment, Indian Health Care, OTA-H-290 
(Washington, DC: U.S. Government Printing Office, April 1986)) 
to American Indian and Alaska Native populations, and based on 
additional information provided by the Department of Health and 
the Office of Hawaiian Affairs of the State of Hawai`i, the 
Office of Technology Assessment report contains the following 
findings:

          The Native Hawaiian population living in Hawai`i 
        consists of two groups, Hawaiians and part-Hawaiians, 
        who are distinctly different in both age distributions 
        and mortality rates. Hawaiians comprise less than five 
        percent of the total Native Hawaiian population and are 
        much older than the young and growing part-Hawaiian 
        populations.
          Overall, Native Hawaiians have a death rate that is 
        thirty-four percent higher than the death rate for the 
        United States all races, but this composite masks the 
        great differences that exist between Hawaiians and 
        part-Hawaiians. Hawaiians have a death rate that is 146 
        percent higher than the U.S. all races rate. Part-
        Hawaiians also have a higher death rate, but only 17 
        percent greater. A comparison of age-adjusted death 
        rates for Hawaiians and part-Hawaiians reveals that 
        Hawaiians die at a rate 110 percent higher than part-
        Hawaiians, and this pattern persists for all except one 
        of the 13 leading causes of death that are common to 
        both groups.
          As in the case of the U.S. all races population, 
        Hawaiian and part-Hawaiian males have higher death 
        rates than their female counterparts. However, when 
        Hawaiian and part-Hawaiian males and females are 
        compared to their U.S. all races counterparts, females 
        are found to have more excess deaths than males. Most 
        of these excess deaths are accounted for by diseases of 
        the heart and cancers, with lesser contributions from 
        cerebrovascular diseases and diabetes mellitus.
          Diseases of the heart and cancers account for more 
        than half of all deaths in the U.S. all races 
        population, and this pattern is also found in both the 
        Hawaiian and part-Hawaiian populations, whether grouped 
        by both sexes or by male or female. However, Hawaiians 
        and part-Hawaiians have significantly higher death 
        rates than their U.S. all races counterparts, with the 
        exception of part-Hawaiian males, for whom the death 
        rate from all causes is approximately equal to that of 
        U.S. all races males.
          One disease that is particularly pervasive is 
        diabetes mellitus, for which even part-Hawaiian males 
        have a death rate 128 percent higher than the rate for 
        U.S. all races males. Overall, Native Hawaiians die 
        from diabetes at a rate that is 222 percent higher than 
        for the U.S. all races. When compared to their U.S. all 
        races counterparts, deaths from diabetes mellitus range 
        from 630 percent higher for Hawaiian females and 538 
        percent higher for Hawaiian males, to 127 percent 
        higher for part-Hawaiian females and 128 percent higher 
        for part-Hawaiian males. (Id.)

    These findings clearly establish that the health status of 
Native Hawaiians is significantly worse than that of other U.S. 
population groups, and that in a number of areas, the evidence 
is compelling that Native Hawaiians constitute a population 
group for whom the mortality rate associated with certain 
diseases exceed that for other U.S. populations in alarming 
proportions.
    Native Hawaiians premise the high mortality rates and the 
incidence of disease that far exceed that of other populations 
in the United States upon the breakdown of the Hawaiian culture 
and belief systems, including the banning of the use of 
traditional healing practices, that was brought about by 
western settlement, as well as the influx of western diseases 
to which the native people of the Hawaiian Islands lacked 
immunities.
    In 1998, an organization of Native Hawaiian health care 
providers, Papa Ola Lokahi, updated the health care statistics 
from the original E Ola Mau report. Additionally Papa Ola 
Lokahi extrapolates the data that the Hawai`i State Department 
of Health annually gathers on Native Hawaiians from the 
Department's behavioral risk assessment and health surveillance 
survey. The findings from those assessments revealed that--

          With respect to cancer, Native Hawaiians have the 
        highest cancer mortality rates in the State of Hawai`i 
        (216.8 out of every 100,000 male residents and 191.6 
        out of every 100,000 female residents), rates that are 
        21 percent higher than that for the total State male 
        population (179.0 out of every 100,000 residents) and 
        64 percent higher than that for the total State female 
        population (117.0 per 100,000). Native Hawaiian males 
        have the higher cancer mortality rates in the State of 
        Hawai`i for cancers of the lung, colon, rectum, 
        colorectum, and for all cancers combined, and the 
        highest years of productive life lost from cancer in 
        the State of Hawai`i. Native Hawaiian females have the 
        highest cancer mortality rates in the State of Hawai`i 
        for cancers of the lung, liver, pancreas, breast, 
        corpus uteri, stomach, colon, rectum, and for all 
        cancers combined.
          With respect to breast cancer, Native Hawaiians have 
        the highest mortality rates in the State of Hawai`i, 
        and nationally Native Hawaiians have the third highest 
        mortality rates due to breast cancer. Native Hawaiians 
        have the highest mortality rates from cancer of the 
        cervix and lung cancer in the State of Hawai`i, and 
        Native Hawaiian males have the third highest mortality 
        rates due to prostate cancer in the State.
          For the year 2000, Native Hawaiians had the highest 
        mortality rate due to diabetes mellitus in the State of 
        Hawai`i, with full-blood Hawaiians having a mortality 
        rate that is 518 percent higher than the rate for the 
        statewide population of all other races.
          In 1990, Native Hawaiians represented 44 percent of 
        all asthma cases in the State of Hawai`i for those 18 
        years of age and younger, and 35 percent of all asthma 
        cases reported, and in 1999, the Native Hawaiian 
        prevalence rate for asthma was 69 percent higher than 
        the rate for the total statewide population.
          With respect to heart disease, the death rate for 
        Native Hawaiians is 68 percent higher than for the 
        entire State of Hawai`i, and Native Hawaiian males have 
        the greatest years of productive life lost in the State 
        of Hawai`i. The death rate for Native Hawaiians from 
        hypertension is 84 percent higher than that for the 
        entire State, and the death rate from stroke for Native 
        Hawaiians is 20 percent higher than for the entire 
        State.
          Native Hawaiians have the lowest life expectancy of 
        all population groups in the State of Hawai`i. Between 
        1910 and 1980, the life expectancy of Native Hawaiians 
        from birth has ranged from 5 to 10 years less than that 
        of the overall State population average, and the most 
        recent data for 1990 indicates that Native Hawaiian 
        life expectancy at birth is approximately 5 years less 
        than that of the total State population.
          With respect to prenatal care, as of 1998, Native 
        Hawaiian women have the highest prevalence of having 
        had no prenatal care during their first trimester of 
        pregnancy, representing 44 percent of all such women 
        statewide. Over 65 percent of the referrals to Healthy 
        Start in fiscal year 1996 and 1997 were Native Hawaiian 
        newborns, and in every region of the State of Hawai`i, 
        many Native Hawaiian newborns begin life in a 
        potentially hazardous circumstance.
          In 1996, 45 percent of the live births to Native 
        Hawaiians mothers were infants born to single mothers. 
        Statistics indicated that infants born to single 
        mothers have a higher risk of low birth weight and 
        infant mortality. Of all low birth weight babies born 
        to single mothers in the State of Hawai`i, 44 percent 
        were Native Hawaiians.
          In 2000, Native Hawaiians had the highest number of 
        fetal deaths in Hawai`i. Twenty-one percent of all 
        fetal deaths in the State were associated with 
        expectant Native Hawaiian mothers and 37 percent of 
        those Native Hawaiian mothers were under the age of 25 
        years.

    These and other health status statistics contained in the 
findings section of S. 702 clearly establish that the health 
care challenges that the Native Hawaiian health care systems 
were established to address require reauthorization of the 
Native Hawaiian Health Care Improvement Act.

Native Hawaiian Health Care Master Plan and Native Hawaiian Health Care 
                                Systems

    The concepts embodied in S. 702 are the result of the 
Committee's work with Native Hawaiian health care professionals 
and others who are dedicated to improving the health status of 
Native Hawaiians. It is based on the beliefs of those with whom 
the Committee has consulted, that to insure that Native 
Hawaiians are able to achieve the healthful harmony of the self 
(body, mind, and spirit) or lokahi, with others and all of 
nature, and to assure that Native Hawaiians are able to 
function effectively as citizens and leaders in their own 
homeland, there must be a restoration of cultural traditions, 
an integration of traditional healing methods in the health 
care delivery system, and a collective effort to restore to the 
Native Hawaiian, a sense of self-esteem and self-worth, for his 
or her culture, as well as for the individual.
    E Ola Mau, a group of Native Hawaiian health care 
professionals, proposed that this effort begin with the 
development of a health care master plan, based on a bio-
psycho-socio-cultural-political model that would be aimed at 
identifying significant events and factors related to specific 
health care needs and issues. E Ola Mau proposed that this 
master plan be implemented at every societal level (individual, 
household, community, county, and state) in the Hawaiian 
Islands. It is its goal to have this Native Hawaiian way of 
dealing with health, eventually become an institutional part of 
the State's health policy for both Native Hawaiian and other 
citizens of the State of Hawai`i.
    After much debate and careful consideration in the Native 
Hawaiian community and amongst those concerned with the health 
status of Native Hawaiians, a consensus was reached that Papa 
Ola Lokahi, the Native Hawaiian Health Board, should be the 
mechanism through which Native Hawaiian health care systems 
would be developed, coordinated, administered, monitored, and 
continually revised to meet the changing health care needs of 
the Native Hawaiian population. Papa Ola Lokahi is currently 
composed of five organizations:
          (1) The Office of Hawaiian Affairs, an agency of the 
        State which was established pursuant to the authority 
        of amendments made to the Constitution of the State of 
        Hawai`i in 1978 to assure the well-being and to advance 
        the interests of Native Hawaiians;
          (2) E Ola Mau, a nonprofit organization of Native 
        Hawaiian professionals dedicated to insuring that 
        Native Hawaiians achieve a healthful harmony of self 
        (body, mind, and spirit) with others and all of nature, 
        and become productive citizens and leaders in their 
        homeland;
          (3) Alu Like, a Federally-funded Native Hawaiian 
        agency that promotes vocational training and the 
        founding of community-based organizations that promote 
        health, education, and economic development for Native 
        Hawaiians;
          (4) The University of Hawai`i; and the
          (5) The Office of Hawaiian Health within the State 
        Department of Health.
    Papa Ola Lokahi has assumed the primary responsibility of 
overseeing the development and maintenance of a Native Hawaiian 
Comprehensive Health Care Master Plan. Papa Ola Lokahi also is 
the entity responsible for certifying to the Secretary of 
Health and Human Services the qualifications and capabilities 
of Native Hawaiian organizations that petition the Secretary to 
carry out, pursuant to contracts with the Secretary, the 
provisions of the Act.
    The Native Hawaiian Health Care Act of 1988, Pub. L. No. 
100-579, 102 Stat. 2916, authorized Papa Ola Lokahi, the Native 
Hawaiian Health Board, to--
           Designate a chairman and vice-chairman from 
        among its member organizations and such other officers 
        as may be deemed necessary to carry out its 
        responsibilities under the Act;
           Adopt bylaws and such other internal 
        regulations or procedures as may be deemed necessary to 
        carry out its responsibilities under the Act;
           Certify to the Secretary that a Native 
        Hawaiian organization meets the definition of ``Native 
        Hawaiian organization'' as set forth in the Act;
           Certify to the Secretary that a Native 
        Hawaiian organization has the qualifications and 
        capacity to provide the services or perform contract 
        requirements pursuant to a contract with the Secretary;
           Oversee the development of a comprehensive 
        Native Hawaiian health care master plan;
           Assure the conduct of health status and 
        health care needs assessments of Native Hawaiian 
        communities desiring to participate in Native Hawaiian 
        health care programs; and
           Coordinate the activities and functions of 
        all Native Hawaiian organizations operating health care 
        programs pursuant to contracts with the Secretary.
    The Native Hawaiian Health Care Act of 1988, Pub. L. No. 
100-579, 102 Stat. 2916 (Oct. 31, 1988) envisions a 
comprehensive health care system that is community-based, 
building upon the Native Hawaiian `ohana system\1\ and 
incorporating traditional healing (la `au lapa `au) practices 
with western medical services to provide a health care system 
that will be culturally sensitive and responsive to the needs 
of Native Hawaiian communities.
---------------------------------------------------------------------------
    \1\ The `ohana system is based upon the fundamental unit of 
societal interaction for Native Hawaiians in which a family or an 
organization is led by a haku (the recognized leader), whose function 
is to coordinate and facilitate the expertise and resources of the 
various households or affiliated organizations in order to accomplish a 
task or resolve a problem. The households or affiliated organizations 
are in turn led by a po`o (the head of the household or designated 
leader of the organization).
---------------------------------------------------------------------------
    As originally enacted, Public Law 100-579 authorized the 
establishment of Native Hawaiian Healing Centers on each of the 
islands comprising the State of Hawai`i, upon the acceptance of 
and in consultation with the Native Hawaiian communities on 
those islands, and wherever possible, using existing health 
care facilities and health care providers now serving the 
Native Hawaiian communities on those islands. These centers 
were intended to lead and coordinate the development and 
implementation of a statewide Native Hawaiian health care 
system which would include: (1) a research and monitoring 
staff, state-certified neighborhood counselors, outreach 
workers and health educators, traditional Native Hawaiian 
healers, and Native Hawaiian cultural educators; (2) primary 
health care providers; (3) primary health care facilities, 
using existing health care facilities where practicable and 
acceptable to the local Native Hawaiian community; (4) 
participation by the State Department of Health, Office of 
Hawaiian Health in the provision of disease prevention and 
health promotion programs, as well as a multidisciplinary 
approach to Native Hawaiian health care which would include 
nursing, dental hygiene, nutrition education, maternal and 
infant child care education; and (5) other Federal, State, 
county, community, and private organizations and agencies that 
could provide services which meet the health care needs of 
their respective communities.
    The development of the master plan by Papa Ola Lokahi was 
intended to include:
          (1) Work with Native Hawaiian communities which 
        support the establishment of a Native Hawaiian Health 
        Center;
          (2) Conducting a community health needs assessment 
        survey for participating communities;
          (3) Facilitating the development, establishment, and 
        effective functioning of such Centers on the islands of 
        O`ahu, Moloka`i, Maui, Hawai`i, Lana`i, Kaua`i and 
        Ni`ihau; and
          (4) Coordinating the work of relevant agencies and 
        organizations to provide participating communities 
        with:
                  (a) Direct health care services and health 
                education, including maternal and child health 
                care and mental health care;
                  (b) Instruction in the Native Hawaiian 
                language, cultural beliefs, and traditions with 
                an emphasis on health concepts and practices;
                  (c) Training and education of health care 
                providers and educators and cultural educators 
                in health promotion and disease prevention;
                  (d) Basic and applied research and monitoring 
                of Native Hawaiian health care approaches to 
                validate outcomes and create standards of 
                quality care;
                  (e) Development of health care services, 
                training and education that would have a Native 
                Hawaiian perspective as its primary focus;
                  (f) Development of Native Hawaiian community 
                health counselors, outreach workers, educators, 
                and community health aide training programs;
                  (g) Prevention-oriented health care services 
                in medical, dental, nutrition, mental health, 
                and in other designated areas as needs 
                assessments may identify as necessary;
                  (h) Data collection related to prevention of 
                diseases and illnesses among Native Hawaiians;
                  (i) Medical and general health-related 
                research into the diseases that are most 
                prevalent among Native Hawaiians;
                  (j) Mental health research in areas of mental 
                health problems that are most prevalent in the 
                Native Hawaiian population;
                  (k) Ongoing health planning for further 
                development of the Native Hawaiian health care 
                system; and
                  (l) The provision of health care referral 
                services when certain health care services are 
                not available within the Native Hawaiian Health 
                Center.
    Following enactment of the Native Hawaiian Health Care 
Improvement Act, the Papa Ola Lokahi Board incorporated and 
began working with health care providers on each island on the 
development of a master plan and an island-specific plan for 
the provision of primary health care and health care referral 
services. Those involved in the planning effort ultimately 
determined that the health care needs of Native Hawaiians would 
be better served by the establishment of five Native Hawaiian 
health care systems which could be composed of as many health 
care centers as might be necessary to serve the health care 
needs of Native Hawaiians on each island.
    Accordingly, Papa Ola Lokahi certified to the Secretary 
that five health care systems qualified as Native Hawaiian 
organizations for purposes of entering into contracts with the 
Secretary, and plans for the provision of primary health care 
services or health care referral services were submitted to the 
Secretary in 1990. The first contract awards were 13 made in 
October of 1991, and since that time, the health care systems 
have been engaged not only in the implementation of the plans 
approved by the Secretary, but the provision of health care 
services. The plans for each health care system vary according 
to the availability of and access to existing health care 
resources on each island and the need for health care services. 
Currently, all five Native Hawaiian health care systems have 
become incorporated as 501(c)(3) non-profit health care 
organizations.
    In general, the capacity to provide critical health care 
services exists only on the island of O`ahu, and thus, it has 
long been the pattern that if a patient requires 
hospitalization and complex surgery or treatment, the patient 
would be referred to a health care provider on the island of 
O`ahu and would have to incur the costs associated with air 
travel to O`ahu. However, it is not uncommon that treatment 
requiring advanced medical technology must be secured in the 
continental United States.
    The Native Hawaiian Health Care Improvement Act provides 
authority for the provision of health promotion, disease 
prevention, and primary health care services to Native 
Hawaiians who reside in the State of Hawai`i. Federal planning 
funds first became available in July of 1990. However, Papa Ola 
Lokahi incorporated in February 1989 and was able to initiate 
its organizing activities in July 1989 with funds provided by 
the Hawai`i State legislature. Between July 1989 and December 
1990, informational meetings and organizational activities took 
place throughout the State, resulting in the establishment or 
recognition of the five Native Hawaiian health care systems 
which would assume the responsibility for providing services: 
(1) Ho`ola Lahui Hawai`i for Kaua`i and Ni`ihau; (2) Ke Ola 
Mamo for O`ahu; (3) Na Pu`uwai for Moloka`i and Lana`i; (4) Hui 
No Ke Ola Pono for Maui; and (5) Hui Malama Ola Na `Oiwi for 
Hawai`i. Papa Ola Lokahi provided planning funds and technical 
assistance to these five health care systems, which then 
developed their service plans from January through June 1991, 
applied for funding under the Native Hawaiian Health Care Act 
in July 1991, and were awarded service grants in October of 
1991.
    The basic set of services that all five health care systems 
must provide include: (1) outreach services to inform Native 
Hawaiians of the availability of health services; (2) education 
in health promotion and disease prevention of the Native 
Hawaiian population by Native Hawaiian health care 
practitioners, community outreach workers, counselors, and 
cultural educators, whenever possible; (3) services of 
physicians, physicians assistants, nurse practitioners or, 
other health professionals; (4) immunizations; (5) prevention 
and control of diabetes, high blood pressure, and otitis media; 
(6) pregnancy and infant care; and (7) improvement of 
nutrition.
    In the initial stages, because the five health care systems 
needed to gain experience in managing health services and 
because of limited funds, each health care system concentrated 
on outreach, health assessments, case management, and disease 
prevention and health promotion activities, with the ultimate 
objective of providing the full range of health and medical 
services that are available through a typical primary health 
care center, and working with traditional healers so that their 
services would also be more readily available to Native 
Hawaiians.
    Now that the five island-wide Native Hawaiian health care 
systems are established and engaged in the provision of health 
care services, Papa Ola Lokahi's role is to provide technical 
support and training to the five health care systems, work with 
each of the systems to develop a statewide, cooperative Native 
Hawaiian health system, develop research activities and 
capacities within the five health care systems, and evaluate 
how well the objectives of the Native Hawaiian Health Care 
Improvement Act are being met.
    The goals and objectives, as well as the services provided 
by each of the five Native Hawaiian health care systems is 
contained in Appendix A of the committee report.
    Through the work of the five Native Hawaiian health care 
systems, on an annual basis, 20,000 Native Hawaiians continue 
to benefit from the range of health care services provided by 
the systems.

          Native Hawaiian Health Care Professions Scholarships

    The Native Hawaiian Health Care Improvement Act also 
provides authority for the provision of scholarships to Native 
Hawaiians who are seeking higher education opportunities in the 
health care professions. The Native Hawaiian Health Scholarship 
Program has been administered by the Kamehameha Schools, but S. 
702 will transfer administration of these scholarships to Papa 
Ola Lokahi.
    Scholarships awarded thus far have resulted in: bachelors 
of science degrees in nursing, clinical psychology doctoral 
degrees, dentists, dental hygienists, osteopathic physicians, 
allopathic physicians, masters degrees in public health, 
masters degrees in social work, nurse midwives, nurse 
practitioners, doctors of psychology, and registered nurses. 
Many of the scholarship recipients have completed their studies 
and their service payback requirements and are practicing in 
the Native Hawaiian community.

                        Reauthorization Process

    In order to assure the maximum involvement of Native 
Hawaiians in the development of a bill to reauthorize the 
Native Hawaiian Health Care Improvement Act (the Act), from 
December of 1997 through January of 1998, eight island `aha 
(island-wide conferences) were held involving more than 1,200 
individuals in an effort to identify the principle Native 
Hawaiian health and wellness issues and concerns. In March 
1998, a statewide Native Hawaiian Health and Wellness Summit, 
Ka `Uhane Lokahi, was held on the island of O`ahu, bringing 
together more than 600 people to identify potential health and 
wellness issues and concerns. In January 1999, a Native 
Hawaiian Health Forum was convened to discuss major health care 
trends and strategies for health care and wellness developed by 
the indigenous peoples of North America and Aotearoa (New 
Zealand).
    In March 1999, the Executive Directors of the Native 
Hawaiian health care systems, the members of the Papa Ola 
Lokahi Board, and the Director of the Native Hawaiian Health 
Scholarship Program met to review the Act and to incorporate 
recommendations from the `aha, the summit, and the health forum 
for inclusion in a bill to reauthorize the Native Hawaiian 
Health Care Improvement Act. Thereafter, a series of public 
meetings were held to discuss and review a draft 
reauthorization bill and based upon the comments received, the 
bill was further refined and then circulated in the Native 
Hawaiian community. A final draft of the bill, incorporating 
and responding to recommendations received from the Native 
Hawaiian community, was submitted to the Congress.

                      Summary of Major Provisions

    S. 702 extends the existing program authorities of the Act 
and authorizes appropriations in such sums as may be necessary 
through fiscal year 2009. The bill contains extensive findings 
on the current health status of Native Hawaiians including the 
incidence and mortality rates associated with various forms of 
cancer, diabetes, asthma, circulatory diseases, infectious 
disease and illness, and injuries, as well as statistics on 
life expectancy, maternal and child health, births, teen 
pregnancies, fetal mortality, mental health, and health 
professions education and training.
    The bill further refines the role of Papa Ola Lokahi and 
the Native Hawaiian health care systems, providing authority 
for the establishment of additional health care systems to 
serve the islands of Lana`i and Ni`ihau. The Board of Papa Ola 
Lokahi has been expanded to include the five Native Hawaiian 
health care systems, the Native Hawaiian Health Task Force, the 
Hawai`i State Primary Care Association (which represents the 
community health centers), the Native Hawaiian Physicians 
Association, and such other organizations as the Papa Ola 
Lokahi Board will admit based upon a satisfactory demonstration 
of a record of contribution to the health and well-being of 
Native Hawaiians.
    The 1992 amendments to the Act adopted the relevant health 
objectives of the U.S. Surgeon General's Healthy People 2000 
objectives as goals to be met by the Native Hawaiian health 
care systems. S. 702 establishes new objectives that the Native 
Hawaiian health care systems must meet based on the objectives 
in the U.S. Surgeon General's Healthy People 2010.
    S. 702 proposes that the providers of health care services, 
including traditional Native Hawaiian healers, who provide 
services under the aegis of the Native Hawaiian health care 
systems be treated as members of the Public Health Service for 
purposes of Federal Tort Claims Act coverage (28 U.S.C. 1346(b) 
and 2671-2680).
    The bill also provides authorization for Papa Ola Lokahi to 
carry out Native Hawaiian demonstration projects of national 
significance in areas such as the education of health 
professionals, the integration of western medicine with 
complementary health practices including traditional Native 
Hawaiian healing practices, the use of tele-wellness and 
telecommunications in chronic disease management and health 
promotion and disease prevention, the development of an 
appropriate model of health care for Native Hawaiians and other 
indigenous people, the development of a centralized data base 
and information system relating to the health care status, 
health care needs, and wellness of Native Hawaiians, and the 
establishment of a Native Hawaiian Center of Excellence for 
Nursing at the University of Hawai`i at Hilo, a Native Hawaiian 
Center of Excellence for Mental Health at the University of 
Hawai`i at Manoa, a Native Hawaiian Center of Excellence for 
Maternal Health and Nutrition at the Waimanalo Health Center, a 
Native Hawaiian Center of Excellence for Research, Training, 
and Integrated Medicine at Moloka`i General Hospital, and a 
Native Hawaiian Center of Excellence for Complementary Health 
and Health Education and Training at the Waianae Coast 
Comprehensive Health Center.

         The Provision of Federal Programs to Native Hawaiians

    In the exercise of the plenary power vested in the Congress 
in Article I, section 8, clause 3 of the United States 
Constitution, the Congress has exercised its authority to 
address the conditions of the aboriginal, indigenous, native 
people of the United States, including the aboriginal, 
indigenous, native people of the states of Alaska and Hawai`i. 
More than one hundred and sixty Federal laws have been enacted 
to address the conditions of Native Hawaiians (see for example, 
S. Rep. No. 108-85). The authority of the Congress to enact 
legislation to address the conditions of Native Hawaiians is 
set forth more fully in Appendix B to the committee report.

         FEDERAL DELEGATION OF AUTHORITY TO THE STATE OF HAWAII

    For the past two hundred and ten years, the United States 
Congress, the Executive Branch, and the U.S. Supreme Court have 
recognized certain legal rights and protections for America's 
indigenous peoples. Since the founding of the United States, 
Congress has exercised a constitutional authority over 
indigenous affairs and has undertaken an enhanced duty of care 
for America's indigenous peoples. This has been done in 
recognition of the sovereignty possessed by the native people--
a sovereignty which pre-existed the formation of the United 
States. The Congress' exercise of its constitutional authority 
is also premised upon the status of the indigenous people as 
the original inhabitants of this nation who occupied and 
exercised dominion and control over the lands over which the 
United States subsequently acquired jurisdiction.
    The United States has long recognized the existence of a 
special political relationship with the indigenous people of 
the United States. As Native Americans--American Indians, 
Alaska Natives, and Native Hawaiians--the United States has 
recognized that they are entitled to special rights and 
considerations, and the Congress has enacted laws to give 
expression to the respective legal rights and responsibilities 
of the Federal government and the native people (see for 
example, S. Rep. No. 108-85).
    From time to time, with the consent of the affected States, 
the Congress has sought to more effectively address the 
conditions of the indigenous people by delegating Federal 
responsibilities to various states. In 1959, the State of 
Hawai`i assumed the Federally-delegated responsibility of 
administering 203,500 acres of land that had been set aside by 
Congress in 1921 for the benefit of the native people of 
Hawai`i under the Hawaiian Homes Commission Act.\2\ In 
addition, the State agreed to the imposition of a public trust 
upon all of the lands ceded to the State upon admission.\3\ One 
of the five purposes for which the public trust was established 
is the ``betterment of the conditions of native Hawaiians[.]'' 
\4\ The Federal authorization for this public trust clearly 
anticipated that the State's constitution and laws would 
provide for the manner in which the terms of trust would be 
carried out.\5\
---------------------------------------------------------------------------
    \2\ Id., Sec. 4; Haw. Const., Art. XVI, Sec. 7.
    \3\ Id., Sec. 5(f); Haw. Const. Art. XII, Sec. 4.
    \4\ Id., Sec. 5(f); Haw. Const. Art. XII, Sec. 4.
    \5\ Id.
---------------------------------------------------------------------------
    In 1978, the citizens of the State of Hawai`i exercised the 
Federally-delegated authority by amending the State 
constitution in furtherance of the special relationship with 
Native Hawaiians. The delegates to the 1978 constitutional 
convention recognized that Native Hawaiians had no other 
homeland, and thus that the protection of Native Hawaiian 
subsistence rights to harvest the ocean's resources, to fish 
the freshwater streams, and to hunt and gather, as well as the 
protection of Native Hawaiians' rights to exercise their rights 
to self-determination and self-governance, and to preserve 
their culture and language, could only be accomplished within 
their native homeland, the present State of Hawai`i.
    Hawai'i's adoption of amendments to the State constitution 
to fulfill the special relationship with Native Hawaiians is 
consistent with the practice of other states that have 
established special relationships with the native inhabitants 
of their areas. Fourteen states have extended recognition to 
Indian tribes that are not recognized by the Federal 
government, and thirty-two states have established commissions 
and offices to address matters of policy affecting the 
indigenous citizenry.

                      Section-by-Section Analysis


Section 1. Short title

    The title of the Act is the Native Hawaiian Health Care 
Improvement Reauthorization Act of 2003.

Section 2. Findings

    Subsection (a) sets forth the findings of the Congress with 
regard to the historical and legal basis for a Federal program 
designed to address the health care needs of Native Hawaiians. 
Subsection (b) sets forth the unmet needs and serious health 
disparities affecting Native Hawaiians, including chronic 
diseases and illnesses, infectious diseases and illnesses, 
injuries, dental health, life expectancy, maternal and child 
health, mental health, and health professions education and 
training.

Section 3. Definitions

    This section sets forth the definitions of terms used in 
the Act.
    Section 3(1) defines ``Department'' to mean the Department 
of Health and Human Services.
    Section 3(2) defines ``disease prevention'' to include 
immunizations, control of high blood pressure, control of 
sexually transmittable diseases, the prevention and control of 
chronic diseases, control of toxic agents, occupational safety 
and health, injury prevention, fluoridation of water, control 
of infectious agents, and provision of mental health care.
    Section 3(3) defines ``health promotion'' to include 
pregnancy and infant care, including prevention of fetal 
alcohol syndrome, cessation of tobacco smoking, reduction in 
the misuse of alcohol and harmful illicit drugs, improvement of 
nutrition, improvement in physical fitness, family planning, 
control of stress, reduction of major behavioral risk factors 
and promotion of healthy lifestyle practices, and integration 
of cultural approaches to health and well-being.
    Section 3(4) defines ``health service'' as the services of 
physicians, physician's assistants, nurse practitioners, 
nurses, dentists, and other health care professionals; 
diagnostic laboratory and radiologic services; preventive 
health services, including perinatal services, well child 
services, family planning services, nutrition services, home 
health services, sports medicine and athletic training, and 
other enhanced health or wellness services; emergency medical 
services, including first responders, emergency medical 
technicians, and mobile intensive care technicians; 
transportation services as required for adequate patient care; 
preventive dental services; and pharmaceutical and medicament 
services; mental health services, including those of 
psychologists and social workers; genetic counseling services; 
health administration services, including those services of 
health program administrators; health research services, 
including those with advanced degrees in medicine, nursing, 
psychology, social work, and other related health programs; 
environmental health services, including those provided by 
epidemiologists, public health officials, medical geographers 
and medical anthropologists, and those specializing in 
biological, chemical, and environmental health determinants; 
primary care services that may lead to specialty or tertiary 
care; and complementary healing practices, including those 
performed by traditional Native Hawaiian healers.
    Section 3(5) defines ``Native Hawaiian'' as any individual 
who is a descendant of the aboriginal people who, prior to 
1778, occupied and exercised sovereignty in the area that now 
constitutes the State of Hawaii as evidenced by genealogical 
records, kama`aina (long-term community residents) witness 
verification from Native Hawaiian kupuna (elders) or birth 
records of the State of Hawai`i or any State or territory of 
the United States.
    Section 3(6) defines ``Native Hawaiian health care system'' 
as any of up to 8 entities that has the following 
characteristics: is organized under Hawai`i law; provides or 
arranges for health services for Native Hawaiians in the State; 
is a public or nonprofit private entity; has Native Hawaiians 
significantly participating in the planning, management, 
provision, monitoring, and evaluation of health services; 
addresses the health care needs of an island's Native Hawaiian 
population, and; is recognized by Papa Ola Lokahi for the 
purpose of planning, conducting, or administering programs, 
authorized by this Act for the benefit of Native Hawaiians, and 
as having the qualifications and the capacity to provide the 
services and meet the requirements under the contract each 
Native Hawaiian health care system enters into with the 
Secretary or the grant each Native Hawaiian health care system 
receives from the Secretary under this Act.
    Section 3(7) defines ``Native Hawaiian Health Center'' as 
an organization that provides primary health care services and 
which Papa Ola Lokahi has certified has met the following 
criteria: a governing board with a membership that has a 
minimum of fifty-percent (50%) Native Hawaiians; has 
demonstrated cultural competency in a predominantly Native 
Hawaiian community; has a patient population that is either 
made up of individuals at least fifty-percent of whom are 
Native Hawaiian or serves not less than 2,500 Native Hawaiian 
clients annually.
    Section 3(8) defines ``Native Hawaiian Health Task Force'' 
as a task force established by the State Council of Hawaiian 
Homestead Associations that implements health and wellness 
strategies in Hawai`i's Native Hawaiian communities.
    Section 3(9) defines ``Native Hawaiian organization'' as a 
public or nonprofit organization that serves Native Hawaiian 
interests and which Papa Ola Lokahi has recognized for purposes 
of planning, conducting, or administering programs authorized 
under this Act.
    Section 3(10) defines ``Office of Hawaiian Affairs'' and 
``OHA'' as the governmental entity established under the 
Hawai`i State Constitution which is charged with the 
responsibility of formulating policy relating to Native 
Hawaiian affairs.
    Section 3(11) defines ``Papa Ola Lokahi'' as an 
organization composed of public and private organizations 
focusing on improving the health status of Native Hawaiians. It 
is governed by a board, whose members may include 
representatives from: E Ola Mau; the Office of Hawaiian 
Affairs; Alu Like, Inc.; the University of Hawai`i; the Hawai`i 
State Department of Health; the Native Hawaiian Health Task 
Force; Hawai`i State Primary Care Association; Ahahui O Na 
Kauka; Ho'ola Lahui Hawai`i (or a health care system serving 
the islands of Kaua`i or Ni`ihau); Ke Ola Mamo (or a health 
care system serving the island of O`ahu); Na Pu`uwai (or a 
health care system serving the islands of Molokai and Lana`i); 
Hui No Ke Ola Pono (or a health care system serving the island 
of Maui); Hui Malama Ola Ha `Oiwi (or a health care system 
serving the island of Hawai`i); other Native Hawaiian health 
care systems that Papa Ola Lokahi certifies and recognizes; and 
such other member organizations as the Board of Papa Ola Lokahi 
may admit from time to time, based upon a satisfactory 
demonstration of a record of contribution to the health and 
well-being of Native Hawaiians. However, organizations will not 
be added to Papa Ola Lokahi if the Secretary determines that an 
organization has not developed a mission statement with clearly 
defined goals and objectives for its contributions to the 
Native Hawaiian health care systems and an action plan for 
carrying out those goals and objectives.
    Section 3(12) defines ``Secretary'' as the Secretary of the 
U.S. Department of Health and Human Services.
    Section 3(13) defines ``State'' as the State of Hawai`i.
    Section 3(14) defines ``traditional Native Hawaiian 
healer'' as a practitioner who is of Hawaiian ancestry and has 
the knowledge, skills and experience in direct personal health 
care of individuals, and whose knowledge, skills, and 
experience are based on demonstrated learning of Native 
Hawaiian healing practices acquired by direct practical 
association with Native Hawaiian elders and the oral traditions 
transmitted from generation to generation.

Section 4. Declaration of national Native Hawaiian health policy

    This section establishes the policy of the Act.
    Section 4 (a) and (b) establish that it is the United 
States' policy, in fulfilling its special responsibilities and 
legal obligations to the indigenous people of Hawai`i which 
result from the unique and historical relationship between the 
United States and the indigenous people of Hawai`i, to raise 
the health status of Native Hawaiians to the highest 
practicable level and to provide existing Native Hawaiian 
health care programs with the resources necessary to effectuate 
this policy. Section 4 also expresses Congress' intent to raise 
Native Hawaiians' health status by 2010 to at least the 
standards contained within the Surgeon General's Healthy People 
2010, and to incorporate within health programs the following 
activities: integration of cultural approaches to health and 
well-being; increasing the number of health and allied-health 
care providers who can provide culturally competent care; 
increasing the use of traditional Native Hawaiian foods in 
peoples' diets and dietary preferences including those of 
students and the use of traditional foods in school feeding 
programs; identifying and instituting Native Hawaiian cultural 
values and practices within the corporate cultures of 
organizations and agencies providing health services to Native 
Hawaiians; facilitating the provision of Native Hawaiian 
healing practices by Native Hawaiian healers for those clients 
desiring such assistance; supporting training and education 
activities and programs in traditional Native Hawaiian healing 
practices by Native Hawaiian healers; and demonstrating the 
integration of health services for Native Hawaiians, 
particularly those that integrate mental, physical, and dental 
services in health care.
    Section 4(c) directs the Secretary to provide the President 
with a report on the progress made toward meeting the national 
policy of the Act which will be included in the President's 
report to the Congress under section 12.

Section 5. Comprehensive health care master plan for Native Hawaiians

    Section 5(a)(1) authorizes the Secretary to make a grant or 
enter into a contract with Papa Ola Lokahi for the purpose of 
coordinating, implementing, and updating the Native Hawaiian 
comprehensive health care master plan which is designed to 
promote comprehensive health promotion and disease prevention 
services, to maintain and improve Native Hawaiian health 
status, and to support community-based initiatives reflective 
of holistic health care.
    Section 5(a)(2) requires Papa Ola Lokahi and the Office of 
Hawaiian Affairs to consult with the Native Hawaiian health 
care systems, the Native Hawaiian health centers, and the 
Native Hawaiian community in carrying out section 5, and 
authorizes Papa Ola Lokahi and the Office of Hawaiian Affairs 
to enter into memoranda of understanding or agreement to 
acquire joint funding and for purposes of addressing other 
issues to accomplish the objectives of this section.
    Section 5(a)(3) requires that within eighteen (18) months 
of the Act's enactment that Papa Ola Lokahi, in cooperation 
with the Office of Hawaiian Affairs and other appropriate State 
and Federal agencies, prepare and submit a study report to the 
Congress detailing the impact of current Federal and State 
health care financing mechanisms and policies on Native 
Hawaiians' health and well-being. The report will include the 
impact of cultural competency, risk assessment data, 
eligibility requirements and exemptions, reimbursement policies 
and capitation rates currently in effect for service providers, 
and any other information that may be important to improving 
the health status of Native Hawaiians as it relates to health 
care financing, including barriers to health care. The report's 
recommendations will be submitted to the Secretary for review 
and consultation with Native Hawaiians.
    Section 5(b) authorizes the appropriation of such sums as 
may be necessary to coordinate, implement, and update the 
master plan and to prepare the health care financing study 
report.

Section 6. Functions of Papa Ola Lokahi and Office of Hawaiian Affairs

    This section sets forth the functions of Papa Ola Lokahi 
and amends the previous Act to include the Office of Hawaiian 
Affairs.
    Section 6(a)(1) authorizes Papa Ola Lokahi to carry out the 
following responsibilities:
          (A) Coordinating, implementing, and updating the 
        comprehensive health care master plan under section 5;
          (B) Training and education of individuals providing 
        health services;
          (C) Identifying and researching the diseases that are 
        most prevalent among Native Hawaiians, including 
        behavioral, biomedical, epidemiological, and health 
        services; and,
          (D) Developing and maintaining an institutional 
        review board for all research projects involving all 
        aspects of Native Hawaiian health.
    Section 6(a)(2) authorizes Papa Ola Lokahi to receive 
special project funds that may be appropriated for the purpose 
of conducting research on the health status of Native Hawaiians 
or for the purpose of addressing the health care needs of 
Native Hawaiians.
    Section 6(a)(3) authorizes Papa Ola Lokahi to serve as a 
clearinghouse for the collection and maintenance of data 
associated with the health status of Native Hawaiians; the 
identification and research into diseases affecting Native 
Hawaiians; the availability of Native Hawaiian project funds, 
research projects, and publications; the collaboration of 
research in Native Hawaiian health; and the timely 
dissemination of information pertinent to the Native Hawaiian 
health care systems.
    Section 6(b) requires the Secretary and the Secretaries of 
other Federal departments consult with Papa Ola Lokahi and to 
provide Papa Ola Lokahi and the Office of Hawaiian Affairs with 
at least one annual accounting of funds and services provided 
in carrying out the Act's policy. This accounting will include, 
but not be limited to, the following: the amount of funds 
expended explicitly for and benefitting Native Hawaiians; the 
number of Native Hawaiians impacted by these funds; the 
collaborations made with Native Hawaiian groups and 
organizations in the expenditure of these funds; and the amount 
of funds used for Federal administrative purposes and for the 
provision of direct services to Native Hawaiians.
    Section 6(c)(1) requires that Papa Ola Lokahi provide 
annual recommendations to the Secretary regarding the 
allocation of all amounts appropriated under this Act.
    Section 6(c)(2) requires that Papa Ola Lokahi, to the 
extent possible, coordinate and assist the health care programs 
and services to Native Hawaiians.
    Section 6(c)(3) requires the Secretary to consult with Papa 
Ola Lokahi and make recommendations for Native Hawaiian 
representation on the President's Advisory Commission on Asian 
Americans and Pacific Islanders.
    Section 6(d) authorizes Papa Ola Lokahi to act as a 
statewide infrastructure to provide technical support and 
coordination of training and technical assistance to the Native 
Hawaiian health care systems and the Native Hawaiian health 
centers.
    Section 6(e)(1) authorizes Papa Ola Lokahi to enter into 
agreements or memoranda of understanding with relevant 
institutions, agencies, or organizations that are capable of 
providing health-related resources or services to the Native 
Hawaiians, the Native Hawaiian health care systems, or 
resources for carrying out the national policy of this Act.
    Section 6(e)(2) addresses health care financing as follows:
    Subsection (A) requires that Federal agencies providing 
health care financing and health care programs consult with 
Native Hawaiians, Papa Ola Lokahi, and organizations providing 
Native Hawaiian health care services prior to adopting any 
policy or regulation which may impact on service provision or 
health insurance coverage. The consultation is to include but 
not be limited to identifying the impact of proposed policies, 
rules, or regulations.
    Subsection (B) requires the State of Hawaii to engage in 
meaningful consultation with Native Hawaiians, Papa Ola Lokahi, 
and organizations providing Native Hawaiian health care 
services prior to making any changes or initiating new 
programs.
    Subsection (C) authorizes the Office of Hawaiian Affairs, 
in concert with Papa Ola Lokahi, to develop consultative, 
contractual, or other arrangements with the following: the 
Centers for Medicare and Medicaid Services; the agency of the 
State which administers or supervises the administration of a 
State plan or waiver approved under Title XVIII, XIX, or XXI of 
the Social Security Act for payment of all or part of the 
health care services to Native Hawaiians who are eligible for 
medical assistance under such a State plan or waiver; or with 
any other Federal agency or agencies providing Native Hawaiians 
with full or partial health insurance. Such arrangements may 
include but are not limited to appropriate reimbursement for 
health care services including capitation and fee for service 
rates for Native Hawaiians who are entitled to insurance, scope 
of services provided, or any other matters which enable Native 
Hawaiians to maximize health insurance benefits provided by 
Federal and State health insurance programs.
    Section 6(e)(3) provides that the Department and other 
Federal agencies that provide health care services may include 
the services of traditional Native Hawaiian healers and 
traditional healers providing traditional health care practices 
as defined in section 4 of the Indian Health Care Improvement 
Act (25 U.S.C. 1603). Such services are to be exempt from 
national accreditation reviews.

Section 7. Native Hawaiian health care

    This section addresses the Secretary's authority to enter 
into contracts and grants with Native Hawaiian health care 
systems for the provision of Native Hawaiian health care and 
health care referral services and the responsibilities of the 
Native Hawaiian health care systems.
    Section 7(a) authorizes the Secretary to consult with Papa 
Ola Lokahi and make grants to or enter into contracts with one 
or more Native Hawaiian health care systems for the purpose of 
providing comprehensive health promotion and disease prevention 
services, as well as health care services to Native Hawaiians 
who desire and are committed to bettering their own health. The 
Secretary may enter into grants or contracts with not more than 
8 Native Hawaiian health care systems.
    Section 7(b) authorizes the Secretary to also make a grant 
to, or enter into a contract with, Papa Ola Lokahi for purposes 
of planning Native Hawaiian health care systems to serve the 
health needs of Native Hawaiian communities on the islands of 
O`ahu, Moloka`i, Maui, Hawai`i, Lana`i, Kaua`i, Kaho`lawe, and 
Ni`ihau.
    Section 7(c) specifies that each qualified entity receiving 
funds under section 7(a) must ensure that the following health 
services are either provided or provision is arranged for: 
outreach services to inform and assist Native Hawaiians in 
accessing health services; health promotion and disease 
prevention education for Native Hawaiians by, wherever 
possible, Native Hawaiian health care practitioners, community 
outreach workers, counselors, cultural educators, and other 
disease prevention providers; services of individuals providing 
health services; collection of data related to the prevention 
of diseases and illnesses among Native Hawaiians; and support 
of culturally appropriate activities enhancing health and 
wellness including land-based, water-based, ocean-based, and 
spiritually-based projects and programs. These services may be 
provided by traditional Native Hawaiian healers, when 
appropriate.
    Section 7(d) provides that individuals who provide medical, 
dental, or other services under subsection (7)(a)(1) for a 
Native Hawaiian health care system shall be treated as if they 
were members of the Public Health Service and shall be covered 
under the provisions of section 224 of the Public Health 
Service Act (42 U.S.C. 233).
    Section 7(e) requires that a Native Hawaiian health care 
system receiving funds under subsection 7(a) may serve as a 
Federal loan repayment facility. This facility must be designed 
to enable health and allied-health professionals to remit 
payments to loans provided to such professionals under any 
Federal loan program.
    Section 7(f) specifies that the Secretary may not make a 
grant or enter into a contract as authorized under subsection 
7(a) unless the qualified entity agrees that the grant or 
contract amount will not, directly or through contract, be 
expended for the following: health care services except as 
described in section 7(c)(1); the purchase or improvement of 
real property (other than minor remodeling of existing 
improvements to real property); or the purchase of major 
medical equipment.
    Section 7(g) provides that the Secretary may not make a 
grant or enter into a contract with any qualified entity under 
subsection 7(a) unless the qualified entity agrees that, 
whether health services are provided directly or through 
contract, health services under the grant or contract will be 
provided regardless of payment ability and the entity will 
impose a charge for the delivery of health services which will 
be made according to a public schedule of charges and will be 
adjusted to reflect the income of the individual involved.
    Section 7(h) authorizes the appropriation of sums as may be 
necessary to carry out the general and planning grant 
activities and health services under subsections 7(a), 7(b), 
and 7(c) for fiscal years 2004 through 2009.

Section 8. Administrative grant for Papa Ola Lokahi

    This section authorizes the Secretary to make a grant or 
enter into a contract with Papa Ola Lokahi for its 
administrative functions.
    Section 8(a) authorizes the Secretary to make grants to or 
enter into contracts with Papa Ola Lokahi for the following: 
the coordination, implementation, and appropriate updating of 
the comprehensive health care master plan; training and 
education for providers of health services; identification of 
and research into the diseases that are most prevalent among 
Native Hawaiians, including behavioral, biomedical, 
epidemiological and health services; a clearinghouse function 
for the collection and maintenance of data associated with the 
health status of Native Hawaiians, the identification of and 
research into diseases affecting Native Hawaiians, and the 
availability of Native Hawaiian project funds, research 
projects, and publications; the establishment and maintenance 
of an institutional review board for all health-related 
research involving Native Hawaiians; the coordination of the 
health care programs and services provided to Native Hawaiians; 
and the administration of special project funds.
    Section 8(b) authorizes the appropriation of sums as may be 
necessary to carry out the activities in subsection 8(a) for 
each of fiscal years 2004 through 2009.

Section 9. Administration of grants and contracts

    This section sets forth the terms and conditions under 
which the Secretary makes grants or enters into contracts.
    Section 9(a) specifies that within any grants made or 
contracts entered include terms and conditions that the 
Secretary considers necessary or appropriate to ensure that the 
grant or contract objectives are achieved.
    Section 9(b) requires that the Secretary periodically 
evaluate the performance of and compliance with grants and 
contracts under this Act.
    Section 9(c) restricts the Secretary's authority to make 
any grant or enter into any contract under this Act with an 
entity unless the entity:
          (1) Agrees to establish such procedures for fiscal 
        control and fund accounting as may be necessary to 
        ensure proper disbursement and accounting with respect 
        to the grant or contract;
          (2) Agrees to ensure the confidentiality of records 
        maintained on individuals receiving health services 
        under the grant or contract;
          (3) With respect to health services provided to any 
        population of Native Hawaiians, a substantial portion 
        of whom has a limited ability to speak the English 
        language, has developed and has the ability to carry 
        out a reasonable plan to provide health services under 
        the grant or contract through individuals who are able 
        to communicate with that population in the language of 
        that population and in the most appropriate cultural 
        context, and has designated at least one individual, 
        fluent in both English and the appropriate language, to 
        assist in carrying out the plan;
          (4) With respect to health services that are covered 
        under title XVIII, XIX, or XXI of the Social Security 
        Act, including any State plan, or under any other 
        Federal health insurance plan, if the entity will 
        provide under the grant or contract any such health 
        services directly, the entity has entered into a 
        participation agreement under such plans and the entity 
        is qualified to receive payments under such plan, or if 
        the entity will provide under the grant or contract any 
        such health services through a contract with an 
        organization, the organization has entered into a 
        participation agreement under such plan, and the 
        organization is qualified to receive payments under 
        such plan; and
          (5) Agrees to submit an annual report to the 
        Secretary and to Papa Ola Lokahi that describes the use 
        and costs of health services provided under the grant 
        or contract, including the average cost of health 
        services per user, and that provides such other 
        information the Secretary determines to be appropriate.
    Section 9(d) addresses the Secretary's evaluation of 
contracts entered into by the Secretary.
    Subsection (1) provides that when the Secretary's 
evaluation reveals that an entity has not complied with or 
satisfactorily performed a contract entered into under section 
7, that before the contract is renewed the Secretary must 
attempt to resolve the areas of noncompliance or unsatisfactory 
performance and modify the contract to prevent future 
noncompliance or unsatisfactory performance.
    Subsection (2) provides that if the Secretary determines 
that the noncompliance or unsatisfactory performance cannot be 
resolved and prevented in the future, the Secretary shall not 
renew that entity's contract and is authorized to enter into a 
new section 7 contract with a qualified entity, as defined in 
section 7(a)(3), that provides services to the same population 
of Native Hawaiians that was served by the entity whose 
contract was not renewed.
    Subsection (3) specifies that in determining whether to 
renew an entity's contract under the Act, the Secretary shall 
consider the results of the evaluations undertaken under the 
authority of section 9.
    Subsection (4) specifies that the contracts the Secretary 
enters under this Act must be in accordance with all Federal 
contracting laws and regulations, but that the Secretary has 
the discretion to negotiate contracts without advertising and 
may be exempt from subchapter III of chapter 31, United States 
Code.
    Subsection (5) specifies that payments made under any 
contract entered into under this Act may be made in advance, by 
means of reimbursement, or in installments and shall be made on 
such conditions as the Secretary deems necessary to carry out 
the purposes of this Act.
    Section 9(e) provides that for each fiscal year during 
which an entity receives or expends funds pursuant to a grant 
or contract under the Act, that entity is to submit an annual 
report to the Secretary and to Papa Ola Lokahi on the entity's 
activities under the grant or contract, the amounts and 
purposes for which Federal funds were expended, and such other 
information as the Secretary may request. The reports and 
records of any entity concerning any grant or contract under 
this Act shall be subject to audit by the Secretary, the 
Inspector General of the Department of Health and Human 
Services, and the Comptroller General of the United States.
    Section 9(f) provides that the Secretary shall allow as a 
cost of any grant made or contract entered into under this Act, 
the cost of an annual private audit by a certified public 
accountant.

Section 10. Assignment of personnel

    This section addresses the assignment of personnel by the 
Secretary.
    Section 10(a) authorizes the Secretary to enter into an 
agreement with Papa Ola Lokahi or any of the Native Hawaiian 
health care systems for assigning personnel from Department of 
Health and Human Services with expertise for the purpose of 
conducting research or providing comprehensive health promotion 
and disease prevention services to Native Hawaiians.
    Section 10(b) specifies that any personnel assignment the 
Secretary agrees to under the authority of subsection 10(a) is 
to be treated as an assignment of Federal personnel to a local 
government that is made in accordance with subchapter VI of 
chapter 33 of title 5 of the United States Code.

Section 11. Native Hawaiian health scholarships and fellowships

    Section 11(a) provides that subject to the availability of 
funds appropriated under the authority of subsection 11(c), the 
Secretary is to provide funds through a direct grant or a 
cooperative agreement with Papa Ola Lokahi for the purpose of 
providing scholarship assistance to Native Hawaiian students.
    Section 11(b) provides authority for employees of the 
Native Hawaiian Health Care Systems and the Native Hawaiian 
Health Centers to have a priority for these scholarships.
    Section 11(c)(1) specifies that subsection 11(a) is to be 
provided in correspondence with the need for each type of 
health care professional to serve the Native Hawaiian community 
as Papa Ola Lokahi identifies; to the maximum extent 
practicable, the Secretary is to select scholarship recipients 
from a list of eligible applicants Papa Ola Lokahi submits; the 
obligated service requirement for each scholarship recipient is 
to be fulfilled through service, in order of priority, in any 
one of the Native Hawaiian health care systems; Native Hawaiian 
health centers; health professions shortage areas, medically 
underserved areas, or geographic areas or facilities similarly 
designated by the U.S. Public Health Service in the State of 
Hawai`i; a Native Hawaiian organization that serves a 
geographical area with a significant Native Hawaiian 
population; any public or non-profit organization providing 
services to Native Hawaiians; or any of the uniformed services 
of the United States. The placement service for a scholarship 
shall assign each Native Hawaiian scholarship recipient to one 
or more appropriate sites for service in accordance with this 
section.
    Subsection (E) further specifies that counseling, 
retention, and other support services will be available to 
scholarship recipients and other scholarship and financial aid 
programs recipients enrolled in appropriate health professions 
training programs.
    Subsection (F) provides that, after consultation with Papa 
Ola Lokahi, financial assistance may be provided to scholarship 
recipients while they are fulfilling their service requirement 
in any one of the Native Hawaiian health care systems or Native 
Hawaiian health centers.
    Subsection (G) allows for the provision of scholarships to 
Native Hawaiians who are enrolled in an appropriate distance 
learning program offered by an accredited educational 
institution.
    Section 11(c)(2) provides that the financial aid provided 
through fellowships may be provided by Papa Ola Lokahi to 
Native Hawaiian health professionals who are Native Hawaiian 
community health representatives, outreach workers, health 
program administrators in professional training programs; to 
Native Hawaiians who provide health services; or Native 
Hawaiians in certificated programs provided by traditional 
Native Hawaiian healers. The financial assistance may include a 
stipend or reimbursement for costs associated with 
participating in the program.
    Section 11(c)(3) provides that scholarship recipients in 
health professions designated in section 338A of the Public 
Health Service Act shall have the same rights and benefits of 
members of the National Health Service Corps while fulfilling 
their service requirements.
    Section 11(c)(4) provides that the financial assistance 
provided under section 11 shall be deemed ``Qualified 
Scholarships'' for purposes of section 117 of the Internal 
Revenue Code of 1986 (26 U.S.C.117).
    Section 11(d) authorizes the appropriation of such sums as 
may be necessary for the purpose of funding the scholarship 
assistance under subsections 11(a) and 11(c)(2) for fiscal 
years 2004 through 2009.

Section 12. Report

    This section provides that at the time the budget is 
submitted, the President is to transmit a report to Congress 
for each fiscal year on the progress made in meeting the Act's 
objectives. The report should include a review of programs 
established or assisted pursuant to the Act and an assessment 
and recommendation of additional programs or assistance 
necessary to provide health services to Native Hawaiians and to 
ensure a health status for Native Hawaiians which are on par 
with the general population's health services and health 
status.

Section 13. Use of Federal Government facilities and sources of supply

    This section authorizes organizations that receive grants 
or contracts to have access to Federal property and supplies.
    Section 13(a) authorizes the Secretary to allow 
organizations, in carrying out their grants or contracts 
authorized under the Act, to use existing facilities and 
equipment therein or under the Secretary's jurisdiction, under 
such terms and conditions as may be agreed upon for their use 
and maintenance.
    Section 13(b) authorizes the Secretary to donate any 
personal or real property determined to be in excess of the 
needs of the Department or the General Services Administration 
to organizations that receive contracts or grants for purposes 
of carrying out such contract or grants.
    Section 13 (c) authorizes the Secretary to acquire excess 
or surplus Federal government personal or real property for 
donation to organizations that receive grants or contracts 
under this Act, provided that the Secretary determines that the 
property is appropriate for the organization's use for the 
purpose for which the contract or grant was authorized.

Section 14. Demonstration projects of national significance

    This section authorizes demonstration projects to improve 
the health status of Native Hawaiians.
    Section 14(a) authorizes the Secretary to consult with Papa 
Ola Lokahi and allocate appropriated amounts under this or any 
other Act to carry out Native Hawaiian demonstration projects 
of national significance. The project areas of interest may 
include the following:
          (A) The development of a centralized database and 
        information system relating to Native Hawaiian health 
        care status, health care needs, and wellness;
          (B) The education of health professionals, and other 
        individuals in higher learning institutions, in health 
        and allied health programs in healing practices, 
        including Native Hawaiian healing practices;
          (C) The integration of Western medicine with 
        complementary healing practices including traditional 
        Native Hawaiian healing practices;
          (D) The use of tele-wellness and telecommunications 
        in chronic and infectious disease management and health 
        promotion and disease prevention;
          (E) The development of appropriate models of health 
        care for Native Hawaiians and other indigenous people 
        including the provision of culturally competent health 
        services, related activities focusing on wellness 
        concepts, and the development of appropriate kupuna 
        care programs, and the development of financial 
        mechanisms and collaborative relationships leading to 
        universal access to health care; and
          (F) the establishment of Native Hawaiian Centers of 
        Excellence for Nursing at the University of Hawai`i at 
        Hilo; for Mental Health at the University of Hawai`i at 
        Manoa; for Maternal Health and Nutrition at the 
        Waimanalo Health Center; and for Research, Training, 
        and Integrated Medicine at Moloka`i General Hospital; 
        and for Complementary Health and Health Education and 
        Training at the Waianae Coast Comprehensive Health 
        Center. Papa Ola Lokahi and any centers established 
        under this paragraph shall be deemed qualified as 
        Centers of Excellence under the Public Health Service 
        Act.
    Section 14(b) provides that funds allocated for 
demonstration projects under subsection 14(a) shall not result 
in a reduction of funds required by the Native Hawaiian health 
care systems, Native Hawaiian Health Centers, the Native 
Hawaiian Health Scholarship Program, or Papa Ola Lokahi to 
carry out their respective responsibilities under this Act.

Section 15. Rule of construction

    This section specifies that nothing in this Act will be 
construed to restrict the authority of the State of Hawai`i to 
license health practitioners.

Section 16. Compliance with Budget Act

    This section provides that any new spending authority 
described in section 401(c)(2)(A) or (B) of the Congressional 
Budget Act of 1974 which is provided under the authority of the 
Act is to be effective only for any fiscal year to the extent 
or in such amounts as are provided in appropriation Acts.

Section 17. Severability

    This section specifies that if any provision of the Act or 
application of any provision of the Act to any person or 
circumstance is held to be invalid, the remainder of the Act 
will be unaffected.

                          Legislative History

    S. 702 was introduced on March 25, 2003, by Senator Daniel 
K. Inouye, for himself and Senator Daniel K. Akaka, and was 
referred to the Committee on Indian Affairs. No hearings were 
held on S. 702, however, during the 106th Congress, the 
Committee did hold a series of hearings on S. 1929 which is the 
predecessor bill to S. 702 and was nearly identical in its 
provisions to S. 702. Those hearings were as follows: Moloka`i 
and Kaua`i (January 18, 2000); Maui (January 19, 2000); Hilo, 
Hawai`i (January 20, 2000); O`ahu (January 21, 2000); Kona, 
Hawai`i and Lana`i (March 16, 2000).

            Committee Recommendation and Tabulation of Vote

    The Committee on Indian Affairs, on May 14, 2003, in an 
open business meeting, by a unanimous vote, recommended that 
the Senate pass S. 702, a bill to reauthorize and amend the 
Native Hawaiian Health Care Improvement Act.

                   Cost and Budgetary Considerations

    The cost estimate for S. 702 as calculated by the 
Congressional Budget Office, is set forth below:

                                     U.S. Congress,
                               Congressional Budget Office,
                                      Washington, DC, June 3, 2003.
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. 702, the Native 
Hawaiian Health Care Improvement Reauthorization Act of 2003.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Alexis 
Ahlstrom.
            Sincerely,
                                       Douglas Holtz-Eakin,
                                                          Director.
    Enclosure.

S.702--Native Hawaiian Health Care Improvement Reauthorization Act of 
        2003

    Summary: S. 702 would reauthorize the Native Hawaiian 
Health Care Program, funded from within the Health Resources 
and Services Administration's Consolidated Health Center 
Program, through 2009.
    The bill would authorize the appropriation of such sums as 
may be necessary for fiscal years 2004 through 2009. Assuming 
the appropriation of the necessary amounts, CBO estimates that 
implementing S. 702 would cost about $5 million in 2004 and $53 
million over the 2004-2009 period. (That estimate assumes that 
annual appropriations are adjusted for inflation. Without such 
adjustments, the six-year total would be $50 million.)
    The bill would extend provisions under section 224 of the 
Public Health Service Act to providers in Hawaiian health 
systems. That section authorizes settlements and awards for 
tort claims to be paid out of the Treasury's Judgment Fund. 
Those payments are considered direct spending, regardless of 
whether the health program involved is an entitlement program 
or subject to appropriation. CBO estimates those payments would 
total less than $500,000 in 2004 and less than $500,000 over 
the 2004-2009 period.
    S. 702 contains no private-sector mandates as defined in 
the Unfunded Mandates Reform Act (UMRA). The bill would require 
the state of Hawaii to consult with Naive Hawaiians, Papa Ola 
Lokahi (an umbrella organization composed of groups involved in 
Native Hawaiian health), and health care organizations that 
provide services to Native Hawaiians before making policy 
changes or implementing new programs. That requirement would be 
an intergovernmental mandate as defined in UMRA, but CBO 
estimates that the costs of the mandate would be minimal and 
would not exceed the threshold established in that act ($59 
million in 2003, adjusted annually for inflation).
    Estimated cost to the Federal Government: The estimated 
budgetary impact of S. 702 is shown in the following table. The 
costs of this legislation would fall within budget functions 
550 (health) and 800 (general government).

----------------------------------------------------------------------------------------------------------------
                                                                 By fiscal year, in millions of dollars--
                                                         -------------------------------------------------------
                                                           2003    2004    2005    2006    2007    2008    2009
----------------------------------------------------------------------------------------------------------------
                                      SPENDING SUBJECT TO APPROPRIATION \1\

                                         With Adjustments for Inflation

Native Hawaiian Health Center Program Spending Under
 Current Law:
    Budget Authority \2\................................       9       0       0       0       0       0       0
    Estimated Outlays...................................       7       4       *       0       0       0       0
Proposed Changes:
    Estimated Authorization Level \3\...................       0       9       9      10      10      10      10
    Estimated Outlays...................................       0       5       9       9      10      10      10
Native Hawaiian Health Center Program Spending Under S.
 702:
    Estimated Authorization Level.......................       9       9       9      10      10      10      10
    Estimated Outlays...................................       7       9       9       9      10      10      10
----------------------------------------------------------------------------------------------------------------
\1\ This bill also would increase direct spending, but by less than $500,000 a year.
\2\ The 2003 level is the amount appropriated for that year for the Native Hawaiian Health Care Program.
\3\ The proposed changes include annual adjustments for inflation for the bill's authorizations of ``such sums
  as necessary.'' Without such inflation adjustments, the six-year totals of costs would be about $3 million
  lower.

Note.--* = less than $500,000.

    Basis of estimate: For the purposes of this estimate, CBO 
assumes that the bill will be enacted by the end of fiscal year 
2003 and that the necessary appropriations will be provided for 
each fiscal year.

Spending subject to appropriation

    Native Hawaiian Health Care Program. S. 702 would authorize 
the appropriation of such sums as necessary for 2004 through 
2009 for the extension of activities carried out under the 
Native Hawaiian Health Care Program. These activities include 
the provision of health care at Native Hawaiian health centers 
and health systems; granting scholarships to students dedicated 
to providing health care to Native Hawaiians; administration of 
the program; and the development of strategies to improve the 
health status of Native Hawaiians. The bill would authorize 
increasing from five to eight the number of health systems 
receiving grants, and would authorize the establishment of a 
fellowship program for health care workers.
    CBO estimates that these activities could be carried out 
with 2003 appropriation levels adjusted for inflation, plus 
additional funding for the increase in the number of health 
systems receiving grants. Those systems would be added to the 
program gradually over the next few years, according to 
information provided by Papa Ola Lokahi. Assuming the 
appropriation of $9 million in 2004, and adjustments for 
inflation in 2005 through 2009, CBO estimates the cost of these 
provisions would be $5 million in 2004 and $53 million over the 
2004-2009 period.

Direct spending

    Under current law, settlements and tort claims arising from 
the actions of licensed heath care providers in federally 
funded health centers are paid from the Treasury's Judgment 
Fund. The bill would expand that coverage to include tort 
claims arising from the actions of licensed providers within 
the Native Hawaiian health systems, as well as non-licensed 
providers and traditional Hawaiian health providers. Based on 
past experience with spending from the Judgment Fund for 
providers covered under section 224, as well as information on 
the number and license status of newly covered providers, CBO 
estimates the cost of this provision to be less than $500,000 
in each year and less than $500,000 over the 2004-2009 period.
    Impact on state, local, and tribal governments: The bill 
would require the state of Hawaii to consult with Native 
Hawaiians, Papa Ola Lokahi, and health care organizations that 
provide services to Native Hawaiians before making policy 
changes or implementing new programs. That requirement would be 
an intergovernmental mandate as defined in UMRA, but CBO 
estimates that the costs of the mandate would be minimal and 
would not exceed the threshold established in that act ($59 
million in 2003, adjusted annually for inflation).
    Impact on the private sector: S. 702 contains no private-
sector mandates as defined in UMRA.
    Estimate prepared by: Federal Costs: Alexis Ahlstrom; 
Impact on State, Local, and Tribal Governments: David Conway; 
and Impact on the Private Sector: Julie Lee.
    Estimate approved by: Peter H. Fontaine, Deputy Assistant 
Director for Budget Analysis.

                        Executive Communications

    The Committee received no communications from the Executive 
branch of government on S. 702.

                    Regulatory and Paperwork Impact

    Paragraph 11(b) of rule XXVI of the Standing Rules of the 
Senate requires each report accompanying a bill to evaluate the 
regulatory and paperwork impact that would be incurred in 
carrying out the bill. The Committee believes that S. 702 will 
have a minimal impact on regulatory or paperwork requirements.

                        Changes in Existing Law


                      UNITED STATES CODE ANNOTATED

                TITLE 42--THE PUBLIC HEALTH AND WELFARE

                CHAPTER 122--NATIVE HAWAIIAN HEALTH CARE


Sec. 11701. Findings

    [The Congress finds that:] (a) General Findings.--Congress 
finds that--
          (1) Native Hawaiians [comprise] begin their story 
        with the Kumulipo, which details the creation and 
        inter-relationship of all things, including the 
        evolvement of Native Hawaiians as healthy and well 
        people;
          (2) Native Hawaiians.--
                  (A) are a distinct and unique indigenous 
                people with a historical continuity to the 
                original inhabitants of the Hawaiian 
                archipelago [whose society was organized as a 
                Nation prior to the arrival of the first 
                nonindigenous people in 1778] within Ke 
                Moananui, the Pacific Ocean; and
                  (B) have a distinct society that was first 
                organized almost 2,000 years ago;
                  (3) the health and well-being of Native 
                Hawaiians are intrinsically tied to the deep 
                feelings and attachment of Native Hawaiians to 
                their lands and seas,
                  (4) the long-range economic and social 
                changes in Hawai`i over the 19th and early 20th 
                centuries have been devastating to the health 
                and well-being of Native Hawaiians;
                  (5) Native Hawaiians have never directly 
                relinquished to the United States their claims 
                to their inherent sovereignty as a people or 
                over their national territory, either through 
                their monarchy or through a plebiscite or 
                referendum;
          [(2) The] (6) the Native Hawaiian people are 
        determined to preserve, develop and transmit to future 
        generations, [their ancestral territory, and their 
        cultural identity] in accordance with their own 
        spiritual and traditional beliefs, their customs, 
        practices, language, [and] social institutions[.], 
        ancestral territory, and cultural identity;
          (7) in referring to themselves, Native Hawaiians use 
        the term `Kanaka Maoli', a term frequently used in the 
        19th century to describe the native people of Hawai`i;
          [(3)] (8) The constitution and statutes of the State 
        of Hawai`i[:]--
                  (A) acknowledge the distinct land rights of 
                Native Hawaiian people as beneficiaries of the 
                public lands trust; and
                  (B) reaffirm and protect the unique right of 
                the Native Hawaiian people to practice and 
                perpetuate their cultural and religious 
                customs, beliefs, practices, and language[.];
          [(4) At] (9) at the time of the arrival of the first 
        nonindigenous people in Hawaii in 1778, the Native 
        Hawaiian people lived in a highly organized, self-
        sufficient, subsistence social system based on communal 
        land tenure with a sophisticated language, culture, and 
        religion[.];
          [(5) A] (10) a unified monarchical government of the 
        Hawaiian Islands was established in 1810 under 
        Kamehameha I, the first King of Hawaii[.];
          [(6) Throughout] (11) throughout the 19th century 
        [and] until 1893, the United States[:]--
                  (A) recognized the independence of the 
                Hawaiian Nation;
                  (B) extended full and complete diplomatic 
                recognition to the Hawaiian Government; and
                  (C) entered into treaties and conventions 
                with the Hawaiian monarchs to govern commerce 
                and navigation in 1826, 1842, 1849, 1875, and 
                1887[.];
          [(7)] (12) [In the year] in 1893, John L. Stevens, 
        the United States Minister assigned to the sovereign 
        and independent Kingdom of Hawai`i, [John L. Stevens,] 
        conspired with a small group of non-Hawaiian residents 
        of the Kingdom, including citizens of the United 
        States, to overthrow the indigenous and lawful 
        [Government] government of Hawai`i[.];
          [(8) In] (13) in pursuance of that conspiracy[,]--
                  (A) the United States Minister and the naval 
                representative of the United States caused 
                armed [naval] forces of the United States Navy 
                to invade the sovereign Hawaiian Nation in 
                support of the overthrow of the indigenous and 
                lawful Government of Hawai`i; and
                  (B) after that overthrow, the United States 
                Minister [thereupon] extended diplomatic 
                recognition of a provisional government formed 
                by the conspirators without the consent of the 
                native people of Hawai`i or the lawful 
                Government of Hawai`i, in violation of--
                          (i) treaties between the [two nations 
                        and of international law.] Government 
                        of Hawai`i and the United States; and
                          (ii) international law,
          [(9) In] (14) in a message to Congress on December 
        18,1893, [then] President Grover Cleveland--
                  (A) reported fully and accurately on [these] 
                those illegal actions[,];
                  (B) [and] acknowledged that by [these] those 
                acts, described by the President as acts of 
                war, the government of a peaceful and friendly 
                people was overthrown[,]; and
                  (C) [the President] concluded that a 
                [``]`substantial wrong has thus been done which 
                a due regard for our national character as well 
                as the rights of the injured people required 
                that we should endeavor to repair[''.]';
          [(10)] (15) Queen Lili`uokalani, the lawful monarch 
        of Hawai`i, and the Hawaiian Patriotic League, 
        representing the aboriginal citizens of Hawai`i, 
        promptly petitioned the United States for redress of 
        [these] those wrongs and [for] restoration of the 
        indigenous government of the Hawaiian nation, but [this 
        petition was not acted upon.] no action was taken on 
        that petition;
          (16) in 1993, Congress enacted Public Law 103-150 
        (107 Stat.1510), in which Congress--
                  (A) acknowledged the significance of those 
                events; and
                  (B) apologized to Native Hawaiians on behalf 
                of the people of the United States for the 
                overthrow of the Kingdom of Hawai`i with the 
                participation of agents and citizens of the 
                United States, and the resulting deprivation of 
                the rights of Native Hawaiians to self-
                determination;
          [(11) In] (17) in 1898, the United States--
                  (A) annexed Hawai`i through [the Newlands] 
                Resolution No. 55 (commonly known as the 
                `Newlands Resolution') (30 Stat. 750), without 
                the consent of, or compensation to, the 
                indigenous people of Hawai`i or [their] the 
                sovereign government [who were thereby] of 
                those people; and
                  (B) denied those people the mechanism for 
                expression of their inherent sovereignty 
                through self-government and self-
                determination[,] of their lands and ocean 
                resources[.];
          [(12) Through] (18) through the Newlands Resolution 
        and the [1900 Organic Act, the United States] Act of 
        April 30, 1900 (commonly known as the `1900 Organic 
        Act') (31 Stat. 141, chapter 339), Congress--
                  (A) received [1.75 million] 1,750,000 acres 
                of [lands] land formerly owned by the Crown and 
                Government of the Hawaiian Kingdom; and
                  (B) exempted the [lands] land from then-
                existing public land laws of the United States 
                by mandating that the revenue and proceeds from 
                [these lands] that land be [``]`used solely for 
                the benefit of the inhabitants of the Hawaiian 
                Islands for education and other public 
                purposes['']', thereby establishing a special 
                trust relationship between the United States 
                and the inhabitants of Hawai`i[.];
          [(13) In] (19) in 1921, Congress enacted the Hawaiian 
        Homes Commission Act, 1920 (42 Stat. 108, chapter 42), 
        which--
                  (A) designated 200,000 acres of the ceded 
                public [lands] land for exclusive homesteading 
                by Native Hawaiians[,]; and
                  (B) [thereby affirming] affirmed the trust 
                relationship between the United States and 
                [the] Native Hawaiians, as expressed by [then] 
                Secretary of the Interior Franklin K. Lane, who 
                was cited in the Committee Report of the 
                [United States] Committee on Territories of the 
                House of Representatives [Committee on 
                Territories] as stating, [``]`One thing that 
                impressed me . . . was the fact that the 
                natives of the islands [who are our wards, I 
                should say, and] . . . for whom in a sense we 
                are trustees, are falling off rapidly in 
                numbers and many of them are in poverty.['']';
          [(14) In] (20) in 1938, [the United States] Congress 
        again acknowledged the unique status of the Native 
        Hawaiian people by including in the Act of June 20, 
        1938 (52 Stat. 781[ et seq.]), a provision--
                  (A) to lease [lands] land within the 
                extension to Native Hawaiians; and
                  (B) to permit fishing in the area [``]`only 
                by native Hawaiian residents of said area or of 
                adjacent villages and by visitors under their 
                guidance[''.]';
          [(15) Under] (21) under the Act [entitled ``An Act to 
        provide for the admission of the State of Hawaii into 
        the Union,'' approved March 18, 1959 (73 Stat. 4)] of 
        March 18, 1959 (48 U.S.C. prec. 491 note; 73 Stat.4), 
        the United States--
                  (A) transferred responsibility for the 
                administration of the Hawaiian [Home Lands] 
                home lands to the State [of Hawai`i]; but
                  (B) reaffirmed the trust relationship [which] 
                that existed between the United States and the 
                Native Hawaiian people by retaining the 
                exclusive power to enforce the trust, including 
                the power to approve land exchanges[,] and 
                legislative amendments affecting the rights of 
                beneficiaries under [such] that Act[.];
          [(16) Under] (22) under the Act [entitled ``An Act to 
        provide for the admission of the State of Hawai`i into 
        the Union'', approved March 18, 1959 (73 Stat. 4)] 
        referred to in paragraph (21), the United States--
                  (A) transferred responsibility for 
                administration over portions of the ceded 
                public lands trust not retained by the United 
                States to the State [of Hawai`i]; but
                  (B) reaffirmed the trust relationship [which] 
                that existed between the United States and the 
                Native Hawaiian people by retaining the legal 
                responsibility of the State for the betterment 
                of the conditions of Native Hawaiians under 
                section 5(f) of [the Act entitled ``An Act to 
                provide for the admission of the State of 
                Hawai`i into the Union'', approved March 18, 
                1959 (73 Stat. 4, 6).] that Act (73 Stat. 6);
          (23) in 1978, the people of Hawai`i--
                  (A) amended the constitution of Hawai`i to 
                establish the Office of Hawaiian Affairs; and
                  (B) assigned to that Office the authority--
                          (i) to accept and hold in trust for 
                        the Native Hawaiian people real and 
                        personal property transferred from any 
                        source;
                          (ii) to receive payments from the 
                        State owed to the Native Hawaiian 
                        people in satisfaction of the pro rata 
                        share of the proceeds of the public 
                        land trust established by section 5(f) 
                        of the Act of March 18, 1959 (48 U.S.C. 
                        prec 491 note, 73 Stat. 6);
                          (iii) to act as the lead State agency 
                        for matters affecting the Native 
                        Hawaiian people; and
                          (iv) to formulate policy on affairs 
                        relating to the Native Hawaiian people;
          [(17) The] (24) the authority of the Congress under 
        the [United States] Constitution to legislate in 
        matters affecting the aboriginal or indigenous 
        [peoples] people of the United States includes the 
        authority to legislate in matters affecting the native 
        [peoples] people of Alaska and Hawai`i[.];
          (25) the United States has recognized the authority 
        of the Native Hawaiian people to continue to work 
        toward an appropriate form of sovereignty, as defined 
        by the Native Hawaiian people in provisions set forth 
        in legislation returning the Hawaiian Island of Kaho 
        `olawe to custodial management by the State in 1994;
          [(18) In] (26) in furtherance of the trust 
        responsibility for the betterment of the conditions of 
        Native Hawaiians, the United States has established a 
        program for the provision of comprehensive health 
        promotion and disease prevention services to maintain 
        and improve the health status of the Hawaiian 
        people[.];
          (27) that program is conducted by the Native Hawaiian 
        Health Care Systems, and Papa Ola Lokahi;
          (28) health initiatives implemented by those and 
        other health institutions and agencies using Federal 
        assistance have been responsible for reducing the 
        century-old morbidity and mortality rates of Native 
        Hawaiian people by--
                  (A) providing comprehensive disease 
                prevention;
                  (B) health promotion activities; and
                  (C) increasing the number of Native Hawaiians 
                in the health and allied health professions;
          (29) those accomplishments have been achieved through 
        implementation of--
                  (A) the Native Hawaiian Health Care Act of 
                1988 (Public Law 100-579); and
                  (B) the reauthorization of that Act under 
                section 9168 of the Department of Defense 
                Appropriations Act,1993 (Public Law 102-396; 
                106 Stat. 1948);
          [(19) This] (30) the historical and unique legal 
        relationship between the United States and Native 
        Hawaiians has been consistently recognized and affirmed 
        by [the] Congress through the enactment of more than 
        160 Federal laws [which] that extend to the Native 
        Hawaiian people the same rights and privileges accorded 
        to American Indian, Alaska Native, Eskimo, and Aleut 
        communities, including--
                  (A) the Native American Programs Act of 1974 
                [[42 U.S.C.A. 2991 et seq.]] (42 U.S.C. 2991 et 
                seq.);
                  (B) the American Indian Religious Freedom Act 
                [[42 U.S.C.A. 1996]] (42 U.S.C. 1996);
                  (C) the National Museum of the American 
                Indian Act [[20 U.S.C.A. Sec. 80q et seq.]] (20 
                U.S.C. 80q et seq.); and
                  (D) the Native American Graves Protection and 
                Repatriation Act [[25 U.S.C.A. 3001 et seq.].] 
                (25 U.S.C. 3001 et seq.);
          [(20) The] (31) the United States has [also] 
        recognized and reaffirmed the trust relationship to the 
        Native Hawaiian people through legislation [which] that 
        authorizes the provision of services to Native 
        Hawaiians, specifically[,]--
                  (A) the Older Americans Act of 1965 [[42 
                U.S.C.A. Sec. 3001 et seq.],] (42 U.S.C. 3001 
                et seq.);
                  (B) the Developmental Disabilities Assistance 
                and Bill of Rights Act Amendments of 1987[,] 
                (42 U.S.C. 6000 et seq.);
                  (C) the Veterans' Benefits and Services Act 
                of 1988[,] (Public Law 100-322);
                  (D) the Rehabilitation Act of 1973 [[29 
                U.S.C.A. 701 et seq.],] (29 U.S.C. 701 et 
                seq.);
                  (E) the Native Hawaiian Health Care Act of 
                1988[,] (42 U.S.C. 11701 et seq.);
                  (F) the Health Professions Reauthorization 
                Act of 1988[,] (Public Law 100-607,102 Stat. 
                3122);
                  (G) the Nursing Shortage Reduction and 
                Education Extension Act of 1988[,] (Public Law 
                100-607; 102 Stat. 3153);
                  (H) the Handicapped Programs Technical 
                Amendments Act of 1988[,] (Public Law 100-630);
                  (I) the Indian Health Care Amendments of 
                1988[,] (Public Law 100-713); and
                  (J) the Disadvantaged Minority Health 
                Improvement Act of 1990[.] (Public Law 101-
                527);
          [(21) The] (32) the United States has [also] affirmed 
        [the] that historical and unique legal relationship to 
        the Hawaiian people by authorizing the provision of 
        services to Native Hawaiians to address problems of 
        alcohol and drug abuse under the Anti-Drug Abuse Act of 
        1986[.] (21 U.S.C. 801 note, Public Law 99-570);
          (33) in addition, the United States--
                  (A) has recognized that Native Hawaiians, as 
                aboriginal, indigenous, native people of 
                Hawai`i, are a unique population group in 
                Hawai`i and in the continental United States, 
                and
                  (B) has so declared in Office of Management 
                and Budget Circular 15 in 1997 and Presidential 
                Executive Order No. 13125, dated June 7, 1999, 
                and
          [(22) Despite] (34) despite [such services,] the 
        United States having expressed in Public Law 103-150 
        (107 Stat. 1510) its commitment to a policy of 
        reconciliation with the Native Hawaiian people for past 
        grievances--
                  (A) the unmet health needs of the Native 
                Hawaiian people [are] remain severe, and
                  (B) the health status of the Native 
                [Hawaiians] Hawaiian people continues to be far 
                below that of the general population of the 
                United States.
    (b) Finding of Unmet Needs and Health Disparities.--
Congress finds that the unmet needs and serious health 
disparities that adversely affect the Native Hawaiian people 
include the following:
          (1) Chronic disease and illness.--
                  (A) Cancer.--
                          (i) In general.--With respect to all 
                        cancer--
                                  (I) Native Hawaiians have the 
                                highest cancer mortality rates 
                                in the State (216.8 out of 
                                every 100,000 male residents 
                                and 191.6 out of every 100,000 
                                female residents), rates that 
                                are 21 percent higher than the 
                                rate for the total State male 
                                population (179.0 out of every 
                                100,000 residents) and 64 
                                percent higher than the rate 
                                for the total State female 
                                population (117.0 per 100,000);
                                  (II) Native Hawaiian males 
                                have the highest cancer 
                                mortality rates in the State 
                                for cancers of the lung, colon, 
                                rectum, and colorectum, and for 
                                all cancers combined;
                                  (III) Native Hawaiian females 
                                have the highest cancer 
                                mortality rates in the State 
                                for cancers of the lung, liver, 
                                pancreas, breast, corpus uteri, 
                                stomach, colon, and rectum, and 
                                for all cancers combined;
                                  (IV) Native Hawaiian males 
                                have 8.7 years of productive 
                                life lost as a result of cancer 
                                in the State, the highest years 
                                of productive life lost in that 
                                State, as compared with 6.4 
                                years for all males; and
                                  (V) Native Hawaiian females 
                                have 8.2 years of productive 
                                life lost as a result of cancer 
                                in the State as compared with 
                                6.4 years for all females in 
                                the State;
                          (ii) Breast cancer.--With respect to 
                        breast cancer--
                                  (I) Native Hawaiians have the 
                                highest mortality rate in the 
                                State from breast cancer (30.79 
                                out of every 100,000 
                                residents), a rate that is 33 
                                percent higher than that for 
                                Caucasian Americans (23.07 out 
                                of every 100,000 residents) and 
                                106 percent higher than that 
                                for Chinese Americans (14.96 
                                out of every 100,000 
                                residents); and
                                  (II) nationally, Native 
                                Hawaiians have the third 
                                highest mortality rate as a 
                                result of breast cancer (25.0 
                                out of every 100,000 residents) 
                                behind African Americans (31.4 
                                out of every 100,000 residents) 
                                and Caucasian Americans (27.0 
                                out of every 100,000 
                                residents).
                          (iii) Cancer of the cervix.--Native 
                        Hawaiians have the highest mortality 
                        rate as a result of cancer of the 
                        cervix in the State (3.65 out of every 
                        100,000 residents), followed by 
                        Filipino Americans (2.69 out of every 
                        100,000 residents) and Caucasian 
                        Americans (2.61 out of every 100,000 
                        residents).
                          (iv) Lung cancer.--Native Hawaiian 
                        males and females have the highest 
                        mortality rates as a result of lung 
                        cancer in the State, at 74.79 per 
                        100,000 for males and 47.84 per 100,000 
                        females, which rates are higher than 
                        the rates for the total State 
                        population by 48 percent for males and 
                        93 percent for females.
                          (v) Prostate cancer.--Native Hawaiian 
                        males have the third highest mortality 
                        rate as a result of prostate cancer in 
                        the State (21.48 out of every 100,000 
                        residents), with Caucasian Americans 
                        having the highest mortality rate as a 
                        result of prostate cancer (23.96 out of 
                        every 100,000 residents).
                  (B) Diabetes.--With respect to diabetes, in 
                2000--
                          (i) Native Hawaiians had the highest 
                        mortality rate as a result of diabetes 
                        mellitus (38.8 out of every 100,000 
                        residents) in the State, which rate is 
                        138 percent higher than the statewide 
                        rate for all racial groups (16.3 out of 
                        every 100,000 residents); and
                          (ii) full-blood Hawaiians had a 
                        mortality rate as a result of diabetes 
                        mellitus of 93.3 out of every 100,000 
                        residents, which is 518 percent higher 
                        than the rate for the statewide 
                        population of all other racial groups.
                  (C) Asthma.--With respect to asthma--
                          (i) in 1990, Native Hawaiians 
                        comprised 44 percent of all asthma 
                        cases in the State for those 18 years 
                        of age and younger, and 35 percent of 
                        all asthma cases reported, and
                          (ii) in 1999, the Native Hawaiian 
                        prevalence rate for asthma was 129.6 
                        out of every 1,000 residents, which was 
                        69 percent higher than the rate for all 
                        others combined in the State (76.7 out 
                        of every 1,000 residents).
                  (D) Circulatory diseases.--
                          (i) Heart disease.--With respect to 
                        heart disease--
                                  (I) the mortality rate for 
                                Native Hawaiians as a result of 
                                heart disease (372.3 out of 
                                every 100,000 residents) is 68 
                                percent higher than the rate 
                                for the entire State (221.9 out 
                                of every 100,000 residents); 
                                and
                                  (II) Native Hawaiian males 
                                have the greatest years of 
                                productive life lost in the 
                                State, because Native Hawaiian 
                                males lose an average of 15.5 
                                years and Native Hawaiian 
                                females lose an average of 8.2 
                                years as a result of heart 
                                disease, as compared with 7.5 
                                years for all males, and 6.4 
                                years for all females, in the 
                                State.
                          (ii) Hypertension.---With respect to 
                        hypertension--
                                  (I) the mortality rate for 
                                Native Hawaiians as a result of 
                                hypertension (3.5 out of every 
                                100,000 residents) is 84 
                                percent higher than that for 
                                the entire State (1.9 out of 
                                every 100,000 residents);
                                  (II) Native Hawaiians have 
                                substantially higher prevalence 
                                rates of hypertension than--
                                          (aa) those observed 
                                        statewide; and and
                                          (bb) those of any 
                                        other ethnic group in 
                                        Hawai`i; and
                                  (III) the prevalence rate of 
                                hypertension for Native 
                                Hawaiians is 37.9 percent, 11 
                                percent higher than that for 
                                all others in the State (34.1 
                                percent).
                          (iii) Stroke.--The mortality rate for 
                        Native Hawaiians as a result of stroke 
                        (72.0 out of every 100,000 residents) 
                        is 20 percent higher than that for the 
                        entire State (60 out of every 100,000 
                        residents).
          (2) Infectious disease and illness.--With respect to 
        infectious disease and illness--
                  (A) in 1998, Native Hawaiians comprised 20 
                percent of all deaths resulting from infectious 
                diseases in the State for all ages; and
                  (B) the incidence of acquired immune 
                deficiency syndrome for Native Hawaiians is at 
                least twice as high per 100,000 residents (10.5 
                percent) than that for any other non-Caucasian 
                group in the State.
          (3) Injuries.--With respect to injuries--
                  (A) the mortality rate for Native Hawaiians 
                as a result of injuries (32.0 out of every 
                100,000 residents) is 16 percent higher than 
                that for the entire State (27.5 out of every 
                100,000 residents);
                  (B) 32 percent of all deaths of individuals 
                between the ages of 18 and 24 years of age 
                resulting from injuries were Native Hawaiian; 
                and
                  (C) the 2 primary causes of Native Hawaiian 
                deaths in that age group were motor vehicle 
                accidents (30 percent) and intentional self-
                harm (39 percent).
          (4) Dental health.--With respect to dental health--
                  (A) Native Hawaiian children exhibit among 
                the highest rates of dental caries in the 
                United States, and the highest in the State as 
                compared with the 5 other major ethnic groups 
                in the State;
                  (B) the average number of decayed or filled 
                primary teeth for Native Hawaiian children aged 
                5 through 9 years was 4.3, as compared with 3.7 
                for all children in the State and 1.9 for all 
                children in the United States; and
                  (C) the proportion of Native Hawaiian 
                children aged 5 through 12 years with unmet 
                dental treatment needs (defined as having 
                active dental caries requiring treatment) is 40 
                percent, as compared with 33 percent for all 
                other racial groups in the State.
          (5) Life expectancy.--With respect to life 
        expectancy--
                  (A) Native Hawaiians have the lowest life 
                expectancy of all population groups in the 
                State;
                  (B) between 1910 and 1980, the life 
                expectancy of Native Hawaiians from birth has 
                ranged from 5 to 10 years less than that of the 
                overall State population average, and
                  (C) the most recent tables for 1990 show 
                Native Hawaiian life expectancy at birth (74.27 
                years) to be about 5 years less than that of 
                the total State population (78.85 years).
          (6) Maternal and child health.--
                  (A) In general.--With respect to maternal and 
                child health, for 2000
                          (i) 39 percent of all deaths of 
                        children under the age of 18 years in 
                        the State were Native Hawaiian; and
                          (ii) perinatal conditions accounted 
                        for 38 percent of all Native Hawaiian 
                        deaths in that age group.
                  (B) Prenatal care.--With respect to prenatal 
                care--
                          (i) as of 1998, Native Hawaiian women 
                        have the highest prevalence (24 
                        percent) of having had no prenatal care 
                        during the first trimester of 
                        pregnancy, as compared with the 5 
                        largest ethnic groups in the State;
                          (ii) of the mothers in the State who 
                        received no prenatal care throughout 
                        their pregnancies in 1996, 44 percent 
                        were Native Hawaiian;
                          (iii) over 65 percent of the 
                        referrals to Healthy Start in fiscal 
                        years 1996 and 1997 were Native 
                        Hawaiian newborns; and
                          (iv) in every region of the State, 
                        many Native Hawaiian newborns begin 
                        life in a potentially hazardous 
                        circumstance, far higher than any other 
                        racial group.
                  (C) Births.--With respect to births--
                          (i) in 1996, 45 percent of the live 
                        births to Native Hawaiian mothers were 
                        infants born to single mothers, a 
                        circumstance which statistics indicate 
                        puts infants at higher risk of low 
                        birth weight and infant mortality;
                          (ii) in 1996, of the births to Native 
                        Hawaiian single mothers, 8 percent were 
                        low birth weight (defined as a weight 
                        less than 2,500 grams); and
                          (iii) of all low birth weight infants 
                        born to single mothers in the State, 44 
                        percent were Native Hawaiian.
                  (D) Teen pregnancies.--With respect to 
                births--
                          (i) in 1993 and 1994, Native 
                        Hawaiians had the highest percentage of 
                        teen (individuals who were less than 18 
                        years of age) births (8.1 percent), as 
                        compared with the rate for all other 
                        racial groups in the State (3.6 
                        percent);
                          (ii) in 1998, nearly 49 percent of 
                        all mothers in the State under 19 years 
                        of age were Native Hawaiian;
                          (iii) in 1998, Native Hawaiians 
                        comprised 31 percent (1,425) of all 
                        live births to mothers with medical 
                        risk factors in the State (4,559); and
                          (iv) lower rates of abortion 
                        (approximately 33 percent lower than 
                        for the statewide population) among 
                        Hawaiian women may account, in part, 
                        for that higher percentage of live 
                        births.
                  (E) Fetal mortality.--With respect to fetal 
                mortality--
                          (i) in 2000, Native Hawaiians had the 
                        highest number of fetal deaths in the 
                        State; and
                          (ii)(I) 21 percent of all fetal 
                        deaths in the State were associated 
                        with expectant Native Hawaiian mothers; 
                        and
                          (II) 37 percent of those Native 
                        Hawaiian mothers were under the age of 
                        25 years.
          (7) Mental health.--
                  (A) Alcohol and drug abuse.--With respect to 
                alcohol and drug abuse--
                          (i) Native Hawaiians represent 38 
                        percent of the total admissions to 
                        substance abuse treatment programs 
                        funded by the Department of Health, 
                        Alcohol, Drugs and Other Drugs of the 
                        State;
                          (ii) in 2000, the prevalence of 
                        cigarette smoking by Native Hawaiians 
                        was 31.0 percent, a rate that is 57 
                        percent higher than that for the total 
                        population in the State, which is 19.7 
                        percent;,
                          (iii) Native Hawaiians have the 
                        highest prevalence rate of acute 
                        alcohol drinking (19.6 percent), a rate 
                        that is 40 percent higher than that for 
                        the total population in the State;
                          (iv) the chronic alcohol drinking 
                        rate among Native Hawaiians is 54 
                        percent higher than that for all other 
                        racial groups in the State;
                          (v) in 1991, 40 percent of the Native 
                        Hawaiian adults surveyed reported 
                        having used marijuana, as compared with 
                        30 percent for all other racial groups 
                        in the State; and
                          (vi) 9 percent of the Native Hawaiian 
                        adults surveyed reported that they use 
                        or have used marijuana within the year 
                        preceding the survey, as compared with 
                        6 percent for all other racial groups 
                        in the State.
                  (B) Crime.--With respect to crime--
                          (i) in 1998, of the 7,789 arrests 
                        that were made for property crimes in 
                        the State, arrests of Native Hawaiians 
                        comprised 23 percent;
                          (ii) Native Hawaiians comprised 40 
                        percent of juvenile arrests in 1998, 
                        the largest percentage of all juvenile 
                        arrests in that year;
                          (iii) in the period of 1996 through 
                        1998, the overrepresentation of Native 
                        Hawaiian juvenile arrests for index 
                        crimes and Part II offenses increased 
                        by 6 percent and 2 percent, 
                        respectively;
                          (iv) in 1998, Native Hawaiians 
                        represented 22 percent of the 2,423 
                        adults arrested for drug-related 
                        offenses in the State;
                          (v) Native Hawaiians are 
                        overrepresented in the prison 
                        population in the State;
                          (vi) of the 2,260 incarcerated Native 
                        Hawaiians, 70 percent are between 20 
                        and 40 years of age;
                          (vii) in 1995 and 1996, Native 
                        Hawaiians comprised 36.5 percent of the 
                        sentenced felon prison population in 
                        Hawaii, as compared with 20.5 percent 
                        for Caucasian Americans, 3.7 percent 
                        for Japanese Americans, and 6 percent 
                        for Chinese Americans;
                          (viii) in 2002, Native Hawaiians 
                        comprised 40 percent of the total 
                        sentenced felon population in the 
                        State, as compared with 25 percent for 
                        Caucasian Americans, 12 percent for 
                        Filipino Americans, 6 percent for 
                        Japanese Americans, and 5 percent for 
                        Samoans; and
                          (ix) based on anecdotal information 
                        from inmates at the Halawa Correction 
                        Facilities, Native Hawaiians are 
                        estimated to comprise between 60 and 70 
                        percent of all inmates in the State.
          (8) Obesity.--Native Hawaiians have the highest 
        prevalence rate of overweightness and obesity (69.4 
        percent), a rate that is 38 percent higher than that 
        for the total State population (50.2 percent).
          (9) Health professions education and training.--With 
        respect to health professions education and training--
                  (A)(i) Native Hawaiians who are at least 25 
                years of age have a comparable rate of high 
                school completion as compared with all people 
                in the State who are at least 25 years of age; 
                but
                  (ii) the rate of baccalaureate degree 
                achievement among Native Hawaiians is 6.9 
                percent, which is less than the average in the 
                State (15.76 percent);
                  (B) Native Hawaiian physicians make up 4 
                percent of the total physician workforce in the 
                State; and
                  (C)(i) in fiscal year 1999, Native Hawaiians 
                comprised--
                          (I) 9 percent of those individuals 
                        who earned Bachelor's degrees;
                          (II) 15 percent of those individuals 
                        who earned 2-year diplomas; and
                          (III) 6 percent of those individuals 
                        who earned Master's degrees; and
                  (ii) in 1997, Native Hawaiians comprised less 
                than 1 percent of individuals who earned 
                doctoral degrees at the University of Hawai`i.

Sec. 11702. Declaration of [policy] National Native Hawaiian Health 
                    Policy

    (a) [Congress] Declaration.--[The] Congress [hereby] 
declares that it is the policy of the United States, in 
fulfillment of [its] special responsibilities and legal 
obligations of the United States to the indigenous people of 
Hawaii resulting from the unique and historical relationship 
between the United States and the [Government of the] 
indigenous people of Hawai`i--
          (1) to raise the health status of Native Hawaiians to 
        the highest [possible] practicable health level; and
          (2) to provide [existing] Native Hawaiian health care 
        programs with all resources necessary to effectuate 
        [this] that policy.
    (b) Intent of Congress.--It is the intent of the Congress 
that--[the Nation meet the following health objectives with 
respect to Native Hawaiians by the year 2000:]
          (1) [Reduce coronary heart disease deaths to no more 
        than 100 per 100,000.] health care programs having a 
        demonstrated effect of substantially reducing or 
        eliminating the overrepresentation of Native Hawaiians 
        among those suffering from chronic and acute disease 
        and illness, and addressing the health needs of Native 
        Hawaiians (including perinatal, early child 
        development, and family-based health education needs), 
        shall be established and implemented, and
          (2) [Reduce stroke deaths to no more than 20 per 
        100,000.] the United States--
                  (A) raise the health status of Native 
                Hawaiians by the year 2010 to at least the 
                levels described in the goals contained within 
                Healthy People 2010 (or successor standards); 
                and
                  (B) incorporate within health programs in the 
                United States activities defined and identified 
                by Kanaka Maoli, such as--
                          (i) incorporating and supporting the 
                        integration of cultural 60 approaches 
                        to health and well-being, including 
                        programs using traditional practices 
                        relating to the atmosphere (lewa lani), 
                        land (`aina), water (wai), or ocean 
                        (kai);
                          (ii) increasing the number of Native 
                        Hawaiian health and allied-health care 
                        providers who provide care to or have 
                        an impact on the health status of 
                        Native Hawaiians;
                          (iii) increasing the use of 
                        traditional Native Hawaiian foods those 
                        in--
                                  (I) the diets and dietary 
                                preferences of people, 
                                including those of students; 
                                and
                                  (II) school feeding programs;
                          (iv) identifying and instituting 
                        Native Hawaiian cultural values and 
                        practices within the corporate cultures 
                        of organizations and agencies providing 
                        health services to Native Hawaiians;
                          (v) facilitating the provision of 
                        Native Hawaiian healing practices by 
                        Native Hawaiian healers for individuals 
                        desiring that assistance;
                          (vi) supporting training and 
                        education activities and programs in 
                        traditional Native Hawaiian healing 
                        practices by Native Hawaiian healers; 
                        and
                          (vii) demonstrating the integration 
                        of health services for Native 
                        Hawaiians, particularly those that 
                        integrate mental, physical, and dental 
                        services in health care.
          [(3) Increase control of high blood pressure to at 
        least 50 percent of people with high blood pressure.
          [(4) Reduce blood cholesterol to an average of no 
        more than 200 mg/dl.
          [(5) Slow the rise in lung cancer deaths to achieve a 
        rate of no more than 42 per 100,000.
          [(6) Reduce breast cancer deaths to no more than 20.6 
        per 100,000 women.
          [(7) Increase Pap tests every 1 to 3 years to at 
        least 85 percent of women age 18 and older.
          [(8) Increase fecal occult blood testing every 1 to 2 
        years to at least 50 percent of people age 50 and 
        older.
          [(9) Reduce diabetes-related deaths to no more than 
        34 per 100,000.
          [(10) Reduce the most severe complications of 
        diabetes as follows:
                  [(A) end-stage renal disease to no more than 
                1.4 in 1,000;
                  [(B) blindness to no more than 1.4 in 1,000;
                  [(C) lower extremity amputation to no more 
                than 4.9 in 1,000;
                  [(D) perinatal mortality to no more than 2 
                percent; and
                  [(E) major congenital malformations to no 
                more than 4 percent.
          [(11) Reduce infant mortality to no more than 7 
        deaths per 1,000 live births.
          [(12) Reduce low birth weight to no more than 5 
        percent of live births.
          [(13) Increase first trimester prenatal care to at 
        least 90 percent of live births.
          [(14) Reduce teenage pregnancies to no more than 50 
        per 1,000 girls age 17 and younger.
          [(15) Reduce unintended pregnancies to no more than 
        30 percent of pregnancies.
          [(16) Increase to at least 60 percent the proportion 
        of primary care providers who provide age-appropriate 
        preconception care and counseling.
          [(17) Increase years of healthy life to at least 65 
        years.
          [(18) Eliminate financial barriers to clinical 
        preventive services.
          [(19) Increase childhood immunization levels to at 
        least 90 percent of 2-year-olds.
          [(20) Reduce the prevalence of dental caries to no 
        more than 35 percent of children by age 8.
          [(21) Reduce untreated dental caries so that the 
        proportion of children with untreated caries (in 
        permanent or primary teeth) is no more than 20 percent 
        among children age 6 through 8 and no more than 15 
        percent among adolescents age 15.
          [(22) Reduce edentulism to no more than 20 percent in 
        people age 65 and older.
          [(23) Increase moderate daily physical activity to at 
        least 30 percent of the population.
          [(24) Reduce sedentary lifestyles to no more than 15 
        percent of the population.
          [(25) Reduce overweight to a prevalence of no more 
        than 20 percent of the population.
          [(26) Reduce dietary fat intake to an average of 30 
        percent of calories or less.
          [(27) Increase to at least 75 percent the proportion 
        of primary care providers who provide nutrition 
        assessment and counseling or referral to qualified 
        nutritionists or dieticians.
          [(28) Reduce cigarette smoking prevalence to no more 
        than 15 percent of adults.
          [(29) Reduce initiation of smoking to no more than 15 
        percent by age 20.
          [(30) Reduce alcohol-related motor vehicle crash 
        deaths to no more than 8.5 per 100,000 adjusted for 
        age.
          [(31) Reduce alcohol use by school children age 12 to 
        17 to less than 13 percent.
          [(32) Reduce marijuana use by youth age 18 to 25 to 
        less than 8 percent.
          [(33) Reduce cocaine use by youth age 18 to 25 to 
        less than 3 percent.
          [(34) Confine HIV infection to no more than 800 per 
        100,000.
          [(35) Reduce gonorrhea infections to no more than 225 
        per 100,000.
          [(36) Reduce syphilis infections to no more than 10 
        per 100,000.
          [(37) Reduce significant hearing impairment to a 
        prevalence of no more than 82 per 1,000.
          [(38) Reduce acute middle ear infections among 
        children age 4 and younger, as measured by days of 
        restricted activity or school absenteeism, to no more 
        than 105 days per 100 children.
          [(39) Reduce indigenous cases of vaccine-preventable 
        diseases as follows:
                  [(A) Diphtheria among individuals age 25 and 
                younger to 0;
                  [(B) Tetanus among individuals age 25 and 
                younger to 0;
                  [(C) Polio (wild-type virus) to 0;
                  [(D) Measles to 0;
                  [(E) Rubella to 0;
                  [(F) Congenital Rubella Syndrome to 0;
                  [(G) Mumps to 500; and
                  [(H) Pertussis to 1,000; and
          [(40) Reduce significant visual impairment to a 
        prevalence of no more than 30 per 1,000.]
    (c) Report.--The Secretary shall submit to the President, 
for inclusion in each report required to be [transmitted] 
submitted to [the] Congress under section [11710 of this title] 
12, a report on the progress made [in each area] toward meeting 
[each of the objectives described in subsection (b) of this 
section.] the national policy described in this section.

Sec. 11703. Comprehensive health care master plan for Native Hawaiians

    (a) Development.--
          (1) In general.--The Secretary may make a grant to, 
        or enter into a contract with, Papa Ola Lokahi for the 
        purpose of coordinating, implementing, and updating a 
        Native Hawaiian comprehensive health care master plan 
        that is designed--
                  (A) to promote comprehensive health promotion 
                and disease prevention services;
                  (B) [and] to maintain and improve the health 
                status of Native Hawaiians; and [The master 
                plan shall be based upon an assessment of the 
                health care status and health care needs of 
                Native Hawaiians. To the extent practicable, 
                assessments made as of the date of such grant 
                or contract shall be used by Papa Ola Lokahi, 
                except that any such assessment shall be 
                updated as appropriate.]
                  (C) to support community-based initiatives 
                that are reflective of holistic approaches to 
                health.
          (2) Consultation.--
                  (A) In general.--In carrying out this 
                section, Papa Ola Lokahi and the Office of 
                Hawaiian Affairs shall consult with 
                representatives of--
                          (i) the Native Hawaiian health care 
                        systems;
                          (ii) the Native Hawaiian health 
                        centers; and
                          (iii) the Native Hawaiian community.
                  (B) Memoranda of understanding.--Papa Ola 
                Lokahi and the Office of Hawaiian Affairs may 
                enter into memoranda of understanding or 
                agreement for the purpose of acquiring joint 
                funding, and for other such purposes as are 
                necessary, to accomplish the objectives of this 
                section.
          (3) Health care financing study report.--
                  (A) In general.--Not later than 18 months 
                after the date of enactment of the Native 
                Hawaiian Health Care Improvement 
                Reauthorization Act of 2003, Papa Ola Lokahi, 
                in cooperation with the Office of Hawaiian 
                Affairs and other appropriate agencies and 
                organizations in the State (including the 
                Department of Health and the Department of 
                Human Services of the State) and appropriate 
                Federal agencies (including the Centers for 
                Medicare and Medicaid Services), shall submit 
                to Congress a report that describes the impact 
                of Federal and State health care financing 
                mechanisms and policies on the health and well-
                being of Native Hawaiians.
                  (B) Components.--The report shall include--
                          (i) information concerning the impact 
                        on Native Hawaiian health and well-
                        being of--
                                  (I) cultural competency;
                                  (II) risk assessment data,
                                  (III) eligibility 
                                requirements and exemptions; 
                                and
                                  (IV) reimbursement policies 
                                and capitation rates in effect 
                                as of the date of the report 
                                for service providers;
                          (ii) such other similar information 
                        as may be important to improving the 
                        health status of Native Hawaiians, as 
                        that information relates to health care 
                        financing (including barriers to health 
                        care); and
                          (iii) recommendations for submission 
                        to the Secretary, for review and 
                        consultation with the Native Hawaiian 
                        community.
    (b) Authorization of Appropriations.--There are authorized 
to be appropriated such sums as [may be] are necessary to carry 
out subsection (a) [of this section].

Sec. 11704. Functions of Papa Ola Lokahi and Office of Hawaiian Affairs

    (a) [Responsibility] In General.--Papa Ola Lokahi--
          (1) shall be responsible for [the]--
                  [(1)] (A) the coordination, implementation, 
                and updating, as appropriate, of the 
                comprehensive health care master plan 
                [developed pursuant to] under section [11703 of 
                this title] 5;
                  [(2)] (B) the training and education of 
                individuals providing health services [for the 
                persons described in section 11705(c)(1)(B) of 
                this title];
                  [(3)] (C) the identification of and research 
                (including behavioral, biomedical, 
                epidemiological, and health service research) 
                into the diseases that are most prevalent among 
                Native Hawaiians[, including behavioral, 
                biomedical, epidemiological, and health 
                services]; and
                  (D) the development and maintenance of an 
                institutional review board for all research 
                projects involving all aspects of Native 
                Hawaiian health, including behavioral, 
                biomedical, epidemiological, and health service 
                research;
          (2) may receive special project funds (including 
        research endowments under section 736 of the Public 
        Health Service Act (42 U.S.C. 293)) made available for 
        the purpose of--
                  (A) research on the health status of Native 
                Hawaiians; or
                  (B) addressing the health care needs of 
                Native Hawaiians; and
          (3) shall serve as a clearinghouse for--
                  (A) the collection and maintenance of data 
                associated with the health status of Native 
                Hawaiians;
                  (B) the identification and research into 
                diseases affecting Native Hawaiians;
                  (C) the availability of Native Hawaiian 
                project funds, research projects, and 
                publications;
                  (D) the collaboration of research in the area 
                of Native Hawaiian health; and
                  (E) the timely dissemination of information 
                pertinent to the Native Hawaiian health care 
                systems.
          [(4) the development of an action plan outlining the 
        contributions that each member organization of Papa Ola 
        Lokahi will make in carrying out the policy of this 
        chapter.]
    [(b) Special Project Funds.--Papa Ola Lokahi [is authorized 
to] may receive special project funds that may be appropriated 
for the purpose of research on the health status of Native 
Hawaiians or for the purpose of addressing the health care 
needs of Native Hawaiians.]
    (b) Consultation.--
          (1) In general.--The Secretary and the Secretary of 
        each other Federal agency shall--
                  (A) consult with Papa Ola Lokahi; and
                  (B) provide Papa Ola Lokahi and the Office of 
                Hawaiian Affairs, at least once annually, an 
                accounting of funds and services provided by 
                the Secretary to assist in accomplishing the 
                purposes described in section 4.
          (2) Components of accounting.--The accounting under 
        paragraph (1)(B) shall include an identification of--
                  (A) the amount of funds expended explicitly 
                for and benefiting Native Hawaiians;
                  (B) the number of Native Hawaiians affected 
                by those funds;
                  (C) the collaborations between the applicable 
                Federal agency and Native Hawaiian groups and 
                organizations in the expenditure of those 
                funds; and
                  (D) the amount of funds used for--
                          (i) Federal administrative purposes; 
                        and
                          (ii) the provision of direct services 
                        to Native Hawaiians.
    [(c) Clearinghouse.--Papa Ola Lokahi shall serve as a 
clearinghouse for:
          [(1) the collection and maintenance of data 
        associated with the health status of Native Hawaiians;
          [(2) the identification and research into diseases 
        affecting Native Hawaiians;
          [(3) the availability of Native Hawaiian project 
        funds, research projects and publications;
          [(4) the collaboration of research in the area of 
        Native Hawaiian health; and
          [(5) the timely dissemination of information 
        pertinent to the Native Hawaiian health care systems.]
    (c) Fiscal Allocation and Coordination of Programs and 
Services.--
          (1) Recommendations.--Papa Ola Lokahi shall provide 
        annual recommendations to the Secretary with respect to 
        the allocation of all amounts made available under this 
        Act.
          (2) Coordination.--Papa Ola Lokahi shall, to the 
        maximum extent practicable, coordinate and assist the 
        health care programs and services provided to Native 
        Hawaiians under this Act and other Federal laws.
          (3) Representation on commission.--The Secretary, in 
        consultation with Papa Ola Lokahi, shall make 
        recommendations for Native Hawaiian representation on 
        the President's Advisory Commission on Asian Americans 
        and Pacific Islanders.
    [(d) Coordination of Programs and Services.--Papa Ola 
Lokahi shall, to the maximum extent possible, coordinate and 
assist the health care programs and services provided to Native 
Hawaiians.]
    [(e)] (d) Technical Support.--Papa Ola Lokahi shall [act as 
a] provide statewide infrastructure to provide technical 
support and coordination of training and technical assistance 
to--
          (1) the Native Hawaiian health care systems; and
          (2) the Native Hawaiian health centers.
    [(f)] (e) Relationships with Other Agencies.--
        (1) Authority.--Papa Ola Lokahi [is authorized to] may 
        enter into agreements or memoranda of understanding 
        with relevant institutions, agencies, or organizations 
        that are capable of providing--
                  (A) health-related resources or services to 
                Native Hawaiians and the Native Hawaiian health 
                care systems; or
                  (B) resources or services for the 
                implementation of the national policy described 
                in section 4.
          (2) Health care financing.--
                  (A) Federal consultation.--
                          (i) In general.--Before adopting any 
                        policy, rule, or regulation that may 
                        affect the provision of services or 
                        health insurance coverage for Native 
                        Hawaiians, a Federally agency that 
                        provides health care financing and 
                        carries out health care programs 
                        (including the Centers for Medicare and 
                        Medicaid Services) shall consult with 
                        representatives of--
                                  (I) the Native Hawaiian 
                                community;
                                  (II) Papa Ola Lokahi; and
                                  (III) organizations providing 
                                health care services to Native 
                                Hawaiians in the State.
                          (ii) Identification of effects.--Any 
                        consultation by a Federal agency under 
                        clause (i) shall include an 
                        identification of the effect of any 
                        policy, rule, or regulation proposed by 
                        the Federal agency.
                  (B) State consultation.--Before making any 
                change in an existing program or implementing 
                any new program relating to Native Hawaiian 
                health, the State shall engage in meaningful 
                consultation with representatives of--
                          (i) the Native Hawaiian community;
                          (ii) Papa Ola Lokahi; and
                          (iii) organizations providing health 
                        care services to Native Hawaiians in 
                        the State.
                  (C) Consultation on federal health insurance 
                programs.--
                          (i) In general.--The Office of 
                        Hawaiian Affairs, in collaboration with 
                        Papa Ola Lokahi, may develop 
                        consultative, contractual, or other 
                        arrangements, including memoranda of 
                        understanding or agreement, with--
                                  (I) the Centers for Medicare 
                                and Medicaid Services;
                                  (II) the agency of the State 
                                that administers or supervises 
                                the administration of the State 
                                plan or waiver approved under 
                                title XVIII, XIX, or XXI of the 
                                Social Security Act (42 U.S.C. 
                                1395 et seq.) for the payment 
                                of all or a part of the health 
                                care services provided to 
                                Native Hawaiians who are 
                                eligible for medical assistance 
                                under the State plan or waiver; 
                                or
                                  (III) any other Federal 
                                agency providing full or 
                                partial health insurance to 
                                Native Hawaiians.
                          (ii) Contents of arrangements.--An 
                        arrangement under clause (i) may 
                        address--
                                  (I) appropriate reimbursement 
                                for health care services, 
                                including capitation rates and 
                                fee-for-service rates for 
                                Native Hawaiians who are 
                                entitled to or eligible for 
                                insurance;
                                  (II) the scope of services; 
                                or
                                  (III) other matters that 
                                would enable Native Hawaiians 
                                to maximize health insurance 
                                benefits provided by Federal 
                                and State health insurance 
                                programs.
          (3) Traditional healers.--
                  (A) In general.--The provision of health 
                services under any program operated by the 
                Department of another Federal agency (including 
                Department of Veterans Affairs) may include the 
                services of--
                          (i) traditional Native Hawaiian 
                        healers; or
                          (ii) traditional healers providing 
                        traditional health care practices (as 
                        those terms are defined in section 4 of 
                        the Indian Health Care Improvement Act 
                        (25 U.S.C. 1603).
                  (B) Exemption.--Services described in 
                subparagraph (A) shall be exempt from national 
                accreditation reviews, including reviews 
                conducted by--
                          (i) the joint Commission on 
                        Accreditation of Healthcare 
                        Organizations; and
                          (ii) the Commission on Accreditation 
                        of Rehabilitation Facilities.

Sec. 11705. Native Hawaiian health care [systems]

    (a) Comprehensive Health Promotion, Disease Prevention, and 
[Primary] Other Health Services.--
          (1)[(A)] Grants and contracts.--The Secretary, in 
        consultation with Papa Ola Lokahi, may make grants to, 
        or enter into contracts with 1 or more Native Hawaiian 
        health care systems [, any qualified entity] for the 
        purpose of providing comprehensive health promotion and 
        disease prevention services, as well as [primary] other 
        health services, to Native Hawaiians who desire and are 
        committed to bettering their own health.
          [(B)] (2) Limitation on number of entities.--[In 
        making grants and entering into contracts under this 
        paragraph, the Secretary shall give preference to 
        Native Hawaiian health care systems and Native Hawaiian 
        organizations and, to the extent feasible, health 
        promotion and disease prevention services shall be 
        performed through Native Hawaiian health care systems.] 
        The Secretary may make a grant to, or enter into a 
        contract with, not more than 8 Native Hawaiian health 
        care systems under this subsection for any fiscal year.
    [2] (b) Planning Grant or Contract.--In addition to 
[paragraph (1)] grants and contracts under subsection (a), the 
Secretary may make a grant to, or enter into a contract with, 
Papa Ola Lokahi for the purpose of planning Native Hawaiian 
health care systems to serve the health needs of Native 
Hawaiian communities on each of the islands of O`ahu, Moloka`i, 
Maui, Hawai`i, Lana`i, Kaua`i, Kaho`lawe, and Ni`ihau in the 
State [of Hawai`i].
    [(b) Qualified Entity.--An entity is a qualified entity for 
purposes of subsection (a)(1) of this section if the entity is 
a Native Hawaiian health care system.]
    (c) Health Services To Be Provided.--
        (1) In general.--Each recipient of funds under 
        subsection (a)[(1) of this section shall] may provide 
        or arrange for--[the following services:]
                  (A) outreach services to inform and assist 
                Native Hawaiians [of the availability of] in 
                accessing health services;
                  (B) education in health promotion and disease 
                prevention [of the] for Native [Hawaiian 
                population by] Hawaiians that, wherever 
                [possible] practicable, is provided by--
                          (i) Native Hawaiian health care 
                        practitioners[,];
                          (ii) community outreach workers[,];
                          (iii) counselors[, and];
                          (iv) cultural educators; and
                          (v) other disease prevention 
                        providers;
                  (C) services of [physicians, physicians' 
                assistants, nurse practitioners or other health 
                professionals] individuals providing health 
                services;
                  (D) [immunizations] collection of data 
                relating to the prevention of diseases and 
                illnesses among Native Hawaiians; and
                  (E) [prevention and control of diabetes, high 
                blood pressure, and otitis media;] support of 
                culturally appropriate activities that enhance 
                health and wellness, including land-based, 
                water-based, ocean-based, and spiritually-based 
                projects and programs.
                  [(F) pregnancy and infant care; and
                  [(G) improvement of nutrition.
          [(2) In addition to the mandatory services under 
        paragraph (1), the following services may be provided 
        pursuant to subsection (a)(1) of this section:
                  [(A) identification, treatment, control, and 
                reduction of the incidence of preventable 
                illnesses and conditions endemic to Native 
                Hawaiians;
                  [(B) collection of data related to the 
                prevention of diseases and illnesses among 
                Native Hawaiians; and
                  [(C) services within the meaning of the terms 
                ``health promotion'', ``disease prevention'', 
                and ``primary health services'', as such terms 
                are defined in section 11711 of this title, 
                which are not specifically referred to in 
                paragraph (1) of this subsection.]
          [(3)] (2) Traditional healers.--The health care 
        services referred to in [paragraphs (1) and (2)] 
        paragraph (1) [which] that are provided under grants or 
        contracts under subsection (a)[(1) of this section] may 
        be provided by traditional Native Hawaiian healers, as 
        appropriate.
    [(d) Limitation of Number of Entities.--During a fiscal 
year, the Secretary under this chapter may make a grant to, or 
hold a contract with, not more than 5 Native Hawaiian health 
care systems.]
    (d) Federal Tort Claims Act.--An individual who provides a 
medical, dental, or other service referred to in subsection 
(a)(1) for a Native Hawaiian health care system, including a 
provider of a traditional Native Hawaiian healing service, 
shall be--
          (1) treated as if the individual were a member of the 
        Public Health Service; and
          (2) subject to section 224 of the Public Health 
        Service Act (42 U.S.C. 233).
    [(e) Matching Funds.--
          [(1) The Secretary may not make a grant or provide 
        funds pursuant to a contract under subsection (a)(1) of 
        this section to a Native Hawaiian health care system--
                  [(A) in an amount exceeding 83.3 percent of 
                the costs of providing health services under 
                the grant or contract; and
                  [(B) unless the Native Hawaiian health care 
                system agrees that the Native Hawaiian health 
                care system or the State of Hawai`i will make 
                available, directly or through donations to the 
                Native Hawaiian health care system, non-Federal 
                contributions toward such costs in an amount 
                equal to not less than $1 (in cash or in kind 
                under paragraph (2) for each $5 of Federal 
                funds provided in such grant or contract.
          [(2) Non-Federal contributions required in paragraph 
        (1) may be in cash or in kind, fairly evaluated, 
        including plant, equipment, or services. Amounts 
        provided by the Federal Government or services assisted 
        or subsidized to any significant extent by the Federal 
        Government may not be included in determining the 
        amount of such non-Federal contributions.
          [(3) The Secretary may waive the requirement 
        established in paragraph (1) if--
                  [(A) the Native Hawaiian health care system 
                involved is a nonprofit private entity 
                described in subsection (b) of this section; 
                and
                  [(B) the Secretary, in consultation with Papa 
                Ola Lokahi, determines that it is not feasible 
                for the Native Hawaiian health care system to 
                comply with such requirement.]
    (e) Site for Other Federal Payments.--
          (1) In general.--A Native Hawaiian health care system 
        that receives funds under subsection (a) may serve as a 
        Federal loan repayment facility.
          (2) Remission of payments.--A facility described in 
        paragraph (1) shall be designed to enable health and 
        allied-health professionals to remit payments with 
        respect to loans provided to the professionals under 
        any Federal loan program.
          (f) Restriction on Use of Grant and Contract Funds.--
        The Secretary [may] shall not make a grant to, or enter 
        into a contract with, [any] an entity under subsection 
        (a) [(1) of this section] unless the entity agrees 
        that[,] amounts received [pursuant to such subsection] 
        under the grant or contract will not, directly or 
        through contract, be expended--
          (1) for any [purpose] service other than [the 
        purposes] a service described in subsection (c) [of 
        this section] (1);
          [(2) to provide inpatient services;
          [(3) to make cash payments to intended recipients of 
        health services; or]
          [(4)] (2) to purchase or improve real property (other 
        than minor remodeling of existing improvements to real 
        property); or
          (3) to purchase major medical equipment.
    (g) Limitation on Charges for Services.--The Secretary 
[may] shall not make a grant to, or enter into a contract with, 
[any] an entity under subsection (a)[(1) of this section] 
unless the entity agrees that, whether health services are 
provided directly or [through] under a contract--
          (1) any health [services] service under the grant or 
        contract will be provided without regard to the ability 
        of an individual receiving the health service to pay 
        for the health [services] service; and
          (2) the entity will impose [a charge] for the 
        delivery of such a health [services, and such charge] 
        service a charge that is--
                  (A) [will be] made according to a schedule of 
                charges that is made available to the public, 
                and
                  (B) [will be] adjusted to reflect the income 
                of the individual involved.
    (h) Authorization of Appropriations.--
          (1) General grants.--There are authorized to be 
        appropriated such sums as [may be] are necessary to 
        carry out subsection (a) for each of fiscal years 
        [1993] 2004 through [2001] 2009 [to carry out 
        subsection (a)(1) of this section].
          (2) Planning grants.--There are authorized to be 
        appropriated such sums as [may be] are necessary to 
        carry out subsection [(a)(2) of this section] (b) for 
        each of fiscal years 2004 through 2009.
          (3) Health services.--There are authorized to be 
        appropriated such sums as are necessary to carry out 
        subsection (c) for each of fiscal years 2004 through 
        2009.

Sec. 11706. Administrative grant for Papa Ola Lokahi

    (a) In general.--In addition to any other grant or contract 
under this [chapter] Act, the Secretary may make grants to, or 
enter into contracts with, Papa Ola Lokahi for--
          (1) coordination, implementation, and updating (as 
        appropriate) of the comprehensive health care master 
        plan developed [pursuant to section 11703 of this 
        title] under section 5;
          (2) training and education for [the persons described 
        in section 11705(c)(1)(B) of this title] providers of 
        health services;
          (3) identification of and research [into the diseases 
        that are most prevalent among Native Hawaiians,] 
        (including behavioral, biomedical, [epidemiological] 
        epidemiologic, and health [services] service research) 
        into the diseases that are most prevalent among Native 
        Hawaiians;
          [(4) the development of an action plan outlining the 
        contributions that each member organization of Papa Ola 
        Lokahi will make in carrying out the policy of this 
        chapter;]
          [(5)] (4) a clearinghouse function for--
                  (A) the collection and maintenance of data 
                associated with the health status of Native 
                Hawaiians;
                  (B) the identification and research into 
                diseases affecting Native Hawaiians; and
                  (C) the availability of Native Hawaiian 
                project funds, research projects and 
                publications;
          (5) the establishment and maintenance of an 
        institutional review board for all health-related 
        research involving Native Hawaiians;
          (6) the coordination of the health care programs and 
        services provided to Native Hawaiians; and
          (7) the administration of special project funds.
    (b) Authorization of Appropriations.--There are authorized 
to be appropriated such sums as [may be] are necessary to carry 
out subsection (a) for each of fiscal years [1993] 2004 through 
[2001] 2009 [to carry out 80 subsection (a) of this section].

Sec. 11707. Administration of grants and contracts

    (a) Terms and Conditions.--The Secretary shall include in 
any grant made or contract entered into under this [chapter] 
Act such terms and conditions as the Secretary considers 
necessary or appropriate to ensure that the objectives of 
[such] the grant or contract are achieved.
    (b) Periodic Review.--The Secretary shall periodically 
evaluate the performance of, and compliance with, grants and 
contracts under this [chapter] Act.
    (c) Administrative Requirements.--The Secretary [may] shall 
not make a grant or enter into a contract under this [chapter] 
Act with an entity unless the entity--
          (1) agrees to establish such procedures for fiscal 
        control and fund accounting as [may be] the Secretary 
        determines are necessary to ensure proper disbursement 
        and accounting with respect to the grant or contract;
          (2) agrees to ensure the confidentiality of records 
        maintained on individuals receiving health services 
        under the grant or contract;
          (3) with respect to providing health services to any 
        population of Native Hawaiians, a substantial portion 
        of which has a limited ability to speak the English 
        language--
                  (A) has developed and has the ability to 
                carry out a reasonable plan to provide health 
                services under the grant or contract through 
                individuals who are able to communicate with 
                the population involved in the language and 
                cultural context that is most appropriate; and
                  (B) has designated at least [one] 1 
                individual[,] who is fluent in [both] English 
                and the appropriate language[,] to assist in 
                carrying out the plan;
          (4) with respect to health services that are covered 
        [in the plan of the State of Hawai`i approved] under a 
        program under title XVIII, XIX, or XXI of the Social 
        Security Act [42 U.S.C.A. Sec. 1396 et seq.] (42 U.S.C. 
        1395 et seq.) (including any State plan), or under any 
        other Federal health insurance plan--
                  (A) if the entity will provide under the 
                grant or contract any [such] of those health 
                services directly--
                          (i) [the entity] has entered into a 
                        participation agreement under each such 
                        [plans] plan; and
                          (ii) [the entity] is qualified to 
                        receive payments under [such] the plan; 
                        and
                  (B) if the entity will provide under the 
                grant or contract any [such] of those health 
                services through a contract with an 
                organization--
                          (i) ensures that the organization has 
                        entered into a participation agreement 
                        under each such plan; and
                          (ii) ensures that the organization is 
                        qualified to receive payments under 
                        [such] the plan; and
          (5) agrees to submit to the Secretary and [to] Papa 
        Ola Lokahi an annual report that--
                  (A) describes the [utilization] use and costs 
                of health services provided under the grant or 
                contract (including the average cost of health 
                services per user); and
                  (B) [that] provides such other information as 
                the Secretary determines to be appropriate.
    (d) Contract Evaluation.--
          (1) Determination of noncompliance._If, as a result 
        of evaluations conducted by the Secretary, the 
        Secretary determines that an entity has not complied 
        with or satisfactorily performed a contract entered 
        into under section [11705 of this title] 7, the 
        Secretary shall, [prior to] before renewing [such] the 
        contract[,]--
                  (A) attempt to resolve the areas of 
                noncompliance or unsatisfactory performance; 
                and
                  (B) modify [such] the contract to prevent 
                future occurrences of [such] the noncompliance 
                or unsatisfactory performance.
          (2) Nonrenewal.--If the Secretary determines that 
        [such] the noncompliance or unsatisfactory performance 
        described in paragraph (1) with respect to an entity 
        cannot be resolved and prevented in the future, the 
        Secretary--
                  (A) shall not renew [such] the contract with 
                [such] the entity; and
                  (B) [is authorized to] may enter into a 
                contract under section [11705 of this title] 7 
                with another entity referred to in section 
                [11705(b)] 7(a)(3) [of this title] that 
                provides services to the same population of 
                Native Hawaiians [which is] served by the 
                entity [whose contract is] the contract with 
                which was not renewed by reason of this 
                [subsection] paragraph.
          [(2)] (3) Consideration of results.--In determining 
        whether to renew a contract entered into with an entity 
        under this [chapter] Act, the Secretary shall consider 
        the results of the [evaluation] evaluations conducted 
        under this section.
          [(3)] (4) Application of federal laws.--[All 
        contracts] Each contract entered into by the Secretary 
        under this [chapter] Act shall be in accordance with 
        all Federal contracting laws [and] (including 
        regulations), except that, in the discretion of the 
        Secretary, such [contracts] a contract may--
                  (A) be negotiated without advertising; and
                  (B) [may] be exempted from [the provisions of 
                the Act of August 24, 1935 (40 U.S.C. 270a et 
                seq.)] subchapter III of chapter 31, United 
                States Code.
          [(4)] (5) Payments.--A [Payments] payment made under 
        any contract entered into under this [chapter] Act--
                  (A) may be made--
                          (i) in advance[,];
                          (ii) by means of reimbursement[,]; or
                          (iii) in installments; and
                  (B) shall be made on such conditions as the 
                Secretary [deems] determines to be necessary to 
                carry out [the purposes of] this [chapter] Act.
    [(e) Limitation on Use of Funds for Administrative 
Expenses.--Except for grants and contracts under section 11706 
of this title, the Secretary may not grant to, or enter into a 
contract with, an entity under this chapter unless the entity 
agrees that the entity will not expend more than 10 percent of 
amounts received pursuant to this chapter for the purpose of 
administering the grant or contract.]
    [(f)] (e) Report.--
          (1) In general.--For each fiscal year during which an 
        entity receives or expends funds [pursuant to] under a 
        grant or contract under this [chapter] Act, [such] the 
        entity shall submit to the Secretary and to Papa Ola 
        Lokahi [a quarterly] an annual report [on] that 
        describes--
                  (A) the activities conducted by the entity 
                under the grant or contract;
                  (B) the amounts and purposes for which 
                Federal funds were expended; and
                  (C) such other information as the Secretary 
                may request.
          (2) Audits.--The reports and records of any entity 
        [which concern] concerning any grant or contract under 
        this [chapter] Act shall be subject to audit by--
                  (A) the Secretary[,];
                  (B) the Inspector General of the Department 
                of Health and Human Services[,]; and
                  (C) the Comptroller General of the United 
                States.
    [(g)] (f) Annual Private Audit.--The Secretary shall allow 
as a cost of any grant made or contract entered into under this 
[chapter] Act the cost of an annual private audit conducted by 
a certified public accountant to carry out this section.

Sec. 11708. Assignment of personnel

    (a) In General.--The Secretary [is authorized to] may enter 
into an agreement with [any entity under which the Secretary is 
authorized to assign] Papa Ola Lokahi or any of the Native 
Hawaiian health care systems for the assignment of personnel of 
the Department of Health and Human Services with relevant 
expertise [identified by such entity to such entity on detail] 
for the [purposes] purpose of--
          (1) conducting research; or
          (2) providing comprehensive health promotion and 
        disease prevention services and health services to 
        Native Hawaiians.
    (b) Applicable Federal Personnel Provisions.--Any 
assignment of personnel made by the Secretary under any 
agreement entered into under [the authority of] subsection (a) 
[of this section] shall be treated as an assignment of Federal 
personnel to a local government that is made in accordance with 
subchapter VI of chapter 33 of [Title] title 5, United States 
Code.

Sec. 11709. Native Hawaiian health scholarships and Fellowships

    (a) Eligibility.--Subject to the availability of [funds] 
amounts appropriated under [the authority of] subsection (c) 
[of this section], the Secretary shall provide to Papa Ola 
Lokahi, through a direct grant or a cooperative agreement, 
funds [through a direct grant or a cooperative agreement to 
Papa Ola Lokahi] for the purpose of providing scholarship 
assistance to students who are Native Hawaiians.[--]
          [(1) meet the requirements of section 254l of this 
        title, and
          [(2) are Native Hawaiians.]
    (b) Priority.--A priority for scholarships under subsection 
(a) may be provided to employees of--
          (1) the Native Hawaiian Health Care Systems; and
          (2) the Native Hawaiian Health Centers.--
    [(b)] (c) Terms and Conditions.--
          (1) Scholarship assistance.--
                  (A) In general.--The scholarship assistance 
                [provided] under subsection (a) [of this 
                section] shall be provided [under the same 
                terms and subject to the same conditions, 
                regulations, and rules that apply to 
                scholarship assistance provided under section 
                254l of this title, provided that--] in 
                accordance with subparagraphs (B) through (G).
                  [(A)] (B) Need.--[the] The provision of 
                scholarships in each type of health [care] 
                profession training shall correspond to the 
                need for each type of health [care] 
                professional [identified in the Native Hawaiian 
                comprehensive health care master plan 
                implemented under section 11703 of this title] 
                to serve the Native Hawaiian [health care 
                systems] community in providing health 
                services, as identified by Papa Ola Lokahi[;].
                  [(B) the primary health services covered 
                under the scholarship assistance program under 
                this section shall be the services included 
                under the definition of that term under section 
                11711(8) of this title;]
                  (C) Eligible applicants.--[to] To the maximum 
                extent practicable, the Secretary shall select 
                scholarship recipients from a list of eligible 
                applicants submitted by [the] Papa [Oka] Ola 
                Lokahi[;].
                  (D) Obligated service requirement.--
                          (i) In general.--An [the] obligated 
                        service requirement for each 
                        scholarship recipient (except for a 
                        recipient receiving assistance under 
                        paragraph (2)) shall be fulfilled 
                        through [the full-time clinical or 
                        nonclinical practice of the health 
                        profession of the scholarship 
                        recipient, in an] service, in order of 
                        priority [that would provide for 
                        practice--] , in--
                                  (I)[(i) first, in] any [one] 
                                of the [five] Native Hawaiian 
                                health care systems; [and]
                                  (II) any of the Native 
                                Hawaiian health centers;
                                  (III) 1 or more health 
                                professions shortage areas, 
                                medically underserved areas, or 
                                geographic areas or facilities 
                                similarly designated by the 
                                Public Health Service in the 
                                State;
                                  (IV) a Native Hawaiian 
                                organization that serves a 
                                geographical area with a 
                                significant Native Hawaiian 
                                population;
                                  (V) any public agency or non-
                                profit organization providing 
                                services to Native Hawaiians; 
                                or
                                  (VI) any of the uniformed 
                                services of the United States.
                          [(ii) second, in--
                                  [(I) a health professional 
                                shortage area or medically 
                                underserved area located in the 
                                State of Hawaii; or
                                  [(II) a geographic area or 
                                facility that is--
                                          [(aa) located in the 
                                        State of Hawaii; and
                                          [(bb) has a 
                                        designation that is 
                                        similar to a 
                                        designation described 
                                        in subclause (I) made 
                                        by the Secretary, 
                                        acting through the 
                                        Public Health Service;]
                          (ii) Assignment.--The placement 
                        service for a scholarship shall assign 
                        each Native Hawaiian scholarship 
                        recipient to 1 or more appropriate 
                        sites for service in accordance with 
                        clause (i).
                  (E) Counseling, retention, and support 
                services.--[the] The provision of academic and 
                personal counseling, retention and other 
                support services--
                          (i) shall not be limited to 
                        scholarship recipients [,] under this 
                        section; and
                          (ii) [but shall also include] shall 
                        be made available to recipients of 
                        other scholarship and financial aid 
                        programs enrolled in appropriate health 
                        professions training programs[,].
                  (F) Financial assistance.--[the obligated 
                service of a scholarship recipient shall not be 
                performed by the recipient through membership 
                in the National Health Service Corps; and] 
                After consultation with Papa Ola Lokahi, 
                financial assistance may be provided to a 
                scholarship recipient during the period that 
                the recipient is fulfilling the service 
                requirement of the recipient in any of--
                                  (i) the Native Hawaiian 
                                health care systems; or
                                  (ii) the Native Hawaiians 
                                health centers.
                  [(G) the requirements of sections 254d 
                through 254k of this title, section 254m of 
                this title, other than subsection (b)(5) of 
                that section, and section 254n of this title 
                applicable to scholarship assistance provided 
                under 254l of this title shall not apply to the 
                scholarship assistance provided under 
                subsection (a) of this section.]
                  (G) Distance learning recipients.--A 
                scholarship may be provided to a Native 
                Hawaiian who is enrolled in an appropriate 
                distance learning program offered by an 
                accredited educational institution.
          [(2) The Native Hawaiian Health Scholarship program 
        shall not be administered by or through the Indian 
        Health Service.]
          (2) Fellowships.--
                  (A) In General.--Papa Ola Lokahi may provide 
                financial assistance in the form of a 
                fellowship to a Native Hawaiian health 
                professional who is--
                                  (i) a Native Hawaiian 
                                community health 
                                representative, outreach 
                                worker, or health program 
                                administrator in a professional 
                                training program;
                                  (ii) a Native Hawaiian 
                                providing health services; or
                                  (iii) a Native Hawaiian 
                                enrolled in a certificated 
                                program provided by traditional 
                                Native Hawaiian healers in any 
                                of the traditional Native 
                                Hawaiian healing practices 
                                (including lomi-lomi, la'au 
                                lapa'au, and ho'oponopono).
                  (B) Types of assistance.--Assistance under 
                subparagraph (A) may include a stipend for, or 
                reimbursement for costs associated with, 
                participation in a program described in that 
                paragraph.
          (3) Rights and benefits.--An individual who is a 
        health professional designated in section 338A of the 
        Public Health Service Act (42 U.S.C. 254l) who receives 
        a scholarship under this subsection while fulfilling a 
        service requirement under that Act shall retain the 
        same rights and benefits as members of the National 
        Health Service Corps during the period of service.
          (4) No inclusion of assistance in gross income.--
        Financial assistance provided under this section shall 
        be considered to be qualified scholarships for the 
        purpose of section 117 of the Internal Revenue Code of 
        1986.
    [(c)] (d) Authorization of Appropriations.--There are 
authorized to be appropriated such sums as [may be] are 
necessary to carry out subsections (a) and (c)(2) for each of 
fiscal years [1993] 2004 through [2001] 2009 [for the purpose 
of funding the scholarship assistance provided under subsection 
(a) of this section].

Sec. 11710. Report

    For each fiscal year, the [The] President shall, at the 
time at which the budget of the United States is submitted 
under section 1105 of [Title] title 31, United States Code, 
submit [for each fiscal year transmit] to [the] Congress a 
report on the progress made in meeting the [objectives] 
purposes of this [chapter] Act, including--
          (1) a review of programs established or assisted 
        [pursuant to this chapter] in accordance with this Act; 
        and
          (2) an assessment of and recommendations [of] for 
        additional programs or additional assistance necessary 
        to provide, at a minimum, [provide] health services to 
        Native Hawaiians, and ensure a health status for Native 
        Hawaiians, [which] that are at a parity with the health 
        services available to, and the health status of, the 
        general population.

SEC. 13. USE OF FEDERAL GOVERNMENT FACILITIES AND SOURCES OF SUPPLY

    (a) In General.--The Secretary shall permit an organization 
that enters into a contract or receives grant under this Act to 
use in carrying out projects or activities under the contract 
or grant all existing facilities under the jurisdiction of the 
Secretary (including all equipment of the facilities), in 
accordance with such terms and conditions as may be agreed on 
for the use and maintenance of the facilities or equipment.
    (b) Donation of Property.--The Secretary may donate to an 
organization that enters into a contract or receives grant 
under this Act, for use in carrying out a project or activity 
under the contract or grant, any personal or real property 
determined to be in excess of the needs of the Department or 
the General Services Administration.
    (c) Acquisition of Surplus Property.--The Secretary may 
acquire excess or surplus Federal Government personal or real 
property for donation to an organization under subsection (b) 
if the Secretary determines that the property is appropriate 
for use by the organization for the purpose for which a 
contract entered into or grant received by the organization is 
authorized under this Act.

SEC. 14. DEMONSTRATION PROJECTS OF NATIONAL SIGNIFICANCE

    (a) Authority and Areas of Interest.--
          (1) In general.--The Secretary, in consultation with 
        Papa Ola Lokahi, may allocate amounts made available 
        under this Act, or any other Act, to carry out Native 
        Hawaiian demonstration projects of national 
        significance.
          (2) Areas of interest.--A demonstration project 
        described in paragraph (1) may relate to such areas of 
        interest as--
                  (A) the development of a centralized database 
                and information system relating to the health 
                care status, health care needs, and wellness of 
                Native Hawaiians;
                  (B) the education of health professionals, 
                and other individuals in institutions of higher 
                learning, in health and allied health programs 
                in healing practices, including Native Hawaiian 
                healing practices;
                  (C) the integration of Western medicine with 
                complementary healing practices, including 
                traditional Native Hawaiian healing practices;
                  (D) the use of telewellness and 
                telecommunications in--
                          (i) chronic and infectious disease 
                        management, and
                          (ii) health promotion and disease 
                        prevention;
                  (E) the development of appropriate models of 
                health care for Native Hawaiians and other 
                indigenous people, including--
                          (i) the provision of culturally 
                        competent health services;
                          (ii) related activities focusing on 
                        wellness concepts;
                          (iii) the development of appropriate 
                        kupuna care programs; and
                          (iv) the development of financial 
                        mechanisms and collaborative 
                        relationships leading to universal 
                        access to health care; and
                  (F) the establishment of--
                          (i) a Native Hawaiian Center of 
                        Excellence for Nursing at the 
                        University of Hawai`i at Hilo;
                          (ii) a Native Hawaiian Center of 
                        Excellence for Mental Health at the 
                        University of Hawai`i at Manoa,
                          (iii) a Native Hawaiian Center of 
                        Excellence for Maternal Health and 
                        Nutrition at the Waimanalo Health 
                        Center;
                          (iv) a Native Hawaiian Center of 
                        Excellence for Research, Training, and 
                        Integrated Medicine at Molokai General 
                        Hospital; and
                          (v) a Native Hawaiian Center of 
                        Excellence for Complementary Health and 
                        Health Education and Training at the 
                        Waianae Coast Comprehensive Health 
                        Center.
          (3) Centers of excellence.--Papa Ola Lokahi, and any 
        centers established under paragraph (2)(F), shall be 
        considered to be qualified as Centers of Excellence 
        under sections 485F and 903(b)(2)(A) of the Public 
        Health Service Act (42 U.S.C. 287c-32, 299a-1).
    (b) Nonreduction in Other Funding.--The allocation of funds 
for demonstration projects under subsection (a) shall not 
result in any reduction in funds required by the Native 
Hawaiian health care systems, the Native Hawaiian Health 
Centers, the Native Hawaiian Health Scholarship Program, or 
Papa Ola Lokahi to carry out the respective responsibilities of 
those entities under this Act.

Sec. 11711. Definitions

    [For purposes of this chapter] In this Act:
          (1) Department.--The term `Department' means the 
        Department of Health and Human Services.
          [(1)](2) Disease prevention.--The term [``]`disease 
        prevention['']' includes--
                  (A) immunizations[,];
                  (B) control of high blood pressure[,];
                  (C) control of sexually transmittable 
                diseases[,];
                  (D) prevention and control of [diabetes,] 
                chronic diseases;
                  (E) control of toxic agents[,];
                  (F) occupational safety and health[,];
                  (G) [accident] injury prevention[,];
                  (H) fluoridation of water[,];
                  (I) control of infectious agents[,]; and
                  (J) provision of mental health care.
          [(2)] (3) Health promotion.--The term [``]`health 
        promotion['']' includes--
                  (A) pregnancy and infant care, including 
                prevention of fetal alcohol syndrome[,];
                  (B) cessation of tobacco smoking[,];
                  (C) reduction in the misuse of alcohol and 
                harmful illicit drugs[,];
                  (D) improvement of nutrition[,];
                  (E) improvement in physical fitness[,];
                  (F) family planning[, and];
                  (G) control of stress[.];
                  (H) reduction of major behavioral risk 
                factors and promotion of healthy lifestyle 
                practices; and
                  (I) integration of cultural approaches to 
                health and well-being (including traditional 
                practices relating to the atmosphere (lewa 
                lani), land ('aina), water (wai), and ocean 
                (kai).
          (4) Health service.--The term `health service' 
        means--
                  (A) service provided by a physician, 
                physician's assistant, nurse practitioner, 
                nurse, dentist, or other health professional;
                  (B) a diagnostic laboratory or radiologic 
                service,
                  (C) a preventive health service (including a 
                perinatal service, well child service, family 
                planning service, nutrition service, home 
                health service, sports medicine and athletic 
                training service, and, generally, any service 
                associated with enhanced health and wellness);
                  (D) emergency medical service, including a 
                service provided by a first responder, 
                emergency medical technician, or mobile 
                intensive care technician;
                  (E) a transportation service required for 
                adequate patient care;
                  (F) a preventive dental service,
                  (G) a pharmaceutical and medicant service;
                  (H) a mental health service, including a 
                service provided by a psychologist or social 
                worker;
                  (I) a genetic counseling service;
                  (J) a health administration service, 
                including a service provided by a health 
                program administrator;
                  (K) a health research service, including a 
                service provided by an individual with an 
                advanced degree in medicine, nursing, 
                psychology, social work, or any other related 
                health program;
                  (L) an environmental health service, 
                including a service provided by an 
                epidemiologist, public health official, medical 
                geographer, or medical anthropologist, or an 
                individual specializing in biological, 
                chemical, or environmental health determinants;
                   (M) a primary care service that may lead to 
                specialty or tertiary care; and
                  (N) a complementary healing practice, 
                including a practice performed by a traditional 
                Native Hawaiian healer.
          [(3)](5) Native hawaiian.--The term [``]`Native 
        Hawaiian['']' means any individual who is [--] Kanaka 
        Maoli (a descendant of the aboriginal people who, prior 
        to 1778, occupied and exercised sovereignty in the area 
        that now constitutes the State), as evidenced by--
                  (A) [a citizen of the United States, and] 
                genealogical records;
                  (B) [a descendant of the aboriginal people, 
                who prior to 1778, occupied and exercised 
                sovereignty in the area that now constitutes 
                the State of Hawai`i, as evidenced by--] 
                kama`aina witness verification from Native 
                Hawaiian Kupuna (elders); or
                          [(i) genealogical records,
                          [(ii) Kupuna (elders) or Kama`aina 
                        (long-term community residents) 
                        verification, or]
                          [(iii)] (C) birth records of the 
                        State [of Hawai`i] or any other State 
                        or territory of the United States.
          [(4)] (6) Native hawaiian health [Center] care 
        system.--The term [``]`Native Hawaiian health [center] 
        care system' means [an entity] any of up to 8 entities 
        in the State that--
                  (A) [which] is organized under the laws of 
                the State [of Hawai`i];
                  (B) [which] provides or arranges for the 
                provision of health [care] services [through 
                practitioners licensed by the State of Hawai`i, 
                where licensure requirements are applicable] 
                for Native Hawaiians in the State;
                  (C) [which] is a public or nonprofit private 
                entity [, and];
                  (D)[ in which] has Native [Hawaiian health 
                practitioners] Hawaiians significantly 
                [participate] participating in the planning, 
                management, provision, monitoring, and 
                evaluation of health services[.];
                  (E) addresses the health care needs of an 
                island's Native Hawaiian population; and
                  (F) is recognized by Papa Ola Lokahi--
                          (i) for the purpose of planning, 
                        conducting, or administering programs, 
                        or portions of programs, authorized by 
                        this Act for the benefit of Native 
                        Hawaiians; and
                          (ii) as having the qualifications and 
                        the capacity to provide the services 
                        and meet the requirements under--
                                  (I) the contract that each 
                                Native Hawaiian health care 
                                system enters into with the 
                                Secretary under this Act; or
                                  (II) the grant each Native 
                                Hawaiian health care system 
                                receives from the Secretary 
                                under this Act.
          [(5)] (7) [Native hawaiian organization] Native 
        hawaiian health center.--The term [``]`Native Hawaiian 
        [organization''] Health Center' means any 
        organization[--] that is a primary health care provider 
        that--
                  (A) [which serves the interests of Native 
                Hawaiians,] has a governing board composed of 
                individuals, at least 50 percent of whom are 
                Native Hawaiians;
                  (B)[ which is--] has demonstrated cultural 
                competency in a predominately Native Hawaiian 
                community;
                  (C) services a patient population that--
                          (i) [recognized by Papa Ola Lokahi 
                        for the purpose of planning, 
                        conducting, or administering programs 
                        (or portions of programs) authorized 
                        under this chapter for the benefit of 
                        Native Hawaiians, and] is made up of 
                        individuals at least 50 percent of whom 
                        are Native Hawaiian; or
                          (ii) [certified by Papa Ola Lokahi as 
                        having the qualifications and capacity 
                        to provide the services, and meet the 
                        requirements, under the contract the 
                        organization enters into with, or grant 
                        the organization receives from, the 
                        Secretary under this chapter,] has not 
                        less that 2,500 Native Hawaiians as 
                        annual users of services; and
                          [(C) in which Native Hawaiian health 
                        practitioners significantly participate 
                        in the planning, management, 
                        monitoring, and evaluation of health 
                        services, and]
                  (D) [which is a public or nonprofit private 
                entity.] is recognized by Papa Ola Lokahi has 
                having met each of the criteria described in 
                subparagraphs (A) through (C).
          [(6)] (8) Native hawaiian [health care system--] 
        health task force.--The term [``]`Native Hawaiian 
        [health care system''] Health Task Force' means [an 
        entity--] a task force established by the State Council 
        of Hawaiian Homestead Associations to implement health 
        and wellness strategies in Native Hawaiian communities.
                  [(A) which is organized under the laws of the 
                State of Hawai`i,
                  [(B) which provides or arranges for health 
                care services through practitioners licensed by 
                the State of Hawai`i, where licensure 
                requirements are applicable,
                  [(C) which is a public or nonprofit private 
                entity,
                  [(D) in which Native Hawaiian health 
                practitioners significantly participate in the 
                planning, management, monitoring, and 
                evaluation of health care services,
                  [(E) which may be composed of as many Native 
                Hawaiian health centers as necessary to meet 
                the health care needs of each island's Native 
                Hawaiians, and
                  [[(F) which is--
                          [(i) recognized by Papa Ola Lokahi 
                        for the purpose of planning, 
                        conducting, or administering programs, 
                        or portions of programs, authorized by 
                        this chapter for the benefit of Native 
                        Hawaiians, and
                          [(ii) certified by Papa Ola Lokahi as 
                        having the qualifications and the 
                        capacity to provide the services and 
                        meet the requirements under the 
                        contract the Native Hawaiian health 
                        care system enters into with the 
                        Secretary or the grant the Native 
                        Hawaiian health care system receives 
                        from the Secretary pursuant to this 
                        chapter.]
          [(7)] (9) [Papa ola lokahi--] Native hawaiian 
        organization.--The term `Native Hawaiian organization' 
        means any organization that--
                  (A) [The term ``Papa Ola Lokahi'' means an 
                organization composed of--] serves the 
                interests of Native Hawaiians; and
                          [(i) E Ola Mau;
                          [(ii) the Office of Hawaiian Affairs 
                        of the State of Hawai`i;
                          [(iii) Alu Like Inc.;
                          [(iv) the University of Hawai`i;
                          [(v) the Office of Hawaiian Health of 
                        the Hawaii State Department of Health;
                          [(vi) Ho`ola Lahui Hawai`i, or a 
                        health care system serving the islands 
                        of Kaua`i and Ni`ihau, and which may be 
                        composed of as many health care centers 
                        as are necessary to meet the health 
                        care needs of the Native Hawaiians of 
                        those islands;
                          [(vii) Ke Ola Mamo, or a health care 
                        system serving the island of O`ahu, and 
                        which may be composed of as many health 
                        care centers as are necessary to meet 
                        the health care needs of the Native 
                        Hawaiians of that island;
                          [(viii) Na Pu`uwai or a health care 
                        system serving the islands of Moloka`i 
                        and Lana`i, and which may be composed 
                        of as many health care centers as are 
                        necessary to meet the health care needs 
                        of the Native Hawaiians of those 
                        islands;
                          [(ix) Hui No Ke Ola Pono, or a health 
                        care system serving the island of Maui, 
                        and which may be composed of as many 
                        health care centers as are necessary to 
                        meet the health care needs of the 
                        Native Hawaiians of that island;
                          [(x) Hui Malama Ola Ha`Oiwi or a 
                        health care system serving the island 
                        of Hawai`i, and which may be composed 
                        of as many health care centers as are 
                        necessary to meet the health care needs 
                        of the Native Hawaiians of that island; 
                        and
                          [(xi) such other member organizations 
                        as the Board of Papa Ola Lokahi may 
                        admit from time to time, based upon 
                        satisfactory demonstration of a record 
                        of contribution to the health and well-
                        being of Native Hawaiians, and upon 
                        satisfactory development of a mission 
                        statement in relation to this chapter, 
                        including clearly defined goals and 
                        objectives, a 5-year action plan 
                        outlining the contributions that each 
                        organization will make in carrying out 
                        the policy of this chapter, and an 
                        estimated budget.]
                  (B) [Such term does not include any such 
                organization identified in subparagraph (A) if 
                the Secretary determines that such organization 
                has not developed a mission statement with 
                clearly defined goals and objectives for the 
                contributions the organization will make to the 
                Native Hawaiian health care systems, and an 
                action plan for carrying out those goals and 
                objectives.] (i) is recognized by Papa Ola 
                Lokahi for planning, conducting, or 
                administering programs authorized under this 
                Act for the benefit of Native Hawaiians; and
                          (ii) is a public or nonprofit private 
                        entity.
          [(8)] (10) [Primary health services] Office of 
        hawaiian affairs.--The term `Office of Hawaiian 
        Affairs' means the governmental entity that--
          [The term ``primary health services'' means--]
                  (A) [services of physicians, physicians' 
                assistants, nurse practitioners, and other 
                health professionals;] is established under 
                Article XII, sections 5 and 6 of the Hawai`i 
                State Constitution; and
                  (B) [diagnostic laboratory and radiologic 
                services;] charged with the responsibility to 
                formulate policy relating to the affairs of 
                Native Hawaiians.
                  [(C) preventive health services (including 
                children's eye and ear examinations to 
                determine the need for vision and hearing 
                correction, perinatal services, well child 
                services, and family planning services);
                  [(D) emergency medical services;
                  [(E) transportation services as required for 
                adequate patient care;
                  [(F) preventive dental services; and
                  [(G) pharmaceutical service, as may be 
                appropriate for particular health centers.]
          [(9)] (11) [Secretary] Papa Ola Lokahi._
          [The term ``Secretary'' means the Secretary of Health 
        and Human Services.]
                  (A) In general.--The term ``Papa Ola Lokahi'' 
                means an organization that--
                          (i) is composed of public agencies 
                        and private organizations focusing on 
                        improving the health status of Native 
                        Hawaiians; and
                          (ii) governed by a board the members 
                        of which may include representation 
                        from--
                                  (I) E Ola Mau;
                                  (II) the Office of Hawaiian A 
                                airs;
                                  (III) Alu Like, Inc.;
                                  (IV) the University of 
                                Hawai`i;
                                  (V) the Hawai`i State 
                                Department of Health;
                                  (VI) the Native Hawaiian 
                                Health Task Force,
                                  (VII) the Hawai`i State 
                                Primary Care Association;
                                  (VIII) Ahahui O Na Kauka, the 
                                Native Hawaiian Physicians
                                  (IX) Ho `ola Lahui Hawai`i, 
                                or a health care system serving 
                                the islands of Kaua`i or 
                                Ni`ihau (which may be composed 
                                of as many health care centers 
                                as are necessary to meet the 
                                health care needs of the Native 
                                Hawaiians of those islands);
                                  (X) Ke Ola Mamo, or a health 
                                care system serving the island 
                                of O`ahu (which may be composed 
                                of as many health care centers 
                                as are necessary to meet the 
                                health care needs of the Native 
                                Hawaiians of that island);
                                  (XI) Na Pu`uwai or a health 
                                care system serving the islands 
                                of Moloka`i or Lana`i (which 
                                may be composed of as many 
                                health care centers as are 
                                necessary to meet the health 
                                care needs of the Native 
                                Hawaiians of those islands);
                                  (XII) Hui No Ke Ola Pono, or 
                                a health care system serving 
                                the island of Maui (which may 
                                be composed of as many health 
                                care centers as are necessary 
                                to meet the health care needs 
                                of the Native Hawaiians of that 
                                island);
                                  (XIII) Hui Malama Ola Na 
                                `Oiwi, or a health care system 
                                serving the island of Hawai`i 
                                (which may be composed of as 
                                many health care centers as are 
                                necessary to meet the health 
                                care needs of the Native 
                                Hawaiians of that island);
                                  (XIV) such other Native 
                                Hawaiian health care systems as 
                                are certified and recognized by 
                                Papa Ola Lokahi in accordance 
                                with this Act; and
                                  (XV) such other member 
                                organizations as the Board of 
                                Papa Ola Lokahi shall admit 
                                from time to time, based on 
                                satisfactory demonstration of a 
                                record of contribution to the 
                                health and well-being of Native 
                                Hawaiians.
                  (B) Exclusion.--The term ``Papa Ola Lokahi'' 
                does not include any organization described in 
                subparagraph (A) for which the `Secretary has 
                made a determination that the organization has 
                not developed a mission statement that 
                includes--
                          (i) clearly-defined goals and 
                        objectives for the contributions the 
                        organization will make to--
                                  (I) Native Hawaiian health 
                                care systems, and
                                  (II) the national policy 
                                described in section 4; and
                          (ii) an action plan for carrying out 
                        those goals and objectives.
          [(10)] (12) [Traditional native hawaiian healer.--] 
        Secretary._The term ``Secretary'' means the Secretary 
        of Health and Human Services.
          [The term ``traditional Native Hawaiian healer'' 
        means a practitioner--
                  [(A) who--
                          [(i) is of Hawaiian ancestry, and
                          [(ii) has the knowledge, skills, and 
                        experience in direct personal health 
                        care of individuals, and
                  [(B) whose knowledge, skills, and experience 
                are based on demonstrated learning of Native 
                Hawaiian healing practices acquired by--
                          [(i) direct practical association 
                        with Native Hawaiian elders, and
                          [(ii) oral traditions transmitted 
                        from generation to generation.]
          (13) State.--The term ``State'' means the State of 
        Hawai`i.
          (14) Traditional native hawaiian healer.--The term 
        ``traditional Native Hawaiian healer'' means a 
        practitioner--
                  (A) who--
                          (i) is of Native Hawaiian ancestry; 
                        and
                          (ii) has the knowledge, skills, and 
                        experience in direct personal health 
                        care of individuals; and
                  (B) the knowledge, skills, and experience of 
                whom are based on demonstrated learning of 
                Native Hawaiian healing practices acquired by--
                          (i) direct practical association with 
                        Native Hawaiian elders, and
                          (ii) oral traditions transmitted from 
                        generation to generation.

Sec. 11712. Rule of construction

    Nothing in this [chapter] Act [shall be construed to 
restrict] restricts the authority of the State [of Hawai`i] to 
[license] require licensing of, and issue licenses to, health 
practitioners.

Sec. 11713. Compliance with Budget Act

    Any new spending authority [(]described in [subsection 
(c)(2)] subparagraph (A) or (B) of section [651] 401(c) (2) of 
[Title 2)] the Congressional Budget Act of 1974 (2 U.S.C. 651 
(c) (2)) [)] [which] that is provided under this [chapter] Act 
shall be effective for any fiscal year only to such extent or 
in such amounts as are provided for in Acts of appropriation 
[Acts].

Sec. 11714. Severability

    If any provision of this [chapter] Act, or the application 
of any such provision to any person or [circumstances] 
circumstance, is [held] determined by a court of competent 
jurisdiction to be invalid, the remainder of this [chapter] 
Act, and the application of [such] the provision [or amendment] 
to a [persons or circumstances] person or circumstance other 
than [those] that to which [it] the provision is held invalid, 
shall not be affected [thereby] by that holding.
                               APPENDIX A

                              ----------                              


  GOALS AND OBJECTIVES AND HEALTH CARE SERVICES PROVIDED BY THE FIVE 
                  NATIVE HAWAIIAN HEALTH CARE SYSTEMS

Islands of Kaua`i and Ni`ihau
    To serve the health care needs of Native Hawaiians on the 
islands of Kaua`i and Ni`ihau, Ho`ola Lahui Hawai`i is a 
nonprofit organization dedicated to elevating the health status 
and overall living conditions of Native Hawaiians. Ho`ola Lahui 
Hawaii has established offices in Waimea and Anahola which 
serve as a base from which outreach is provided to the East and 
West sides of Kaua`i. Service to the island of Ni`ihau is 
provided through the office in Waimea. Ho`ola Lahui Hawaii is 
working with existing health and health-related organizations 
in an effort to assure access to services for Native Hawaiians 
that were either inaccessible or unacceptable. Ho`ola Lahui 
Hawai`i is organized around the concept of lokahi (unity in all 
aspects of life) in which they seek to maintain a balance of 
body, mind, and soul. As a community-based organization, the 
concern of Ho`ola Lahui Hawai`i for Native Hawaiians grows out 
of a shared history, for those involved in Ho`ola Lahui Hawai`i 
are Native Hawaiian.
    Ho`ola Lahui Hawai`i provides health education and teaching 
on cancer, diabetes, hypertension, high cholesterol, gout, 
hygiene, and diet/exercise. Ho`ola Lahui Hawai`i also conducts 
monitoring on blood pressure, blood sugar, weight, and diet. 
Ho`ola Lahui Hawai`i offers information and referral to outside 
agencies through case management. In addition, Ho`ola Lahui 
Hawai`i is sponsoring the traditional Native Hawaiian diet 
regimen on the island of Kaua`i. Ho`ola Lahui Hawai`i completed 
one diet project in Waimea in conjunction with the State 
Department of Health and started another in Kapa`a in May of 
1992.
    Traditional healing is also an area Ho`ola Lahui Hawai`i 
addresses with sponsorship of a statewide la`au lapa`au 
(training in traditional medicine) in the spring of 1992 in 
conjunction with E Ola Mau and Ka Wai Ola `o Kalani. In 
addition, Ho`ola Lahui Hawai`i offers lomi lomi (traditional 
massage therapy). Ho`ola Lahui Hawai`i intends to expand its 
services to include health education and teaching on sexually-
transmitted diseases, family planning, maternal and infant 
care, and alcohol/substance abuse. Ho`ola Lahui Hawai`i's plans 
include establishing a health education component in 
kindergarten, elementary, and high schools, tailored to the 
physical and psychological needs of the particular age group.
Island of O`ahu
    Ke Ola Mamo is committed to improving the health status of 
Native Hawai`ians on the island of O`ahu through the 
development of a system of culturally-competent services that 
build upon rather than duplicate the existing health care 
service delivery system. Through outreach referral and case 
consultation, Ke Ola Mamo's goal is the empowerment of Native 
Hawaiian families and individuals to access appropriate health 
care services; the development of partnerships with existing 
health care services in a collaborative effort to improve 
access to health care; and working with Native Hawaiian 
communities and neighborhoods to assist them in meeting their 
health care needs.
    In 1986, there were 137,481 Native Hawaiians living on the 
island of O`ahu, who comprise approximately two-thirds of the 
total Native Hawaiian population in the entire State of 
Hawai`i. The Native Hawaiian population living on O`ahu can be 
roughly divided into three equal groups by geographic location; 
those living on the leeward coast, including Pearl City; those 
living on the windward and north coasts; and those living in 
the urban Honolulu complex. There are estimated to be at least 
20 distinct communities and neighborhoods where Native Hawaiian 
families reside. At the outset of its work, Ke Ola Mamo 
selected four of these communities to develop service delivery 
projects. Three projects involve rural communities: the 
Waimanalo community, the Wai`anae community, and the Ko`olauloa 
community. A fourth project is being proposed as a community 
education and planning process for the urban Honolulu 
communities with future service implementation proposals.
Island of Moloka`i
    The goal of Na Pu`uwai is to raise the health status of the 
Native Hawaiian residents of the island of Moloka`i, including 
Kalaupapa, and the island of Lana`i to the highest possible 
level and to encourage the maximum participation of Native 
Hawaiians to achieve this goal. The strategy of the program is 
two-fold: (1) to develop a personalized schedule of recommended 
health care activities, referred to as a ``personalized health 
care plan'' for each client; and (2) to use case management 
methodologies as a behavioral intervention to assure client 
adherence to their ``personalized health care plan.''
    To implement this strategy, the program: (1) conducts 
screening and enrollment for those who are self-referred, 
provider-referred, or recruited by staff; (2) conducts a health 
risk appraisal on each enrollee to assess current health 
maintenance status; (3) develops a personalized health care 
plan with each client, based on recommended primary, secondary, 
and tertiary health maintenance guidelines and the client's 
concerns and needs; (4) coordinates and provides health 
promotion and disease prevention programs and health screening; 
(5) provides clinic-based primary health care services; (6) 
provides multi-disciplinary case management services as 
appropriate, to enrolled participants; and (7) reassesses 
client status as dictated in the case management plan and 
conducts ongoing followup on all clients, case management and 
non-case management.
    Na' Pu`uwai's service delivery plan provides for (1) direct 
outpatient care services of a physician and nurse; (2) case 
management services of a social worker and multi-disciplinary 
case management team; (3) direct health education and health 
screening services; and (4) patient followup and outreach 
services.
Island of Maui
    Hui No Ke Ola Pono, an association to strengthen and 
perpetuate life, is Maui's Native Hawaiian Health Care System, 
providing services that are culturally relevant to Native 
Hawaiians of Maui, including identification, treatment, 
control, and reduction of the incidence of preventable 
illnesses and conditions frequently occurring in the Native 
Hawaiian population. The services provided by Hui No Ke Ola 
Pono include health promotion and disease prevention; referrals 
for immunizations; improvement of nutrition; referrals for 
pregnancy and infant care; prevention and control of diabetes, 
high blood pressure, and middle ear infections; community 
outreach services; referrals to physician and nursing services; 
and education on traditional practitioner services.
    In addition, traditional Hawaiian healers provide the 
following services: ho`oponopono (family or group counseling); 
la`au lapa`au (traditional Hawaiian herbal medicine); and lomi 
lomi (Hawaiian massage therapy).
Island of Hawai`i
    Hui Malama Ola Na `Oiwi (caring for our people) is the 
Native Hawaiian health care system for Native Hawaiians on the 
Island of Hawai`i. The program mission of Hui Malama Ola Na 
`Oiwi is to assist Native Hawaiians in restoring a high quality 
health care system by creating and developing a non-threatening 
healing environment inclusive of traditional health assistance 
and to provide and facilitate a process of awareness and 
addressing the health needs, both physical and spiritual, of 
Native Hawaiians.
    Hui Malama's objectives are to (1) promote physical, 
emotional, and spiritual health and well-being of Native 
Hawaiians on the island of Hawai`i; (2) assist and promote 
personal responsibility among Native Hawaiians toward making 
sound, informed decisions which would decrease unhealthy 
behaviors and reduce morbidity and mortality rates; (3) support 
and advocate the use of health care services that come from the 
traditions of the Native Hawaiian culture and of western 
science; and (4) work toward the establishment of primary 
health care centers in appropriate locations where quality 
primary care can be provided and where primary care services 
are not currently available.
    The death rates of Native Hawaiians exceed the death rates 
for all races in the United States caused by diseases of the 
heart, cancer, strokes, and diabetes. Achieving good health for 
Native Hawaiians appears difficult, but these diseases can be 
controlled through early detection, proper diet and treatment, 
and regular exercise.
    Hui Malama Ola Na `Oiwi provides the following services:
          (1) Outreach--enrolling participants in the program, 
        assessing their health risk factors, assisting in 
        securing medical insurance where needed, assisting in 
        access to a physician, providing transportation to and 
        from the physician for those who need it, and making 
        home visits when necessary;
          (2) Health promotion and disease prevention--
        providing education regarding the prevention and 
        control of diabetes, high blood pressure 
        (hypertension), use of tobacco, alcohol and other 
        harmful drugs, sexually transmitted diseases, stress, 
        cancer, the importance of sound nutrition habits, 
        regular exercise, and proper maternal and infant care 
        practices;
          (3) Primary health services--Hui Malama Ola Na `Oiwi 
        assists patients in securing access to the primary 
        health care services of a physician, a physician's 
        assistant, or a nurse practitioner.

                               APPENDIX B

                              ----------                              


            Constitutional Source of Congressional Authority

    The United States Supreme Court has so often addressed the 
scope of Congress' constitutional authority to address the 
conditions of the native people that it is now well-
established.\6\ Although the authority has been characterized 
as ``plenary,'' \7\ the Supreme Court has addressed the broad 
scope of the Congress' authority.\8\ It has been held to 
encompass not only the native people within the original 
territory of the thirteen states but also lands that have been 
subsequently acquired.\9\
---------------------------------------------------------------------------
    \6\ The power of the general government over these remnants of a 
race once powerful, now weak and diminished in numbers, is necessary to 
their protection. As well as to the safety of those among whom they 
dwell. It must exist in that government, because it never has existed 
anywhere else, because the theater of its exercise is within the 
geographical limits of the United States * * * From their very weakness 
and helplessness, so largely due to the course of dealing of the 
Federal government with them, and the treaties in which it has been 
promised, there arises a duty of protection, and with it the power. 
This has always been recognized by the executive, and by congress, and 
by this court, whenever the question has arisen.'' United States v. 
Kagama, 118 U.S. 375 (1886).
    \7\ Morton v. Mancari, 427 U.S. 535 (1974).
    \8\ Delaware Tribal Business Council v. Weeks, 430 U.S. 73 (1977); 
United States v. Sioux Nation, 448 U.S. 371 (1980). The rulings of the 
Supreme Court make clear that neither the conferring of citizenship 
upon the native people, the allotment of their lands, the lifting of 
restrictions on alienation of native land, the dissolution of a tribe, 
the emancipation of individual native people, the fact that a group of 
natives may be only a remnant of a tribe, the lack of continuous 
Federal supervision over the Indians, nor the separation of individual 
Indians from their tribes would divest the Congress of its 
constitutional authority to address the conditions of the native 
people. Cherokee Nation v. Hitchock, 187 U.S. 294 (1902); United States 
v. Celestine, 215 U.S. 278 (1909); Tiger v. Western Inv. Co., 221 U.S. 
286 (1911); United States v. Nice, 241 U.S. 591 (1916); Chippewa 
Indians v. United States, 307 U.S. 1 (1939); Delaware Tribal Business 
Council v. Weeks, 430 U.S. 73 (1977); United States v. John, 437 U.S. 
634 (1979).
    \9\ United States v. Sandoval, 231 U.S. 28 (1913).
---------------------------------------------------------------------------
    The ensuing course of dealings with the indigenous people 
has varied from group to group, and thus, the only general 
principles that apply to relations with the first inhabitants 
of this nation is that they were dispossessed of their lands, 
often but not always relocated to other lands set aside for 
their benefit, and that their subsistence rights to hunt, fish, 
and gather have been recognized under treaties and laws, but 
not always protected nor preserved.
    Some commentators have suggested that no other group of 
people in America has been singled out so frequently for 
special treatment, unique legislation, and distinct expressions 
of Federal policy. Although the relationship between the United 
States and its native people is not a history that can be said 
to have followed a fixed course, it is undeniably a history 
that reveals the special status of the indigenous people of 
this land. American laws recognize that the native people do 
not trace their lineage to common ancestors and, from time to 
time, our laws have in fact discouraged the indigenous people 
from organizing themselves as ``tribes.'' But this much is 
true--that for the most part, at any particular time in our 
history, the laws of the United States have attempted to treat 
the native people, regardless of their genealogical origins and 
their political organization, in a consistent manner.
Organization as a Tribe and the Scope of Constitutional Authority
    It has been suggested that the scope of constitutional 
authority vested in the Congress is constrained by the manner 
in which the native people organize themselves. Under this 
theory, if the native people are not organized as tribes, then 
the Congress lacks the authority to enact laws and the 
President is without authority to establish policies affecting 
the native people of the United States. However, the original 
language proposed for inclusion in the Constitution made no 
reference to ``tribes'' but instead proposed that the Congress 
be vested with the authority ``to regulate affairs with the 
Indians as well within as without the limits of the United 
States.'' \10\ A further refinement suggested that the language 
read ``and with Indians, within the Limits of any State, not 
subject to the laws thereof[.]''.\11\
---------------------------------------------------------------------------
    \10\ The Records of the Federal Convention of 1787, Volume II, 
Journal Entry of August 18, 1787, p. 321.
    \11\ The Records of the Federal Convention of 1787, Volume II, 
Journal Entry of August 22, 1787, p. 367.
---------------------------------------------------------------------------
    The exchanges of correspondence between James Monroe and 
James Madison concerning the construction of what was to become 
Article I, Section 8, Clause 3 of the Constitution make no 
reference to Indian tribes, but they do discuss Indians.\12\ 
Nor is the term ``Indian tribe'' found in any dictionaries of 
the late eighteenth century, although the terms ``aborigines'' 
and ``tribe'' are defined.'' \13\
---------------------------------------------------------------------------
    \12\ In his letter to James Monroe of November 27, 1784, James 
Madison observes, ``The foederal articles give Congs, the exclusive 
right of managing all affairs with the Indians not members of any 
State, under a proviso, that the Legislative authority, of the State 
within its own limits be not violated. By Indian[s] not members of a 
State, must be meant those, I conceive who do not live within the body 
of the Society, or whose Persons or property form no objects of its 
laws. In the case of Indians of this description the only restraint on 
Congress is imposed by the Legislative authority of the State.'' The 
Founders' Constitution, Volume Two, Preamble through Article 1, Section 
8, Clause 4, p. 529, James Madison to James Monroe, 27 Nov. 1784, 
Papers 8:156-57; See also, James Monroe to James Madison, 15 Nov. 1784, 
Madison Papers 8:140.
    \13\ The term ``aborigines'' is defined as ``the earliest 
inhabitants of a country, those of whom no original is to be traced,'' 
and the term ``tribe'' is defined as ``a distinct body of the people as 
divided by family or fortune, or any other characteristic.'' A 
Dictionary of the English Language (Samuel Johnson ed., 1755). The 
annotations accompanying the term ``Indian'' in the 1901 Oxford 
dictionary indicates the use of the term as far back as 1553. Oxford 
English Dictionary (James A.H. Murray ed., 1901).
---------------------------------------------------------------------------
Native Hawaiians and the Meaning of ``Indian''
    Whether the reference was to ``aborigines'' or to 
``Indians'', the Framers of the Constitution did not import a 
meaning to those terms as a limitation upon the authority of 
Congress, but as descriptions of the native people who occupied 
and possessed the lands that were later to become the United 
States--whether those lands lay within the boundaries of the 
original thirteen colonies, or any subsequently acquired 
territories. This construction is consistent with more than two 
hundred Federal statutes which establish that the aboriginal 
inhabitants of America are a class of people known as ``Native 
Americans'' and that this class includes three groups--American 
Indians, Alaska Natives and Native Hawaiians.
    The unique native peoples of Alaska have been recognized as 
``Indian'' and as ``tribes'' for four hundred years. The 
Founders' understanding of the ``Eskimaux'' as Indian tribes, 
and Congress' recognition of its power over Alaska Natives ever 
since the passage of the Fourteenth Amendment and the 
acquisition of the Alaskan territory, help illuminate Congress' 
power over, and responsibility for, all Native American 
peoples.
    The treatment of Alaskan Eskimos is particularly 
instructive because the Eskimo peoples are linguistically, 
culturally, and ancestrally distinct from other American 
``Indians.'' Many modern scholars do not use the word 
``Indian'' to describe Eskimos or the word ``tribe'' to 
describe their nomadic family groups and villages. The Framers, 
however, recognized no such technical distinctions. In the 
common understanding of the time, Eskimos, like Native 
Hawaiians, were aboriginal peoples; they were therefore 
``Indians.'' Their separate communities of kind and kin were 
``tribes.'' Congress' special power over these aboriginal 
peoples is beyond serious challenge.
    During the Founding Era, and during the Constitutional 
Convention, the terms ``Indian'' and ``tribe'' were used to 
encompass the tremendous diversity of aboriginal peoples of the 
New World and the wide range of their social and political 
organizations. The Founding generation knew and dealt with 
Indian tribes living in small, familial clans and in large, 
confederated empires. Native Alaska villages and Native 
Hawaiians residing in their aboriginal lands (i.e., the small 
islands that comprise the State of Hawaii) are ``Indian 
Tribes'' as that phrase was used by the Founders. The Framers 
drafted the Constitution not to limit Congress' power over 
Indians, but to make clear the supremacy of Congress' power 
over Indian affairs. The Congress has exercised the power to 
promote the welfare of all Native American peoples, and to 
foster the ever-evolving means and methods of self-governance 
as exercised by Native people.
    This history is accurately reflected in nearly two 
centuries of U.S. Supreme Court jurisprudence. Beginning with 
Chief Justice Marshall, the Supreme Court has recognized the 
power of the United States to provide for the welfare, and to 
promote the self-governance, of Indian peoples. This 
recognition of the right of the indigenous, native people of 
the United States to self-determination and self-governance is 
part of the structure of America's complex multi-sovereign 
system of governance.
    In the language and understanding of the Founders, 
``tribes'' or ``peoples'' did not lose their identity as such 
when conquered or ruled by kings. Like other Native American 
people, Native Hawaiians lived for thousands of years as 
``tribes,'' then as confederations of tribes, now as conquered 
tribes. All aboriginal peoples of the New World were 
``Indians.'' That is what it meant to be an ``Indian.'' The 
Founders knew that Columbus had not landed in India or the 
Indies; Columbus's navigational error had been corrected, but 
his malapropism had survived. And so, in the words of one of 
the earliest English books about America, the native people 
were ``Indians,'' for the simple reason that ``so caule wee all 
nations of the new founde lands.'' \14\
---------------------------------------------------------------------------
    \14\ Gonzalo Fernandez de Oviego y Valdez, De la natural hystoria 
de las Indias (1526), trans. by R. Eden (1955), in E. Arber, ed., The 
First Three English Books on America (Birmingham, Eng., 1885) (emphasis 
added).
---------------------------------------------------------------------------
    The Founding generation used ``tribes'' to denote peoples 
of like kind or kin. As used in the Constitution, the word 
``tribe'' does not refer to some specific type of government or 
social organization. All Native American peoples were 
``tribes,'' whether they lived in villages or spread out in 
vast federations or empires. ``Tribe'' and ``nation'' were used 
to refer not to governments, but to groups of people 
recognizing a common membership or identity as such. 
Application of the biblical concept of ``tribes'' to the 
``Indians'' reflected the understanding that the natives of the 
New World were not one people, but many ``peoples,'' 
``nations,'' or ``tribes''--terms used interchangeably well 
into the Nineteenth Century.\15\
---------------------------------------------------------------------------
    \15\ Robert F. Berkhofer, Jr., The White Man's Indian 16 (1979).
---------------------------------------------------------------------------
    The Founders had seen analogies to the complex tribal 
history of the Bible. The Founders knew the native peoples 
evolved, united and divided in ever shifting forms of 
government. The native peoples had formed ``powerful 
confederac[ies],'' tribes united under common chiefs, and 
federations of tribes joined with other federations.\16\ The 
colonies and the States under the Articles of Confederation had 
repeatedly dealt with vast federations of tribes, including the 
``Six Nations'' in the north and the ``Five Civilized Tribes'' 
in the south.\17\ The Indian peoples were ``tribes'' not 
because they formed any particular organization, but because 
they recognized themselves as distinct peoples, with cultures, 
languages and societies separate from each other and from the 
European invaders.
---------------------------------------------------------------------------
    \16\ Jefferson, Notes, at 221.
    \17\ See, e.g., Treaty with the Six Nations, Oct. 22, 1784 (treaty 
with the many tribes of Senecas, Mohawks, Onondagas, Cayugas, Oneida 
and Tuscarora), in C.J. Kappler, ed., Indian Affairs: Laws and Treaties 
2:5-6; Treaty of Treaty of Forth McIntosh, Jan. 21, 1785 (treaty with 
the Wiandot, Delaware, Chippewa, and Ottawa ``and all their tribes''), 
in id. at 2:6-8; Treaty of Hopewell, Nov. 28, 1785 (treaty with all the 
``tribes'' of the Cherokee), in id. at 2:8-11.
---------------------------------------------------------------------------
    As Jefferson's ``Notes on the State of Virginia'' and other 
contemporary works show, the division of the world into 
``European settlers'' and ``Indians'' was not essentially 
racial. The Indians were not a race, they were many peoples, 
thought to share diverse ancestry with peoples all over the 
world. The distinction between European and Native American 
peoples was political. The European settlers (who arrived with 
Royal charters) recognized the ``aboriginal peoples'' as 
separate nations--separate sovereigns with whom they would have 
to deal as one nation to another. Before and after the 
Constitution, the new settlers treated the Indian peoples as 
separate nations, with whom they made war, peace and treaties. 
The treatment of the aboriginal peoples under the Constitution 
was systematically and structurally distinct from the inhumane 
and unendurable treatment accorded to ``slaves.'' This 
distinctive nation-to-nation relationship survived the 
settlement of the West, the Civil War Amendments to the 
Constitution, and two hundred years of Congressional action and 
judicial construction.
History of the Origins of the Constitutional Term ``Tribe''
    The Articles of Confederation gave the Continental Congress 
power over relations with the Indians only so long as Congress' 
dealings with Indians within a State did not ``infringe'' that 
State's legislative power. This created constant friction over 
where the States' power ended and Congress' power began. The 
sole stated purpose of the Indian terms of the new Constitution 
was to eliminate any uncertainty as to Congress' supremacy. The 
Framers intended to grant Congress broad, supreme authority to 
regulate Indian affairs. The two references to ``Indians'' in 
the Constitution generated virtually no debate at any time in 
the Constitutional Convention. That relations with the Indians 
should be one of the Federal powers appears to have been 
universally accepted. The Framers sought only to make clear 
that Congress' power here was supreme.
    The Articles had given the Continental Congress ``sole and 
exclusive right and power'' of regulating relations with 
Indians who were ``not members of any of the states, provided 
that the legislative right of any state within its own limits 
be not infringed or violated.'' \18\ As Madison explained, this 
language created two major problems. First, no one knew when or 
whether Indians were ``members of states''; second, the grant 
to Congress of ``sole and exclusive power,'' so long as 
Congress did not ``intrud[e] on the internal right'' of States 
was ``utterly incomprehensible.'' The provision had been a 
source of ``frequent perplexity and contention in the federal 
councils.'' \19\ Capitalizing on the uncertainty, several 
states (Georgia, New York and North Carolina) had infringed 
Congress' power by making their own arrangements with local 
Indians. As a result, during the Constitutional Convention and 
Ratification, Georgia was in armed conflict, and on the verge 
of war, with the powerful Creek Nation.
---------------------------------------------------------------------------
    \18\ Articles of Confederation, Art. X, March l, 1778.
    \19\ Federalist 42, in XIV Documentary History of the Ratification 
of the Constitution (J. Kaminiski, ed., 1983) (``Documentary 
History''), XV: 431.
---------------------------------------------------------------------------
    The only debate on the issue in the Convention focused on 
the need for federal supremacy over the states. Madison 
objected early on to the ``New Jersey Plan'' on the ground that 
it failed to bar states from encroaching on Congress' power 
over ``transactions with the Indians.'' \20\ In August, Madison 
proposed that Congress be given the power ``[t]o regulate 
affairs with the Indians as well within as without the limits 
of the United States.'' \21\ Madison's proposal was submitted 
to the Committee on Detail without discussion. The Committee on 
Detail recommended that power over Indians be dealt with in the 
Commerce clause, which would provide Congress with power over 
commerce ``with the Indians, within the limits of any State, 
not subject to the laws thereof.'' The proposal provoked no 
debate. \22\ On August 31st, the Convention referred various 
``parts of the Constitution'' (including the Commerce Clause) 
to a ``Committee of eleven,'' including Madison. \23\ Without 
recorded discussion, the Committee recommended that the 
language be simplified to commerce ``with the Indian tribes.'' 
\24\ The Convention accepted the recommendation without debate 
or dissent. \25\
---------------------------------------------------------------------------
    \20\ Notes of James Madison,'' June 19, 1787, in The Records of the 
Federal Convention of 1787, at 3:316 (Max Farrand, rev. ed. 1966) 
[hereafter, ``Federal Convention''] (``By the federal articles, 
transactions with the Indians appertain to Congress. Yet in several 
instances, the States have entered into treaties & wars with them''); 
see also, id. at 325-26.
    \21\ 2 Federal Convention, at 321, 324; see also id. at 143 
(Rutledge noted that ``Indian affairs'' should be added to Congress' 
powers).
    \22\ Id. at 367. Similarly, since Indians did not pay tax, the 
proposal to exclude ``Indians not taxed'' from the apportionment clause 
was accepted without discussion.
    \23\ Id. at 481.
    \24\ Id. at 493, 496-97, 503 (emphasis added).
    \25\ See id. at 495. The language appears in the final version. Id 
at 569, 595.
---------------------------------------------------------------------------
    As noted above, the debate in the Convention focused solely 
on making clear the supremacy of Congress' power. During the 
ratification debates, the new Constitution was defended on the 
ground that it gave Congress power over ``Indian affairs'' and 
``trade with the Indians.'' \26\ In the only extended 
discussion of the issue during ratification, Madison used the 
phrases ``commerce with the Indian tribes'' and ``trade with 
Indians'' interchangeably; Madison explained that the purpose 
of the new provision was to eliminate the limitation on 
Congress' power over trade with the Indians living within the 
States. \27\ The notion that the reference to ``tribes'' was a 
limit on Congress' ability to deal with the native peoples is 
without support in history and is contrary to the only 
expressions of the Framers' original intent. The Constitution 
gave Congress power over the Indian peoples, however and 
wherever it found them.
---------------------------------------------------------------------------
    \26\ Federalist 40, in Documentary History, XV: 406. (Constitution 
represents ``expansion on the principles which are found in the 
articles of confederation,'' which gave Congress power over ``trade 
with the Indians''); Federal Farmer, October 8, 1787, in id. at XIV: 24 
(under the new Constitution, federal government has power over ``all 
foreign concerns, causes arising on the seas, to commerce, imports, 
armies, navies, Indian affairs''); Federal Farmer, October 10, 1787, in 
id. at 30, 35 (federal power over ``foreign concerns, commerce, impost, 
all causes arising on the seas, peace and war, and Indian affairs''). 
The Federal Farmer Letters are considered ``one of the most significant 
publications of the ratification debate.'' Id. at 14.
    \27\ Madison, Federalist 42, in Documentary History XIV: 430-31.
---------------------------------------------------------------------------
    The First Federal Congress treated the Constitution as 
granting broad power to regulate ``trade and intercourse'' with 
``Indians,'' ``Indian tribes,'' ``nations of Indians,'' and 
``Indian country.'' \28\ Congress understood its power to 
``operate immediately on the persons and interests of 
individual citizens.'' \29\ The actions of the new government 
also show that even when the Framers knew nothing about the 
organization of Indian peoples, they nevertheless intended to 
assert Federal power over those peoples. Shortly after taking 
office, President Washington gave instructions to Commissioners 
to negotiate with the Creeks. It was, as noted, the war between 
the Creeks and Georgia that had fostered the apparently 
universal conclusion that the new Federal government must be 
given supremacy over Indian affairs. Washington instructed the 
Commissioners to determine the nature of the Creek's political 
divisions and governments, including ``[t]he number of each 
division''; ``[t]he number of Towns in each District''; ``[t]he 
names, Characters and residence of the most influential 
Chiefs--and . . . their grades of influence.'' And, most 
tellingly, the Commissioners were to learn ``[t]he kinds of 
Government (if any) of the Towns, Districts, and Nation.'' \30\ 
Washington, like other Founders, did not know how the Creek 
lived and how they governed themselves. But however the Indian 
peoples lived, and however they governed themselves, they were 
still Indian peoples and they were still subject to the supreme 
power of the Federal government over Indian tribes.
---------------------------------------------------------------------------
    \28\ ``An Act to regulate trade and intercourse with the Indian 
tribes,'' July 22, 1790, ch. 33, Sec. 4, 1 Stat. 137, in 1 Doc. Hist. 
of the First Federal Congress, 1789-1791 (De Pauw, ed., 1972) (``First 
Federal Congress''), at 440.
    \29\ Madison, Federalist 40, in Documentary History, XV: 406.
    \30\ Washington, Instructions to the Commissioners for Southern 
Indians, August 29, 1789, in 2 First Federal Congress, at 207 (emphasis 
added).
---------------------------------------------------------------------------
    President Jefferson gave similar instructions to Lewis and 
Clark. When they encountered unknown Indian peoples, the 
explorers were to learn the ``names of the nations''; ``their 
relations with other tribes or nations''; their ``language, 
traditions, monuments''; and the ``peculiarities in their laws, 
customs & dispositions.'' \31\ Like Washington, Jefferson knew 
there was much he and his fellow citizens did not know about 
the ``Indian'' peoples; but he intended to find out and to 
assert Federal authority over whatever he found.
---------------------------------------------------------------------------
    \31\ Thomas Jefferson, ``Instructions to Captain Lewis,'' June 20, 
1803, in Jefferson, Writings, supra, at 1126, 1128.
---------------------------------------------------------------------------

Fourteenth Amendment to the United States Constitution

    It is inconceivable anyone thought that if Washington's 
Commissioners or Lewis and Clark found a native people living 
without ``chiefs,'' like many Eskimo, or under a King like 
Montezuma or Kamehameha, these people would be beyond Congress' 
power over Indian ``tribes'' or nations. Nor did the Framers of 
the Fourteenth Amendment intend to eliminate Congress' special 
power to adopt legislation singling out and favoring Indians; 
they did not intend to alter the nation-to-nation relationships 
between the United States and the Indian peoples created by the 
Constitution. Indeed, the Framers of the Amendment were at 
pains to make certain that they preserved that structure.
    ``Indians'' are expressly singled out for special treatment 
by the text of the Amendment. In order to eliminate the morally 
repugnant language which counted slaves as three-fifths 
persons, the Framers of the Fourteenth Amendment redrafted the 
apportionment clause. The Framers deleted the ``three-fifths 
persons,'' but retained the express exclusion of ``Indians not 
subject to tax'' (Amend. XIV, Sec. 1), because, while they 
intended to wipe out the badges and incidents of slavery, they 
intended to preserve the special relationship between the 
United States and the Indian people. Before and after the 
Amendment, Indians were not citizens of the United States, they 
did not have the right to vote, they did not count for purposes 
of apportionment, but they were subject to special legislation 
in furtherance of Congress' historic trust responsibilities.
    The only debate during the drafting and ratification of the 
Fourteenth Amendment was not about whether the special 
relationship with the Indian people should be preserved, but 
about how to make certain it was preserved. When one Senator 
suggested that specific reference be made excluding ``Indians'' 
from the citizenship clause, the Senator presenting the clause 
argued this was unnecessary. The Amendment provided citizenship 
only to persons ``within the jurisdiction'' of the United 
States,\32\ and Indian nations were treated like alien peoples 
not fully within the jurisdiction of the government:
---------------------------------------------------------------------------
    \32\ Similar limiting language occurs in the Equal Protection 
Clause.

        in the very Constitution itself there is a provision 
        that Congress shall have power to regulate commerce, 
        not only with foreign nations and among the States, but 
        also with Indian tribes. That clause, in my judgment, 
        presents a full and complete recognition of the 
        national character of the Indian tribes.\33\
---------------------------------------------------------------------------
    \33\ Cong. Globe, 39th Congress, 1st Sess. 2895.

    Congress debated what language to adopt in order to make 
certain that the special status of the Indian tribes was 
preserved.\34\ There was no support for, or consideration given 
to, eliminating the special relationship between the United 
States and the Indian peoples. The uniform intent was to 
preserve Congress' ability to decide when Indians would be 
granted citizenship, when Indians would be taxed, and when 
Indians would be subject to special legislation.\35\
---------------------------------------------------------------------------
    \34\ See, e.g., Remarks of Sen. Doolittle, Cong. Globe, 39th Cong., 
1st Sess., 2895-2896 (1866) (``[Senator Howard] declares his purpose to 
be not to include Indians within this constitutional amendment. In 
purpose I agree with him. I do not intend to include them. My purpose 
is to exclude them'').
    \35\ Congress expressed the same intent in the Civil Rights Act 
that same year. The Act, granting citizenship to the emancipated 
slaves, specifically excluded ``Indians not taxed.'' Civil Rights Act, 
ch. 31, 14 Stat. 27 (1866).
---------------------------------------------------------------------------
    For nearly two hundred years, the Supreme Court has 
recognized the political distinction the Constitution draws 
between ``Indian tribes'' and all other people. The early 
opinions of Chief Justice John Marshall reflect the original 
intent of the Framers and lay the groundwork for the Supreme 
Court's jurisprudence. Marshall wrote that ``[t]he condition of 
the Indians in relation to the United States is perhaps unlike 
that of any other two people in existence.'' \36\ With 
deliberate irony, he called the Indian tribes ``domestic 
dependent nations.'' \37\ The Indian peoples had surrendered 
``their rights to complete sovereignty,'' \38\, and yet they 
continued to be ``nations'' that governed themselves.\39\
---------------------------------------------------------------------------
    \36\ Cherokee Nation v. Georgia, 30 U.S. (5 Pet.) 1, 16 (1831).
    \37\ Id., at 17.
    \38\ Johnson v. McIntosh, 21 U.S. (8 Wheat.) 543, 572-74 (1823).
    \39\ See Worcester v. Georgia, 31 U.S. (6 Pet.) 515, 561 (1832).
---------------------------------------------------------------------------
    Marshall knew that the constitutional text reflected this 
preexisting nation-to-nation relationship. The Indian Commerce 
Clause, U.S. Const. art. I., Sec. 3, cl. 8, and the Treaty 
Clause, art. II, Sec. 2, cl. 2, granted Congress broad power to 
regulate Indian affairs. These provisions permitted the United 
States to fulfill its obligations to the dependent Indian 
``nations'' that were its ``wards.'' \40\ As ``guardian,'' 
Congress had both the obligation and the power to enact 
legislation protecting the Indian nations.\41\
---------------------------------------------------------------------------
    \40\ Cherokee Nation, 30 U.S. (5 Pet.) at 17-18; Worcester, 31 U.S. 
(6 Pet.) at 558-59.
    \41\ See Worcester, 31 U.S. (6 Pet.) at 560-61; accord Cherokee 
Nation, 30 U.S. (5 Pet.) at 16 (``[t]hey look to our government for 
protection, rely upon its kindness and its power; appeal to it for 
relief to their wants'').
---------------------------------------------------------------------------
    Marshall defined ``Indians'' broadly to include all of the 
``original inhabitants'' or ``natives'' who occupied America 
when it was discovered by ``the great nations of Europe.'' \42\ 
He also conceived of ``tribes'' in broad, inclusive terms. He 
used ``tribe'' and ``nation'' interchangeably: A ``tribe or 
nation,'' he noted, ``means a people distinct from others''--a 
``distinct community.'' \43\ Like the Founders, Marshall 
defined an ``Indian tribe'' as nothing more than a community, 
large or small, of descendants of the peoples who inhabited the 
New World before the Europeans.
---------------------------------------------------------------------------
    \42\ Johnson, 21 U.S. (8 Wheat.) at 572-74; Worcester, 31 U.S. (6 
Pet.) at 544 (1832) (Indians are ``those already in possession [of 
land], either as aboriginal occupants, or as occupants by virtue of a 
discovery made before the memory of man''). See also Johnson, 21 U.S. 
(8 Wheat.) at 575 (Indians in French Canada); id. at 581 (Indians in 
Nova Scotia); Id. at 584-87 (Indians in Virginia, Kentucky, the 
Louisiana Purchase, and Florida). Marshall noted the United States had 
dealt with variously organized ``tribes'' or ``confederacies.'' See id. 
at 546-49.
    \43\ Worcester, 31 U.S. (6 Pet.) at 559, 561. See also Cherokee 
Nation, 30 U.S. (5 Pet.) at 20 (``an Indian tribe or nation within the 
United States''); Johnson, 21 U.S. (8 Wheat.) At 590 (``the tribes of 
Indians inhabiting this country'').
---------------------------------------------------------------------------
    Although the aboriginal ``tribes'' or ``nations'' or 
``peoples'' were defined in part by common ancestry, their 
constitutional significance lay in their separate existence as 
``independent political communities,'' \44\. The ``race'' of 
Indian peoples was constitutionally irrelevant. Native peoples 
were ``nations,'' \45\ and the relationship between the United 
States and the natives reflected a political settlement between 
conquered and conquering nations.
---------------------------------------------------------------------------
    \44\ Id., at 559.
    \45\ Id., at 559-60.
---------------------------------------------------------------------------
    The Supreme Court has kept faith with Marshall's 
conception. The Indian nations have always been defined by 
ancestry and political affiliation. In the native cultures, the 
two are inextricably intertwined. The Supreme Court's 
definition is legal, and the Native American's self-definition 
is historic, religious or cultural; but the two reduce to the 
same elements: ``Indians'' are (1) the descendants of 
aboriginal peoples who (ii) belong to some Native American 
``people,'' ``nation,'' ``tribe,'' or ``community,'' as the 
founding generation understood those terms.\46\
---------------------------------------------------------------------------
    \46\ See, e.g., Montoya v. United States, 180 U.S. 261, 266 (1901) 
(``a body of Indians of the same or a similar race, united in a 
community under one leadership or government, and inhabiting a 
particular though sometimes ill-defined territory''); United States v. 
Candelaria, 271 U.S. 432, 442 (1926); see Oklahoma Tax Comm'n v. Sac & 
Fox Nation, 508 U.S. 114, 123 (1993); United States v. Antelope, 430 
U.S. 641, 647 n.7 (1977) (individuals ``anthropologically'' classified 
an Indians may be outside Congress's Indian commerce power if they 
sever relations with tribe).
---------------------------------------------------------------------------
    These interwoven qualifications reflect the Supreme Court's 
consistent understanding that constitutionally-relevant Indian 
status, while based in part on ancestry, is a political 
classification.\47\ It is an individual's membership in a 
``political community'' of Indians--even a community in the 
making--and not solely his or her racial identity, that brings 
him or her within Congress' broad authority to regulate Indian 
affairs.\48\
---------------------------------------------------------------------------
    \47\ United States v. Antelope, 430 U.S. 641, 646-47 (1977).
    \48\ Id., at 646.
---------------------------------------------------------------------------

Indian Tribes and Blood Quantum

    Nor does the use of blood quantum as part of the formula to 
determine who is and is not a Native American constitute 
impermissible ``racial'' discrimination. The Supreme Court has 
repeatedly made clear that Indian tribes are the political and 
familial heirs to ``once-sovereign political communities''--not 
``racial groups.'' \49\ The Court has long recognized that a 
tribe's ``right to determine its own membership'' is ``central 
to its existence as an independent political community.'' \50\ 
From time immemorial, Native American communities have defined 
themselves at least in part by family and ancestry.\51\ Kinship 
and ancestry is part of what it means to be an ``Indian.'' 
Indians by ancestry or blood is what the Framers meant by 
``Indians.'' It is what Chief Justice Marshall meant by 
``Indians.'' It is what the Framers of the Fourteenth Amendment 
meant by ``Indians.'' This central conception of ``Indian'' 
identity is woven into the Constitution and the entire body of 
law that has grown up in reliance on that conception.
---------------------------------------------------------------------------
    \49\ Antelope, 430 U.S. at 646; see Fisher v. District Court, 424 
U.S. 382, 389 (1976); Mancari, 417 U.S. at 553-54; see also Sac & Fox 
Nation, 508 U.S. at 123; United States v. Mazurie, 419 U.S. 544, 557 
(1975).
    \50\ Santa Clara Pueblo v. Martinez, 436 U.S. 49, 72 n.32 (1978); 
Cherokee Intermarriage Cases, 203 U.S. 76, 95 (1906); Boff v. Burney, 
168 U.S. 218, 222-23 (1897).
    \51\ See Indian Policy Report at 108-09 (``the tribe, as a 
political institution, has primary responsibility to determine tribal 
membership for purposes of voting in tribal elections * * * and other 
rights arising from tribal membership. Many tribal provisions call for 
one-fourth degree of blood of the particular tribe but tribal 
provisions vary widely. A few tribes require as much as one-half degree 
of tribal blood * * *''); accord Felix S. Cohen, Handbook of Federal 
Indian Law 22-23 & n.27 (1982 ed.).
---------------------------------------------------------------------------
    Congressional authority to use such traditional 
requirements for tribal membership or benefits has never been 
doubted. In United States v. John, the Supreme Court approved 
Congress' establishment of an Indian reservation for the 
benefit of ``Chocktaw Indians of one-half or more Indian blood, 
resident in Mississippi.'' \52\ The Court unhesitatingly 
applied the definition of ``Indian'' that appears in the Indian 
Reorganization Act, which has governed Indian tribes since 
1934: ``all other persons of one-half or more Indian blood.'' 
\53\ Similarly, the Alaska Native Claims Settlement Act's use 
of a blood quantum formula as one factor in determining 
``native'' status is a valid method of defining those belonging 
to the group eligible for statutory benefits, and the use of 
the blood quantum ``does not detract from the political nature 
of the classification.'' \54\ The use of blood ties is integral 
to the nature of the political deal struck between the 
conquering Europeans and the native peoples, as they set out to 
maintain partially separate existences while inhabiting the 
same country.
---------------------------------------------------------------------------
    \52\ Id., 437 U.S. at 646.
    \53\ Id. at 650 (quoting 25 U.S.C. Sec. 479).
    \54\ Alaska Chapter v. Pierce, 694 F.2d 1162, 1168-69 n. 10 (9th 
Cir.1982) (noting absence of other practicable methods, like tribal 
rolls or proximity to reservations).
---------------------------------------------------------------------------
    This is not to suggest, however, that the Constitution 
imposes any minimum blood quantum requirement for tribal 
membership, and suggestions to the contrary have no legal or 
historical basis.
    The constitutional text and historic relationship gives 
Congress not just the ``right'' to discriminate between Native 
Americans and others, but the responsibility to do so. As the 
Supreme Court has long recognized, from the relationship 
between these former sovereign peoples and the ``superior 
nation'' that conquered them arises ``the power and the duty'' 
of the United States to ``exercis[e] a fostering care and 
protection over all dependent Indian communities within its 
borders. . . .'' \55\ Recently, the Supreme Court acknowledged 
the continued significance of this historic trust 
relationship.\56\
---------------------------------------------------------------------------
    \55\ Kagama, 118 U.S. 375, 384-85 (1886) (emphasis added); See 
Seminole Nation v. United States, 316 U.S. 286, 296 (1942) (the 
government owes a ``distinctive obligation of trust'' to Indians).
    \56\ See Greater New Orleans Broadcasting Assn v. United States, 
527 U.S. 173, 193 (1999) (recognizing ``special federal interest in 
protecting the welfare of Native Americans'').
---------------------------------------------------------------------------
    Like the 556 Indian tribes currently recognized by the 
United States, Native Hawaiians are a group of people defined 
by their common descent from an ancestral class, each forming a 
distinct polity and having a unique historical existence. Any 
contemporary group whose members are defined by their lineal 
descendancy from a historically-defined class will necessarily 
share an ethnic identity with the original members of the 
historical class, even though intermarriage may attenuate the 
degree of blood quantum shared by the original historical class 
members. Nevertheless, a definition that is based primarily on 
the historical uniqueness of the original class is no more 
race-based than the definition of those who are members or 
citizens of the historic Indian tribes that greeted the first 
Europeans immigrants to this nation's shores.
    The Supreme Court has repeatedly applied the concepts of 
``Indian'' and ``tribe'' to a wide variety of Native American 
communities, recognizing the constant evolution of Native 
community life and that the questions of whether and how to 
treat with these changing communities are assigned by the 
Constitution to Congress. In The Kansas Indians,\57\, the Court 
recognized that the Ohio Shawnees remained a ``tribe,'' even 
though tribal property was no longer owned communally and the 
tribe had abandoned Indian customs ``owing to the proximity of 
their white neighbors.'' \58\
---------------------------------------------------------------------------
    \57\ 72 U.S. 737 (1866).
    \58\ Id., 72 U.S. at 755-57.
---------------------------------------------------------------------------
    Fifty years later, the Supreme Court approved a similar 
tribal designation for the Pueblo Indians of New Mexico. After 
long experience under Spanish rule, the Pueblo Indians seemed 
little like the ``savages'' of James Fennimore Cooper. The 
Pueblo Indians lived in villages with organized municipal 
governments; they cultivated the soil and raised livestock; 
they spoke Spanish, worshiped in the Roman Catholic Church; and 
prior to the acquisition of New Mexico by the United States, 
they enjoyed full Mexican citizenship.\59\ Nevertheless, the 
Pueblo Indians lived in ``distinctly Indian communities,'' and 
Congress acted properly under the Indian Commerce Clause in 
determining that they were ``dependent communities entitled to 
its aid and protection, like other Indian tribes.'' \60\ For 
Native American ``communities,'' the Court held that ``the 
questions whether, to what extent, and for what time they shall 
be recognized and dealt with as dependent tribes requiring the 
guardianship and protection of the United States are to be 
determined by Congress. . . .'' \61\
---------------------------------------------------------------------------
    \59\ See United States v. Joseph, 94 U.S. (4 Otto.) 614, 616 
(1877).
    \60\ United States v. Sandoval, 231 U.S. 28, 46-47 (1913); 
Candelaria, 271 U.S. at 439-40, 442-43.
    \61\ Sandoval, 231 U.S. at 46; accord Tiger v. Western Inv. Co., 
221 U.S. 286, 315 (1911).
---------------------------------------------------------------------------
    As indicated above, sixty years later, in United States v. 
John,\62\ the Supreme Court recognized Congress' authority to 
establish a reservation for the benefit of Choctaw Indians in 
Mississippi, even though (1) they were ``merely a remnant of a 
larger group of Indians'' that had moved to Oklahoma; (2) 
``federal supervision over them had not been continuous''; and 
(3) they had resided in Mississippi for more than a century and 
had become fully integrated into the political and social life 
of the State.\63\ The Mississippi Choctaw were Indians. They 
had recently organized into a distinctly Indian community. The 
Court therefore deferred to Congress' determination that they 
were a ``tribe for the purposes of Federal Indian law.'' \64\
---------------------------------------------------------------------------
    \62\ 437 U.S. 634 (1978).
    \63\ Id., 437 U.S. at 652-53.
    \64\ Id., at 650 n.20, 652-53.
---------------------------------------------------------------------------
    Similarly, the Supreme Court has recognized Congress' broad 
authority to deal with individual ``Indians.'' \65\ or large 
organizations comprised of numerous ``tribes.'' \66\ Congress 
may recognize new aggregations of Native Americans, so long as 
such legislation is rationally related to the fulfillment of 
Congress' trust obligation to the historic Indian peoples.\67\ 
Congress' treatment of the Alaska native people--including the 
establishment of unique regional corporations whose 
shareholders comprise numerous Native villages--has properly 
been upheld as within Congress' special power over and 
responsibility for the Native American peoples.\68\
---------------------------------------------------------------------------
    \65\ United States v. Holliday, 70 U.S. (3 Wall.) 407, 417 (1865) 
(regulation of ``commerce with the Indian tribes means'' regulation of 
``commerce with the individuals composing those tribes''); see Morton 
v. Ruiz, 415 U.S. 199, 230-38 (1974) (addressing the scope of federal 
Indian welfare benefits for individuals living in Indian communities); 
Mancari, 417 U.S. at 551-55.
    \66\ See Cherokee Nation v. Journeycake, 155 U.S. 196 (1894) 
(Delaware Indians entitled to rights of Cherokee Nation which Delawares 
had joined); United States v. Blackfeather, 155 U.S. 218 (1894) (same 
for Shawnee).
    \67\ See John, 437 U.S. at 652-53; Moe v. Confederated Salish & 
Kootenai Tribes, 425 U.S. 463, 480 (1976).
    \68\ Although the Alaska natives' situation is ``distinctly 
different from that of other American Indians,'' Alaska Chapter, 694 
F.2d at 1168-69 n.101, see Metlakatla Indian Community v. Egan, 369 
U.S. 45, 50-51 (1962), it is ``well established'' that Athabascan 
Indians, Eskimos, and Aleuts are ``dependent Indian people'' within the 
meaning of the Constitution. Alaska Pacific Fisheries v. United States, 
248 U.S. 78, 87-89 (1918); see also Pence v. Kleppe, 529 F.2d 135, 138-
39 n.5 (9th Cir. 1976) (``Indian'' means ``the aborigines of America'' 
and includes Eskimos and Aleuts in Alaska); United States v. Native 
Village of Unalakleet, 411 F.2d 1255, 1256-57 (Ct. Cl. 1969) (``Eskimos 
and Aleuts are Alaskan aborigines'' and, therefore, ``Indians'').
---------------------------------------------------------------------------

Citizens of the Kingdom of Hawai`i

    Contrary to well-established principles of Federal-Indian 
law that recognize the right of a tribe to determine its own 
members as a fundamental aspect of the tribe's sovereignty,\69\ 
some have argued that the Kingdom of Hawai`i somehow lost its 
``native'' character because some non-Hawaiians became 
naturalized citizens of the Kingdom. This argument is used as 
the basis for asserting that Native Hawaiians cannot now be 
``recognized'' as a native group with which the United States 
may maintain a special legal and political relationship.\70\ 
However, as evident from the preceding discussion of Supreme 
Court rulings and precedent, this argument lacks any 
constitutional basis. The Supreme Court has often decided cases 
relating to the status of non-Indians who had become members or 
citizens of Indian tribes,\71\ but the Court has never 
suggested that a tribal law that provides for the membership or 
citizenship in the tribe of previously non-tribal members 
renders those tribes or their modern-day successors ineligible 
for recognition as having a special legal and political 
relationship with the United States pursuant to the Indian 
Commerce Clause. Similarly, opposition to the recognition of a 
Native Hawaiian governing entity premised upon the attenuation 
of the blood quantum of its citizens lacks any historical or 
constitutional basis.
---------------------------------------------------------------------------
    \69\ Santa Clara Pueblo v. Martinez, 436 U.S. 49, 72 n.32 (1978).
    \70\ See, e.g., Stuart Minor Benjamin, Equal Protection and the 
Special relationship: The Case of Native Hawaiians, 106 Yale L.J. 537, 
607-8 & n.287 (1996) (discussing this argument, while noting that 
``[i]nclusion of some Westerners would not necessarily defeat a claim 
of tribal status'' as the Supreme Court has never directly addressed 
the question, and noting that ``some Indian tribes included Westerners. 
. . .''.
    \71\ See, e.g., United States v. Rogers, 45 U.S. (4 How.) 567 
(1846); Boff v. Burney, 168 U.S. 218 (1897); Daniel Red Bird v. United 
States, 203 U.S. 76 (1906).
---------------------------------------------------------------------------
    Many contemporary tribes define their citizenship or 
membership based upon lineal descendancy from a tribal roll, 
and the Congress has from time to time established criteria for 
membership in certain tribes.\72\ What neither the Congress nor 
the Supreme Court has done is to suggest that the Constitution 
imposes a blood quantum limitation or requirement on tribal 
citizenship.
---------------------------------------------------------------------------
    \72\ Public Law No. 129, Sec. Sec. 1-4, 34 Stat. 137, 137-38 (April 
26, 1906) (setting forth enrollment criteria for members of the 
Choctaw, Chickasaw, Cherokee, Creek and Seminole Tribes of Oklahoma).
---------------------------------------------------------------------------

The Significance of ``Federal Recognition''

    It is important to recognize that the legal distinctions 
that have been drawn in contemporary times between Indian 
tribes that are ``acknowledged'' by the Department of the 
Interior \73\ or ``recognized'' by the Congress--tribes that 
have a direct government-to-government relationship with the 
United States and are thereby eligible for various Federal 
benefits--and Native American groups that are not so recognized 
and have no such government-to-government relationship, is a 
relatively recent phenomenon. ``[A] close scrutiny of the 
various executive orders, Congressional legislation, 
departmental policies, Solicitor's opinions, and judicial 
decisions since 1783 . . . discloses an astonishing oblivion of 
the need for an express declaration or statement regarding 
which Indian tribes were to be recognized, until the enactment 
of the Wheeler-Howard (Indian Reorganization) Act of 1934,'' 
\74\ thirteen years after the enactment of the Hawaiian Homes 
Commission Act. In fact, there was no systematic procedure by 
which a Native American group could petition the United States 
for recognition until 1978, when regulations were promulgated 
to implement the Federal Acknowledgment process.\75\
---------------------------------------------------------------------------
    \73\ See 25 CFR Part 83.
    \74\ William W. Quinn, Jr., Federal Acknowledgment of American 
Indian Tribes: The Historical Development of a Legal Concept, 34 Am. J. 
Leg. Hist. 331, 332 (1990) (citing 48 Stat. 984 (1934) (codified as 
amended at 25 U.S.C. Sec. Sec. 461 et seq.)); see generally, William W. 
Quinn, Jr., Federal Acknowledgment of American Indian Tribes: 
Authority, Judicial Interposition, and 25 CFR Sec. 83, 17 Am. Indian L. 
Rev. 37 (1992); L.R. Weatherhead, What is an ``Indian Tribe''?--The 
Question of Tribal Existence, 8 Am. Indian L. Rev. 1 (1980).
    \75\ 25 CFR, Part 83. Quinn 1992, at 40-41.
---------------------------------------------------------------------------
    An administrative process for the acknowledgment of Native 
groups by the United States that was established almost twenty 
years after Hawaians admission to the Union could not have 
informed the provisions of the Hawaiian Homes Commission Act 
nor the Hawai`i Admission Act and it is thus not surprising 
that the language of those Acts do not conform neatly with 
categorizations that had yet to be developed.
    Although the authority of Congress to formally 
``recognize'' tribes through legislation is unquestioned, the 
Department of the Interior's regulations associated with the 
administrative process for the acknowledgment of tribes 
pursuant to 25 CFR Part 83 exclude Native Hawaiians from that 
process, and thus legislation is the only mechanism available 
to Native Hawaiians.\76\ The present legislation thus 
establishes no precedent applicable to groups eligible to apply 
for recognition under the existing administrative framework.
---------------------------------------------------------------------------
    \76\ See 25 CFR Sec. Sec. 83.1, 83.3 (administrative process 
available only to groups within the ``continental United States,'' 
defined as the ``contiguous 48 states and Alaska''). Native Hawaiians 
have twice sought unsuccessfully to challenge their exclusion from this 
process. Price v. State of Hawaii, 764 F.2d 623 (9th Cir. 1985); 
Kahawaiolaa v. Norton, 222 F. Supp. 2d 1213 (D. Haw. 2002).
---------------------------------------------------------------------------

                                  
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