Mr. Chairman and Members of the Committee:
Good morning. I am Michel Lincoln, Deputy Director of the Indian
Health Service (IHS). Today I am accompanied by ADM Gary Hartz,
Acting
Director of the Office of Public Health, and Dr. Craig
Vanderwagen, Director of Clinical and Preventive Services. We
are pleased to have this opportunity to testify on the FY 2000
President's budget request for the Indian Health Service.
As you know, the IHS has the responsibility for the delivery of
health services to Federally-recognized American Indians and
Alaska Natives (AI/AN's)through a system of IHS, tribal, and
urban (I/T/U) operated facilities and programs based on treaties,
judicial determinations, and Acts of Congress. The mission of
the agency is to raise the physical, mental, social, and
spiritual health of American Indians and Alaska Natives to the
highest level, in partnership with the population served. The
agency goal is to assure that comprehensive, culturally
acceptable personal and public health services are available and
accessible to the service population. The mission and goal are
addressed through four strategic objectives, which are to 1)
improve health status; 2) provide health services; 3) assure
partnerships and consultation with IHS, Tribal, and Urban
programs; and 4) perform core functions and advocacy.
For the second year now, development of the IHS budget request
originated at the health services delivery level. As full
partners with the IHS in delivering needed health care to
AI/AN's, tribal and urban programs participate at all levels of
formulating the budget request and annual performance plan. The
combined expertise of the IHS, Tribal, and Urban Program health
providers, Administrators, technicians, and elected officials, as
well as the public health professionals at the Area and
Headquarters offices, has resulted in a powerful statement of the
health care funding priorities for AI/AN people. The FY 2000
President's budget request and performance plan represents the
first of many incremental steps necessary to reduce the health
disparities that prevail in the American Indian and Alaska Native
population. It is consistent with the Agency's mission, the
Department's strategic plan, and the Department of Health and
Human Services' Initiative to Eliminate Racial and Ethnic
Disparities in Health.
The President proposes an increase of $170.1 million to the IHS
budget in FY 2000 above the FY 1999 appropriation, more than
double the rate of medical inflation. This substantial increase
provides an additional $82.6 million for current services items
including health care facilities construction, $68.4 million in
program increases for Services, and $19.1 million in program
increases for Facilities and Environmental Health. The eight
percent increase will allow I.H.S. to finance 44 new dental unit
teams to provide an additional 25,000 dental visits, reduce
incidence of complications related to chronic diseases such as
diabetes, and enable approximately 100 new community based Public
Health Nurses to provide outreach activities, including home
visits, well child examinations, immunizations, pre-natal care,
health fairs, follow-up visits, and missed clinical appointments.
On top of the proposed $170 million increase, I.H.S. expects to
collect an additional $82 million in reimbursements due to
Medicaid collection rate increases from 1998 to 2000.
From a policy perspective, this budget request is perhaps the
most strongly supported proposal in the Agency's history; it is
based on both new and longstanding Federal policy and commitment
for improving health status by assuring the availability of basic
health care services for members of federally recognized Indian
tribes. The request supports the following three policy
initiatives:
- the President's Race Initiative, specifically the HHS
Initiative to Eliminate Racial and Ethnic Disparities in
Health,
- the proposed Healthy People 2010 and its goal of achieving
equivalent and improved health status for all Americans over
the next decade,
- the DHHS strategic plan with goals to reduce major threats to
health and productivity of all Americans; improve the
economic and social well-being of individuals and families,
and communities in the United States
; improve access to
health services and ensure the integrity of the Nation's
health entitlement and safety net program; improve the
quality of health care and human services; and improve public
health systems.
In addition, the Indian Health Care Improvement Act also reflects
the reaffirmation of the U.S. government's commitment to Indian
tribes to improve the health of their people. The Act states
"The Congress hereby declares that it is the policy of this
Nation, in fulfillment of its special responsibilities and legal
obligations to the American Indian people to assure the highest
possible health status for Indians and urban Indians and to
provide all the resources necessary to affect that policy."
Furthermore, the President of the United States
reaffirmed the
significance of the "government to government" relationship
between tribes and the federal government in his Executive
memorandum of April 1994, concerning consultation with American
Indian and Alaska Native tribal leadership.
The primary policy basis for this budget request is eliminating
health disparities between the AI/AN population and the general
U.S. population. The request supports this intent by restoring
access to the basic health services, including assuring that
there are adequate facilities and equipment for the provision of
health services, providing adequate support services to the
tribal health delivery systems.
The request also supports a four-pronged funding strategy for the
I.H.S., which includes: 1) increased resources; 2) a coordinated
effort to ensure that HHS health grants provide assistance to
Native Americans; 3) review of reimbursements from Medicaid and
Medicare based on cost data; and 4) increased vigilance to ensure
that Federal funds are used properly.
A major priority in the budget proposal is to restore access to
basic health services. The IHS has demonstrated the ability to
effectively utilize available resources to provide effective
services and improve the health status of AI/AN people. However,
this record of achievement has eroded in recent years in the face
of budget constraints and the need to shift to providing more
acute and urgent care treatment in the face of limited resources.
Thus, to redress the declining access to essential individual and
community health services, the Area IHS, Tribal, and Urban
programs identified funding of pay increases and current
services items as their first priority for budget increases for
FY 2000. In an effort to maintain the current level of services,
the budget request includes $34.8 million for pay cost increases
,$2.8 million to address the increased GSA rental rates, and $8.6
million to fund the staffing and operating costs of those
facilities that will open in FY 2000 or have recently opened.
Another essential component of supporting access to services and
improving health status in the long run, is to assure that there
are adequate facilities and equipment for the provision of health
services. The average age of IHS facilities is 32 years. The
budget request includes a total of $51 million for replacement,
maintenance and improvement of health care facilities, and new or
replacement medical equipment. This amount will fund second
phase construction of the hospital at Fort Defiance, Arizona, and
the health center at Parker, Arizona; allow for the completion of
planning and design of the Red Mesa and Pawnee health centers,
and provide five to eight modular dental units. It will also
address the deferred maintenance needs and replacement of medical
equipment that has exceeded its useful life, and the purchase of
ambulances to provide needed emergency medical services.
Also critical is the provision of adequate contract supports
costs necessary to support the health services provided through
tribal health programs. These requested funds are necessary for
tribal communities to assure that there are utilities, training,
clerical staff, administrative and financial services needed to
operate health programs. Without this contract support funding,
these support services are either not available or must be funded
from resources that would otherwise fund health service
activities. This investment is consistent with the
Administration's commitment to expand tribal participation in the
management of federally funded programs, and reinforces the
principles of the Indian Self-Determination Act.
The FY 2000 budget includes an increase of $35 million over the
FY 1999 enacted level for contract support costs (CSC). This
amounts to a 17 percent increase over the FY 1999 level. The
increase is necessary to address the CSC of ongoing compactors
and contractors and, to the extent possible to provide initial
CSC funding for new and expanded tribal programs to be contracted
in FY 2000. The FY 1999 Conference Report asked the IHS to
provide solutions to the critical issues surrounding CSC funding.
Contract Support Costs has become one of the most challenging
problems faced by the IHS and Indian Country since the inception
of Indian Self-Determination in 1975. The IHS has been
assembling data and analyzing this problem since last October.
We have consulted with Tribes, the National Congress of American
Indians, the General Accounting Office, the Bureau of Indian
Affairs, and the Department of Interior Office of Inspector
General and we believe we are nearing some solutions that will
enable the IHS and tribes to manage CSC responsibly in an era of
constrained Federal budgets and increasing CSC demands. The IHS
will be conducting ongoing tribal consultation on these
alternative solutions throughout the summer months but we are
confident that a jointly supportable Federal/tribal solution will
be adopted and implemented for FY 2000. We will share these
solutions with the Committee before they are finalized.
The requests that I have just described provide the investment
required to begin restoring the IHS, tribal, and urban Indian
public health system to provide access to high quality medical
and preventive services as a means of improving health status.
Funds are included that target segments of the population that
are particularly vulnerable to disproportionate disease burden
and identified as health priorities by the IHS, Tribal, and urban
programs: children and youth, women, elders, and urban Indians.
To address the multiple health issues affecting these
populations, the budget request includes increases totaling $24.4
million in the areas of women's health, alcohol and substance
abuse, public health nursing, and urban Indian health. The
request also includes increases to target the specific disease
entities identified as priority areas by the IHS, Tribal, and
Urban programs and responsible for much of the disparity in
health status for the AI/AN population, including dental
diseases, injuries, already mentioned and cancers. The budget
provides a dental program increase of $7 million and $2.8 million
for injury prevention, and an additional $24 million for contract
health services.
Public health infrastructure is fundamental to these proposals.
$22.8 million is requested for information and telecommunication
systems, the Indian Health Care Improvement Fund, and Facilities
and Environmental Health Support.
The budget also provides for sanitation facility projects for new
and existing homes at the community level. The American Indian
and Alaska Native homes are seven times more likely to be without
clean water than homes in the broader U.S. A $3 million increase
is requested to provide for needed water, sewer, and solid waste
facilities, as well as to clean up and replace open dumps. This
construction is integral to making sure that further progress is
to be made in preventing infectious diseases and improving the
quality of life in Indian country.
In summary this budget request and performance plan will address
access to individual and community health service and allow I.H.S
to increase services in a number of important areas listed
previously in this testimony, including breast and cervical
cancer screening, and prenatal care. The request provides the
initial increment required to enhance the IHS, Tribal, and Urban
public health system so that it can again continue to make
significant improvements in the health status of American Indian
and Alaska Native people.
Thank you for this opportunity to discuss the FY 2000 President's
budget request for the IHS. We are pleased to answer any
questions that you may have.