<DOC>
[108 Senate Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:86420.wais]
S. Hrg. 108-62
INDIAN HEALTH CARE
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
ON
S. 556
TO AMEND THE INDIAN HEALTH CARE IMPROVEMENT ACT TO REVISE AND EXTEND
THAT ACT
__________
APRIL 2, 2003
WASHINGTON, DC
86-420 U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 2003
____________________________________________________________________________
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COMMITTEE ON INDIAN AFFAIRS
BEN NIGHTHORSE CAMPBELL, Colorado, Chairman
DANIEL K. INOUYE, Hawaii, Vice Chairman
JOHN McCAIN, Arizona, KENT CONRAD, North Dakota
PETE V. DOMENICI, New Mexico HARRY REID, Nevada
CRAIG THOMAS, Wyoming DANIEL K. AKAKA, Hawaii
ORRIN G. HATCH, Utah BYRON L. DORGAN, North Dakota
JAMES M. INHOFE, Oklahoma TIM JOHNSON, South Dakota
GORDON SMITH, Oregon MARIA CANTWELL, Washington
LISA MURKOWSKI, Alaska
Paul Moorehead, Majority Staff Director/Chief Counsel
Patricia M. Zell, Minority Staff Director/Chief Counsel
(ii)
C O N T E N T S
----------
Page
S. 556, text of.................................................. 2
Statements:
Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado,
chairman, Committee on Indian Affairs...................... 1
Davis-Wheeler, Julia, chairperson, National Indian Health
Board...................................................... 351
Grim, M.D., Charles, interim director, Indian Health Service,
Department of Health and Human Services.................... 345
Kashevaroff, Don, representative, Tribal Self-Governance
Advisory Committee, president and chairman of the Alaska
Native Tribal Health Consortium............................ 354
Murkowski, Hon. Lisa, U.S. Senator from Alaska............... 357
Appendix
Prepared statements:
Benjamin, Melanie, chief executive, Mille Lacs Band of Ojibwe 361
Davis-Wheeler, Julia......................................... 362
3Grim, M.D., Charles (with attachments)...................... 365
Kashevaroff, Don............................................. 392
National Kidney Foundation, Inc., New York, NY............... 400
INDIAN HEALTH CARE IMPROVEMENT ACT REAUTHORIZATION OF 2003
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WEDNESDAY, APRIL 2, 2003
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The committee met, pursuant to notice, at 10 a.m. in room
485, Senate Russell Building, Hon. Ben Nighthorse Campbell
(chairman of the committee) presiding.
Present: Senators Campbell, Inouye, and Murkowski.
STATEMENT OF HON. BEN NIGHTHORSE CAMPBELL, U.S. SENATOR FROM
COLORADO, CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS
The Chairman. The committee will be in session.
Good morning and welcome to the Committee on Indian Affairs
hearing on Secretary Thompson's proposed reorganization of the
Department of Health and Human Services. This proposal, known
as the One-HHS Initiative, is being vigorously debated on
Capitol Hill, in Indian Country and elsewhere. Today, we will
hear how the One-HHS Initiative will impact health delivery to
Native people.
We are focusing on this One-HHS Initiative today, but in a
sense this hearing is the first in a series this committee will
be holding on legislation to reauthorize and extend the Indian
Health Care Improvement Act that I introduced, along with my
friends and colleagues Senator Inouye and Senator McCain.
Effort to consolidate Federal programs are not new and at times
have proven very successful, such as the employment and
training program known as the 477 Program. We are trying to
achieve the same success with alcohol, drug and mental health
programs, and will hold a hearing on that bill next week.
Nevertheless, the Tribes have expressed concerns with the One-
HHS proposal, and today we will hear about some of those
concerns.
[Text of S. 556 follows:]
<GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT>
The Chairman. Senator Inouye will not be able to be here
today. He is in a defense appropriations hearing. As you might
know, that is extremely important now, so we will just go ahead
with the testimony.
We will start with the first panel, Charles Grim, interim
director of the Indian Health Service. He will be accompanied
by Mr. Lincoln, Craig Vanderwagen, and Gary Hartz.
Dr. Grim, before I start, I also wanted to congratulate
you. I understand 2 days ago we received official papers from
the White House nominating you to be the permanent director of
the IHS, and we will schedule a hearing on your nomination
right after the Easter break, and we look forward to your
service in that capacity. Congratulations.
Mr. Grim. Thank you, Chairman Campbell.
The Chairman. Go ahead and proceed.
STATEMENT OF CHARLES GRIM, M.D., INTERIM DIRECTOR, INDIAN
HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES
Mr. Grim. It is a pleasure to be here before you and the
committee, Mr. Chairman. I would like to request that my
written statement that has been submitted be entered to the
record.
The Chairman. Your complete statement will be in the
record.
Mr. Grim. Thank you.
I am Dr. Charles W. Grim, interim director of the Indian
Health Service. I am accompanied today by several of my staff,
Michel Lincoln, deputy director for the Indian Health Service;
Craig Vanderwagen, acting chief medical officer for the Indian
Health Service; Gary Hartz, acting director for the Office of
Public Health; and Bob McSwain, director for the Office of
Management Support.
Today we are here to speak about the reauthorization of the
Indian Health Care Improvement Act. There is no single piece of
legislation that will affect the future health status of the
American Indians and the Alaska Natives more than the Indian
Health Care Improvement Act Reauthorization of 2003, S. 556. In
the intervening 28 years since it was first authorized,
achievements in tribal self-determination, decisions by this
committee and other authorizing and appropriations committees
of Congress, and the Indian Health Service Programs have
improved the health status of Indian people.
To continue the momentum of improvement and to achieve the
goals shared by Indian country, this committee and the
Administration, to eliminate health disparities between all
Americans, it is critical that the Indian Health Care
Improvement Act reflect the health and world realities of
today, and not those of 28 years ago.
From the beginning of the tribal-Federal relationship, the
provision of health care services to Indians has been a key
component of the Federal Government's trust responsibility. Two
major pieces of legislation are at the core of the Federal
Government's responsibilities for meeting the health needs of
American Indians and Alaska Natives--the Snyder Act of 1921,
Public Law 67-85 and the Indian Health Care Improvement Act,
Public Law 94-437. The Snyder Act authorized regular
appropriations for relief of distress and conservation of
health of American Indians and Alaska Natives. It remains the
basic authority for appropriations for major Indian programs.
The Indian Health Care Improvement Act was originally
authorized in 1976, and was enacted to implement the Federal
responsibility for the care and education of the Indian people
by improving the services and facilities of the Federal Indian
health programs, and encouraging maximum participation of
tribes in such programs.
Like the Snyder Act, the Indian Health Care Improvement Act
provided the authority for the programs of the Federal
Government to deliver health services to Indian people, but it
also provided additional guidance in several areas. The Indian
Health Care Improvement Act contained specific language that
addressed the recruitment and retention of a number of health
professionals serving Indian communities. It focused on health
services for urban Indian people and addressed the
construction, replacement and repair of health care facilities.
S. 556 is the product of extensive consultation that the
Indian Health Service undertook during 1999 with Indian
country. In anticipation of the reauthorization of the act and
the changes in the health care environment of the country, IHS
wanted to consult with Indian country to ascertain how these
changes have impacted on the ability of tribes and urban Indian
health programs to deliver high quality and much-needed
services.
During consultation with Indian country, we learned that
tribes were anxious to discuss the impact of managed care and
other changes in the health care field that affected their
ability to administer quality health programs and services.
Based on this consultation, the tribes and urban Indian health
programs determined that they would draft a legislative
proposal reflecting their concerns and issues.
S. 556 contains a variety of new, expanded and strengthened
provisions, activities and services. The Department supports
the reauthorization of this cornerstone legislative authority,
and Secretary Thompson has made Indian health care a priority
of the Department. In the Department's review of the proposed
language, to ascertain its relationship to its policies and
budget priorities during this time in our Nation's history,
there are certain provisions in S. 556 that generate some
concern.
Key provisions in S. 556 are inconsistent with current
Medicare and Medicaid provider payment practices and could
inappropriately increase costs. As an example, the bill
proposes a new provider type called Qualified Indian Health
Provider for IHS, tribal and urban Indian providers
participating in Medicare and Medicaid programs. The most
problematic aspects of the QIHP are the structure and operation
of the payment provisions, which are not only burdensome, but
more importantly would not be feasible to administer. In
addition to the burden and feasibility issues, on a more
fundamental level, the full cost, plus other costs of the QIHP
payment approach would be contrary to the way that Medicare
generally pays providers.
The bill also expands the current 100 percent Federal
matching rates to States for Medicare and SCHIP services
provided through IHS facilities to include services provided to
American Indians and Alaska Natives by non-Indian health care
providers. This proposed change would substantially increase
the Federal program and administrative costs, with no guarantee
and little likelihood of increasing access to services for
Indian beneficiaries or better payments to Indian providers.
We are also concerned that S. 556 would appear to broadly
mandate the use of negotiated rulemaking to develop all
regulations to implement the act. Negotiated rulemaking is very
resource-intensive for both Federal and non-Federal
participants. While it can be effective and appropriate in
certain circumstances, it may not be the most effective way to
obtain the necessary Indian input in the development of the
Indian Health Care Improvement Act rules and regulations in
every given case.
In addition to our expressed concerns with S. 556, I would
like to present a little bit of an explanation of the
Secretary's One-Department Initiative and its benefits to the
Indian Health Service. The Secretary's One-Department
Initiative has been of great benefit to the IHS, as well as the
Native American constituents of the Department. The fundamental
premise of the initiative is that the Department of Health and
Human Services must speak with one consistent voice. Nothing is
more important to our success as a Department.
With regard to our tribal constituents, the Secretary
observed on his first trip to Indian country that tribal
programs were often stovepiped and that their existed within
HHS an assumption that the Indian Health Service has sole
responsibility for the health issues facing tribes.
In the 2 short years since the Secretary launched this
initiative, he has reestablished the Intradepartmental Council
for Native American Affairs. The membership on this council is
comprised of the heads of all HHS operating and staff
divisions, with the IHS director serving as the vice-chair.
This council serves as an advisory body to the Secretary and
has the responsibility to assure that Indian policy is
implemented across all divisions. The council provides the
Secretary with policy guidance and budget formulation
recommendations that span all divisions of HHS. The profound
impact of this council on the IHS is the revised premise within
HHS that all agencies bear responsibility for the government's
responsibility and obligation to the Native people of this
country.
I want to assure you and the committee that we are
committed to working with you to ensure that this key
legislative authority can be reauthorized. We will be happy to
answer any questions that you may have regarding the
Department's view on S. 556.
Thank you.
[Prepared statement of Mr. Grim appears in appendix.]
The Chairman. Thank you, Dr. Grim.
I was listening very carefully to your explanation about
the One-HHS, and we are getting quite a bit of uncomfortable
feelings back from the tribes. Is it still on track? Has it
been revised to reflect the comments and recommendations from
the review group or from tribes themselves?
Mr. Grim. The Indian Health Service at the current time is
also going through a reorganization of its own, as part of the
President's management agenda. This is an initiative that we
started prior to the President's management agenda, which asked
agencies to de-layer their bureaucracies and try to become more
effective and efficient. As part of the IHS HQ reorganizatiobn
process, we have been taking input for the Department relative
to some of the One-HHS initiatives.
We received numerous comments from tribes, as well as
resolutions. Primarily the comments have been around the
consolidation efforts of the Human Resources Department. We
have made those informations known at all departmental meetings
on such consolidations.
The Indian Health service has had a seat at the table. We
have been involved in all of the planning sessions that the
Department is holding relative to the HR consolidations. We are
making all of our unique considerations known in those
meetings.
The Chairman. I see. Well, as I understand it, the
initiative is going to involve the transfer of $838,000 from
the IHS to the HHS. Clearly, that is one of the tribal
concerns, that they are going to lose their tribal shares. I
think you can understand their worry. How do you propose to
preserve the tribal shares?
Mr. Grim. One of the initial issues that you brought up,
Senator, on the $838,000 transfer of funds from Indian Health
Service into the Department was actually dealt with by the
Congress. That was restored to the Indian Health Service
budget. One of the things that we are trying to do to ensure
that Indian country and Indian Health Service needs are dealt
with is that our staff, both in legislative and public affairs
and in HR, have been in attendance at all of the meetings that
the Department has called relative to having public affairs,
legislative affairs and other departments try to speak with one
voice.
The Chairman. I understand that sometimes when they speak
with one voice, though, it is a majority voice that leaves a
lot of people out in the cold. If that money was transferred,
can the functions that they are now used for under IHS and the
dollars that are going to be associated with it, are they still
be contractable once they are consolidated with the HHS?
Mr. Grim. One of the things we have been making the
Department aware of are the special needs relative to our
budget around tribal shares. A large portion of our
headquarters and regional office budgets, as well as 100
percent of our service unit budgets, are contractable and
compactable for tribal shares. One of the things that the
Department is looking at right now in these consolidation
efforts are just those issues. Many of these things are still
in the planning phases, and as I said, we do attend those
meetings. One of the things the Department is aware of, though,
is that the Indian Health Service HR budget, parts of the
legislative and public affairs budget, are eligible for tribal
shares. Should a tribe who is not currently taking those shares
come in and ask for said shares, then we would--make those
moneys available. So those issues have been made known to the
Department.
The Chairman. And I further understand that you believe the
IHS will realize a cost of $21.3 million from the reduction of
195 FTEs and $9.3 million from information technology. Your
testimony says that every effort will be made to minimize the
impact at the service delivery level of the organization. I can
tell you, Indian people from the health standpoint, they do not
have an awful lot of slack. A lot of them are right on the
edge, and I would be interested in knowing the specific impacts
that, if you foresee any now, that it is going to have on
service delivery because of the reduction of those FTEs.
Mr. Grim. One of the things that we have always tried to
do, Senator, in the past when the agency has been asked to take
any sort of budget reductions or FTE reductions, a primary
policy of the agency has been to take those in the
administrative realm, to try to reduce the impact on the care
delivery level. The 195 FTE reduction that is being proposed in
the Indian Health Service budget is because of savings that are
being requested in that amount for the Indian Health Service.
The way that the Indian Health Service plans on dealing with
those is that we will be looking at any sorts of economies and
efficiencies that we can achieve in the way of administrative
operations of the agency, as well as consolidating and
streamlining certain functions like IT and the HR
consolidations that are occurring within the Health and Human
Services Department.
We do not have specific information yet because it is a
fiscal year 2004 budget proposal on exactly where those 195
FTEs might come from. What we will be looking at, however, will
be administrative vacancies that currently exist. We are at
both the headquarters and regional levels being very careful
now about the administrative vacancies that we are filling.
Also the Department is going forward with some early-out and
buyout authority requests that were granted in the Homeland
Security Act. We will make wise and judicious use of buyout and
early-out authorities targeted at areas where we may have
overages in certain areas. And then, as a last resort, we would
touch the service unit or the health care delivery level, if
necessary.
The agency will look very, very closely, though, at our
administrative ranks to ensure that what is left will be able
to fulfill our fiduciary and accountability standards that are
expected of us.
The Chairman. Well, I appreciate your answering, but they
are somewhat broad terms for me. Do you foresee the elimination
of any existing programs or disease prevention or health
promotion activities that now tribes avail themselves to?
Mr. Grim. No, sir; we do not.
The Chairman. I did not ask all the way. I should have.
Would any of the other people that are accompanying you--were
they going to make statements, too?
Mr. Grim. They do not have any initial statements, no sir.
The Chairman. Okay. Tell me about the consultation that has
taken place, if any, with tribes on this proposal.
Mr. Grim. On the One-HHS?
The Chairman. Yes.
Mr. Grim. As I said, the Indian Health Service, as part of
our own internal reorganization, had a restructuring initiative
work group that was put together well over 1 year ago--about 1
year ago January. They had a series of meetings, and in those
meetings--and that was a group composed of primarily tribal
leaders from all regions of Indian Health Service--with four
Federal representatives. In that process, they dealt
extensively in discussions about the One-HHS Initiative. They
provided both an interim and a final report to the director of
Indian Health Service. As part of the restructuring initiatives
that we are doing at headquarters of Indian Health Service, we
put together then a final team that developed essentially the
organizational charts, functional statements and things like
that, that took into account all of the comments that came in
from the restructuring initiative work group.
Further, we sent comments after that out to Indian country
to each of our regions and asked that they hold meetings with
their tribes in whatever format they used to do tribal
consultation. They would then take a look at the restructuring
of Indian Health Service headquarters as currently proposed in
draft. We have also been making the Department aware, as we and
other of the operating divisions have meetings on the HR
consolidation, of the issues that the tribes have brought
forward relative to their concerns about HR consolidation.
The Chairman. How long has this been going on--the
consultation process?
Mr. Grim. The consultation process started, I believe it
was in January 2002 for the restructuring of Indian Health
Service.
The Chairman. Well, my own personal view is that I would
want to know a lot more about any specific impacts,
particularly if they are going to adversely affect tribes,
before the 2004 money is going to be triggered. I would think
that Senator Inouye would be equally interested in that.
Over the years, the success of tribes with 638 contracts
and self-governance compacts has resulted in the reduction of
the IHS headquarters and area staff offices. Are there
administrative functions that are essentially Federal in nature
that they cannot be contracted-out to tribes now?
Mr. Grim. Yes, sir.
The Chairman. What are a couple of those?
Mr. Grim. We take a lot of these from an OMB circular that
talks about inherently Federal functions. One, for example, is
doing a Federal budget, proposing a Federal budget; dealing
with Federal contracting; supervising Federal employees--things
like that. If you would like, I could submit to the record a
further list.
The Chairman. Would you please submit that for the record?
Now that the RIW final report is completed, what is your
next step in meeting the goals of this One-HHS program?
Mr. Grim. The agency is almost ready to make some final
decisions on an organizational structure for the Indian Health
Service.
The Chairman. Will there be any further consultation with
tribes before that report is issued?
Mr. Grim. What we had indicated to tribes was that at the
same time we submitted our reorganization plan to the
Department, we would be submitting it out to Indian country for
a final look at the plan. At that point, there is still time
for very minor adjustments in the plan, but the majority of the
comments received back from Indian country relative to the
headquarters reorganization itself were relatively minor sorts
of changes that were requested. We think we have got most of
those incorporated into the final changes. So we will send it
out at the same time.
I think the Department would be willing to allow us to make
minor adjustments as it is going through its approval process
there.
The Chairman. In Alaska for a number of years, the health
care has been delivered under one compact. In a sense, they
have already consolidated for literally a unified health
system. Have you looked at that consolidation process in Alaska
to see if there is anything you can apply to this One-HHS
program?
Mr. Grim. I think we always try to learn from some of the
things that the tribes are doing. Many times they have
flexibilities, as you are aware, that we do not, when they take
over their programs under that act. It frees them from some of
the constraints that we have as a Federal program.
The Alaska region and some of those tribes have been making
us aware of some of the efficiencies they have realized. As an
example, regarding their human resources that are being managed
up there, they have a more efficient HR employee to total
employees ratio now than we are trying to achieve as a
Department. So I think we do have some things that we can learn
from looking at the way things are done by some of our compact
tribes.
The Chairman. Okay. Well, I have no further questions, Dr.
Grim, but I may submit some and request an answer in writing.
Senator Inouye may also, or other members of the committee.
With that, I appreciate your appearing today and thank you
very much.
We will now move to the second panel, which will be Julia
Davis-Wheeler, the Chairperson for the National Indian Health
Board, from Denver; and Don Kashevaroff, who is the
Representative of the Tribal Self-Governance Advisory Committee
from Anchorage, AK.
We will go ahead and start with you, Julia, if you would.
And just as the former panel, you are welcome to submit your
complete written testimony. That will be included in the record
if you would like to just summarize.
STATEMENT OF JULIA DAVIS-WHEELER, CHAIRPERSON, NATIONAL INDIAN
HEALTH BOARD
Ms. Davis-Wheeler. Yes; thank you, Senator Campbell. It is
good to see you this morning.
Good morning, everyone. It is a pleasure to be here to
testify on behalf of the National Indian Health Board. I would
like to state that I have two Board members with me in the
audience. I would request Buford Rolin from Nashville and
Everett Vigil from Albuquerque, stand please with our NIHB
staff. Thank you.
I also represent the Northwest Portland Area Indian Health
Board. I serve as chair for that. I am also the secretary for
the Nez Perce Tribal Council.
So it is a pleasure to appear before you today to make
comments on the Indian Health Care Improvement Act, which is
important authorizing legislation for the care of all of our
American Indians and Alaska Natives.
In June 1999, the director of the Indian Health Service at
that time, Dr. Michael Trujillo, convened a National Steering
Committee composed of representatives from tribes and national
Indian organizations to provide assistance and advice regarding
the reauthorization of the Indian Health Care Improvement Act.
Over the course of 5 months, the National Steering Committee
drafted proposed legislation. In October 1999, the National
Steering Committee forwarded their final proposed bill to the
Director of the Indian Health Service and to each authorizing
committee in the House and Senate. I have testified on the
Indian Health Care Improvement Act before and I once again want
to express my appreciation to you.
Last year, the Northwest Portland Area Indian Health Board,
with the Billings tribes, California tribes, and the Nashville
tribes, hosted a meeting at Portland, OR on May 28 to 30, to
talk about the recommendations on the changes for the current
legislation, S. 212. The purpose of the meeting was to address
concerns expressed in the September 27, 2001 letter that
Senator Inouye received from the Secretary of the Department of
Health and Human Services Tommy Thompson. These concerns
focused on the large cost of the bill, and it raised legitimate
questions about what we were trying to achieve in the bill. The
participants at the Portland meeting also discussed concerns
raised about high-cost elements from the score on S. 212,
prepared by the Congressional Budget Office, CBO, in March
2001.
I am very glad you have chosen to introduce S. 556 this
year. The bill has very few apparent changes to S. 212, so we
look forward to bringing you up to date on some of the changes
recommended by the National Steering Committee.
The National Steering Committee is also working this year
on a House bill that is expected to be introduced soon that
will reflect the 2002 Portland meeting changes, and the changes
discussed in subsequent meetings with House legislative
counsel, and other legislative staff meetings at the March 20
and 21, 2002 National Steering Committee meeting at Portland. A
lot of good things are possible if we pass the bill with our
recommended changes. The titles have exciting new authorities.
I want to briefly review the titles contained in the Indian
Health Care Improvement Act. Time only permits mentioning
highlights in each title, but I am ready to answer your
questions of any of the titles to the best of my ability.
Although I have worked on the bill these past 4 years, there
are only three or four experts who know everything in the bill
and I may have to look to them for assistance in answering some
of your questions.
The preamble section of the Act has been revised, including
sections on findings, declaration of Nation policy, and
definitions. Emphasis has been placed on the trust
responsibility of the Federal Government to provide health
services and the entitlement of Indian tribes to these
services.
Title I, covering the Indian health human resources and
development has been substantially rewritten, primarily to
shift priority setting and decisionmaking to the local area
levels where appropriate. The importance of education is
highlighted by changes proposed in this Act.
Title II, the health services, represents a collection of
diverse sections addressing issues related to the delivery of
health services to American Indians and Alaska Native
populations. Diabetes programs and epidemiology centers are
just two of the many health programs authorized by this title.
Title II also offers us the opportunity to improve the long-
term care needed for Indian elders. As you know, there has
never been specific authority for long-term care in the Indian
Health Care Improvement Act. Nursing homes are only a small
part of the long-term care needs of what we want to accomplish
with home and community-based health care for our elders.
Title III, facilities, proposes that tribal consultation be
required for any and all facility issues, not just facility
closures. It protects and projects on the current priority
list, while moving toward a new method of selecting facility
projects. This title gives permanent authority to small
ambulatory facility construction.
Title IV, access to health services, seeks to maximize
recovery from all third-party coverage, including Medicaid,
Medicare and State children's health insurance programs, and
any new federally funded health care programs. It also will
contain protection against estate recovery proceedings, to make
heirs pay the Medicaid bills of deceased American Indians and
Alaska Natives. This was the title that resulted in the largest
dollar total in the CBO score, but the National Steering
Committee has agreed to some modifications to the provisions in
the first tribal bill, and this has resulted in billions less
in costs to the Federal Government.
Title V, the health services for urban Indians, addresses
facility construction authority and coverage by the Federal
Tort Claims Act for the 35 urban programs. Urban
representatives were very active members of the leadership
group on the National Steering Committee, and they feel that
the changes in Title V will result in millions of dollars in
new funding for urban programs.
Title VI, the organizational improvements, includes very
few changes, including the elevation of the Indian Health
Service Director to Assistant Secretary in the Department of
Health and Human Services. Although tribes are generally very
satisfied with the relationship that Interim Director Dr.
Charles Grim has with top policymakers in the Department of
Health and Human Services, we want to institutionalize this
access with this change.
Title VII, the newly titled behavioral health title, with
major revisions, specifically to integrate alcohol and
substance abuse provisions, with mental health and social
services authorities. I know the committee is having a hearing
next week on consolidation of alcohol and substance abuse
programs, and I think this title can be complementary to the
goals of that legislation.
Title VIII, miscellaneous, was largely rewritten. It now
includes a proposal to establish an Entitlement Commission to
study and make recommendations on making Indian health an
entitlement in the same manner as Medicaid and Medicare. Ten
sections were moved out of Title VIII to more appropriate
sections in the Indian Health Care Improvement Act. All the CHS
provisions were moved to Title II, a majority of the free-
standing and severability provisions from other titles were
incorporated into Title VIII.
I pray that this Act will pass this year, with Congress
hearing from tribes that it is a priority for us in 2003. The
National Indian Health Board and tribes nationwide are renewing
their efforts to make this happen. The National Steering
Committee, working with the National Congress of American
Indians, the tribal leaders Self-Governance Advisory Committee,
and the National Council on Urban Indian Health, stand ready to
work with this committee to make necessary changes and
improvements to craft a bill that will assist us in our goal of
raising the health status of American Indians and Alaska
Natives.
I hope this hearing can be the final kick-off of the
renewed effort to reauthorize the Indian Health Care
Improvement Act. The Indian Health Service is no longer able to
assist the National Steering Committee as it did in 1999, with
support for travel and staff expenses. So it is a challenge to
the tribes and the national Indian organizations, including the
National Indian Health Board, to move this effort forward. We
will meet this challenge and the continued support of this
committee is a critical element of our efforts to pass this
bill in this session of this Congress.
Just a note, I would like to support the confirmation of
Dr. Grim. I was pleased to hear the announcement by Senator
Campbell regarding his confirmation. I would also like to
comment, as a tribal leader, that the One-DHHS Initiative that
my counterpart here is going to comment on, needs to be
reviewed thoroughly by tribal governments. Speaking as a tribal
leader, having the head offices in Baltimore is a concern that
we have as tribal leaders. The other concern is keeping the
government-to-government relationship intact that we have with
the Federal Government.
Thank you for this time and I would be happy to answer any
questions that you have.
[Prepared statement of Ms. Davis-Wheeler appears in
appendix.]
The Chairman. Thank you, Julia.
We will now move to Chairman Kashevaroff.
STATEMENT OF DON KASHEVAROFF, REPRESENTATIVE, TRIBAL SELF-
GOVERNANCE ADVISORY COMMITTEE; PRESIDENT AND CHAIRMAN OF THE
ALASKA NATIVE TRIBAL HEALTH CONSORTIUM
Mr. Kashevaroff. Thank you, Mr. Chairman.
I would also request that my written testimony be put in
the record.
The Chairman. Yes; it will be included in the record.
Mr. Kashevaroff. Thank you. And I would like to thank you
for the opportunity to testify here on the reauthorization of
the Indian Health Care Improvement Act and on the One-HHS
proposal that is going through. Since Ms. Davis-Wheeler touched
a lot on the Indian Health Care Improvement Act, I would just
like to add a few things from my viewpoint.
First, I also represent the Tribal Self-Governance Advisory
Committee. This committee is of tribal leaders, convened by the
Indian Health Service, to address the health care needs of all
eligible American Indian and Alaska Natives, especially those
served by tribal health programs operated through self-
governance compacts. Even though we have somewhat compacted and
separated and started to do our own direct operations apart
from the IHS, we are still very concerned and take both the
Indian Health Care Improvement Act Reauthorization and the One-
HHS proposals--we take them both seriously.
The Indian Health Care Improvement Act, as stated before,
was worked out in 1999, 4 years ago, and a lot has happened
since then. We have been going through and making
modifications. We have been making compromises to some of the
requests that came down. I think even though we have some
compromises, we have a much better bill that the House side
again is working up, and we would ask that that bill when it
becomes available in the next couple of weeks be substituted
for the current bill on the Senate side.
There were a couple of criticisms that we heard back on the
1999 bill that took immediate offense. There was discussion
about the high score of the bill, and looking at the Medicaid-
Medicare provisions and the amount of costs that they will
require. My viewpoint is that the Indian Health Service and the
U.S. Government should fully fund the tribes in this country.
We do not get fully funded. We are basically forced to go out
and find the funding on our own.
As compacted tribes, we have taken that on as our own
responsibility and have been trying to run our hospitals, our
clinics, like a private organization. Private organizations, go
out and bill for everything they can bill. They bill private
insurance. They bill Medicaid. They bill Medicare. We have been
doing that also. It would be nice if we did not have to. It
would be nice if we were 100 percent fully funded, but knowing
that is not the case, I do not think it should be an issue that
we are doing the same thing the rest of the country does in
health care. I think we should be allowed to do that. There are
also some demonstration projects that were underway that we
think should be made available to all tribes, and I think
contributed somewhat to the high score also.
So when the substitute bill comes, we hope, or when the
House bill comes, we hope that that can be substituted and we
look forward to working with this committee and taking on any
extra questions or extra concerns, and working with this
committee to make sure that we have a good bill for you.
[Prepared statement of Mr. Kashevaroff appears in
appendix.]
The Chairman. Okay. Thank you, Mr. Kashevaroff.
You have a major job, Alaska being so big, and I am
delighted to see Senator Murkowski has just arrived. I am sure
you know that your new Senator is doing a great job, just like
her Dad did when he was here.
I note with interest that neither one of you talked very
much, or in fact almost not at all, about the One-HHS proposal.
Would either one of you like to comment on that? If you don't,
I would like to ask you to give us some feedback, some written
explanation or evaluation of the proposal, if you could.
Mr. Kashevaroff. Thank you, Mr. Chairman. I will comment on
that. In my written testimony, we have a couple of pages on it.
Basically, I understand that HHS is a very large Department,
and in a large Department there should be efficiencies that can
be obtained. Change is not bad. Change is usually good. I would
have no problem, actually. I applaud Secretary Thompson for
trying to make change, trying to create efficiencies, and
trying to do a better service.
What I think is missing is the understanding that IHS is a
unique agency. IHS provides direct health service, and by
providing direct health service, that brings a whole host of
other parts that you need. You need a better HR system. You
need an HR system that looks at the nursing shortage in
America, and says, how can we compete for the same nurses that
the private sector is competing for? Now, that is somebody you
need there at the hospital, getting those nurses to come to
your hospital, not somebody back in Baltimore who is out of the
loop, away from the local level, not knowing what is going on.
Similarly, on the information technology--on IT, we need
data systems of patients that have clinical data; we need
information systems. We need those type of systems. The rest of
HHS does not really need those type of systems. We also have
what we call the RPMS, or Resource Patient Management System,
that collects data from all of IHS and the tribes, combines it
together to provide data to the Congress. That is unique among
HHS also, and that is something that takes a lot of work to
keep going.
It was an antiquated system. We have proposals on the IHS
side, the tribes have been putting forth proposals, IHS has put
forth proposals--around $36 million for a better centralized
system that looks at a business perspective of what a hospital
needs to be efficient and be successful. So we are looking for
a $36-million increase.
At the same time, HHS has come out and said that we need to
reduce the $54 million IT budget by $9 million. At the same
time, the IHS hospitals and clinics are very far behind the
private sector, we cannot be reducing the budget. We need to be
increasing that.
As I said again, I do not mind HHS combining a lot of
things. I am sure they can combine like agencies that just do a
lot of granting, but when you turn over to the IHS and see the
unique status of it, it needs to stand out by itself and be
recognized for that.
If they want One-HHS, they should have One-HHS. They should
look at the disparities in health for the American Indians and
Alaska Natives, and see that we have the worst statistics
across the country. One-HHS should come together and say, we
are going to handle the Indian population, we are going to
bring them up to the rest of the population, that would be our
One-HHS mission, and that is what we are going to do first.
When they do that, then we can talk about all being equal
again, and then putting everybody back together.
The Chairman. Julia?
Ms. Davis-Wheeler. Yes; thank you, Senator Campbell.
As a tribal leader and participating in the One-HHS
restructuring initiative with Indian Health Service, one of the
concerns that came forward many times and was a very hot issue
at the very beginning of our meetings with certain tribal
leaders was the down-sizing of the Indian Health Service again.
I can truly say that in a couple of those meetings, we had some
tribal leaders just almost walk out on the whole process,
because they felt that down-sizing the Indian Health Service
any more was just a catastrophe for us to take care of our
people.
The one other big concern that came forward, and I
appreciate Dr. Grim's response to you on the question of
consultation, was that the timeframe for proper consultation on
the One-DHHS Initiative was very short. We had basically seven
months to try to consult with all the tribes across the United
States. We did the best that we could under the circumstances,
but I think in all reality it really needs to be like hearings
or field hearings or that type of issue. I know that the
Department of Health and Human Services was really putting a
lot of pressure on the Indian Health Service agency to do this.
So as a tribal leader, we worked very hard to help the Indian
Health Service meet that deadline. It does need some more
reviewing.
Thank you.
The Chairman. Okay. Well, since Dr. Grim is still here, I
might say in his presence that if you think that some of the
tribes have not had an adequate voice in that, we probably
ought to ask him to extend that consultation process at least a
few more months, Dr. Grim.
Senator Murkowski, did you have an opening statement or any
questions of our witnesses?
STATEMENT OF HON. LISA MURKOWSKI, U.S. SENATOR FROM ALASKA
Senator Murkowski. Thank you, Mr. Chairman. With your
permission I would like to submit my opening remarks for the
record.
I did have some questions, just general questions, that I
will also submit for the record.
I would like to take the opportunity to welcome my
constituent, Mr. Kashevaroff. We had a little bit of a chance
yesterday to speak, but I am pleased to have you here this
morning and you have you answer the questions from this
committee.
You did address briefly in your comments here the issue of
the merger and how that might affect, for instance, the IT end
of things within the Indian Health Services. A more general and
broad question for you this morning would be how tribal self-
governance, with the Alaska Natives, has affected the Indian
Health Service Program and the delivery of the health services.
I am not looking for specifics, but if you can just briefly
describe how is this all working with the tribal self-
governance.
Mr. Kashevaroff. Thank you, Senator Murkowski. Alaska looks
forward to another long tenure of a Senator Murkowski, and keep
adding the years to the same name. So that will be good.
I appreciate your question. Alaska, as mentioned earlier by
Dr. Grim, has pretty much, or is 100 percent contracted-
compacted. The tribes all operate their own organizations
themselves, and IHS has a residual there. The residual does
have 10 HR people that will come over to the tribal side as the
number of Federal employees dropped. So there are still some
residual, plus some transition.
But we think from Alaska, and think this because we have
been told from around the country, and we have many people from
around the country coming up to Alaska to see what was
accomplished in our compacting. I think the shining example,
the first thing that comes to our mind when we talk about what
we accomplished, is we took 229 tribes and we built a consensus
and built a working relationship amongst each other. We have
been able to expand this relationship now to Federal partners,
to do projects such as the telemedicine project.
The idea of working together, cooperating is not unique
among Indian Nations, but in Alaska, with so many tribes, it
was amazing that we could come together, and we pretty much try
to speak with one voice now. I think the power we gain by that
can be shared across the Nation, not only among Indian tribes,
but other groups, to say that if you can come together and work
together, there is a lot that can be accomplished.
What we have done for the Indian Health Service is we took
over a system back in 1998, 1999--actually it was 1997--that
was not meeting the needs of our customers, our owners. We call
them customer-owners now because every one of the 115,000
Natives in Alaska own the health system now because we are
compacted. We took over a system, and we have been steadily
improving it. The reason we improve it now is that control has
been passed from Rockville to the local villages, to Anchorage.
I sit as Chair of that, the Tribal Health Consortium, but I am
also President of my tribe. I am elected by 400-and-some tribal
members. When those folks come to our hospital, I want to make
sure that they get the best care possible. They are treated
with the highest respect possible, because I know that my
election depends on it.
Every one of our tribal leaders now that are overseeing
health care know that, and we have taken this to heart, that
our people come first. Now that we have local control, we can
see the needs at a local level and adjust to it. We are very
agile now. We can make changes when needed. We can also go out
and get more resources. We have been getting new grant funding
we are bringing in to supplement what we have. Again, I know
that you do not want specifics, but a quick example--my small
tribe, IHS just refused to give us a clinic. They gave us
contract health money. Unfortunately, with contract money, they
would give us 2 or 3 percent a year. Our costs from the private
doctor we went to were 14 to 15 percent increase every year. We
are going in the red every year. By taking over our own
services and doing it ourselves, we then have to go out and get
grant money, and now we lease a clinic, and hopefully we are
going to build a clinic here, too, pretty quick; but we are
leasing a clinic; we are doing it ourselves; we are controlling
our costs--something that IHS just would never have been in a
position to do.
So there are a lot of examples. I guess one last thing that
I want to say about how IHS can work with the compactors, is
they can take and look at the success the compactors have had
all across the country, not just in Alaska. And they can pick
out the items that we have been successful in and try to
duplicate those, called best practices, looking at what one
organization does best and taking that and spreading it across
the rest of IHS.
I think if IHS takes that mentality, and I know Dr. Grim,
who I have had some work with the last year, I know he has come
to the IHS with a business mind, wanting to do that. I do
support his nomination. I think he is a great choice to take a
government agency and try to mold it into a very efficient and
top-rated health system. I think working with the tribes, he
can probably accomplish that.
Senator Murkowski. That is great. It is nice to hear that
Alaska can be used as a model throughout the rest of the
country. I am pleased to hear that.
Mr. Kashevaroff. Thank you.
The Chairman. Julia?
Ms. Davis-Wheeler. Yes, Chairman Campbell, I would like to
respond to Senator Murkowski's question on self-governance. The
Nez Perce Tribe in Idaho, we just recently in 1999, 2000 went
to compact. One of the things that we have done with the
compacting process that we went through is we were able to
build two clinics--one a small satellite clinic for our up-
river people that live 70 or 80 miles away from the main
headquarters, because they were in a community building. So we
have one building for them. It is not a big one, but a small
building where all the health programs are together. We did
that with some of our compact money reserves that we had, and
then other grants.
Now, recently, we are working on the main tribal health
clinic for the Nez Perce Tribe where the headquarters sits. So
if we did not do the self-governance compact, we would not have
been able to do that. So that shows that if tribes have the
initiative or know how to do this, that they can get some
things done. Whereas if we would have gone through the
facilities priority selection process, we would have never
gotten a new facility. So I just wanted to comment on that.
Thank you.
Senator Murkowski. Thank you.
Mr. Chairman, I would just like to take the opportunity to
thank you. With your assistance last week, we were able to bump
up the number for the funding for IHS. I know it is not as much
as some would have liked, but I think we agreed it was an
attempt to address the need and we will work toward additional
funding. I thank you for your initiative.
The Chairman. It was a 10-percent increase, was it not?
Senator Murkowski. 10 percent over the President's number.
So every little bit, I think we all would agree, helps.
Thank you for your assistance when we worked on that.
The Chairman. Thank you.
I appreciate your testimony and your support of S. 556. I
have to tell you, I am really concerned about this One-HHS
proposal. I understand that we need to streamline and
consolidate and not duplicate efforts and make better, more
efficient use of tax money and so on, but I have seen too many
times in the past when Indian programs get folded into bigger
programs, money that had formerly been designated for Indian
programs somehow gets transferred or moved or something. The
Indian people have never had a real strong voice in the
Administrations, any Administration or here either,
unfortunately. I am really concerned about that.
When one out of every two Pimas on this earth, for
instance, suffer from diabetes, and there are people who three
out of their whole 7-day week and sometimes four is spent on a
road somewhere just so they get dialysis, I sometimes worry
that folding things into making things look more efficient
sometimes is going to leave Indian people out.
I would appreciate your looking at this One-HHS proposal in
depth and giving the committee back some written guidance. We
will look forward to that, too, and hopefully you can do that
in the next few weeks if you could, Julia. I think Senator
Inouye would be equally concerned about it.
With that, I have no further questions, but we may have
some that will be submitted in writing. Thank you for
appearing.
The committee is adjourned.
[Whereupon, at 10:54 a.m., the committee was adjourned, to
reconvene at the call of the Chair.]
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A P P E N D I X
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Additional Material Submitted for the Record
=======================================================================
Prepared Statement of Melanie Benjamin, Chief Executive, Mille Lacs
Band of Ojibwe
Mr. Chairman and members of the committee, this testimony is
offered in support of Reauthorization of the Indian Health Care
Improvement Act. The Mille Lacs Band of Qjibwe is a federally-
recognized tribe with 3,570 enrolled members. Located in east central
Minnesota, we operate three separate clinics offering services to more
than 2,000 Mille Lacs Band members, as well as other non-members,
through 20 different programs.
When Congress first enacted the Indian Health Care Improvement Act
(IHCIA) in 1976, one of the major policy reasons for doing so was to
address the health disparities in Indian Country by raising the health
status of the Indian population to a level consistent with that of the
general population of the United States. Unfortunately, the overall
health status of Indian people has improved very little, and those same
disparities continue to exist in alarming numbers. Reauthorization of
the IHCIA would greatly assist efforts to rectify the continuing health
disparities in Indian country.
One of the primary purposes of the IHCIA is to authorize
appropriations for tribal health programs so that they may better
satisfy their health care goals. Even so, federal funding levels have
not kept pace with inflation or with the increasing needs that directly
impact the costs of health care delivery. In fact, today's medical
dollar is worth less than the funding received, making it very
difficult to provide comprehensive health care.
As is true for most tribal communities, the Mille Lacs Band is
confronting an increased health care burden due to growing incidents of
conditions such as diabetes, heart disease, and cardiovascular disease.
These health conditions, which are approaching epidemic proportions,
are impacting not only our adult population, but also our youth. This
weighs heavy on our hearts as our children are our future.
Factors such as poor diet and lack of exercise contribute greatly
to the increase of these chronic health conditions. The Mille Lacs Band
would like to develop preventative programs addressing these
significant health deficiencies. Soaring treatment costs for chronic
health conditions quickly drain program dollars, and the reality is
that preventative programs are, in the long run, far more cost-
effective.
Our health care burden is impacted further by our ever-growing user
population, which has increased by more than 30 percent in recent
years. As a result, we have outgrown our current facilities. Inadequate
space does not permit us to effectively address the existing needs of
our members, much less those that continue to emerge each year.
Presently, we are limited as to the services we are able to
provide. While we currently employ one full-time dentist, two full-time
physicians, and a handful of certified nurse practitioners, we are not
capable of providing the comprehensive health care that our people rely
upon, and frankly, deserve. Examples are programs targeted at substance
abuse, mental health, and other behavioral health programs that
contribute toward wellness beyond basic medical and dental care. We
greatly need to expand our facilities and construct additional space to
meet those growing demands for health services.
Present funding levels are not sufficient to keep up with
increasing health care needs and the associated costs. Level of need
funding is designed to bring tribal health care programs to the
equivalent of mainstream funding agencies throughout the United States.
Our level of need funding is currently at 30 percent, an amount far
below comparable non-tribal agencies. As a consequence, the Mille Lacs
Band consistently faces a challenge in meeting the health care needs of
our members and other tribal members who utilize our clinic services.
The Mille Lacs Band makes every effort to access outside funding
services to complement Federal funding. Third party billings are
submitted to insurance providers and payments are sought from Medicare
and Medicaid reimbursements. Regardless, these efforts are not
sufficient to keep up with increased costs of health care delivery and
frequently, the Mille Lacs Band must provide the difference. The
problem with this is that it means other tribal programs and services
are affected when dollars must be shifted.
The impacts of non-reauthorization to the Mille Lacs Band of Ojibwe
and other Tribes are numerous. Educational programs and campaigns may
be eliminated, which will reduce health awareness. There will be an
inability to provide comprehensive health care services to our clinic
users, especially if clinic staff numbers are not increased. There will
also be reduced access to the latest technology, a problem we already
face with outdated technology that does not keep up with the latest
medical advances. These are just some of the problems tribes will face
without reauthorization of the IHCIA.
Reauthorization of the Indian Health Care Improvement Act is
beneficial to the Mille Lacs Band of Ojibwe and to all tribes who
depend upon federal funding to provide comprehensive health care for
our communities. Reauthorization will allow the Mille Lacs Band of
Ojibwe to pursue our health care objectives and goals intended to
rectify the significant health disparities that the United States
acknowledges exist on our reservation and reservations across the
United States.
Underlying the Indian Health Care Improvement Act Reauthorization
is the Federal trust responsibility of the United States. The Federal
trust responsibility extends to all the federally-recognized tribes of
the United States who have a government-to-government relationship with
the United States. This trust obligation arises out of the government-
to-government relationship that is articulated in article 1, section 8,
clause 3, of the U.S. Constitution, the governing instrument of the
United States. The trust responsibility also arises out of the numerous
treaties, executive orders, court decisions and Federal laws of the
United States, and frequently is acknowledged in the same.
Reauthorization of the IHCIA is the means by which the United States
can continue to fulfill its trust obligation to tribal nations.
Encompassed within the government-to-government relationship is the
United States' recognition of tribes' right to self-governance. The
Mille Lacs Band of Ojibwe is a self-governance tribe under the Tribal
Self-Governance Act of 1994. We were one of the first tribes to enter
into a self-governance compact, and not long after, entered into an
Annual Funding Agreement, an arrangement which allows the Mille Lacs
Band to design its health care programs and services in a manner that
best addresses goals and objectives we have identified in our
community. The Mille Lacs Band has been able to prioritize its health
care needs and attempts to meet those needs as best we can through
sound policy decisions. However, our self-governance status does not
interfere with the federal trust responsibility of the United States.
Indian health care must be improved. Reauthorization of the Indian
Health Care Improvement Act is essential to improving the lives of
Indian people and the health care that they receive. Mii Gwetch.
______
Prepared Statement of Julia Davis-Wheeler, Chairperson, National Indian
Health Board
Chairman Campbell, Vice Chairman Inouye, and distinguished members
of the Senate Indian Affairs Committee, I am Julia Davis-Wheeler,
chairperson of the National Indian Health Board (NIHB). I am an elected
official of the Nez Perce Tribe, serving as Secretary, and also Chair
the Northwest Portland Area Indian Health Board. On behalf of the
National Indian Health Board, it is an honor and pleasure to offer my
testimony this morning on S. 556 to reauthorize the Indian Health Care
Improvement Act, which is the most important authorizing legislation
for American Indian and Alaska Native health delivery. As you recall, I
stated in my recent testimony on the FY 2004 Budget that I looked
forward to coming back and testifying on the Indian Health Care
Improvement Act. I am pleased that this day has come and it
demonstrates your commitment to American Indian and Alaska Natives as
we work toward eliminating the unique health problems facing Indian
Country.
As you are well aware, the NIHB serves nearly all Federally
Recognized American Indian and Alaska Native (AI/AN) Tribal governments
in advocating for the improvement of health care delivery to American
Indians and Alaska Natives. It is our mission to advance the level of
health care in Indian Country and the adequacy of funding for health
services that are operated by the Indian Health Service, programs
operated directly by Tribal Governments, and other programs. Our Board
Members represent each of the twelve Areas of IHS and are elected at-
large by the respective Tribal Governmental Officials within their
regional area.
I have been associated with the reauthorization effort since May
1999 when I first met with other tribal leaders and the Indian Health
Service to explore how we, along with Congress and the Administration,
could work together to pass this vital legislation.
In June 1999, the director of the IHS, Dr. Michael Trujillo
convened a National Steering Committee (NSC) composed of
representatives from tribal governments and national Indian
organizations to provide assistance and advice regarding the
reauthorization of the IHCIA. Over the course of 5 months, the National
Steering Committee drafted proposed legislation, which was based upon
the consensus recommendations developed at four (4) regional
consultation meetings held earlier in that year. The consensus
recommendations formed the foundation upon which the National Steering
Committee began to draft proposed legislation to reauthorize the IHCIA.
In October 1999, the National Steering Committee forwarded their final
proposed bill to the IHS Director and to each authorizing committee in
the House and Senate and the President. Previously, the House and
Senate introduced legislation based on the tribal bill, but neither
passed.
Last year the Northwest Portland Area Indian Health Board and other
Area Health Boards hosted a May 28-30, 2003 Indian Health Care
Improvement Act meeting. The purpose of the meeting was to consider
changes and provide recommendations on the proposed legislation in
response to concerns raised in a September 27, 2001 letter and
memorandum from Health and Human Services Secretary Tommy G. Thompson
to Senator Daniel Inouye. The primary issues raised in Secretary
Thompson's correspondence focused on the high costs associated with
some of the bill provisions, questions about what outcomes were sought
in regards to certain sections of the bill, and it also included
opposition to certain elements in the bill. The participants at the
Portland meeting took a hard look at the high Congressional Budget
Office (CBO) score on S. 212 and the other concerns and forwarded
recommendations to the House and Senate in July 2002.
I am very pleased you have introduced S. 556 early this year and
have held prompt hearings. The Bill appears to be identical to S. 212
introduced during the 107th Congress, so we look forward to bringing
you up-to-date on some changes recommended by the National Steering
Committee. The National Steering Committee is currently working with
House members and committee staff on a House bill that is expected to
be introduced very soon that incorporates the recommendations developed
at the 2002 NSC meeting in Portland, further changes discussed in
subsequent meetings with House Legislative Counsel, other legislative
staff meetings, and at the March 20 and 21, 2003 NSC meeting hosted by
the Northwest Portland Area Indian Health Board just a couple of weeks
ago.
I should tell you that in December 2002 the NSC met in Rockville,
MD and selected Lone Pine Paiute Shoshone Tribal Chairperson Rachel
Joseph and me to cochair this year's effort. In addition, Don
Kashevaroff representing the Tribal Self-Governance Advisory Committee,
former Navajo Nation Vice President Taylor McKenzie, and Kay Culbertson
of the National Council of Urban Indian Health make up this years NSC
leadership group. The balance of members represent each of the 12 areas
of the Indian Health Service and several national Indian organizations
that I mention below. A lot of good things are possible if we pass the
bill with our recommended changes. The titles have exciting new
authorities.
I want to briefly review the titles contained in the Indian Health
Care Improvement Act. Time only permits mentioning highlights in each
title, but I am ready to answer your questions on any of the titles to
the best of my ability. Although I have worked extensively on the bill
over the past 4 years, I may have to call upon one of the technical
advisers who possess a detailed knowledge of the legislation to assist
with my answers to your questions.
The Preamble section of the act has been revised, including
sections on Findings, Declaration of Nation Policy and Definitions.
Emphasis has been placed on the trust responsibility of the Federal
Government to provide health services and the entitlement of Indian
tribes to these services
Title I--Indian Health, Human Resources and Development, has been
substantially rewritten primarily to shift priority setting and
decisionmaking to the local Area levels, where appropriate. The
importance of education is highlighted by changes proposed to the act.
Title II--Health Services represents a collection of diverse
sections addressing issues related to the delivery of health services
to American Indian and Alaska Native populations. Diabetes programs and
epidemiology centers are just two of the many health programs
authorized by this title.
Title III--Facilities, proposes that tribal consultation be
required for any and all facility issues, not just facility closures.
It shelters projects on the current priority list while moving toward a
new method for selecting facilities projects. This title gives
permanent authority to small ambulatory facilities construction.
Title IV--Access to Health Services, seeks to maximize recovery
from all third-party coverage, including Medicaid, Medicare, and the
State Children's Health Insurance Program (S-CHIP) and any new
federally funded health care programs. It also will contain new
authority for long-term care and protection against estate recovery.
This was a title that resulted in the largest dollar total in the CBO
score, but the NSC has agreed to some modifications to the provisions
in the first tribal bill and this has resulted in billions less in
costs to the Federal Government. The main change is that States will
not receive huge increases in reimbursements.
Title V--Health Services for Urban Indians, adds facility
construction authority and coverage by the Federal Tort Claims Act for
the 35 urban programs. Urban representatives were very active members
of the leadership group on the NSC and they feel that the changes in
title V will result in million of dollars in new funding for urban
programs.
Title VI--Organizational Improvements, includes changes including
the elevation of the Indian Health Service Director to Assistant
Secretary in the Department of Health and Human Services. Although
tribes are generally very satisfied with the relationship Interim
Director Dr. Charles Grim has with top policymakers in the Department
of Health and Human Services, we want to institutionalize this access
with this role change.
Title VII--Contains the newly named Behavioral Health title with
major revisions, specifically to integrate Alcohol and Substance Abuse
provisions with Mental Health and Social Service authorities. I know
the committee is having a hearing next week on consolidation of alcohol
and substance abuse programs and I think this title can be
complementary to the goals of that legislation.
Title VIII--Miscellaneous was largely rewritten. It now includes a
proposal to establish an entitlement commission to study and make
recommendations on making Indian Health an ``Entitlement,'' in the same
manner as Medicaid and Medicare. Ten sections were moved out of title
VIII to more appropriate sections in the IHCIA. All CHS provisions were
moved to title II. A majority of the ``free-standing and severability''
provisions from other titles were incorporated into title VIII.
Conclusion
On behalf of the National Indian Health Board, I would like to
thank the committee for its consideration of our testimony and for your
interest in the improvement of the health of American Indian and Alaska
Native people. I know that this act will not pass this year unless
Congress hears from tribes that it is indeed a priority in 2003. The
National Indian Health Board and tribes nationwide are renewing their
efforts to make this happen. The National Steering Committee, working
with the National Congress of American Indians, the Tribal Leaders
Self-Governance Advisory Committee and the National Council of Urban
Indian Health stand ready to work with this committee to make necessary
changes and improvements to craft a bill that will assist us in our
goal of raising the health status of American Indian and Alaska
Natives.
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