<DOC> [108 Senate Hearings] [From the U.S. Government Printing Office via GPO Access] [DOCID: f:88509.wais] S. Hrg. 108-199 INDIAN HEALTH CARE IMPROVEMENT ACT ======================================================================= JOINT HEARING BEFORE THE COMMITTEE ON INDIAN AFFAIRS UNITED STATES SENATE AND THE COMMITTEE ON RESOURCES UNITED STATES HOUSE OF REPRESENTATIVES ONE HUNDRED EIGHTH CONGRESS FIRST SESSION ON S. 556 TO AMEND THE INDIAN HEALTH CARE IMPROVEMENT ACT TO REVISE AND EXTEND THAT ACT AND H.R. 2440 TO IMPROVE THE IMPLEMENTATION OF THE FEDERAL RESPONSIBILITY FOR THE CARE AND EDUCATION OF INDIAN PEOPLE BY IMPROVING THE SERVICES AND FACILITIES OF FEDERAL HEALTH PROGRAMS FOR INDIANS AND ENCOURAGING MAXIMUM PARTICIPATION OF INDIANS IN SUCH PROGRAMS __________ JULY 16, 2003 WASHINGTON, DC __________ Serial No. 108-41 __________ U.S. GOVERNMENT PRINTING OFFICE 88-462 WASHINGTON : 2003 _______________________________________________________________________ For sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800, DC area (202) 512-1800 Fax: (202) 512-2250 Mail: stop SSOP, Washington, DC 20402-0001 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 ______ COMMITTEE ON RESOURCES RICHARD W. POMBO, California, Chairman NICK J. RAHALL II, West Virginia, Ranking Democrat Member DON YOUNG, Alaska DALE E. KILDEE, Michigan W.J. ``BILLY'' TAUZIN, Louisiana ENI F.H. FALEOMAVAEGA, American JIM SAXTON, New Jersey Samoa ELTON GALLEGLY, California NEIL ABERCROMBIE, Hawaii JOHN J. DUNCAN, Jr., Tennessee SOLOMON P. ORTIZ, Texas WAYNE T. GILCHREST, Maryland FRANK PALLONE, Jr., New Jersey KEN CALVERT, California CALVIN M. DOOLEY, California SCOTT McINNIS, Colorado DONNA M. CHRISTENSEN, Virgin BARBARA CUBIN, Wyoming Islands GEORGE RADANOVICH, California RON KIND, Wisconsin WALTER B. JONES, Jr., North JAY INSLEE, Washington Carolina GRACE F. NAPOLITANO, California CHRIS CANNON, Utah TOM UDALL, New Mexico JOHN E. PETERSON, Pennsylvania MARK UDALL, Colorado JIM GIBBONS, Nevada, ANIBAL ACEVEDO-VILA, Puerto Rico Vice Chairman BRAD CARSON, Oklahoma MARK E. SOUDER, Indiana RAUL M. GRIJALVA, Arizona GREG WALDEN, Oregon DENNIS A. CARDOZA, California THOMAS G. TANCREDO, Colorado MADELEINE Z. BORDALLO, Guam J.D. HAYWORTH, Arizona GEORGE MILLER, California TOM OSBORNE, Nebraska EDWARD J. MARKEY, Massachusetts JEFF FLAKE, Arizona RUBEN HINOJOSA, Texas DENNIS R. REHBERG, Montana CIRO D. RODRIGUEZ, Texas RICK RENZI, Arizona JOE BACA, California TOM COLE, Oklahoma BETTY McCOLLUM, Minnesota STEVAN PEARCE, New Mexico ROB BISHOP, Utah DEVIN NUNES, California VACANCY Steven J. Ding, Chief of Staff Lisa Pittman, Chief Counsel James H. Zoia, Democrat Staff Director Jeffrey P. Petrich, Democrat Chief Counsel (ii) C O N T E N T S ---------- Page S. 556 and H.R. 2440, text of.................................... 2 Statements: Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado, chairman, Senate Committee on Indian Affairs............... 1 Carson, Hon. Carson, Hon. Brad, U.S. Representative from Oklahoma................................................... 674 Christensen, Hon. Donna M., U.S. Delgate from Virgin Islands. 675 Cole, Hon. Tom, U.S. Representative from Oklahoma............ 673 Culbertson, Kay, president, Denver Indian Health and Family Services................................................... 698 Faleomavaega, Hon. Eni F.H., U.S. Delegate from American Samoa...................................................... 672 Grijalva, Hon. Raul M., U.S. Representative from Arizona..... 673 Grim, Charles, director, Indian Health Service, Department of Health and Human Services.................................. 676 Hartz, Gary, acting director, Office of Public Health, Indian Health Service............................................. 676 Jimmie, Andrew, chief, Minto Traditional Council............. 697 Joseph, Rachel, cochair, National Steering Committee of the Reauthorization of the Indian Health Care Improvement Act.. 694 Kildee, Hon. Dale E., U.S. Representative from Michigan...... 671 Muneta, Dr. Ben, president, Association of American Indian Physicians................................................. 696 Murkowski, Hon. Lisa, U.S. Senator from Alaska............... 672 Nesmith, Steve, assistant secretary for Congressional and Intergovernmental Affairs, Department of Housing and Urban Development................................................ 679 Olson, Richard, acting director, Division of Clinical and Preventive Services, Indian Health Service................. 676 Pallone, Hon. Frank, Jr., U.S. Representative from New Jersey 674 Pombo, Hon. Richard W., U.S. Representative from California, chairman, House Committee on Resources..................... 671 Rhoades, Dr. Everett, Oklahoma City Urban Indian Clinic...... 700 Skeeter, Carmelita Wamego, executive director, Indian Health Care Resource Center of Tulsa.............................. 701 Snyder, Rae, acting director, Urban Health Office, Indian Health Service............................................. 676 Udall, Hon. Mark, U.S. Representative from Colorado.......... 673 Weaver, Steve, director, Division of Environmental Health and Engineering, Alaska Native Tribal Health Consortium........ 697 Appendix Prepared statements: Beaver, R. Perry, principal chief, Muscogee (Creek) Nation... 705 Culbertson, Kay (with attachment)............................ 708 Grim, Charles (with attachment).............................. 725 Guzman, Victoria, Walker River Paiute Tribe.................. 752 Jimmie, Andrew............................................... 705 Joseph, Rachel............................................... 760 Muneta, Dr. Ben (with attachment)............................ 778 Nesmith, Steve............................................... 785 Rhoades, Dr. Everett (with attachment)....................... 789 Skeeter, Carmelita Wamego (with attachment).................. 802 Sossamon, Russell, chairman, National American Indian Housing Council.................................................... 814 Weaver, Steve (with attachment).............................. 817 Zacharof, chairman, Alaska Native Health Board............... 705 Additional material submitted for the record: Letters: Citizens Potawatomi Nation................................... 839 Edwards, James Lee, Governor, Absentee Shawnee Tribe......... 841 Ration, Norman, executive director, National Indian Youth Council, Inc. (with attachment)............................ 842 Romberg, Carolyn, Health Director, AST Health Programs, Absentee Shawnee Tribe of Oklahoma......................... 841 INDIAN HEALTH CARE IMPROVEMENT ACT ---------- WEDNESDAY, JULY 16, 2003 U.S. Senate, Committee on Indian Affairs, Meeting Jointly With the Committee on Resources, U.S. House of Representatives Washington, DC. The committees met, pursuant to notice, at 10:15 a.m. in room 106, Dirksen Senate Office Building, Hon. Ben Nighthorse Campbell (chairman of the Senate Committee on Indian Affairs) presiding. Present from the Senate Committee on Indian Affairs: Senators Campbell, Inouye, Reid, Conrad, Dorgan, and Murkowski. Present from the House of Representatives Committee on Resources: Representatives Pombo, Mark Udall, Faleomavaega, Cole, Kildee, Grijalva, Pallone, Brad Carson, Christensen, and Napolitano. STATEMENT OF HON. BEN NIGHTHORSE CAMPBELL, U.S. SENATOR FROM COLORADO, CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS The Chairman. We will now move to the joint hearing with the House Resources Committee and the Senate Committee on Indian Affairs bills to reauthorize the Indian Health Care Improvement Act. The two bills before our committee, S. 556 and H.R. 2440, reflect literally years of hard work by tribal leaders, the National Steering Committee and various Federal officials. Most members know the shameful state of Indian health. Senator Dorgan just reiterated that as did Senator Conrad, so I won't go through the litany of statistics this morning but they are common knowledge. Today is the second in a series of hearings on the reauthorization bill. We will receive testimony regarding one, health disparities; two, health facilities; and three, urban Indian health issues. In the interest of time, I'll place my full statement in the record but I will say this to the members of both committees. After years of work and countless hours of meetings and hearings, the time certainly has come for the tribes, Congress and the Administration to roll up our sleeves and do what we need to do to move this bill and get the act reauthorized this year. To achieve that goal I look forward to working with my colleagues on both committees. [Prepared statement of Senator Campbell appears in appendix.] [Text of S. 556 and H.R. 2440 follow:] <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT 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IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> <GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT> The Chairman. Now I would like to turn to our chairman from the House. Chairman Pombo, do you have an opening statement? Mr. Pombo. Yes; I do. Thank you, Mr. Chairman. STATEMENT OF HON. RICHARD W. POMBO, U.S. REPRESENTATIVE FROM WASHINGTON, CHAIRMAN, HOUSE COMMITTEE ON RESOURCES Mr. Pombo. I want to thank Senator Campbell for agreeing to make today's hearing a joint hearing with the House Resources Committee. Holding a joint hearing should send a signal that we can develop a bill to address the health care needs of American Indians and Alaska Natives on a bipartisan basis. Anyone who has studied the statistical data compiled by the Census Bureau and by health care experts understands there is a profound lack of and access, to quality health care for American Indians and Alaska Natives. Living conditions for hundreds of thousands of Native Americans lag far behind the rest of the population, whether they live in a reservation or an urban area. These conditions are unacceptable and there have to be new approaches that maximize the huge potential in Indian country to improve health care and disease prevention. Exploring new ways to raise the quality of health services for American Indians and Alaska Natives is not an option for Congress. It is a basic obligation. One way to address health problems for American Indians and Alaska Natives is to improve basic infrastructure needs such as safe water, sewer, waste disposal and modern medical facilities. Unless the bricks and mortar are in place, then we will be reduced only to responding to outbreaks of health problems, not preventing them. I am glad today's witnesses will especially address these issues. I look forward to the testimony on these aspects of H.R. 2440 and S. 556. I thank the chairman for yielding. The Chairman. Thank you, Chairman Pombo. I'm delighted to see some of my old friends from the years I served in the House. I don't know if you have opening statements but why don't we start with Congressman Kildee. If you have a statement, go ahead. Mr. Kildee. Thank you very much, Mr. Chairman. STATEMENT OF HON. DALE E. KILDEE, U.S. REPRESENTATIVE FROM MICHIGAN Mr. Kildee. I am happy you and Mr. Pombo are having these hearings as a member of the House Resources Committee and cochairman of the House Native American Caucus, I think this is very important. If by chance we are called back for votes, I will leave Kim TeeHee of my staff who handles all matters of the Native American Caucus to hear all the testimony. The reauthorization of this act will provide a more comprehensive approach to the delivery of medical care to Native people. The House bill is based upon the recommendation made by the Indian health community including tribal leaders, tribal health directors, health care experts and Native patients themselves. Its primary objective is to improve access to quality medical care for the Native American population. I look forward to hearing testimony this morning and would ask consent that my entire statement be included in the record. The Chairman. It will be included in the record. [Prepared statement of Mr. Kildee appears in appendix.] The Chairman. Why don't we go back and forth? Senator Murkowski, did you have any comments? STATEMENT OF HON. LISA MURKOWSKI, U.S. SENATOR FROM ALASKA Senator Murkowski. Thank you, Mr. Chairman. Good morning and thank you for the hearing this morning with our House members on a very important issue for us in my State. I would like to welcome those Alaskans we will be hearing from this morning, Chief Andrew Jimmie from Minto and Steve Weaver from Anchorage. I also see some other Alaskans in the audience. This is our committee's second hearing on Indian health care reauthorization but it's the first one that has taken place after the National Steering Committee's bill was introduced in the other body. There are many good things in this legislation but what I particularly like about it is that it is not necessarily an Alaskan bill or a Navajo bill or an urban bill, it is a national bill which was derived through the very diligent work of Native health leaders throughout Indian country. I hope, Mr. Chairman, that through the good work of the National Steering Committee, we will form the nucleus of this bill that we will markup in the Committee on Indian Affairs. I am very pleased that we will be hearing from Steve Weaver on the second panel. Oftentimes when you think of Indian health, we think of the doctors and the nurses. Steve is an engineer, specializing in sanitation and environmental health. His expertise is in preventing disease by focusing on water quality and sanitation. It is so important that we do focus on these preventative first step measures, so I am pleased he is here today to help us as we talk about healthy families and healthy communities. Mr. Chairman, thank you. The Chairman. Thank you. Mr. Faleomavaega. Mr. Faleomavaega. Thank you, Mr. Chairman. STATEMENT OF HON. ENI F.H. FALEOMAVAEGA, U.S. DELEGATE, AMERICAN SAMOA Mr. Faleomavaega. I would like to echo the sentiments expressed earlier by my colleagues to thank you for the initiative and your leadership in calling this joint hearing, along with our distinguished chairman, Mr. Pombo from California. I think this effort certainly demonstrates the urgency of this legislation that has been on the shelf now for 4 years. Our Indian communities have deliberated and have had so many consultations for many years now and I sincerely feel this joint hearing gives it a sense of urgency that we need to pass this legislation as soon as possible. We thank you for doing this. For those of us on the House side, it's nice to be here once in a while to see how glorious and big the chambers are. The Chairman. Actually, we're a pretty friendly crowd. You didn't have to sit that far away. Mr. Faleomavaega. I don't know about that, Mr. Chairman. We kind of felt we were being intimidated by the gloriousness of this beautiful chamber but as a former colleague and certainly as a member of our committee, Mr. Chairman, we are delighted to be here and look forward to hearing from our witnesses this morning. The Chairman. Congressman Cole, did you have a statement? Mr. Cole. Just briefly, Mr. Chairman. STATEMENT OF HON. TOM COLE, U.S. REPRESENTATIVE FROM OKLAHOMA Mr. Cole. I'd like to echo my colleagues' appreciation for you and Chairman Pombo having this joint session. It is an extraordinarily important problem an one that's been allowed to languish far too long. I appreciate your initiative. I hope we can develop a bipartisan consensus on this legislation and move ahead. I particularly hope during the course of the hearing if we have an opportunity to look at not only the depth of the problem overall but some of the disparities in funding at the tribal level. Representing a State that has many, many Native Americans but not much in the way of reservations, we've lagged in funding compared to some of the other tribes. Certainly we appreciate your initiative and this opportunity to look at these problems and move ahead. The Chairman. Congressman Udall from the great State of Colorado, any comments? Mr. Udall. Thank you, Mr. Chairman. STATEMENT OF HON. MARK UDALL, U.S. REPRESENTATIVE FROM COLORADO Mr. Udall. I too want to associate myself with the remarks of my Chairman, Mr. Pombo, Mr. Faleomavaega and the rest of the panel. I want to underline my commitment to proceeding as quickly as possible. We all know this has been long in arriving and we need to get this legislation passed and to the President's desk. I look forward to working with everybody here to see that we do that as soon as possible. Thank you, Mr. Chairman. The Chairman. Congressman Grijalva? Mr. Grijalva. Thank you, sir. STATEMENT OF HON. RAUL M. GRIJALVA, U.S. REPRESENTATIVE FROM ARIZONA Mr. Grijalva. I also would join with my colleagues in extending the appreciation to you, Senator, and to our Chairman for having this hearing. I want to associate myself with the comments made by my colleagues and look forward to an expedient process and some quick movement in assuring that access and a health delivery system is available to our Native American brothers and sisters. Thank you, sir. The Chairman. Thank you. Congressman Pallone, any comments? Mr. Pallone. Thank you, Mr. Chairman. STATEMENT OF HON. FRANK PALLON Jr., U.S. REPRESENTATIVE FROM NEW JERSEY I just wanted to say that both of you, Senator Campbell, as well as our House Chairman Pombo, have really highlighted and shown a tremendous concern over this issue. Senator Campbell obviously for a number of years and Congressman Pombo over the last couple months, particularly last week, has shown on the House Resources side that he is willing to move forward on a number of these initiatives because he realizes how important they are. I just wanted to say briefly I think there is a tremendous problem, I would call it a crisis, in terms of health care services in Native America primarily because you've had an explosion in the Native American population but that the IHS has not been able to keep up, primarily because of funding. I think lack of funding is a major issue. There is also the fact that in Congress, I think we have not paid enough attention to the lack of money for facilities, for new construction and perhaps the Administration more and more, and I don't just mean this Administration but the last 10 years or so, seems to be relying on the tribes more and more to pay for their own services, particularly with regard to new facilities and renovation of facilities. I think that is wrong. I really see provision of health care services for Native Americans as an entitlement, as something we are required pursuant to the Constitution and treaties over the years to provide. I don't think we should rely more and more on their providing their own money. I think we have to increase the funding. In addition, there are just so many changes that we haven't paid attention to over the last 10 or 20 years, the need for more preventative services, home health care, nursing homes, the changes in the demographics so that more and more Native Americans are now in urban areas and that those problems need to be addressed. Although there is a crisis, I think that we can identify what the needs are. I know that people on this committee, including the leadership, are very concerned and know what to do. What we need to do is educate the rest of Congress and try to move the legislation and get our other colleagues motivated beyond these two committees to move these measures and realize the crisis we face, and that it is going to take a lot more money and time to address this. I'm very pleased we are having this hearing today. I want to thank the two Chairmen in particular for their concerns. The Chairman. Thank you. Any comments, Congressman Carson. Mr. Carson. Thank you very much, Senator Campbell. STATEMENT OF HON. BRAD CARSON, U.S. REPRESENTATIVE FROM OKLAHOMA Mr. Carson. I'd like to thank you and Chairman Pombo for holding this hearing too. Of course I have a great interest in this issue representing the most Native American congressional district in the country, being a member of the Cherokee Nation myself and the son of a career of Bureau of Indian Affairs employee. I know how important this legislation is to the many Native Americans both in Oklahoma and across the country. I am particularly proud that two Oklahomans will today be testifying before this committee, Carmelita Skeeter who runs a tremendously successful health care center in Tulsa, Oklahoma serving the Native American population, as well as Dr. Charles Grimm, the interim director of the IHS. He did a tremendous job in the State of Oklahoma and I understand his nomination and the hearings on his confirmation are proceeding nicely and we look forward to this service to this Administration as the Director of IHS. Oklahoma has more than 300,000 patients in IHS and there is only 1.6 million nationwide. You can imagine when you have 20 percent of the IHS population, you are very concerned about what is going on within the institution. We appreciate your holding this hearing today. I am proud to be a cosponsor of H.R. 2440, the House version of the Indian Health Care Improvement Act reauthorization, and we look forward to what the panel has to say on this very important matter. The Chairman. Thank you. Congresswoman Christensen. Ms. Christensen. Thank you, Mr. Chairman. STATEMENT OF HON. DONNA M. CHRISTENSEN, U.S. DELEGATE FROM VIRGIN ISLANDS Ms. Christensen. I want to join my colleagues in thanking both you, Chairman Campbell, and Chairman Pombo for holding this very important meeting and also to say it is very timely as the Minority caucuses in the House are working with members of the Senate to put all of the initiatives that we have been advocating over several past Congresses into one comprehensive minority health bill. Also, to say as chair of the Health Brain Trust of the Congressional Black Caucus and as a physician, it is my hope that at the end of this process, we will reauthorize the Indian Health Care Improvement Act in such a way that we can truly begin to rectify the deficiencies of past efforts and pass a bill that will bring the health of Native Americans not just on par with what we consider average for Americans, because if we include the African American, the Hispanic American, the Asian Pacific Islanders what is considered American health will be far below what we should be aspiring to. Rather, we want to develop a vehicle that will develop the high level of health attained by those of full and unfettered access to health services to a bill that provides equal access to culturally sensitive, comprehensive, easily and universally accessible health care provided mostly by the increasing cadre of Native American health providers that will be trained under this bill, with best practices determined by Native American and Alaska Native led and specific research provided in communities that are environmentally and socio-economically supportive of good health and developed and directed by the communities and the tribes themselves fully funded and supported with technical assistance from the Federal Government and the agencies that can provide such technical assistance. I want to once again thank you for this hearing and I look forward to the testimony of our witnesses. The Chairman. Thank you. We will now start with the first panel which will be Charles Grim, director, Indian Health Service, accompanied by Gary Hartz, acting director, Office of Public Health, Indian Health Service; Richard Olson, acting director, Division of Clinical and Preventive Services; Mrs. Rae Snyder, acting director, Urban Health Office; and Steven Nesmith, assistant secretary for Congressional Affairs, Department of Housing and Urban Development. We'll start by telling you that all of your written testimony will be included in the record. If you would like to abbreviate, that would be fine. We will start with Mr. Grim first. STATEMENT OF CHARLES GRIM, DIRECTOR, INDIAN HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES, ACCOMPANIED BY GARY HARTZ, ACTING DIRECTOR, OFFICE OF PUBLIC HEALTH, INDIAN HEALTH SERVICE; RICHARD OLSON, ACTING DIRECTOR, DIVISION OF CLINICAL AND PREVENTIVE SERVICES, INDIAN HEALTH SERVICE; AND MRS. RAE SNYDER, ACTING DIRECTOR, URBAN HEALTH OFFICE, INDIAN HEALTH SERVICE Mr. Grim. Thank you, Chairman Campbell, Chairman Pombo, and distinguished members of both committees. We are very excited too within the Indian Health Service for this joint hearing to be able to talk about the issues before both the House and the Senate. You have introduced the staff I have here. They won't be making any opening statements. I will be making the opening statement for the agency but they are here should we have questions. They are technical matter experts on a number of these issues today. We are pleased to have this opportunity to be able to testify on behalf of Secretary Thompson on both the House and Senate bills to reauthorize the Indian Health Care Improvement Act. For the record, I'm submitting my written statement and it contains specific information about the agency including the legislative and legal history regarding the United States' commitment to tribal nations and some of the national challenges that we're facing to improve the health of American Indians and Alaska Natives. My written statement also contains comments on specific aspects of the proposed legislation that I won't cover in my oral statement so that we can conserve time. As I testified last April, there is no single piece of legislation that will affect the future health status of American Indians and Alaska Natives more than the Indian Health Care Improvement Act Reauthorization of 2003. For the past 28 years, the Indian Health Care Improvement Act has been the basis for extending the life span of Indian people by 7 years which is still 6 years below that of the rest of the Nation. It has helped us to address the basic health needs of a population that was not benefiting from the technological and medical advances of an industrialized nation and it has also assisted us in identifying current and future health challenges. To continue to make progress in raising the health status of Indian people to at least the level of the rest of the Nation requires us to modify the Indian Health Care Improvement Act of 1976 to reflect the health status of the Indian population of 2003 as best we can and to have it reflect the health status of Indian people as we project it into the future until the next reauthorization. The legislation under consideration today reflects the proposed language developed over a 2-year period by Indian tribes across the Nation and adopted by both committees of Congress. Our Nation faces many priorities today, many of which overshadow but do not diminish the importance of other priorities. As requested by the committee, I am going to focus my brief remarks on the highlighted areas of health disparities, health care facilities and urban Indian health. My written statement includes some health statistics and the agency can supply members with more information if requested. Three simple statements to remember regarding American Indian and Alaska Native health disparities are: First, Indian people continue to experience disease and illness at greater rates than the rest of the Nation; second, Indian people continue to prematurely die at rates greater than the rest of the Nation; and third, Indian people continue to experience reduced access to health services and care compared to the rest of the Nation. It is well publicized and referenced that Indian people continue to experience health disparities and death rates that are significantly higher than the rest of the United States general population. Many American Indians and Alaska Natives who receive a diagnosis of diabetes, high blood pressure and high cholesterol levels, cardiovascular disease, alcoholism and obesity consider it a fatal diagnosis. The proposed language of the Indian Health Care Improvement Act can help the Indian health system of the Indian Health Service, tribal health programs and urban Indian health to develop and implement health promotion and disease prevention strategies so that healthy behavior choices and lifestyles will begin to significantly reduce the health disparity rates. It also yields an even more important humanitarian benefit of reducing pain and suffering and prolonging life. We were successful in working with Indian nations through the Indian Health Service with infectious diseases and conquering those and I think we can do it again for chronic diseases with the help of Congress. The IHS Health Care Facilities Program, including the tribal program specifically, are responsible for managing and maintaining the largest inventory of real property in the Department of Health and Human Services with over 9 million square feet of space. In the proposed bill, section 302(B)(3)(c) specifically proposes that IHS Sanitation Facilities Construction funds will not be used to support service of sanitation facilities to the Department of Housing and Urban Development homes. The bill is not clear that homes constructed through HUD should also include the necessary infrastructure to make a home complete including safe water and sewer and wastewater disposal systems for the home. The IHS and HUD have cooperated over many decades on the construction of homes and reservation communities with IHS providing the expertise and development of supporting the sanitation and sewage systems that the HUD homes would then hook into. Without clarity in the language, there may come a time when interpretation may result in IHS funds being expended on sanitation systems of HUD homes which would in turn redirect IHS funds from providing services to existing homes without water, sewer and solid waste facilities. Newly constructed HUD homes should be funded to cover everything including the home itself and to the street hookup. We request that you consider clarifying this point in the proposed bill. Title V of the Indian Health Care Improvement Act provides specific authority focused on the provision of health services for urban Indian people with funds appropriated to the Indian Health Service. The IHS currently contributes funds toward the operating expenses of 34 independent urban Indian health programs including programs in Oklahoma City and Tulsa that are demonstration programs. These programs provide a range of services. In 1978, the entire State of Oklahoma was designated as a contract health service delivery area which means that the Indian beneficiaries could reside anywhere in the State and maintain their eligibility for both direct services and contract health services. The 1992 Congress amended the Health Care Improvement Act to establish two demonstration projects with Tulsa and Oklahoma City clinics to be treated as service units in the allocation of resources and the coordination of care. This new and innovative approach to ensuring health services were accessible to all eligible populations in Oklahoma has resulted in a hybrid system. Each program maintains its status under the title V as an urban Indian organization, yet the programs function like other IHS service units and report on the resources and patient management system of the Indian Health Service with data utilized for inclusion in the allocation of resources. Most service populations and overall utilization of services have dramatically increased since these programs became demonstration projects and from the fiscal year 1994 specific congressional line item funding increases. They have been able to use the best of both urban and IHS structures to build a community controlled, high quality health system in a State designated as a contract health service delivery area. On the other hand, the hybrid system has raised a few concerns with some of the Oklahoma tribes that operate their own health programs under the Indian Self Determination and Education Assistance Act, Public Law 93-638 as amended. The issue in its most basic terms is that the two urban programs have some aspects of a service unit but their funding is not subject to transfer to the tribes under Public Law 93-638 contracts or compacts as our non-hybrid service units are. With an environment of reduced resources and an increasing population with greater health needs, it's expected that the issue of tribe shares of urban Indian programs, especially the hybrid programs, will receive more attention than they have in the past. As review of this far-reaching, complex legislation continues, we may have further comments. However, we wish to reiterate our strong commitment to reauthorization and improvement of the Indian Health Care Improvement Act and will be happy to work with the committees, the National Tribal Steering Committee and other representatives of the American Indian and Alaska Native communities to develop a bill that is fully acceptable to all stakeholders in this important program. Mr. Chairman, that concludes my statement. I want to thank you for the opportunity to discuss reauthorization of the Indian Health Care Improvement Act. We will be happy to answer any questions you may have. [Prepared statement of Dr. Grim appears in appendix.] The Chairman. Thank you, Dr. Grim. I understand Admiral Hartz, Dr. Olson, and Ms. Snyder are resource people but do not have statements, is that correct? Mr. Grim. That is correct. The Chairman. Now we will go to Steven Nesmith. I might tell my colleagues that Mr. Nesmith is really assistant secretary for Congressional Affairs. I understand your background is not in Indian health. Is that correct? Mr. Nesmith. That is correct, sir. The Chairman. Hopefully we won't put you on the spot too much. Go ahead. STATEMENT OF STEVEN NESMITH, ASSISTANT SECRETARY FOR CONGRESSIONAL AND INTERGOVERNMENTAL AFFAIRS, DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Mr. Nesmith. As this is a joint hearing, Chairman Campbell and Chairman Pombo, Vice Chairman Inouye, and members of both committees, thank you for inviting me here to provide comments on S. 556, the Indian Health Care Improvement Act Reauthorization of 2003. My name is Steven Nesmith and I am the assistant secretary for Congressional and Intergovernmental Affairs at HUD. As you know, the Public and Indian Housing, PIH, is responsible for the management and operation and oversight of HUD's Native American programs. These programs are available to 560 federally-recognized and a limited number of State- recognized Indian tribes. We serve these tribes directly or through tribally designated housing entities by providing grants and loan guarantees designated to support affordable housing community and economic development activities. Our tribal partners are diverse. They are located on Indian reservations, in Alaska Native villages and other traditional Indian areas. In addition to those duties, PIH's jurisdiction encompasses the Public Housing Program which aides the Nation's 3,000 plus public housing agencies in providing housing and housing related assistance to low income families. It is a pleasure to appear here before you and I would like to take the opportunity to express my appreciation for all of your continuing efforts to improve the housing conditions of American Indians and Alaska Native peoples. Much progress has been made and tribes are taking advantage of new opportunities to improve the housing conditions of the Native American families residing on Indian reservations, on trusts or restricted Indian lands and in Alaska Native villages. This momentum needs to be sustained as we continue to work together toward creating a better living environment throughout Indian country. At the outset, let me reaffirm the Department of Housing and Urban Development's support for the principle of government to government relations with Indian tribes. HUD is committed to honoring this fundamental precept in our work with American Indians and Alaskan Natives. On behalf of Secretary Martinez, thank you for the opportunity to provide this testimony on S. 556. The Department agrees that the Indian Health Service, a division of the Department of Health and Human Services, is vital to the well being of individual Indian families and the Native American community as a whole. Native Americans often have no other means to receive the health care assistance and related activities provided by IHS. HUD's Office of Native American Programs continues its ongoing dialogue with IHS representatives to coordinate our activities in a manner that supports tribal sovereignty, self determination and self governance. The Department also participates in a Federal Interagency Task Force on Infrastructure with the IHS, the Environmental Protection Agency, the Bureau of Indian Affairs and the Department of Agriculture. It is within this perspective that the following comments are offered on behalf of HUD and this bill. As you are aware, in 1996, the Native American Housing Assistance and Self Determination Act became law. NAHASDA changed the way in which housing and housing related assistance is provided to Native American families. Prior to the Act, Indian housing authorities and Indian tribes applied for a variety of competitive and categorical grant programs usually with differing program eligibility and reporting requirements. NAHASDA created the Indian Housing Block Grant Program which is a non-competitive formula grant made to Indian tribes or tribally designated housing entities. Under the Indian Housing Block Grant Program, an Indian tribe or the tribal designated housing entity submits to HUD a 5-year and a one year housing plan. The housing plan contains information about how the recipient will use its block grant funds to engage in the six affordable housing activities authorized by NAHASDA. Once the Indian housing plan is found to be in compliance with the statutory and regulatory requirements, the tribe or that designated entity executes a grant agreement to receive the Indian housing block grant allocation. The Indian housing block grant formula is based on housing needs of each of the tribes and the tribes designated entity ongoing operation, maintenance needs and for the dwelling units previously developed under the Indian Housing Program authorized by the U.S. Housing Act. The Indian housing block grant formula is calculated by dividing the total amount appropriated for each fiscal year among the number of eligible grant recipients. Formula components and variables are weighted to ensure that the complexities and differences among tribes are taken into consideration. Each tribe's formula allocation reflects these factors. The NAHASDA regulations as described in the Code of Federal Regulations requires that the Indian housing block grant formula be reviewed by the calendar year 2003 for possible modification or revision. At present, HUD is engaged in negotiating rulemaking commonly referred to as NEGREG with a 26-member committee comprised of a broad cross section of tribal stakeholders. The first NEGREG session was held in April of this year and additional monthly meetings are ongoing and are scheduled through September. Let me turn to the specific comments on S. 556, the Indian Health Care Improvement Act Reauthorization of 2003. As you know the Administration is actively reviewing S. 556 and will provide you with specific details of our analysis very shortly. The Administration has not taken a position regarding the transfer of NAHASDA funds between HUD and HHS. We do, however, have concerns about transferring NAHASDA funds between Federal agencies when NAHASDA now provides for the direct distribution of Indian housing block grant funds to tribes and their housing designated entities based on a formula negotiated between the tribes and HUD. An affordable housing activity under the Indian Housing Block Grant Program is development which includes infrastructure such as site improvements and the development of utilities and utility services for housing. The provision of water and sanitation facilities are included within this category. Tribes and tribal designated housing entities may currently enter into agreements with IHS to provide these services or they may choose another service provider. We believe that this is in keeping with the policy of self determination that is articulated in NAHASDA. Since 1997, nearly $228 million has been transferred to IHS through the tribal designated housing entities for offsite sanitation facilities. Tribes and their designated entities continue to make difficult budgetary and management decisions on how to prioritize their Indian housing block grant dollars which is consistent again with tribal self determination and self government. Let me assure the committee that we will work with both committees and with our Federal partners in HHS and other Federal agencies, the tribes and their designees to ensure that the housing infrastructure needs in the Native American communities are met in the most efficient manner possible. We are nevertheless concerned about any provision that might erode the self determination which we believe is critical in NAHASDA. Thank you for the opportunity to express the Department's views. [Prepared statement of Mr. Nesmith appears in appendix.] The Chairman. Thank you. Since our colleagues in the House are going to have further to walk because there is a vote than we have to in the Senate, I am going to yield to them for questions first. We will start with Chairman Pombo. Mr. Pombo. Thank you very much. I appreciate the opportunity. The House Interior Appropriations bill specifically included committee language which states that IHS sanitation funds should not be used to provide sanitation facilities for new homes funded by the housing programs of the Department of Housing and Urban Development. I know, Dr. Grim, that in your opening statement you talked about this issue. Could you expand upon that for me as to what your level of support or opposition to that particular language is? Mr. Grim. Yes, Mr. Chairman; the way that came about was our appropriations committees have over the years included that language because HUD funded home projects prior to NAHASDA had infrastructure funds included for sanitation facilities for newly funded HUD homes. Once NAHASDA was put in place, it was the tribes choice of what to use those funds for, whether to build housing infrastructure and so forth. The IHS program separates and, apart from that, looks at existing homes without adequate sanitation facilities or newly built homes built with other than HUD funds. We currently have a backlog of those homes as well, so the two programs are separate. So our committees have wanted to ensure that moneys coming through the Indian Health Service were used for existing homes with that need or with newly built homes other than HUD homes. Mr. Pombo. So you generally in support of that because you want to keep those two programs separate? Mr. Grim. As mentioned by Mr. Nesmith, we've worked jointly with HUD over the years to try to ensure that the two programs work together but they are two separate programs. Mr. Pombo. Can you tell me a bit more about what you are currently doing to deal with that backlog? I've been told that the backlog is substantial at this point. Can you expand upon that a bit for me? Mr. Grim. The current backlog we have estimated in feasible projects, those able to be completed roughly is around $900 million right now. We keep records on that and those records do not sometimes include newly built HUD homes that may or may not have adequate facilities. Once they become existing homes, we try to get those added to our inventory. One of the things we try to do on an annual basis, we have currently a $94-million appropriation to deal with new and existing homes and we have a priority system where we try to prioritize those in most need. We are trying on an annual basis to work on those backlogs. Mr. Pombo. You said something I have a real question on and that is when a newly constructed HUD home becomes an existing home, then you can use funding to provide the sanitation services. Why would you allow a home to be built without the sanitation services? Mr. Grim. I may let Admiral Hartz take a crack at this after I finish but regarding existing HUD homes, the Indian Health Service staff work in concert with HUD on those homes. However since the passage of NAHASDA the block grants have now been transferred to tribes. There is extreme pressures out there due to the backlog and need for housing in Indian country and there are more and more pressures on tribes to get existing homes in place. The IHS does not have direct control over any of the NAHASDA housing projects themselves. We come in as technical assistants but we do have funds, the $94 million I referenced, to help existing homes or those that have been built with funds other than HUD such as State programs or tribal funds and things like that to try to get adequate water and sanitation facilities to them. Many times, in Indian country it's not like it is in an urban setting like Washington, DC or Maryland where all you have to do is hook up to a water main that is a few feet from the house. Sometimes there are many, many miles to traverse to get to a water or sewer system. So it is not as easy as it sounds sometimes when a home goes up many, many miles from a location where there is adequate hookups to sanitation and water. Sometimes that occurs. The point I would make is the IHS works in tandem with HUD and with tribes trying to ensure that safe water and sanitation facilities go in but the IHS itself is not the one responsible for the building programs. We just assist with sanitation and those facilities. Mr. Hartz. Mr. Chairman, I can build on that with a couple of points. I think historically as pointed out, we have had an excellent relationship with HUD in making sure that the door knob is talking to the toilet seat as we get these new homes built. I think that's been shown going back to when Congress actually started putting that language in our appropriations bill which dates back to the early 1980's. It had to do with some arrangements that were worked out at that time with OMB and Secretary Pierce I believe in 1981. The money started flowing to ensure that the HUD units were provided sanitation facilities either through an arrangement with HUD directly or through the Indian Housing Authorities and/or the Indian tribes depending on how they were set up locally. Those resources contributed from the HUD Indian Housing Program at that time grew from $5-$6 million to $25 million. That contribution to the Sanitation Facilities Program of IHS was of tribes' choosing. They could do the construction themselves, they could provide it to IHS. Many times the reason they would provide it to IHS is because you can then do a total community concept in development of infrastructure as opposed to doing a piecemeal approach where houses get dropped in a location and you only have dollars to do just that little piece for infrastructure. Infectious diseases don't follow those kinds of boundaries when the same children from different places show up in the school system. It grew in 1994 to almost $25 million, the contribution that was coming out of the Indian Housing Program from HUD most of the time, 90 plus percent of the time, the money actually was a decision made by the tribes exercising self determination before that was even passed through the HUD authorizations to provide those dollars to IHS to carry it out. There were lots of arrangements by which that was done. Sometimes the tribes would pool the dollars and the tribes actually did the construction as on the Navajo Reservation to this day, they do 99 percent of all construction related to infrastructure on water, sewer, solid waste, et cetera. It was only after the passage of NAHASDA that the numbers dramatically dropped. We were down as low as $1.3 million. Last year in 2002, it was about $4.4 million that was provided. That is totally a tribe decision. We concur with that. Getting back to your original question about why that language was put in our appropriation, we are so limited in our resources to address the sanitation deficiency system that Congress asked us to identify in that universe of need being at $1.5-$1.6 billion for all of the existing homes, plus address anything new coming on, we weren't in a position, at least the appropriators thought, to pick up additional responsibility for HUD sponsored units because we have $94 million we are addressing against the feasible amount of $900 million and of that $94 million, we put about half of it to address new units every year. In 2002, we had a few hundred units we weren't even able to address, about 350 units, where individuals were financing and paying for their homes themselves that we couldn't get to within the priority systems that exist. That's a little more background. I hope I haven't expounded to far in some of the detail but I'm prepared to expound further as needed. Mr. Pombo. Thank you, Mr. Chairman. The Chairman. I can look at the clock and see that by the time we get done with the next panel, we are going to run out of time. I would ask my colleagues to keep their questions down to 3 or 4 minutes. Congressman Kildee. Mr. Kildee. On the question of sanitation, the Senate bill apparently prohibits the use of IHS funds for sanitation in HUD housing whereas the House bill does not contain that prohibition. How does the IHS suggest we clarify the language referring to IHS funding for sanitation in HUD constructed houses? Mr. Grim. As I pointed out earlier, right now the two programs are really separate programs. We are serving that backlog of existing homes that do not have adequate safe water and sanitation facilities as well as newly built homes that are built with other than HUD funds. There are a large number of those being built annually. There are currently two separate programs. The two bills that have been introduced with differing language, I suspect in conference committee will be dealt with but if our funds were to be merged with HUD funds, it appears it would be taking two separate programs and merging them into one. We would have a difficult time then perhaps addressing the existing home backlog. Mr. Kildee. Perhaps the House and Senate can get together and try to bring our language to more compatibility to see what we can do to encourage the IHS. In some very remote parts of Michigan where I come from where there are no water lines as such and no sewer lines, they do have septic facilities and there is groundwater they can use for the operation. I think remoteness alone, there might be some areas where you don't have the groundwater, would not always preclude the possibility. This certainly relates to health, there is no question about that. The Saginaw Chippewa Tribe, in my State but not my district, in 1934 the Federal Government built a number of half houses for the Indians. Some of those half houses are still there, maybe have been finished off and changed a bit but I guess the Indians were grateful to get the half houses but they really were half. I think we certainly should have come a long way since 1934 and a long way since 1980. I'm willing to work with you to see what we can do to help the IHS and HUD work more closely together to provide this. I also believe we should elevate your position to that of assistant secretary. Mr. Grim. Thank you, Congressman Kildee. I might point out for everyone's information that the language in the Senate bill relative to the way we work with sanitation facilities is the current practice that is being carried on. The Chairman. Congressman Cole, any questions? Mr. Cole. No; Mr. Chairman. The Chairman. Congressman Faleomavaega. Mr. Faleomavaega. Again, I want to thank Dr. Grim for his testimony. Mr. Grim, I think one of the problems that left this proposed legislation for authorization hanging was the question of scoring. I notice that some estimates come out to $2 billion, $3 billion, $6.9 billion for the 10-year period. It seems we are squeezing blood out of a turnip. Why is it we are having such a difficult in time in trying to arrived the best cost estimate when it is so simple to get $70 billion to clean up Saddam Hussein's mess, so instantly it seems. We're asking for a mere $3 billion. From the statement here, I am concerned that alcoholism, is 770 percent higher than the U.S. population; diabetics, 420 percent higher; accidents, 280 percent higher; suicide, 190 percent higher; homicide, 200 percent higher and we can't even find a common ground to get the proper money. The bottomline, Dr. Grim, is funding. What is the Administration's best estimate of the level of authorization needed for the 10-year period, because I'm getting all kinds of figures. I'm a little confused. Can you give us your best estimate of how much authorization is needed to properly fund our Indian Health Care Program? Mr. Grim. The current bill, both House and Senate, I don't currently have available today to be able to tell you. Because of the variabilities in the two bills, there are some significant variabilities in title IV for example. Mr. Faleomavaega. We can clear that up on our side. I'm asking the Administration's position. What is your position on this? How much should be authorized for of this legislation? Mr. Grim. We have a study that's been done internally that only looks at the personal health care expenditure needs and doesn't look at our public health infrastructure which is also a big need. We also have a tribal needs based budget the tribes have presented. Mr. Faleomavaega. Dr. Grim, you still aren't understanding my question. The bottomline, what is the Administration's recommendation regarding the level of authorization needed to assist our Indian community for the next 10-year period? If you can't answer it right now, can you submit that for the record? Mr. Grim. Yes, sir; I will submit that for the record. Because of the variability in the bills, I can't answer that. Mr. Faleomavaega. I really would appreciate that. The second question, I believe the total population of Alaskans and American Native Indians is over 14 million. Am I correct? Mr. Grim. The American Indian and Alaska Natives we serve in our facilities is about 1.6 million. The most recent census places the number of American Indians and Alaska Natives in combination with another race at over 4 million. Mr. Faleomavaega. $4 million. I thought it was more than that. If you could give us exactly what the Administration proposes. I made the estimate that we have about 14 million American Indians and Native Alaskans in this country. You are saying the entire health care system provides services for about one point six million American Indians and Alaska Native? Mr. Grim. Yes, sir. Mr. Faleomavaega. For the rest of our Native American community, they are out there on their own, really flat out, just in the worse situation than any other ethnic group here in our country. Would you agree with me on that? Mr. Grim. I would say a portion of that population we are not serving has private insurance and is seeking care but that's a very small percentage. It is hard for us to place a handle on it since they don't access our health care system. The remainder of that group that is not that small percentage with private insurance or the ones seeking care from us, many of them are without health care. Mr. Faleomavaega. One quick question to Mr. Nesmith. I know HUD is not part of the Indian health care authorization legislation. For the last fiscal year, how much monetary assistance did HUD provide Native Americans for housing? Mr. Nesmith. The last fiscal year? Mr. Faleomavaega. Yes. Mr. Nesmith. About $650 million. Mr. Faleomavaega. How much are you proposing for the coming fiscal year? I hope it is an increase. Mr. Nesmith. I'm not sure if it's level but I can get back to you. Mr. Faleomavaega. The $650 million in the last fiscal year provides for how many of our Native American community people? Mr. Nesmith. We believe that would provide for the numbers you just mentioned. Mr. Faleomavaega. My point is we are totally underserved, even with the amount of funding that HUD is providing, it is not even the tip of the iceberg as far as the community housing needs of our Native American community throughout the country. Would you agree with me on that? Mr. Nesmith. Not being able to compare, you said it was $14 million. I would say there needs to be some improvement. Mr. Faleomavaega. Thank you, Mr. Chairman. The Chairman. Senator Murkowski, did you have any questions? Senator Murkowski. No; thank you. The Chairman. Congresswoman Napolitano. Ms. Napolitano. I'd like to followup on my colleagues' questions and the health disparities issues. I'm wondering how much of the funding is going into addressing the education or training of Native Americans to be able to deal with the issues. It is not the first year that I've heard of the high percentages of these individual groups. How are we dealing with the alcoholism, the diabetes, suicide and homicide? Accidents, that is another issue but all the others are lumped into an area that has been very prevalent in the American Indian community for many decades. It isn't the first time. What are you doing? How much money is being put into programs that will help these communities be able to deal with those issues? Mr. Grim. I will need to submit part of the answer to that question for the record in writing. What I can say is that our current budget is approaching $3 billion. Ms. Napolitano. Total budget of what? Mr. Grim. Of the Indian Health Service. You initially asked about education and we do have a scholarship and loan repayment program that we do work with trying to get American Indian and Alaska Native Youth into the health professions so they are back into their own communities. We also have a large portion of that budget that is in the health care delivery area. Approximately 50 percent of our budget in rough terms is now being administered by tribes themselves through Public Law 93- 638. They are making their own decisions about the delivery of health care in their communities. The other locations where the Indian Health Service operates the programs directly, we work closely with community health boards and tribal health boards and programs in the communities to determine priorities they want within the communities. Ms. Napolitano. What has been the result of these health delivery organizations? According to what I see here, the alcoholism is astounding. Do you have programs to actually help deal with the alcoholism problem? Mr. Grim. Yes; the majority of the programs that are alcohol and substance abuse programs in Indian country are run and managed by the tribes themselves. As a rough estimate, I'd say in excess probably of 95 percent of the programs and the money the Indian Health Service receives, about $130 million is what we receive in our line item for alcohol and substance abuse, well over 95 percent of that is going directly to the tribes themselves to run their programs. Ms. Napolitano. Is there an issue that what is happening is not actually being effective in taking another look at how else to approach it, working with the tribes you have authorized the money for? Mr. Grim. I think a large part of it is the complex nature of alcoholism. We have programs directed at both prevention and treatment, although we don't have enough inpatient treatment facilities or long term treatment facilities in many of the communities that need it. However, it is a complex mix of socio-economic factors, isolation issues, lack of adequate jobs, housing and things like that that all feed into the mix. Many of the diseases we are facing in Indian country today are behavioral and chronic as opposed to the infectious diseases we saw early on. So it requires a different mix of factors and programs that are more than just health programs alone to try to address them. Ms. Napolitano. Are those being implemented? That is what I'm trying to get at, thinking out of the box, doing new, effective methods that are going to break that cycle, that are going to assist families in being able to be supportive of each other, the tribes to be able to get to those in alcoholism. My husband died of alcoholism so I understand it very well. Thank you. Mr. Grim. Yes; I think the programs are ongoing out there, I think they are effective, I think the tribes are working within the communities to implement a more whole body wellness approach, physical, mental. emotional and spiritual. Many of them are involving their traditional ways into the programs and I think we are seeing progress. The issue is just the overwhelming numbers that we face right now. Ms. Napolitano. I'd like to hear more. If you have anything you can submit to the committee on what is actually being done, I think it is a great problem and is very hurtful to Native Americans. I think we need to be able to understand it, to be able to look at how we as a society can assist in being able to address it and help them be able to understand how hurtful it is to them and their communities. Mr. Grim. We will submit some information to you for the record on our programs and the things going on with the tribes. You are right, there is a huge disparity and a huge need in that arena. Ms. Napolitano. Thank you, Mr. Chairman. The Chairman. Congressman Grijalva, any questions? Mr. Grijalva. Yes; thank you, Mr. Chairman. In the tribal working group that worked with the Indian Health Service throughout this process and as a result, much of what we're deliberating is a product of that work, did this working group take a position on the point we spend a lot of time talking about as to who is going to have the responsibility, HUD or Indian Health Service for sanitation and sewer? Mr. Grim. The group did take a long look at that. There are two versions as you see before you right now, one in the Senate and one in the House. I don't think there is a consensus in Indian country right now relative to how that issue should be handled, whether the money should be lumped into one sum or whether these two existing programs which have separate goals should be kept separate. I just don't think there is consensus out there in Indian country yet either. Mr. Grijalva. Along the same lines, in reference to the steering committee you worked with, long and hard, as you see both bills, the Senate and the House, are there any serious omissions in this legislation, issues that those of us here should be aware of? Mr. Grim. I've submitted in my written testimony a number of things, some of the things this committee asked us to focus on today. Then there are a couple of overarching issues also in my written testimony. In the interest of time, I can submit some further issues in writing because it is a complex piece of legislation. Mr. Grijalva. I would appreciate that, sir. Thank you. The Chairman. Congressman Pallone. Mr. Pallone. Dr. Grim, I like you personally so I don't want you to take offense from anything I say but I just don't get the sense of crisis from your testimony. When you go out to Indian country, you hear stories about people dying because of lack of access to health care, you hear about the disparities with diabetes and alcoholism and so many other issues, and the inability to attend to those problems, and particularly with the facilities. Every time you go to a tribe, they talk about how they are on a 10- or 15-year waiting list to get a new facility or to renovate their facilities. Then you get all this stuff about funding. As Mr. Faleomavaega said, we just hear the funding is so inadequate and even more so that the notion the Federal Government is relying on the tribes to provide funding, particularly if they have a little money because they have a casino or whatever. I'm trying to look at the larger picture and I guess I could ask two questions and if you can answer them, fine. If not, get back to me. Do you see a real crisis because I do and where is that crisis? Is it in the lack of money for facilities, is it in the diabetes area, is it an inability to provide funding for nursing home services? I hear about all these things. The second question is, the tribes really feel, a lot of them say to me that the Government is not following through on its commitment to provide the funding federally and that they are now expected to use their own resources to build new diabetes clinics or new hospitals and almost built into the IHS the notion that the tribes are going to pay for a significant part of their health care. That's not the way it's supposed to be. Do you see a crisis? Where is it? Do you assume that they are going to pay a significant portion of their own services or construction? Mr. Grim. First, let me say that yes, I see a crisis. The percentage of mortality rates that our population exceeds relative to the U.S. population is not acceptable to me as the director of the Indian Health Service or as an American Indian. Is there a funding issue? I think we are starting to see potentially higher rates of inflation in health care than we have in past years. That impacts our budget significantly. Whenever health care inflation exceeds the amount of money we receive, we have loss in buying power. We have stayed relatively static in buying power over the last decade. We have not seen a large increase in buying power in the Indian Health Service budget, not withstanding the increases Congress has appropriated to us. I think the issue is a very complex one as I said earlier. We certainly need greater access to health care in Indian country. There are certain services that need higher levels of access than currently available but the other issue is the complex nature of health. It is not just being able to access a clinic, it is adequate and safe housing, it is economic opportunities on the reservations. Mr. Pallone. What about the backlog in facilities? Mr. Grim. We have a large estimated backlog in facilities needs in Indian country. Right now, the average age of an Indian health care facility is about 36 years of age. In the private sector, the current age of a facility is about 9 years. About 20 percent of our facilities meet that 9 years or younger average, so we have a large backlog in facility needs in Indian country. Regarding the issue of appropriating funds for facilities, Congress has been consistent over the years in trying to keep a number of Indian health facilities projects ongoing but there is a large backlog of need out there. Mr. Pallone. Do you assume that a lot of these tribes are going to take care of their own needs? That is what they tell me. They say, we have to build our own clinic, we have to build our own hospital, we have to pay for this ourselves. Is there an assumption on the part of the Federal Government that is going to happen? Mr. Grim. No, sir; Congressman Pallone, I do not assume that and I don't think the Administration assumes that. One of the things we have seen over time is sometimes when tribes take over their own health programs and sometimes when the Federal Government still runs them, tribes have donated tribal funds or placed tribal funds into programs because of the need in particular sectors for their communities. I do hear the same things you hear when I'm out there visiting Indian country, that they feel we should be doing more. Mr. Pallone. Thank you. The Chairman. Congresswoman Christensen, did you have questions? Ms. Christensen. Yes; I'll try to make them short. I've been fortunate to have Native American interns and one of them is with me, Caryle Begay, and another. I want to ask a question that comes from some of the discussions we have had. Considering there has been a significant increase of Native Americans, Alaska Natives into urban areas, away from rural reservation areas where the majority of Indian health services are provided, what measures are being taken to focus on providing health services for this growing urban Indian population. Natalia Arosco, an Indian on the San Pasqual Reservation, lives in a very small urban tribal reservation. They also have some unique needs for research data collection, publications and guidance for health care providers. What in this reauthorization addresses that? Mr. Grim. You are right in that we have seen a large demographic shift of American Indians and Alaska Natives now in urban areas. We still have 34 urban Indian programs that we provide grant funding for to operate in some existing locations. Those funds were put together through title V when Congress adopted title V of the current Indian Health Care Improvement Act. Those funds were intended to stimulate some health care services. Some are just referral and outreach and some provide more comprehensive care for areas where there were large urban Indian populations. Under the former director, Michael Trujillo, when the Indian Health Service started consulting with Indian Health Service, tribal and urban programs more, we brought the urban partners to the table. They now take part in our work groups and policy decisions within the agency and we are trying to work more closely with them for their needs. Ms. Christensen. You also say under the negotiated rulemaking part of the bill that the tribal consultation may not be the most effective way to obtain necessary Indian provider input. As a physician and member of the Small Business Committee and my colleague, Grace Napolitano can attest to this, we spend a fair amount of time with CMS and their rulemaking as it relates to providers of all backgrounds. What would be a more effective way because through the Office of Advocacy and through the Regulatory Flexibility Act we have been able to improve on their consultation. I think the Native American and Alaska Native providers deserve the same treatment. Mr. Grim. Specifically to the tribal consultation process, the Indian Health Service believes very strongly in that and works with tribes to that end. One of the comments made in my written testimony was that due to the number of regulations that come out of CMS, there was concern on behalf of the Administration that tribal consultation on all of the regulations coming through CMS might place an undue burden on the agency, on CMS. Ms. Christensen. Maybe they ought to simplify their regulation and rulemaking. Mr. Grim. I'll take back that information. The Chairman. Congressman Udall Mr. Udall. First, I want to ask about the reauthorization and the bill that is before us. In doing that, I compliment Chairman Campbell. He has introduced a piece of legislation, S. 212, in the 107th Congress; we now have before us in the 108th Congress, S. 556. There has been a great deal of consensus building done on this bill. Is the Administration at the point of supporting the bill before this committee now, weighing in and trying to make sure it gets passed? Mr. Grim. The Indian Health Care Improvement Act Reauthorization bill, S. 212? Mr. Udall. S. 556 which Chairman Campbell has worked on very hard. It is a bill that has been around a long time and I don't believe you have a reauthorization. You're just going year by year, aren't you? Mr. Grim. Currently, that is correct. The reauthorization I don't believe has been extended currently but it had been extended in previous Congresses and we are still operating. I was very excited to see a joint hearing today between the House and the Senate on the various versions of the bill. Again, both bills are complex, very long bills and the Administration has made some comments relative to their issues or concerns on specific parts of the legislation and we are still doing side by side comparisons right now, so we don't have a full analysis. Mr. Udall. How soon do you think you will have that? Mr. Grim. I would have to submit that for the record, sir, about the length of time. I'd have to check with our assistant secretary for Legislation. Mr. Udall. Do you think you are going to be in a position in the next couple months to be able to support this bill? Mr. Grim. We work very closely with both committees so that we can try to do that. Mr. Udall. I think that is very important because I think the approach Chairman Campbell and Don Young have taken in introducing this legislation is looking at the long term and looking at 10 years. It seems to me the more you're required to go year by year, you aren't looking at those big issues that many members of the panel have been raising. Would you agree with that? Mr. Grim. I think we have continued to operate our program with a long term focus, notwithstanding the fact this current bill has been pending reauthorization for a number of years, but we are very, very anxious in the Indian Health Service and in the Department of Health and Human Services to see the bill reauthorized. Mr. Udall. I'm happy that is the case. I want to ask one other question on this whole diabetes epidemic. I have a congressional district that is 22 percent Native American in the State of New Mexico, 9 percent Native American. I had a very poignant story told to me by a renal specialist in Santa Fe about diabetes in our community surrounding Santa Fe which we have a number of Pueblos. He told me that 20 to 25 years ago, a gentleman that started a practice quite a while ago, they did not see very many cases of diabetes in Native American individuals that came into the Indian Health Service hospital or that were being seen privately. In his lifetime, he said this has dramatically changed. We truly have an epidemic. I'm not a doctor. It is what he described to me but he says a lot of what is going on here has to do with diet, obesity, sedentary lifestyle, lack of exercise and it seems if this is the key, education and prevention are the way to go. What are you proposing as to how to tackle this epidemic and how to move us out of this horrible cycle we are going into? Mr. Grim. I think you have seen the President and the Secretary have an increased emphasis on health promotion and disease prevention in the last couple of years. Since I've been in the Indian Health Service, I've initiated a health promotion disease prevention initiative within this past year involving tribal leadership and health expertise from our facilities and clinics to try to reemphasize or bring to the forefront again health promotion and disease prevention efforts. I think the Indian Health Service has always been strong over the years in our health promotion efforts. We run a public health program in the communities as you have heard today and some of the testimony is not only the delivery of health care but environmental health and sanitation facility issues as well. We are trying to focus on those chronic disease issues because they are not as easily solved as some of the diseases we faced in the past. As a Nation, we are now starting to address it. Internally, Congress has been good to devote $100 million over the last 6 years and an additional $50 million to the huge problem of diabetes in Indian country. I cannot report to you specific numbers but if you'd like them for the record, we have a large number of primary prevention programs going on in Indian communities right now. We have a large number of secondary and some minor tertiary sorts of initiatives going on with that $100 million Congress appropriated. We are seeing successes out there. We are looking at five to six overall clinical indicators and seeing movement in the right direction. We think we are staring to make impacts on the diet issues, the obesity issues, and such things that not only lead to diabetes but a lot of other chronic diseases like cardiovascular disease. Right now, cardiovascular disease is on the rise in Indian populations, 25 percent greater than the Nation as a whole. A number of years back, we were lower than the rest of the Nation. The rest of the Nation is seeing reductions in those, we are seeing some increase. So we are working very hard on the control of blood pressure and things like that in our population. I think there is a lot going on out there on issues like this, it is going to take years before we see significant improvements in the indicators to show success is coming. Mr. Udall. With the Chairman's permission, could you submit those for the record, what you are doing, what you anticipate you need in terms of money to tackle the diabetes epidemic in terms of prevention and education. As a final followup, wouldn't you agree that it is far better to tackle these at the front end with prevention and education than dealing at the tail end where you have end stage renal disease and dialysis and the enormously expensive options that patients have at that point? Mr. Grim. I believe that 100 percent because I think that not only will it reduce the cost of health care in the long run and allow us to do more but I also believe it is better for our people, they will lead longer, healthier lives. Mr. Udall. Thank you. Let me compliment Chairman Pombo and Chairman Campbell for convening this joint hearing. I hope it will move this legislation along and we can get a 10-year authorization for the Indian Health Service. The Chairman. If it moves along as fast as this hearing, it may be 10 years before we finish the hearing. I'm going to submit my questions in writing. We have a series of votes starting at 12:10 p.m. in the Senate and the House will be voting right after that. We still have six people and I'm dividing the time to make sure they have equal time at the microphone. We will thank this panel and move to the second panel which will be: Rachel Joseph, cochair, National Steering Committee on the Reauthorization of Indian Health Care Improvement Act from Lone Pine, CA and Dr. Ben Muneta, president, Association of American Indian Physicians from Oklahoma City and Steve Weaver, director, Division of Environmental Health and Engineering, Alaska Native Health Consortium. As I told the first panel, your complete written testimony will be included in the record, but in order to give everyone equal time before we have to close it down unless you want to come back later this afternoon which most don't, I'd ask you to limit your testimony to about 5 minutes or less. Why don't we ask the third panel to be seated too: Kay Culbertson, president, Denver Indian Health and Family Services; Dr. Everett Rhoades, Oklahoma City Urban Indian Health Clinic; and Carmelita Skeeter, executive director, Indian Health Care Resources Center of Tulsa. Rachel, would you start. Remember we have about 5 minutes apiece. STATEMENT OF RACHEL JOSEPH, COCHAIR, NATIONAL STEERING COMMITTEE ON THE REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT Ms. Joseph. Good morning. My name is Rachel Joseph, chairperson of the Lone Pine Paiute-Shoshone Tribe and cochair of the National Steering Committee on the Reauthorization of the Indian Health Care Improvement Act. I'm also chairperson of the Toiyabe Indian Health Project a consortium of nine tribes serving California's Inyo and Mono counties. Thank you for holding this joint hearing providing us an opportunity to state our strong support for S. 556 and H.R. 2440, the Reauthorization of the Indian Health Care Improvement Act. These bills contain provisions that are necessary to improve the ability of tribal and urban programs and the Indian Health Service to provide comprehensive, personal and public health services. In 1976, when Congress found that ``the unmet health needs of American Indian people are severe and the health status of Indians is far below that of the general population of the United States,'' the Indian Health Care Improvement Act was enacted. Federal health services to Indians and Alaska Natives has resulted in a reduction in prevalence and incidence of some illnesses. For example, since we delivered our proposed bill, the death rate for pneumonia and influenza decreased from 71 percent higher than all races in the United States to 52 percent higher. However, the unmet health needs of our people remain alarmingly severe and continues to decline. Our health status, as already stated, is far below that of the general U.S. population. This crisis and disparity to be addressed is formidable. The oral health of our patients is poor and we experience approximately three times the amount of tooth decay and periodontal disease than the U.S. general population. As already stated, the mortality rate for diabetes, 420 percent greater than the rest of the Nation, and Type II diabetes is rising faster among our children and young people than any other population and is 2.6 times the national average. Our suffering due to diabetic end stage renal disease is 6 times the rate of the national population and amputations due to diabetes is three and four times the rate. In my community, diabetes is among the three top chronic diseases. We serve our population with three clinics and just at the Bishop Clinic, we see an increase of two diabetes patients every month. Cardiovascular disease is now the leading cause of mortality among Indian people with a rate that is almost 2 times that of the U.S. general population. The recent fully analyzed and racially adjusted mortality data [fiscal year 1999] from the National Center for Health Statistics documents an overall 4.5 percent increase rate for American Indian and Alaska Native people, from 698.4 per 100,000 population for the period 1994-96 to 730.1 per 100,000 for the period 1997-99. In recognition of the conditions just reiterated, tribes engaged in the consultation with a goal to develop consensus and the NSC membership acknowledged that all of our constituents included the ``lesser haves'' the ``least haves'' and ``have nots''; thus, we agreed not to ``take from each other''. One of our ground rules was that ``provisions will not adversely affect or diminish funding which is available to other Indian programs or the I/T/U system. . . '' Now, I will highlight title III of the bills which now provides a broader approach to address the unmet facilities needs and provides innovative funding options. Language concerning Safe Water and Sanitary Waste Disposal Facilities in section 302 of S. 556 reiterates a cooperative relationship between HHS and HUD regarding safe water and sanitary disposal. After consensus was reached on this issue, reflected in S. 556, there has been an effort by some housing advocates to amend the language that prohibits the use of I.H.S. funds for newly constructed HUD homes. Why do it since the I.H.S. Section 302 funding is already critically under funded for this ``Safe Water and Sanitary Waste Disposal Facilities'' program? Approximately 21,500 American Indians and Alaska Native homes lack safe water and the current backlog of need for this program construction is $900 million. Since 1982 Congress has repeatedly expressed its intent that funds appropriated to the IHS not be used for sanitation facilities for new HUD homes. This system worked fairly well until 1996 when NAHASDA was enacted and funding is now distributed by a formula which does not account for deficiencies or cost of offsite sanitation facilities. One of IHS Government Performance Results Acts [GPRA] indicators for fiscal year 2005 is to increase the proportion of American Indians and Alaska Natives receiving optimally fluoridated water by 0.5 percent over 2004 levels. An IHS fiscal year 2002 indicator committed to a 5-percent increase of American Indian and Alaska Natives benefiting from fluoridated drinking water. While the fiscal year 2002 indicator was not fully achieved, 15 small systems not previously fluoridated became fluoridated adding 20,580 individuals to those receiving the benefits of fluoridated water. Since fluoridation is one of the most cost effective public health measures for reducing the prevalence of dental decay of all ages, we must do what we can to ensure that these limited funds remain available for these purposes. If I may share a personal experience. This spring, the Indian Health Service replaced a water pump, replaced asbestos pipes, fluoridated our community drinking water and pressurized our system. Before that, my parents had to utilize water that would not allow for the brushing of teeth at the same time you washed dishes. My dad did not allow us to wash his dress shirts at home because our water was tainted with rust color. Now, the 228 young people in our community will experience the long term benefits of fluoridated water. The middle-aged and us elders will experience those benefits as well. An IHS indicator, No. 35, for fiscal year 2005 is to provide sanitation facilities to 22,300 homes, in 2002, 15,255 homes were served. I support addressing the need and those tribes that are next in line to receive these services and I hope the dollars are there. A new provision of S. 556, section 310 and section 309 of 2440 authorize a loan guarantee, a revolving loan fund and a grant program for loan repayment. The authorization to appropriate funds for an Indian health care facility loan program could be tremendous support to those tribes that want to build their own facilities. The joint venture, section 312 of S. 556 and section 311 of H.R. 2440, provides for creative, innovative financing by tribes for construction of health facilities. This joint venture with the Indian Health Service is a viable option for those tribes that can construct their own facility. The IHS obligation is for equipment, staffing and to operate it. In 2001 and 2002, Congress appropriated dollars for this program which resulted in the construction of four facilities which included two on the IHS priority list. The small ambulatory program, section 306 of 556 and section 305 of 2440, another popular program with the tribes, authorized in 1992, received its first appropriation in 2001 and 2002 of approximately $10 million which provided for the construction of 17 tribally owned facilities that the tribes equip, staff and operate. Unfortunately, neither S. 1391 or H.R. 2691 includes 2004 funds for this small ambulatory program. Another new provision ``Other Funding'' provides for alternative financing options. The Chairman. Rachel, I apologize, but we are going to run out of time. Ms. Joseph. The National Steering Committee appreciates this opportunity. We completed the process of consultation and collaboration with broad support and we want to urge you respectfully to consider any procedural actions necessary to move this legislation as quickly as possible. Thank you for your time. [Prepared statement of Ms. Joseph appears in appendix.] The Chairman. Thank you. Dr. Muneta. STATEMENT OF Dr. BEN MUNETA, PRESIDENT, ASSOCIATION OF AMERICAN INDIAN PHYSICIANS Mr. Muneta. Good morning. I am president of the Association of American Indian Physicians. I would like to add our organization's support for the reauthorization of the Indian Health Care Improvement Act. I am somewhat reflective of our membership in that I worked in urban, tribal and Federal health care facilities and we have all come to the consensus that this Act is for the good of Indian people. The Indian Health Service is a highly efficient organization. You can't find anything in government that is more efficient in the use of dollars as the IHS. We feel any money that is directed that way is money well spent by the Government. I would add that American Indians are living longer but one of the big problems we see is in several cities American Indians are going to have the lowest quality of life of any minority group in this country. The reason is simple. Chronic diseases like diabetes are going to sap the health of Indian people. Diabetic patients are 4 times more expensive than a non-diabetic patient under usual medical care. This translates into people being sicker, not having jobs, and economic loss to the communities. It is a ripple effect throughout Indian communities, not just in the health care system. One of the ways we look at these disparities is by training more Indian doctors, more health professionals who go back to these communities and provide long term, quality care. This is one of the great success stories that we have, the health scholarships that IHS operates. I think that is all I have to say. [Prepared statement of Mr. Muneta appears in appendix.] The Chairman. Thank you. Mr. Weaver. I might mention Senator Murkowski had to preside at 12 p.m. She has already left but she did tell me that she particularly wanted to hear your testimony, so I am sure she will read it with great interest. STATEMENT OF STEVE WEAVER, DIRECTOR, DIVISION OF ENVIRONMENTAL HEALTH & ENGINEERING, ALASKA NATIVE TRIBAL HEALTH CONSORTIUM, ACCOMPANIED BY ANDREW JIMMIE, CHIEF, MINTO TRADITIONAL COUNCIL Mr. Weaver. Thank you for the opportunity to testify regarding S. 556 and H.R. 2440, the Senate and the House bills that would reauthorize the Indian Health Care Improvement Act. I am appearing today on behalf of the Alaska Native Tribal Health Consortium where I serve as Director of the Division of Environmental Health & Engineering. I am accompanied by Chief Andrew Jimmie of the Minto Traditional Council who appears this morning in his capacity as the vice chair of the Alaska Native Health Board. Chief Jimmie is also the president of the Tanana Chiefs Council Conference of Regional Health Boards and recently received the prestigious Alaska Federation of Natives Health Award. Under the leadership of the National Steering Committee, the language in what has been introduced as H.R. 2440 was developed in nearly complete consensus by tribal leaders. I am pleased to testify this morning that from a sanitation facilities operations perspective, I recommend to the Senate that it substitute the sanitation and facilities provisions of H.R. 2440 in place of S. 556. I would particularly like to thank the committee for its long term support of the SFP program. Sanitation facilities construction is first and foremost about public health. It has a documented history of success in raising the health status of American Indians and Alaska Natives. While much as been accomplished, much remains to be done. IHS estimates the current national unmet need both feasible and infeasible of Indian sanitation unmet need of $1.6 billion. Alaska's component is $640 million. Alaska has a unique and demanding living environment. Suvonga, displayed to your left, is typical of remote Alaska Native communities, accessible by air year round and in the summer by boat but it is not connected on land by any road network. Cooper Bay is also typical of rural Alaska. For the last 40 years, they have packed in their drinking water and packed out their human waste in honey buckets. They are not atypical. One- third of Alaska Native homes still lack piped water and sewer facilities. Other Indian communities throughout the United States face similar challenges. Current national funding levels are not nearly sufficient to make meaningful progress. The Indian Health Service sanitation deficiencies, unmet needs inventory is increasing at a rate of $50 million a year in addition to the construction activities. The National IHS Priority List for new health facilities has stood without major addition for some 15 years. Language improvements in title III of H.R. 2440 represent an opportunity to provide flexibility in how we address this backlog and enhance how we do business. It establishes requirements to set priorities for limited facilities resources. It provides more flexibility of program management for tribes and the potential for innovation as tribes develop and diversify alternative funding sources. It enhances the ability of IHS and the tribes to deliver critically needed services as well as clarifying operational authorities. It also provides the tribes a real opportunity to aggregate funding sources and to utilize those to the best opportunity of the community. The impact of public health is not in the construction of the facility, it's in the long term operations and maintenance of that facility to deliver the lifestyle improvement and the health improvements so badly needed. In conclusion, I'd like to thank Chairman Campbell and Chairman Pombo and the respective committee members for this opportunity to give an engineer's perspective as we move forward together building healthy and safe American Indian and Alaska Native communities. [Prepared statement of Mr. Weaver appears in appendix.] The Chairman. Thank you. Ms. Culbertson. STATEMENT OF KAY CULBERTSON, PRESIDENT, DENVER INDIAN HEALTH AND FAMILY SERVICES Ms. Culbertson. Good morning. My name is Kay Culbertson. I am an enrolled member of the Ft. Peck Assiniboine/Sioux Tribes from Poplar, MT; the executive director of the Denver Indian Health and Family Services; and also serve on the board of the National Council of Urban Indian Health. I am honored today by the presence of my father and I am very happy he could be here with me. Let me start by saying I'm not a lawyer or a policy analyst. My testimony both oral and written are from my heart and reflect a combination of my brief experience as a program director and my lifelong experience of growing up between the reservation and the city. Some of my testimony may sound strong but I find I must stress these issues or I would not be true to my upbringing and values I hold as an Indian person and as a wife and as a mother of three, all of whom are enrolled members of federally recognized tribes. It is time that urban Indian health issues are seriously considered and I believe S. 556 is a good beginning. I would like to thank you for the improvements in the bill. The designation that a major goal of the United States is to provide the quantity and quality of health services which will permit the health status of Indians regardless of where they live to be raised to the highest level that is no less than that of the general population and to provide for the maximum participation of Indian tribal organizations and urban Indian organizations in the planning, delivery and management of those health services. I would also like to point out at this point, the urban Indian health programs receive not even a full two percent but almost two percent of the Indian Health Service budget. Some key points have been very positive for urban Indian health programs in this legislation, allowing urban programs to receive reimbursement from insurance programs when the urban Indian health provider is considered to be an out of network provider; the disregard of payments received through third party revenue and determining funding appropriations for health care and services to Indians; the ability of current programs to create satellite clinics to better address the health needs of the Indian community; the establishment of a self sustaining, revolving loan fund that will be solely for urban Indian health facilities; and permanency for the Oklahoma City and Tulsa demonstration projects. The development and construction of two residential treatment centers for urban Indian youth in each State where need exists and where there is a lack of culturally constant residential treatment services for youth, as mental health and substance abuse needs continue to grow and State facilities and funding are cut, we must address these needs for the city youth. Increased consultation with urban Indian health programs and Federal Tort Claims Act coverage for urban Indian organizations who receive funding under this legislation are also items of concern to me as an urban program director. Urban programs are not eligible to apply for chronic shortage demonstration projects. We experience shortages in personnel all the time through the urban Indian health clinics. The sections that address the mental health training and community education programs as well as prevention control and elimination of communicable and infectious disease programs includes urban Indian programs and studies and consultation processes but do not include us in the development, technical assistance and funding of these programs. Urban Indian health programs are not authorized to benefit from the Indian Health Care Improvement Fund or the Catastrophic Health Emergency Fund. Lack of funding authorization for critical services primarily home and community based services, public health functions and traditional health care in urban programs, we do use traditional health care. Title VIII, which has been very hard for me, addresses the provision of health services to non-eligible persons. This is of great concern to me as a tribal member and all members who live off reservation. I believe it takes away services from legitimate tribal members regardless of where they live. It appears unfair that tribal members who reside off reservation are subject to minimal care while non-Indians on the reservation may receive comprehensive services and possible access to contract health care services. On behalf of my community and all tribal members who live off reservation, I'd like to thank you for the opportunity to provide testimony on S. 556. I would like to close with this statement. The United States continues to have a legal obligation to fulfill with Indian people. Our ancestors, the people that live in the cities, also signed treaties with this Government that included provision of health care for their descendants in exchange for this great country. Whether an Indian lives off or on the reservation should not be an issue. These obligations should follow our people regardless of where they live. If all urban Indian people were to return home today or even one-half of us returned home today, being we have over 60- percent of the population, and exercised our right to those health benefits, how would the Federal Government meet the trust and treaty responsibilities to Indian people? Thank you. [Prepared statement of Ms. Culbertson appears in appendix.] The Chairman. Thank you, Kay. Let the record reflect that not being a lawyer doesn't hurt you in the eyes of the committee. Ms. Culbertson. Thank you. The Chairman. We don't have an objection from Congressman Udall. Dr. Rhoades. STATEMENT OF Dr. EVERETT RHOADES, OKLAHOMA CITY URBAN INDIAN CLINIC Mr. Rhoades. Chairman Campbell, Chairman Pombo, members of the joint committees that are considering perhaps the most revolutionary health bill related to Indians that has been passed, my name is Everett Rhoades. I'm a member of the Kiowa Tribe. I was one of the incorporators of the original Urban Indian Clinic in Oklahoma City and I also had the privilege of being one of the outside witnesses that appeared in the deliberations of the original bill in 1975. I appeared as a predecessor to the imminent Dr. Muneta on behalf of the Association of American Indian Physicians at that time where our primary interest was in title I, the Indian manpower provisions as well as in the disparities. I am here today on behalf of the Oklahoma City Urban Indian Clinic. Because of the importance of this hearing, I'm accompanied by our board president, Rufus Cox, a member of the Muskogee Creek Tribe of Oklahoma; our chief executive officer, Terry Hunter, a Kiowa from Oklahoma City; and our chief operating officer, Robyn Sunday, a member of the Cherokee Tribe in Oklahoma City. Let me make two points in the interest of time. First, there is a general conception that the basic authorization for provision of health services to urban Indians, title V of the Indian Health Care Improvement Act, I do not believe that to be true and many other individuals do not believe that to be true either. A reading of the 1921 so-called Snyder Act which really provides basic authorization for health services simply says at that time the Commissioner of Indian Affairs should expend such moneys as Congress should from time to time appropriate for various programs, including interesting language that says conservation of health and relief of distress and for physicians, for Indians throughout the United States and does not provide additional guidance. It is my understanding that the enactment of title V went beyond simply the authorization of services to urban Indians but it defined the nature of those services, it defined the nature of the receiving entity and part of the consideration was to avoid what I would call the intrusion of the Indian Health Services' program itself into urban communities recognizing that even by the 1970's, a dramatic diaspora of Indians into urban communities would really ultimately require the entire budget of the Indian Health Service. As a result of all that, a new entity was created set out in the definition of paragraph (g) or (h) in section IV that says these programs are to be located in urban areas, to be run by a local urban Indian board which, in my opinion, distinguishes them from both Indian Health Service and tribal programs. In that regard, we would ask that the Congress keep that in mind in its deliberations in regard to title V and we very strongly support the Senate language contained in section V. In 1987, as a result of what I would call the growth and evolution of urban programs in this country, the Congress set two important demonstration programs into being in Oklahoma City and in Tulsa which further defined urban health care in these two demonstration projects, basically to determine whether or not they would be more apt to succeed if they received their funding from the hospitals and clinics account of the Indian Health Service rather than the urban account in title V but the contracts were still executed under title V, so they are hybrid programs with a peculiar special characteristic that should treat them in many instances as service units are now operating units. The second point we feel strongly about in Oklahoma City is that we respectfully ask the Congress to direct that funds that are received in the Oklahoma area by virtue of the fact the entire State of Oklahoma is a contract health service delivery area and the populations in both Oklahoma City and Tulsa therefore are counted in those allocations, unfortunately with the present arrangement of distribution of those funds, both Tulsa and Oklahoma City receive a minority of the funds that their own populations generate. We believe the Indian Health Service would welcome direction from the Congress that the allocations of additional funds, particularly under Indian Health Care Improvement Act, should be treated as service units or operating units within themselves. In closing, I would reiterate in regard to section 512, the Senate language I think is excellent. It really continues language that has been in place since 1992 and I would respectfully ask the House members if they would accede to the language of the Senate where there may be differences. Thank you. [Prepared statement of Dr. Rhoades appears in appendix.] The Chairman. Thank you. Your institutional memory is of great value to the committee. Ms. Skeeter. STATEMENT OF CARMELITA WAMEGO SKEETER, EXECUTIVE DIRECTOR, INDIAN HEALTH CARE RESOURCE CENTER OF TULSA Ms. Skeeter. Good morning and thank you for inviting me to make this presentation today. I am very happy to see that it is a joint hearing. I'm the executive director of Indian Health Care Resource Center in Tulsa and I have been with this organization for 27 years, so it is very dear to my heart. I have I hope a very good story to tell you on the demonstration programs. I am citizen Potawotami enrolled in my tribe and very active. Becoming a demonstration project in 1987, we did that with the help of Indian Health Service, the Urban Directors, coming together and seeing how we could make sure these two programs existed even though urban programs nationally were zeroed out of the budget. Because of IHS and the tribal people seeing our programs were so vital to the State of Oklahoma, they wanted to make sue we were able to continue, so we were put into the 01 of the budget, line item. Since then, we have been able to double our resources and in some areas, triple our resources. It was like opening a new door or opening a window to a home that had been very stale and unsupported. We were able to then start receiving GSA vans to do transportation for our patients, we were able to start getting health care providers from IHS, able to start purchasing medications from the GSA pharmaceutical contract, so it was opening a new door. The program in Tulsa has a $2.5 million Indian Health Service budget. We have been able to turn that budget into over $6.5 million by contracting with other agencies competing with other Federal programs on grants and contracts. We have five contracts with the State of Oklahoma to provide substance abuse and mental health services. We are State certified. We are accredited through the Association of Accreditation for Ambulatory Health Centers. We have a contract with the Cherokee Nation where they provide the WIC services in our clinic and have done so since 1979. We have a contract with seven other tribes in the State of Oklahoma, a program called BEACH which is through the State health department and CDC working with children on obesity, drugs, physical fitness, the prevention of diabetes and we are in three Tulsa public schools with gym teachers working with these children daily. I believe that we are a very good partner with all the tribes in Oklahoma. We work very closely with them and our board is a community elected board, we have elections once a year. Any tribal member in Tulsa can run for our board. We have in the past had councilmen from the Creek Nation on our board, councilmen from the Cherokee Nation on our board. The tribes hold meetings at our facility. Oklahoma City and Tulsa are the only two urban programs in the United States that have been able to get new facilities in the past 25-30 years. The facility in Tulsa is 27,000 square feet, the facility in Oklahoma City I believe is about 27,000 square feet. We have been able to do that because we have been able to collect Medicaid at the OMB rate because we are treated as a service unit. This makes us different than the other urban programs. We have been able to tap into this resource of Medicaid reimbursement. That has allowed us to expand our services. Tulsa, we do not receive any IHS funds for dental but we are able to provide dental services by having one dentist because we are able to collect Medicaid at the OMB rate. We are able to have an optometry clinic, full-time optometrist because we are able to fund that with the Medicaid OMB rate. I feel very proud of what we have been able to do in Oklahoma, the services we are able to provide. Our service population is 15,000 active patients at our facility. We have over 6,000 patient visits a month. I have a staff of 85. I have the largest mental health outpatient department in the State of Oklahoma for Indian people. We take referrals from all over the State. I have four clinical psychologists full time, two psychiatrists part time, one for children, one for adults; I have a developmental pediatrician part time and I have four counselors that work out of our behavioral health department. I have a full time pediatrician in medical, family practice physician assistant, nurse practitioner, so I have a very large operation in Tulsa. We work very closely and are very integrated with the entire health system of the city. We carry a caseload of 120 to 130 OBs continually. I have a contract with an obstetrician that comes in 1 day a week to see those OBs and the mothers if they qualify or have third party reimbursement, they are able to deliver in the city. If not, we provide transportation for the mothers to Claremore Indian Hospital which is 30 miles away one way. We are very entrenched in the community. We are 27 years old. We try to tap into every resource we possibly can. We work very closely with the tribes and I do support S. 556. I want to thank the Senators for honing the language that would protect us from sovereignty. We do not want to get into the sovereignty issue. We serve over 150 tribes and as an urban program, we want to continue to serve that 150 tribes. We want to continue operating as a 501(c)(3) under a community elected board and have the board set the policies that run the organization. As I say, I am very passionate about this program. I've been there 27 years. I started out as the resource coordinator, clinic administrator and I've been the executive director for the last 14 years. I feel very strongly and would be more than happy to answer any questions. [Prepared statement of Ms. Skeeter appears in appendix.] The Chairman. Thank you, Ms. Skeeter. We have managed to keep it within the timeframe. I'm going to ask our colleagues to submit any questions in writing as I will because we have run out of time but would like to yield to Chairman Pombo if he has any closing comments. Mr. Pombo. I want to thank this panel for your testimony. It was extremely informative and very valuable for the committee as we move forward with this bill. On behalf of myself and my colleagues in the House, I want to thank you for taking the time to come here and share your stories with us. I do have a number of questions as my colleagues do and we will be submitting those to you in writing. If you can respond to those in a timely manner in writing so they can be included as part of the hearing, we would appreciate it. Thank you very much. Mr. Pallone. Could I just ask a procedural question? I thought it was very valuable to have this joint hearing today. I don't want to suggest to our chairman what he should do on this issue but I know that the Senate committee is planning to have future hearings. Either we have our own or if not, if we could possibly continue this joint hearing idea, it is certainly a way for the House members to participate and also for us all to continue with investigation of the issues. The Chairman. I will have our staff work with Chairman Pombo's staff and see if we can't do that dealing with health care. We will submit those questions and if you could get those back to in writing at your earliest convenience, that would be good. I want to thank all the panels and we will keep the record open for four weeks on this particular hearing because we will be doing another on the same subject. Next week we will continue the series on health care. This hearing is adjourned. [Whereupon, at 12:17 p.m., the committees were adjourned, to reconvene at the call of their respective Chairs.] ======================================================================= A P P E N D I X ---------- Additional Material Submitted for the Record ======================================================================= Prepared Statement of Mike Zacharof, Chairman and Andrew Jimmie, Vice Chairman, Alaska Native Health Board The Alaska Native Health Board [ANHB], established in 1968, is recognized as the statewide voice of Alaska Natives on health issues. With contributions from its member tribes and tribal organizations, ANHB has been active for 35 years as an advocate on behalf of health needs and concerns of all Alaska Natives. On behalf of 229 tribes within the State of Alaska, and over 119,000 Alaska Natives, the Alaska Native Health Board strongly encourages Congress to support and enact H.R. 2440, a bill to reauthorize the Indian Health Care Improvement Act. H.R. 2440 is an update to the 1999 National Steering Committee draft of the Indian Health Care Improvement Act. Over the last year, under the direction of Representative Young, the 1999 National Steering Committee draft reauthorization bill and the first House and Senate versions of that draft were examined and updated to respond to concerns expressed by the Administration to provisions contained in S. 212--the predecessor to S. 556--to resolve differences between the bills before the Senate and the House in the last session, and to consider tribal concerns that have arisen since 1999. This work is reflected in H.R. 2440. We are pleased that Steven Weaver has been invited to testify regarding before this joint hearing of the Senate Committee on Indian Affairs and House Resources Committee regarding the provisions of Title M of the Indian Health Care Improvement Act. As Director of the Division of Environmental Health and Engineering for the Alaska Native Tribal Health Consortium, he brings to you a wealth of experience and technical knowledge. We strongly endorse the recommendations made in his testimony. Reauthorization of the Indian Health Care Improvement Act is one of the highest priorities of the tribes in Alaska. We urge the earliest possible action. ______ Prepared Statement of R. Perry Beaver, Principal Chief, Muscogee [Creek] Nation Chairman Campbell, Vice Chairman Inouye, and members of the committee. Thank you for this opportunity to share some of my thoughts with you about S. 556, the ``Indian Health Care Improvement Act Reauthorization of 2003.'' My name is R. Perry Beaver and I have served as the Principal Chief of the Muscogee [Creek] Nation for the past 8 years, and as a National Council representative for several years before that. I request that my written testimony be made part of the hearing record. Due to my years of service to the Muscogee Nation and my residence in Tulsa County for many years, I am familiar with the many health problems faced by Native Americans in Oklahoma, including Creek citizens residing in the Tulsa urban area. I have also been a part of the development and implementation of Department of the Interior and Health and Human Services tribal 638 contracts and self-governance compacts under the Indian Self-Determination and Education Assistance Act [``ISDEAA''] amendments during the past decade. These programs have provided the Muscogee Nation with a great opportunity to identify the specific needs of its citizens and to administer programs for that purpose, including health programs. The Muscogee Nation has made significant progress in its development as a government and in making improvements related to the provision of health care due in part to the opportunities presented by the ISDEAA. Unfortunately, S. 556 contains a proposed amendment to the Indian Health Care Improvement Act that would severely limit the Nation's ability to exercise self-governance in the area of health care. Section 512(a) would amend the IHCIA to permanently remove the Indian Health Care Resource Center, Inc. in Tulsa, OK [``Tulsa Clinic''] from the umbrella of self-governance and make it a permanent direct care program of the Indian Health Service. This would be accomplished by the following provisions in section 512 (a) of the bill: Notwithstanding any other provision of law, the Tulsa and Oklahoma City Clinic demonstration projects shall become permanent programs within the Service's direct care program and continue to be treated as service units in the allocation of resources and coordination of care, and shall continue to meet the requirements and definitions of an urban Indian organization in this title, and as such will not be subject to the provisions of the Indian Self-Determination and Education Assistance Act. A large number of the Native American population in Tulsa are citizens of the Muscogee Nation and the Cherokee Nation. The northern jurisdictional boundary of a portion of the Muscogee Nation and the southern boundary of a portion of the Cherokee Nation encompass separate areas in what is now Tulsa County. The Nation has strong roots in Tulsa, which originated as a Creek Tribal Town in the 1830's. The Nation owns trust lands in Tulsa County and also still owns a one- hundred acre tract of land in Tulsa that has been recognized by Federal courts as ``historic reservation lands.'' Our capital complex in Okmulgee is only 30 miles from Tulsa. Although the Muscogee Nation has not fully exercised its self-governance related to its citizens' health needs in the Tulsa urban area in recent years, it maintains a strong governmental interest in meeting the health needs of Indians within its service area. The Tulsa Clinic has been existence for approximately 20 years, many years before Congress amended the ISDEAA to include self- governance programs that would enable Indian nations to exercise greater control over Federal funds formerly awarded to them under ``638 contracts.'' During much of that time, the Tulsa Clinic has been providing health services to Native Americans in Tulsa as a demonstration project under the IHCIA. The Nation has not made a strong attempt to obtain tribal control of the provision of health services in Tulsa currently provided by the Tulsa Clinic for various reasons, including the Nation's concentration on development of its existing health programs and its recent conversion to funding through a self- governance compact. I believe that the indefinite continuation of the Tulsa Clinic as a demonstration project would be in the interests of Native Americans in Tulsa. However, the Muscogee Nation is opposed to making the Clinic a permanent program and permanently removing it from the authority of the ISDEAA. This would eliminate the Nation's ability to compact for IHS funding allocated for the needs of Indians in Tulsa. This would infringe on the Nation's sovereignty within its jurisdictional boundaries in a significant portion of Tulsa County. I believe that at some point in the not too distant future, the Muscogee Nation will be ready to take an even stronger role in the provision of health care in Tulsa. The proposed amendment would prevent the Nation from doing so, through what would be, in effect, a Congressional delegation of the Nation's governmental authority to the Indian Health Services and the Tulsa Clinic as its grant recipient. The Board of the Tulsa Clinic would be in a permanent position to make decisions which are better left to tribal governments. I respectfully ask that this committee refrain from approval of S. 556 unless and until the offending language in section 512(a) is removed or amended. I have reviewed new draft language provided by the Cherokee Nation, and have no strong objections to use of that language, except to language that would make the Tulsa Clinic a ``permanent program'' within the Indian Health Service [``IHS''] direct care program. I suggest that the language in section 512(a) be revised to read as follows: Sec. 512(a). TULSA AND OKLAHOMA CITY CLINIC--Notwithstanding any other provision of law, the Tulsa and Oklahoma City Clinic demonstration projects shall--(1) remain demonstration programs within the Service's direct care program; (2) continue to be treated as service units in the allocation of resources and coordination of care; and (3) be subject to the provisions of the Indian Self-Determination and Education Assistance Act, except that the programs shall not be divisible. Thank you for this opportunity to provide this testimony to you today. 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