<DOC>
[109 Senate Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:20611.wais]
S. Hrg. 109-26
INDIAN HEALTH
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED NINTH CONGRESS
FIRST SESSION
ON
OVERSIGHT HEARING ON THE STATUS OF INDIAN HEALTH CARE
__________
APRIL 13, 2005
WASHINGTON, DC
U.S. GOVERNMENT PRINTING OFFICE
20-611 WASHINGTON : 2005
_____________________________________________________________________________
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COMMITTEE ON INDIAN AFFAIRS
JOHN McCAIN, Arizona, Chairman
BYRON L. DORGAN, North Dakota, Vice Chairman
PETE V. DOMENICI, New Mexico DANIEL K. INOUYE, Hawaii
CRAIG THOMAS, Wyoming KENT CONRAD, North Dakota
GORDON SMITH, Oregon DANIEL K. AKAKA, Hawaii
LISA MURKOWSKI, Alaska TIM JOHNSON, South Dakota
MICHAEL D. CRAPO, Idaho MARIA CANTWELL, Washington
RICHARD BURR, North Carolina
TOM COBURN, M.D., Oklahoma
Jeanne Bumpus, Majority Staff Director
Sara G. Garland, Minority Staff Director
(ii)
C O N T E N T S
----------
Page
Statements:
Coburn, M.D., Hon. Tom, U.S. Senator from Oklahoma........... 3
Dorgan, Hon. Byron L., U.S. Senator from North Dakota, vice
chairman, Committee on Indian Affairs...................... 1
Grim, M.D., Charles W., director, IHS, Department of Health
and Human Service.......................................... 4
Hartz, Gary, director, Office of Environmental Health and
Engineering, Department of Health and Human Service........ 4
Ignace, Georgiana, president, National Council on Urban
Indian Health.............................................. 23
Inouye, Hon. Daniel K., U.S. Senator from Hawaii............. 2
Joseph, Rachel, cochairperson, National Steering Committee
for the Reauthorization of the Indian Health Care
Improvement Act, and chairwoman, Lone Pine Paiute Shoshone
Reservation................................................ 22
McCain, Hon. John, U.S. Senator from Arizona, chairman,
Committee on Indian Affairs................................ 1
Petherick, J.T., executive director, National Indian Health
Board...................................................... 19
Power, Kathryn, director, Center for Mental Health, Substance
Abuse, and Mental Health Services Administration,
Department of Health and Humane Services................... 6
Roanhorse, Anslem, executive director, Navajo Nation,
Department of Health....................................... 25
Rolin, Buford, vice chairman, Poarch Creek Band of Indians
and cochairperson, National Steering Committee for the
Reauthorization of the Indian Health Care Improvement Act.. 22
Russell, Beverly, executive director, National Council on
Urban Indian Health........................................ 23
Smith, H. Sally, chairman, National Indian Health Board...... 19
Thomas, Hon. Craig, U.S. Senator from Wyoming................ 4
Vanderwagen, M.D., Craig, acting chief medical officer, IHS,
Department of Health and Human Service..................... 4
Appendix
Prepared statements:
Grim, M.D., Charles W........................................ 37
Johnson, Anthony D., chairman, Nez Perce Tribal Executive
Committee.................................................. 44
Joseph, Rachel (with attachment)............................. 46
Murkowski, Hon. Lisa, U.S. Senator from Alaska (with
attachment)................................................ 81
Power, Kathryn............................................... 88
Roanhorse, Anslem............................................ 98
Russell, Beverly (with attachment)........................... 111
Smith, Chad, principal chief, Cherokee Nation................ 150
Smith, H. Sally (with attachment)............................ 155
Walker, M.D., R. Dale, director, One Sky Center: American
Indian/Alaska Native National Resource Center for Substance
Abuse and Mental Health Services, Oregon Health and
Sciences University (with attachment)...................... 180
Additional material submitted for the record:
Hobbs, Straus, Dean and Walker, LLP, resolution and report... 188
INDIAN HEALTH
----------
WEDNESDAY, APRIL 13, 2005
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The committee met, pursuant to notice, at 9:33 a.m. in room
485, Senate Russell Building, Hon. John McCain (chairman of the
committee) presiding.
Present: Senators McCain, Burr, Coburn, Dorgan, Inouye,
Murkowski, and Thomas.
STATEMENT OF HON. JOHN McCAIN, U.S. SENATOR FROM ARIZONA,
CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS
The Chairman. Welcome to the committee oversight hearing on
the status of Indian health care. While the Indian Health
Service has reported progress, the mortality rate among Native
Americans from causes as diverse as diabetes, tuberculosis,
certain types of cancer and suicide remain shockingly high,
above the national average and unacceptably high.
For a number of Congresses, this Committee has sought to
reauthorize the Indian Health Care Improvement Act, but to date
this has not been done. I hope that the testimony we receive
today will inspire and inform our efforts as we again seek to
update the law to reflect the current health needs in Indian
Country.
Senator Dorgan.
STATEMENT OF HON. BYRON L. DORGAN, U.S. SENATOR FROM NORTH
DAKOTA, VICE CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS
Senator Dorgan. Mr. Chairman, thank you very much. We will
hold many hearings in this committee, none more important than
the issue of focusing on health care, because most other things
in life are not very satisfactory if you do not have access to
good health care.
I want to mention that we held a meeting in the Oval Office
1 day some years ago with certain tribal chairs, and they came
in. One of them stood up and said, ``I come from a Third World
country,'' and he read for the President the data, the
statistics about his reservation. They are likely similar to
the statistics nationally. Native American youths are twice as
likely to commit suicide, in the Northern Great Plains, 10
times more likely to commit suicide than other Americans
statistically. They are five times more likely to die from
alcoholism. They are six times more likely to die from
tuberculosis. The rate of death from diabetes is three to four
times that of other Americans, twice the rate of accidental
deaths.
So this is a very serious issue. I held a meeting, Mr.
Chairman, several weeks ago in North Dakota because there had
been a rash of five suicides of young people on an Indian
reservation in North Dakota. I did not invite the press or
others. We just had a long quiet meeting with a lot of people
who were involved in these issues. It is heartbreaking.
You hear stories that are just devastating. I will not go
into great length today, but I have spoken about Avis Little
Wind, a young girl who took her life a while back after
spending 90 days in bed in a fetal position, missing 90 days of
school. I went up to that reservation and talked to all the
people about it. They could not figure out how to put together
somebody to help this young woman. Her sister committed
suicide. Her dad had committed suicide. Her mother was
dysfunctional.
And this goes on and on and on. I asked today to have some
special testimony from some experts who are involved in mental
health, and I am really pleased that Kathryn Power is with us
today. We have others who will testify today about these
issues. I just want to say that as we try to work through the
health issues, I want to see if we can spend some time on this
issue, particularly teen suicide on Indian reservations.
I also want to make the point that Medicare spends about
$6,000 per person on health care. The VA spends about $5,200
per person; Medicaid about $3,900 per person. We spend about
$3,800 per prisoner because we have Federal responsibilities
for the health care of Federal prisoners. The Indian Health
Service spends about $1,600 per person for health care of
American Indians, and there we have a trust responsibility as
well.
We have a very big challenge. I look forward to working
with you, Mr. Chairman, and other members of this committee to
address these health care issues, which we talk about every
year and on which very slight progress is made and so much is
yet to be done.
Mr. Chairman, thank you very much.
The Chairman. Thank you.
Senator Inouye.
STATEMENT OF HON. DANIEL K. INOUYE, U.S. SENATOR FROM HAWAII
Senator Inouye. I thank you very much, Mr. Chairman. I wish
to commend you for holding this hearing on such an important
issue.
As you have indicated, Mr. Chairman and Mr. Vice Chairman,
Indian health has improved over the years, but when you compare
it to the general population of the United States, or for that
matter to the Third World, we still rank the lowest on
practically every health indicator. Preventive health programs
and services are needed more than ever. A few weeks ago, we
were once again tragically reminded that one's health involves
much more than physical health. It is also mental health. I
refer to the Red Lake, Minnesota Reservation. I hope that we
can do much more than we are doing now.
Thank you very much.
The Chairman. Senator Coburn.
STATEMENT OF HON. TOM COBURN, M.D., U.S. SENATOR FROM OKLAHOMA
Senator Coburn. Mr. Chairman, thank you for holding this
hearing. We have the largest number of Native Americans of any
State in Oklahoma. We have a diversity of care given in our
State. Hastings Hospital in Tahlequah does a wonderful job.
They are overburdened because of the load they have, but we
have other hospitals that do a terrible job. One of the markers
for that is what we paid out in malpractice claims, the Federal
Government did, for poor delivery of care in many places in
Oklahoma.
Although I will not be able to stay for the hearing because
I have two other committees going on at the same time, I think
it is really important that what Senator Inouye said,
prevention is our key, whether it is mental health, whether it
is diabetes, and we need to be about putting more dollars into
prevention than we do in treatment because we are going to save
billions of dollars over the years.
The other point that I would make, and I think everybody
ought to be aware of, in the long run we will not be able to
continue to increase the funding for any of the programs for
Native Americans if we do not get a handle on our other
spending. As you look to see what the demands on Native
American health care is going to be, and then the demands on
the discretionary budget that we are going to be facing, it is
very important that wherever we spend money, we spend it
wisely. We spend the money not on facilities, but on programs
that make a big difference in health.
So I appreciate your having this hearing. There is a lot of
work to do in the Native American community to bring their
health care up to par and to meet our obligations and our
treaty obligations. Part of that is quality enhancement through
the physicians that are working there. I hope to bring to you
in the very near future an analysis of the malpractice claims
paid through the Federal courts in this country by area so that
you can see where we are lacking. There are significant areas
where we do not have the quality individuals treating Native
Americans that we should. Part of that is pay and part of it is
other problems, but we can correct that and we should correct
that, and we should bring up the standard.
The final thing that I would say is best practices are the
way we do that. We need to incentivize that through Native
American health and Indian health services so that they follow
that. We have great programs that are out there now that will
improve care, cut costs and increase availability of those
services, and we ought to be about enforcing that that becomes
a part of the Indian Health Service.
Thank you, Mr. Chairman.
The Chairman. Thank you very much.
Senator Thomas.
STATEMENT OF HON. CRAIG THOMAS, U.S. SENATOR FROM WYOMING
Senator Thomas. Thank you, Mr. Chairman. I too have to go
to another hearing this morning, but I did want to thank you
for having this. The tribes in our State, this is probably one
of the outstanding issues that we need to talk about. So I
certainly want to work with this as we go, and I do not have an
opening statement. I just wanted to tell you how important it
is.
The Chairman. Thank you very much, Senator Thomas.
Our first panel is Dr. Charles W. Grim, who is the director
of the Indian Health Service, Department of Health and
Services; and A. Kathryn Power, the director of the Center for
Mental Health, Substance Abuse and Mental Health Service
Administration of the Department of Health and Human Services.
Dr. Grim, we will begin with you, and perhaps for the
record, we can identify who is with you, and you as well, Ms.
Power.
Mr. Grim. Certainly, Mr. Chairman.
STATEMENT OF CHARLES W. GRIM, M.D., DIRECTOR, INDIAN HEALTH
SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES, ACCOMPANIED
BY CRAIG VANDERWAGEN,
ACTING CHIEF MEDICAL OFFICER; AND GARY HARTZ,
DIRECTOR, OFFICE OF ENVIRONMENTAL HEALTH AND
ENGINEERING
Mr. Grim. Mr. Chairman and members of the committee, my
name is Charles Grim, director of the Indian Health Service. I
will be the only one giving an opening statement today, but I
have with me Gary Hartz, our director for the Office of
Environmental Health and Engineering, and Craig Vanderwagen,
our acting chief medical officer.
The Chairman. Welcome.
Mr. Grim. We are very pleased today to be able to have this
opportunity to testify on behalf of Secretary Leavitt on the
status of Indian health. I will summarize my prepared statement
and submit a complete written statement for the record.
The Chairman. Without objection.
Mr. Grim. It is also a pleasure to testify along with
Kathryn Power, the director of the Center for Mental Health
Services with the Substance Abuse and Mental Health Services
Administration. The Indian Health Service [IHS] and SAMHSA have
strengthened our partnerships over the last several years and
are doing more than we ever have together for Indian country
around mental health and substance abuse issues.
You have asked us here today to discuss the status of
Indian health by focusing on health disparities and other
related issues such as urban Indian health, Indian health care
facilities, Indian self-determination, and part D of the
Medicare Modernization Act. I would also like to share with you
our concerns and efforts related to the recent tragic events at
Red Lake.
I spent part of last week at the Red Lake Chippewa
Reservation in Minnesota and witnessed first-hand the results
of the devastation brought by the shootings at the Red Lake
High School. I met with the tribal chairman and the council. I
met with our hospital staff who treated the victims, and I met
with many of the mental health teams that we had brought in to
provide some additional surge assistance to the community.
I also saw a community that was beginning to unite and draw
strength from the support of these mental health professionals
and also from their tribal spiritual leaders and the various
community traditional healing ceremonies they were having.
In the midst of the trauma and the upheaval caused by the
shootings, I also saw a sense of hope and a spirit of
collaboration among the community and the tribal leaders, among
the State, and among the many Federal programs that were there.
The IHS is working closely with SAMHSA, with the Administration
for Children and Families, and its Administration for Native
Americans, the Office of Minority Health and other departments
within the Department of Health and Human Services to aid the
tribe.
We have also been joined by the Department of the Interior,
Bureau of Indian Affairs, the Department of Justice and the
Department of Education. I want to thank all those Federal
departments that are working together to help us improve the
overall health of Indian people in the Red Lake community
during this crisis.
The thing we need to ask ourselves is how do we prevent
such incidents from occurring in the future. First, the IHS
continues to focus on screening and primary prevention in
mental health, especially for depression which manifests itself
in our population in suicide, domestic violence and addictions.
Second, we must continue to focus on the effective utilization
of treatment modalities that are available and we are currently
seeking to improve the documentation of our mental health
problems.
The IHS is currently utilizing effective tools for
documentation to the behavioral health software package and we
are working with the communities who are focusing more on these
mental health needs. Today, approximately 80 percent of the
mental health budget and 97 percent of the alcohol and
substance abuse budget in the IHS is going directly to tribally
operated programs, and the tribes and communities themselves
are now taking responsibility for their own healing. They are
providing effective treatment and prevention services within
their own communities, and in addition our fiscal year 2006
budget request included a $59-million increase for that mental
services line item, which is a 7.7-percent increase over the
2005 level.
Fortunately, the incidence and prevalence of many of the
infectious diseases that we once faced as the leading cause of
death and disability among American Indians and Alaska Natives
have dramatically decreased due to the increased medical care
and public health efforts, including massive vaccination
programs and sanitation facility construction programs. As the
population lives longer and adopts more of a Western diet and
often a more sedentary lifestyle, chronic diseases have emerged
as the dominant factor in the health and longevity of Indian
people. We are seeing increasing rates of cardiovascular
disease, hepatitis C virus, obesity and diabetes. Many of the
chronic disease are affected by lifestyles and behavioral
health choices.
Our primary focus today is on the development of more
effective prevention programs in American Indian and Alaska
Native communities. We have begun many programs along with
those communities to encourage the employees of the agency, as
well as our tribal and health program partners, to lose weight
and exercise. There are programs such as Walk The Talk, Just
Move It, and the Take Charge Challenge. We have found that they
are all cost-effective in that they help prevent both diabetes
and many other chronic diseases and the sequela of them such as
heart disease.
We are trying to address many of the things that we face in
Indian country with three primary focus areas now. Those are
health promotion, disease prevention, continued and increased
focus on behavioral health, and the third focus area of chronic
disease management. As you indicated in some of your opening
comments, Indian health has progressively improved since the
passage of the Indian Health Care Improvement Act in 1976. The
IHS has honored its commitment to improve the health status of
eligible American Indian and Alaska Natives as provided by the
Indian Health Care Improvement Act, and has worked with tribes
since the Indian Self-Determination and Education Assistance
Act was enacted in 1975 to assist in the successful transition
of IHS-administered health programs to tribal control and
administration.
Prevention and health promotion programs continue to be a
personal priority of mine and the Secretary, and they have
received a $33 million funding increase in the President's
fiscal year 2006 proposed budget for the IHS.
We recognize, however, that many health disparities
continue to exist between American Indians and Alaska Natives
and all other groups in the United States. We seek to address
this through continued support of these health promotion and
disease prevention programs targeted at some of the diseases
that have the highest mortality rates in our population.
In addition, our scholarship and loan repayment programs
provide opportunities to recruit and retain young Indian
professionals to serve their communities, wile the Sanitation
Facilities Construction Programs continue to provide safe
water, wastewater disposal, and solid waste systems for the
well-being of many communities. Through effective ongoing
consultation with tribes, and urban Indian programs, the
Federal Government is benefiting from the communication that
enables all parties to understand the needs and the most
effective ways to address them.
Mr. Chairman, this concludes my statement. Thank you for
the opportunity to discuss the Indian health programs that are
serving our communities today and their impact of the health
status on American Indians and Alaska Natives. We will be happy
to answer any questions the Committee might have.
[Prepared statement of Dr. Grim appears in appendix.]
The Chairman. Thank you very much.
Ms. Power.
STATEMENT OF A. KATHRYN POWER, DIRECTOR, CENTER FOR MENTAL
HEALTH, SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES
ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES
Ms. Power. Good morning, Mr. Chairman and members of the
committee. I am Kathryn Power, director of the Center for
Mental Health Services within the Substance Abuse and Mental
Health Services Administration, SAMHSA.
I am very pleased to offer testimony this morning on behalf
of Charles Curie, the administrator of SAMHSA. I will submit
written testimony for the record.
The Chairman. Without objection.
Ms. Power. I want to thank you for the opportunity to
describe how SAMHSA is working to provide effective mental
illness and substance abuse treatment services, as well as
substance abuse prevention and mental health promotion services
in Indian country.
It is also a privilege to testify along with Dr. Charles
Grim, director of the Indian Health Service, particularly this
morning about this very important issue. SAMHSA and IHS have
developed a very strong working partnership reflected in our
current interagency agreements to work efficiently and
effectively together to help meet the public needs of American
Indians and Alaska Natives.
My testimony will focus on two specific issues of great
concern to the public health of American Indian and Alaska
Native youth. These issues are suicide and violence.
Sorrowfully, there are real-life examples to illustrate the
impact of suicide and violence in Indian country. Recently, a
suicide cluster occurred on the Standing Rock Reservation in
North and South Dakota. Eight young people took their lives and
dozens more attempted to do so.
Tragically, many other reservations have similar stories to
tell. Suicide is now the second-leading cause of death behind
accidents for Alaska Native and American Indian Native youth
aged 15 through 24. The suicide rate for this population is 2.5
times or 250 percent times higher than the national average.
More than one-half of all persons who commit suicide in Indian
communities have never been seen by mental health providers.
For particular groups of American Indians, depression and
substance abuse are the most common risk factors for completed
suicide. Mental health and substance use disorders are also
risk factors for violence. The recent example of violence in
Indian country is the tragedy at Red Lake. On March 21, 2005, a
17-year-old high school junior shot and killed his
grandparents, five students, a teacher and a security officer
and himself. Red Lake Nation is an impoverished community.
Thirty-nine percent of the population lives below the poverty
line. Four out of five students at Red Lake High School qualify
for free or reduced lunch. One-third of the teenagers on this
reservation are not in school, are not working and are not
looking for work, compared with about 20 percent on all
reservations.
This event has led to community grief, to community turmoil
and trauma. In response, SAMHSA has sent several staff on-site
to coordinate services and technical assistance in
collaboration with the IHS and the tribe. This involves support
of the health care team, the educational programs, social
services, support of the tribal council, and the community at
large. SAMHSA staff has also provided technical assistance to
the tribe in an effort to help them access emergency funds,
especially those funds available through the SERGE grant
mechanism.
With regard to programs that address violence and suicide,
we know that in 1999 in response to school shootings in
Kentucky, Arkansas, Oregon, and other States, Congress took
action and launched the Safe Schools/Healthy Students
Initiative under the collaborative leadership of the
Departments of Education, Health and Human Services and
Justice. The Safe Schools/Healthy Students Program awards 3-
year grants of $1 million to $3 million per year to school
districts to do the following: Collaborate with local law
enforcement and mental health agencies; promote the healthy
development of school-age children; and promote mental health
and prevent violence in youth by using evidence-based programs
with demonstrated long-term positive effects.
Two tribal sites were funded in the initial cohort of 54
grantees out of a pool of close to 500 applications. In
particular, these two tribal grantees emphasized the poverty of
their communities. Repeatedly, researchers from different
fields have firmly established that poverty and its contextual
life circumstances are major determinants of violence. Violence
is most prevalent among the poor regardless of race. It is
common knowledge that conditions on Indian reservations are
deplorable, but the information presented by these applications
was shocking nonetheless.
Our Safe Schools/Healthy Students grantee in Pinon, Arizona
wrote in its application, and I quote,
Within the boundaries of the richest country in the world
exist a Third World nation. The Navajo Nation in Northern
Arizona is among the poorest and most desolate regions of the
United States. The area has only one paved road for travel, 92
percent of the children receive free or reduced-price lunches,
and 60 to 90 percent of residents live without basic services
such as plumbing, running water, kitchen, sewers, and
telephones, compared to less than 1 percent of the U.S.
population at large.
Close quote.
These are the problems that this Safe Schools/Healthy
Students grantee worked to address and by and large they were
successful in turning a school community away from violence and
toward resilience and toward productive and meaningful lives.
In January, SAMHSA launched the National Suicide Prevention
Lifeline, 1-800-273-TALK. The national hotline is part of the
National Suicide Prevention Initiative.
Additionally, SAMHSA under the authority of the Garrett Lee
Smith Memorial Act announced the availability of fiscal year
2005 funds for State-sponsored youth suicide prevention and
early intervention programs.
Mr. Chairman and members of the committee, SAMHSA takes
very seriously the challenges present in Indian country, which
include very few trained service providers, major
transportation barriers, and multi-generational poverty. SAMHSA
is engaged in addressing the issues and challenges in Indian
country that rob communities of their most valuable resources,
their children and their future. The vital treatment and
prevention efforts that SAMHSA has undertaken are designed to
address these problems and are improving services for all of
the children, youth and families in Alaska and across Indian
Country. These programs are working and our cooperation and
collaboration with IHS is effective.
Mr. Chairman and members of the committee, thank you for
the opportunity to appear before you today. I will be pleased
to answer any questions you may have.
[Prepared statement of Ms. Power appears in appendix.]
The Chairman. Thank you very much.
Ms. Power, more than one-half of all persons who commit
suicide in Indian communities have never been seen by a mental
health provider. Is that right?
Ms. Power. That is correct.
The Chairman. How does that compare with the non-Indian
population?
Ms. Power. I think that there are statistics, Mr. Chairman,
that show that of those individuals who have committed suicide,
that many of them have in fact seen a primary care physician
prior to the completion of suicide, but statistically I
probably will have to get you that information. But we do have
indications that for those individuals, both children and
adults, who have completed suicide, they do have usually an
interaction with someone, whether it is a mental health
provider or a primary care provider in the 90 days before the
completed act of suicide.
The Chairman. Do you see a connection between substance
abuse or alcohol abuse and suicide?
Ms. Power. Absolutely, Mr. Chairman.
The Chairman. Is it usually associated with suicide?
Ms. Power. There is often the presence of either a
substance abuse disorder or the presence of the use of
substances, either alcohol or drugs, prior to the completion of
a suicide.
The Chairman. Is there a large percentage that are from
single-parent homes?
Ms. Power. Of those individuals, Mr. Chairman, who are
suicidal?
The Chairman. Yes.
Ms. Power. I think that the family conditions and the
economic conditions contribute enormously to the presence of
depression. We know that depression is the single most dominant
indicator of pre-suicidal activity. If depression exists, then
depression comes from a variety of not only internal factors,
but also external factors. The fact that there may be disrupted
family life, there may be a low socioeconomic condition. All of
those contribute to the factors that would lead individuals who
have experience of depression to then move further and consider
taking their own lives.
The Chairman. Senator Murkowski probably knows more about
this than I do, but is there an isolation factor here of tribes
either in the Lower 48 or in Alaska that contributes to this?
Ms. Power. I think both. This is certainly not just a Lower
48 issue. I think that the isolation leads to the social
disconnectedness, which leads to the discontinuity, which leads
to the lack of hope, which leads to the lack of belief in the
future. I know that in particular the school violence that
occurred in Bethel, AK and in Springfield and in Paducah was
actually the reason why Congress developed the Safe Schools/
Healthy Students Program.
So yes, in fact isolation is a major contributor to the
identity of the culture, to the disconnectedness of their lives
and to the belief and the hope of their own future.
The Chairman. Obesity or diabetes?
Ms. Power. I am going to ask Dr. Grim.
Mr. Grim. I think Ms. Power did an outstanding job of
talking about the multi-factorial nature of suicide and
depression. Certainly, people in our population that have
obesity and have gone on to get other chronic diseases,
diabetes and others, we have seen that, often they will have
co-occurring depression along with the chronic disease. In many
people, we are still educating them about the preventive
aspects of diabetes, but for many, many years we would see
youth that would automatically come into some of our facilities
and say ``when will I get diabetes and how long will it be
before I die?''
With the moneys that Congress has given us over the last
several years to work on the special diabetes program for
Indian funding that is now at $150 million a year, those grants
have made huge, huge impact on getting a lot more educational,
physical activity and nutrition sorts of primary prevention
programs out in the communities that are starting to impact
that sort of a feeling of hopelessness about chronic diseases.
The Chairman. Switching gears just for a second, on January
31, the committee sent a letter to Secretary Leavitt seeking
his commitment to reauthorizing the Indian Health Care
Improvement Act. We still have not gotten a response. Do you
know anything about that?
Mr. Grim. I know that a response is being prepared,
Senator. I was told that it should be on the way. The committee
should have it shortly. I have not had an opportunity, as you
know, Secretary Leavitt has been here less than 60 days, to
speak with him directly about that, but I know they are
preparing the response.
The Chairman. I know he has a very heavy schedule. I hope
that you could schedule a phone call to him to ask him to get
us a response.
I thank the witnesses.
Senator Dorgan.
Senator Dorgan. Mr. Chairman, thank you.
Dr. Grim, thank you.
Ms. Powers, thank you for being here.
Dr. Grim, let me ask you about Contract Health Services. I
was on a reservation some months ago and they were telling me
about the Contract Health Service problem. This is a
reservation that has inadequate health care, inadequate
facilities to address a chronic health problem that comes up in
a short period. So you transport somebody or someone is moved
to a hospital 60 miles away, gets service under Contract Health
Services and then the bill is not paid. This goes on. They try
to collect the bill from the patient. The patient gets a bad
credit rating because the Contract Health Service's bill has
never been paid.
There was a recent court decision about this with respect
to two tribes, and the Supreme Court handed down a decision in
the Cherokee Nation of Oklahoma v. Leavitt that the Indian
Self-Determination Act required the Indian Health Service to
pay tribes certain contract support costs, which the Federal
Government had not been paying.
So how much does the IHS owe the tribes that were at the
center of that case, number one, if you can tell me? And how
much are owed to other tribes with respect to Contract Health
Services that have no been paid?
Mr. Grim. The case was just adjudicated. We estimate that
the amount the agency owes the two tribes that were in that is
approximately $15.6 million for contract support costs that
were due the tribe between 1994 and 1997. From 1998 on, the
Congress put a statutory cap on our contract support costs,
which is a different line item within our budget than the other
one you were asking about, contract health services. The
contract health services line item does not have that statutory
cap and we do distribute those funds on a formula basis
throughout the Nation. As you indicated, each region of the
country is asked to live within that budget on an annual basis
because it is limited. Each area is at different levels
throughout the year. I would ask our Chief Medical Officer if
he would like to add anything to that, but the Supreme Court
hearing affected contract support costs, and not our contract
health service budget.
Senator Dorgan. Thank you.
Mr. Grim. Is there anything you would like to add, Dr.
Vanderwagen?
Mr. Vanderwagen. Senator, I think you highlighted a chronic
issue that afflicts many communities, and that is, the
inability to fully cover those costs that are accrued when we
have to purchase care from a private sector environment. We
have electronic payment systems now that we can turn most bills
around in 45 days, but there continue to be problems with
certain locations where we do need to fix that problem.
Senator Dorgan. I am going to send you some additional
questions on that because, as I said, I have heard from people
who say their credit rating is ruined despite the fact that
they had approved contract health services that they accessed.
Let me tell you about the meeting I held recently, Ms.
Power and Dr. Grim. What they were telling me, the people who
came to that meeting, particularly from the Standing Rock
Tribe, if a young kid is addicted to drugs or alcohol, there is
virtually no opportunity to quickly get that person into long-
term treatment that is able to shed that addiction. The
treatment is just not available.
So you have these people that are hopelessly addicted,
young kids that are hopelessly addicted to alcohol or to drugs
who really need to be put in a program, an in-residence
program, and it is not available. Is that true around the
country on reservations generally?
Ms. Power. I believe it is a difficulty, Senator, in terms
of first of all identifying individuals who have those problems
and who are willing to step forward and want to get into
treatment. Then the second difficulty is access to the
treatment. Is the treatment available to them in a location
where they can actually get to it? And third, the difficulty
that comes over the long term. You really do have to have a
personal commitment to wanting to stay engaged in both drug and
alcohol prevention and treatment programs.
I think one of the things that we have tried to do,
particularly with Indian tribes, is to make sure that all of
the American Indian and Native Alaskan and tribal
organizations, first of all, are eligible for all of our
substance abuse prevention and treatment grants. That has
really been an effort that my boss has really extended to us at
the staff level, saying you will in fact do everything you can
to make sure, unless there are overriding compelling reasons,
to make sure that every opportunity for substance abuse
prevention and substance abuse treatment grants are available
to the tribal organizations.
We also, of course, are looking to use our resources at
SAMHSA to make sure that the need is addressed, particularly
through our Access to Recovery Program. We had several tribal
organizations that competed for the Access to Recovery.
Senator Dorgan. Ms. Power, I am sorry for interrupting you,
but isn't it the case, wouldn't you and Dr. Grim both agree
that there simply are not enough treatment opportunities
available around the country on reservations for those who are
addicted to alcohol and drugs? I mean, we are woefully short of
treatment. You are talking about what we are doing, and I
appreciate all that, but isn't it the case that we are just way
short of what is necessary to get a young person into a
treatment facility when they are addicted to drugs and alcohol?
Ms. Power. I think that certainly in talking about the
access issue, Senator, I believe it is correct that it is very
difficult for many people across America, and particularly on
the tribes, to have access to those services, very difficult.
Senator Dorgan. Yes; some of those young people say it is
impossible almost. At this meeting I held, we were talking
about suicides and attempted suicides. They said that in 1 year
on the Standing Rock Reservation there were 288 suicides or
attempted suicides in 1 year; 288. They talked about the lack
of mental health treatment available to them. They said, well
you know, you have to go to your family, you have to reach out.
And one young girl stood up and she said, ``Well, you know, I
was being raped repeatedly by my father when I was thinking
about suicide. I could not go to him and I could not go to my
mother. She was in a dysfunctional situation and would have
been angry about it and no believe me in any event.'' So she
said, ``I had to work through this myself somehow.'' But she
said, ``There really was no avenue for me to express myself on
these issues.'' She fortunately got through this.
But as you indicated, there are a lot of young kids that
are not getting through it, and the young boy on the Red Lake
Reservation, I do not know much about that case except what I
have read in the press. But once again, a serious lack of
mental health services, just a serious lack. I have had people
at witness tables who were in charge of these issues for
tribes, and who broke down in sobs saying, ``I had to even beg
to try to borrow a car to take a young kid to a clinic who was
having a desperate time.'' This was a reservation where this
little Avis Little Wind hung herself recently. She did not have
access to psychological care that she should have had. There
are lots of people who knew she needed it, but there was no
access to get it to her in a remote location.
So the only point I am making is that this is a real
serious crisis and we have to say that instead. I know we are
making some progress in all these areas, and Dr. Grim, your
testimony described that. But I am much more interested not in
the 16 percent improvement here or 18 percent improvement
there. I am interested in how far are we from the goal, because
I think Senator McCain indicated and my colleague Senator
Inouye indicated, we are still, even with our improvements,
which are reasonably small, we are still so far from where the
rest of America's population is on these circumstances with
respect to tuberculosis, mental health, all these issues.
So we just have to do much more. I appreciate very much the
contribution, Ms. Power, you have made this morning on a very
important issue. Dr. Grim, I hope that you will work closely
with us to identify where are the urgent priorities here so
that we can begin thinking through, Senator McCain and I and
the committee, how we deal with them.
Thank you very much for your testimony.
The Chairman. Senator Inouye.
Senator Inouye. Thank you.
It is true that statistically the health of Indian country
has improved, but the demographic picture of Indian country is
like any other community. You have your very wealthy and your
very poor. My question is, are the improved statistics in some
sense due to the self-help programs that Indians have had
because they are making money?
Mr. Grim. I think that certainly is a part of it, Senator
Inouye. I do not know that we can statistically quantify what
that is, but it is clear that tribes that have done well and
are doing well economically have put some of those tribal
revenues into health programs, both preventive as well as
treatment. So we would have to say that certainly that is part
of it. Plus, as you heard, the multi-factorial nature not only
of mental health and suicide issues, but of health in general.
It is more than having just a clinic or a hospital in your
community, but it is also having educational opportunities,
good jobs and socio-economic development.
So I think there are many tribes that have seen that it is
wise to put the moneys that they have made into the health of
their people and they have done that in a variety of ways. I am
not sure we can quantify that.
Senator Inouye. I am certain you know that there are many
tribes who run their own schools, run their own hospitals and
clinics. Have they done well?
Mr. Grim. Yes, sir; they most certainly have. They are able
to make the decisions at a local level on the programs that
they want to run. One of the things that we are looking forward
to seeing the results of soon is that the Office of Management
and Budget is going to be looking through their PART analysis
at the tribal side of our health program. They have looked at
the Federal side, at our facilities programs and sanitation
facilities; at our Urban Indian Health Program and in this next
cycle, they will be looking at that particular program. The
preliminary data are showing outstanding results.
Senator Inouye. In other words, if they were not helping
themselves, the statistics would be much worse.
Mr. Grim. That is perhaps a fair assessment.
Senator Inouye. Can you tell us whether the budget that has
been presented is a good and fair one? Or in your professional
opinion, do you think we should get more?
Mr. Grim. I think the President's budget proposal for 2006
for the IHS is a very good budget when you take a look at the
priorities that are on the nation right now, The department has
listened to tribal consultation throughout the country, and one
of the things that you will see in this budget that you have
not seen requested in a while is inflation and population
growth. Tribal leaders have told the department and the
Administration over the course of the last year's consultations
that the Indian community was growing at a rate that needed to
be addressed in the budget. So you do see a sizable increase
for both population growth and in inflation in almost every
line item of the budget. So we were very pleased with the
budget.
Senator Inouye. Are you suggesting that the budget that was
presented would be adequate to cope with the problems that the
Chairman and the Vice Chairman all indicated this morning?
Mr. Grim. The issues that we all raised around the Red Lake
incident, we are not sure if the resources that the department,
speaking just for HHS here, the funds that we are making
available have been what have been asked for to date. We are
still waiting to see from the council what their overall list
of needs are. We do not know whether those immediate crisis
needs are going to be able to be met within the budget, but the
priorities that were raised by the Chairman and the Vice
Chairman this morning are addressed in the fiscal year 2006
budget.
Senator Inouye. My last question, in determining the
budget, is Indian country given an opportunity to provide an
input? Do you consult with them?
Mr. Grim. Yes, sir; we have regional consultations within
each of the 12 regions of Indian Health Service. We also then
have a national budget consultation around the formulation of
this year's budget. It just so happens that today and tomorrow
are the national budget formulation sessions for the fiscal
year 2007 budget that we are holding with representatives from
Indian country. So there is extensive input at the regional and
national levels to our budget.
Senator Inouye. So you are suggesting that Indian country
is satisfied with the budget?
Mr. Grim. You would have to ask them that, sir.
Senator Inouye. In your consultation, did they say they
were happy?
Mr. Grim. They have asked for higher priorities in some
areas in total dollar amounts, but the agency has always tried
to follow the priorities that they have set out in categorical
order when the budget is presented and in the intervening
months with the department and OMB we have tried to follow
those priorities consistently for the last 7 or 8 years that we
have been holding these tribal budget consultations.
Senator Inouye. Thank you.
The Chairman. Senator Murkowski.
Senator Murkowski. Thank you, Mr. Chairman. I do have an
opening statement that I would like included in the record.
The Chairman. Without objection.
[Prepared statement of Senator Murkowski appears in
appendix.]
Senator Murkowski. Thank you.
Welcome to you, Dr. Grim and welcome to you, Ms. Power.
As we look at those factors and those issues in our lives
that cause things like depression that lead to suicide, there
are certain things that are going to be tough in my State. We
are always going to be a big State. We are probably never going
to be connected like the rest of the Lower 48 is connected, but
I would like to think that through the assistance of the
communities, through the assistance of the State and others, we
really can provide for that level of service.
The point was raised by the Vice Chairman in terms of
access. We know that when it comes to treatment facilities, I
would agree we are woefully lacking. It is an issue where we
might know that we have a problem coming up. We might have a
child who has sent the message, and yet we are not picking up
on it. We do not know what to do quite with it. Both in the
incident in Red Lake and the incident in Bethel, the young man
had told others that they were going to do harm. I do not know
whether it is we do not believe the kids, we do not know what
to do next, but we are not picking up and we are not offering
the help that needs to be given in a timely enough manner.
I want to ask you, the fact that in Bethel and the Red Lake
High School, both of these were public high schools. They were
not BIA schools, and yet IHS is the significant provider of
behavioral health services in both of these communities. What
kind of collaboration goes on between the public schools and
the BIA and IHS in an effort to deal with instances like this?
This is a question directed to either one of you.
Mr. Grim. I will ask Dr. Vanderwagen if he would respond
for the agency.
Mr. Vanderwagen. Senator, I have not seen you.
Congratulations on the reelection.
I think in these small communities, we are the provider of
the community. Because they are small communities, I think all
the staff, whether they are on the public education side or
whether they are on the health side, recognize a common purpose
and a common need to act in a common way. I think in both
Bethel and in Red Lake, well certainly in Red Lake, I can say
that the psychology staff from our facility at Red Lake was
working with the school system to try and assure that there
were counseling services available.
I think that the Chairman and Mr. Inouye helped us back in
the mid-1980's to try and get treatment center capacity, but we
are at the state where we essentially have one treatment
facility per State. I think in Alaska we split that into two,
but that does not offer many opportunities for the school and
us to refer children and youth when they have the kind of needs
that you have just identified.
Senator Murkowski. So then tell me what it is that we do.
None of us want to repeat any of these incidents in any
community across the country. When the signal is sent by the
young person, are we intervening?
Mr. Vanderwagen. It is a fairly complex situation, but to
simplify it as much as I can, it is family; it is educational
systems and it is the health system and often the law and order
system that have to work comprehensively in those small
communities to provide the support structure. We know that
foster care is a real challenge and a real issue, so that
children for instance who have troubled families do not have
many options within a community for referral, and that is a
real challenge for tribal communities to work out.
It is very difficult because there are not always the full
range of alternatives that we might have elsewhere in the
country vis-a-vis dealing with isolation as it impacts on the
availability of those resources and the use of those resources.
There is not a simple solution to these issues. It has to
be a community-wide effort. Certainly, what we are trying to
demonstrate with Red Lake is that there is a Federal-wide
effort that has to be there to support the community. Those are
the lessons we have learned about this thus far.
Senator Murkowski. I think one of the lessons that we
learned out of the Bethel incident was that after that horrific
incident, the community came together and there was a healing
process, for lack of a better term, but the community really
galvanized. Unfortunately, it took multiple deaths in order to
galvanize that community, in order to get that support. So we
are not there if the action is coming after the deaths.
Mr. Vanderwagen. That is true.
Senator Murkowski. Dr. Grim, I would like to ask you very
quickly about village safe water and sanitation facilities. I
am pleased to see that IHS sanitation facilities construction
program has received a small bump-up in the President's budget.
You have been working in conjunction with the EPA and rural
development in USDA to move forward with some of the progress
that we have made in my State to provide for sanitation
facilities. I am disappointed because in the USDA budget and
the EPA budget, in both of those, we have seen very significant
reductions, which means that IHS sanitation facilities
construction budget is the only one that is actually holding
steady.
My question to you is, are you going to be able to do it
alone? What does this do to the progress that we have made and
that we continue to need to make in order to be able to meet
the health and sanitation needs our in rural Alaska?
Mr. Grim. I am going to ask Mr. Hartz to address that. He
is our expert on sanitation facilities. We are doing everything
we can to work with both those other agencies.
Mr. Hartz. Senator Murkowski, thank you for the question.
The cooperation that has come from the other agencies has been
real critical, and especially what we have gotten through the
State of Alaska. The 121 Program, as we have referred to
sanitation facilities, brings in typically anywhere from 30
cents to 50 cents on every $1 appropriated to enhance further
what we can get with the amount appropriated.
Secretary Thompson was extremely helpful in continuing to
advocate for sanitation facilities funding, so we have been
able to sustain our funding level. We are aware that what is
happening elsewhere could have some impact on funding, but we
are really pleased at how the tribes and our own staff are
using our dollars as seed money to try to continue to get
additional resources to supplement our $93-plus million
appropriation. Within the last year, we have actually had
contributions in the range of nearly $50 million added to those
appropriations.
Senator Murkowski. We need to keep working on this one
together, because you know that this is too significant in my
State. I was just home this weekend and you make some progress
with health statistics and then this weekend I read that the
tuberculosis rate is now up again among Alaska Native people.
You make progress on one end and then you lose it on another.
So we need to keep working on this.
Thank you, Mr. Chairman.
The Chairman. Senator Burr.
Senator Burr. Thank you, Mr. Chairman.
I thank our panel.
I am going to try to keep focused on whether we have
sufficiently addressed the funding need that is out there. By
my calculation, the Administration's budget recommends about a
2-percent increase. Is there anywhere else in health care today
where a 2-percent increase would meet the rising cost of health
care?
Mr. Grim. I am not sure about the answer to the question
you pose about anywhere else that could be met with 2.1
percent. I think one of the things, if you look at our budget
detail a little bit, we are taking a pause in construction for
this year. That was an ability to shift those funds over into
the health care side. What appears to be a $63-million increase
really on the health care side ends up being around $146
million increase. So in essence that more than doubles that 2
percent increase.
Senator Burr. So now we are up to 4 percent. Is there
anywhere in health care today that a 4-percent increase would
meet the current inflation rate in health care?
Mr. Grim. In general medical inflation, perhaps it would.
In specifics, for example pharmaceuticals that are increasing
at a greater rate, it does not keep pace with that level of
inflation.
Senator Burr. There have been tremendous successes within
the population, with the decrease of disease, the decrease of
mortality specifically. Those decreases in mortality also bring
a higher cost of maintenance. Is that figured into the model?
Mr. Grim. It is very true what you say, that with the
increased longevity of our population, and it has gone up
significantly over the years that the IHS has been in
operation. With that lengthening of their life span have come
more chronic diseases that are more expensive to treat and
often have higher levels of pharmaceutical care costs and
things like that. Those things are being factors into the
health system, but again the chronic diseases that we face have
forced the agency to look at our initiatives and our
priorities.
As I mentioned in my testimony, we are focusing very
heavily on three areas now: Health promotion/disease prevention
because we are trying to get ahead of that curve of the chronic
diseases, and so we are putting more money and more time and
energy into that, and focus very heavily on behavioral health
in collaboration with other agencies like SAMHSA and with
tribal communities because not only the mental health needs of
the communities, but many of the chronic diseases have
behavioral health and lifestyle choice issues that we are
working on. And then we are working more diligently on chronic
disease management.
There are a lot of chronic disease management models out
there that we do not have fully implemented in all of our
programs that can allow us to be more cost-effective in the way
we manage chronic diseases. I think we are doing an outstanding
job and have been for a number of years in the way we manage
diabetes as a chronic disease. We are starting to get a handle
on that, I believe. But many of the emerging chronic diseases
that we are facing now, cardiovascular disease, obesity,
certain types of cancer and asthma and things like that, we
could I think manage better. So we are looking at many chronic
disease management models and trying to implement those.
So with the focus of those three areas, we are trying to
get the most out of every dollar that we receive.
Senator Burr. I certainly commend you for the progress.
Clearly, the individuals covered are benefited from that
progress. I also look at the unique ability that we have to
identify those genetic traits that come in the form of disease,
and really other medical-related areas that we really can put
our finger on and understand how much of an impact it has on
select communities.
My only warning is, and I understand the constraints that
we have in budgets, but the one thing that we have learned from
health care is that if you try to shortcut the process, the
back end is much more expensive; that our ability to educate,
to insert prevention and wellness into the system saves us
money from a standpoint of per-incident emergency treatment,
in-patient care. We continue to vacillate in the entire health
care atmosphere of where do we put our emphasis. Every time we
go to prevention and education, the back-end savings are
significant. I just do not want us to lose perspective.
I think it is difficult to do everything that you just
talked about when we look at a 2- or a 4-percent increase. I
know I am not telling you anything you do not already know, but
I think it is important that we really keep in the center of
this debate, that if we want to accomplish this, it is going to
cost something.
I thank you, Mr. Chairman.
The Chairman. I want to thank the witnesses, and we look
forward to seeing you again. Dr. Grim, I hope we can move
forward on the reauthorization of the Indian Health Care Act.
We need to have the Administration's position on it.
Mr. Grim. Yes, sir.
The Chairman. Thank you very much.
Mr. Grim. Thank you.
Ms. Power. Thank you, Mr. Chairman and members of the
committee.
The Chairman. Thank you.
Our next panel is H. Sally Smith, chairman, National Indian
Health Board of Washington, DC. She is accompanied by J. T.
Petherick, executive director, National Indian Health Board.
Rachel Joseph, Cochairperson, National Steering Committee for
the Reauthorization of the Indian Health Care Improvement Act,
and chairwoman of the Lone Pine Paiute Shoshone Reservation in
Lone Pine, CA. She is accompanied by Buford Rolin, vice
chairman, Poarch Creek Band of Indians; Georgiana Ignace,
president, National Counsel on Urban Indian Health. She is
accompanied by Beverly Russell, executive director, National
Council on Urban Indian Health; Anslem Roanhorse, executive
director, Navajo Nation, Department of Health, Window Rock, AZ.
Ms. Smith, we will begin with you.
STATEMENT OF H. SALLY SMITH, CHAIRMAN, NATIONAL INDIAN HEALTH
BOARD, ACCOMPANIED BY J.T. PETHERICK, EXECUTIVE DIRECTOR
Ms. Smith. Thank you very much.
Chairman McCain, Vice Chairman Dorgan, distinguished
members of the Senate Indian Affairs Committee, I come from
Dillingham, AK in the southwest part of Alaska. I am Yupik
Eskimo. On behalf of the National Indian Health Board, it is an
honor and a pleasure to provide a broad overview today of our
public health needs in terms of access to care, health
disparities and public health issues throughout Indian country.
In the coming weeks, we look forward to working with the
committee on crafting and achieving the implementation of the
reauthorization of the Indian Health Care Improvement Act. We
hope that today this snapshot of health care in Indian country
will assist the committee as we work toward this goal.
With limited time, Mr. Chairman, I am going to touch on a
few topics. My written statement provides a far more extensive
survey of health care in Indian country and I ask that it be
included in the record.
The Chairman. All of the written statements of the
witnesses will be included in the record without objection,
including yours. Please proceed.
Ms. Smith. Thank you.
The National Indian Health Board serves federally
recognized American Indians' and Alaska Natives' tribal
governments, and certainly we do this by advocating for health
care, as well as upholding, as described earlier, the Federal
Government's trust responsibility to the American Indians and
the Alaska Natives.
I want to now go into a framework for discussion by saying
that on September 11, 2001 the United States changed forever.
While we knew the threats of terrorist attacks were possible,
as a Nation we did not collectively confront the issue and make
as necessary sweeping changes until the events of September 11
occurred. We are now facing a similar dilemma in Indian
country. Across Indian country, the crisis in health care is
well documented and well known to both lawmakers and Indian
communities for which they are tasked with addressing basic
human needs and health care needs as well.
For example, at several congressional hearings before this
one, we have testified, and I go to my notes to make sure that
I have this correct, the United States invests nearly twice the
funds for the health care of a Federal prisoner as it does on
an American Indian or Alaska Native, as earlier described by
Mr. Dorgan.
Our life expectancy is nearly 6 years less than any other
race or ethnic group in America; 13 percent of our deaths occur
in those younger than 25, a rate three times higher than the
average U.S. population.
Two years ago, the U.S. Commission on Civil Rights reported
that American Indian youths are twice as likely to commit
suicide, again underscoring earlier comments. Our people are
630 percent more likely to die from alcoholism; 650 percent
more likely to die from tuberculosis; 318 percent more likely
to die from diabetes; and 204 percent more likely to suffer
accidental death as compared with other groups. All of this
information is shocking, but none of it is new.
The health care crisis in Indian country continues. Nowhere
is the need more urgent, as earlier again described, than the
incidents that happened at the Red Lake Reservation. That
tragedy has left Indian country with a heavy heart, but it has
also brought to light the collective resolve and ability of our
Native peoples to respond to tragedy in a supportive and awe-
inspiring manner. Tribes across this Nation quietly delivered
support and aid to the Red Lake community.
As in any community, unanswered need can foster
unimaginable tragedy. As we review the status of health care
delivery systems in Indian communities, we cannot afford to
allow the behavioral and the mental health infrastructure in
Indian country to continue unaddressed. Today, let us begin
again and do as a great Lakota leader, Sitting Bull, said,
``Let us put our minds together and see what life we can make
for our children.''
I want to touch a little bit on public health, to follow-up
with my comments with regard to the incident at the Red Lake
Reservation. In Indian country, we realize that we have a
public health epidemic. There is a growing body of empirical
evidence in the Americas, as well as across Europe, Asia and
other continents, that very clearly demonstrates the
effectiveness of prevention. Prevention works. It is much
easier and less costly to prevent disease, disability, injury
and premature death than to treat poor health conditions once
present.
Today, little is known about the capacity for preventing
disease and reducing mortality throughout Indian country. By
leveraging the Indian Health Service shares, other public
resources, and private revenues, many tribal governments make
substantial contributions to prevention investments, but these
investments are not the scale in order to address adequately
the needs of an improved prevention infrastructure.
Tribes are increasingly developing ideas on new programs,
services, capacities and approaches needed to help improve the
health in Indian country. Additionally, Indian country is
learning about changes in communities that impact both
positively or negatively the health of Native populations. But
these programs are grossly underfunded, and relative to State
and county governments, tribes do not benefit equally from
Federal and State resources intended for the public good.
I want to talk about the WIN! Initiative.
The Chairman. I would like to remind you, Ms. Smith, that
we have about a 5-minute limit on opening statements, so
please.
Ms. Smith. Thank you.
The Chairman. Thank you.
Ms. Smith. Thank you, very quickly.
The WIN! Initiative, earlier you were talking about
prevention, the National Indian Health Board has launched this
initiative and I would be happy to provide information for you.
Again, it covers a new vision for preventing disease and
promoting health in Indian country.
There is one area that my written testimony covers. It is a
dental health aid program and the therapists in Alaska. I call
your attention to that. I will not cover that at this time, but
I do want to very quickly talk about the Medicare Modernization
Act of 2003, as well as the drug card, and then close my
comments. Thank you.
There are several provisions contained in the Medicare
Modernization Act of 2003 that have the potential to seriously
negatively impact the Indian health care system. Chief among
these is a new prescription drug benefit. As implemented by the
CMS, it will severely impact American Indians and Alaska
Natives because of lost Medicaid revenue to the Indian health
care system. The loss is estimated to be between $25 million to
$50 million. The new provisions will severely impact Native
people who are dual-eligible, those eligible for both Medicaid
and Medicare, by eliminating the Medicaid prescription drug
benefits, and with them a much-needed funding source.
With regard to the drug card, very quickly, there is no
requirement in the drug card plan. CMS will chose, will be the
ones that will work with Indian and tribal pharmacies. Further
complicating the situation, the plan into which the Alaska
Native and American Indian dual-eligible will be enrolled may
not be the plan into which the local ITU pharmacy contracted.
Our people receive prescription drugs from ITU pharmacies at no
cost to them. I am asking very quickly that we need help in
rectifying this particular issue.
In closing, on behalf of the National Indian Health Board,
we certainly want to thank the Senate Committee on Indian
Affairs for its investment of time, expertise and action into
investigating and improving the health care delivery systems
for American Indians and Alaska Natives.
Thank you for considering our testimonies, and we
certainly, from the National Indian Health Board, pledge to
work with the committee in any area that we can. Again, I will
provide written testimony, but let me close by saying again
what the great leader said, and that is, ``Let us put our minds
together and see what life we can make for our children.'' They
are critically important.
Thank you.
[Prepared statement of Ms. Smith appears in appendix.]
The Chairman. Thank you very much.
Rachel Joseph.
STATEMENT OF RACHEL JOSEPH, COCHAIRPERSON, NATIONAL STEERING
COMMITTEE FOR THE REAUTHORIZATION OF THE INDIAN HEALTH CARE
IMPROVEMENT ACT, AND CHAIRWOMAN, LONE PINE PAIUTE SHOSHONE
RESERVATION, ACCOMPANIED BY BUFORD ROLIN, VICE
CHAIRMAN, POARCH CREEK BAND OF INDIANS, AND
COCHAIRPERSON, NATIONAL STEERING COMMITTEE FOR THE
REAUTHORIZATION OF THE INDIAN HEALTH CARE
IMPROVEMENT ACT
Ms. Joseph. Mr. Chairman, Vice Chairman Dorgan, Senators of
the committee, I am Rachel Joseph, chairwoman of the Lone Pine
Paiute Shoshone Reservation and cochairperson for the National
Steering Committee for the Reauthorization of the Indian Health
Care Improvement Act.
Our project last year served 3,514 Indians, active users at
three clinics. It takes 6 hours to drive north to south; 10
percent of our population is 65 years and older, 26 percent of
our population is below the poverty level, and 15 percent of
our households do not have telephones. Our pneumoccal
vaccination rate is 48 percent below the Healthy People 2010
goal and our mammography rate is 49 percent below the Healthy
People 2010 goal.
Our rate for diabetics having blood sugar levels within the
recommended range of 15 percent above the Healthy People 2010
goal. And diabetics having blood pressure within the
recommended range is only 4 percent below the Healthy People
2010 goal. We believe these two indicators are a reflection of
our special diabetes funding and funding for cardiovascular
risk reduction, which we receive through the competitive
process.
Among the disparities articulated today was the significant
rates of mental health disorders. There is approximately one
psychologist per 8,333 American Indians, compared to one per
2,213 for the general population.
Medical inflation has grown over 200 percent since 1984.
Unfortunately, the Government calculation is not the same rate
used by the private sector. OMB uses a rate of 1.9 percent to 4
percent per year for inflation, when medical inflation is
between 6.2 percent and 18 percent. This discrepancy has
seriously diminished the purchasing power of our programs
because pharmaceuticals, medical equipment and other costs are
the same for the private sector and tribes. From yesterday's
USA Today front page, ``Drug Prices Outstrip Inflation, Costs
Up 7.1 Percent.'' A number of months ago, I was looking at the
inflationary cost for pharmaceuticals. I noted that among those
inflationary costs, the drugs for diabetes and cardiovascular
disease are the highest, only behind antidepressant meds. So we
are affected even greater.
The Northwest Portland Area Indian Health Board estimates
that the IHS budget has lost over $2.46 billion in purchasing
power over the last 14 years. In California, like so many other
programs in the country, we are seeing employee benefit take-
backs, reduced hours of operation, and reductions in staffing
levels, and more staff burnout.
As Dr. Grim testified, there is a request in the
President's 2006 budget for $33 million for population growth,
and we heartily support that because this is the first time in
over a decade that we have seen a request for population
growth. The National Center for Health Statistics reports that
our population is increasing at 1.7 percent a year, which
translates to 70,000 additional Indians coming into the health
care system annually.
In 1999, tribes consulted extensively and presented
consensus recommendations on these issues, and these issues we
want addressed in the reauthorization in the Indian Health Care
Improvement Act. We wanted reauthorization to be responsive to
the current needs and to enhance opportunities for more revenue
and to facilitate more self-determination.
To accomplish these following recommendations, we included
the authorization that scholarship assistance be tax exempt. We
would authorize funding for critically needed dialysis
programs, and to authorize screening for all scans for cancers,
and not just mammographies. We want to authorize more options
for tribes to address facility needs and to authorize a
comprehensive continuum of behavioral health care which
emphasizes a collaboration between alcohol and substance abuse
programs, social services, and mental health care.
The conclusion of the 1928 Marion Commission, and I will
summarize, reflects the status almost the same as it was then
today. The inadequacy of appropriations has prevented the
development of an adequate system of public health
administration and medical relief work. I felt great
frustration and even anger as I prepared my oral thoughts and
testimony for today because our plight remains almost the same
decade after decade.
I questioned myself, are we not telling the story? And I
know we are, because I see it reflected in testimony after
testimony. I see it in newspaper editorials and more recently
in the reports from the U.S. Civil Rights Commission. I
respectfully ask your support and assistance in doing whatever
is necessary to reauthorize the Indian Health Care Improvement
Act and help us deal with the many budget challenges that we
face every single day. The statistics we talked about today are
our grandparents, our nieces and our nephews, and our aunties.
Thank you for this opportunity to present testimony. My
written testimony has been submitted. Thank you.
[Prepared statement of Ms. Joseph appears in appendix.]
Senator Dorgan. Ms. Joseph, thank you very much for your
testimony.
Senator McCain had to attend another committee gathering,
and so we will proceed. The next witness is Georgiana Ignace,
the president of the National Council of the Urban Indian
Health organization in Washington, DC. Ms. Ignace, you may
proceed.
STATEMENT OF GEORGIANA IGNACE, PRESIDENT, NATIONAL COUNCIL ON
URBAN INDIAN HEALTH, ACCOMPANIED BY BEVERLY RUSSELL, EXECUTIVE
DIRECTOR
Ms. Ignace. Chairman McCain and committee members, my name
is Georgiana Ignace. I am Menominee from Wisconsin and
president of the National Council on Urban Indian Health.
In 1998, NCUIH was formed and they have a membership
representing urban Indian health programs in 34 cities. But
first, let's briefly account how the Indians became urban
Indians: The BIA Relocation Act, the promise that the American
Indian will have a better life, a job and education; the
General Allotment Act, where many lost their land and were
forced to move to nearby cities and towns; adoption of Indian
children to non-Indian families; boarding schools where
children were removed from their families to boarding schools
far away from home.
Today, the urban Indians consider the Indian community in
the cities their home.
Another statistic: In 1976, Congress passed the Indian
Health Care Improvement Act. This act was to raise the status
of health care for American Indians and Alaska Natives; 29
years, and those 22 years were a deadline for achieving it has
passed. And yet today, Indians whether reservation or urban
still continue to have the highest health care statistics that
are negative.
What we know about the urban Indian, urban Indian
unemployment is double that of all races. Urban Indian poverty
levels are three times that of any other race. Urban Indian
high school dropout rate is over 75 percent. Urban Indians have
a high mortality rate from alcoholism and related causes than
any other races. The urban Indian suicide rate is four times
that of all other races, and urban Indians have three times the
national rate for diabetes and heart disease.
How can the health status of urban Indians be improved?
Certainly by the passage of the Indian Health Care Improvement
Act and also adequate funding for IHS so that they may
accomplish that goal set in 1976 by Congress.
NCUIH supports the recommendations of the national steering
committee and with the reauthorization of the Indian Health
Improvement Act, title V Access to Health Services, section 511
Grants for Alcohol and Substance Abuse-related Services,
section 515, Federal Tort Claims Act coverage, section 521,
authorization of appropriations. Also increased funding for
urban Indian programs.
The urban Indian represents 60 percent of all Indian
populations and receives only 1 percent of Indian health
dollars. Although NCUIH requested a $6.4-million increase to
the 2006 budget, urban Indian health programs only received an
estimated increase of $1 million. NCUIH urges this committee
and Congress to recognize this need and help increase the
funding for these programs. Also, Federal medical assistance
percentage, to place FMET back into the words of the Indian
Health Care Improvement Act policy.
NCUIH urges this committee and Congress to help urban
Indians expand State Medicaid funding. As you heard, America is
nowhere near the lofty goal that they set in 1976.
In conclusion, I would like to take this opportunity to
thank you for your support last year for making permanent
section 512, Demonstration Projects in Oklahoma. As a result,
these excellent clinics will be able to continue to provide
very valuable health care services to urban Indians in Oklahoma
City and Tulsa.
Also, in conclusion, NCUIH looks forward to working with
this committee toward achieving the goal they set in 1996.
Thank you for this opportunity on behalf of NCUIH to provide
testimony on urban Indian health care issues.
Senator Dorgan. Ms. Ignace, thank you very much for being
present and providing testimony to the committee today.
Finally, we will hear from Anslem Roanhorse, executive
director, Navajo Nation, Department of Health, Window Rock, AZ.
Mr. Roanhorse, welcome, you may proceed.
STATEMENT OF ANSLEM ROANHORSE, EXECUTIVE DIRECTOR, NAVAJO
NATION DEPARTMENT OF HEALTH
Mr. Roanhorse. Vice Chairman Dorgan, distinguished members
of the Senate Committee on Indian Affairs, my name is Anslem
Roanhorse. I am the executive director for the Navajo Division
of Health in Window Rock, AZ.
On behalf of the Navajo Nation, I am honored to present
this testimony to you. I would like to highlight some of the
information that we have given you in our written statement,
and also we would like to request that our written statement be
made part of the record.
Senator Dorgan. Without objection.
Mr. Roanhorse. The Navajo Nation expands into three States
and three Federal regional offices, region VI Texas, region
VIII Colorado and region IX in California. The Navajo Division
of Health operates with a budget of around $79 million. That
includes Federal funds, State funds, tribal resources and we
employ over 1,000 staff members that work with Indian people
throughout the Navajo Nation.
We also administer 18 programs, that includes health
education, nutrition services, alcohol and substance abuse
counseling and treatment. We do diabetes prevention, public
health nursing, and also work with breast and cervical cancer
prevention.
The IHS is still the primary health care provider for the
Navajo Nation. The health care network includes 5 hospitals, 6
health centers, 15 health stations, and 22 dental clinics. The
Navajo Nation appreciates the slight increases to the IHS
budget for the past fiscal year. Senators, those increases were
absorbed by increasing medical costs, pharmaceutical and
mandatory inflationary costs.
Although the fiscal year 2006 IHS budget request includes
increases to the contract health services and preventive
health, which we appreciate, it however reveals a cut to the
health care facilities construction by nearly $86 million.
Health care facilities construction has been the Navajo
Nation's top priority for the past 3 fiscal years. Although the
Navajo area has been very fortunate to receive Federal funds
for new hospitals and new health care centers in recent years,
there remains a great unmet need for new facilities on the
Navajo Nation, with their current population of about 237,000
people and growing.
Some existing facilities are inadequate, too small, and
require replacement. There are many areas within Navajo Nation
that will require new hospitals and health centers in the
coming years to support our increasing population. That being
said, the Navajo Nation is grateful for the new staffing funds
proposed for the Pinon Health Care Center and Four Corners
Regional Health care Center in Red Mesa, AZ. A new health care
center in Kayenta was recently added which we also ask for your
support.
By the way, the Navajo Nation does not support the IHS plan
to pause in construction. The Navajo Nation is challenged by
numerous complex and unique barriers to reach its public health
goals, including funding, facilities, transportation,
information, technology and workforces. Despite these barriers,
we are doing our best to provide services that include
prevention services and also education.
Recruitment and retention of additional health care
professionals is a great concern for the Navajo Nation.
Currently, the Navajo Area Indian Health Services is
experiencing a high vacancy rate for doctors, nurses, dentists,
and pharmacists ranging from 17 percent to 20 percent.
Recently, the Navajo Nation embarked on developing a trauma
system development to reduce death and disability caused by
traumatic injuries among the Navajo people. Presently after the
initial care is provided by local hospitals, the majority of
our critical care patients are transferred to off-reservation
trauma centers. The Navajo Nation is now wanting to do
something about this to try to work with facilities to
establish and upgrade our own facilities.
Over the past 2 years, the Navajo Division of Health has
been battling with increased numbers of transmission of
syphilis and HIV cases. Again, we are trying to do our best to
address some of these emerging needs.
Currently, the Navajo Department of Health Services
operates two adolescent treatment centers, which is for
approximately 35,000 Navajo adolescents who are in need of
treatment. But again, we are doing our best to meet the unmet
needs, and then the Division of Health also operates two adult
treatment centers for population of about 179,000 Navajos.
Again, we are trying to do our best to meet the needs. There is
an emerging issue with methamphetamine and also of course we
also have to deal with the alcohol abuse and substance abuse.
With respect to the Navajo Nation, we also have always
included the use of traditional healers and our conventional
medicine. Again, we would like to continue to work on expanding
traditional services to incorporate it as part of our treatment
modalities.
Then we also do our best to meet the needs of those people
that are afflicted by cancers. Right now, we do not have any
cancer center on the reservation, but again we have to work
with the surrounding towns to have our patients treated.
Especially diabetes is also another area that we have been
doing a lot of work on, and we think that we beginning to make
some impact. We are doing education. We are teaching patients
on nutrition , and then also beginning to really promote
exercise.
Poor roads in Indian country have been a great challenge
for us. Right now because of the rising cost of gasoline, it is
now also beginning to impact our services. Certainly, it is
impacting the Navajo families because of the cost of gasoline
which is, as you all know, over $2 per gallon. This is what the
Navajo people have always been experiencing for the past
several years. So again, a lot of these services have to be
taken to remote and isolated communities.
In conclusion, on behalf of the Navajo Nation, thank you
for your time and assistance in considering our issues and
recommendations to improve our health care in Indian country. I
will be pleased to respond to any questions that you may have.
Thank you.
[Prepared statement of Mr. Roanhorse appears in appendix.]
Senator Dorgan. Mr. Roanhorse, thank you very much.
Let me ask a couple of questions and call on my colleagues,
and then I will finish with a couple of additional questions.
Senator Burr asked a question of Dr. Grim and Ms. Power
that I think is on point. I would ask any of you, with a
roughly 2-percent increase in funding for Indian Health
Services, is there any other conclusion but that we will lose
ground on our health care issues on Indian reservations because
we all know that the health care medical inflation is running
at a very high rate, much above the amount that is requested
for additional services in the budget. In addition to that, the
one area where we see a rather substantial increase in
population in my State, and I expect most States, is on Indian
reservations. So the budget fails to not only keep pace with
the increased population, but also medical inflation.
So isn't it a case, as I think Senator Burr was attempting
to ask, isn't a case that we are almost certain to lose ground
in our efforts here in trying to make progress in Indian health
care? Ms. Smith, do you want to answer that?
Ms. Smith. Thank you very much.
Absolutely. I come from Alaska. I have been in Alaska since
1970. The Native population in Alaska has doubled. With the
type of funding, the slight increases that we have been
receiving, and I appreciate the fact that we have, the Indian
Health Service has received a slight increase, still and all
across Indian country during the budget formulation process, it
reverberates that we are funded at about 59 percent level of
need.
Translated, there is not enough money out there to meet the
needs of Indian communities. Many, many of our tribes and
tribal organizations have compacted and contracted. In doing
so, it brings the ability for us to be more flexible in
delivering health care. We have tried to be as innovative,
partnering, to stretch the dollar to make more services
available, more culturally available. But your primary question
is, no there is never enough money.
Senator Dorgan. But that is not my question, is there ever
enough money. My question is more specific than that. Let me
just say, I am going to ask the other three as well. I have
always liked Dr. Grim. I think the Indian Health Service
struggles with limited resources to do a very significant job.
But I also know that he would not be in that job very long
if he came to this table to say, you know something, the
President's budget here dramatically underfunds what we really
need. He would not keep his job, so he cannot do that. He must
come to this table to represent the Administration's budget. I
understand that.
But I think the lack of the siren here that is necessary to
say, we have a bona fide, full-scale crisis on many
reservations, particularly with young children, but also the
elderly and other not getting the care they need because we do
not have a system that works and it is not funded properly.
When I say we do not have a system that fully works, I
mentioned earlier when kids have addictions or adults have
addictions, there is just very few opportunities for them to
get in-residence help for that addiction, which all of us
understand is necessary to shed the addiction of substance
abuse to alcohol or drugs and so on.
Ms. Joseph, do you want to respond?
Ms. Joseph. Thank you, Senator Dorgan.
As I stated, we are losing purchasing power. We are moving
our resources around, reducing staff in some instances,
shortening our hours of service. So we certainly are not going
to gain ground when we have to approach health care delivery in
that way.
Senator Dorgan. Ms. Ignace?
Ms. Ignace. For the urban Indian health programs, the
Federal Government only pays the States the regular Federal
Medicaid matching rate. The urban Indians cannot really take
advantage of this. As a result, we would certainly agree to
increases in FMET.
Senator Dorgan. Okay.
Mr. Roanhorse.
Mr. Roanhorse. Thank you for the question, Senator.
The 2 percent and 4 percent recommendation by IHS, this is
not supported by the Navajo Nation. The instruction that was
given to me as a representative from the Navajo Area to go to
the national budget formulation process is to accept a minimum
of 20 percent. So the tribal leaders on my reservation, the
health care providers are seeing a huge gap and the need.
If I can maybe personalize this, and tell you about some of
the things that we have to do. Just imagine that we have a
person that is afflicted by cancer. Currently because of no
cancer center close to the Navajo Nation, we are expected to
send our clients to Albuquerque, NM, which is a 3-hour drive
away, and in most cases 4 hours. Or they have to go to Phoenix,
AZ. So just imagine that. These are the people that have
limited income.
Sometimes they have to take off work in order to travel.
And then once they get to Albuquerque, they have to figure out
a way to maybe perhaps if they need to stay there for radiation
therapy, then they need to dish out some money, whatever that
they may have for overnight lodging, meals. And then in some
cases, they may not even have any adequate transportation, no
vehicles.
So what happens? What happens is that they just sit at home
and then also just until it is too late, and they finally go to
the hospital and the doctor will say, we are doing our best to
treat you, but it may be a very advanced state. That is the
situation that we encounter, Senator.
Senator Dorgan. I am going to ask about addiction treatment
and some other issues, but let me call on my colleagues.
Senator Murkowski.
Senator Murkowski. Thank you.
When we get to budget time, and I think it is universal, at
least from the witness stand, that we do not have enough to do
the job, and that is something that we have to reckon with. We
have to deal with.
I have been very troubled by the statistics that face
Alaska Natives in my State. We are at the top of all the bad
categories for many, many reasons. But I have had multiple
conversations with Dr. Grim and conversations with you, Ms.
Smith, about the emphasis on prevention. We know that when we
are talking about diabetes, particularly the onset of adult
diabetes, much of that is related to diet. When we look to, you
mentioned the dental care issue in the State. Our children up
north are wandering around with no teeth, and it is not because
the baby teeth have come out. It is because the adult teeth are
rotted by the time they are in high school.
So much of that is due to the diet, due to the fact that we
do not have drinking water for the children to drink; that we
do not have fresh milk for them to drink. And so much of this
comes back to prevention. We can discuss at every budget
hearing whether or not we have enough money, but until we take
control of those things that we can control, and we can control
our diet, and we can control aspects of our life about living
healthier lifestyles.
I am not convinced that we are doing enough when it comes
to the education component; when it comes to teaching our young
people about healthy lifestyles. Ms. Smith, you mentioned an
initiative I believe it was called the WIN! Initiative.
Ms. Smith. Yes.
Senator Murkowski. Are we giving the focus that you think
we need to give when it comes to education and prevention so
that we will in successive generations hopefully have healthier
children, healthier people?
Ms. Smith. Thank you very much.
Every time we have the opportunity to advance education in
any area and particularly in the area of prevention, it is
critical that we do so. Are we doing enough? We are beginning
and moving forward today, but we are also just beginning this
entire discussion about prevention. If we do not continue to
build on health promotion and disease prevention today, we will
not ever be able to afford down the road the causes of
neglecting to put money into health promotion and disease
prevention initiatives and programs.
I believe that the tribes and the tribal organizations
across the Nation stand ready and are working very closely in
collaboration with the IHS on the health promotion and disease
prevention initiative, and recognize that we need to take the
forward steps as tribes and as parents to see about prevention
within our own families, within our own tribes, within our own
nations.
And so every time that the question is asked, are we doing
enough, for the moment maybe we are, but no, it is really never
enough. So I am very excited about the WIN! Initiative that I
mentioned from the National Indian Health Board. Again, I say
it is a new vision; it is an ongoing vision of living healthy
lives, making behavioral changes, and moving toward all
American Indians at last being healthy at the onset, and not
having to spend huge amounts of money later on in life when a
good prevention program could have prevented such maybe tragic
outcomes.
Senator Murkowski. Let me ask you just one more question
here. I appreciate your being here, Sally.
When we talk about how we might have prevented either the
incident in Bethel or the incident in Red Lake, and we try to
look for those warning signs, we try to pick up on them. The
point was made earlier that we do not have access to
appropriate or certainly enough treatment facilities.
So oftentimes, it is not the structured treatment
facilities that we need. What we need are culturally
appropriate or culturally significant programs within the
communities that are going to make a difference, that are going
to make a difference for that Evan Ramsay who would then feel
part of his community and not feel that he has to react in the
manner in which he did.
Do you feel that we are doing enough to provide for the
flexibility through the funding to allow for communities to
create programs that might work within their own unique
situation? Do they have that flexibility currently?
Ms. Smith. I will give you a two-part answer. With regard
to flexibility, compacting and contracting tribes have the
ability to be flexible in delivering a program. That is the
flexibility part. With regard to the funding, it is critically
important as funding comes into the country, that tribes and
tribal organizations be mentioned specifically in the language
so that the money can come from the funding agencies directly
to tribes and tribal organizations.
That is a critical piece in making sure that at least
within the American Indian and Alaska Native communities, the
needs of those people, our people are being addressed, and
addressed in that culturally compatible way that you just
described.
Senator Murkowski. Thank you, Mr. Chairman.
Senator Dorgan. Senator Murkowski, thank you very much.
Dr. Grim, could you scoot your chair back up? I want to ask
you another question if I might, and ask others to respond to
it. Thank you very much.
I mentioned at the start of this that the IHS spends $1,600
per person per year for health care. That is less than one-half
of what we spend for Federal prisoners, and we have trust
responsibility for American Indians, for health care. We also
have sole responsibility for the health care of those we have
incarcerated in Federal prisons.
If we spend $3,800 per person in Federal prisons for health
care, and less than one-half of that for American Indians,
compare that with $6,000 that Medicare spends per person, VA
$5,200, Medicaid at $3,900. Can you describe for me the
disparity here? Why would we spend one-half as much per person
on Indian reservations for health care as we do for Federal
prisoners?
Mr. Grim. I do not know if I can explain the disparity to
you in exactly the way you asked, Senator, but what I will say
is that one of the things that the agency has done along with
tribes as partners is that, and that the department itself has
looked at a change in philosophy, is that it is not just Indian
Health Service dollars that should be trying to serve our
Indian population, but it should be moneys within SAMHSA, as
Ms. Power pointed out, and within other parts of the
department, too. And we are making many more grants available
throughout the rest of the department.
We are also very actively, both tribes and the IHS, tapping
into Medicare and Medicaid funding. We have the ability through
the Indian Health Care Improvement Act to bill Medicare and
Medicaid and private insurances and we are trying to bring
additional resources through those programs into the agency,
too. So we are looking at it as an entire Government
responsibility, not just IHS, and we are trying to reach out to
other partners across the Government with tribes that perhaps
in the past did not.
One of the things that Ms. Smith said that anytime new
funding comes up, it should mention tribal governments. The
department took a very strong effort and initiative to make
sure that any grants within the Department of Health and Human
Services that were appropriate for tribes, spelled out in fact
in their grant announcement that tribes were available. So we
have tried to make changes like that. While they may seem like
they are changes on the margin, I think they are very important
changes.
Senator Dorgan. You see, Dr. Grim, that is why I said I
like you. You always see things, the glass is always half full
for you. I say that with some admiration because I think it is
important to be hopeful and to see things in a positive light.
On the other hand, with respect to health, if the glass if
half empty, the half that is gone relates to people's ability
to live a healthy lifestyle. In some cases, it relates to the
difference between life and death. It relates to the difference
between having a good day and a day filled with pain.
So I am not insistent on seeing the glass half full, but I
am insisting on seeing if we have met our trust
responsibilities. If not, why not? And if not, how do we start
doing that?
When I asked the question about the amount of money we
spend per Federal prisoner, and we have a responsibility when
we incarcerate someone to meet their medical needs, and we do.
From a small jail cell, even someone on death row, when they
are ill, they are taken someplace to treat that illness. When
they need surgery, they get surgery. The fact is, we have a
responsibility and we meet it for people that we put in Federal
prison.
We also have a trust responsibility for health care for
American Indians. My sense is if it is not one-half of that
which we spend on Federal prisoners, it is something still
substantially below that which we spend on Federal prisoners. I
am not certain how we get to the point where we meet our
obligation if we always say, well, we are just making
improvements.
We really have to set a baseline to say, here is the
responsibility the Government has and here is how the
Government meets that responsibility. I will give you a
specific example. I toured a reservation. I do not remember. I
think they have 7,000 people or somewhere in that neighborhood.
They had one dentist working out of an old trailer house. Now,
if you think taking care of your teeth is part of good health,
and I do, and I think most people would, is that sufficient? If
not, then how do we correct that?
Do you all see that kind of anecdotal evidence virtually
everywhere you go? One dentist working out an old trailer
house, trying to do the best he or she can, but dramatically
understaffed on all these issues and underfunded and working
long hours, but really not making much progress against a
population base that is far too large.
Ms. Joseph.
Ms. Joseph. Thank you, Senator.
Among the family, we always hope to compliment each other.
As Dr. Grim talked about the half-full glass, I will talk about
the half-empty glass.
You know, the disparities in funding can take different
approaches, but we did have a work group to address the Federal
disparities index. It was early, you recall, to addressing the
level of need funded.
Senator Dorgan. Yes.
Ms. Joseph. That work group primarily was constituted to
make some recommendations on how the distribution from the
Indian Health Care Improvement Fund would be made to death
inequities. What they did, and it was I believe a very
objective, scientific approach to addressing this disparities
index. What they established as the yardstick was the Federal
employees' benefit package. And then they moved that package
around to 100 different geographic areas in the country and
made a determination of what it would cost to provide that
package of benefits to a Federal employee.
Of course, you know, the highest costs tended to be in
Alaska and San Diego County. That was kind of the denominator.
And then for the numerator, what they did was total the amount
of dollars that was actually provided for personal health care.
So that excluded wrap-around services such as community health
representatives, public health nurses, health educators and
emergency medical services need.
That denominator reflected a level of need or disparity in
funding of the Indian programs compared to the benefits
provided to the Federal employee. Based on that effort, it was
determined it would take at least an additional $9 billion to
$10 billion to address that disparity in personal health care
services.
Senator Dorgan. Let me ask Dr. Grim about that. Again, you
represent the Administration's budget. I understand that. I do
not want you to lose your job. But I also want you to respond
to the proposition Ms. Joseph has just advanced that if we
really were going to provide parity with the meeting of our
responsibility here, and in cases of the type I just described
you would have not one dentist working out of a trailer house,
you would have sufficient dentists to meet the population, just
to take that small piece.
Isn't it the case if you were really trying to meet the
parity that I think our trust responsibilities require, that
there would need to be substantial additional funding?
Mr. Grim. I could cite for you a number of statistics and
we can provide those for the record about our access to care in
dental that we have right now. It is between 20 and 25 percent
of our population are able to access that. That is not the same
in the Nation as a whole. It has been pointed our numerous
times today the disparities in the various health indicators.
And some of that is money issues, Senator Dorgan; some of it is
access issues, recruitment and retention of providers. In many
of our locations, it is the ability to have adequate housing
for providers available when they come on-site.
So it is a very complex issue and I cannot answer the
question as simply as you place it.
Senator Dorgan. But I think that if you say, for example,
American Indians have access at the rate of 25 percent to
dental services, that means 75 percent do not have access to
dental services. It means that we are substantially short of
the resources necessary to provide at least that kind of care.
Is that not accurate?
Mr. Grim. That would be an accurate statement.
Senator Dorgan. Yes; and let me go back just for 1 moment
to the issue of substance abuse. One of the things that I was
told at a meeting I had recently was that the young person who
was for example hooked on methamphetamine, a deadly drug with
dramatic addiction capabilities, or a young person who had
become an alcoholic or addicted to some other drug, that person
then goes into a cycle of dependency, depression, perhaps
threatened suicide.
And to the extent that they reach out and find somebody in
mental health in that tribe or in IHS, what happens they say is
they are sent then to, perhaps they are sent to a psychiatric
unit for evaluation, released in probably 1 or 2 days, and with
no follow-up. And that goes on and on and on.
Again, in most cases, reservations, not all, but in most
cases reservations are very remote, and so access, if you are
referred to mental health treatment, is somewhere else, and if
they turn you out in 2 days with no follow-up, you really have
not addressed the fundamental issue.
Again, that gets back to the question of how many people
are available to work in mental health on these reservations,
psychologists, psychiatrists, and so on? The young woman named
Avis Little Wind who took her life recently, there was one
psychologist. I went and met with the school counselors, met
with the young girl's classmates and others. It was quite clear
that there was not the kind of health care capability for
mental health that should have been available that might have
saved this young girl's life.
I expect that is true on most reservations. That is why I
raise the question today. Your testimony, Dr. Grim, is always
helpful to us because it does describe where we are in fact
making some progress. But I think we might be better off
starting from the proposition of where we expect to be, where
we should be, and then measuring the distance from there to
where we are, and then describing how we get there and what
kind of resources are necessary, what kind of reorganization is
necessary. We seldom ever talk about it in those terms and I
think we should because all of us who visit reservations and
sit down and have long serious talks about the health care
issue, and I should mention that we have a crisis not only in
health care, but in housing and also in other areas as well.
I think that health care is just primary because if you do
not have your health, you do not have the capability to live
the life you want to live, and nothing else is able. You cannot
hold a job. You cannot go to school.
So health care is primary and I think we really need to
identify this as a crisis, an emergency, and try to look at
this differently, rather than just each year saying, all right,
we are short of money, this is a problem, let's incrementally
move toward solving it. We need to re-think that. I know
Senator McCain is very aggressive and very interested in
addressing these health care issues in a positive way and so am
I.
I would ask the panel as we close, any final last comment,
and then I will ask Dr. Grim for a last comment.
Ms. Joseph. Senator Dorgan, I got a note here that said,
Rachel, when you spoke about the disparity in funding, I stated
$9 million to $10 million, and did I mean that. Absolutely, I
did mis-speak. It is $9 billion to $10 billion.
Senator Dorgan. I think you said billion.
Ms. Joseph. Oh, that is right. I did mean to say $10
billion.
Senator Dorgan. In your testimony, I did not expect you
were talking in $9 million or $10 million in quantity.
[Laughter.]
Ms. Joseph. I appreciate your comments on the alcohol and
substance abuse problems. In the reauthorization consultation
process, we heard from tribal leader after tribal leader that
urged us to authorize a comprehensive approach. Very often, we
provide treatment in recovery programs, but do not provide the
necessary after-care, which will certainly facilitate the
reduction of the recidivism rates that we are all challenged
with.
Senator Dorgan. But isn't it true that most of the
treatment is outpatient treatment and not the kind of treatment
in most instances you need? In-residence treatment for
addiction is critical and it exists in very few locations.
Ms. Joseph. Yes.
Senator Dorgan. I find that all over.
Ms. Joseph. Outpatient is mostly provided.
Senator Dorgan. Is there anybody else that feels like they
want to make a final comment here? Then I am going to turn to
Dr. Grim and then we are going to adjourn the hearing. All
right, yes, Mr. Roanhorse.
Mr. Roanhorse. Thank you, Senator Dorgan.
I just wanted to add a few more information to my testimony
this morning. I appreciate your interest in behavioral health
services. Again, the Navajo Division of Health through the
Department of Health, behavioral health services is trying to
meet a lot of demands for our work which has to do with
addressing alcohol abuse, substance abuse, and then now with
meth. And then also we do this by operating two adolescent
treatment centers which only have a few beds.
Senator Dorgan. How many beds?
Mr. Roanhorse. One has 20 beds, the second one has 24 beds.
And then we also have 13 outpatient centers that serve over
11,000 clients. And then we also, this summer the Navajo Nation
Council also passed the Controlled Substance Act of 2004, which
I think would be one way of banning meth, but again it is a
huge endeavor. We have to deal with some people that have to go
into the remote areas of the Navajo Nation and then with $12
they can be able to purchase ingredients, and then they can in
turn then sell for a huge amount of funds. And then that in
turn causes a lot of behavioral problems. So these are some of
the situations that we encounter on a daily basis.
And then another plan that we are trying to address is
there is a 72-bed hospital that we are trying to, or a 72-bed
residential treatment center that we are planning on setting up
in Shiprock, NM. That is taking the former IHS facility, but in
order to get to that point, it is going to cost of $10 million,
so we have been going to the State legislature. We have been
going to the Navajo Nation Council just to raise funds to make
sure that facility is renovated. So we hope that we can start
at least the renovation started this summer.
So at least, these are some of the things that we are
beginning to work on. Anything that you can do to help us out,
I know money is tight everywhere, but I also think that, and I
am reminded by my tribal leaders.
Senator Dorgan. Mr. Roanhorse, we must be brief. I asked
for a brief comment.
Mr. Roanhorse. I am sorry. Okay. So than you very much for
allowing me to share these thoughts with you.
Senator Dorgan. Thank you for your testimony. Your
testimony is very significant and we appreciate it.
Anyone else?
Ms. Smith. Yes, thank you; thank you, Senator. I wanted to
place on the record, earlier you mentioned about dental health
care. In Alaska, our children are 2\1/2\ times the national
rate for and the need for dental health care. I mean, it is
just incredible up there. As part of meeting that challenge,
the Alaska Native Health Board has gone on and took a step in
something called the Dental Health Aid Therapist Program.
Senator Dorgan. I am familiar with that.
Ms. Smith. Thank you very much, but I wanted you to know
that again as part of recognizing that we have a need and being
proactive about it, we are moving forward in that regard. So
thank you very much.
Senator Dorgan. Thank you, Ms. Smith.
Ms. Ignace.
Ms. Ignace. Yes; in the past several years, versions of the
Indian Health Care Improvement Act did not include a reference
to urban Indians. We would like that to remain in that policy,
simply because we serve, we consider ourselves a multi-tribal
clinic, where we serve not just one tribe, but many tribes that
live in the city.
Senator Dorgan. All right. Thank you very much.
Dr. Grim, in the construction of the Administration's
budget, I do not know whether you are able to provide this for
me, but I would be interested in what the IHS request was to
OMB for funding in this coming fiscal year. Do you have that at
hand?
Mr. Grim. I do not have that at hand. We could respond to
you for the record.
Senator Dorgan. Was it substantially higher than that which
now is in the President's budget?
Mr. Grim. I just do not have that at hand, Senator, right
now.
Senator Dorgan. Was it higher or lower?
Mr. Grim. I do not recall. We can get that to you for the
record.
I appreciate your support of Indian health issues.
Senator Dorgan. Dr. Grim, I said I liked you. [Laughter.]
Mr. Grim. I have always liked you, Senator Dorgan.
Senator Dorgan. I find it hard to believe you do not know
that. My expectation would have been that you would have asked
for a rather substantial amount of money that is necessary to
fund the Indian Health Service programs and that the Office of
Management and Budget, as they kick these things up to the
White House where the President's budget has cut them
substantially. But you do not know that at this moment, is that
correct?
Mr. Grim. I would prefer if I could respond for the record
to you on that.
Senator Dorgan. All right. You respond for the record and I
will make it a part of the record at the next hearing.
Mr. Grim. Okay, thank you.
Senator Dorgan. Let me, Dr. Grim, thank you for being here,
and let me thank the four witnesses on this panel. On behalf of
Senator McCain and I, we pledge to continue to work hard on
Indian health care issues because we think it is an urgent
priority.
This hearing is adjourned.
[Whereupon, at 1:33 a.m., the committee was adjourned, to
reconvene at the call of the Chair.]
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A P P E N D I X
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Additional Material Submitted for the Record
=======================================================================
Prepared Statement of Charles Grim, M.D., Director of the Indian Health
Service [IHS]
Mr. Chairman and members of the committee.
Good morning, I am Dr. Charles Grim, Director of the Indian Health-
Service [IHS]. Today, I am accompanied by Robert G. McSwain, Deputy
Director; Gary J. Hartz, Director, Office of Environmental Health and
Engineering; and Dr. W. Craig Vanderwagen, Acting Chief Medical
Officer. We are pleased to have this opportunity to testify on behalf
of Secretary Leavitt on the status of Indian Health.
The IHS has the responsibility for the delivery of health services
to an estimated 1.8 million federally recognized American Indians and
Alaska Natives through a system of IHS, tribal, and urban [I/T/U]
operated facilities and programs based on treaties, judicial decisions,
and statutes. The mission of the agency is to raise the physical,
mental, social, and spiritual health of American Indians and Alaska
Natives to the highest level, in partnership with the population we
serve. The agency goal is to assure that comprehensive, culturally
acceptable personal and public health services are available and
accessible to the service population. Our foundation is to uphold the
Federal Government's obligation to promote healthy American Indian and
Alaska Native people, communities, and cultures and to honor and
protect the inherent sovereign rights of tribes.
Two major pieces of legislation are at the core of the Federal
Government's responsibility for meeting the health needs of American
Indians/Alaska Natives: The Snyder Act of 1921, Public Law 67-85, and
the Indian Health Care Improvement Act [IFICIA], Public Law 94-437, as
amended. The Snyder Act authorized regular appropriations for ``the
relief of distress and conservation of health'' of American Indians/
Alaska Natives. The IHCIA was enacted ``to implement the Federal
responsibility for the care and education of the Indian people by
improving the services and facilities of Federal Indian health programs
and encouraging maximum participation of Indians in such programs.''
Like the Snyder Act, the IHCIA provided the authority for the provision
of programs, services and activities to address the health needs of
American Indians and Alaska Natives. The IHCIA also included
authorities for the recruitment and retention of health professionals
serving Indian communities, health services for people and the
construction, replacement, and repair of health care facilities.
We are here today to discuss the status of the Indian health by
focusing on health disparities and other related issues such as Urban
Indian health, Indian health care facilities, Indian self
determination, and portions of the Medicare Modernization Act.
While the mortality rates of Indian people have improved
dramatically over the past 10 years, Indian people continue to
experience health disparities and death rates [1999-2001] that are
significantly higher than the rest of the U.S. general population
(2000):
<bullet> \\\\\\Tuberculosis--533 percent higher
<bullet> \\\\\\Alcoholism--517 percent higher
<bullet> \\\\\\Diabetes--208 percent higher
<bullet> \\\\\\Accidents--150 percent higher
<bullet> \\\\\\Suicide--60 percent higher
<bullet> \\\\\\Homicide--87 percent higher.
While some view these statistics as insurmountable facts, they are
influenced by behavior choices and lifestyle. Making significant
reductions in health disparity rates can be achieved by implementing
best practices, using traditional community values, and building the
local capacity to address these health issues and promote healthy
choices. For fiscal year 2006, IHS is requesting a total budget of $3.8
billion, including an increase of $80 million for inflation and
population growth which will allow for a renewed focus on health
disparities.
It is the mission of the Indian Health Service to provide services
and programs that promote healthy choices and assist in enabling tribes
to educate their members about prevention and treatment programs that
address the unique needs of their individual communities.
I just returned from the Red Lake Band of Chippewa Indians in
Minnesota and saw firsthand the results of the devastation brought
about by the shootings at the Red Lake High School. I also saw the
community coming together and drawing strength from the support of
mental health professionals and tribal spiritual leaders. There is much
to do, yet there is a sense of hope and a spirit of collaboration among
the community and tribal leaders, the State and Federal programs.
Within the Department of Health and Human Services alone, the Office of
the Secretary's Office of Intergovernmental Affairs as well as the
Department's operating divisions, including the Substance Abuse and
Mental Health Services Administration [SAMHSA], the Administration for
Children and Families [ACF] and its Administration for Native
Americans, and the Office of Minority Health are joining the Bureau of
Indian Affairs [BIA] within the Department of the Interior, the
Department of Justice [DOJ], and the Department of Education to assist
the tribe and community. My thanks to all those involved that are
working together to improve the overall health of Indian people in Red
Lake and throughout Indian country.
How do we prevent such incidences from occurring? First, IHS
focuses on screening and primary prevention in mental health especially
for depression which manifests itself in suicide, domestic violence,
and addictions. Second, we focus on the effective utilization of
treatment modalities that are available; and, we are seeking to improve
the documentation of mental health problems. IHS is currently utilizing
effective tools for documentation through the behavioral health
software package. And, we are working with communities who are focusing
more on these mental health needs. In addition, our budget request
includes $59 million for IHS mental health services, an increase of 7.7
percent over fiscal year 2005.
With 80 percent of the mental health budget and 97 percent of the
alcohol and substance abuse budget in IHS going directly to tribally
operated programs, the tribes and communities themselves are now taking
responsibility for their own healing. They provide effective treatment
and prevention services within their own
communities.
A primary area of focus that I have identified based on these
statistics is a renewed emphasis on health promotion and disease
prevention. I believe this will be our strongest front in the ongoing
battle to eliminate health disparities plaguing our people for far too
long. Although IHS has long been an organization that emphasizes
prevention, I am calling on the agency to undertake a major
revitalization of its public health efforts in health promotion and
disease prevention. Field, tribal, and urban participation in the
initial stages of planning and implementation of this revitalization is
critical to its success.
Fortunately, the incidence and prevalence of many infectious
diseases, once the leading cause of death and disability among American
Indians and Alaska Natives, have dramatically decreased due to
increased medical care and public health efforts including massive
vaccination and sanitation facilities construction programs. As the
population lives longer and adopts more of a Western diet and sedentary
lifestyle, chronic diseases emerge as the dominant factors in the
health and longevity of the Indian population with the increasing rates
of cardiovascular disease, Hepatitis C virus, and diabetes. Most
chronic diseases are affected by lifestyle choices and behaviors.
The incidence and prevalence of diabetes has been increasing
dramatically since 1972. American Indians and Alaska Natives have the
highest prevalence of type 2 diabetes in the world. The prevalence of
type 2 diabetes is rising faster among American Indian and Alaska
Native children and young adults than in any other ethnic population,
increasing 106 percent in just one decade from 1990 to 2001. As
diabetes develops at younger ages, so do related complications such as
blindness, amputations, and end stage renal disease. We are hopeful,
though, that we may be seeing a change in the pattern of diabetes
mortality because the diabetes mortality rate for the entire American
Indians and Alaska Natives population did not increase between 1996-98
and 1999-2001. In fact, the overall mortality rate for American Indians
and Alaska Natives decreased approximately 1 percent between these same
time periods. And there is good news that we have recently measured a
slight, but statistically significant, decline in kidney failure in the
American Indians and Alaska Natives diabetic population as well.
What is most distressing however about these statistics is that
type 2 diabetes is largely preventable. Lifestyle changes, such as
changes in diet, exercise patterns, and weight can significantly reduce
the chances of developing type 2 diabetes. Focusing on prevention not
only reduces the disease burden for a suffering population, but also
lessens and sometimes eliminates the need for costly treatment options.
The cost-effectiveness of a preventive approach to diabetes management
is an important consideration, since the cost of caring of diabetes
patients is staggering. According to a recent American Diabetes
Association study, the managed care cost for treating diabetes annually
per patient exceeds $13,000.
In 1997, the Special Diabetes Program for Indians [SDPI] was
enacted and provided $150 million over a 5-year period to IHS for
prevention and treatment services to address the growing problem of
diabetes in American Indians and Alaska Natives. In 2001, Congress
appropriated an additional $70 million for fiscal years 2001 through
2002, and an additional $100 million for fiscal year 2003. Then in 2002
Congress extended the SDPI through 2008, and increased the annual
funding to $150 million with the directive to address ``primary
prevention of type 2 diabetes.'' These funds have substantially
increased the availability of services--physical activity specialists,
registered dietitians and nurses, wellness and physical activity
centers, newer and better medications--which have led to a steady
increase in the percentage of diabetics with ideal blood sugar control.
We are proud to announce that our Division of Diabetes Treatment and
Prevention launched a competitive grant demonstration project focused
on primary prevention of type 2 diabetes in 35 American Indians and
Alaska Natives communities in November 2004. This program is focusing
on American Indians and Alaska Natives adults with pre-diabetes to
determine if an intensive lifestyle intervention can be successfully
implemented in American Indians and Alaska Natives communities. Our
efforts are based on a model developed by the National Institutes of
Health [NIH] that proved diabetes could be prevented. These programs
will cover a 4-year period. The outcomes of the demonstration projects
will enable us learn what may be applicable to other communities
throughout Indian country.
Cardiovascular disease [CVD] is the leading cause of mortality
among Indian people. The Strong Heart Study, a longitudinal study of
cardiovascular disease in 13 American Indians and Alaska Natives
communities, has clearly demonstrated that the vast majority of heart
disease in American Indians and Alaska Natives occurs in people with
diabetes. In 2002, we were also directed to address ``the most
compelling complications of diabetes,''which of course is heart disease
with the increased SDPI funding. The IHS is working with other DHHS
programs, including the Centers for Disease Control and Prevention and
the National Institutes of Health's National Heart, Lung, and Blood
Institute, to develop a Native American Cardiovascular Disease
Prevention Program.
Also contributing to the effort are the IHS Disease Prevention Task
Force and the American Heart Association.
Our primary focus is on the development of more effective
prevention programs for American Indians and Alaska Natives
communities. The IHS has begun several programs to encourage employees
and our tribal and health program partners to lose weight and exercise,
such as ``Walk the Talk'' and ``Take Charge Challenge'' programs.
Programs like these are cost effective in that prevention of both
diabetes and heart disease, as well as a myriad of other chronic
diseases, are all addressed through healthy eating and physical
activity.
In summary, preventing disease and injury, promoting healthy
behaviors and managing chronic diseases are a worthwhile financial and
resource investment that will result in long-term savings by reducing
the need for providing acute care and expensive treatment processes. It
also yields the even more important humanitarian benefit of reducing
pain and suffering, and prolonging life. This is the path we must
follow if we are to reduce and eliminate the disparities in health that
so clearly affect American Indians and Alaska Natives people. We will
spend $330 million on specific health promotion and disease prevention
activities in fiscal year 2005.
IHS, Tribe and Urban Indian health programs could not function
without adequate health care providers. The Indian Health Manpower
program which is also authorized in the Indian Health Care Improvement
Act [Public Law 94-437, as amended] consists of several components:
<bullet> \\\\\\The IHS Scholarship Program;
<bullet> \\\\\\The IHS Loan Repayment Program; and
<bullet> \\\\\\The IHS Health Professional Recruitment Program.
The IHS Scholarship Program plays a major role in the production of
American Indians and Alaska Natives health care professionals. Since
its inception in 1977, more than 7,000 American Indians and Alaska
Natives students have participated in the program, with the result that
the number of American Indians and Alaska Natives health professionals
has been significantly increased. The program is unique in that it
assists students who are interested in or preparing for entry into
professional training. Most scholarships only provide assistance to
those who have been accepted into a health professional training
program. By providing this preparatory assistance, the program ensures
that even those participants who do not complete their health
professions training are better prepared to return to their communities
and become productive members.
The IHS Scholarship Program [LRP] has been the starting point for
the careers of a number of American Indians and Alaska Natives health
professionals now working in IHS, tribal, and health programs. Many are
also involved in academia, continuing to help identify promising
American Indians and Alaska Natives students and recruit them to the
health professions, thereby helping to produce a self-sustaining
program. We have had several instances of parents going through the
program, followed later by their children, and in some cases, we have
even seen children being followed by their parents. The average age of
our students is 28 years, well above the norm for college students. It
is not uncommon for students to have attended 5 or more colleges or
universities during the course of their academic careers, not because
they failed in the first four, but because they had to move in order to
have the employment they needed to support their families.
The IHS Loan Repayment Program is very effective in both the
recruitment and retention areas. The program provides an incentive both
to bring health professionals into the IHS and to continue their
employment with the agency. Keeping health professionals for longer
periods of time provides a benefit to the overall Indian health program
by increasing continuity of care.
The scholarship and loan repayment programs complement one another.
Scholarships help individuals rise above their economic background to
become contributing members of the community and participate in
improving the well-being of the community. Loan repayment participants
often graduate with large debt burdens which cause them to accept jobs
with the highest salaries. The program is a way for them to provide
service in return for assistance in repaying loans that could otherwise
be overwhelming.
The recruitment program seeks to maximize the effectiveness of both
programs, as well as to make the IHS more widely known within the
health professional community and to assist interested professionals
with job placement that best fits their professional and personal
interests and needs. Our fiscal year 2006 request includes $32 million
for Indian Health Professions, an increase of 3.6 percent over fiscal
year 2005.
Another important aspect of our health care delivery system is the
Urban Indian Health Program [UIHP] authorized by Congress in 1976 with
the passage of the Indian Health Care Improvement Act. Title V of the
IHCIA was intended to make health services available to communities
that were not otherwise met by an IHS administered health program.
Urban American Indians and Alaska Natives are often times not included
in the urban community health planning process because they represent a
smaller percentage of the population in the urban areas in which they
reside.
For many urban Indians, the UIHP may serve as a primary care
provider or may provide critical assistance in helping urban Indians to
access health care in the urban community. In this regard, UlHPs are
remarkably successful. All UIHPs conduct extensive eligibility
determinations, education about services, training in how to access
services, assistance in applying for and qualifying for and state
health benefits' programs, assessment of patient needs and referral,
and in some cases transportation to other health care sites. Many Urban
Indians now get health care services from a variety of sources for
which they are eligible as a result of the UIHP efforts. However, some
may experience economic, cultural, and language barriers which can make
it difficult for Urban Indians to access such programs. In addition,
eligibility may vary over time in response to job conditions, personal
circumstances and eligibility guidelines making continuity of care
difficult to achieve.
In order to address the growing needs of Urban Indian populations,
UIRP organizations partner with and received assistance and funding
from many Federal health care agencies, including DHHS sister agencies,
the Department of Veterans Affairs, and State and local governments. In
fact, during 2003, title V funding represented 48 percent of all
funding received by the UIHPs, with the remaining 52 percent received
as a result of collaborations. Through these collaborative efforts, the
U1HPs work to obtain maximum health care services for Urban Indians.
In summary, the UIHP was established to provide basic services to
eligible Indians who are not living on or near a reservation where the
IHS or a tribal program would otherwise provide for their healthcare.
The UIHP is very successful in assisting eligible Urban Indians to
utilize health care services when such services are available. When
Urban Indians are not eligible for other programs, or lack access to
basic health care, the UIHP provides basic services to Indian clients
to the extent resources are available. Equal access and utilization of
health care services by Urban Indians is achievable in combination with
UIHP and other public and private sources. Our fiscal year 2006 request
includes $33 million for Urban Health, an increase of 4.4 percent over
fiscal year 2005.
The Environmental Health and Engineering program is a comprehensive
public health program administered by IHS and tribes. Two examples are
the sanitation facilities construction program which provides safe
water, wastewater disposal, and solid waste disposal system; and the
injury prevention program which focuses on unintentional injuries. As a
result of these two successful programs, 88 percent of American Indians
and Alaska Natives homes now have safe water and unintentional injuries
have been reduced by 53 percent between 1972 and 1996. Unfortunately,
12 percent of the homes still lack adequate sanitation facilities
compared to 1 percent of the rest of the United States population; and
the leading cause of death for American Indians and Alaska Natives
between the ages of 1 and 44 years of age is unintentional injuries.
Improving in these areas is integral to our mission. Our fiscal year
2006 request will provide water and waste disposal services to 20,000
existing Indian homes.
The Environmental Health and Engineering program provides access to
health care services through the health care facilities program which
funds Federal and tribal construction, renovation, maintenance, and
improvement of health care facilities where health care services are
provided. There are 49 hospitals, 231 health centers, 5 school health
centers, over 2000 units of staff housing, and 309 health stations,
satellite clinics, and Alaska village clinics supporting the delivery
of health care to American Indians and Alaska Natives people. The IHS
is responsible for managing and maintaining the largest inventory of
real property in the DHHS, with over 9.5 million square feet [880,000
gross square meters] of space and the Tribes own over 3.7 million
square feet [353,000 gross square meters]. This is in part the result
of tribally funded construction of millions of dollars worth of space
to provide health care services by the Indian Health Service funded
programs.
Over the past decade, $600 million in funding has been invested in
the construction of health care facilities which include, 1 Medical
Center, 5 Hospitals, 9 Health Centers, 3 Youth Regional Treatment
Centers, 500 units of Staff Quarters, 27 Dental Units, and 21 Small
Ambulatory Program construction projects. IHS has substantially
improved its health care delivery capability in the newer health care
facilities but we are still providing health care in a number of older
and overcrowded facilities. At the same time, the resources to maintain
and improve this space have remained steady over this past decade at
$38 million 10 years ago to $49 million in fiscal year 2005.
In response to a Congressional request to revise the Health Care
Facilities Construction Priority System, we have been working to better
identify the health care delivery needs. This will enable us to
prioritize the need for health care facilities infrastructure. We are
using a master planning process to address the complex nature of health
care delivery for American Indians and Alaska Natives communities. Both
the Federal Government and Tribes will be able to use these plans to
identify our greatest needs for services and health care facilities. In
the time of fewer resources, we want to plan carefully on how to best
utilize any possible resources. The IHS Health Care Facilities
Construction program is fully prepared to address the needs identified
through this process. The program recently received one of the highest
Program Assessment Rating Tool scores in the Department of Health and
Human Services.
The IHS has been contracting with Tribes and Tribal organizations
under the Indian Self-Determination and Education Assistance Act,
Public Law 93-638, as amended, since its enactment in 1975. IHS has
implemented the act in a manner that re-affirms and upholds the
government-to-government relationship between Indian tribes and the
United States. The share of the IHS budget allocated to tribally
operated programs has grown steadily over the years to the point where
today over 50 percent of our budget is transferred through self-
determination contracts/compacts. This percentage includes 30 percent
of our budget transferred to 303 tribes and tribal organizations
through self-governance compacts and funding agreements. Our budget
request for Contract Support Costs includes an increase of $5 million,
sufficient to cover the contract support costs of the estimated number
of new contract requests in fiscal year 2006.
As the principal author of major statutes affecting Indian health,
this committee is aware that a primary goal has always been to involve
Indian and people in the activities of the IHS. I would like to
acquaint the committee with an initiative that I undertook last year to
revise the policy that governs tribal consultation and participation in
the activities of the IHS. Over the last 7 months, the IHS has worked
closely with a representative group of tribal leaders and officials to
revise our present Consultation policy with the intention of improving
the process to ensure, to the maximum extent permitted by law, that
leaders and officials are true partners with the IHS in policy
development, budget allocation, and other activities. I anticipate that
our ``new'' Consultation Policy and the improvements to the
consultation process that it sets forth will be formally adopted by me
next month, in May 2005. Our new policy will be our third revised
Consultation Policy since 1997. The IHS is committed to improving
consultation based on our experiences in this important area and our
continuing discussions with Leaders concerning consultation activities
in the IHS.
American Indians and Alaska Natives will also benefit from several
provisions in the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 [MMA]. In 2004 and 2005, the transitional
assistance credit of $600 per year for low-income Medicare
beneficiaries, including American Indians and Alaska Natives, might
provide additional Medicare revenue for prescription drugs dispensed at
IHS facilities in fiscal year 2005. The Medicare part D prescription
drug benefit program, when implemented in January 2006, will make the
new part D prescription drug benefit available to American Indians and
Alaska Natives Medicare beneficiaries. Other sections of the act
authorize a 5-year expansion of benefits covered under Medicare part B
for American Indians and Alaska Natives beneficiaries.
In addition, the MMA introduced a number of provisions that
expanded preventive benefits coverage in January 1, 2005. Beneficiaries
whose Medicare part B coverage begins on or after January 1, 2005, will
be covered for an initial preventive physical examination within 6
months of enrollment. This exam includes counseling or referral with
respect to screening and preventive services such as pneumococcal,
influenza, and hepatitis B vaccinations; screening mammography;
screening pap smear and pelvic exam; prostate cancer screening;
colorectal cancer screening; diabetes outpatient self-management
services; bone mass measurement; glaucoma screening; medical nutrition
therapy services; cardiovascular screening blood test; and diabetes
screening test which will be given to beneficiaries at risk for
diabetes.
The cardiovascular screening blood test and diabetes screening test
do not have a deductible or co-pays, so beneficiaries do not incur any
cost. This is an additional incentive for those with limited resources
who might not otherwise access these benefits.
The Centers for Medicare and Medicaid Services [CMS] is
collaborating on education and outreach with the American Cancer
Society, the American Diabetes Association, and the American Heart
Association to help maximize attention to Medicare's new preventive
benefits and help seniors to use them. CMS also plans to assist IHS in
training IHS, tribal, and urban Indian health pharmacy staff on
Medicare part D, so staff and Indian Medicare beneficiaries will better
understand the new Medicare prescription drug benefit.
In summary, Indian health has improved progressively since
enactment of the Indian Health Care Improvement Act in 1976. The IHS
has honored its commitment to improve the health status of all eligible
American Indians and Alaska Natives as provided by IHCIA and has worked
with tribes since the passage of the ISDEAA in 1975 to assist in the
successful transition of the IHS administered health programs to tribal
control and administration. Prevention and health promotion programs
continue to be a personal priority of mine and have received a $33
million funding increase in the President's fiscal year 2006 proposed
budget.
We recognize, however, that health disparities continue to exist
between American Indians and Alaska Natives and all other groups in the
U.S., and we seek to address this need through continued support of
health education and disease prevention programs targeted at diseases
with some of the highest mortality rates. In addition, our scholarship
and loan program provides opportunities to recruit and retain young
Indian professionals to serve their communities, while the sanitation
facilities construction program continues to provide safe water,
wastewater disposal, and solid waste disposal systems for the well
being of many communities. And, through ongoing consultation, both
Tribes and the Federal Government benefit from communication that
better identify priorities and how they might best be addressed.
Finally, enactment of the MMA will provide much needed prescription
drug coverage in a manner intended to enhance the well being of tribal
members.
Mr. Chairman, this concludes my statement. Thank you for this
opportunity to discuss the Indian health programs serving American
Indians and Alaska Natives and their impact on the health status of
American Indians and Alaska Natives. We will be happy to answer any
questions that you may have.
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