Honorable Chairman and Members of the Committee:
I am Dr. Michael H. Trujillo from Laguna Pueblo, New Mexico. I am the
Director of the Indian Health Service (IHS). Accompanying me today are Mr.
Michel E. Lincoln, Deputy Director; Dr. W. Craig Vanderwaoen, Acting Associate
Director, Office of Health Programs, Mr. Gary J. Hartz, Acting Associate
Director, Office of Environmental Health and Engineering; and Mr. Reuben T.
Howard, Deputy Associate Director, Office of Administration and Management. We
are pleased to be here today to discuss the President's fiscal year (FY) 1997
budget request for the Indian Health Service.
Mr. Chairman, as the Director of the Indian Health Service and as an
American Indian I want to express my appreciation for the critical support which
you and this committee have given to Indian health programs during the past
year. Your support enabled the Indian Health Service to respond to dramatic
changes and enormous pressures confronting Indian people and their health
system. Together we are dealing with immense pressure to reorganize and
streamline our operations, while the demand for resources continues to increase.
I am committed to working with the Committee to review the Indian health
priorities for fiscal year 1997 and address any concerns you or other Committee
members may have about the Indian Health Service budget request.
The provision of Federal health services to American Indians and Alaska
Natives is based upon a special government-to-government relationship between
Indian tribes and the United States. This relationship was first set forth in
the 1830s by the U.S. Supreme Court and has subsequently been reconfirmed by
numerous treaties, laws, constitutional provisions, court decisions and
executive orders. The Indian Health Service, as the Federal Agency charged with
administering the principal health program for American Indians and Alaska
Natives provides a comprehensive health services delivery system in partnership
with Indian people to develop and manage programs to meet their health needs.
In addition, the Indian Health Service also acts as the principal federal health
advocate for Indian people. The goal of Indian Health Service is to raise the
health status of American Indians and Alaska Natives to the highest level
possible.
This description of the government's responsibility, purpose, and goal is
extremely important so I would like to restate it from a different perspective.
American Indians and Alaska Natives believe strongly in the treaties our
forefathers signed with the United States Government. Many of our ancestors
lost their lives to establish the legal, legislative, executive and
constitutional basis for the unique government-to-government relationship with
the United States. They gave up land, water rights, mineral rights, and forests
in exchange for, among other things, health care. I believe it is our solemn
responsibility to provide the best health care this Nation has to offer to
assure that we elevate the health status of American Indians and Alaska Natives
to the highest possible level. The trend to reduce the size of the federal
government cannot result in the reduction or dilution of historic treaty and
trust obligations.
As an organization, the Indian Health Service maintains a truly unique
health delivery system that provides its customers with wide- ranging medical
services. Those services respect and attempt to blend traditional healing
beliefs with the latest advances in medical technology. The Indian Health
Service employees work with more than 547 federally recognized tribes and 34
urban Indian organizations in the delivery of health care to communities that
range from Point Barrow, Alaska, to Hollywood, Florida, and from Maine to
California. Care is provided in some of the most remote and beautiful locations
in the nation, as well as within the metropolitan areas of major cities.
Direct and contract patient care, although a mainstay of our community based
primary care system, is only a part of the picture at the Indian Health Service.
With tribal participation, we also provide environmental planning and
maintenance services, build and maintain clean water treatment systems, carry
out educational outreach and preventive health programs, and assist in
ground-breaking research and application of scientific information. This
combination of patient care and preventive health activities has produced
unequaled improvements in the health of American Indians and Alaska Natives. A
few examples of pioneering achievements include: development and application of
advanced life support for trauma victims; development of a world model plague
control program, and the introduction of federal health care resource sharing
programs.
American Indians and Alaska Natives continue to bear an increased burden of
illness and premature mortality compared to other U.S. populations, although
their health status has improved dramatically over the past 25 years. American
Indians and Alaska Natives have less access to health care than does the
general U.S. population and the number of physicians per 100,000 population has
decreased from 99.7 in FY 1982 to 89.8 in FY 1994. In 1995, the Indian Health
Service estimates for per capita health care expenditure was $1,153, compared to
the U.S. civilian per capita expenditure of $2,912. In other words Indian
people served by the Indian Health Service only receive 40 percent of the health
care funding of the general population.
The Indian Health Service has historically been oriented to the delivery of
acute medical services as well as public health services such as immunizations
and sanitation facilities construction. The Agency has directed its resources
in this manner because epidemiologic evaluation and other analytic tools have
indicated that the health needs of American Indians and Alaska Natives could
best be served through these program emphasis areas. This approach is
consistent with the principles of community oriented primary care. The
Institute of Medicine has recently defined primary care as "the provision of
integrated, accessible health care services by clinicians who are accountable
for addressing a large portion of personal health care needs, developing a
sustained partnership with patients, and practicing in the context of family and
community." The Indian Health Service practices community oriented primary care
by including needs and resources of Indian communities in defining its health
care system.
The Agency has been effective in using community oriented primary care.
Successes include dramatic decreases in death rates for infant and mothers, as
well as reductions in the number of deaths associated with alcoholism, injuries,
tuberculosis, gastroenteritis, and other conditions. I also believe that these
achievements underscore the success of intervention targeted at specific desired
outcomes. A comprehensive curative and preventive health system based on the
specific needs of communities has proven to be very beneficial to the people we
serve.
Last year the Indian Health Service responded to dramatic changes taking
place inside and outside the government. The causes for these changes included
federal deficit reduction measures, the greater and welcomed involvement of
American Indian and Alaska Native governments and urban Indian organizations in
the Indian health care system, and technological innovations. For example,
under the Indian Self- Determination Act amendments, Indian tribes can compact
or contract for programs and functions carried out at all levels of the
organization by Indian Health Service and redesign them to meet local tribal
needs. This accelerates the rate at which participating compact and contracting
tribal governments are assuming direct control of Indian Health Service programs
and thus will require the Agency to transfer resources in a more expeditious
manner.
Almost 14 years ago I gave a speech and identified pressures facing the
Indian Health Service. They were: an increasing number of beneficiaries for
health services; demand for all services; costs for health services, other goods
and staff, number of elderly; and increasing mandates for cost containment. I
saw politics beginning to play a larger role in the health care arena replacing
the historic health-based focus of the Indian Health Service. Changing patterns
of disease to more chronic conditions also were influencing social and economic
factors and the quality of life for American Indians and Alaska Natives.
Today those pressures of 14 years ago still exist, but have been intensified
by an environment of unparalleled federal budget reductions, the transfer of
many federal programs and resources to individual states, decreases to
discretionary programs in the federal budget, the skyrocketing costs of
providing medical care, and the changing patterns of disease. These are the
forces that challenge our ability to provide quality health care to American
Indian and Alaska Native people.
The environment in which the Indian Health Service, tribal, and urban
programs operate has also changed. The population is aging. Although the birth
rate is still high, increasingly the health issues are those of an aging
population. Survival in infancy has led to greater challenges in meeting the
health needs of children and youth. Survival into adult life has led to greater
stressors on the economic capacity of the communities in which people live.
Survival into later adult life has led to changes in social roles and disease
patterns.
Correspondingly, communities are seeing different health problems. Economic
hardship contributes to a variety of health problems. Assimilation into the
dominant society has led to disruptions in family and community values.
Suicide, homicide, family violence, and chemical dependency are more significant
issues than in the past. Raising children and encouraging young people in this
environment is difficult. Accidents still claim a disproportionate number of
young people. There are a significant number of homes without access to water
and sewer systems. An increasing population of elders, who are dependent on the
family and community, at a time of such pressure adds to the stressors in the
environment. The chronic diseases of an aging population such as diabetes and
end stage renal disease also demand special program interventions. But these
issues vary from community to community. The Agency budget proposes health
program increases to address the changing health needs of these vulnerable
populations.
This year we will be crossing bridges that none of us have crossed before.
To succeed we must continue to forge an even stronger partnership with the
Congress and Indian people. One of our challenges is the reorganization of the
agency. We are working with Indian people to change and restructure the agency
to better meet their health needs. The guidance for the design of a new Indian
Health Service is provided by the Indian Health Design Team. Of the 29 people
serving on this team, 22 are representatives of Indian communities. In
November, the Indian Health Design Team submitted its report titled, "Design for
a New IHS," to Indian people and the Indian Health Service. The report includes
50 recommendations for designing a new Indian Health Service.
Redesigning the Indian Health Service is to be accomplished in two phases.
Phase I is focused on Headquarters restructuring and is to be completed in 1997.
Phase 2 implementation involves Area restructuring and is to be completed in
1998. The Indian Health Design Team is committed, and I support their position,
to an approach that ensures that Area level restructuring be guided by the
health needs of Indian people. Progress thus far on our redesign includes a
reduction of more than 900 administrative positions. Local service units have
gained about 400 staff in the process, and we have transferred about $16 million
which had formerly supported Indian Health Service program operations to tribal
programs. Because I believe absolutely in the Indian Health Design Teams's
principal that "patient care comes first," I will continue to direct those
resources recovered from future streamlining efforts to federal and tribal
health care. These efforts will continue along with working closer with tribal
and urban programs so that better health care is provided to American Indians
and Alaska Natives.
To help the Agency become more efficient and effective will involve the
participation of a number of other partners, in addition to Indian
organizations. We have to look to foundations, universities, independent
organizations, and others who can assist us in the delivery of care. We must
expand our search for partners in the health care arena.
During my tenure, there is going to be continued emphasis throughout the
Agency and in our interactions with other health partners for complete
recognition of the Indian Self-Determination process. All tribes and urban
Indian organizations will be included in the processes of the Agency to ensure
fairness and balance. Major decisions of the Agency will include all tribes;
those that contract, those that compact, and those that choose to stay within
the federal system of health care delivery as well as urban Indian
organizations. I also want the development of the Indian Health Service budget
to reflect the commitment to Self-Determination by including tribal and urban
Indian participation in the budget process. At the present time, almost
one-third of the Indian Health Service budget is going to tribes and urban
Indian organizations through contracts and compacts. I expect over the next 3-5
years for that to increase to at least half, if not more, while maintaining the
direct delivery services of the Agency.
We recently participated in the government shutdown which caused
considerable hardship within Indian communities. One result of staff furloughs
was difficulty in processing funds for direct services and to contracting and
compacting tribes so the delivery of health services could continue. Those
staff that continued providing health services were not paid on time. Threats
to shut off utilities to our health facilities and even to stop food deliveries
were endured. We reached a point where some private sector providers indicated
that they might not accept patients who were referred from Indian health
facilities because of the Federal shutdown. I am proud to say that not one
tribal program or compacting tribe considered, much less voiced, halting the
delivery of care. There were some urban programs that were faced with closing
because they had exhausted their resources. By working closely with the Indian
Health Service they were able to remain open. I believe that we stood together
with confidence in one another, and with faith in the strength of the treaties
Indian governments have with the government of the United States, and that it is
because of our faith that we came through and continued to provide services for
Indian people.
In spite of these challenges, we continue to look to the future and to
strive for better health and better lives for Indian people. In the coming year
I will continue to emphasize programs in elder care, women's health, child
abuse, and injury prevention. The needs of urban Indians is also is of special
concern to me. This population, while residing in major metropolitan areas has
extremely poor access to culturally appropriate health care. The rapid growth
of the urban Indian population has made it difficult to keep pace with their
needs. Therefore, this budget request includes provisions for increased access
to health care for urban Indians. In addition, we are requesting an increase of
$46 million for Contract Support Costs and an increase of $43 million for
Sanitation Facilities Construction of water and sewer lines to American Indian
homes.
The fiscal year 1997 budget request for the Indian Health Service is $2.4
billion which is an 8.7 percent increase over FY 1996. Additional funds will be
used primarily for sanitation construction, to make it easier for tribes to take
over operation of their local health programs, to provide additional staff in
six new or expanded health facilities and to increase services for the most
vulnerable segments of the population such as women, elderly, children and urban
Indians. The request assumes collections of $222 million from third party
health carriers for Indian patients consistent with the FY 1996 levels.
This year will be very important and challenging for the Indian Health
Service and American Indian and Alaska Native people. Federal deficit reduction
measures, the possibility of transfer of other federal programs vital to the
Indian Health Service to the states, and anti-government sentiment by the
American public are relatively new and vastly different from the pressures we
faced in the past. These external pressures are a challenge to the quality of
life for all American Indians and Alaska Natives. We are responding to these
pressures by strengthening our priority and commitment to patient and preventive
health care. We must meet these challenges as we maintain our accomplishment in
elevating the health status of Indian people. With the partnership between the
Indian Health Service, tribes, Indian organizations and the support of this
Committee, we will strive to be the best primary health care system in the
world.
Mr. Chairman, this concludes my statement. We will be pleased to answer any
questions you may have. Thank you.
