- INDIAN HEALTH CARE IMPROVEMENT ACT

[Senate Hearing 108-199]
[From the U.S. Government Publishing Office]

S. Hrg. 108-199

INDIAN HEALTH CARE IMPROVEMENT ACT

=======================================================================

JOINT HEARING

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE

AND THE

COMMITTEE ON RESOURCES
UNITED STATES HOUSE OF
REPRESENTATIVES

ONE HUNDRED EIGHTH CONGRESS

FIRST SESSION

S. 556

TO AMEND THE INDIAN HEALTH CARE IMPROVEMENT ACT TO REVISE AND EXTEND
THAT ACT

AND

H.R. 2440

TO IMPROVE THE IMPLEMENTATION OF THE FEDERAL RESPONSIBILITY FOR THE
CARE AND EDUCATION OF INDIAN PEOPLE BY IMPROVING THE SERVICES AND
FACILITIES OF FEDERAL HEALTH PROGRAMS FOR INDIANS AND ENCOURAGING
MAXIMUM PARTICIPATION OF INDIANS IN SUCH PROGRAMS

__________

JULY 16, 2003
WASHINGTON, DC

__________

Serial No. 108-41

__________

U.S. GOVERNMENT PRINTING OFFICE

88-462 WASHINGTON : 2003
_______________________________________________________________________
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COMMITTEE ON INDIAN AFFAIRS

BEN NIGHTHORSE CAMPBELL, Colorado, Chairman

DANIEL K. INOUYE, Hawaii, Vice Chairman

JOHN McCAIN, Arizona, KENT CONRAD, North Dakota
PETE V. DOMENICI, New Mexico HARRY REID, Nevada
CRAIG THOMAS, Wyoming DANIEL K. AKAKA, Hawaii
ORRIN G. HATCH, Utah BYRON L. DORGAN, North Dakota
JAMES M. INHOFE, Oklahoma TIM JOHNSON, South Dakota
GORDON SMITH, Oregon MARIA CANTWELL, Washington
LISA MURKOWSKI, Alaska

Paul Moorehead, Majority Staff Director/Chief Counsel

Patricia M. Zell, Minority Staff Director/Chief Counsel

______

COMMITTEE ON RESOURCES

RICHARD W. POMBO, California, Chairman

NICK J. RAHALL II, West Virginia, Ranking Democrat Member

DON YOUNG, Alaska DALE E. KILDEE, Michigan
W.J. ``BILLY'' TAUZIN, Louisiana ENI F.H. FALEOMAVAEGA, American
JIM SAXTON, New Jersey Samoa
ELTON GALLEGLY, California NEIL ABERCROMBIE, Hawaii
JOHN J. DUNCAN, Jr., Tennessee SOLOMON P. ORTIZ, Texas
WAYNE T. GILCHREST, Maryland FRANK PALLONE, Jr., New Jersey
KEN CALVERT, California CALVIN M. DOOLEY, California
SCOTT McINNIS, Colorado DONNA M. CHRISTENSEN, Virgin
BARBARA CUBIN, Wyoming Islands
GEORGE RADANOVICH, California RON KIND, Wisconsin
WALTER B. JONES, Jr., North JAY INSLEE, Washington
Carolina GRACE F. NAPOLITANO, California
CHRIS CANNON, Utah TOM UDALL, New Mexico
JOHN E. PETERSON, Pennsylvania MARK UDALL, Colorado
JIM GIBBONS, Nevada, ANIBAL ACEVEDO-VILA, Puerto Rico
Vice Chairman BRAD CARSON, Oklahoma
MARK E. SOUDER, Indiana RAUL M. GRIJALVA, Arizona
GREG WALDEN, Oregon DENNIS A. CARDOZA, California
THOMAS G. TANCREDO, Colorado MADELEINE Z. BORDALLO, Guam
J.D. HAYWORTH, Arizona GEORGE MILLER, California
TOM OSBORNE, Nebraska EDWARD J. MARKEY, Massachusetts
JEFF FLAKE, Arizona RUBEN HINOJOSA, Texas
DENNIS R. REHBERG, Montana CIRO D. RODRIGUEZ, Texas
RICK RENZI, Arizona JOE BACA, California
TOM COLE, Oklahoma BETTY McCOLLUM, Minnesota
STEVAN PEARCE, New Mexico
ROB BISHOP, Utah
DEVIN NUNES, California
VACANCY

Steven J. Ding, Chief of Staff

Lisa Pittman, Chief Counsel

James H. Zoia, Democrat Staff Director

Jeffrey P. Petrich, Democrat Chief Counsel

(ii)

C O N T E N T S

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Page
S. 556 and H.R. 2440, text of.................................... 2
Statements:
Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado,
chairman, Senate Committee on Indian Affairs............... 1
Carson, Hon. Carson, Hon. Brad, U.S. Representative from
Oklahoma................................................... 674
Christensen, Hon. Donna M., U.S. Delgate from Virgin Islands. 675
Cole, Hon. Tom, U.S. Representative from Oklahoma............ 673
Culbertson, Kay, president, Denver Indian Health and Family
Services................................................... 698
Faleomavaega, Hon. Eni F.H., U.S. Delegate from American
Samoa...................................................... 672
Grijalva, Hon. Raul M., U.S. Representative from Arizona..... 673
Grim, Charles, director, Indian Health Service, Department of
Health and Human Services.................................. 676
Hartz, Gary, acting director, Office of Public Health, Indian
Health Service............................................. 676
Jimmie, Andrew, chief, Minto Traditional Council............. 697
Joseph, Rachel, cochair, National Steering Committee of the
Reauthorization of the Indian Health Care Improvement Act.. 694
Kildee, Hon. Dale E., U.S. Representative from Michigan...... 671
Muneta, Dr. Ben, president, Association of American Indian
Physicians................................................. 696
Murkowski, Hon. Lisa, U.S. Senator from Alaska............... 672
Nesmith, Steve, assistant secretary for Congressional and
Intergovernmental Affairs, Department of Housing and Urban
Development................................................ 679
Olson, Richard, acting director, Division of Clinical and
Preventive Services, Indian Health Service................. 676
Pallone, Hon. Frank, Jr., U.S. Representative from New Jersey 674
Pombo, Hon. Richard W., U.S. Representative from California,
chairman, House Committee on Resources..................... 671
Rhoades, Dr. Everett, Oklahoma City Urban Indian Clinic...... 700
Skeeter, Carmelita Wamego, executive director, Indian Health
Care Resource Center of Tulsa.............................. 701
Snyder, Rae, acting director, Urban Health Office, Indian
Health Service............................................. 676
Udall, Hon. Mark, U.S. Representative from Colorado.......... 673
Weaver, Steve, director, Division of Environmental Health and
Engineering, Alaska Native Tribal Health Consortium........ 697

Appendix

Prepared statements:
Beaver, R. Perry, principal chief, Muscogee (Creek) Nation... 705
Culbertson, Kay (with attachment)............................ 708
Grim, Charles (with attachment).............................. 725
Guzman, Victoria, Walker River Paiute Tribe.................. 752
Jimmie, Andrew............................................... 705
Joseph, Rachel............................................... 760
Muneta, Dr. Ben (with attachment)............................ 778
Nesmith, Steve............................................... 785
Rhoades, Dr. Everett (with attachment)....................... 789
Skeeter, Carmelita Wamego (with attachment).................. 802
Sossamon, Russell, chairman, National American Indian Housing
Council.................................................... 814
Weaver, Steve (with attachment).............................. 817
Zacharof, chairman, Alaska Native Health Board............... 705
Additional material submitted for the record:
Letters:
Citizens Potawatomi Nation................................... 839
Edwards, James Lee, Governor, Absentee Shawnee Tribe......... 841
Ration, Norman, executive director, National Indian Youth
Council, Inc. (with attachment)............................ 842
Romberg, Carolyn, Health Director, AST Health Programs,
Absentee Shawnee Tribe of Oklahoma......................... 841

INDIAN HEALTH CARE IMPROVEMENT ACT

----------

WEDNESDAY, JULY 16, 2003

U.S. Senate, Committee on Indian Affairs, Meeting
Jointly With the Committee on Resources, U.S.
House of Representatives
Washington, DC.
The committees met, pursuant to notice, at 10:15 a.m. in
room 106, Dirksen Senate Office Building, Hon. Ben Nighthorse
Campbell (chairman of the Senate Committee on Indian Affairs)
presiding.
Present from the Senate Committee on Indian Affairs:
Senators Campbell, Inouye, Reid, Conrad, Dorgan, and Murkowski.
Present from the House of Representatives Committee on
Resources: Representatives Pombo, Mark Udall, Faleomavaega,
Cole, Kildee, Grijalva, Pallone, Brad Carson, Christensen, and
Napolitano.

STATEMENT OF HON. BEN NIGHTHORSE CAMPBELL, U.S. SENATOR FROM
COLORADO, CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

The Chairman. We will now move to the joint hearing with
the House Resources Committee and the Senate Committee on
Indian Affairs bills to reauthorize the Indian Health Care
Improvement Act. The two bills before our committee, S. 556 and
H.R. 2440, reflect literally years of hard work by tribal
leaders, the National Steering Committee and various Federal
officials.
Most members know the shameful state of Indian health.
Senator Dorgan just reiterated that as did Senator Conrad, so I
won't go through the litany of statistics this morning but they
are common knowledge.
Today is the second in a series of hearings on the
reauthorization bill. We will receive testimony regarding one,
health disparities; two, health facilities; and three, urban
Indian health issues. In the interest of time, I'll place my
full statement in the record but I will say this to the members
of both committees. After years of work and countless hours of
meetings and hearings, the time certainly has come for the
tribes, Congress and the Administration to roll up our sleeves
and do what we need to do to move this bill and get the act
reauthorized this year. To achieve that goal I look forward to
working with my colleagues on both committees.
[Prepared statement of Senator Campbell appears in
appendix.]
[Text of S. 556 and H.R. 2440 follow:]

The Chairman. Now I would like to turn to our chairman from
the House. Chairman Pombo, do you have an opening statement?
Mr. Pombo. Yes; I do. Thank you, Mr. Chairman.

STATEMENT OF HON. RICHARD W. POMBO, U.S. REPRESENTATIVE FROM
WASHINGTON, CHAIRMAN, HOUSE COMMITTEE ON RESOURCES

Mr. Pombo. I want to thank Senator Campbell for agreeing to
make today's hearing a joint hearing with the House Resources
Committee. Holding a joint hearing should send a signal that we
can develop a bill to address the health care needs of American
Indians and Alaska Natives on a bipartisan basis.
Anyone who has studied the statistical data compiled by the
Census Bureau and by health care experts understands there is a
profound lack of and access, to quality health care for
American Indians and Alaska Natives.
Living conditions for hundreds of thousands of Native
Americans lag far behind the rest of the population, whether
they live in a reservation or an urban area. These conditions
are unacceptable and there have to be new approaches that
maximize the huge potential in Indian country to improve health
care and disease prevention.
Exploring new ways to raise the quality of health services
for American Indians and Alaska Natives is not an option for
Congress. It is a basic obligation.
One way to address health problems for American Indians and
Alaska Natives is to improve basic infrastructure needs such as
safe water, sewer, waste disposal and modern medical
facilities. Unless the bricks and mortar are in place, then we
will be reduced only to responding to outbreaks of health
problems, not preventing them. I am glad today's witnesses will
especially address these issues.
I look forward to the testimony on these aspects of H.R.
2440 and S. 556. I thank the chairman for yielding.
The Chairman. Thank you, Chairman Pombo.
I'm delighted to see some of my old friends from the years
I served in the House. I don't know if you have opening
statements but why don't we start with Congressman Kildee. If
you have a statement, go ahead.
Mr. Kildee. Thank you very much, Mr. Chairman.

STATEMENT OF HON. DALE E. KILDEE, U.S. REPRESENTATIVE FROM
MICHIGAN

Mr. Kildee. I am happy you and Mr. Pombo are having these
hearings as a member of the House Resources Committee and
cochairman of the House Native American Caucus, I think this is
very important. If by chance we are called back for votes, I
will leave Kim TeeHee of my staff who handles all matters of
the Native American Caucus to hear all the testimony.
The reauthorization of this act will provide a more
comprehensive approach to the delivery of medical care to
Native people. The House bill is based upon the recommendation
made by the Indian health community including tribal leaders,
tribal health directors, health care experts and Native
patients themselves. Its primary objective is to improve access
to quality medical care for the Native American population.
I look forward to hearing testimony this morning and would
ask consent that my entire statement be included in the record.
The Chairman. It will be included in the record.
[Prepared statement of Mr. Kildee appears in appendix.]
The Chairman. Why don't we go back and forth? Senator
Murkowski, did you have any comments?

STATEMENT OF HON. LISA MURKOWSKI, U.S. SENATOR FROM ALASKA

Senator Murkowski. Thank you, Mr. Chairman. Good morning
and thank you for the hearing this morning with our House
members on a very important issue for us in my State.
I would like to welcome those Alaskans we will be hearing
from this morning, Chief Andrew Jimmie from Minto and Steve
Weaver from Anchorage. I also see some other Alaskans in the
audience. This is our committee's second hearing on Indian
health care reauthorization but it's the first one that has
taken place after the National Steering Committee's bill was
introduced in the other body.
There are many good things in this legislation but what I
particularly like about it is that it is not necessarily an
Alaskan bill or a Navajo bill or an urban bill, it is a
national bill which was derived through the very diligent work
of Native health leaders throughout Indian country. I hope, Mr.
Chairman, that through the good work of the National Steering
Committee, we will form the nucleus of this bill that we will
markup in the Committee on Indian Affairs.
I am very pleased that we will be hearing from Steve Weaver
on the second panel. Oftentimes when you think of Indian
health, we think of the doctors and the nurses. Steve is an
engineer, specializing in sanitation and environmental health.
His expertise is in preventing disease by focusing on water
quality and sanitation. It is so important that we do focus on
these preventative first step measures, so I am pleased he is
here today to help us as we talk about healthy families and
healthy communities.
Mr. Chairman, thank you.
The Chairman. Thank you.
Mr. Faleomavaega.
Mr. Faleomavaega. Thank you, Mr. Chairman.

STATEMENT OF HON. ENI F.H. FALEOMAVAEGA, U.S. DELEGATE,
AMERICAN SAMOA

Mr. Faleomavaega. I would like to echo the sentiments
expressed earlier by my colleagues to thank you for the
initiative and your leadership in calling this joint hearing,
along with our distinguished chairman, Mr. Pombo from
California. I think this effort certainly demonstrates the
urgency of this legislation that has been on the shelf now for
4 years. Our Indian communities have deliberated and have had
so many consultations for many years now and I sincerely feel
this joint hearing gives it a sense of urgency that we need to
pass this legislation as soon as possible. We thank you for
doing this.
For those of us on the House side, it's nice to be here
once in a while to see how glorious and big the chambers are.
The Chairman. Actually, we're a pretty friendly crowd. You
didn't have to sit that far away.
Mr. Faleomavaega. I don't know about that, Mr. Chairman. We
kind of felt we were being intimidated by the gloriousness of
this beautiful chamber but as a former colleague and certainly
as a member of our committee, Mr. Chairman, we are delighted to
be here and look forward to hearing from our witnesses this
morning.
The Chairman. Congressman Cole, did you have a statement?
Mr. Cole. Just briefly, Mr. Chairman.

STATEMENT OF HON. TOM COLE, U.S. REPRESENTATIVE FROM OKLAHOMA

Mr. Cole. I'd like to echo my colleagues' appreciation for
you and Chairman Pombo having this joint session. It is an
extraordinarily important problem an one that's been allowed to
languish far too long. I appreciate your initiative. I hope we
can develop a bipartisan consensus on this legislation and move
ahead. I particularly hope during the course of the hearing if
we have an opportunity to look at not only the depth of the
problem overall but some of the disparities in funding at the
tribal level. Representing a State that has many, many Native
Americans but not much in the way of reservations, we've lagged
in funding compared to some of the other tribes.
Certainly we appreciate your initiative and this
opportunity to look at these problems and move ahead.
The Chairman. Congressman Udall from the great State of
Colorado, any comments?
Mr. Udall. Thank you, Mr. Chairman.

STATEMENT OF HON. MARK UDALL, U.S. REPRESENTATIVE FROM COLORADO

Mr. Udall. I too want to associate myself with the remarks
of my Chairman, Mr. Pombo, Mr. Faleomavaega and the rest of the
panel. I want to underline my commitment to proceeding as
quickly as possible. We all know this has been long in arriving
and we need to get this legislation passed and to the
President's desk.
I look forward to working with everybody here to see that
we do that as soon as possible.
Thank you, Mr. Chairman.
The Chairman. Congressman Grijalva?
Mr. Grijalva. Thank you, sir.

STATEMENT OF HON. RAUL M. GRIJALVA, U.S. REPRESENTATIVE FROM
ARIZONA

Mr. Grijalva. I also would join with my colleagues in
extending the appreciation to you, Senator, and to our Chairman
for having this hearing. I want to associate myself with the
comments made by my colleagues and look forward to an expedient
process and some quick movement in assuring that access and a
health delivery system is available to our Native American
brothers and sisters.
Thank you, sir.
The Chairman. Thank you.
Congressman Pallone, any comments?
Mr. Pallone. Thank you, Mr. Chairman.

STATEMENT OF HON. FRANK PALLON Jr., U.S. REPRESENTATIVE FROM
NEW JERSEY

I just wanted to say that both of you, Senator Campbell, as
well as our House Chairman Pombo, have really highlighted and
shown a tremendous concern over this issue. Senator Campbell
obviously for a number of years and Congressman Pombo over the
last couple months, particularly last week, has shown on the
House Resources side that he is willing to move forward on a
number of these initiatives because he realizes how important
they are.
I just wanted to say briefly I think there is a tremendous
problem, I would call it a crisis, in terms of health care
services in Native America primarily because you've had an
explosion in the Native American population but that the IHS
has not been able to keep up, primarily because of funding. I
think lack of funding is a major issue.
There is also the fact that in Congress, I think we have
not paid enough attention to the lack of money for facilities,
for new construction and perhaps the Administration more and
more, and I don't just mean this Administration but the last 10
years or so, seems to be relying on the tribes more and more to
pay for their own services, particularly with regard to new
facilities and renovation of facilities. I think that is wrong.
I really see provision of health care services for Native
Americans as an entitlement, as something we are required
pursuant to the Constitution and treaties over the years to
provide. I don't think we should rely more and more on their
providing their own money. I think we have to increase the
funding.
In addition, there are just so many changes that we haven't
paid attention to over the last 10 or 20 years, the need for
more preventative services, home health care, nursing homes,
the changes in the demographics so that more and more Native
Americans are now in urban areas and that those problems need
to be addressed. Although there is a crisis, I think that we
can identify what the needs are. I know that people on this
committee, including the leadership, are very concerned and
know what to do.
What we need to do is educate the rest of Congress and try
to move the legislation and get our other colleagues motivated
beyond these two committees to move these measures and realize
the crisis we face, and that it is going to take a lot more
money and time to address this.
I'm very pleased we are having this hearing today. I want
to thank the two Chairmen in particular for their concerns.
The Chairman. Thank you.
Any comments, Congressman Carson.
Mr. Carson. Thank you very much, Senator Campbell.

STATEMENT OF HON. BRAD CARSON, U.S. REPRESENTATIVE FROM
OKLAHOMA

Mr. Carson. I'd like to thank you and Chairman Pombo for
holding this hearing too. Of course I have a great interest in
this issue representing the most Native American congressional
district in the country, being a member of the Cherokee Nation
myself and the son of a career of Bureau of Indian Affairs
employee. I know how important this legislation is to the many
Native Americans both in Oklahoma and across the country.
I am particularly proud that two Oklahomans will today be
testifying before this committee, Carmelita Skeeter who runs a
tremendously successful health care center in Tulsa, Oklahoma
serving the Native American population, as well as Dr. Charles
Grimm, the interim director of the IHS. He did a tremendous job
in the State of Oklahoma and I understand his nomination and
the hearings on his confirmation are proceeding nicely and we
look forward to this service to this Administration as the
Director of IHS.
Oklahoma has more than 300,000 patients in IHS and there is
only 1.6 million nationwide. You can imagine when you have 20
percent of the IHS population, you are very concerned about
what is going on within the institution.
We appreciate your holding this hearing today. I am proud
to be a cosponsor of H.R. 2440, the House version of the Indian
Health Care Improvement Act reauthorization, and we look
forward to what the panel has to say on this very important
matter.
The Chairman. Thank you.
Congresswoman Christensen.
Ms. Christensen. Thank you, Mr. Chairman.

STATEMENT OF HON. DONNA M. CHRISTENSEN, U.S. DELEGATE FROM
VIRGIN ISLANDS

Ms. Christensen. I want to join my colleagues in thanking
both you, Chairman Campbell, and Chairman Pombo for holding
this very important meeting and also to say it is very timely
as the Minority caucuses in the House are working with members
of the Senate to put all of the initiatives that we have been
advocating over several past Congresses into one comprehensive
minority health bill. Also, to say as chair of the Health Brain
Trust of the Congressional Black Caucus and as a physician, it
is my hope that at the end of this process, we will reauthorize
the Indian Health Care Improvement Act in such a way that we
can truly begin to rectify the deficiencies of past efforts and
pass a bill that will bring the health of Native Americans not
just on par with what we consider average for Americans,
because if we include the African American, the Hispanic
American, the Asian Pacific Islanders what is considered
American health will be far below what we should be aspiring
to.
Rather, we want to develop a vehicle that will develop the
high level of health attained by those of full and unfettered
access to health services to a bill that provides equal access
to culturally sensitive, comprehensive, easily and universally
accessible health care provided mostly by the increasing cadre
of Native American health providers that will be trained under
this bill, with best practices determined by Native American
and Alaska Native led and specific research provided in
communities that are environmentally and socio-economically
supportive of good health and developed and directed by the
communities and the tribes themselves fully funded and
supported with technical assistance from the Federal Government
and the agencies that can provide such technical assistance.
I want to once again thank you for this hearing and I look
forward to the testimony of our witnesses.
The Chairman. Thank you.
We will now start with the first panel which will be
Charles Grim, director, Indian Health Service, accompanied by
Gary Hartz, acting director, Office of Public Health, Indian
Health Service; Richard Olson, acting director, Division of
Clinical and Preventive Services; Mrs. Rae Snyder, acting
director, Urban Health Office; and Steven Nesmith, assistant
secretary for Congressional Affairs, Department of Housing and
Urban Development.
We'll start by telling you that all of your written
testimony will be included in the record. If you would like to
abbreviate, that would be fine. We will start with Mr. Grim
first.

STATEMENT OF CHARLES GRIM, DIRECTOR, INDIAN HEALTH SERVICE,
DEPARTMENT OF HEALTH AND HUMAN SERVICES, ACCOMPANIED BY GARY
HARTZ, ACTING DIRECTOR, OFFICE OF PUBLIC HEALTH, INDIAN HEALTH
SERVICE; RICHARD OLSON, ACTING DIRECTOR, DIVISION OF CLINICAL
AND PREVENTIVE SERVICES, INDIAN HEALTH SERVICE; AND MRS. RAE
SNYDER, ACTING DIRECTOR, URBAN HEALTH OFFICE, INDIAN HEALTH
SERVICE

Mr. Grim. Thank you, Chairman Campbell, Chairman Pombo, and
distinguished members of both committees.
We are very excited too within the Indian Health Service
for this joint hearing to be able to talk about the issues
before both the House and the Senate.
You have introduced the staff I have here. They won't be
making any opening statements. I will be making the opening
statement for the agency but they are here should we have
questions. They are technical matter experts on a number of
these issues today.
We are pleased to have this opportunity to be able to
testify on behalf of Secretary Thompson on both the House and
Senate bills to reauthorize the Indian Health Care Improvement
Act. For the record, I'm submitting my written statement and it
contains specific information about the agency including the
legislative and legal history regarding the United States'
commitment to tribal nations and some of the national
challenges that we're facing to improve the health of American
Indians and Alaska Natives. My written statement also contains
comments on specific aspects of the proposed legislation that I
won't cover in my oral statement so that we can conserve time.
As I testified last April, there is no single piece of
legislation that will affect the future health status of
American Indians and Alaska Natives more than the Indian Health
Care Improvement Act Reauthorization of 2003. For the past 28
years, the Indian Health Care Improvement Act has been the
basis for extending the life span of Indian people by 7 years
which is still 6 years below that of the rest of the Nation. It
has helped us to address the basic health needs of a population
that was not benefiting from the technological and medical
advances of an industrialized nation and it has also assisted
us in identifying current and future health challenges.
To continue to make progress in raising the health status
of Indian people to at least the level of the rest of the
Nation requires us to modify the Indian Health Care Improvement
Act of 1976 to reflect the health status of the Indian
population of 2003 as best we can and to have it reflect the
health status of Indian people as we project it into the future
until the next reauthorization.
The legislation under consideration today reflects the
proposed language developed over a 2-year period by Indian
tribes across the Nation and adopted by both committees of
Congress. Our Nation faces many priorities today, many of which
overshadow but do not diminish the importance of other
priorities. As requested by the committee, I am going to focus
my brief remarks on the highlighted areas of health
disparities, health care facilities and urban Indian health.
My written statement includes some health statistics and
the agency can supply members with more information if
requested. Three simple statements to remember regarding
American Indian and Alaska Native health disparities are:
First, Indian people continue to experience disease and illness
at greater rates than the rest of the Nation; second, Indian
people continue to prematurely die at rates greater than the
rest of the Nation; and third, Indian people continue to
experience reduced access to health services and care compared
to the rest of the Nation.
It is well publicized and referenced that Indian people
continue to experience health disparities and death rates that
are significantly higher than the rest of the United States
general population. Many American Indians and Alaska Natives
who receive a diagnosis of diabetes, high blood pressure and
high cholesterol levels, cardiovascular disease, alcoholism and
obesity consider it a fatal diagnosis.
The proposed language of the Indian Health Care Improvement
Act can help the Indian health system of the Indian Health
Service, tribal health programs and urban Indian health to
develop and implement health promotion and disease prevention
strategies so that healthy behavior choices and lifestyles will
begin to significantly reduce the health disparity rates. It
also yields an even more important humanitarian benefit of
reducing pain and suffering and prolonging life.
We were successful in working with Indian nations through
the Indian Health Service with infectious diseases and
conquering those and I think we can do it again for chronic
diseases with the help of Congress.
The IHS Health Care Facilities Program, including the
tribal program specifically, are responsible for managing and
maintaining the largest inventory of real property in the
Department of Health and Human Services with over 9 million
square feet of space. In the proposed bill, section
302(B)(3)(c) specifically proposes that IHS Sanitation
Facilities Construction funds will not be used to support
service of sanitation facilities to the Department of Housing
and Urban Development homes. The bill is not clear that homes
constructed through HUD should also include the necessary
infrastructure to make a home complete including safe water and
sewer and wastewater disposal systems for the home. The IHS and
HUD have cooperated over many decades on the construction of
homes and reservation communities with IHS providing the
expertise and development of supporting the sanitation and
sewage systems that the HUD homes would then hook into.
Without clarity in the language, there may come a time when
interpretation may result in IHS funds being expended on
sanitation systems of HUD homes which would in turn redirect
IHS funds from providing services to existing homes without
water, sewer and solid waste facilities. Newly constructed HUD
homes should be funded to cover everything including the home
itself and to the street hookup. We request that you consider
clarifying this point in the proposed bill.
Title V of the Indian Health Care Improvement Act provides
specific authority focused on the provision of health services
for urban Indian people with funds appropriated to the Indian
Health Service. The IHS currently contributes funds toward the
operating expenses of 34 independent urban Indian health
programs including programs in Oklahoma City and Tulsa that are
demonstration programs. These programs provide a range of
services. In 1978, the entire State of Oklahoma was designated
as a contract health service delivery area which means that the
Indian beneficiaries could reside anywhere in the State and
maintain their eligibility for both direct services and
contract health services.
The 1992 Congress amended the Health Care Improvement Act
to establish two demonstration projects with Tulsa and Oklahoma
City clinics to be treated as service units in the allocation
of resources and the coordination of care. This new and
innovative approach to ensuring health services were accessible
to all eligible populations in Oklahoma has resulted in a
hybrid system. Each program maintains its status under the
title V as an urban Indian organization, yet the programs
function like other IHS service units and report on the
resources and patient management system of the Indian Health
Service with data utilized for inclusion in the allocation of
resources.
Most service populations and overall utilization of
services have dramatically increased since these programs
became demonstration projects and from the fiscal year 1994
specific congressional line item funding increases. They have
been able to use the best of both urban and IHS structures to
build a community controlled, high quality health system in a
State designated as a contract health service delivery area.
On the other hand, the hybrid system has raised a few
concerns with some of the Oklahoma tribes that operate their
own health programs under the Indian Self Determination and
Education Assistance Act, Public Law 93-638 as amended. The
issue in its most basic terms is that the two urban programs
have some aspects of a service unit but their funding is not
subject to transfer to the tribes under Public Law 93-638
contracts or compacts as our non-hybrid service units are.
With an environment of reduced resources and an increasing
population with greater health needs, it's expected that the
issue of tribe shares of urban Indian programs, especially the
hybrid programs, will receive more attention than they have in
the past.
As review of this far-reaching, complex legislation
continues, we may have further comments. However, we wish to
reiterate our strong commitment to reauthorization and
improvement of the Indian Health Care Improvement Act and will
be happy to work with the committees, the National Tribal
Steering Committee and other representatives of the American
Indian and Alaska Native communities to develop a bill that is
fully acceptable to all stakeholders in this important program.
Mr. Chairman, that concludes my statement. I want to thank
you for the opportunity to discuss reauthorization of the
Indian Health Care Improvement Act. We will be happy to answer
any questions you may have.
[Prepared statement of Dr. Grim appears in appendix.]
The Chairman. Thank you, Dr. Grim.
I understand Admiral Hartz, Dr. Olson, and Ms. Snyder are
resource people but do not have statements, is that correct?
Mr. Grim. That is correct.
The Chairman. Now we will go to Steven Nesmith.
I might tell my colleagues that Mr. Nesmith is really
assistant secretary for Congressional Affairs. I understand
your background is not in Indian health. Is that correct?
Mr. Nesmith. That is correct, sir.
The Chairman. Hopefully we won't put you on the spot too
much. Go ahead.

STATEMENT OF STEVEN NESMITH, ASSISTANT SECRETARY FOR
CONGRESSIONAL AND INTERGOVERNMENTAL AFFAIRS, DEPARTMENT OF
HOUSING AND URBAN DEVELOPMENT

Mr. Nesmith. As this is a joint hearing, Chairman Campbell
and Chairman Pombo, Vice Chairman Inouye, and members of both
committees, thank you for inviting me here to provide comments
on S. 556, the Indian Health Care Improvement Act
Reauthorization of 2003.
My name is Steven Nesmith and I am the assistant secretary
for Congressional and Intergovernmental Affairs at HUD.
As you know, the Public and Indian Housing, PIH, is
responsible for the management and operation and oversight of
HUD's Native American programs. These programs are available to
560 federally-recognized and a limited number of State-
recognized Indian tribes. We serve these tribes directly or
through tribally designated housing entities by providing
grants and loan guarantees designated to support affordable
housing community and economic development activities. Our
tribal partners are diverse. They are located on Indian
reservations, in Alaska Native villages and other traditional
Indian areas.
In addition to those duties, PIH's jurisdiction encompasses
the Public Housing Program which aides the Nation's 3,000 plus
public housing agencies in providing housing and housing
related assistance to low income families. It is a pleasure to
appear here before you and I would like to take the opportunity
to express my appreciation for all of your continuing efforts
to improve the housing conditions of American Indians and
Alaska Native peoples.
Much progress has been made and tribes are taking advantage
of new opportunities to improve the housing conditions of the
Native American families residing on Indian reservations, on
trusts or restricted Indian lands and in Alaska Native
villages. This momentum needs to be sustained as we continue to
work together toward creating a better living environment
throughout Indian country.
At the outset, let me reaffirm the Department of Housing
and Urban Development's support for the principle of government
to government relations with Indian tribes. HUD is committed to
honoring this fundamental precept in our work with American
Indians and Alaskan Natives. On behalf of Secretary Martinez,
thank you for the opportunity to provide this testimony on S.
556.
The Department agrees that the Indian Health Service, a
division of the Department of Health and Human Services, is
vital to the well being of individual Indian families and the
Native American community as a whole. Native Americans often
have no other means to receive the health care assistance and
related activities provided by IHS.
HUD's Office of Native American Programs continues its
ongoing dialogue with IHS representatives to coordinate our
activities in a manner that supports tribal sovereignty, self
determination and self governance. The Department also
participates in a Federal Interagency Task Force on
Infrastructure with the IHS, the Environmental Protection
Agency, the Bureau of Indian Affairs and the Department of
Agriculture. It is within this perspective that the following
comments are offered on behalf of HUD and this bill.
As you are aware, in 1996, the Native American Housing
Assistance and Self Determination Act became law. NAHASDA
changed the way in which housing and housing related assistance
is provided to Native American families. Prior to the Act,
Indian housing authorities and Indian tribes applied for a
variety of competitive and categorical grant programs usually
with differing program eligibility and reporting requirements.
NAHASDA created the Indian Housing Block Grant Program
which is a non-competitive formula grant made to Indian tribes
or tribally designated housing entities. Under the Indian
Housing Block Grant Program, an Indian tribe or the tribal
designated housing entity submits to HUD a 5-year and a one
year housing plan. The housing plan contains information about
how the recipient will use its block grant funds to engage in
the six affordable housing activities authorized by NAHASDA.
Once the Indian housing plan is found to be in compliance
with the statutory and regulatory requirements, the tribe or
that designated entity executes a grant agreement to receive
the Indian housing block grant allocation. The Indian housing
block grant formula is based on housing needs of each of the
tribes and the tribes designated entity ongoing operation,
maintenance needs and for the dwelling units previously
developed under the Indian Housing Program authorized by the
U.S. Housing Act.
The Indian housing block grant formula is calculated by
dividing the total amount appropriated for each fiscal year
among the number of eligible grant recipients. Formula
components and variables are weighted to ensure that the
complexities and differences among tribes are taken into
consideration. Each tribe's formula allocation reflects these
factors.
The NAHASDA regulations as described in the Code of Federal
Regulations requires that the Indian housing block grant
formula be reviewed by the calendar year 2003 for possible
modification or revision. At present, HUD is engaged in
negotiating rulemaking commonly referred to as NEGREG with a
26-member committee comprised of a broad cross section of
tribal stakeholders. The first NEGREG session was held in April
of this year and additional monthly meetings are ongoing and
are scheduled through September.
Let me turn to the specific comments on S. 556, the Indian
Health Care Improvement Act Reauthorization of 2003. As you
know the Administration is actively reviewing S. 556 and will
provide you with specific details of our analysis very shortly.
The Administration has not taken a position regarding the
transfer of NAHASDA funds between HUD and HHS. We do, however,
have concerns about transferring NAHASDA funds between Federal
agencies when NAHASDA now provides for the direct distribution
of Indian housing block grant funds to tribes and their housing
designated entities based on a formula negotiated between the
tribes and HUD.
An affordable housing activity under the Indian Housing
Block Grant Program is development which includes
infrastructure such as site improvements and the development of
utilities and utility services for housing. The provision of
water and sanitation facilities are included within this
category. Tribes and tribal designated housing entities may
currently enter into agreements with IHS to provide these
services or they may choose another service provider.
We believe that this is in keeping with the policy of self
determination that is articulated in NAHASDA. Since 1997,
nearly $228 million has been transferred to IHS through the
tribal designated housing entities for offsite sanitation
facilities. Tribes and their designated entities continue to
make difficult budgetary and management decisions on how to
prioritize their Indian housing block grant dollars which is
consistent again with tribal self determination and self
government.
Let me assure the committee that we will work with both
committees and with our Federal partners in HHS and other
Federal agencies, the tribes and their designees to ensure that
the housing infrastructure needs in the Native American
communities are met in the most efficient manner possible.
We are nevertheless concerned about any provision that
might erode the self determination which we believe is critical
in NAHASDA.
Thank you for the opportunity to express the Department's
views.
[Prepared statement of Mr. Nesmith appears in appendix.]
The Chairman. Thank you.
Since our colleagues in the House are going to have further
to walk because there is a vote than we have to in the Senate,
I am going to yield to them for questions first. We will start
with Chairman Pombo.
Mr. Pombo. Thank you very much. I appreciate the
opportunity.
The House Interior Appropriations bill specifically
included committee language which states that IHS sanitation
funds should not be used to provide sanitation facilities for
new homes funded by the housing programs of the Department of
Housing and Urban Development. I know, Dr. Grim, that in your
opening statement you talked about this issue. Could you expand
upon that for me as to what your level of support or opposition
to that particular language is?
Mr. Grim. Yes, Mr. Chairman; the way that came about was
our appropriations committees have over the years included that
language because HUD funded home projects prior to NAHASDA had
infrastructure funds included for sanitation facilities for
newly funded HUD homes. Once NAHASDA was put in place, it was
the tribes choice of what to use those funds for, whether to
build housing infrastructure and so forth.
The IHS program separates and, apart from that, looks at
existing homes without adequate sanitation facilities or newly
built homes built with other than HUD funds. We currently have
a backlog of those homes as well, so the two programs are
separate. So our committees have wanted to ensure that moneys
coming through the Indian Health Service were used for existing
homes with that need or with newly built homes other than HUD
homes.
Mr. Pombo. So you generally in support of that because you
want to keep those two programs separate?
Mr. Grim. As mentioned by Mr. Nesmith, we've worked jointly
with HUD over the years to try to ensure that the two programs
work together but they are two separate programs.
Mr. Pombo. Can you tell me a bit more about what you are
currently doing to deal with that backlog? I've been told that
the backlog is substantial at this point. Can you expand upon
that a bit for me?
Mr. Grim. The current backlog we have estimated in feasible
projects, those able to be completed roughly is around $900
million right now. We keep records on that and those records do
not sometimes include newly built HUD homes that may or may not
have adequate facilities. Once they become existing homes, we
try to get those added to our inventory.
One of the things we try to do on an annual basis, we have
currently a $94-million appropriation to deal with new and
existing homes and we have a priority system where we try to
prioritize those in most need. We are trying on an annual basis
to work on those backlogs.
Mr. Pombo. You said something I have a real question on and
that is when a newly constructed HUD home becomes an existing
home, then you can use funding to provide the sanitation
services. Why would you allow a home to be built without the
sanitation services?
Mr. Grim. I may let Admiral Hartz take a crack at this
after I finish but regarding existing HUD homes, the Indian
Health Service staff work in concert with HUD on those homes.
However since the passage of NAHASDA the block grants have now
been transferred to tribes. There is extreme pressures out
there due to the backlog and need for housing in Indian country
and there are more and more pressures on tribes to get existing
homes in place.
The IHS does not have direct control over any of the
NAHASDA housing projects themselves. We come in as technical
assistants but we do have funds, the $94 million I referenced,
to help existing homes or those that have been built with funds
other than HUD such as State programs or tribal funds and
things like that to try to get adequate water and sanitation
facilities to them. Many times, in Indian country it's not like
it is in an urban setting like Washington, DC or Maryland where
all you have to do is hook up to a water main that is a few
feet from the house. Sometimes there are many, many miles to
traverse to get to a water or sewer system. So it is not as
easy as it sounds sometimes when a home goes up many, many
miles from a location where there is adequate hookups to
sanitation and water. Sometimes that occurs.
The point I would make is the IHS works in tandem with HUD
and with tribes trying to ensure that safe water and sanitation
facilities go in but the IHS itself is not the one responsible
for the building programs. We just assist with sanitation and
those facilities.
Mr. Hartz. Mr. Chairman, I can build on that with a couple
of points.
I think historically as pointed out, we have had an
excellent relationship with HUD in making sure that the door
knob is talking to the toilet seat as we get these new homes
built. I think that's been shown going back to when Congress
actually started putting that language in our appropriations
bill which dates back to the early 1980's. It had to do with
some arrangements that were worked out at that time with OMB
and Secretary Pierce I believe in 1981.
The money started flowing to ensure that the HUD units were
provided sanitation facilities either through an arrangement
with HUD directly or through the Indian Housing Authorities
and/or the Indian tribes depending on how they were set up
locally. Those resources contributed from the HUD Indian
Housing Program at that time grew from $5-$6 million to $25
million. That contribution to the Sanitation Facilities Program
of IHS was of tribes' choosing. They could do the construction
themselves, they could provide it to IHS. Many times the reason
they would provide it to IHS is because you can then do a total
community concept in development of infrastructure as opposed
to doing a piecemeal approach where houses get dropped in a
location and you only have dollars to do just that little piece
for infrastructure. Infectious diseases don't follow those
kinds of boundaries when the same children from different
places show up in the school system.
It grew in 1994 to almost $25 million, the contribution
that was coming out of the Indian Housing Program from HUD most
of the time, 90 plus percent of the time, the money actually
was a decision made by the tribes exercising self determination
before that was even passed through the HUD authorizations to
provide those dollars to IHS to carry it out.
There were lots of arrangements by which that was done.
Sometimes the tribes would pool the dollars and the tribes
actually did the construction as on the Navajo Reservation to
this day, they do 99 percent of all construction related to
infrastructure on water, sewer, solid waste, et cetera.
It was only after the passage of NAHASDA that the numbers
dramatically dropped. We were down as low as $1.3 million. Last
year in 2002, it was about $4.4 million that was provided. That
is totally a tribe decision. We concur with that.
Getting back to your original question about why that
language was put in our appropriation, we are so limited in our
resources to address the sanitation deficiency system that
Congress asked us to identify in that universe of need being at
$1.5-$1.6 billion for all of the existing homes, plus address
anything new coming on, we weren't in a position, at least the
appropriators thought, to pick up additional responsibility for
HUD sponsored units because we have $94 million we are
addressing against the feasible amount of $900 million and of
that $94 million, we put about half of it to address new units
every year. In 2002, we had a few hundred units we weren't even
able to address, about 350 units, where individuals were
financing and paying for their homes themselves that we
couldn't get to within the priority systems that exist.
That's a little more background. I hope I haven't expounded
to far in some of the detail but I'm prepared to expound
further as needed.
Mr. Pombo. Thank you, Mr. Chairman.
The Chairman. I can look at the clock and see that by the
time we get done with the next panel, we are going to run out
of time. I would ask my colleagues to keep their questions down
to 3 or 4 minutes.
Congressman Kildee.
Mr. Kildee. On the question of sanitation, the Senate bill
apparently prohibits the use of IHS funds for sanitation in HUD
housing whereas the House bill does not contain that
prohibition. How does the IHS suggest we clarify the language
referring to IHS funding for sanitation in HUD constructed
houses?
Mr. Grim. As I pointed out earlier, right now the two
programs are really separate programs. We are serving that
backlog of existing homes that do not have adequate safe water
and sanitation facilities as well as newly built homes that are
built with other than HUD funds. There are a large number of
those being built annually.
There are currently two separate programs. The two bills
that have been introduced with differing language, I suspect in
conference committee will be dealt with but if our funds were
to be merged with HUD funds, it appears it would be taking two
separate programs and merging them into one. We would have a
difficult time then perhaps addressing the existing home
backlog.
Mr. Kildee. Perhaps the House and Senate can get together
and try to bring our language to more compatibility to see what
we can do to encourage the IHS. In some very remote parts of
Michigan where I come from where there are no water lines as
such and no sewer lines, they do have septic facilities and
there is groundwater they can use for the operation. I think
remoteness alone, there might be some areas where you don't
have the groundwater, would not always preclude the
possibility. This certainly relates to health, there is no
question about that.
The Saginaw Chippewa Tribe, in my State but not my
district, in 1934 the Federal Government built a number of half
houses for the Indians. Some of those half houses are still
there, maybe have been finished off and changed a bit but I
guess the Indians were grateful to get the half houses but they
really were half. I think we certainly should have come a long
way since 1934 and a long way since 1980.
I'm willing to work with you to see what we can do to help
the IHS and HUD work more closely together to provide this. I
also believe we should elevate your position to that of
assistant secretary.
Mr. Grim. Thank you, Congressman Kildee. I might point out
for everyone's information that the language in the Senate bill
relative to the way we work with sanitation facilities is the
current practice that is being carried on.
The Chairman. Congressman Cole, any questions?
Mr. Cole. No; Mr. Chairman.
The Chairman. Congressman Faleomavaega.
Mr. Faleomavaega. Again, I want to thank Dr. Grim for his
testimony.
Mr. Grim, I think one of the problems that left this
proposed legislation for authorization hanging was the question
of scoring. I notice that some estimates come out to $2
billion, $3 billion, $6.9 billion for the 10-year period. It
seems we are squeezing blood out of a turnip. Why is it we are
having such a difficult in time in trying to arrived the best
cost estimate when it is so simple to get $70 billion to clean
up Saddam Hussein's mess, so instantly it seems. We're asking
for a mere $3 billion.
From the statement here, I am concerned that alcoholism, is
770 percent higher than the U.S. population; diabetics, 420
percent higher; accidents, 280 percent higher; suicide, 190
percent higher; homicide, 200 percent higher and we can't even
find a common ground to get the proper money.
The bottomline, Dr. Grim, is funding. What is the
Administration's best estimate of the level of authorization
needed for the 10-year period, because I'm getting all kinds of
figures. I'm a little confused. Can you give us your best
estimate of how much authorization is needed to properly fund
our Indian Health Care Program?
Mr. Grim. The current bill, both House and Senate, I don't
currently have available today to be able to tell you. Because
of the variabilities in the two bills, there are some
significant variabilities in title IV for example.
Mr. Faleomavaega. We can clear that up on our side. I'm
asking the Administration's position. What is your position on
this? How much should be authorized for of this legislation?
Mr. Grim. We have a study that's been done internally that
only looks at the personal health care expenditure needs and
doesn't look at our public health infrastructure which is also
a big need. We also have a tribal needs based budget the tribes
have presented.
Mr. Faleomavaega. Dr. Grim, you still aren't understanding
my question. The bottomline, what is the Administration's
recommendation regarding the level of authorization needed to
assist our Indian community for the next 10-year period? If you
can't answer it right now, can you submit that for the record?
Mr. Grim. Yes, sir; I will submit that for the record.
Because of the variability in the bills, I can't answer that.
Mr. Faleomavaega. I really would appreciate that.
The second question, I believe the total population of
Alaskans and American Native Indians is over 14 million. Am I
correct?
Mr. Grim. The American Indian and Alaska Natives we serve
in our facilities is about 1.6 million. The most recent census
places the number of American Indians and Alaska Natives in
combination with another race at over 4 million.
Mr. Faleomavaega. $4 million. I thought it was more than
that. If you could give us exactly what the Administration
proposes. I made the estimate that we have about 14 million
American Indians and Native Alaskans in this country. You are
saying the entire health care system provides services for
about one point six million American Indians and Alaska Native?
Mr. Grim. Yes, sir.
Mr. Faleomavaega. For the rest of our Native American
community, they are out there on their own, really flat out,
just in the worse situation than any other ethnic group here in
our country. Would you agree with me on that?
Mr. Grim. I would say a portion of that population we are
not serving has private insurance and is seeking care but
that's a very small percentage. It is hard for us to place a
handle on it since they don't access our health care system.
The remainder of that group that is not that small percentage
with private insurance or the ones seeking care from us, many
of them are without health care.
Mr. Faleomavaega. One quick question to Mr. Nesmith. I know
HUD is not part of the Indian health care authorization
legislation. For the last fiscal year, how much monetary
assistance did HUD provide Native Americans for housing?
Mr. Nesmith. The last fiscal year?
Mr. Faleomavaega. Yes.
Mr. Nesmith. About $650 million.
Mr. Faleomavaega. How much are you proposing for the coming
fiscal year? I hope it is an increase.
Mr. Nesmith. I'm not sure if it's level but I can get back
to you.
Mr. Faleomavaega. The $650 million in the last fiscal year
provides for how many of our Native American community people?
Mr. Nesmith. We believe that would provide for the numbers
you just mentioned.
Mr. Faleomavaega. My point is we are totally underserved,
even with the amount of funding that HUD is providing, it is
not even the tip of the iceberg as far as the community housing
needs of our Native American community throughout the country.
Would you agree with me on that?
Mr. Nesmith. Not being able to compare, you said it was $14
million. I would say there needs to be some improvement.
Mr. Faleomavaega. Thank you, Mr. Chairman.
The Chairman. Senator Murkowski, did you have any
questions?
Senator Murkowski. No; thank you.
The Chairman. Congresswoman Napolitano.
Ms. Napolitano. I'd like to followup on my colleagues'
questions and the health disparities issues. I'm wondering how
much of the funding is going into addressing the education or
training of Native Americans to be able to deal with the
issues. It is not the first year that I've heard of the high
percentages of these individual groups.
How are we dealing with the alcoholism, the diabetes,
suicide and homicide? Accidents, that is another issue but all
the others are lumped into an area that has been very prevalent
in the American Indian community for many decades. It isn't the
first time. What are you doing? How much money is being put
into programs that will help these communities be able to deal
with those issues?
Mr. Grim. I will need to submit part of the answer to that
question for the record in writing. What I can say is that our
current budget is approaching $3 billion.
Ms. Napolitano. Total budget of what?
Mr. Grim. Of the Indian Health Service. You initially asked
about education and we do have a scholarship and loan repayment
program that we do work with trying to get American Indian and
Alaska Native Youth into the health professions so they are
back into their own communities. We also have a large portion
of that budget that is in the health care delivery area.
Approximately 50 percent of our budget in rough terms is now
being administered by tribes themselves through Public Law 93-
638. They are making their own decisions about the delivery of
health care in their communities.
The other locations where the Indian Health Service
operates the programs directly, we work closely with community
health boards and tribal health boards and programs in the
communities to determine priorities they want within the
communities.
Ms. Napolitano. What has been the result of these health
delivery organizations? According to what I see here, the
alcoholism is astounding. Do you have programs to actually help
deal with the alcoholism problem?
Mr. Grim. Yes; the majority of the programs that are
alcohol and substance abuse programs in Indian country are run
and managed by the tribes themselves. As a rough estimate, I'd
say in excess probably of 95 percent of the programs and the
money the Indian Health Service receives, about $130 million is
what we receive in our line item for alcohol and substance
abuse, well over 95 percent of that is going directly to the
tribes themselves to run their programs.
Ms. Napolitano. Is there an issue that what is happening is
not actually being effective in taking another look at how else
to approach it, working with the tribes you have authorized the
money for?
Mr. Grim. I think a large part of it is the complex nature
of alcoholism. We have programs directed at both prevention and
treatment, although we don't have enough inpatient treatment
facilities or long term treatment facilities in many of the
communities that need it. However, it is a complex mix of
socio-economic factors, isolation issues, lack of adequate
jobs, housing and things like that that all feed into the mix.
Many of the diseases we are facing in Indian country today are
behavioral and chronic as opposed to the infectious diseases we
saw early on. So it requires a different mix of factors and
programs that are more than just health programs alone to try
to address them.
Ms. Napolitano. Are those being implemented? That is what
I'm trying to get at, thinking out of the box, doing new,
effective methods that are going to break that cycle, that are
going to assist families in being able to be supportive of each
other, the tribes to be able to get to those in alcoholism. My
husband died of alcoholism so I understand it very well.
Thank you.
Mr. Grim. Yes; I think the programs are ongoing out there,
I think they are effective, I think the tribes are working
within the communities to implement a more whole body wellness
approach, physical, mental. emotional and spiritual. Many of
them are involving their traditional ways into the programs and
I think we are seeing progress. The issue is just the
overwhelming numbers that we face right now.
Ms. Napolitano. I'd like to hear more. If you have anything
you can submit to the committee on what is actually being done,
I think it is a great problem and is very hurtful to Native
Americans. I think we need to be able to understand it, to be
able to look at how we as a society can assist in being able to
address it and help them be able to understand how hurtful it
is to them and their communities.
Mr. Grim. We will submit some information to you for the
record on our programs and the things going on with the tribes.
You are right, there is a huge disparity and a huge need in
that arena.
Ms. Napolitano. Thank you, Mr. Chairman.
The Chairman. Congressman Grijalva, any questions?
Mr. Grijalva. Yes; thank you, Mr. Chairman.
In the tribal working group that worked with the Indian
Health Service throughout this process and as a result, much of
what we're deliberating is a product of that work, did this
working group take a position on the point we spend a lot of
time talking about as to who is going to have the
responsibility, HUD or Indian Health Service for sanitation and
sewer?
Mr. Grim. The group did take a long look at that. There are
two versions as you see before you right now, one in the Senate
and one in the House. I don't think there is a consensus in
Indian country right now relative to how that issue should be
handled, whether the money should be lumped into one sum or
whether these two existing programs which have separate goals
should be kept separate. I just don't think there is consensus
out there in Indian country yet either.
Mr. Grijalva. Along the same lines, in reference to the
steering committee you worked with, long and hard, as you see
both bills, the Senate and the House, are there any serious
omissions in this legislation, issues that those of us here
should be aware of?
Mr. Grim. I've submitted in my written testimony a number
of things, some of the things this committee asked us to focus
on today. Then there are a couple of overarching issues also in
my written testimony. In the interest of time, I can submit
some further issues in writing because it is a complex piece of
legislation.
Mr. Grijalva. I would appreciate that, sir.
Thank you.
The Chairman. Congressman Pallone.
Mr. Pallone. Dr. Grim, I like you personally so I don't
want you to take offense from anything I say but I just don't
get the sense of crisis from your testimony. When you go out to
Indian country, you hear stories about people dying because of
lack of access to health care, you hear about the disparities
with diabetes and alcoholism and so many other issues, and the
inability to attend to those problems, and particularly with
the facilities. Every time you go to a tribe, they talk about
how they are on a 10- or 15-year waiting list to get a new
facility or to renovate their facilities. Then you get all this
stuff about funding. As Mr. Faleomavaega said, we just hear the
funding is so inadequate and even more so that the notion the
Federal Government is relying on the tribes to provide funding,
particularly if they have a little money because they have a
casino or whatever.
I'm trying to look at the larger picture and I guess I
could ask two questions and if you can answer them, fine. If
not, get back to me. Do you see a real crisis because I do and
where is that crisis? Is it in the lack of money for
facilities, is it in the diabetes area, is it an inability to
provide funding for nursing home services? I hear about all
these things.
The second question is, the tribes really feel, a lot of
them say to me that the Government is not following through on
its commitment to provide the funding federally and that they
are now expected to use their own resources to build new
diabetes clinics or new hospitals and almost built into the IHS
the notion that the tribes are going to pay for a significant
part of their health care. That's not the way it's supposed to
be. Do you see a crisis? Where is it? Do you assume that they
are going to pay a significant portion of their own services or
construction?
Mr. Grim. First, let me say that yes, I see a crisis. The
percentage of mortality rates that our population exceeds
relative to the U.S. population is not acceptable to me as the
director of the Indian Health Service or as an American Indian.
Is there a funding issue? I think we are starting to see
potentially higher rates of inflation in health care than we
have in past years. That impacts our budget significantly.
Whenever health care inflation exceeds the amount of money we
receive, we have loss in buying power. We have stayed
relatively static in buying power over the last decade. We have
not seen a large increase in buying power in the Indian Health
Service budget, not withstanding the increases Congress has
appropriated to us.
I think the issue is a very complex one as I said earlier.
We certainly need greater access to health care in Indian
country. There are certain services that need higher levels of
access than currently available but the other issue is the
complex nature of health. It is not just being able to access a
clinic, it is adequate and safe housing, it is economic
opportunities on the reservations.
Mr. Pallone. What about the backlog in facilities?
Mr. Grim. We have a large estimated backlog in facilities
needs in Indian country. Right now, the average age of an
Indian health care facility is about 36 years of age. In the
private sector, the current age of a facility is about 9 years.
About 20 percent of our facilities meet that 9 years or younger
average, so we have a large backlog in facility needs in Indian
country.
Regarding the issue of appropriating funds for facilities,
Congress has been consistent over the years in trying to keep a
number of Indian health facilities projects ongoing but there
is a large backlog of need out there.
Mr. Pallone. Do you assume that a lot of these tribes are
going to take care of their own needs? That is what they tell
me. They say, we have to build our own clinic, we have to build
our own hospital, we have to pay for this ourselves. Is there
an assumption on the part of the Federal Government that is
going to happen?
Mr. Grim. No, sir; Congressman Pallone, I do not assume
that and I don't think the Administration assumes that. One of
the things we have seen over time is sometimes when tribes take
over their own health programs and sometimes when the Federal
Government still runs them, tribes have donated tribal funds or
placed tribal funds into programs because of the need in
particular sectors for their communities.
I do hear the same things you hear when I'm out there
visiting Indian country, that they feel we should be doing
more.
Mr. Pallone. Thank you.
The Chairman. Congresswoman Christensen, did you have
questions?
Ms. Christensen. Yes; I'll try to make them short.
I've been fortunate to have Native American interns and one
of them is with me, Caryle Begay, and another. I want to ask a
question that comes from some of the discussions we have had.
Considering there has been a significant increase of Native
Americans, Alaska Natives into urban areas, away from rural
reservation areas where the majority of Indian health services
are provided, what measures are being taken to focus on
providing health services for this growing urban Indian
population.
Natalia Arosco, an Indian on the San Pasqual Reservation,
lives in a very small urban tribal reservation. They also have
some unique needs for research data collection, publications
and guidance for health care providers. What in this
reauthorization addresses that?
Mr. Grim. You are right in that we have seen a large
demographic shift of American Indians and Alaska Natives now in
urban areas. We still have 34 urban Indian programs that we
provide grant funding for to operate in some existing
locations. Those funds were put together through title V when
Congress adopted title V of the current Indian Health Care
Improvement Act. Those funds were intended to stimulate some
health care services. Some are just referral and outreach and
some provide more comprehensive care for areas where there were
large urban Indian populations.
Under the former director, Michael Trujillo, when the
Indian Health Service started consulting with Indian Health
Service, tribal and urban programs more, we brought the urban
partners to the table. They now take part in our work groups
and policy decisions within the agency and we are trying to
work more closely with them for their needs.
Ms. Christensen. You also say under the negotiated
rulemaking part of the bill that the tribal consultation may
not be the most effective way to obtain necessary Indian
provider input. As a physician and member of the Small Business
Committee and my colleague, Grace Napolitano can attest to
this, we spend a fair amount of time with CMS and their
rulemaking as it relates to providers of all backgrounds.
What would be a more effective way because through the
Office of Advocacy and through the Regulatory Flexibility Act
we have been able to improve on their consultation. I think the
Native American and Alaska Native providers deserve the same
treatment.
Mr. Grim. Specifically to the tribal consultation process,
the Indian Health Service believes very strongly in that and
works with tribes to that end. One of the comments made in my
written testimony was that due to the number of regulations
that come out of CMS, there was concern on behalf of the
Administration that tribal consultation on all of the
regulations coming through CMS might place an undue burden on
the agency, on CMS.
Ms. Christensen. Maybe they ought to simplify their
regulation and rulemaking.
Mr. Grim. I'll take back that information.
The Chairman. Congressman Udall
Mr. Udall. First, I want to ask about the reauthorization
and the bill that is before us. In doing that, I compliment
Chairman Campbell. He has introduced a piece of legislation, S.
212, in the 107th Congress; we now have before us in the 108th
Congress, S. 556. There has been a great deal of consensus
building done on this bill. Is the Administration at the point
of supporting the bill before this committee now, weighing in
and trying to make sure it gets passed?
Mr. Grim. The Indian Health Care Improvement Act
Reauthorization bill, S. 212?
Mr. Udall. S. 556 which Chairman Campbell has worked on
very hard. It is a bill that has been around a long time and I
don't believe you have a reauthorization. You're just going
year by year, aren't you?
Mr. Grim. Currently, that is correct. The reauthorization I
don't believe has been extended currently but it had been
extended in previous Congresses and we are still operating. I
was very excited to see a joint hearing today between the House
and the Senate on the various versions of the bill.
Again, both bills are complex, very long bills and the
Administration has made some comments relative to their issues
or concerns on specific parts of the legislation and we are
still doing side by side comparisons right now, so we don't
have a full analysis.
Mr. Udall. How soon do you think you will have that?
Mr. Grim. I would have to submit that for the record, sir,
about the length of time. I'd have to check with our assistant
secretary for Legislation.
Mr. Udall. Do you think you are going to be in a position
in the next couple months to be able to support this bill?
Mr. Grim. We work very closely with both committees so that
we can try to do that.
Mr. Udall. I think that is very important because I think
the approach Chairman Campbell and Don Young have taken in
introducing this legislation is looking at the long term and
looking at 10 years. It seems to me the more you're required to
go year by year, you aren't looking at those big issues that
many members of the panel have been raising. Would you agree
with that?
Mr. Grim. I think we have continued to operate our program
with a long term focus, notwithstanding the fact this current
bill has been pending reauthorization for a number of years,
but we are very, very anxious in the Indian Health Service and
in the Department of Health and Human Services to see the bill
reauthorized.
Mr. Udall. I'm happy that is the case. I want to ask one
other question on this whole diabetes epidemic. I have a
congressional district that is 22 percent Native American in
the State of New Mexico, 9 percent Native American. I had a
very poignant story told to me by a renal specialist in Santa
Fe about diabetes in our community surrounding Santa Fe which
we have a number of Pueblos.
He told me that 20 to 25 years ago, a gentleman that
started a practice quite a while ago, they did not see very
many cases of diabetes in Native American individuals that came
into the Indian Health Service hospital or that were being seen
privately. In his lifetime, he said this has dramatically
changed. We truly have an epidemic.
I'm not a doctor. It is what he described to me but he says
a lot of what is going on here has to do with diet, obesity,
sedentary lifestyle, lack of exercise and it seems if this is
the key, education and prevention are the way to go. What are
you proposing as to how to tackle this epidemic and how to move
us out of this horrible cycle we are going into?
Mr. Grim. I think you have seen the President and the
Secretary have an increased emphasis on health promotion and
disease prevention in the last couple of years. Since I've been
in the Indian Health Service, I've initiated a health promotion
disease prevention initiative within this past year involving
tribal leadership and health expertise from our facilities and
clinics to try to reemphasize or bring to the forefront again
health promotion and disease prevention efforts.
I think the Indian Health Service has always been strong
over the years in our health promotion efforts. We run a public
health program in the communities as you have heard today and
some of the testimony is not only the delivery of health care
but environmental health and sanitation facility issues as
well.
We are trying to focus on those chronic disease issues
because they are not as easily solved as some of the diseases
we faced in the past. As a Nation, we are now starting to
address it.
Internally, Congress has been good to devote $100 million
over the last 6 years and an additional $50 million to the huge
problem of diabetes in Indian country. I cannot report to you
specific numbers but if you'd like them for the record, we have
a large number of primary prevention programs going on in
Indian communities right now. We have a large number of
secondary and some minor tertiary sorts of initiatives going on
with that $100 million Congress appropriated. We are seeing
successes out there. We are looking at five to six overall
clinical indicators and seeing movement in the right direction.
We think we are staring to make impacts on the diet issues, the
obesity issues, and such things that not only lead to diabetes
but a lot of other chronic diseases like cardiovascular
disease. Right now, cardiovascular disease is on the rise in
Indian populations, 25 percent greater than the Nation as a
whole. A number of years back, we were lower than the rest of
the Nation. The rest of the Nation is seeing reductions in
those, we are seeing some increase. So we are working very hard
on the control of blood pressure and things like that in our
population.
I think there is a lot going on out there on issues like
this, it is going to take years before we see significant
improvements in the indicators to show success is coming.
Mr. Udall. With the Chairman's permission, could you submit
those for the record, what you are doing, what you anticipate
you need in terms of money to tackle the diabetes epidemic in
terms of prevention and education.
As a final followup, wouldn't you agree that it is far
better to tackle these at the front end with prevention and
education than dealing at the tail end where you have end stage
renal disease and dialysis and the enormously expensive options
that patients have at that point?
Mr. Grim. I believe that 100 percent because I think that
not only will it reduce the cost of health care in the long run
and allow us to do more but I also believe it is better for our
people, they will lead longer, healthier lives.
Mr. Udall. Thank you. Let me compliment Chairman Pombo and
Chairman Campbell for convening this joint hearing. I hope it
will move this legislation along and we can get a 10-year
authorization for the Indian Health Service.
The Chairman. If it moves along as fast as this hearing, it
may be 10 years before we finish the hearing.
I'm going to submit my questions in writing. We have a
series of votes starting at 12:10 p.m. in the Senate and the
House will be voting right after that. We still have six people
and I'm dividing the time to make sure they have equal time at
the microphone.
We will thank this panel and move to the second panel which
will be: Rachel Joseph, cochair, National Steering Committee on
the Reauthorization of Indian Health Care Improvement Act from
Lone Pine, CA and Dr. Ben Muneta, president, Association of
American Indian Physicians from Oklahoma City and Steve Weaver,
director, Division of Environmental Health and Engineering,
Alaska Native Health Consortium.
As I told the first panel, your complete written testimony
will be included in the record, but in order to give everyone
equal time before we have to close it down unless you want to
come back later this afternoon which most don't, I'd ask you to
limit your testimony to about 5 minutes or less.
Why don't we ask the third panel to be seated too: Kay
Culbertson, president, Denver Indian Health and Family
Services; Dr. Everett Rhoades, Oklahoma City Urban Indian
Health Clinic; and Carmelita Skeeter, executive director,
Indian Health Care Resources Center of Tulsa.
Rachel, would you start. Remember we have about 5 minutes
apiece.

STATEMENT OF RACHEL JOSEPH, COCHAIR, NATIONAL STEERING
COMMITTEE ON THE REAUTHORIZATION OF THE INDIAN HEALTH CARE
IMPROVEMENT ACT

Ms. Joseph. Good morning. My name is Rachel Joseph,
chairperson of the Lone Pine Paiute-Shoshone Tribe and cochair
of the National Steering Committee on the Reauthorization of
the Indian Health Care Improvement Act. I'm also chairperson of
the Toiyabe Indian Health Project a consortium of nine tribes
serving California's Inyo and Mono counties.
Thank you for holding this joint hearing providing us an
opportunity to state our strong support for S. 556 and H.R.
2440, the Reauthorization of the Indian Health Care Improvement
Act. These bills contain provisions that are necessary to
improve the ability of tribal and urban programs and the Indian
Health Service to provide comprehensive, personal and public
health services.
In 1976, when Congress found that ``the unmet health needs
of American Indian people are severe and the health status of
Indians is far below that of the general population of the
United States,'' the Indian Health Care Improvement Act was
enacted. Federal health services to Indians and Alaska Natives
has resulted in a reduction in prevalence and incidence of some
illnesses. For example, since we delivered our proposed bill,
the death rate for pneumonia and influenza decreased from 71
percent higher than all races in the United States to 52
percent higher.
However, the unmet health needs of our people remain
alarmingly severe and continues to decline. Our health status,
as already stated, is far below that of the general U.S.
population. This crisis and disparity to be addressed is
formidable.
The oral health of our patients is poor and we experience
approximately three times the amount of tooth decay and
periodontal disease than the U.S. general population. As
already stated, the mortality rate for diabetes, 420 percent
greater than the rest of the Nation, and Type II diabetes is
rising faster among our children and young people than any
other population and is 2.6 times the national average. Our
suffering due to diabetic end stage renal disease is 6 times
the rate of the national population and amputations due to
diabetes is three and four times the rate.
In my community, diabetes is among the three top chronic
diseases. We serve our population with three clinics and just
at the Bishop Clinic, we see an increase of two diabetes
patients every month.
Cardiovascular disease is now the leading cause of
mortality among Indian people with a rate that is almost 2
times that of the U.S. general population.
The recent fully analyzed and racially adjusted mortality
data [fiscal year 1999] from the National Center for Health
Statistics documents an overall 4.5 percent increase rate for
American Indian and Alaska Native people, from 698.4 per
100,000 population for the period 1994-96 to 730.1 per 100,000
for the period 1997-99.
In recognition of the conditions just reiterated, tribes
engaged in the consultation with a goal to develop consensus
and the NSC membership acknowledged that all of our
constituents included the ``lesser haves'' the ``least haves''
and ``have nots''; thus, we agreed not to ``take from each
other''. One of our ground rules was that ``provisions will not
adversely affect or diminish funding which is available to
other Indian programs or the I/T/U system. . . ''
Now, I will highlight title III of the bills which now
provides a broader approach to address the unmet facilities
needs and provides innovative funding options. Language
concerning Safe Water and Sanitary Waste Disposal Facilities in
section 302 of S. 556 reiterates a cooperative relationship
between HHS and HUD regarding safe water and sanitary disposal.
After consensus was reached on this issue, reflected in S. 556,
there has been an effort by some housing advocates to amend the
language that prohibits the use of I.H.S. funds for newly
constructed HUD homes. Why do it since the I.H.S. Section 302
funding is already critically under funded for this ``Safe
Water and Sanitary Waste Disposal Facilities'' program?
Approximately 21,500 American Indians and Alaska Native homes
lack safe water and the current backlog of need for this
program construction is $900 million. Since 1982 Congress has
repeatedly expressed its intent that funds appropriated to the
IHS not be used for sanitation facilities for new HUD homes.
This system worked fairly well until 1996 when NAHASDA was
enacted and funding is now distributed by a formula which does
not account for deficiencies or cost of offsite sanitation
facilities. One of IHS Government Performance Results Acts
[GPRA] indicators for fiscal year 2005 is to increase the
proportion of American Indians and Alaska Natives receiving
optimally fluoridated water by 0.5 percent over 2004 levels.
An IHS fiscal year 2002 indicator committed to a 5-percent
increase of American Indian and Alaska Natives benefiting from
fluoridated drinking water. While the fiscal year 2002
indicator was not fully achieved, 15 small systems not
previously fluoridated became fluoridated adding 20,580
individuals to those receiving the benefits of fluoridated
water. Since fluoridation is one of the most cost effective
public health measures for reducing the prevalence of dental
decay of all ages, we must do what we can to ensure that these
limited funds remain available for these purposes.
If I may share a personal experience. This spring, the
Indian Health Service replaced a water pump, replaced asbestos
pipes, fluoridated our community drinking water and pressurized
our system. Before that, my parents had to utilize water that
would not allow for the brushing of teeth at the same time you
washed dishes. My dad did not allow us to wash his dress shirts
at home because our water was tainted with rust color. Now, the
228 young people in our community will experience the long term
benefits of fluoridated water. The middle-aged and us elders
will experience those benefits as well.
An IHS indicator, No. 35, for fiscal year 2005 is to
provide sanitation facilities to 22,300 homes, in 2002, 15,255
homes were served. I support addressing the need and those
tribes that are next in line to receive these services and I
hope the dollars are there.
A new provision of S. 556, section 310 and section 309 of
2440 authorize a loan guarantee, a revolving loan fund and a
grant program for loan repayment. The authorization to
appropriate funds for an Indian health care facility loan
program could be tremendous support to those tribes that want
to build their own facilities.
The joint venture, section 312 of S. 556 and section 311 of
H.R. 2440, provides for creative, innovative financing by
tribes for construction of health facilities. This joint
venture with the Indian Health Service is a viable option for
those tribes that can construct their own facility. The IHS
obligation is for equipment, staffing and to operate it.
In 2001 and 2002, Congress appropriated dollars for this
program which resulted in the construction of four facilities
which included two on the IHS priority list. The small
ambulatory program, section 306 of 556 and section 305 of 2440,
another popular program with the tribes, authorized in 1992,
received its first appropriation in 2001 and 2002 of
approximately $10 million which provided for the construction
of 17 tribally owned facilities that the tribes equip, staff
and operate. Unfortunately, neither S. 1391 or H.R. 2691
includes 2004 funds for this small ambulatory program. Another
new provision ``Other Funding'' provides for alternative
financing options.
The Chairman. Rachel, I apologize, but we are going to run
out of time.
Ms. Joseph. The National Steering Committee appreciates
this opportunity. We completed the process of consultation and
collaboration with broad support and we want to urge you
respectfully to consider any procedural actions necessary to
move this legislation as quickly as possible.
Thank you for your time.
[Prepared statement of Ms. Joseph appears in appendix.]
The Chairman. Thank you.
Dr. Muneta.

STATEMENT OF Dr. BEN MUNETA, PRESIDENT, ASSOCIATION OF AMERICAN
INDIAN PHYSICIANS

Mr. Muneta. Good morning.
I am president of the Association of American Indian
Physicians. I would like to add our organization's support for
the reauthorization of the Indian Health Care Improvement Act.
I am somewhat reflective of our membership in that I worked in
urban, tribal and Federal health care facilities and we have
all come to the consensus that this Act is for the good of
Indian people.
The Indian Health Service is a highly efficient
organization. You can't find anything in government that is
more efficient in the use of dollars as the IHS. We feel any
money that is directed that way is money well spent by the
Government.
I would add that American Indians are living longer but one
of the big problems we see is in several cities American
Indians are going to have the lowest quality of life of any
minority group in this country. The reason is simple. Chronic
diseases like diabetes are going to sap the health of Indian
people. Diabetic patients are 4 times more expensive than a
non-diabetic patient under usual medical care. This translates
into people being sicker, not having jobs, and economic loss to
the communities. It is a ripple effect throughout Indian
communities, not just in the health care system.
One of the ways we look at these disparities is by training
more Indian doctors, more health professionals who go back to
these communities and provide long term, quality care. This is
one of the great success stories that we have, the health
scholarships that IHS operates.
I think that is all I have to say.
[Prepared statement of Mr. Muneta appears in appendix.]
The Chairman. Thank you.
Mr. Weaver. I might mention Senator Murkowski had to
preside at 12 p.m. She has already left but she did tell me
that she particularly wanted to hear your testimony, so I am
sure she will read it with great interest.

STATEMENT OF STEVE WEAVER, DIRECTOR, DIVISION OF ENVIRONMENTAL
HEALTH & ENGINEERING, ALASKA NATIVE TRIBAL HEALTH CONSORTIUM,
ACCOMPANIED BY ANDREW JIMMIE, CHIEF, MINTO TRADITIONAL COUNCIL

Mr. Weaver. Thank you for the opportunity to testify
regarding S. 556 and H.R. 2440, the Senate and the House bills
that would reauthorize the Indian Health Care Improvement Act.
I am appearing today on behalf of the Alaska Native Tribal
Health Consortium where I serve as Director of the Division of
Environmental Health & Engineering. I am accompanied by Chief
Andrew Jimmie of the Minto Traditional Council who appears this
morning in his capacity as the vice chair of the Alaska Native
Health Board. Chief Jimmie is also the president of the Tanana
Chiefs Council Conference of Regional Health Boards and
recently received the prestigious Alaska Federation of Natives
Health Award.
Under the leadership of the National Steering Committee,
the language in what has been introduced as H.R. 2440 was
developed in nearly complete consensus by tribal leaders. I am
pleased to testify this morning that from a sanitation
facilities operations perspective, I recommend to the Senate
that it substitute the sanitation and facilities provisions of
H.R. 2440 in place of S. 556.
I would particularly like to thank the committee for its
long term support of the SFP program. Sanitation facilities
construction is first and foremost about public health. It has
a documented history of success in raising the health status of
American Indians and Alaska Natives. While much as been
accomplished, much remains to be done.
IHS estimates the current national unmet need both feasible
and infeasible of Indian sanitation unmet need of $1.6 billion.
Alaska's component is $640 million. Alaska has a unique and
demanding living environment. Suvonga, displayed to your left,
is typical of remote Alaska Native communities, accessible by
air year round and in the summer by boat but it is not
connected on land by any road network.
Cooper Bay is also typical of rural Alaska. For the last 40
years, they have packed in their drinking water and packed out
their human waste in honey buckets. They are not atypical. One-
third of Alaska Native homes still lack piped water and sewer
facilities.
Other Indian communities throughout the United States face
similar challenges. Current national funding levels are not
nearly sufficient to make meaningful progress. The Indian
Health Service sanitation deficiencies, unmet needs inventory
is increasing at a rate of $50 million a year in addition to
the construction activities.
The National IHS Priority List for new health facilities
has stood without major addition for some 15 years. Language
improvements in title III of H.R. 2440 represent an opportunity
to provide flexibility in how we address this backlog and
enhance how we do business. It establishes requirements to set
priorities for limited facilities resources. It provides more
flexibility of program management for tribes and the potential
for innovation as tribes develop and diversify alternative
funding sources. It enhances the ability of IHS and the tribes
to deliver critically needed services as well as clarifying
operational authorities.
It also provides the tribes a real opportunity to aggregate
funding sources and to utilize those to the best opportunity of
the community. The impact of public health is not in the
construction of the facility, it's in the long term operations
and maintenance of that facility to deliver the lifestyle
improvement and the health improvements so badly needed.
In conclusion, I'd like to thank Chairman Campbell and
Chairman Pombo and the respective committee members for this
opportunity to give an engineer's perspective as we move
forward together building healthy and safe American Indian and
Alaska Native communities.
[Prepared statement of Mr. Weaver appears in appendix.]
The Chairman. Thank you.
Ms. Culbertson.

STATEMENT OF KAY CULBERTSON, PRESIDENT, DENVER INDIAN HEALTH
AND FAMILY SERVICES

Ms. Culbertson. Good morning. My name is Kay Culbertson. I
am an enrolled member of the Ft. Peck Assiniboine/Sioux Tribes
from Poplar, MT; the executive director of the Denver Indian
Health and Family Services; and also serve on the board of the
National Council of Urban Indian Health.
I am honored today by the presence of my father and I am
very happy he could be here with me.
Let me start by saying I'm not a lawyer or a policy
analyst. My testimony both oral and written are from my heart
and reflect a combination of my brief experience as a program
director and my lifelong experience of growing up between the
reservation and the city. Some of my testimony may sound strong
but I find I must stress these issues or I would not be true to
my upbringing and values I hold as an Indian person and as a
wife and as a mother of three, all of whom are enrolled members
of federally recognized tribes.
It is time that urban Indian health issues are seriously
considered and I believe S. 556 is a good beginning. I would
like to thank you for the improvements in the bill. The
designation that a major goal of the United States is to
provide the quantity and quality of health services which will
permit the health status of Indians regardless of where they
live to be raised to the highest level that is no less than
that of the general population and to provide for the maximum
participation of Indian tribal organizations and urban Indian
organizations in the planning, delivery and management of those
health services.
I would also like to point out at this point, the urban
Indian health programs receive not even a full two percent but
almost two percent of the Indian Health Service budget.
Some key points have been very positive for urban Indian
health programs in this legislation, allowing urban programs to
receive reimbursement from insurance programs when the urban
Indian health provider is considered to be an out of network
provider; the disregard of payments received through third
party revenue and determining funding appropriations for health
care and services to Indians; the ability of current programs
to create satellite clinics to better address the health needs
of the Indian community; the establishment of a self
sustaining, revolving loan fund that will be solely for urban
Indian health facilities; and permanency for the Oklahoma City
and Tulsa demonstration projects.
The development and construction of two residential
treatment centers for urban Indian youth in each State where
need exists and where there is a lack of culturally constant
residential treatment services for youth, as mental health and
substance abuse needs continue to grow and State facilities and
funding are cut, we must address these needs for the city
youth.
Increased consultation with urban Indian health programs
and Federal Tort Claims Act coverage for urban Indian
organizations who receive funding under this legislation are
also items of concern to me as an urban program director. Urban
programs are not eligible to apply for chronic shortage
demonstration projects. We experience shortages in personnel
all the time through the urban Indian health clinics.
The sections that address the mental health training and
community education programs as well as prevention control and
elimination of communicable and infectious disease programs
includes urban Indian programs and studies and consultation
processes but do not include us in the development, technical
assistance and funding of these programs.
Urban Indian health programs are not authorized to benefit
from the Indian Health Care Improvement Fund or the
Catastrophic Health Emergency Fund. Lack of funding
authorization for critical services primarily home and
community based services, public health functions and
traditional health care in urban programs, we do use
traditional health care.
Title VIII, which has been very hard for me, addresses the
provision of health services to non-eligible persons. This is
of great concern to me as a tribal member and all members who
live off reservation. I believe it takes away services from
legitimate tribal members regardless of where they live. It
appears unfair that tribal members who reside off reservation
are subject to minimal care while non-Indians on the
reservation may receive comprehensive services and possible
access to contract health care services.
On behalf of my community and all tribal members who live
off reservation, I'd like to thank you for the opportunity to
provide testimony on S. 556. I would like to close with this
statement. The United States continues to have a legal
obligation to fulfill with Indian people. Our ancestors, the
people that live in the cities, also signed treaties with this
Government that included provision of health care for their
descendants in exchange for this great country. Whether an
Indian lives off or on the reservation should not be an issue.
These obligations should follow our people regardless of where
they live.
If all urban Indian people were to return home today or
even one-half of us returned home today, being we have over 60-
percent of the population, and exercised our right to those
health benefits, how would the Federal Government meet the
trust and treaty responsibilities to Indian people?
Thank you.
[Prepared statement of Ms. Culbertson appears in appendix.]
The Chairman. Thank you, Kay.
Let the record reflect that not being a lawyer doesn't hurt
you in the eyes of the committee.
Ms. Culbertson. Thank you.
The Chairman. We don't have an objection from Congressman
Udall.
Dr. Rhoades.

STATEMENT OF Dr. EVERETT RHOADES, OKLAHOMA CITY URBAN INDIAN
CLINIC

Mr. Rhoades. Chairman Campbell, Chairman Pombo, members of
the joint committees that are considering perhaps the most
revolutionary health bill related to Indians that has been
passed, my name is Everett Rhoades. I'm a member of the Kiowa
Tribe. I was one of the incorporators of the original Urban
Indian Clinic in Oklahoma City and I also had the privilege of
being one of the outside witnesses that appeared in the
deliberations of the original bill in 1975. I appeared as a
predecessor to the imminent Dr. Muneta on behalf of the
Association of American Indian Physicians at that time where
our primary interest was in title I, the Indian manpower
provisions as well as in the disparities.
I am here today on behalf of the Oklahoma City Urban Indian
Clinic. Because of the importance of this hearing, I'm
accompanied by our board president, Rufus Cox, a member of the
Muskogee Creek Tribe of Oklahoma; our chief executive officer,
Terry Hunter, a Kiowa from Oklahoma City; and our chief
operating officer, Robyn Sunday, a member of the Cherokee Tribe
in Oklahoma City.
Let me make two points in the interest of time. First,
there is a general conception that the basic authorization for
provision of health services to urban Indians, title V of the
Indian Health Care Improvement Act, I do not believe that to be
true and many other individuals do not believe that to be true
either.
A reading of the 1921 so-called Snyder Act which really
provides basic authorization for health services simply says at
that time the Commissioner of Indian Affairs should expend such
moneys as Congress should from time to time appropriate for
various programs, including interesting language that says
conservation of health and relief of distress and for
physicians, for Indians throughout the United States and does
not provide additional guidance.
It is my understanding that the enactment of title V went
beyond simply the authorization of services to urban Indians
but it defined the nature of those services, it defined the
nature of the receiving entity and part of the consideration
was to avoid what I would call the intrusion of the Indian
Health Services' program itself into urban communities
recognizing that even by the 1970's, a dramatic diaspora of
Indians into urban communities would really ultimately require
the entire budget of the Indian Health Service.
As a result of all that, a new entity was created set out
in the definition of paragraph (g) or (h) in section IV that
says these programs are to be located in urban areas, to be run
by a local urban Indian board which, in my opinion,
distinguishes them from both Indian Health Service and tribal
programs.
In that regard, we would ask that the Congress keep that in
mind in its deliberations in regard to title V and we very
strongly support the Senate language contained in section V.
In 1987, as a result of what I would call the growth and
evolution of urban programs in this country, the Congress set
two important demonstration programs into being in Oklahoma
City and in Tulsa which further defined urban health care in
these two demonstration projects, basically to determine
whether or not they would be more apt to succeed if they
received their funding from the hospitals and clinics account
of the Indian Health Service rather than the urban account in
title V but the contracts were still executed under title V, so
they are hybrid programs with a peculiar special characteristic
that should treat them in many instances as service units are
now operating units.
The second point we feel strongly about in Oklahoma City is
that we respectfully ask the Congress to direct that funds that
are received in the Oklahoma area by virtue of the fact the
entire State of Oklahoma is a contract health service delivery
area and the populations in both Oklahoma City and Tulsa
therefore are counted in those allocations, unfortunately with
the present arrangement of distribution of those funds, both
Tulsa and Oklahoma City receive a minority of the funds that
their own populations generate. We believe the Indian Health
Service would welcome direction from the Congress that the
allocations of additional funds, particularly under Indian
Health Care Improvement Act, should be treated as service units
or operating units within themselves.
In closing, I would reiterate in regard to section 512, the
Senate language I think is excellent. It really continues
language that has been in place since 1992 and I would
respectfully ask the House members if they would accede to the
language of the Senate where there may be differences.
Thank you.
[Prepared statement of Dr. Rhoades appears in appendix.]
The Chairman. Thank you. Your institutional memory is of
great value to the committee.
Ms. Skeeter.

STATEMENT OF CARMELITA WAMEGO SKEETER, EXECUTIVE DIRECTOR,
INDIAN HEALTH CARE RESOURCE CENTER OF TULSA

Ms. Skeeter. Good morning and thank you for inviting me to
make this presentation today. I am very happy to see that it is
a joint hearing.
I'm the executive director of Indian Health Care Resource
Center in Tulsa and I have been with this organization for 27
years, so it is very dear to my heart. I have I hope a very
good story to tell you on the demonstration programs.
I am citizen Potawotami enrolled in my tribe and very
active. Becoming a demonstration project in 1987, we did that
with the help of Indian Health Service, the Urban Directors,
coming together and seeing how we could make sure these two
programs existed even though urban programs nationally were
zeroed out of the budget.
Because of IHS and the tribal people seeing our programs
were so vital to the State of Oklahoma, they wanted to make sue
we were able to continue, so we were put into the 01 of the
budget, line item. Since then, we have been able to double our
resources and in some areas, triple our resources. It was like
opening a new door or opening a window to a home that had been
very stale and unsupported. We were able to then start
receiving GSA vans to do transportation for our patients, we
were able to start getting health care providers from IHS, able
to start purchasing medications from the GSA pharmaceutical
contract, so it was opening a new door.
The program in Tulsa has a $2.5 million Indian Health
Service budget. We have been able to turn that budget into over
$6.5 million by contracting with other agencies competing with
other Federal programs on grants and contracts. We have five
contracts with the State of Oklahoma to provide substance abuse
and mental health services. We are State certified. We are
accredited through the Association of Accreditation for
Ambulatory Health Centers.
We have a contract with the Cherokee Nation where they
provide the WIC services in our clinic and have done so since
1979. We have a contract with seven other tribes in the State
of Oklahoma, a program called BEACH which is through the State
health department and CDC working with children on obesity,
drugs, physical fitness, the prevention of diabetes and we are
in three Tulsa public schools with gym teachers working with
these children daily.
I believe that we are a very good partner with all the
tribes in Oklahoma. We work very closely with them and our
board is a community elected board, we have elections once a
year. Any tribal member in Tulsa can run for our board. We have
in the past had councilmen from the Creek Nation on our board,
councilmen from the Cherokee Nation on our board. The tribes
hold meetings at our facility. Oklahoma City and Tulsa are the
only two urban programs in the United States that have been
able to get new facilities in the past 25-30 years.
The facility in Tulsa is 27,000 square feet, the facility
in Oklahoma City I believe is about 27,000 square feet. We have
been able to do that because we have been able to collect
Medicaid at the OMB rate because we are treated as a service
unit. This makes us different than the other urban programs. We
have been able to tap into this resource of Medicaid
reimbursement. That has allowed us to expand our services.
Tulsa, we do not receive any IHS funds for dental but we
are able to provide dental services by having one dentist
because we are able to collect Medicaid at the OMB rate. We are
able to have an optometry clinic, full-time optometrist because
we are able to fund that with the Medicaid OMB rate.
I feel very proud of what we have been able to do in
Oklahoma, the services we are able to provide. Our service
population is 15,000 active patients at our facility. We have
over 6,000 patient visits a month. I have a staff of 85. I have
the largest mental health outpatient department in the State of
Oklahoma for Indian people. We take referrals from all over the
State. I have four clinical psychologists full time, two
psychiatrists part time, one for children, one for adults; I
have a developmental pediatrician part time and I have four
counselors that work out of our behavioral health department. I
have a full time pediatrician in medical, family practice
physician assistant, nurse practitioner, so I have a very large
operation in Tulsa. We work very closely and are very
integrated with the entire health system of the city.
We carry a caseload of 120 to 130 OBs continually. I have a
contract with an obstetrician that comes in 1 day a week to see
those OBs and the mothers if they qualify or have third party
reimbursement, they are able to deliver in the city. If not, we
provide transportation for the mothers to Claremore Indian
Hospital which is 30 miles away one way.
We are very entrenched in the community. We are 27 years
old. We try to tap into every resource we possibly can. We work
very closely with the tribes and I do support S. 556. I want to
thank the Senators for honing the language that would protect
us from sovereignty. We do not want to get into the sovereignty
issue.
We serve over 150 tribes and as an urban program, we want
to continue to serve that 150 tribes. We want to continue
operating as a 501(c)(3) under a community elected board and
have the board set the policies that run the organization.
As I say, I am very passionate about this program. I've
been there 27 years. I started out as the resource coordinator,
clinic administrator and I've been the executive director for
the last 14 years. I feel very strongly and would be more than
happy to answer any questions.
[Prepared statement of Ms. Skeeter appears in appendix.]
The Chairman. Thank you, Ms. Skeeter.
We have managed to keep it within the timeframe. I'm going
to ask our colleagues to submit any questions in writing as I
will because we have run out of time but would like to yield to
Chairman Pombo if he has any closing comments.
Mr. Pombo. I want to thank this panel for your testimony.
It was extremely informative and very valuable for the
committee as we move forward with this bill. On behalf of
myself and my colleagues in the House, I want to thank you for
taking the time to come here and share your stories with us.
I do have a number of questions as my colleagues do and we
will be submitting those to you in writing. If you can respond
to those in a timely manner in writing so they can be included
as part of the hearing, we would appreciate it.
Thank you very much.
Mr. Pallone. Could I just ask a procedural question? I
thought it was very valuable to have this joint hearing today.
I don't want to suggest to our chairman what he should do on
this issue but I know that the Senate committee is planning to
have future hearings. Either we have our own or if not, if we
could possibly continue this joint hearing idea, it is
certainly a way for the House members to participate and also
for us all to continue with investigation of the issues.
The Chairman. I will have our staff work with Chairman
Pombo's staff and see if we can't do that dealing with health
care.
We will submit those questions and if you could get those
back to in writing at your earliest convenience, that would be
good.
I want to thank all the panels and we will keep the record
open for four weeks on this particular hearing because we will
be doing another on the same subject. Next week we will
continue the series on health care.
This hearing is adjourned.
[Whereupon, at 12:17 p.m., the committees were adjourned,
to reconvene at the call of their respective Chairs.]
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A P P E N D I X

----------

Additional Material Submitted for the Record

=======================================================================

Prepared Statement of Mike Zacharof, Chairman and Andrew Jimmie, Vice
Chairman, Alaska Native Health Board

The Alaska Native Health Board [ANHB], established in 1968, is
recognized as the statewide voice of Alaska Natives on health issues.
With contributions from its member tribes and tribal organizations,
ANHB has been active for 35 years as an advocate on behalf of health
needs and concerns of all Alaska Natives.
On behalf of 229 tribes within the State of Alaska, and over
119,000 Alaska Natives, the Alaska Native Health Board strongly
encourages Congress to support and enact H.R. 2440, a bill to
reauthorize the Indian Health Care Improvement Act.
H.R. 2440 is an update to the 1999 National Steering Committee
draft of the Indian Health Care Improvement Act. Over the last year,
under the direction of Representative Young, the 1999 National Steering
Committee draft reauthorization bill and the first House and Senate
versions of that draft were examined and updated to respond to concerns
expressed by the Administration to provisions contained in S. 212--the
predecessor to S. 556--to resolve differences between the bills before
the Senate and the House in the last session, and to consider tribal
concerns that have arisen since 1999. This work is reflected in H.R.
2440.
We are pleased that Steven Weaver has been invited to testify
regarding before this joint hearing of the Senate Committee on Indian
Affairs and House Resources Committee regarding the provisions of Title
M of the Indian Health Care Improvement Act. As Director of the
Division of Environmental Health and Engineering for the Alaska Native
Tribal Health Consortium, he brings to you a wealth of experience and
technical knowledge. We strongly endorse the recommendations made in
his testimony.
Reauthorization of the Indian Health Care Improvement Act is one of
the highest priorities of the tribes in Alaska. We urge the earliest
possible action.
______

Prepared Statement of R. Perry Beaver, Principal Chief, Muscogee
[Creek] Nation

Chairman Campbell, Vice Chairman Inouye, and members of the
committee.
Thank you for this opportunity to share some of my thoughts with
you about S. 556, the ``Indian Health Care Improvement Act
Reauthorization of 2003.'' My name is R. Perry Beaver and I have served
as the Principal Chief of the Muscogee [Creek] Nation for the past 8
years, and as a National Council representative for several years
before that. I request that my written testimony be made part of the
hearing record.
Due to my years of service to the Muscogee Nation and my residence
in Tulsa County for many years, I am familiar with the many health
problems faced by Native Americans in Oklahoma, including Creek
citizens residing in the Tulsa urban area. I have also been a part of
the development and implementation of Department of the Interior and
Health and Human Services tribal 638 contracts and self-governance
compacts under the Indian Self-Determination and Education Assistance
Act [``ISDEAA''] amendments during the past decade. These programs have
provided the Muscogee Nation with a great opportunity to identify the
specific needs of its citizens and to administer programs for that
purpose, including health programs. The Muscogee Nation has made
significant progress in its development as a government and in making
improvements related to the provision of health care due in part to the
opportunities presented by the ISDEAA.
Unfortunately, S. 556 contains a proposed amendment to the Indian
Health Care Improvement Act that would severely limit the Nation's
ability to exercise self-governance in the area of health care. Section
512(a) would amend the IHCIA to permanently remove the Indian Health
Care Resource Center, Inc. in Tulsa, OK [``Tulsa Clinic''] from the
umbrella of self-governance and make it a permanent direct care program
of the Indian Health Service. This would be accomplished by the
following provisions in section 512 (a) of the bill:
Notwithstanding any other provision of law, the Tulsa and Oklahoma
City Clinic demonstration projects shall become permanent programs
within the Service's direct care program and continue to be treated as
service units in the allocation of resources and coordination of care,
and shall continue to meet the requirements and definitions of an urban
Indian organization in this title, and as such will not be subject to
the provisions of the Indian Self-Determination and Education
Assistance Act.
A large number of the Native American population in Tulsa are
citizens of the Muscogee Nation and the Cherokee Nation. The northern
jurisdictional boundary of a portion of the Muscogee Nation and the
southern boundary of a portion of the Cherokee Nation encompass
separate areas in what is now Tulsa County. The Nation has strong roots
in Tulsa, which originated as a Creek Tribal Town in the 1830's. The
Nation owns trust lands in Tulsa County and also still owns a one-
hundred acre tract of land in Tulsa that has been recognized by Federal
courts as ``historic reservation lands.'' Our capital complex in
Okmulgee is only 30 miles from Tulsa. Although the Muscogee Nation has
not fully exercised its self-governance related to its citizens' health
needs in the Tulsa urban area in recent years, it maintains a strong
governmental interest in meeting the health needs of Indians within its
service area.
The Tulsa Clinic has been existence for approximately 20 years,
many years before Congress amended the ISDEAA to include self-
governance programs that would enable Indian nations to exercise
greater control over Federal funds formerly awarded to them under ``638
contracts.'' During much of that time, the Tulsa Clinic has been
providing health services to Native Americans in Tulsa as a
demonstration project under the IHCIA. The Nation has not made a strong
attempt to obtain tribal control of the provision of health services in
Tulsa currently provided by the Tulsa Clinic for various reasons,
including the Nation's concentration on development of its existing
health programs and its recent conversion to funding through a self-
governance compact. I believe that the indefinite continuation of the
Tulsa Clinic as a demonstration project would be in the interests of
Native Americans in Tulsa. However, the Muscogee Nation is opposed to
making the Clinic a permanent program and permanently removing it from
the authority of the ISDEAA. This would eliminate the Nation's ability
to compact for IHS funding allocated for the needs of Indians in Tulsa.
This would infringe on the Nation's sovereignty within its
jurisdictional boundaries in a significant portion of Tulsa County. I
believe that at some point in the not too distant future, the Muscogee
Nation will be ready to take an even stronger role in the provision of
health care in Tulsa. The proposed amendment would prevent the Nation
from doing so, through what would be, in effect, a Congressional
delegation of the Nation's governmental authority to the Indian Health
Services and the Tulsa Clinic as its grant recipient. The Board of the
Tulsa Clinic would be in a permanent position to make decisions which
are better left to tribal governments.
I respectfully ask that this committee refrain from approval of S.
556 unless and until the offending language in section 512(a) is
removed or amended. I have reviewed new draft language provided by the
Cherokee Nation, and have no strong objections to use of that language,
except to language that would make the Tulsa Clinic a ``permanent
program'' within the Indian Health Service [``IHS''] direct care
program. I suggest that the language in section 512(a) be revised to
read as follows:
Sec. 512(a). TULSA AND OKLAHOMA CITY CLINIC--Notwithstanding any
other provision of law, the Tulsa and Oklahoma City Clinic
demonstration projects shall--(1) remain demonstration programs within
the Service's direct care program; (2) continue to be treated as
service units in the allocation of resources and coordination of care;
and (3) be subject to the provisions of the Indian Self-Determination
and Education Assistance Act, except that the programs shall not be
divisible.
Thank you for this opportunity to provide this testimony to you
today.
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