Draft Report

**On the**

**Indian Health Service Regional I/T/U Consultation Meeting held**

**April 6, 7, 1999**

**In**

**New Orleans, Louisiana**

**"SPEAKING WITH ONE VOICE**

**IHS, TRIBES, URBAN"**

**Consultation on the Reauthorization of the Indian Health Care
Improvement Act**

**For the**

**Bemidji, Nashville and Oklahoma Area**

**I/T/U's**

**This draft report is prepared pursuant to IHS contract #282-97-0053
Task Order 5,**

**The Office of Director's Consultation Initiative on the
Reauthorization of the Indian Health Care Improvement Act**

**INDIAN HEALTH SERVICE**

**Michael H. Trujillo, M.D., M.P.H., M.S.**

**Assistant Surgeon General**

**Director**

**Indian Health Service**

**Rockville, MD**

**Michael Mahsetky**

**Director of Legislative Affairs**

**Office of the Director**

**Indian Health Service**

**Rockville, MD**

**Kitty M. Rogers, M.S., R.N.**

**Nurse Consultant**

**Phoenix Area Indian Health Service**

**Phoenix, AZ**

**Submitted by**

**Kauffman and Associates, Inc.**

**P.O. Box 1401**

**Kamiah, ID 83536**

**(208) 935-0665**

**email: kauffman@camasnet.com**

**Jo Ann Kauffman, President**

###### Table of Contents {#table-of-contents .unnumbered}

# Introduction

# Background

**Summary of Recommendations**

**Titles of the Indian Health Care Improvement Act**

**Crosscutting and Emerging Issues**

**Consensus Recommendations**

**Individual Recommendations**

**Attachments**

###### INTRODUCTION

Of the various statutes, which form the foundation of the U.S. Indian
Health Service (IHS), the Indian Health Care Improvement Act is one of
the most comprehensive and significant in terms of contemporary federal
policies. First enacted in 1976, the IHCIA was authorized the IHS
*"...to implement the Federal responsibility for the care and education
of the Indian people by improving the services and facilities of Federal
Indian health programs and encouraging maximum participation of Indians
in such programs and for other purposes."* The IHCIA was amended over
the years four different times, most recently in 1992. At that time the
IHCIA was extended through the end of Fiscal Year 2000, when it is
scheduled to expire.

The Director of the Indian Health Service is committed to ensuring that
IHS, tribal and urban (I/T/U) providers are fully consulted throughout
the process to reauthorize the Indian Health Care Improvement Act. Only
through a comprehensive I/T/U consultation process can the IHS ensure
that appropriate language is built into the Indian Health Care
Improvement Act, which addresses the changes in the current health care
environment and reflects the concerns and priorities of the I/T/U
systems. It is the hope of the IHS that this comprehensive consultation
process will help promote a unified position on the reauthorization of
the Indian Health Care Improvement Act. The theme of this effort is
***"Speaking with one voice".***

For this reason, the IHS has launched a series of four regional
consultation meetings to be held across the United States to incorporate
the major policy issues and recommendations from I/T/U's in each of the
twelve areas of the IHS. Prior to regional meetings, each IHS Area
convened I/T/U's in their Area for the purpose of reviewing the Indian
Health Care Improvement Act and to develop specific recommendations. At
the regional consultation meetings the Area I/T/U's had the opportunity
to discuss their issues and recommendations with other Areas, in an
effort to reach consensus and resolution. The results of each regional
meeting have been consolidated into four draft Regional Reports. After
all four regional meetings have been conducted a Final National Report
will be issued, based upon the guidance from a National 437 Steering
Committee composed of I/T/U representatives. IHS headquarters identified
the stated goals and objectives of this consultation process as follows:

GOAL: To conduct a comprehensive consultation process which will result
in Indian Country reaching consensus on key policy issues that will be
reflected in the reauthorization of the Indian Health Care Improvement
Act.

OBJECTIVES :

1.  Present Area policy issues and recommendations;

2.  Identify cross-cutting and emerging policy issues;

3.  Build consensus on major policy issues of the IHCIA;

4.  Identify and develop collaborative relationships with key partners
    (Area, regional, national) in the reauthorization process;

5.  Further the consultation process to include all stakeholders in
    Indian health.

The fourth regional meeting was held in New Orleans, Louisiana. It
provided a forum for representatives from three IHS Areas, including the
Bemidji Area, the Oklahoma City Area and the Nashville Area. A total of
144 participants registered for the New Orleans meeting. A list of all
participants is attached to this report. The meeting was facilitated by
IHS contractor, Kauffman and Associates, Incorporated (KAI) and
coordinated by the IHS 437 Team and IHS 437 Coordinators from each of
the three Areas. The results of the New Orleans regional consultation
meeting are contained in this report

Currently, the following regional meetings have occurred:

####### Regional Meeting Site Dates Areas Involved Area Coordinators 

Rapid City, SD January 12, 13 Aberdeen Claudia Valandra

########  Billings Pete Conway 

Reno, NV February 1, 2 Alaska Dave Schraer, Jim Armburst

California Rachael Joseph, A. Nelson

########  Portland Clark Marquart 

Las Vegas, NV March 30, 31 Albuquerque Anthony Yepa

Navajo D. Hutchinson, A. Roanhorse

Phoenix Chuck Grimm

########  Tucson Robert Price, Juana Casilla 

New Orleans, LA April 6,7 Bemidji Charlene Red Thunder

Nashville Bill Drew

Oklahoma Luke McIntosh

The IHS approach to regional consultation on the reauthorization of the
Indian Health Care Improvement Act is a direct result of the feedback
received from Indian health experts and tribal leaders convened earlier
in the year for an IHS roundtable discussion.

The IHS convened health experts from Indian and non-Indian communities
to begin discussing the reauthorization of the IHCIA and alternative
approaches for a consultation process. During this roundtable
discussion, the participants reached consensus that the IHS consultation
process with I/T/U's should include the following features:

-   **Meeting should promote a partnership environment**

-   **Need to be cognizant of the government-to-government
    relationship**

-   **Keep meetings positive; keep communications open**

-   **Work toward consensus**

-   **Need to take a new look at how we approach the Act; encourage
    creativity and new ideas**

-   **Keep an approach simple and documentation brief**

-   **Provide results of the meetings to tribal leaders for feedback**

The initial analysis conducted by the IHS roundtable, served as one of
several resource documents for the participants at the New Orleans
regional consultation meetings. The Regional Consultation meetings were
very much shaped by the recommendations from the participants in the IHS
Roundtable on Reauthorization. In particular, the agenda for the
consultation meeting provided ample time and resources for participants
to ask questions of speakers and panel presenters. The facilitators
encouraged questions or statements from the audience.

Written materials were available for all registered participants to
assist in their review and consideration of the Indian Health Care
Improvement Act and related Indian health policy issues. In each packet
were the following materials:

-   Agenda

-   IHS Roundtable Report on Reauthorization of IHCIA

-   IHS Status Report on IHCIA section-by-section

-   Annotated Codification of the IHCIA (as amended through 1996)

-   Current Issues in Indian Health Policy (Roubideaux)

-   Medicaid Managed Care Issues and Recommendations (NIHB)

-   "How a bill becomes a law" (Government Affairs Institute)

-   Timeline for FY 2001 Budget Formulation (IHS)

-   Meeting evaluation form

In keeping with the recommendations of the IHS Reauthorization
Roundtable, the agenda was presented in two phases. The first day,
participants were provided the opportunity to give input on key policy
issues and recommendations related to the specific titles of the
existing IHCIA. Workgroups during included the following:

Day One Workgroups:

-   Health Professions (Title I)

-   Health Services (Title II and Title VII)

-   Health Facilities (Title III)

-   Access and Miscellaneous (Title IV and Title VIII)

-   Urban Health (Title V)

The second day, participants were asked to think beyond the restrictions
of the existing statute and examine new and emerging issues.

Day Two Workgroups:

-   Entitlements, Benefits Package and Health Disparities

-   Behavioral Health Issues (mental health and substance abuse)

-   I/T/U Partnerships for the Future

-   Medicaid and Managed Care

-   Preamble and Organizational Improvements (Title VI and VIII)

Consensus based recommendations were developed in each of the
workgroups. When possible consensus statements are included in this
report. In cases where consensus was not reached or a final
recommendation is not suggested, a summary of the discussion issues is
provided.

The theme of **"Speaking with one voice",** was integrated into the
facilitation of each workgroup. Participants were advised that the goal
of the workgroups was to identify those key policy issues and
recommendations around which consensus could be built. The workshop also
identified those issues or recommendations where no consensus was
reached. On the first morning of the meeting, Michael E. Lincoln, Deputy
Director for IHS provided an opening statement reinforcing the theme of
the meeting. Michael Mahsetky, IHS, provided an overview of the
reauthorization process.

Each of the three Areas was invited to share their specific policy
issues and recommendations for reauthorization during the first morning
of the meeting. The first panel presentation was from the Bemidji Area.
It included statements from Deanna Bauman, Health Director from the
Oneida Nation in Wisconsin, and from Frances "Candy" Smith, Director of
an urban health program called the United Amerindian Center of Green
Bay. Bill Thorn, Health Director, made the panel presentation
representing the Oklahoma City Area for Cherokee Nation, and Carmelita
Skeeter, Director for the Tulsa Indian Health Resource Center. The
Nashville Area presentation was made by Michael Cook, Administrator for
the Oneida Nation of New York, Brenda Shore-Fuller, United South and
Eastern Tribes, Barbara Namias, Health Director for the North American
Indian Center of Boston and Rae Snyder, consultant for the United South
and Eastern Tribes. A copy of the written recommendations developed by
each of the three Areas is attached to this draft report.

Concerns expressed by I/T/U representatives on the Area panels covered a
wide range of topics, including strengthening the
government-to-government relationship; avoiding "means testing" as a
requirement for health services; reviewing reports on 437 activities,
examining innovative approaches to facility construction, opening
programs to fee-for-service systems, eligibility, negative impact of
minimal appropriations on the intent of the IHCIA, and the need to
support urban Indian health programs.

The panel presentations were followed by lively discussion from the
participants and questions from the audience. There was discussion about
the importance for the IHS consultation process to be directly with
elected tribal leaders or chairpersons of the tribes. This discussion
also addressed the activities planned for the National 437-consultation
meeting scheduled for July 28, 29, 1999, and the importance for
continued I/T/U involvement. There was also considerable discussion
regarding the composition and functions of a proposed "National 437
Steering Committee", such as how will participants be selected, what
will their functions be and how will their activities be reported back
to the tribes. It was recommended that the tribes make the selection for
participants on the steering committee. The IHS has received approval to
move forward in the selection process and will be asking tribes to
nominate a tribal representative and alternate from each of the 12 IHS
Areas to serve on the committee. In addition to these tribal
representatives, the steering committee will also include an urban
representative, a self-governance representative and a representative
from the National Indian Health Board (NIHB).

Another area of discussion focused on the importance of monitoring the
appropriations process and the impact it has on diluting the
significance of authorizing legislation such as the IHCIA. A
section-by-section comparison of what was authorized compared to what
was appropriated will reveal a true picture of Congressional priorities.

On the second day of the consultation meeting, discussion shifted to the
political climate of current efforts to reauthorize the IHCIA. A special
panel presentation of tribal and urban health leaders was assembled to
address "Strategizing Politically for Reauthorization". Presenters
included NIHB Chairperson, Buford Rolin; Tom Maulson, Chairperson of the
Lac du Flambeau Chippewa; Merle Boyd, Second Chief of the Sac and Fox
Nation of Oklahoma; and Terrance Hunter, Executive Director of the
Oklahoma City Urban Indian Clinic. The panel members had participated in
previous successful efforts to reauthorize the IHCIA and other federal
Indian legislation. There was mention of the 1994 Executive Order from
President Clinton outlining his policy of tribal consultation for each
of the agencies under his Administration. Political support and
opposition was also examined by the panel participants, including a
growing list of "friends of Indian health" and over 200 Members of the
U.S. House of Representatives who are signing up for the American Indian
Caucus. This was tempered with the realization that the next year and a
half represent a difficult political climate, which will likely be
overshadowed by Presidential elections in 2000.

###### BACKGROUND ON THE INDIAN HEALTH CARE IMPROVEMENT ACT REAUTHORIZATION

The United States maintains a legal and moral responsibility to provide
health services to America's Indian and Alaska Native population. These
obligations are based upon numerous treaties signed between the U.S. and
tribes which ceded millions of acres of land in exchange for certain
reserved rights and basic provisions guaranteed by the United States,
including health care. The unique relationship between tribes and the
Unites States is underscored in the U.S. Constitution (Article I,
Section 8). Federal laws and court decisions have confirmed the unique
relationship between tribes and the federal government, and upheld the
obligation of the United States to provide health services to American
Indians and Alaska Natives.

In 1921, President Hoover signed into law the Snyder Act, which provides
the underpinning for a variety of federal Indian programs, including the
Indian Health Service. The Snyder Act provided, *"...such sums as
Congress may from time to time appropriate for the benefit care and
assistance of Indians".* The transfer of these responsibilities to the
U.S. Public Health Service in 1955 sparked the beginning of the U.S.
Indian Health Service, and a slow but measured rebound in the health
status of American Indians today. The legislative history of Indian
health care can be traced back to the Snyder Act in 1921. Only the
Indian Health Care Improvement Act has provided more direction and
foundation for the improvement of Indian health status.

-   *The Snyder Act* *of 1921 (25 U.S.C. 13)*

The Snyder Act authorizes Congress to appropriate funds for the "relief
of distress and conservation of health and for the employment of
physicians" for Indians through-out the United States. It represents
permanent statutory authority for Indian health programs.

-   *The Johnson O'Malley Act of 1934, Amended 1936 (25 U.S.C. 452)*

The JOM Act authorizes the Secretary of the Interior to contract with
states and other local governments to provide education, medical
attention, agricultural assistance and social welfare for Indian people
in hardships related to the allotment process or other hardships related
to Indians living off the reservation.

-   *The Transfer Act of 1954, Amended 1973, (42 U.S.C. 2001 et seq.)*

The Act established the U.S. Indian Health Service under the Department
of Health, Education and Welfare, and removed responsibilities for
Indian health services from the Department of Interior.

-   *Indian Health Facilities Act of 1957 (42 U.S.C. 2005)*

This Act provides the IHS with the authority to fund construction of
hospitals for the benefit of Indian tribal patients.

-   *The Indian Sanitation Facilities and Services Act of 1959, (42
    U.S.C. 2004)*

This federal law expanded the duties of the IHS to ensure public health
requirements were being met, including safe and sanitary drinking water,
sewer systems, drainage facilities, waste and access to of water and
sewer systems for Indian homes.

-   *Public Law 91-224 of 1970, (16 U.S.C. 459; 33 U.S.C. 446; 31 U.S.C.
    529;*

*41 U.S.C. 5)*

This law provided authority for the Departments of Interior and Health
and Human Services to collaborate on demonstration projects, which would
provide central community systems for safe drinking water in Alaska
Native villages.

-   *The Indian Self-Determination and Education Assistance Act of 1975,
    Amended in 1988 and 1994, (25 U.S.C. 450 et seq)*

The Act authorizes federally recognized Indian tribes the means to
contract with the federal government for the purpose of administering
and operating federal programs, services, functions and activities which
were established to serve that tribe.

-   *The Indian Health Care Improvement Act of 1976, Amended 1980, 1988,
    1990, 1992 and 1996 (25 U.S.C. 1601 et seq)*

This is landmark legislation, which elevated and invigorated Indian
health care improvement measures to a higher level within Indian
communities and within the federal government. The Act provided clear
policy for the Nation to elevate the health status of Indians and Alaska
Natives to the highest possible level. The current IHCIA provides a
"Declaration of Health Objectives", which it proposes be met by the year
2000. The Act set out specific new programs and initiatives, including

> **Title I "Health Professions**"(Recruitment, Scholarships, Externs,
> Continuing Education, Community Health Representatives, School Loan
> Repayment, Advanced Training, Nursing Recruitment and Schools, Tribal
> Culture/History, INMED Program, Community Colleges, Incentives Ruse
> Residency, Alaska Community Health Aid, Matching Grants to Tribes,
> Tribal Health Administration, U of South Dakota Program)
>
> **Title II "Health Services"** (Indian Health Care Improvement Fund;
> Catastrophic Health Emergency Fund; Health Promotion and Disease
> Prevention Services; Diabetes Prevention, Treatment and Control;
> Hospice Care Feasibility Study; Reimbursement from Certain Third
> Parties; Crediting of Reimbursements; Health Research; Mental Health
> Prevention and Treatment Services; Managed Care Feasibility;
> California CHS Demonstration; Mammography Screening; Patient Travel
> Costs; Epidemiology Centers; School Health Education; Indian Youth
> Grants; Indians into Psychology Program; Tuberculosis Control;
> Contract Health Service Study; Prompt Payments, Electronic Payments
> Demonstration; Liability for Payment, Office of Indian Women's Health)
>
> **Title III "Facilities",** (Consultation on closure of facilities;
> Safe Water and Sanitary Waste Disposal Facilities; Indian preference
> on Firms; Soboba Sanitation; Expenditure of non-Service funds for
> renovation; Grants for Construction, Expansion of Ambulatory Care
> Facilities; Indian Health Care Delivery Demonstration Project; Land
> Transfers and Buy American applicability.)
>
> **Title IV "Access to Health Services;** (Treatment of payments under
> Medicare; Treatment of Payments under Medicaid; Report Requirements;
> Grants and Contracts with Tribal Organizations; Demonstration for
> Direct Billing; Emergency Contract Health Services)
>
> **Title V "Urban Health";** (Contacts and Grants to Urban Indian
> Organizations; Contracts and Grants for Health Care and Referral
> Services; Contract and Grants to Determine Unmet Needs; Evaluations
> and Renewals; Other Requirements; Limits on Authority; Facilities
> Renovation; Urban Programs Branch; Alcohol and Substance Abuse;
> Treatment of Certain Demonstration Projects and Urban NIAAA
> Transferred Programs)
>
> **Title VI "Organizational Improvements";** (Establishment of the IHS
> as an agency of the Public Health Service; and Automated Management
> Information System)
>
> **Title VII "Substance Abuse Programs";** (Defines IHS
> responsibilities; IHS Programs; Indian Women's Treatment; IHS Youth
> Treatment; Training and Community Education; Gallup ASA Treatment
> Center; Fetal Alcohol Syndrome grants; Pueblo Substance Abuse
> Treatment; Thunderchild Treatment Center; Counselor Education Project;
> Gila River Alcohol Treatment Facility; Alaska Native Drug and Alcohol
> Abuse Demonstration)
>
> **Title VIII "Miscellaneous Provisions",** (Leases with tribes;
> Limitations of use of funds; Nuclear Resource Development Health
> Hazards; Arizona CHSDA; Eligibility of California Indians; California
> CHSDA, Contract Health Facilities; National Health Service Corps;
> Health Services for Ineligible Persons; Infant and Maternal Mortality
> and FAS; CHS for Trenton Service Area; IHS/VA Facilities and Sharing
> of Services; Reallocation of Base Resources; Demonstration Project for
> Tribal Management; Child Sexual Abuse Treatment Programs; Tribal
> Leasing; Home and Community-based Demonstrations; Shared Services
> Demonstration; Priority of Indian Reservations.)

-   *Indian Alcohol and Substance Abuse Prevention and Treatment Act,
    (Subtitle C of the Omnibus Drug Act o f1986: P.L. 99-570, Amended in
    1988, 1990 and 1992)*

This Act provided specific authorizations to address the problem of
alcoholism, alcohol abuse and drug abuse in Native American communities.
Each tribe developed an action plan to combat addictions, and inpatient
treatment centers for Indian adolescents were authorized.

The IHS is an agency established under the U.S. Public Health Service
within the Department of Health and Human Services (DHHS). The mission
of the IHS is to provide a comprehensive health service delivery system
for American Indians and Alaska Natives. The range of services provided
through the IHS includes a broad spectrum of preventive, curative,
rehabilitative and environmental services. The IHS has developed a model
of service delivery, which incorporates direct outpatient and inpatient
facilities, contracting for the provision of services from the private
sector, contracting with tribes and urban providers of health services.
The IHS approach is comprehensive and includes public health nurses,
community health representatives, sanitation initiatives and housing
quarters for providers in rural remote areas.

The IHS provides health services through 144 Service Units which are
composed of more than 500 direct healthcare delivery facilities,
including 49 hospitals, 190 health centers, 7 school health centers, and
287 health stations, satellite clinics, and Alaska village clinics.

In addition to direct services provided by IHS, within the system 1)
Indian tribes deliver IHS funded services to their own communities with
about 35 percent of the IHS direct services budget in 11 hospitals, 129
health centers, 3 school health centers, and 240 health stations; 2)
various health care and referral services are provided to Indian people
away from the reservation settings through 34 urban center programs;
and, 3) the purchase of contract health services from non-IHS providers
to support, or in some cases in lieu of, direct care services that IHS
is unable to provide in its facilities. Services are administered
directly by the IHS, Tribes or urban providers (I/T/U).

Many of the American Indian and Alaska Native people served by the IHS
live in some of the most remote and poverty stricken areas of the United
States. For them, the IHS represents the only source of health care
available. Others reside in larger communities but face cultural or
financial barriers to care. While the IHS represents the primary health
resource for most Indian people in the U.S., Indian people are also
eligible for a variety of alternate resources, such as Medicaid,
Medicare, state programs and private insurance. The IHS requires
beneficiaries to exhaust these alternate resources before expending
contract health resources. For federal, tribal and urban providers of
services under the IHS, this myriad of alternate resources and
requirement makes providing vital health services to American Indians
and Alaska Natives a challenge.

American Indians and Alaska Natives, while gradually improving in health
status, remain one of the most vulnerable populations in the United
States, dying at rates higher than other racial groups in America in
many categories.

-   The median age for Indians living in the 34 reservation States is
    24.2 compared to 32.9 for the U.S. All Races and 34.4 for the White
    Race.

-   For Indians, 33 percent of the population was younger than 15 years
    and 6 percent was older than 64 years. For the U.S. All Races
    population, the corresponding percentages were 22 and 13,
    respectively.

-   According to the 1990 Census, the median household income in 1989
    for Indians residing in the current Reservation States was \$19,897,
    compared with \$30,056 for the U.S. All Races population. During
    this period, 31.6 percent of Indians lived below the poverty level,
    in contrast to 13.1 percent for the U.S. All Races population.

    The Indian Health Care Improvement Act represents this nation's
    commitment to improving the health status of American Indians and
    Alaska Natives. The U.S. Indian Health Service has conducted its'
    own assessment of the provisions of the IHCIA and provided these
    materials to I/T/U participants during the consultation process.

###### MAJOR POLICY ISSUES AND CONSENSUS RECOMMENDATIONS

##### Specific Titles of the Indian Health Care Improvement Act

# 

# 1. Health Professions (Title I)

The Indian Health Manpower Title I, commonly referred to as [Health
Professions]{.underline}, has twenty three (23) sections which describe
methods of increasing the number of Indians entering the health
professionals to the Indian Health Service, Indian Tribes, Tribal
organizations, and urban Indian organizations that are involved in
delivering health care to Indian people.

-   **Section 102 Health Professions Recruitment program for Indians**:
    In this section grants are made to public or nonprofit private
    health or educational entities or Indian tribes or tribal
    organizations to assist such entities in meeting the costs of
    identifying Indians with a potential for education or training in
    the health professions and encouraging and assisting them in the
    process of preparation to enroll and study for a health career. The
    work group reviewed this section and stated they wanted it to be
    reauthorized with the same provisions.

-   **Section 103 Health Professions preparatory scholarships for
    Indians**: The purpose of this section is to provide scholarships
    for undergraduate degrees leading towards a field of study in a
    health profession. Yearly re-applications are required. The work
    group wanted the scholarships to be non-taxable. They wanted funds
    to be regionalized. They stated eligibility criteria should be (a)
    members of Federally recognized tribes only, or (b) per 1988
    amendments which includes eligibility for state recognized tribal
    members.

-   **Section 104 Indian Health Professions Scholarships**: The
    workgroup made the same recommendations as described above for
    Section 103. They support regionalized programming, non-taxable
    scholarships and revised eligibility criteria.

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-   **Section 105 Indian Health Service Extern Program:** The purpose of
    this section is to provide scholarship recipients an opportunity to
    work in the medical field during the non-academic period to gain
    experience and exposure in the medical field. The work group wanted
    this section to have intern provisions. In addition they wanted a
    high school internship program established.

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-   **Section 106 Continuing Education Allowance**: This section grants
    continuing education funds to health professions in order to
    encourage them to provide health services in the rural and remote
    areas where Indian people reside. The work group wanted continuing
    education to be tied to maintaining the credentials that are
    required for specific professions or positions.

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-   **Section 107 Community Health Representative Program:** This
    section provides for the training of CHR's and sets out the
    standards for such training. The work group wanted the CHR program
    continued with the added provision that this program becomes
    eligible for HCFA reimbursement.

-   **Section 108 and Section 108(A) Indian Health Service Loan
    Repayment Program-** Individuals who are interested in serving in
    the Indian Health Service, Tribal or Urban Health programs as a
    medical provider that are health manpower shortage areas can receive
    school loans. As part of their pay back a percent of loan funds is
    forgiven over a four-year period. The work group stated that the
    Loan Repayment Program benefits should be tax deductible or not
    taxable. They also wanted the authority for this program delegated
    to the area. The work group stated that they wanted section 108A
    reauthorized with an amendment that allowed direct payment to
    original funding sources.

-   **Section 109 Nursing Program and Nursing Schools**: This section
    provides grants to higher education institutions to recruit and
    train nurses, nurse midwifes, and nurse practitioners to provide or
    continue to provide health care services to Indians.

# The work group agreed that this section should be reauthorized without changes

# Section 110 Tribal Recruitment and Retention Program: This section provides funds to Indian tribes and tribal and Indian organizations for recruiting and retaining health professionals in hard to fill positions. The work group wanted this provision to remain.

-   **Section 111 Advance Training and Research:** This program enables
    health professionals who have worked in an Indian health program for
    a substantial period of time to pursue advanced training or research
    areas of study for which the secretary determines a need exists. The
    work group wanted this provision reauthorized.

# Section 112 Nursing Program: This section provides grants to public or private schools of nursing, tribally-controlled colleges and tribally controlled post-secondary vocational institutions to train nurses, nurse midwifes, nurse practitioners for the purpose of increasing the number of these professionals who deliver health care services to Indians. The work group wanted this section moved to Section 115 and amended to include Indian preference and change eligibility requirement the same as recommended for Section 103. 

-   **Section 112(A) Nursing School Clinics:** This provision allows the
    grantees of the nursing program to administrate outpatient clinics
    to Indians that may reside near. The work group wanted this
    subsection to move to Section 115.

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-   **Section 113 Tribal Culture and History:** This is a program where
    appropriate employees of the service who serve particular Indian
    tribes shall receive educational instruction in the history and
    culture of such tribes and in the history of the service.
    Furthermore it is to be carried out by tribally controlled colleges
    in consultation with the tribe affected. The work group wanted this
    section reauthorized and expanded to include traditional medicine.

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-   **Section 114 InMed Program: This** section authorizes three grants
    to colleges to expand "Indians going into Medicine (INMED). The work
    group wanted this reauthorized.

-   **Section 115 Health Training Programs of Community Colleges:** This
    section provides funds to community colleges for the purpose of
    assisting the community college in establishing education programs
    in a health profession leading to a degree or diploma in a health
    profession for individuals who desire to practice such profession on
    an Indian reservation or in a tribal clinic. The work group stated
    that this section should be reauthorized and incorporated with
    Section 112 and 112A. They wanted to add health-training programs to
    include community colleges and universities and they also wanted the
    same Indian eligibility as in Section 112.

-   **Section 116 Additional Incentives for Health Professionals:** This
    section provides an additional incentive bonus for hard to fill
    positions. The work group wanted this section reauthorized.

-   **Section 117 Retention:** This section authorizes retention bonus
    is paid to any physician or nurse of the service. The work group
    wanted this reauthorized and to amend to include all health
    professions.

-   **Section 118 Nursing Residency Program:** This section allows for
    Licensed Practical Nurses, Licensed Vocational Nurses and Registered
    Nurses that are working in an Indian Program to pursue advanced
    training. The work group wanted this program reauthorized.

-   **Section 119 Community Health Aide Program for Alaska**: This
    section provides for the training of Alaska Natives as health aides
    or community health practitioners. The work group wanted this
    program to be reauthorized to include all tribes.

-   **Section 120 Matching Grant to Tribes for Scholarship Programs**: A
    grant is made to the tribe for providing scholarships to their
    tribal members for a health profession education. The grant is for
    80% of the scholarship while the tribe pays 20% of the cost. The
    work group wanted this reauthorized and amended to allow tribal
    health care funds to be able to meet match requirements associated
    with the scholarship. (for example: Ameri-Corps and I.H.S.,etc.)

-   **Section 121 Tribal Health Program Administrator**: Provide
    training for individuals in the administration and planning of
    tribal health programs. The work group stated that they wanted this
    reauthorized.

-   **Section 122 University of South Dakota Pilot Program:** to
    establish a pilot program on an Indian reservation at one or more
    service units in South Dakota to address the chronic manpower
    shortage in the Aberdeen Area of the service. The work group stated
    that they wanted to reserve pilot programs to address specific
    health care manpower needs.

2.  **Health Services (Title II)**

This workgroup dealt with the many issues covered under Title II
addressing direct services delivery programs. The following areas were
specifically addressed through consensus recommendations. There were
many other areas that were not addressed by this workgroup.

-   **Section 201 Indian Health Care Improvement Fund**: There was
    consensus that there should be a mechanism to provide "equity" in
    funding under IHS. There was no consensus regarding how equity
    should be accomplished, however, any formula proposed should not
    penalize small tribes for innovative programs. General language
    should be developed which enumerating which services are included
    under this section, including durable medical equipment. A new
    component of Section 201 should clearly delineates a "public health
    function" within the IHS.

-   **Section 202 Catastrophic Health Emergency Fund**: A cap should be
    placed on the CHEF threshold, which is proportionate to the overall
    funding increases.

-   **Section 204 Diabetes Prevention, Treatment and Control**:
    Reauthorize.

-   **Section 208 Health Services Research**: Language should be added
    to require the reporting to all I/T/U's of the results of any
    special studies or model programs.

-   **Section 210 Managed Care Feasibility Study**: Recommend
    elimination of section.

-   **New Section on Gender Health**: Both men and women's health issues
    should be addressed equitably by the IHS, including access to
    screenings, funding, and expanding the definition of "health".

# Health Facilities (Title III)

Health Facilities (Title III) of the IHCIA describes the methods of
funding for new and replacement facilities. There are provisions for
tribal consultation, reporting to congress and methods for implementing
the Indian self-determination Act. It includes safe water and sanitary
waste disposal facilities provision and other alternative methods for
funding facilities.

-   Section 301 Health Facility Priority System: The work group stated
    that all tribes should have equal access to resources. A report to
    Congress on total unmet health facility need should be made on an
    annual basis.

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-   Section 301 Accreditation: The current document identifies Joint
    Commission Accreditation of Hospital Organizations (JCAHO). The work
    group stated that accreditation should not be limited to JCAHO.

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-   Section 302 Safe Water and Sanitary Waste Disposal Facilities: This
    section provides for financial and technical assistance to Indian
    tribes and communities the establishment, training, and equipping of
    utility organizations to operate and maintain Indian sanitation
    facilities in addition to other emergency services pertaining to
    sanitation facilities. The work group wanted tribes to be reimbursed
    by IHS for funds obtained from other federal agencies. In addition
    they wanted IHS. to be more flexible and collaborative with other
    federal agencies (such as HUD, BIA, etc.) I provision of sanitation
    facilities. They wanted the ability to use IHS dollars to leverage
    dollars from other agencies (matching funds, loan support, etc.)

-   Section 303 Preference to Indians and Indian Firms: This provision
    authorizes Indian preference to Indian firms in construction. The
    work group stated that this section should be reauthorized with the
    option for tribes to waive the Davis Bacon Act and use wage rates
    determined locally.

-   Section 305 Expenditure of Non-Service Funds for Renovation: This
    section authorizes the IHS to enter into an agreement with a tribe
    for renovation or modernization of a facility with the tribe funding
    the facility changes and the I.H.S. funding the equipment and
    personnel. A separate priority list is kept when the project is
    approved. The work group was concerned that there were two lists.
    They recommended that this section be reauthorized. In addition they
    stated that there should be annual reporting of staffing and
    operating needs for facilities where tribes have built or proposed
    to build under this section.

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-   Section 306 Grant Program for the Construction Expansion and
    Modernization of small Ambulatory Care Facilities: Authorizes funds
    to expand and modernize small outpatient clinics. The work group
    stated that they wanted the first paragraph to change wording from
    "eligible Indians" to read \"eligible Indian and eligible non-Indian
    beneficiaries as defined by CHS regulations." They wanted to include
    loan guarantees in this section. In addition they wanted to remove
    the language limiting to tribes less than 500 tribal members. They
    also were concerned with the reversionary clause. They felt that
    tribes would have difficulty obtaining financing with this
    provision. They wanted it deleted.

-   Section 307 Health Care Demonstration Projects: This section
    provides for grants and contracts to Indian tribes or tribal
    organizations for the purpose of testing alternative means of
    delivery health care. This section should be reauthorized.

-   New Section on Carry Over Funds: The work group stated that health
    service carry-over funds should have the flexibility to be used for
    construction.

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-   New Section Medicaid and Medicare Construction fund approval: The
    appropriations committee currently must approve use of M&M funds for
    renovation and construction projects over \$1 million dollars. The
    work group stated that there should be no approval by congress. They
    disagreed with Oklahoma Area's recommendation to reauthorize as is.

-   Section 804 Leasing: The IHCIA authorizes IHS to lease health care
    space from tribes under a twenty-year lease. However the Balance
    Budget Act requires that the full amount of these leases be "scored"
    in the first year of the lease. New language in the IHCIA should
    waive the requirement that the full lease amount be "scored" in the
    first year.

-   Section 308 Land Transfer: This provision should be generic to
    permit transfer between agencies without cost.

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-   Section 310 Applicability of Buy American Requirement: Tribes and
    Tribal Organizations should be able to opt out of Buy American Act.
    The work group stated that this measure would strengthen the
    government to government relationship.

-   New Section for Definition of Health Facility: A clear definition of
    health care facilities is needed. Current IHS definition does not
    include the variety of health care services provided. The definition
    should include mental health, elder care, rehabilitation services,
    alcohol/drug abuse and any other health facilities.

-   Section 818 Joint Venture: A tribe which has begun and substantially
    completed the process of acquisition or construction of an
    ambulatory health facility during the period beginning October 1,
    1993 through September 30, 2000 shall be eligible to establish a
    joint venture project with IHS utilizing such ambulatory health
    facility. Appropriation should include pool for capital dollars for
    replacement or renovation (emergency). The responsibility for
    facility construction should be added to the Preamble under findings
    and objectives. This section should be moved to Title III. There was
    also consensus from the workgroup that tribes should be able to
    construct staff quarters under the Joint Venture Program and charge
    prevailing market rates.

3.  Access to Health Services (Title IV)

Title IV provides authority for the I/T/U's to access other federal
reimbursement sources, such as Medicaid and Medicare. Discussions
regarding this title also addressed issues related to state initiated
reforms, which require participation in managed care organizations
(MCO's).

-   Section 401Treatment of Payments Under Medicare Programs: There was
    consensus among the workgroup that this section should be amended to
    provide for several changes. Language should be inserted to cover
    "contract or compact" tribes specifically. Language should also be
    inserted to state that "any service Medicare will pay to any
    provider, it must also pay to an I/T/U under Medicare that meets the
    same conditions". It should clarify that "tribal" means any tribally
    owned or operated health facility and not only tribal 638 programs.
    Statutory language should be added to prohibit any mandatory
    enrollment of IHS beneficiaries in MCO's for Medicare or Medicaid. A
    retroactive provision should enable I/T/U's to back bill for lost
    revenues for services provided to their patients who were
    involuntarily enrolled in MCO's. Finally, it was agreed that all
    Medicare beneficiaries should have the right of self-referral to an
    I/T/U of their choice, regardless of HMO or MCO system, and the
    I/T/U has the right to payment without regard to MCO provisions.

-   Section 402 Treatment of Payments Under Medicaid Programs: There was
    consensus that accreditation requirements should be amended to allow
    for a more general term, such as "a nationally recognized
    accrediting body" and not tie it to state approvals, so that any
    third party payor must reimburse an I/T/U as if licensed by a state.
    The allowable uses of Medicaid revenues should not be restricted,
    except that funds to maintain accreditation should be a priority,
    but I/T/U's should have flexibility to allocate for other purposes.
    Language should be added to ensure that "any I/T/U can bill and
    collect for any Medicaid services covered in the state Medicaid plan
    for eligible patients". Section 1905(b) of the Social Security Act
    should be amended so that any State that reimburses for services
    provided by or through any I/T/U for any Medicaid service will be
    entitled to 100% FMAP reimbursement. Language should also be added
    that state there will be "no mandatory enrollment of American
    Indians in MCO's for Medicaid, except that those that choose to
    enroll still have that right of self-referral to an I/T/U and that
    program is guaranteed payment".

-   Section 404 Grants to Tribes: There was consensus that this section
    should be reauthorized.

-   Section 405 Demonstration Projects: It was the consensus of the
    group that this section should be made permanent for all I/T/U's
    operate to as "direct billing/collection" entities.

-   New Section on Co-Payments and CHIP/Medicaid/Medicare: A new section
    406 is proposed by the Cherokee Nation and endorsed by the New
    Orleans participants to insert a provision on "Co-Insurance,
    Co-Payments and Deductibles", which would protect IHS beneficiaries
    from Medicare and Medicaid (and CHIP) co-payments, co-insurance and
    deductibles when they use an IHS, tribal or urban Indian health
    program. The workgroup agreed that CHIP reimbursement and
    participation should be available to I/T/U's on the same basis as
    Medicaid and waivers should be provided for all co-payments and
    premiums for IHS beneficiaries.

-   New Section on "Spend Down" Requirements for Medicaid Beneficiaries:
    The requirement under Title XIX Medicaid that beneficiaries "spend
    down" their assets should be amended to waive it for American Indian
    and Alaska Natives or allow states to count the costs of I/T/U
    services to count toward the required spend down. Title XVII
    Medicare should also be amended to waive co-payments, premiums or
    deductibles for IHS beneficiaries.

-   Section 406 Emergency CHS: This section should be reauthorized and
    amended so that I/T/U outpatient departments operating as a part of
    a hospital facility or as a part of a tribal organization are
    authorized to receive reimbursement as if affiliated with a hospital
    under Medicare, but are not subject to the provisions of the
    Emergency Medical Treatment and Active Labor Act (EMTALA).

# 

# Health Services for Urban Indians (Title V)

The purpose of this title is to establish programs in urban centers to
make health care services more accessible to urban Indians.

-   **Reauthorization:** The work group agreed that the following
    sections should be authorized with the same language standing;
    Sections 501, 502, 504, 511, 514.

-   **Section 503 Contracts and Grants for the Provision of Health Care
    and Referral Services:** this section provides an explanation of the
    types of activities and services that are expected in this title.
    The work group stated that there should be a uniform report system
    and adequate recurring funding to ensure that a reporting system is
    continually updated and upgraded. They also wanted the language
    removed regarding duplication of services.

-   **Section 505 Evaluations and Renewals:** This section provides for
    an annual evaluation and renewal process. The work group wanted the
    reviews combined with other organizations with Indian Health Service
    evaluations. They wanted them coordinated with the accrediting
    reviews of Indian Health Service governing bodies.

-   **Section 506 Other Contract and Grant Requirements:** This section
    states the contracting authority and lists the various federal law
    requirements. The work group stated that they wanted to be approved
    for GSA leasing under grant conditions. They wanted the Urban Indian
    programs to be included in the Memorandum of Understanding that
    I.H.S has with the Veterans Administration and the HCFA 100% FMAP
    reimbursement to the states. In addition, they wanted the Urban
    Indian programs to be approved for Federal Torts Claim coverage. The
    work group wanted Urban Indians programs to receive indirect cost
    funds as additional funds under the Title V provision. Finally they
    wanted to use their third party revenue for facilities.

-   **Section 507 Reports and Records:** This section states the types
    of reports that the Urban Indian Health programs will make and also
    the types of information that I.H.S. will report to Congress. The
    work group wanted the reporting frequency changed from quarterly to
    semi-annual reports. They wanted Congress to appropriate funds based
    on HIS report submitted, specifically per section 507(d)(3)(a) and
    (b). In section 507(c), regarding audits, they wanted the language
    "shall allow" removed and this statement inserted, "independent
    financial audit conducted by a CPA or CPA certified to conduct
    federal compliance audits". In addition they wanted funding for
    increased Independent auditing costs.

-   **Section 508 Limitation of Contract Authority:** States the
    limitations of contracting shall be the amount provided for in the
    appropriation acts. The work group wanted the word "and grants"
    after contracts.

-   **Section 509 Facilities Renovation:** Authorizing funds be made
    available for minor renovation to facilitates to assist in meeting
    Joint Commission for Accreditation of Health Care Organizations
    (JCAHO) standards. The work group wanted the language to be changed
    to reflect "A nationally recognized accreditation body" and not
    limit it to JCAHO.

-   **Section 510 Urban Indian Health Branch:** This section establishes
    a branch in I.H.S. to be responsible for carrying out the provisions
    of Title V and providing central oversight of the programs. The work
    group wanted the phrase "as may be needed to carry out are
    responsibilities to the current language regarding area office staff
    to support urban programs. In addition they wanted contract health
    service funding for urban\'s to be authorized with appropriations
    for new money. They also recognized support for traditional healing,
    including funding for support of such services. (travel, lodging,
    meals) Traditional health cannot be regulated by federal agencies.
    This needs to be determined by local areas.

-   **Section 512 Treatment of Certain Demonstration Projects:** This
    section allows for the Oklahoma City and Tulsa population to receive
    funds which they are legally eligible for but never received due to
    the method I.H.S. historically used to serve these two urban
    populations. A report to Congress is due for fiscal year 1999 on the
    findings and conclusions derived from the two demonstration
    projects. The work group discussion centered on reauthorizing this
    section and no consensus was reached. Some Oklahoma tribes view the
    urban program exemption from the Indian self-determination Act as an
    infringement on tribal sovereignty. Urban programs advocate that
    Tulsa and Oklahoma City programs become permanent programs within
    I.H.S. direct care programs and that all Title V programs and funds
    are ineligible from provisions of the Indian Self Determination Act
    because they do not qualify as a tribe or tribal organization. There
    was no final consensus on bill language. Both sides agree that a
    forum to continue the dialogue between tribes and urban programs is
    needed.

-   **Section 513 Urban NIAAA Transferred Programs:** This section
    provides for the transfer of NIAAA programs to I.H.S. and granted to
    the urban program in that area. The work group advocated for the
    NIAAA transfers to be completed with funding to follow them in a
    timely basis.

5.  **Preamble, Title VI and Title VIII**

On the second day, time was set aside to address recommendations related
to Preamble, Title VI (Organizational Improvements) and Title VIII
(Miscellaneous). The recommendations from this group are provided along
with the other Title specific recommendations from New Orleans.

-   **Preamble:** The preamble to the IHCIA should be amended to
    re-insert "trust responsibility" as a fundamental basis for the Act.

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-   **Section 601 Establishment of IHS as an Agency of PHS:** This
    section should include the designation of the Director of the IHS as
    an Assistant Secretary for Indian Health under DHHS. Also this
    section should be amended to provide sovereign tribal nations the
    authority to exercise procurement functions as a federal agency.

-   **Section 602 Automated MIS:** It was recommended that this section
    be amended to include "compact" along with the word "contract" when
    referring to contracting tribes, through-out. It was agreed that
    Self-Governance Tribes should still be able to access "public
    domain" products, such as the IHS MIS systems. If that is not clear,
    then language should be inserted in the Act to clarify the status of
    Self-Governance Tribes. The MIS system should be targeted to address
    issues related to managed care, inventory control, prevention and
    prevalence issues. Tribes and IHS should be on compatible systems. A
    national/regional effort should be initiated to ensure compatibility
    of I/T/U data and the ability for national reporting.

-   **Title VIII General:** Current language does not include compacting
    tribes. Language should be amended throughout to include both
    contracting and compacting tribes. Another provision should be
    inserted to allow tribes to utilize "government rates" for travel or
    other purposes for other than 638 contract activities.

-   **Section 816 VA Coordination:** A provision should be added to
    provide I/T/U's access to Veteran's Administration supply
    agreements. While there was discussion about using Section 816 to
    provide for a study to develop government computerized patient
    records in coordination with the VA or the Department of Defense in
    partnership with the IHS, there was [no consensus
    reached]{.underline}.

-   **Title VIII New Provision on Supplies:** A new provision should be
    inserted to allow for the Secretary to enter into an agreement on
    behalf of the Indian tribes for the acquisition of any goods,
    services or supplies available to the General Services
    Administration (GSA) or other Federal agencies which are not
    currently available to tribes.

-   **Section 813 on Ineligible Patients:** Eligibility language should
    be modified to allow children who have not attained the age of 19,
    reside in the eligible Indian's household and are defined as a legal
    dependent as defined by the IRS, to be eligible to receive health
    services.

-   **Title VIII New Provision on Co-payments:** A provision is
    recommended which would allow tribes to charge co-payments for
    services provided to both IHS eligible and non-eligible users, for
    purposes of generating revenues and expanding services.

-   **Title VII New Provision on Tribal Self-Insurance:** A provision
    should be added to allow IHS to bill self-insured tribes for
    services provided to IHS beneficiaries.

**B. Cross Cutting and Emerging Issues**

1.  **Medicaid and Managed Care**

Medicaid and Managed Care work group had a variety of cross cutting
issues that were discussed. Most of the dialogue was how to remedy some
of the gaps in the systems (state, federal and I/T/U). The work group
consisted primarily of tribal health directors, Indian Health Service
staff and regional HCFA staff

-   **Medicaid and Medicare Reimbursement Rate:** The group discussed
    what the impact of phasing out FQHC would have on Indian programs.
    They discussed the need to protect full cost recovery for services
    provided. The Cherokee Proposal is modeled after FQHC creation of a
    Qualified Indian Health Program (QIHP) however it does not address
    the issue of non-beneficiaries. There was concern about expanding
    this provision to all sources of payment, specifically private
    providers. The work group supported pursuing the concept of a
    separate I/T/U provider type. As part of this provision, the issue
    of licensure of I/T/U's would all fall under the same federal
    credentialling standards. HCFA would be billed directly for
    Medicaid, Medicare and CHIP or a federal set aside of M/M should be
    considered.

-   **Memorandum of Understanding (Between HCFA and I.H.S.)**: The work
    group discussed a variety of issues that centered on the 100%
    matching was implemented differently throughout Indian Country state
    be state. The work group agreed with the National Indian Health
    Board's recommendation in their recent study, *Indian Health in Nine
    State Medicaid Managed Care Programs,* "The provisions for 100
    percent FMAP and the I.H.S. encounter rate for tribally-operated
    facilities should be specified in law.

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-   **Memorandum of Understanding regarding Medicare:** The work group
    wanted to pursue the MOA expanding to Medicare. It was explained
    that there is an issue with facilities and their status. Currently
    hospitals and skilled nursing facilities can bill for Medicare. It
    was stated that the separate provider type for I/T/U's would cover
    Medicare reimbursement.

2.  **I/T/U Partnerships:**

**Service Linkages:**

-   The workshop began by discussing how to develop service linkages
    between the I/T/U's. The participants felt like it was important for
    I/T/U's that were located in a contiguous geographic area to have
    service linkages. Examples were given on how the St. Regis Mohawk
    Tribe developed a joint project with the American Indian Community
    House of New York City. Other examples cited included the Indian
    Health Care Resource Center and the Cherokee Nation contract for WIC
    services. In addition the IHCRC provides HIV/AIDS services to all
    tribes in NE Oklahoma.

**Policy Partnerships:**

-   The work group participants listed policy partnerships that have
    developed in the last year which includes the Special Initiative on
    Diabetes, FY 2001 budget process and welfare reform issues.

-   A coalition of tribes has organized to develop strategies for "Joint
    venture Projects."

**Summary of other discussion topics:**

-   It was felt that that Indians needed to start thinking "outside the
    box." That the traditional barriers needed to be discarded and that
    new ways of getting business done needed to be developed. Statements
    were made such as "I/T/U's must work together to meet needs of the
    old facilities" and "It is important to educate ourselves on I/T/U
    complexity and issues surrounding it." They felt that the
    composition of the 437steering committee should reflect I/T/U's and
    take into consideration diversity in the population base. The work
    group discussed the "I" in the I/T/U because it was felt that many
    times the direct care tribes might be under represented due to the
    complications of representation. The IHS direct care tribes
    generally feel that IHS should be representing them in all business
    they conduct. Sometimes it is difficult because it is hard to
    distinguish what is for the direct tribes and what is for
    self-preservation by IHS. It was stated that each tribe need to
    continue progress already made during times of strife.

3.  **Behavioral Health and Indian Communities**

Specific issues related to mental health and substance abuse were
discussed in this workgroup. It was the intent of this workgroup to
identify recommendations which may be outside the boundaries of existing
provisions of the IHCIA.

-   **New Provision for Half-way House:** It was recommended that the
    IHCIA be amended to provide for the development of half-way houses
    or transitional living arrangements. It was also recommended that
    incentives for collaboration be provided to encourage Indian
    communities, law enforcement, courts and other services to work as a
    "drug team".

-   **Section 702 Comprehensive Prevention and Treatment Program:** This
    section should be amended to develop "age-specific" and
    "age-appropriate" drug prevention messages and methods for Indian
    children. Strong language should be included which will require the
    collaboration of related federal agencies, such as SAMHSA, DEA, and
    DOJ.

-   **Section 703 Indian Women Treatment Programs:** New treatment
    models should be developed specifically for Indian women and
    children, which are culturally based and family oriented.

4.  **Entitlements, Benefits Package and Health Disparities**

The health disparities experienced by American Indian populations in
comparison to the U.S. general population have been well documented by
the IHS in terms of morbidity and mortality, and by the National Indian
Health Board in terms of per capita expenditures. The workgroup
discussion about "entitlements, benefits package and health
disparities", first focused upon the notion of a new Indian entitlement.
It is important to note, that there was no definitive consensus
recommendation, which emerged from this gathering, except to continue to
examine the option of creating a new Indian health entitlement or to
substantially expand existing entitlements.

A.  **Creating a New Indian Entitlement:** Similar to other regional
    consultation meetings, there was overwhelming consensus, that the
    nature of the historic legal and moral obligation of the federal
    government to provide health services to American Indians and Alaska
    Natives would best be served by establishing an Indian health
    entitlement. Agreeing upon an appropriate mechanism to achieve an
    entitlement health system, proved to be more difficult. There were
    three basic types of entitlement which the group examined.

-   **Tribal Based Entitlement:** This model would establish for each
    Federally Recognized Tribe an entitlement for health services.
    Quantifying the entitlement for each tribe would likely require a
    uniform eligibility definition and a standard benefits package to
    determine each tribe's allocation. The strengths of this model
    include, reinforcement of tribal sovereignty and self-determination,
    it would focus resources on local priorities, and new tribes would
    require additional resources. The weakness of this model include,
    possibility for funds to be redirected, reaching agreement on an
    allocation plan nationally, uncertain or discretionary coverage for
    off-reservation Indians.

-   **Individual Based Entitlement:** This model is similar to existing
    entitlement programs of the federal government, such as Medicaid and
    Medicare. An individual Indian would be entitled to federally
    covered health services by meeting certain criteria, such as tribal
    enrollment. The strengths of this model include, understanding of an
    existing system, portability of coverage for the individual,
    likelihood of equity for all areas, access to multiple providers.
    The weaknesses of this model include, the loss of culturally
    sensitive health providers (I/T/U's), the likelihood that
    poverty-based "means testing" would be required for patient
    eligibility, covering quality control problems, covering cost
    increases by reduced benefits, loss of public health model, and
    elimination of a tribally driven system.

-   **I/T/U Based Entitlement:** This model assumes entitlement funding
    directly to the existing service delivery structure of the I/T/U's.
    It would require a formula, probably based upon a predetermined
    benefits package, which would be applied to the total number of
    eligible patients. The strengths of this approach includes, it would
    build upon an existing infrastructure; it would support culturally
    sensitive health care for Indian patients; tribes would still retain
    the option for self-determination or tribal administration, some
    portability possible for patients and predictable funding for
    minimum benefits package. The weaknesses of this approach include,
    the existing infrastructure is already under-funded and in need of
    improvements; it would perpetuate an inefficient system, it is a
    fixed-facility focus, patient eligibility could be chaotic and vary
    from place to place, there would still be geographic restrictions
    and health disparities. Unserved areas may continue to be unserved.

### Expanding Existing Entitlement Systems: The second approach to creating an entitlement for Indian health, is to build upon the existing entitlement system of the federal government. There are numerous improvements, which could be made to better access Medicaid, Medicare, CHIPS and other entitlement based health programs. One approach presented by the Cherokee Nation and found of interest by the participants was the "Qualified Indian Health Program" or QUIP. This approach basically provides for a permanent extension of a cost-based reimbursement system for Medicaid, Medicare and CHIP or other federal health reimbursements for I/T/U's (much like the Federally Qualified Health Center provisions scheduled to expire).

#### Summary of

**Consensus**

**Recommendations**

+------------+---------------------------------------------------------+
| # Health P | # Recommendations                                       |
| rofessions |                                                         |
|            |                                                         |
| #          |                                                         |
|  (Title I) |                                                         |
+------------+---------------------------------------------------------+
| # Indian   | ##  Health Professions recruitment program for Indians  |
| Health Man |                                                         |
| power 102  | ##  Reauthorize                                         |
|            |                                                         |
|            | #                                                       |
+------------+---------------------------------------------------------+
| # S        | ##  Regionalize                                         |
| ection 103 |                                                         |
|            | ##  Scholarships should be non-taxable                  |
| # Heal     |                                                         |
| th Profess | ## Eligibility criteria (2 options)                     |
| ions prepa |                                                         |
| ratory sch | ## a. Federally recognized tribes only                  |
| olarship f |                                                         |
| or Indians | # b. Per 1988 amendments to include state tribes        |
+------------+---------------------------------------------------------+
| # S        | ## Same as 103:                                         |
| ection 104 |                                                         |
| : Indian H | ## Regionalize                                          |
| ealth Prof |                                                         |
| essions Sc | ## Scholarships should be non-taxable                   |
| holarships |                                                         |
|            | ## Eligibility criteria (2 options)                     |
| #          |                                                         |
|            | ## a. Federally recognized tribes only                  |
|            |                                                         |
|            | # b. Per 1988 amendments to include state tribes        |
+------------+---------------------------------------------------------+
| # 10       | ## Amend to establish an internship program             |
| 5: Indian  |                                                         |
| Health Ser | ## Reauthori                                            |
| vice Exter | ze & amend to include a high school internship programs |
| n Programs |                                                         |
|            | #                                                       |
+------------+---------------------------------------------------------+
| # 106: C   | ## Reauthorize and amend to ref                         |
| ontinuing  | lect that continuing education should be tied to the cr |
| Education  | edentials that are required to maintain your position.  |
| Allowances |                                                         |
|            | #                                                       |
+------------+---------------------------------------------------------+
| # 107:     | ## Reauthorize and amend to authorize                   |
| Community  |  CHR program to become eligible for HCFA reimbursement. |
| Health Rep |                                                         |
| resentativ | #                                                       |
| e Programs |                                                         |
+------------+---------------------------------------------------------+
| 108:       | ##                                                      |
| Indian     |  Reauthorize and amend to make LRP benefits non-taxable |
| Health     |                                                         |
| Service    | ## Delegate authority to the Areas                      |
| Loan       |                                                         |
| Repayment  | #                                                       |
| Program    |                                                         |
+------------+---------------------------------------------------------+
| # 10       | ## Reauthorize and amend to ...                         |
| 8A: Schola |                                                         |
| rship & Lo | ## Allow direc                                          |
| an Repayme | t payment to original funding source for default loans. |
| nt Program |                                                         |
|            | #                                                       |
| #          |                                                         |
+------------+---------------------------------------------------------+
| # 109: Re  | ## Reauthorize                                          |
| cruitment  |                                                         |
| Activities | #                                                       |
+------------+---------------------------------------------------------+
| # 110:     | ## Reauthorize                                          |
| Tribal Rec |                                                         |
| ruitment a | #                                                       |
| nd Retenti |                                                         |
| on Program |                                                         |
+------------+---------------------------------------------------------+
| # 111      | ## Reauthorize                                          |
| : Advanced |                                                         |
|  Training  | #                                                       |
| & Research |                                                         |
+------------+---------------------------------------------------------+
| #          | ## Mov                                                  |
| 112: Nursi | e 112 to Section 115 and amend to include Indian prefer |
| ng Program | ence and change eligibility requirement the same as 103 |
|            |                                                         |
| #          | #                                                       |
+------------+---------------------------------------------------------+
| # 112A: Nu | ## Move to 112A to Section 115                          |
| rsing Scho |                                                         |
| ol Clinics | #                                                       |
|            |                                                         |
| #          |                                                         |
+------------+---------------------------------------------------------+
| # 1        | ## Expand to include traditional medicine               |
| 13: Tribal |                                                         |
|  Culture a | # 2.                                                    |
| nd History |  Reauthorize and amend to include traditional medicine. |
+------------+---------------------------------------------------------+
| # 114: INM | ## Reauthorize                                          |
| ED PROGRAM |                                                         |
|            | #                                                       |
+------------+---------------------------------------------------------+
| # 1        | ## Reauthorize and include Section 112 and 112A here.   |
| 15: Health |                                                         |
|  Training  | ##  Amend health-training p                             |
| Programs o | rograms to include community colleges and universities, |
| f Communit |                                                         |
| y Colleges | ## Add Indian eligibility as in Section 112.            |
|            |                                                         |
|            | #                                                       |
+------------+---------------------------------------------------------+
| # 1        | ## Reauthorize                                          |
| 16: Additi |                                                         |
| onal Incen | #                                                       |
| tives for  |                                                         |
| Health Pro |                                                         |
| fessionals |                                                         |
+------------+---------------------------------------------------------+
| # 117:     | ## Re                                                   |
|  Retention | authorize and amend to include all health professionals |
|            |                                                         |
|            | #                                                       |
+------------+---------------------------------------------------------+
| #          | ## Reauthorize                                          |
| 118: Nursi |                                                         |
| ng Residen | #                                                       |
| cy Program |                                                         |
+------------+---------------------------------------------------------+
| # 119:     | # Reauthorize to include all tribes.                    |
| Community  |                                                         |
| Health Aid |                                                         |
| e Program  |                                                         |
| for Alaska |                                                         |
+------------+---------------------------------------------------------+
| # 120:     | # Reauthoriz                                            |
| Matching G | e and amend to allow tribal health care funds to be abl |
| rants to T | e to meet match requirements associated with the schola |
| ribes for  | rship program (for example: Ameri-corps and IHS, etc.)  |
| Scholarshi |                                                         |
| p Programs |                                                         |
+------------+---------------------------------------------------------+
| #          | # Reauthorize.                                          |
| 121: Triba |                                                         |
| l Health P |                                                         |
| rogram Adm |                                                         |
| inistrator |                                                         |
+------------+---------------------------------------------------------+
| # 122:     | ## Reserv                                               |
| University | e pilot programs to address health care manpower needs. |
|  of South  |                                                         |
| Dakota Pil | #                                                       |
| ot Program |                                                         |
+------------+---------------------------------------------------------+

# 

+------------+---------------------------------------------------------+
| #          | # Recommendations                                       |
| Health Ser |                                                         |
| vices (Tit |                                                         |
| les 2 & 7) |                                                         |
|            |                                                         |
| #          |                                                         |
+------------+---------------------------------------------------------+
| # 20       | ## Formula sh                                           |
| 1: Equity  | ould not penalize small tribes for innovative programs. |
| of Funding |                                                         |
|            | # 2.                                                    |
|            |  There is consensus there should be equity in funding.  |
+------------+---------------------------------------------------------+
| #          | ## Language providing the                               |
| 201: India | ability to add services as they support the objectives. |
| n Health C |                                                         |
| are Improv | ## A general set of statements p                        |
| ement Fund | roviding guidance on which services should be included. |
|            |                                                         |
| #          | # Durable medical equip                                 |
|            | ment should be included & should provide for diagnosis  |
|            |                                                         |
|            | #  & treatment of identified illness.                   |
+------------+---------------------------------------------------------+
| #          | ## General language which enumerates se                 |
| 201: India | rvices including those addressed by specific sections.  |
| n Health C |                                                         |
| are Improv | #                                                       |
| ement Fund |                                                         |
+------------+---------------------------------------------------------+
| #          | # A new sect                                            |
| 201: India | ion which clearly delineates a public health component. |
| n Health C |                                                         |
| are Improv |                                                         |
| ement Fund |                                                         |
+------------+---------------------------------------------------------+
| #          | ## Place a cap on the threshold equal to the increase.  |
| 202: Catas |                                                         |
| trophic He | #                                                       |
| alth Emerg |                                                         |
| ency Funds |                                                         |
+------------+---------------------------------------------------------+
| # 2        | ## No recommendations                                   |
| 03: Health |                                                         |
|  Promotion | #                                                       |
|  & Disease |                                                         |
|  Preventio |                                                         |
| n Services |                                                         |
+------------+---------------------------------------------------------+
| # 204: D   | ## Reauthorization of Model Diabetes Projects           |
| iabetes Pr |                                                         |
| evention,  | #                                                       |
| Treatment, |                                                         |
|  & Control |                                                         |
+------------+---------------------------------------------------------+
| #          | ## Add provisions in the act to address report          |
| 208: Healt | ing of results from special studies or model programs.  |
| h Services |                                                         |
|  Research  | ##                                                      |
+------------+---------------------------------------------------------+
| # 210:     | ## Recommended the elimination of this section          |
| Managed Ca |                                                         |
| re Feasibi |                                                         |
| lity Study |                                                         |
+------------+---------------------------------------------------------+
| # *Ne      | ##  Women's & Men's Heal                                |
| w Section* | th should be addressed equitably, including screenings. |
|            |                                                         |
| #          | a\. Equity in funding to be addressed                   |
|            |                                                         |
|            | b\. Need to have broader definition of "health"         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| # HEALTH F | ######## RECOMMENDATIONS                                |
| ACILITIES  |                                                         |
| (TITLE 3)  |                                                         |
+------------+---------------------------------------------------------+
| # S        | ## 1. All Tribes shall have access to resources         |
| ection 301 |                                                         |
|            | ## Report to Con                                        |
|            | gress total unmet health facility need on annual basis. |
|            |                                                         |
|            | # 3. Accreditation not be limited to JCAHO.             |
+------------+---------------------------------------------------------+
| # 30       | ## Permit tribes to be reimbursed                       |
| 2: Safe Wa |  by IHS for funds obtained from other Federal agencies. |
| ter & Sani |                                                         |
| tary Waste | ## Permit flexibility &                                 |
|  Disposal  | collaborative efforts with other federal agencies (I.e. |
| Facilities |  HUD, BIA, etc.) in provision of sanitation facilities. |
|            |                                                         |
| #          | # Ability to use IHS dollars to leve                    |
|            | rage dollars from other agencies (matching funds, loan  |
|            |                                                         |
|            | #  support, etc.)                                       |
+------------+---------------------------------------------------------+
| # 3        | # Should be reauthorized with option for tribe to w     |
| 03: Prefer | aive Davis Bacon to use wage rates determined locally.  |
| ence to In |                                                         |
| dians & In |                                                         |
| dian Firms |                                                         |
+------------+---------------------------------------------------------+
| # 304:     | #                                                       |
|  Soboba Sa |                                                         |
| nitation F |                                                         |
| acilities  |                                                         |
+------------+---------------------------------------------------------+
| # 30       | ## Recommend reauthorization of 305.                    |
| 5: Expendi |                                                         |
| ture of No | ## TTO concerned there are two lists.                   |
| n-Service  |                                                         |
| Funds for  | # Annually report staffing and operating n              |
| Renovation | eeds for facilities where tribes have built or propose  |
|            |                                                         |
|            | #  to build under this section.                         |
+------------+---------------------------------------------------------+
| #          | ## For the Construction, Expansi                        |
|  306: Gran | on, & Modernization of Small Ambulatory Care Facilities |
| t Program. |                                                         |
|            | # Change first paragraph 306(a) so that                 |
|            |  "eligible Indians" reads "eligible Indian and eligible |
|            |                                                         |
|            | #  non-Indian as defined by CHS regulations."           |
+------------+---------------------------------------------------------+
| #          | ## Not include just grants but include loan guarantee.  |
|  306: Gran |                                                         |
| t Program. | ## Remov                                                |
|            | e language limiting to tribes with 500 or more members. |
|            |                                                         |
|            | # Concern of tribes having difficulty obt               |
|            | aining financing with provision requiring revisions to  |
|            |                                                         |
|            | #  IHS, so delete 306(d)                                |
+------------+---------------------------------------------------------+
| #          | ## Retain with no changes                               |
|  307: Heal |                                                         |
| th Care De | #                                                       |
| monstratio |                                                         |
| n Projects |                                                         |
+------------+---------------------------------------------------------+
| # *New*    | # Tribes & T                                            |
|  *Section* | ribal Organizations should have flexibility to use heal |
|            | th services carry-over funds for facility construction  |
+------------+---------------------------------------------------------+
| # 308: Lan | ## Should be ge                                         |
| d Transfer | neric to permit transfer between agencies without cost. |
|            |                                                         |
|            | #                                                       |
+------------+---------------------------------------------------------+
| # 309: A   | # No Issues.                                            |
| uthorizati |                                                         |
| on of Appr |                                                         |
| opriations |                                                         |
+------------+---------------------------------------------------------+
| # 310: A   | ## Tribe and Tribal O                                   |
| pplicabili | rganizations should be able to opt out of Buy American  |
| ty of Buy  | Act. Strengthens government to government relationship. |
| American R |                                                         |
| equirement | #                                                       |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| # HEALTH   | ## Appropriation should include pool for cap            |
| FACILITIES | ital dollars for replacement or renovation (emergency). |
|            |                                                         |
|            | 1.  Facility Construction responsibility be added to    |
|            |     Preamble under findings and objectives.             |
+------------+---------------------------------------------------------+
| # Sectio   | ## Move to Title III                                    |
| n 818 Join |                                                         |
| t Venture  | ## A Tribe, including one which has begu                |
|            | n & substantially completed the process of acquisition  |
|            |                                                         |
|            | ##  Or construction of an ambulatory health             |
|            | facility on/after October 1, 1993 shall be eligible to  |
|            |                                                         |
|            | ##  establish a joint venture proj                      |
|            | ect with IHS utilizing such ambulatory health facility. |
|            |                                                         |
|            | ## Add protection language for tribes in th             |
|            | e event of IHS failure to keep its end of the bargain.  |
+------------+---------------------------------------------------------+
| # Secti    | ## Move to Title III                                    |
| on 804 Lea |                                                         |
| se of trib | ## Amend to define "lease" as                           |
| al buildin | operating lease for purposes of Budget Enforcement Act. |
| gs by IHS  |                                                         |
|            | ## Appropriation should include pool for cap            |
|            | ital dollars for replacement or renovation (emergency). |
|            |                                                         |
|            | ## 4. Facility Construction responsibili                |
|            | ty be added to Preamble under findings and objectives.  |
+------------+---------------------------------------------------------+
| # HEALTH   | ## RECOMMENDATIONS                                      |
| FACILITIES |                                                         |
+------------+---------------------------------------------------------+
| # Ne       | Expanded definition of Health Facility.                 |
| w Section: |                                                         |
+------------+---------------------------------------------------------+
| # N        | ## Language needed to allow                             |
| ew Section | I/T/U use of M/M revenue for development of facilities. |
+------------+---------------------------------------------------------+

## * *

+------------+---------------------------------------------------------+
| # ACCESS   | # RECOMMENDATIONS                                       |
|            |                                                         |
| #          |                                                         |
| (TITLE 4)  |                                                         |
+------------+---------------------------------------------------------+
| # 401      | ## 1. Language to inclu                                 |
|            | de "contract/compact" throughout or "funding agreement" |
|            |                                                         |
|            | # Any                                                   |
|            |  service Medicare will pay any provider, it will also p |
|            | ay I/T/U under Medicare that meet the same conditions.  |
|            |                                                         |
|            | # Tr                                                    |
|            | ibal is *any* tribally owned or operated health facilit |
|            | y/program, [and]{.underline} doesn't have to be only a  |
|            |                                                         |
|            | #  638 tribe.                                           |
+------------+---------------------------------------------------------+
| # 401: Sel | ## Add sub-section "C"                                  |
| f Referral | from Oklahoma Area report & the Cherokee Nation report. |
|  of Medica |                                                         |
| re & MCO's | ## No mandatory enro                                    |
|            | llment of AI/AN in MCO's for M/M - for those that choos |
| #          | e to enroll, they have right to self-referral to I/T/U. |
|            |                                                         |
|            | ## Effective date of enactment to include t             |
|            | hose currently enrolled in a Medicare MCO & in future.  |
|            |                                                         |
|            | ## I/T/U is guaranteed reimb                            |
|            | ursement effective retroactive as far back as possible. |
|            |                                                         |
|            | #                                                       |
+------------+---------------------------------------------------------+
| # 4        | ## Recommend accred                                     |
| 01 & 402:  | itation by a Nationally recognized accrediting body not |
| State Lice |  via State for facilities as per Oklahoma Area report.  |
| nsure for  |                                                         |
| Facilities | # 2. Any 3                                              |
|            | rd party payer must pay I/T/U as if licensed by State.  |
+------------+---------------------------------------------------------+
| # Sectio   | ## Make demonstration projects permanent & any I/       |
| ns: 401, 4 | T/U that chooses to can bill & collect Medicare/Medicai |
| 02, & 405  | d directly & use of funds unrestricted by special fund. |
|            |                                                         |
|            | ## Use of funds to maintain accre                       |
|            | ditation is still a priority, but tribes should have mo |
|            | re flexibility to use funds once accreditation is met.  |
|            |                                                         |
|            | #                                                       |
+------------+---------------------------------------------------------+
| # 402      | ## Any I/T/U ca                                         |
| : Medicaid | n bill or collect for any Medicaid services covered in  |
|            | the State Medicaid Plan for Medicaid eligible patients. |
|            |                                                         |
|            | ## Amend "Section 190                                   |
|            | 5 b of the Social Security Act" so that *any* State tha |
|            | t reimburses for service provided by or through I/T/U f |
|            | or any Medicaid services will be entitled to 100% FMAP. |
|            |                                                         |
|            | # No manda                                              |
|            | tory enrollment of AI/AN in MCO's for Medicaid. For tho |
|            | se that choose to enroll, they still have right of self |
|            | -referral to I/T/U & I/T/U is guaranteed reimbursement. |
+------------+---------------------------------------------------------+
| #          | ## Issue: Tr                                            |
| 402: Acces | ibes still have to go through States & MCO's, when they |
| s & Misc.  |  should be a direct government to government with HCFA. |
|            |                                                         |
|            | ## No recommendation                                    |
|            |                                                         |
|            | #                                                       |
+------------+---------------------------------------------------------+
| # 4        | Reauthorize this section *and* Support recommendations  |
| 04: Grants | from 3 Areas.                                           |
|  to Tribes |                                                         |
+------------+---------------------------------------------------------+
| # New Sect | ## CHIP reimbursement & participati                     |
| ion: Child | on should be available to I/T/U's on the same basis as  |
| ren's Heal | Medicaid & waivers provided for all co-pays & premiums. |
| th Insuran |                                                         |
| ce Program | # 2. See Cherokee recommendation on Section 406.        |
+------------+---------------------------------------------------------+
| # Issue:   | ## Title 19 requirement for spend down b                |
|  Spend Dow | e amended to waive AI/AN from requirements or allow Sta |
| n Requirem | tes to count I/T/U cost for services toward spend down. |
| ent for Me |                                                         |
| dicaid Ben | # Amend Title 18 to waive                               |
| eficiaries | Part A & B premiums for AI/AN beneficiaries & to waive  |
|            |                                                         |
|            | #  deductibles & co-pays.                               |
+------------+---------------------------------------------------------+
| # 406: 3   | ## Reauthorize Section 406                              |
| 0 Day Noti |                                                         |
| ce for Eme | # 2. New Section Added: To the extent tha               |
| rgency CHS | t I/T/U Outpatient Departments are operating as a part  |
|            |                                                         |
| #          | # of                                                    |
|            | hospital facility, not subject to provisions of EMTALA  |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| **URBAN    | ####### RECOMMENDATION                                  |
| PROGRAMS   |                                                         |
| (TITLE     |                                                         |
| 5)**       |                                                         |
+------------+---------------------------------------------------------+
| 501        | Reauthorize                                             |
+------------+---------------------------------------------------------+
| 502        | Reauthorize                                             |
+------------+---------------------------------------------------------+
| 503        | There should be uniform reporting system and adequate   |
|            | recurring funding to ensure that reporting system is    |
|            | updated and upgraded.                                   |
|            |                                                         |
|            | \(4\) Reauthorize. Remove language "Which may not       |
|            | duplicate existing services".                           |
+------------+---------------------------------------------------------+
| 504        | Reauthorize.                                            |
+------------+---------------------------------------------------------+
| 505        | To combine reviews with other organizations with Indian |
|            | Health Service evaluations. Indian Health Service       |
|            | reviews coincide with review periods of other national  |
|            | accrediting bodies (e.g. JCAHO)                         |
+------------+---------------------------------------------------------+
| 506        | 1\. Allow GSA Leasing                                   |
|            |                                                         |
|            | 2\. Include Urban Programs in Indian Health Service/VA  |
|            | MOA                                                     |
|            |                                                         |
|            | 1.  Include Urban Programs under FTCA                   |
|            |                                                         |
|            | 2.  Urban programs eligible for indirect cost (provided |
|            |     under Title V with additional funds).               |
|            |                                                         |
|            | 5\. Urban Programs may use 3rd party revenue for        |
|            | facilities.                                             |
|            |                                                         |
|            | 6\. Urban Programs included in agreement to provide     |
|            | 100% FMAP reimbursement to states.                      |
+------------+---------------------------------------------------------+
| 507        | Change quarterly reports to semi-annual reports         |
|            |                                                         |
|            | Appropriate funds per section 507(d)(3)(A) and (B) to   |
|            | provide funds for welfare of Urban Indians              |
|            |                                                         |
|            | In section 507 ( c ) regarding audits, remove "shall    |
|            | allow" and insert "independent financial audit          |
|            | conducted by a CPA or CPA certified to conduct federal  |
|            | compliance audits".                                     |
|            |                                                         |
|            | Provide funding for increased independent auditing      |
|            | costs.                                                  |
+------------+---------------------------------------------------------+
| 508        | Change wording to allow the Secretary to enter into     |
|            | grants as well as contracts.                            |
+------------+---------------------------------------------------------+
| 509        | Reauthorize with change in language to reflect "A       |
|            | Nationally Recognized Accrediting Body", not limited to |
|            | just JCAHO.                                             |
+------------+---------------------------------------------------------+
| 510        | Add "As may be necessary to carry out area              |
|            | responsibilities" to current language regarding area    |
|            | office staff to support urban programs.                 |
|            |                                                         |
|            | Add contract health service funding for Urban Programs  |
|            | with authorization and appropriation of new money.      |
|            |                                                         |
|            | Recognize support for traditional healing, including    |
|            | funding for support of such services (travel, lodging,  |
|            | meals). Traditional health cannot be regulated by       |
|            | Federal Agencies, needs to be determined by Local       |
|            | Areas.                                                  |
+------------+---------------------------------------------------------+
| 511        | Reauthorize.                                            |
+------------+---------------------------------------------------------+
| 512        | No consensus reached here. Some Oklahoma Tribes view    |
|            | the Urban Programs recommendation for exemption from    |
|            | the Indian Self Determination Act as an infringement on |
|            | Tribal Sovereignty                                      |
|            |                                                         |
|            | Urban Programs advocate that Tulsa and Oklahoma City    |
|            | Programs become permanent programs within the Indian    |
|            | Health Service direct care program and that all Title V |
|            | Programs are exempted from provisions of the Indian     |
|            | Self Determination Act                                  |
|            |                                                         |
|            | Both sides agree that a forum to continue the dialogue  |
|            | between Tribes and urban programs is needed.            |
+------------+---------------------------------------------------------+
| 513        | Transfer of NIAAA Programs be completed, with funding   |
|            | to follow them, on a timely basis.                      |
+------------+---------------------------------------------------------+
| 514        | Reauthorize.                                            |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| FQHC phase | 1.  Pursue the concept of a separate I/T/U provider     |
| out, need  |     types.                                              |
| protect    |                                                         |
| full cost  | 2.  As part of this provision, the issue of licensure   |
| recovery   |     of I/T/U's all fall under the same federal          |
| for        |     credential standards.                               |
| services   |                                                         |
| provided.  | 3.  Bill HCFA directly for M/M and CHIPO or there would |
|            |     be a federal set aside of M/M funds that I/T/U's    |
|            |     would receive.                                      |
+------------+---------------------------------------------------------+
| MOA 100%   | MOA 100% map (Between HCFA & IHS); MOA in early 1997,   |
| FMAP       | but HCFA would not allow tribes to back bill to the MOA |
|            | signature date.                                         |
|            |                                                         |
|            | -   Support the language in the NIHB paper, Issue #2    |
|            |     and recommend placing into law.                     |
+------------+---------------------------------------------------------+
| Is it      | Separate provider type for I/T/Us covers Medicare       |
| possible   | reimbursement.                                          |
| to have    |                                                         |
| the MOA    |                                                         |
| expanded   |                                                         |
| to cover   |                                                         |
| Medicare?  |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| **MENTAL   | **RECOMMENDATIONS**                                     |
| HEALTH     |                                                         |
| SUBSTANCE  |                                                         |
| ABUSE**    |                                                         |
+------------+---------------------------------------------------------+
| 701: MH/SA | 1.  Need halfway house or transitional living           |
|            |     arrangement.                                        |
|            |                                                         |
|            | 2.  Form collaborations with community, law             |
|            |     enforcement, courts, other services, as in a "Drug  |
|            |     Court" team as model program.                       |
+------------+---------------------------------------------------------+
| 702:       | 1.  Develop age appropriate prevention methods          |
| Com        |                                                         |
| prehensive | 2.  Include requirement in the IHCIA that all federal   |
| Prevention |     agencies and other agencies that receive federal    |
| and        |     dollars collaborate.                                |
| Treatment  |                                                         |
| Program    |                                                         |
+------------+---------------------------------------------------------+
| 703:       | 1\. Development of new treatment models for women and   |
| Indian     | children, cultural based, family treatment, community   |
| Women      | based.                                                  |
|            |                                                         |
| Treatment  |                                                         |
| Programs   |                                                         |
+------------+---------------------------------------------------------+
| 704:       | No recommendations listed.                              |
| Deto       |                                                         |
| xification |                                                         |
| and        |                                                         |
| Rehab      |                                                         |
| ilitation: |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| **I/T/U    | **DISCUSSION POINTS**                                   |
| PART       |                                                         |
| NERSHIPS** |                                                         |
+------------+---------------------------------------------------------+
| Continue   | A.  Develop service linkage between I/T/U's             |
| dialogue   |                                                         |
| of         | Example: St. Regis Mohawk Nation and the American       |
| st         | Indian Community House developed a                      |
| rategizing |                                                         |
| p          | joint project together.                                 |
| olitically |                                                         |
| and how to | Example: Tulsa has contract with Cherokee Nation to     |
| link       | provide W.I.C. services and provide                     |
| together   |                                                         |
| I/T/U's.   | HIV/AIDS services to all tribes in North East Oklahoma. |
|            |                                                         |
|            | B.  Policy on Partnerships                              |
|            |                                                         |
|            | Examples of Partnerships: Special initiative --         |
|            | Diabetes fund                                           |
|            |                                                         |
|            | F.Y. 2001 Budget Process                                |
|            |                                                         |
|            | -   We have all worked together on Welfare Reform.      |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   Share and demonstrate things happening in I/T/U's   |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   Important to educate Congress on Indian Issues,     |
|            |     i.e., gaming.                                       |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   Coalition of tribes strategizing for joint venture  |
|            |     projects.                                           |
+------------+---------------------------------------------------------+
| Forget the | -   Thinking "outside the box".                         |
| t          |                                                         |
| raditional | -   I/T/U's must work together to meet needs of old     |
| barriers.  |     facilities.                                         |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   It is important to educate ourselves on I/T/U       |
|            |     complexity and issues surrounding it.               |
|            |                                                         |
|            | -   The composition of the National '437 Steering       |
|            |     Committee should reflect I/T/U's and taking into    |
|            |     consideration diversity in the population base.     |
|            |                                                         |
|            | -   There was discussion of "I" in I/T/U -- this        |
|            |     requires direct care tribal representation.         |
|            |                                                         |
|            | -   NIHB advocates for all tribes and urbans.           |
|            |                                                         |
|            | -   Each tribe to continue progress already made during |
|            |     times of strife.                                    |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| **         | **RECOMMENDATIONS**                                     |
| PREAMBLE** |                                                         |
+------------+---------------------------------------------------------+
| Current    | 'The Congress finds the following: (a) Federal health   |
| language   | services to maintain and improve the health of the      |
| reads:     | Indians are consonant with and required by the Federal  |
|            | government's historical and unique legal relationship   |
|            | with, and resulting responsibility to, the American     |
|            | Indian people."                                         |
|            |                                                         |
|            | Recommendation: Amend the finding to insert: "resulting |
|            | [trust]{.underline} responsibility"                     |
+------------+---------------------------------------------------------+
| 601:       | A.  Designation of Director                             |
| Orga       |                                                         |
| nizational | B.  At general session regarding title, discussion      |
| Im         |     regarding the enactment date. Bemidji Area and      |
| provements |     Oklahoma Areas provided different recommendations.  |
| -- Title   |                                                         |
| VI         | Recommendation: Reauthorize & amend to designate        |
|            | Director as Assistant Secretary for Indian Health.      |
+------------+---------------------------------------------------------+
| 601:       | Provision for tribal governments, as sovereign nations, |
| Orga       | to have full procurement rights as afforded to IHS, as  |
| nizational | an agency.                                              |
| Im         |                                                         |
| provements |                                                         |
| Title VI   |                                                         |
+------------+---------------------------------------------------------+
| 602 --     | Should self governance tribes enjoy equal access to     |
| Automated  | improvements to MIS?                                    |
| MIS        |                                                         |
|            | 1.  Any language referencing "contract" must also       |
|            |     include "compact".                                  |
|            |                                                         |
|            | 2.  Self-governance tribes should have access because   |
|            |     improvements are still public domain through        |
|            |     Freedom of Information Act.                         |
|            |                                                         |
|            | 3.  Is current language sufficient? If not, what        |
|            |     expansion of existing system is required to support |
|            |     data needs within the legislation?                  |
|            |                                                         |
|            | 4.  Subsection D, p. 131, delete "office" a reference   |
|            |     point. See subsection B, p. 130.                    |
|            |                                                         |
|            | 5.  Include early recognition, managed care, prevention |
|            |     and prevalence. More user friendly system is        |
|            |     needed. An inventory system. Tribes/Agency systems  |
|            |     need to be compatible. Both IHS and Tribes work     |
|            |     toward this at a nation and Area level.             |
|            |                                                         |
|            | 6.  Tribes will need to support GPRA because it will    |
|            |     impact funding of IHS and tribes. Without good data |
|            |     you cannot justify the budget.                      |
|            |                                                         |
|            | 7.  There are systems available to solve some of these  |
|            |     problems, such as EDI, sharing of health records,   |
|            |     computerized patient records through Internet       |
|            |     technologies.                                       |
|            |                                                         |
|            | 8.  Identify funding to support compatibility between   |
|            |     tribes and IHS. Also to support the need for        |
|            |     current technology.                                 |
|            |                                                         |
|            | 9.  A two-year time frame is recommended.               |
+------------+---------------------------------------------------------+
| Title VII  | Current language does not address the compacted         |
| --Misc.    | programs                                                |
|            |                                                         |
| Compacted  | Recommendation: Any language referencing "contract"     |
| Prgm.      | must also include "compact".                            |
+------------+---------------------------------------------------------+
| Title VII  | Tribes desire to have direct access to VA supply        |
| -- Misc.   | agreements                                              |
|            |                                                         |
| Supply     | Recommendation: Amend VA agreements to provide tribes   |
| Agreements | direct access as a part of the agency.                  |
|            |                                                         |
|            | (Section 816)                                           |
+------------+---------------------------------------------------------+
| Title VII  | Government rates are available only for 638 funded      |
| -- Misc.   | source.                                                 |
|            |                                                         |
| Gov't      | Recommendation: Tribes should access Government rates   |
| Rates      | for travel for all health programs                      |
|            |                                                         |
|            | Regardless of the funding source.                       |
+------------+---------------------------------------------------------+
| Title VII  | Study or develop Government Computerized Patient Record |
| -- Misc.   | in coordination with VA, DOD, and IHS (Information      |
|            | System Partnership)                                     |
| Co         |                                                         |
| mputerized | No consensus recommendation.                            |
| Patient    |                                                         |
| Record     |                                                         |
+------------+---------------------------------------------------------+
| Title VII  | Recommendation: Speedy acquisition goals, services or   |
| -- Misc.   | supplies. At the request of the Secretary, enters into  |
|            | an Agreement on behalf of the Indian Tribes for the     |
| Speedy     | acquisition of any goods, services, or supplies         |
| a          | available to the GSA or other Federal agencies that are |
| cquisition | not directly available to the Indian Tribes. Under this |
| goals,     | section or any other federal law, including             |
| services   | acquisitions from prime vendors. All such acquisitions  |
| or         | shall be undertaken through the most efficient and      |
| supplies.  | practical method, including electronic order            |
|            | arrangements.                                           |
+------------+---------------------------------------------------------+
| 813: Title | 1.  Health Services for Ineligible Persons. The         |
| VII --     |     eligibility language should be modified to allow    |
| Misc.      |     children who have not attained the age of 19,       |
| Ineligible |     reside in the eligible Indian's household and is    |
| Persons    |     defined as a legal dependent as defined by the IRS  |
|            |     to be eligible to receive health services through   |
|            |     the Indian health facilities.                       |
|            |                                                         |
|            | 2.  "Added on" programs under this Title should be      |
|            |     redistributed appropriately in the text of the      |
|            |                                                         |
|            | > reauthorization language.                             |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| **         | **RECOMMENDATIONS**                                     |
| PREAMBLE** |                                                         |
+------------+---------------------------------------------------------+
| Title VII  | 1\. Allow Tribes to charge co-pay for services to       |
| -- Misc.   | eligible and non-eligible users. This will allow for    |
|            | revenue generation for service expansion.               |
| Co-Pay     |                                                         |
+------------+---------------------------------------------------------+
| Title VII  | 1\. Allow IHS to bill self-insured tribes.              |
| -- Misc.   |                                                         |
|            |                                                         |
| Allow IHS  |                                                         |
| to bill    |                                                         |
| se         |                                                         |
| lf-insured |                                                         |
| tribes.    |                                                         |
+------------+---------------------------------------------------------+
| Other      | I/T/U's must be allowed to provide prosthetics.         |
| Emerging   |                                                         |
| Issues     |                                                         |
| P          |                                                         |
| rosthetics |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| **ENT      | **RECOMMENDATION**                                      |
| ITLEMENT** |                                                         |
|            |                                                         |
| **AND**    |                                                         |
|            |                                                         |
| **HEALTH   |                                                         |
| DIS        |                                                         |
| PARITIES** |                                                         |
+------------+---------------------------------------------------------+
| En         | -   Consensus that Indian health is an entitlement.     |
| titlement, |                                                         |
| Benefits   | -   Opposition to any means testing of IHS              |
| Package &  |     beneficiaries under an entitlement scenario.        |
| Health     |                                                         |
| D          | -   There could be three types of new entitlements to:  |
| isparities |                                                         |
|            | (1) Tribes                                              |
|            |                                                         |
|            | (2) I/T/U's or                                          |
|            |                                                         |
|            | (3) Individual patients.                                |
|            |                                                         |
|            | -   Another option is to support the Cherokee proposal  |
|            |     to extend FQHC provisions for I/T/U under a         |
|            |     "Qualified Indian Health Program" (QUIP)            |
+------------+---------------------------------------------------------+

Summary of

**Individually Submitted**

**Recommendations**

**INDIVIDUAL RECOMMENDATIONS**

**NEW ORLEANS**

+-----------+----------------------+-----------------------------------+
| #         | # ISSUES             | # RECOMMENDATIONS                 |
|  TITLE-II |                      |                                   |
|           |                      |                                   |
| **Health  |                      |                                   |
| S         |                      |                                   |
| ervices** |                      |                                   |
+-----------+----------------------+-----------------------------------+
| Title-    | Contract Health      | 1)  [ALL]{.underline} providers   |
| II-Health | Services             |     of Heath Care for American    |
| Services  |                      |                                   |
|           |                      | Indian/Alaska Native, (i.e.       |
|           |                      | Hospitals, Clinics,               |
|           |                      |                                   |
|           |                      | Out Patient Surgery, Physicians,  |
|           |                      | Dentists,                         |
|           |                      |                                   |
|           |                      | Mental Health, Equipment, etc. -  |
|           |                      | [ALL]{.underline}                 |
|           |                      |                                   |
|           |                      | Providers., shall bill for        |
|           |                      | compensation for the              |
|           |                      |                                   |
|           |                      | provision of medical care and     |
|           |                      | receive for that                  |
|           |                      |                                   |
|           |                      | care a rate or charge [NOT TO     |
|           |                      | EXCEED]{.underline} the           |
|           |                      |                                   |
|           |                      | Medicare rate or reimbursement    |
|           |                      | established at                    |
|           |                      |                                   |
|           |                      | that time. Make it Law!           |
|           |                      |                                   |
|           |                      | 2)  No provider can deny an       |
|           |                      |     American                      |
|           |                      |                                   |
|           |                      | Indian/Alaska Native Medical      |
|           |                      | Care.                             |
+-----------+----------------------+-----------------------------------+
| Title-II  | IHS- Coverage for    | [Add language to law              |
| Health    | Tribal members       | that]{.underline} :               |
| Services  | living off of        |                                   |
|           | "Reservation" or     | Health Care benefits go with      |
|           | service area are     | Indian(s) regardless of residency |
|           | ineligible for       | status, including the necessary   |
|           | health care and      | appropriations.                   |
|           | services.            |                                   |
+-----------+----------------------+-----------------------------------+
| 103       | Early career track   | Include K-12 career track         |
|           | development          | development authorization. Fund   |
| Health    |                      | as a demonstration project to     |
| Pr        |                      | allow time to develop a           |
| ofessions |                      | comprehensive national approach   |
| Sch       |                      | to promote the Indian Health      |
| olarships |                      | Service and monitor students over |
|           |                      | time to determine success of      |
|           |                      | career development activities.    |
+-----------+----------------------+-----------------------------------+
| 203 Or    | Access authorization | Include broadly defined           |
| 208(?)    | to emerging          | definitions or statements, or     |
|           | (approved)           | subsections that would give       |
| Health    | technology/health    | tribes future flexibility as      |
| Promotion | care/medications to  | health research produces          |
| and       | address diseases now | aggressive health mitigation      |
| Disease   | undergoing extensive | tools to combat diseases          |
| P         | research (e.g. AIDs, | currently being researched.       |
| revention | Cancer, etc.)        |                                   |
+-----------+----------------------+-----------------------------------+

**INDIVIDUAL RECOMMENDATIONS**

######### NEW ORLEANS

+-----------+----------------------+-----------------------------------+
| #         | # ISSUES             | # RECOMMENDATIONS                 |
|  TITLE-II |                      |                                   |
|           |                      |                                   |
| # Health  |                      |                                   |
|  Services |                      |                                   |
+-----------+----------------------+-----------------------------------+
| 401(?)    | -   In rural areas   | Allow ITU's to bill 3^rd^ party   |
|           |     where            | payers for multiple services      |
| Access to |     transportation   | provided on a single day by       |
| Health    |     is a problem,    | multiple providers for different  |
| Services  |     people must      | services.                         |
|           |     travel long      |                                   |
|           |     distances. It    |                                   |
|           |     would be         |                                   |
|           |     beneficial to    |                                   |
|           |     the patient to   |                                   |
|           |     receive several  |                                   |
|           |     services at one  |                                   |
|           |     time (i.e. eye   |                                   |
|           |     exam, dental     |                                   |
|           |     exam, foot exam, |                                   |
|           |     and diabetes     |                                   |
|           |     clinic);         |                                   |
|           |     however, under   |                                   |
|           |     current billing  |                                   |
|           |     and all          |                                   |
|           |     inclusive rate,  |                                   |
|           |     the Health       |                                   |
|           |     Facility can     |                                   |
|           |     only bill for    |                                   |
|           |     the services of  |                                   |
|           |     one provider per |                                   |
|           |     day.             |                                   |
|           |                      |                                   |
|           | ```{=html}           |                                   |
|           | <!-- -->             |                                   |
|           | ```                  |                                   |
|           | -   This provision   |                                   |
|           |     of multiple      |                                   |
|           |     services         |                                   |
|           |     essentially      |                                   |
|           |     decreases        |                                   |
|           |     collections for  |                                   |
|           |     the facility but |                                   |
|           |     offers needed    |                                   |
|           |     services for the |                                   |
|           |     patient in an    |                                   |
|           |     effective        |                                   |
|           |     manner.          |                                   |
+-----------+----------------------+-----------------------------------+
| 402(?)    | -   IHS / Tribal /   | Type of "federal provider" number |
|           |     Urban (I/T/U)    | that will enable accredited or    |
|           |                      | certified programs to collect for |
|           |    Alcohol-Substance | services.                         |
|           |     abuse programs   |                                   |
|           |     cannot           |                                   |
|           |     bill/collect for |                                   |
|           |     services for     |                                   |
|           |     clients that     |                                   |
|           |     come from out of |                                   |
|           |     state.           |                                   |
|           |                      |                                   |
|           | -   HCFA and many    |                                   |
|           |     states do not    |                                   |
|           |     recognize that   |                                   |
|           |     many I/T/U       |                                   |
|           |                      |                                   |
|           |    alcohol-substance |                                   |
|           |     abuse programs   |                                   |
|           |     have cultural    |                                   |
|           |     components that  |                                   |
|           |     are essential in |                                   |
|           |     recovery for     |                                   |
|           |     some alcohol/    |                                   |
|           |     substance abuse  |                                   |
|           |     clients.         |                                   |
+-----------+----------------------+-----------------------------------+

**Attachments**

**List of Participants**

**Tribal Resolutions**

**Area or Other Resolutions**

**Area I/T/U Recommendations**

**Bemidji Area**

**Nashville Area**

**Oklahoma Area**